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INTRODUCTION

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Much has changed in the care of patients who are human immunodeficiency virus (HIV) positive since the ­epidemic was first recognized in the early 1980s. Women comprise over half the of the almost 37 million people worldwide who are living with HIV infection and about 25% of those in the United States. It is estimated that about one in five patients infected with HIV are unaware of their status. Since the 2006 recommendation that everyone be tested for HIV infection and simultaneous intensified efforts to have all HIV-infected people treated with antiretroviral drugs (antiretroviral therapy [ART]), the annual number of HIV diagnoses in the United States fell by 19% between 2005 and 2014 according to a Centers for Disease Control and Prevention (CDC) analysis. The number of HIV diagnoses in women declined 40% during this time. In 2014, African-American women accounted for 60% of the new HIV diagnoses in women. Despite these favorable trends, there still are about 40,000 HIV infections diagnosed each year with about 8500 HIV positive women giving birth every year. The number of perinatal HIV transmissions dropped to 69 (1.8/100,000 live births) in 2013 from 216 (5.4/100,000 live births) in 2002. From 1994 to 2010, the CDC estimates that almost 22,000 perinatally acquired were prevented by the use of antiretroviral medications. This favorable trend correlates with more pregnant women being tested and the expanded use of antiretroviral drugs; however, 63% of the infected mothers were African American and 18.3 were Latino suggesting targeted interventions may decrease the perinatal ­infection rate even more. See Fig. 26-1.

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FIGURE 26-1

New HIV infections by gender and race/ethnicity. (Reproduced with permission from Centers for Disease Control and Prevention [CDC]. Available at https://www.cdc.gov/hiv/statistics/overview.)

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The care of HIV-infected pregnant women is more complex today than ever and pregnant women who are infected with the HIV virus present a challenge to even the most experienced clinician. Drug therapies have increased exponentially since the epidemic was first recognized. Obstetricians caring for HIV-infected women should only manage them in concert with clinicians who are fluent with current recommendation regarding drug therapies. A team experienced in the medical, obstetrical, and psychosocial needs of these women should manage HIV-infected patients.

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It is important to remember that HIV seropositivity is not synonymous with acquired immune deficiency syndrome (AIDS) (see Appendix). This is especially true today, as current HIV drug regimens have allowed many HIV seropositive patients to survive free from an AIDS-defining condition. During the early period of the epidemic, most obstetricians had no experience of treating an HIV-infected pregnant woman but with the dramatic increase in HIV infections in women, more and more obstetricians can expect to have an HIV-infected pregnant woman among their patients.

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The vast majority of infected women is of reproductive age and overwhelmingly acquires HIV infection from high-risk ...

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