HIV & pregnancy.

When the AIDS epidemic began, its most innocent victims were the babies. Infected in utero or via breastfeeding, most died before they were old enough for kindergarten.

Today that's all changed. Given the appropriate treatment, the transmission rate from mother to infant is as low as two percent, with some studies showing a zero transmission rate, says Susan R. Barringer, RN, MPH, a consultant for the Connecticut AIDS Education and Training Center at the Yale School of Nursing in New Haven. Without treatment, however, women have a one in four chance of passing the virus on to their babies.

Those figures are important, since between 6,000 and 7,000 HIV-infected women give birth every year in the U.S. (14) It's a figure likely to increase as the virus becomes more prevalent in women and as more HIV-positive women, optimistic about their future because of the newer therapies, choose to have babies.

As one HIV-infected woman wrote on an Internet bulletin board for women with the disease: "Having a child is, in my book, the one thing I don't think I could live without ... I think it is time for (HIV) positive women to recognize the possibilities for them of childbirth."

Still, about 90 percent of pregnancies in HIV-infected women are unplanned.

The good news is that infected women who become pregnant do not have higher rates of miscarriage, ectopic pregnancy and stillbirth than women not infected with the virus, indicating that HIV-positive status does not necessarily affect the pregnancy itself. (15)

The first step to preventing transmission between mother and baby is identifying HIV-positive pregnant women. Yet in 2000, 29 percent of HIV-infected infants (between 80 and 110) were born to mothers who either didn't know or didn't tell anyone they had HIV infection prior to the birth. (16)

One reason pregnant women don't get tested is because their health care provider doesn't recommend it or doesn't send the message that it's important. If they do, Ms. Barringer says, "women are very, very open to testing," particularly if they trust their provider and the issue is framed as a way of maintaining good health for mom and baby.

To that end, Ms. Barringer has a message for women's health care professionals who don't recommend screening: "Make no assumptions about your patients' risk or apparent lack of risk."

As soon as an HIV-positive woman finds herself pregnant, or a pregnant woman tests HIV-positive, she should discuss treatment during pregnancy with her health care professional. If she has a low viral load and a high CD4 count, and she hasn't started retroviral therapy yet, she may only need to take AZT (zidovudine), the first drug ever approved for the treatment of AIDS, during pregnancy. Most women, however, will likely need a combination of drugs.

Another way to reduce the risk of transmission to the baby, says Ms. Barringer, is to have an elective caesarian. This avoids the trauma of a vaginal birth, during which tiny tears and scrapes in the baby's skin could provide access to the virus.

After birth, babies born to HIV-infected women test positive for the virus, because they have their mother's antibodies (HIV tests measure antibodies to the virus). The infants' true status, however, won't be known for another three to six months. Nonetheless, all of the babies receive treatment just in case, until their HIV status is verified.

After the birth, HIV-infected women should not breastfeed, said Ms. Barringer, because breastfeeding increases the risk of transmission by 15 percent. The only exception is if women live in areas with unsafe water, are unable to provide formula for their babies or face stigma associated with not breastfeeding that could threaten their safety.

In the end, she says, the message she'd like to get to pregnant women or women planning a pregnancy is that testing for HIV not only benefits their own health, but their babies', too. "I think that's a really important message for women to share with others they know."

References

14 Lindegren ML, Byers RH Jr, Thomas P, et al. Trends in perinatal transmission of HIV/AIDS in the United States. JAMA. 1999 Aug 11;282(6):531-8.

15 Massad LS, Springer G, Jacobson L, et al. Pregnancy rates and predictors of conception, miscarriage and abortion in US women with HIV, AIDS. 2004 Jan 23;18(2):281-6.

16 US Department of Health and Human Services. Office of the Inspector General. Reducing Obstetrician barriers to offivering HIV testing. Apr 2002. Available at: http://oig.hhs.gov/oei/