HIV in Pregnancy

March 1^st is international Zero Discrimination day for HIV led by the United Nations. HIV remains of global concern, with many lacking the access to life-saving antiretroviral treatment. In this article Professor Yvonne Gilleece, Honorary Clinical Professor and Consultant in HIV and Sexual Health, Brighton & Sussex Medical School and University Hospitals Sussex NHS Foundation Trust, Brighton, writes of the importance of appropriate testing and care for those living with HIV during pregnancy, birth and beyond.

HIV in Pregnancy

Worldwide more than half of the 40 million global population of people living with HIV are women. People living with HIV can expect to have a near normal life expectancy if they have access to lifelong combination antiretroviral treatment (cART) once diagnosed. Many women living with HIV are adolescent girls and young women of childbearing potential, and live in countries where healthcare, including contraception and family planning, as well as HIV care and education, are not easy to access. In addition there are now transgender people living with HIV who are also having pregnancies. The passing of HIV from a pregnant person with HIV to their baby is called vertical or perinatal transmission and it is largely preventable. With no intervention, the vertical transmission of HIV can be as high as 25-30%. But because we know it mostly occurs during labour and delivery there are many things we can do to reduce the risk of this happening.

The incidence of vertical transmission of HIV in the UK is at its lowest ever at 0.27% for all delivering with HIV, and even lower at 0.14% for those on effective cART. But not all people living with HIV globally can access free HIV treatment and care the way we can in the UK.

Importance of HIV testing

So what can we do to help people living with HIV deliver as safely as possible? Firstly we need to diagnose HIV before delivery as this gives us time to put things in place to reduce HIV transmission risk from parent to baby. This should be done at booking for all those who are pregnant and, if it isn’t clear it has been done, then an HIV test should be performed. Opt Out HIV testing works really well in the pregnant population as they are very protective of their baby’s health. The highest risk of transmission is in those who have not been tested. But it is really important to note that even when someone presents in labour with untreated HIV there are still many things we can do to reduce or stop HIV transmission. Therefore anyone in labour without a documented HIV test should be urgently tested. Remember, this could change a baby’s life.

When I first speak with someone living with HIV who wants to conceive I talk to them about the following interventions which, when combined, work really effectively to reduce HIV transmission to their baby:

Starting on good HIV treatment if not already on it;
How we will manage their labour;
Avoidance of breast feeding unless their HIV treatment means the level of the HIV virus in their blood (HIV viral load) is undetectable;
Giving the baby HIV treatment for 2-4 weeks after delivery.

HIV viral load is the most important determinant of whether or not a baby will acquire HIV. We have known since 1994 that HIV treatment can reduce the chance of passing the virus on to the baby. Now we have even better HIV treatment but it is not yet universally available to all who wish to conceive or who are pregnant. This is really the key thing we need in order to manage all HIV pregnancies as safely as possible.

Is vaginal birth safe?

I work with my obstetric and paediatric colleagues to help each pregnant individual to safely plan how they want to deliver. If a patient living with HIV is on effective cART they can aim to have a normal vaginal birth unless there is an obstetric reason not to. Labour should be managed in the standard way, apart from starting antiobiotics, and going to labour ward when rupture of membranes (ROM) occurs. Forceps or ventouse may be used to help delivery and fetal scalp monitoring or blood sampling can be performed if clinically indicated.

If not on treatment, or where the viral load is not known, then ROM duration greater than 4 hours causes a significant increase in risk of HIV transmission to the baby. This again shows how important it is know that your patient has had an HIV test which is negative before labour. Elective caesarean section (C-section) as late as possible, and after 39 weeks, or emergency section is recommended in women with an unknown or high HIV viral load as this can reduce HIV risk to the baby. HIV emergency treatment can also be given in labour which again can protect the baby.

Breastfeeding

Breastfeeding remains a very controversial topic in the context of HIV, even now that we have effective treatment for HIV in pregnancy and the post partum period. In the UK we not only have the luxury of access to HIV treatment but often also to free formula milk. Therefore we recommend first line that breastfeeding is avoided by individuals living with HIV. In many countries globally, however, there may be no free formula milk available and therefore there may be no choice about whether or not to breastfeed.

In this context breastfeeding is safe as long as the parent is on effective HIV treatment. In addition, in some cultures, not breastfeeding can be like a neon sign indicating that they may be HIV positive. Therefore, for confidentiality reasons, someone may choose to breastfeed their baby. Because of global data we have learnt that individuals with HIV may be supported to breastfeed their babies if on good treatment for a maximum of 6 months. Solid food must be avoided until after breastfeeding has stopped. HIV transmission risk during breastfeeding may change if mastitis or gastroenteritis occur or if the baby becomes unwell with vomiting and diarrhoea. Therefore multidisciplinary input and support at this time is hugely important for both parent and baby.

Treatment for baby

All babies born to pregnant persons living with HIV will receive post exposure prophylaxis (PEP) HIV treatment for 14-28 days and this must be given within 4 hours of delivery to work properly. PEP treatment will be planned in advance. The baby will be tested at birth, and then twice more after finishing PEP, which is usually by 3 months. Although there is still a final test at 22-24 months, the HIV status of the baby can usually be confirmed by the first 3 tests. It is really important to keep parent and baby in regular care during this time.

Peer mentors can also be hugely supportive during pregnancy and after delivery but may not be available in all units where HIV deliveries are happening.

All the HIV and obstetric care I have described is what will happen in an ideal situation when healthcare is free and easily accessible. Even with all these interventions HIV treatment in pregnancy can be very complex but will be even more so without access to good HIV care, obstetric care, paediatric support and HIV treatment. However, managing a newborn baby with a new HIV diagnosis is even more complex but is, as I hope I have convinced you, completely avoidable.

Access to care

So how can we all help? We must support our global colleagues in their effort to provide safe and effective care for their patients. Also we must ensure that all prospective parents have a negative HIV test documented in their antenatal notes as everything else recommended follows on from this. Also you may have noticed that instead of saying women I have talked about individuals, parents or pregnant people living with HIV. This is because transgender people living with HIV are increasingly conceiving with HIV. They have to date not been considered when writing guidelines for HIV in pregnancy but we must not continue to marginalise this group.

Thank you for taking the time to read this blog. If you would like to learn more there are lots of resources available online (see below) but also your nearest HIV clinic may be able to provide further education sessions for your department.

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