The Uphill Battle

For many HIV-positive women, preventing transmission of the virus to their infants isn't as simple as following a step-by-step plan. For them, HIV exists within a cross section of any number of life stressors, including substance abuse, mental illness, coinfection with hepatitis C, homelessness, poverty, and domestic abuse. These women's pregnancies are often far from planned, and their ability to prepare for a healthy birth may be seriously hampered by a life that seems out of their control. Situations like these are where medical centers like St. Vincent's Comprehensive HIV Center in New York City and other social-service agencies around the country work to provide a helping hand. 'The majority of women'once they become pregnant'do everything they can to prevent transmitting HIV to their baby,' says Antonio Urbina, MD, who is medical director of HIV education and training at St. Vincent's as well as a contributing editor to HIV Plus and a member of the President's Advisory Council on HIV/AIDS. 'It's really those who have mental illness or substance abuse where you really get into difficulties, because then addiction kind of overrules that maternal instinct.' But Urbina, who says St. Vincent's treats 10 to 20 HIV pregnancies a year, most of them unplanned, points out that he hasn't seen a seropositive birth since 2004. That's because of the team approach used to help these women. Urbina arranges monthly interdisciplinary meetings among the hospital staff to discuss all the current HIV cases. There, the social workers, obstetricians, and nurses discuss with him how to work in tandem to help pregnant women who have trouble helping themselves. 'The goal of managing an HIV-positive woman is really to treat her virus effectively,' Urbina says, 'and you do that by providing competent HIV care, but then also by managing psychosocial aspects that may prevent them from adhering to their regimens.' Evelyn Harrington, a social worker at St. Vincent's, is known as Mama or sometimes Grandma among the women she helps guide through pregnancy, providing them with a sense of family when outside sources of community may be lacking. 'The first thing anyone wants is to be accepted for who they are,' she says of her leave-judgment-at-the-door approach to care. During a pregnancy, she helps the women establish goals and sets them up with parenting classes. 'I've seen women who've been substance abusers'who've been incarcerated because of drug use and sale'completely turn their lives around,' Harrington says of the life-changing effects of pregnancy. Sometimes, 'they're in college, and they're looking forward to graduation.' Harrington even accompanies the women into delivery for support whenever family isn't available. Russelle Miller-Hill, who is herself an HIV-positive mother of a teenage boy, works as a reproductive health worker at the Albert Einstein College of Medicine in New York and is part of a team that provides a wide array of services to pregnant HIVers. One element of her program that helps women keep their infants healthy is there is no discharge from the program after delivery. In fact, many mothers keep coming back, she says, well after they've given birth. In addition to support groups, individual counseling, and accompaniment to prenatal visits, Miller-Hill's team members help out with baby clothes, furniture, and disposable diapers, and they throw a yearly shower for all the moms. 'We try to make the pregnancy a great event so that it doesn't become a hindrance,' she says. 'It actually is a happy time in their life. For some women, they've never experienced the joy of a baby shower.'