AIDS and Pregnancy

As the HIV epidemic becomes increasingly feminized and concentrated among young people, the reproductive health rights and needs of HIV-positive women and their children are becoming more of an urgent health concern. While the mother herself faces only a small risk of increased morbidity due to HIV during pregnancy, mother-to-child HIV transmission has been a major source of new infections in the past. Also called perinatal or vertical transmission, an HIV-posi-tive woman can transmit the HIV virus to her baby during pregnancy, labor, and delivery, or while breast-feeding. If a woman takes no preventative drugs, the chance of passing on the virus to an infant is approximately 15 to 30 percent, rising to about 45 percent with prolonged breastfeeding. In 2005, approximately 700,000 children under 15 acquired HIV, largely from mother-to-child transmission. Ninety percent of the more than 5 million children who have been infected with HIV live in Africa.

While preventing unwanted pregnancies among HIV-positive women is an important step in reducing the number of mother-to-child HIV infections, many HIV-positive women want to or will become pregnant. Fortunately, a short course of antiretroviral drugs taken before birth, around the time of delivery, together with formula feeding, can reduce the risk of mother-to-child transmission to less than 2 percent. Zidovudine (AZT) has proved particularly effective in preventing mother-to-child transmission. While AZT should ideally be started shortly following the completion of the first trimester, in limited-resource settings, AZT will be given from 28 weeks gestation onward, along with a single dose of AZT and nevirapine administered during labor. Although many women have taken antiretroviral medication during pregnancy to treat their own illness without drastic effects on infant growth and development, little population data [Page 44]are available regarding side effects of antiretrovirals taken during the first trimester, when the fetus faces the highest risk of developing developmental defects.

While previous research suggests that particular delivery methods, such as Caesarian births, might prove effective in preventing mother-to-child transmission, this evidence is still considered inconclusive. In many countries, the increased risk of maternal death due to complications from Caesarian surgery probably outweighs the decreased probability of HIV transmission to the infant.

While these drugs were largely unavailable in the past, much progress has been made in using short courses of drugs to cut mother-to-child HIV transmission rates even in rural areas lacking much health infrastructure. Continuing challenges to mother-to-child transmission prevention programs include refusal to take an HIV test, a fear of HIV-based discrimination, and a lack of follow-up care. Women in many countries who are HIV positive and pregnant often face discrimination from medical care providers, which also discourages them from returning to clinics for follow-up visits. Many women also report that they are afraid their children will be taken away from them, either because they are HIV positive or because they engage in high-risk behaviors such as intravenous drug use or sex work.

The proven effectiveness of short-term antiretroviral therapy combined with formula feeding in preventing mother-to-child HIV transmission has posed a dilemma to many new mothers in developing countries, where the health risks of feeding infants formula mixed with unclean water potentially outweigh the benefits of avoiding HIV transmission. Furthermore, in many countries formula is unavailable or prohibitively expensive, or women face cultural pressure to breastfeed. In these settings, additional doses of antiretroviral drugs may help decrease mother-to-child transmission during breastfeeding.

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