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HIV, pregnancy, mothers and babies

Can HIV be transmitted from a mother to her baby?

An HIV positive woman can transmit the virus to her baby during pregnancy, labour and delivery, and through breastfeeding. If she takes no preventive drugs and breastfeeds then the chance of her baby becoming infected is around 20-45%.

Can this risk be reduced?

Modern drugs are highly effective at preventing HIV transmission during pregnancy, labour and delivery. When combined with other interventions, including formula feeding, a complete course of treatment can cut the risk of transmission to below 2%. Even where resources are limited, a single dose of medicine given to mother and baby can cut the risk in half. AVERT is currently running a campaign to ensure that all women have access to these drugs.

Planning ahead

Advantages of a planned pregnancy

A woman who knows that she or her partner is HIV positive before she becomes pregnant is better able to plan ahead. If she does not want to have a child then she should consider effective contraception. If she decides to become pregnant then early interventions may be able to help protect her, her partner and her baby. Doctors will be able to advise which interventions are best suited to her situation, and whether she should adjust any treatment she is already receiving.

Pregnancy does not make a woman's own health worse in respect of HIV.¹ Being pregnant may cause her CD4 count (see below) to drop slightly, but it should return to its pre-pregnancy level soon after her baby is born.

Protection at conception

An HIV positive woman with an HIV negative partner can become pregnant without endangering her partner by using artificial insemination (the process by which sperm is placed into a female's genital tract using artificial means rather than by natural sexual intercourse). This simple technique provides total protection for the man, but does nothing to reduce the risk of HIV transmission to the baby.

If the man has HIV then the only effective way to prevent transmission is sperm washing. This involves separating sperm cells from seminal fluid, and then testing these for HIV before artificial insemination or in vitro fertilisation. Sperm washing is a very effective way to protect both the mother and her baby, but it is only available at a few clinics and can be difficult to access, even in well resourced countries.

When both partners are HIV positive, it might still be sensible for them not to engage in frequent unprotected sex, because there might be a small risk of one re-infecting the other with a different strain of HIV.

If a couple do decide to try conceiving a child by unprotected sex then they should seek advice on how to limit the risk to each other and to their baby. It is worth noting that someone is less likely to transmit HIV if they are receiving effective antiretroviral treatment, and also if neither they nor their partner has any other sexually transmitted infections. In addition, by limiting unprotected sex to the time of ovulation, a couple can reduce the number of opportunities for HIV to be transmitted between them.

The rest of this page is written from the point of view of a woman who knows she is HIV positive and pregnant.

What drugs should I take and when should I take them?

The drugs that can prevent HIV being passed from a mother to her baby are called antiretroviral (ARV) drugs. ARVs are the drugs that are also taken by HIV positive women who are not pregnant, to prevent them from becoming ill.

The most important time for an HIV positive pregnant woman to take ARVs is during labour. Depending on your particular circumstances it may be suggested that you take ARVs at other times as well.

Which ARVs should I take?

Deciding exactly which ARVs to take and when to take them can be quite difficult, because there is a need to balance a number of different things including:

1. Your health as an HIV positive pregnant woman
2. Reducing the risk of HIV being passed from you to your baby
3. The possibility of you having side effects if you start taking drugs
4. The possibility of drugs causing harm to your baby.

There may also be a difference between which drugs you would ideally take and which ones it is actually possible for you to take, as there is considerable variation worldwide in the cost of ARVs and their availability.

How do I know if I need treatment for my own health as an HIV positive woman?

There are two tests, the CD4 test and the viral load test, that can help you and your doctor decide whether you need treatment for your own HIV infection. The CD4 test tells you how much HIV has weakened your immune system, and most HIV positive pregnant women should be able to have a CD4 test. The viral load test tells you how much HIV is in your blood. A pregnant HIV positive woman with a low viral load is less likely to have an HIV positive baby than a woman with a high viral load. Viral load tests may not be available to all women because of the cost.

If you have a high CD4 count (exactly how high depends on your exact circumstances and which country you are in), this means that you still have a strong immune system. Your health care provider will probably recommend that you do not need to start taking drugs for your own HIV infection but will probably advise that you do start taking drugs to prevent HIV infection in your baby. A high viral load measurement means that you have a lot of HIV in your blood and you probably do need treatment yourself.

AVERT.org has more about CD4 and viral load tests.

I don’t need treatment for my own HIV infection. Which ARVs should I take to prevent my baby being infected?

Taking Zidovudine

If the drug Zidovudine (also known as AZT or ZDV) is available it will often be suggested that you take it. This is because AZT has been shown to be particularly useful for preventing HIV from being passed from a mother to her child. AZT is usually taken two or three times daily, starting after the first trimester sometime between 14 to 34 weeks of pregnancy, as well as being taken during labour.

The first trimester

The first trimester is when the first stage of your baby’s development takes place. Delaying starting drug treatment until after the first trimester means in practice delaying until 12 to 14 weeks from the date of your last missed period. The main reason for delaying treatment until after the first trimester is that the baby’s main organs develop in the first 12 weeks in the womb. And this is the time the baby may be particularly likely to suffer negative effects from any drugs the mother takes.

Combination therapy

If a number of different ARVs are available then it will probably be recommended that you take other drugs at the same time as AZT as combination therapy. Drug combinations will usually be even more effective at lowering a woman’s viral load, and so will be more effective in preventing transmission from mother to child.

AZT monotherapy

Some women with a low viral load may not wish to take several drugs during pregnancy, because of concerns about the effect that this may have on their baby, and so they may choose to take AZT on its own as monotherapy. Taking one drug on its own means that the HIV in your body may become resistant to the drug, and the drug will then stop working. It can also mean that other similar ARV drugs will also not work. But drugs differ in the length of time you can take them for before you become resistant to them, and if you have a low viral load the risk of becoming resistant to AZT when just taken during pregnancy is probably very small.

If only a limited number of drugs are available then AZT monotherapy from 28 weeks of pregnancy is likely to be recommended, with single dose nevirapine and AZT being taken during labour.

Stopping the drugs

If a woman is on combination therapy purely to prevent mother to child transmission (MTCT) then she can stop taking the drugs after her baby is born. Generally when drugs are discontinued after the birth of the baby all the drugs should be stopped at the same time. But it is also important that you stop them in such a way that you limit the amount of time that you have just one drug in your body, to limit the development of resistance. Sometimes it will be recommended that you take a combination including a protease inhibitor, since these drugs are less likely to cause resistance. Your health care provider will be able to advise you on how to stop taking your drugs.

Nevirapine

If a woman has a high CD4 count (above 250) and is taking combination therapy purely to prevent transmission to her baby then she will probably be advised not to take the drug nevirapine (NVP) as part of the combination, as taking NVP could cause an increased risk of side effects for the woman. But although NVP is not suitable in these circumstances, at other times it can be very useful. If there are only a few ARVs available where you live then it is likely that one of them will be NVP, and taking NVP on its own during labour will help to prevent HIV being passed to your baby. AVERT.org has more about single dose nevirapine in our mother to child transmission page.

I do need treatment for my own HIV infection. Which ARVs should I take to prevent my baby being infected, as well as to protect my own health?

You may well wish to delay starting treatment until after your baby’s first trimester, for the same reasons that you delay if you don’t need treatment for your own infection.

When you do start taking treatment there are many different ARV drug combinations that your healthcare provider might recommend. The recommendations are likely to be similar to those they would make if you were not pregnant, but they will take into account the need to avoid any drug that might have an adverse effect on your baby even after the first trimester of its development.

It will often be recommended that you take the drug AZT as part of the drug combination. This is because of the proven effect AZT has in preventing HIV being passed from a mother to her child. AZT is started at between 14 to 34 weeks of pregnancy, and you also take it during labour, as you would if you did not need treatment for your own HIV infection.

If there are very few drugs available where you live then you can take a single dose of NVP during labour to reduce the chances of your baby becoming infected, but you must not take it on its own at any other time. If you take it on its own it will not help your own health - you will just become resistant to it in only a few days, and then it will not work if you want to take it during labour to protect your baby. AVERT.org has more about single dose nevirapine in our mother to child transmission page.

If I suddenly go into labour and I am not taking any ARVs, are there any drugs I can take to help my baby?

There are several ARVs you can start during labour. You can take AZT, or you can take AZT combined with either the drug 3TC or with NVP. If AZT is not available then you can take a single dose of NVP on its own.

Which drugs should my baby take?

If an HIV positive woman is taking AZT then it will probably be recommended that her baby is given AZT (usually as a syrup) for the first six weeks of its life starting 8-12 hours after birth. Alternatively, if the mother has taken AZT and 3TC during labour then an effective regime for the baby would be one week of AZT and 3TC.

If only limited AZT is available then one week of AZT can be given to the baby. If only single dose AZT is available then the baby can have this combined with a single dose of NVP, and if no AZT is available then the baby can have a single dose of NVP to help protect it.

Is it really safe to take HIV drugs during pregnancy?

Pregnant women are often advised not to take any medications during their pregnancy, so it can seem strange that HIV positive women are advised to take ARVs when pregnant. But many thousands of women have taken HIV drugs during pregnancy without it causing harm to their babies, and it has resulted in many babies being HIV negative who might otherwise have been infected. The health of many HIV positive women has also been improved as a result of them taking ARVs during pregnancy.

But it cannot be guaranteed that HIV drugs taken when a woman is pregnant will not harm her baby. And if a woman is not already taking ARVs then as explained above she will probably be advised to wait until after the first trimester before starting treatment.

Doctors around the world are collecting together information about the effect of different drugs taken during pregnancy, in order that they can advise women on the best ARVs to take.^{2 3} There is currently some conflicting data as to whether taking ARVs during pregnancy is associated with adverse pregnancy outcomes such as preterm delivery.⁴

I’m already on antiretroviral drugs and now I've found out I'm pregnant - what should I do?

Sometimes an HIV positive woman who is already on treatment will find out that she is pregnant. If this happens you should seek advice from your health care provider, because your doctor may suggest that you change one or more of the drugs you are taking in order that you don’t harm your baby. It is usually not a good idea to come off or change your therapy before seeing your doctor. If you stop treatment suddenly during pregnancy then your viral load may suddenly increase, and this could increase the risk of your baby becoming infected with HIV. Stopping treatment also needs to be done carefully in order to prevent the development of resistance.

If your pregnancy is identified after the first trimester then it will usually be recommended that you continue with your ARV therapy. If it is feasible, it is likely to be recommended that this includes the drug AZT, and it will also be recommended that you take AZT during labour. If your pregnancy is identified during the first trimester then you may wish to consider temporarily stopping ARV therapy, but your really do need specialist advice as some drugs are of more concern than others when taken during pregnancy.

What else can I do to prevent my baby becoming infected with HIV?

Is a pre labour caesarean section (PLCS) better than a natural vaginal delivery?

A caesarean section is an operation used to deliver a baby through its mother’s abdominal wall. When a mother is HIV positive it is done to protect the baby from direct contact with her blood and other bodily fluids.

But recent research suggests that with many women now taking ARV combination therapy during pregnancy, having a caesarean isn’t a significant factor in preventing the transmission of HIV from mother to baby. So unless you are ill with HIV or have a detectable viral load it usually won’t be recommended by your health care provider, as having a caesarean does itself have some risks for the woman. One exception to this is if you are taking AZT on its own, when a PLCS may still be recommended.

Should I breastfeed?

HIV is found in breast milk, and if you do breastfeed there is a significant chance of passing HIV to your baby. So if you have access to safe breast milk substitutes (formula) then you are advised to not breastfeed.

But if you live in a country where safe water isn’t available, the risk of life-threatening conditions from formula feeding may be higher than the risk from breastfeeding. Formula can also be too expensive to use regularly in some countries. If you are in this situation it is better to feed your baby breast milk alone.

Mixed feeding is when a baby is fed with breast milk and other liquids such as formula, glucose water, gripe water or traditional medicine. It is now thought that there is a higher risk of a baby becoming HIV positive from mixed feeding than exclusive formula feeding alone or breastfeeding. Mixed feeding may damage the lining of the baby’s stomach and intestines making it easier for HIV in breast milk to infect the baby.

What's this?

WHERE NEXT?

AVERT.org has more about:

• Transmission and testing
• Mother-to-child transmission
• Breastfeeding & HIV
• The AVERT Stop AIDS in Children campaign