Preconceptional Counseling and Care for HIV-infected Women of Childbearing Age

Many women infected with HIV (nearly 60% in some centers) enter pregnancy with a known diagnosis, and nearly half of these women enter the 1^st trimester of pregnancy receiving treatment with single or multiagent antiretroviral therapy. Additionally, as many as forty percent of women who have initiated antiretroviral therapy pre-pregnancy, may require adjustment of their therapeutic regimen during their pregnancy course (83).

The American College of Obstetrics and Gynecology advocates extending to all women of childbearing age the opportunity to receive preconceptional counseling as a component of routine primary medical care. It is recognized that unintended pregnancy may occur in > 40% of pregnancies, and that the diagnosis of pregnancy most frequently occurs late in the 1^st trimester when organogenesis is nearly completed. The purpose of preconceptional care is to identify risk factors for adverse maternal or fetal outcome (e.g., age, diabetes, hypertension, etc.), provide education and counseling targeted to the patient's individual needs, and treat or stabilize medical conditions prior to conception in order to optimize maternal and fetal outcomes (84).

For women with HIV infection, preconceptional care must also focus on maternal infection status, viral load, immune status, and therapeutic regimen, as well as education regarding perinatal transmission risks and prevention strategies, expectations for the child's future, and --where desired-- effective contraception until the optimal maternal health status for pregnancy is achieved.

Recommended components of preconceptional counseling for HIV-infected women include:

• Selection of effective and appropriate contraceptive methods to reduce the likelihood of unintended pregnancy.
• Education and counseling about perinatal transmission risks and strategies to reduce those risks, and potential effects of HIV or treatment on pregnancy course and outcomes.
• Initiation or modification of antiretroviral therapy prior to conception in order to:
  • Avoid agents with potential reproductive toxicity for the developing fetus (e.g. efaverenz, hydroxyurea). *See Safety and Toxicity of Individual Antiretroviral Drugs in Pregnancy
  • Choose agents effective in reducing the risk of perinatal HIV transmission
  • Attain a stable, maximally suppressed maternal viral load
  • Evaluate and control for therapy associated side-effects which may adversely impact maternal-fetal health outcomes (e.g. hyperglycemia, anemia, hepatic toxicity)
• Evaluation for opportunistic infections and initiate appropriate prophylaxis, and administration of medical immunizations (e.g. influenza, pneumovax, or hepatitis B) as indicated.
• Optimization of maternal nutritional status.
• Institution of the standard recommendations for preconception evaluation and management (e.g. assessment of reproductive and familial genetic history, screening for infectious diseases/STD's and initiation of folic acid supplementation).
• Screening for maternal psychological and substance abuse disorders.
• Planning for perinatal consultation if desired or indicated.

HIV-infected women of childbearing potential engage primary health care services in a variety of clinical settings, e.g. family planning, family medicine, internal medicine, obstetrics/gynecology. It is imperative that primary health care providers consider the fundamental principles of preconceptional counseling an integral component of comprehensive primary health care for improving maternal-child health outcomes.

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