Perinatal HIV Transmission and Birth Options for HIV-Positive Mothers
HIV Treatment Series II: Part Two of Four
Many people are misinformed about the risks of perinatal HIV transmission, including many healthcare providers. Some people mistakenly believe that all babies born to HIV-positive women will be infected, or that HIV-positive women are too sick to have healthy pregnancies and give birth to healthy children. Many people also don't know that there are ways to greatly reduce the risk of mother-to-child HIV transmission. About 25% of children born to HIV-positive women who receive no treatment or interventions against perinatal HIV transmission become infected with HIV -- that means an average of 25 out of 100 babies, or 1 in 4, can pick up HIV from their mothers during pregnancy, birth, or afterward from breastfeeding. But perinatal HIV infection rates can drop to as low as 1% or 2% for babies whose mothers are able to use combination antiretroviral therapy during pregnancy, AZT or nevirapine prophylaxis during labor and after birth, and choose the birth option that's safest, according to maternal viral load levels, for both mother and baby.
You are a good place for your baby to grow, and you deserve respectful care. If your HIV care specialist or prenatal care provider tries to dissuade you from becoming pregnant or recommends you terminate a wanted pregnancy, get another provider! With good care and support, your risk of transmitting HIV to your fetus or baby is very low. Don't let that worry stop you if you want to be a mother.
No one knows the exact mechanisms involved in perinatal transmission, but it's believed to occur three different ways:
Prenatally (in utero): Some babies acquire HIV because the virus crossed the placenta during pregnancy -- this doesn't happen very often, but it can. During pregnancy, the mother's blood supply is connected to the fetal blood supply via the umbilical cord and placenta. The mother and the baby do not share the same blood supply, but sometimes HIV in the mother's blood is able to cross the placenta and infect the baby. The following conditions can increase the risk of transmission during gestation:
At birth: During labor and delivery, the baby comes into contact with her/his mother's blood and cervical/vaginal secretions while passing through the cervix and vagina. Research indicates that the majority of babies who pick up HIV infection from their mothers probably acquire the virus during the birth process.
During breastfeeding: There have been several documented cases in which HIV has been transmitted through breastfeeding. HIV has been isolated in breast milk, and the documented cases of transmission through breastfeeding indicate that the virus was passed through the milk rather than during gestation or the birth process. Blood from cracked nipples or breast infection (mastitis) may also be present during breastfeeding, and may contribute to the risk of infection.
The risk of perinatal transmission risk at any stage can be greatly reduced by:
During prenatal care, your OB should avoid the following tests and procedures unless they are considered medically necessary, because they are invasive and may increase the risk of HIV transmission to your fetus during pregnancy:
Amniocentesis: a diagnostic test for chromosomal abnormalities like neural tube defects and Down's syndrome. It involves inserting a long, very thin needle through your abdomen and into your uterus to obtain a sample of amniotic fluid. Another screening method that checks for alfa fetal protein (AFP) levels in a blood sample can be done instead.
Chorionic villi sampling (CVS): taking a sample of the chorionic villi, tissue which will form the placenta. This is another way to check for chromosomal abnormalities, but because it disturbs the placental site and causes some bleeding, it's not as safe for your fetus as AFP testing.
Your provider may also want to perform more ultrasounds (visualizing the fetus in the uterus) than they would for a woman without HIV, especially if there is a question about your fetus's gestational age due to irregular menstration. If this bothers you, talk with your provider about how to keep ultrasound use at a minimum while still getting information that will help you both decide when an elective cesarean section can be done safely if you decide to give birth via C-section.
Avoid Sustiva! It's not recommended for use at any time during pregnancy due to risk of birth defects. If you find out you're pregnant while using Sustiva, don't panic! Just consult your HIV specialist and change your regimen for the remainder of your pregnancy. If Sustiva is working well for you, you should be able to go back to it again after your baby is born.
For your own safety, you should also avoid using the following meds in combination with each other during pregnancy:
If you're already on combination therapy when you become pregnant, most healthcare providers will recommend that you stay on your regimen during the first trimester of pregnancy unless you're too nauseous to keep your meds down. Pregnancy-related nausea and vomiting ("morning sickness") tends to be worst during the first trimester for women who experience it -- puking up your pills isn't helpful, so for some women it's safer to stop meds until morning sickness subsides. If you decide to take a break from your meds, all drugs should be stopped at the same time and then re-started at the same time in order to reduce the risk of developing resistance (consult your physician).
If you've never used combination therapy before, many providers will recommend waiting until after 12-14 weeks of pregnancy, unless your viral load is very high or your health would benefit from starting combination therapy right away. There are two reasons for this recommendation: 1) to avoid potential side effects such as nausea/vomiting and diarrhea at the same time you may be struggling with morning sickness, and 2) because the risk of medication-related birth defects (for any medication, not just antiretrovirals) is considered highest in the first trimester, when the fetal organ and skeletal systems are forming. However, a woman cannot be denied therapy at any time during a pregnancy -- if you want it, you should be given it.
AZT is currently the standard prophylactic treatment against perinatal transmission used in the United States. If you use AZT during labor and birth, it will be administered to you through an IV regardless of whether you give birth vaginally or by elective C-section. After birth, your baby will be given AZT syrup within 8 to 12 hours, and you'll be shown how to give the syrup yourself at home for the next six weeks.
Antiretroviral Pregnancy Registry are indicating that children born to mothers who have used antiretroviral medications during pregnancy do not appear to be statistically at higher risk for birth defects than babies born to mothers who didn't use HAART. The preliminary results for the study following the children who were born to women who participated in ACTG 076 (the study that demonstrated AZT's effectiveness in reducing perinatal transmission) show that, after 6 years, these children do not appear to be experiencing a greater degree of health problems than are noted in the general population of children. However, we can't yet know the long-term outcomes for children born to women who used combination therapy during pregnancy and/or AZT prophylaxis. Research is being conducted continuously, though, so we're getting more and more information as time goes on.
No one can force you to take meds while pregnant. If you don't want to or can't take meds during your pregnancy, you cannot legally be made to take any medication on behalf of yourself or your fetus. Right now, the use of AZT and other antiretroviral medications in pregnancy is recommended because the known risks of pediatric AIDS are thought to outweigh the unknown possible long-term risks of their use during pregnancy for both mother and child. If you have concerns about the effect AZT or other meds may have on your child, now or in the future, discuss them with your healthcare provider, HIV/OB specialist, or a local agency that advocates for HIV-positive people. The information in these links may also be useful to you:
To reduce tissue damage, extra bleeding, and infection risk during vaginal birth, your care provider will avoid the following invasive procedures and use of instruments unless medically indicated:
If your viral load is over 1,000 copies/ml, research shows that elective cesarean section done prior to rupture of membranes can reduce the risk of HIV transmission by preventing contact between the fetus and the blood and cervical secretions that are present during the birth process ("elective" means you choose to do it, rather than have it done for emergency reasons). C-section after the membranes have been ruptured for at least four hours has not shown to be statistically helpful in reducing HIV transmission, so elective C-sections done to reduce HIV transmission are usually performed at 38 weeks gestation (well before most women's water breaks on its own). Because of the increased risk of post-operative infections in women who give birth by C-section, your care provider may give you antibiotics to take after the surgery.
The choice of how to give birth is ultimately yours. Your healthcare provider should discuss your options with you and provide their professional opinion based on your lab tests and overall health of both you and your fetus, but you are still the person who makes the final decision.
HIV-positive women living in places where clean water and consistent supplies of safe formulas are not available need to weigh the risks and benefits of breastfeeding their babies. If their children are at high risk for starvation, dehydration, and diarrhea associated with unsafe formula-feeding, breastfeeding may be the safer alternative even though it increases the risk of HIV transmission to the baby. In the U.S. and Canada, HIV-positive women are largely able to safely formula-feed, and are therefore encouraged to do so. If you live in the United States and are considered "low income", please know that you should also qualify for Medicaid and WIC supplements that provide free infant formula (regardless of your immigration status, if that's a concern). In many places, services may be prioritized for HIV-positive mothers, so ask your healthcare provider or case manager for more information.
Note: This article was written with assistance from the Pediatric AIDS Chicago Prevention Initiative (PACPI). For more information on PACPI's Chicago-area services and classes for HIV-positive pregnant women, call (773) 327-0509. Clinicians and social service providers can call the 24-hour hotline at (312) 926-7380. Thanks to Anne and Brenda!
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