Reducing the risk of HIV transmission to the baby
Antenatal testing for HIV and early diagnosis and taking HIV treatment can help to reduce the risk of passing HIV to your baby.
There are two ways in which HIV treatment reduces the risk of you passing on HIV to your baby.
Firstly, HIV treatment reduces your viral load – the level of virus in your blood – so that your baby is exposed to less of the virus while in the womb and during birth. The aim of HIV treatment is to get your viral load below 50 copies/ml. This is often referred to as an undetectable viral load. Having an undetectable viral load means that HIV is still in your body, but at a much lower level.
Second, some anti-HIV drugs can also cross the placenta and enter your baby’s body where they can prevent the virus from taking hold. This is also why newborn babies are given a short course of anti-HIV drugs (this is called PEP, or post-exposure prophylaxis) after they have been born, if their mother is HIV-positive.
A number of factors may make it more likely that you will pass on HIV to your baby. These include:
During pregnancy
- Being ill because of HIV.
- Having a high HIV viral load or a low CD4 cell count.
- Having a sexually transmitted infection. You should have a sexual health screen early in your pregnancy and another one at 28 weeks.
- Having used recreational drugs, particularly injected drugs.
During delivery
- Your waters breaking four or more hours before delivery.
- Having an untreated sexually transmitted infection when you give birth.
- If you have a vaginal delivery (rather than a caesarean delivery) when you have a detectable viral load.
- If you have a difficult delivery; for example, forceps need to be used.
- If you have a premature baby.
After delivery
- To avoid passing HIV to your baby, it is safest to formula feed because breast milk can contain virus. Help should be available with getting formula milk and feeding equipment. Ask your healthcare team about this and how to protect your confidentiality if a friend or family member asks why you are not breastfeeding.
Treatment during pregnancy
If you are in good health
If you have a good CD4 cell count and low viral load, and are not ill because of HIV infection, the UK guidelines recommend that you start taking AZT (zidovudine, Retrovir) in the final three months (the third trimester) of your pregnancy. You will also need to have an intravenous injection of AZT during delivery and to have a caesarean, rather than vaginal, delivery.
Another option is to take a short course of combination antiretroviral therapy during the last few months of pregnancy in order to get your viral load down to below 50 copies/ml. You may then have the option of a planned vaginal delivery.
Talk to your doctor or specialist midwife about your options so you can make an informed decision about the best mode of delivery for you.
If you are in good health at the beginning of your pregnancy, but become ill because of HIV later in your pregnancy and have to start taking antiretroviral therapy, then the aim should be to reduce your viral load to an undetectable level. You should continue to take HIV treatment after your baby has been delivered.
Your baby will receive treatment with AZT syrup for four weeks after it is born.
If you have a high viral load
If HIV has significantly damaged your immune system, or if you have a high viral load, then you are advised to start HIV treatment. This will include two drugs from the nucleoside reverse transcriptase inhibitor class (NRTIs), ideally AZT and 3TC (lamivudine, Epivir), and either the non-nucleoside reverse transcriptase inhibitor (NNRTI) nevirapine (Viramune) or a protease inhibitor. You can find out more about the classes of drugs in NAM’s Anti-HIV drugs booklet in this information series.
The higher your viral load, the earlier during your pregnancy you will need to start taking treatment. If you still have a detectable viral load before giving birth, then you need to have a caesarean delivery, but if your viral load is below 50 copies/ml and there are no apparent problems with the pregnancy, you may be able to have a planned vaginal birth.
Your baby will receive treatment with AZT syrup for four weeks after it is born.
If you are already on treatment
If you become pregnant whilst taking effective HIV treatment, you are recommended to continue taking this treatment.
Your baby will receive treatment with antiretroviral syrup (usually AZT) for four weeks after it is born.
If you become pregnant whilst on HIV treatment and your anti-HIV drugs are not suppressing your viral load to an undetectable level, then you should have a resistance test to determine your best drug options and then change to these drugs. The aim should be to get your viral load undetectable by the time you deliver.
Your baby will receive treatment with an antiretroviral syrup (to which your virus is not resistant) for four weeks after it is born.
If you are diagnosed late in pregnancy
If you are diagnosed with HIV late in your pregnancy (32 weeks or later), then you will need to start taking HIV treatment immediately. A blood test will be used to determine any resistance you have to anti-HIV drugs. The most common drugs used in this situation are AZT, 3TC and nevirapine, as these drugs are able to rapidly pass over the placenta into your baby’s body.
Your baby will usually receive treatment with the same combination of three drugs (AZT, 3TC, and nevirapine) as syrups for four weeks after it is born.
If you are diagnosed during delivery or afterwards
If you are diagnosed HIV-positive just before or during delivery, you will usually be given a dose of AZT by injection and oral doses of 3TC and nevirapine. Your baby will also need to take a triple combination of anti-HIV drugs for four weeks.
If you are diagnosed just after delivery, you won’t receive any anti-HIV drugs, but your baby will need to take a triple combination of anti-HIV drugs for four weeks.
Safety of treatment to prevent mother-to-baby transmission
There’s some evidence of a slightly increased risk of having a premature, or low birth-weight baby if the mother takes anti-HIV drugs during pregnancy, particularly if the mother takes a protease inhibitor. However, this is a controversial issue and other evidence suggests that taking anti-HIV drugs does not cause premature delivery.
A baby’s development is most likely to be affected by any drugs you take during the first 14 weeks of pregnancy. AZT is the only drug that has been tested specifically for use during pregnancy and found to be safe. Only two drugs – ddI (didanosine, Videx, Videx EC) and efavirenz (Sustiva) – have caused any concerns about a possible link with birth defects. However, research now suggests that none of the anti-HIV drugs are linked to an increased rate of birth defects.
The anomaly scan pregnant women normally have between weeks 18 and 20 of a pregnancy can check for possible physical problems in your baby’s development.
HIV and childbirth
The risk of your baby contracting HIV is reduced if you have a planned caesarean section. This is usually scheduled to take place for the 38th week of pregnancy. If your labour begins early, the surgical delivery will be performed sooner. Taking anti-HIV drugs during a caesarean delivery reduces the risk of you passing on HIV to your baby to very low levels. However, as with all surgery, caesarean delivery carries some risks. These risks should be explained to you before you agree (give consent) to the procedure.
You are strongly recommended to have a caesarean delivery if you have a detectable viral load, or if the only anti-HIV drug you took during pregnancy was AZT.
If your viral load has been consistently below 50 copies/ml, then you may be able to have an actively managed vaginal birth. This means that your doctors and midwife will monitor you carefully and make sure that your labour doesn’t last too long to reduce the risk of you passing on HIV to your baby.
Breastfeeding and HIV
Breastfeeding carries a risk of passing on HIV to your baby. The risk of transmission can be as high as one in eight, depending on your own state of health, how long breastfeeding continues, and whether the baby receives any food or water in addition to breast milk (this seems to make the transmission of HIV more likely).
In the UK and other countries where safe alternatives to breastfeeding are available, you are advised to feed your baby with formula milk from birth.
Detailed advice and support on how to do this is available from your healthcare team, as well as from support organisations. Ask your healthcare team or support organisation if you have difficulty meeting the cost of formula and the equipment needed.
For help and support on explaining to others why you are not breastfeeding when you want to keep your HIV status confidential, talk to other mothers with HIV about how they have successfully done this. Your healthcare team or support organisation can also help you with this.
See the British HIV Association guidelines on infant feeding for more information (www.bhiva.org).
Health care during your pregnancy
You are likely to be looked after by a multidisciplinary antenatal team during your pregnancy. Your care will still be offered at your HIV clinic, but as well as your HIV doctor and clinic staff, you are likely to see an obstetrician, a specialist midwife and a paediatrician. Other people you may see, depending on your wishes or needs, could include a peer support worker, community midwife, a counsellor, a psychologist, a social worker or a patient advocate.
Good antenatal care will help support you in reducing the risk of transmission of HIV as well as staying well during your pregnancy. Your healthcare team and support organisation can help you adhere to any treatment you need to take and answer questions you may have about your health and that of your baby. They can provide support and advice on your eligibility for free NHS treatment, as well as help with any other issues you might have, such as housing, finances or alcohol and recreational drug use.
Effectiveness of treatment in women
To find out more about specific types of HIV treatment, or antiretroviral therapy, see the NAM bookletAnti-HIV drugs in this series.
Women tend to get higher levels of some anti-HIV drugs in their blood than men. This is probably because men tend to weigh more than women. Having higher levels of a drug in your blood can mean that there's more of it available to fight HIV but, on the downside, it could mean that you might be more likely to experience side-effects.
Gender differences in side-effects may also be due to an interaction between HIV medications and female hormones.
Starting treatment
You may feel anxious about starting and adhering to your treatment. Discuss your concerns with your doctor and talk with other people who are already on HIV treatment. You will find out about how they successfully manage to keep taking the treatment regularly and what strategies they use to minimise any side-effects.
Adhering to your treatment
HIV treatment involves powerful drugs which work very well when your adherence is good. Adherence is a term used to refer to taking your drugs on the right day and at the right time, every day, as prescribed by your doctor.
Taking your treatments every day, as prescribed by your doctor, and not missing any doses, is one of the most important aspects of managing your HIV. If you are finding it difficult to take your treatment in the right way, talk to one of your HIV healthcare team as soon as possible. You could also talk to other women who are successfully managing their treatment at home and work. Maintaining a healthy lifestyle and having a good support network are other important means of staying well.
You can find out more about taking your HIV treatment properly in NAM’s booklet Adherence & resistance.
Side-effects of HIV treatment in women
Like any drugs, HIV treatment can cause side-effects. It is important to always talk to your doctor or nurse and let them know whenever you experience any new symptoms that may be due to side-effects, as they may be able to help you deal with them.
Most often, side-effects occur soon after a drug is started and lessen over time. Common side-effects include nausea, diarrhoea, headaches and feeling tired. Your healthcare team should talk to you about what side-effects you can expect and how to minimise their impact. Some drugs can cause a rash on the skin and it’s very important that you report rashes to your doctor, in case it is a sign of an allergic reaction.
To find out more about possible side-effects of HIV treatment generally, see the NAM booklet Side-effects in this series. Because of possible side-effects, women prescribed certain drugs may need closer clinical and laboratory monitoring in order to avoid potential problems. If you are concerned about any aspect of your treatment, always talk to your doctor, pharmacist, support worker or treatment advocate about this and they will help you to make the treatment choices that suit you best. The side-effects listed below, while not common, are thought to affect women more often than men.
Lipodystrophy: This is where fat accumulates in certain parts of the body, resulting in visible body shape changes. There may also be a reduction in fat in other areas of the body, known as lipoatrophy. Some studies suggest that lipodystrophy may affect women more than men, and that women are more likely to get unusual fat accumulation in certain parts of the body such as the breasts without the fat loss that often occurs in men.
Body changes can be distressing. If this happens, discuss it with your doctor and talk to other HIV-positive women who have had, and dealt with, similar experiences.
Changes in the levels of fat and sugars in the blood are also part of lipodystrophy. These can result in high blood glucose, high blood pressure and increased cholesterol and triglycerides. Regular monitoring of these is important as high levels are often associated with an increased risk of diabetes, heart disease and stroke.
If you are taking HRT (hormone replacement therapy, for women undergoing the menopause), and HIV treatment, ensure that you discuss the risk factors with your doctor, as HRT can also increase the risk of stroke.
Lactic acidosis: Lactic acidosis is an increased lactate level in the blood (hyperlactatemia). Lactate, or lactic acid, is a by-product of processing sugar in the body, especially during exercise, which causes muscle problems and liver damage. Lactic acidosis is a serious side-effect of treatment with older drugs from the NRTI class, chiefly d4T, but is very rare with the medicines from this group most commonly used in the UK, such as abacavir (Ziagen), FTC (emtricitabine, Emtriva), 3TC (lamivudine, Epivir) and tenofovir (Viread). Women seem to be more at risk of developing lactic acidosis than men. You can find out more about the symptoms of lactic acidosis in NAM’s Side-effects booklet. If you think you are experiencing any of them, it is important to tell your doctor as soon as possible.
Menstrual changes: Menstrual changes, including irregular, heavy and painful periods, are associated with some protease inhibitors. Talk to your doctor if you have concerns.
Breast screening
If you are over 50, you should be called for a breast screen (mammogram) every three years to check for the presence of breast abnormalities and breast cancer. You should also do regular self-examinations of your breasts. Ask for advice on how to do this from your healthcare team.
Human papillomavirus vaccine
If you are aged 13 to 26, it is recommended that you have the preventive quadrivalent HPV vaccine, unless your CD4 count is less than 200 or you have been previously exposed to HPV through sexual contact (a blood test can detect this).
Protection from varicella
Varicella zoster (VZV) is the virus that causes chickenpox and shingles. If you have never had chickenpox or shingles and you are exposed to either illness, you should consult your doctor immediately. If you also test seronegative for the varicella zoster virus (that is, you don’t have any antibodies to VZV in your blood) you should be given post-exposure prophylaxis with a drug called VariZIG within 96 hours.
If you test seronegative to VZV and your CD4 count is over 200, you could consider being vaccinated against the virus.
HIV and hepatitis co-infection
Hepatitis is a viral infection that affects your liver. Some types – hepatitis B and C – can cause long-term, serious health problems. Many people with HIV also have hepatitis B or C, known as co-infection. However, treatments for both types of hepatitis are available.
Treatment decisions for co-infection are made on an individual basis. The British HIV Association(BHIVA) recommends that the infection that is the greatest threat to your health should be treated first. You can find out more about HIV and hepatitis co-infection and treatment in NAM’s booklet HIV & hepatitis.
Ribavirin is an important drug in the treatment of hepatitis C. It must not be taken if you are pregnant as it is possible that this could lead to the loss of the baby, or the birth of a baby with deformities or other problems.
Ribavirin can enter the sperm. It is important that sperm from a man on ribavirin treatment is prevented from starting a pregnancy and that ribavirin is not allowed to reach an unborn child. Couples who have been treated with ribavirin should avoid pregnancy (and unprotected sex) for at least six months after the completion of treatment.
Mental health, emotional wellbeing and depression
Women with HIV often report experiencing feelings of isolation, depression, loss of sleep and anxiety on diagnosis. An HIV diagnosis is a life-changing event and these responses are not unexpected. Sometimes support from others with HIV, friends and family is sufficient to help you find a way forward, but you may also want to see a counsellor or therapist at some point, or need some medication to help with depression or other mental health problems.
And don't forget your own health needs even if you have responsibilities for looking after others.
Your HIV clinic or GP may be able to refer you to specialist services. You can contact a support organisation providing these services.
You can also find out more about emotional and mental health, and get more information on how to access different mental health services and treatments, in NAM’s booklet HIV, mental health and emotional wellbeing.
Disclosure
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Disclosing your HIV status can be frightening. It is important to take time to think about the advantages and disadvantages of doing so. You may fear you will experience rejection or exclusion, or even violence, if you reveal your HIV status to your partner, family, friends or employer.
Many people tell their partners, family, friends and colleagues about being HIV-positive and receive acceptance and support. However, some may become upset or react badly. In some cases, women have been subjected to domestic violence when disclosing to their partners.
There is generally no requirement to tell your employer if you are HIV-positive (unless your work would carry a risk of transmission), or your child’s school if your child is HIV-positive.
If you have any concerns about disclosure, support or treatment, advocacy organisations provide specialist services and support to women and families living with HIV. Speak to a support organisation about managing your disclosure, especially to children so they can have a safe, trusted person to talk with about their concerns.
Confidentiality
Your medical records are confidential and nobody can see them without your consent. If you are worried about telling somebody that you have HIV, or are concerned about somebody finding out, ensure that you make your concerns clear to the hospital, your GP or any care and support agencies you are in contact with. Your HIV clinic or support organisation can also help and act as an advocate: this means speaking on your behalf with health or social care professionals if you are not comfortable doing so yourself.
Prosecution for transmission of HIV
Some people have been prosecuted for passing on HIV. People have been accused of ‘intentional’ transmission of HIV (deliberately setting out to infect someone) and ‘reckless’ transmission. Someone can be considered reckless if they know they can pass on HIV during sex and still go on to take that risk.
If you have unprotected sex with a partner without telling them of your HIV status and, as a result, your partner then becomes HIV-positive, they could try to prosecute you for reckless transmission of HIV. It is not against the law just to have ‘unsafe’ sex – a prosecution can only happen if your partner did not know you had HIV, you didn’t have safe sex and your partner becomes infected as a result.
If someone makes a complaint against you, it is important you seek expert legal advice and personal support as soon as possible.
Scientifically, it is very difficult to prove who may have infected whom, but being investigated, going to court, and having your personal and sexual history made public can be devastating.
If you are thinking about starting a case against someone, it is also a good idea to discuss your situation with your doctor and support network. The process can be long and traumatic.
HIV and your children
Breastfeeding carries a risk of transmitting HIV and the current advice in the UK is to formula feed. If you breastfeed, the law might consider this a danger to your baby. So far no case has been successfully brought against a mother. It may be considered a child protection issue, and your local authority social services department may become involved in considering your child’s welfare.
If you have children who were born before your HIV diagnosis, it is recommended that they are tested for HIV, whatever their age. If you are anxious about doing this, ask for the help of your support organisation and healthcare team.
Source - http://www.aidsmap.com
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