Preconceptional optimization of couples with HIV infection
The preconceptional evaluation of couples with human immunodeficiency virus (HIV) includes many aspects of care including preconceptional health, mental health, antiretroviral (ARV) medications, transmission between partners, and perinatal transmission to the fetus.
With the evolving nature of the prevalence of disease, advancements in treatment options, and evolution of the virus itself, the interpretation of research before the discovery of ARVs and recommendations must evolve as well. Historically, people living with HIV had significantly reduced life expectancy; however, with the introduction of highly successful ARVs, couples can now have the same life expectancy as the general population (78).Preliminary preconceptional assessment of women with positive HIV infection must include assessment of overall health, discussion of prevention of infection to others, including the risk of horizontal and vertical transmission, and provision of support and close monitoring. Studies have shown that there is an association of an increased risk of perinatal transmission of HIV with certain behaviours including smoking, illicit drug use, and sexual intercourse with multiple partners (79, 80); however, caution should be taken with interpretation of potential confounding factors (81). Specific considerations that should be assessed at the initial preconception visit include general diet and weight, possible issues of smoking and/or substance use, obesity/ diabetes, hypertension, possible cultural context, vaccination status, possible hepatitis C coinfection, and signs of immunosuppression including fevers and history of opportunistic infections. Careful physical examination should also include signs of immunosuppression, including signs of thrush, cachexia, genital ulcers, or vaginal discharge. Optimization of maternal health in the preconception period is paramount to a healthy pregnancy, and should include folic acid supplementation of 1 mg per day for at least 3 months preconceptionally, treatment of any active infections, evaluation of maternal psychosocial health, and counselling regarding smoking cessation, alcohol and drug use, and safe sex practices.
The initial evaluation of couples with HIV includes measuring levels of CD4 counts as well as HIV viral load.
It is important to evaluate these levels in regards to the initiation of ARVs, and for a baseline assessment in the preconception period. Monitoring of CD4 counts and HIV viral load should be continued throughout pregnancy, in regard to the potential need for prophylaxis for opportunistic infections such as Pneumocystis, toxoplasmosis, or Mycobacterium avium complex. Mode of delivery can be affected by viral load, and therefore should be discussed during the preconception period (82, 83). In women with an undetectable viral load who have been compliant with ARV therapy, there is no contraindication to vaginal delivery, and caesarean section should be considered for obstetrical indications.There is a risk of HIV transmission in HIV-discordant couples, as well as a risk of superinfection between concordant couples, and therefore discussion in the preconception period should include options for reducing the risk of horizontal HIV transmission during conception. Previously, naturally timed conception was inconceivable for discordant couples; however, with the advancement of ARVs, this is now a possible option (84). HIV-discordant couples in which the woman is HIV positive and the man is HIV negative should take precautions, as a study has shown that despite the effectiveness in ARVs demonstrating no detectable viral load, there can still be detectable viral shedding from the female genital tract (85). Couples should be counselled extensively regarding the risk of transmission, and provided with conception options including unprotected sex only during times of ovulation to reduce the number of times the HIV seronegative partner is exposed, as well as home insemination for HIV-discordant couples in which the woman is HIV positive and the man is HIV negative, and semen washing for HIV-discordant couples in which the man is HIV positive and the woman is HIV negative (86).
More on the topic Preconceptional optimization of couples with HIV infection:
- Arulkumaran S., Ledger W., Denny L., Doumouchtsis S. (eds.). Oxford Textbook of Obstetrics and Gynaecology. Oxford University Press,2020. — 928 p., 2020
- Drugs to avoid preconceptionally
- 24 HIV in Pregnancy