HIV in Canada: A primer for service providers

 

Fertility Options and Prevention of Vertical Transmission

Key Points

  • Pregnancy planning, fertility options and advances in HIV are allowing many HIV-positive people in Canada to conceive while reducing the risk of HIV transmission to their partners.
  • The rate of HIV transmission from parent to child is exceedingly low in Canada.
  • If a pregnant person is on HIV treatment prior to pregnancy and maintains an undetectable viral load throughout pregnancy and childbirth, they will not transmit HIV to their newborn.
  • Because HIV can be transmitted through breast milk Canadian guidelines recommend that HIV-positive mothers in Canada do not breastfeed/chestfeed1

With advances in HIV treatment, increasing numbers of HIV-positive people in Canada are having children. Transmission to partners and transmission to the child are two significant concerns when considering HIV and conception.

Canadian HIV pregnancy planning guidelines, updated in 2018, provide guidance on options to reduce transmission between partners during conception. If the person living with HIV is not already on treatment, they are advised to begin HIV treatment as soon as possible in the preconception period. Using treatment to achieve and maintain an undetectable viral load prior to conception prevents passing HIV to sexual partners. Ideally, their viral load should be undetectable for at least three to six months before trying to conceive. Conception options can include condomless sex or timed condomless sex (during periods of peak fertility to increase the chance of conception), pre-exposure prophylaxis (PrEP) taken by the HIV-negative partner, sperm washing or use of donor sperm with intra-uterine insemination and more advanced techniques such as in vitro insemination.

HIV transmission from parent to child can occur during pregnancy, during labour and delivery, and through breastfeeding. Without treatment, there is a 15% to 30% chance that a baby born to a woman living with HIV will acquire HIV during pregnancy or delivery, with an additional 5% to 20% chance of getting HIV if breastfed.

If a pregnant person starts HIV treatment prior to pregnancy and maintains an undetectable viral load they will not transmit HIV to their newborn during pregnancy or delivery. However, this is only possible if the person is diagnosed before pregnancy. If diagnosed with HIV after getting pregnant, starting treatment as soon as possible and maintaining an undetectable viral load is most likely to prevent HIV transmission to the baby the sooner it is started and the sooner an undetectable viral load is achieved. All pregnant people with HIV in Canada also receive intravenous HIV treatment during labour, as an additional precaution, and their babies receive a short course (four to six weeks) of HIV treatment after birth.

While the risk is very low, there is a small chance of passing HIV to a baby through breastfeeding, even with an undetectable viral load. Canadian guidelines recommend that HIV-positive parents exclusively feed their babies formula to prevent transmission. However, experts also recommend that people who are on treatment and maintaining an undetectable viral load, who have a strong desire to breastfeed, should receive clinical support to do so as safely as possible.

Almost all pregnant people in Canada access prenatal care, making this an opportune time to offer HIV testing. To decrease the number of HIV-positive babies born to people who don’t know they have HIV, all Canadian provinces and territories have developed universal testing policies for pregnant people. These help to increase the likelihood that physicians will offer HIV testing during pregnancy.

In 2017, 240 infants were born to women living with HIV. Only three of these infants were confirmed HIV positive – one woman did not receive any HIV treatment during her pregnancy while two did receive HIV treatment during pregnancy. No data exists on how long they were on treatment or whether they maintained an undetectable viral load.  

Barriers to preventing perinatal transmission include lack of antenatal care, lack of HIV testing in pregnancy, undiagnosed seroconversion (new HIV infection) in pregnancy, and lack of HIV treatment or suboptimal therapy in pregnancy (e.g., low adherence, late start of HIV treatment). Some groups of women in Canada, such as women who inject drugs, immigrants and refugees may be more likely to experience the above barriers and less likely to receive adequate care.

Resources

Pregnancy and infant feeding: Can we say U=U about the risk of passing HIV to an infant? - CATIE

Having an HIV-negative baby – CATIE

HIV treatment and an undetectable viral load to prevent HIV transmission - CATIE

Pregnancy Planning Information for HIV+ Women and Their Partners – Women's College Hospital

Information for Women who are Diagnosed with HIV during Pregnancy – Women's College Hospital

Information for HIV+ New Moms – Women's College Hospital

Pregnancy Planning Information for HIV+ Men and Their Partners – Women's College Hospital

Sources

  1. Loufty MR, Kennedy VL, Poliquin V, et al. Canadian HIV pregnancy planning guidelines. Journal of Obstetrics and Gynaecology Canada. 2018 Jan;354:94–114. Available from: https://www.jogc.com/article/S1701-2163(17)30701-6/abstract
  2. Haddad N, Li JS Totten S, McGuire M. HIV in Canada-Surveillance Report, 2017. Canada Communicable Disease Report. 2018;44(12):324–332. Available from: https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-12-december-6-2018/article-3-hiv-in-canada-2017.html
  3. Bitnun A, Brophy J, Samson L, et al. Prevention of vertical transmission and management of the HIV-exposed infant in Canada in 2014. Canadian Journal of Infectious Disease and Medical Microbiology. 2014;25(2):75-77.
  4. Bispo S, Chikhungu L, Rollins N, et al. Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis. Journal of the International AIDS Society. 2017 Feb 20;20(1):1–8.
  5. Mandelbrot L, Tubiana R, Le Chenadec J, et al. No perinatal HIV-1 transmission from women with effective antiretroviral therapy starting before conception. Clinical Infectious Diseases. 2015;61:1715–1725.
  6. Luoga E, Vanobberghen F, Bircher R et al. No HIV transmission from virally suppressed mothers during breastfeeding in rural Tanzania. Journal of acquired immune deficiency syndrome. 2018;79(1):e17-e20.
  7. Flynn PM, Taha TE, Cababasay M et al. Prevention of HIV-1 transmission through breastfeeding: Efficacy and safety of maternal antiretroviral therapy versus infant nevirapine prophylaxis for duration of breastfeeding in HIV-1-infected women with high CD4 count (IMPAACT PROMISE): a randmomized, open label, clinical trial. Journal Acquired Immune Deficiency Syndrome. 2018;77(4):383-392.
  8. Shapiro RL, Hughes MD, Ogwu A, et al. Antiretroviral regimens in pregnancy and breast-feeding in Botswana. New England Journal of Medicine. 17 June 2010;362(24):2282–2294.
  9. Palombi L, Pirillo MF, Andreotti M, et al. Antiretroviral prophylaxis for breastfeeding transmission in Malawi: drug concentrations, virological efficacy and safety. Antiviral Therapy. 2012;17:1511–1519.
  10. Kahlert C, Aebi-Popp K, Bernasconi E, et al. Is breastfeeding an equipoise option in effectively treated HIV-infected mothers in a high-income setting? Swiss Medical Weekly. 2018 Jul 23;148:w14648. Available from: https://smw.ch/article/doi/smw.2018.14648
  11. Nashid N, Khan S, Loutfy M. Breastfeeding by women living with Human Immunodeficiency Virus in a resource-rich setting: A case series of maternal and infant management and outcomes. Journal of the Pediatric Infectious Disease Society. 2019; in-press.
  • 1. Chestfeeding refers to nursing an infant using one’s chest. It is a term sometimes used by people on the trans masculine spectrum who feel more comfortable with this language.