European Journal of Cardiovascular Medicine

Human Immunodeficiency Virus or HIV is a retrovirus that targets the immune system, specifically the CD4 cells. By altering the immune system and the CD4 cell count, HIV renders the infected individual highly vulnerable to life-threatening opportunistic infections and certain types of cancers. If left untreated, HIV can progress to acquired immunodeficiency syndrome or AIDS, which represents the advanced stage of HIV infection.

The term “vertical transmission” refers to the spread of infection from mother to child, which can occur during pregnancy (in utero), childbirth (peri-natal), or postpartum through breastfeeding. WHO revised its recommendations to initiate Highly Active Antiretroviral Therapy (HAART) for all HIV-infected pregnant and breastfeeding women in 2013 ⁽¹⁾. The global standard of care for pregnant women living with HIV is to receive antiretroviral therapy (ART). Today, in high-income settings, the risk of vertical transmission of HIV with optimal use of ART in pregnancy approaches zero ⁽²⁾. 

Mother-to-child transmission is linked to viral load. As such, antepartum antiretroviral therapy (ART) should be offered to all pregnant women infected with HIV to reduce the risk of perinatal transmission to below 2% ⁽³⁾.

By 2025, 95% of all people living with HIV should have a diagnosis, 95% of whom should be taking lifesaving antiretroviral treatment, and 95% of people living with HIV on treatment should achieve a suppressed viral load for the benefit of the person’s health and for reducing onward HIV transmission. In 2023, these percentages were 86%, 89%, and 93%, respectively. WHO, the Global Fund, and UNAIDS all have global HIV strategies that are aligned with the SDG target 3.3 of ending the HIV epidemic by 2030 ⁽⁴⁾.

The data used in this study were retrospectively collected from the department of Obstetrics & Gynaecology at Govt Medical College and Associated Hospital, Kathua (J&K). The study was done for a period of five years from 2019 to 2024. The HIV-infected women who were included in this study comprised those diagnosed as infected on routine antenatal screening, as well as women who were known cases of HIV on ART. Approval from the Institute’s Ethical Committee was obtained to use this data.

This study included 31 patients. After confirmation of diagnosis, all women were linked to the ART centre and started on treatment.

After obtaining informed written consent, a detailed history was taken from the patient, i.e., age, parity, occupation, educational qualification, last menstrual period, obstetrical history, family history, whether on ART or not, drug allergy or toxicity. After a detailed history, general physical examination, and systemic and obstetrical examination were done.

Investigations such as complete blood count, liver function test, kidney function test, blood grouping, blood sugar estimation, HIV, HBsAg, HCV Ab, VDRL, and CD4 count were done. Both the maternal and neonatal health and well-being were recorded every day until the day of discharge

There was a total of 21688 deliveries during the study period, and out of these, 31 pregnant women were HIV infected. This gives the incidence of HIV in this study to be 0.14%. The mean age of patients in the study was 25.06 years (SD±3.27 years), and the median age was 25 years within the range of 19 to 30 years. As shown in Table 1, six patients (19.4%) were <20 years, 11 patients (35.5%) were 21-25 years, and 14 patients (45.1%) were 26-30 years.  13 patients (41.9%) were already diagnosed cases of HIV and were on ART. However,18 patients (58.1%) were new cases diagnosed for the first time in the index pregnancy. In the study, 21 patients (67.7%) had an education level of primary school,6 patients (19.4%) had secondary school education,1 patient (3.2%) had a college degree, and 3 patients (9.7%) were illiterate, as depicted in Table 1. Positive seroprevalence in husbands was seen in 23 patients (74.2%), and negative serology was seen in 8 patients (25.8%).

Table 1: Basic demographic details of the patients.

In Table 2, 15 patients (48.4%) were primigravida, 12 patients (38.7%) were gravida 2, and only 4 patients (12.9%) were gravida 3.  Out of 18 patients diagnosed in pregnancy, 6 patients (19.4%) were detected in the first trimester of pregnancy, 3 patients (9.7%) were detected in the second trimester of pregnancy, and 9 patients (29%) were detected in the third trimester.  Out of 13 patients who were already on ART, 6 patients (19.4%) were diagnosed <2 years before pregnancy, while 7 patients (22.6%) were diagnosed >2 years before pregnancy.

As shown in Table 2, about 17 patients (54.8%) were delivered by LSCS and 14 patients (45.2%) were delivered by NVD. CD4 cell counts analysed in the patients revealed that the highest no. of patients (38.7%) had cell counts between 451-650 cells/μL   . However, cell counts in range of 651-850    cells/μL were seen only in 19.4% of patients.   

Table 2: Table depicting maternal variables and outcomes of patients.

In Table 3, out of 31 patients, only 1 patient (3.2%) delivered <37 weeks,27 patients (87.1%) delivered between 37-40 weeks, and 3 patients (9.7%) delivered > 40 weeks.  The mean birth weight of babies born to HIV patients in this study was 2.7 kg. 8 babies (25.8%) were born with a weight<2.5 kg, 18 babies (58%) had a birth weight 2.5- 3.5 kg and 5 babies (16.2%) had birth weight > 3.5 kg. Two neonatal deaths were seen in this study, with a rate of 6.8%. One baby died due to dehydration following diarrhoea, and the second neonate died due to complicated chickenpox. One maternal death was recorded in this study. The patient was diagnosed with HIV in labor and was not taking ART properly post-delivery, with non-compliance. Out of 31 babies, all babies were followed up with HIV PCR and were all negative at 6 weeks. Hence, there was no vertical transmission in our study. 

Table 3:Table depicting the neonatal outcome of the patients.

Vertical transmission of HIV infection from mother to child is the primary means of infection in infants. In our study, the incidence of HIV infection was 0.14%. The rate is similar to the national HIV prevalence of 0.20% (in 2022-23) ^(19,5). A study done by Malik A et al ⁽⁶⁾ in Aligarh revealed the prevalence of 0.40% in their study. However, there is quite a variation in the global prevalence of HIV infection.

The mean age of patients in the study was 25 years, with majority of patients in age group of 26-30 years (45.1%). In study by Matthew Anyanwu et al ⁽⁷⁾ , 53% of the HIV patients were in the age of 26-35 years. Similar age prevalence was observed in studies by Ezechi OC et al ⁽⁸⁾ and Onah HE et al ⁽⁹⁾. 

25.8% of patients had negative HIV serology in their spouse in this study. Dadhwal et al ⁽¹⁰⁾ observed serodiscordancy in 15.1% of cases. Also, Prameela et al ⁽¹¹⁾ found a non-reactive status of husband in 11.7% of subjects.

Dadhwal et al ⁽¹⁰⁾ reported that out of a total of 212 HIV patients, 94.35% of patients were detected during index pregnancy. In comparison, 58.1% of patients were detected in the index pregnancy in our study.  Zigmee Dorjee Tamang et al ⁽¹²⁾ reported that 38.2% of cases were without ART at the time of delivery. 

The majority of the patients were primigravida (48.4%), followed by gravida 2 (38.7%), and least by gravida 3 (12.9%) in the present study. Prameela et al ⁽¹¹⁾ and Ezechi OC et al ⁽⁸⁾ also found an increased rate of primigravida in their studies.  Zigmee Dorjee Tamang et al ⁽¹²⁾ found most cases to be para1, with only 29.4% of cases as primigravida. Since HIV infection is more common in sexually active people, age of marriage and early age at first pregnancy affect the demographic variation globally, and as per social and cultural norms of the area studied. 

The rate of LSCS and NVD was 55% and 45%, respectively, in this comparable study. LSCS was done after assessing both obstetric factors and taking into consideration patient’s decision after detailed counselling. Ezechi OC et al ⁽⁸⁾ reported a LSCS rate of 46.9%, while a 55% rate of LSCS was documented by Azria et al ⁽¹³⁾.  Prameela et al ⁽¹¹⁾ had 73.7% of cases delivered vaginally and Gautam S et al ⁽¹⁴⁾ had NVD in 70.8% cases. 

HIV infection in pregnancy has been associated with low birth weight and preterm deliveries.  Our study showed a quite low rate of preterm delivery at 3.2%. In the study by Prameela et al ⁽¹¹⁾ in Mysore, the preterm delivery rate was 1.8%, and the study by Malik et al ⁽⁶⁾ done in U.P. reported a rate of 4%, which was quite similar to our results. However, in comparison, Dwivedi S et al ⁽¹⁵⁾ reported a high preterm delivery rate at 25% and Ezechi et al ⁽⁸⁾ at 13.1%. 

Our study showed low birth weight (<2.5 kg) in 25.8% of babies. Similarly,32.5% of cases were low birth weight (LBW) in the study by Dwivedi S et al ⁽¹⁵⁾.  Prameela et al ⁽¹¹⁾ reported that 49.2% of babies delivered were of low birth weight in their study. On the other hand, Zigmee Dorjee Tamang et al ⁽¹²⁾ observed low birth weight in only 14.7% of cases. Merwe V et al ⁽¹⁶⁾ and Kim et al ⁽¹⁷⁾ have concluded in their study that women with CD4 cell counts < 350 cells/μL have higher chances of LBW. 

Akinbami et al (¹⁸⁾ studied the factors influencing the CD4 count in 143 pregnant women with HIV and found that the mean CD4 count was 413.87±212.09 cells/μL, with a range of 40 to 1,252 cells/μL. The study also found that there was no relation between CD4 count with gestational age or maternal age.

In our study, we had 2 neonatal deaths accounting for about 6.8% of the cases. Prameela et al ⁽¹¹⁾ reported stillbirth in 3.9% of cases, and Gautam S et al ⁽¹⁴⁾ in 3.1% cases. However, Dwivedi S et al ⁽¹⁵⁾   observed a high rate of neonatal deaths in 17.5% of subjects. Similarly high rate was also seen by Ezechi OC et al ⁽⁸⁾ and Ellis et al ⁽¹⁹⁾.

Offering routine ANC services and high-risk pregnancy care for women with HIV is crucial for management. Rapid ART initiation and adherence to achieve viral suppression to eliminate vertical transmission, birth planning, and post-delivery breast-feeding counselling remain the cornerstone in the care of pregnant HIV mothers.

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