December 1st is World AIDS Day. AIDS or Acquired Immunodeficiency Syndrome is caused by Human Immunodeficiency Virus (HIV). HIV affects 1.1 million Americans, one quarter of whom are women. The majority of women acquire HIV through having sex with infected male partners. Other routes of HIV transmission include: IV drug use, childbirth, breastfeeding, and blood transfusion. Because most women are infected with HIV during their reproductive years, it is important to consider the effects of HIV on pregnancy and childbirth.
All women should take prenatal vitamins and be up to date on vaccinations before becoming pregnant. Prior to pregnancy, HIV positive women should have good viral control in order to prevent transmission to their baby. If you are taking antiretrovirals it is imperative to discuss this with your doctor prior to becoming pregnant, because some medications should be avoided. If your partner is HIV negative, there are methods to avoid exposing him to HIV in order to become pregnant. Your doctor can direct you to the best options for becoming pregnant and protecting your partner and baby from HIV infection.
Before antiretroviral medications were available, pregnant women had a 25% risk of transmitting HIV to their baby. The majority of babies become infected during pregnancy, half at the time of delivery. The rest are infected through breastfeeding. Currently, women taking anti-retroviral medications have a 1-5% risk of having an HIV positive baby. During pregnancy, the goal is to suppress the virus in the bloodstream to a very low level in order to reduce the rate of transmission to less than 1%. HIV positive women should not breastfeed.
The Center for Disease Control recommends routine HIV screening in all pregnant women. Some women are known to have HIV before they become pregnant, but many are diagnosed at their first prenatal visit. Antiretroviral therapy is recommended during every pregnancy in order to prevent transmission to the baby. Most women can start antiretrovirals by 14 weeks of pregnancy. For the best prevention of transmission, the latest start of anti-retrovirals is 28 weeks of pregnancy. All pregnant mothers with HIV should be seen by an Infectious Disease specialist to determine the safest, most effective anti-retrovirals during pregnancy. HIV positive women require more visits and lab tests during pregnancy in order to ensure a good medication response.
HIV positive women should take antiretrovirals until delivery. HIV positive women with low viral loads can attempt a vaginal delivery. Women with higher viral loads should consider a c-section to prevent HIV transmission to their baby. Typically, the c-section should be done before the start of labor, at approximately 38 weeks of pregnancy. HIV positive women with prior c-sections are encouraged to consider a repeat c-section. All HIV positive women should receive IV zidovudine (AZT) at least 3 hours before delivery. AZT is an anti-retroviral and can decrease the rate of HIV transmission during labor. After delivery, women should resume taking their medications for HIV.
After delivery, it is extremely important to continue with the planned anti-retroviral therapy. All patients should discuss their postpartum HIV medication regimen with their doctor. Stopping these medications without your doctor’s input can cause HIV to become resistant and difficult to treat. All babies born to HIV positive mothers will be advised to take anti-retroviral therapy for approximately six weeks. Babies need frequent blood tests up to 6 months of age to ensure they are HIV negative.
Lastly, all women should have a plan for reliable birth control after delivery and experience the freedom to determine when their next child is born. HIV positive women can use all the available methods of contraception: pills, injections, patches, vaginal rings, and IUDs. Women who are interested in permanent sterilization should talk to their doctor in advance to ensure legal documentation is completed before delivery. Condoms are the only method that can prevent HIV transmission during sex; therefore, HIV positive women should use condoms to protect partners from infection.
by: Gweneth Lazenby, M.D.
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