HIV in pregnancy is the presence of an HIV/AIDS infection in a woman while she is pregnant. There is a risk of HIV transmission from mother to child in three primary situations: pregnancy, childbirth, and while breastfeeding. This topic is important because the risk of viral transmission can be significantly reduced with appropriate medical intervention, and without treatment HIV/AIDS can cause significant illness and death in both the mother and child. This is exemplified by data from The Centers for Disease Control (CDC): In the United States and Puerto Rico between the years of 2014–2017, where prenatal care is generally accessible, there were 10,257 infants in the United States and Puerto Rico who were exposed to a maternal HIV infection in utero who did not become infected and 244 exposed infants who did become infected. In 2014 report, the burden of the HIV/AIDS pandemic, including mother-to-child transmission of HIV, disproportionately affects low- and middle-income countries, in particular the countries of Southern Africa. The World Health Organization (WHO) estimates that 1.3 million women and girls living with HIV become pregnant each year. The risks of both neonatal HIV infection and maternal illness are reduced by appropriate prenatal screening, treatment of the HIV infection with antiretroviral therapy (ART), and adherence to recommendations after birth. Notably, without antiretroviral medications, obstetrical interventions, and breastfeeding recommendations, there is approximately a 30% risk of mother-to-child HIV transmission. This risk is reduced to less than 1% when the previously mentioned interventions are employed. The American College of Obstetrics and Gynecology (ACOG) therefore recommends HIV testing as a routine component of both pre-pregnancy and first trimester prenatal care to ensure expedient and appropriate interventions. HIV infection is not a contraindication to pregnancy. Women with HIV may choose to become pregnant if they so desire, however, they are encouraged to talk with their doctors beforehand. Notably, 20-34% of women in the United States living with HIV are unaware of their diagnosis until they become pregnant and undergo prenatal screening.
Mechanism of transmission HIV can be transmitted from an infected mother to the neonate in three circumstances: across the placenta during pregnancy (in utero), at birth due to fetal contact with infected maternal genital secretions and blood, or postnatally through the breast milk. This type of viral transmission is also known of as vertical transmission. It is thought that mother-to-child HIV transmission most commonly occurs at the time of delivery when the baby comes into direct contact with the mother's infected blood or genital secretions/fluid in the birth canal. Maternal treatment with ART therapy prior to delivery decreases the viral load, or the amount of virus present in the mother's blood and other body fluids, which significantly reduces the chance of viral transmission to the fetus during labor.
Signs or symptoms
Maternal HIV infections in adults typically follow a 3-stage course, as described below:
Early, acute stage The early stage of an HIV infection involves rapid viral replication and infection. This stage typically lasts for 2–4 weeks following an infection and subsequently resolves spontaneously. Between 50 and 90% of adults experience symptoms during this phase of infection. At this time, women can experience fever, sore throat, lethargy, swollen lymph nodes, diarrhea, and a rash. The rash is described as maculopapular, which means it is composed of flat and raised skin lesions, and it appears on the trunk, arms and legs but does not appear on the palms of the hands or sole of the feet. Middle, chronic/latent stage The middle stage of an HIV infection can last for 7–10 years in a patient who is not being treated with ART therapy. During this time, the virus itself is not latent or inactive, but it is sequestered inside of the lymph nodes, where it is replicating at low levels. Women are generally asymptomatic during this period but some can experience persistent fevers, fatigue, weight loss, and swollen lymph nodes, which is known as the AIDS-related complex (ARC). Late, advanced/immunodeficient stage AIDS is caused by the progressive destruction of CD4 T-helper cells of the immune system by the HIV virus. AIDS is defined by either a CD4 cell count of less than 200 cells per microliter (which is indicative of severe immunodeficiency), or the development of an AIDS-specific condition. Because they are immunocompromised, women in this stage are at risk for serious, opportunistic infections that the general population either does not contract or contracts very mildly. These types of infections cause significant illness and death in patients with HIV/AIDS. People with such advanced HIV infections are also at greater risk for developing neurological symptoms (for example dementia and neuropathy), and certain cancers (for example Non-Hodgkin's B-Cell Lymphoma, Kaposi's Sarcoma, and HPV-associated cancers including anal, cervical, oral, pharyngeal, penile and vulvar cancer).
Infant
The clinical presentation of HIV in untreated infants is less predictable and specific than that of an adult infection. Notably, if an HIV diagnosis is diagnosed and appropriately treated, symptoms and complications in the infant are rare. Without ART therapy, infants born with HIV have a poor prognosis. If symptoms develop, the most common include persistent fevers, generalized lymph node swelling, enlarged spleen and/or liver, growth failure, and diarrhea. These children can also develop opportunistic infections, notably including recurrent oral thrush (Candidiasis) and/or Candida diaper rash, pneumonia, or invasive bacterial, viral, parasitic, or fungal infections. Neurologic symptoms, particularly HIV encephalopathy, are common in infants with untreated HIV.
Diagnosis/screening
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