HIV in pregnancy is the presence of HIV virus in women during pregnancy. There are concerns because women who are diagnosed with HIV/AIDS can transmit the infection to their child during pregnancy. Infection is transmitted to infants during pregnancy, labor, or breastfeeding. However, the risk of mother-to-child HIV transmission can be reduced by the use of HIV drugs known as antiretroviral therapy (ART). These medications can be used by women before, during, and after pregnancy. After childbirth, children are also given medications to reduce the risk of infection. Because HIV can spread through breast milk, women with infections are advised to avoid breastfeeding.
Infection with HIV/AIDS is not contraindicated for pregnancy. Women with this disease may choose to become pregnant if they wish, however, they are encouraged to talk to their doctor first. Some women do not realize they have the disease until they are pregnant. In this case, they should start antiretroviral therapy as soon as possible. With appropriate treatment, the risk of mother-to-child infection can be reduced to below 1%. Without treatment, the risk of transmission is 15-45%.
There are approximately 1.4 million HIV-positive women who become pregnant and contribute to over 300,000 neonatal and fetal deaths each year. With the use of ART, mother-to-child transmission of HIV decreases according to a report by the World Health Organization (WHO). In 2009, there were about 400,000 children born with HIV and by 2013, there were 240,000. Countries in South Africa are most affected by the HIV/AIDS pandemic. In 2010, 30% of all pregnancies in the region were exposed to HIV. In 2011, HIV was responsible for 50% of deaths for children under 5 years of age. In the United States, fewer than 200 babies are born with HIV every year.
By 2015, Cuba has become the world's first country to combat mother-to-child transmission of HIV. In 2010, WHO partnered with the Pan American Health Organization (PAHO) to implement an initiative that will provide early prenatal care and HIV testing for all pregnant women in the country. For women who tested positive, ART was given for mothers and children, a caesarean section was performed, and an alternative to breastfeeding was provided. In implementing these measures, the country managed to eradicate HIV transmission during pregnancy.
Video HIV and pregnancy
Planning pregnancy
In couples in which both men and women are both HIV positive, conception can occur normally regardless of disease transmission. However, in couples where only one partner is HIV positive, there is a risk of transmission of infection to an uninfected partner. This couple, known as a serodiscordant partner, is advised not to have unprotected sexual intercourse. Instead, it is recommended that assisted reproductive methods. In all serodiscordant couples, infected couples are advised to initiate antiretroviral therapy so that the infection rate is undetectable before attempting conception.
In couples where the woman is HIV negative and the man is HIV positive, the sperm is collected from the male partner using a technique called washing sperm. This process is then followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). Couples can also use donor sperm from uninfected men if desired.
In couples where the woman is HIV positive and the man is HIV negative, artificial insemination is recommended.
In areas where assisted reproductive techniques such as IUI or IVF are not available, techniques for reducing HIV transmission during conception can be tried to reduce, but not eliminate, the risks. Most importantly, HPTN 052 trials show that when an HIV-infected partner is on ART, there is 96% less HIV transmission and none of the partners with undetectable viral load.
Many serodiscordant couples use pre-exposure prophylaxis (PrEP) to limit transmission of infection to uninfected partners. Daily use of PrEP has been shown to reduce infection by an average of 63-75%. However, the use of PrEP during pregnancy has not been studied and its long-term effects are unknown and should not be the only safety feature in the prevention process.
Although assisted reproduction techniques are available for serodiscordant couples, there are still limits to achieving successful pregnancies. Women with HIV have been shown to have decreased fertility that may affect the choice of reproduction available. Women with HIV are also more likely to be infected with other sexually transmitted diseases, placing them at a higher risk of infertility. Men with HIV appear to have decreased the volume of semen and sperm motility that decrease their fertility. Antiretroviral drugs can also affect male and female fertility and some drugs can be toxic to newly developed embryos. In addition, there are cases where the HIV-negative partner is infected with the disease even if using artificial insemination is processed.
Maps HIV and pregnancy
HIV test in pregnancy
The Centers for Disease Control and Prevention (CDC) recommends HIV testing for all pregnant women as part of routine prenatal care. This test is usually performed in the first trimester of pregnancy with other routine laboratory tests. HIV testing is recommended because HIV-infected women who are not receiving the test are more likely to transmit the infection to their children.
HIV testing can be offered to pregnant women with an opt-in option or opt-out . In the participation model , women were counseled about HIV testing and chose to receive the test by signing the consent form. In the opt-out model, HIV testing is automatically performed with other routine prenatal tests. If a woman does not wish to be tested for HIV, she should specifically reject the test and sign a declining test form. The CDC recommends testing opt-out for all pregnant women as it improves disease detection and treatment and helps reduce transmission in children.
If a woman chooses to refuse a test, she will not accept the test. However, she will continue to receive HIV counseling during pregnancy so she can be advised of the disease and its effects. She will be offered an HIV test at all stages of her pregnancy if she changes her mind.
HIV testing begins with a screening test. The most common screening test is a rapid HIV antibody test that tests HIV antibodies in the blood, urine, or oral fluid. HIV antibodies are only produced if a person is infected with the disease. Therefore, the presence of antibodies is an indication of HIV infection. Sometimes, however, a person may be infected with HIV but the body has not yet produced enough antibodies to be detected by the test. If a woman has risk factors for HIV infection but a negative test on early screening tests, she should be retested within 3 months to ensure that she does not have HIV. Another more specific screening test is the HIV antigen/antibody test. This is a newer blood test that can detect HIV infection faster than antibody tests because it detects viral particles and antibodies in the blood.
Any woman who has an HIV-positive screening test should receive further tests to confirm the diagnosis. Follow-up tests can differentiate HIV-1 from HIV-2 and more specific antibody tests. It may also detect the virus directly in the bloodstream.
Prevention of mother-to-child transmission
HIV/AIDS can be transmitted vertically from mother to child. This means the infection can spread during pregnancy, labor, delivery, or breastfeeding. 70% of transmissions are believed to occur during labor when the baby is in direct contact with the mother's infected blood or genital fluid in the birth canal. 30% of infections occur in the uterus during pregnancy with 66% occurring within the last 14 days of pregnancy. The mechanism for uterine infection is not well understood, but the current belief is that the secretion of an infected mother may cross the placenta during pregnancy.
The risk of mother-to-child transmission of HIV is most directly related to maternal plasma viral load. Mothers not treated with viral load & gt; 100,000 has a transmission risk of more than 50%. For women with viral loads & lt; 1000 copies/ml, transmission risk less than 1%. In general, the lower the viral load, the lower the risk of transmission. For this reason, antiretroviral therapy is recommended during pregnancy so that viral load levels remain as low as possible and the risk of transmission is reduced.
Women with established HIV diagnoses often start antiretroviral therapy before becoming pregnant to treat the infection. It is recommended that all pregnant women start ART regardless of CD4 cell count or viral load to reduce the risk of transmission. Earlier ART was started, the more likely the viral load was suppressed at the time of delivery. Some women worry about taking ART early in pregnancy because babies are most susceptible to drug toxicity during the first trimester. However, delays in ART initiation may prove less effective in reducing transmission of infection.
Antiretroviral therapy is used at the following times in pregnancy to reduce the risk of mother-to-child transmission of HIV:
- During pregnancy: HIV-infected pregnant women receive an oral regimen of at least three different anti-HIV drugs.
- During labor and delivery: pregnant women who are HIV-infected and already on ART three times are advised to proceed to their oral regimen. If their viral load is & gt; 1,000 copies or there is a question about whether the drug has been drunk consistently, then intravenous zidovudine (AZT) is added at the time of delivery. Pregnant women who have not taken ART before delivery should also be given intravenous zidovudine (AZT).
Indications for starting treatment
According to current recommendations by WHO, the US CDC and the US Department of Health and Human Services (DHHS), all individuals with HIV should start ART. Recommendations are stronger under the following conditions:
- CD4 count below 350
- High viral load (& gt; 100,000 copies/ml)
- The progression of HIV to AIDS
- Development of HIV-related infections and diseases
- Pregnancy
Women are encouraged to start treatment as soon as they are diagnosed with HIV. If they are diagnosed before pregnancy, they should continue antiretroviral therapy during pregnancy. If HIV diagnosis is made during pregnancy, ART should begin immediately.
Medication during pregnancy
The purpose of antiretroviral use during pregnancy is to reduce the risk of mother-to-child transmission of HIV. It is important to choose a safe medication for mother and fetus and that is effective to reduce total viral load. Several studies have shown an increase in stillbirth, preterm labor, and delayed fetal growth in women taking high-dose antiretroviral drugs during pregnancy. However, overall ART benefits are believed to outweigh risks and all women are encouraged to take ART during their pregnancy.
Due to physiological changes in the body during pregnancy, it may be necessary to change the dose of the drug so that they remain effective. Generally, the dose or frequency of dosing is increased to account for this change.
Recommended HAART regimens for HIV-positive pregnant women consist of medicines from 4 different drug classes listed below. In the United States, the preferred regimen is a three-drug regimen where the first two drugs are NRTIs and the third is a protease inhibitor, an integrase inhibitor, or an NNRTI.
- Nucleoside reverse transcriptase inhibitors (NRTIs) are considered the "backbone" of ART and 2 drugs commonly used in combination. Due to known safety profiles and widespread use in pregnant patients, zidovudine-lamivudine (ZDV/3TC) is the preferred choice as the NRTI backbone. Zidovudine may aggravate anemia, so patients with anemia are advised to use alternative agents. For women co-infected with hepatitis B, tenofovir with emtricitabine or lamivudine is the preferred NRTI backbone. Use of NRTIs can lead to lactic acidosis in some women, so it is important to monitor patients for these complications. Deaths from lactic acidosis and liver failure have been associated with the use of two NRTIs, stavudine and didanosine (Zerit and Videx, respectively); Therefore, combinations involving these drugs should be avoided in pregnancy.
- Protease inhibitors (PIs) have been studied extensively in pregnancy and are therefore the third preferred drug in the regimen. Atazanavir-ritonavir and darunavir-ritonavir are the two most common protease inhibitors used during pregnancy. There is conflicting data regarding their association with preterm delivery, so women at high risk for preterm delivery are advised not to use protease inhibitors. Some protease inhibitors have been linked to hyperglycemia but it is unclear whether they add to the risk of developing gestational diabetes. Some protease inhibitors have been known to cause hyperbilirubinemia and nausea, so these side effects should be closely monitored.
- Integrase inhibitors (II) are generally the third drug in the regimen when protease inhibitors are unusable. They rapidly reduce viral load and for this reason, they are often used in women diagnosed with HIV at the end of pregnancy. Raltegravir is the most commonly used II.
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs), the most popular being efavirenz and nevirapine, can be used during pregnancy. However, there is significant toxicity associated with its use, making it a less desirable option.
- Efavirenz (Sustiva brand name, and Atripla combination drug component) is classified as a category D drug by the US Food and Drug Administration showing there are risks associated with its use during pregnancy. In a study analyzing drug use in pregnant women, 2.3% of births were associated with birth defects. However, a systematic review of the safety of efavirenz use in humans during the first trimester found no increase in birth defects among women taking the drug. Given the potential for uncertain risks, the US. DHHS recommends not to take efavirenz in the first trimester of pregnancy or in women who may be pregnant. They instead recommend a PI-based regimen with either lopinavir or atazanavir. However, to simplify the regimen and provide uniform recommendations for people infected with HIV during pregnancy, WHO continues to recommend efavirenz as a first-line agent for HIV-positive women. Women who use efavirenz before pregnancy can continue with the drug because it is more dangerous to stop or change drugs during pregnancy because this can lead to improper control of viral load.
- Nevirapine (the trade name Viramune) increases the risk of serious liver damage in women with CD4 counts greater than 250 . It is generally avoided in pregnant women. Women who take nevirapine safely before pregnancy can continue treatment because nevirapine-associated liver damage has not been seen in women who previously used the drug.
Nutritional supplements
Vitamin A plays a role in the immune system and is a low-cost intervention that has been suggested to help prevent mother-to-child transmission of HIV. A Cochrane review summarizes evidence from five trials conducted in Malawi, South Africa, Tanzania and Zimbabwe between 1995 and 2005, in which no participants received antiretroviral therapy. They found that providing vitamin A supplementation to pregnant women or women after they delivered a baby may have little or no effect on mother-to-child transmission of HIV. Intervention has largely been replaced by antiretroviral therapy.
Labor & amp; Shipping
Women should continue their ART regimen through labor. In addition to the three-drug regimen described above, infusion (IV) zidovudine should be given if the mother's viral load is & gt; 1,000 copies/mL or if unknown. This will help reduce the risk of HIV transmission during labor.
Viral load helps determine the safest type of delivery for both mother and baby. In cases where low viral load (& lt; 1000), transmission risk is low and vaginal delivery is possible. Caesarean section, on the other hand, is generally performed at 38 weeks gestation in the following situations:
- High viral load (& gt; 1000 copies/mL) or unknown at the time of delivery
- Mothers are not receiving ART during pregnancy
- Mom worries about exposing her child to infected blood and genital secretions during labor
If, before she takes a cesarean section, a woman drinks water and she gives birth, a cesarean section may not reduce the risk of transmitting the infection significantly. In these circumstances, if there are no other medical reasons for continuing cesarean section, vaginal delivery is possible and probably safest for both mother and baby.
Women coming to hospitals with unknown HIV status should be tested for HIV immediately. If the initial screening test is positive, the mother should start immediately on infusion AZT and the infant should receive prophylactic ART after birth. Confirmation HIV tests should also be done temporarily. If the test is positive, treatment should be continued with antiretroviral therapy. If the result is negative, the medication can be stopped.
Breastfeeding
Women can transmit HIV to their children through breast milk. For this reason, breastfeeding is not recommended among HIV positive women. In a study conducted in South Africa, 14.1% of children born to HIV-infected mothers were infected within 6 weeks of breastfeeding and 19.5% were infected by 6 months of age. A study in Malawi found that the risk of HIV transmission through breastfeeding was 7% in children who breastfed for one year and 10% in children who were breastfed for two years. The risk of HIV infection appears to be highest in the early months of breast-feeding and HIV-infected mothers should avoid full breastfeeding where possible.
In developed countries where clean water and formula milk are accessible and available, HIV-positive women should not breast-feed. They should use a formula to reduce the risk of HIV transmission to children. Even if the mother is on ART, she should avoid breastfeeding because HIV can still be transmitted through breast milk. Some women choose to use donor milk (breast milk donated from HIV uninfected mothers) rather than infant formula so that their children can receive the health benefits of breast milk, the most important being immune enhancement.
In underdeveloped countries where clean water and formula milk are not available, breastfeeding is recommended to provide children with adequate food and nutrition. The benefits of food outweigh the risks of HIV transmission, malnutrition, and other infections so breastfeeding is acceptable.
Other considerations during pregnancy
Pregnant women with HIV may still receive inactivated trivalent influenza vaccines and tetanus, diphtheria and pertussis (Tdap) vaccinations during pregnancy.
Many HIV positive patients also have other health conditions known as comorbidities. Hepatitis B, hepatitis C, tuberculosis and injecting drug use are some of the most common comorbidities associated with HIV. Women who screen for HIV positive should also be tested for this condition so that they can be treated or controlled adequately during pregnancy. Comorbidities may have serious adverse effects on mothers and children during pregnancy, so it is important to identify them early in pregnancy.
Postnatal care
Infants born to HIV-positive mothers should receive a 6-week course of zidovudine (AZT). Medication should begin within the first 6 to 12 hours of life. Infants should be tested for HIV at 14 to 21 days, at 1 to 2 months of age, and again at 4 to 6 months of age. Normal antibody-based tests are unreliable in infants due to the transmission of maternal antibodies. Qualitative DNA PCR DNA testing is recommended because it will detect pro-viral HIV DNA because HIV RNA can be suppressed by ART. To ensure an HIV-negative baby, there must be two negative test results. Since zidovudine has been known to cause or aggravate anemia, infant blood counts should be checked routinely during AZT therapy.
To reduce the risk of pneumonia (Pneumocystis jirovecii pneumonia), all infants born to HIV-positive mothers should receive trimethoprim/sulfamethoxazole at 4-6 weeks of age.
Although the risk is very low, HIV can also be transmitted to infants through foods previously chewed (chewed) by HIV-infected mothers or caregivers. To be safe, babies should not be fed chewed foods.
References
World Health Organization. (2013). SEXUAL SEXUAL INFECTION (STI). Retrieved from http://apps.who.int/iris/bitstream/10665/82207/1/WHO_RHR_13.02_eng.pdf
External links
- aidsinfo.nih.gov
This article incorporates public domain material from a US Government website or document.
Source of the article : Wikipedia
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