hiv and pregnancy hiv and pregnancy 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. 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: maculopapular rash, note: this image shows a nonspecific rash that is not necessarily associated with an acute hiv infection early symptoms of hiv diagram. early, acute stagethe 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 stagethe 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 stageaids 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 oral candidiasis (oral thrush) in a child. 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 pregnancy planning the main factors to consider in pregnancy planning for hiv positive individuals are the risk of disease transmission between the sexual partners themselves and the risk of disease transmission to the fetus. both risks can be mitigated with appropriate perinatal planning and preventative care. acog and the national institutes of health (nih) recommends all couples in which one or both partners are hiv positive seek pre-pregnancy counseling and consult experts in obstetrics and gynecology, infectious disease, and possibly reproductive endocrinology and infertility to ensure couples are getting appropriate, individualized guidance based on their specific disease states and weighing the risks to the fetus associated with taking art medications. couples in which only one partner is hiv positive are at risk of transmitting hiv to the uninfected partner. these couples are known as serodiscordant couples. the cdc reports that hiv positive people who are able to sustain undetectable viral loads while taking art therapy have a negligible risk of transmitting hiv to their partner through sex based on observational data from multiple large scale studies, most notably the hptn052 clinical trial, the partner study, the partner2 study, and the opposites attract study. the nih therefore advises that hiv positive people who maintain an undetectable viral load via adherence to long-term art therapy can attempt conception via condomless sex with minimal risk of disease transmission to the hiv negative partner. the nih further recommends that aligning condomless sex with peak fertility, which occurs at ovulation, via ovulation test kits and consultation with clinical experts can maximize the chance for conception. in-vitro fertilization. when the hiv positive individual in a serodiscordant partnership has not achieved viral suppression or his or her viral status is unknown, there are other options for preventing transmission amongst partners. the first option includes administering pre-exposure prophylaxis art therapy (prep) to the hiv negative partner, which involves once daily dosing of a combination drug to prevent the transmission of hiv following condomless sex. the nih advises administering prep to serodiscordant couples who are going to attempt conception via condomless sex, however, they emphasize that adherence is absolutely necessary to effectively protect the hiv negative partner. the other option for achieving conception while simultaneously preventing hiv transmission amongst partners is reproductive assistance. when the female attempting to conceive is hiv positive, she can undergo assisted insemination with semen from her partner to reduce the risk of transmission. when the man in the partnership is hiv positive, the couple can choose to use donor sperm or utilize sperm preparation techniques (for example, sperm washing and subsequent viral testing of the sample) and intrauterine or in vitro fertilization to achieve conception to reduce the risk of transmission to his partner. in couples where the male and female are both hiv positive, conception may occur normally without concern for disease transmission amongst each other. however, it is vital for any hiv positive mother to initiate and maintain appropriate art therapy under the guidance of an hiv expert prior to and throughout pregnancy to reduce the risk of perinatal transmission to the fetus. although assisted reproductive techniques are available for serodiscordant couples, there are still limitations to achieving a successful pregnancy. women with hiv have been shown to have decreased fertility, which can affect the available reproductive options. women with hiv are also more likely to be infected with other sexually transmitted diseases, placing them at higher risk for infertility. males with hiv appear to have decreased semen volume and sperm motility, which decreases their fertility. art may also affect both male and female fertility and some drugs can be toxic to embryos. testing in pregnancy further information: diagnosis of hiv/aids hiv rapid test being administered to a patient. early identification of maternal hiv infection and initiation of art in pregnancy is vital in preventing viral transmission to the fetus and protecting maternal health, as hiv-infected women who do not receive testing are more likely to transmit the infection to their children. the cdc, nih, acog, and american academy of pediatrics each recommend first trimester hiv testing for all pregnant women as a part of routine prenatal care. the nih further elaborates on this recommendation, indicating that hiv testing should be conducted as early as possible wherever a woman seeks care and initially determines she is pregnant (for example, in the emergency department). first trimester hiv testing is conducted simultaneously with other routine, early pregnancy lab work in the united states, including: a complete blood count, blood typing and rhesus factor, urinalysis, urine culture, rubella titer, hepatitis b and c titers, sexually transmitted infection testing, and tuberculosis testing. acog advises that prenatal caregivers repeat third trimester hiv testing prior to 36 weeks gestation for the following women: those who remain at high risk for contracting an hiv infection, those who reside in areas with a high incidence of hiv infection in pregnancy, those who are incarcerated, or those with symptoms suggestive of an acute hiv infection. for women who have not received prenatal care or who have not been previously tested for hiv infection during pregnancy, acog and the nih suggest performing rapid hiv screening in the labor and delivery unit prior to delivery or immediately postpartum. hiv testing in the united states is currently offered on an opt-out basis, per the cdc's recommendation. opt-out testing involves educating the patient on the impact of an hiv infection on pregnancy, notifying the patient that hiv screening is recommended for all pregnant women, and informing her that she will automatically receive the test with her other routine lab work unless she explicitly declines the test and signs a consent form to have it removed from her lab panel. the alternative model, known as the opt-in model, involves counseling women on hiv testing, following which they elect to receive the test by signing a consent form. the opt-in model is not recommended by the cdc, as it is associated with lower testing rates. if a woman chooses to decline testing, she will not receive the test. however, she will continue to receive hiv counseling throughout pregnancy so that she may be as informed as possible about the disease and its potential impact. she will be offered hiv testing at all stages of her pregnancy in case she changes her mind. the most updated hiv testing protocols recommend using the hiv-1 and hiv-2 antigen/antibody combination immunoassay as the initial screening test for an hiv infection. this blood test assesses whether or not the mother has created antibodies, which are disease-fighting proteins of the immune system, against the hiv-1 and hiv-2 viruses. these antibodies will only be present if the patient has been exposed to hiv, therefore, they act as a marker of infection. this test