• Reproductive Health: Fertility Issues, Pregnancy Choices, Contraception and HAART. Effect of HIV on Pregnancy and Vice Versa
  Authored by Ade Fakoya (London, U.K.)
  Abstract PL11.1

The World Health Organization (WHO) defines reproductive health as not just the absence of disease but includes social well being, sexual health and family planning as necessities. This session covered mother-to-child transmission (MTCT) of HIV, issues around HIV and pregnancy/fertility.

MTCT

Eight hundred thousand children around the world were infected with HIV last year, mostly in resource-poor settings. This figure could have been dramatically reduced if HIV had been identified in the mother before she gave birth.

Antenatal testing for HIV in industrialized countries has been extremely successful at not only preventing MTCT but also at identifying HIV-infected women early -- before they themselves become unwell. Some 84 percent of HIV-infected women identified at antenatal clinics are well.

With no intervention, the risk of a mother passing HIV on to her baby is about 15-25 percent. With intervention, the risk is now below 1 percent. The risk of a mother passing HIV on to her baby is higher if her viral load is high. Women with low viral loads also benefit, demonstrating that there is more to the treatment than just lowering viral load.

A cesarean section done before a woman's water has broken is very effective at preventing HIV from passing on to the baby (12 percent risk reduced to 1 percent). Whether it adds extra protection if the mother has an undetectable viral load has yet to be shown. In France about 50 percent of HIV-infected women have a cesarean section, while in the U.K. cesarean rates are variable.

Breast milk carries HIV but at lower levels than in blood. HIV is often passed onto babies this way and so, if possible, breastfeeding should be avoided. In some parts of the world this may not be possible and in this situation breastfeeding alone, for as short a time as possible, carries a lower risk than mixed feeding.

Maternal health must not be forgotten as tragically many babies survive as orphans. HIV can cause increased disease progression in women who already have advanced HIV and babies may be more at risk of the complications of childbirth.

Involvement of the male partners is useful also and helps men access testing and counseling.

In a situation where a male partner is HIV infected and the female partner is not then "sperm washing" to remove HIV is possible and has been offered in some circumstances. Risk of HIV transmission and the risks of a woman seroconverting during early pregnancy should be discussed. If both partners have HIV, the theoretical risks of passing a new strain or drug resistant strain during sex should also be discussed.

Gender

In general, women with HIV require sexually transmitted disease screening, cervical smear testing, pre-conception advice and advice on contraception and fertility. Protease inhibitors and non-nucleoside reverse transcriptase inhibitors can affect oral contraceptives and so this should be discussed (further information can be found on www.hiv-druginteractions.org). HIV can affect fertility in both men and women and awareness of this is important.

Women having sex for the first time are more likely to acquire HIV if they are under 15 years of age and more likely if their male partner is more than ten years older than themselves. This raises issues of sex education and prevention.

Condoms remain the best protection against HIV. Vaginal microbicides are under development but an effective form has yet to be produced. Male circumcision has been postulated as a way of reducing HIV acquisition but further information from clinical trails is awaited.