The care of pregnant women diagnosed with HIV/AIDS can be challenging because their management entails addressing their health needs and that of their unborn child or children. The goals and objectives of the presentation for pregnant women diagnosed with HIV/AIDS revolves around the health of the mother and the unborn child or children during the pregnancy, understanding the treatment that should be used, and preventive measures that should be applied to eliminate the risks of opportunistic infections or complications. Knowledge of women’s HIV/AIDS status through frequent testing and counseling is usually conducted to ensure pregnant women know their status, the risks they face, and feeding approaches that they can use to prevent transmission of the virus through breast milk if they test positive for HIV/AIDS. Specialty care for pregnant women with HIV/AIDS entails using HIV/AIDS drug therapies, meeting the women’ patient education needs during and after the pregnancy, and ensuring that the delivery process is conducted in a manner that reduces the infant’s risks of transmission.
Population at Risk
The population at risk of testing HIV/AIDS positive during pregnancy includes women of reproductive age and pregnant women. The population at risk can be divided into two major groups, which includes women who were previously diagnosed with HIV/AIDS or women living with HIV/AIDS (WLWH) and are pregnant or pregnant women who find out during their prenatal clinic visits that they have contracted the virus. The number of HIV/AIDS-infected women getting pregnant has increased over the years due to increased life expectancy associated with use of anti-retroviral therapies (ART). In a research that examined the prevalence of pregnancies among WLWH, the results showed that among 1,165 WLWH that were included in the study, 278 of the participants reported finding out about their pregnancy after their HIV diagnosis, 60.8% of which were unplanned pregnancies (Salters, et al., 2017). The total number of successful pregnancies among 278 women, who were included in the research, were 492. Pregnancy incidents among women who had started using ART were higher than among those who had started their treatment plan during their pregnancies (Salters et al., 2017). During the pregnancy duration, HIV/AIDS testing is essential to promote development of effective care plans.
Numerous risk factors and medical histories place women in their reproductive age or those who are already pregnant at risk of getting HIV/AIDS. Some of the risk factors for HIV/AIDS include sharing injections with infected people and engaging in high-risk behavior such as having multiple intimate partners or having unprotected sex. Additionally, direct contact with other bodily fluids that can spread the virus such as blood, rectal fluids, or the breast milk of an infected person can also lead to the spread of HIV if the uninfected person has a cut, a pre-existing genital ulcer, or pre-existing STI. Among women who are already diagnosed with HIV/AIDS, some of the risk factors for unplanned pregnancies include unprotected sex or lack of proper adherence to contraceptives (Abbai, Wand, & Ramjee, 2016). During the pregnancy period, some of the risks and medical histories that might affect pregnant WLWH include risk of anemia, co-infection with Tuberculosis, and risks of diarrheal infections, pneumonia, and candidiasis. The risks of these conditions increase with poor adherence to medication, drug resistance, and poor nutrition (Rubaihayo, et al., 2016). Prevention of exposure from the risk factors affecting pregnant WLWH reduces morbidity and mortality rates among these populations.
Evidence-Based Management of Pregnant WLWH
For pregnant WLWH, proper management during the pregnancy is essential in eliminating the risks of transmission. Management of the pregnant WLWH should entail monthly assessment of the mother’s viral loads or after every two months for mothers who had a suppressed HIV-1 RNA viral load that was below the level of detection before and had been using ARTs effectively. The assessment can be conducted by nurses or physicians in primary care units or other healthcare facilities that offer prenatal services. For pregnant women that were already taking ARTs, it is essential to assess their compliance, examine the drugs the different drugs they are using to determine whether they are safe for pregnant women. According to the guidelines used to manage pregnant WLWH, if the woman experiences intractable vomiting or other conditions that affect their oral intake, the ART drugs should be stopped and reintroduced simultaneously as soon as possible or after the suppression of the vomiting episodes. If the woman does not experience intractable vomiting, antepartum vaccines meant for conditions like hepatitis B, hepatitis A, tetanus, influenza, pneumococcal and meningococcal should be offered (Rimawi, Haddad, Badell, & Chakraborty, 2016). Offering these vaccines to pregnant WLWH reduces the risk of various diseases and increases the likelihood of a successful pregnancy.
Other aspects that should be considered during the management of pregnant WLWH include educating them about the correlation between adherence to treatment and viral load, delivery processes considerations, and preparation for delivery. Intrapartum management entails assessing the viral load to determine the delivery methods that will be used. If the viral load is less than 1000 copies/mL, then spontaneous vaginal delivery (SPV) can be considered (Rimawi, Haddad, Badell, & Chakraborty, 2016). Additionally, when the viral load is low, the pregnant WLWH should be advised to continue taking her antepartum ARTs (Rimawi, Haddad, Badell, & Chakraborty, 2016). If the viral load exceeds 1000 copies/mL, intravenous Zidovudine should be included in the woman’s therapy for approximately three hours before childbirth on the delivery day. The woman should also continue taking the other ARTs. In cases whereby the viral load exceeds 1000 copies/mL, cesarean section delivery is advised to reduce the child’s risks of infection (Rimawi, Haddad, Badell, & Chakraborty, 2016; CDC, 2019). These management approaches are put in place to promote the health of the mother and child.
The management of the pregnant WLWH after the delivery is as important as the management during the pregnancy period. Research has shown that postpartum management has been effective in reducing the transmission of HIV/AIDS from mothers to infants. Some of the measures included in the post-partum management include; contraceptive counseling, avoidance of breastfeeding, continuation of ART regiment, and introduction of zidovudine prophylaxis to the infant. The prophylaxis should be given to infants within the first eight hours after delivery and continued at a dosage of 2mg per kilogram given after every six hours for six weeks (AIDSinfo, 2020). After the first six weeks, the infant should be tested for HIV/AIDSThe test results determine whether the infant would be started on ART therapies for infants in case they are infected. The counseling offered to mothers on avoiding breastfeeding offers infants additional protection from infection (Rimawi, Haddad, Badell, & Chakraborty, 2016; AIDSinfo, 2020). Protecting the infant during the first six weeks increases their chances of not being infected.
Different drugs are prescribed to pregnant WLWH depending on their health status, drug tolerance, and viral load. The development of the guidelines used in determining the right drug therapies for pregnant WLWH and other populations is conducted by a team of professionals from the Center for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and the Health Resources and Services Administration (HRSA) (AIDSinfo, 2020). The main regimen used in the management of HIV/AIDS among infected pregnant women includes Trizivir (ABC/3TC/ZDV), Abacavir (ABC), or Triumeq (ABC/DTG/3TC). These drugs are considered the first line treatment for HIV/AIDS management. They are usually interchanged in case of complications with other HIV/AIDS regiment like Emtricitabine (FTC), Atripla (FTC/EFV/TDF), and Biktarvy (FTC/BIC/TDF), among other regiments that exist (AIDSinfo, 2020; AIDSinfo, 2020). These treatment regimens are often introduced and the patients assessed to determine their tolerance, possible adverse drug reactions that they might experience, and the effectiveness of the drugs in lowering their viral loads.
A viral load assessment should be done within 2-4 weeks after initiation of the treatment for WLWH who start their treatment or change some of the drugs in their regimen while pregnant, The assessment is conducted to ensure that the medication used suppresses the viral load. After it has been confirmed that the treatment plan is effective in suppressing the viral load, monitoring tests should be done every three months. If the woman’s adherence to treatment is a concern during the early months of her pregnancy, either due to negative reactions with drugs or disregard for counseling provided to them, frequent assessments should be done to determine the viral load and the potential risks of perinatal transmission of the virus (AIDSinfo, 2020). The women’s viral load should also be checked at about 34 to 36 weeks of pregnancy in preparation for delivery, as well as in ensuring that an informed decision is made regarding the delivery method that will be recommended.
In terms of drug complications and tests done to determine whether the pregnant WLWH has a negative asymptomatic reaction to a drug that could affect the pregnancy, tests should be done based on the expected adverse reactions of the drugs. For instance, when managing a woman who is taking a drug associated with hematological complications like Zidovudine, the tests done should entail routine hematological assessments. Liver functioning tests should be conducted on all the pregnant WLWH. Women taking protease inhibitor based HIV/AIDS drugs should be monitored for gestational diabetes as these drugs have been linked to increased risks of gestational diabetes (AIDSinfo, 2020). Continued monitoring of these patients increases their chances of maintaining a low viral load and promotes positive pregnancy outcomes.
HIV/AIDS among women has contributed to a high morbidity and mortality rate. The quality of care offered to pregnant WLWH is essential in reducing the transmission of the virus to the unborn children. The recommendations offered to pregnant women living with HIV/AIDS by the CDC and other national prevention networks such as the AIDSinfo platform focus on ensuring that the mother’s viral load is maintained at a low level or lowered during the pregnancy, as well as in promoting the mother’s adherence to her treatment plan. The recommendations also emphasize the need to ensure that mothers with a high viral load use cesarean section delivery to reduce the risks of HIV transmission.
Abbai, N. S., Wand, H., & Ramjee, G. (2016). Biological factors that place women at risk for HIV: evidence from a large-scale clinical trial in Durban. BMC Women’s Health, 16:19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4799526/.
AIDSinfo. (2020, January 1). Recommendations for the Use of Antiretroviral Drugs in. Retrieved from AIDSinfo: https://aidsinfo.nih.gov/contentfiles/lvguidelines/perinatalgl.pdf
AIDSinfo. (2020, January 17). Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States. Retrieved from AIDSinfo: https://aidsinfo.nih.gov/guidelines/html/3/perinatal/489/table-8–arv-drug-use-in-pregnant-women-with-hiv
CDC. (2019, November 12). Pregnant Women, Infants and Children. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/hiv/group/gender/pregnantwomen/index.html
Rimawi, B. H., Haddad, L., Badell, M. L., & Chakraborty, R. (2016). Management of HIV Infection during Pregnancy in the United States: Updated Evidence-Based Recommendations and Future Potential Practices. Infectious Diseases in Obstetrics and Gynecology, Article ID 7594306. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967680/pdf/IDOG2016-7594306.pdf.
Rubaihayo, J., Tumwesigye, N. M., Konde-Lule, J., Wamani, H., Nakku-Joloba, E., & Makumbi, F. (2016). Frequency and distribution patterns of opportunistic infections associated with HIV/AIDS in Uganda. BMC Research Notes, 9: 501. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5142427/.
Salters, K., Loufty, M., Pokomandy, A. d., Money, D., Pick, N., Wang, L., . . . Kaida, A. (2017). Pregnancy incidence and intention after HIV diagnosis among women living with HIV in Canada. PLOS| ONE, 12(7), 1-19. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0180524&type=printable.