Due to advances in HIV care and treatment, many women living with HIV (HIV+ women) are living longer, healthier lives. As HIV+ women think about the future, some women are deciding to have the babies they always wanted.

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, including taking HIV drugs, the rate of transmission can be reduced from about 25 percent to below 2 percent. In addition, studies have shown that being pregnant will not make HIV progress faster in the mother.

It is important to plan carefully before getting pregnant:

• Discuss your plans with your HIV doctor to make sure you are on the right treatment for your own health and to reduce the risk of transmitting HIV to your baby (more about this in the next sections).
• 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.
• Ask your HIV doctor and your OB to communicate and coordinate to insure you receive appropriate care before and during your pregnancy.
• Get screened and treated for sexually transmitted diseases (STDs).
• 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.

HIV drugs can reduce the risk of transmitting HIV from mother to baby. For this reason HIV drugs are recommended for all pregnant women regardless of CD4 count and viral load. Even if the mother does not need HIV treatment for her own health, it is important for her to take HIV drugs to lower the risk of transmission. The drugs need to be taken just as they are prescribed to have the best chance of working. (See TWP sheet on adherence for more info.)

A group of experts on pregnancy in women with HIV has developed pregnancy guidelines to help HIV+ women and their doctors make treatment decisions. The first step is to have a thorough check up, including blood tests, to find out about your health and the status of your HIV infection. A resistance test can also help you and your doctor choose the best drugs to take. The guidelines 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

There are certain HIV drugs that should be avoided or used with caution because of possible side effects in the mother or the developing baby. Some examples are Sustiva (efavirenz) and the combination of Videx (didanosine or ddI) and Zerit (stavudine or d4T). Viramune (nevirapine) is not recommended for first-time treatment in HIV+ pregnant women with CD4 cell counts over 250. Discuss the risks and benefits of the HIV drugs with your doctor so that you can decide which treatments are best for you and your baby.

Deciding when to start treatment depends on your own health and when you find out you are pregnant. The pregnancy guidelines make the following recommendations:

1. If it is determined that HIV treatment is needed for the health of the woman, she should receive a combination of HIV drugs based on treatment guidelines for non-pregnant adults. Retrovir (zidovudine or AZT) should be used as one of the drugs in the combination if possible. HIV treatment should start as soon as possible, including in the first trimester (three months) of pregnancy.
2. HIV+ pregnant women who do not need HIV treatment for their own health should also receive HIV treatment to prevent mother-to-child transmission. Retrovir should be used and, in most cases, combined with other HIV drugs. Women in the first trimester may consider waiting to start the HIV drugs until after the first 10 – 12 weeks of pregnancy. After the birth of the baby, the mother should be evaluated to see if she needs to continue HIV treatment for her own health.

In both of the above cases, HIV drug treatment should continue during labor and delivery. At that time, the Retrovir should be switched to intravenous (IV) administration. The baby should receive liquid Retrovir for 6 weeks.

Continue current HIV drugs if they are working well to control the virus. If the drugs are not working, switch to a more effective combination. Retrovir should be used as one of the drugs in the combination if possible. The drugs should be continued during labor and delivery, during which time IV Retrovir should be given to the mother. The baby should receive liquid Retrovir for 6 weeks.

A woman in labor who has not taken HIV drugs can still reduce the risk of infecting her baby by using HIV drugs during labor and delivery and to treat the baby for a short time after birth. The guidelines recommend the following options:

1. IV Retrovir for the mother during labor and liquid Retrovir for the baby for 6 weeks after birth.
2. Single-dose Viramune for the mother at the beginning of labor and IV Retrovir during labor. Consideration should be given to adding Epivir (lamivudine or 3TC) during labor and continuing Retrovir and Epivir for 3-7 days. This may reduce the possibility of the mother’s virus becoming resistant to Viramune. The baby receives single-dose Viramune plus liquid Retrovir for 6 weeks.
3. IV Retrovir given to the mother during labor and liquid Retrovir plus additional drugs for the baby. However, it is unclear if this strategy further reduces the risk of transmission.
   

After the baby is born, it is recommended that the mother be evaluated to determine whether HIV treatment is recommended for her.

The baby can still receive treatment to reduce the risk of transmission. The guidelines recommend the following options:

1. Liquid Retrovir given to the baby for 6 weeks, started as soon as possible after birth.
2. Liquid Retrovir, plus additional drugs, given to the baby. However, it is unclear if this strategy further reduces the risk of transmission.

After the baby is born, it is recommended that the mother be evaluated to determine whether HIV treatment is recommended for her.

HIV+ women may want to avoid some of the more invasive prenatal tests, such as amniocentesis, chorionic villus sampling (CVS), and percutaneous umbilical blood sampling. Talk to your doctor about whether you need these tests. Certain procedures during delivery, such as invasive monitoring and forceps- or vacuum-assisted delivery, should be avoided if possible.

There are 2 types of delivery: Cesarean (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 and may reduce the risk of transmission in certain cases. 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. C-sections are recommended for HIV+ pregnant women whose:

• Viral load is unknown or is greater than 1,000 copies at 36 weeks of pregnancy
• Have not taken any HIV drugs or have only taken Retrovir during pregnancy

For a woman on combination HIV treatment 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. The decision of which type of delivery is most appropriate should be discussed with your doctor early in your pregnancy.

The baby will receive several HIV tests during the first 6 months of life. The test results will give you a good idea of whether your baby is infected or not. A definitive test is done at 12-18 months to make the final determination.

During the first few months, the baby will 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.

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.

Deciding to have a baby is a big step for any woman, but for an HIV+ 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.

One final note: Researchers are interested in learning more about the effects of HIV drugs during pregnancy. HIV+ pregnant women are encouraged to register (through their doctors) with the Antiretroviral Pregnancy Registry at http://www.APRegistry.com.