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In the early years of the AIDS epidemic, pregnant women infected with the virus frequently passed the infection to their unborn children. The term “AIDS Baby” became a shorthand to describe these children in the nursery, unclaimed by mothers who themselves were seriously ill. Continued advances in treatment of the disease have helped to empty the nursery of these babies by teaching their mothers how to protect them before they are born and cope with what has become a chronic disease.

Who Needs the Help?

Research during the past 20 years has demonstrated that most of the transmissions of HIV from mother to baby occur during the birth process. For years, pregnant women were advised to opt for cesarean section. This is no longer the case, and many HIV-positive women are able to deliver vaginally, providing their viral loads are low enough. Naturally, this presupposes that the woman knows that she carries the HIV virus.

In New York State, as in a dozen other states, healthcare providers are required to offer HIV testing to pregnant women at the beginning of pregnancy. If the woman declines the test, it is offered again during labor. She has the option to decline the test at each opportunity, but if her HIV status is not ascertained by testing, her newborn is required by law to undergo HIV testing.

Even women who are negative at the beginning of their pregnancy sometimes convert to seropositive during pregnancy, so the test should be repeated during the third trimester, says Roberto Posada, MD, assistant professor of Pediatrics, Mount Sinai School of Medicine. He recommends making the test a routine part of the perinatal treatment program, so there is no stigma associated with a risk category, and the woman is more likely to agree to the testing. At the Mount Sinai Medical Center Ambulatory Obstetrical and Gynecology Clinic, pregnant patients are routinely offered HIV testing. The National Institutes of Health (NIH) notes that the best time to begin counseling regarding HIV transmission and treatment is before conception.

“The issue is really getting the woman into care and helping her get the information she needs,” says Ann Marie Bentsi-Addison, RN, CNM, MSN, clinical nurse manager of the clinic. The clinic is a Prenatal Care Assistance Program (PCAP) participating facility, a New York State program geared to offer complete prenatal care to teenagers and women. Nurses work collaboratively with the social workers on staff to offer women pretesting counseling.

Counseling is geared towards educating the woman about exposure and risk factors regarding HIV, prevention and how treatment is effective. Fears about the diagnosis are addressed and treatment options are offered. When the mother to be is a teenager, she is referred to a special clinic for teenagers, managed by a midwife, and follow-up continues there.Whatever her age, the woman carries inside her a vulnerable patient-to-be, and the risks of doing nothing are explained as well as the benefits of treatment. If the woman refuses to submit to HIV testing, she is informed that by regulation her baby must be tested at birth.

“We stress the importance of early testing and make sure that they really understand that they can make a big difference in the likelihood of transmitting the infection to their baby by getting the proper treatment and follow-up,” says Bentsi-Addison.

Two Vulnerable Patients

“Early in the course of the infection is the time of highest risk of transmission,” says Posada “If we can begin treatment during this period, the risk of transmission is dramatically decreased. Without medication, the risk of transmission from mother to baby is 20 to 30%. With medication, that risk drops to between 1 and 2%,” he says.

Treatment to achieve the maximally suppressed viral load is recommended to prevent transmission to the baby. The medication regimen is initiated at the start of the second trimester, says Bentsi-Addison. This prevents complications from the possible teratogenic effects of the medications. The long-term effects of treatment on the child are not thoroughly documented, but enough data is available to make recommendations about treatment. In general, the risk of in utero damage to the baby during the second and third trimesters from the medications is less than the problems encountered during and after delivery when the mother has had no treatment. Usually, the patient is treated the same as any nonpregnant patient, with one difference. Bentsi-Addison notes that pregnant patients are usually more compliant with the medication regimen than are nonpregnant patients.

“Pregnant women are in an emotionally vulnerable state, and the fact that they are able to do something to protect their unborn children usually compels them to be more compliant with her medication regimen,” she says.

Treatment Options

When treatment is initiated, it usually includes azidothymidine (AZT), also known as Retrovir®. This is one of the oldest antiretroviral medications, and its effects are well documented. Sometimes, the primary healthcare provider opts for single-medication therapy, depending on the patients’ viral load and CD4 count. The NIH recommends highly active antiretroviral therapy (HAART) even for women who do not need the therapy for their own health. HAART includes AZT whenever possible. The NIH recommends the use of a Zidovudine® given in combination with Lamivudine®, two of the nucleoside reverse transcriptase inhibitors (NRTI) class of medications, as part of the medication regimen, along with AZT. The safety of many of the medications used to treat HIV is not known for pregnancy, and medication selection is done with care (http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf).

The Antiretroviral Pregnancy Registry is an ongoing observational study of the effects of these medications, and every pregnant woman who is treated should be registered (http://www.apregistry.com).

If treatment is not started at the beginning of the second trimester, it is useful to begin at any time during the second or third trimester. Giving AZT intravenously during labor can decrease the chance of mother-to-baby transmission. Usually, if treatment was not started during the pregnancy, or if the viral load is high, a cesarean section delivery is the preferred method (http://aidsinfo.nih.gov/contentfiles/PerinatalGL.pdf).

If the mother is positive, the newborn usually tests positive for the antibodies for the first year even if he or she has not been infected, because the baby continues to carry the mother’s antibodies. The NIH recommends that the newborn be tested using methods that directly look for the HIV virus, like the HIV-PCR test, and that the testing be repeated at 1 to 2 months of age and between 3 and 6 months of age. After 18 months, the baby no longer carries the mother’s antibodies, and the regular HIV test is used. If the test is negative at that point, the baby is not infected. All babies born to HIV-positive mothers are treated with AZT for six weeks, beginning within six to 12 hours of life.

Bentsi-Addison points out that support for the mother-to-be is important and that newly positive women are offered medical social worker intervention. The additional stress of pregnancy makes dealing with the new diagnosis that much more difficult. At the Jack Martin Fund Clinic at Mount Sinai, there are support groups for people with HIV, and they benefit those with the diagnosis as they struggle to understand the implications.

When a woman is pregnant she is never alone. She has a new life inside her that becomes more insistently alive as time passes, kicking and turning when she would prefer to sleep or read. Testing for HIV and being brave enough to take the actions needed to protect her baby can be the first time she acts like a mother.

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Marylisa Kinsley, RN, BSN, is a contributing writer for Nursing Spectrum.

To comment on this article, e-mail editorNY@nursingspectrum.com.