Gay Men's Health Crisis Treatment Issues, Vol. 5, No. 6 - August 30, 1991
Risa Denenberg, F.N.P.

Where women's health is concerned, there is often an intense focus on the well-being of the fetus or the potential fetus. This is also true where health care for HIV is concerned. the potential for pregnancy in all women of childbearing age has been the foremost reason given for withholding experimental drugs, as well as for coercive and directive counselling regarding contraception, abortion, and sterilization. In 1985, the CDC published recommendations which, in effect, advised clinicians to discourage HIV-positive women from carrying pregnancies, as a means of avoiding transmission to their infants. These recommendations were endorsed by the American College of Obstetrics and Gynecologists (ACOG). But many women with HIV, 73% of whom are women of color, their community leaders, and feminist AIDS activists view these recommendations as an infringement on reproductive rights. While HIV serostatus is considered an important factor in the informed decision of an HIV- infected woman to carry a pregnancy to term or not, the decision must ultimately remain hers. One study found no difference in the frequency of voluntary abortions in methadone clinics between women who were HIV-positive and women who were HIV- negative. This indicates that other factors, not accounted for by the CDC and ACOG, are involved in a woman's decision regarding her pregnancy.

STUDIES SHOW . . . OR DO THEY?

In the U.S., perinatal transmission accounts for over 80% of all cases of pediatric AIDS. Despite the fact that the epidemiology for women and HIV infected is skewed, we have a fairly precise figure for the number of HIV-positive babies born each year. It has been estimated that every year approximately 5,000 women give birth to HIV-positive infants. Early studies indicated that 40%-60% of infants born to HIV-positive women became infected with HIV. But more recent studies, with longer follow-up periods, suggest that transmission rates from HIV- infected mother to child range from 25%-40%. And one of the most recent European studies indicates that the rate of transmission may be as low as 13%. While the exact transmission rate is hard to predict based on different populations studied, many professionals in the U.S. commonly accept that 30% of children born to HIV-positive mothers may be infected.

At 12-18 months after birth, infants lose their maternal antibodies, and, if actually infected with the virus, start to make their own. Many officials have suggested antibody testing of all newborns, a procedure which indicates only the serostatus of the mother, an may conflict directly with her right to confidentiality.

Notably, studies do not suggest that HIV disease is accelerated by pregnancy in women who are asymptomatic. Some of the early studies indicated an adverse impact of pregnancy on the course of disease; however, preliminary data from more recent studies indicate that if there is an adverse effect it is uncommon. Women do have lower T4 cell counts during pregnancy and in HIV- positive women these lowered counts may be more sever and may persist after pregnancy. However, this depletion of T4 cells due to pregnancy has not been correlated with disease progression.

Ideally, care for the HIV-positive pregnant woman should be provided in the same setting where the woman goes for general primary care. However, if a women is a patient in an obstetrical clinic, consultation with a primary care provider experienced in HIV infection must be readily available. Medical care for the child should be arranged in a way that considers the mother's needs as well. A well coordinated, team-approach to care is often needed.

Drug detoxification and treatment is difficult to procure for pregnant women. Nevertheless, it is essential for women actively using alcohol, crack, heroine, speed, or cocaine. the use of prescription and street drugs, alcohol, and tobacco are all known to affect the outcome of pregnancy for both mother and baby.

It is important to note that pregnant women are at risk for the same opportunistic infections (Ois) as other people with HIV, and should be treated accordingly. Respiratory infections during pregnancy should be identified early and treated aggressively. The medical literature reports incidents of pregnant women dying of PCP and high rates of bacterial pneumonia, asthma, and bronchitis. Tuberculosis (TB) should be ruled out by aggressive screening with skin tests, chest x-rays (using appropriate shields), and sputum analysis. For women with active TB, medication regimens against his infection must be continued during pregnancy, with careful monitoring of liver function tests.

SCREENING More rigorous screening for sexually transmitted diseases (STDs) in HIV-positive women is recommended. STDs have increased dramatically in the past decade and alone account for a significant number of complications and deaths in pregnant women. One study conducted at prenatal clinics found a 10% rate of syphilis in HIV- infected female patients versus a 4% rate in all female patients visiting the clinic. Routine prenatal screening for pneumonia, TB, hepatitis, CMV, toxoplasmosis and herpes simplex virus (HSV) is recommended. To avoid transmission of HSV, which is particularly damaging to newborns, a Caesarian section (surgical removal of the fetus) may be necessary if active lesions are present in the cervix or vagina. It is notable, though, that while Caesarian sections may assist in the avoidance of transmission of herpes from mother to infant, there have been no data to suggest that the procedure avoids HIV transmission.

THERAPIES

The CDC has provided little guidance regarding the use of antivirals and prophylaxis for Ois in pregnant women. One CDC guide stated that the use of aerosolized pentamidine (AP) is "inadvisable" for treatment of PCP in pregnancy, but AP results in little systemic absorption, making it a good potential regimen in pregnancy. Bactrim (Septra), another treatment for PCP, may cause some problems in the third trimester, such as jaundice in newborns. Prophylaxis for PCP must be initiated when T4 counts drop to 200 in all patients, including pregnant women.

No findings have been reported regarding the use of acyclovir for herpes simplex virus during pregnancy, but its use in the gird trimester calls for further investigation. Urinary tract infections and vaginitis should be treated with full 7-14 day antibiotic regimens during pregnancy, and not with abbreviate antibiotic therapy. Vaginal thrush may be especially troublesome during pregnancy in women who are HIV-positive. Such a condition may require continuous suppression with Nystatin vaginal suppositories daily or every other day. Oral antifungals such as ketaconazole or fluconazole must be considered in the second or third trimester of pregnancy if the infection is refractory.

AZT therapy has been studied for safety in HIV-positive pregnant women in a federally-funded trial, which enrolled 20 participants. Outside of trials, 41 other pregnant women have been observed. Experience with the drug in human pregnancies is very limited. In animal models it is worth noting that, according to Burroughs Wellcome studies reported in 1989, a significant incidence of vaginal cancers in female rats and mice treated with high-dose AZT was observed. However, preliminary analysis of the data on AZT in pregnant women suggests that AZT is safe in this population, as long as frequent blood monitoring and dose reduction or drug withdrawal is provided. Of the 61 HIV-positive pregnant women who took AZT, two had babies born with extra digits. No other abnormalities in maternal or fetal health were noted on AZT, with the possible exception of increased risk for anemia. Many clinicians withdraw AZT therapy during the first trimester in the HIV-positive patient because the concern for fetal harm is concerned greater early in pregnancy. The pregnant woman then often starts taking AZT again in the second or third trimester when the antiviral benefits to her may outweigh harm to the fetus.

A study to evaluate the safety and efficacy of AZT as a means of preventing vertical transmission (from mother to fetus) in pregnant mice was recently reported in The Journal of Infectious Diseases. Evidence exists that AZT is nontoxic for mice during mid-gestation pregnancy, but this study was designed to determine the effectiveness of chronic use of AZT before and during gestation. The resulting data indicate that AZT had a direct toxic effect on the developing mouse embryo, and led to considerable pregnancy failure. The data indicate that early pregnancy failure, rather than fetal malformation, is the primary result from AZT exposure during gestation.

The prepartum effects of AZT were recently studies in 15 pregnant women. Six of the participants conceived while taking AZT, and four of these six elected to terminate the pregnancy within the first trimester. The other nine patients began taking AZT during the second or third trimester of pregnancy because T4 counts dropped to below 500. These patients gave birth to live, full-term infants, after an average of almost 13 weeks of AZT exposure. The infants had normal birth weights, and no abnormalities were observed. During the eight months of follow- up two of the nine infants have developed clinical symptoms of HIV infection, including lymphadenopathy, oral thrush, and failure to thrive.

The AIDS Clinical Trial Group (ACTG) is planning a phase II, randomized, placebo-controlled trial to evaluate the efficacy, safety and tolerance of AZT in pregnant HIV-infected women and their infants. The trial, called 076, plans to enroll 748 HIV- positive women in the second or third trimester of pregnancy with T4 counts between 200-500. The trial is primarily designed to see if AZT can prevent transmission of HIV from mother to child. Much controversy has been raised over the ethics of this trial. Since most animal models indicate that AZT does not stop transmission of the virus from mother to fetus, many feel that the purpose of the study is misguided. The informed consent, a paper which explains the pros and cons of the study, does not include some of the negative effects of AZT on female rats and mice. Others think that the data from the 61 pregnant HIV- positive women who have been on AZT, ought to be further evaluated before the start of this trial. Additionally, the study results of 076 will not be available until 1995, at which time other antivirals, such as ddC or ddI may be more widely used. Neither NIAID nor Burroughs Wellcome is paying for any of the long-term medical care that may be required due to the effects of the trial. Lastly, many activists feel that since no studies have been designed specifically to observe HIV in women, more complete studies might make better use of research money.

CONCLUSION

It is important to note that this article reflects the artificial nature of isolating pregnancy as a single issue, or as the only issue concerning women and HIV. It is difficult and often misleading to do so. More research is desperately needed to understand HIV in women, and such research will also shed more light on HIV in all aspects of women's health and lives, including pregnancy.

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