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Positive Pregnancy
by Vaughn Taylor and Hanna Tessema

Many HIV-positive women are reluctant to become pregnant because they fear they will pass the virus to their fetuses or that they will become too sick or disabled to care and provide for their children properly. But with counseling and guidance, along with comprehensive healthcare and treatment, many HIV-positive women can have healthy, HIV-negative children.

The key to a successful pregnancy is the health of the mother-to-be.  The HIV-positive woman who is pregnant – or is considering having children – has an additional reason to take care of herself.  Living well with HIV isn’t just about antiretrovirals – it’s also about adequate nutrition, quitting smoking, getting enough exercise, and not using recreational drugs (especially those that involve needles).  These recommendations will become even more vital during pregnancy, and will be joined by others – avoiding alcohol and caffeine, for example.  The aim is a healthy pregnancy, an HIV-negative baby, and a long, healthy life as a caring mother.

The prospective mother needs to learn everything she can about risks to the fetus during pregnancy and to the baby after delivery.  She needs to discuss her options with both her HIV specialist and her obstetrician (and later her baby’s pediatrician), in order to determine the choices that are best for her.  This article will explore some of those options.

The Importance of Prenatal Care and Counseling
Researchers are not sure exactly when  HIV is transmitted during pregnancy.  While some fetuses can be infected with HIV while developing inside their mothers’ uteruses (wombs), the vast majority of infections occur during labor (the time of delivery) or after the baby is born and is breastfed by an HIV-infected mother.

Ideally, preparation for reducing risks to mother and child begins before conception, when the woman and her partner are deciding if, when, and how to have a baby.  Without treatment, there is a 25% to 30% chance of an HIV-positive woman passing the virus to her child – so-called “vertical transmission.”  Risk of mother-to-child transmission is generally dependent on the pregnant woman’s viral load – the higher the amount of virus during pregnancy and delivery, the greater the higher the chance of transmitting the virus to her baby.

Throughout pregnancy, a developing fetus has its own blood supply.  In other words, the developing fetus generally does not come into contact with the blood of the mother.  This helps protect the fetus from infections, such as HIV, in the mother’s blood. Developing fetuses do, however,  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 antibody test at birth.

At the time of birth (labor), a baby often comes into contact with his or her mother’s blood.  If the mother’s blood enters the baby’s body, HIV can be transmitted.  But with good prenatal care and antiretroviral treatment, the risk of transmission can be reduced to less than 2%.

Sperm Washing
Sperm washing is a process that was developed to reduce risk of transmission from an HIV-positive man to his HIV-negative partner, and subsequently to the fetus, while enabling them to conceive a child.  If both partners are positive, sperm washing also reduces the risk of cross-infection with a different strain of HIV.

HIV is carried primarily in the seminal fluid rather than in the sperm itself.  Sperm washing involves separating the sperm from the seminal fluid, then using it to impregnate the woman when she is ovulating and most likely to become pregnant, or to fertilize her egg through in vitro fertilization.

Integrated Pregnancy Care
A comprehensive approach to care is the most effective way for a pregnant woman with HIV infection to have a healthy pregnancy and delivery.  While an obstetrician and an HIV specialist are safely and effectively managing the woman’s pregnancy, she should also be provided with professional support to help manage psychological, social, and economic challenges should they arise.  This might include assistance from a social services agency to help her with counseling, housing, food, and childcare needs, both during pregnancy and after delivery.

Professional counseling before pregnancy can also be extremely helpful.  Working closely with her healthcare provider, an HIV-positive women and her partner can learn a great deal about the risks and benefits associated with pregnancy, including treatment options, and different ways of achieving conception. 

Antiretroviral Therapy   
Women who are HIV positive can drastically reduce the risk of transmitting HIV to their babies with the use of antiretroviral drug treatment during pregnancy and at the time of delivery.  Deciding when to begin antiretroviral therapy during pregnancy, however – if it’s not already being taken – and which medications to use can be confusing.

Working with a healthcare provider, HIV-positive women can make important perinatal treatment decisions that best suit their individual needs, while at the same time following state-of-the-art recommendations from the U.S. Department of Health and Human Services (DHHS), the federal agency responsible for setting healthcare policies in the United States. The most recent version of the agency’s guidelines, entitled Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, was published on November 2, 2007.

When to Use Treatment During Pregnancy
Generally speaking, if an HIV-positive woman requires treatment to protect her own health – if her CD4 cell count is below 350, for example – she should not be denied therapy, regardless of whether she is pregnant or plans to become pregnant.

There are lingering questions about the safety of antiretrovirals when used during the first three months (first trimester) of pregnancy, when a developing fetus is believed to be most susceptible to drug toxicity.  According to the DHHS, antiretrovirals can be avoided during this three-month period provided the woman does not require treatment to maintain her own health.  Otherwise, HIV treatment should be continued throughout pregnancy.

HIV-positive pregnant women who do not require antiretroviral therapy to maintain their own health may be able to stop treatment after giving birth – a decision that should only be made in consultation with her healthcare team.   

Which HIV Drugs to Use During Pregnancy
As for specific HIV medications, the DHHS guidelines spell out a number of important considerations that HIV-positive pregnant women and their healthcare providers should be aware of.

First, the nucleoside reverse transcriptase inhibitor (NRTI) Retrovir (zidovudine) has been studied extensively in HIV-positive pregnant women and has been shown to be safe and effective at reducing the transmission of HIV from mother to fetus.  In turn, it is almost always recommended as a treatment component during pregnancy and delivery (and given to the infant after birth), even when the woman has HIV that is resistant to it.

The non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz, found in Sustiva and Atripla, should not be used by pregnant women and only cautiously by women who might become pregnant.  Because efavirenz may cause birth defects if taken during the first trimester – the first three months of pregnancy – it is recommended that HIV-positive women have a pregnancy test before starting efavirenz and use adequate birth control while using the drug.

The NNRTI Viramune (nevirapine) has been shown to reduce the risk of mother-to-child HIV transmission, but it is recommended only for women with CD4 counts below 250 cells. There is a higher risk of serious allergic reactions, including liver damage, occurring in women who start Viramune with CD4s higher than 250.

The protease inhibitor Viracept (nelfinavir) should also be avoided during pregnancy, until further notice.  In September 2007, Pfizer reported the discovery of a manufacturing impurity, ethyl methanesulfonate (EMS), in U.S. batches of Viracept.  As EMS has been found to be cancerous and capable of causing birth defects in animals, the U.S. Food and Drug Administration (FDA) recommends avoiding Viracept during pregnancy until Pfizer has found a way to remove EMS from the drug.

It is also a good idea to switch off medications known to cause serious side effects in women during pregnancy.  For example, the FDA has warned that HIV-positive pregnant women should not take Zerit (stavudine) and Videx (didanosine) at the same time.  Some pregnant women who took these drugs together developed lactic acidosis – a serious and sometimes fatal buildup of lactic acid in the blood, which can cause fatigue, nausea/vomiting, painful inflammation of the pancreas, and liver damage.

Other Considerations During Pregnancy
It is important to remember that pregnancy-related complications typically seen in women who are not living with HIV, such as hypertensive disorders, ectopic pregnancy, gestational diabetes, psychiatric illness, preterm delivery, and STDs, also can occur in pregnant women living with HIV.

Finally, there are some aspects of typical prenatal care that might not be suitable for HIV-positive pregnant women. 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.  Before undergoing amniocentesis, HIV-positive pregnant women may want to discuss its benefits and risks with their healthcare provider.

Labor and Delivery
Labor and delivery are believed to be riskiest time for HIV transmission during pregnancy, as babies are most likely to be exposed to their mother’s blood during the birthing process.  To reduce this risk, healthcare providers should avoid performing amniotomies – intentionally rupturing the amniotic sac to “make the water break” and induce labor.  The risk of transmission increases by 2% for every hour after membranes have been ruptured. 

An episiotomy – a surgical incision through the perineum made to enlarge the vagina and assist childbirth – can also expose the infant to the mother’s blood and increase the danger of transmission.  What’s more, the use of birthing instruments and common procedures, such as forceps/vacuum extractors, scalp electrodes, scalp blood sampling, and internal fetal monitoring, can cause small tears in the baby’s skin and increase the risk of transmission further. 

Cesarean Sections vs. Vaginal Delivery
A Cesarean section – also referred to as C-section – is delivery via a surgical incision through the maternal abdomen and uterus.  It is one of the oldest documented surgical procedures.  A C-section is performed when a vaginal birth is not possible or is not safe for the mother or child.  Because of a variety of medical and social factors, C-sections have become fairly common – about 26% of all births in the United States in 2002 were C-sections. 

C-sections can greatly reduce an HIV-positive woman’s risk of passing along the virus to her baby at the time of birth, as they greatly reduce the amount of time a baby remains in contact with his or her mother’s blood and other fluids during delivery.  It is still not known, however, if C-sections are any more effective than if the woman takes a powerful combination of antiretroviral drugs throughout her pregnancy.  It is also not known if a woman who takes a powerful 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 HIV drugs and has a vaginal delivery.

Some experts do not like the idea of C-sections used solely to reduce the risk of mother-to-child HIV transmission.  Because C-sections are a type of surgery, there are risks of infection and other complications.  In fact, HIV-positive women may be at a higher risk for infection while undergoing C-section delivery or other complications than HIV-negative women. It is also important to remember that combination HIV treatment might do a better job of stopping transmission than 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%, even with vaginal delivery. It is not known if C-sections reduce this risk further.

In its perinatal treatment guidelines, the DHHS says that C-sections are only recommended for the purpose of reducing the risk of mother-to-child HIV transmission when the mother’s viral load is higher than 1,000 at week 36 of the pregnancy.  A woman with a viral load below 1,000 should be counseled that her risk of transmitting the virus to her baby is low and that there is currently no information concluding that performing a scheduled cesarean section will lower her risk further.  DHHS also says that, if C-section delivery is chosen, it should be scheduled for week 38 of the pregnancy.

Postnatal Treatment
The months following delivery of a baby by an HIV-positive woman are also crucial to keeping the risk of vertical transmission to a minimum.

After the baby is born, the doctor will likely advise that he or she take anti-HIV drugs for four to six weeks, usually a liquid form of Retrovir taken two or four times a day, possibly in combination with other HIV medications.  Studies suggest that the use of antiretroviral treatment during the first few weeks of life plays a role in further lowering the risk of HIV infection in a newborn baby.  No significant side effects of Retrovir have been observed, other than a mild anemia in some infants that cleared up when the drug was stopped.  Follow-up studies show that the HIV-negative treated babies continued to develop normally.

Learning the Baby’s HIV Status
An HIV-positive new mother usually wants to know right away whether her baby is infected.  It can take several months to learn definitively the HIV status of a newborn. Moreover, it is important to keep in mind what an HIV test is. The standard test looks for antibodies to HIV; it does not look for the virus itself.  Because a fetus is exposed to the mother’s HIV antibodies, the baby will automatically test “positive” after birth. These antibodies can remain in the baby’s body for more than 18 months after birth.

Most hospitals now conduct nucleic acid testing, which looks for the virus itself, on babies born to HIV-infected women.  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.

Breastfeeding
Breast milk also carries HIV, and breastfeeding adds considerable risk of transmission.  As with transmission via blood, there’s some indication that risk increases along with viral load (the amount of HIV in the mother’s blood).  So far, research shows that the risk of breast milk transmission is highest in the first six months of life.  There’s no threshold, however, or point beyond which it becomes absolutely safe to breastfeed.

Wherever clean water and formula are available, it is recommended that HIV-positive women exclusively formula feed their infants.

In recent years, 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.

Vaughn Taylor is Manager and Hanna Tessema Associate Manager of ACRIA’s Older Adults Training and Technical Assistance Program.