Slide 2
The objectives of this presentation are to review the
significance of HIV in pregnancy and the magnitude of this issue; to
review HIV-related issues to be considered prior to pregnancy; to discuss
the effects of pregnancy on HIV infection and the effects of HIV on
pregnancy course and outcome; to discuss mother-to-child transmission or
MTCT of HIV and its prevention; and, to discuss the care of the pregnant
woman with HIV.
Slide 3
Why is it important to talk about HIV and pregnancy? HIV
may have an adverse effect on pregnancy course or outcome and more than
90% of pediatric HIV/AIDS cases are caused by MTCT. In addition, most
children born to HIV-positive mothers in limited-resource settings will be
orphaned when one or both parents die. These children also are at
increased risk of early death, even if they are not themselves infected.
Because the most common route of HIV transmission is through sexual
contact, women who are not HIV-positive may place themselves at risk for
HIV infection while trying to get pregnant. The majority of women with HIV
throughout the world are young and of childbearing potential.
Slide 4
The seroprevalence of HIV-1 among pregnant women varies
widely by geographic location, but in several African countries, HIV
affects at least 20 to 30% of pregnant women.
Slide 5
This graph shows the HIV prevalence rate in urban and
rural areas of Africa among young women either in their teens or early
twenties. These same women are beginning or in the midst of their
childbearing years.
Slide 6
Before addressing the issues and concerns related to
caring for pregnant women with HIV, some things about the subject of HIV
and pregnancy should be addressed. Recent studies in Africa, as well as in
developed countries, suggest that HIV has an adverse effect on fertility.
This effect may be the result of tubal damage secondary to a prior
sexually transmitted infection or pelvic inflammatory disease or it may be
a direct result of HIV. This decrease in fertility is seen even after
adjustment for age, lactation, illness and other STIs. Furthermore,
according to a study from Uganda, likelihood of pregnancy is lower in
women with symptomatic or later stage HIV or in those who are co-infected
with syphilis. There is also some evidence that pregnancy loss, including
spontaneous abortion or miscarriage, stillbirth and perinatal death, may
be more common with HIV infection, particularly in developing countries.
Finally, it has been shown that individuals with more advanced HIV disease
or AIDS have decreased sexual activity. It is important to include this
information in education and counseling about HIV for both individuals and
the community in general. It may be an additional motivation for people to
use safe sex and drug-use practices.
Slide 7
Because women of childbearing age are at significant
risk of contracting HIV, they are an appropriate group to target for
voluntary HIV counseling and testing or VCT. As part of VCT they should
receive information about HIV and pregnancy and should be evaluated for
personal risk characteristics and behaviors that may put them at increased
likelihood of being or becoming HIV-positive. VCT provides an opportunity
to counsel about practices to prevent HIV transmission or acquisition.
Whether in the context of VCT or other health information or services, all
women of childbearing age should be educated and counseled about their
contraceptive options with the goal of preventing unintended pregnancies
and promoting safer sexual activities. The use of male or female condoms
for dual protection against both pregnancy and transmission of HIV and
other STIs should be emphasized. If the person chooses other, more
effective forms of contraception, encourage her to use condoms along with
the chosen method. It is important to find ways to involve the male
partners specifically and men in general in VCT, because this has been
shown to increase the effectiveness of counseling and testing in changing
behaviors.
Slide 8
One of the primary goals of VCT in antenatal care
settings is to educate pregnant women about HIV. Accurate information can
help reduce myths and misperceptions about HIV and reduce stigma. Another
important goal is to help women who are HIV-negative remain HIV-negative
by preventing HIV acquisition during pregnancy. All women in antenatal
care settings, including those who refuse or do not have access to
testing, should receive counseling about safer sexual practices, treatment
for drug abuse or safe drug use behaviors, when appropriate, and
prevention and early treatment of STIs. The goals of VCT for women who are
found to be HIV-positive during pregnancy include stabilizing and
maintaining maternal health, preventing HIV transmission to uninfected
sexual partners, reducing the risk of MTCT, and planning for the future,
especially care for the children if the mother becomes ill or dies.
Slide 9
When counseling HIV-positive women who are pregnant or
are considering pregnancy, remember to discuss several special issues with
them. It is also appropriate to discuss these issues with women who are of
unknown HIV status, but live in areas of high HIV prevalence and with
women who have HIV risk factors, but do not have access to or have refused
HIV testing. Review the potential impact of HIV on fertility. Discuss the
impact of HIV on pregnancy course and outcome and the impact of pregnancy
on HIV disease; the risk and timing of MTCT and interventions that are
available to prevent MTCT; and the use of antiretrovirals and other drugs
during pregnancy, if these are available.
Slide 10
In addition, discuss newborn feeding options and their
risks in terms of newborn health and HIV transmission; issues relating to
disclosure of HIV status and issues of stigma and potential violence with
a diagnosis of HIV; the need to use male or female condoms throughout
pregnancy; and long-term health concerns of the mothers and future care
for both potentially infected and uninfected children; and finally, the
option to terminate the pregnancy, if this is legally available.
Slide 11
There is no evidence that pregnancy worsens HIV
infection or hastens its progression. The CD4 cell count, which is used to
monitor immune function in HIV-positive individuals, declines during
pregnancy in both HIV-positive and -negative women because of increased
plasma volume during pregnancy. However, the CD4 percentage remains
relatively stable during pregnancy in HIV-positive women. The HIV-RNA
level or viral load also remain stable during pregnancy in the absence of
antiretroviral treatment. Recent studies have also shown no significant
differences in HIV progression or survival between pregnant and
nonpregnant women with HIV infection.
Slide 12
On the other hand, there are some adverse pregnancy
outcomes that appear to be associated with HIV infection, including
spontaneous abortion or miscarriage, intrauterine growth restriction, low
birth weight and preterm delivery, especially with more advanced disease.
In addition, stillbirth and perinatal and newborn mortality may be
increased in developing country settings.
Slide 13
These adverse outcomes, however, are overshadowed by the
problem of MTCT of HIV, which is responsible for more than 90% of
pediatric HIV infections globally. During the year 2000, approximately
600,000 new infections occurred in children, with more than 80% occurring
in Sub-Saharan Africa.
Slide 14
This table shows the timing and baseline rate of MTCT in
three different groups of women: those not breastfeeding at all, those
breastfeeding through the first 6 months of the newborn’s life, and
those breastfeeding through 18-24 months of life. The risk is lowest in
nonbreastfeeding women, with a total risk of 15 to 30% transmission, the
majority of which occurs around the time of childbirth. It appears that
although the risk of breast milk transmission is greatest in the earliest
months, risk continues for the duration of breastfeeding. It is also
important to note that the majority of newborns born to HIV-positive
mothers will not become infected themselves.
Slide 15
The next two slides list factors that have been shown to
impact the risk of MTCT of HIV. Perhaps the most important factor is
plasma viral load. There is a direct correlation between HIV-RNA level and
risk of MTCT, although there is no level below which transmission never
occurs and no level above which transmission always occurs. Viral load in
the genital tract, which appears to be a separate viral compartment, is an
independent predictor of MTCT. Risk of transmission is increased when
women have low CD4 counts or have either advanced disease or acute
infections. This is probably due to high viral load. Unprotected sex with
multiple partners, smoking cigarettes, other substance abuse and vitamin A
deficiency have also been associated with increased MTCT.
Slide 16
Sexually transmitted infections and other co-infections
increase risk, possibly by increasing HIV viral load in the genital tract.
ARV agents, as we will discuss later, lower the risk of MTCT. Preterm
childbirth, placental disruption, as may occur with abruption or
chorioamnionitis, and invasive fetal monitoring may increase risk of
transmission. A recent meta-analysis of more than 4500 mother-newborn
pairs found that duration of membrane rupture has a dramatic effect on
MTCT, with an approximate 2% increase in risk per each hour of rupture.
Mode of childbirth also affects risk of transmission. We will discuss this
in more detail later. Finally, as has already been noted, timing and
duration of breastfeeding and other practices related to breastfeeding
affect risk of MTCT.
Slide 17
What can be done to prevent MTCT in low-resource
settings? There are simple behavioral practices that should be emphasized
to all HIV-positive and at risk women. These practices include consistent
condom use during pregnancy and in the postpartum period and avoidance of
the use of drugs, alcohol and cigarettes. In addition, screening and
treating identified STIs and other co-infections and treating substance
abuse, when possible, may decrease risk. Although vitamin A deficiency was
associated with an increased risk of MTCT in a cross-sectional study, a
recent clinical trial of vitamin A supplementation did not demonstrate a
decrease in risk with supplementation.
Slide 18
Minimizing viral exposure which should decrease risk of
MTCT can be done in several ways. Healthcare providers should avoid
artificially rupturing membranes and should consider shortening the
duration of membrane rupture when possible. Transfusion of blood or blood
products, particularly in areas where the blood supply is not safe, should
be given only when necessary in the presence of life-threatening
complications. The precise role of vaginal cleansing or bathing of the
newborn remains unclear. A clinical trial conducted in Malawi using
vaginal cleansing with a dilute solution of chlorhexidine did not result
in a decreased rate of MTCT, except in a subgroup who had ruptured
membranes more than 4 hours before delivery. Another similar clinical
trial in Kenya also found no overall effect on MTCT from vaginal lavage
with dilute chlorhexidine. However, in this study, the data did suggest
that lavage before membrane rupture might be associated with a reduction
in MTCT, especially with higher concentrations of chlorhexidine. ARV
agents lower viral load both in the plasma and the genital tract and this
is thought to be the primary way in which they reduce the risk of MTCT.
Treatment of STIs is also associated with reductions in viral load,
especially in the genital tract, and may decrease the risk of MTCT by this
mechanism.
Slide 19
There are now several short oral antiretroviral regimens
that have been found to be effective in lowering the risk of MTCT in
limited-resource settings and in both breastfeeding and non-breastfeeding
populations. In Thailand, zidovudine or ZDV, also known as AZT, reduced
transmission by 50% in a non-breastfeeding cohort when started at 36 weeks
of gestation and continued orally through labor. Both ZDV alone or in
combination with lamivudine or 3TC, have been found to decrease
transmission risk in breastfeeding populations, although with somewhat
lower effectiveness than in nonbreastfeeding cohorts. More recently, a
clinical trial in Uganda that gave a single dose of nevirapine or NVP, to
the mother at the onset of labor and a single dose to the newborn within
48 to 72 hours after childbirth reported a decrease in MTCT by almost 50%
at a 4 month follow-up.
Slide 20
Antenatal care for the HIV-positive woman should aim to
stabilize and maintain her health and should include the basic care
recommended for all pregnant women. The resources to prevent or treat
common opportunistic infections are often available, even in areas with
limited resources. Both HIV and pregnancy are demanding metabolically and
can result in nutritional deficiencies for the mother. Nutritional
deficiencies, in turn, put her at risk for adverse pregnancy outcomes and
may hasten HIV progression. Therefore, it is important to counsel
HIV-positive pregnant women about adequate intake of calories and
micronutrients to prevent problems. Screening for STIs should be performed
when possible and early treatment of STIs and other co-infections should
be administered. The woman should be monitored for signs and symptoms of
progressive HIV or AIDS. Each antenatal care visit is an opportunity to
reinforce the importance of safer sexual practices.
Slide 21
Invasive diagnostic procedures, such as amniocentesis or
external cephalic version, should be avoided during pregnancy, because
these may increase risk of MTCT. Antiretroviral agents should be used, if
available, to decrease risk of transmission. Decisions about whether they
should be administered in the antenatal period or only during labor and
childbirth will depend on the availability of specific agents and stage of
maternal disease. The woman and her family should be helped to plan for
the future, including decisions about newborn feeding, family planning,
and the long-term care needs for both mother and children. It is very
important to give the woman emotional support during her pregnancy because
this is a time of unique stress due to concerns about her health, the
health of her unborn child and confidentiality and disclosure.
Slide 22
During the labor and childbirth period, avoid invasive
procedures that may increase the risk of transmission of HIV between
mother and child such as artificial rupture of membranes, use of fetal
scalp electrodes and sampling of fetal scalp blood. In general, use of
forceps or vacuum extractor and episiotomy should be avoided, but may be
justified for judiciously shortening the duration of membrane rupture. ARV
agents should be given, if available, according to one of the regimens
that has been effective in lowering risk of transmission. The
considerations about mode of childbirth and the risks and benefits of
cesarean section will be discussed in more detail. It is reasonable to
quickly remove maternal blood and other secretions from the newborn’s
body by thoroughly wiping with a dry cloth, although this has not been
shown to decrease risk of HIV transmission.
Slide 23
Infection prevention practices reduce the risk of HIV
infection, as well as other infections, for the healthcare provider. Hands
should be washed thoroughly before and after each procedure and
examination. Gloves should be worn during vaginal childbirth and cesarean
section and protective eyewear should also be used if available. Using
safe work practices such as not recapping or bending needles, safely
handling instruments and properly disposing of waste materials and
supplies are also important to protect healthcare providers. Finally, all
surgical instruments, gloves to be reused and other reusable items should
be processed after use by decontamination, cleaning and either
sterilization or high-level disinfection.
Slide 24
Cesarean section before the onset of labor and membrane
rupture is associated with a 50-80% decrease in the risk of MTCT compared
to other modes of childbirth. Furthermore, cesarean section provides
additional protection against HIV transmission in women who are either
taking no antiretroviral drugs or are taking zidovudine alone. There is no
evidence, however, of benefit of cesarean section after labor begins or
membranes have ruptured.
Slide 25
There are special concern about performing cesarean
sections in limited-resource settings, however. First, there is an
increased risk of maternal morbidity and possible mortality from peri-operative
infections or from hemorrhage. Because of the amount of blood loss
associated with cesarean section, a safe blood supply needs to be
available when a transfusion is required. Iatrogenic prematurity may
result from attempts to perform cesarean section before the onset of
labor. Antibiotics should also be available to administer for prevention
of postoperative infections prophylactically, as is recommended when
cesarean section is performed. Other limitations in these settings include
availability of anesthetic agents and equipment and human limitations such
as those relating to nursing care and time considerations. Therefore, in
most limited-resource settings, the risks in performing cesarean section
for the purpose of reducing MTCT will likely outweigh potential benefits
and vaginal childbirth will offer the safest form of delivery for both
mother and child.
Slide 26
During the postpartum period, the healthcare provider
should assess maternal healing following childbirth and review newborn
feeding, growth and development. Safer sexual practices should be
reinforced and contraceptive options reviewed and discussed again. The
healthcare provider should refer both mother and newborn for ongoing care.
Slide 27
Breastfeeding should be avoided if there are acceptable,
affordable, sustainable and safe alternatives available. If these
alternatives are not possible, correct breastfeeding techniques should be
taught to minimize trauma to the breast. The woman should be taught to
recognize and seek prompt treatment for mastitis or breast abscess or
other breast lesions, as well as newborn oral lesions, such as thrush.
Exclusive breastfeeding, without addition of other solids or liquids
including water, should be encouraged for up to 6 months followed by rapid
weaning to minimize risk of transmission and to take advantage of the
benefits for the newborn in terms of reduced risk of other infectious
morbidity and mortality.
Slide 28
Unless effective interventions are introduced to prevent
MTCT in women with HIV, to help women with HIV live longer and be
healthier and to prevent new HIV infections in women of childbearing age,
there will be a significant erosion in the advances made in past decades
to reduce newborn mortality in many countries. At current rates of
infection, this graph presents the increase in under-5 child mortality
rates related to AIDS that may be expected by the year 2010 in several
countries with limited resources. These mortality rates not only represent
the deaths of children directly caused by HIV infection, but also the
deaths that occur when children are orphaned when their mothers die of
HIV.
Slide 29
By the end of 1999 it is estimated that more than 13
million children without HIV worldwide had been orphaned by the death from
AIDS of their mother or both parents. More than 12 million of these
orphans live in Sub-Saharan Africa. In addition to their risk for early
death, these children are less likely to receive education, more likely to
go hungry and live in poverty and perhaps more at risk themselves for
becoming HIV-positive later in life.
Slide 30
In summary, HIV infection in pregnant women affects the
life and health of both mother and newborn and has enormous impact on the
health and vitality of developing regions. Prevention of HIV infection in
women in their childbearing years and prevention of unintended pregnancies
in women with HIV are important goals. It is equally important to identify
HIV infection in pregnant women so that effective antenatal, labor and
childbirth, and postpartum care can be given to prolong the life and
health of women and to take advantage of effective interventions to reduce
MTCT of HIV.
