HIV/AIDS

• Acquired immunodeficiency syndrome was

first described in 1981
 DEFENITION
AIDS has been defined by the Centers For Disease
Control And Prevention (CDC) as ‘an acquired defect of
cellular immunity associated with infection by the human
immunodeficiency virus (HIV), a CD4 –positive T-
lymphocyte count under 200 cells/µL or less than 14% of
the total lymphocytes and increased susceptibility to
opportunistic infections and malignant neoplasm’.
 EPIDEMIOLOGY
The NACO technical estimate report (2015)
estimated that out of 29 million annual pregnancies in
India, 35,255 occur in HIV positive pregnant women.
Most of the children are infected by their HIV
positive mother during pregnancy, childbirth or
breastfeeding (2015).The vast majority of people
living with HIV are in low and middle income
countries. Sub-Saharan Africa is the most affected
region.
As per the recently released, India HIV
Estimation 2015 report, National adult (15–49
years) HIV prevalence in India is estimated at
0.26% (0.22%– 0.32%) in 2015. In 2015, adult
HIV prevalence is estimated at 0.30% among
males and at 0.22% among Females.
 SCREENING
Benefits to HIV testing
• Early counseling and treatment of HIV
infection
• Ability to make decisions regarding pregnancy
• Implementation of strategies to attempt to
prevent transmission to fetus
 Tests are;

The enzyme immunoassay (EIA) is used as a

screening test for HIV antibodies.
CD4 lymphocyte count- HIV infects CD4 + cells
will result in a progressive decrease in number
of CD4 cells.. Normal laboratory ranges for CD4
+ lymphocyte counts are approximately 500 to
1400 cells/mm3.
Western blot tests(WB)-It is used for
confirmation of HIV positive.
Quantitative viral load assay- it indicates
degree of viral activity and can predict the rate
of disease progression.
 HIV
ELISA 3 Months 2 days–2 weeks >99% >98%
antibodies

Antigen test P24 viral

11 days–1 month 2 days–1 week 90% 100%
(p24) proteins

4th
Antibodies
generation 11 days–1 month 2 days–2 weeks >99.7% >99.3%
and p24
tests

Genetic
PCR/NAAT
material of 12 days 2 days–1 week >99% >99%
tests
HIV

Within 20
Rapid test Antibodies 3 Months >99% >98%
minutes
PARENT TO CHILD TRANSMISSION (PTCT)
• Reducing pediatric HIV infection and disease
involves three stages
– Preventing HIV infection among women of
childbearing age
– Preventing unwanted pregnancy among HIV-
positive women
– Preventing mother to child transmission during
pregnancy, labor and delivery, and breastfeeding
Estimated risk of MTCT timing transmission
rate without any interventions
• During pregnancy 5-10%
• During labor and delivery 10-15%
• During breastfeeding 5-20%
• Overall without breastfeeding 15-25%
• Overall with breastfeeding to six months 20-
35%
• Overall with breastfeeding to 18-24 months
30-45%
 Risk factors of MTCT of HIV

Antepartum factors Intrapartum factors Post partum factors

High maternal viral load Cervicovaginal HIV levels Breast feeding

Low maternal CD4 count Mode of delivery

Vitamin A deficiency Prolonged rupture of membrane

Illicit drug use Premature delivery

Amniocentesis Vaginal laceration

Lack of antenatal care Episiotomy

Invasive fetal monitoring

Instrumental delivery
 PROPHYLAXIS FOR MOTHER AND
BABY
The only interventions proven to be effective in
reducing mother-to-child transmission (MTCT) of
HIV at present are the use of Zidovudine (either
as long-course through pregnancy, labour and
for six weeks to the infant, or as short-course),
and the avoidance of breastfeeding.
 Pharmacology

Classes of Antiretrovirals
• NRTIs – Nucleoside reverse transcriptase
inhibitors – Nucleotide reverse transcriptase
inhibitors (NtRTI)
• NNRTIs – Non-nucleoside reverse
transcriptase inhibitors
• PIs – protease inhibitors
 management
PRENATAL CARE:
• Integrated counseling and testing (ICT)
• In seropositive cases the following additional tests should be
done
• Counseling with education
• Progression of the disease is assessed
• The patient should have T lymphocyte count in each trimester.
• Highly active antiretroviral therapy (HAART)
• Principles of HAART are to: (viii) Prophylactic antibiotics should
be starte
 Antenatal Care
• Women needs screening against opportunistic
infections specially when CD4+ cell count is
<200/mm3
• Women on HAART should be screened for
GDM.
• Screening for aneuploidy anomaly scan.
• Monitoring of plasma viral load and drug
toxicities, vaccination against HBV and
pneumococcal infection should be done.
 INTRAPARTUM CARE
Women presenting in labor;
• Zidovudine (ZDV)
• Women taking HAART
• Elective cesarean delivery
• Perioprative or peripartum broad spectrum antibiotics
• Invasive procedures
• Amniotomy
• Place of cesarean delivery to reduce MTCT
• Risk factors for increased perinatal transmission Health-care workers
• Post exposure prophylaxis.
• Disposable syringes and needles
• Long-term safety of anti-retroviral drugs
 POSTPARTUM CARE:
• Women
• Formula feeding or breast-feeding
• Neonatal care:
• Antiretroviral therapy (ARV)
• Zidovudine syrup – 2 mg/kg,
 STANDARD SAFETY MEASURES
• Precautions before surgery include prophylactic antibiotics and
anesthetist should be aware of HIV status.
• Reducing needle stick injuries
• Washing hands with soap and water immediately after contact with blood
or body fluids
• Covering broken skin or open wounds with watertight dressings.
• Wearing an impermeable plastic apron for delivery.
• Wearing eye shield for operating or assisting at Caesarean Section, and
for suturing episiotomies.
• Wearing double gloves, if possible, for all operations, which reduces
considerably the amount of blood carried through if the glove is
punctured.
• Using an appropriate sized needle (21 gauge, 4 cm, curved) for the repair
of episiotomy, together with a technique using a needle holder.
• Passing all sharp instruments onto a receiver,
• Using long-cuffed gloves for manual removal of a placenta
• Avoiding the need for suction of newborns and using wall suction or a
suction machine when suction is required. Suction pressure should be
less than 140 mm Hg to avoid damage to the neonate.
• Disposing of solid waste such as blood soaked dressings or placentas
safely.
• After surgery outer gloves removed before dressing the wound,
remove all contaminated articles.
• in spite of all precautions there has been contact with HIV infected
material, then use of soap and water to wash any wound or skin.
Allow the injury to bleed but do not squeeze it forcefully.
• Each individual with occupational exposure to HIV should receive
follow-up counseling, post exposure testing and medical evaluation
regardless of whether they receive PEP.
Disinfectant solution
• 0.5% sodium hypochloride / house hold bleach
for cleaning.
• 10% Lysol for cleaning metallic table and
chairs.
• Dip all linen in household bleach for half an
hour before sending to laundry.
• Put placenta in a yellow or red bag with
bleaching powder and either burn or bury with
bleaching powder in the soil.
 Post exposure prophylaxis
General guidelines for PEP
• Assessment of risk.
• Therapy should be initiated within 1-2 hours, 2 and 3 drug
regimens, based on level of risk and source patient’s HIV status.
• Where delay of more than 24 hours has occurred then expert
advice from HIV physician should be taken.
• Post-exposure drug prophylaxis should take into account the type
and source of the injury and is not recommended for superficial
needle stick injuries or cutaneous exposure. For deeper injuries or
lacerations, the use of post exposure prophylaxis should be
considered, and treatment started as soon as possible after the
injury, with the first dose of ZDV ideally taken within two hours.
• Combination therapy, such as ZDV and 3TC (Lamivudine), is
currently recommended. The addition of a protease inhibitor is
recommended for deep exposures in the United States and
Canadian guidelines.
 COUNSELING
Counseling is mandatory for HIV positive mothers. It preferable start
early in pregnancy and she take decision for continue the pregnancy.
Pretest counseling for HIV infection
• Explain that testing is confidential.
• Assess the client’s understanding of HIV risk.
• Obtain a careful sexual history.
• Explain the modes of HIV transmission
• Explain the relationship between infection and transmission
• Discuss the prevention of transmission to others including methods
of safe sex
• Describe and explain the serologic tests used to confirm HIV
infection.
• Discuss what test results mean, including false negative and false
positive results.
Post test counseling for HIV negative results

• Inform client of negative results need for future testing

related to exposure
• Offer contraception information
• Offer counseling and education to partners
• Review safe sex practice
• Advice client not to donate blood, plasma, or organs until
HIV status is firmly established
• For HIV positive results
• Offer immediate psychological support
• Help the client understand what the text result means
• Review method of transmission and assess the client’s risk of
transmitting HIV to others.
• Explain the treatment is available
• Identify immediate healthcare resources
• Identify immediate psychiatric services, as appropriate
• Assist the client in developing a plan to notify sexual partner of
exposure
• Help the client develop a plan to notify all others who may need
to know about her HIV status
• Offer counseling and education to partners
• Offer contraception information
• Review safe sex practices and other risk reduction strategies
• Advise client not to donate blood, plasma or organs.
 BREAST FEEDING ISSUES
There is evidence that breastfeeding increases
postnatal HIV- 1 transmission by as high as 30-
40%. Complete avoidance of breastfeeding is the
surest way to avoid MTCT of HIV through
breastfeeding.
The risk of transmission varies with:-

 The period of breast feeding

 The maternal HIV load

 HIV disease status

 Associated breast abscess

 Cracks in nipple

 Duration of breast feeding

 Whether exclusive breastfeeding or mixed feeding

Breastfeeding Issues
• Warmth for newborn
• Nutrition for newborn
• Protection against other infections
• Risk of HIV transmission
• Contraception for mother
• AFASS - the mother who is infected with HIV
should breastfeed unless replacement feeding
is acceptable, feasible, affordable, safe, and
sustainable (AFASS).
NATIONAL POLICIES AND GUIDELINES
• In response to demand from both international
agencies and indigenous organization, the
government of India is reviewing public policy
and guidelines relating to HIV and AIDS.
• 1986: 1st case of HIV detected in Chennai
• 1990: HIV/AIDS cell set up in MOHFW
• 1992: NACP-I launched
• 1992: NACO established with MOHFW
• 1999-2006: NACO-II launched
• 2007-2012: NACP-III launched
ISSUES: LEGAL, ETHICAL, PSYCHOLOGICAL AND
REHABILITATION

• Legal issues-
• The law constitutes body of principles
recognized or enforced by public or
administration. The purposes are safeguarding
the public and safe guarding the nurse.
Safeguarding the public;
• The public safety is guaranteed because the
practice of nursing is restricted to those
accredited practitioners who would seek to
provide highest possible level of
comprehensive care for the individual and
community taking in to account the total need
for an HIV client.
• The individual with HIV is secure to the event
of sickness or disability with no fear of anxiety
of being cared for by a competent person.
Safeguarding the nurse;
• Licensure
• Good Samaritan laws
• Good rapport
• Standards of care
• Standing orders
• Consent
• Correct identity
 Ethical issues-
• MTCT prevention programs should enable women to
make informed choices concerning all of the interventions
on offer and their decisions should be supported. The
involvement of man should be promoted.
• The convention on the rights of the child places high value
on children’s rights. At the same time, every individual has
the right to health.
• Resource allocation is an ethical as well as rational issues
• Any donation of infant formula or other breast milk
substitute must comply with the international code of
marketing breast milk substitutes.
• The life of the mother is usually values over that
of an unborn child. Women must be appropriately
counseled about interventions that carry risk to
them, in particular elective CS to prevent MTCT.
• Short term ART for want prevention of MTCT may
have psychological and social value to the mother,
but does not benefit her health. Some see this as
treating the mother’s body as merely a conduit for
an intervention that benefits only the baby, which
they consider unethical. Others see little
difference between this and other actions a
mother might take to benefit her unborn child,
such as modifying her diet.
• In some setting, HIV positive pregnant women
may be offered preferential access to services
of higher quality than those normally available
for example in the use of highly trained birth
attendants or provision of antibiotic
prophylactic before birth. This raises questions
of equity and the rationale for allocation of
resources.
• If access to MTCT prevention programs
remains confined to urban populations the
implications for equity are likely to be
negative.
Psychological issues-
• Stress when asked for testing, pregnancy, MTP
needed/ not, unborn child and other children
• Stigma – act of identifying that they are
shamefully different and deviant from the
social ideal
• Discrimination – action based on stigma and
directed towards the stigmatzed and as
harassment and violence based on HIV
Psychological concerns:
• A perception of HIV as a threat
• Feelings of vulnerability and loss of control
• Death related concerns
Rehabilitation-
Rehabilitation is any service or activity that can
address or prevent the health-related challenges
(or disabilities) that people living with HIV might
face. Rehabilitation services can include
physiotherapy, occupational therapy or speech–
language therapies, as well as complementary or
alternative therapies such as acupuncture,
massage therapy and counselling.
 ROLE OF NURSE
• Assess history of IV drug use, prostitution, infection of
spouse
• Assess for malaise, progressive weight loss,
lymphadenopathy, evidence of infection
• Assess anxiety about future self and baby
• Analyses for risk of fetal injury and infection
• During postpartum care mother encouraged to manage baby
herself
• Counselling – prepregnancy and early pregnancy counselling
should be done for HIV infected women. The counselor
should provide up-to-date knowledge which enables the
women to make an informed choice. Information as regard to
the medical issues is also to be discussed.
Health education to the public regarding;
• The transmission and practice of safer sex.
• Continuation or initiation of antiretrovirals for
maternal disease in the first trimester of
pregnancy.
• Use of antiretrovirals for prevention of MTCT.
• Information regarding the benefits of Cesarean
section than a vaginal delivery.
• Avoidance of breast feeding if possible.
• Do not share unsterile needles or syringes.
• Women having potentially exposed should
seek HIV antibody testing before becoming
pregnant and, if the test is positive, should
consider avoiding pregnancy.
• HIV seropositive pregnant women should be
informed about the impact and allow them to
take choice of their own.
 SUMMARY
Women with HIV infection require focused antenatal care
provided in accordance with national protocols. HIV can be
transmitted from an infected mother to her child during
pregnancy, labour and delivery, or through breastfeeding.
Antiretroviral therapy regimens reduce the risk of MTCT and
improve maternal survival in both breastfeeding and non-
breastfeeding women. Women should be monitored for signs
or symptoms of progressive HIV/AIDS, and opportunistic
infections, particularly tuberculosis (TB). Exclusive
breastfeeding should be recommended to reduce the risk of
MTCT during the postnatal period unless the mother chose to
give replacement feeding. Decisions about infant feeding
options should be made before delivery.