HIV in Canada: A primer for service providers

 

Fertility Options and Prevention of Vertical Transmission

Key Points

  • Pregnancy planning and fertility options are allowing many HIV-positive people in Canada to conceive while reducing the risk of HIV transmission to their partners.
  • The rate of transmission of HIV 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, they will not transmit HIV to their newborn.
  • Because HIV can be transmitted through breast milk it is recommended that HIV-positive mothers in Canada not breastfeed/chestfeed.1

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

Canadian HIV pregnancy planning guidelines, developed in 2018, provide guidance on options to reduce transmission to partners when a couple tries to conceive. Options can include timed condomless sex (taking into account HIV viral load in the HIV-positive partner and other factors), pre-exposure prophylaxis, sperm washing or use of donor sperm with intra-uterine insemination and more advanced techniques such as intra-uterine insemination or in vitro insemination.

HIV transmission from parent to child can occur before birth, during labour and delivery, and through breastfeeding. In the absence of HIV treatment, between 15% and 30% of infants born to HIV-positive women will acquire HIV during pregnancy and delivery; a further 5% to 20% would be at risk for 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 during prenatal care, starting treatment as soon as possible and maintaining an undetectable viral load for the remainder of the pregnancy will substantially reduce the risk of HIV transmission to the infant. If diagnosed during labor and delivery or treatment is not started during pregnancy, a shorter course of HIV treatment before delivery, although not as effective, can also help reduce the risk of transmission. In all cases, HIV treatment is also given to the infant 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. Canada guidelines recommend that HIV-positive parents 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 women in Canada access prenatal care, making this an opportune time to provide counselling regarding HIV testing. However, some groups of women, such as women who inject drugs, immigrants and refugees may not receive adequate prenatal care. To decrease the number of HIV-positive babies born to mothers who are unaware that they themselves are HIV positive, all Canadian provinces and territories have developed universal testing policies for pregnant women. These are designed to increase the likelihood that physicians will offer HIV testing to pregnant women. Some provinces offer opt-in approaches, whereby women must consent specifically to an HIV test. Other provinces offer opt-out approaches, whereby women are notified that an HIV test will be included in the routine prenatal tests and that they may refuse testing.

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

Barriers to preventing mother-to-child 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., poor adherence, late start of HIV treatment).

Resources

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

You can have a healthy pregnancy if you are HIV positive – 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. Arkell C. Pregnancy and infant feeding: Can we say U=U about the risk of passing HIV to an infant? Prevention in Focus. Spring 2018; CATIE. Available from: https://www.catie.ca/en/pif/spring-2018/pregnancy-and-infant-feeding-can-we-say-uu-about-risk-passing-hiv-infant
  • 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.