What is HIV?

* What is HIV?
* How is HIV diagnosed?
* How is HIV transmitted?
* How common is HIV/AIDS in women and children?
* How are most women infected?
* What women are at highest risk of getting HIV through sex?
* Who should be tested for HIV?
* What HIV/AIDS treatments should a pregnant woman get?
* Does drug treatment help prevent HIV/AIDS in babies of HIV-infected mothers?
* Does a cesarean birth reduce the risk of passing on HIV to the baby?
* What other steps can women with HIV/AIDS and their providers take to protect the baby?
* Is it safe for a woman with HIV/AIDS to breastfeed her baby?
* What are the symptoms of AIDS in babies?
* What steps can a pregnant woman take to remain uninfected?
* Where is HIV testing available?
* Where can health care professionals get more information?
* References

AIDS stands for acquired immune deficiency syndrome. HIV stands for human immunodeficiency virus. HIV causes AIDS. An infected woman can pass HIV on to her baby during pregnancy, birth or breastfeeding. All pregnant women should be tested for HIV because proper treatment usually can prevent HIV in the baby.

What is HIV?
HIV attacks the immune system and destroys immune-system cells called CD4 cells that the body needs to fight infections. A person infected with HIV may not develop AIDS immediately. In fact, it may take many years. As the immune system becomes weaker, the infected person becomes less able to fight off infections and certain cancers, which can be life-threatening or fatal. Powerful drugs can treat AIDS and have dramatically improved the outlook for people with HIV/AIDS.

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How is HIV diagnosed?
HIV is diagnosed with blood tests. After HIV enters the bloodstream, the body begins to produce disease-fighting antibodies. If a blood test detects these antibodies, the person is “HIV-positive” but does not necessarily have AIDS. A person who is HIV-positive can transmit the virus to others.

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How is HIV transmitted?
HIV is passed from one person to another through contact with infected body fluids. The virus is found in:

* Blood
* Semen
* Vaginal fluids
* Breastmilk

Most people get HIV through sex or sharing needles. Infected babies most often get it from exposure to their mother’s blood and vaginal secretions during labor and delivery. Less often, the virus crosses the placenta and infects the baby before birth or the mother passes the virus to the baby after birth in breastmilk.

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How common is HIV/AIDS in women and children?
In the United States, 73 percent of individuals living with HIV/AIDS are male and 27 percent are female (3). An estimated 278,400 women in the United States are living with the virus, and many do not know it (1, 2). Most of these women are of childbearing age.

Since 1985, approximately 9,200 children in the United States have contracted AIDS, and about 5,400 have died (3). More than 90 percent got the virus from their mother during pregnancy or birth (3).

A 1994 study showed that drug treatment during pregnancy greatly reduces the risk that an HIV-infected mother will pass the virus on to her baby (4). Since then, the number of babies in the United States who get the virus from their mothers has dropped dramatically, from a high of about 1,650 in 1991 to an estimated 100 to 200 in 2005 (5).

Worldwide, about 420,000 babies get HIV from their mothers each year (6). About 90 percent of cases occur in developing countries where new treatments are not widely available. Researchers are studying new approaches to preventing HIV infection in these areas. There are many initiatives to make medications available throughout the world.

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How are most women infected?
The most common way women become infected is through unprotected (without a condom) heterosexual intercourse with infected partners. The Centers for Disease Control and Prevention (CDC) estimates that of new infections in women in the United States (7):

* About 80 percent are contracted through heterosexual intercourse. (Women are more likely than men to become infected via heterosexual sex.)
* About 20 percent are contracted through injection drug use by needle sharing.

A small number of women have contracted HIV by receiving infected blood transfusions, blood components or transplanted tissue.

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What women are at highest risk of getting HIV through sex?
Women at highest risk include:

* Women whose heterosexual partners use intravenous (IV) drugs
* Women whose partners also have sex with men
* Adolescents and young adults with multiple sex partners
* Women with sexually transmitted infections (STIs) other than HIV

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Who should be tested for HIV?
The CDC recommends that all pregnant women be screened for HIV infection(8). The CDC advises that providers inform pregnant women that HIV testing is routinely included in the standard blood tests for all pregnant women, and that providers perform the blood test unless a woman declines it. In states that mandate pretest counseling and written informed consent before HIV testing, providers should recommend and provide testing and counseling. The CDC also recommends that the test be repeated in the third trimester for women who are at increased risk of HIV infection or who live in an area with high rates of HIV infection (8). Women who learn they carry the virus can get treatment and can help protect their babies from getting infected.

The CDC also recommends screening for all adults and adolescents between the ages of 13 and 64 as part of routine medical care (8). Ideally, all women should be aware of their HIV status before conception. The March of Dimes urges all women of childbearing age to know their HIV status by being tested before they become pregnant. All women, whether tested before pregnancy or not, should be tested for HIV during pregnancy.

Women who have not been tested during pregnancy can be tested during labor and delivery with tests that produce results quickly. This allows treatment, when necessary, to help protect the baby.

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What HIV/AIDS treatments should a pregnant woman get?
People with HIV/AIDS generally are treated with combinations of HIV-fighting drugs. These drug combinations often slow the spread of HIV in the body, keep blood levels of the virus low (or even undetectable), and help prevent AIDS-related infections. The U.S. Public Health Service recommends that an HIV-infected pregnant woman receive treatment with these drugs throughout pregnancy (9). Medications may need to be modified as pregnancy progresses.

If a woman learns she has HIV in her first trimester and she has not yet been treated with any HIV-fighting drugs, she should be evaluated and decide about treatment with her provider. An infected pregnant woman who is already taking HIV-fighting drugs should continue to take them throughout pregnancy. However, her provider may recommend adjusting or changing medications.

Since HIV-fighting drugs are new, it is not yet known whether they pose a risk to the fetus. But these drugs do not appear to pose a significant risk to the fetus when they are used during pregnancy. However, a few of the newer drugs, including efavirenz (Sustiva) and delavirdine (Rescriptor), generally are not recommended in pregnancy because they may pose a risk of birth defects (9).

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Does drug treatment help prevent HIV/AIDS in babies of HIV-infected mothers?
Treatment with a combination of HIV-fighting drugs, along with use of cesarean section in certain circumstances, can reduce the risk of a mother passing HIV on to her baby to 2 percent or less, compared to 25 percent for untreated women (9). Infected pregnant women should take HIV-fighting drugs starting in the early second trimester and continue taking them throughout pregnancy, labor and birth. Babies born to an infected mother should be treated for the first 6 weeks of life to prevent transmission of the virus (9).

HIV-infected women who have not received any drug treatment before labor should be treated with HIV-fighting drugs during labor and delivery. Their babies should be treated with oral medicine for 6 weeks after birth (9). Even this short duration of treatment may reduce the risk of passing the infection on to the baby by about 60 percent (9).

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Does a cesarean birth reduce the risk of passing on HIV to the baby?
Studies show that some HIV-infected women can reduce their risk of passing the virus on to their baby by having a cesarean birth before labor begins and their membranes have ruptured. The U.S. Public Health Service and the American College of Obstetricians and Gynecologists (ACOG) recommend that HIV-infected women be offered a cesarean delivery at 38 completed weeks of pregnancy to further reduce the risk of passing HIV to their baby, unless they have very low (less than 1,000 copies/mL) or undetectable amounts of the virus in their blood (9, 10). It is unclear whether a cesarean birth further reduces the risk of transmitting the virus to the baby when a woman has very low or undetectable amounts of the virus in her blood as a result of drug treatment (9, 10).

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What other steps can women with HIV/AIDS and their providers take to protect the baby?
Health care providers can recommend other precautions to help protect the baby. A provider who knows that a woman is HIV-positive can avoid using procedures that could increase the exposure of the baby to the mother’s blood during pregnancy or labor, such as amniocentesis, fetal-scalp blood sampling or rupturing the membranes.

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Is it safe for a woman with HIV/AIDS to breastfeed her baby?
A woman with HIV/AIDS in the United States should not breastfeed her baby because breastfeeding can transmit the virus to the baby. This recommendation may differ in developing countries.

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What are the symptoms of AIDS in babies?
HIV-infected babies appear normal at birth, but about 15 percent of untreated babies develop serious symptoms and may die in the first year of life (11). Before combination drug treatment, about half of HIV-infected children died by age 9 (12). Now more than 95 percent of treated children survive, and most are free of serious symptoms much of the time (12).

Babies of women with HIV should be tested for the virus at 14 to 21 days, 1 to 2 months, and 4 to 6 months (11). Some providers also test babies within 48 hours of birth (11). These early tests, which detect the virus itself instead of the antibodies, can identify most infected babies by 1 month and virtually all by 4 months (11).

The HIV antibody test is not reliable for an infant born to an infected mother. This is because the mother’s antibodies may be present in her baby’s blood for up to 18 months, even if the baby has not been infected.

The U.S. Public Health Service recommends that all infants with HIV be treated with a combination of HIV-fighting drugs because the disease tends to progress more rapidly in infants than in older children and adults (11). Studies show that combination therapy slows the progress of the disease and improves survival in infected babies and children, as it does in adults.

Most adults with AIDS suffer opportunistic infections, which rarely occur in people whose immune systems are not weakened. A child with AIDS is at special risk of serious illness from common bacteria. But early diagnosis of HIV infection and frequent follow-up can help prevent or reduce the severity of these infections.

Babies with HIV infection generally should receive all routine childhood immunizations, plus some additional ones. Babies with HIV/AIDS should be vaccinated yearly against influenza starting at 6 months of age. Some children with serious symptoms should not receive live-virus vaccines, such as chickenpox, rotavirus and measles, mumps and rubella (MMR) (9, 12, 13).

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What steps can a pregnant woman take to remain uninfected?
Women should avoid all possible sources of infection before and throughout pregnancy, including:

* Using needles, razors or other items possibly contaminated with the blood of an infected person
* Having sexual contact with someone who is infected; using condoms helps protect against HIV and other STIs

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Where is HIV testing available?
Health care providers, local health departments, hospitals, clinics and special testing sites all offer HIV testing. The CDC provides information and referrals to local testing sites, including free and anonymous testing. Women can access this information:

* Through a toll-free telephone hotline at (800) CDC-INFO begin_of_the_skype_highlighting (800) CDC-INFO end_of_the_skype_highlighting (232-4636)
* On the Web at http://www.hivtest.org/

State and some local governments and health departments also provide hotlines for information about HIV/AIDS services.

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Where can health care professionals get more information?
ACOG offers information on perinatal HIV on its Web site.

The American Academy of Pediatrics offers information on pediatric HIV at its Web site.

The National Perinatal HIV Consultation and Referral Service at (888) 448-8765 begin_of_the_skype_highlighting (888) 448-8765 end_of_the_skype_highlighting and through its Web site provides free, 24-hour clinical consultation and advice on:

* Treatment of HIV-infected pregnant women and their infants
* Indications and interpretations of rapid and standard HIV testing in pregnancy

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References

1. Centers for Disease Control and Prevention (CDC). HIV Prevalence Estimates–United States, 2006, Morbidity and Mortality Weekly Report, volume 57, number 39, October 2, 2008, pages 1073-1076.
2. Centers for Disease Control and Prevention (CDC). Questions and Answers: HIV Prevalence Estimates–United States, 2006. October 2, 2008.
3. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report 2007, volume 19, February 2009.
4. Connor, E.M., et al. Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 With Zidovudine Treatment. New England Journal of Medicine, volume 333, number 18, 1994, pages 1173-1180.
5. Centers for Disease Control and Prevention (CDC). Mother-to-Child (Perinatal) HIV Transmission and Prevention. October 2007.
6. World Health Organization (WHO). Children and AIDS: Second Stocktaking Report. 2007.
7. Centers for Disease Control and Prevention (CDC). HIV/AIDS Among Women, CDC, August 2008.
8. Centers for Disease Control and Prevention (CDC). Revised Recommendation for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. Morbidity and Mortality Weekly Report, September 22, 2006, volume 55, No. RR-14.
9. U.S. Department of Health and Human Services. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. July 8, 2008.
10. American College of Obstetricians and Gynecologists (ACOG). Scheduled Cesarean Delivery and the Prevention of Vertical Transmission of HIV Infection. ACOG Committee Opinion, number 234, May 2000, reaffirmed 2008.
11. Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. February 23, 2009, www.aidsinfo.nih.gov.
12. American Academy of Pediatrics (AAP). Human Immunodeficiency Virus Infection. Red Book: 2006 Report of the Committee on Infectious Diseases, 27th edition. Elk Grove, IL, 2006.
13. Centers for Disease Control and Prevention (CDC). Gastroenteritis Among Infants and Children: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, volume 58, number RR-2, February 6, 2009