Wednesday, November 21, 2012


Well, as you suspected, your pregnancy test is positive. Congratulations! Pregnancy can be an exciting time, and a really wonderful experience.
Of course, now that you’re expecting, you probably have lots of questions, some of which relate to how your HIV-positive status will impact your pregnancy and your baby.
The goal in every pregnancy is to keep both mom and baby healthy, and I’m happy to say that this is a goal that’s well within your reach. Just because you have HIV does not mean you can’t have a happy, healthy pregnancy, and a happy, healthy baby. Basically, the same things that keep you healthy will keep your baby healthy. Risks of transmitting the virus to your baby decrease as your own viral load decreases.
So let’s talk about what you need to do to keep both you and your little one healthy. Many women wonder how HIV can be transmitted to the baby. HIV can be transmitted during pregnancy, during labor and delivery, or by breastfeeding. We’ll talk about what you can do during pregnancy, during labor, and after your baby is born to decrease the chances of transmitting the virus.
It can be very helpful to have an obstetrician with experience treating HIV-positive women, in part because the decisions regarding whether to use certain “invasive” genetic tests can be difficult. Many pregnant women undergo a variety of screening tests
Because these tests are invasive, they involve at least a theoretical increased risk of transmitting the virus to the baby. To date, there have been 159 reported invasive procedures on HIV-positive moms with no transmission of HIV to the baby. In all cases, women were on HAART (highly active antiretroviral therapy) with undetectable viral loads and though no transmissions of HIV have occurred, a small increase in risk can’t be ruled out. Therefore, any HIV-positive woman undergoing any invasive procedure should be on HAART and have an undetectable viral load at the time of the procedure.
Some experts consider CVS too risky to offer to their HIV-positive patients and recommend limiting invasive procedures to amniocentesis only, but existing data on transmission risk associated with these procedures are limited. Invasive testing procedures should be discussed thoroughly with your OB and between you and your partner. Your OB (or genetic counselor) will discuss the pros and cons of invasive testing with you. But ultimately, whether to test (or not to test) is a personal decision.
Keeping your viral load low is important during pregnancy to reduce the risk of transmission. Regardless of what is recommended based solely on your CD4+ and VL levels, you may want to start taking HIV meds as soon as you learn you are pregnant. Yes, there are guidelines from the Department of Health and Human Services (DHHS) that recommend when to start treatment based on CD4+ and VL, but there are groups of people for which treatment is recommended no matter what. Pregnant women are one of those groups. We are trying to prevent your baby from becoming infected.
Earlier and sustained control of HIV viral replication is associated with decreased residual risk of transmission and favors initiating HAART drugs as early in pregnancy as possible for all women.” In other words, starting HAART (highly active antiretroviral therapy) drugs early to control the viral load as much as possible decreased the chances that the virus would be transmitted to the baby. In fact, we know that having an undetectable viral load substantially lowers the risk of transmission of HIV to the fetus and lessens the need for consideration of cesarean delivery (C-section). That’s why it is always suggested that my patients start HAART immediately after learning about their pregnancy.
So, if you are not currently taking HIV medications (whether you are treatment-naive or have taken them in the past), tell your HIV specialist about what medications you’ve taken in the past and provide all laboratory tests (genotypes, phenotypes, HLA B*5701) and be honest about any adherence issues that you’ve had in the past. Also talk about any tolerability issues and drug allergies you have had with any old regimen(s).
As soon as you learn that you’re pregnant, you should contact your HIV specialist to discuss your options for medication and to review what you’re currently taking to make sure your medications are safe for the baby. If you are taking HIV medication, like HAART, your clinician will likely continue your treatment.
So there is a lot to consider here, and you should have discussions with both your obstetrician and HIV specialist to help determine what is best for you and your baby. Assuming that you have an HIV specialist, your specialist will refer you to an obstetrician who has experience with HIV-positive mothers. If you don’t have a specialist, now might be a good time to seek one out.
Again, the goal is to limit the baby’s exposure to the virus. So it’s probably not surprising that your options for labor and delivery depend upon your viral load (another important reason to take your HIV meds as prescribed). It is also recommended for women who did not receive HIV medication during pregnancy. In these situations, ACOG recommends a scheduled C-section at 38 weeks’ gestation in order to decrease the likelihood of onset of labor or rupture of membranes before delivery.
To help prevent transmission, your baby will be given liquid AZT immediately after birth and this will be continued (by you at home) twice a day for six weeks, HIV can also be transmitted to a baby through food that was pre-chewed by an HIV-positive mother (or caretaker). To be completely safe, babies should not be fed pre-chewed food.
There are two types of tests that will be performed on your baby to find out if he or she has HIV. The first is the HIV antibody test. All babies born to a mom with HIV will test positive for the first several months of their lives. This does not mean that they have HIV. Rather, it means that the baby has simply been exposed to his/her mother’s HIV. The second test, PCR testing, looks for the virus and not just the antibodies to the virus. It is this test that can tell whether the baby has HIV or not. This test will be done during the first few days of his/her life.
The PCR test will be repeated several times on your baby. To know for certain that your baby is not infected with HIV, the baby must not be breastfeeding and must have two negative PCR tests, the first at one month (or older) and the second at four months (or older). Many experts confirm the HIV-negative status of the baby with an HIV antibody test at age 12 to 18 months. To be diagnosed with HIV, a baby must have two positive PCR tests.
Again, just because you have HIV does not mean you can’t have a healthy pregnancy and baby. In fact, obstetrician from Regency Medical Centre confirmed to serve an HIV-positive patient who followed her regimen and had a healthy pregnancy, and an uncomplicated vaginal birth. She and her husband welcomed a healthy HIV-negative baby into the world. It can be done, and it is done by lots of women.

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