HIV and pregnancy
HIV/AIDS in pregnancy has a risk of causing mother-to-child transmission. However, the risk is decreased substantially with preventive measures such as anti-HIV medications during pregnancy and childbirth as well as to the child after delivery, and that mothers with HIV avoid breastfeeding their children.
Women with HIV have been shown to have decreased fertility which can affect available reproductive options. In cases where the woman is HIV negative and the man is HIV positive, the primary assisted reproductive method used to prevent HIV transmission is sperm washing followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). Preferably this is done after the man has achieved an undetectable plasma viral load. In the past there have been cases of HIV transmission to an HIV-negative partner through processed artificial insemination, but a large modern series in which followed 741 couples where the man had a stable viral load and semen samples were tested for HIV-1, there were no cases of HIV transmission.
For cases where the woman is HIV positive and the man is HIV negative, the usual method is artificial insemination. With appropriate treatment the risk of mother-to-child infection can be reduced to below 1%.
HIV testing in pregnancy
HIV testing is recommended for all pregnant women. The Centers for Disease Control and Prevention recommends that this is performed on an opt-out basis, wherein the test is automatically performed as part of routine prenatal care unless the pregnant woman actively asks specifically not to be tested and sign a form refusing HIV testing. Those refusing can still be properly counseled on how HIV is spread and ways to prevent HIV transmission, as well as encouraged to reconsider the decision not to be tested.
The most common HIV test is the HIV antibody test. When a person has a positive result from an HIV antibody test, a second and different type of antibody test is done to confirm that the person is indeed infected with HIV. Getting results from an HIV antibody blood test generally takes a few days, but can be done within an hour with some devices.
Prevention of mother-to-child transmission
HIV/AIDS is a disease that can be transmitted from mother to child, also called a vertically transmitted disease. This transmission can occur during pregnancy, during labor and delivery, or by breastfeeding. The risk of transmission from mother to child is proportional to the plasma viral load of the mother. Untreated mothers with a viral load >100,000 copies/ml have a transmission risk of over 50%. The risk when viral loads are < 1000 copies/ml are less than 1%. ART for mothers both before and during delivery and to mothers and infants after delivery are recommended to substantially reduce the risk of transmission.
- During pregnancy: pregnant women infected with HIV receive a regimen (combination) of at least three different anti-HIV medications.
- During labor and delivery; pregnant women infected with HIV are recommended to receive zidovudine (also called AZT) by intravenous route and continue to take the medications in their regimens by mouth.
- After birth, babies born to women infected with HIV are recommended to receive liquid zidovudine for 6 weeks. Babies of mothers who did not receive anti-HIV medications during pregnancy may be given other anti-HIV medications in addition to AZT.
In addition to taking anti-HIV medications to reduce the risk of mother-to-child transmission of HIV, a pregnant woman infected with HIV may also need anti-HIV medications for her own health. Some women may already be on a regimen before becoming pregnant. However, because some medications in pregnancy may not be safe to use or may be absorbed differently by the body, the medications in a woman's regimen may change.
Taking anti-HIV medications during pregnancy reduces the amount of HIV virus particles in an infected mother's body, thereby decreasing the risk of transmission. Some anti-HIV medications also pass from the pregnant mother to her unborn baby through the placenta, protecting the baby from HIV infection. This is especially important during delivery when the baby may be exposed to HIV in the mother's genital fluids or blood.
Indications to start medications
In general, people infected with HIV who are not pregnant begin taking anti-HIV medications when their CD4 counts fall below 500 cells/mm3 or if they develop AIDS-defining infection. Women who need anti-HIV medications only to prevent mother-to-child transmission of HIV can consider waiting until after the first trimester of pregnancy to take anti-HIV medications. However, starting medications earlier may be more effective at reducing the risk of mother-to-child transmission of HIV. All pregnant women infected with HIV should be taking anti-HIV medications by the second trimester of pregnancy. Women diagnosed with HIV later in pregnancy should start taking anti-HIV medications as soon as possible. Women who are already taking anti-HIV medications and learn that they are pregnant should continue taking the current anti-HIV regimen in the meantime before a regimen plan tailored to the pregnancy is made, as stopping treatment could harm both the woman and the child.
Medications during pregnancy
The anti-HIV regimen for pregnant women infected with HIV is recommended to consist of a combination of at least three anti-HIV medications.
- Protease inhibitors (PIs) has, for some of the medications included in this group, an association with hyperglycemia. It is unclear if taking such protease inhibitor adds to the risk of gestational diabetes.
- Nucleoside reverse transcriptase inhibitors (NRTIs) may cause lactic acidosis, so women taking NRTIs are watched carefully for signs of this complication. Two NRTSIs, stavudine and didanosine (trade names Zerit and Videx, respectively), have caused deaths from lactic acidosis and liver failure. Therefore, the combination of these two should not be used in pregnancy.
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs) is a group of anti-HIV medications whereof two, efavirenz and nevirapine, may need to be used only under certain conditions in pregnant women.
- Efavirenz (brand name Sustiva, and included in the combination named Atripla) has been labelled as pregnancy category D by the US Food and Drug Administration due to a study showing neural tube defects in 3 of 20 cynomolgus monkeys. A systematic review of the safety of efavirenz in humans during the first trimester found no increase in birth defects among women given efavirenz. Given the uncertain potential for risk the US DHHS recommends against using efavirenz in the first trimester of pregnancy or in women who could potentially get pregnant. They instead recommend a protease inhibitor based regimen with lopinavir or atazanavir. The WHO however recommends efavirenz as their first line regimen in pregnancy to simplify regimens across all HIV positive adults.
- Nevirapine (trade name Viramune) increases the risk of very serious liver damage in women with CD4 counts greater than 250 cells/mm3. Women taking nevirapine without problems before they become pregnant can safely continue to take the medication, because liver damage from nevirapine in pregnancy has not been seen in women already taking the medication without side effects.
If the viral load is more than 500 copies/mL despite taking anti-HIV medications, the current regimen may not be effective, and drug-resistance testing is recommended.
During childbirth, women are recommended to continue to take the anti-HIV medications they took throughout their pregnancies. It is also recommended to add zidovudine(AZT) intravenously to protect child from HIV in the mother's genital fluids or blood during childbirth.
The risk of mother-to-child transmission of HIV is low for women who take anti-HIV medications during pregnancy and have a viral load less than 1,000 copies/mL near the time of delivery.
For some HIV-infected mothers, a scheduled Cesarean section at 38 weeks of pregnancy (2 weeks before the usual due date) can reduce the risk of mother-to-child transmission of HIV. A scheduled cesarean delivery is recommended for HIV-infected women who:
- have not received anti-HIV medications during pregnancy.
- have a viral load greater than 1,000 copies/mL or an unknown
viral load near the time of delivery.
If, before her scheduled cesarean delivery, a woman's water breaks or she goes into labor, a Cesarean section may not reduce the risk of mother-to-child transmission of HIV. If there is not another pregnancy-related reason to have a Cesarean section, the risks of going ahead with the scheduled cesarean delivery may be greater than the benefits, and a vaginal delivery may be the best alternative.
For the mother, the risk of perinatal infection or deep vein thrombosis is greater with a Cesarean section than with a vaginal delivery. For the infant, the risk of temporary breathing difficulties may be greater with a Cesarean section.
Within 6 to 12 hours after delivery, babies born to women infected with HIV are recommended to receive zidovudine (AZT), and to continue this medication for 6 weeks. HIV testing for babies born to women with known HIV infection is recommended at 14 to 21 days, at 1 to 2 months, and again at 4 to 6 months. Testing for babies is done using a virologic HIV test. To be diagnosed with HIV, a baby must have positive results from two virologic HIV tests. To know for certain that a baby is not infected with HIV, the baby must have two negative virologic HIV tests, the first at 1 month of age or older, and the second at least 1 month later.
Babies who are HIV-infected are recommended to receive a combination of anti-HIV medications to treat HIV. At 4 to 6 weeks of age, babies infected with HIV are also recommended to start taking the antibiotic trimethoprim/sulfamethoxazole. This is also given as a precaution when it's not known if a baby is HIV infected or not.) Trimethoprim/sulfamethoxazole helps prevent pneumocystis pneumonia.
Because HIV can be transmitted through breast milk, women infected with HIV should not breastfeed their babies. In developed countries, baby formula is a safe and healthy alternative to breast milk. Although the risk is very low, HIV can also be transmitted to a baby through food that was previously chewed (pre-chewed) by a mother or caretaker infected with HIV. To be safe, babies should not be fed pre-chewed food. In eveloping countries, the WHO balances the low risk of transmission through breast feeding from women who are on ART with the benefits of breastfeeding against diarrhea, prneumonia and malnutrition.
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