A Guide To Primary Care For People With HIV/AIDS, 2004 edition< Previous | Home | Next >
Chapter
12
Care of HIV-Positive Women of Childbearing Age TOP When should you provide pregnancy counseling to women living with HIV who are of childbearing age? More than half the pregnancies in the United States are unplanned. For women living with HIV, education and counseling about pregnancy and HIV should be done early in the course of HIV care, not delayed until the woman is pregnant, so that she can make informed decisions about contraception and pregnancy. Many women with HIV mistakenly assume they cannot get pregnant and need to be educated before it is too late. What counseling interventions should be included in primary care? All women of childbearing age should receive the benefit of preconceptional counseling as part of routine primary medical care (ACOG, 1995). Women who have HIV should also be counseled about:
What primary care interventions are appropriate for women with HIV who want to become pregnant? Certain measures can help facilitate a successful pregnancy if a woman with HIV wants to become pregnant:
Are there options for HIV-positive individuals who are considering reproduction? There are centers in the United States and in Europe that provide "sperm washing" to decrease the possibility of HIV transmission to the woman during planned conception. However, this method has not been well studied and, as a practical matter, is not available to most HIV discordant couples (Kim et al, 1999). Discordant couples who choose to become pregnant need to be educated about the risk of HIV transmission. To reduce the risk if the man is HIV-positive, his viral load should be as low as possible, intercurrent STDs should be treated, and attempts to conceive should be well timed around ovulation to avoid unnecessary exposures during periods of decreased fertility. The American College of Obstetricians and Gynecologists has recently endorsed the use of reproductive technology in HIV-infected patients (ACOG, 2004). Which patients should be offered assisted reproduction and what the optimal methods are of decreasing heterosexual and perinatal HIV transmission must be determined. When should pregnancy testing be done? Since most pregnancies are unplanned, the diagnosis of pregnancy frequently occurs late in the first trimester, when organogenesis is nearly complete. In order to make the diagnosis earlier, pregnancy tests should be done when sexually active women have:
In addition, women with the potential of becoming pregnant should be tested before starting potentially teratogenic therapies such as efavirenz (EFV), which is the only antiretroviral drug that is contraindicated in pregnancy. Patients should be alerted to potential teratogenic effects on the fetus, and suitable contraception should be prescribed. What contraceptive methods are recommended for women with HIV who do not want to become pregnant? Condoms are
the most common contraceptive method used by women living with HIV.
Condoms, consistently used, have the added advantage of providing
protection against STDs, including potential reinfection with HIV.
This benefit should be emphasized when contraceptive advice is given
to an HIV-positive or at-risk woman even if she is not seeking or
does not need contraception but is sexually active. What are the most common drug interactions between oral contraceptives and drugs used in HIV disease? Oral contraceptives significantly interact with amprenavir/fosamprenavir (APV/FAPV), efavirenz (EFV), lopinavir (LPV), nelfinavir (NFV), nevirapine (NVP), and ritonavir (RTV); an additional method of contraception, such as condoms, is recommended. Similarly, other drugs commonly used by HIV-infected patients, including tetracycline, rifampin, oral anticoagulants, beta-blockers, and antidepressants interact with oral contraceptives, and an additional means of contraception is advisable. Indinavir and atazanavir do not appear to have an interaction. What contraceptive methods are not highly recommended for women with HIV who do not want to become pregnant? Spermicides: Generally, a spermicide should be used along with a barrier method to increase its effectiveness. However, in some studies nonoxynol-9 (the active ingredient in spermicidal contraceptives) has been found to cause vaginal irritation and epithelial inflammation when used as the sole contraceptive method and on a regular and frequent basis. This may increase the risk of HIV transmission. Intrauterine Device: The intrauterine device (IUD) is not recommended for HIV-infected women. The IUD is associated with pelvic inflammatory disease and is also associated with increased menstrual flow. Some studies even suggest that this device is linked to increased susceptibility to HIV transmission. Preventing Mother-to-Child Transmission (MTCT) TOP Which are the current recommendations for HIV testing of pregnant women? Since prevention of vertical transmission (from mother to child) of HIV is so effective, identification of HIV infection in all women who are pregnant is imperative. Therefore:
How should HIV testing be done? HIV testing should be voluntary, and providers should carefully document informed consent. Providers should offer pre- and post-test counseling that includes information on modes of transmission of the virus, risk factors that might be present even if a woman has only one sex partner, and effective interventions to reduce the risk of perinatal transmission of HIV. There should be a discussion of services available for the provision of medical care, and the woman should be reassured that care for her and her infant will not be denied if she declines the test. Laws and regulations on HIV screening of pregnant women and their infants vary by State. Therefore, providers should be familiar with the State regulations and policies that apply to them (CDC, 2001). When does transmission from mother to infant occur and what are risk factors for transmission? Vertical transmission can occur during the perinatal period and infancy, that is, before or close to the time of birth or during breastfeeding. Risk factors associated with vertical transmission include (CDC, 2001):
How common is vertical transmission of HIV with and without ART? In the absence of antiretrovirals, the perinatal transmission rate of HIV infection is approximately 25%. There is a direct correlation between maternal viral load as measured by plasma HIV-1 RNA and probability of perinatal transmission. A large study showed that the rate of perinatal transmission among women with viral load >100,000 c/mL was 40.6%, with 50,001 to 100,000 c/mL it was 30.9%, with 10,001 to 50,000 c/mL it was 21.3%, with 1,000 to 10,000 c/mL it was 16.6%; and with <1,000 c/mL it was 0% (Garcia et al, 1999). Treatment with zidovudine (AZT) alone can reduce transmission to close to 8%. Multi-agent antiretroviral therapy can reduce the transmission rate even further (see Table 12-1).
Do pregnant women with very low or undetectable viral loads need ART? Yes. All pregnant women should receive ART. Analysis of the first study of the effectiveness of ART in reducing perinatal transmission (ACTG 076 study) showed that zidovudine (AZT) significantly reduced perinatal transmission even when the baseline viral load was <1,000 c/mL (Ioannidis et al, 2001). This study provides the rationale for zidovudine monotherapy in untreated pregnant women with a baseline viral load of <1,000 c/mL. What pharmacologic interventions are recommended to reduce the risk of MTCT? ART should be offered to all HIV-infected pregnant women, and zidovudine chemoprophylaxis should be incorporated into the antiretroviral regimen to prevent perinatal transmission because safety and efficacy data are greatest for zidovudine (PHS, 2002) (see Pocket Guide Pregnancy Table 1). Zidovudine prophylaxis is associated with significant reduction in perinatal transmission that is independent of viral load (Sperling, 1996; Shapiro et al, 1999) and of zidovudine resistance (Eastman et al, 1998). Are there additional interventions to reduce the risk of MTCT and improve maternal/fetal health? When the woman is HIV positive there are interventions that can reduce the risk of MTCT.
Can cesarean section reduce the risk of MTCT? Elective cesarean section reduces the risk of perinatal transmission and should be offered at 38 weeks to pregnant women when the viral load is likely to be >1,000 c/mL at delivery (Dominguez, 2003). ACOG in a joint statement with the American Academy of Pediatrics (AAP) recommended offering HIV-positive pregnant women scheduled cesarean section at 38 weeks gestation (AAP, ACOG, 1999; CDC, 2001), rather than waiting until 39 weeks. There is no evidence of benefit of C-section after onset of labor, after rupture of membranes, or in women with viral loads of <1000 c/mL. What interventions should occur during a scheduled cesarean section? When a scheduled cesarean section is planned, intravenous zidovudine should start 3 hours before surgery according to standard dosing (see Pocket Guide Pregnancy Table 5). Since infectious morbidity is potentially increased, the obstetrician should consider antibiotic prophylaxis. Other antiretrovirals should not be interrupted at the time of delivery regardless of route of delivery. What should you advise mothers about breastfeeding? The risk of HIV transmission with breastfeeding is approximately 16%. Avoidance of breastfeeding is recommended in the United States and other industrialized countries since replacement feeding is safe and accessible. In resource-poor countries where risks of replacement feeding include malnutrition and infections other than HIV, the World Health Organization recommends exclusive breastfeeding during the first 3 months of life since exclusive breastfeeding carries a lower risk of HIV transmission than mixed feeding. To minimize the risk of HIV transmission in these settings, breastfeeding by HIV-positive women should be discontinued as soon as feasible, taking into consideration local circumstances and the risks of replacement feeding (WHO, 2001). What testing should neonates of HIV-positive mothers receive? When neonates
are born to HIV-positive mothers, serial testing for HIV should
be done within the first few days of life, at age 1 month, and again
at 4-6 months or later (AAP, ACOG, 2002). Early identification of
HIV in neonates is crucial for adequate management. Since maternal
antibody may be present, HIV antibody testing is not useful until
the baby is 18 months old. Using either HIV-DNA PCR or HIV culture,
however, pediatricians can usually determine the HIV status of infants
by the age of 4 months. Perinatal Care for Pregnant Women with HIV TOP What medical and counseling interventions are appropriate for pregnant women with HIV? Initial evaluation of an HIV-positive pregnant woman should include an assessment of her HIV disease status. Besides the standard components of prenatal care indicated for all pregnant women, the provider should obtain CD4 cell counts and viral loads, and resistance tests should be performed. Viral loads and CD4 counts should be repeated every 3 months. The goals of ART during pregnancy are to:
Clinicians should discuss short- and long-term benefits and risks for both the woman and the fetus before initiating or modifying ART. Options should be presented in a non-coercive way, and the final decision always lies with the patient. A long-term plan should be developed, and the importance of adherence to ART should be stressed. What antiretroviral regimens are recommended for pregnant women with HIV? The use of the 3-part zidovudine (AZT) chemoprophylaxis regimen, alone or in combination with other antiretroviral agents, should always be offered and discussed with all infected pregnant women to reduce the risk of perinatal HIV transmission (see Pocket Guide Pregnancy Table 3). Any pregnant woman with HIV should be offered a treatment regimen that adheres to the currently recommended treatment for HIV-infected adults, which generally consists of 2 reverse transcriptase inhibitors into which zidovudine is incorporated, plus a protease inhibitor (see Pocket Guide Pregnancy Table 4). Efavirenz (EFV) is contraindicated in the first trimester because it has been associated with birth defects in a monkey model. Referral to providers who are experienced in the care of pregnant HIV-infected women is recommended. Are there special considerations when a woman already on ART becomes pregnant? When an HIV-infected women receiving ART is found to be pregnant after the first trimester she should be counseled to continue therapy. Zidovudine should be a component of the antenatal ART regimen after the first trimester whenever possible, although this may not always be feasible. A woman receiving ART whose pregnancy is recognized during the first trimester should be counseled regarding the benefits and potential risks of continuing ART during this period of organogenesis. As discussed above, efavirenz (EFV) is contraindicated in the first trimester. Also, dapsone, a folic acid antagonist, has been reported to increase the risk for neural tube defects. Maternal absorption and metabolism of protease inhibitors (PIs) change during pregnancy, and there are specific recommendations for dose adjustments of nelfinavir (NFV) (http://www.aidsinfo.nih.gov). What are some of the problems that may occur when antiretroviral agents are prescribed during pregnancy? Hyperglycemia and diabetic ketoacidosis have been reported with PI use during pregnancy. Therefore, pregnant women using PIs should be carefully instructed to watch for symptoms of hyperglycemia, and blood glucose levels should be closely monitored. Lactic acidosis is more common in the last trimester of pregnancy, and hepatic enzymes and serum electrolytes should be monitored frequently during the last trimester in pregnant women receiving nucleoside analogues. The combination of stavudine (d4T) and didanosine (ddI) in HIV-positive pregnant women is not recommended as it has been associated with maternal mortality from severe lactic acidosis. Hyperemesis gravidarum is a common complication of pregnancy. If a women needs to discontinue ART because of pregnancy-related hyperemesis, she should not restart medications until sufficient time has elapsed to ensure that the drugs will be tolerated; all drugs should be stopped at once and reintroduced simultaneously to reduce the potential for emergence of resistance. What medical and counseling interventions are appropriate for postpartum followup of women with HIV? Comprehensive care and support services, including primary, obstetric, pediatric, and HIV specialty care, family planning services, mental health and substance abuse treatment, and coordination of care through case management for the woman, her children, and other family members are important for women with HIV and their families. Maternal medical services during the postpartum period must be coordinated between the obstetric care provider and the HIV specialist. When treatment is required for the woman's HIV infection, continuity of ART must be assured. What followup should be done for the infants of mothers with HIV? Infants of HIV-positive women on ART should be followed for potential side effects of antiretroviral medications even if the infants are HIV-negative; followup should continue into adulthood because of the theoretical concerns regarding potential carcinogenicity of the nucleoside analogue antiretroviral drugs. Infected children should be followed to determine their need for prophylactic treatment or ART, as well as to assess possible delays in growth and development. Where should prenatal exposure cases be reported? Cases of prenatal exposure should be reported to the Antiretroviral Pregnancy Registry. This registry collects anonymous observational data. The Registry can be contacted at:
References TOP American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th Ed. Elkgrove, IL: American Academy of Pediatrics; 2002. American College
of Obstetricians and Gynecologists. Ethics
in Obstetrics and Gynecology,
2nd Ed. Washington, DC: American College of Obstetricians American College of Obstetricians and Gynecologists. "Human immunodeficiency virus screening." Joint statement of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. Pediatrics. 1999;104:128. American College of Obstetricians and Gynecologists. Technical Bulletin Number 205: Preconceptional Care. Washington, DC: American College of Obstetricians and Gynecologists; 1995. Centers for Disease Control and Prevention. "Advancing HIV Prevention: New Strategies for a Changing Epidemic - United States, 2003." MMWR. 2003;52:329-332. Centers for Disease Control and Prevention. "Revised Recommendations for HIV Screening of Pregnant Women." >MMWR . 2001;50(RR19):59-86. Accessed 1/04. Centers for Disease Control and Prevention. "Recommendations of the U.S. Public Health Service Task Force on the Use of Zidovudine to Reduce Perinatal Transmission of Human Immunodeficiency Virus." MMWR. 1995;43(RR11):1-20. Cooper ER, Charurat M, Mofenson L, et al. "Combination antiretroviral strategies for the treatment of pregnant HIV-1-infected women and prevention of perinatal HIV-1 transmission." J Acquir Immune Defic Syndr. 2002;29:484-494. Dominguez KL, Lindergren ML, D'Almada PJ, et al. "Increasing trend of cesarean deliveries in HIV-infected women in the United States from 1994 to 2000." J Acquir Immune Defic Syndr. 2003;33:232-238. Eastman PS, Shapiro DE, Coombs RW, et al. "Maternal viral genotypic zidovudine resistance and infrequent failure of zidovudine therapy to prevent perinatal transmission of human immunodeficiency virus type 1 in pediatric AIDS Clinical Trials Group Protocol 076." J Infect Dis. 1998;177:557-564. Garcia PM, Kalish LA, Pitt J, et al. "Maternal levels of plasma human immunodeficiency virus type 1 RNA and the risk of perinatal transmission." N Engl J Med. 1999;341:394-402. Ioannidis JP, Abrams EJ, Ammann A, et al. "Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads <1000 copies/ml."J Infect Dis. 2001;183:539-545. Kim LU, Johnson MR, Barton S, et al. "Evaluation of sperm washing as a potential method of reducing HIV transmission in HIV-discordant couples wishing to have children." AIDS. 1999;13:645-651. Public Health Service Task Force (2002). Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. Shapiro DE, Sperling RS, Coombs RW. "Effect of zidovudine on perinatal HIV-1 transmission and maternal viral load". Lancet.1999;354:156-158. Sperling RS, Shapiro DE, Coombs RW, et al. "Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group." N Engl J Med. 1996;335:1621-1629. |
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