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Patient information: HIV and pregnancy (Beyond the Basics)

HIV AND PREGNANCY OVERVIEW

If their mothers have HIV, infants can become infected during the pregnancy, during labor and delivery, and, to a lesser degree, through breastfeeding. Fortunately, the use of certain HIV medications during pregnancy and labor can dramatically reduce the risk of passing HIV to the infant.

However, not all women are aware that they are infected with HIV. Therefore, experts strongly recommend that all pregnant women undergo screening for HIV infection. (See "Patient information: Testing for HIV (Beyond the Basics)".)

This topic review discusses factors that can reduce HIV transmission from mothers to babies in developed countries such as North America. Therapies that may be useful in the developing world are reviewed elsewhere. (See "Prevention of mother-to-child HIV transmission in resource-limited settings".)

CARE BEFORE PREGNANCY

Women who have HIV should talk to their HIV specialist and an obstetrician before trying to become pregnant. Some HIV medications are not safe to take during pregnancy, and it may be necessary to switch before trying to conceive. It is also important to take your HIV medications regularly. Women who have complete viral suppression (no virus detected in their blood) have a much lower risk of passing HIV to their baby than women who have virus detected in their blood.

A number of studies have been done to better understand how HIV infection and HIV treatment affect the health of women and infants. Pregnancy does not appear to worsen HIV or increase the risk of death from HIV. It is not clear if HIV or HIV treatments increase the risk of pregnancy complications, such as prematurity, low birth weight, and stillbirth. However, it is very clear that certain HIV medications, such as zidovudine (ZDV or AZT) and other medications that cross the placenta, can significantly reduce the risk that the infant will become infected with HIV when the medication is taken during pregnancy and labor, and then given to the infant after delivery. That is why HIV treatment guidelines strongly recommend a combination of medications to prevent the transmission of HIV to an infant from an HIV-infected mother. Generally, zidovudine is given with other medications for HIV as part of a three-drug regimen. Some HIV medications, such as efavirenz, should not be used among women who are planning pregnancy. (See 'HIV medication regimens' below.)

Talk to your healthcare provider about the risks and benefits of taking HIV medications during pregnancy.

CARE DURING PREGNANCY

Women with HIV usually require the assistance of several healthcare providers during pregnancy, including an HIV specialist and obstetrical care provider.

Initial evaluation — After your pregnancy is confirmed, you should meet with your HIV specialist and obstetrical provider. During these visits, you will discuss how to manage your HIV during pregnancy and minimize the risk of passing HIV to your infant.

During the initial evaluation, you will have blood tests to determine the amount of HIV virus in your blood (eg, HIV viral load) and the strength of your immune system (eg, the number of CD4 T cells). You may also have other blood tests to evaluate general health and to monitor side effects of medications.

HIV medication regimens — During pregnancy, all women with HIV are advised to take combination antiretroviral regimens using three HIV drugs. When possible, zidovudine (ZDV) is included because it has been shown to significantly reduce the risk of passing HIV to the infant and is safe to take during pregnancy.

Timing of HIV medications — Studies suggest that women who start HIV medications earlier in pregnancy are more likely to have a low amount of virus in the blood by the time of delivery. However, some women may prefer to start after the first trimester of pregnancy to avoid unnecessary drug exposure to the fetus. You should discuss this with your doctor. Once started, HIV medications are continued throughout pregnancy to prevent HIV transmission to the fetus.

Even if zidovudine is not used during pregnancy, it is still recommended for some women during labor and for the infant for six weeks after birth. Information about other HIV medications is available separately. (See "Patient information: Initial treatment of HIV (Beyond the Basics)" and "Patient information: Tips for taking HIV medications (Beyond the Basics)".)

Medication adherence during pregnancy — It is extremely important to take your medications exactly as prescribed during pregnancy to decrease the risk of developing drug resistance. Furthermore, taking your medications on time can lessen the risk of HIV transmission to the baby.

Medications to avoid — There are several HIV medications that should not be used in pregnancy. Nevirapine is generally not started in women with a CD4 count >250/mm3.

Efavirenz should not be started during the first few weeks of pregnancy. However, women who become pregnant while taking efavirenz can continue that medication.

Monitoring during pregnancy — Throughout your pregnancy, you will see your obstetrical provider and HIV specialist at regular intervals. During these visits, you will have routine obstetrical care as well as HIV monitoring, including blood testing of your CD4 count and HIV viral load.

A detailed ultrasound is usually recommended at 18 to 20 weeks of pregnancy to evaluate the growing fetus. A follow-up ultrasound is often recommended during the second and/or third trimester to monitor the fetus' growth.

LABOR AND DELIVERY WITH HIV

Medications during labor — The HIV drug zidovudine is given through an intravenous catheter during labor when the woman does not have a low amount of HIV in the blood near the time of delivery, regardless of how the woman delivers. In these cases, zidovudine helps to reduce the risk of HIV transmission. Women who are taking combination HIV medications should continue them on schedule during labor or before a cesarean section; this helps to provide maximal protection to the mother and infant and to minimize the risk that the mother could develop drug resistance due to a missed dose of medication.

Delivery method — The safest way for women with HIV to deliver a baby (ie, by vaginal or cesarean delivery), depends upon her HIV viral load during pregnancy. In general, a vaginal delivery is preferred for the safety of both mother and infant if the risk of transmission of HIV is low (when the HIV viral load is low). For women with high levels of virus in their blood or who are very concerned about infant exposure to infected blood or vaginal fluids, a cesarean section is recommended.

Undetectable viral load — Pregnant women with HIV who have been taking HIV medications throughout pregnancy and have an undetectable HIV viral load at 34 to 36 weeks of pregnancy may choose to have a vaginal delivery. In this situation, the risk of transmitting HIV to the infant during a vaginal delivery is very low, and it is not clear that a cesarean delivery will decrease this risk any further [1]. You should discuss the risks and benefits of cesarean versus vaginal delivery with your obstetrical provider. (See "Patient information: C-section (cesarean delivery) (Beyond the Basics)".)

Viral load ≥1000 copies/mL — Pregnant women with HIV who have taken HIV medications throughout pregnancy but have a viral load above 1000 copies/mL at 34 to 36 weeks of pregnancy are usually advised to have a cesarean delivery rather than a vaginal delivery [1]. In this situation, the cesarean is usually scheduled at 38 weeks of pregnancy.

Viral load <1000 copies/mL — Women with an HIV viral load between 0 and 1000 copies/mL who have been taking HIV medications during pregnancy may choose between a vaginal or cesarean delivery. There is not enough information from studies to know if cesarean delivery decreases the already small risk of passing HIV to the infant [1].

CARE AFTER DELIVERY

For women after delivery — After delivery, women who took HIV medications during pregnancy should discuss the benefits that continuing HIV medications has on her own health with her doctor. This decision is best made along with an HIV specialist. Ongoing care and support services, including HIV-related medical care, psychosocial support, and assistance with family planning and birth control, can help the woman to care for the needs of herself and her family. (See "Patient information: Birth control; which method is right for me? (Beyond the Basics)".)

Breastfeeding — Women with HIV who breastfeed can pass HIV to the infant. In one study of over 600 mother-infant pairs from Malawi, the risk of transmitting HIV to the infant through breastmilk was 7 percent for infants who breastfed for one year and 10 percent for infants who breastfed for up to two years.

In the United States and other resource-rich countries, clean water and infant formulas are readily available and are safe alternatives to breastfeeding. Therefore, the United States Public Health Service recommends that women in resource-rich countries who are infected with HIV not breastfeed their babies, even if the woman is taking HIV medications. While risk of HIV transmission through breast milk can be lowered by HIV medications, HIV can still be transmitted through breastmilk, even if the woman is taking HIV medications.

The same advice cannot be given to women in resource-poor countries because safe alternatives to breastmilk (eg, clean water and formula) may not be consistently available.

For newborns and infants

HIV treatment regimens — Infants of women with HIV are usually treated with zidovudine for the first six weeks of life. Zidovudine can help to prevent the infant from becoming infected with HIV as a result of exposure to the mother's blood during delivery.

In certain situations, another HIV medication may be given instead of or in addition to zidovudine. Talk to your child's healthcare provider to determine which HIV medication is best.

Testing infants for HIV — Normally, adults and children undergo HIV antibody testing to see if they are infected with HIV. However, HIV antibody tests are not accurate in infants since HIV antibodies may be transferred from the mother to the baby. This may result in the infant having a positive HIV antibody test. However, this does not mean that the baby necessarily has HIV infection.

For this reason, a special test that directly measures the virus itself is performed in infants to see if they are infected. If this specialized virus test (called HIV PCR test) is negative, then the baby is not infected with HIV.

Long-term follow-up of children — Studies of infants who were exposed to zidovudine and who did not become infected with HIV have not shown any increased risk of serious problems with growth, the immune system, brain function, cancers, or other problems for up to six years [2]. However, long-term data regarding the safety of HIV medications during pregnancy, particularly combination regimens, are not available. As a result, infants and children who were exposed to antiretroviral drugs during their mother's pregnancy should be monitored over their lifetime.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: HIV/AIDS (The Basics)
Patient information: Starting treatment for HIV (The Basics)
Patient information: Vaccines for people with HIV (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Testing for HIV (Beyond the Basics)
Patient information: Initial treatment of HIV (Beyond the Basics)
Patient information: Tips for taking HIV medications (Beyond the Basics)
Patient information: C-section (cesarean delivery) (Beyond the Basics)
Patient information: Birth control; which method is right for me? (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

HIV and women
Prevention of mother-to-child HIV transmission in resource-limited settings
Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient
When to initiate antiretroviral therapy in HIV-infected patients
Diagnostic testing for HIV infection in infants and children younger than 18 months
Prevention of HIV transmission during breastfeeding in resource-limited settings
Use of antiretroviral medications in pregnant HIV-infected patients and their infants in resource-rich settings
Prenatal evaluation and intrapartum management of the HIV-infected patient in resource-rich settings

The following organizations also provide reliable health information.

The National Library of Medicine

     (www.nlm.nih.gov/medlineplus/aidsandpregnancy.html)

Centers for Disease Control and Prevention (CDC)

     (www.cdc.gov/hiv/topics/perinatal/index.htm)

HIV/AIDS Treatment Information Service

     (http://www.aidsinfo.nih.gov/)

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Literature review current through: Nov 2014. | This topic last updated: Sep 27, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. http://aidsinfo.nih.gov/guidelines/html/3/perinatal-guidelines/0/ (Accessed on March 28, 2014).
  2. Culnane M, Fowler M, Lee SS, et al. Lack of long-term effects of in utero exposure to zidovudine among uninfected children born to HIV-infected women. Pediatric AIDS Clinical Trials Group Protocol 219/076 Teams. JAMA 1999; 281:151.
  3. Committee on Obstetric Practice. ACOG committee opinion scheduled Cesarean delivery and the prevention of vertical transmission of HIV infection. Number 234, May 2000 (replaces number 219, August 1999). Int J Gynaecol Obstet 2001; 73:279.

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.