The problem of HIV infection is becoming increasingly relevant every year. Just a few decades ago, infection with the immunodeficiency virus was associated mainly with an antisocial lifestyle. Currently, the infection is widespread among all segments of the population, including those who are not at risk. Pregnant women are no exception. That is why the questions: “HIV and pregnancy”, “How to give birth to a healthy child?” worries a lot of people today.

With the introduction of a retrovirus into the body, the natural function of protection against infections is disrupted. Of course, the expectant mother does not feel any symptoms and is unaware of the problem. Even a test to identify the disease may not show it immediately, due to the long incubation period (in some cases up to one year). All this time, the disease is actively developing and can be transmitted to the embryo.

Attention!
In a body infected with HIV, immune cells die every minute. Gradually, the protective forces are so depleted that AIDS (acquired immunodeficiency syndrome) occurs.

According to official statistics, almost 2 million women with HIV give birth every year in the world. The number of infected newborns exceeds 600 thousand. The number of such births is constantly increasing, but doctors have ways to prevent infection. For example, in Russia this figure over the past 10 years has decreased from 20 to 10%, i.e. 2 times.

The impact of HIV on pregnancy and fetal development

Doctors do not provide comprehensive information about how HIV affects pregnancy. Most often, cases of hospitalization of expectant mothers with a diagnosis of bacterial pneumonia are recorded. It has also been established that a reduction of white blood cells, responsible for the body’s immune response, by up to 30%, can provoke:

• stillbirth;
• early birth;
• inflammation of the chorioamniotic (fetal) membranes;
• postpartum endometritis;
• the birth of a baby with insufficient body weight.

Obstetricians say that the more severe the stage of the disease, the more seriously it affects pregnancy and the formation of the embryo. 80% of children infected with HIV from their mother develop AIDS before the age of 5. The first symptoms of intrauterine infection are:

• chronic digestive disorder;
• dystrophic lesion of the spine;
• lack of pupillary reaction to light.

Subsequently, these manifestations are accompanied by repeated diarrhea, oral candidiasis, enlarged lymph nodes, chronic pneumonia, developmental delay and other pathologies.

Important! The effect of pregnancy on the course of the disease has not been fully studied. Presumably, it is known that the period from the moment of infection to the appearance of AIDS symptoms has been reduced from 6 to 2-4 years.

Ways of infecting a child

Perinatal routes of retrovirus penetration into the body of the embryo and newborn are classified into:

• antenatal - through the embryonic membranes, placenta, amniotic fluid;
• intrapartum – during the process of delivery;
• postnatal – during lactation.

Practical experience in obstetrics shows that HIV and pregnancy are not compatible at any stage. Infection of the embryo in the first trimester, as a rule, leads to spontaneous termination of gestation. Infection in a later period does not provoke a miscarriage, and fetal development continues. Most often, infection occurs during the birth of a child. Postnatal transmission is diagnosed less frequently.

Factors that increase the risk of perinatal infection:

• prematurity;
• acute stage of HIV;
• violation of the integrity of the mucous membranes of the newborn;
• taking drugs and smoking;
• combination with STIs (sexually transmitted infections);
• generic instrumental manipulations;
• protracted labor.

The chances of having a healthy baby from an HIV-positive mother are increased by a cesarean section performed after antiviral treatment.

Diagnosis of HIV during pregnancy

Diagnostic measures are carried out in two stages: testing for HIV during pregnancy in order to establish the fact of infection, determining the nature of the course and stage of the disease. The examination includes:

1. A screening test (ELISA) to detect antibodies to the immunodeficiency virus in blood serum. If the analysis shows a positive result, the test is repeated.
2. Immunoblotting is an additional method for confirming ELISA, detecting the presence of antibodies to viral proteins.
3. PCR (polymerase chain reaction). Makes it possible to clarify the severity, viral load and predict the outcome of therapy. The huge advantage of the technique is that it allows you to detect HIV during the incubation period even before the appearance of antibodies.

During diagnosis, the total number of lymphocytes, the level of the immunoregulatory index and other indicators are assessed. When an HIV-positive diagnosis is made, the stage is indicated and a description of secondary diseases is given.

For timely detection of the immunodeficiency virus, it is recommended to be examined:

• when registering with a antenatal clinic;
• again at 28-30 weeks.

If a woman who is pregnant is in a relationship with an infected partner, she should be screened for antibodies every 3 months and then upon admission for delivery.

HIV therapy during pregnancy

A positive result obtained after PCR requires mandatory HIV treatment. Pregnant women are prescribed antiretroviral therapy during gestation and childbirth. After delivery, the child undergoes chemoprophylaxis. The goal of all therapeutic measures is to bring the patient to a state where the number of viral particles in the blood corresponds to the lower threshold required for determination by the test.

If HIV is diagnosed in the early stages, a conversation is held with the expectant mother about the possibility of interrupting the gestation. The HIV pregnancy management protocol involves identifying:

1. Concomitant diseases: pneumonia, enlargement of superficial lymph nodes, spleen, liver.
2. Sexual infections: chlamydia, syphilis, herpes.
3. Tuberculosis.
4. Malignant changes in the cervix.

During the management of HIV pregnancy, antiviral treatment with Zidovudine is carried out. The drug tends to quickly penetrate the placenta and is relatively safe for the fetus. Timely initiation of therapy (in the early stages of the disease) reduces the risk of perinatal infection of the embryo by 3 times. Throughout the entire 9 months, the woman should be observed by an obstetrician-gynecologist and an infectious disease specialist. Obstetrics tactics are selected depending on the specific clinical situation.

Attention! HIV-positive mothers are 2 times more likely to experience vaginal candidiasis and 5 times more likely to experience progressive cervical dysplasia. Violation of the immune status leads to pelvic inflammation, human papillomavirus infection, and bacterial vaginosis. With a decrease in the number of lymphocytes (white blood cells), relapses of vaginosis become more frequent, which may indicate the transition of HIV to AIDS.

Postpartum tactics

After delivery is completed, the newborn is left with the mother. Natural lactation is not recommended. The administration of a live vaccine does not begin until the fact of infection has been determined. Antiviral therapy is carried out only after completion of the examination. PCR analysis allows you to diagnose the retrovirus within two weeks after birth.

There is a high probability that within 12-15 months the tests will show a positive result in the child. This does not indicate the presence of a virus, since the analysis can detect antibodies passed on from the mother. The picture changes when the baby turns one year old.

The body of an HIV-positive newborn is initially very weakened, so parents need to be prepared for possible consequences:

• delayed growth and weight gain;
• recurrent thrush;
• pneumonia;
• otitis and other infectious diseases;
• skin candidiasis.

From the first month of life after birth, the child should be regularly observed by specialists at the AIDS center, local pediatrician and pediatric phthisiatrician. It is important for parents to understand that they are now obliged to protect not only themselves, but also their baby from the active progression of HIV. To do this, you must follow all medical recommendations regarding taking medications, carefully monitor your diet, personal hygiene and cleanliness in the house.

Doctors advise remembering that although antiviral therapy reduces the risk of infection of the fetus, the most effective HIV prevention is preventing infection of a woman who plans to become a mother in the future.

Most HIV-positive women want to have children. Modern methods of medical intervention during the prenatal and childbirth period help reduce the risk of transmission of HIV infection from mother to child to almost zero. Still, any HIV-positive woman should weigh the pros and cons before taking this step.

There is no evidence that pregnancy accelerates the course of HIV infection in asymptomatic women. Therefore, it makes sense for an HIV-positive woman who wants to get pregnant to seek the necessary information and seek advice. Knowledge of mother-to-child transmission is rapidly evolving. It is becoming increasingly clear that some situations are better suited for conception than others in order to minimize (but not eliminate) the risk of transmitting HIV infection to the fetus.

Some are concerned that a child (even if not infected) may remain an orphan (due to the death of one or both parents) before reaching adulthood. It is important that the mother (and her partner, if relevant) makes the decision herself, and does not shift it to the shoulders of doctors. For HIV-positive women taking combination therapy, it is important to discuss fertility (or contraception) with a health care professional or other professional. If possible, this discussion should take place before conception.

Some women want to stop treatment either before becoming pregnant or when they realize they are pregnant. This issue needs to be discussed in detail. In general, it is important that the woman continues her treatment. If treatment is stopped, there is a risk of a rapid rebound of the viral load and this may increase the risk of so-called vertical transmission. The risk of abnormal fetal development is also a concern, although the only evidence of side effects to date is the risk of premature birth in mothers undergoing double or triple therapy.

Problems of HIV-positive women who want to become pregnant from HIV-negative men

During unprotected sexual intercourse, there is a slight risk of infection to the male partner. This can be avoided if the woman uses a self-insemination kit. In this simple procedure, a woman inseminates herself during ovulation with her partner's sperm, collected in a sterile container. Most hospitals and women's health organizations can offer advice and equipment.

Problems of HIV-negative women who want to become pregnant from HIV-positive men

Transmission of the infection to the child occurs when the virus is transmitted from an infected mother to the child in the womb, during childbirth or breastfeeding. If the father is HIV positive but the mother is not, the child will not be directly infected through the father's sperm. If a woman becomes infected at the time of conception, there is a significant risk of transmission to the baby, as the woman's viral load is likely to be high at the time of seroconversion. Although there have been cases of women becoming pregnant by HIV-positive men and not becoming infected, there is no reliable information explaining why this was possible.

Some couples wishing to conceive may try to minimize a woman's risk of becoming infected by having unprotected sex only when her chances of becoming pregnant are high and the possibility of contracting HIV is low. This happens during a woman's ovulation, or at a time when her partner's viral load is undetectable. However, the theory that the risk of HIV transmission decreases during this period has not yet been proven.

Sperm cleansing

One possible option is sperm purification. Sperm do not contain CD4 or CCR5 receptors, which can allow HIV infection, although they may contain CXCR4 receptors, which can allow HIV entry.

A sperm sample can be "cleaned" by separating the sperm from the seminal fluid; the sperm is then placed in an incubator where the live sperm is separated from the dead sperm and can then be used for insemination. This method is effective for men whose semen has medium or high sperm content. The results of a study of 11 HIV-positive men showed that this separation technique reduced the viral load to the point where the virus was undetectable (although this does not exclude the presence of HIV in very small quantities), and no embedded viral DNA was detected in semen samples.

There have been no cases of HIV transmission to female partners using this method. According to the Italian group that pioneered the method, 1,000 fertilization attempts were performed on a group of 350 couples, resulting in 200 women becoming pregnant. This method is currently being studied at Chelsea and Westminster hospitals in London.

A woman wishing to conceive in this way will be monitored to determine when ovulation begins, after which her partner must provide sperm for purification before testing for HIV. If the sample turns out to be negative, you can proceed with artificial insemination. Specialists at Chelsea and Westminster Hospitals warn spouses who wish to use this method that even after purification, about 5-6% of samples remain HIV-positive (as confirmed by testing results). It should also be recalled that this procedure is not free.

Artificial insemination

Another option for an HIV-negative woman whose partner is infected is artificial insemination with the sperm of another man - an anonymous donor or someone known to both partners (for example, a member of the male partner's family). This option is used by many women whose husbands are infertile and may pass on infections or congenital diseases.

Problems of HIV-positive married couples

If both partners are HIV-positive, unprotected sex may pose risks to the woman's health, such as contracting STIs or other strains of HIV. If each or both partners are receiving combination treatment, there is a theoretical risk of transmitting drug-resistant types of the virus between spouses, or to the child if he is also infected. This may limit treatment options for family members in the future. However, the main (and proven) danger remains the risk of transmitting HIV to the fetus. It is important that medical professionals discuss the challenges of conceiving children with these couples.

Problems of continuing pregnancy if HIV-positive status is detected

Women who learn during pregnancy that they are infected with HIV must process a lot of different information and make important decisions quite quickly. To make these decisions, it is important to give women enough time, accurate information and good support, and the opportunity to explore all their options. Whatever decisions they make, the results can be both positive and negative. Women who knew their HIV status before conception should consider the following questions.

Risk of vertical transmission

Based on current research, the baby will remain negative in six out of seven cases (one in seven will be positive, and this probability can be reduced further by receiving antiretroviral therapy, caesarean section and bottle feeding). Key factors in transmission are maternal viral load, CD4 cell count, and overall progression of HIV disease.

Studies have shown that HIV can be transmitted to a fetus as early as 8 weeks, as it has been found in aborted fetuses. However, researchers are confident that most transmission of the virus occurs in late pregnancy or around the time of delivery. This confidence is based in part on the fact that some infants showed no signs of HIV infection at birth, suggesting that they were infected just before birth or during the birth process. There are three periods during which an infected mother can pass the virus to her child.

Gestation period

During pregnancy, a mother can pass the virus from her bloodstream through the placenta to her fetus. The placenta is the organ that connects the mother and fetus during pregnancy. The placenta allows nutrients from the mother's body to pass into the fetus, and normally protects the fetus from infectious agents such as HIV in the mother's blood. However, if the placenta membrane is inflamed or damaged, it is no longer as effective at protecting against viruses. In this case, HIV infection can be transmitted from mother to fetus. Factors that increase or change the risk of antenatal transmission of the virus during pregnancy:

• high maternal viral titer (the amount of virus in the mother’s blood);
• maternal neutralizing antibodies (maternal antibodies can inactivate HIV in the fetus);
• inflammation of the placental membrane (in this case it is not so effective against the penetration of the virus);
• conditions during childbirth leading to increased exposure of the fetus to maternal blood
• (early separation of the placenta from the uterus, damage to the baby’s skin (obstetric forceps);
• for drug addiction: using shared needles to inject drugs during pregnancy;
• other infectious diseases (other infections weaken the mother's immune system, which increases the risk of the baby becoming infected with HIV).

Childbirth period

During passage through the birth canal, the baby is exposed to the blood and vaginal secretions of the infected mother. Early separation of the placenta from the mother's uterus, as well as anything that causes damage to the baby's skin (for example, the use of obstetric forceps) can lead to increased exposure of the baby to maternal blood.

Postpartum period

After childbirth, a mother can pass the virus to her baby through breastfeeding. Several reasons may contribute to this:

• breast milk is the main nutrition of a newborn, which is quite rich in leukocytes, including CD4 cells;
• the gastrointestinal tract of a newborn is not perfect and actively absorbs albumin;
• During breastfeeding, the baby may be exposed to blood if the mother has broken skin around the nipple.

The possible ways to reduce the risk of transmitting infection to a child listed above are aimed at reducing the mother’s viral load and minimizing the child’s possible contact with infected biological fluids of the mother, such as secretions from the cervix or vagina, blood, and breast milk. If a woman takes all these precautions, it is possible to reduce the risk to a large extent. However, the risks associated with ART and caesarean section for both mother and baby exist and should be discussed. The long-term effects of taking strong drugs by an HIV-negative child are still unknown. Additionally, the emotional and cultural importance of breastfeeding for some mothers cannot be underestimated.

Possibility of abortion

A woman must understand that she has a strictly defined time to make a decision, and understand what this entails. For example, there is a significant difference between early and late pregnancy termination. Unfortunately, a woman who is tested at a antenatal clinic will not be able to find out the result until her pregnancy reaches 14 weeks. This may mean late termination of pregnancy through induced labor. What does she think about the interruption? Does she have certain religious beliefs that might influence her decision? What support can she get if she has a termination? HIV-positive women who decide to terminate a pregnancy need extensive support and counseling. Just like other women who have recently experienced a termination of pregnancy, they should not be immediately offered sterilization. This contraceptive measure is a decision likely to be regretted and should not be considered before the woman has come to terms with the trauma of pregnancy loss and knowledge of her HIV status, especially if it has only recently been discovered.

If this pregnancy is terminated, what are the chances of getting pregnant again? How important is it for this woman to have children? Does she have other children? Does her partner (if she has one) know about her HIV status? What does he think about continuing the pregnancy? What kind of support can it offer? Has he tested himself? Does he want to get tested? What support will she receive if she continues with the pregnancy? What could this mean for her future? Who will take care of the child if she or her partner is unwell? How will they cope with their ill health?

HIV is the human immunodeficiency virus.
AIDS - acquired immunodeficiency syndrome.

HIV infection is a stagewise developing retroviral disease of humans with parenteral transmission of the pathogen, characterized by a chronic course and steadily progressive damage to the immune, nervous and other systems with the gradual development of AIDS, manifested by opportunistic infections, peculiar tumor lesions and immunopathological processes.

SYNONYMS

AIDS (Acquired Immune Deficiency Syndrome).
ICD-10 CODE
R75 - laboratory detection of HIV.
Z11.4 - a special screening examination to detect HIV infection.
Z71.7 - counseling on issues related to HIV.

EPIDEMIOLOGY

HIV/AIDS is a severe anthroponosis. The source and reservoir of infection is an infected person at any stage (phase) of the infectious process.

The mechanism of infection is parenteral (non-transmissible). There are no reliable facts about other possibilities for natural circulation of the virus in humans.

The mechanism of transmission of the pathogen distinguishes between natural and artificial routes. Natural routes include sexual and vertical (in utero, more often during childbirth), as well as during breastfeeding.

The risk of sexual transmission of the pathogen during unprotected heterosexual vaginal contact is about 30% and increases sharply with promiscuity. Among men who have sexual relations with HIV-infected men, the risk of infection previously reached 60–70%; it increased even more in cases of sexual perversion, accompanied by trauma to the skin and mucous membranes, as well as with concomitant STIs, hepatitis B and C (risk in the presence of the latter increases 20 times or more). In recent years, heterosexual contacts have become predominant in HIV transmission (previously, homo- and bisexual relationships predominated). The number of women infected with HIV is almost equal to HIV+ men. The tragedy of recent years has been the increase in the number of HIV-infected pregnant women; the frequency of their detection has increased 600 times during this time (from 0.2 per 100 thousand examined in 1995 to 119.4 per 100 thousand examined in 2007) , and in some regions even higher.

The risk of vertical transmission of HIV varies in different regions from 13 to 52% (on average 30–35%). During pregnancy (if program antiviral protection was not carried out), the pathogen is transmitted to the fetus in 20–25% of cases; When carrying out this program, the risk can be reduced to 7.5%. 80% of fetuses become infected during childbirth, and in the case of twins, the risk of infection for the first child is twice as high as for the second. In 10–20% of children born, infection can occur during breastfeeding. Cases have been described (1989, Russia, Elista) of a mother becoming infected while breastfeeding a child infected during medical procedures.

Artificial routes are numerous and practically coincide with the routes of transmission of hepatitis B and HS (see section “Viral hepatitis”). At the end of the 20th century. About 90% of HIV/AIDS incidence was caused by intravenous drug users and their surrogates. The risk of infection from blood transfusions today is negligible (1 case per 1,000,000 transfusions) thanks to mandatory HIV testing of donor blood and tissue. However, the phenomenon of seronegative window characteristic of HIV infection (lasting from 1 week to 3 months, according to some data up to 5 months), when antibodies in the serum of an infected person are either absent or their concentration is lower than the sensitivity of test systems for their detection, does not allow complete a guarantee of the safety of transfusion of even HIV-inactivated blood. In this regard, in most countries of the world (but, unfortunately, not in Russia), donor blood is administered to the recipient only after 3–6 months of storage and mandatory re-examination of donors for HIV.

The risk of occupational infection through contact with infected biological fluids, primarily blood, and if the integrity of the skin is damaged is 0.3–0.35%.

In 15–18% of HIV-infected people, it is impossible to reliably determine the source of infection and the route of transmission of the pathogen.

People's susceptibility to HIV is high. There are observations indicating that some people (most of them are Russians and Tatars) are less sensitive and even resistant to the pathogen, since the CCR5 chemokine receptors are absent or expressed in low concentrations on their CD4+ cells (macrophages).

The populations and factors for high risk of HIV infection are similar to those for hepatitis B and HS.

The disease has a tendency to spread epidemically and pandemically. During the study of the infection, about 30 million people died from it. In recent years, due to widespread preventive measures at the global level and the development of optimized therapy programs for various purposes, the rate of increase in incidence has been slowed down, but it continues to grow, but the epidemic is still in the early stages of its development.

CLASSIFICATION

The most widely used classifications are those proposed by the CDC (1993) for adults and adolescents (Table 48-14), and the CDC classification (1994) for children under 13 years of age.

Table 48-14. Classification of HIV infection in adults and adolescents (CDC, 1993)

The HIV/AIDS classification for children under 13 years of age (CDC, 1994) provides 4 clinical categories (H - asymptomatic, A - with mild symptoms, B - with moderate symptoms and C - with severe AIDS symptoms), each divided into 3 subcategories in depending on the severity of immunosuppression (based on the level of CD4+ T-lymphocytes in peripheral blood) and is characterized by various secondary indicator diseases.

ETIOLOGY (CAUSES) OF HIV INFECTION

The causative agent of the disease is the Human Immunodeficiency Virus from the Retroviridae family, represented by two types: HIV-1 (HIV-1) and HIV-2 (HIV-2) with numerous subtypes. HIV-1 is a pandemic virus, more common in North America and Europe. HIV-2 is found primarily in West Africa. In India, HIV-1 and HIV-2 are isolated.

HIV is complex, today its structure has been studied in great detail, the identified features of its structure and life cycle are extremely important for verification of diagnosis, epidemiological research and anti-epidemic measures.

Every day, about 10´109 virions are produced in the body of an infected person, capable of infecting almost 2´109 CD4+ T-lymphocytes per day. This super-intensive replication of the virus determines an exceptionally high degree of its resistance. All this leads to different cytopathic activity of HIV, “escape” of the antiviral effect of sensitized lymphocytes and specific antibodies from immune surveillance, rapid development of drug resistance and, finally, little chance of creating an effective preventive vaccine against HIV/AIDS in the foreseeable future.

HIV is unstable in the environment, very sensitive to heat: it is inactivated at 56 ° C in 30 minutes, when boiled - in 5 minutes, and is killed by the action of hydrogen peroxide and other disinfectants. Resistant to UV rays and radiation.

PATHOGENESIS

From the entrance gate, the pathogen enters with the blood and inside macrophages into all organs and tissues, including the central nervous system (passing through the blood-brain barrier), after which it penetrates into target cells that have CD4 protein: T4 lymphocytes, thymocytes, dendritic lymphocytes, part of B-lymphocytes (5% of the pool), monocytes (40% of the pool) and resident macrophages, megakaryocytes, stem cells and bone marrow fibroblasts, eosinophils, neuroglia, astrocytes, myocytes, vascular endothelium, intestinal M-cells, placental chorionic trophoblast cells; possibly into sperm.

Then the fusion (fusion) of the viral and cell envelopes occurs, followed by endocytosis of the viral nucleotide into the cytoplasm of the target cell. After appropriate transformations (stripping of HIV RNA, synthesis of viral DNA on its matrix, then its copies), the DNA of the virus is integrated into the genome (DNA) of the target cell. 2.6 days after endocytosis, a new generation of virus leaves the target cell, captures part of the cell membrane, leading to the death of the infected cell (cytopathic effect of HIV). The latter is more pronounced in relation to type 1 T4 lymphocytes and is not expressed in macrophages. Gradually, the pool of target cells is depleted, and immune hemostasis is disrupted.

As a result of progressive disorders of the immune system, the protective properties of the skin and mucous membranes decrease, and inflammatory reactions to microflora decrease. Such conditions are conducive to the development of opportunistic infections (viral, bacterial, protozoal, fungal, helminthic), the occurrence of tumors (Kaposi's sarcoma, non-Hodgkin's lymphoma, etc.), and the appearance of autoimmune processes. The development of such symptoms marks the picture of AIDS, followed by the inevitable death of the patient.

Pathogenesis of gestational complications

The range, nature, severity, frequency and pathogenesis of gestational complications in HIV-infected people are almost the same as in the population. A special feature is the risk of vertical transmission of the pathogen to the fetus, associated with viremia at all stages of the disease.

CLINICAL PICTURE (SYMPTOMS) OF HIV/AIDS IN PREGNANT WOMEN

The duration of the incubation period is from 2 weeks to 2 months (sometimes up to 6 months). Clinical manifestations are completely absent, but due to high viremia, infected individuals act as an active source of infection.

An idea of ​​the variety of clinical manifestations of HIV infection can be obtained by studying the sections “Classification” and “Differential diagnosis”. In table 48-15 show the most common pathogens of opportunistic infections that characterize the course of the disease category C (CDC, 1993) or stage III B, C (Pokrovsky V.I. et al., 2001), i.e. AIDS itself.

Table 48-15. The most common pathogens of AIDS-associated infections

Each of the pathogens can cause a typical and atypical picture of the corresponding disease. Often these pathogens are involved in the development of various mixed infections and mixed invasions. Neurological disorders are common with AIDS. They develop due to the fixation of HIV on nerve cells (multifocal leukoencephalopathy with HIV dementia), or are the result of viral, bacterial, mycotic damage to the brain (meningoencephalitis), or the result of the formation of a brain abscess of toxoplasma nature. Primary lymphoma or metastases of other tumors can also develop here. A frequent companion to AIDS is Kaposi's sarcoma and other lymphomas with corresponding symptoms. In the AIDS stage, damage to the eyes, endocrine system, and autoimmune manifestations are common. In the early stages of AIDS and against the background of adequate therapy, all symptoms can develop rather slowly, torpidly, but over time the rate and severity of the complications that arise worsen, and the disease leads to death.

The total duration of the disease can vary from several years to several decades.

Complications of gestation

During pregnancy, an HIV-positive woman is subject to any obstetric and extragenital complications of the gestational period, but, according to most obstetricians, their frequency practically does not exceed the frequency of the same complications in the general population of pregnant women at a given time and in a given region. The most common and severe complication of gestation is perinatal infection of the fetus with HIV, which, in the absence of measures to prevent the transmission of HIV from mother to child, can reach 30-60% in full (with adequate prevention of transmission of the virus from mother to fetus, this percentage drops to 8% and lower (Russia), in some countries up to 1%).

DIAGNOSIS OF HIV IN PREGNANCY

ANAMNESIS

Anamnestic data (epidemiological and disease history data) are very important, especially in the early stages of the disease. First of all, we are talking about the patient’s belonging to a high-risk group for HIV infection and/or indication of sexual contact with a partner from these groups, long-term, recurrent STIs, stay in AIDS-endemic regions.

Of diagnostic significance is an indication that the patient has had a fever of unknown origin above 38 °C for 1 month or more, diarrhea of ​​unknown origin, unexplained loss of body weight by 10% or more, severe sweating, persistent cough, especially at night, of unknown origin or intractable to normal treatment of prolonged or recurrent pneumonia, severe weakness and fatigue.

During clinical observation, the identification of a number of signs obliges the doctor to examine the patient for HIV/AIDS: long-term and difficult to treat infectious and non-infectious lesions of the skin and mucous membranes (herpes simplex, leukoplakia, mycoses, papillomas, etc.); other recurrent viral, bacterial, protozoal, fungal diseases; sepsis; swollen lymph nodes for 1 month or more in two or more groups; symptoms of lymphomas, as well as Kaposi's sarcoma; pulmonary tuberculosis, repeated pneumonia, resistant to therapy; encephalopathy (under 50 years of age).

LABORATORY RESEARCH

When a woman first contacts an antenatal clinic regarding pregnancy, an anamnestic examination and an obstetric-gynecological examination are carried out, possible risk factors for HIV infection are clarified, and risk factors for a complicated pregnancy are determined. Next, the woman is offered to undergo laboratory tests recommended during pregnancy.

Specific diagnosis of HIV infection is carried out only with the consent of the patient (or his legal successors). Isolation and identification of HIV is carried out in laboratories equipped to work with pathogens of the 1st and 2nd hazard groups.

According to Order of the Ministry of Health No. 606 and Order of the Ministry of Health and Social Development No. 375, an HIV test is included in the list of routine tests offered during pregnancy to all women planning to continue pregnancy. Russian legislation specifies that testing a pregnant woman for HIV is voluntary and must be accompanied by pre-test and post-test counseling. During observation of a pregnant woman in the antenatal clinic, testing is carried out twice: during the initial visit regarding pregnancy and, if infection was not detected during the first test, then repeated testing is carried out in the third trimester of pregnancy (34–36 weeks).

Laboratory diagnosis is based on the determination of circulating antibodies, Ag, and immune complexes; isolating the virus from blood, semen, cerebrospinal fluid, urine and other biological fluids (or in autopsy material), identifying its genomic material and enzymes, as well as assessing the functions of the cellular component of immunity.

Serological methods are most widely used in practice. To detect antibodies to HIV, ELISA methods are used, which allow obtaining positive results 1–1.5 months after infection.

However, they require confirmation by immunoblotting (verification of antibodies to various viral proteins).

A reliable result is considered to be the detection of antibodies to 4 or more pathogen proteins. Antibodies to viral proteins appear at different times, so they are verified again within 6–12 weeks. Serological examination of children born from HIV-positive mothers becomes reliable 18 months after birth (if breastfeeding is excluded).

Highly specific and sensitive methods for confirming the diagnosis of HIV/AIDS are methods for quantitative determination of HIV RNA using PCR, DNA provirus, and methods of molecular hybridization of nucleic acids with assessment of the intensity of HIV replication (“viral load” or viral load). PCR detects HIV RNA already on days 11–15 from the moment of infection. The use of this method in dynamics makes it possible to evaluate the effectiveness of etiotropic therapy and helps to clarify the prognosis of the disease.

Sensitive test systems have been developed for the rapid diagnosis of HIV infection (Serodia HIV-1/2, Fujirebic Inc., etc.). They are used, in particular, in pregnant women arriving for childbirth without previous testing for HIV infection, i.e. not observed in the antenatal clinic, with an unknown HIV history (marginal groups of women).

Immunological methods used to assess the depth of immunity disorders, clarify the stage of the disease, prognosis and evaluate the effectiveness of antiviral therapy, include determination of the population size of CD4 and CD8 lymphocytes, their ratio, production of interferons (a and c), IL, etc.

During the AIDS stage, all necessary methods are used to identify and confirm AIDS-associated infections, diagnose lymphomas, and the nature of brain damage.

Monitoring of HIV/AIDS patients (clinical and laboratory, instrumental, for example, x-ray) is carried out regularly, at least every 36 months, and more often against the background of specific antiviral therapy, which allows assessing the dynamics of the disease and timely identifying AIDS-associated diseases. Observation is carried out by infectious disease doctors specially trained in AIDS Centers (republican, regional, city), in departments for HIV/AIDS patients in infectious diseases hospitals. Pregnant women infected with HIV are treated there, and delivery is carried out in the obstetric department of an infectious diseases hospital or an observational maternity hospital.

INSTRUMENTAL RESEARCH

Patients with HIV/AIDS regularly (every 3–6 months) undergo clinical, laboratory and instrumental examinations; the spectrum of the latter is determined primarily by the intrusion of new symptoms.

To determine the condition of the fetus of an infected pregnant woman, the methods indicated for this purpose are used: ultrasound transabdominal and transvaginal examination in real time with Doppler assessment of blood flow velocity in the heart and blood vessels of the fetus (ideally obtaining a color image of blood flows), as well as the umbilical cord and in the uterine arteries. The frequency of ultrasound examination is determined by the doctor, focusing on the clinical situation, but not less than 3 times during pregnancy.

During an ultrasound scan of the fetus using developed tables of organometric parameters of the fetus, depending on the stage of pregnancy, deviations in the development of almost all organs and bone formations of the fetus can be detected with fairly high accuracy. To monitor the condition of the fetus of an HIV-infected woman, cardiotocography (CTG) is also used for continuous simultaneous recording of the fetal heart rate and uterine tone both during pregnancy (especially in the third trimester) and during childbirth, with subsequent analysis and assessment of the most important CTG indicators .

DIFFERENTIAL DIAGNOSTICS

Clinical and anamnestic manifestations of HIV/AIDS at different stages of the disease are polymorphic and numerous and may be similar to dozens of diseases. Under these conditions, differential diagnosis based only on history and clinical presentation is hardly possible. High alertness of a doctor of any profile in relation to HIV/AIDS and timely appointment of a screening examination for HIV antibodies using the ELISA method are required.

HIV carriers are observed by specially trained doctors; in the AIDS stage, if necessary, a gastroenterologist, neurologist, pulmonologist, dermatologist, psychologist, psychiatrist and doctors of other specialties are invited for consultation, taking into account the characteristics of the clinical course of the disease.

EXAMPLE OF FORMULATION OF DIAGNOSIS

Pregnancy 16–17 weeks. HIV infection, stage II B (persistent generalized lymphadenopathy).

TREATMENT OF HIV/AIDS DURING PREGNANCY

TREATMENT GOALS

HIV suppression, correction of immune disorders, treatment of opportunistic infections, tumor, autoimmune diseases.

Treatment is carried out taking into account the stage and phase of the disease, the degree of viral load, the depth of immunological disorders, the age of the patient, and the presence of concomitant diseases. Antiviral therapy programs for HIV/AIDS in pregnant women have been developed with the main goal of preventing (or minimizing the risk of) infection of the fetus and newborn.

NON-DRUG TREATMENT

Treatment of AIDS-associated diseases is carried out taking into account their etiology and severity; in most cases, polytropic massive therapy is carried out.

In recent years, new approaches to the treatment of HIV-infected patients using genetic engineering technologies (CD4-soluble, chemokine receptor blockers, regular gene inhibitors, vaccine therapy, etc.) have been actively developed.

DRUG TREATMENT OF HIV/AIDS IN PREGNANT WOMEN

The basis of modern treatment of patients with HIV/AIDS is Highly Active Antiretroviral Therapy. Currently, several dozen drugs from 4 groups have been created and are used: nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors. In 2002, the first drug from the group of fusion inhibitors was created, which prevents the fusion of the virus and the target cell and thereby prevents HIV from entering human cells.

Monotherapy (one drug) is possible, but combination therapy of several drugs from different groups is usually prescribed. Three-drug therapy is the most widely used in the world. Ready-made combination preparations have been created, initially containing 2-3 drugs in one tablet. The duration of therapy depends on its tolerability by the patient and the effectiveness of treatment. The choice of drugs and their combination is a complex and responsible procedure; it is carried out by AIDS specialists under constant clinical and laboratory supervision.

SURGICAL TREATMENT

If an HIV-positive person, including a pregnant woman, develops clinical signs of a surgical disease or pregnancy complication requiring surgical intervention (abortion, minor caesarean section, caesarean section, etc.), it is carried out as in HIV-uninfected persons with special paying attention to the implementation of all regulated anti-epidemic measures. Caesarean section, which potentially reduces the risk of mother-to-child transmission of HIV, for example, was performed in 17.2% of women in 2005 (mainly for obstetric indications).

PREVENTION AND PREDICTION OF GESTATION COMPLICATIONS

A significant proportion of HIV-infected people prefer to terminate pregnancy in the early stages. During the AIDS stage, pregnancy is rare. In HIV-infected pregnant women in the early stages of the disease, gestation proceeds without any peculiarities, and the frequency of its complications, as a rule, does not exceed the population level.

The main complication is the risk of infection of the fetus and newborn with HIV.

Achievements in recent years include the development of antiretroviral monotherapy for pregnant women with HIV/AIDS to prevent infection of the fetus. Zidovudine from the group of nucleoside reverse transcriptase inhibitors is used: 0.1 g orally 5 times a day 1434 weeks before birth, during labor intravenously 2 mg/kg in the first hour and 1 mg/kg per hour until the end of labor. An alternative to zidovudine is nevirapine from the group of non-nucleoside reverse transcriptase inhibitors, 200 mg 2 times a day. According to indications, pregnant women are also given tritherapy.

A newborn is prescribed Azidotimidine in syrup at 2 mg/kg (if necessary intravenously at 1.5 mg/kg) 4 times a day for 6 weeks.

If an HIV-infected woman experiences certain complications of gestation in any trimester, during childbirth and the postpartum period, then their treatment is no different from the treatment of uninfected pregnant women (with the exception of antiretroviral therapy).

INDICATIONS FOR CONSULTATION WITH OTHER SPECIALISTS

In the vast majority of cases, an HIV-infected pregnant woman is treated by an obstetrician-gynecologist and an AIDS specialist. If AIDS-associated infections and other diseases occur, consultation with appropriate specialists is indicated.

INDICATIONS FOR HOSPITALIZATION

HIV/AIDS patients are hospitalized in the presence of clinical symptoms and the need for additional therapy, as well as for correction of therapy and complications. HIV-infected people without clinical manifestations can be observed and treated on an outpatient basis.

ASSESSMENT OF TREATMENT EFFECTIVENESS

The effectiveness of therapy is assessed based on clinical data (if any), but most importantly, based on the magnitude of the viral load and data from a quantitative assessment of the cellular component of immunity.

CHOICE OF DATE AND METHOD OF DELIVERY

Pregnancy can be terminated (at the woman's request) within the time limits accepted in obstetrics. If a woman intends to carry a fetus, then she should seek an urgent birth through the natural birth canal.

INFORMATION FOR THE PATIENT

An HIV-infected woman must strictly follow all instructions and examination dates prescribed by the doctor. Impeccable adherence to prescribed therapy with antiretroviral drugs will reduce the risk of fetal infection (up to 8% or lower; without therapy, the risk reaches 30%). At any stage of gestation, if an STI is detected, it is necessary to treat them. Breastfeeding a child is not allowed.

Emergency post-exposure prophylaxis of HIV infection is indicated for medical workers in case of skin damage in the process of working with HIV/AIDS patients and when infected material gets on the mucous membranes. Its regimen depends on the depth of the injury and on the HIV status (based on the results of determining HIV RNA) and the immune status (based on the level of CD4+ cells) of the patient. If there is a low or moderate risk of infection (shallow lesions and low HIV replication in a patient with a good immune status), the main regimen of chemoprophylaxis is carried out: zidovudine 0.6 g in 2-3 doses per day and lamivudine 0.15 g twice a day (or Combivir© 1 tablet 2 times a day). In case of a high risk of infection (deep injury and intensive HIV replication in a patient with severe immunodeficiency and symptoms of AIDS), the main regimen is supplemented with three times a day of nelfinavir 0.75 g or Crixivan 0.8 g. Post-exposure prophylaxis begins no later than 24 hours after injury and continues for 4 weeks.

Currently, there are about 40 million people with HIV infection in the world. When the new disease was first discovered, people with HIV were treated as death row. This was due to the late detection of HIV in patients, most of whom were already in the AIDS stage (the final stage of development of HIV infection) and lived no more than a year from the date of diagnosis. Nowadays, a timely diagnosis and proper treatment can delay the development of the disease for a long time. Therefore, women with HIV today can also experience the joy of motherhood - of course, subject to careful medical supervision and treatment.

The causative agent of the disease

HIV belongs to the Retrivi ridae family, subfamily Lentivirus. True to its name (Lentivirus is Latin for “slow” virus), HIV is in no hurry.

Once HIV enters the body, it attacks certain blood cells - T-lymphocytes. These cells play an important role in the immune system: they recognize various foreign agents (bacteria, viruses, cancer cells and toxins) and instruct other cells to destroy them. On the surface of these lymphocytes there are CD-4 molecules, which is why they are also called CD-4 cells. The virus encounters a cell on the surface of which there is a CD-4 molecule, the shell of the virus and the cells merge, and the genetic material of the virus enters the cell, integrates into the nucleus and begins to control it until the cell dies. By the time HIV infection progresses to AIDS, billions of blood cells already contain the genetic material of the virus.

HIV cannot live in air for more than a few minutes. In fact, this is precisely the reason for the absence of cases of household HIV infection. In general, HIV can be transmitted only in three ways: through blood, sexual intercourse, and from mother to child during pregnancy and childbirth.

Symptoms of HIV

When HIV enters the human body, the immune system begins a long-term fight against the disease. For a long time, only special blood tests can determine the presence of HIV, as well as how successfully the body fights the virus.

Only in some cases are symptoms of HIV present immediately after infection. The first signs of HIV are subtle: a few weeks after infection, a person may have a slight increase in temperature, enlarged lymph nodes, a sore throat, and diarrhea. Such symptoms are most often mistaken for signs of a cold or poisoning, especially since they disappear quite quickly.

The presence of HIV in the body can be completely invisible for 10-12 years. The only thing that may bother a person is a slight enlargement of the lymph nodes. When the number of CD-4 cells (the same T-helper cells) sharply decreases, specific diseases associated with immunodeficiency appear. Such diseases are frequent pneumonia, cytomegalovirus infection, and herpes. In patients at this stage, such infections quickly develop into generalized (widespread) forms and lead to death. This stage of the disease is called AIDS.

Diagnostics

The only reliable method for diagnosing HIV infection is laboratory testing. During pregnancy, HIV blood tests are offered to all women three times during pregnancy. Tests cannot be prescribed forcibly without the patient’s consent. But you also need to understand that the sooner the correct diagnosis is made, the greater the patient’s chances of living a long life and giving birth to a healthy child, even if she is a carrier of HIV. A doctor observing a pregnant woman must tell her about this, and he must also explain the benefits of timely diagnosis of HIV in pregnant women.

The most common method for diagnosing HIV infection is an enzyme-linked immunosorbent assay (ELISA), which detects antibodies to HIV in the patient’s blood serum. ELISA can give both false negative and false positive results. A false negative ELISA result is possible with a fresh infection, while antibodies to HIV have not yet been produced by the patient’s body. False-positive results can be obtained when examining patients with chronic diseases and in some other cases. Therefore, when a positive ELISA result is obtained, it must be rechecked using more sensitive methods.

Polymerase chain reaction (PCR) allows you to directly determine the presence of the virus. Using PCR, the amount of free viruses circulating in the blood is determined. This amount is referred to as the “viral load.” Viral load shows how active the virus is in the blood. PCR, like ELISA, can give a false positive result. Therefore, when positive results are obtained, in addition to the listed methods, other diagnostic methods are used.

After the diagnosis of HIV infection is made, further examination of the patient is carried out, during which the nature of the disease and the degree of immune damage are clarified. The degree of immune damage is assessed by the level of CD-4 cells in the blood.

Course of pregnancy

Pregnancy does not accelerate the progression of HIV infection in women at an early stage of the disease. The number of pregnancy complications in such women is not much higher than in women without HIV. Cases of bacterial pneumonia are somewhat more common. There are no significant differences in mortality and the incidence of AIDS in HIV-infected women who have and have not had a pregnancy.

At the same time, if there is a pregnancy at the AIDS stage, pregnancy complications are much more common. These include more frequent and severe bleeding, anemia, premature birth, stillbirth, low fetal weight, chorioamnionitis, postpartum endometritis (inflammation of the inner lining of the uterus). In general, the more severe the disease and the higher its stage, the more likely pregnancy complications are.

Congenital HIV infection

Mother-to-child transmission of HIV is an established fact. In the absence of special antiviral therapy, children become infected in 17-50% of cases. Antiviral treatment significantly reduces the rate of perinatal transmission of the disease (up to 2%). Factors that increase the likelihood of HIV transmission are: late stage of the disease, infection during pregnancy, premature birth, damage to the fetal skin during childbirth.

HIV can be transmitted in three ways: transplacentally, during childbirth, or after birth through breast milk. The placenta normally protects the fetus from bacteria and viruses in the maternal blood. However, if the placenta is inflamed or damaged, its protective function is affected and HIV infection can be transmitted from mother to fetus. Most often, HIV is transmitted during childbirth. During passage through the birth canal, the baby is exposed to the mother's blood and vaginal secretions. Unfortunately, cesarean section is also not a reliable protection of the fetus from HIV infection; its use is justified when a large number of viruses are detected.

The third way of transmitting the virus to a newborn is breastfeeding, which doubles the risk of infection. Therefore, an HIV-infected woman should not breastfeed her baby.

Children born to HIV-positive mothers will also be HIV-positive immediately after birth. However, this does not mean that they are infected, since children are born with their mothers' antibodies. Maternal antibodies disappear from the baby's blood between 12 and 24 months. It is after this time that one can confidently judge whether the child has become infected. PCR diagnostics can help determine a child’s HIV status earlier. Already 4 weeks after birth, the reliability of PCR is 90%, and after 6 months - 99%.

Some diseases of newborns can also indicate the likelihood of an HIV-positive diagnosis in children: pneumonia caused by pneumocystis, systemic candidiasis (fungal infection of many organs and systems), herpes zoster, chronic diarrhea, tuberculosis. Approximately 20% of infected children develop a severe form of immunodeficiency by the age of one year, with the development of concomitant infections and, in many cases, encephalopathy (brain damage). Most of them die before reaching the age of five. In the remaining 80% of children, on the contrary, immunodeficiency develops after a period of time that exceeds the same period in adults.

Treatment during pregnancy

In non-pregnant women, the decision to initiate antiviral therapy is made based on two tests: the level of CD-4 cells and the viral load.

Modern treatment requires combination therapy - the simultaneous use of two, three or more antiviral drugs. One drug for treating HIV infection is currently used only in one case - in pregnant women, to prevent transmission of HIV to the newborn.

If a woman took combination antiviral therapy before pregnancy, then doctors usually recommend that she take a break from treatment for the first three months of pregnancy. This reduces the risk of developing malformations in the unborn child, and in addition, avoids the development of resistance (a condition in which the virus does not treatable).

Prevention

Prevention of congenital HIV infection is carried out in three ways:

1) HIV prevention among women of childbearing age;

2) prevention of unwanted pregnancies among women with HIV;

3) prevention of HIV transmission from mother to child.

Currently, thanks to combination antiviral therapy, people with HIV live for many years, some for more than 20 years. Many women with HIV do not want to miss the opportunity to become mothers. Therefore, prevention of mother-to-child transmission of HIV has become a central element of most government HIV programs.

HIV and AIDS

The first information about HIV infection (human immunodeficiency virus) appeared in the mid-1980s, when an unknown disease was discovered in which adults suffered from immunodeficiency, which had previously only occurred as a congenital defect. Unlike immunodeficiency in newborns, in these patients the decrease in immunity was acquired in adulthood. Therefore, in the first years after its discovery, the disease began to be called AIDS - acquired immune deficiency syndrome.

Pregnancy with HIV infection is carefully planned. But there are cases when a woman finds out about the infection while she is already pregnant. She will undergo antiretroviral therapy (ARV), monitoring the level of essential antibodies, and monitoring the condition of the fetus. To avoid health complications, it is necessary to adhere to the instructions of specialists, because the main task is the birth of a healthy child.

Is it possible to conceive with HIV infection?

Despite the risk of infecting the unborn child with HIV infection, many families, where one of the spouses, and sometimes both, are immunodeficient, decide to have a baby. In such a difficult situation, even the method of conception can reduce the risk of infection of the baby. In fact, the germ cells of both parents are sterile, but the virus is found in abundance in biological fluids.

In this regard, doctors have provided several methods of conception in which this possibility is minimized:

1. If a woman is sick, she is asked to undergo the procedure of artificial insemination - during ovulation, that is, the maturation and release of an egg ready for fertilization, pre-collected male sperm is introduced into the vagina.

2. For families and couples where a man is infected, several options are considered:

• Semen purification HIV-positive partner and direct insertion into the woman’s vagina when the mature egg has already been released into the abdominal cavity. This method reduces the risk of infection of the woman, and, consequently, the child.
• In Vitro Fertilization, when the female gamete is collected using the laparoscopic method, and in men, sperm are separated from the seminal fluid. The germ cells are artificially fertilized and then placed in the uterine cavity.
• Easy way– unprotected sex is used extremely rarely. To do this, the day of ovulation must be accurately determined so that conception occurs for sure. Otherwise, with repeated attempts, the woman’s risk of infection increases.

3. There is also a safest option– artificial conception of a woman through the seed of a healthy man, eliminating any risks associated with the body of the mother and baby, but not all couples are ready to take such a step, based on its moral and legal aspects.

How is the diagnosis done?

A timely detected infection can help a woman give birth to a normal baby, so it is advisable to take HIV tests at the stage of pregnancy planning. For this, venous blood is taken from both the expectant mother and the intended father.

The main diagnostic procedures in this case:

• ELISA– enzyme immunoassay. Laboratory blood test to determine specific antigens and antibodies to HIV proteins. If the serum gives a positive result two times in a row, an immunoblot test is performed, which excludes or confirms infection.
• Polymerase chain reaction– for such an examination, blood is taken, and biomaterial of sperm and secretions from the woman’s genital organs are also collected. The purpose of the study is to establish the genotype (HIV-1, HIV-2) and determine the concentration of the virus in the body. The method helps determine the presence of infection within 10-15 days after infection, but usually it is used to confirm enzyme immunoassay screening.

During pregnancy, it is advisable for a woman to be diagnosed early - within the first two months. Since there is a risk of later infection, it is recommended to conduct HIV tests at 30 and 36 weeks of gestation, as well as after childbirth.

Main symptoms of HIV infection in pregnant women

HIV infection can appear as early as 2 weeks after a woman is infected, but sometimes, when the immune system is strong, signs of the disease appear much later - after several months. Their one-time appearance may not raise any suspicion of a health hazard, so the diagnosis of immunodeficiency becomes unpleasant news.

Pregnant women in the acute stage experience the following typical symptoms:

• temperature rise to high values;
• severe myalgia – muscle pain;
• body aches, joint pain;
• intestinal dysfunction in the form of diarrhea;
• skin rashes on the face, torso and limbs;
• enlarged lymph nodes.

A pregnant woman may have such general symptoms as weakness, fatigue, chills and fever, and headache. They can easily be confused with feeling unwell during a common cold.

After an exacerbation, a latent stage begins, during which practically no obvious manifestations of the disease are detected. If an immunodeficiency condition quickly becomes chronic, a woman may develop various diseases caused by fungal, bacterial and viral infections.

During pregnancy and HIV infection, it is realistic to carry and give birth to a healthy child only if the disease is at the initial and second stages of development. And only if the woman immediately begins treatment and antiretroviral prophylaxis.

How does HIV infection affect pregnancy?

It is known that HIV infection can negatively affect the course of pregnancy.

Pathology can provoke in a woman:

• development of opportunistic infections: tuberculosis, disruption of the urinary organs and other complications associated with immunodeficiency and negatively affecting pregnancy;
• infection by herpes, syphilis, trichomoniasis and other sexually transmitted infections that can lead to stillbirth of a child;
• unsatisfactory development of the fetus, and sometimes intrauterine death of the baby;
• violation of the fetal membrane and detachment of placental tissues;
• spontaneous miscarriages, which are much more common than in uninfected mothers.

Due to the influence of a dangerous infection, patients with HIV are more likely to have premature births, and children are born with less weight. If pregnancy is accompanied by characteristic symptoms of the disease, the risk of negative effects on the course of pregnancy also increases.

At the conception planning stage, there is a high percentage that the embryo can be implanted outside the uterine cavity, which increases the risk for the life of the woman herself and the death of the fetus.

Transmission of the virus and its effect on the fetus

Despite the fact that there are cases of healthy offspring being born from an infected mother, the risk of infection of the child always exists.

Transmission of the HIV virus can occur:

• During pregnancy– the fetus can become infected if, against the background of HIV, multiple pathological processes develop in the mother’s body, including bacterial infection of the placenta, amniotic fluid and umbilical cord. As a result of such a lesion, prenatal rupture of amniotic fluid, stillbirth, or miscarriage may occur. Childbirth, however, is difficult and protracted.
• At the time of birth– passing through the birth canal, the baby comes into close contact with the mother’s mucous tissues and any slight damage to the skin allows the virus to enter the newborn’s body. To protect it, a caesarean section is used at 38 weeks of pregnancy; the operation halves the risk of infection, but there is no guarantee in such a situation.
• After labor– the infection can pass from mother to baby through breast milk; the infection is not transmitted to the child by other means.

As a result of infection during and after childbirth, a baby may experience pneumonia, chronic diarrhea, ENT diseases, encephalopathy, anemia, kidney dysfunction, dermatitis, herpes, and delayed mental and physical development.

The course of pregnancy against the background of HIV

During pregnancy, due to the irresponsible attitude of the woman, as well as complications associated with the infection, there is a high percentage of miscarriages, placental abruption, and growth retardation of the child.

First trimester

At this time, as throughout the entire period of gestation, the immunological indicators of white blood cells CD4 decrease markedly, and many concomitant infections may occur. Most often, the expectant mother has to undergo treatment with special drugs that prevent transmission of the virus to the baby. But usually treatment begins from 10 to 14 weeks, and before that the woman does not use any medications, as they can have a detrimental effect on the development of the baby.

Second trimester

Starting from the 13th week, intensive therapy with the main antiretroviral drugs is prescribed, these are:

• Nucleosides and nucleotides – Phosphazide, Abacavir, Tenofovir, Lamivudine.
• Non-nucleoside reverse transcriptase inhibitors - Efavirenz, Nevirapine, Etravirine.
• HIV protease inhibitors – Nelfinavir, Ritonavir, Atazanavir.

In addition to medications in the early and later stages of pregnancy, women are recommended to take vitamin complexes, folic acid, and iron supplements.

Third trimester

Highly active drugs are used to suppress the retrovirus HAART (the most effective Retrovir (Zidovudine) is prescribed at 7 months), often they are used in combination with each other, but can have significant side effects in the form of liver dysfunction, allergies, decreased blood clotting, and dyspepsia. Therefore, doctors often adjust therapy or replace some drugs with others that are safer for the fetus.

With antiviral therapy throughout pregnancy, following proper nutrition and other doctor’s recommendations, the risk of infection is reduced to 2%, despite the fact that without treatment, 30 children out of a hundred become infected - during pregnancy, childbirth and the postpartum period.

Management of pregnant women with HIV infection

When pregnancy occurs against the background of HIV infection, a crucial period begins for a woman, when all efforts should be aimed at giving birth to a healthy baby. All this time she will be under the supervision of doctors - AIDS center specialists will conduct a full medical examination and will support the woman throughout her pregnancy, as well as her direct gynecologist-obstetrician and infectious disease specialist.

In this difficult time, a woman needs:

• take antiviral drugs;
• regularly visit an infectious disease specialist to identify dangerous diseases that arise due to weakened immunity;
• if the fetus is in normal condition, medications can be prescribed to prevent spontaneous abortion, which often occurs in the early stages of gestation;
• It is mandatory to undergo monthly tests to study the state of the immune system, as well as a general and extensive blood test.

Constant monitoring is necessary for the effective use of ARV and IVART drugs, in addition, this is how the most favorable time and option for delivery are determined.

Prevention

When conceiving, preventing the child from becoming infected consists of purifying the sperm of an infected father, in vitro fertilization, and conception using the sperm of a healthy donor. In women, antiviral treatment is acceptable to reduce the viral load before planning pregnancy.

Throughout pregnancy, before and after childbirth, chemoprophylaxis of HIV infection with drugs is carried out.

If a woman is already carrying a child, the following preventive measures are applied:

• a pregnant woman with the immunodeficiency virus can only have sexual intercourse using a condom;
• when prescribing medical procedures, only disposable or maximally sterilized instruments should be used;
• Perinatal invasive diagnostics are prohibited;
• prevention of diseases and complications associated with HIV infection is carried out;
• If the fetus is infected before the 12th week, termination of pregnancy may be proposed.

Regarding childbirth, optimal delivery is planned in advance. Basically, surgical extraction of the newborn is used.

After the birth of the baby, the woman must stop breastfeeding and continue the course of antiviral treatment. In some cases, drug prophylaxis against retroviruses is also prescribed for a newborn.

The desire of some couples to have a child cannot be stopped even by such a terrible diagnosis as HIV infection. But a woman needs to understand that she will have to go through a difficult path and make considerable efforts to ensure that the baby is born healthy. This is a big responsibility and an undeniable risk that must be remembered.

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