An HIV-infected woman becomes pregnant. Purification of sperm from HIV. Both spouses are infected

HIV infection today, unfortunately, is a very common disease. As of November 1, 2014, the total number of registered Russians living with HIV was 864,394, and in 2016 the epidemiological threshold was even exceeded in some cities. Among them are women of childbearing age who want and can fulfill their desire to have a child. With a carefully planned approach and coordinated work of the patient and doctors at several levels, it is possible to have a healthy baby with minimal risk to their own health.

Research to find the most effective set of measures to prevent the transmission of the virus from mother to child has been conducted for more than one year. These studies began with the examination and treatment of HIV-infected women in Malaysia, Mozambique, Tanzania and Malawi, that is, those countries where the percentage of HIV-infected women of childbearing age reached 29% (!) Of the total number of these women. The urgency of the problem was that in these and a number of other countries there was an extremely high level of maternal and child mortality. Further studies were carried out in a number of European countries, certain schemes for the management of pregnant women and preventive measures in childbirth were developed, which are now regulated in the standards of medical care.

HIV infection is a chronic infectious disease caused by two types of human immunodeficiency virus (HIV-1 and HIV-2). The essence of this infection is that the virus is built into the immune cells (directly into the genetic material of the cell) of the body, damages and suppresses their work. Moreover, when the protective cells multiply, they reproduce copies that are also infected with the virus. As a result of all these processes, the body's immune defenses are gradually destroyed.

HIV infection does not have any specific symptoms, it is dangerous for the development of opportunistic (comorbid) infections and malignant neoplasms. This is due to the fact that the body is not able to resist the invasion of pathogenic flora from the outside, the reproduction of pathogenic and conditionally pathogenic flora of its own body, and the oncological protection of the body is also reduced. In the body, genetic breakdowns occur regularly at the cellular level, normally “wrong” cells are quickly destroyed and do not pose a danger, while with HIV infection, the number of killer cells (a special population of cells that recognize altered genetic material and destroy it) is significantly reduced. The body is defenseless not only before oncology, but also before a banal cold. The final stage of HIV infection is acquired immunodeficiency syndrome (AIDS).

Source of HIV infection are people infected with HIV at any stage of the disease, including during the incubation period.

Ways of transmission of infection

1. Natural: contact (mainly sexual in all types of sexual contact) and vertical (from mother to fetus through blood).

2. Artificial:

Artifical non-medical (use of contaminated instruments for manicure, pedicure, piercing, tattooing; use of a common syringe for intravenous drug use);

Artificial medical (virus exposure as a result of tissue and organ transplantation, transfusion of blood and plasma components, use of donor sperm).

Diagnosis for HIV during pregnancy:

1. Determination of antibodies to HIV by ELISA performed three times during pregnancy (at registration, at 30 weeks and at 36 weeks). If a positive result is obtained for the first time, then blotting is carried out.

HIV testing is always carried out with the patient's consent; recently, some centers allocate a quota for a single HIV test of the child's father.

Initially, pre-test counseling is carried out, an infectious and sexual history is collected, the presence, nature and length of bad habits and intoxications are ascertained. You should not be offended by an obstetrician - gynecologist for seemingly inappropriate questions about intravenous drugs and the number of sexual partners, about alcohol and smoking. All of this information helps you determine your obstetric risk, and it's not just about HIV infection. They will also tell you what HIV infection is, how it threatens a person, how it is transmitted and how infection can be prevented, what results can be and in what time frame. You may have read and are aware of the main aspects of this problem (we hope so), but listen to the doctor and you may have new questions that you would like to ask. Don't treat pre-test counseling as a formality.

Post-test counseling is carried out in case of a positive result for HIV. All the same information is repeated as in pre-test counseling, because now this information is no longer introductory, but practical. Then it explains in detail the impact of HIV infection on pregnancy, the risk of transmission to the fetus and how to minimize it, how to live with such a disease, what to treat and where to go in certain cases.

The patient should be consulted by an infectious disease specialist of the AIDS center (inpatient or outpatient, it depends on the obstetric situation) and registered. Without an account, it is impossible to get antiretroviral therapy drugs, they are given at a discount, and few people can afford to buy them on their own. The price of drugs ranges from about 3,000 to 40,000 thousand rubles per drug, and, as a rule, a patient receives from two to five types of drugs.

2. Immune and linear blotting is a highly sensitive method of research to confirm or refute the diagnosis of HIV infection. This method is used if a doubtful or positive result for antibodies to HIV has come. In this case (if the blood is taken at the second stage of the study), the result “HIV delayed” is sent to the antenatal clinic.

3. Determination of the immune status.

Immune status is the number of CD4+ T cells in a cubic millimeter of blood. These are protective cells of the lymphocytic system, their number reflects the degree of infection of the immune system, the depth of the infectious process. Depending on the number of CD4+ T cells, the activity of antiretroviral therapy is selected.

In a healthy person, the number of CD4+ T cells is in the range of 600 - 1900 cells/ml of blood. Immediately after infection (after 1-3 weeks), the level of cells can drop sharply (but we rarely see a patient at this stage), then the body begins to resist and the number of lymphocytes increases, but no longer reaches the initial level. Thereafter, the level of CD4+ T cells gradually decreases by about 50 cells/ml per year. For a long time, the body can resist HIV infection on its own, but with the onset of pregnancy, the situation changes, here the prescription of approved antiretroviral drugs is made to all women without exception.

4. Determination of viral load. Viral load reflects the number of copies of the viral RNA (genetic basis) that circulates in the blood. The higher this indicator, the more dangerous the course of the disease, the faster the damage to the immune system and the higher the risk of transmission by any route. An indicator of less than 10,000 copies per µl is considered a low viral load, and more than 100,000 copies/µl is considered a high viral load.

5. Express testing for HIV. This type of study is performed if a woman enters the maternity hospital unexamined, and there is no time to wait for the results of an ELISA for HIV (an emergency requiring delivery). In such a situation, blood is taken for analysis by ELISA and express testing at the same time. The final diagnosis of "HIV infection" according to the result of the express test cannot be set. But a positive or doubtful result of such an emergency analysis already serves as an indication for HIV chemoprophylaxis during childbirth and the appointment of antiretroviral prophylaxis for the child on the first day (syrup). The likely toxic effect of a chemotherapy drug is not comparable to the possible prevention of the transmission of HIV infection to a baby. Then, within 1 - 2 days, the result of the ELISA comes, depending on the result, an additional examination is carried out, consultation by the infectious disease specialist of the AIDS center.

Planning for pregnancy with HIV

The realization of her childbearing function is the right of every woman, no matter how others treat it. But in the case of HIV infection, a planned pregnancy is practically the only chance to give birth to a healthy baby and not transmit the virus to him. There are also families where only one of the spouses is infected. Next, we will describe how conception is carried out in these cases.

1. Both spouses are infected.

Complete examination of the couple for significant infections. Tests for hepatitis B and C, microreaction for syphilis, tests for STIs (gonorrhea, chlamydia, trichomoniasis, ureaplasma, mycoplasma), herpes viruses, cytomegalovirus and Epstein-Barr virus should be taken. All identified diseases should be treated as fully as possible, as this reduces the risk of intrauterine infection of the fetus.

General examination (general blood and urine tests, biochemical blood test, fluorography, consultations of specialists according to indications).

Consultation with an AIDS center infectious disease specialist and timely administration of highly active antiretroviral therapy (HAART) to both partners. This is necessary to reduce the viral load and protect partners as much as possible, as they can be infected with early types of the virus. In addition, getting into the human body, the virus inevitably mutates.

2. The wife is infected, the husband is healthy.

This situation is the most “simple” for doctors in terms of safe conception, since unprotected sexual contact is not required, but with great risks for the unborn child.

You should also conduct a general examination and specific tests for infections, treat identified infections.

A woman needs to consult an infectious disease specialist at the AIDS Center, if she is not yet registered, then register, report a planned pregnancy and receive antiretroviral therapy.

The safest method of conception is artificial insemination. This is a method in which during the period of ovulation (on the 12th - 15th day of the menstrual cycle), the partner's sperm is artificially injected into the woman's vagina.

3. The husband is infected, the wife is healthy.

It is much easier for a woman to get HIV infection through contact with an infected man than for a man in the same conditions. This is because the contact of semen and the vaginal mucosa is much longer than the contact of the skin and penile mucosa with vaginal secretions. For this reason, natural conception in this situation is associated with a high risk of infection, and the more attempts, the higher the likelihood.

The general examination and treatment is the same as in the previous cases.

The preferred method of conception is the introduction of purified sperm into the woman's vagina on the days of ovulation. Few people know that the spermatozoa themselves cannot be infected with the immunodeficiency virus, but the seminal fluid surrounding them, on the contrary, carries a very high viral load. If purified semen is introduced, then the risk of infection is minimal (the virus content during purification can be reduced to 95%). This method is preferred for couples with the indicated infectious history.

In some cases, in vitro fertilization methods (IVF, ICSI) are used. As a rule, these methods are used if there is also a pathology of the partner's sperm (azoospermia, asthenozoospermia, and others) or other forms of infertility.

Management of pregnancy with HIV

1. How does pregnancy affect HIV infection?

Pregnancy is a state of natural immunosuppression due to high levels of progesterone (a hormone that maintains pregnancy). Some suppression of the immune system is necessary so that the mother's body does not reject the fetus's body, since the child is an independent organism that half inherits the father's genetic material, which means it is alien.

In the absence of antiretroviral therapy, HIV during pregnancy can progress, from a latent stage to a stage with complications, which threatens not only health, but also life.

With timely treatment, there is no significant dynamics in the development of HIV infection. According to some reports, after childbirth, the state of immunity even improves, but they don’t know how to explain this yet, but there are such data.

During pregnancy, a woman living with HIV is seen by two obstetrician-gynecologists. The obstetrician-gynecologist of the antenatal clinic carries out general management of pregnancy, prescribes an examination in accordance with order No. 572 and treatment of obstetric pathology (threat of abortion, nausea and vomiting of pregnant women, preeclampsia, and others).

The obstetrician-gynecologist of the AIDS Center examines the patient at least three times during pregnancy. Here, an obstetric examination is combined with data on the immune status and viral load, based on a combination of examinations, management and treatment tactics are developed, it is possible to change antiretroviral therapy or add another drug to the regimen. At the last visit in the period of 34-36 weeks, the patient is given not only a medical opinion, but also a drug for HIV chemoprophylaxis during childbirth (intravenous administration), as well as a drug for HIV chemoprophylaxis for a child in the form of a syrup. Also, a woman is given a detailed scheme for the use of both forms of drugs.

2. How does HIV infection affect pregnancy?

Of course, first of all, we are interested in the risk of transmitting the virus to the child. Other complications of pregnancy are rarely directly related to HIV infection. Infection does not directly affect the ability to become pregnant.

Without HIV chemoprophylaxis, the risk of transmission of the virus from mother to fetus ranges from 10% to 50%. The virus can be transmitted in several ways:

1. Infection during pregnancy.
2. Infection during childbirth.
3. Infection during breastfeeding.

The percentage of types of infection of the child is shown in the figure.

There are many aspects and risks in this issue that determine the outcome of pregnancy with HIV.

Maternal aspects:

Viral load (the higher the viral load, the higher the risk of passing HIV to the child);

Immune status (the lower the number of CD4 + T cells, the less protected the mother's body and the higher the risk of any bacterial, viral and fungal complications that cannot affect the child);

Associated diseases and bad habits.

All chronic diseases (especially inflammatory ones) reduce immunity to some extent. Your doctor is especially interested in the presence of hepatitis B and C (which is not uncommon in women who have injected drugs in the past or who have had sexual contact with a drug user), STIs (syphilis, gonorrhea, chlamydia, trichomoniasis and others), as well as bad habits (alcohol, smoking, drugs and psychoactive substances in the past or at the moment). Drugs are the risk of direct intravenous infection with a number of infections, as well as the formation of severe complications, from infective endocarditis to sepsis. Alcohol is a strong factor in the formation of immunodeficiency in itself, and in combination with an existing HIV infection, it significantly worsens the prognosis.

Obstetric - gynecological aspects during pregnancy:

Sometimes there is a need for invasive diagnostics during pregnancy (amniocentesis - amniotic fluid sampling, cordocentesis - blood sampling from the umbilical vein), if for a healthy woman these activities are carried out with minimal risk (less than 1% of spontaneous miscarriages and leakage of amniotic fluid), then for an infected woman patients, these manipulations can be dangerous, as the possibility of transmitting the virus to the child increases. In the event of such a situation, when a geneticist (or ultrasound doctor) recommends an invasive diagnosis, it is necessary to explain to the patient all the risks (possible birth of a fetus with a genetic syndrome and an increased risk of infection), weigh and make an agreed decision. The patient always makes the final decision.

Pathology of the placenta (chronic fetoplacental insufficiency, placentitis). With many pathologies of the placenta, one of its main functions, the barrier, suffers, thus creating prerequisites for the virus to enter the child's bloodstream. Also, the virus can enter the cells of the placenta and multiply, and then infect the fetus.

During childbirth (more in the article "Childbirth and the postpartum period with HIV infection")

Premature opening of the fetal bladder and outpouring of water,
- rapid childbirth
- protracted labor and anomalies of labor activity,
- Birth trauma.

Risks on the part of the child (for more details, see the article “Childbirth and the postpartum period with HIV infection”):

big fruit,
- prematurity and hypotrophy of the fetus weighing less than 2500 grams,
- the first child of twins,
- intrauterine infection of the fetus with damage to the skin (pemphigus of the newborn, vesiculopustulosis),
- ingestion of amniotic fluid and aspiration (inhalation of amniotic fluid).

Chemoprophylaxis of HIV transmission during pregnancy

For chemoprophylaxis of HIV transmission, drugs from the same range as for basic treatment are used. However, some drugs are contraindicated. They are not prescribed, and if a woman received them before pregnancy, then they are replaced with permitted ones. The list of recommended drugs is prescribed in the Decree of the Government of the Russian Federation dated December 30, 2014 No. 2782-r.

Preparations:

1) HIV protease inhibitors (nelfinavir, atazanavir, ritonavir, darunavir, indinavir, lopinavir + ritonavir is a combination drug, fosamprenavir, saquinavir, telaprevir).

2) Nucleosides and nucleotides (telbivudine, abacavir, phosphazid, didanosine, zidovudine, stavudine, tenofovir, entecavir, lamivudine).

3) Non-nucleoside reverse transcriptase inhibitors (nevirapine, efavirenz, etravirine).

All these drugs are prescribed in a period of 14 weeks (at earlier periods, a teratogenic effect of drugs is possible, that is, provoking congenital malformations of the fetus). HAART (highly active antiretroviral therapy) drugs are started even if HIV infection is detected a few days before delivery, since most cases of prenatal infection occur in the third trimester. Prescribing treatment helps to significantly reduce the viral load almost immediately, which reduces the risk of passing the infection to the child. If the HIV status has been known for a long time and the patient is taking therapy, then it should not be stopped (substitution of drugs is possible). In rare cases, during the first trimester, HAART drugs are stopped (all at the same time).

Side effects and toxic effects of HAART drugs:

Effect on the blood system: anemia (decrease in hemoglobin and erythrocytes), leukopenia (decrease in leukocytes), thrombocytopenia (decrease in blood clotting cells - platelets);

Dyspeptic phenomena (nausea, vomiting, heartburn, pain in the right hypochondrium and epigastrium, loss of appetite and constipation);

Hepatotoxicity (impaired liver function), detected by biochemical blood tests (bilirubins, AlAT, AST, alkaline phosphatase, GGT), in severe cases clinically (jaundice, itching, lightening of feces, darkening of urine and other symptoms);

Dysfunction of the pancreas (pancreatitis), manifested by pain in the left hypochondrium or shingles, nausea, vomiting, fever, diarrhea and changes in tests (increased blood and urine amylase);

Osteoporosis and osteopenia (increased bone fragility) develops, as a rule, with long-term use;

Headaches, weakness, drowsiness;

Allergic reactions (often like urticaria).

Fetal risk of HAART:

The toxic effect on the hematopoietic system is the same as that of the mother.

Babies on HAART tend to be born at a lower weight than the general population and gain weight more slowly early in life. Then the difference levels out and there are no significant differences in physical development.

Previously, the influence of HAART drugs on the formation of the fetal nervous system was discussed, but at the moment it is still concluded that the lag in psychomotor development and neurological symptoms are associated with the use of drugs by the mother. In the absence of a drug history, the indicators of psychomotor development of children from HIV-infected mothers on therapy and other children do not have a significant difference.

The risks of HAART to the fetus are not commensurate with the potential benefits of treatment.

After the start of chemoprophylaxis, the patient is taken under control at the AIDS center, she is invited to consultative visits to assess the effect of the drug, monitor compliance (adherence to treatment, adherence to the prescribed regimen), tolerability and severity of side effects. During the visit, a general examination, a patient interview and laboratory tests are performed (more on them below). After the start of chemoprophylaxis, the first follow-up examination is performed after 2 weeks, and then every 4 weeks until delivery.

KLA is taken every visit, since the most common side effect of HAART drugs (in particular, azidothymidine) is a toxic effect on the hematopoietic system and the development of anemia, thrombocytopenia, granulocytopenia (a decrease in the number of all blood cells).

The CD4+ T cell count is assessed 4, 8, 12 weeks after the start of prophylaxis and 4 weeks before the expected date of delivery. If the number of CD4+ T cells is less than 300 cells/ml, the chemoprevention regimen is revised in favor of more active drugs.

Viral load is controlled after 4, 12 weeks from the start of therapy and 4 weeks before the expected birth. A viral load of 300,000 copies per ml is also an indication for increased therapy. A high viral load detected before childbirth is an additional indication for a caesarean section.

Concomitant treatment

1. Reception of multivitamin complexes for pregnant women (elevit pronatal, vitrum prenatal, femibion ​​natalkea I and II).

2. Iron preparations in the development of anemia (sorbifer, maltofer and others).

3. Hepatoprotectors for signs of toxic liver damage (Essentiale).

HIV infection in a woman of childbearing age is not a contraindication to pregnancy, but a serious and deliberate approach is required. Perhaps there are not many pathologies in which almost everything depends on the well-coordinated work of the patient and doctors. No one guarantees a woman with HIV the birth of a healthy child, but the more a woman is committed to therapy, the more likely it is to bear and give birth to an uninfected child. Pregnancy will be accompanied by taking a large number of different drugs, which is also risky for the fetus, but all this serves a good purpose - the birth of an uninfected baby. Look after yourself and be healthy!

Discordant couples, where one partner is HIV positive and the other is not, are not uncommon today. Using a condom with every sexual intercourse, you can be sure that infection will not occur, but it will also not work to get pregnant. In the event that a woman is infected and a man is healthy, everything is quite simple: you need to collect sperm and perform artificial insemination. But if a healthy woman wants to get pregnant from an HIV-infected woman, the situation becomes more complicated, but there are several ways.

Reducing the risk of HIV transmission during conception

Children with HIV can only be born from HIV-infected mothers, the status of the father does not matter, so the main thing is not to infect a woman, but it is quite possible to achieve this. The fact is that the risk of sexual transmission of the virus is not so great, and if desired, it can be reduced to almost zero.

To do this, both partners must contact the infectious diseases center of the AIDS center and tell that they are planning a pregnancy. An infectious disease specialist may suggest that the couple start taking special antiretroviral drugs. Men - to reduce the viral load, women - to reduce the risk of infection. After drinking a course of pills, you can have unprotected sex, but it is better to do it as little as possible - on the days of ovulation. If pregnancy has occurred, the first step is to find out if infection has occurred. HIV can only be completely eliminated after a window period of three months has elapsed. Thereafter, a condom must be used with every intercourse until the end of the pregnancy.

Sperm cleaning from HIV

Unlike the previous method, cleaning sperm from HIV protects the expectant mother from infection by 100%. The fact is that the spermatozoa themselves do not contain the virus, it is present only in the seminal fluid. In order to purify the sperm in the laboratory, the spermatozoa are separated from the seminal fluid, after which the egg is artificially fertilized.

Unfortunately, the purification of sperm from HIV is a complex procedure that requires special equipment, which is not available in Russia. At the moment, sperm purification is only done in a few European countries, and it is not cheap.

Pregnancy due to HIV infection

When deciding to give birth from an HIV-infected person, it is important to remember that even if a woman becomes infected at conception, she has every chance of giving birth to a healthy child. The main thing is to diligently follow all the recommendations of the doctor. In this case, the risk of vertical transmission of HIV infection does not exceed 2%.

HIV is a virus that enters the human body and leads to suppression of immune function. An immunodeficiency state is expressed in the inability of the body to resist the most common diseases that in a healthy person pass without a trace.

There are 4 stages of the disease:

1. The stage of the incubation period is the moment from the entry of the virus into the blood and to the manifestation of primary signs.
2. The stage of the primary manifestation of the disease is the appearance of typical signs of pathology.
3. Secondary subclinical changes.
4. Terminal (ending) stage.

The syndrome of acquired immunodeficiency develops less often from 3, more often from 4 stages of the pathological process, and is briefly called AIDS.

AIDS is a human condition in which, against the background of infection of the underlying pathology, infections, bacterial and viral diseases are added. The immune system of a healthy person copes with incoming pathogenic agents, inactivating their actions. With HIV in the AIDS stage, the immune system is not able to resist the infection, and severe consequences develop.

Unfortunately, there is no cure for HIV, but supportive therapy has been developed to prevent the onset of AIDS. You can live with HIV infection for decades, but in the final terminal stage, a lethal outcome is observed in less than six months.

Previously, pathology concerned more people leading an antisocial lifestyle. Currently, the disease has become widespread and can affect every person, regardless of their status, gender and position. Even pregnant and newborn children are at risk.

Ways of transmission of infection

The virus is extremely unstable in the environment and is not able to exist outside a living organism, so the transmission routes are:

• Sex is the main route of infection. The source is a sick person, regardless of the stage of the disease. You can get infected through any kind of sexual contact (oral, vaginal and especially anal). With oral intercourse, the risk decreases only if there are no bleeding open wounds on the oral mucosa of one of the partners. The virus is found in mucous vaginal secretions and semen.
• Vertical - from an infected mother to a newborn child. Possible infection is observed when the fetus passes through the birth canal, as well as at the time of breastfeeding of a sick mother.
• Hematogenous - enters the human blood. This route of transmission is common among people who inject drugs. The use of one syringe leads to mass infection. You can pick up an infection in the office of a doctor, nurse, in a beauty salon, where the tools have not passed the necessary stages of sterilization. Also, medical personnel are subject to infection if protective measures are not observed.
• Transplant. HIV can enter the human body through a blood transfusion, or in the case of an organ transplant from an infected person.

Through household items, hygiene items, dishes and kisses, the transmission of the virus is impossible even to the smallest extent.

Diagnosis of the disease in pregnant women

A patient who is in an “interesting” position may not be aware of the presence of immunodeficiency in her body, and will face this problem after receiving the tests.

When a antenatal clinic is given a number of laboratory tests, including blood for venereal pathologies:. Within two weeks, the biological fluid is examined and the presence or absence of a pathogenic agent is determined by ELISA. There is no other way to diagnose the disease. In specialized AIDS centers there is an opportunity for a small fee to undergo express diagnostics of immunodeficiency.

AIDS is a dangerous disease, both for the pregnant woman herself and for the fetus she is carrying. The results obtained are reported incognito to the patient, but if the woman is aware of the presence of the disease, then the medical staff should be warned to exclude nosocomial infection. For unknown reasons, patients may withhold a known diagnosis from doctors.

Can analyzes be wrong and why

In the gestational period, according to the established scheme, blood for venereal pathologies is donated three times:

1. When registering with the LCD;
2. At 30 weeks of gestation;
3. Before childbirth.

The analysis forms must indicate the address, diagnosis and full name.

In the results obtained, there can be 2 possible answers:

• Positive;
• Negative.

In both cases, there may be an error. A "negative" result can be obtained at the time of blood sampling during the seronegative window. This is the state of the body in which the virus is in it, but does not cause an immune response. The window period lasts from 1 month to half a year, so blood is collected several times during the gestational period. The same applies to medical workers who undergo a medical examination 2 times a year.

A “positive” result is bad news, but it does not mean infection. For reliable information, the pregnant woman, together with her partner, is subject to a complete diagnostic study.

A false positive result can be identified for several reasons:

1. Chronic diseases of the mother, in particular hepatic pathologies;
2. The production of antibodies to protect against DNA foreign to the maternal organism;
3. Irresponsible analysis. For example, in case of mixing up blood samples.

With the subsequent delivery of the analysis, more reliable results are obtained, but if a woman doubts, then it is possible to anonymously take tests and make sure of the diagnosis. It is important that both partners are subject to research.

Features of pregnancy with HIV infection

The identified human virus does not adversely affect the child's body if the woman does not neglect the recommendations and follows the rules established for her. The patient must be registered with two specialists: a gynecologist in a antenatal clinic, and a venereologist in a specialized center against AIDS. The danger for the child is secondary pathologies that have joined as a result of reduced immunity. The bad habits of the sick person are also negatively reflected: smoking, the use of narcotic or toxic drugs.

Intrauterine development of the baby

The detection of pathology in the mother's body is not a reason to terminate the pregnancy, because the placenta does not allow large-dispersed pathogenic agents into the baby's body. The baby develops without any pathologies, but only if the pregnant woman monitors her health and complies with all requirements.

An asocial lifestyle against the background of HIV infection causes a violation of organogenesis. The child lags behind in development, he develops hypoxia and chromosomal abnormalities. Not uncommon and miscarriage regardless of gestational age. In the absence of appropriate antiretroviral therapy, the chance of having a healthy baby is greatly reduced.

The likelihood of infection of the baby

The risk of infection of the child increases with the refusal of maintenance therapy. A child can become infected in several cases:

• During the intrauterine period of development;
• At the time of passage through the birth canal;
• In the case of breastfeeding by an HIV-positive mother or another woman in labor.

Infection during childbirth

It is during natural childbirth that particles of a pathogenic agent enter the weakened and fragile body of the baby. The earlier the baby is born, the higher the risk of infection. During the birth period, from 2 to 40% of cases, children “catch” the virus from the mother, depending on the therapy performed.

intrauterine infection

It accounts for no more than 7% of cases. Born children are extremely weak, during their stay in the womb, the virus entered the vital organs and settled there. The prognosis in this situation is unfavorable. If the pathology developed in the womb, then the mother either was not registered or refused treatment. The lethal outcome of the immunodeficiency virus in the postpartum period is 80%.

HIV therapy during pregnancy

Treatment of positive patients should begin as early as possible. Timely therapy is considered to be started before 12 weeks. This period is important for the development of the baby. When choosing medications, the stage of pathology, the age of the mother and the presence of concomitant diseases are taken into account.

Medications and their features in the appointment

The main treatment is highly active antiretroviral therapy. To achieve the best effect, therapy with several drugs is carried out, or combined agents are preferred.

The most used drugs:

• Retrovir;
• Epivir;
• Zidolam;
• Ziagen.

The tablet form is used in the treatment of the adult population, children are given preference to a suspension containing the same components.

Pregnant women take medication orally 5 times a day. At the beginning of labor activity, the drugs are administered intravenously every 2 hours, and at the end of labor, massive therapy with nucleoside inhibitors is carried out 2 times a day. Childbirth is carried out with the help, less often in a natural way.

A newborn baby is tested after 72 hours from birth, the analysis taken earlier has traces of maternal blood, and gives a false positive result. Antiretroviral therapy is given immediately after birth to prevent infection.

Concomitant treatment

During the gestation period, a weakened body can hardly tolerate even a minor disease. So a mild cold can lead to bronchitis or. Concomitant therapy is intended to eliminate infection not associated with immunodeficiency.

With microbial pathologies, treatment is carried out, chronic diseases are treated with a complex of medicines, as well as vitamins.

HIV treatment tactics:

1. antiviral therapy;
2. Immunostimulating therapy;
3. Treatment of associated pathologies.

Is it possible to give birth to a healthy baby with HIV-positive status?

It is possible to give birth to a healthy child. It is necessary to comply with all medical prescriptions, carefully examine and pass a control to determine the condition of the baby. If the second half “wears” a positive status, then all measures of individual protection should be taken:

• Use a condom during intercourse;
• Do not share towels and hygiene products (toothbrushes, razors and soap).

There is no guarantee that a child will be born absolutely healthy from an infected mother, because the risk always remains.

Due to the nature of the infection, it turned out that most carriers of the virus are young boys and girls who dream of love, family, and children. HIV does not make this impossible, you just need to know how to protect yourself and prevent the infection from passing from mother to baby.

The risk of acquiring a child with HIV in pregnant women

If you rely on luck and do not take any preventive measures, almost half of the children, 40-45%, will be born with the virus. Subject to all necessary measures, artificial feeding, this figure can be reduced to 6-8%, and according to some sources, up to 2%.

More than half of babies become infected during childbirth, approximately 20% - in different periods of pregnancy (especially in the second half) and while breastfeeding.

Planning for pregnancy with HIV

The good old truth that links the health of mother and child is right here too. If a woman knows about her status and wants to become pregnant, she definitely needs to determine the viral load in the blood and find out the number of CD4 cells.

If the test results are not very good (high levels of viruses and insufficient - lymphocytes), you will first have to seek to improve them. This makes the pregnancy easier and the risk of HIV transmission much lower.

Eg, with CD4 less than 200 the probability of infection of the baby will become 2 times more, and the viral load over 50.000 is considered 4 times more dangerous.

Estimated sample regimen for taking antiretroviral drugs during a future pregnancy:

• if the woman's condition and laboratory data did not require medication before, it is better to do without them for the first three months after conception;
• it is undesirable to interrupt the treatment that has been started earlier. First, a sharply increasing number of viruses can lead to transmission to a child. In addition, there is a possibility of developing opportunistic infections and the development of drug resistance;
• if ifavirenz was included in the therapy regimen, they try to replace it with other drugs due to the pathological effect on the development of the fetus;
• it is not recommended to prescribe stavudine and didanosine, this regimen is not easily tolerated by pregnant women, serious liver problems are possible.

Conception with HIV infection

Since sexual intercourse must be protected (with a condom) with a positive status, pregnancy can be problematic.

Somewhat easier if both partners live with the virus, but even here there is a risk of exchanging different strains of it, including drug-resistant ones. In addition, it is believed that the likelihood of passing the infection to the child is higher. If there is only HIV in the family one, then we must try not to infect him.

It is easier to save an uninfected man- it is enough to collect his sperm in a sterile vessel and carry out self-fertilization using a special kit.

It is more difficult if the virus is found only in a man. In the semen, the concentration of HIV is usually very high, so the danger to the woman is very likely.

There are several possible solutions:

• reduce the viral load in men to a minimum and choose the period of ovulation in women. Unfortunately, this cannot completely protect a woman. And infection during conception is also dangerous for the baby, because in the first few months of infection, the number of viruses in the blood is maximum;
• to carry out a special manipulation to clean the partner's sperm, to separate the spermatozoa from the seminal fluid (the location of the viruses). The resulting material is then injected to the woman.
• . The method is quite complicated, expensive and not available to all couples. Selected individual spermatozoa in a test tube are combined with eggs received from a woman, then embryos in the early stages of development are injected directly into the uterus;
• use of donor sperm from special banks. But some men categorically refuse such an opportunity, and for women it is important to give birth to a beloved child.

HIV Infection and Pregnancy – Basic Principles for Having a Healthy Baby

Antiretroviral therapy after three months pregnancy. The safest drug zidovuddin often used in combination with nevirapine.

Observation by doctors, adequate nutrition, prevention. A premature baby (especially with a period of less than) is not able to resist the virus, it is easily infected.

Treatment and prevention opportunistic diseases in the mother.

Birth type planning. Since most babies become infected during childbirth, being at term can reduce this chance. But if such an operation is forced to resort to, due to problems that have arisen, the risk may be even higher.

If it is possible to reduce the concentration of viruses to less than 1000 in 1 μl, conventional childbirth also becomes quite safe. It is necessary to avoid opening the membranes of the fetal bladder, various obstetric manipulations.

Refusal to breastfeed. Preventive purpose antiretroviral drugs for newborns in syrups.

It is not immediately possible to determine whether a child is infected or not. All his HIV tests can be positive up to a year and a half of life, because maternal antibodies are in his blood and are gradually destroyed. If after this period the result does not change, then it is infected.

More exact method- detection of the virus in the blood by PCR (polymerase chain reaction). At 3, 6 and 12 months, the reliability of this type of diagnosis is 90-99%.

Statistics show an annual increase in the number of HIV-infected people. The virus, which is very unstable in the external environment, is easily transmitted from person to person during sexual intercourse, as well as in childbirth from mother to child and breastfeeding. The disease is controllable, but a complete cure is impossible. Therefore, pregnancy with HIV infection should be under the supervision of a doctor and with appropriate treatment.

About the pathogen

The disease is caused by the human immunodeficiency virus, which is represented by two types - HIV-1 and HIV-2, and many subtypes. It affects cells of the immune system - CD4 T-lymphocytes, as well as macrophages, monocytes and neurons.

The pathogen multiplies rapidly and infects a large number of cells during the day, causing their death. To compensate for the loss of immunity, B-lymphocytes are activated. But this gradually leads to the depletion of protective forces. Therefore, opportunistic flora is activated in HIV-infected people, and any infection proceeds atypically and with complications.

The high variability of the pathogen, the ability to lead to the death of T-lymphocytes allows you to get away from the immune response. HIV quickly forms resistance to chemotherapy drugs, so at this stage in the development of medicine, it is not possible to create a cure for it.

What signs indicate the disease?

The course of HIV infection can be from several years to decades. The symptoms of HIV during pregnancy do not differ from those in the general population of those infected. Manifestations depend on the stage of the disease.

At the stage of incubation, the disease does not manifest itself. The duration of this period is different - from 5 days to 3 months. Some already after 2-3 weeks are worried about the symptoms of early HIV:

• weakness;
• flu-like syndrome;
• enlarged lymph nodes;
• a slight unreasonable increase in temperature;
• rash on the body;

After 1-2 weeks, these symptoms subside. The quiet period can last for a long time. For some it takes years. The only signs may be recurrent headaches and permanently enlarged, painless lymph nodes. Skin diseases such as psoriasis and eczema can also join.

Without the use of treatment, the first manifestations of AIDS begin in 4-8 years. In this case, the skin and mucous membranes are affected by a bacterial and viral infection. Patients lose weight, the disease is accompanied by candidiasis of the vagina, esophagus, pneumonia often occurs. Without antiretroviral therapy, after 2 years, the final stage of AIDS develops, the patient dies from an opportunistic infection.

Management of pregnant women

In recent years, the number of pregnant women with HIV infection has increased. This disease can be diagnosed long before pregnancy or during the gestational period.

HIV can pass from mother to child during pregnancy, childbirth or breast milk. Therefore, planning pregnancy with HIV should be done in conjunction with a doctor. But not in all cases, the virus is transmitted to the child. The following factors influence the risk of infection:

• the immune status of the mother (the number of viral copies is more than 10,000, CD4 is less than 600 in 1 ml of blood, the CD4/CD8 ratio is less than 1.5);
• clinical situation: a woman has an STI, bad habits, drug addiction, severe pathologies;
• genotype and phenotype of the virus;
• the condition of the placenta, the presence of inflammation in it;
• gestational age at infection;
• obstetric factors: invasive interventions, duration and complications in childbirth, anhydrous time;
• the condition of the skin of the newborn, the maturity of the immune system and the digestive tract.

The consequences for the fetus depend on the use of antiretroviral therapy. In developed countries, where women with infection are monitored and instructions are followed, the effect on pregnancy is not pronounced. In developing countries, HIV can develop the following conditions:

• spontaneous miscarriages;
• antenatal fetal death;
• joining STIs;
• premature;
• low birth weight;
• postpartum infections.

Examinations during pregnancy

All women give blood for HIV when they register. A re-examination is carried out at 30 weeks, a deviation up or down by 2 weeks is allowed. This approach makes it possible to identify at an early stage pregnant women who are already registered as infected. If a woman becomes infected on the eve of pregnancy, then the examination before childbirth coincides in time with the end of the seronegative period, when it is impossible to detect the virus.

A positive HIV test during pregnancy warrants referral to an AIDS center for further diagnosis. But only one express test for HIV does not establish a diagnosis; this requires an in-depth examination.

Sometimes an HIV test during gestation turns out to be a false positive. This situation can scare the expectant mother. But in some cases, the features of the functioning of the immune system during gestation lead to such changes in the blood, which are defined as false positive. And this may apply not only to HIV, but also to other infections. In such cases, additional tests are also prescribed, which allow an accurate diagnosis.

The situation is much worse when a false-negative analysis is obtained. This can happen when blood is taken during the seroconversion period. This is the period of time when infection occurred, but antibodies to the virus have not yet appeared in the blood. It lasts from several weeks to 3 months, depending on the initial state of immunity.

A pregnant woman who tests positive for HIV and further testing confirms the infection is offered a legal termination of pregnancy. If she decides to keep the child, then further management is carried out simultaneously with the specialists of the AIDS Center. The need for antiretroviral (ARV) therapy or prophylaxis is decided, the time and method of delivery are determined.

Plan for women with HIV

For those who were already registered as infected, as well as with a detected infection, in order to successfully bear a child, it is necessary to adhere to the following observation plan:

1. When registering, in addition to the main routine examinations, an ELISA for HIV, an immune blotting reaction is required. The viral load is determined, the number of CD lymphocytes. The specialist of the AIDS Center gives advice.
2. At 26 weeks, the viral load and CD4 lymphocytes are re-determined, a general and biochemical blood test is given.
3. At 28 weeks, a specialist from the AIDS Center consults a pregnant woman, selects the necessary AVR therapy.
4. At 32 and 36 weeks, the examination is repeated, the AIDS Center specialist also advises the patient on the results of the examination. At the last consultation, the term and method of delivery are determined. If there are no direct indications, then preference is given to urgent delivery through the natural birth canal.

Throughout pregnancy, procedures and manipulations that lead to a violation of the integrity of the skin and mucous membranes should be avoided. This applies to holding and. Such manipulations can lead to contact of the mother's blood with the baby's blood and infection.

When is urgent analysis needed?

In some cases, an express HIV test at the maternity hospital may be prescribed. This is necessary when:

• the patient was never examined during pregnancy;
• only one analysis was passed when registering, there was no second test at 30 weeks (for example, a woman comes with a threat of preterm birth at 28-30 weeks);
• the pregnant woman was tested for HIV at the right time, but she has an increased risk of infection.

Features of HIV therapy. How to give birth to a healthy child?

The risk of vertical transmission of the pathogen during childbirth is up to 50-70%, while breastfeeding - up to 15%. But these figures are significantly reduced by the use of chemotherapeutic drugs, with the refusal of breastfeeding. With a properly selected scheme, a child can get sick only in 1-2% of cases.

Antiretroviral drugs for prevention are prescribed to all pregnant women, regardless of clinical symptoms, viral load and CD4 count.

Prevention of transmission of the virus to the child

Pregnancy in HIV-infected people takes place under the guise of special chemotherapy drugs. To prevent infection of the child, use the following approaches:

• prescribing treatment for women who were infected before pregnancy and are planning to conceive;
• use of chemotherapy for all infected;
• during childbirth, drugs for ARV therapy are used;
• after childbirth, similar medications are prescribed for the child.

If a woman has a pregnancy from an HIV-infected man, then ARV therapy is prescribed to the sexual partner and to her, regardless of the results of her tests. Treatment is carried out during the period of bearing a child and after his birth.

Particular attention is paid to those pregnant women who use drugs and have contacts with sexual partners with similar habits.

Treatment at the initial detection of the disease

If HIV is detected during gestation, treatment is prescribed depending on the time when this happened:

1. Less than 13 weeks. ART drugs are prescribed if there are indications for such treatment until the end of the first trimester. For those who are at high risk of fetal infection (with a viral load of more than 100,000 copies / ml), treatment is prescribed immediately after the tests. In other cases, in order to exclude a negative effect on the developing fetus, with the start of therapy, it is timed until the end of the 1st trimester.
2. Term from 13 to 28 weeks. If the disease is detected in the second trimester or an infected woman applied only in this period, treatment is prescribed urgently immediately after receiving the results of tests for viral load and CD
3. After 28 weeks. Therapy is prescribed immediately. Use the scheme of three antiviral drugs. If treatment is first started after 32 weeks with a high viral load, a fourth drug may be added to the regimen.

A highly active antiviral therapy regimen includes certain groups of drugs that are used in a strict combination of three of them:

• two nucleoside reverse transcriptase inhibitors;
• a protease inhibitor;
• or a non-nucleoside reverse transcriptase inhibitor;
• or an integrase inhibitor.

Preparations for the treatment of pregnant women are selected only from groups whose safety for the fetus is confirmed by clinical studies. If it is impossible to use such a scheme, you can take drugs from the available groups, if such treatment is justified.

Therapy in patients previously treated with antiviral drugs

If HIV infection was detected long before conception and the expectant mother underwent appropriate treatment, then HIV therapy is not interrupted even in the first trimester of gestation. Otherwise, this leads to a sharp increase in viral load, worsening test results and the risk of infection of the child during the gestation period.

With the effectiveness of the scheme used before gestation, there is no need to change it. The exception is drugs with a proven danger to the fetus. In this case, the replacement of the drug is made on an individual basis. Efavirenz is considered the most dangerous of those for the fetus.

Antiviral treatment is not a contraindication for pregnancy planning. It has been proven that if a woman with HIV consciously approaches the conception of a child, follows the medication regimen, then the chances of giving birth to a healthy baby increase significantly.

Prevention in childbirth

The protocols of the Ministry of Health and WHO recommendations define the cases when it is necessary to prescribe a solution of Azidothymidine (Retrovir) intravenously:

1. If antiviral treatment was not used with a pre-delivery viral load of less than 1000 copies / ml or more than this amount.
2. If a rapid HIV test in the maternity hospital gave a positive result.
3. If there are epidemiological indications, contact with a sexual partner infected with HIV within the last 12 weeks while injecting drugs.

Choice of method of delivery

To reduce the risk of infection of the child during childbirth, the method of delivery is determined on an individual basis. Childbirth can be performed through the natural birth canal in the case when the woman in labor received ART during pregnancy and the viral load at the time of delivery is less than 1000 copies/ml.

Be sure to note the time of the outflow of amniotic fluid. Normally, this occurs in the first stage of labor, but sometimes prenatal effusion is possible. Considering the normal duration of labor, this situation will result in an anhydrous gap of more than 4 hours. For an HIV-infected woman in labor, this is unacceptable. With such a duration of the anhydrous period, the likelihood of infection of the child increases significantly. A long waterless period is especially dangerous for women who have not received ART. Therefore, a decision can be made to complete the birth by.

In childbirth with a living child, any manipulations that violate the integrity of tissues are prohibited:

• amniotomy;
• episiotomy;
• vacuum extraction;
• application of obstetrical forceps.

Also do not carry out labor induction and labor intensification. All this significantly increases the chances of infection of the child. It is possible to carry out the listed procedures only for health reasons.

HIV infection is not an absolute indication for caesarean section. But it is highly recommended to use the operation in the following cases:

ART was not performed before delivery or it is impossible to do this during childbirth.

Caesarean section completely excludes the contact of the child with the discharge of the mother's genital tract, therefore, in the absence of HIV therapy, it can be considered an independent method of preventing infection. The operation can be performed after 38 weeks. Planned intervention is performed in the absence of labor. But it is possible to carry out a caesarean section and according to emergency indications.

In childbirth through the natural birth canal, at the first examination, the vagina is treated with a 0.25% solution of chlorhexidine.

A newborn after childbirth must be bathed in a bath with aqueous chlorhexidine 0.25% in an amount of 50 ml per 10 liters of water.

How to prevent infection during childbirth?

To prevent infection of the newborn, it is necessary to carry out HIV prevention during childbirth. Drugs are prescribed and administered to a woman in labor and then to a newborn child only with written consent.

Prevention is necessary in the following cases:

1. Antibodies to HIV were detected during testing during pregnancy or using a rapid test in a hospital.
2. According to epidemic indications, even in the absence of a test or the impossibility of conducting it, in the case of a pregnant woman injecting drugs or her contact with an HIV-infected person.

The prevention scheme includes two drugs:

• Azitomidine (Retrovir) intravenously, is used from the moment labor begins until the umbilical cord is cut, and it is also used within an hour after childbirth.
• Nevirapine - one tablet is drunk from the moment of the onset of labor. With a duration of labor of more than 12 hours, the drug is repeated.

In order not to infect the child through breast milk, it is not applied to the breast either in the delivery room or subsequently. Also, bottled breast milk should not be used. Such newborns are immediately transferred to adapted mixtures. A woman is prescribed Bromkriptine or Cabergoline to suppress lactation.

The postpartum woman in the postpartum period continues antiviral therapy with the same drugs as during the gestation period.

Prevention of infection in the newborn

A child born to an HIV-infected mother is given drugs to prevent infection, regardless of whether the woman has been treated. It is optimal to start prophylaxis 8 hours after birth. Until this period, the drug that was administered to the mother continues to act.

It is very important to start medicines within the first 72 hours of life. If a child becomes infected, then for the first three days the virus circulates in the blood and does not penetrate into the DNA of cells. After 72 hours, the pathogen is already attached to the host cells, so infection prevention is ineffective.

For newborns, liquid forms of drugs have been developed for use by mouth: Azidothymidine and Nevirapine. The dosage is calculated individually.

Such children are under dispensary registration up to 18 months. The criteria for deregistration are as follows:

• no antibodies to HIV in the study by ELISA;
• no hypogammaglobulinemia;
• no symptoms of HIV.