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Guide to HIV, Pregnancy and Women's Health: HIV Care and Treatment During Pregnancy

By Polly Clayden

March 2013

What Is Prenatal Care?

Prenatal care is also called antenatal care. This covers all the extra care that you receive during your pregnancy in preparation for your baby's birth.

Prenatal care is not only about medicine and about tests. It includes counselling and providing information like this guide. It also includes advice on your general health such as taking exercise and stopping smoking.

As with all aspects of HIV care, it is very important that members of your healthcare team have had specialist experience with HIV positive women. This includes your obstetrician, midwife, paediatrician and other support staff.

It is also important that the people responsible for providing your care understand the most recent developments in preventing vertical transmission and in HIV treatment.


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Does Every HIV Positive Woman Need to Use Treatment in Pregnancy?

Everyone with a CD4 count of 350 or less needs to start ART. As do some people with higher CD4 counts but HIV-related health reasons (like an opportunistic infection or hepatitis coinfection).

Some HIV positive women with CD4 counts above 350 might have started ART to protect their negative partners.

So some women will already be on ART when they become pregnant.

Some women with higher CD4 counts will receive a short course of ART during pregnancy, to prevent vertical transmission.

Treatment recommendations for pregnant women can be slightly different than those for other HIV positive adults.

Usually it is best once you start HIV treatment, to continue for the rest of your life. In some circumstances in pregnancy women use treatment just until delivery, then they stop.


What If I Am Already Using HIV Treatment When I Become Pregnant?

Many women decide to have a baby when they are already on ART. This speaks volumes about the tremendous advances made with these drugs.

Women feel better. They are healthier. They are thinking about long-term relationships. They are thinking about a future and possibly a family.

It is now increasingly common for women who conceive while they are on treatment to continue on treatment throughout their pregnancy.

Studies have not shown any increased risk to the mother or baby from using continuous treatment throughout the pregnancy.

BHIVA guidelines recommend that women conceiving on an effective ART regimen should continue this.


What If I Need Treatment for My Own HIV?

All HIV positive people with CD4 counts of 350 and below should be on ART, including pregnant women. Women needing ART for their own health should start ART as soon as possible.

If you are diagnosed early on in your pregnancy, you might delay starting treatment until the end of the first trimester.

This is the first 12 to 14 weeks from your last missed period. You might also want to delay treatment over this period if you already know your HIV status but have not yet started treatment.

There are two main reasons for delaying treatment.

The first is that the baby's main organs develop in the first 12 weeks in the womb. This is called organogenesis. During this time a baby might be vulnerable to negative effects from any medicines, including antiretroviral drugs. Although for antiretrovirals there is increasing data to show that these medicines are generally quite safe.

A second reason to delay treatment is that some women will experience nausea or "morning sickness" in the early stage of pregnancy. This is very normal.

Symptoms of morning sickness are very similar to the nausea that can occur when starting ART. This can also make adherence harder. If you have morning sickness you might delay starting treatment until after the first trimester.

All women should have started ART by 24 weeks of pregnancy. This will mean you have the have time to get your viral load to undetectable. That way you have the least risk of transmission and you will be able to have a vaginal birth.

If you are diagnosed at 28 weeks or after you will need to start ART straight away.

If your CD4 count is very low and your viral load high and/or you have an opportunistic infection, or you are diagnosed late in pregnancy, ART should not be delayed.


What Drugs Will I Start With If I'm in This Situation?

ART usually consists of a two drugs called nucleoside or nucleotide reverse-transcriptase inhibitors (NRTI) as a backbone, plus a third one, which is either a non-nucleoside reverse-transcriptase inhibitor (NNRTI) or a boosted protease inhibitor (PI).

i-Base has a guide, "Introduction to Combination Therapy" that you could use to find out more about antiretrovirals:

The AZT and 3TC (Combivir) NRTI backbone has been used the most (so has the most information about it) in pregnancy, so some doctors prefer to recommend this. But tenofovir and FTC (Truvada), and ABC and 3TC (Kivexa) are now more widely used in pregnancy, and are also good options.

A European study (including data from the UK) looked at use of non-AZT ART in pregnant women between 2009 and 2009. About 60 percent of women received this in the study. There were no greater rates of vertical transmission, undetectable viral load at delivery or abnormalities in the babies for women who received non-AZT ART.

The third drug for women in this situation will usually be an NNRTI (efavirenz or nevirapine) or a ritonavir boosted PI.

Nevirapine has been used widely in pregnancy but there is a caution against starting nevirapine-based ART for women with CD4 counts above 250. This is because of a risk of liver (hepatic) toxicity. It is only recommended for women with lower CD4 counts.

Efavirenz was not previously recommended in pregnancy because the drug caused neural tube (the developing brain) damage to a foetus in a single animal study. Efavirenz has now been used and studied a lot in pregnancy and does not appear to be more risky than any other antiretroviral in humans. BHIVA and several other guidelines recommend it in pregnancy.

Recommended boosted PIs are lopinavir (boosted lopinavir is called Kaletra and in one pill) and atazanavir.


What If I Do Not Need Treatment for My Own HIV?

ART is not generally recommended at much higher than 350 CD4 unless you have HIV-related health problems or want to use treatment to protect your negative partner.

If you do not need treatment for you own health you will still need to take antiretrovirals to prevent transmission to the baby. You will also need to start by 24 weeks of pregnancy or as soon as possible after that.

The recommended NRTI backbones are the same as for women who need treatment for their own HIV.

The third drug will probably be a boosted PI. A PI has an advantage over an NNRTI if you plan to stop ART straight after your baby is born. Your body processes PIs relatively quickly. You can stop all the drugs in your ART combination with a low risk of resistance.

For women with a viral load of less than 100,000 copies/mL before treatment a third NRTI, abacavir, is sometimes recommended, instead of a PI.

Occasionally, a woman with a very low viral load (less than 10,000 copies/mL), not on treatment, might choose to use a short course of AZT alone (monotherapy) with a planned Caesarean section. This strategy is being used less and less in the UK. Only about 2 percent of HIV positive women chose this way of preventing transmission to their baby in 2009 to 2010.

A very small proportion of HIV positive people, known as elite controllers, have undetectable viral loads less than 50 copies/mL for years without treatment. This is very rare, only about 1-in-300 HIV positive people are elite controllers. Pregnant elite controllers could either use AZT monotherapy or a 3-drug ART regimen including abacavir, 3TC and AZT.

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.


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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.

Tips to reduce nausea, and help with adherence are here.

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.


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