With the advances in HIV care and treatment, many HIV+ women are living longer, healthier lives. As they think about the future, some of these women are deciding to have the babies they always wanted. HIV+ positive women who want to be come pregnant should discuss their plans with a doctor who is very experienced in treating women with HIV.

The good news is that the advances in HIV treatment have also brought down the rate of mother-to-child HIV transmission significantly. If the mother takes appropriate medical precautions, the rate of transmission can be reduced from 25 percent to below 2 percent. In addition, studies have shown that being pregnant will not make HIV progress faster in the mother.

• Find an obstetrician (OB) who is familiar with HIV care. He or she can explain your options for getting pregnant with as little risk to your partner as possible.
• Get screened and treated for sexually transmitted diseases
• Give up smoking, drinking and drugs. All of these can have a negative impact on your health and the health of your baby
• Start taking prescription pregnancy vitamins that contain folic acid and calcium while you are trying to become pregnant. This can reduce the rates of some birth defects.
• If friends and family are unsupportive or critical of your decision to have a child, put together a support network of people who are caring, non-judgmental, and well educated about HIV and pregnancy. Your network can consist of medical providers, counselors and other HIV+ women who are considering pregnancy or have had children.

Although HIV can be transmitted from mother to child with any viral load level in the mother, there is evidence that a low viral load decreases the risk. The best way to reduce viral load is through a combination regimen of HIV medications. Talk to your doctor about what medications to take in the best interest of your health and the baby’s health.

The U.S. government has put together guidelines to help HIV-positive women make treatment decisions. The guidelines can be summarized as follows:

All HIV-positive pregnant women should receive standard clinical and laboratory evaluations including

For HIV-positive pregnant women who havenever taken any HIV drugs– the standard 3-part AZT (or Retrovir) treatment (see below) is recommended. Women who have a viral load of more than 1000 or whose disease status requires HIV treatment, should be given the standard 3-part AZT treatment (see below) plus additional antiretroviral drugs according to treatment guidelines for non-pregnant women. Women who are in the first trimester of pregnancy may consider delaying therapy until after the first 10 – 12 weeks of the pregnancy. Women should be counseled that combination HIV drugs have been shown to be even more effective than AZT alone in preventing transmission of HIV from mother to child.

• For HIV-positive women already taking HIV drugs who learn they are pregnant after the 12^th week of pregnancy- Therapy should be continued with AZT included as part of therapy whenever possible.
• For HIV-positive women already taking HIV drugs who learn they are pregnant within the first 12 weeks of pregnancy- After patient-doctor discussions, continuation of therapy should be considered. If a decision is made to stop therapy, all drugs should be stopped at once; however, AZT should be given to the mother during delivery and to the infant from 8 – 12 hours after birth up until 6 weeks of age.
• For HIV-positive pregnant women who are in labor and havenever been exposed to HIV drugs– several choices are available for prevention of transmission of the virus

1. AZT given intravenously to the mother during labor and AZT for the baby for the first six weeks after birth
2. AZT and 3TC (Combivir) given orally to the mother during labor and 6 weeks of oral AZT+3TC for the baby
3. a single dose of Viramune for the mother at the onset of labor followed by a single dose of Viramune for the baby at 48 hours after birth
4. the single-dose Viramune regimen (above) for the mother and infant combined with AZT given intravenously to the mother during labor and AZT given to the baby for 6 weeks after birth

If single-dose Viramune is given to the mother, alone or in combination with AZT, consideration should be given to giving AZT+3TC (Combivir) to the mother starting as soon as possible (during or immediately after labor) and continuing for 3 to 7 days; this may reduce the possibility of the mother’s virus becoming resistant to Viramune.

In the period immediately after the birth of the baby, it is recommended that the mother have appropriate laboratory tests (e.g., CD4+ count, HIV viral load, and hemoglobin) to determine whether HIV treatment is recommended for her.

• For babies born to HIV-positive women who have never been exposed to HIV drugs prior to, or during labor
• Six weeks of AZT following birth should be offered to the baby
• AZT should be started in the baby as soon as possible after birth - preferably within 6-12 hours.
• Some doctors may recommend treating with AZT in combination with other anti-HIV drugs, particularly if the mother is known or suspected to have AZT-resistant virus. However, this therapy for preventing transmission of HIV to the baby has not been proven in clinical trials, and the appropriate doses for babies of many HIV drugs have not been determined.
• In the period immediately following labor, it is recommended that the woman have appropriate laboratory tests (e.g., CD4+ count, HIV viral load, and hemoglobin) to determine whether HIV treatment is recommended for her. The baby should have early HIV testing so that, if he or she is infected, treatment can be started as soon as possible.

Certain drugs, such as Sustiva and the liquid formulations of Agenerase and Norvir, and combinations of drugs, such as Videx (or ddI) and Zerit (or d4T), should be avoided because of possible side effects in the pregnant woman or her developing baby.  Talk to your doctor about these drugs if you are pregnant.

Standard 3-part AZT treatment for prevention of transmission of HIV from pregnant mother to child: 

1. AZT given as 300 mg twice a day (or 200 mg three times a day) throughout the pregnancy.
2. AZT given intravenously to mother during labor in a one-hour initial dose of 2 mg/kg body weight, followed by a continuous infusion of 1 mg/kg body weight/hour until delivery.
3. AZT syrup given to newborn infant at a dose of 2 mg/kg body weight every 6 hours beginning at 8 – 12 hours after delivery for the first 6 weeks of life. (If infant cannot take the syrup by mouth, the drug can be given intravenously.)

Special Considerations for HIVtherapy in Pregnant Women

1. Viramune (nevirapine) – Viramune has been associated with an increased risk for liver toxicity and rash, particularly in women with CD4 counts more than 250. Therefore, it is not recommended that Viramune be given to pregnant  HIV-positive women with CD4 higher than 250 unless the benefit clearly outweighs the risk.
2. Videx +Zerit - In some cases fatal cases of lactic acidosis have occurred in pregnant women receiving Videx plus Zerit along with other HIV drugs. Therefore, these two drugs in combination are not recommended for women who are pregnant.
3. Protease Inhibitors (PIs) – High blood sugar, development of diabetes, or worsening of already existing diabetes have been reported in  HIV-positive patients receiving PIs. Since being pregnant is itself a risk factor for these conditions; it is not known whether PIs will increase the risk for these conditions in pregnant women. Pregnant women taking PIs should closely watch their blood sugar levels.
4. Rescriptor , Sustiva – These drugs are not recommended for pregnant women or for women who are trying to become pregnant.
5. Agenerase liquid formulation– The liquid formulation of Agenerase contains propylene glycol which can be harmful to pregnant women and infants. However, women can take Agenerase capsules because they do not contain any propylene glycol.
6. Reyataz – Higher blood levels of indirect bilirubin are often seen in patients treated with Reyataz. It is not known whether Reyataz treatment during pregnancy will increase the risk of jaundice in the baby.
7. Crixivan – Levels of Crixivan are much lower in pregnant women than in non-pregnant women. Therefore, taking Crixivan as the only PI is not recommended  For HIV+ pregnant women.
8. Viracept – the dose of Viracept may have to be increased in pregnant women. Talk to your doctor if you are taking or planning to start taking Viracept.

9.       Hydroxyurea – hydroxyurea is not recommended for women who are pregnant or who are trying to become pregnant.

The U.S. government has developed guidelines to help HIV-positive women make treatment decisions. The guidelines can be summarized as follows:

All HIV-positive pregnant women should receive standard clinical and laboratory evaluation. The guidelines also recommend pregnant women take a resistance test if they:

• have never taken HIV drugs before
• are taking HIV drugs, but have a detectable viral load

To prevent transmission of HIV to the baby, it may be necessary for pregnant women to start or switch HIV drugs; a resistance test will help determine what drugs will work best for you.

For HIV-positive Pregnant Women who have not Received Previous HIV Drugs

The standard three-part Retrovir (zidovudine, AZT, ZDV) treatment (described below) is recommended. Women who have a viral load of more than 1,000 copies/mL or whose disease status otherwise requires HIV treatment, should be given the standard three-part Retrovir treatment plus additional HIV drugs according to treatment guidelines for non-pregnant women. Women who are in the first trimester (three months) of pregnancy may consider delaying therapy until after the first 10 – 12 weeks of the pregnancy; discuss the risks and benefits of this with your doctor.

The standard three-part Retrovir treatment for prevention of transmission of HIV from pregnant mother to child is:

1. Retrovir throughout the pregnancy
2. Retrovir intravenously to mother during labor and delivery
3. Retrovir syrup given to newborn infant beginning at six to twelve hours after delivery for the first six weeks

All HIV-positive pregnant women should be counseled that a combination of HIV drugs (usually three) has been shown to be even more effective than Retrovir alone in preventing transmission of HIV from mother to child.

For HIV-positive women already taking HIV drugs who learn they are pregnant after the first 12 weeks of pregnancy (First Trimester)

HIV drugs should be continued with Retrovir included as part of the drug combination whenever possible.

For HIV-positive women already taking HIV treatment who learn they are pregnant during the first 12 weeks of pregnancy (First Trimester)

Women should talk to their doctor about the benefits and risks of continuing HIV drugs during this time.An HIV-positive pregnant woman may decide to stop taking HIV drugs during her pregnancy, if so, all drugs should be stopped at once. Even if a pregnant woman decides not to take HIV drugs during the majority of her pregnancy, Retrovir should be given to the mother during delivery and to the infant after birth to prevent mother-to-child transmission.

Note on Viramune: The guidelines advise against the use of single-dose Viramune in pregnant women who are already taking an effective HIV treatment regimen, since adding Viramune in these cases won't further reduce the risk of a woman passing HIV to her baby and may cause the development of Viramune resistance in the mother.

For HIV-positive women in labor who have not taken HIV drugs

A woman in labor who has not taken HIV drugs can still reduce the risk of infecting her baby by using medication during labor and delivery and to treat the baby for a short time after birth. The U.S. guidelines recommend the following options for women in labor who have no history of taking HIV drugs:

1. Retrovir given intravenously to the mother during labor and Retrovir for the baby for the first 6 weeks after birth
2. Combivir (Retrovir plus Epivir) given orally to the mother during labor and 6 weeks of oral Combivir for the baby
3. A single dose of Viramune (nevirapine) for the mother at the onset of labor followed by a single dose of Viramune for the baby at 48 hours after birth*
4. The single-dose Viramune regimen (above) for the mother and infant combined with Retrovir given intravenously to the mother during labor and Retrovir given to the baby for 6 weeks after birth

*If single-dose Viramune is given to the mother alone or in combination with Retrovir, consideration should be given to treating the mother with  Combivir (Retrovir plus Epivir) starting as soon as possible (during or immediately after labor) and continuing for three to seven days; this may reduce the possibility of the mother’s virus becoming resistant to Viramune. In the period immediately after the birth of the baby, it is recommended that the mother have appropriate laboratory tests to determine whether HIV treatment is recommended for her.

For babies born to HIV-positive women who have not taken HIV drugs prior to, or during, labor

The recommended course of treatment is 6 weeks of Retrovir following birth which should be started in the baby as soon as possible after birth - preferably within 6 to 12 hours.

Importance of NOT interrupting HIV therapy during pregnancy

A recent study showed that interrupting HIV therapy during pregnancy increases the chances of transmission of HIV to the infant dramatically.  The risk of transmission is increased 4 to 14 fold, depending on when HIV treatment is interrupted.

HIV-positive women may want to avoid some of the more invasive prenatal tests, such as amniocentesis, chorionic villus sampling, and percutaneous umbilical blood sampling. Talk to your doctor about whether you need these tests.

There are two types of delivery: Cesarean section (C-section) and vaginal delivery. Elective or planned C-sections are done before labor begins and before the mother’s "water" (membranes that surround the baby) breaks. This reduces the baby’s contact with the mother’s blood.

Early studies showed that elective C-sections lowered transmission rates. (Emergency C-sections, i.e. those done after the membranes break, do not reduce HIV transmission.)

But today HIV-positive women who are on effective HIV therapy and have undetectable viral loads have low transmission rates for vaginal births without C-sections. Since C-sections require surgery, they carry some risks. Women who have C-sections are more likely to get infections than those who give birth vaginally.

For a woman on HIV therapy with a low viral load (less than 1,000), a C-section is not likely to further reduce her already low risk of transmitting HIV. But for a woman with a viral load over 1,000 or one who is not already receiving treatment at the time of delivery, a C-section may reduce the chances of transmission. Speak to your doctor about the pros and cons of each method of delivery.

Since a baby can be infected with HIV through breast milk, it is important not to breast feed if you have other options. You can still have a strong bond with your child even if you bottle feed.

Once the baby is born, he or she will receive 3 or 4 HIV tests before getting the final results after several months. During this time, the baby may need to take HIV medication and anti-pneumonia medication. This doesn’t mean the baby is sick; it is just a precaution to decrease the chances of transmission and illness.

Deciding to have a baby is a big step for any woman, but for an HIV-positive woman, it is even more complicated. Talk to your doctor and OB for "preconception" health care and counseling before you start trying to get pregnant. If you plan ahead, there are many things you can do to protect your health and the health of your new baby. 

1		Dole, P. (2003). Preconception issues in HIV. Numedx 5(1). 47.
2		Public Health Service Task Force. (2006). 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: Retrieved July 2006 from http://www.aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf
3		U.S. Department of Health and Human Service. (2006). HIV during pregnancy, labor and delivery, and after birth. AIDSInfo Fact Sheet: Retrieved July 2006 from http://aidsinfo.nih.gov/ContentFiles/Perinatal_FS_en.pdf
4		U.S. Food and Dug Administration. (2001). FDA/Bristol-Myers Squibb issues caution for HIV combination therapy with Zerit and Videx in pregnant women. FDA Talk Paper: Retrieved July 2003 from http://www.fda.gov/bbs/topics/ANSWERS/ANS01063.html.
5		Galli, Luisa et al.  Is the interruption of antiretroviral therapy during pregnancy an additional major risk factor for mother-to-child transmission of HIV Type 1? Clin. Infect. Dis. May 1, 2009, 48: 1310 - 1317  http://www.journals.uchicago.edu/doi/abs/10.1086/597774