HOW DO BABIES GET HIV?
HIV, the virus that causes AIDS, can be transmitted from a person with HIV to their child anytime during pregnancy, childbirth, or breastfeeding. This is called perinatal transmission. According to the World Health Organization (WHO), without antiretroviral therapy (ART), up to 30% of babies born to pregnant people with HIV get HIV. If the birthing person breastfeeds, the overall risk rises to 35-50%. Read more about HIV among children.
Pregnant people with higher viral loads are more likely to infect their babies. However, no viral load is low enough to be totally safe. Infection can occur any time during pregnancy, but usually happens just before or during delivery. During delivery, the newborn is exposed to the pregnant parent’s blood, which is a high-risk exposure. The baby is more likely to get HIV if the delivery takes a long time.
PREVENTING PERINATAL TRANSMISSION
Family planning
Family planning is one of the most important measures for prevention of perinatal transmission. Reducing the number of unintended pregnancies among people with HIV reduces the number of children born with HIV. Pregnant people with HIV are also at greater risk of dying from pregnancy-related complications than people who do not have HIV.
Sperm washing
Cisgender men and transgender women with HIV can transmit HIV to their sex partners who can then pass HIV on to their children. To reduce this risk, some people have used sperm washing. Studies have shown that it is possible to wash the sperm of a person with HIV so that the sperm can be used to produce a healthy baby. These procedures are effective, however they are very expensive and not easily available.
Early and regular prenatal care
Prenatal care is when a pregnant person gets checkups from a doctor, nurse, or midwife throughout their pregnancy. It helps keep the pregnant person and their baby healthy.
HIV testing during pregnancy
Pregnant people with HIV may not know they have the virus. HIV testing is recommended for all pregnant people as part of routine prenatal care. According to recent research, more pregnant people take the prenatal HIV test if the opt-out approach is used. Opt-out prenatal HIV testing means that a pregnant person is told they will be given an HIV test as part of routine prenatal care unless they opt out — that is, chooses not to have the test. In some parts of the world where HIV is more common among women and other people assigned female at birth (AFAB), a second test during the third trimester of pregnancy is recommended.
Antiretroviral medications
The risk of perinatal transmission is extremely low if antiretroviral medications (ARVs) are used in pregnancy and labor and the birthing person does not breastfeed. Taking ART as prescribed reduces the amount of HIV in the body (viral load) to a very low level, called viral suppression or an undetectable viral load. Getting and keeping an undetectable viral load is the most effective thing pregnant people with HIV can do to stay healthy and prevent perinatal transmission.
The risk of transmitting HIV to the baby can be 1% or less if:
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- The birthing parent takes ART daily as prescribed throughout pregnancy, labor, delivery, and breastfeeding
- The baby receives ART for 4-6 weeks after birth
WHO recommends lifelong ART for all people with HIV, regardless of CD4 cell count and clinical stage of disease; this includes pregnant and breastfeeding people.
Short delivery times
The risk of perinatal transmission increases with longer delivery times. If the pregnant person takes ART and has a viral load less than 1,000 copies of HIV per milliliter of blood, the risk is almost zero. Birthing people with a high viral load might reduce the risk of perinatal transmission if they deliver the baby by cesarean.
Newborn feeding
Up to 20% of babies may get HIV from infected breast milk if the birthing person is not taking ART. The best way to prevent perinatal transmission of HIV to an infant through breast milk is to not breastfeed.
In the U.S., where parents and caregivers have access to clean water and affordable replacement feeding (infant formula), the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend that birthing people with HIV completely avoid breastfeeding their infants, regardless of ART and maternal viral load. Healthcare providers should be aware that some birthing people with HIV may experience social or cultural pressure to breastfeed. These parents may need ongoing feeding guidance and/or emotional support.
In resource-limited settings, such as some parts of Africa, replacement feeding can increase the risk of infant death. This can be due to loss of disease protection provided by breast milk or the use of contaminated water to mix baby formula. In these areas, WHO recommends that birthing people with HIV breastfeed exclusively for the first 6 months of life and continue breastfeeding for at least 12 months with the addition of complementary foods. Birthing people with HIV should be given ART to reduce the risk of transmission through breastfeeding.
A recent study showed that it is possible for newborns to become infected by eating food that is chewed by a person with HIV. This practice should be avoided.
HOW DO WE KNOW IF A NEWBORN IS INFECTED?
All babies born to pregnant people with HIV test positive for HIV. They have antibodies to HIV even if they are not infected because the pregnant person’s antibodies were passed to them during pregnancy and/or childbirth. This does not mean the baby is infected.
Another test, similar to the HIV viral load test, can be used to find out if the baby is infected with HIV. Instead of antibodies, these tests detect HIV in the blood. This is the only reliable way to determine if a newborn is infected with HIV.
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- If babies are infected with HIV, their own immune systems will start to make antibodies and they will continue to test positive.
- If babies are not infected, the birthing person’s antibodies will eventually disappear and they will test negative after about 12-18 months.
For babies with HIV, starting ART early is important because the disease can progress quickly in children. Providing ART early can help children with HIV live longer, healthier lives.
PROTECTING THE HEALTH OF PREGNANT PEOPLE
Short-course ART to prevent infection of a newborn is not the best choice for the pregnant person’s health. If a pregnant person takes ART only during labor and delivery, HIV might develop resistance. This can reduce future treatment options. Read more about HIV drug resistance.
A pregnant person should consider all the possible problems with taking ARVs during pregnancy, childbirth, and breastfeeding.
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- Do not use efavirenz (Sustiva) during the first 3 months of pregnancy.
- If CD4 cell count is greater than 250 cells/mm3, do not start using nevirapine (Viramune).
- Some healthcare providers suggest that pregnant people interrupt their treatment during the first 3 months of pregnancy for the following reasons:
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- The risk of missing doses due to nausea and vomiting during early pregnancy, giving HIV a chance to develop resistance.
- The risk of birth defects, which is highest during the first 3 months. There is almost no evidence of this, except with efavirenz (Sustiva).
- ART might increase the risk of premature or low birth weight babies.
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If you have HIV and you are pregnant, or if you want to become pregnant, talk with your healthcare provider about your options for taking care of yourself and reducing the risk of HIV infection or birth defects for your child.
THE BOTTOM LINE
People with HIV who become pregnant need to think about their own health and the health of their child.
The risk of transmitting HIV to a newborn is very low when the pregnant person takes antiretroviral therapy (ART) during pregnancy, labor, delivery, and breastfeeding. Short-course treatments increase the risk of resistance to antiretroviral medications (ARVs). This can reduce the success of future treatment for both the parent and child.
If a person is pregnant or planning to get pregnant, they should get tested for HIV as soon as possible. If they have HIV, the sooner they start treatment the better — for their health and their baby’s health and to prevent transmitting HIV to their sex partner(s). If they don’t have HIV but their partner does, medicine to prevent getting HIV, called pre-exposure prophylaxis (PrEP), can be taken. Read more about HIV in mixed status relationships.
There is some risk of birth defects caused by any drug during the first 3 months of pregnancy. If a pregnant person chooses to stop taking some ARVs during pregnancy, their HIV could get worse. Any person with HIV who is thinking about getting pregnant should carefully discuss treatment options with their healthcare provider.
MORE INFORMATION
CDC: HIV among pregnant women, infants, and children
Avert: Women and Girls, HIV and AIDS
American Academy of Pediatrics: Preventing Mother-to-Baby HIV Transmission
WHO: Consolidated guideline on sexual and reproductive health and rights of women living with HIV
Reviewed July 2024
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