HIV & Pregnancy: Discussing and Evaluating HIV among Pregnant Women and Their Infants
Since its discovery in early 1980s, HIV or human immunodeficiency virus has been noted to kill approximately 39 million people worldwide, with another 1.5 million dying of HIV-related causes, making it the number one deadliest infectious agent worldwide (US Dept. of Health & Human Services, 2014). Attacking primarily the immune system of the body, HIV generally makes the body susceptible to a wide array of diseases that normally do not cause life-threatening complications to an uninfected body. HIV affects people regardless of sex, age, race, and socioeconomic status and it is primarily acquired through sexual activities. As a sexual disease, HIV has been the center of various public health concerns including its effect on pregnant women, their pregnancy, and infant.
Overview
As mentioned above, HIV is most likely acquired through sexual activity and operates by substantially weakening the immune response of an infected individual and exposing him/her to increased health risks (Coffin & Swanstrom, 2013). As a disease, HIV infection presents symptoms that include fever, wasting, opportunistic infections, neurological symptoms, and viremia or virus in blood (Coffin & Swanstrom, 2013). HIV progresses very slowly, taking up as much as 20 years before tangible and observable symptoms could develop (Coffin & Swanstrom, 2013). HIV remains incurable up to this date but due to its slow progression phase, HIV becomes highly manageable with the administration of antiretroviral drugs that improve the quality of patient’s life and the prognosis of the disease (Coffin & Swanstrom, 2013). As of 2013, approximately 35 million people are diagnosed with HIV/AIDS worldwide, majority of which may be found in low- and middle-income countries, particularly the sub-Saharan Africa (US Dept. of Health & Human Services, 2014). Among such 35 million HIV-infected people are women of various races and demographic origin. In USA, there is a wide racial disparity among women affected by HIV. As demonstrated by one study conducted in 2007, Black, Hispanic, and White women were disproportionately affected by the epidemic (Aziz & Smith, 2011). Black or African-American women accounted for as much as 66% of the total HIV cases among women in USA while Hispanics accounted for 16% (Aziz & Smith, 2011). Such prevalence of HIV among Black women is estimated to be 20 times greater in comparison to that of White women who only accounted for 3.3% of total HIV cases in the same year (Aziz & Smith, 2011). Aside from racial diversity, demographic disparity is also common with women residing in sub-Saharan African regions being more affected by the virus (Hampanda, 2013). Women affected by HIV contract the virus through various methods. As exemplified by one study, 83% of HIV-infected women contracted the virus through heterosexual contact, while 16% acquired the virus through the use of syringes for substance abuse, and 1% through unidentified risk factors (Aziz & Smith, 2011). The problem of wide prevalence of HIV among women becomes more complicated when taking into consideration pregnant women and their infants.
As estimated, 1% of pregnant women worldwide are HIV-infected, majority of which may be found in sub-Saharan African region (Hampanda, 2013). Without treatment, 25-50% of all the HIV-infected pregnant women pass the virus to their infants (Hampanda, 2013). To date, such mother-to-child HIV transmission has affected 3.2 million children worldwide who are now living with HIV in the most recent study conducted in 2013 (US Dept. of Health & Human Services, 2014). Furthermore, it is estimated that over 1,000 newborns contract HIV everyday primarily through their infected mothers and every year, there are an estimated 260,000 pediatric deaths caused by HIV/AIDS worldwide (Hampanda, 2013).
Disease Pathogenesis
Labeled as the world’s leading infectious killer, HIV works primarily in weakening the immune system of the body (Coffin & Swanstrom, 2013; US Dept. of Health & Human Services, 2014). Starting with a single virion, HIV enters the body and infects a single target cell (Coffin & Swanstrom, 2013). Over time, the virus replicates quietly through the CD4+ cells within the body, showing little to no symptoms at all (Coffin & Swanstrom, 2013). As the virus replicates without any pharmacological intervention, the CD4+ cells fatally declines in number, making the body extremely weak and susceptible to various kinds of infections and illnesses including opportunistic diseases (Coffin & Swanstrom, 2013). Although this kind of disease progression is extremely slow, usually taking up more or less a decade even without intervention, it is still highly lethal with no definite and total cure (Coffin & Swanstrom, 2013). Over time, patients suffering from HIV will experience wasting and dementia and they become easy targets of diseases that are otherwise harmless to uninfected, healthy individual (Coffin & Swanstrom, 2013).
Transmission of virus normally happens through unprotected sexual intercourse and transfusion of infected blood. Among infants, HIV transmission happens during pregnancy, childbirth and breastfeeding (Hampanda, 2013). Infants who get infected by HIV have a very short life span. As reported, one-third of children who get infected with HIV die before they reach their first birthday and one-half die before reaching their second birthday (Hampanda, 2013). This result shows that HIV has an extremely lethal effect on children whose immune systems are not yet fully developed at the time of virus transmission.
Diagnostic Procedures
In order to determine the presence of HIV among pregnant women, an array of methods and procedures is strongly recommended in order to ensure early detection and treatment and to avoid mother-to-children HIV transmission. As recommended, antenatal HIV testing must be done to pregnant women to determine the absence or presence of HIV before birth (Drake, Wagner, Richardson, & John-Stewart, 2014). And since HIV may be acquired during and after pregnancy, repetitive HIV testing should be done (Drake et al., 2014). As suggested by one study, repeating HIV testing during third trimester and/or delivery should be applied in order to diagnose the virus early, especially if the mother is exposed to increased risk of contracting the virus (Drake et al., 2014). Aside from HIV testing, cervical smear should also be performed especially if it has not been done in the recent past (Vallone, Rigon, Lucantoni, Putignani, & Signore, 2012). Cervical smear helps in properly diagnosing any vaginal or cervical inflammation and any abnormal discharge that may be indicative of STD and may be related to the presence of HIV (Vallone et al., 2012). If the cervical smear shows any abnormal result, the pregnant woman may be referred for a colposcopy to examine more closely the cervix, vagina, and vulva to determine the source of abnormal cervical result (Vallone et al., 2012).
Treatment Modalities
Despite the incurability of HIV, various treatment modalities may still be employed to prevent the transmission of the various particularly between mother and infant. Treatment modalities that prevent the vertical transmission of virus from mother to child may involve the administration of the so-called antiretroviral (ARV) drugs during the entire course of pregnancy and for as long as the children is breastfeeding should be observed (Hampanda, 2013). ARVs significantly reduce the chance of vertical transmission of the virus and improve the overall health of the mother (Drake et al., 2014). Aside from ARVs, preventing the prolonged rupture of membranes for more than four (4) hours during labor and delivery should also be observed as any break in the skin of the baby may be an entry point for HIV (Vallone et al., 2012). In relation to this, forceps are preferable to vacuum extraction as the latter can cause microlacerations on the scalp of the infant, exposing him/her to increased risk of acquiring HIV (Vallone et al., 2012). Applying antiseptic and antiviral agents to cleanse the birth canal during labor and delivery is also seen as a potential way to reduce vertical HIV transmission (Vallone et al., 2012). Antiseptics that may be used to cleanse the birth canal include clorhexidine and Benzalkonium Chloride (Vallone et al., 2012).
Education
Given that HIV-infected women are more prone to postpartum complications such as urinary tract infection, episiotomy infections, and caesarean section wound infections, they are in special need of close guidance and monitoring as well as health education and counseling (Vallone et al., 2012). Mothers who have just given birth, particularly those infected with HIV, should be given instructions regarding proper perineal care, safe management of lochia or the discharge after birth, and the handling of sanitary pads and other materials (Vallone et al., 2012). Aside from instructions regarding proper postpartum care, new mothers should also be counseled regarding the importance of follow-up check-ups and contraception system after giving birth (Vallone et al., 2012). The importance of ARVs and proper health to improve the prognosis of HIV among HIV-positive mothers should also be taught so that they would adhere strictly on scheduled administration of ARVs and other medications which will ensure their recovery to health and the safety of their infants from HIV.
Cultural/Underserved/Disadvantage Implications
In high-income societies, such as USA and other European countries, vertical transmission of HIV from mother to children has been widely uncommon and easily prevented with the use of pharmacological interventions and close monitoring and guidance by the health providers (Hampanda, 2013). However, in low- and middle-income countries, controlling vertical transmission of HIV between mother and children is still very challenging (Hampanda, 2013). In countries such as the sub-Saharan Africa, HIV transmission between mother and child remains a challenging consequence for authorities to handle (Hampanda, 2013). Obviously, women in low-income countries who have contracted HIV, particularly those who are pregnant, face challenges that are rooted in their socioeconomic background (Aziz & Smith, 2011). HIV-positive pregnant women who are poor have limited access to methods and treatments that will improve the prognosis of their illness and improve their health (Aziz & Smith, 2011). Aside from this, the stigma and violence associated with a positive HIV status is also a common cause of discouragement for HIV-positive pregnant women to seek proper care and medication (Aziz & Smith, 2011).
Evaluation of Disease
In order to improve the health of HIV-positive women and their children, physicians and other healthcare providers for this group should be diligent in monitoring their health conditions (Aziz & Smith, 2011). Healthcare providers should be efficient in linking consistent treatment with active health status monitoring (Aziz & Smith, 2011). Physicians and all other healthcare providers must make sure that patients with HIV, particularly those nursing newborns, continue attending regular follow-up checkups and scheduled administration of treatment (Aziz & Smith, 2011). Apart from active monitoring and linkage to treatment, healthcare providers should also be efficient in removing the barriers that usually keep patients from seeking professional help and intervention despite its wide accessibility (Aziz & Smith, 2011). Among such barriers are the cultural differences among populations. As was reported by one source, religion and traditions play a big role in a patient’s openness to report their concerns and seek care (Aziz & Smith, 2011). Usually, such barrier is made even worse by the discrimination of some healthcare providers, yielding a closed line of communication between them and the patients (Aziz & Smith, 2011). In order to solve this, healthcare providers should be culturally competent: open, knowledgeable, and comfortable with the beliefs and views of others that may be different from their own (Aziz & Smith, 2011). Aside from this, screening for mental illness and violence should be a top priority for healthcare providers as such scenarios are indicative of an increased risk for HIV infection (Aziz & Smith, 2011).
Conclusion
HIV is labeled as the world’s leading infectious agent after killing millions of people worldwide since its discovery in early 1980s. Present in bodily fluids such as semen and blood, HIV is typically transmitted through sexual intercourse and transfusion of infected blood. But aside from such modes of transmission, HIV may also be transmitted vertically from mothers to their children either during pregnancy or after childbirth through breastfeeding. Killing infants before they reach their first or second birthday, HIV is considered to be one of the leading causes of pediatric death worldwide particularly in African regions. Disproportionately, HIV affects mostly African-American females and their infants. Due this, extensive campaigns are initiated by various health-related agencies such as WHO to eliminate vertical mother-to-child HIV transmission, particularly among African-American and African females residing in sub-Saharan African regions.
References
Aziz, M., and Smith, K. (2011). Challenges and Successes in Linking HIV-Infected Women to Care in United States. Clinical Infectious Diseases, 52(S2), S231-S237. DOI: 10.1093/cid/ciq047
Coffin, J., and Swanstrom, R. (2013). HIV Pathogenesis: Dynamics and Genetics of Viral Populations and Infected Cells. Cold Spring Harbor Perspectives in Medicine, 2013(3), 1-17. DOI: 10.1101/cshperspect.a012526
Drake, A.L., Wagner, A., Richardson, B., and John-Stewart, G. (2014). Incident HIV during Pregnancy and Postpartum and Risk of Mother-to-Child HIV Transmission: A Systematic Review and Meta-Analysis. Plos Med, 11(2), 1-16. DOI: 10.1371/journal.pmed.1001608
Hampanda, K. (2013). Vertical Transmission of HIV in sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT. ISRN Infectious Diseases, 2013, 1-6. DOI: 10.5402/2013/420361
US Dept. of Health & Human Services. (2014). HIV/AIDS 101: Global Statistics. AIDS.gov. Retrieved from https://www.aids.gov/hiv-aids-basics/hiv-aids-101/global-statistics/
Vallone, C., Rigon, G., Lucantoni, V., Putignani, L., and Signore, F. (2012). Pregnancy in HIV-Positive Patients: Effects on Vaginal Flora. Infectious Diseases in Obstetrics and Gynecology, 2012, 1-4. DOI: 10.1155/2012/287849
