Heterosexual spread of HIV has surpassed intravenous drug use as the most common mode of transmission. HIV infection leads to progressive debilitation of the immune system, rendering infected individuals susceptible to opportunistic infections and neoplasias that rarely afflict patients with intact immune systems. Furthermore, the unborn fetus may become infected either by transplacental passage or during the delivery process. The neonate may acquire HIV from infected breast milk. Because measures during pregnancy, during delivery, and postpartum can dramatically decrease the risk of vertical transmission to the fetus, HIV serostatus should be obtained for every pregnant women as early as possible during pregnancy and repeated at the time of labor or delivery.
Initially, patients either may be asymptomatic or have symptoms that mimic a mononucleosis-like illness. Antibodies to HIV usually are detectable I month after infection and almost always are detectable within 3 months. Studies have been unable to determine with certainty the effect of pregnancy on HIV disease progression. There continues to be correlation between maternal disease stage at the time of diagnosis with the viral load and transmission rates. When loads are reduced to undetectable levels, transmission to the fetus becomes uncommon. Viral load and CD4 T-cell testing are ways to monitor a woman's health status. In pregnancy, the viral load should be evaluated monthly until it is no longer detectable. The goal in pregnancy is maintaining a viral load of less than 1000 RNA copies per milliliter.
Treatment regimens include polytherapy to decrease resistance, and compliance is a must. Patients should have regular monitoring of liver function tests and blood counts to detect toxicity. Combination retroviral therapy decreases the risk of perinatal transmission to less than 2%. Evidence shows that route of delivery can further decrease vertical transmission. Scheduled cesarean delivery (prior to labor or rupture of membranes) should be discussed for HIV positive women. HIV-infected women who choose to deliver vaginally should receive intravenous ZDV during labor. Breast-feeding should be discouraged. The neonate generally also receives oral ZDV syrup.
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