What is HIV in Pregnancy?
Studying HIV during pregnancy is crucial because many women first learn they are HIV positive while they are pregnant. This study is also vital for couples where one or both partners are HIV positive and want to have a baby. In recent years, practices like testing all pregnant women for HIV, using antiretroviral therapy (a medication used to treat HIV), planning a cesarean delivery for HIV positive women with a high amount of the virus in their blood, giving infants the right antiretroviral therapy, and not breastfeeding have shown positive outcomes. The Centers for Disease Control and Prevention now has the goal to end the transmission of HIV from mother to baby by bringing down the rate to fewer than one infection per 100,000 live births.
What Causes HIV in Pregnancy?
HIV, a disease in humans, can be caused by two different types of virus: HIV-1 or HIV-2. The more common one is HIV-1, which is also more infectious, harmful, and can be spread more easily through sexual intercourse between a male and a female.
The chance of passing HIV from a mother to her child, known as vertical transmission, also differs between these two types. It’s between 20% to 25% for HIV-1 and around 5% for HIV-2. This vertical transmission doesn’t only occur during pregnancy; it can also happen during childbirth and through breastfeeding. This entire process is commonly referred to as perinatal transmission of HIV.
Risk Factors and Frequency for HIV in Pregnancy
Every year in the United States, about 5,000 women who are HIV positive give birth. Thanks to current health guidelines for HIV and pregnancy, both the U.S. and Europe have seen a significant decrease in the number of babies born with HIV, reducing it to 1% or less. However, in the U.S., black babies are five times more likely than white babies to be born with HIV. Based on data from the Centers for Disease Control and Prevention, only 44 babies were born with HIV in the U.S. in 2016. This figure corresponds to a tiny rate of 1.1 cases for every 100,000 live births. Additionally, as access to anti-retroviral therapy (ART) for pregnant women becomes more widespread around the world, the number of new HIV cases among children has gone down by 47% since 2010, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Signs and Symptoms of HIV in Pregnancy
When it comes to pregnant women with HIV, doctors need to consider a range of health issues that can affect not just the mother, but also the unborn baby. It’s critical to look into past instances of serious infections related to HIV, sexually transmitted infections, substance abuse, and vaccination history. If the woman has new symptoms, like a fever, doctors need to consider that it might be due to an infection that hasn’t been diagnosed yet.
During a physical exam, doctors should look for specific signs. For example, a condition like oral thrush could suggest that the HIV infection is getting worse. Doctors also need to be on the lookout for signs of other sexually transmitted infections that might occur along with HIV. And a comprehensive exam should include checking for any signs of liver disease.
- Check for past instances of serious infections related to HIV
- Examine past sexually transmitted infections
- Investigate substance abuse history
- Review vaccination history
- Watch out for new symptoms like fever
- Look for signs such as oral thrush
- Examine for indications of other sexually transmitted infections
- Perform a comprehensive exam for signs of liver disease
Testing for HIV in Pregnancy
If you’re an HIV-positive pregnant woman, there are some specific tests that will be needed to assess your health and plan treatment:
* Estimating your baby’s due date:
We use an ultrasound during the first trimester, which is more accurate than basing it on your last period. This can have implications for HIV-positive pregnant women, as some will need to deliver earlier to decrease the risk of passing along the virus to the baby during childbirth.
* CD4 cell counts:
We take this measurement on your first visit and then every three months during pregnancy. CD4 cells are a type of white blood cells that help your immune system fight off infections. This count might drop during pregnancy but the percentage of total white blood cells that are CD4 cells should typically remain the same.
* Viral load measurement:
This is a test that measures the amount of HIV in your blood. We’ll do this at your first visit, again when you start antiretroviral therapy (ART), two weeks afterwards, and then monthly until your viral load is fully suppressed. After that, it will be every 3 months for the rest of your pregnancy.
* Drug resistance testing:
This test is done to find out if your HIV is resistant to any of the drugs in the ART regimen. If you’re starting ART, especially later in pregnancy, we’ll initiate the treatment and adjust it later according to the test results.
* Monitoring drug toxicity:
Before starting ART, we’ll check your blood count, kidney function, and liver function. These tests are then repeated every 3-6 months.
* Screening for gestational diabetes:
If you are taking ART that includes protease inhibitors, we’ll screen for gestational diabetes earlier than the typical 24-28 weeks.
* Viral hepatitis testing:
We’ll screen you for Hepatitis B and C, which are often co-infections with HIV. If you are not infected with Hepatitis B, we’ll give you a safe vaccine. If you are infected with Hepatitis B, we can give you antivirals against both HIV and Hepatitis B.
* Tuberculosis testing:
HIV makes you more prone to getting active tuberculosis from latent infection. So, we’ll test you for TB if that was not done before or if you were diagnosed with HIV during this pregnancy.
* Screening for sexually transmitted infections (STIs):
HIV positive pregnant women are at risk for complications if they have STIs. We’ll therefore screen you for syphilis, gonorrhoea, chlamydia, and trichomonas infection.
* Testing for Toxoplasma and CMV:
We recommend toxoplasma testing in HIV positive pregnant women whereas in HIV-negative ones, it is usually not done. If you test positive and your CD4 count is below 100/mL, we’ll start suppressive therapy.
* Vaccination assessment:
Apart from regular vaccines during pregnancy, you might also need pneumococcal and Hepatitis A & B vaccines depending on your previous infection status.
* Mental health evaluation and counselling:
We’ll also keep an eye on your mental well-being and any factors that might impact your health or the health of your baby, such as smoking, alcohol use, drug use, unprotected sex, and any signs of domestic violence.
* Evaluation for opportunistic infections:
If your CD4 count is very low, we might consider prophylactic antibiotics to prevent infections that could take advantage of your weakened immune system.
Treatment Options for HIV in Pregnancy
When it comes to partners who are looking to conceive a child where one partner has HIV, specific considerations need to be taken into account. If the HIV positive partner is currently on antiretroviral therapy (ART – medications to help slow down the spread of HIV) and does not have detectable levels of the virus, they can try to conceive naturally without sexual transmission risk.
If the levels of HIV in the body are unknown or have not been successfully reduced, the partner without HIV can take pre-exposure prophylaxis – a method of preventing the disease before coming into contact with it- and try to conceive during the most fertile period. This minimizes the risk of passing on the HIV.
Starting ART even before trying to conceive not only decreases the chances of HIV being transmitted during sex, but also lowers the likelihood of HIV being passed onto the baby during pregnancy. Assisted reproduction methods can also be considered to minimize transmission risks further.
If a couple is struggling to conceive, it may be helpful to start infertility treatments earlier than is standard. This is because both HIV and ART have been associated with infertility. Any inflammation in the genital tract can increase the levels of HIV in genital secretions, potentially increasing transmission, so both partners should be tested for any infections.
Once a woman becomes pregnant, the focus is to minimize transmission to the baby. ART therapy should be a key part of both pre-pregnancy and pregnancy care, regardless of the mother’s current state of health or HIV RNA levels. Being religiously adherent to an ART regimen can benefit the baby in several ways, such as decreasing the levels of the virus in the mother’s blood and genital tract secretions.
While pregnant, women should be aware of the potential impacts ART medications might have on them or their baby and all possible interactions with other medications. Typically, a regimen of multiple medications is preferred over a single medication. This helps reduce the baby’s exposure to HIV even before birth.
When it comes to delivery, women with higher HIV RNA viral load levels or unknown levels may need to have a cesarean section at 38 weeks. If the viral load is lower and the patient is on ART, then a c-section is not typically needed. The timing of vaginal delivery should follow standard recommendations for patient care.
After the child is born, both the mother and baby should continue to receive the necessary medical support and treatment. This includes ART treatment as well as regular check-ups, mental support, and continuous HIV-care. HIV positive mothers should not breastfeed as it can transmit the virus to the baby through breast milk.
Finally, the newborn should be given a course of ART within the first few hours after delivery, depending on the mother’s viral load. Regular blood tests will be needed to monitor the baby, and the potential exposure to HIV should be documented in the child’s long-term medical records for future reference.
What else can HIV in Pregnancy be?
When a pregnant woman shows signs of acute HIV infection, doctors need to consider other conditions that cause similar symptoms. These may include:
- Infectious mononucleosis (IM)
- Syphilis
- Rubella
- Toxoplasmosis
- Viral hepatitis
- Disseminated gonococcal infection
- New-onset autoimmune disease
What to expect with HIV in Pregnancy
If no treatment is provided, the likelihood that HIV will be passed from a mother to her child during pregnancy, childbirth, or through breastfeeding can be as high as 25% to 30%. However, in the United States, if the necessary precautions are taken, this rate can be reduced significantly. With extensive testing, proper guidance before conception, consistent and proper use of antiretroviral therapy (which are medications used to manage HIV), a planned cesarean birth, and protective measures for the infant, the chance of passing HIV to the baby can fall to less than 1% to 2%.
Possible Complications When Diagnosed with HIV in Pregnancy
In women with HIV who are not receiving treatment, the risk of getting opportunistic infections (illnesses caused by various microorganisms that usually do not cause disease in people with healthy immune systems) increases as the number of immune cells (CD4 cells) decreases. Certain opportunistic infections like CMV and toxoplasmosis have the ability of reaching the unborn baby through the placenta, which can cause congenital abnormalities, or conditions present at birth. Additionally, if HIV isn’t treated, it’s highly likely to be passed on to the baby during pregnancy, childbirth or breastfeeding.
There can also be complications associated with the medicines used for HIV, known as antiretroviral therapy (ART). For instance, Dolutegravir, a specific drug, can result in neural tube defects in the baby, while others such as the protease inhibitors have been connected to premature birth. ZDV, an antiretroviral drug, might cause blood disorders in the newborn. Also, exposing the unborn child to HIV or ART drugs might lead to problems with their mitochondria, the powerhouses of cells, later in life.
Common Risks for Untreated HIV in Women and Newborns:
- Increased risk of opportunistic infections with HIV
- Certain infections can affect the unborn baby
- Unborn babies can develop congenital abnormalities
- High chances of mother-to-child HIV transmission during pregnancy, childbirth, or breastfeeding
- Complications associated with antiretroviral therapy (ART)
- Specific ART drugs can cause neural tube defects or premature birth
- Babies may experience blood disorders
- Long-term risk of mitochondrial dysfunction in children exposed to HIV or ART drugs in utero
Preventing HIV in Pregnancy
It’s important to understand why some patients choose not to get tested for HIV during their first prenatal appointment. It’s suggested to offer testing again in the third trimester to women who did not get tested in the first trimester or who are at a higher risk of contracting HIV. The Centers for Disease Control and Prevention (CDC) categorizes high-risk groups as those who use intravenous drugs, the sexual partners of these individuals, sex workers, people who have sex with a person infected with HIV, and women who have had a new or multiple sexual partners during pregnancy.
Women who have HIV need to understand how vital it is to have a low virus level in the blood (viral suppression) before getting pregnant. Sticking to their antiretroviral therapy (ART) – HIV medication – is crucial in keeping both the risk of passing the virus to the baby during pregnancy (vertical transmission) and to their partners (secondary sexual transmission) as low as possible. They should also be advised about the importance of safe sex, avoiding alcohol and tobacco, and not using illegal drugs.
Patients should also be informed about the different birth control methods available, the availability of Pre-exposure prophylaxis (PrEP) – a medication that people at risk for HIV take to prevent contracting the virus – for their HIV-negative partners, the importance of not breastfeeding, and how they can deal with painful breast swelling if not breastfeeding (breast engorgement).
