A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 12: Family Planning and Pregnancy
• Testing should be performed as early as possible
in pregnancy to allow for timely interventions and
decisions.
• HIV-negative women who are at high risk of acquiring
HIV should be retested in the third trimester of
pregnancy (ideally before 36 weeks). Women are at
high risk if they have a history of STDs, exchange sex
for money or drugs, have multiple sex partners during
pregnancy, use illicit drugs, have HIV-positive or highrisk
sex partners, and/or show signs and symptoms of
seroconversion.
• Women whose HIV status is unknown and/or who
present late in pregnancy or already in labor should
be assessed promptly for HIV infection, using rapid
HIV testing, to allow for timely prophylactic treatment.
Standard confirmatory tests should be done after
delivery for women with positive rapid test results.
• CDC recommends timely, routine screening of an
infant if the mother has not been tested during
pregnancy or delivery (CDC, 2003).
How should HIV testing be done?
HIV testing should be voluntary, and providers should
carefully document informed consent. Providers
should offer pre- and post-test counseling that includes
information on modes of transmission of the virus, risk
factors that might be present even if a woman has only
one sex partner, and effective interventions to reduce
the risk of perinatal transmission of HIV. There should
be a discussion of services available for the provision
of medical care, and the woman should be reassured
that care for her and her infant will not be denied if she
declines the test. Laws and regulations on HIV screening
of pregnant women and their infants vary by State.
Therefore, providers should be familiar with the State
regulations and policies that apply to them (CDC, 2001).
When does transmission from mother to
infant occur and what are risk factors for
transmission?
Vertical transmission can occur during the perinatal
period and infancy, that is, before or close to the time
of birth or during breastfeeding. Risk factors associated
with vertical transmission include (CDC, 2001):
• Advanced disease in the mother
• High plasma viral load
• Maternal injection drug use during pregnancy
• Preterm delivery
• HCV coinfection
• Failure to follow the recommended regimen of
zidovudine prophylaxis
• Breast-feeding
• Delivery more than 4 hours after rupture of
membranes
• Concurrent STDs
• Chorioamnionitis
• Certain obstetrical procedures
How common is vertical transmission of HIV
with and without ART?
In the absence of antiretrovirals, the perinatal
transmission rate of HIV infection is approximately
25%. There is a direct correlation between maternal
viral load as measured by plasma HIV-1 RNA and
probability of perinatal transmission. A large study
showed that the rate of perinatal transmission among
women with viral load >100,000 c/mL was 40.6%,
with 50,001 to 100,000 c/mL it was 30.9%, with 10,001
to 50,000 c/mL it was 21.3%, with 1,000 to 10,000
c/mL it was 16.6%; and with