The management of HIV infection during pregnancy is complex, and the scenario box on this page illustrates the complexities involved. In 2005, UNAIDS (the Joint United Nations Programme on HIV/AIDS) estimated that 38.6 million people had HIV, of whom 17.3 million were women (with most being in their reproductive years). At least 3.28 million pregnant women infected with HIV are estimated to give birth each year, with more than 75% of these in sub-Saharan Africa; this is where most of the annual 700000 new infections of HIV in children occur.
A 27 year old woman is referred to the antenatal clinic at 16 weeks of pregnancy. This is her second pregnancy—her first child, delivered by caesarean section, is now 8 years old. The mother was diagnosed with HIV four years ago when she developed herpes zoster. She has been taking zidovudine, lamivudine, and nevirapine for four weeks through an antiretroviral treatment access programme. At the time of starting treatment, her CD4 count was 124×106 cells/l, her viral load 50000 copies/ml, and her haemoglobin 104 g/l. She had received a negative screening result for tuberculosis and was receiving daily co-trimoxazole prophylaxis for preventing opportunistic infections. At the 16 week visit she was found to have a haemoglobin concentration of 87 g/l. She is from an African community and has not disclosed her HIV status to her family; she is concerned about the possible stigma associated with not breast feeding her infant.
- • It is important to establish whether the woman's first child was infected with HIV (or whether the child ever had an HIV test), and what her partner's HIV status is
- • As her first delivery was via a caesarean section, this would be the preferred method for her second baby
- • At 34 weeks her viral load and CD4 count should be repeated to ensure she has undetectable viraemia and that her CD4 count has responded to therapy
- • Even though nevirapine is recommended for women of reproductive potential, efavirenz might have been started. Efavirenz has been associated with neural tube defects in both human and non-human primates
- • Of concern in this case, is the worsening anaemia. If zidovudine is the cause of this anaemia, she should switch to stavudine. However, stavudine has additional complications when used in pregnancy—such as lactic acidosis, so the patient should be warned of this potential side effect and taught to identify its signs and symptoms
- • She should be seen more often by her physician and referred for psychological counselling on the importance of disclosure of her status, to ensure that she is supported in infant feeding choices