understanding and supporting hiv - infected women 's awareness of their own status and their options regarding pregnancy requires an understanding of their backgrounds and the potential barriers to care and safe pregnancy . studies have shown that both social pressures and concerns for vertical transmission play a large role in hiv - infected women 's choices about pregnancy [ 13 ] . information from around the world supports the fact that since the introduction of reliable methods for the prevention of mother - to - child transmission ( pmtct ) , fewer hiv - infected women are choosing terminations and many are choosing to become pregnant , even to have multiple pregnancies , after their hiv diagnosis [ 2 , 46 ] . options for safe conception , especially in serodiscordant couples , now include artificial insemination and  sperm washing  . these methods , even where they are available , however , remain relatively unknown and infrequently recommended by many healthcare providers , even in developed countries   and may be prohibitively expensive or inaccessible for some couples . in addition to these planned pregnancies , a large number of pregnancies remain unplanned [ 9 , 10 ] . women who live in developing countries , where safer methods of conception are relatively unknown or unavailable , are nevertheless choosing to become pregnant after their hiv diagnosis . a survey of 459 hiv - infected men and women in cape town , south africa found that two - thirds of women , who became pregnant after commencing highly active antiretroviral therapy ( haart ) , had intended to become pregnant . furthermore , 50% of hiv - infected men and women were open to the possibility of conceiving children after their hiv diagnosis ; being on haart had no significant impact on whether or not men intended to pursue pregnancy , but did make women more likely to consider pregnancy . it is unclear what impact moving from a developing to a developed country may have on childbearing intentions , but it is possible that this change in their socioeconomic environment and perceived options for care and support may play a role in women 's childbearing intentions . women in the usa , who are hiv - infected and foreign - born , may have additional issues to consider during pregnancy . they are more likely to have language , educational , and economic barriers to care and to exercising their options , but may be even more likely to choose to keep a pregnancy because of cultural emphasis on childbearing and negative views of termination . women who are born in areas of the world where fertility rates are between 5 and 7 children per woman , especially africa and parts of south and southeast asia , may experience particular spousal and familial pressure to become pregnant , even if they have disclosed their hiv status [ 13 , 14 ] . a cross - sectional study done in canada revealed that 69% of 490 hiv - infected women desired future pregnancy and african ethnicity was significantly correlated with intention to become pregnant . although foreign - born persons with hiv living in the us appear to be a growing proportion of the hiv - infected population , current national sociodemographic data do not accurately reflect this demographic , as they are generally listed under their ethnicity without distinction about place of birth [ 17 , 18 ] . thus , persons who are originally from sub - saharan africa , where the highest number of hiv - infected individuals exists , are listed as black / african - american in data used for determining funding and resource allocation . african - born persons often live within their own communities and may not be reached by programs that target african - americans [ 19 , 20 ] . in washington state , for example , the hiv diagnosis rate among blacks in the state is five times higher than the rate among whites , and 40% of all hiv diagnoses among blacks in washington state have been among foreign - born persons . similar data collected from five different states and high - prevalence areas show that across all areas , up to 41% of diagnoses in women and up to 50% of diagnoses in blacks occurred among african - born individuals . additionally , we should not presume all foreign - born persons were necessarily infected with hiv prior to arrival in the usa . data suggest that in some parts of the country , especially those parts with high numbers of hispanic immigrants , patients are more likely to have been infected after arrival , which may indicate increased vulnerability among foreign - born persons . unfortunately , the complex social issues that contribute to women becoming hiv - infected often present barriers to adherence with prescribed medication regimens and prenatal followup , as well as with ensuring adequate testing and followup of the hiv - exposed infant . studies have shown that 45% of mothers of hiv - infected infants had missed opportunities for perinatal hiv prevention , indicating that although appropriate protocols are in place , additional factors contribute to transmission . rhode island , the smallest state in the united states , had an hiv prevalence of 209 per 100,000 population by the end of 2009 . among the general population , 81% of persons identified themselves as white , 12% identified themselves as hispanic , and 6% identified themselves as black or african - american . amongst the 3,080 hiv - infected persons who have been diagnosed in rhode island since 1982 , 54% identified themselves as white , thus , 45% of hiv cases in the state have occurred in the 18% of the population identified as hispanic or african - american . no data is available on the percentage of hiv - infected persons in the state who are immigrants or foreign - born . following the lead of several other states , rhode island adopted a law mandating testing of pregnant women during pregnancy or their children immediately after birth . this was done in order to ensure that children receive medication to prevent mother - to - child transmission in a timely manner , and that women are appropriately identified if they need hiv - related services . this law has already led to increased rates of hiv testing during pregnancy , from 52.8% in 2005 - 2006 to greater than 95% after the law changed in 2007 , but it is unclear if it has led to an increased number of hiv diagnoses . we seek to describe the experiences of hiv - infected pregnant women and their children followed at a large hiv clinic in rhode island . the immunology center at the miriam hospital in providence , rhode island , is an urban hiv clinic with 1400 active patients . in 2009 , 25% of hiv patients followed at the miriam immunology center were uninsured or covered only by the hospital 's free care program and 32% were foreign - born . all hiv - infected patients in rhode island have access to antiretrovirals either through health insurance or through the ryan white program , provided they have been registered as rhode island residents . the immunology center has been caring for hiv - infected women before , during , and after their pregnancies since its establishment in 1986 . the hasbro children 's hospital pediatric infectious diseases ii clinic in providence generally sees all the hiv - exposed infants delivered to these women . these clinics follow dhhs guidelines for perinatal prevention of mother - to - child transmission and follow - up testing for hiv - exposed infants . the two clinics are the largest providers for hiv - infected women and their children in rhode island . this study aims to characterize and understand the recent trends in the hiv - infected pregnant population and hiv - exposed children in rhode island . social and clinical data from hiv - infected pregnant women collected regularly by the immunology center staff for care and research purposes were analyzed to identify and characterize trends in demographics , viral control , terminations , miscarriages , timing of diagnosis , and adherence to followup . data on the adherence with follow - up appointments and testing for the hiv - exposed infants were obtained from paper and online charts from both hasbro children 's hospital 's primary care clinics and pediatric infectious diseases ii clinic . data were analyzed for means of continuous variables ( viral load , cd4 counts , etc . ) , percentages of descriptive variables ( us - born versus foreign - born , outcome of pregnancy , mode of delivery , etc . ) and significant correlations between variables using statistical package for the social sciences ( spss ) version 17.0 ( chicago , il , usa ) . this project was reviewed and approved by the miriam and rhode island hospital ( including hasbro children 's hospital ) institutional review boards . between january 2004 and december 2009 , 321 hiv - infected women between 18 and 45 years old were seen at the immunology center . seventy - six hiv - infected women became pregnant , with a total of 95 pregnancies . sixteen of the women ( 21% ) were diagnosed with hiv during their pregnancy while 79% knew their hiv status prior to becoming pregnant . sixteen of the women chose to terminate their pregnancies ( 17% of total pregnancies in this cohort ) ; two of these women were diagnosed during this pregnancy and both were us - born . the trends by year and breakdown of specifics between foreign - born and us - born women are presented in tables 1 and 2 . the breakdown by continent / region of origin of the women is shown in figure 1 . among the thirty women from africa , sixteen were from liberia , three from burundi , two from guinea , kenya , and senegal and one each from angola , ghana , ivory coast , mali , and sierra leone . among the seven women from latin america , there were three women from the dominican republic , two from guatemala , and one each from venezuela and argentina . while the number of hiv - infected women becoming pregnant increased only slightly over the years of the study , the proportion of women that were foreign - born rose from 41% between 2004 and 2005 to 57.5% between 2006 and 2009 . there was no significant difference between us - born and foreign - born women in terms of their likelihood of being diagnosed with hiv during pregnancy , choosing termination or choosing to have a second or third pregnancy . us - born women were more likely to have fewer than two visits during the pregnancy or department of children , youth & families ( dcyf ) involvement with their children . of the 72 women who had pregnancies that did not end in miscarriage or termination , mode of delivery was known for 49 . seventeen ( 35% ) delivered vaginally , twenty - five ( 51% ) underwent elective caesarian section , and seven ( 14% ) required emergency caesarian sections . sixty - three women had cd4 counts and plasma viral loads ( pvl ) measured during pregnancy . fifteen ( 24% ) women had detectable plasma viral loads on their last test prior to delivery , and all but one of them underwent caesarian section ( information on the mode of delivery for one woman is missing ) . thirty women had both information on viral load prior to delivery and mode of delivery available . of these , sixteen ( 53% ) had undetectable viral loads and six ( 20% ) had viral loads less than 1000 . only eight of the women who underwent caesarian section had viral loads above 1000 , and five of these women had either repeat caesarian section or underwent the procedure due to emergency indications unrelated to viral load . nine women were considered to have aids at the time of delivery , based on a last cd4 count prior to delivery less than 200 cells/l . all of them were born to mothers with psychological and/or social issues that had a significant impact on their ability to adhere to appropriate followup and preventive measures . one mother was a young perinatally - infected teenager at the time of her first pregnancy . she received care in both rhode island and massachusetts , but was unable to adhere adequately to care and treatment at either site . the second child was born to a woman from west africa who had been diagnosed with hiv three years before the pregnancy upon immigration to the usa . she did not adhere to her medication regimen during pregnancy and dcyf was involved soon after the child was born . the third child was born to a us - born woman who had been diagnosed with hiv during a prior pregnancy . she had delivered an hiv - negative child at that time , who was subsequently removed from her custody . she had been out of care and off hiv medications for many months when she presented to the emergency department with complaint of abdominal pain . as has been seen around the world , our data suggest that hiv - infected women are increasingly choosing to become pregnant and to keep pregnancies that may have been unplanned . this is consistent with other studies that have shown that fewer hiv - infected women are choosing termination now that the efficacy of methods for prevention of mother - to - child transmission ( ptmct ) are well - known and well - validated [ 2 , 46 ] . additionally , a growing number of women are having second and even third pregnancies after their hiv diagnosis . this trend likely reflects both the strength of the desire to have children and the perception of hiv as a controllable illness that does not preclude the creation of a family . our data indicate that rhode island 's relatively new opt - out law for hiv testing among pregnant women , and the resultant increased rate of testing , has not resulted in a higher number of hiv diagnoses ; however , its effects may not yet be reflected in our data as this law was only passed in july 2007 . in addition , rhode island is known to have a low prevalence of hiv , and the increased testing may not result in a significantly higher number of diagnoses . furthermore , laws to encourage testing during physician encounters outside of pregnancy may negate any potential increase in diagnoses during pregnancy . while the number of hiv - infected women becoming pregnant in our clinic has increased only slightly , the proportion that are foreign - born has been steadily rising , from an average of 41% between 2004 and 2005 to 57.5% between 2006 and 2009 . now that the obama administration has lifted the travel ban on hiv - infected persons entering the usa ( as of january 2010 ) , this trend may increase as the number of foreign - born hiv - infected women entering the usa continues to grow . however , the numbers seen in rhode island may also decline , as the freedom to enter any state may lead to some choosing to settle elsewhere . previously , rhode island was one of the few states that was allowed to accept hiv - infected individuals emigrating to the usa under the travel ban . available virologic control data for our clinic indicate that most women have favorable cd4 counts and undetectable viral loads prior to delivery . all the women who had detectable viral loads underwent caesarian section , which is associated with a lower risk of viral transmission for women with hiv plasma viral loads > 1000 copies / ml near the time of delivery . the three cases of perinatal transmission are not necessarily representative of the overall outcomes of pregnancy among hiv - infected women . however , they are indicative of the fact that while pmtct protocols are now able to reduce the risk of hiv transmission to less than 2% , they can not do so if patients are unable to adhere to them . in our small state , during the time period of this study , there was essentially one clinic and one hiv - trained obstetrician / gynecologist who saw the women during pregnancy , one hospital where they delivered , and one pediatric infectious disease clinic where the children were followed . each of these settings has robust medical , social work and support staff that fully supported each hiv - infected pregnant woman in order to optimize her care and adherence to therapy . these data highlight the fact that despite this level of coordination and support , nonadherence does occur and perinatal hiv transmission may ensue . further study to identify  at - risk  women may be warranted , in order to target further medical and psychosocial interventions in order to improve outcomes and decrease maternal - to - child transmission . these study results support prior trends noted from us and international studies that hiv - infected women are increasingly choosing to become pregnant or to continue a pregnancy . studies are needed to determine the knowledge and attitudes of foreign - born and us - born hiv - infected women regarding childbearing and prevention of maternal - to - child transmission . additionally , comparative studies among women in high hiv - prevalence regions and women who have moved from those regions to resource - rich settings would help healthcare providers and systems to anticipate and meet the needs of a growing population of hiv - infected women who may have different understandings of , and barriers to , exercising options for safe pregnancy . hiv - infected women in rhode island are more likely to be foreign - born , to know their hiv status prior to pregnancy , and to actively choose to become pregnant or to continue pregnancies , whether planned or unplanned . despite increasing rates of hiv testing in pregnancy , an increased number of hiv diagnoses has not been seen . when hiv - infected pregnant women engage with appropriate prenatal care , virologic control is generally excellent and outcomes are good for mother and child . however , risks for hiv transmission beyond lack of awareness of hiv status are emerging , especially among women with psychological or social issues , which may preclude adherence to pmtct protocols and lead to unnecessary infection of infants . foreign - born women are a growing percentage of the population of hiv - infected women becoming pregnant in the usa and may benefit from further study and targeted interventions . identifying  at - risk women during their pregnancy and providing extra social , psychological , and other support to them may be an important additional focus for pmtct programs in order to continue to prevent perinatal hiv transmission .
meeting the needs of hiv - infected pregnant women requires understanding their backgrounds and potential barriers to care and safe pregnancy . 
 foreign - born women are more likely to have language , educational , and economic barriers to care , but may be even more likely to choose to keep a pregnancy . 
 data from hiv - infected pregnant women and their children in rhode island were analyzed to identify trends in demographics , viral control , terminations , miscarriages , timing of diagnosis , and adherence to followup . between january 2004 and december 2009 , 
 76 hiv - infected women became pregnant , with a total of 95 pregnancies . 
 seventy - nine percent of the women knew their hiv status prior to becoming pregnant . 
 fifty - four percent of the women were foreign - born and 38 percent of the 16 women who chose to terminate their pregnancies were foreign - born . 
 while the number of hiv - infected women becoming pregnant has increased only slightly , the proportion that are foreign - born has been rising , from 41 percent between 2004 and 2005 to 57.5 percent between 2006 and 2009 . 
 a growing number of women are having multiple pregnancies after their hiv diagnosis , due to the strength of their desire for childbearing and the perception that hiv is a controllable illness that does not preclude the creation of a family .