HIV+ and pregnant

MAKING IT WORK FOR YOU

Many women consider becoming a mother a highlight and defining aspect of their lives, and for HIV-positive women, this doesn’t have to change, writes Louise Gilbert

WITH ADEQUATE AND prompt medical intervention, an HIV-infected woman is able to live a long and healthy life, which includes experiencing a healthy pregnancy, a safe delivery and giving birth to a healthy baby without HIV. Ideally, an HIV-infected woman should know her HIV status before she falls pregnant and should plan her pregnancy together with her healthcare provider. Unless she already knows that she is HIV-positive, it is essential for all pregnant women to test for HIV as soon as pregnancy is confirmed. For HIVnegative women, HIV testing should be conducted every three months during pregnancy and while breastfeeding.

ANTENATAL CARE

The first step to a healthy pregnancy is early booking for antenatal care, ideally within the first trimester of pregnancy. For the HIV-positive woman, early booking will provide enough time for her healthcare provider to optimise her health before she delivers her baby and to ensure she’s using the correct medication to protect her baby from acquiring HIV. Delaying antenatal care could result in a greater risk of pregnancy-related complications, a difficult delivery and a higher chance of the baby contracting HIV. The correct treatment to ensure that the woman is healthy and that her baby is protected from acquiring HIV is triple therapy with three antiretroviral (ARV) drugs. These drugs are now available in a fixed-dose combination tablet, meaning that people living with HIV only need to take one tablet once a day. In South Africa antiretroviral therapy (ART) is available free of charge at any government healthcare facility. It’s possible for HIV to become resistant to the medication, so in order to prevent this, it is essential that the infected person takes the medication every day and at roughly the same time every day. To further reduce the risk of HIV transmission to the baby, the woman should ensure that she uses a condom consistently during pregnancy, that she seeks medical treatment as soon as possible if she falls ill and that she never misses an appointment with her healthcare provider.

LABOUR AND DELIVERY

In the days before easy access to ART the majority of HIV transmissions from mother to child occurred during the birth, where the baby came into contact with the mother’s blood and bodily fluids. In order to lessen the exposure to these HIV-infected fluids and thereby minimise the risk of baby acquiring HIV, HIV-infected pregnant women were advised that an elective caesarean section was the safest way of giving birth. Nowadays the decision between elective caesarean section and normal vaginal delivery is less straightforward. For an otherwise healthy HIVinfected pregnant women who is considering an elective caesarean section solely on the basis of her HIV status, her viral load should play an integral part in making the decision. The viral load is a measure of the amount of virus in an infected person’s blood. Provided that ART is used as prescribed, within six months of initiating therapy an HIVinfected person’s viral load should be suppressed. This means that the virus has stopped replicating (making more of itself) and the blood is almost clean of the virus. Unfortunately the virus hides in certain sites within the body, so if the person stopped taking their medication the HIV would start replicating again and the viral load would again increase. Babies born through normal vaginal delivery to moms with a suppressed viral load should therefore have no greater risk of HIV transmission than babies born by elective caesarean section. It’s important to remember that while a vaginal delivery is a normal physiological process, caesarean section is a major surgical procedure with a higher risk of complications. With a C-section you have to stay in hospital for longer, your recovery time is longer and you have a higher risk of complications in subsequent pregnancies. In government health facilities in South Africa, elective caesarean section is not offered to HIV-infected women based on their HIV status alone. HIV-infected women are advised to continue using their ARV medication as normal during labour and after delivery. Delivery facility staff will also try to avoid delivery procedures that may place the baby at additional risk of HIV infection.

POSTNATAL CARE

Immediately after birth babies exposed to HIV are offered HIV PCR testing. This type of HIV test is able to immediately detect infection in the baby so that baby can be initiated on ART as soon as possible. In the first years of life HIVexposed babies (babies who were born to an HIV-positive mom but have not tested HIV-positive themselves) should receive HIV PCR testing again at 10 weeks of age and yet again six weeks after breastfeeding is stopped. HIV-exposed babies should also be tested for HIV again at 18 months of age. If at any time a baby becomes ill, it is important for the mother to disclose her HIV status to her healthcare provider as baby may need additional tests to rule out HIV infection. Provided the initial test is negative, in an effort to further reduce the chance of the baby acquiring HIV he/she will be given ARV syrup to take daily for between six and 12 weeks after birth. Immunisation and breastfeeding recommendations remain the same for both HIV-exposed and -unexposed babies. South Africa has adopted a universal breastfeeding policy. This means that all moms (irrespective of their HIV status) are advised to breastfeed their babies. A suppressed viral load results in an HIV-infected mom having a greatly reduced chance of transmitting HIV to her baby through breastmilk.

KNOWLEDGE IS POWER

In order for HIV-positive moms to make the best decisions for themselves and their unborn babies, moms should aim to learn as much about HIV as possible, including understanding the medication they should use, any side effects related to the medication and how these can be managed. Moms should also aim to understand all the advantages and disadvantages of different delivery and feeding methods as these relate to being HIV-positive. With the correct medication and medical management, HIV has been transformed into a chronic disease; one which is compatible with a healthy and long life.

TO FURTHER REDUCE THE RISK OF HIV TRANSMISSION TO THE BABY, THE WOMAN SHOULD ENSURE THAT SHE USES A CONDOM CONSISTENTLY DURING PREGNANCY