Those of us who have been involved in medicine for a few decades have grown up, professionally speaking, with the Human Immunodeficiency Virus—better known as HIV. We remember a time when certain risk groups such as gay men and IV drug users were thought to be primarily responsible for the spread of this virus, which causes Acquired Immune Deficiency Syndrome (AIDS). We also knew early on that a pregnant woman with HIV could pass the infection on to her baby. And in those days, with little hope for life beyond a few years and the looming stigma of the infection, many were less inclined to get tested.
Fast forward to 2018. We know that anyone can be at risk for HIV, and although science is still working on a cure, so far there isn’t one. Yet there is still much good news out there. We know much more about how the virus is transmitted (and how it’s not). And there are a host of medications—known as antiretroviral therapy (ART)—that help prevent progression and, more recently, transmission of the disease.
Happily, one of the earliest achievements in preventing the virus from being passed on involved our youngest victims. Previously, almost one third of all infants born to infected mothers contracted HIV. Thanks to careful prenatal management and medication, that figure has decreased to as low as two percent. However, do note the word “careful”: although the news is better, it’s important for a pregnant woman to take care of her illness in a manner that will ensure the best outcome for herself and her baby.
Before Becoming Pregnant
Clearly the only ways for a mother to totally avoid having a baby with HIV are to either not contract the virus or to not become pregnant. However, pregnancy is desired by some women who have HIV (or who are HIV-negative with an HIV-positive partner). Also, a large percentage of pregnancies are unplanned.
It’s important for women living with HIV who are thinking of becoming pregnant to discuss their decision with their health care providers. If she decides to pursue pregnancy, it’s essential that she and her provider take steps to keep her viral load—the amount of virus in the body—as low as possible. This is accomplished through an ever-increasing variety of ART medications.
Some of the medications can have effects on the unborn baby’s development. For that reason, the provider may change Mom’s HIV medication to one that is safer for the baby. Whatever the decision, it’s essential for her to consult her provider rather than making any medication changes on her own.
Similarly, if a woman who doesn’t have HIV desires pregnancy by her HIV-positive partner, there are medications that may reduce the chances of acquiring the virus from her partner.
HIV During Pregnancy and Delivery
Because a pregnant woman may not know she has HIV, her obstetric provider will generally do a test for the virus. All pregnant women, regardless of history, are recommended to have the test. Although a woman can opt out, it’s important to say yes. The provider will likely do another test closer to delivery for women at higher risk for HIV.
Whether an expectant Mom finds she’s HIV positive during pregnancy or knows her status before becoming pregnant, there are many important things to do. First, she should maintain regular contact with her providers and keep up her overall health (again, this includes taking the prescribed HIV medications!).
Second, begin planning for delivery. Do you have a choice as to where you will have your baby? If so, it’s worth seeking out a hospital with reliable procedures in place to take care of HIV-positive mothers and their babies. This includes having a pharmacy with easy 24/7 access to necessary medications, and a laboratory that can efficiently and accurately perform critical testing on mother and baby for viral activity. It’s also important that the hospital’s delivery and newborn teams have complete information about your health status; this issue often comes up when much of a mother’s prenatal and general health care is performed at a location remote from the hospital.
Although much about delivery of an infant to an HIV-positive mother doesn’t differ all that much from other deliveries, there are a couple of extra considerations. If Mom’s viral load is high, she will get an extra dose of antiviral medicine. Also, her provider may choose to deliver the baby by cesarean section to lower the risk of HIV transmission.
HIV and Newborns
OK, so a healthy-appearing baby is born to an HIV-positive mother. What happens now? The good news is that researchers who deal with pregnant women and newborns have developed testing and treatment recommendations that have greatly reduced the number of newborns who acquire HIV and, subsequently, the number of children living with the virus.
However, this requires lots of cooperation between treating providers, laboratories, pharmacies, insurers—and parents! Fortunately, many hospitals and health agencies have case managers than can help families navigate the landscape of HIV exposure in newborns. If there is a large population that’s affected, there may be a case manager specific to HIV. Certainly parents should take advantage of any help out there.
There may be variations on what newborns exposed to HIV may undergo based on differences between providers and local HIV experts. Also, the recommendations are updated from time to time. However, at a minimum, the following is likely to happen:
- The baby will have blood drawn for an HIV test at birth. Because the rapid test used on adults is likely to only reflect Mom’s HIV infection when performed on a newborn, a more specific test will be used. This generally takes several days to come back.
- The baby will be started on an antiretroviral. Most often this is zidovudine (AZT). This is continued at home for at least six weeks.
- The baby’s blood will be tested several more times for HIV up to at least six months of age.
For newborns that are higher risk—for example, if Mom acquired HIV during pregnancy or did not take anti-HIV medications—there will likely be more tests and treatments. It’s very important to follow through with the recommendations as given: giving medicine according to the schedule, making sure you don’t run out of medicine (pharmacies vary in their ability to stock some of the less common medications), and coming in for rechecks according to schedule are all essential. The newborn period is by far the most opportune time to lower an exposed baby’s chances of contracting the virus!
Finally, maternal HIV infection is one of the very few times where experts recommend that Mom not breastfeed, since the virus is found in breast milk. Also, at feeding time, an infected mother should not prechew food for her baby.
There was a time in the 1990s that AIDS was the number one killer of young children. Medications and preventive measures have made a big difference in the number of HIV-infected children who develop the disease. And, as we have seen, we’ve made huge strides in preventing infection altogether in babies. However, in 2016, there were still 99 infected babies born. That’s 99 too many. While researchers do their part, the rest of us still need to do ours to get that number down to zero.