HIV and Pregnancy- AVERT article


Can HIV be transmitted from a mother to her baby?

If a pregnant woman is infected with HIV, she can transmit the virus to her baby during pregnancy, labour and delivery, or breastfeeding. Without treatment, around 15-30 percent of babies born to HIV-infected women will become infected with HIV during pregnancy and delivery. A further 5-20 percent will become infected through breastfeeding.1

Modern drugs are highly effective at preventing mother-to-child transmission of HIV. When combined with other interventions, including formula feeding, a complete course of treatment can cut the risk of transmission to below 2 percent. Even where resources are limited, a single dose of medicine given to mother and baby can cut the risk in half.

A woman who knows that she or her partner is HIV positive before she becomes pregnant can find out about interventions that may be able to protect herself, her partner or her baby from becoming infected with HIV. Doctors will be able to advise which interventions are best suited to her situation, and whether she should adjust any treatment she is already receiving if she is HIV positive.

Protection at conception

There are a number of interventions that can reduce the risk of HIV transmission between a couple when attempting to conceive a child. If a couple decide they want to conceive a child through unprotected sex, they should first seek advice on how to limit the risk to each other and to their baby. It is worth noting that someone is less likely to transmit HIV if they are receiving effective antiretroviral treatment, and also if neither they nor their partner has any othersexually transmitted infections.

If the woman is HIV positive and the man is HIV negative

An HIV positive woman and an HIV negative man can conceive without HIV transmission occurring by using artificial insemination (the process by which sperm is placed into a female’s genital tract using artificial means rather than by natural sexual intercourse). This simple technique provides total protection for the man, but does nothing to reduce the risk of HIV transmission to the baby.

If the man is HIV positive and the woman is HIV negative

Sperm washing is a process used to prevent HIV transmission from an HIV positive man to his partner during conception. Sperm washing involves separating sperm cells from seminal fluid, testing these cells for HIV, then inserting the cells into the woman’s womb (intrauterine insemination), or directly into the egg (in vitro fertilisation or intracytoplasmic sperm injection). Sperm washing is a very effective way to reduce the risk of HIV transmission during conception, but it is not widely available and can be difficult to access, even in well resourced countries. Alternatives to sperm washing have been researched, such as the method of using pre-exposure prophylaxis and timed intercourse when the HIV-positive male partner is taking antiretroviral drugs.2

If both man and woman are HIV positive

When both partners are HIV positive, it might still be sensible for them not to engage in frequent unprotected sex, because there might be a small risk of one re-infecting the other with a different strain of HIV.

Protection during pregnancy, labour and breastfeeding

The rest of this page is written from the point of view of a woman who knows she is HIV positive and pregnant.

What drugs should I take and when should I take them?

The drugs that can reduce the risk of HIV transmission from a mother to her baby are called antiretroviral (ARV) drugs. ARVs are the drugs that are taken by people living with HIV to prevent them from becoming ill.

The most important time for an HIV positive pregnant woman to take ARVs to prevent her baby becoming infected is during labour. Depending on your particular circumstances it may be suggested that you take ARVs at other times as well.

Deciding exactly which ARVs to take and when to take them can be quite difficult, because there is a need to balance a number of different things, including:

  1. Your health as an HIV positive pregnant woman
  2. Reducing the risk of HIV being passed from you to your baby
  3. The possibility of developing ARV side effects
  4. The possibility of drugs causing harm to your baby.

There may also be a difference between which drugs you would ideally take and which ones it is actually possible for you to take, as there is considerable variation worldwide in the cost of ARVs and their availability.

How do I know if I need treatment for my own health as an HIV positive woman?

There are two tests, the CD4 test and the viral load test, that can help you and your doctor decide whether you need treatment for your own HIV infection. The CD4 test tells you how much HIV has weakened your immune system. The viral load test tells you how much HIV is in your blood. A pregnant HIV positive woman with a low viral load is less likely to have an HIV positive baby than a woman with a high viral load. Viral load tests may not be available to all women because of the cost.

If you have a high CD4 count (exactly how high depends on your circumstances and which country you are in), this means that you still have a strong immune system. Your health care provider will probably suggest that you do not start taking drugs for your own HIV infection but will probably advise that you start taking drugs to prevent HIV transmission to your baby.

I don’t need treatment for my own HIV infection. Which ARVs should I take to prevent my baby being infected?

The choice of drugs you take will depend on a number of factors, including the country you are living in, which drugs are available in the area, and your own personal circumstances. While new WHO guidelines for PMTCT were released in 2010, it is yet to be seen whether these recommendations will be widely adopted. Until then, most women might be able to access recommended drug regimens from the 2006 guidelines which are described below.

If available, you should take longer drug regimens starting earlier in pregnancy (for example, starting 28 weeks into pregnancy), rather than shorter regimens (for example, starting at 36 weeks of pregnancy). However, it will often be recommended that you delay starting treatment until after your first trimester (the first three months of pregnancy). If the drug Zidovudine (also known as AZT or ZDV) is available it will often be suggested that you take it, starting from 28 weeks of pregnancy (or as soon as possible thereafter). AZT is usually taken two or three times daily.

During labour, if available, it will be recommended that you take a combination of ARVs. Combinations are more effective at lowering a woman’s viral load than single-drug regimens and so will be more effective in preventing transmission from mother-to-child. The World Health Organization (WHO) recommend taking AZT and lamivudine (3TC) as well as a single-dose of nevirapine during childbirth/delivery.

Finally you will probably be given ARVs to take for a few weeks after the birth. WHO recommend taking AZT and 3TC for seven days after the birth. Taking this dual combination reduces the chance of developing resistance to the single-dose of nevirapine.

WHO recommend giving the infant a single-dose of nevirapine immediately after the birth and AZT for one week. The nevirapine can be taken up to 72 hours after childbirth, but ideally as soon as possible.

The decision whether or not to stop taking the ARVs after the prescribed regimen has finished depends upon your personal circumstances. Any decision should be made with your health care provider and should be based upon certain situations, such as CD4 count and clinical symptoms. If stopping the drugs, it is important that you stop them in a way that limits the amount of time there is just one drug in your body, as this will reduce the chances of developing drug resistance.

I do need treatment for my own HIV infection. Which ARVs should I take to prevent my baby being infected, as well as to protect my own health?

If you need ARVs for your own HIV infection, treatment should be started as soon as possible, even if you are still in the first trimester. Most ARVs do not have any major affects on the fetus during this time, although some drugs are more of a concern than others.3 It is therefore very important to discuss your treatment options with your health care provider.

There are many different ARV drug combinations and those that are recommended are likely to be similar to those recommended if you were not pregnant. AZT will probably be part of the recommended regimen, due to its proven effect to reduce the risk of HIV transmission from mother to child. WHO guidelines recommend an initial regimen of AZT + 3TC + nevirapine (NVP).

If there are very few drugs available where you live then you can take a single dose of NVP during labour to reduce the chances of your baby becoming infected, but you must not take it on its own at any other time. If you do you will increase the chances of drug resistance, and it will not work if you want to take it during labour to protect your baby. has more about single dose nevirapine in our mother to child transmission page.

I’m already on antiretroviral drugs and now I’ve found out I’m pregnant – what should I do?

If you have found out you are pregnant and are already taking ARVs you should seek advice from your health care provider as soon as possible. It is not recommended that you stop taking your ARVs or change your therapy before seeing your doctor. If you stop treatment suddenly during pregnancy then your viral load may increase, which can increase the risk of your baby becoming infected with HIV. Stopping treatment also needs to be done carefully in order to prevent the development of resistance.

If your pregnancy is identified during the first trimester, the benefits and potential risks of taking treatment for both you and the infant will need to be considered. In particular, efavirenz is not recommended during the first trimester and can be substituted for NVP.

If your pregnancy is identified after the first trimester then it will usually be recommended that you continue with your ARV treatment.

If I suddenly go into labour and I am not taking any ARVs, are there any drugs I can take to help my baby?

There are several ARVs you can take during labour. The question of which ones to take and how long to take them for will depend upon drug availability.

WHO recommended in 2006 a combination of single-dose nevirapine + AZT + 3TC for the woman during labour and delivery, followed by a seven-day tail of AZT and 3TC. Immediately after delivery, it is recommended that the baby is given a single-dose of nevirapine, followed by a course of AZT for four weeks.

If drug availability is very limited, a single-dose of nevirapine for the mother during labour and a single-dose of nevirapine for the baby will probably be recommended as a minimum.

Is it really safe to take HIV drugs during pregnancy?

Pregnant women are often advised not to take any medications during their pregnancy, so it can seem strange that HIV positive women are advised to take ARVs when pregnant. However, thousands of women have taken HIV drugs during pregnancy without it causing harm to their babies, and it has resulted in many babies being born HIV negative who might otherwise have been infected.

It cannot be guaranteed that HIV drugs taken when a woman is pregnant will not harm her baby. If a woman is not already taking ARVs then as explained above she will probably be advised to wait until after the first trimester before starting treatment. There are specific recommendations and guidelines (see the sources at the end of the page), about certain antiretroviral drugs and which ones are more of a concern than others. The Antiretroviral Pregnancy Registry monitors the birth defects induced by ARVs.

What else can I do to prevent my baby becoming infected with HIV?

Is a pre labour caesarean section (PLCS) better than a natural vaginal delivery?

A caesarean section is an operation used to deliver a baby through its mother’s abdominal wall. When a mother is HIV positive it is done to protect the baby from direct contact with her blood and other bodily fluids.

Research suggests that with many women now taking ARV combination therapy during pregnancy, having a caesarean isn’t a significant factor in preventing the transmission of HIV from mother to baby. Unless you are ill with HIV or have a detectable viral load it usually won’t be recommended by your health care provider, as having a caesarean does itself have some risks for the woman. One exception to this is if you are taking AZT on its own, when a PLCS may still be recommended.

Should I breastfeed?

HIV is found in breast milk, and if you breastfeed there is a significant chance of passing HIV to your baby. So if you have access to safe breast milk substitutes (formula) then you are advised to not breastfeed.4

If you live in a country where safe water isn’t available, the risk of life-threatening conditions from formula feeding may be higher than the risk from breastfeeding. Formula can also be too expensive to use regularly in some countries. If you are in this situation it is better to feed your baby breast milk alone.

Mixed feeding is when a baby is fed with breast milk and other liquids such as formula, glucose water, gripe water or traditional medicine. It is now thought that there is a higher risk of a baby becoming HIV positive from mixed feeding than exclusive formula feeding alone or breastfeeding. Mixed feeding may damage the lining of the baby’s stomach and intestines making it easier for HIV in breast milk to infect the baby but when taking ARVs to prevent mother to child transmission, the risk is reduced and is currently recommended by the WHO.blank

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