HIV In Pregnancy: Signs, Causes, Risks, Diagnosis, & Treatment

A woman can contract HIV during pregnancy through unprotected sex or infected body fluids (for example, infected blood could enter the body through an open wound). When HIV (human immunodeficiency virus) infects a person, it attacks the T helper cells (CD4 cells). These immune cells are white blood cells (T-lymphocytes) with CD4 receptors. Thus, when the virus enters the body, the CD4 cells signal the immune system.

If left untreated, HIV can result in AIDS (acquired immunodeficiency syndrome). Infected mothers can pass the virus to the baby through the placenta or through the blood and vaginal fluids at the time of labor and delivery. However, the baby’s risk of contracting HIV increases multifold if the amniotic sac breaks (water breaks) during labor. In such conditions, prompt prenatal treatment is essential to safeguard the mother and baby’s health (1).

Read about the tests, treatment, prenatal care, effects of HIV infection in pregnancy, and the ways to prevent spread to the baby.

How To Test HIV During Pregnancy?

All pregnant women are offered HIV tests during routine antenatal care. This testing will help begin the medical treatment to prevent the spread of HIV to the baby and plan delivery accordingly. HIV test is done along with antenatal blood tests that check complete blood count, blood group and Rhesus factor, hepatitis B, syphilis, and rubella.

The following tests help determine the HIV infection (2):

• Enzyme-linked immunosorbent assay (ELISA) detects antibodies to HIV in the blood. Usually, tests are repeated, or the Western blot test is used to confirm the diagnosis. If the ELISA test result is positive then it confirms the disease. In case of a negative result, other tests are not needed. However, there is a chance of false-negative results in the early weeks of infection.

• Polymerase chain reaction (PCR) detects the genetic material (RNA) of the HIV or HIV DNA in the infected white blood cells. This could be more useful to detect infection in the early weeks.

• An indirect fluorescent antibody (IFA) detects HIV antibodies under a microscope with special fluorescent dyes. This test can also be done to confirm the results of ELISA-positive cases.

• Home tests kits for HIV are also approved by the US Food and Drug Administration (FDA). These are done with swabs from cheeks or blood from fingers using a lancet. False-positive and false-negative results are common with home tests kits, so FDA recommends visiting a doctor for accurate results.

HIV tests are free of cost in most countries for pregnant women. If the results are positive, the treatment regimes are planned accordingly. It is also recommended to inform the sex partners about the positive test results and begin treatment before complications develop.

How Can Pregnant Women With HIV Plan Pregnancy?

Healthcare specialists offer consultation and counsel the HIV-positive couples or women who are pregnant or planning to have a baby, to understand the risks and special care required to continue their pregnancy.

The following recommendations are given for people with HIV planning to have a baby (3):

• Artificial insemination is recommended for HIV-positive women with an HIV-negative male partner to conceive.

• Sperm washing and artificial insemination are advised if the male partner is HIV-positive and the female is HIV-negative. The sperm washing procedure separates sperm cells (without virus) from the seminal fluid (that may carry the virus) with a machine. The washed sperm is inserted into the uterus using a special catheter.

• Seroconcordant couples (both partners with HIV) can take treatment to keep the viral load at undetectable levels before conceiving and throughout pregnancy to have an HIV-negative child. The risk for the baby to have HIV is almost zero if both parents are on treatment.

• HIV-positive male partners can take effective treatment to achieve undetectable viral load. There is no risk of transmitting the virus if the undetectable viral load is stable.

Initiation of treatment does not lower the viral load in the body. You may take the HIV medications prescribed by the healthcare provider and get the recommended tests to ensure the viral load has become undetectable before planning to conceive naturally.

Are HIV Treatments Safe During Pregnancy?

HIV medications are considered safe in pregnancy. Doctors may prescribe the treatment regime based on the risk vs. benefits.

HIV-positive mothers are recommended antiretroviral therapy (ART) throughout pregnancy to help prevent perinatal transmission (mother-to-child transmission) of HIV. These medications prevent the multiplication of HIV in the body and reduce viral load (amount of virus). The HIV treatments goal is to keep the viral load at undetectable levels. This may help reduce the risk of perinatal transmission during pregnancy and childbirth. These treatments can also keep the mother healthy.

The Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission recommends the following guidelines for the use of antiretroviral drugs during pregnancy (4):

• Dolutegravir (DTG) is a preferred antiretroviral (ARV) drug to treat HIV throughout pregnancy and for women planning to conceive. The risk for neural tube defects (NTDs) is low, and the once-daily dosing can help pregnant women achieve low viral loads.

• Ritonavir/lopinavir are not recommended for pregnant women due to the requirement of twice-daily dosing and its effects such as vomiting and nausea. However, this can be an alternative to ARV when there is an increased risk of preterm delivery and small for gestational age infants.

• Tenofovir alafenamide (TAF) can be used as an alternative to ARV in women who are HIV-positive or trying to conceive. This drug is also recommended to use in hepatitis B virus and HIV coinfection.

• Direct-acting antiviral agents for women with Hepatitis C infection and HIV coinfection should be considered on postpartum due to lack of safety data.

The choice of medication may vary depending on its effects on the fetus, previous treatments, viral load, and drug resistance tests. Pregnant women with HIV should continue HIV medicines during childbirth to prevent transmission.

Do Pregnant Women With HIV Need Additional Antenatal Care?

HIV-positive pregnant women require a multi-care approach to have healthy pregnancy and delivery. These approaches address the medical, social, and psychological issues related to pregnancy with HIV. A team of specialists, including obstetrician and HIV specialist, offer the below prenatal care (5):

• Parental counseling and support: Both partners can receive counseling support and other support from social agencies. Additional care is provided for women who require lifestyle counseling, such as for substance abuse. Most prenatal care can be continued to postpartum and later, depending on the programs and policies available in your country.

• Additional prenatal visits: Pregnant women living with HIV may require additional checkups and ultrasound scans to monitor the baby.

• Extra blood tests: The viral load, antibodies to CD4 cells, and the HIV drug levels in the blood are frequently measured throughout the pregnancy.

• Tests for infection: Pregnant women with HIV may also receive regular prenatal testing of rubella (German measles), syphilis, and hepatitis B like any other pregnant woman. In addition to these, tests for toxoplasmosis, chickenpox (varicella-zoster), and hepatitis C are also offered.

• Vaccinations: HIV-positive pregnant women can also receive whooping cough vaccines offered in pregnancy. In addition to these, doctors may offer flu vaccine (seasonal flu shot), pneumococcal vaccine, and hepatitis B vaccine (if no immunity) for HIV- positive pregnant women to prevent these infectious diseases.

• Vaginal swab tests: Pregnant women with HIV infection are tested for vaginal infections in early and later pregnancy to plan treatment and delivery. If the swab shows HIV viruses, the treatment is offered to reduce the risk of perinatal transmission.

• Down syndrome screening test: Pregnant women with HIV are also offered screening for Down syndrome like other pregnant women. The serum levels of certain factors (triple test) can show a high risk for Down syndrome in HIV-positive women compared to non-infected women. The results are interpreted by special fetal medicine units based on the HIV infection status and treatment to avoid unnecessary invasive procedures. However, maternal HIV infection is not associated with Down syndrome in the baby (6).
• Gestational diabetes screening: HIV-positive women on ART regimens from early pregnancy are at an increased risk of developing gestational diabetes mellitus (GDM). Early testing and treatment for GDM are recommended to avoid adverse pregnancy outcomes related to GDM.

With appropriate prenatal care and HIV treatment, an HIV-positive mother can have a healthy pregnancy and baby. You may talk to the doctor to know more about individualized prenatal care plans and postpartum care.

How Can HIV Affect Pregnancy?

HIV infection might affect pregnancy in the following ways (7):

• Prenatal infections: Pregnant women with untreated HIV infections are more vulnerable to opportunistic infections (infections affecting people with weakened immune systems) due to decreased CD4 cell counts.

• Congenital anomalies: Opportunistic infections such as toxoplasmosis and cytomegalovirus (CMV) can spread to the fetus through the placenta and result in congenital anomalies.

• Complications of ART Regimens: In utero exposure to some drugs can cause mitochondrial dysfunction in later life. Neural tube defects (NTDs) are often linked to antiviral treatment with dolutegravir. Treatment with protease inhibitors may result in preterm birth and ZDV (zidovudine), which can cause hematological abnormalities in the baby.

Doctors recommend taking HIV treatment during pregnancy since an untreated HIV infection has a higher chance to transmit to the baby during uterine life, delivery, or breastfeeding. HIV-related maternal infection can also affect pregnancy outcomes.

Which Mode Of Delivery Is Right For Pregnant Women With HIV Infection?

Obstetricians and HIV specialists may recommend the mode of delivery depending on the viral load. A scheduled C-section (cesarean delivery) is recommended for women with a high viral load that is more than 1,000copies/mL or unknown viral load near delivery. The likelihood of perinatal transmission of HIV can be lowered with a scheduled C-section, and it is often done two weeks before the expected due date on the 38th week of pregnancy (8).

C-section is not recommended for pregnant women who are on HIV medicines and have a low viral load. However, C-sections can be planned or done in an emergency due to other medical reasons. HIV-positive women with undetectable viral load can opt for a vaginal birth if they do not have any indications for C-section delivery.

How To Lower The Rate Of Passing HIV To The Baby?

Health care providers recommend the following ways to help reduce the risk of transmitting HIV to the baby (1):

• Treating HIV with antiretroviral therapy before conception and throughout the pregnancy to achieve undetectable viral loads.
• Performing cesarean delivery for mothers with high HIV viral load near the time of delivery
• Taking anti-HIV medication during labor and delivery.
• Providing HIV prevention treatment (HIV prophylaxis) in newborns with antiretroviral therapy
• Avoiding breastfeeding
• Avoiding pre-chewing the baby foods

According to the American College of Obstetricians and Gynecologists (ACOG), following these guidelines, 99% of HIV-infected women will not pass HIV to their babies (1). Although there is no evidence of lowering the transmission risk, the World Health Organization (WHO) mentions providing immune therapy and micronutrient supplementation for babies born to HIV-infected mothers (9).

How Is HIV Transmitted?

HIV is transmitted when the body fluids of an HIV-positive person with a detectable viral load come in contact with the bloodstream of another person.

These body fluids could be (10):

• Blood
• Vaginal fluids
• Semen and pre-seminal fluids
• Rectal fluids
• Breast milk

HIV in the body fluids can reach another person’s bloodstream through the following ways (10):

• Open cuts or sores
• Direct injection
• Mucous membranes in the vagina, the tip of the penis, rectum, or mouth

The most common ways of HIV transmission in the US are (10):

• Unprotected vaginal sex or anal sex (without using condoms) with the HIV-positive person can cause HIV infection. The risk is high if the HIV-positive person is not taking medications to treat HIV.
• Sharing injection drug equipment such as needles with HIV-positive person

Some less common ways of HIV spread in the US are (10):

• Mother-to-child transmission (vertical transmission) during pregnancy, birth, or breastfeeding. HIV treatment and other strategies lower the risk of perinatal HIV transmission to 1% or less in the US.
• Getting stuck with HIV-contaminated needles or other sharp objects can cause infection.

Extremely rare cases of HIV spread are (10):

• Oral sex with HIV- infected person
• Bitten by HIV-infected person if there is severe trauma with skin damage
• Receiving blood transfusions, organ transplants, or blood products or tissues contaminated with HIV
• Contact of broken skin, wound, or mucous membranes with HIV-infected blood or body fluids.
• Deep, open-mouth kissing if both people have mouth sores or bleeding gums.
• Eating food pre-chewed by an infected person can transmit HIV if the blood from the mouth mixes while chewing. Infants are known to get HIV from infected caregivers.

HIV-positive people following prescribed treatment regimes and having undetectable viral loads have no risk of sexually transmitting the infection to their partners. HIV is not spread through regular contacts such as hugging and shaking hands, closed-mouth (social) kissing, toilets, drinking fountains, mosquito bites, flies, ticks, air, and saliva. In addition, HIV cannot pass through healthy, intact (unbroken) skin (10).

What Are The Risk Factors For HIV Infection In Pregnancy?

High-risk behaviors such as having unprotected sex (without using condoms) and sharing needles with an HIV-positive person increase the risk for HIV infection in all population groups, including pregnant women.

Other risk factors may include (11):

• Sharing needle and other equipment during drug use
• Having sexually transmitted infections (STIs) such as syphilis, gonorrhea, genital herpes, genital warts, and chlamydia.
• Receiving blood, blood products, and artificial insemination that are not tested for HIV
• Undergoing unsterile cutting and piercing
• Having sex partners with high-risk behaviors

What Are The Signs And Symptoms Of HIV?

There are no specific signs and symptoms, and testing is the only way to confirm HIV infection. Usually, the HIV infection progresses into advanced stages if left untreated.

The signs and symptoms based on the stages of HIV infection are (12):

• Stage 1: Acute HIV infection

Some people may experience flu-like symptoms within two to four weeks after the exposure, called acute HIV infection. These symptoms can last a few days or weeks and often go unnoticed. Some may not even feel sick during this time.

Possible signs and symptoms of acute HIV infection may include:

• Fever and chills
• Skin rashes
• Night sweats
• Sore throat
• Swollen lymph nodes
• Mouth ulcers
• Muscle aches
• Tiredness

All these symptoms can also develop from other illnesses. It is recommended to seek healthcare provider’s advice if you are concerned about HIV exposure or symptoms. Viral loads can be high during acute infection, and HIV-infected people can be more contagious during this time.

• Stage 2: Chronic HIV infection

Chronic HIV infection can also be called clinical latency or asymptomatic HIV infection. In this stage, people may not have symptoms or get sick. Although the virus reproduces in lower levels, an infected person can transmit the virus to others.

This phase may last for longer, even years, or progress into the last stage faster without treatment. HIV-positive people on treatment may never progress into stage 3.

• Stage 3: Acquired immunodeficiency syndrome (AIDS)

AIDS is the most severe phase of HIV infection diagnosed when the CD4 cell count is below 200cells/mm. People with AIDS have severely compromised immune systems, making them vulnerable to opportunistic infections. This is also a highly contagious phase due to high viral loads. Without treatment, the survival rate can be about three years in people with AIDS.

Appropriate prenatal care and HIV treatment in pregnancy can help reduce the risk of perinatal transmission of HIV infection. Preconception care and planning pregnancy can help HIV-positive couples or women to have a baby without infection. However, the risk of transmission and other outcomes may vary based on individual response to treatment and resources.

References

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