12 Questions About HIV Treatment and Care in Pregnancy
November 29, 2012
How has the treatment of pregnant women changed with the times, and with our increased understanding of how the virus works? How have the official U.S. HIV treatment guidelines reflected those changes? And, most important, how do those changes translate into the lives and options of pregnant women living with HIV? To get some answers, we sat down with renowned HIV care provider and researcher Monica Gandhi, M.D., M.P.H.. Dr. Gandhi directs the AIDS Consult Service at San Francisco General Hospital and is an HIV and primary care provider in the Women's HIV Program at the University of California, San Francisco. She's also a research investigator with the Women's Interagency HIV Study, a large, multisite prospective cohort.
We drilled down into the newest edition of the official U.S. HIV treatment guidelines for pregnant women living with HIV and discussed some of the most notable changes -- with a healthy helping of wisdom from Dr. Gandhi's extensive experience treating HIV-positive women -- through the lens of some important questions a pregnant woman might likely ask about her treatment.
Whether you're considering getting pregnant or you're already there, it is vital to find a provider you trust, who supports what you're doing. To deepen the conversation about your treatment options, consider sharing the article below with your providers.
Table of Contents
- I'm not on HIV meds yet. Should I start taking them before I start trying to get pregnant?
- If I'm already pregnant, when should I start taking meds?
- Does my viral load need to be undetectable before I start trying to get pregnant?
- Which HIV meds are safe for me to take while I'm pregnant?
- Is Sustiva dangerous to take when I'm pregnant?
- Are there any side effects of certain regimens that might be particularly severe in a pregnant woman? If so, how are they managed?
- How should I handle a switch in HIV med regimens during my pregnancy?
- Should I give birth vaginally or via Cesarean (C-section)?
- Will I need intravenous (IV) HIV treatment during labor and while I'm delivering my baby?
- Is it possible for me to give birth in a birthing center, or even at home, with HIV-trained professionals in attendance?
- What treatment will I be giving my baby, and when? How will I know if the meds are harming my baby?
- Is it safe for women living with HIV to breastfeed their babies?
Short answer: Yes, if you're able to delay conceiving until you feel comfortable with your HIV treatment regimen.
Back in the day (and by "the day," we mean prior to March 27, 2012), there was no mandate for everyone living with HIV to be on antiretroviral therapy. The official guidelines for treating HIV in the U.S. indicated CD4 count cut-offs below which treatment was recommended. Oftentimes providers would suggest that women who were trying to get pregnant not start therapy until the second trimester of their pregnancy because of the chance they'd feel sick during the first.
What has changed in the last year, in both the general treatment guidelines and the guidelines specifically dealing with pregnancy, is that it's now recommended that every HIV-positive person in the United States be on HIV therapy, no matter what. There have been a number of big studies recently that spurred this change -- not the least of which is HPTN 052, which revealed that effective treatment is also good for HIV prevention, to the tune of an up-to-96 percent decrease in the likelihood of transmitting HIV.
So ideally, a woman who is trying to get pregnant and knows she's HIV positive should likely be on HIV meds already; in fact, she should start taking meds as soon as she's diagnosed.
However, just because an official recommendation recently changed does nothing to eliminate the myriad social factors and structural barriers that lead to so few people in this country being on therapy and having their virus under control. Of the 1.1 million people living with HIV in the U.S., only 25 percent have undetectable viral loads, according to the U.S. Centers for Disease Control and Prevention (CDC).We still have far to go in making the optimal conditions described within the guidelines into a reality for all people living with HIV.
The unfortunate state of HIV care in the U.S. won't change overnight, but Gandhi believes it will also never be the same following this recent recommendation that all people with HIV start treatment. One of the best things to do when preparing to conceive, for your own health and the health of your baby, is to make sure (as soon as possible) that you're on a stable regimen that works for you, even before you get pregnant. With the current wealth of treatment options available in 2012, there's bound to be a comfortable regimen out there for you.
As Dr. Gandhi says to many of her patients: "If you're having a side effect, it is not your fault; it is my fault. We have so many options, I should be able to find a regimen where you can feel relatively side-effect free." Once you're settled into a stable regimen, just go ahead and get pregnant; then relax, try not to worry too much, and prepare to watch your family grow!
Short answer: As soon as you're comfortable, but no later than the start of your second trimester.
If you're already pregnant, talk to your provider about whether you want to start meds right away or wait until 12 weeks into your pregnancy, when you may be feeling a bit better (in terms of first-trimester nausea and discomfort) and more ready to adhere. It is also after the 12-week mark that mother-to-child HIV transmission becomes more of a risk, making HIV medications more important for the mother-to-be.
Pregnancy is a particularly fraught situation, because it's a time when treatment matters not just for the health of the mother, but for the fetus as well, in terms of protecting it from acquiring HIV. But if you're concerned you won't be able to take your HIV meds properly, here's some good news: Amazingly, many studies have shown that pregnancy is often a time where women who don't otherwise want to be on antiretroviral therapy really pull it together. They may not be able to take medications before or after their pregnancy because of any number of adherence barriers, yet they manage to take their meds faithfully during pregnancy, to protect their babies.
We'll never go back to a time in which CD4 count cut-offs are used to guide therapy decisions; from here on out, providers will be guided to recommend HIV meds for anyone who's found to be HIV positive. That includes women at any stage of pregnancy. "What people do from there is up to them; and how we as providers help support them around that is up to us," Dr. Gandhi says.