For women with HIV, there is little evaluated evidence available regarding delivery options, though research has shown that by substantially lowering viral load, HAART can diminish the advantage of a cesarean section in reducing perinatal transmission (Sharma and Spearman, 2008; Rongkavilit and Asmar, 2011; Coovadia and Newell, 2012). Cesarean sections are not always available or safe in many developing country settings. In situations where a safe cesarean section can be provided however, further research is needed to determine whether women with HIV suffer more adverse events due to the procedure. Further research is also needed on whether elective cesarean sections provide PMTCT benefits for HIV-positive pregnant women who have viral loads lower than 1,000 copies/mL (Anderson and Cu-Uvin, 2009; USHHS, 2011). While cesarean sections may not be the best option for the delivery for HIV-positive women in resource poor settings, they remain necessary surgical procedures in some cases to reduce the maternal mortality associated with difficult deliveries.
In vaginal deliveries, routine episiotomies have been shown to be particularly risky for HIV-positive women. A study in South Africa of 241 HIV-positive women compared to 427 HIV-negative women who gave birth and were evaluated at four intervals (within 72 hours post delivery, and at one, two, and six weeks) for clinical signs of postpartum infection, found that episiotomy was associated with a two-fold increased risk of postpartum infections among the HIV-positive women. Among HIV-positive women with low CD4 counts, the risk of postpartum infection associated with episiotomy was even higher. Because the majority of postpartum infections were detected at the one-week review, it is important to have a skilled attendant examine the woman postpartum within the week following delivery (Sebitloane et al., 2009).
"I felt extremely bad... when I was writhing with labour pains in the corridor... when a nurse shouted at me on top of her voice, 'have you swallowed your tablet.' Everyone looked at me and instantly knew I have HIV" --HIV-positive woman in Uganda (Were and Hasunira, 2010:24)The mode of delivery does not seem to affect HIV disease progression. A study from 1990 to 2004 in the United States found no difference in HIV-related disease progression after delivery for HIV-1-positive women delivering through elective cesarean section (before membrane rupture), non-elective cesarean section (after membrane rupture), or vaginally. Of the 1,491 births where mode of delivery was documented, 1,087 were vaginal, 183 were elective cesarean, and 221 were non-elective cesarean and the mode of delivery was not associated with viral load increase or CD4 count decrease within 18 months after delivery or progression to AIDS or death within an average of 2.7 years after delivery (Navas-Nacher et al., 2006).
Globally many HIV-positive women experience violations of human rights, as well as stigma and discrimination during labor and delivery. Women living with HIV have faced coerced and forced sterilization (Mthembu et al., 2011) and FIGO has issued guidance that "consent to sterilization must not be made a condition of receipt of any other medical care, such as HIV/AIDS treatment..." (FIGO, 2011). Health care providers need training to reduce this stigma and discrimination against HIV-positive women in the delivery setting. They also need access to appropriate personal protective equipment (PPE) such as gloves, gowns, needleless systems and eye shields so that they can protect their own health as they care for their patients (WHO, 2009f). [See Structuring Health Services to Meet Women’s Needs] Health care providers must ensure HIV-positive women's confidentiality regarding HIV serostatus. HIV-positive women, as all women, need support and information about their choices in childbirth.
In settings where many women do not present for antenatal care, HIV testing to establish serostatus has been offered during labor and delivery (Bello et al., 2011b). However, "...most women with unknown HIV status in labour represent a particularly vulnerable group in a particularly vulnerable situation" (Bello et al., 2011b: 30) and voluntary consent is called into question if women are first offered testing during labor and delivery (Center for Reproductive Rights, 2005). "HIV testing at the time of labor should be treated as the last resort for prevention of MTCT, because the women then miss the opportunity to receive the full prophylactic regime as well as other PMTCT services. Moreover, being confronted with a positive HIV result is associated with great distress and labor is not the optimal time for conveying such information" (Hahn et al., 2011: 7).
As previously mentioned in the introduction to the treatment section above, the WHO released new guidelines in 2010, with a newer update in 2012, for the use of ARVs in pregnant women that expands treatment to women with CD4 counts below 350 cells/cubic mm, rather than below 200 cells/cubic mm and provides for earlier ARV prophylaxis at 14 weeks gestation, rather than 28 weeks gestation (WHO, 2010i).