HIV And Pregnancy
By R. Morgan Griffin
Most children infected with HIV contract the virus directly from their mother (called mother-to-child, perinatal or vertical transmission). However, even though having HIV as an expectant mother poses risks, it does not mean that you and your baby are destined to have medical problems and poor health.
HIV-positive women can often, with treatment, have a normal pregnancy. Medical treatment greatly diminishes the danger of your baby's contracting HIV from you. A mother's risk of transmitting the virus to her baby is at most 2% with standard medical care in the United States, whereas it is about 25% without any treatment.
So if you are a woman who is HIV-positive, don't rule out motherhood as an option for you.
Experts believe that HIV can reduce fertility in women. If you are HIV-positive and interested in becoming pregnant, you should consult an expert in the care of HIV-positive women to review your options. You should also speak to your physician about your HIV medications before becoming pregnant. Some HIV medications have been linked to birth defects if taken during the first trimester of pregnancy.
If you are HIV-negative but have become pregnant by an HIV-positive man, you must be tested to rule out the possibility that you have acquired the infection. Although a man's sperm does not seem to directly infect the fetus, it can infect you. You, in turn, can spread the disease to your baby. It is now recommended that all women — regardless of their partners' HIV status — be tested for HIV, because treatment can dramatically lower the risk of mother-to-child transmission.
With the prognosis for HIV-positive people so improved as a result of new treatments, many have become interested in raising a family. But an HIV-negative woman who wants to have children with an HIV-positive man should discuss the risk extensively with her physician. It is critical to determine your level of risk, and to develop ways to reduce the chances of acquiring HIV infection. One option is sperm washing with in vitro fertilization, which dramatically reduces the risk of HIV transmission to the uninfected female partner.
Any woman who is pregnant, HIV-positive or both needs to get regular medical attention. You should preferably see an obstetrician to check on the health of your baby, as well as a doctor who specializes in treating HIV. You won't get proper treatment unless both doctors understand your condition and know about all of the medications you're taking.
There is no evidence that pregnancy exacerbates HIV. Although there are reports that HIV-infected patients have an increased risk of preterm delivery, the virus does not typically make pregnancy more difficult. However, reactions to both pregnancy and the virus — and side effects from HIV medications — can be severe in some people. You should always consult with your doctor if you think that pregnancy has exacerbated your HIV symptoms or drug side effects.
In addition to providing regular prenatal care, your doctor will want to monitor your HIV medications and keep a careful watch on your CD4 cell counts and your viral load (the amount of virus in your body). If the virus is still detectable in your blood despite treatment, your doctor will probably want to administer a drug resistance test to make certain that the HIV in your bloodstream is not building up immunity to any of your medications. If it is, your doctor might substitute other drugs.
HIV medications are powerful drugs. Many expectant mothers worry about the danger to their unborn child. Although some studies have indicated potential risks with certain HIV medications, current scientific consensus is that most HIV drugs pose insignificant risks, especially compared with not taking any HIV drugs. Still, you should always ask your doctor about the dangers and side effects of these medications when taken during pregnancy. Your doctor may change your medications once you become pregnant.
Current recommendations for initiation of antiretroviral therapy for the treatment of HIV infection are the same for pregnant women as for non-pregnant patients. The standard treatment is a combination of medicines that should be started when there are particular signs that the HIV virus is weakening the immune system (a combination of clinical signs and laboratory tests are used to determine when antiretroviral therapy should be started). The goal of antiretroviral therapy is to reduce the blood viral load as much as possible. In general, if a woman requires antiretroviral treatment for HIV/AIDS, these drugs should be continued throughout pregnancy.
Antiretroviral therapy is also critical for the prevention of mother-to-child transmission of the HIV virus, even for women who do not yet meet indications for antiretroviral therapy for the treatment of their own HIV disease. Pregnant women should take a combination of medications, preferably including zidovudine, or AZT (also called Retrovir). Although the recommendations are that treatment be started after the first trimester to prevent mother-to-child transmission, even therapy that is begun substantially later than this markedly lowers the risk of transmission. During labor, zidovudine or other HIV medication is given to the mother. The baby is also given AZT by mouth for the first 6 weeks of his or her life.
Studies suggest that AZT treatment, by itself, drops the risk of mother-to-child HIV transmission from 25% to about 8% Highly active antiretroviral therapy (a combination of three HIV medications) can decrease the risk to about 1%.
Caesarean section is usually offered to pregnant women who still have an elevated viral load (a blood test that calculates the amount of HIV virus in the blood) at the time of delivery.
Make sure your obstetrician knows exactly what medicines you are taking for your HIV. Studies indicate that the lower your viral load, the lower your risk of spreading the disease.
In the past, it was recommended that HIV-infected women deliver by Caesarean section. In a Caesarean section, the baby does not pass through the birth canal. Instead, it is delivered through a surgical incision made in the mother's abdomen. The advantage of a Caesarean section, especially when performed before your water breaks, is that it limits the baby's exposure to your blood and mucous membranes, both of which can transmit HIV.
However, because of the success of HIV medications in reducing the risk of mother-to-child transmission, Caesarean sections are no longer routinely recommended, as long as your viral load is very low. If it is anticipated that your viral load will not be low enough at the time of delivery, your doctor will probably recommend that you have a Caesarean section. Caesarean sections, like any form of surgery, carry some risk. Consult with your doctor to see whether he or she would suggest the procedure in your particular case.
Preventing HIV In Your New Baby
Expectant mothers can pass HIV to their unborn children through the exchange of bodily fluids. For example, it is possible that the risk of HIV transmission may be higher in women who undergo amniocentesis. This procedure involves inserting a needle into the womb to take a sample of the amniotic fluid. You should discuss the risks and benefits of this procedure with your physician.
However, most cases of mother-to-child transmission do not take place while the baby is still in the womb. Instead, the majority of cases occur either when the baby is exposed to the mother's blood or mucous membranes during birth or to her breast milk afterwards.
Your child should undergo HIV testing soon after birth and several times after that. This should be done under the direction of a pediatrician experienced in the diagnosis and management of children with HIV. However, be aware that even if your child is HIV-negative, he or she may initially test positive. HIV antibodies are passed from mother to child in the womb even if the virus is not. Because of these potential false-positive results, your doctor will do a special test looking for the presence of the virus itself in your baby's blood.
Doctors recommend that the baby of an HIV-positive woman immediately be given a regimen of AZT or other HIV medication for about six weeks. If your baby eventually tests HIV-negative, no further treatment is necessary. If he or she tests positive, your child will need to continue taking HIV medications and be followed by an HIV specialist.
Talk with your doctor about the precautions you should take to prevent the spread of HIV to your baby. Although it is safe to hug, kiss and share food with your baby, you should avoid sharing any items that may have come in contact with blood. These include earrings, toothbrushes and, obviously, any needles that may be used for injections (such as insulin).
Doctors in the United States recommend that HIV-positive mothers do not breastfeed their children. Breast milk can contain HIV, and breastfeeding increases the risk of mother-to-child transmission by up to 10%.
Evidence also suggests that the higher the viral load in the mother, the higher the risk of transmission through breast-feeding. However, in developing nations where breast milk is an important and irreplaceable source of food — and where formula and clean water are not always easily available — it is recommended that women breastfeed if they cannot reliably provide formula to their baby. Intensive efforts are underway to decrease the transmission of HIV during breastfeeding in resource-poor settings.
Again, if you are HIV-positive and pregnant, you must be certain to get regular check-ups. Experts also recommend some commonsense and traditional advice: Eat healthfully, get plenty of rest and avoid alcohol and drugs. Taking care of yourself will benefit both you and your baby.