Listen up, HIV positive ladies: As long as you're on the right treatment during pregnancy, you have only about a 2% chance of passing the virus on to your child. All you need to do is take care of yourself, get good prenatal care and avoid risk factors that can complicate your pregnancy. "Being prepared for a pregnancy is the best gift parents can give to their baby," says Brown University obstetrics and gynecology professor Susan Cu-Uvin, MD, who treats HIV positive women at the Miriam Hospital in Providence, Rhode Island.
Whether you're pregnant, working on it or just want to be ready if a baby is in your future, the best place to begin is an honest discussion with your doctor about your health as well as any thoughts about having a baby. Not all doctors are supportive or have the HIV smarts to help you with the care you'll need. So if you need to switch HIV docs or find an obstetrician-gynecologist (ob-gyn) who has experience working with positive women, ask your local AIDS service organization (ASO) for recommendations or check the AIDS Services Directory at www.directory.poz.com.
Goal One: Get Healthy
If you're not taking good care of yourself, now's the time to start. "Regardless of HIV status, healthy women are needed for healthy babies," says Vicki Cargill-Swiren, MD, who directs minority research and clinical studies at the National Institutes of Health's Office of AIDS Research.
With your doctor's help, you'll need to make sure that you're on top of existing health problems, such as diabetes and high cholesterol, that can be made worse by taking certain HIV meds during pregnancy and increase the risk of complications. Treating sexually transmitted diseases is important too. One study showed that women diagnosed with genital herpes during pregnancy were nearly five times more likely to transmit HIV to their babies.
Your doctor and ob-gyn can also give you advice about maintaining your overall good health through diet and exercise. Drinking alcohol, smoking and doing drugs can cause serious problems for your baby. And raw foods, like meat, seafood and eggs, may pose a double danger since they can contain germs that are risky for both pregnant women and people with compromised immune systems.
Checkups for HIV positive moms-to-be should include the same basic tests that negative women get. But skip any unnecessarily invasive tests, such as amniocentesis or scalp monitoring during labor, since these can increase the risk of HIV transmission (ultrasound is safe). Get your viral load and CD4 count tested before you become pregnant and then often as the big day approaches. Having an undetectable viral load is the best way to make sure your baby doesn't get HIV. If your viral load isn't there yet, talk to your doctor about starting, adding or switching meds.
And don't forget about eating a diet (or taking supplements) rich in folic acid, iron and vitamin A, which can help prevent certain types of birth defects and other problems.
Finding a baby-safe drug regimen is the most important defense against giving HIV to your child. Pregnant moms need to safely lower their viral loads as much as possible: A low viral load reduces the risk of babies coming into contact with maternal blood and other fluids that contain HIV.
But aren't all those powerful antiviral medications dangerous for the baby? There is some concern about preterm births, but study results have been encouraging. According to a recent report form the Antiretroviral Pregnancy Registry, which tracks side effects among babies exposed to HIV drugs during pregnancy, birth defects were no more likely to occur among babies exposed to HIV drugs during the first trimester of pregnancy (the most vulnerable period) than among babies born to HIV negative moms. Of course, certain HIV meds are dangerous for both pregnant mom and baby—but more on that later.
The one med all expecting mommies will want to take is AZT (generic now but also known by the brand name Retrovir), which has proved very effective at preventing mother-to-child HIV transmission. Even if you don't yet need treatment for your HIV, most docs will prescribe combination therapy that includes AZT (you may be able to stop treatment after delivery).
If you're pregnant or trying and already on combo therapy, you and your doc may need to adjust your regimen to include AZT or otherwise make sure your meds are baby friendly.
AZT may be combined with Epivir (3TC), another nucleoside analogue with a good safety record during pregnancy. Other "preferred" HIV drugs to consider are the protease inhibitors Invirase (saquinavir) combined with low-dose Norvir (ritonavir) or Viracept (nelfinavir). All three have been shown to be safe in studies involving pregnant women. A recent study conducted in Ireland found that blood levels of Invirase/Norvir were more likely than Viracept to remain stable during pregnancy—which is good news since PI levels in the blood are often low during pregnancy. In the same study, Invirase/Norvir was also more likely than Viracept to decrease viral load during the third trimester of pregnancy.
Viramune (nevirapine) is another preferred choice during pregnancy. It has been known to cause liver problems in some women with CD4 counts above 250, however, and should not be taken alone because of resistance concerns. Rodney Wright, MD, director of HIV programs in the Department of Obstetrics and Gynecology at Montefiore Medical Center in the Bronx, is too concerned about liver complications to prescribe it to many of his pregnant patients.
* Moms-to-be should be especially wary of the drug Sustiva (efavirenz), which the FDA recommends avoiding because of the risk of birth defects. According to Dr. Wright, the risk is low, "but it's higher than in women not on this drug." He adds, "We try to switch drugs as soon as possible" after a woman learns she's pregnant or—even better—before she starts trying to become pregnant. The combo Videx (ddI) + Zerit (d4t) and Viramune can cause trouble for pregnant women too, specifically liver problems and fatal lactic acidosis. And if you're coinfected with hepatitis B or C, wait until after delivery to start the hep treatments interferon or ribavirin.
When it's time to give birth, you can expect your experience to be much like any other woman's except that you'll receive intravenous AZT to further cut the chances of HIV transmission. As a newborn, your baby will get the same drug orally for six weeks after birth. Studies show that AZT is safe for newborns, and there don't seem to be any problems later on for children and teenagers who took HIV meds before and after birth.
Although babies are born with their mother's HIV positive antibodies, they don't have the virus itself. It can take 18 months for HIV negative babies to lose these antibodies, so it can be slow and frustrating to rely on standard antibody tests to confirm a baby's HIV status. Viral load tests are an ever more common alternative because they check for HIV in the blood and can help rule out infection in most babies as quickly as one month after birth.
After your baby is born, there's one last step to preventing transmission: Don't breast-feed. HIV positive women shouldn't breast-feed because the virus can be passed along in breast milk. Studies in Africa suggest that breast-feeding might increase the risk of transmission up to 15%. Lots of babies are formula-fed nowadays—and positive moms and their new babies form bonds that are just as strong and joyous as those of breast-feeding families. Not to mention the peace of mind of knowing that you've done everything you can to protect your baby's good health—and your own.
* The print version of this paragraph contained factual errors. This online version has been corrected.