12 Questions About HIV Treatment and Care in Pregnancy
November 29, 2012
Short answer: No, if your viral load is less than 400.
This is another aspect of the pregnancy guidelines that has recently changed. The results of PACTG 076, a landmark 1994 New England Journal of Medicine study, dictated that the best way to reduce vertical HIV transmission was oral AZT to the mother during pregnancy, IV AZT to the mother while she was giving birth, and then oral AZT to the baby. Now we have such highly effective regimens that, as with C-sections, IV AZT can be reserved for specific scenarios, namely if a woman's viral load is 400 copies/mL or greater. That same person who had a viral load greater than 1,000 copies/mL who needed a C-section will also need IV AZT during labor. Someone who comes in and the first time she's even found out she's HIV positive is when she's giving birth, and her providers don't even know what her vial load is, should also definitely be given IV AZT.
But if you've been on an effective HIV med regimen for your entire pregnancy, and you've had an undetectable viral load almost the whole time, and especially at 36 weeks into your pregnancy: That's when you'd be encouraging to have a vaginal delivery, and you would not immediately be given IV AZT. It's expensive; it's difficult to administer; it discourages labor and birth outside of hospital settings.
Is it possible for me to give birth in a birthing center, or even at home, with HIV-trained professionals in attendance?
Short answer: Likely? No. Possible? Yes!
Let's be very clear: There is no discussion in the official U.S. HIV treatment guidelines about giving birth anywhere but in a hospital. The overwhelming majority of women in the U.S., whether they are living with or without HIV, give birth in hospitals, according to CDC. But with qualified midwives and other professionals involved, no complications detected, and a plan in place to transfer mom and/or baby to a hospital if medically necessary, a planned out-of-hospital birth -- in a birth center, or at home with qualified home birth midwives -- can be a safe alternative to birth in a hospital setting for low-risk women. And if an HIV-positive woman's viral load is undetectable, her labor is proceeding normally and there are no other complications present, she should not be considered high risk. There's no reason to pathologize the experience of giving birth while living with HIV; and there's no more reason for a pregnant woman living with controlled HIV to view her birth as a medical event than there is for an HIV-negative low-risk woman to do so. In these ideal circumstances, with contingencies in place to transfer to a setting for a C-section if needed, Dr. Gandhi sees no reason for a woman who wanted to explore out-of-hospital birth not to do so. In her opinion, the fact that the latest iteration of the guidelines no longer recommends IV AZT for women whose viral loads are less than 400 may open the door to wider consideration of HIV-positive women giving birth -- and HIV-knowledgeable professionals supporting these births -- in less medicalized settings.
Short answer: Liquid AZT, every 12 hours, for six weeks. Babies whose moms' viral loads were detectable during birth may get another drug in their regimen. Nearly two decades of monitoring babies born to HIV-positive moms has shown these to be safe regimens for newborns.
One aspect of the pregnancy guidelines that remains unchanged: Every baby born to an HIV-positive mom should get six weeks of oral AZT. Babies born to women whose viral loads were detectable when they delivered would likely get combination therapy, usually containing Viramune, as opposed to AZT by itself. Giving an infant six weeks of medications may be challenging for a new mother who's already exhausted. But this is another case in which studies have shown that people are really willing to keep up with that regular dosing, again, for the health of their babies. And in the past, dosing for babies was far more frequent; nowadays, dosing at 12-hour intervals, or twice a day, can make the process smoother. (Read four women's accounts of giving their babies AZT, and waiting for the infants' HIV test results.)
The major concern with AZT is anemia. It's not uncommon in newborns taking AZT, but it tends to disappear after they've stopped the drug. A baby's pediatrician would be monitoring the baby's hemoglobin levels throughout her or his six weeks on AZT.
For those who are concerned about the effects of HIV meds on a baby, a note to ease your minds: The Antiretroviral Pregnancy Registry, a program run by U.S. health authorities, has been monitoring babies born to women living with HIV since 1994. So far, they have found no evidence of long-term side effects in children of moms who took HIV meds during pregnancy. Women are encouraged to talk to their providers about enrolling them in the registry.
Short answer: No; in areas of the world where replacement feeding is safe and available, the risks of breastfeeding with HIV outweigh the benefits.
The World Health Organization's most recent guidelines for infant feeding in the setting of HIV do not discourage mothers living with HIV from breastfeeding in the majority of the world. That's because in the parts of the world where women living with HIV are most likely to reside, the risks of not breastfeeding your baby -- in terms of other communicable diseases that could be acquired through the water used to mix infant formula, or because the baby failed to receive immunities through Mom's breast milk -- are more significant than the risk of HIV transmission. In these settings, breastfeeding may be encouraged whether or not HIV meds are available to the mother and/or the baby. Individual countries are supposed to set their own recommendations for infant feeding, taking into account the WHO's guidelines as well as the conditions in their own nation as far as availability of replacement feeding or HIV meds. Again, we're talking about areas of the globe where options are severely limited; in highly resourced countries such as the U.S., where water systems are clean and infant formula plentiful, breastfeeding is not recommended by the WHO, on the basis that any risk is unacceptable when there are other available options.
It may be difficult to be an expectant mom living with HIV -- often one who may already have had the experience of breastfeeding a previous child -- witnessing the American Academy of Pediatrics and many other institutions, and individuals, pushing breastfeeding as the best thing for bonding and for infant nutrition, while she and other moms living with HIV get a completely different message. In some areas there's even stigma associated with not breastfeeding. But it is still completely possible to nourish and bond with a baby who's not being breastfed.
Olivia Ford is the community manager for TheBody.com and TheBodyPRO.com.
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