Finding out about HIV after pregnancy: Can I still have a healthy baby?

"Doctor, I am 35 years old this year, and I want this child very much, but..." It was an ordinary day, Professor He Kejing, the head of the obstetrics and gynecology department of chengdu public health clinical medical center, was busy receiving treatment as usual, but a woman sitting in front of her was full of sorrow, wanted to stop talking, and even tears flashed in her eyes. The husband who accompanied her was even more anxious and gaunt.

It turned out that this lady, named Xiaofang (pseudonym), pulled her husband early in the morning and rushed from a small township around Chengdu to the public health center for consultation, and she wanted to confirm whether the baby in her belly could still come down!

Xiaofang is 35 years old this year, a remarried woman, because the remarried family has no children, so when she and her husband learned the news of pregnancy, they jumped up happily. But life's joys and sorrows often go hand in hand, and suddenly a non-intersecting word "AIDS" hit her - during a routine test less than 3 months pregnant, she was told that she was infected with HIV.

Gray's encounter did not frustrate Xiaofang's confidence, she firmly and sincerely revealed her heart to her husband, and said that she must give birth to the baby. Fortunately, her husband was not infected with HIV and gave her a positive answer and support.

With the help of Professor He Kejing and Professor He Shenghua, head of the Department of Infection of Chengdu Public Health Clinical Medical Center, Xiaofang's HIV virus was controlled and she gave birth to the most important baby in her life.

The most worrying things: the deterioration of the pregnant mother's condition and the birth of the child

Professor He Shenghua said that Xiaofang, who was only found to be infected with HIV during pregnancy, had a viral load of up to 160,000, but the CD4 value was very low, only 97, which undoubtedly highlighted a result: the risk of mother-to-child transmission of HIV was very high.

"For women who are infected during pregnancy, or who become infected women who become pregnant without antiviral therapy, their babies can have a risk of HIV infection of up to 15% to 45%, and there is a risk of viral transmission or public health problems during pregnancy." Professor He Shenghua pointed out that in such a situation, the primary task for infectious disease doctors is to communicate closely with obstetrics and gynecology experts to formulate targeted treatment plans for the individual situation of patients, the most important of which is to choose the antiviral treatment programs that are unanimously recommended by HIV-related guidelines at home and abroad, which can effectively and quickly reduce the viral load and have a relatively high safety.

It is understood that the current common antiviral treatment regimens in China mainly include two nucleoside reverse transcriptase inhibitors (NRTIs) and one non-nucleoside reverse transcriptase inhibitor (NNRTIs) or protease inhibitors.

"Because pregnant women's acceptance of many drugs is weakened, the tolerance of the above treatment regimens needs to be considered for pregnant women with antiviral drugs. It may be that she (Xiaofang) has not yet adapted to antiviral drugs and will have obvious adverse reactions such as digestive tract symptoms, liver function damage, kidney damage, etc., and the incidence of pregnant women is higher than that of ordinary people. "The Chinese GUIDELINEs for HIV Diagnosis and Treatment (2021 Edition) recommend a new treatment plan that is more friendly to the HIV pregnant population - potent and safer integrase inhibitors." We followed the guideline recommendations and developed a more targeted treatment plan for this expectant mother. ”

Integrase inhibitors can effectively inhibit the replication of HIV in vivo by inhibiting HIV integrases, while having higher therapeutic effect and lower toxicity, which is more friendly to pregnant women. It is understood that a trial based on the integrase inhibitor reteravir treatment regimen showed that pregnant women were well tolerated during pregnancy, and no patients discontinued treatment due to adverse events; the median birth weight of newborns was 3.1 kg, and HIV DNA/RNA testing at 6 months of age showed that all young children were not infected with HIV.

In addition, another issue that everyone (HIV pregnant women) are most worried about is whether children will have malformations, especially neural tube malformations. Professor He Shenghua said: "The results of a real-world study show that antiviral treatment regimens based on raltegravir have shown good efficacy and safety in HIV-infected pregnant women, and there is no vertical transmission between mother and child, and newborns have no birth defects. Therefore, the relevant treatment guidelines in Europe and the United States have recommended that in the whole process of pregnancy of an infected person, the integrase inhibitor Essenter (raltegravir potassium) can be selected to block the mother-to-child transmission of HIV virus and better protect the health of pregnant women and babies. ”

Reducing the rate of mother-to-child transmission still requires the efforts of many sectors of society

It is understood that the National Health Commission's "Implementation Plan for the Implementation of the 2021-2035 China Women's and Children's Development Program" clearly mentions that the rate of mother-to-child transmission of HIV/AIDS will drop to less than 2% by 2030. Professor He Kejing said that as of July 2020, there are more than 20 million HIV-infected women in the world, and the vast majority of them are women of childbearing age aged 15-49, and to achieve this goal, it will take a lot of cooperation.

"From the perspective of obstetrics and gynecology management, to improve the transmission rate of mother-to-child interruption and reduce the risk of transmission, the first task is to detect HIV-infected pregnant women in time, so pregnancy screening is particularly important." Professor He Kejing pointed out, "For women of childbearing age who have not been found to be infected with HIV, the current management mode in Sichuan Province is 'three lines and one network bottom': the third line refers to the CDC, antiviral treatment points and maternal and child health hospitals, and the bottom of the network refers to the township level or the community, trying to detect the infection situation at an early stage; then it is to establish management goals, carry out one-on-one management of HIV-infected pregnant women, and work with infectious disease experts to ensure that they achieve sustained viral suppression during pregnancy." In addition, in the midwifery process, we will also strictly follow the relevant midwifery requirements and medical indications to choose the method of vaginal delivery and caesarean section delivery, and the postpartum screening, antiviral treatment and feeding links of newborns also have clear norms, interlocking to ensure the lowest mother-to-child transmission rate. ”

"For women of childbearing age who are infected with HIV, we will regularly learn about their fertility intentions, and if they are about to become pregnant in the near future, we will provide advice based on informed consent for antiviral therapy, so that she can start the integration enzyme inhibitor treatment program before she is pregnant, so that the success rate of maternal and infant blocking can be achieved almost 100%. Professor He Shenghua said, "The mother-to-child transmission rate in Sichuan Province is still about 3%, and there is still some gap from the target of less than 2%, partly because pregnant women cannot tolerate drugs in the treatment plan of Efaviren or Kris, and there are obvious reactions such as nausea, vomiting, anorexia, etc., affecting the adherence of pregnant women to medication, and may fail to block the mother and baby." The ideal state is to provide free safe and good integrase inhibitors for pregnant women, which is highly feasible, and some provinces in China have corresponding support policies. ”

It is reported that Zhejiang Province, Yunnan Province and other places have earlier carried out hierarchical management of high-risk groups of mother-to-child transmission from the provincial level, classified guidance, and provided free integrase inhibitors for pregnant women with high risk of mother-to-child transmission, giving more protection to the health of mothers and babies at the drug level.

"At present, Chengdu provides at least three free CD4 and viral load tests (first, second and third trimester) to HIV pregnant women, hoping to reduce their burden. In the future, we hope to help them win more policy support. At present, maternal and infant blockade has the support of new technologies and new drugs, and medical practitioners have more than ten or twenty years of clinical practice, on this basis, medical staff can help more HIV-positive families to have one or more healthy babies like ordinary families. The two experts expressed their expectations for the future.

Professor He Shenghua

Director of the Department of Infection, Chengdu Public Health Clinical Medical Center

Master Supervisor Chief Physician

Member of the National Health and Wellness Council's Clinical Expert Group on AIDS

Member of the AIDS Group of the Infectious Diseases Branch of the Chinese Medical Association

Member of the Clinical Virology Group of the Medical Virology Branch of the Chinese Medical Association

Vice Chairman of the AIDS and Opportunistic Infections Special Committee of the Chinese Association for the Prevention and Control of STDs and AIDS

Member of the Editorial Board of China AIDS and Venereal Diseases Magazine

Leader of the Clinical Expert Group on AIDS Treatment of Sichuan Provincial Health Commission

Vice Chairman of the AIDS Clinical Committee of Sichuan Sexual AIDS Association

Professor He Kejing

Director of the Department of Obstetrics and Gynecology of Chengdu Public Health Clinical Medical Center

National outstanding worker in the prevention of mother-to-child transmission of AIDS, syphilis and hepatitis B

Vice Chairman of the Obstetrics Committee of Sichuan Rehabilitation Medicine Association

Expert in the prevention of mother-to-child transmission of HIV, syphilis and hepatitis B in Sichuan Province and Chengdu

Member of the 5th Medical Malpractice Technical Appraisal Expert Database of Chengdu Medical Association

Expert of Quality Control Center for AIDS Treatment in Sichuan Province and Chengdu City

Expert in maternal and child health in Sichuan Province

Expert of Chengdu Obstetrics and Gynecology Medical Quality Control Center

Standing Committee Member of cervical Lesion Prevention and Control Professional Committee of Sichuan Health Care Association

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This article is a reprinted article for communication reference only