21 June 2012
New Canadian HIV Guidelines for planning pregnancy
The widespread availability of potent combination anti-HIV therapy (commonly called ART or HAART) has made deaths from AIDS-related infections relatively uncommon in high-income countries such as Canada, Australia and the U.S. and regions such as Western Europe. ART has helped to improve quality of life and tremendously extend the life expectancy of people living with HIV. This has led some HIV-positive people to consider having children.
Safe pregnancies and healthy babies
Today, the risk of mother-to-child transmission (also known as vertical transmission) in Canada is generally less than 1%, thanks to a combination of the following steps:
- use of ART during pregnancy so that viral load is as low as possible
- prenatal counselling and care
- intravenous AZT (zidovudine, Retrovir) for the mother during delivery
- Caesarean section (when medically necessary)
- a short course of oral anti-HIV medicines for the baby after birth
- use of formula rather than breastfeeding (HIV can be transmitted via breastfeeding)
- not pre-chewing food for the baby when solids are introduced. Adults who have both HIV and oral infections can inadvertently cause a small amount of blood to leak and be present in the food if they pre-chew. This blood can contain HIV and if the pre-chewed food is fed to the infant, it may transmit HIV.
Bridging the gap
As a result of the reduced risk of vertical transmission, more and more HIV-positive women (and some HIV-positive men) are thinking about and having babies. A team led by infectious disease specialist Mona Loufty, MD, one of Canada’s leading researchers, has found that “a gap exists between the desires and intentions of people living with HIV to have children and their need for support in doing so and the resources, relevant research and support networks necessary for them to do so in a medically safe manner.”
Several studies in Canada and elsewhere have documented that many HIV-positive people would like to have children. Therefore, Loufty and her colleagues note that “specialized counselling, services and support will be required to meet the needs of [HIV-positive people who wish to have a baby].”
Dr. Loufty and a team of researchers across Canada have produced an outstanding document called the Canadian HIV Pregnancy Planning Guidelines to help health care practitioners advise HIV-positive people about issues related to fertility and pregnancy. The guidelines contain 33 recommendations that will assist health care providers and fertility centres to do the following:
- reduce the risk of HIV transmission from mother to child
- reduce the risk of HIV transmission from one person to another when people are trying to conceive
- improve the health of HIV-positive women and their children
- reduce the stigma linked to HIV infection
- increase access to pregnancy planning and fertility services
The guidelines are to the point, highly focused and rich in knowledge essential to producing excellent care and advice for HIV-positive people who want to have a baby.
Dr. Loufty and her team remind readers that basic general advice for HIV-negative women also applies to HIV-positive women. As such, they recommend the following publications from the Public Health Agency of Canada:
The guidelines deal with many issues related to healthy pregnancy planning and fertility. Some recommendations in the document include the following:
- “Reproductive health counselling, including contraception and pregnancy planning, should be offered to all reproductive-aged HIV-positive individuals soon after HIV diagnosis and on an ongoing basis.”
- “Men and women should be counselled on all relevant aspects of pregnancy planning, such as maintaining a healthy diet and lifestyle, the risk of genetic disease occurrence, and integrated prenatal screening, as outlined in current Canadian practice guidelines irrespective of their known HIV status.”
- “Women with no risk factors should start taking the B vitamin folic acid at a dose of 1 mg a day for three months before becoming pregnant and for at least the first three months of their pregnancy.”
- “Women should be encouraged to give up smoking, drinking alcohol and using recreational drugs and should be referred for support if required.”
- “Both prospective parents should be tested for other sexually transmitted infections, even if they have conceived in the past and have no symptoms of infection.”
The guidelines also discuss psychosocial and mental health issues, legal and ethical issues related to pregnancy planning and fertility, and options for reducing the risk of HIV transmission when serodiscordant couples (where one partner is HIV-negative and the other is positive) are trying to conceive.
A highly practical guide
One of the many useful aspects of the guidelines is that they visit scenarios that health care professionals may experience and provide concrete solutions. For instance, the reader is presented with pregnancy planning advice for HIV-positive people in the following situations:
- an HIV-positive woman and an HIV-negative man
- an HIV-negative woman and an HIV-positive man
- HIV-positive single women
- HIV-positive men or a same-gender couple
The guidelines also provide advice for fertility clinics. Since such clinics are supposed to be operating under the Canadian Standards Association procedures for universal precautions and infection control, the guidelines state that “there are no scientific grounds on which to refuse services to people living with HIV.”
Dr. Loufty and colleagues should be congratulated on the Canadian HIV Pregnancy Planning Guidelines. They are a tremendous leap forward in assisting care providers and HIV-positive people to have safe pregnancies and healthy babies.
—Sean R. Hosein
- Loufty MR, Margolese S, Money DM, et al. Canadian HIV Pregnancy Planning Guidelines. Journal of Obstetrics and Gynaecology Canada. 2012 Jun;34(6):575-90.
- Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Sep. 14, 2011; pp 1-207.
- Loutfy M, Raboud J, Wong J, et al. High prevalence of unintended pregnancies in HIV-positive women of reproductive age in Ontario, Canada: a retrospective study. HIV Medicine. 2012 Feb;13(2):107-17.
- Centers for Disease Control and Prevention (CDC). Premastication of food by caregivers of HIV-exposed children--nine U.S. sites, 2009-2010. Morbidty and Mortality Weekly Reports. 2011 Mar 11;60(9):273-5.
- Gaur AH, Dominguez KL, Kalish ML, et al. Practice of feeding premasticated food to infants: a potential risk factor for HIV transmission. Pediatrics. 2009 Aug;124(2):658-66.
- Ivy W 3rd, Dominguez KL, Rakhmania NY, et al. Premastication as a route of pediatric HIV transmission: case-control and cross-sectional investigations. Journal of Acquired Immune Deficiency Syndromes. 2012 Feb 1;59(2):207-12.