Step Perspective, Volume 5, Number 1; A Publication Of The Seattle Treatment Education Project - February 1993
Scott Fulford, MD, MPH

HIV testing is not routinely offered at most health care centers providing prenatal care. Surveys have shown that a majority of women regard this as an acceptable practice and willingly give consent for testing. For various reasons, including perceptions of being in a low-risk group for HIV infection, initiation of prenatal care is the first situation where many women consider HIV testing. As the rate of heterosexual transmission of the virus increases, this unfortunately is often the time when newly diagnosed HIV positive women learn that their male partners are from high-risk groups.

Research has shown that HIV disease in females frequently presents differently than in males, that is, the typical symptoms which raise suspicion of early HIV infection in males do not necessarily appear in females. Many believe that this partly explains why diagnosis is often delayed in women. Pregnancy is an example of where such confusion arises as fatigue, anorexia, nausea, weight loss and shortness of breath common in pregnancy, may also represent expression of HIV disease.

Every woman, whether or not she is HIV infected, must have access to comprehensive prenatal care where medical emotional and social support is provided. Accurate information regarding the possible effects of pregnancy on the progression of HIV disease, treatment options, considerations for labor and delivery and the risks to the unborn fetus is essential. In pregnancy, a natural suppression of the immune function similar to that of HIV disease occurs; specifically, a decrease in the ratio of CD4 to CD8 cells is observed. Although the immunosuppression of pregnancy is relatively mild, it may contribute to a more rapid progression of HIV infection than expected in the absence of pregnancy. At the beginning of prenatal care for an HIV positive woman, the following tests are recommended: blood tests for complete cell count, CD4 counts and syphilis, Hepatitis B, cytomegalovirus and toxoplasmosis antibodies; cervical swabs for gonorrhea culture and chlamydia testing; and skin testing for tuberculosis. Most of these tests are already routinely given to all women receiving prenatal care. Careful screening for other health conditions in the mother such as genital herpes and drug, alcohol or tobacco use is also necessary. In addition to the usual surveillance for fetal defects and maternal infections, anemia and metabolic abnormalities, CD4 counts should be obtained during each of the three thirds [trimesters] of pregnancy. This information guides the treatment of the pregnant woman's HIV disease. At CD4 counts below 200, most agree that it is prudent to start AZT at 500 mg per day, although preferably after the first trimester, the most crucial time in the development of fetal tissues. It is theorized that AZT may decrease the amount of viral shedding and potentially decrease the risk of transmission of HIV from mother to fetus. Conclusive data on the safety of AZT for the human fetus is not currently available, but animal studies are reassuring. Aerosolized pentamidine is recommended for prophylaxis of Pneumocystis carinii pneumonia (PCP) in pregnant women with CD4 counts less than 200. This method minimized exposure of the fetus to potentially harmful substances but the risk of breakthrough PCP or infection outside the lung exists as it does for non-pregnant people with HIV disease.

Trimethoprim/sulfamethoxazole (Bactrim, Septra) is probably safe during the first and second trimesters but may cause severe jaundice (kernicterus) in the fetus if used during the third trimester. An HIV positive pregnant woman with a CD4 count between 200 and 500 should discuss with her health care provider the known and potential risks and benefits to herself and the fetus of treatment before starting any medications.

There is conflicting data as to whether or not there is an increased risk of transmission with vaginal delivery vs. Cesarean section. At this time, no firm recommendations can be made as to the mode of delivery. However, there are several recommendations aimed at potentially reducing the risk of transmission: avoiding the use of fetal scalp monitoring and blood sampling before delivery if possible; bathing the newborn before blood sampling or injections are given; and discouraging breast feeding by HIV positive mothers as HIV has been cultured from both colostrum ( the secretions from the breast during the first few days after delivery) and breast milk. Clearly, in developing nations where breast milk is the only readily available food for infants, this last recommendation is not applicable.

Vertical transmission or the transmission of HIV from mother to child before or around the time of birth now accounts for nearly all HIV infections in children. A large European study of children born to HIV positive mothers found that fourteen percent of the children were definitely HIV positive by eighteen months of age. This same study showed that infants who were breast- fed and/or born more than six weeks early were at greatest risk of becoming HIV positive. It is also suspected that women infected just before the time of delivery, may harbor larger viral loads and therefore may have a greater chance of passing the infection on to the infant just before or during delivery. There are no documented cases of transmission of HIV from mothers to their older children or other household contacts. Since a child receives some of its mothers antibodies before birth which may last until fifteen months of age, standard HIV antibody testing is not adequate for determining whether or not an infant is infected. Currently, culture of HIV and the polymerase chain reaction, two tests which detect HIV directly and are expensive and relatively difficult to perform, offer the best hope of early diagnosis. yet even these sensitive tests have failed to confirm HIV positivity in up to seventy percent of infants tested at birth leading researchers to believe that there is most likely an increase in viral replication sometimes after birth. recently, analysis of a subclass of antibodies to HIV shows that there many be a role for immunizing infants at birth with these protective antibodies in order to prevent replication of the virus.

The right to make choices about reproduction belongs to every woman. For HIV positive women, it is particularly important that decisions are based on comprehensive and accurate information. While barrier methods of contraception, particularly condoms, are most widely recommended by health care providers, surveys have shown that they are probably not the most desired by patients. Many women prefer oral contraceptive pills which have not been found to have significant interactions with AZT but which may diminish effectiveness when used with certain antibiotics such as rifampin ( a medicine used to treat tuberculosis). Although little information abut their use in HIV positive women exists, depo-provera and Norplant are most likely effective and safe. Intrauterine devices(IUDs) may predispose to infections such as pelvic inflammatory disease and therefore are not recommended for use in women with HIV disease. Considerations for tubal ligation are identical for all women regardless of their HIV status. While all methods of contraception provide protection against pregnancy, it is important to remember that only abstinence and latex condoms limit the transmission of HIV and other sexually transmitted diseases.

As the HIV epidemic continues, there is increasing awareness that the disease affects everyone regardless of gender, age, sexual orientation or socioeconomic status. While a cure for the disease may lie in the future, at this time only prevention can be based to the next generation.
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