Pre-Conception
Although many women don’t learn their HIV status until they become pregnant, for those women who know they are HIV-positive prior to choosing to become pregnant, pre-conception assessments may inform both her and her partner of the safest way to become pregnant without HIV transmission to the infant or HIV transmission between serodiscordant couples. Therefore, throughout their reproductive years, women living with HIV need ongoing comprehensive pre-conception care that is incorporated into primary care services so they can make informed choices about pregnancy prior to conception.
While maternal health services traditionally do not provide pre-conception care but rather start once a woman is pregnant with antenatal care, women with HIV can benefit from pre-conception care. As PMTCT programs are scaled up, including pre-conception care as part of maternal health services should be considered.
Pre-conception care should include counseling on barrier methods of family planning to decrease transmission of HIV and prevent secondary infection, skills to negotiate condom use, assessment of a woman’s nutritional status, education and counseling on perinatal HIV transmission and pregnancy risks, and support and counseling for partner disclosure on HIV status before pregnancy. Specific recommendations include for health care providers to “ask about pregnancy intentions to every woman, every visit,” and to discuss “the risks and effects of pregnancy on…[preexisting] medical condition[s], and the effects of the medical condition on pregnancy outcomes…so that the patient can make an informed decision about becoming pregnant… Education and counseling for HIV-infected women about perinatal HIV transmission risks, strategies to reduce those risks, the potential effects of HIV or its treatment on pregnancy, and the risk of transmission during breastfeeding, allows patients to be fully aware of the issues concerning HIV infection and pregnancy before conception” (Aaron and Criniti, 2007).
“Because it is important for HIV-positive women receiving HAART to time their pregnancies at a point when their CD4 cell count is high and their viral load is low, women should be counseled to use contraceptives until laboratory testing can determine that these levels are optimal for becoming pregnant” (Sable et al., 2008). [See also Chapter 7C. Treatment: Reducing Transmission] Women should also know that studies conflict regarding an increased risk of HIV acquisition during pregnancy (Morrison et al., 2007 and Gray et al., 2005), but that pregnancy does not increase the risk of early death (Allen et al., 2007a). “For those with access to fertility centers, longitudinal data show that conception can occur with a very low risk of HIV transmission… While the experience with assisted reproductive health technologies is encouraging, access to these treatments remains limited even for those individuals in resource-rich settings… Teaching couples about ovulation and intercourse timed to fertile periods offers a means for decreasing the number of unprotected sexual encounters” (Mathews and Mukherjee, 2009: S7).
Increasingly, services will be needed to provide counseling and support for perinatally infected adolescents who will want to know their options for pregnancy, birth and infant feeding to minimize the probability of transmission to the infant and yet protect their own health (Birungi, 2009a,b). Maternal health providers often lack the knowledge needed to guide women living with HIV through a safe pregnancy process and may discriminate against women living with HIV. Training is needed to ensure that providers will support women’s choices in reproductive health. [See also Chapter 8. Meeting the Sexual and Reproductive Health Needs of Women Living With HIV]
Focus groups in South Africa found men and women to be very careful in weighing the choice to have a child and acutely mindful of the long-term consequences for themselves, their partners and their future child (London et al., 2008); however studies have found that women and men living with HIV do not always seek pre-conception counseling due to fear of stigmatization by health care providers. This obstacle must be overcome in order to minimize the risk of perinatal transmission at the earliest possible point.