HIV/AIDS During Pregnancy

The HIV virus and the AIDS disease has struck terror into the hearts of people since its outbreak in the 1980s. Pregnancy, already a challenge in itself becomes further complicated when the mother is infected with the virus. However, medical advances have not only made HIV pregnancy safe but have also reduced the chances of the baby contracting the virus.

What Is HIV/AIDS?

HIV (Human immunodeficiency virus) is an infamous virus known to cause AIDS (Acquired immunodeficiency syndrome). As the name suggests, it’s a virus that gradually breaks down the immune system making you prone to opportunistic infections and various other complications. One point of confusion amongst people is that they believe HIV and AIDS are similar when that is not the case. A person may be HIV infected for years without having AIDS. You are HIV positive from the moment the virus is detected in your blood. But only after the symptoms set in and the immune system breaks down the person is said to have AIDS. It usually takes several years to reach the last stage of HIV – that is AIDS.

How Does HIV Spread During Pregnancy?

Unlike viral flu, HIV does not spread by contact, breathing the same air or through food and water. HIV can be spread in ways similar to the Hepatitis B virus:

1. Sexual intercourse (most common)
2. Blood / blood-contaminated products / other body fluid / organ transplantation
3. Vertical transmission: From mother to child via the placenta or breast milk

The chance of transmission depends on the viral load, that is the number of viruses per ml of the blood. Also, during pregnancy, high levels of the hormone progesterone increase the level of virus receptors. This aids the entry of virus and increases the chance of transmission.

Symptoms of HIV & AIDS

Once the HIV virus gets into the blood, it begins to multiply and infect a specific type of white blood cell called the T lymphocytes. It usually takes 3 to 6 weeks for the symptoms to set in which last for less than 10 days. These symptoms include:

• Fever and night sweats
• Fatigue
• Rash
• Headache
• Swelling in neck, armpits, groin
• Sore throat
• Body ache, joint pains
• Nausea, vomiting, and diarrhoea

Thus, the symptoms of an HIV positive pregnancy are not different from flu during pregnancy. Later, after the symptoms are gone, the virus continues to multiply and attack the immune system silently, until it breaks down. It may take as long as 10 years for this to happen.

AIDS in pregnant women has symptoms depending on how low the immunity is. Your doctor would check the immune status by asking for the CD4 count. CD4 is a type of blood cell that helps the body’s immune system and a low count of it is the strong indication of AIDS. Various problems that AIDS can cause are:

1. Infections: As the CD4 count falls, more serious and deadly infections set in, tuberculosis being the most common.

2. Cancer: Various forms of cancer are common in AIDS. Women may suffer from genital tumours which may be cancerous.

3. STDs: Other sexually transmitted infections in addition to HIV like syphilis may add to the problem for the mother and child.

Factors Which Increase the Risks Associated With Transmission of HIV

Some of the issues that increase the likelihood of the spreading of AIDS include:

• Viral load: The most important factor that determines the transmission is the viral load in the mother. For example, the rate of transmission is 1% if the load of the HIV virus in the maternal blood is less than 400 copies/mL, but this increases drastically to more than 30% when maternal viral levels are more than 100,000 copies / mL. But viral load in the blood may differ from that in the genital secretions. So, the transmission through genital secretions may occur even before it is detectable in maternal blood in some cases.

• Pre-term delivery: There is a four-fold increased risk of a baby being exposed to the HIV virus in pre-term delivery.

• Breastfeeding: If you are breastfeeding your baby, there is a 30-40% chance that your baby will be infected by the virus.

• Mode of transmission: The mode by which the mother acquired HIV also determines the rate of transmission. If it was a sexually transmitted infection, the rate of vertical transmission to the baby is higher.

• Initiation of anti-HIV treatment: The period of gestation at which the anti-HIV treatment was initiated to the mother affects the transmission to the baby.

• Medical intervention: Some medical procedures done during delivery like forceps application, artificial rupture of membranes, and invasive fetal monitoring increase the risk of transmitting the virus from the mother to the baby.

Should Pregnant Women Get Tested for HIV?

It is mandatory for all pregnant women to undergo screening HIV test in some countries (opt-in approach) whereas in others the mother has the right to refuse after being counselled and informed about HIV (opt-out approach). Pregnant women who are injectable drug users, sex workers along with those who have HIV-infected sexual partners, multiple sexual partners or are diagnosed with an STD are recommended to repeat the test in the last trimester.

How Is HIV Testing Done?

HIV screening test is performed using an ELISA test (enzyme-linked immunoassay)

If the test comes positive, it is confirmed with either a Western blot or immunofluorescence assay (IFA). A rapid detection using PCR can also be done.

Effects of HIV on the Mother’s and Baby’s Health

If the CD4 count is maintained high and the viral load is kept low it does not grossly affect the outcome of your pregnancy. All said and done, it is multifactorial and can manifest with variations. The real problems arise when HIV turns into full-blown AIDS.

• Effect on mother’s health:

The mother is at a high risk of various infections that can be life-threatening. Various cancers, both benign and malignant are common in AIDS which may affect the course of pregnancy. Some pregnancy-related complications like pre-term labour, hypertension, diabetes are common in HIV positive cases.

• Effect on baby’s health:

An HIV positive mother can also infect the baby. The infections acquired by the mother can be transmitted to the baby which can be life-threatening. It can potentially affect all the bodily functions of the baby.

Accuracy of HIV Test Result

HIV tests are highly accurate. The ELISA test has a sensitivity of more than 99.5%. This means that in more than 99.5 of 100 tests performed will pick up HIV if it is there. There is less than a 0.5% chance of missing HIV by ELISA. For further confirmation, the IFA and western blot have very high specificity. This means these tests very rarely will be a false-positive.

How Is HIV Transmitted From the Mother to the Child During Pregnancy?

The transmission that occurs from mother to child in the perinatal period is called vertical transmission. This transmission can be via the placenta and via breast milk.

Transmission in early pregnancy:

Normally placenta forms a barrier between the mother’s and the baby’s blood. This forms a protective barrier for HIV transmission. But in very early pregnancy, while the fertilised egg is attaching to the uterus and the placenta is being formed, there is a chance of contact between their blood. Thus, HIV transmission can occur even before pregnancy is detected.

HIV and labour: Transmission during late pregnancy

There is a high chance of transmission of HIV from mother to baby during the time of onset of labour. When the water bag ruptures, during the delivery process, and during placenta separation.

Transmission during breastfeeding:

It has been proven that the HIV virus is present in breast milk and babies who are breastfed are at an increased risk of being HIV positive.

Does Caesarean Delivery Reduce the Risk of Mother to Child Transmission of HIV?

There is only a 50% chance of the baby contracting the HIV virus if they are delivered via caesarean birth. In addition, the risk of transmission reduces by 87% when a caesarean section is combined with anti-HIV treatment.

Will My Baby Need Treatment After Birth?

Yes. Babies born to HIV positive mothers are given HIV treatment for 4-6 weeks after birth. This reduces the HIV multiplication if any, and protects the child.

Preventing Mother to Child Transmission of HIV & Its Challenges

Antiretroviral therapy (ART) is the anti-HIV medicines used as a remedial measure. ART plays a major role in preventing mother to child transmission of HIV. Being HIV positive and pregnant has a lot of challenges such as social stigma and non-medical hospital staff being hesitant to approach the patient. Many women suffer from anxiety in revealing that they have HIV may make them outcasts.

Here are some preventive measures which you need to keep in mind if you are trying to get pregnant:

• Planning pregnancy: If you are planning to become pregnant, get yourself tested for HIV. If you test positive start right away with the antiretroviral therapy. This will not only reduce the viral load in the mother but also reduce the risk of transmission.
• Post-exposure prophylaxis: If you are HIV negative but your partner has been diagnosed with HIV, you need to take the ART to prevent yourself from getting HIV.
• Plan delivery: Planned c-section at 38 weeks is the preferred mode of delivery to minimise the risk of transmission of HIV.
• Post-exposure prophylaxis for the baby: After birth, your baby will be given ART medicines to kill HIV virus if any has entered the baby’s blood from the mother.
• Avoid breastfeeding: If good alternatives are available without compromising the baby’s nutrition, it is advised to avoid breastfeeding the baby.

With all these precautions taken the risk of transmission may be reduced to less than 1%.

Complications of HIV

HIV infection can add to the pregnancy-associated complications. These include:

1. Pre-term delivery
2. Low birth weight
3. Growth restriction of the baby
4. High blood pressure
5. Gestational diabetes
6. HIV Treatment

HIV treatment consists of antiretroviral therapy (ART). It consists of various regimens with different combinations of medicines either to be taken orally or injected. The regimen will be decided by your doctor based on the viral load, the CD4 count, previous treatments taken, the drug resistance pattern and the week of gestation. If you were on HIV treatment before conceiving, the treatment is usually continued.

Should Pregnant Women With HIV Take HIV Medicines?

The treatment of women infected with HIV should not be stopped because of pregnancy. Certain modifications in the regimen may be necessary as it may affect the development of the baby but the treatment needs to be continued throughout the pregnancy.

How Does HIV Affect Labor & Birth

Usually, a C-section is advised at 38 weeks, but there is a high rate of preterm delivery and the associated complications in HIV infected mothers.

Some mothers may be given an injection of Zidovudine during labour which reduces the chance of transmission of HIV to the baby.

Certain procedures like artificial rupture of membranes to induce labour, using fetal scalp electrodes for fetal heart rate monitoring and delivery with vacuum or forceps are generally avoided given the potential of increased risk of transmission.

What If the Baby Tests HIV Positive?

All babies who test positive for HIV need to be given ART medicines. If the baby cannot tolerate oral medicines, then injectable medicines are given. It is a life-long treatment for the child. As with adults, there are different treatment regimens available for babies who test positive for HIV.

Can an HIV Positive Mother Breastfeed?

Breastfeeding is generally not recommended for mothers who are HIV positive as it significantly increases the risk of HIV transmission to the baby.

HIV Positive & Prenatal Care

As a protocol in hospitals, you will be treated like any other mother. Your healthcare professional will maintain professional secrecy. From counselling to appropriate treatment the healthcare professionals will take the necessary prenatal care required. As a mother, the prenatal care responsibility that you have is to provide the doctor with all the information without maintaining any secrets.

You can live a normal life with HIV. This includes becoming pregnant as well. Though there are complications involved, there is nothing stopping HIV positive women from getting pregnant. But you need to understand that despite all the precautions you may deliver HIV positive baby. As HIV reduces your immunity take extra precautions to keep yourself away from infections. Good hygiene, healthy food and exercise are key to a healthy pregnancy with HIV. With the advancements in HIV treatment, many babies born to HIV positive mothers test HIV negative.

Also Read: Infections During Pregnancy