Slide 1

There are many issues that relate to HIV and pregnancy, but this talk will mainly focus on issues of preventing mother-to-child transmission, particularly the issue of breastfeeding.

Slide 3

Counseling before pregnancy is important. It should focus on the effects of HIV on pregnancy, health of the mother, long-term health of the mother and child, how perinatal transmission occurs and how to prevent it with medicines.

Slide 4

Pregnancy does not the effects that HIV has on the body. 

Slide 5

There may be association between HIV and:

• Spontaneous abortion

• Stillbirth

• Maternal mortality

• Newborn mortality

• Low birth weight

• Preterm delivery

• Amnionitis

Slide 7

Most HIV transmission (70%) occurs at the time of delivery, but a substantial amount (30%) occurs antenatally. A significant contributor to transmission is breastfeeding.

In 1998, 10% of all new HIV infections were in children, almost all mother-to-child transmissions (90%) were in Africa.

These statistics are given to emphasize that this is a serious worldwide problem, and a particular problem in Africa.

The percentages given are of all cases of HIV transmission, not of all pregnancies. It suggests to us that we should be focusing our efforts on interventions at the time of delivery and with breastfeeding.

In sub-Saharan Africa mortality rates for children under age 5 are now 1/3-2/3 higher than they would be in the absence of AIDS, contributing to the progressive reduction in life expectancy.

Slide 9

There are many interventions that may help reduce mother-to-child transmission, including obstetric interventions and newborn feeding. Antenatal care and antiretroviral agents play a significant role in reducing transmission.

Slide 10

Discuss the advantages and disadvantages of HIV testing during pregnancy. There are many disadvantages to consider. A woman who is HIV positive, may be abandoned by her husband and family.

Slide 11

When providing antenatal care, there is no need to increase the number of visits unless symptoms or complications develop. If available, antiretroviral agents given during antenatal care can benefit both the mother and child.

Good nutrition is important. Anemia is an independent predictor of progression and death in HIV-infected individuals. Vitamin A deficiency has also been associated with increased risk of mother-to-child transmission.

Slide 12

Several antiretroviral regimens exist that have been shown to reduce mother-to-child transmission in clinical trials. Short-course ZDV and nevirapine are most affordable and are associated with good patient compliance.

Long course ZDV, given from 14 weeks of pregnancy orally, IV during labor and to the non-breastfed newborn for 6 weeks showed significant decrease in transmission (22.6% in placebo group vs. 7.6% in ZDV group). (Sperling RS et al. 1996. Maternal viral load, ZDV treatment, and the risk of transmission of HIV type 1 from mother to infant. N Engl J Med 335 (22): 1621-1629.) There were no ill effects on the fetus except for mild and temporary anemia.

A short-course ZDV trial in Thailand compared placebo group with group given one tablet of ZDV 300 mg twice a day from 36 weeks gestation and every 3 hours from onset of labor until delivery. Newborns were not breastfed. This regimen reduced risk of transmission by 50% at a cost of $50 per patient. (Shaffer N et al. 1999. Short-course ZDV for perinatal HIV-1 transmission in Bangkok, Thailand: A randomized controlled trial. Lancet 353: 773-780.)

Combination of ZDV and lamivudine given in mostly breastfeeding population given at 36 weeks and onset of labor and for 1 week postpartum to newborn and mother reduced transmission by about 50% compared to placebo. (Gray G. 2000. The PETRA study: Early and late efficacy of three short ZDV/3TC combinations regimens to prevent mother-to-child transmission of HIV-1. XIII International AIDS Conference, Durban, South Africa.)

Nevirapine. A single 200 mg dose at the onset of labor and a single 2 mg/kg dose to the newborn at 48-72 hours resulted in a 47% decrease in transmission compared to ZDV during labor and for 1 week to newborn. The cost is approximately $4 to the patient. 

Slide 14

Advantages of nevirapine include:

• Inexpensive

• Oral regimen

• Simple, easy to administer

• Can give directly observed treatment

Disadvantages

• Unknown efficacy if mother has nevirapine-resistant virus

Slide 15

Advantages:

• Oral regimen

• Compliance easier than 6 weeks of ZDV alone as newborn regimen is only 1 week

Disadvantages:

• Potential toxicity of multiple drug exposure

Slide 16

Advantages:

• Has been standard recommendation based on clinical trial results 

Disadvantages:

• Requires IV administration, availability of ZDV IV formulation

• Compliance with 6 week newborn regimen

Slide 17

Advantages:

• Potential benefit if maternal virus is resistant to either nevirapine or ZDV

• Synergistic inhibition of HIV replication with combination in vitro

Disadvantages:

• Requires IV administration, availability of ZDV intravenous formulation

• Compliance with 6 week newborn regimen

• Unknown efficacy and limited toxicity data

Slide 18

During delivery, any procedures that either increase the chance of the mother bleeding or may cause breaks in the skin of the fetus through which there may be direct contact with the mother’s blood or vaginal secretions will increase the risk of transmission of HIV from mother to child.

Avoid amniotomy, fetal scalp electrode/sampling, operative vaginal delivery and episiotomy/vaginal trauma. These procedures can increase risk of transmission.

Slide 19

Pregnancy may increase the risk of HIV shedding in maternal cervico-vaginal secretions.

In a recent meta-analysis from 15 prospective studies, the risk of mother-to-child transmission increased 2% each hour after membranes have been ruptured.
Cesarean section before the onset of labor or ruptured membranes can significantly reduce the risk of transmission from mother to child, especially if antiretroviral agents are not available. Cesarean sections however, have increased the risk of morbidity and possible mortality for the mother, particularly in low-resource settings because of anesthesia risks, blood loss, pain and increased recovery time. 

Slide 20

Universal precautions to protect yourself are very important.

Slide 22

Wash maternal blood and secretions off the newborn as soon as possible, particularly off the face. Beware of hypothermia!

If available, give antiretroviral agents to the newborn to reduce the risk of HIV transmission.

Slide 23

Breastfeeding is associated with a 14% risk of HIV transmission to newborns, yet provides nutrition for the newborn and an inexpensive method of feeding and contraception.

Formula feeding also poses risks to the newborn, such as diarrhea from contamination of formula with unclean water or malnutrition from formula being too dilute.

Factors associated with breastfeeding and mother-to-child transmission:

• Cracked nipples/breast abscess or mastitis

• Newborn oral thrush

• Duration of breastfeeding

• Exclusively breastfeeding versus breastfeeding and formula feeding.