HIV and pregnancy

An estimated 1.3 million persons living with the HIV become pregnant, and approximately 1.1 million, or 85%, of them receive antiretroviral therapy during pregnancy.

In 2021, approximately 19.7 million of the 38.4 million people worldwide living with HIV were females older than 15 years, and approximately 79% were of childbearing age.

Each year about 1.3 million people with HIV worldwide, and about 5000 in the US give birth.

HIV/AIDS in pregnancy may transmit the infection to the child during pregnancy, childbirth and while breastfeeding.

The risk of mother-to-child transmission of HIV may be reduced by treatment of the HIV infection with antiretroviral therapy (ART).

The vast majority of pregnant persons living with HIV reside in low in middle income countries.

In the absence of antiretroviral therapy (ART), 15 to 30% of infants born to persons with HIV, acquire HIV antenatally or perinatally, with additional transmission risk during  breast feeding.

ART should be started at first diagnosis of HIV, and people diagnosed with HIV prior to conception should be taking ARTT when they learn of their pregnancy.

Blood levels of most antiretrovirals are usually slightly lower in pregnant than nonpregnant people, but dose adjustment is typically not required.

For pregnant women with HIV infection, a dolutegravir based regimen is preferred as first line antiviral therapy.

The choice of ART is generally similar for people who are pregnant, and those who are not pregnant, as long as pharmacokinetic data show drug concentrations during pregnancy are within the therapeutic range.

Therapy for HIV may be initiated in women before, during, and after pregnancy.

ART is essential for preserving maternal health and preventing perinatal and sexual HIV transmission.

Without ART approximately 15 to 40% of pregnant or breast-feeding people with HIV will have a child who acquires HIV.

The risk of perinatal and postpartum transmission is less than 2% if ART is used from early in pregnancy with sustained viral suppression.

Approximately 80% of pregnant women with HIV are receiving a RT worldwide that is resulting in a 50% reduction in new perinatal infections globally.

After delivery, children are also given the medication temporarily as a prophylactic measure to reduce the risk of infection.

Mothers who are infected with HIV are encouraged to avoid breastfeeding, as the virus may be transmitted in the milk.

Infection with HIV/AIDS is not a contraindication to pregnancy.

With appropriate treatment, the risk of mother-to-child infection can be reduced to below 1%.

Vertical HIV transmission is essentially eliminated in non-breast-feeding women who have sustained a viral suppression level of less than 50 copies per millimeter, with a three drug ART regimen, taken from conception throughout pregnancy, and transmission through breast-feeding is very rare with maternal viral suppression from ART.

Without treatment, the risk of transmission of HIV is 15–45%.

Approximately 1.4 million HIV positive women who become pregnant and contribute to more than 300,000 neonatal and fetal deaths each year.

Fewer than 200 babies are born with HIV every year in the US.

In couples where only one partner is HIV positive there is risk of transmitting the infection to the uninfected partner, are they advised not to engage in unprotected intercourse and to seek assisted reproductive methods.

In such couples, the infected partner is advised to begin ART so that their viral load is undetectable prior to attempting conception.

If the woman is HIV negative and the man is HIV positive, sperm can be collected from the male partner and HIV is removed fusing a technique called sperm washing: followed by intrauterine insemination (IUI) or in vitro fertilization (IVF).

The HPTN 052 trial showed that when HIV infected partners were on ART and their viral load was undetectable no transmission occurred

In partners with a detectable viral load on ART there was 96% less transmission.

The daily use of preexposure prophylaxis decreases transmission of the infection by an average of 63–75%.

Women with HIV have decreased fertility, as they are more likely to be infected with other sexually transmitted diseases, placing them at higher risk

Males with HIV appear to have decreased semen volume and sperm motility, which decreases their fertility.

ART may also affect both male and female fertility.

There have been reported cases where an HIV-negative partner was infected with the disease despite artificial insemination with washed sperm.

The Centers for Disease Control and Prevention (CDC) recommends HIV testing for all pregnant women as a part of routine prenatal care.

Pregnancy testing is usually performed in the first trimester of pregnancy with other routine laboratory tests.

The most common screening test is the rapid HIV antibody test which tests for HIV antibodies in blood, urine, or oral fluid.

HIV/AIDS may be vertically transmitted from a mother to her child, during pregnancy, labor, delivery, or breastfeeding.

70% of transmissions of HIV during pregnancy are believed to occur during delivery when the baby comes into direct contact with the mother’s infected blood or genital secretions/fluid in the birth canal.

It is estimated that 30% of infections occur in utero during the pregnancy with 66% occurring within the last 14 days of a pregnancy, suggesting that infected maternal secretions may cross the placenta during the pregnancy.

Mother to child HIV transmission risk is related to the plasma viral load of the mother.

Untreated mothers with a viral load >100,000 copies/ml have a transmission risk of over 50%, while women with a viral load <1000 copies/ml, the risk of transmission is less than 1%.

Anti-retroviral therapy is, there, recommended throughout the pregnancy so that viral load levels remain as low as possible and the risk of transmission is reduced.

Women with an established diagnosis of HIV often begin anti-retroviral therapy before becoming pregnant to treat the infection, and it is recommended that all pregnant women begin ART regardless of CD4 counts or viral load to reduce the risk of transmission.

The earlier Anti-retroviral therapy is initiated, the more likely the viral load will be suppressed by the time of delivery.

Pregnant women infected with HIV receive an oral regimen of at least three different anti-HIV medications such as tenofovir, emtricitabine and efavirenz.

Current recommendations by the WHO, US CDC and U.S. Department of Health and Human Services (DHHS), all individuals with HIV should begin ART.

The recommendation is enhanced if :

CD4 count is below 350 cells/mm3

High viral load (>100,000 copies/ml)

Progression of HIV to AIDS

Development of HIV-related infections and illnesses

If diagnosed prior to pregnancy, women should continue with ART during the pregnancy. If the diagnosis of HIV is made during the pregnancy, ART should be initiated immediately.

The goal of antiretroviral use during pregnancy is to reduce the risk of transmission of HIV from mother to child.

There appears to be increase in stillbirths, preterm delivery, and delayed fetal growth in women using high doses of antiretroviral drugs during pregnancy.

Nevertheless, the overall benefits of ART outweigh the risks and all women are encouraged to use ART for the duration of their pregnancy.

The recommended treatment regimen is a three-drug regimen where the first two drugs are NRTIs and the third is either a protease inhibitor, an integrase inhibitor, or an NNRTI.

Nucleoside reverse transcriptase inhibitors (NRTIs) are considered the mainstay of ART and 2 medications are generally used in combination.

Zidovudine-lamivudine (ZDV/3TC) is the pref2242ed choice as the NRTI backbone in pregnancy.

For women who are coinfected with hepatitis B, tenofovir (TDF) with either emtricitabine (FTC) or lamivudine is the pref2242ed NRTI backbone.

Protease inhibitors (PIs) are the pref2242ed third drug in the regimen: Atazanavir-ritonavir (ATV/r) and darunavir-ritonavir (DRV/r) are two of the most common PIs used during pregnancy.

Women who are at a high risk for premature delivery are advised not to use PIs.

Non-nucleoside reverse transcriptase inhibitors (NNRTIs), may be used during pregnancy: the most popular being efavirenz (EFV) and nevirapine (NVP).

Women should continue their ART regimen through childbirth.

When the viral load is low (<1000 copies/mL), the risk of transmission is low and a vaginal delivery may be performed.

A cesarean section, on the other hand, is generally performed at 38 weeks gestation when:

Viral load is high (>1000 copies/mL) or unknown at the time of delivery.

Mother did not receive ART during the pregnancy

Mother is concerned about exposing her child to infected blood and genital secretions during the delivery

If, before a scheduled cesarean section, a woman’s water breaks and she goes into labor, a cesarean section may not significantly reduce the risk of infection transmission.

Women presenting to the hospital in labor with an unknown HIV status should undergo immediate HIV testing.

If the initial screening test is positive, the mother should immediately be treated with antiviral treatment and the baby should receive prophylactic ART after birth.

As women may transmit HIV to their child via breastmilk, it is is discouraged amongst HIV-positive women.

Breastfeeding for infants born to mothers on lifelong ART is beneficial in terms of HIV‐free survival at least up to 24 months of age – increasing HIV-free survival rates from 89% to 96%.

Pregnant women with HIV may should receive the trivalent inactivated influenza vaccine and the tetanus, diphtheria, and pertussis (Tdap) vaccination during pregnancy.

Many patients who are HIV positive also have other health conditions known as comorbidities including Hepatitis B, hepatitis C, tuberculosis and injection drug use.

It is necessary identify these comorbidities early during the pregnancy.

HIV-positive women’s babies should receive a 6-week or 12-week course of zidovudine (AZT).

The usual antibody based testing is unreliable in infants until the age of 18 months due to the transmission of maternal antibodies, and a qualitative HIV DNA PCR assay is recommended.

To reduce the risk of developing Pneumocystis jirovecii pneumonia (PJP), all infants born to HIV-positive mothers should receive trimethoprim/sulfamethoxazole (cotrimoxazole) from 4–6 weeks after birth, and stop prophylaxis when they are no longer at risk of contracting HIV from their mother.

ART before and throughout pregnancy is strongly recommended for the improvement of maternal, fetal and child health outcomes.

There is a higher stillbirth rate among patients with HIV than among those without HIV, and this remains true, even with ART, but at lower rates.

Women living with HIV are more than twice is likely to have a preterm birth at <37 weeks as persons without HIV (21.1% versus 9.4%).

ART during pregnancy, partially mitigates this excess preterm birth risk, but not with all regimens.

ART therapy may increase the risk of small for gestational age neonates.





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