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Patient education: HIV and pregnancy (Beyond the Basics)

Patient education: HIV and pregnancy (Beyond the Basics)
Literature review current through: May 2024.
This topic last updated: Mar 06, 2023.

HIV AND PREGNANCY OVERVIEW — If a person with human immunodeficiency virus (HIV) has a baby, it is possible to pass the infection on to the baby during the pregnancy, during labor and delivery, and, to a lesser degree, through breastfeeding. Fortunately, the use of certain HIV medications during pregnancy and labor can dramatically reduce this risk.

However, not everyone with HIV is aware they have it. For this reason, experts strongly recommend that all pregnant people undergo screening for HIV infection. This can be done with a blood test and is a standard part of prenatal care in the United States and many other places. (See "Patient education: Testing for HIV (Beyond the Basics)".)

This topic review discusses factors that can reduce HIV transmission from mothers to babies in "resource-rich" areas such as the United States and Europe. The approach may be different in other parts of the world where resources are more limited.

CARE BEFORE PREGNANCY — If you have HIV, you should talk to your HIV specialist and an obstetrician before you start trying to get pregnant. Ideally, you should be taking HIV medications and have an undetectable viral load before trying to conceive (the viral load is the amount of virus in your blood at a given time). Most medications are safe during pregnancy, and most people do not need to switch medications when they get pregnant, but this should ideally be discussed before pregnancy. It is also important to take your HIV medications regularly and follow your doctors' instructions. If you have complete viral suppression (no virus detected in your blood) during pregnancy, you will have a much lower risk of passing HIV to your baby than if you do have detectable virus in your blood.

Many studies have been done to better understand how HIV infection and HIV treatment affect the health of pregnant people and their babies. Pregnancy does not appear to worsen HIV or increase the risk of death from HIV. It is not clear if HIV or HIV treatments increase the risk of pregnancy complications, such as prematurity or low birth weight. However, it is very clear that certain HIV medications can significantly reduce the risk that the baby will become infected with HIV when the medication is taken during pregnancy and labor, and then given to the baby after delivery. That is why HIV treatment guidelines strongly recommend a combination of medications to lower the risk of transmission. (See 'HIV medication regimens' below.)

Your health care provider can talk to you in detail about the risks and benefits of taking HIV medications during pregnancy. More information about HIV treatment is available separately. (See "Patient education: Initial treatment of HIV (Beyond the Basics)" and "Patient education: Tips for taking HIV medications by mouth (Beyond the Basics)".)

CARE DURING PREGNANCY — If you have HIV, you will likely work with several health care providers during pregnancy, including an HIV specialist, an obstetrical care provider, possibly a high-risk obstetrician, and, in some cases, a case manager. The role of the case manager is to make sure you have all the resources and information you need to care for yourself and follow your treatment plan.

Initial evaluation — After your pregnancy is confirmed, you should meet with your HIV specialist and obstetrical provider. During these visits, you will discuss how to manage your HIV during pregnancy and minimize the risk of passing HIV to your baby.

During the initial evaluation, you will have blood tests to determine the amount of HIV virus in your blood (that is, HIV viral load) and the strength of your immune system (as measured by the number of CD4 T cells). If you are not taking HIV medications, you will also have a blood test to look for mutations in the HIV virus, but you do not have to wait for the results to start HIV medications. You may also have other blood tests to evaluate your general health and to monitor side effects of medications.

HIV medication regimens — During pregnancy, anyone with HIV should take combination antiretroviral regimens using multiple HIV drugs. People who become pregnant while on a regimen that successfully controls the virus can usually continue that same regimen.

More information about medications used to treat HIV infection is available separately. (See "Patient education: Initial treatment of HIV (Beyond the Basics)" and "Patient education: Tips for taking HIV medications by mouth (Beyond the Basics)".)

Timing of HIV medications — Studies suggest that starting HIV medications earlier in pregnancy increases the likelihood that you will have a low amount of virus in the blood by the time of delivery. In general, it is best to start HIV medications as soon as possible during pregnancy if you are not already taking them. However, some people may prefer to start after the first trimester of pregnancy if pregnancy-related nausea makes it difficult to take pills. Talk to your doctor if you are concerned about this. Once started, HIV medications are continued throughout pregnancy to prevent HIV transmission to the baby, and they are continued indefinitely after birth.

An HIV medication called zidovudine is recommended (in addition to the current drug regimen) for some pregnant people just prior to delivery; it is given intravenously (by IV). HIV medications are also given orally to the baby after birth to lower the risk of acquiring HIV infection.

Medication adherence during pregnancy — "Medication adherence" means following your treatment plan as directed. It is extremely important to take your medications exactly as prescribed during pregnancy to decrease the risk of developing drug resistance, which is when a medication becomes less effective. Furthermore, taking your medications on time can lower the risk of HIV transmission to the baby.

Medications to avoid — There are some HIV medications that should not be used during pregnancy except in certain circumstances. Talk to your health care provider about the safety of HIV medications during pregnancy. Don’t stop taking medications you already take unless your health care provider tells you to do so.

Monitoring during pregnancy — Throughout your pregnancy, you will see your obstetrical provider and HIV specialist at regular intervals. During these visits, you will have routine obstetrical care as well as HIV monitoring, including blood testing of your CD4 count and HIV viral load.

An early ultrasound is recommended to obtain an accurate due date. A detailed ultrasound is usually recommended at 18 to 20 weeks of pregnancy to evaluate the growing fetus. A follow-up ultrasound may be recommended during the second and/or third trimester to monitor growth.

LABOR AND DELIVERY WITH HIV

Medications during labor — During labor, if the amount of HIV in your blood (the "viral load") is above a certain level, you will get the HIV drug zidovudine through an intravenous (IV) catheter. In these cases, zidovudine helps to reduce the risk of HIV transmission. If you are taking combination HIV medications, you should continue them on schedule during labor or before your cesarean delivery ("C-section") if you have one scheduled; this helps to provide maximal protection to you as well as your baby and to minimize the risk that you could develop drug resistance due to a missed dose of medication.

Delivery method — The safest way to deliver your baby (by vaginal or cesarean delivery) depends upon your HIV viral load during pregnancy. In general, you can plan for a vaginal delivery if the risk of transmission of HIV is low (that is, if your HIV viral load is low) and there are no other reasons (such as your baby's position) to need a cesarean delivery. If your viral load is high, a cesarean delivery may be recommended.

Viral load <1000 copies/mL — If you have been taking HIV medications throughout your pregnancy and have a confirmed HIV viral load <1000 copies/mL within four weeks of your due date, you may have the option of a vaginal delivery. In this situation, the risk of transmitting HIV to the baby during childbirth is very low, and it is not clear that a cesarean delivery will decrease this risk any further. Your obstetrical provider can talk to you about the risks and benefits of cesarean versus vaginal delivery.

Viral load ≥1000 copies/mL — If you have taken HIV medications throughout your pregnancy but have a viral load above 1000 copies/mL within four weeks of your due date, you will likely be advised to have a cesarean delivery before you go into labor rather than planning for a vaginal delivery. In this situation, the cesarean is usually scheduled at 38 weeks of pregnancy (2 weeks before your due date). (See "Patient education: C-section (cesarean delivery) (Beyond the Basics)".)

CARE AFTER DELIVERY

For mothers after delivery — After delivery, you should continue taking your HIV medications. Your health care provider can also help make sure you have the support and care you need after delivery. This includes providing screening for postpartum depression and help with medication adherence if needed; they can also give you information about family planning and birth control. (See "Patient education: Birth control; which method is right for me? (Beyond the Basics)".)

Breastfeeding — It is possible to pass HIV to your baby through breastfeeding, although the risk is small if you have been consistently taking HIV medications during pregnancy and at the time of birth your viral load is undetectable.

In the United States and other resource-rich countries, clean water and baby formulas are readily available as a safe alternative to breastfeeding. Therefore, the United States Public Health Service (an expert group) recommends that health care providers initiate a discussion of the risks and benefits of breastfeeding and formula-feeding. Although the risk of transmitting HIV to your baby is small if you have been consistently taking and will continue to take HIV medications, the risk is not zero. The expert group recommends that if a person has a detectable HIV viral load or has had difficulty taking HIV medications consistently throughout pregnancy, they should not breastfeed their babies.

If you do choose to breastfeed your baby despite the risk, talk to your doctor about minimizing the risks as much as possible. In addition to you taking HIV medications consistently to control the infection, there are also medications your baby can get to reduce the risk of getting HIV through breastmilk.

In countries where safe alternatives to breast milk (eg, clean water and formula) may not be consistently available, recommendations for breastfeeding may be different.

For newborns and babies

HIV treatment regimens — Babies born to mothers with HIV are usually treated with HIV medications for the first two to six weeks of life. These can help to prevent the baby from becoming infected with HIV as a result of exposure to the mother's blood during delivery. Your child's health care provider can talk to you about which medication or combination of medications is best.

Testing babies for HIV — Normally, HIV "antibody testing" is used to determine whether an adult or child is infected with HIV. However, HIV antibody tests are not accurate in young babies. This is because HIV antibodies may be transferred from the mother to the baby, which can result in the baby having a positive HIV antibody test. However, this does not necessarily mean that the baby actually has HIV infection.

For this reason, a special test that directly measures the virus itself is used to look for HIV infection in babies. If this test (called an "HIV PCR" test) is negative, it means the baby is not infected with HIV.

If you take all your HIV medications as directed throughout your pregnancy, the chances of your baby having HIV are very small. If it turns out that your baby does test positive after birth, try not to panic. With the right treatment, they can still live a normal and healthy life.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: HIV and AIDS (The Basics)
Patient education: Starting treatment for HIV (The Basics)
Patient education: Vaccines for adults with HIV (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Testing for HIV (Beyond the Basics)
Patient education: Initial treatment of HIV (Beyond the Basics)
Patient education: Tips for taking HIV medications by mouth (Beyond the Basics)
Patient education: C-section (cesarean delivery) (Beyond the Basics)
Patient education: Birth control; which method is right for me? (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

HIV and women
Prevention of vertical HIV transmission in resource-limited settings
Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach
When to initiate antiretroviral therapy in persons with HIV
Diagnostic testing for HIV infection in infants and children younger than 18 months
Prevention of HIV transmission during breastfeeding in resource-limited settings
Antiretroviral selection and management in pregnant individuals with HIV in resource-rich settings
Prenatal evaluation of women with HIV in resource-rich settings

The following organizations also provide reliable health information.

The National Library of Medicine

     (https://medlineplus.gov/hivandpregnancy.html)

Centers for Disease Control and Prevention (CDC)

     (https://www.cdc.gov/hiv/group/gender/pregnantwomen/index.html)

HIV/AIDS Treatment Information Service

     (https://clinicalinfo.hiv.gov/en)

Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. 2024© UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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