Antiretroviral Treatment for Pregnant Women Living with HIV: A Summary of Issues, Interventions, and Evidence

Each year, approximately 42,000 women living with HIV die of HIV and pregnancy-related complications. Despite significant progress, not all pregnant women can access treatment, particularly in low- and middle-income countries, where availability of medications and standardized treatment eligibility criteria have traditionally prioritized prevention of HIV transmission to the infant over treatment for the woman's health. The World Health Organization's (WHO) September 2015 guidance states that antiretroviral treatment should be initiated in all pregnant and breastfeeding women living with HIV at any CD4 cell count and continued lifelong, also known as Option B+. This treatment regimen aims to reduce global inequality in access to antiretroviral treatment. However, not all women will benefit immediately, as fewer than one out of 10 people living with HIV live in a country where antiretroviral treatment upon HIV diagnosis is current policy or practice. Antiretroviral medications are beneficial for women living with HIV, but drug resistance remains a concern. Studies show that women living with HIV who access antiretroviral treatment prior to pregnancy or very early in pregnancy have no differences in rates of birth defects in fetuses/infants compared to those who initiate treatment later in pregnancy. Since Option B+ calls for lifelong treatment, women living with HIV are at lesser risk of developing drug resistance, unless they stop and start the recommended treatment, are non-adherent, face drug stockouts, receive inappropriate regimens, etc. All women living with HIV need timely access to antiretroviral treatment, ideally prior to pregnancy. Adolescent girls are especially important in antenatal care treatment programming due to their increased vulnerability. Women who are part of key populations, such as women who use drugs and women who are sex workers, also require intensified programming to ensure access to antiretroviral treatment. Maternal HIV status and health are key to survival for infants and children in the post-neonatal period. A recent study in Malawi found that the mother's HIV-positive status correlated with more than one-third of deaths of children up to age four. Children whose mothers died were at greater risk of dying than those whose mothers were alive. Focus group discussions among women living with HIV in Malawi found that Option B+ is presented to women as a program primarily to protect the baby, with their health unimportant. Few countries have comprehensive registers that follow the mother-infant pair after delivery to measure longer-term antiretroviral treatment adherence. To adequately assess if mothers are adhering well and are being kept alive, national governments should continue to track the percentage of pregnant women living with HIV who access antenatal care and antiretroviral treatment, the percentage of pregnant women living with HIV who are virally suppressed with antiretroviral treatment, and the percentage of women living with HIV who remain virally suppressed with antiretroviral treatment by number of years postpartum. Women need information, support, and respect in decision-making about antiretroviral therapy. While WHO does not specify how quickly a pregnant woman should initiate antiretroviral treatment upon an HIV-positive diagnosis, countries implementing Option B+ are interpreting the guidance to mean immediately. However, initiating treatment upon diagnosis may be too challenging for some pregnant women, and insufficient counseling or respect for women's decision-making time can drive women away from accessing treatment. Fear of disclosure, violence, and stigma can influence treatment initiation and adherence. Pregnant women living with HIV still remain highly stigmatized in many countries, and disclosure of their HIV status can place them at risk. Addressing gender norms and supporting women may be key to eliminating vertical transmission. Community-based support programs for pregnant women living with HIV can be helpful, and a recent study found that community-based adherence clubs for stable antiretroviral treatment patients showed high adherence rates and low viral load rebound. Additional efforts are needed to better engage men in supporting safe motherhood and prevention of vertical transmission. Little work has been done to explain vertical transmission to male partners and how men can support pregnant partners living with HIV. Interviews with male partners of pregnant women living with HIV in South Africa found that men felt responsible for their children but were deterred from accessing services due to long clinic lines and the view that clinics for maternal healthcare are women-only spaces. It is possible to eliminate vertical transmission. Between 2009 and 2015, there was a 46% decline in the number of AIDS-related deaths among women of reproductive age in the 21 priority countries. In June 2015, Cuba became the first country to be validated as having met the global criteria for eliminating vertical transmission as a public health problem. Several interventions have been successful in improving treatment for pregnant women living with HIV. Initiating antiretroviral treatment as early as possible to achieve low viral load is optimal, improves maternal health, and reduces the risk of vertical transmission. Peer counseling by mother mentors may improve treatment adherence among pregnant women