HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.): INTRODUCTION

HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.)

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EXECUTIVE SUMMARY

INTRODUCTION

SECTION A : HIV IN PREGNANCY

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Epidemiology of HIV

Susceptibility of women to HIV infection

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Biological factors

Socio-cultural factors

Effect of pregnancy on the natural history of HIV infection

Effect of HIV infection on pregnancy

Mother-to-child transmission

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Factors affecting mother-to-child transmission of HIV-1

Interventions to prevent mother-to-child transmission of HIV

Appropriate interventions to reduce mother-to-child transmission

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Antiretroviral therapy

Immune therapy

Nutritional interventions

Mode of delivery

Vaginal cleansing

Modification of infant feeding practice

Voluntary HIV counselling and testing in pregnancy

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Testing of antenatal women

Counselling before and after HIV testing in pregnancy

Counselling about pregnancy-related issues

SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN

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Antenatal care

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Obstetrical management

Examination and investigations

Medical treatment during pregnancy

Antiretroviral therapy

Care during labour and delivery

Postpartum care

Care of neonates

SECTION C : INFECTION CONTROL MEASURES

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Universal precautions

Risks of needlestick injuries

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Management of needlestick injuries and other accidental blood exposure

REFERENCES

INTRODUCTION

At the end of 1998, more than thirty-three million people were living with HIV, almost half of whom were women in their reproductive years^1,2. Over one million children are living with HIV, contracted predominantly through infection from their mothers. The majority of these women and children are in the developing world with two thirds of the infected adults and over 90% of the world's HIV-infected children in Africa. The face of the epidemic is changing as the increasing rate of infection in south-east Asia now accounts for an increasing proportion of new cases. In sub-Saharan Africa, HIV-1-related diseases may account for over 75% of annual deaths in the 15 to 60 age group within the next 15 to 20 years. Life expectancy at age 15 in countries severely affected by the AIDS epidemic could drop from 50 to below 30 years³. It is projected that by 2010, if the spread of HIV has not been contained, AIDS will increase infant mortality by 25 percent and under-five mortality by over 100 percent in the regions most affected by the disease. There have been 8.2 million children who have lost their mothers or both parents to AIDS to date in the epidemic¹, at least 95% of whom have been African.

HIV infection in pregnancy has become the most common complication of pregnancy in some developing countries. This has major implications for the management of pregnancy and birth. With an estimated one and a half million HIV-positive women becoming pregnant each year, almost 600 000 children will be infected by mother-to-child transmission annually: over 1600 each day^1,4. Maternity services in areas of high HIV prevalence have several responsibilities. Firstly, to enable women to be tested and to use these results to maintain their health in an optimal manner; secondly to utilize appropriate interventions to reduce the rate of mother-to-child transmission of HIV; and thirdly to train staff and provide equipment to prevent nosocomial transmission of HIV and other pathogens⁵.

There are two main types of HIV: type 1 (HIV-1) is the most common, with HIV type-2 (HIV-2) found predominantly in West Africa, with some pockets in Angola and Mozambique⁶,⁷. While HIV-1 prevalence is increasing in these areas, the prevalence of HIV-2 has remained fairly stable, and the clinical course of HIV-2 infection is slower than that of HIV-1. Dual infection with HIV-1 and HIV-2 is possible, although it has been suggested that HIV-2 infection may confer some protection against HIV-1 acquisition⁷. Although mother-to-child transmission of HIV-2 has been documented, this occurs less frequently than with HIV-1^8,9. In view of the lesser prevalence of HIV-2 in pregnancy, this document will focus on HIV-1 infection.

The first section of the review consists of a summary of what is known about HIV in pregnancy, transmission of HIV from mother to child, and interventions to prevent transmission. The second part of the review provides some suggestions on the appropriate management of HIV-positive women during pregnancy, delivery and postpartum, and the third section lists guidelines for infection control and safe working conditions with regard to HIV in pregnancy.