Human immunodeficiency virus in pregnancy

There are already many millions of women and children infected with human immunodeficiency virus across the world, and their numbers are expected to rise. There are effective strategies to reduce the risks of perinatal transmission of the virus and to ensure the long-term health of the mother. These measures include the use of antiretroviral therapy in pregnancy, Caesarean section for delivery and the prevention of breastfeeding.     

Human immunodeficiency virus and pregnancy

Management of infection with human immunodeficiency virus (HIV) dramatically improved during the 1990s. The advent of high-performance quantitative HIV assays and highly active anti-retroviral therapy (HAART) were the two most important developments in HIV medicine. As a result, HIV mortality and morbidity have significantly reduced. This improvement in life quality and expectancy through the use of HAART has led to an increase in the number of HIV-infected patients wishing to have children. The mother-to-child transmission which was of major concern previously can now be significantly reduced by newer management strategies. This review stresses on the management of pregnancy in HIV.     

Human immunodeficiency virus infection in pregnancy

Many aspects of HIV infection in pregnancy remain unclear. Subsets at increased risk for perinatal transmission, adverse pregnancy outcome, and development of symptomatic HIV infection need to be identified. For instance, relative risks may be quite different in asymptomatic HIV infected patients with T4 lymphocyte counts greater than 200 cells per cubic millimeter compared to those with either symptoms of HIV infection or T4 cell counts less than 200 cells per cubic millimeter. At present, antiviral therapeutic trials do not include pregnant women or neonates less than 3 months of age. In the future, antiviral therapy with agents, such as AZT, may reduce the risk of transplacental and intrapartum HIV transmission. Obstetricians will be involved increasingly in providing care to HIV-infected patients and educating patients in order to prevent HIV infection.     

Human immunodeficiency virus infection in pregnancy

Among an estimated 1 million to 1.5 million Americans infected with HIV, about 10 per cent are women. Moreover, almost 30 per cent of HIV infection among women is acquired through heterosexual activity. Therefore, the average obstetrician/gynecologist is not sheltered from dealing with HIV. This article offers guidelines for caring for HIV-infected pregnant women during antepartum, intepartum, and postpartum phases.     

Human immunodeficiency virus infection in pregnancy

The transformation of the human immunodeficiency virus (HIV) epidemic over the last 20 years has been remarkable. With access to appropriate therapies, clinicians can now offer infected women a much improved prognosis as well as a very high likelihood of birthing children who will be HIV uninfected. However, these advances are purchased through the use of complicated, expensive medical regimens (highly active antiretroviral therapy) that are associated with a litany of toxicities and risks. In caring for HIV-infected pregnant women and prescribing these medications, obstetricians must always bear in mind their dual responsibilities, providing optimal care to the mother and reducing the likelihood of mother-to-child transmission of HIV. To accomplish those goals, the physician must first monitor the patient's immunological and virological status including resistance testing. The results of those tests will guide the clinician in choosing when to initiate therapy and in deciding whether to use regimens directed solely at transmission interruption or those that will simultaneously treat the mother's infection. When using highly active antiretroviral therapy, physicians must be cognizant of the pregnancy-specific risks associated with some of the component agents. The core goal of all medical therapy is to bring the patient's viral load to an undetectable level. When that goal is reached, the chance of transmission to the child is minimized, the need for a cesarean delivery is reduced, and the patient's prognosis is optimized. However, if a woman is not pregnant, then the initiation of therapy can be delayed because long-term adherence with medications can be difficult, side effects are not uncommon, and prognosis is not adversely affected so long as the CD4 count and the viral load remain in a reasonable range. None of the advantages cited above can be achieved unless all women have their HIV status determined as early in pregnancy as possible.     

Human immunodeficiency virus infection and pregnancy

The human immunodeficiency virus (HIV) epidemic is clearly one of the most serious health-care crises in the professional lives of contemporary physicians. It cannot be regarded as a curiosity to be dealt with by inner-city infectious-disease experts, but rather must be considered a problem for all health-care providers and a problem in which the obstetrician-gynecologist has a special role to play.     

Human immunodeficiency virus infection in women. I. The effects of human immunodeficiency virus on pregnancy

The clinical courses and initial neonatal outcomes of 50 patients with human immunodeficiency virus infection were followed on antepartum, intrapartum, and/or postpartum bases, between July 18, 1986, and December 27, 1987, at the University of Miami School of Medicine/Jackson Memorial Medical Center. The mean age at the time of the most recent delivery was 27 years. Cases attributable to the single risk factor of heterosexual transmission acounted for 76% of the cumulative number. Twenty-eight, or 56%, of the total sample were of Haitian ancestry. The patients in this study group did experience several complications of pregnancy. Interestingly, more than one third of the pregnancy courses (34.6%) were complicated by preterm labor. Only 15.4% of the patients had premature rupture of membranes. A higher rate of infection of the genitourinary tract and an increased incidence of sexually transmitted diseases in women known to be infected with human immunodeficiency virus are suggested. Less clear is the contribution of genitourinary tract infections and sexually transmitted diseases to the risk of acquired immunodeficiency syndrome or of perinatal human immunodeficiency virus transmission. Although a total of 10 patients in the study group were known to have children infected with human immunodeficiency virus, only longitudinal studies of the children of the mothers in this group will shed light on the number of children who ultimately become infected with human immunodeficiency virus. Similarly, although the majority of patients in this report remained asymptomatic during the course of their pregnancies, a matched, controlled study is necessary to confirm that pregnancy does not accelerate the progression of human immunodeficiency virus infection.     

Human immunodeficiency virus-associated nephropathy in pregnancy

Background: Human immunodeficiency virus (HIV)-associated nephropathy typically leads to endstage renal disease requiring dialysis within 3-4 months. This report describes the prenatal course of a patient with HIV-associated nephropathy requiring dialysis during pregnancy.Case: A 23-year-old nulliparous, black female presented at 13 weeks gestation with a history of HIV-associated nephropathy and anemia. She had a CD4 count of 350/mm(3), a total urinary protein of 1.7 g/day, and a serum creatinine of 4.8 mg/dl. The patient was begun on zidovudine, 500 mg daily, and erythropoietin, 4,000 units weekly. At 23 weeks gestation, when she developed hypertension, a total urinary protein of 3.4 g/day, and a serum creatinine of 4.4 mg/dl, she was hospitalized. Her renal function continued to deteriorate, requiring hemodialysis. At 29-4/7 weeks, she developed preterm labor, for which she was placed on indomethacin. Four days later, at 30 weeks gestation, she delivered a viable male infant.Conclusion: HIV-associated nephropathy during pregnancy can be successfully managed with hemodialysis.     

Human immunodeficiency virus infection, women, and pregnancy. Ethical issues

Should women of childbearing age be screened for the presence of infection with the human immunodeficiency virus? If infected, should they be instructed not to become pregnant or not to bear children? Should pregnant women and their offspring be included in research protocols that explore ways to prevent or treat perinatally acquired HIV disease? This article examines ethical controversies related to HIV screening, counseling, and research and suggests that resolutions may come from achieving greater clarity about the ultimate goals of obstetric and gynecologic care.     

Human immunodeficiency virus infection in gynaecology

By the end of 2002, an estimated 40 million people were infected with the human immunodeficiency virus worldwide, the greater proportion of these infections occur in sub-Saharan Africa, where the prevalence is substantially high amongst young women. Females are said to be particularly more susceptible to HIV infection, and it is reported that HIV transmission from men to women is more efficient than from women to men.The presence of a sexually transmitted infection (STI) is known to increase the risk of both acquiring and transmitting the HI virus, whilst the presence of HIV infection, especially advanced disease, may alter the clinical presentation, course and response to conservative treatment for most STIs, as well as pelvic inflammatory disease. Though there are theoretical concerns regarding some methods of fertility control and the risk of HIV acquisition, most contraceptive methods can be used by infected women under close medical surveillance.HIV infection has been associated with an increased prevalence or a more aggressive behavior of certain gynaecological neoplasms. This probably occurs as a result of alterations in the immune response in the lower genital tract to HIV.     

Human immunodeficiency virus infection in women

Heterosexual transmission is the leading route of transmission worldwide of human immunodeficiency virus (HIV) infection, although the cumulative rate of infection is significantly higher among female partners of infected intravenous drug abusers and men from central African countries than among female partners of bisexual men or blood product recipients. Factors associated with an increased risk of heterosexual transmission are currently under investigation, but number of sexual partners and the presence of genital ulceration appear to be significant. The natural history and clinical manifestations of acquired immunodeficiency syndrome (AIDS) are the same in men and women. Despite initial reports to the contrary, it appears that pregnancy does not have an adverse effect on the course of HIV infection. However, there is clear evidence that HIV is transmitted to the fetus during pregnancy and lactation. A transmission rate of 25-35% has been recorded in follow-up studies of infants born to mothers infected with the AIDS virus. Pregnancy termination should thus be suggested to pregnant AIDS patients, and asymptomatic seropositive women should be advised to delay pregnancy until more is known about the natural history of their infection. The most feasible approach, however, is to identify women at high risk of AIDS before they become pregnant and offer antenatal blood screening.     

Human immunodeficiency virus retesting during pregnancy: costs and effectiveness in preventing perinatal transmission

OBJECTIVE: To estimate the incremental societal costs and effectiveness of a second human immunodeficiency virus (HIV) antibody test during the third trimester of pregnancy compared with no second test. METHODS: We used a decision tree in this cost-effectiveness analysis to model outcomes among pregnant women in high-risk communities and nationwide who received an initial, negative HIV antibody test during the first trimester. The main outcome measure was discounted costs per year of infant life saved. RESULTS: In high-risk communities with estimated HIV incidence of 6.2 per 1000 person-years, a second HIV test compared with no second test would detect 192 infections in women, prevent approximately 37 infant infections, and save 655 infant life-years per 100,000 women tested. Net savings would be 5.2 million US dollars. Applied to an estimated national incidence of.17 per 1000 person-years, a second test would detect 5.3 infections in women, prevent 1.3 infant infections, and save 23.3 infant life-years per 100,000 women tested. Net costs would be 1.06 million US dollars, or 45,708 US dollars for each year of infant life saved. A second test would result in net savings in populations with HIV incidence of 1.2 per 1000 person-years or higher. CONCLUSION: Health care providers serving women in communities with an HIV incidence of 1 per 1000 person-years or higher should strongly consider implementing a second voluntary universal HIV test during the third trimester. Providers serving lower-risk communities should pilot second testing to assess community-specific costs.