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Treatment Guidelines for Pregnant Women with HIV

Many HIV positive women who are pregnant are concerned about the risks and benefits of anti-HIV medications to their health and to the health of the fetus.

Treatment decisions need to take into account many different factors, including:

• the current health status of the woman
• the prevention of the risk of HIV transmission from mother to fetus
• the health of the fetus
• the impact of medication side effects on the mother
• the potential toxicity of medications to the fetus

The basic principle is that all HIV positive women should be offered the full range of potentially beneficial treatments and that all treatments must be taken with informed consent.

Planning pregnancy
HIV positive women interested in becoming pregnant should avoid using certain anti-HIV medications that are known to have potential toxic effects in pregnancy or to the fetus. The commonly used anti-HIV medications known to cause problems in pregnancy are efavirenz (Sustiva), delavirdine (Rescriptor), hydroxyurea, and the combined use of d4T and ddI together.

Prenatal Care
An HIV positive woman who is pregnant needs to find a health care provider who is experienced and sensitive to the many issues that affect women with HIV during their pregnancy.

In general, basic pregnancy care should include:

• good nutrition
• Pap smear and sexually transmitted diseases screening
• vitamin and folic acid supplement
• addressing other lifestyle issues, including alcohol and tobacco use

For HIV positive women, the following additional measures are recommended: Combination anti-HIV medications should be offered to all HIV positive women regardless of their CD4 and viral load counts. The exceptions are efavirenz, delavirdine, hydroxyurea and using ddI and d4T together, which are not recommended in pregnancy. Women on those medications when they get pregnant should discuss with their physicians whether they need to adjust their medications.

• CD4 cell count and viral load should be monitored every 4 to 6 weeks.
• if anti-HIV medications are started during pregnancy, blood tests should be done 2 weeks after starting to check for any potential toxic side effects to different body organs and systems (liver, kidney, blood glucose, etc.).
• ultrasound should be offered at 18-19 weeks of pregnancy.
• if the CD4-cell count of an HIV positive woman is less than 200/uL, prophylactic treatment against PCP (Pneumocystis carinii pneumonia), MAC (Mycobacterium avium complex) and other common opportunistic infections should be offered according to the usual adult treatment guidelines.

Treatment during delivery
Research studies have shown that Caesarean section decreases the likelihood of transmission of HIV from mother to fetus, especially in women not on anti-HIV medications and who have a detectable viral load.

Studies have also shown that women with non-detectable viral loads who are on anti-HIV medications are much less likely to pass their HIV to the baby and therefore may not require a Caesarean section.

In every case, the risks and benefits of delivery by surgery and infection of the baby must be considered and weighed by the woman.

• Caesarian section should be offered at 38 weeks of pregnancy to all HIV positive women who have a detecable level of viral load.
• Intravenous AZT should be given during both vaginal delivery and Caesarean section until the baby is delivered.
• For HIV positive women who were not on anti-HIV medications before delivery, a single dose of nevirapine (Viramune) should be given in addition to the intravenous AZT.

Postpartum care
Since HIV can be transmitted through breast milk, breast-feeding is not recommended for HIV positive women. Supportive measures to manage breast engorgement (enlargement) after delivery should be provided to the mother.

Women who were on anti-HIV medications should resume treatment after as soon after delivery as they can tolerate.

Women who were not on anti-HIV medications before delivery should receive information and counselling on treatment options according to general treatment guidelines.

Treatment recommendations for the baby
Regardless of whether the mother has been on anti-HIV medications, the baby should be offered anti-HIV medications after delivery. Treatment should start within 6 hours of birth and is usually continued for 6 weeks.