Monday, October 5, 2009

Pregnancy, what's the risk?

Hi there,

Thought I'd do today's blog as a bit of a tutorial because the whole issue of pregnancy and transmission of HIV to the baby is very confusing, even for the professionals. Part of the reason it gets so confusing is because we use different rules in the private sector and state sector. For example, in the private sector all women should receive triple therapy HAART for the duration of their pregnancy. However, in the public sector, women get different treatment according to their CD4 count and according to their province, clinic and stage of pregnancy they are in.

If you are pregnant and HIV + , then you have about a one in three chance of passing HIV on to your baby. That is the scenario if we do nothing, we dont intervene, we dont treat, we stand back and watch. A 30% chance that your baby will be positive.

Now, the chance of passing the virus on depends on your own health status, your CD4 count, your viral load (how many copies of HIV are detected in your blood) and other factors. So, for each person, the risk will vary, but on average we are looking at one in three.

If your viral load is high ( say over 100 000 copies) then your risk of infecting your baby becomes much higher (around 50%). Similarly, if your CD4 count is very low, your risk is much higher (around 40 to 50%).
It is very important for you to sit down with your doctor and assess your own personal risk according to your CD4 count and Viral Load and health. If you are Stage IV (i.e. you are sick with an AIDS defining illness like PCP or Kaposi Sarcoma or Extrapulmonary TB) then your risk of infecting your baby is also higher.

So, how do we intervene and protect your baby from HIV?

The first thing to know and understand is that there is a different standard of care in the private sector and public sector. This is a reality that we face, and we have had a government that has, in the past, been reluctant to step up to the challenge of HIV. Unfortunately, this left pregnant women in the public sector receiving inferior treatment to those of the private sector and first world countries. In fact, its not just first world countries, Botswana has been leading the way in providing first world treatment to pregnant mothers for many years now. I am pleased to say that in 2008 pregnant women in public care began to receive AZT (Zidovudine) therapy in their third trimester ( 7 years after the Western Cape began to do this)

If you are a patient at a public hospital/clinic, then you will expect to start AZT tablets at 28 weeks (about 7 months pregnancy). When you go into labour, you take your single dose of Nevirapine that has been provided to you. The combination of these two medications (and hence the term dual therapy) will reduce your chance of infecting your baby to about 6%, or one in sixteen.

If you do not book at your antenatal clinic and do not go for follow up care then you might not receive this care at all. If you arrive at the clinic and are in labour, then you will be given the single dose of Nevirapine to take, but will not have had the benefit of the AZT from 7 months. With a single dose of Nevirapine, your risk of infecting your baby is 13% or about one in eight.

However, if your CD4 count is low (less than 250) then all of the above options are skipped and you go straight to the full ARV (Antiretroviral) treatment, otherwise known as HAART (Highly Active Antiretroviral Therapy), ART (Antiretroviral Therapy) or triple therapy (so-called because we always use a minimum of three ARV drugs).

The same applies in private care. If you are fortunate enough to afford private care, then you will also go straight to the third option of HAART during your pregnancy (this applies whether your CD4 count is 900, 500 or 100). If your CD4 count is over 350, then you will stop the HAART once your deliver your baby. If your CD4 count is less than 350 you will continue the HAART lifelong for your own health. If you receive HAART, then your risk of infecting your baby is less than 2%, ie. less than 1 in 50 babies will be infected.

So, let's recap: If we do nothing, a 30% chance of an HIV+ baby.
                      option 1:  with a Single dose of Nevirapine: a 13% chance
                      option 2 :With dual therapy (AZT and Nevirapine) a 6% chance.
                      option 3: With triple therapy (HAART/ARV) < 2% chance of an HIV+ baby.

Which do you ideally want for your pregnancy? Option 3 - because this provides the best option for you and your baby - and for both of your futures.

All babies that are born to an HIV + mother should receive their own medication too: a single dose of Nevirapine within 72 hours of birth, and AZT syrup to be taken for between one week and six weeks (again depending on various factors).

To see my presentation to the HIV Clinicians Society in Sept 2009 discussing HIV in Pregnancy: