FACULTY OF NURSING

UNIVERSITY OF IBADAN

HIV/AIDS IN PREGNANCY

BY

GROUP 8

COURSE CODE: NSG 414

COURSE TITLE: MIDWIFERY III

LECTURER-IN-CHARGE: MRS OJO

JULY, 2024

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GROUP MEMBERS

S/N NAMES MATRIC NUMBER

1. OBEMBE 220945
OLUWATOBILOBA
ANUOLUWAPO

2. OGUNYEMI DEBORAH 220948

FUNMILAYO

3. OBISESAN ADEDAYO 220947

ESTHER

4. ELIJAH DAVID 220934

UGBEDEOJO

5. OBIMEH 220946
OLUWATUMININU
ENIOLA

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TABLE OF CONTENTS

I. Introduction

II. Transmission of HIV from mother to child

III. Effects of HIV on pregnancy

IV. Diagnosis and testing

V. Management of HIV in pregnancy

VI. Prevention of mother-to-child transmission (PMTCT)

VII. Complications and challenges

VIII. Postpartum care and follow-up

IX. Conclusion

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 I. INTRODUCTION

A. DEFINITION OF HIV/AIDS

HIV (Human Immunodeficiency Virus) is a virus that attacks the body's immune system,
specifically the CD4 cells (T cells), which are crucial for immune defense. If left untreated, HIV
reduces the number of these cells, making the body more vulnerable to infections and certain
cancers. Centers for Disease Control and Prevention. (2020).

AIDS ( Acquired Immune Deficiency Syndrome) is a condition that represents the advanced
stage of HIV infection, marked by a critically low number of CD4 cells and the occurrence of
specific diseases associated with severe immunodeficiency. World Health Organization. (2021).

Over time, HIV can lead to AIDS (acquired immunodeficiency syndrome), the final stage of HIV
infection, characterized by a severely compromised immune system and the occurrence of
opportunistic infections or cancers.

B. IMPORTANCE OF MANAGING HIV IN PREGNANCY

Managing HIV in pregnancy is crucial to ensure the health and well-being of both the mother
and the baby. Key reasons for the importance of managing HIV during pregnancy include:

1. Reducing Mother-to-Child Transmission: Effective management and antiretroviral therapy

(ART) can significantly reduce the risk of transmitting HIV from mother to child during
pregnancy, childbirth, and breastfeeding.

2. Maintaining Maternal Health: ART helps in maintaining the mother’s health by keeping the
viral load low, thereby reducing the risk of opportunistic infections and complications.

3. Preventing Premature Birth and Low Birth Weight: Proper management of HIV can
reduce the risk of adverse pregnancy outcomes such as premature birth and low birth weight.

4. Promoting Long-term Health for the Child: By preventing transmission, the child can avoid
lifelong HIV infection, promoting better long-term health and quality of life.

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II. TRANSMISSION OF HIV FROM MOTHER TO CHILD

A. VERTICAL TRANSMISSION

Vertical transmission, also known as mother-to-child transmission (MTCT), occurs when HIV is
passed from an HIV-positive mother to her child during pregnancy, childbirth, or breastfeeding.

MOST COMMON ROUTE OF HIV INFECTION IN CHILDREN.

1. During Pregnancy: HIV can cross the placental barrier and infect the fetus. This can happen
at any stage of pregnancy, but the risk is higher in the later stages.

2. During Childbirth: The process of labor and delivery exposes the infant to the mother's
blood and bodily fluids, increasing the risk of transmission.

3. Breastfeeding: HIV can be transmitted through breast milk. The risk is cumulative and
increases with the duration of breastfeeding.

B. RISK FACTORS FOR TRANSMISSION

Several factors can influence the risk of vertical transmission of HIV:

1. Viral Load: Higher maternal viral loads significantly increase the risk of transmission.

2. Maternal Health: Advanced HIV disease or low CD4 cell counts in the mother are associated
with higher transmission rates.

3. Mode of Delivery: Vaginal deliveries carry a higher risk compared to elective cesarean
sections performed before the onset of labor and rupture of membranes.

4. Duration of Rupture of Membranes: Prolonged rupture increases the risk of transmission.

5. Breastfeeding: Mixed feeding (breast milk combined with other foods) increases the risk
compared to exclusive breastfeeding.

6. Co-infections: Maternal infections such as syphilis or other sexually transmitted infections

(STIs) can increase the risk.

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C. WAYS TO REDUCE TRANSMISSION RISK

Reducing the risk of mother-to-child transmission involves a combination of antiretroviral

therapy (ART), safe delivery practices, and careful infant feeding choices:

1. Antiretroviral Therapy (ART): Administering ART to HIV-positive pregnant women

significantly reduces the viral load, decreasing the risk of transmission. ART should be started as
early as possible and continued throughout pregnancy, delivery, and breastfeeding.

2. Safe Delivery Practices: Elective cesarean delivery can reduce the risk of transmission,
especially for women with high viral loads. Proper management of labor to avoid prolonged
rupture of membranes is crucial.

3. Infant Prophylaxis: Newborns exposed to HIV should receive antiretroviral prophylaxis

immediately after birth.

4. Infant Feeding Choices: Exclusive breastfeeding for the first six months, followed by rapid
weaning, or complete avoidance of breastfeeding with the use of formula milk, can minimize
transmission risks. The choice depends on the mother's health, availability of safe alternatives,
and local guidelines.

III. EFFECTS OF HIV ON PREGNANCY

A. HIV infection in pregnant women is associated with several adverse outcomes:

1. Miscarriage: HIV-positive women have a higher risk of miscarriage, particularly in cases of

advanced disease or poor immune function.

2. Stillbirth: The risk of stillbirth is increased, often due to complications related to HIV or
concurrent infections.

3. Preterm Labor: HIV infection is a known risk factor for preterm labor and delivery, which
can lead to a range of complications for the newborn, including respiratory distress and
developmental delays.

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B. IMPACT OF HIV ON FETAL DEVELOPMENT AND GROWTH

HIV can adversely affect fetal development and growth through various mechanisms:

1. Intrauterine Growth Restriction (IUGR): HIV-infected women are at higher risk for IUGR,
leading to low birth weight and related complications.

2. Congenital Infections: Infants born to HIV-positive mothers may be at risk for other
congenital infections, which can affect growth and development.

3. Placental Insufficiency: HIV can cause placental insufficiency, reducing the nutrient and
oxygen supply to the fetus, thereby impairing growth.

4. Developmental Delays: Children born to HIV-positive mothers, especially those who acquire
HIV, may experience cognitive and developmental delays.

IV. DIAGNOSIS AND TESTING

A. HIV TESTING IN PREGNANCY

HIV testing during pregnancy is crucial for the health of both the mother and the baby. The
Centers for Disease Control and Prevention (CDC) recommend that all pregnant women get
tested for HIV at their first prenatal visit. This test is usually a routine part often included in the
standard battery of tests that women receive during their first trimester.

If the test is positive, treatment can be started early thereby reducing the risk of transmitting HIV
from mother to baby and improve maternal health outcomes. CDC also recommends repeat
testing in the third trimester for women who have a high risk of getting HIV or who live in areas
with high HIV rates. Early detection and treatment of HIV can significantly reduce the risk of
mother-to-child transmission

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B. TYPES OF HIV TESTS IN PREGNANCY

There are various types of HIV tests in pregnancy, few include;

1. Rapid Tests

A quick test that uses a finger prick blood sample or oral fluid to detect HIV antibodies. Results
are available in 1-2 minutes. It is often used for initial screening, especially in labor and delivery
settings where quick results are necessary. Though quick, may require confirmation with a more
specific test if positive, e.g. ELISA test.(CDC, 2014).

2. Enzyme-Linked Immunosorbent Assay (ELISA)

A blood test that detects HIV antibodies. It's highly sensitive but may require a follow-up test to
confirm results. it is also used for routine screening during prenatal visits.(UNAIDS, 2015).

3. Western Blot

This test is used to confirm a positive ELISA result. It detects specific proteins associated with
HIV which reduces the chance of false positives. It is more complex and time-consuming. It
should be noted that if the ELISA was positive and the Western blot is negative, the initial result
may have been a false positive.(WHO, 2016).

4. p24 Antigen Test

It detects a protein (p24) present in the HIV virus. The p24 antigen is a protein that makes up
most of the HIV viral core, or "capsid." It is one of the earliest markers of HIV infection,
appearing in the blood within a few days to weeks after exposure to the virus. This protein is
produced in large quantities when HIV is actively replicating. It's used in combination with other
tests to diagnose acute HIV infection.

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V. MANAGEMENT OF HIV IN PREGNANCY

Effective management of HIV in pregnancy is crucial to ensure the health of both the mother and
the baby. The primary goals are to maintain maternal health, prevent mother-to-child
transmission, and avoid drug resistance. Here are the key components of managing HIV in
pregnancy:

1. Early Antenatal Care: Encourage early registration for antenatal care to ensure timely HIV
testing and treatment.

2. HIV Testing: Offer routine HIV testing to all pregnant women, and retest in the third
trimester if initial test is negative.

3. Antiretroviral Therapy (ART): Initiate ART as soon as possible after diagnosis, regardless
of CD4 count or viral load. It involves a combination of at least three antiretroviral drugs from at
least two different classes. This combination is known as combination antiretroviral therapy
(cART) or highly active antiretroviral therapy (HAART) (Panel on Treatment of HIV-Infected
Pregnant Women and Prevention of Perinatal Transmission, 2020).

Antiretroviral therapy (ART) plays a vital role in HIV management in pregnancy, and its early
initiation and consistent use have been shown to significantly reduce the risk of MTCT. The
World Health Organization (WHO) recommends that all pregnant women with HIV initiate ART
as soon as possible, regardless of their CD4 cell count or viral load. In addition to reducing the
risk of MTCT, ART also improves maternal health outcomes. By suppressing the viral load,
ART reduces the risk of opportunistic infections and other HIV-related complications, allowing
women to live healthier lives and reducing the risk of transmission to others.

4. Viral Load Monitoring: Regularly monitor viral load to ensure suppression of virus (less
than 50 copies/mL).

5. Ensure adherence to therapy: In order to manage HIV effectively in pregnancy, adherence

to ART is critical for achieving and maintaining viral suppression and preventing drug
resistance. Pregnant women may face barriers to adherence, such as nausea, vomiting, and the
complexity of managing multiple medications. Providing education or counseling and also
simplifying regimens, when possible, can improve adherence.(Nachega et al., 2012)

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6. Obstetric Care: Provide routine obstetric care, including regular ultrasound and prenatal
visits to monitor child's health.

7. Mode of Delivery: Plan for a cesarean section or vaginal delivery depending on individual
circumstances. Planned C- Section at 38 weeks' gestation is recommended for women with high
viral loads (>1,000 copies/ml) or those yet to receive ART during pregnancy. While vaginal
delivery is considered for women with undetectable viral loads (<50copies/ml) who have
received ART.

8. Postpartum Care: Continue ART postpartum to maintain viral suppression and prevent
transmission to the baby.

9. Breastfeeding Counseling: Advise on breastfeeding options and risks, and provide support
for alternative feeding methods if necessary. Exclusive formula feeding or replacement feeding
(donor) should be considered.

VI. PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) OF HIV

A. ART for Pregnant Women with HIV

Antiretroviral therapy (ART) is a cornerstone in the prevention of mother-to-child transmission

(PMTCT) of HIV. When administered to pregnant women living with HIV, ART significantly
reduces the viral load, thereby decreasing the risk of transmitting the virus to the baby during
pregnancy, labor, delivery, and breastfeeding. According to WHO guidelines, all pregnant and
breastfeeding women living with HIV should start ART regardless of their CD4 count and
continue lifelong treatment to maintain viral suppression and improve maternal health outcomes
(WHO, 2021).

B. Caesarean Section and Avoidance of Breastfeeding

Elective caesarean section (C-section) is recommended for women with a high viral load near the
time of delivery to further reduce the risk of HIV transmission to the infant. The procedure
minimizes the infant’s exposure to HIV in the maternal genital tract. However, for women who
achieve viral suppression on ART, vaginal delivery is often considered safe (AIDS info, 2022).

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Avoidance of breastfeeding is another strategy, especially in settings where safe alternatives such
as formula feeding are available and affordable. In resource-limited settings, where breastfeeding
might be necessary, ART for both mother and infant significantly reduces the risk of
transmission through breast milk. The WHO recommends exclusive breastfeeding for the first
six months of life, with continued ART, to optimize infant survival while minimizing HIV
transmission risks (WHO, 2021).

C. Neonatal Prophylaxis

Neonatal prophylaxis involves administering antiretroviral drugs to the newborn to prevent HIV
infection. Typically, a course of zidovudine or nevirapine is given to the infant for 4-6 weeks,
depending on the maternal viral load and ART regimen. This prophylactic treatment is crucial
for reducing the risk of HIV transmission during the immediate postnatal period (UNAIDS,
2020).

VII. COMPLICATIONS AND CHALLENGES

A. Increased Risk of Opportunistic Infections

HIV-infected pregnant women are at an increased risk of opportunistic infections due to their
compromised immune system. These infections can complicate pregnancy and pose significant
risks to both maternal and fetal health. Common opportunistic infections include tuberculosis,
pneumonia, and candidiasis, which require prompt diagnosis and management to improve
outcomes (Nachega et al., 2021).

B. Anemia, Neutropenia, and Thrombocytopenia

HIV and its treatment can lead to hematological complications such as anemia, neutropenia, and
thrombocytopenia. Anemia is particularly common due to HIV-associated bone marrow
suppression, nutritional deficiencies, and the side effects of certain antiretroviral drugs like
zidovudine. Neutropenia and thrombocytopenia can result from direct viral effects or drug
toxicity, increasing the risk of infections and bleeding disorders (Shah et al., 2021).

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C. Mental Health and Social Support

Mental health issues and the need for robust social support are critical considerations in
managing pregnant women with HIV. The stigma associated with HIV can lead to significant
psychological stress, depression, and anxiety, adversely affecting maternal and fetal health.
Comprehensive care for these women includes mental health support, counseling, and
community resources to ensure adherence to ART and improve overall quality of life
(Kalichman et al., 2022).

VIII. POSTPARTUM CARE (ANTIRETROVIRAL THERAPY)AND FOLLOW-UP

Continuous ART is currently recommended for all pregnant mothers with HIV to reduce the risk
of disease progression, and prevent sexual and vertical transmission, and should be continued
after delivery. Postnatal care also provides the opportunity to protect their lives by optimizing
HIV care and treatment. To receive optimal medical care and desired outcomes, HIV-positive
mothers during their postnatal visits must be consistently engaged in care of uninterrupted ART
treatment (Adewole & Kwaghe, 2023).
There is need for comprehensive medical care and supportive services particularly for people
with HIV and their families, who often face multiple medical and social challenges. Components
of comprehensive care during postpartum include the following services, as needed:
1). ART should be offered, and the person should be given a supply of ART before postpartum
hospital discharge to prevent treatment interruption. Modifying ART after delivery should be
made in consultation with the individual and their HIV care provider.
2). Immediate linkage to HIV care and comprehensive follow-up also is needed. For instance,
those who struggle with ART adherence, should have a follow-up appointment with the health
care provider who manages their HIV care, within 2 to 4 weeks of postpartum hospital discharge.
3). Infants of people who have HIV newly diagnosed in the intrapartum period should begin
presumptive HIV therapy, and a supply of ART for their infants should be provided before
postpartum hospital discharge.
4). People with HIV should receive evidence-based counseling to support shared decision-
making about infant feeding options prior to and during pregnancy; counseling and plans for
infant feeding should be reviewed again after delivery.

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5). Clinicians should discuss future reproductive plans and timing, as well as the risks and
benefits of conceiving while on specific antiretroviral (ARV) medications and this should start
during the prenatal period.
6). The use of appropriate contraceptive options to prevent unintended pregnancy and optimal
interpregnancy intervals should also be discussed.
7). Mental health services e.g. Mood disorders
8). Substance use prevention and treatment
9). Supportive services should be tailored to the individual’s needs and can include screening for
intimate partner violence, case management, childcare, assistance with basic needs, such as
housing, food, and transportation.
10). Legal and advocacy services.
11). People who have difficulty attending in-person appointments should consider telemedicine
visits.
12). After giving birth, the mother has to eat many meals, eat a lot of energy-rich foods, eat a
balanced diet with enough nutrients to fight diseases...
13). Also, after giving birth, the mother needs to pay attention to hygiene to prevent dental and
oral diseases.
14). Early exercise can promote the body's recovery, help blood circulation, beneficial for
contraction and return to the original position of the uterus, bringing blood out, thereby reducing
the possibility of infection. and opportunistic infections (the most common feature in HIV
disease).
15). Mothers and caregivers of babies need to regularly trim their nails and keep their hands
clean. To prevent transmission of the virus through scratches.
16). Ventilation in the room is really important and necessary to keep fresh air in the room,
minimizing the proliferation of bacteria.

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IX. CONCLUSION
In conclusion, The American College of Obstetricians and Gynecologists recommends that all
people have contact with their obstetrician-gynecologists within 3 weeks postpartum and that
postpartum care be provided as an ongoing process based on an individual’s needs rather than as
a single postpartum visit. Antiretroviral therapy (ART) is the use of a combination of HIV
medicines to treat HIV infection. After birth, all babies born to people with HIV should receive
HIV medicines. This should be given as soon as possible after birth, preferably within 6 hours of
delivery, to prevent perinatal transmission of HIV (also called mother-to-child transmission of
HIV). HIV medicines given to babies after birth protect against HIV that could have passed from
mother to child during pregnancy or childbirth. HIV testing is recommended for all babies born
to people with HIV at 14 to 21 days of life, at 1 to 2 months, and again at 4 to 6 months.
Additional testing at birth and other time points is recommended for babies at higher risk of
perinatal transmission of HIV. There is need to create a patient-centered, stigma-free
environment with fewer barriers at the societal, health system, clinic, and individual levels is
essential for achieving such. Because the immediate postpartum period poses unique challenges
to ART adherence and retention in HIV care, arrangements for continuous supportive services
should be made available to mothers during pregnancy before postpartum hospital discharge
(Adewole & Kwaghe, 2023). Additionally, babies should not eat food that was pre-chewed by a
person with HIV.

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