Pregnancy and HIV FAQ
Many babies born of HIV-positive women do not have or will not develop HIV infection. Without any antiretroviral treatment, the risk of vertical transmission is one in four, about 25%. Fortunately, optimal antepartum, intrapartum and postpartum treatment can reduce the risk to less than 2%1 . HIV-infected pregnant women who receive this specialized care and whose babies receive special medications can profoundly reduce the HIV transmission rate to the babies. By universally screening all expectant mothers for HIV infection, health care providers are taking a critical step to reduce mother to child HIV transmission.
This fact sheet highlights questions about the management of HIV during pregnancy and how to reduce the risk of perinatal transmission.
Diagnosis Issues
Q: How is HIV diagnosed?
A:
All pregnant women should be counseled on the importance of knowing their HIV status. In Illinois, state law requires that all pregnant women be counseled and recommended an HIV test. This counseling should ideally take place during the first prenatal visit. Additionally, it is recommended that women at high risk for contracting HIV be retested during the third trimester of pregnancy. In Illinois, women who do not receive prenatal care and/or have an undocumented HIV status at the time of labor and delivery, are counseled and recommended a rapid HIV test. All preliminary positive rapid HIV tests must then be confirmed by a Western blot.
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Q: How should indeterminate Western blot test results in a pregnant patient be managed?
A:
Clinicians should interview the patient to assess risk of HIV infection and counsel about safer sex practices until the results of further testing clarifies the patient’s status. Clinicians should interview the patient about signs and symptoms of acute retroviral syndrome (including fevers, sore throat, headache, rash, lymphadenopathy). If the risk of HIV infection appears high or if the patient has had recent illness consistent with acute retroviral syndrome, we urge that health care workers contact the Illinois Perinatal HIV Hotline at 1-800-439-4079 or another infectious disease specialist.
If an indeterminate Western blot test result is identified during the first trimester, the test should be repeated in 4-6 weeks to ensure that the woman is not in the process of seroconversion (the process of developing HIV antibodies). An HIV PCR (polymerase chain reaction) viral load test is also sent. If follow-up tests are read as negative, the woman is usually considered HIV negative. If repeated test results are read as indeterminate, you should consider having the sample run in a different laboratory that utilizes a different assay in order to discern whether there is a problem with cross reactivity with a specific antigen or if the woman is in fact HIV positive. If test results are found to be indeterminate at or around the time of delivery, protocols for HIV positive patients should be followed until a true determination can be made. Please feel free to call the Illinois Perinatal HIV Hotline at 1-800-439-4079 with specific questions or concerns.
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Antepartum Issues
Q: Why is integrated HIV/OB care important?
A:
Integrated HIV/OB care is essential for the best treatment of a woman who is pregnant and infected by HIV/AIDS. Both obstetric and infectious disease issues must be considered when recommending an antiretroviral regimen. A regimen needs to be followed and adjusted throughout pregnancy to achieve the goal of viral suppression at delivery. Ideally, infectious disease and obstetrical visits can be scheduled together to make it easier for the patient to make all appointments.
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Q: Who should provide prenatal care for an HIV-infected pregnant woman?
A:
If possible, prenatal care for all HIV positive women should be provided by an obstetrician experienced in the care of HIV positive patients. If this is not possible, physicians caring for these women should request a consultation with a physician experienced in the care of HIV positive patients who can assist with mapping out an appropriate care plan for the patient.
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Q: Why is it important that infectious disease specialists be involved in the care of HIV positive pregnant women?
A:
Infectious disease specialists are imperative when it comes to prescribing medications which can help to achieve rapid and sustained viral suppression. Infectious disease specialists are experienced in identifying possible drug interactions, monitoring for signs of drug toxicity and managing the troubling side effects which sometimes hinder medical compliance of antiretroviral therapies. Finally it is important that persons infected with HIV who have severely compromised immune systems be monitored by infectious disease specialists for the possible development of opportunistic infections and to receive appropriate prophylactic medications.
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Q: How are antiretroviral medications used during pregnancy?
A:
A combination of antiretroviral medications should be taken as prescribed during pregnancy in order to achieve an undetectable viral load and reduce the risk of vertical transmission. Most pregnant women receive a combination that includes AZT. A multi-drug regimen is the only therapy which has been shown to achieve effective and sustained viral suppression for those infected by HIV/AIDS. It is important to realize that certain medications are contraindicated during pregnancy and that some medications require alterations in dosing during pregnancy. For this reason, women who are HIV positive and contemplating pregnancy as well as those who become pregnant should have their drug regimen reviewed by an infectious disease specialist. Women who are inadvertently exposed to certain contraindicated medications during pregnancy may require additional surveillance. Please contact the Illinois Perinatal HIV Hotline for additional information or specific questions.
Note: Some women may not be placed on AZT due to previous resistance –the infectious disease specialist will consult with the obstetrician to determine the most effective disease specific regimen.
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Intrapartum Issues
Q: What maternal treatment should be given during labor and delivery?
A:
The Department of Health and Human Services Perinatal Guidelines recommend intravenous AZT to be given during labor and delivery. Ideally, this should be started at the onset of uterine contractions with a goal of completing at least a 3 hour course prior to delivery in order to achieve adequate maternal and neonatal serum levels. AZT is given as an intravenous 2mg/kg load infusion given over the first hour followed by 1mg/kg/hour intravenously until delivery. Other antiretroviral medications should be continued during labor to ensure that their normal antiretroviral regimen is uninterrupted.
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Q: How is the decision made to deliver vaginally or by c-section?
A:
The best decisions about route of delivery are made together between a woman and her doctor. Obstetric indications regarding previous pregnancies and the current pregnancy (non-HIV related) must be factored into this decision. The Department of Health and Human Services Perinatal Guidelines cover this topic. The general summary of these recommendations on route of delivery are:
- Vaginal delivery is safe if viral load is less than 1000 copies/ml at 36 weeks of pregnancy and the mother reports recent good adherence with antiretroviral medications. Physicians delivering women who are HIV positive should avoid all invasive monitoring devices including fetal scalp electrodes. Every attempt should be made to delay artificial rupture of membranes. Instrumental vaginal delivery with forceps should be avoided due to the potential to introduce fetal trauma and potentially increase viral exposure.
- C-Section delivery is recommended if the viral load is unknown or is greater than 1000 copies/ml at 36 weeks of pregnancy. In these instances, delivery should be scheduled for 38 weeks gestation prior to the onset of labor and spontaneous rupture of membranes in order to achieve maximum benefit.
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Q: How should staff manage a patient who presents to labor and delivery with no prenatal care?
A:
Any woman who presents to labor and delivery without prenatal care should be offered and recommended rapid HIV testing. Women with a preliminary positive rapid HIV test who are in active labor should be counseled on the test result, the risk of vertical transmission and the potential benefit of a cesarean delivery in reducing that risk. The mother should receive appropriate treatment for an HIV-infected woman in labor until confirmatory tests prove otherwise.
Intravenous AZT should be initiated immediately and blood sent for a Western blot test to confirm the positive rapid HIV result. The neonate should also be managed as though the mother is positive until confirmatory tests prove otherwise. Click here for the IL Perinatal HIV Hotline’s best practices for labor and delivery care for patients with a positive rapid HIV test.
If the woman is not in labor, and delivery is not imminent, confirmatory testing should be conducted and the patient managed accordingly. Expedited Western blot testing is available through the Illinois Perinatal HIV Hotline with results generally obtained within 24 hours. Please call 1-800-439-4079 for additional information or specific questions.
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Postpartum Issues
Q: What else should be done to reduce the risk of perinatal transmission?
A:
An early infant bath should be completed in the delivery room prior to the administration of intramuscular injections or any invasive intervention. An appropriate protocol should include cleansing with chlorhexidine antiseptic solution, which is readily available in most labor and delivery units.
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Q: Is it safe for HIV positive women to breastfeed their babies?
A:
Breastfeeding is strongly discouraged in the United States and other developed countries as this significantly increases the risk of vertical transmission. Exclusive formula feeding is recommended. Counseling of the mother ahead of time about this is preferred.
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Q: Should mothers be encouraged to continue antiretroviral therapy after delivery?
A:
A number of trials have looked at the feasibility of structured treatment interruptions in obstetric populations as well as in non-obstetric populations. It was found that patients who were allowed to take treatment holidays following viral suppression experienced significant disease progression, developed viral mutations at higher rates and experienced poorer immune reconstitution once therapy was restarted. For this reason, motivated patients who are HIV positive should be encouraged to continue antiretroviral therapy after delivery.
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Neonatal Issues
Q: What neonatal treatment should be prescribed?
A:
The Department of Health and Human Services Perinatal Guidelines discuss neonatal treatment. Mothers and caregivers who will be responsible for giving medications to the newborn should be educated on the appropriate dosing and administration of all neonatal antiretroviral medications prior to discharge from the hospital. Close follow-up is also helpful to reinforce dosing protocols and to monitor medical compliance. Appropriate AZT dosing for neonates is as follows: 2 mg/kg orally every 6 hours for 6 weeks or 2.67mg/kg orally every 8 hours for 6 weeks. Click here for the Illinois Perinatal HIV Hotline’s neonatal treatment guidelines.
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Q: What type of pediatric care should an HIV-exposed newborn receive?
A:
Pediatric infectious disease monitoring of the newborn is essential. This should be established prior to discharge from the hospital. If possible, discussions should be initiated during the third trimester to impress upon the parent the importance of adequate newborn care during the first few weeks of life. It is necessary that the baby’s HIV status be determined by administering a series of tests during the first 2 years of life so that appropriate medications can be initiated if necessary.
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Q: How is HIV diagnosed in an infant?
A:
HIV is diagnosed in adults through antibody testing; positive antibody tests are confirmed by Western blot. These tests are not used in infants because all babies carry the mother’s HIV antibodies, whether or not the babies are truly HIV infected. DNA PCR (polymerase chain reaction) tests are used to detect particles of the virus in the baby’s blood. These tests are usually performed at birth, 2 weeks, 4 weeks and 4 months. At four months, if PCR testing is negative, the baby is often observed until the age of 18-24 months when the child clears the maternal antibodies and standard testing will also show the infant to be negative for HIV antibodies.
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Social Service Issues
Q: Why is it important to link HIV positive pregnant women with social services?
A:
Many women find out about their HIV status through prenatal testing. HIV and pregnancy can be very isolating therefore it is important to stress to the patient that she is not alone. Many people become overwhelmed and experience depression when they are first diagnosed. We recommend that you refer patients to a social worker or case manager who specializes in caring for people with HIV. There are many government-sponsored programs for persons with HIV who have limited or no resources. An HIV case manager or social worker can help link the patient to an individual counselor or a support group (online or in person). There are trained professionals that can help patients talk about their feelings, talk to partners about the diagnosis, safe sex and dealing with learning about the diagnosis during pregnancy.
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Q: How can I link a woman to an HIV case manager or social worker?
A:
You can call the Illinois Perinatal HIV Hotline at 1-800-439-4079 to link a woman with social service resources (food, housing, transportation, support groups, benefits, respite care and referrals) in her area.
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Other
Q: Is there a risk for transmission if the woman is HIV negative and the partner is HIV positive?
A:
If a woman is HIV negative and her partner is HIV positive, there is no risk of perinatal transmission to the baby. However, pregnant women are STILL AT RISK for acquiring HIV infection and condoms must be used every time the couple has intercourse to prevent transmission of HIV to the mother while pregnant. A woman who becomes HIV positive while pregnant has a greater chance of transmitting the virus to her baby. Women in this and all high risk situations should be retested for HIV during the third trimester.
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Q: Where can I get more information about treatment guidelines for pregnant women with HIV?
A:
The US Department of Health and Human Services publishes the Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. These guidelines are reviewed and updated often. It is best to check for the most recent treatment guidelines at AIDSinfo. Another way to ensure up-to-date treatment information is to call the Illinois Perinatal HIV Hotline at 1-800-439-4079 and consult with the physician on call.
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1U.S. Centers for Disease Control and Prevention, "Pregnancy and Childbirth",
http://www.cdc.gov/hiv/topics/perinatal/index.htm, accessed January 15, 2008.