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Issues for HIV-positive women deciding to have a child
For many women, being diagnosed with a life–threatening condition may intensify the desire for children, especially if she is not yet a mother. The desire to create a new life and ensure the continuity of oneself is a common reaction to a life–threatening situation. Especially amongst African communities there are strong pressures to have children.
Until recently it was thought that pregnancy could have a negative effect on a woman's health as the immune system might be further suppressed by pregnancy. It now seems that pregnancy is only likely to have an impact on a woman's physical health if she is already unwell, or has very low CD4 counts. There is no evidence that pregnancy accelerates the course of HIV infection in asymptomatic women.
It makes sense for HIV-positive women who wish to become pregnant to seek information and advice. Knowledge about transmission from mother to baby is developing swiftly. It is becoming increasingly clear that some times may be better suited than others for conception in order to minimise (but not to eliminate) risks of passing on HIV to the foetus. For further information see Mother-to-baby transmission in HIV transmission.
For some HIV–positive women the risk of passing on HIV to the foetus is too high for them to carry on with a pregnancy, or to take the risk of conceiving a child. This may be more of an issue for mothers who have already developed symptoms, or whose viral load is not successfully suppressed on treatment, since the chance of mother to baby transmission increases as the mother's viral load increases and CD4 count falls.
Some may also be concerned that the child (if uninfected) is likely to be orphaned (by one or both parents) before adulthood. It is important that these decisions are made by the mother (and her partner if relevant), and not assumed by health care providers.
For an HIV–positive women taking combination treatments, it is important to discuss conception (and contraception) plans with their health care provider or a suitably qualified person. If possible this discussion should take place before conception.
Some women want to stop taking their treatment either before or when they first realise they are pregnant. This should be fully discussed with her doctor. It is normally important that a woman continues with her treatment. There is a risk of viral rebound if she stops and this may increase the risk of vertical transmission. The risk of foetal abnormality is of great concern, but to date the only clear evidence of adverse effects concerns a possible increased risk of premature delivery in mothers taking dual or triple therapy. However, foetal abnormality was found in macaques taking efavirenz, and this drug is contra–indicated for any woman trying to conceive or already pregnant. Any woman who conceives whilst taking efavirenz should be counselled about the potential effects of the drug on the unborn child and the options for changing therapy.
Balancing the interests of mother and child is difficult, and there has been considerable criticism of the practice of continuing to offer AZT monotherapy during pregnancy. The long-term risks and benefits of the two approaches are still poorly characterised, and there is evidence that the risk of acquiring AZT resistance during the 076 course of treatment (up to 18 weeks pre–delivery) is low.
See The HIV & AIDS Treatments Directory, or aidsmap.com, also produced by NAM, for the latest information on treatment during pregnancy.