Pregnancy & HIV

Is it safe to be HIV+ and Pregnant?

Yes. Of course, as is the case with the rest of HIV and its treatment, they are no absolute certainties or across the board truths. Every woman is different.

However, there's no data suggesting that pregnancy accelerates the rate of HIV disease progression. HIV by itself won't stop you from having a safe pregnancy. If you're generally healthy, get good prenatal care, and are careful to avoid risk factors, your chances of avoiding things like premature delivery and birth defects are not significantly different from those of your HIV-negative counterparts.

It can be hard to deal with the judgemental attitudes of people, including doctors, who think that it is morally wrong for HIV-positive women to get pregnant. The good news is that there are many strategies for dramatically reducing the risk of passing the virus to your infant - often referred to as perinatal or vertical transmission - which you and your doctor should be ready to discuss. If your health-care provider isn't supportive or is being judgmental, it's your right to find someone who will be supportive.

What are the risks of Transmitting HIV?

An HIV-positive pregnant woman - provided that she does not take nay anti-HIV medications - has a 25% chance of passing HIV to her baby. However, if she takes anti-HIV drug therapy while she is pregnant, the risk of her passing the virus to her baby is much lower - in some cases as low as 2%.

How Does Transmission Work?

Researchers are not exactly sure when babies are infected with HIV during pregnancy. It has been said that a small percentage of all babies are infected with HIV with developing inside their mothers uteruses. However, this has not really been proven. It is known that the vast majority of infections occur during labor or after the body is born and is breast-fed by his or her HIV-infected mother.

Throughout pregnancy, a developing fetus has his or her own blood supply. In other words, the developing fetus does not come into contact with the blood of his or her mother. This helps protect the fetus from infections in the mother's blood, such as HIV. However, developing fetuses do receive nutrients and various proteins, such as immune system antibodies, from their mothers. While a mother's HIV may not enter the fetus, her antibodies to the virus will. These antibodies cannot harm the fetus, but will cause the baby to test "positive" to an HIV antibodies test when he or she is born.

At the time of birth, a baby often comes into contact with his or her mother's blood. If the mother's blood enters the baby's body, this is when HIV can be transmitted.

Don't all babies born to HIV-infected Mothers Test Positive for the Virus?

Yes, they do. It is important to keep in mind what the HIV test is. These tests look for antibodies to HIV, they do not look for the virus itself. Because a fetus is exposed to his or her mother's HIV antibodies, he or she will automatically test "positive" after birth. These antibodies can remain in the baby's body for more than 18 months after he or she is born.

Most hospitals now test babies born to HIV-infected women using "PCR". This test can be performed within a few days after delivery and looks for HIV itself in a blood sample collected from the baby. If the test is negative, it should be repeated within a few months after the birth to look for HIV.

Why is Prenatal Care So Important?

Every pregnant woman, regardless of her HIV status, should see a doctor regularly to receive prenatal care. Simply put, prenatal care is a specialized type of health care designed to protect the health of both the woman and her developing baby. Prenatal care can help all pregnant women figure out what they should do to improve their diets and vitamin/mineral intake and to reduce unhealthy habits such as smoking, drinking alcohol, and doing drugs.

If a pregnant woman does not know whether or not she's HIV positive, most prenatal care programs now recommend HIV testing. While some states are hoping to make HIV testing a requirement for all pregnant women, no prenatal care program has the right to test a pregnant woman for HIV without her consent. In New York State, the law allows for any newborn baby to be tested for HIV, regardless of whether or not the baby's mother permits the test to be performed.

If a pregnant woman finds out that she is positive while she is pregnant, or knew that she was positive before getting pregnant, prenatal care programs can help protect her health and the health of her developing baby. Usually, a prenatal care program calls for monthly visits to a clinic or doctor's office for the first eight months of pregnancy. During the eighth and ninth months of pregnancy, visits are more frequent, typically every two weeks.

Prenatal care for women who are HIV infected may include T-cell counts and viral loads tests, treatments to prevent AIDS-related infections, anti-HIV drug therapy, management of drug side effects, and importance nutritional care.

HIV-positive women might want to avoid some aspects of typical prenatal care. For example, amniocentesis, used to test for genetic defects in the baby, is done with a needle that passes through the mother's abdomen and into the womb. While this test may be necessary to look for any genetic problems that a developing baby may have, it can also increase the risk of transmitting HIV.

How can you Reduce the Risk of Transmission?

In the following sections, we'll discuss three topics that a pregnant woman should discuss with her doctor that can reduce the risk of transmission to her baby anti-HIV drug therapy. Cesarean sections, and the risk of breast-feeding.

For pregnant women who are infected with HIV, the topic of anti-HIV drugs will most definitely come up as a part of a prenatal care program. These drugs, if taken correctly, can drastically reduce the amount of HIV in a mother's blood at the time of birth. This can help reduce the chances of passing the virus along.

Cesarean sections - an operation in which the baby is removed through an incision in the belly - reduces the amount of time the baby comes into contact with his or her mother's blood and has been shown to reduce the risk of transmitting HIV.

Since breast milk can also transmit HIV, formula feeding, whenever clean water and formula are available, is strongly recommended.

What about Anti-HIV drug therapy?

Only one anti-HIV drug - Retrovir - has been approved by the U.S. Food and Drug Administration for the prevention of mother-to-infant HIV transmission. According to a major study conducted several years ago about the National Institute of Health, Retrovir therapy can reduce the risk of perinatal transmission from 25% to approximately 8%. While there are no guarantees that Retrovir therapy will prevent HIV from being transmitted from a mother to her baby, if greatly reduces this chance that transmission will occur.

Retrovir therapy during pregnancy is a three-part program :

1. A standard dose of the drug is started after the first trimester of pregnancy. In other words, and HIV-infected pregnant would should take Retrovir for Six months prior to giving birth to the baby. The dose is one 300 mg tablet taken twice a day.
2. At the time of delivery, whether it is by vaginal birth or C-section, higher doses of Retrovir are administered through an intravenous line.
3. A liquid form of Retrovir is given to the baby immediately after birth and continued for six weeks.

Is this the Only Regimen Available?

Researchers are still looking at other ways to use Retrovir to prevent mother-to-child transmission. For example, one study has already demonstrated that one does of Retrovir given either to the mother during labor or to the newborn within 48 hours after birth, reduced the risk of transmission by more than half.

Results from another study suggest that giving a single dose of Virmune to both mother and newborn infant reduces transmission rates by nearly 50%. This study was actually conducted in African women, many of whom do not receive adequate prenatal care. Nevirapine is current being studied in the United States and, if used in the setting of prenatal care or in combination with other anti-HIV drugs, the drug may prove to be very effective in reducing the risk of mother-to-child HIV transmission.

What about Combination Anti-HIV Therapy?

More and more women are taking combinations of anti-HIV therapies to keep themselves healthier and alive longer. Effective combination therapy can lower viral load to below the limits of detection and ease the pressure on the immune system. Not only are the effects of combination therapy good for the mother, they have also been said to further reduce the risk of transmitting HIV.

Given what is known about Retrovir, it is recommended that any combination of drugs used during pregnancy include this drug.

Figuring out whether or not to start combination therapy - or remain on combination therapy - is a difficult decision for all HIV-infected pregnant women. If you are HIV-positive and pregnant, here are some questions you should consider discussion with your doctor before starting combination therapy.

How have you been feeling?

What was your most recent T-cell count?

What was your most recent viral load?

Does your doctor think that you/re at risk for developing HIV-related illnesses?

Of course, HIV-infected pregnant women will want to consider how the drugs they're thinking of taking might affect the baby. There's new research being produce all the time about the safety and tolerability of different medications for pregnant women and their developing babies.

What about the Potential side effects of Combination Therapy?

Anybody who is HIV-positive and taking an anti-HIV drug combination faces the risk of side effects. HIV-infected pregnant women are no different. Side effects include metabolic changes and lipodystrophy, which can cause an increase in blood levels of flats and sugars. By itself, pregnancy is a risk factor for elevated glucose levels. It's not yet known if anti-HIV medications increase the risk of these metabolic problems occurring in pregnant women.

Some anti-HIV drugs can cause liver damage, such as increases in the liver enzyme bilirubin. Too much of this enzyme can harm a fetus. While most HIV-infected people taking a protease inhibitor only experience mild increases in this enzyme, pregnant women taking these drugs - especially the protease inhibitor Crixivan - should be extra careful and have their bilirubin levels checked regularly.

Another possible side effect of combination therapy is pre-term delivery. In early clinical trials, some women who used a combination of anti-HIV drugs that included protease inhibitors gave birth to their babies earlier than they should have. This can cause health problems for the baby. However, a number of studies conducted in recent years have not found that HIV-positive women receiving combination therapy are any more likely than other women to give birth to pre-term babies. But there is a risk.

There has also been concern about the drug efavirenz Sustiva. Pregnant monkeys who received this drug gave birth to babies with deformities, some of them quite severe. However, a number of HIV-infected pregnant women have used this drug and, to date, none have given birth to babies with the same deformities seen in the monkey experiments. Again, there is a risk of damage and many experts do not recommend this drug for HIV-infected pregnant women.

Some drugs, especially the nucleoside analogues, can damage the mitochondria- the tiny "powerhouses" inside cells that provide cells with energy. Cells that contain too many severely damaged mitochondria must resort to an abnormal type of energy production that doesn't rely on the mitochondria. Lactic acid is the chemical byproduct of this sort of abnormal energy production. If too much lactic acid builds up in the body, serious illness can occur, including fatigue, nausea/vomiting, painful inflammation of the pancrease, and liver damage.

Severe cases of lactic acidosis can be deadly. The U.S. food and drug administration ahs issued an important warning that HIV-positive women should not take Zerit and Videx or Videx EC at the same time if they are pregnant. Some pregnant women who took these drugs together developed lactic acidosis, some of whom died. It is not clear if any of the other nucleoside analogues cause lactic acidosis in women or mitochondiral damage in babies born to mothers taking these drugs. Fortunately, Retrovir has been studied for many years in pregnant women and babies and has not been shown to cause any of these problems.

What if I Become Pregnant While I'm on Therapy?

If you become pregnant while you're receiving anti-HIV drug therapy, you have several options. The first is to stay with your combination. If it's working - that is, it's keeping your viral load at or near undetectable levels and doesn't cause you lots of side effects - staying on therapy might be a good option. A recent review of roughly 3,500 pregnancies in HIV-positive women found that the rates of "adverse events" - complications during or after pregnancy- weren't increased in women who took combination therapy.

You may also consider stopping therapy for the first three months of your pregnancy to minimize fetal exposure to drugs during the earliest stages of development. After the first three months, you can restart your old regimen. Or, you may choose to stay off therapy altogether for the remainder of your pregnancy. No matter what, you should strongly consider taking AZT to reduce the risk of transmission.

If you've been having a hard time taking all your pills, or if the side effects are really bothering you, it may be a good idea to stop, at least for the beginning of your pregnancy. There's no way of knowing how you'll feel while you're pregnant - morning sickness on top of daily drug-related nausea could be the last straw. Stopping a complicated drug regimen also minimizes the risk of developing drug -resistant virus, which can limit your subsequent treatment options, and could even get passed on to your baby.

A word of caution: Accidents happen. Some oral contraceptives - birth-control pills - do not mix well with some anti-HIV drugs. For example, efavirenz can increase blood levels of oral contraceptives and, in turn, may increases the side effects of the hormones found in these pills. The protease inhibitors ritonavir and nelfinavir can decrease the amount of oral contraceptives in the blood. This can increase the chance of becoming pregnant. If you're trying to avoid pregnancy, it might be best to use a barrier method - e.g., condoms, diaphragm, etc - while using anti-HIV drugs.

Should HIV+Pregnant Women have drug - resistance Tests?

Seeing that the goal of anti-HIV drug therapy is to reduce viral load to undetectable levels - preferably to less than 50 copies/mL - all HIV-positive pregnant women should consider having a drug resistance test if their viral load becomes detectable while receiving therapy. These tests can determine which drugs are no longer working and help figure out which drugs to switch to. In this way, drug-resistance tests are valuable for anyone who is receiving anti-HIV drug therapy, not just pregnant women.

What About Cesarean Sections?

Cesarean Section - often called a "C-section" - is a type of surgery that has been said to greatly reduce an HIV-positive woman's risk of passing along the virus to her baby at the time of birth. However, it is still not known if C-sections are nay more effective than taking a powerful andit-HIV drug combination in reducing this risk. It is also not known if a woman who takes a powerful anti-HIV drug combination and has a C-section has a lower chance of passing along the virus to her baby than a woman who takes anti-HIV drugs and has a vaginal delivery.

To perform a C-section, a needle is inserted into the woman's spine and injected with morphine. This causes numbness from the waist down, allowing the doctor to make a long incision under the bellybutton to remove the baby.

There is also a surgical procedure called a "bloodless C-section". This type of surgery goes a sleep further than regular C-sections. In a bloodless C-section, the blood vessels near the womb are weided, or "cauterized", using a laser to prevent them from bleeding. This procedure lowers the risk that the baby will come into contact with his or her mother's blood.

Some experts do not like the idea of C-sections. Because C-sections are a type of surgery, there are risks of infection and other complications. It is also important to remember that a combination of anti-HIV-drugs - which may include AZT plus two other drugs - might do a better job of stopping transmission, without even needing a C-section. According to some studies, in HIV-positive pregnant women who have an undetectable viral load at the time of birth, the risk of delivering a baby infected with the virus is less than 2%. Again, it is not known if C-sections reduce this risk any further.

Many doctors - particularly obstetricians and gynecologists - recommend to their HIV-infected pregnant patients that they have a C-section to deliver their babies. However, it is important that HIV-infected pregnant women.
Ÿ C-sectors are an option, not a requirement. No patient should ever be forced to have a surgical procedure. An HIV-infected pregnant woman has the right to refuse a C-section.
Ÿ If a doctor has recommended a C-section, he or she should explain the procedure and discuss the possible benefits and the potential risks.

What about breast - feeding?

Breast milk carries HIV too, and breast-feeding adds considerable risk of transmission. As with transmission via blood, there's some indication that risk increases along with viral load. So far, research shows that the risk of breast milk transmission is highest in the first six months of life. However, there's no threshold or time point beyond which it becomes absolutely safe to breast - feed.

Wherever clean water and formula are available. It's recommended that HIV-positive women exclusively formula feed their infants.

In the past year, a handful of studies have also looked at breast milk pasteurization, a procedure that allows women to express their breast milk and treat it themselves so that it becomes safe for their infants to drink. Right now, these studies have been done in resource-poor settings; your doctor may have more information about this strategy.

What Else Can I Do?

What's good advice for people with HIV is great advice for pregnant women: take good care of yourself and gets lots of support. Support can mean a lot of different things, but it definitely means having someone to talk to someone who can listen, who won't judge you and your decisions, and will help you figure out what to do when things get murky. This could be a counselor, family member, partner or friend. Ideally, it will be a collection of these folks.

Look for a team of people to work with you: a good OB/GYN and an HIV specialist, and possibly a case manger who will help you navigate whatever benefits and services you need during and after your pregnancy. Find a nutritionist who can help you satisfy your cravings - and will also help you to eat right. And talk, talk, talk to other positive mothers about their experiences. Be sure you have a plan for yourself and the baby so you're prepared after the birth.

Taking great care of yourself while you're pregnant is important - but it's just as important that you pay attention to yourself after your baby is born. Lots of women have trouble keeping to their pill schedules once the whirlwind of nursing and feeding and cleaning begins. It's fine to stop all your drugs. Just discuss it with your doctor first. Or, you may want to switch to a simpler regimen. Just remember, your health matters too. Look for ways to make things more manageable - for instance, some clinics are set up so that you and your baby can have doctor's visits on the same day.

Most of all, do whatever you need to feel good about yourself. Trust your instincts. Take time to pamper yourself. You, and your baby, are worth it.