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Division of Infectious Diseases
Department of Medicine
Harvard Medical School
Director, HIV in Women & Youth
Division of Infectious Diseases
Department of Medicine
Brigham & Women's Hospital
Sigal Yawetz, MD, has disclosed that she has received consulting fees from Gilead Sciences.
The novel coronavirus disease (COVID-19), caused by SARS-CoV-2, is now widespread throughout the world and continues to spread rapidly. As of this writing, 71.6 million people have been infected with SARS-CoV-2 worldwide and 1.6 million people have died from COVID-19. One group of individuals that may be of particular concern during this pandemic is women with HIV who are pregnant, since both HIV and pregnancy could potentially result in immunologic and physiologic changes that increase an individual’s susceptibility to viral respiratory infections, possibly including COVID-19. In addition, COVID-19 could have adverse effects on pregnancy in women with HIV. Here, I discuss what we know, and much that we do not know, about the impact of COVID-19 on pregnancy in women with HIV and what we must consider going forward.
Impact of COVID-19 on Pregnancy for Women With HIV
Pregnant women with HIV not only need to consider themselves if they are infected with SARS-CoV-2, but are also confronted with questions about how COVID-19 will affect their pregnancy course and developing fetus. There has been increasing evidence that pregnant women with COVID-19 may be at increased risk for more severe illness and hospitalization. Indeed, in an updated report that included 409,462 women from the United States with symptomatic COVID-19, after adjusting for age, race/ethnicity, and underlying medical conditions, pregnant women were significantly more likely than nonpregnant women to be admitted to the ICU, receive invasive ventilation, receive extracorporeal membrane oxygenation, and die. Pregnant women hospitalized with COVID-19 also have an increased risk of preterm birth and cesarean delivery, mostly due to maternal illness. Fortunately, in utero transmission to the fetus seems rare, although several case reports have documented such cases. At this stage in the pandemic, the impact of maternal SARS-CoV-2 infection during earlier stages of pregnancy is not yet fully known and data are limited to a few case reports of pregnancy losses and intrauterine fetal death.
Women infected with SARS-CoV-2 around the time of labor also face the challenge of preventing transmission to their infant postpartum. Although there is currently no evidence that breastmilk transmits SARS-CoV-2, there is a risk that the act of breastfeeding, due to the proximity of mother to child, could result in SARS-CoV-2 transmission. In the United States, the CDC and the American Academy of Pediatrics recommend that women with HIV formula-feed to prevent HIV transmission, and thus, a healthy caregiver could provide the formula and reduce the risk of SARS-CoV-2 transmission. In locales where breastfeeding is recommended for women with HIV, however, a combination of hand hygiene and a mask, and, if possible, pumping and feeding by a healthy caregiver, is recommended to provide protection from respiratory transmission of SARS-CoV-2 while mothers are still infectious.
Antiretroviral Therapy Considerations for Pregnant Women Infected With HIV During the COVID-19 Pandemic
One question that has arisen during the COVID-19 pandemic is whether HIV antiretrovirals could be effective against COVID-19 since several antiretrovirals used to treat HIV demonstrated in vitro activity against SARS-CoV-2. One study from Spain seeking to begin to answer this question examined the incidence and severity of COVID-19 in patients with HIV by the nucleos(t)ide reverse transcriptase inhibitors included in their HIV regimens and showed that patients receiving tenofovir disoproxil fumarate/emtricitabine had a lower risk of contracting COVID-19 and a lower risk of hospitalization due to COVID-19 than those receiving other therapies. Although this finding is certainly intriguing, it is currently premature to draw any conclusions regarding a direct impact of antiretroviral choice on SARS-CoV-2 susceptibility and/or risk of developing severe disease. Therefore, with the goal of keeping pregnant women with HIV as healthy as possible during this pandemic, uninterrupted ART with a regimen with established safety and efficacy in pregnancy remains the strongest recommendation.
Currently, the information about pregnancy and maternal outcomes in individuals who have HIV and COVID-19 are limited. However, data are accumulating that the risk for severe illness, morbidity, or mortality with COVID-19 may be greater among pregnant individuals than among the general population. Therefore, during the COVID-19 pandemic, pregnant women with HIV should practice caution and follow standard COVID-19 prevention recommendations (such as distancing, masking, hand hygiene, avoiding large gatherings, especially those that are indoors) when there is community transmission. Working pregnant women with HIV should follow general COVID-19 guidance for pregnancy in their locale, wear protective equipment, and, if possible, be assigned to jobs with a lower risk of exposure. Of most importance, HIV treatment with proven efficacy and safety in pregnancy should be continued uninterrupted to both prevent mother-to-child transmission of HIV and maximize maternal health during the COVID-19 pandemic.
How has COVID-19 affected the way you manage your pregnant patients with HIV? Please join the conversation and share your experiences in the comments box.