HIV and mother-to-child transmission of the disease remain global problems.1 As of 2015, 36.7 million people worldwide were living with HIV.2 Worldwide, 6% to 20% of all maternal deaths are related to HIV, with the predominant association being infectious disease complications related to HIV.3 The estimated worldwide rate of mother-to-child transmission is 14%4 but is less than 1% in the United States due to the success of antiretroviral therapy (ART). In the United States, there is a perception that HIV has become less of a public health issue. The goal of elimination of mother-to-child transmission remains elusive, yet it has been attained in countries with fewer economic resources.5,6
There are several barriers to elimination of mother-to-child transmission such as lack of access to healthcare, family planning, HIV testing and preconception counseling.7 Significant racial and ethnic disparities are apparent. Infants born to African-American women with HIV are 50 times more likely than infants born to white women and 8 times more likely than Hispanic infants to be perinatally infected with HIV. These trends in the United States have not changed over the past decade.8
The complex cascade of interventions required to further reduce mother-to-child transmission relies heavily on the ob/gyn. The “Recommendations for Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States” (HIV Perinatal Guidelines) are updated regularly as new data emerge and provide the most comprehensive recommendations for care of women and babies.9 The goal of this article is to summarize the recommendations for care of pregnant women with HIV, highlighting recent changes in the guidance, which could bring us closer to our goal to eliminate mother-to-child transmission of HIV in the United States.
Preconception counseling: effective and safe conception
Many men and women with HIV desire children, but data suggest their providers fail to discuss family planning goals.10,11 A study of 181 women with HIV found that only 31% reported a personalized discussion with their provider about childbearing plans, and those conversations were typically initiated by the patient rather than the provider.12 Discussion about pregnancy desires should occur during routine appointments, including primary care, well-woman exams, and infectious disease visits. Based on these discussions, women can receive counseling either regarding safe methods of conception or appropriate contraceptive options.
A World Health Organization expert group reviewed evidence regarding drug-drug interactions and hormonal contraception and recommended that women with HIV can continue to use all existing methods without restriction.9 However, some forms of ART can interact with hormonal contraceptives, decreasing the efficacy of the contraceptives. This should be discussed and options reviewed with patients. Table 3 in the HIV Perinatal Guidelines lists these drug interactions based on the specific ART.9
Below are key components to reduce transmission in HIV-discordant couples (i.e., one partner is HIV-positive and the other
HIV-negative) that desire pregnancy:
- Couples should be tested and treated for other sexually transmitted infections before attempting conception.
- HIV-positive women contemplating pregnancy should be on an antiretroviral (ARV) regimen with a low risk of teratogenicity.
- HIV-positive partners should have a suppressed (undetectable) viral load prior to conception.8,13
- Pre-exposure prophylaxis (PrEP) should be offered for 30 days prior to and 30 days after attempting conception, or for as long as the risk of HIV acquisition persists, such as remaining sexually active without barrier protection with condoms.14,15 This is particularly important when the HIV-positive partner has not achieved viral suppression or the viral status is unknown.8
For HIV-positive women in a discordant couple, options include:
- assisted insemination at home or in a provider’s office with a partner’s semen during the peri-ovulatory period.9
- adding PrEP for the male partner as outlined above PLUS timed intercourse, which may further decrease the risk of HIV for her partner.15
For HIV-positive men, options include:
- artificial insemination with donor sperm from an HIV-uninfected man or with washed sperm coupled with PrEP for the female partner.15
- in vitro fertilization with washed sperm.15 It should be noted that recommendations about the need for semen preparation techniques may change as additional data about the efficacy of PrEP for serodiscordant couples emerge.
The authors report no potential conflicts of interest with regard to this article.
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