Prenatal care and HIV treatment

Prenatal care is also called antenatal care. This covers all the extra care that you receive during your pregnancy in preparation for your baby’s birth.

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• Does every HIV-positive woman need to use treatment in pregnancy?
• What if I do not need treatment for my own HIV?
• What if I'm HIV-positive and need treatment for my own HIV?
• What if I discover I am HIV-positive late in pregnancy?
• What if I am already using HIV treatment when I become pregnant?

Prenatal care is not only about medicine and about tests. It includes counselling and providing information like this booklet. It also includes advice on your general health such as taking exercise and stopping smoking.

As with all aspects of HIV care, it is very important that members of your healthcare team have had specialist experience with HIV-positive women. This includes your obstetrician, midwife, paediatrician and other support staff.

It is also important that the people responsible for providing your care understand the most recent developments in preventing mother-to-child transmission and in HIV care.

Does every HIV-positive woman need to use treatment in pregnancy?

Every pregnant woman with HIV should strongly consider treatment during pregnancy, even if it is only used for a short time or just at the end of the pregnancy and stopped after the baby is born. This is to prevent transmitting HIV to the baby. This is regardless of the mother's CD4 count or viral load.

“Treat as non-pregnant adult” is advice generally given when caring for HIV-positive pregnant women who need treatment. However, treatment recommendations for pregnant women are slightly different than those for other HIV-positive adults.

Usually it is best once you start HIV treatment, you continue for the rest of your life. In pregnancy people often use treatment just for a period; then they stop.

What if I do not need treatment for my own HIV?

UK guidelines recommend starting treatment while your CD4 count is about 350 cells/mm3. Treatment is not usually recommended at much higher CD4 levels unless you have HIV related health problems.

However, studies show that HIV treatment can reduce the risk of transmission even with mothers who had low viral loads that are less than 1,000 copies/ml before they started treatment, (Transmission dropped from almost 10% in untreated women to less than 1% in women treated with anti-HIV drugs.)

As a result, treatment is offered to all HIV-positive pregnant women, even those with CD4 counts over 350 cells/mm3 who have never been on treatment before.

British HIV pregnancy guidelines recommend two options for women in this situation who have higher CD4 counts:

1. Use Short Term Triple Antiretroviral Therapy (START). With START, you begin treatment during the second trimester at 20 to 28 weeks, and then stop after delivery. You can choose to plan a C-section at 38-39 weeks or a vaginal birth.

2. Use AZT three-part monotherapy (as in the 076 study) and have a planned pre-labour C-section at 38 weeks.

You will need to recognise the benefits and risks of these two options. Discuss and consider the following very carefully until you are happy with the approach you are going to use:

Benefits of START:

• Using three drugs will reduce your viral load to undetectable
• You will have a choice over mode of delivery.

Risks of START:

• You and your baby will be exposed to a greater number of drugs, which may increase the risk of premature delivery.

Benefits of AZT/C-section:

• The risk of transmission is also low (less than 1%)
• You will use fewer drugs

Risks of AZT/C-section:

• Caesarean sections are major surgery and can carry additional risks for the mother.
• A very low risk of developing resistance to AZT

The second option is only suitable for women with a high CD4 count and a low viral load who would not need to use ARV treatment for several years.

Choosing START does not mean you will definitely not have a C-section. You may need to for other obstetric reasons.

What if I'm HIV-positive and need treatment for my own HIV?

Guidelines currently recommend that all HIV-positive people with CD4 counts under 350 cells/mm3 should be on treatment, including pregnant women. Treatment will also depend on when in your pregnancy you are diagnosed with HIV.

You may only find out that you are HIV-positive when you are already pregnant. As mentioned earlier, this can be a very difficult time practically and emotionally. Ask for extra support if you need it.

If you are diagnosed early on in your pregnancy, you may wish to delay starting treatment until the end of the first trimester. This is the first 12 to 14 weeks from your last missed period. You may also want to delay treatment over this period if you already know your HIV status but have not yet started treatment.

There are two main reasons for delaying treatment.

• The first is that the baby's main organs develop in the first 12 weeks in the womb. This is called organogenesis. During this time the baby may therefore be vulnerable to negative effects from any medicines, including anti-HIV drugs.
• Studies have not shown any increased risk to babies whose mothers have used HIV treatment during the first trimester, compared to those who did not use treatment in this period. But some women and their doctors may still prefer to delay treatment.
• A second reason to delay treatment is that most women will experience nausea or “morning sickness” in the early stage of pregnancy. This is very normal. But symptoms of morning sickness are very similar to the nausea that can occur when starting HIV treatment. You do not want (or need) to have both at the same time.
• This can also make adherence harder. If you feel rough because of morning sickness, you are unlikely to want to take any treatments that increase this nausea. And if you are unlucky and get bad morning sickness or are being sick, this could cause problems with missed doses which may lead to the treatment failing and the development of resistance to anti-HIV drugs.
• If morning sickness continues after the first trimester, you and your doctor should take this seriously as it could signal other problems.

If you want to begin treatment immediately, or need to start urgently because you have a low CD4 count, your doctor will recommend it.

What if I discover I am HIV-positive late in pregnancy?

Even late in pregnancy, there is still a benefit to using treatment. Even after 36 weeks, it can reduce your viral load to very low levels.

Treatment for one week with combination therapy can reduce your viral load very quickly by a large amount and some anti-HIV drugs reduce the risk of HIV transmission by crossing the placenta to the baby and blocking the infection, regardless of the amount of HIV in the mother’s blood.

Which drugs should I use?.

What if I am already using HIV treatment when I become pregnant?

Many women decide to have a baby when they are already on therapy. This speaks volumes about the tremendous advances made with HIV drugs.

Women feel better. They are healthier. They are thinking about long-term relationships. They are thinking about a future and possibly a family.

It is now increasingly common for women who conceive while they are on treatment to continue on treatment throughout their pregnancy.

Studies have not shown any increased risk to the mother or baby from using continuous treatment throughout the pregnancy.

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This is the web edition of the i-Base guide HIV, pregnancy & women's health. This guide is available in UK clinics. You can order free printed copies or download a PDF version (364 Kb). There are also several translations.

Information on this website is provided as a guide only. All treatment decisions should be taken in consultation with your doctor or other healthcare professional. Authors and credits. Full section index. Glossary.