Guide to HIV, Pregnancy and Women's Health: HIV Care and Treatment During Pregnancy
What If I Only Discover I Am HIV Positive Late in Pregnancy?
Diagnosis after 28 weeks of pregnancy, before labour starts, is happening less and less frequently since HIV screening for all pregnant women was introduced in the UK.
But if this happens to you, there is plenty that can be done to help you have a negative baby.
As viral load testing can now be turned around quickly, some women will still be able to have a vaginal birth (if they start ART immediately and get an undetectable viral load in time).
If a woman's viral load is unknown when she starts treatment or above 100,000 copies/mL, a fourth drug, an integrase inhibitor called raltegravir, might be added to the three-drug ART regimen.
Raltegravir drives the viral load down to undetectable levels very quickly.
What About If My HIV Status Is Only Discovered When I Am in Labour?
Even at this late stage there are things that can be done.
A woman in this situation will be given a single dose of nevirapine immediately. There will probably not be time to do a CD4 test but even at higher CD4 counts there are no risks to the mother's liver with a single dose alone. ART of 3TC and AZT in a single pill and raltegravir should also be given straight away.
Both nevirapine and raltegravir cross the placenta very rapidly.
Intravenous (by injection into a vein) AZT throughout labour and delivery might be added as well.
If the mother goes into labour prematurely she might be also given a double dose of tenofovir. This is because preterm babies are not able to absorb medicines very well when they are given them by mouth. Like nevirapine and raltegravir, tenofovir crosses the placenta very quickly.
Can I Carry on Taking ART After a Short Course to Prevent Vertical Transmission?
If you had a CD4 count between 350 and 500 before you started and you have no other reason to continue treatment you could decide to either stop or continue your ART.
If you are doing well, not experiencing unmanageable side effects and are adherent, continuing might be a good choice. If you haven't found taking ART very easy in pregnancy and are not sure if you can be adherent at the moment then it might be better to stop.
You can discuss the advantages and disadvantages with your healthcare team.
If your CD4 was above 500 before you started you will usually stop ART, unless you wish to continue to take it protect your partner or there is a health related reason to carry on.
Are Any Antiretrovirals Not Recommended In Pregnancy?
The liquid formulation of amprenavir, a less commonly used PI, is not recommended in pregnancy (or for children under four). This is because pregnant women and young children are unable to break down one of its components called propylene glycol. The capsule form of amprenavir does not contain propylene glycol.
The NRTI ddI is not recommended in pregnancy. There may be a small increased risk of birth defects with this drug. Also there is a mild possible increase with the PI nelfinavir. These drugs are rarely used in the UK now.
There is also a strong warning to avoid using the NRTIs ddI and d4T together in pregnancy. There have been several reports of deaths in pregnancy in women using both these drugs together.
d4T (stavudine) is no longer recommended in the UK, except as a last resort.
Nevirapine is not recommended for women with higher CD4 counts (above 250).
Should I Expect More Side Effects When I Am Pregnant?
Approximately 80 percent of all pregnant women using ART will experience some sort of side effects with these drugs. This is similar to the percentage of people using HIV treatment who are not pregnant.
Most side effects are minor and include nausea, headache, feeling tired and diarrhoea. Sometimes, but more rarely, they can be very serious.
i-Base have produced a guide "HIV and Your Quality of Life," which includes managing side effects.
One big advantage of being pregnant is the thorough monitoring at regular clinic visits. This will make it easier to discuss any side effects with your doctor.
Some side effects of antiretrovirals are very similar to the changes in your body during pregnancy, such as morning sickness. This can make it harder to tell whether treatment or pregnancy is the cause.
Many antiretrovirals can cause nausea and vomiting.
This is more common when you first begin taking them. If you are pregnant, though, such side effects can present extra problems with morning sickness and adherence.
If your morning sickness is bad your doctor may prescribe anti nausea drugs (antiemetics), which are safe to use in pregnancy.
You may feel more tired than usual.
Again, this is to be expected, especially if you are starting ART and pregnant at the same time. Anaemia (low red blood cells) can cause tiredness. It is a very common side effect of both AZT and pregnancy. A simple blood test checks for this. If you have anaemia you may need to take iron supplements.
All pregnant women are at risk of developing a high blood sugar (hyperglycemia) and diabetes during pregnancy.
Women taking PIs in pregnancy may have a higher risk of this common complication. So, you should be sure to have your glucose levels closely monitored and be screened for diabetes during pregnancy. This is routine for all pregnant women.
Outside of pregnancy, PIs have been associated with increased levels of bilirubin.
While this is usually a measure of the health of your liver this is not always the case as with the PI atazanavir. Here bilirubin levels can be very high but without causing any problems.
Pregnancy may be an additional risk factor for raised levels of lactic acid.
Your liver normally regulates this. Lactic acidosis is a rare but dangerous and potentially fatal side effect of nucleoside analogues.
Using d4T and ddI together in pregnancy appears to be particularly risky for lactic acidosis.
This combination is now not recommended in the UK. Consequently the risk of lactic acidosis is now extremely low.