HIV and Pregnancy – You and Your Baby
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HIV Infection and Pregnancy
HIV testing is routinely offered with other bloods tests to all pregnant women when they attend for antenatal care. You may have been given this leaflet if you have been newly diagnosed with HIV in pregnancy on your antenatal blood tests or because you already know you are HIV positive and have decided to have a baby.
HIV positive women can become mothers
HIV treatment makes this much safer
Transmission of HIV from mother to child is now a rare occurrence in the UK History of looking after pregnant women with HIV in UK
1993 – Without health interventions 25.6% of babies born to HIV positive women were born HIV positive (1 in every 4).
Today – When HIV positive pregnant women receive effective HIV treatment, the rate of passing HIV infection to the baby drops to 0.1% (1 in every 1000). Whatever your situation, we know that you will have many questions and worries, about how the virus might affect you and your baby. Please share your concerns with the mutli disciplinary team, so that we can tailor care to suit your needs. The most important thing to remember if you have been newly diagnosed with HIV, is that there is effective treatment and life expectancy of those with HIV is almost same as those without the condition.
Confidentiality – Who Needs To Know
During your pregnancy, you will receive care from a multi disciplinary team of health professionals who will need to share information about your HIV status, in order to support you through your pregnancy, so that you and your baby receive the best possible care and support. The team will include, the following health professionals in the community and in the hospital settings
• Community Midwives and Health Visitors
• Obstetrician and Hospital Midwives
• HIV Consultant Doctor and Nurse team
• Paediatric Consultant Doctor and Nurse team
The importance of confidentiality is recognised and will be respected by all of those involved in your care. It is very important to discuss your HIV status with your regular sexual partner; even if he is not the father of your baby. This can be a very difficult and upsetting conversation. The HIV nurse team will help support you and encourage your partner to attend for HIV testing. It will be important to practise safe sex from now on. If you have any other children, the HIV nurse team will help you arrange for them to have HIV testing also, so that you can know about their health.
What Is HIV HIV – Human Immunodeficiency Virus
HIV is a virus which attacks the immune system and weakens your ability to fight infections and disease. There is no cure for HIV, but there are treatments to enable most people with the virus to live a long and healthy life.
HIV is treated with antiretrovirals (ARVs), these work by stopping the virus replicating in the body, allowing the immune system to repair itself and preventing further damage. They also reduce the chance of pregnant women passing HIV to her unborn child. Regular blood tests are taken to determine how HIV is affecting your body. They are called CD4 and Viral Load.
CD4 count– CD4 cells are part of your immune system and are attacked by HIV. The higher your CD4 count, the less damage HIV is doing. A CD4 count of 350 and below indicates that you should start taking anti-HIV medication.
HIV Viral load (VL) – this measures the concentration of HIV in your blood. The higher your viral load, the more virus you have in your blood. The lower your viral load, the less damage HIV is doing. The success of any anti-HIV medication you take will be measured by the extent to which your viral load is kept down. On antiretroviral medications, the viral load should become <40 copies/ml. Some people call this undetectable as it is the lowest level that can be detected in the laboratory. It does not mean that HIV has gone away or been cured. It means that the HIV is well controlled by the antiretroviral medications. If antiretroviral medications are stopped, the viral load level will increase.
Your Own Health Care Needs
Your own health and your own treatment are the most important things to consider for ensuring a healthy baby. Women newly diagnosed or known HIV+ off treatment If your CD4 count is 350 or below you will be advised to take antiretroviral medication for your own health and to continue these beyond pregnancy on a long term basis. If your CD4 count is above 350, you may only need antiretroviral medications during the pregnancy and can stop after baby is born. Some mothers with higher CD4 counts may chose to continue with treatment to reduce risk of transmission to their sexual partners or because they are planning further pregnancies. Women known HIV+ already on ARV treatment If you conceived whilst taking antiretroviral therapy you should continue to take your treatment throughout the pregnancy. You should inform your clinic doctor you are pregnant.
After your baby is born, it is very important to continue attending the HIV clinic for your own care, as you need to stay well and healthy. You will be reviewed every 4- 6 months with blood tests and a doctor appointment, whether you are still taking ARVs or not.
How is HIV transmitted to a baby?
It’s possible for HIV to be passed from a woman to her baby:
• during pregnancy : the baby is infected with HIV through the mother’s blood crossing the placenta
• during labour and birth : the baby is infected with HIV through the mother’s genital secretions or blood during childbirth.
• through breast feeding : the baby is infected with HIV through the mother’s breast milk or blood during breastfeeding.
How Can HIV transmission to baby be prevented?
• Taking antiretroviral medications to reduce viral load
• Consider mode of birth If VL < 40 copies/ml safe to have a vaginal delivery If VL > 40 copies/ml caesarean section recommended
• Feeding newborn with formula milk from birth.
• Baby antiretroviral medications for first 2-4 weeks of life.
Using antiretroviral medications in pregnancy reduces the risk of a baby becoming HIV positive. Thousands of women have taken these medications all over the world without any complications to their baby. This has resulted in many healthy HIV negative babies. The HIV Consultant and nurse team will work closely with all pregnant ladies to find the best antiretroviral medications for each individual. There are a variety available and the particular drug regimen that a pregnant lady receives will be tailored to her specific CD4/viral load levels, her lifestyle needs, medical history and whether she has been on antiretroviral mediations in the past or developed any resistance to any of the medications. The antiretroviral medications will be prescribed by the HIV team and the medicine will be dispensed by the hospital pharmacy (free of charge). When taking the medication it is extremely important to take the medication at the same time every day and avoid missing doses. This will give the drugs best chance of working, reducing the VL <40 copies/ml thereby reducing risk of transmission.
Initial side effects of the medications (noticed by some) include nausea/vomiting, diarrhoea and rash. The HIV team will want to see you and monitor any side effects and how well you are tolerating the medications 2 weeks and 4 weeks after starting. Blood tests will be undertaken at these intervals to check the medication effects on the organs of the body, as well as checking the CD4/VL levels. Appointments will be a mixture of HIV team only in the specialist clinic setting and joint Antenatal/HIV appointments held in the Antenatal clinic for your convenience.
Birth of your baby
The mode of birth of your baby will invariably depend on the level of viral load prior the expected date of delivery. All pregnant HIV positive ladies will have an individualised care plan which is kept on the Labour Ward of the hospital and it will contain a record of your recent CD4/VL levels, a record of the antiretroviral medications you are taking, and a birth plan agreed by the Obstetrician and HIV team. The care plan is an essential document that will assist the hospital team to plan the safe arrival of your baby. It is important that whenever you ring the Labour Ward that you mention that you have an individualised care plan, so that it can be accessed. When the VL <40 copies/ml, then a vaginal delivery will be offered. The obstetrician and the midwives will monitor carefully for any signs of labour. You will be advised to contact the Labour Ward immediately when contractions commence so that you can be advised as to when to come to the hospital for prompt admission. However if the VL >40 copies/ml, detectable HIV virus is present and the safest mode of birth will be by caesarean section. You will be given a date for the birth, by the Obstetrician in the Antenatal Clinic, so that you can prepare for the admission to hospital. You may be advised to come to the hospital the night before the birth, so that an intravenous infusion (a drip) of antiretroviral medications can be started prior to surgery to reduce the viral load further. Your birthing partner can be present in the operating room with you for the Caesarean section.
The ward midwives will care for you on the ward following the birth of your baby and will assess your caesarean section wound for any signs of infection. All pregnant ladies are advised to continue taking their daily antiretroviral medications up to the time of your baby is born. So it will be important to bring your antiretroviral medications to the hospital with you when you are admitted for the birth of your baby. The decision as to whether you can stop the medications after baby is born will have been discussed with you by this time. The HIV team will visit you on the ward to ensure that you and baby have all the medications required, and to provide ongoing support. You will have a viral load test after baby is born and baby will have their first HIV test at birth, whilst still on the ward. The baby test at birth and at 6 weeks of age will be sent to the laboratory with mums blood sample – so that both samples can be linked together. Baby will have further blood tests at 12 weeks with a final test between 18 months and 2 years of age. The Paediatric team will visit you on the ward once your baby has been born, so that they can prescribe the baby antiretroviral medications according to the baby’s weight, so that the dose of medication can be calculated accurately. The first dose should be given within 4 hours of birth. The baby medication will be in liquid form and given twice a day. The hospital midwives will show you how to administer the baby medications whilst you are an inpatient. Your baby will be given 2 – 4 weeks of antiretroviral medications upon discharge home from the ward. At the time of discharge from hospital after delivery, you will be informed whether your baby needs to take the medication(s) for 2 week or 4 weeks. The duration of your inpatient stay on the ward following birth of your baby will depend on your health post birth, post operative care and baby health. You and baby will need follow-up appointments arranged by the HIV and Paediatric teams before you are discharged home.
To prevent the transmission of HIV from mother to child, the complete avoidance of breast feeding for the infant born to HIV infected mothers is recommended, regardless of maternal disease status, viral load levels or antiretroviral medications. Mother to child transmission can occur through breastfeeding, with an ongoing infection risk throughout the breast feeding period; by contrast- there is no risk of postnatal HIV transmission if the infant is not breast fed. Breast feeding for a large proportion of ladies is a cultural norm and so it can be difficult time for new mothers to explain reasons to well meaning family and friends, as to why breast feeding is not occurring. The HIV team advise that the Obstetric team will prescribe a medicine to stop the breast milk being produced so that there is no breast discomfort. This tablet is given to you ,after baby is born, on the ward. If you have any worries or concerns regarding equipment needed for bottle feeding, or need assistance and / or advice on bottle feeding, please speak with your midwife /HIV nurse team. Recent research indicates that HIV infected mothers can exclusively breastfeed only if their viral load had been consistently undetectable throughout pregnancy, but this needs to be discussed at length with the HIV team and considered on an individual basis. If exclusive breastfeeding is agreed – then both mother and baby will require more frequent blood testing than the usual birth, 6 wk,12 wk and 18-month baby blood testing interval. Close monitoring is essential to prevent mother to child transmission. Please refer to the following link for the BHIVA leaflet: https://www.bhiva.org/file/5bfd3080d2027/BF-Leaflet-1.pdf
How will I know that my baby is HIV negative?
Your baby will be tested for HIV at – birth, – 6 weeks, – 12 weeks, – and then between 18 months and 2 years of age. To make the diagnosis in a baby, a sensitive test called a PCR (polymerase chain reaction) will be undertaken to look for actual virus in the baby’s blood. The baby test results will tend to reflect the mothers HIV illness in the tests from birth to 12 weeks, but loss of maternal antibodies will be confirmed by 18 months to 2 years of age. An infected baby may be diagnosed at any of these stages of testing – so it is very important to attend all the appointments, so baby health can be monitored carefully. All babies born to HIV mothers will be reviewed by paediatricians at 6 weeks of age, to monitor for side effects of the antiretroviral medications and check their development. They will want to know in particular if your baby has had any of the following: breathing difficulties, fevers, bad cough/chest infections, feeding problems, diarrhoea which does not stop after 1 day , oral thrush (white patches in the mouth). All mums will be given a HIV clinic appointment for 6 weeks after birth of baby, and a baby appointment will be arranged for the same day in the Paediatric Unit, so that blood samples can be sent to the laboratory and linked to each other for processing. The BCG vaccination is usually delayed until the 12 week test result is known, as a measure of safety for your baby. If you have any concerns regarding this vaccination or any vaccinations please speak directly with the Paediatric team.
The Paediatric and HIV teams will be very aware that these are very difficult and worrying times for you and your partner and we will provide ongoing support, by ensuring that you get results of each test result promptly. If there is anything in this leaflet that you have not understood, please let us know, so that we can discuss it with you Please know that you can phone the HIV nursing team and your Community Midwife to discuss any worries that you have regarding your HIV diagnosis during your pregnancy. The Paediatric team will also be happy to answer any concerns you may have regarding your baby’s health. Someone will always be happy to discuss your concerns and if necessary, they will arrange an appointment for you to be seen as soon as possible.
Contact Telephone Numbers
HIV Nurse Team Mobile 07770643214 Clinic 01908 995291
Community Midwife / Labour Ward Community Midwife 01908 996484 Labour Ward 01908 996471
Paediatric Team Phone the hospital switchboard 01908 660033, ask for extension 3958.
Name of drug
Dose of drug
I plan to continue ARV’s beyond pregnancy YES / NO
I plan to stop ARV’s after baby is born YES / NO
My blood tests
I plan to take medication to stop breast milk YES / NO
My first appointment in HIV clinic after baby born – 6 weeks
Baby Medication – Baby should take for 28 days
Name of drug
Dose of drug
Baby Blood tests
Time of blood test
Date of blood test
Day baby born
Baby appointments with Paediatricians
Name of doctor
Infants born to HIV infected mothers should be immunised as normal with the exception of BCG which should not be given until the infant has tested negative at 12 weeks.
References / Bibliography
BHIVA Guidelines, Updated Version 2014
– British HIV Association and Children’s HIV Association Guidelines for Management of HIV Infection in Pregnant Women 2008
– World Health Organisation Guidelines on HIV and Infant Feeding