Human Immunodeficiency Virus ;

Prevention of Mother-to-Child
Transmission.
Presented by ; Dr Onu Chioma
Pharm Ose Iyayi
Nurse Jennifer Okwara
Sct Enem Rosemary
2
Outline
 Introduction to HIV and AIDS
 Epidemiology
 Natural History and Transmission of HIV
 Introduction to PMTCT
 Laboratory Diagnosis
 ART
 Nursing Management
 References
3 Introduction to HIV and AIDS

 HIV infection is a global pandemic and remains a major public health problem in sub- Saharan
Africa. In Nigeria, the number of people living with HIV is the second-largest number in the
world (after South Africa).

 It is a blood-borne virus.

 HIV-1 is the most common type worldwide, including Nigeria.

 The most common route of HIV transmission worldwide is heterosexual transmission

 Sexual transmission is the most common mode by which the virus spreads in this region
4 HIV-1 and HIV-2
 HIV-1 and HIV-2
 Transmitted through the same routes
 Associated with similar opportunistic infections
 HIV-1 is more common worldwide.
 HIV-2 is found predominantly in West Africa, Angola and Mozambique.
 Differences between HIV-1 and HIV-2
 HIV-2 is less easily transmitted.
 HIV-2 develops more slowly as there tend to be a lower viral load
 MTCT is relatively rare with HIV-2.
 Some ARV drugs (NNRTIs) are ineffective against HIV-2
5
Global Scope of the HIV Infection

By the end of 2020, estimates from UNAIDS:

37.7 million people worldwide were living with HIV and AIDS.
1.7 million people with HIV and AIDS were children younger than 15 years old.
60% of the children living with HIV and AIDS were from sub- Saharan Africa.
150,000 children worldwide were newly infected.
99,000 child deaths are estimated to have occurred as a result of HIV and AIDS.
6 Adults and children estimated to be
living with HIV  2020

Eastern Europe
and central
North America and western and central Asia
Europe 1.6 million
2.2 million [1.5 million–1.8 million]
[1.9 million–2.6 million]
Caribbean Middle East and North
330 000 Africa
[280 000–390 000] Western [190 000–310 000]
Africa Asia and the Pacific
and24.7
c3e0million
n0tr0al0
Latin America [3.9 million–5.8 million]
5.8 million
Eastern and southern [4.3 million–7.0 million]
2.1 million Africa
[1.4 million–2.7 million]
20.6 million
[16.8 million–24.4 million]

Total: 37.7 million [30.2 million–45.1 million]

7 HIV in Nigeria (2019)

National HIV Prevalence 1.4%

Estimated number of people living with
1.8 million
HIV/AIDS
Final Vertical transmission rate
including Breastfeeding 23.8%

New HIV infection 100,000

130,000 total infection
21,000 new infections
Children 12,000 deaths

Source: NAIIS & UNAIDS

8 HIV prevalence by state in Nigeria (NAIIS 2018)
9 Natural History and Transmission of HIV

HIV can be transmitted during each stage.

 Seroconversion
 People infected with HIV usually develop antibodies 4 to 6 weeks after being infected, but it
may take as long as 3 months for antibodies to develop. The period of time between when a
person is infected with HIV and when the antibody test result is positive is called the
"window period ”
 Clinically Asymptomatic(lasts for average of 10 years)
 No signs of HIV; immune system controls virus production
 Sins of persistent generalized lymphoadenopathy
 Symptomatic
 Physical signs of HIV infection, some immune suppression
 Severe manifestation of malaria, reactivation of TB
 AIDS Death in 2 years
 Opportunistic infections, end-stage disease
10 WHO Clinical Staging
11 Background information on CD4 count

 The CD4+ count and viral load are two measures of the progression of HIV.

 When HIV actively multiplies, it infects and kills CD4+ T cells (a specific type of white blood cell).

 The CD4+ count is the number of CD4+ cells in the blood and reflects the state of the immune
system.

 The effect of HIV can be measured by the decline in the number of CD4+ cells.

 The normal count in a healthy adult is between 500 and 1,400 cells/mm3
12 Background information on viral load

 Viral load is the amount of HIV in the blood.

 Viral load can be measured by the HIV ribonucleic acid polymerase chain reaction blood test
(HIV-RNA PCR).

 High viral load in increases the risk of transmission of HIV from mother to child.

 Antiretroviral drugs can significantly reduce viral load

NB: viral load is the most reliable measure of disease progression

15
 13
AIDS

 AIDS is the late and severe stage of HIV infection

 As HIV infection progresses, the CD4+ count continues to decrease and the infected person
becomes susceptible to opportunistic infections.

 An opportunistic infection is an illness caused by a germ that might not cause illness in a healthy
person, but will cause illness in a person who has a weakened immune system. For example, herpes
zoster (shingles) is very common in people infected with HIV
14 HIV-Related Opportunistic Infections

Nigeria National PMTCT Training Slides Module 1

15 HIV Progression in Children

 HIV progresses more rapidly in infected newborns than in adults.

 Some children will show signs of HIV infection within
months.
 Without Intervention, 50% of infected children will die before
2 years.
 Disease progression is more varied and less
predictable.
16 Transmission of HIV

HIV is transmitted by:

 Sexual contact:
 Unprotected sex (anal, vaginal, or oral)
 Direct contact with HIV-infected body fluids such as semen and vaginal secretions
 Blood to Blood transmission:
 Transfusion with HIV-infected blood
 Direct contact with HIV-infected blood
 Re-use of unsterilized sharps (needles, surgical blades, razors used in scarification
practices)
 Needle stick injury
 Injection of drugs with needles or syringes contaminated with HIV
 Mothers infected with HIV to infants during pregnancy, delivery and breastfeeding
17
 Vertical transmission encompasses MTCT before delivery (antepartum),
during labour and delivery (intrapartum), or through breastfeeding.

 Risk factors for MTCT of HIV can be classified into:

 Viral load and characteristics
 Maternal
 Obstetrical
 Foetal
 Infant-related factors
18
Risk Factors for MTCT

Pregnancy Labour and Delivery Breastfeeding

•High maternal viral load •High maternal viral load •High maternal viral load
•Infection •Prolonged rupture of •Duration
membranes
•STIs •Chorioamnionitis •Early mixed feeding
•Prolonged labour
•Malnutrition •Invasive delivery procedures •Breast fissures, infections
•Instrumental delivery
•Haemorrhage • Episiotomy & genital •Poor maternal nutrition
lacerations
•Oral disease in infant
19 Mother-to-Child Transmission

MTCT can occur during:

 Pregnancy
 Labour and delivery
 Breastfeeding
20 Mother-to-Child Transmission

100 infants born to HIV-infected 60 to 75 infants

women who breastfeed, without any will not be HIV-
interventions infected

About 15 5–15
5–10 infants infants
infants infected infected
infected during during
during labour breast-
pregnancy and feeding
delivery

25–40 infants will be HIV-infected

21
Prevention of Mother-to-Child Transmission of HIV
Infection(PMTCT)
The goal of the PMTCT is the elimination of new
HIV infections among children and keeping their
mothers alive.
 National Strategies

 Ensure HIV testing for all

pregnant women
 Providing ARV and other HIV services to
pregnant and breastfeeding women living
with HIV
 Diagnosing infants living with HIV
and link identified HIV positive to ART
services
22
4 ELEMENTS FOR PMTCT
23 Element 1:Primary Prevention of HIV Infection

• Safer and responsible sexual behaviour and practices

• Make HIV testing services widely available
• Provide suitable counselling for women who are HIV-negative
• Provide early diagnosis and treatment of STIs

ABCs of primary HIV prevention for parents-to-be:

A = Abstain
B = Be faithful to one HIV-uninfected partner
C = Condom use – use condoms consistently and correctly
24 Element 2: Prevention of Unintended Pregnancies
Among Women Infected with HIV

 Access to HIV testing services and counselling on family planning

including dual protection messages

 Provide safe, consistent and effective contraceptives

options
25 Element 3: Prevention of HIV Transmission from Women Infected
with HIV to Their Infants

Core Interventions
 HIV testing services at ANC and in Labour
 Anti-retroviral Therapy (ART)
 Safer delivery practices
 Safer infant-feeding practices

Maternal ART can reduce the MTCT rate to as low as 2% even with
exclusive breastfeeding up to 6 months of age.
26 Element 4: Provision of Treatment, Care, and Support for Women
Infected with HIV, their Infants and their Families

 ART
 Prevention and treatment of OIs
 Palliative care
 Nutritional support
 Reproductive health care
 Psychosocial and community support
27 Male Partner Involvement in PMTCT

 Comprehensive PMTCT services acknowledge that both mothers and fathers have a
role to play in MTCT

 Both partners need to be aware of the importance of safer sex throughout

pregnancy and breastfeeding.

 Both partners should be tested and counselled for HIV.

 Both partners should be made aware of and

provided with PMTCT interventions
28 Reproductive, Maternal, Newborn, Child, Adolescent,
Elderly, Health and Nutrition (RMNCAEH+N) for HIV
Positive Pregnant Women
 Antenatal care
 Counselling and support for infant-feeding practice
 ARV treatment for mother and prophylaxis for infants
 Safer delivery practices
 Postnatal care
 Family planning services
 Cervical screening services
 Syndromic management of STIs
 PMTCT Cascade: The PMTCT cascade provides
29 an effective tool to visualize efforts on MTCT and to
identify opportunities for closing cascade gaps

HIV Positive Pregnant

HEI outcomes
women delivered at the
at 18months
facility
HEI outcomes

Estimated
number Pregnant
HIV +ve HEI
of women Maternal
HEI HEI
test result prophyla
Pregnant attending received received received HIV +ve
received xis
women in ANC prophyl DNA PCR HIV test infant
initiated
Nigeria axis test at 6 at 18 initiate
weeks months
s ART

HIV+ve woman Mother alive and on ART HIV Exposed Infant HIV Free Child
 30 Laboratory Diagnosis

LABORATORY METHODS FOR DIAGNOSIS OF HIV

INFECTION IN INFANTS AND CHILDREN
HIV infection at any age requires diagnostic testing that confirms the
presence of HIV. Serological testing identifies HIV antigen and/or
antibody generated as part of the immune response to infection with
HIV. In children older than 18 months of age, serological testing
should be used in the same manner as in adults. However, maternal
HIV antibody is transferred to the baby passively during pregnancy
and then declines. Infected infants then go on to produce HIV
antibody, however, most commonly used HIV serological assays
cannot distinguish between maternal HIV antibody and HIV antibody
produced by the infant, making the interpretation of reactive HIV
serological test results difficult. In order to diagnose HIV infection
definitely in children aged less than 18 months, assays are required
that detect the virus or its components (i.e. virological tests). A range
of laboratory-based techniques are available, and these are discussed
in more detail in the following slides.
31 TYPES OF HIV TESTS
What types of HIV tests are available, and how do they work?
There are three types of HIV tests:
 Antibody Tests
 Antigen/Antibody Tests, And
 Nucleic Acid Tests (NAT).
Antibodies are produced by your immune system when you’re exposed to viruses
like HIV. Antigens are foreign substances that cause your immune system to activate.
If you have HIV, an antigen called p24 is produced even before antibodies develop.
HIV tests are typically performed on blood or oral fluid. They may also be performed
on urine.
 32 ANTIBODY TEST

An antibody test looks for antibodies to HIV in

your blood or oral fluid. Most rapid tests and the
only HIV self-test approved by the U.S. Food and
Drug Administration (FDA) are antibody tests. In
general, antibody tests that use blood from a vein
can detect HIV sooner than tests done with blood
from a finger stick or with oral fluid.
33 NUCLEIC ACID TEST (NAT)

 A Nucleic Acid Test looks for the actual virus in the blood. With a NAT, the
health care provider will draw blood from your vein and send the sample to a lab
for testing. This test can tell if a person has HIV or how much virus is present in
the blood (HIV viral load test). A NAT can detect HIV sooner than other types of
tests.
 This test should be considered for people who have had a recent exposure or a
possible exposure and have early symptoms of HIV and who have tested negative
with an antibody or antigen/antibody test.
34
ANTIBODY/ANTIGEN TEST

 An antigen/antibody test looks for both HIV antibodies and antigens.

 Antigen/antibody tests are recommended for testing done in labs. This lab test
involves drawing blood from a vein.
 There is also a rapid antigen/antibody test available that is done with blood from a
finger stick.
35 STILL ON NUCLEIC ACID TEST …
Virological Test (Recommended by the WHO)
 This is the most reliable method for diagnosing HIV infection in infants and children less than 18
months of age. However it is expensive, and requires a sophisticated laboratory set up with trained staff
to carry out the test.
 While such laboratories are situated in central hospitals away from most of the population, the use of
the Dried Blood Spots (DBS) system should enable all health facilities in a country to access virological
testing services.
 It is strongly recommended that all HIV-exposed infants, and all infants with unknown or uncertain HIV
status, should have an HIV virological test performed at 4–6 weeks of age or at the earliest opportunity
thereafter.
 For infants and children with a positive result, a confirmatory test should be done.
36 NAT… INFANT VIROLOGICAL TESTING
In infants and children undergoing virological testing, the following assays can be
used;
 HIV DNA on whole blood specimen or DBS
 HIV RNA on plasma or DBS
 Up24 Ag on plasma or DBS
37
38 WHEN TO EXPECT HIV TEST RESULTS?

 It depends on the type of HIV test and where you get tested. HIV self-tests provide
results within 20 minutes.
 With a rapid antibody test, usually done with blood from a finger stick or with oral
fluid, results are ready in 30 minutes or less.
 The rapid antigen/antibody test, done with blood from a finger stick, takes 30
minutes or less.
 It may take several days to receive your test results with a NAT or antigen/antibody
lab test.
39 CAN A HIV TEST DETECT THE VIRUS IMMEDIATELY
AFTER EXPOSURE?

 No HIV test can detect HIV immediately after infection. That’s because of the
window period - the time between HIV exposure and when a test can detect HIV
in your body. The window period depends on the type of HIV test.
 A nucleic acid test can usually detect HIV the soonest (about 10 to 33 days after
exposure).
40 IN CONCLUSION…
 If you’ve recently been tested for HIV or you’re thinking about getting tested, you might have
concerns about the possibility of receiving an incorrect test result.
 With current methods of testing for HIV, incorrect diagnosis are very uncommon. But in rare
cases, some people do receive a false-positive or false-negative result after being tested for HIV.
 In general, it takes multiple tests to accurately diagnose HIV. A positive test result for HIV will
require additional testing to confirm the result. In some cases, a negative test result for HIV may
also require additional testing.
41 Anti-Retroviral Therapy

Antiretroviral Therapy popularly referred to as ART involves using a combination of two or more
drugs (Antiretroviral drugs) in the management of HIV.

Effective antiretroviral therapy is the most important intervention in terms of improving longetivity
and preventing opportunistic infections in patients with human immunodeficiency virus(HIV)
infection.

It is important to note that these drugs do not cure HIV but they aid in helping patients with HIV
have better quality of life by reducing the amount of the virus in the blood thereby keeping the
immune system strong enough to fight the disease.
42 Cont…

Antiretrovirals have the following effects;

 They stop the virus from multiplying in the blood.
 They reduce the amount of HIV in the blood.
 They increase the number of CD4 cells, which are immune cells that the virus
targets.
 They prevent/slow down the advancement of HIV to AIDS
 They stop the virus from transmitting to other people
 They reduce the risk of severe complications
 They increase survival rates.
43
Classification of Anti-retroviral Drugs

Anti-Retroviral drugs can be classified based on their mechanism of action

into seven(7) groups which include;

 Nucleoside reverse transcriptase inhibitors (NRTIs) e.g Abacavir, Emtricitabine, Lamivudine,

Tenofovir.

 Non- Nucleoside reverse transcriptase inhibitors (NNRTIs) e.g Efavirenz, Nevirapine.

 Post-attachment Inhibitors e.g Ibalizumab

 Protease Inhibitors(PIs) e.g Ritonavir, Tipranvir, Lopinavir

44 Cont…..

 Chemokine coreceptor antagonists (CCR5) e.g Maraviroc

 Integrase Strand Transfer Inhibitors e.g Dolutegravir, Cabotegravir, Raltegravir

 Fusion Inhibitors e.g Enfurvitide

N:B - HIV is always treated with atleast two different medications. The reason for
this combination is because attacking HIV from multiple directions lowers the viral
load better and also prevents development of resistance to the medication.
45
ART in PMTCT

 Pregnant women infected with HIV/AIDS can transmit the virus to their child during
pregnancy, delivery or while breast-feeding.

 Without Anti-retroviral Therapy, the chance that a HIV-positive mother in Africa will pass the
virus to her infant is estimated to be 25-35%.

 ART reduces but does not eliminate the chance that an infant will be infected by its mother, by
reducing the concentration of the virus in the blood.
 When is ART indicated?
46

 In pregnant women with confirmed HIV infection, the initiation of ART for maternal health is
recommended for all women with CD4 cell counts of ≤350 cells/mm 3, irrespective of the WHO
clinical staging, and for all women in WHO clinical stage 3 or 4, irrespective of the CD4 cell count.

 HIV-infected pregnant women in need of ART for their own health should start ART as soon as
feasible regardless of gestational age and continue throughout pregnancy, childbirth, breastfeeding
(if breastfeeding), and thereafter.

 HIV-infected pregnant women who are not in need of ART for their own health require effective
ARV prophylaxis to prevent HIV infection in their infants.

 Prophylaxis should be started as early as 14 weeks of gestation or as soon as feasible during

pregnancy, labour and delivery or thereafter
 47
Table 1:Eligibility criteria for initiating antiretroviral
treatment or prophylaxis in HIV-infected pregnant women
based on CD4 cell count and WHO clinical stage

CD4 cell count not CD4 cell count available

available
CD4 ≤350 cells/mm3 CD4 > 350 cells/mm3

WHO clinical stage 1 ARV prophylaxis ART ARV prophylaxis

WHO clinical stage 2 ARV prophylaxis ART ARV prophylaxis

WHO clinical stage 3 ART ART ART

WHO clinical stage 4 ART ART ART

48 ARV PROPHYLAXIS
There are two main options recommended for ARV prophylaxis and they include ;
 Option A-Maternal Zidovudine(AZT) + infant ARV prophylaxis
• This involves the use of Zidovudine twice daily before childbirth, plus Single-dose
Nevirapine(NVP) given at the onset of labor , plus twice daily Zidovudine(AZT) and
Lamivudine (3TC) during labor and delivery and continued for 7 days postpartum.
• In breastfeeding infants , daily administration of NVP is given from birth until 1 week after all
exposure to breastmilk has ended or for 4-6weeks if breastfeeding stops before 6 weeks.
• In infants receiving only replacement feeding, daily administration of NVP from birth or
single-dose NVP at birth plus twice daily AZT from birth until 4-6weeks of age is
recommended.
49 Cont….

 OPTION B-Maternal triple ARV prophylaxis

• This consists of daily triple ARV prophylaxis until delivery, or, if
breastfeeding, until 1 week after all exposure to breast milk has ended.
• Recommended regimen include AZT + 3TC + LPV/r , AZT + 3TC + ABC,AZT +
3TC+EFV or TDF + 3TC (OR FTC) + EFV.
• In infants , regardless of feeding practices, the maternal triple ARV prophylaxis
should be combined with daily administration of NVP or twice daily AZT to the
infant from birth until 4-6 weeks of age.
 Table 2:Considerations for the choice of first-line ART for HIV-infected pregnant women
50

Recommended Classes Dosing Feasibility and operational Safety considerations

regimens considerations

1) AZT + 3TC + NVP 2 NRTIs + 1 NNRTI • AZT 300 mg twice • Regimen could potentially be provided •Risk of anemia with
daily as a fixed-dose combination prolonged use of AZT
• 3TC 150 mg twice
daily • Extensive experience with AZT + 3TC •Risk of hepatotoxicity and
• NVP 200 mg twice backbone in pregnancy hypersensitivity with use
daily of NVP resulting in need
• Hb assessment is recommended (but for close clinical
not necessary) before use of AZT observation for first 12
weeks
• Need for close clinical toxicity
monitoring for first 12 weeks with use •Not recommended in
of NVP pregnant women with CD4
>350 cells/mm3
• NVP dose escalation from once-daily
to twice-daily regimen after 2 weeks
 51 Cont….
Recommended Regimen Classes Dosing Feasibility and operational Safety considerations
considerations

2) AZT + 3TC + EFV • AZT 300 mg twice daily • Extensive experience with AZT +
3TC backbone in pregnancy
• 3TC 150 mg twice daily
• Hb assessment is recommended (but
• EFV 600 mg once daily not necessary) before use of AZT

• Effective contraception after

delivery is required to prevent
(subsequent) pregnancy with use of
EFV

• EFV is recommended for women

presenting with TB
 52 Cont….
Recommended Classes Dosing Feasibility and operational Safety considerations
Regimen considerations

3) TDF + 3TC (or 2 NRTIs + 1 NNRTI • TDF 300 mg once daily • Could be given as once-daily • Risk of
FTC) + EFV 3TC 300 mg once daily regimen in a fixed-dose nephrotoxicity with
EFV 600 mg once daily combination use of TDF

or • Effective contraception after • Limited data available

delivery is required to prevent on potential maternal
• TDF 300 mg once daily (subsequent) pregnancy with use and infant bone
FTC 200 mg once daily of EFV toxicity with use of
EFV 600 mg once daily TDF
• EFV use is recommended for
women presenting with TB • Potential risk
(probably <1%) of
• TDF + 3TC (or FTC) use is neural tube defect
recommended for women with with use of EFV in
HBV infection requiring HBV first month of
treatment pregnancy (before 6
weeks gestation
 53
Cont….
Recommended Regimen Classes Dosing Feasibility and operational Safety considerations
considerations

4) TDF + 3TC (or FTC) + 2 NRTIs + 1 NNRTI • TDF 300 mg once daily • Need for close toxicity Risk of nephrotoxicity with
NVP 3TC 150 mg twice daily monitoring for 12 weeks use of TDF
NVP 200 mg twice daily with use of NVP Limited data available on
or potential maternal and infant
TDF 300 mg once daily • NVP dose escalation bone toxicity with use of
FTC 200 mg once daily from once-daily to TDF
NVP 200 mg twice daily twice-daily regimen Risk of hepatotoxicity and
after 2 weeks hypersensitivity with use of
NVP resulting in need for
• TDF + 3TC (or FTC) close clinical observation
use is recommended for for first 12 weeks
women presenting with
HBV infection requiring
treatment
54 Antiretroviral prophylaxis for infants born to women receiving ART

 A short duration of antiretroviral prophylaxis (for 4-6 weeks) is indicated for infants born to HIV-infected
women receiving ART, to further reduce peripartum and postpartum HIV transmission, in addition to the
protection received from the mother's ART regimen.
 Regardless of infant feeding choice, infant prophylaxis provides added protection from early postpartum
transmission, particularly in situations where women have started ART late in pregnancy, have less than
optimal adherence to ART and have not achieved full viral suppression .
 The choice of infant prophylaxis should be guided by national programme considerations with regard to
experience, availability, feasibility and potential toxicity.
55 Table 3:Considerations for choice of infant prophylaxis.

Infant Dose and duration Feasibility and operational Safety considerations

prophylaxis considerations
AZT 15 mg per dose twice daily if birth •Twice-daily regimen •Potential risk of anaemia (reversible)
weight >2500 g (or 10 mg per dose twice
daily if birth weight ≤2500 g) from birth •Substantial experience among infants
until 4 to 6 weeks of age receiving replacement feeding
NVP 15 mg once daily if birth weight >2500 g •Once-daily regimen •Risk of acquired drug resistance for
(or 10 mg once daily if birth weight infants becoming infected despite
≤2500 g) from birth until 4 to 6 weeks of •Limited safety monitoring required interventions
age
•Substantial experience among •Potential risk for NVP toxicity if mother
breastfeeding infants receives NVP-based ART regimen
during breastfeeding (there is some
•No evidence assessing the efficacy passage of NVP to the infant through
among infants receiving breast milk)
replacement feeding for any duration
beyond a single dose at birth

•NVP is not recommended for infants

born to mothers infected solely with
HIV-2
56 Counselling and Considerations

 HIV-infected women already receiving ART and who become pregnant require appropriate antenatal
counselling, which should cover the risk of infant HIV infection, risk factors and PMTCT, potential
drug toxicity for mother and infant, safer sexual practices to prevent STIs, and other general health
messages.

 Alternative combinations, such as a triple NRTI regimen or a PI-based regimen, can be considered if
a recommended antiretroviral regimen is not indicated or not available.

 EFV should not be initiated in the first trimester of pregnancy but may be initiated in the second and
third trimesters because of its potential to cause neural tube effects.
57
Cont….
 Most women are not enrolled in antenatal care during the early stages of pregnancy, when most
organogenesis occurs (i.e. the first trimester). Since the neural tube closes at approximately 28
days of gestation, fetal exposure to EFV during the risk period for neural tube defects will have
occurred before the recognition of pregnancy in the vast majority of women.

 If a woman receiving EFV is recognized as pregnant before 28 days of gestation, EFV should be
stopped and substituted with NVP or a PI. If a woman is diagnosed as pregnant after 28 days of
gestation, EFV should be continued. There is no indication for abortion in women exposed to
EFV in the first trimester of pregnancy.
58
ARV Drugs Side effects and Management
 HIV drugs have improved over the years and serious side effects are less likely than they used to be.
However , HIV drugs can still cause some side effects which may be mild, severe or even life-
threatening.

 Hence, it is important for patients to be counselled on the possible side effects that may occur in order
to improve adherence.

 Patients are also advised to report any new or unusual side effects to a healthcare professional.

 There is also a possibility of drug-drug interactions ,drug-food interactions. So at the initiation of

therapy, the patient should talk to the healthcare professional about all the other medications ,
supplements , herbs e .t. c they are taking.
 59 Table 4: Common side effects and management.
Side Effects Drugs Implicated Management
Loss of Appetite Abacavir, Zidovudine Take nutritional supplements to ensure the body gets
enough vitamins and minerals
Weight gain NRTIs e.g Abacavir, Regular exercising for weight loss.
zidovudine, Lamivudine
PIs e.g Lopinavir, Ritonavir

Diarrhea NRTIs , Pis , Maraviroc, Eat fewer greasy, fatty, spicy and dairy foods.
Raltegravir Antidiarrheal medications such as loperamide can also
be used

Fatigue Zidovudine, Efavirenz Eat nutritious foods to increase energy.

Avoid smoking and drinking alcohol.
Medication can be taken at night
Mood changes, depression and anxiety Efavirenz,Dolutegravir Avoid alcohol and other unprescribed drugs.

Nausea and vomiting Almost all HIV drugs Eat bland foods such as plain rice,crackers.
Avoid fatty foods.
Antiemetic medications e.g promethazine can also be
used
60 Cont…
Side Effects Drugs Implicated Management
Rash NNRTIs e.g Efavirenz , Nevirapine. Moisturize with unscented lotion.
Raltegravir, Emtricitabine e.t.c
Wear breathable fabrics such as cottons.

Antihistamine medications such as

Chlorpheniramine may be used.
Insomnia Emtricitabine, Indinavir, Dolutegravir e.t.c Stick to a set sleep schedule and avoid taking
naps.

Relax before bedtime with a warm bath or any

other calming activity.

Avoid caffeine and other stimulants within a few

hours of bedtime.
Drugs for insomnia such as Diazepam may also
be used.
61 References
 Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants:
Recommendations for a Public Health Approach: 2010 Version.
 World Health Organization. Antiretroviral therapy for HIV infection in adults and
adolescents (2010 revision). 2010
 Volmink, J., et al. 2007. Antiretrovirals for reducing the risk of mother-to-child transmission
of HIV transmission of HIV infection. Cochrane Database of Systematic Reviews.
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