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Reproductive and Pregnancy Care

Reproductive Health Care for Women and Men

image of birth control pillsMost persons with HIV in the United States acquired HIV through sexual exposure during their reproductive years, and most continue sexual activity after their diagnosis. Reproductive health is an essential consideration for persons with HIV because unplanned pregnancies are common in HIV-infected women, and an estimated 25% of HIV-infected women express a desire to become pregnant after an HIV diagnosis.57 Unplanned pregnancies that go to term may complicate a woman’s HIV care and may result in perinatal transmission. Physiologic changes in pregnancy also increase the risk of both HIV transmission and acquisition.58

The forthcoming recommendations will address several reproductive health strategies that can influence the risk of sexual and perinatal HIV transmission. All of the forthcoming recommendations are consistent with these recommendations from existing federal government guidance for clinicians:

Clinicians who serve women and men of reproductive age with HIV

  • Assess the pregnancy status of HIV-infected women.59-61
  • Assess the reproductive plans of women and men with HIV.56-61
  • Offer family planning, condoms, and emergency contraception to women and men with HIV who are not seeking conception.60, 61
  • Offer preconception counseling for persons with HIV who are considering conception.60, 61
  • Offer special conception methods that reduce risk of sexual and perinatal transmission when persons with HIV are seeking conception, including
    • antiretroviral therapy to maximally suppress viral load before attempting conception;
    • timed, periovulatory intercourse to reduce risk of sexual transmission; and
    • intravaginal or intrauterine artificial insemination, in vitro fertilization, or intracytoplasmic sperm injection using semen of an HIV-uninfected donor, and if this is unacceptable, specially prepared (“washed”) semen of the HIV-infected man.60, 61

Prevention of HIV Transmission Related to Pregnancy

Sexual HIV transmission during pregnancy may occur when persons with HIV have sexual contact with uninfected pregnant women or when pregnant women with HIV have sexual contact with uninfected partners. Pregnancy can also increase a woman’s risk of transmitting and acquiring HIV. This may be due to changes in systemic or genital mucosal immunity, increases in the amount of HIV, or other factors.62 Perinatal transmission occurs when HIV is transmitted from a woman to a fetus or child during pregnancy, labor, delivery, or breastfeeding. Unprotected sexual activity is common throughout pregnancy, especially when condoms are no longer used for contraception.63 The start of prenatal care provides opportunities to inform pregnant women and their partners about how to prevent sexual transmission during pregnancy and to offer initial or repeat HIV testing to persons whose infection status was negative or unknown before conception. It also provides opportunities to offer antiretroviral medications and other interventions to mothers and newborns that can reduce risk of mother-to-child transmission.

image of pregnant woman and manThe forthcoming recommendations will provide guidance about preventing HIV transmission related to pregnancy for clinicians and non-clinical community-based HIV prevention providers who serve pregnant women and health department surveillance staff who monitor pregnant women with HIV and infants exposed to HIV during pregnancy. The forthcoming recommendations are consistent with recommendations from existing federal government guidance for these types of providers:

Clinicians and non-clinical HIV prevention providers serving pregnant women with HIV

  • Promptly link HIV-infected pregnant women to providers who have expertise in managing pregnancy in HIV-infected women.64-68
  • Inform women (and partners, if served) about risks of perinatal, sexual, and drug-injection-related HIV transmission, and recommend behaviors and interventions that reduce transmission risk.64-68
  • Encourage women to disclose their HIV status to sex and drug-injection partners, and refer to health department partner services to provide assistance in notifying partners about possible HIV exposure.66, 67
  • Encourage HIV testing of women’s sex partners and drug-injection partners.64, 66, 67
  • Offer antiretroviral therapy (ART) regimens recommended by the U.S. Department of Health and Human Services (DHHS) to prevent perinatal and sexual HIV transmission, including prenatal ART 68; antiretroviral prophylaxis during labor and the postpartum period, whether or not prenatal ART was used;67-69 and postexposure infant prophylaxis within 12 hours of birth to all HIV-exposed infants.65, 68
  • Offer support to maintain good adherence by mother and infant.64, 67-69
  • Offer delivery options that may reduce risk of perinatal HIV transmission, e.g., cesarean delivery for women with suboptimal viral suppression near delivery 67,68 or symptomatic genital herpes at the onset of labor.70
  • Avoid invasive prenatal and intrapartum procedures in women who do not have maximally suppressed viral load.67,68
  • Early in pregnancy, screen, treat, and offer repeat testing for selected sexually transmitted diseases (STDs) that may increase risk of HIV transmission to partners or the fetus according to CDC’s 2010 STD Treatment Guidelines.64, 66, 67, 70, 71
  • After delivery, provide education, counseling, and/or referral, as appropriate to setting, for
    • safe infant feeding practices, i.e., using formula instead of breast milk, avoiding food pre-chewed by HIV-infected parents or caregivers;67,68
    • family planning, condoms, and emergency contraception for women who do not want to conceive again; 67, 68, 69, 72, 73 and
    • substance use treatment, mental health services, and social support services for women who warrant these services.67, 68
  • Perform virologic testing of all HIV-exposed infants one or more times during the first months of life to determine the infant’s infection status,65, 68 notify pediatricians of test results, and report perinatally exposed or HIV-infected infants to health departments according to local reporting requirements.74, 75

Providers serving pregnant women who are not HIV infected or have unknown HIV infection status and have sex or drug-injection partners with HIV, including

Clinicians and non-clinical HIV testing providers

  • Offer women routine, universal HIV testing early in pregnancy as appropriate to setting (e.g., part of routine prenatal screening panel in clinical settings, as early in pregnancy as possible in non-clinical settings).65, 67, 68, 71
  • Address objections of women who initially decline testing, continue to encourage testing when appropriate, and reassure that services will be provided even if testing is declined.65, 67, 71
  • Offer testing for acute infection to women who have symptoms of acute retroviral syndrome or who suspect recent HIV exposure.65, 67

Clinicians who provide prenatal care

  • Offer repeat testing during the third trimester of pregnancy to women who had an earlier negative HIV test, continue to have unprotected sex or share drug-injection equipment with an HIV-infected partner, have signs or symptoms of acute HIV infection, reside in jurisdictions with an elevated incidence of HIV or AIDS among women, or are otherwise at high risk for HIV.65, 67, 71, 17
  • Offer rapid HIV testing to women of unknown HIV status who first present for pregnancy care during labor (using an opt-out consent strategy when allowed by jurisdiction).65,71
  • Provide the newborns of women who decline HIV testing or whose infection status remains unknown at delivery rapid antibody testing as soon as possible after birth and inform the mothers that a positive newborn test indicates maternal HIV infection but not necessarily infant infection.65, 67
  • Early in pregnancy, screen, treat, and offer repeat testing for selected STDs that may increase risk of acquring HIV, according to CDC’s 2010 STD Treatment Guidelines.71
  • Assess women for eligibility for nonoccupational postexposure prophylaxis (nPEP), and offer eligible women preexposure prophylaxis (PrEP) regimens that are suitable during pregnancy based on DHHS recommendations.67, 76, 76a (see topic page on adherence to antiretroviral medication).

Clinicians serving HIV-infected partners of pregnant women who are not HIV infected or have unknown HIV infection status

  • Link partners who are not currently engaged in care to HIV care providers.64-67
  • Refer partners to health department partner services if they have not notified pregnant partners of possible HIV exposure.64, 66

17For a list of jurisdictions with elevated incidence see reference 4.

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