HIV in pregnancy

Outline
Introduction
PMTCT
Describe Antepartum, intrapartum and post partum management of
HIV positive women
What is HIV ?
HIV / AIDS is one of the public health problem caused by infection
with the human immunodeficiency virus.
HIV is a member of the Retroviridae family, characterized by
spherical, enveloped viruses.
Retroviruses are unique because the viral genome is transcribed into
DNA via the viral enzyme reverse transcriptase
HIV also has the capacity to become latent within quiescent infected
cells
HIV predominantly infects CD4+ cells, including T cells, monocytes,
and macrophages
Epidemiology
37 million individuals affected
An estimated 0.8% of adults aged 15–49 years worldwide are living with HIV
<15 years=1.8 million living with HIV
n Ethiopia: 0.9% in 15-49 age range
◦ Age 15-49 is 0.6%
◦ Peak is 3% at 35-39 years.
HIV prevalence among women
◦ Age 15-49 is 1.2%
◦ Peak is 3% at the age group 30-44 years
Urban =2.9% and rural 0.9%
Mode of HIV infection and transmission
sexual contacts,
MTCT
IV drug and/or crack cocaine use
the presence of other STD
Blood transfusion
MTCT
MTCT is the transmission of HIV virus from the mother to the fetus
and child during pregnancy, childbirth and breastfeeding.
Several factors put a woman at a higher risk of transmitting HIV to
her child
Cont..
Factors that increase MTCT
The risk of mother to child transmission (MTCT) varies during
pregnancy, labor and delivery and breastfeeding
The factors are:
◦ Maternal factory
◦ Obstetric factors
◦ Infants factors
Maternal factors
High maternal viral load.
New or recently acquired maternal HIV infection.
Low CD4 count.
Advanced maternal disease.
Viral or parasitic placental infections during pregnancy, labor and childbirth.
Maternal malnutrition.
Nipple fissures, cracks, mastitis and breast abscess.
Poor ART adherence.
Active lower genital tract infections like herpes simplex
Infant factors
First infant in multiple birth
Pre-maturity and low birth weight
Longer duration of breastfeeding
Mixed feeding during the first six months of life
Oral diseases in child
Obstetric and delivery practices
vaginal and cervical tears
Invasive childbirth procedures (e.g. episiotomy).
The first twin in vaginal delivery of multiple pregnancies.
instrumental deliveries (vacuum & forceps).
Fetal birth trauma
Ante-partum procedures (e.g. amniocentesis, external cephalic
version) and Rupture of membrane for more than four hours
Cont..
Trans-placental HIV transmission can occur early, and the virus has
even been identified in specimens from elective abortion
20 percent
50 percent in the days before delivery
30 percent intrapartum.
Transmission rates for BF as high as 30 to 40
PREVENTION OF MTCT OF HIV
PMTCT is the prevention of transmission of HIV virus from the
mother to the fetus and child during pregnancy, childbirth and
breastfeeding
Effective use of: available medications, appropriate labor and delivery
protocols, optimal breastfeeding practices can reduce a child’s overall
risk to less than 5%.
For example, provision of ART to a mother throughout the
breastfeeding period can reduce the risk of postnatal MTCT by more
than 50%.
PRONG 1: Primary prevention of HIV
infection
Focuses on keeping people HIV-negative.
Prevention of new infections means that fewer women and men will
have HIV and fewer infants will be exposed to HIV.
Promote ABCD (Abstinence, Be-faithful, use Condom and Discussion on
sex and sexuality issues)
Provide early diagnosis and treatment of sexually transmitted infections.
Make HTC widely available.
Provide pretest test information.
promote the benefits of early HIV diagnosis and ART initiation
PRONG 2: Prevention of unintended
pregnancies in HIV-positive women
Emphasizes on reducing the number of unplanned or unwanted
pregnancies
PITC in all family planning (FP) services and adhere to FP
Provide 24/7 emergency contraceptives for HIV positive women and
girls
Provide safe pregnancy counseling
Integrate FP services in routine postpartum care of all women,
including those living with HIV
Prong 3 Prevention of HIV transmission from
infected women to their infants
Ensure PITC integrated into ANC, labor & delivery and postnatal care
and FP services and management of cases accordingly
Provide ART for pregnant, laboring and lactating women HIV positive
Promote safer obstetric practices
Involve and encourage mutual disclosure and couple’s counseling and
testing
Promote disclosure counseling and manage accordingly, as well as in
the emergency and birth preparedness planning during pregnancy
and delivery
Prong 4 Treatment, care and support of HIV
infected women, their infants and their families
Provide life long ART for pregnant, laboring and breastfeeding women living
with HIV to improve their own health, and prophylaxis for their newborns
Monitoring viral suppression with viral load testing
For newly diagnosed pregnant mother VL done after three months of ART
initiation and then every six months
Provide HIV testing early during pregnancy and follow-up care for families
to increase access and utilization of PMTCT services
Provide follow-up for HIV-exposed infants and cotrimoxazole prophylaxis
Give nutritional support infants and HIV-infected women
Early screening of OI based no their CD4+
Management of HIV positive pregnant women
The management principle of HIV positive pregnant women are
◦ Preconception
◦ Antepartum including mode of delivery
◦ Intrapartum
◦ Post partum
Preconception
In addition to baseline investigations, CD4 and viral load determined
Adequate caloric intake; consumption of iron rich foods
iron and folate for three months;
Screening & treatment for opportunistic infections & STIs.
Avoid pregnancy for 6 months after recovery from any chronic
infections (e.g. Tb).
Cont..
Initiate ART/ link to PMTCT unit.
Discuss on future plan for pregnancy and necessary preparations
Provision of prophylaxis for opportunistic infections: Cotrimoxazole
for stages 2, 3, 4 HIV/AIDS and those with CD4 <=350
If the patient has plan of pregnancy counsel on the following:
◦ The impact of HIV on pregnancy.
◦ The risk of MTCT.
◦ Available methods for reduction of MTCT
Antepartum Care/Antenatal care
In addition to the routine ANC, HIV positive pregnant women need
special care and should have more visits.
Prior and ongoing ARV drug use, duration, whether treatment was for
maternal benefit and/or to prevent perinatal HIV transmission,
adherence and tolerance issue
CD4 count and HIV viral load
All HIV positive pregnant, laboring and lactating women should be
retested at the initiation of HAART in order to ensure correct diagnosis
All HIV positive pregnant, laboring and lactating mothers start HAART
for life (TDF, 3TC and DTG)
Cont..
HIV positive woman already on ART at time of pregnancy should
continue and stay on the same regimen.
WHO clinical stage 1 and 2 can safely be initiated on ART in ANC
(WHO stage 3 and 4) and opportunistic infections should promptly be
referred to ART clinic for diagnosis and treatment of OI and initiation
of ART
Monitoring and support for HAART adherence
Cont..
Routine laboratory screening tests
Discuss on the postpartum infant feeding plan
Nutritional supplementation like in other pregnant women.
Follow the fetal growth with serial US every 3-4 weeks.
Viral load monitoring to detect emergence of treatment failure.
Cont..
Patients who enter pregnancy on ART with complete viral
suppression should continue their current therapy;
if a component of their regimen is contraindicated in pregnancy, the
regimen should be altered without therapy interruption
If pregnancy-associated vomiting interferes with ongoing adherence
to therapy, antiemetics should be aggressively used prior to
discontinuing therapy
Follow the fetal growth with serial US every 3-4 weeks
For the best pregnancy outcome and
reduction of potential risk, HIV positive
pregnant women should be assessed for:
◦ Past history of HIV-related illness
◦ Duration of knowledge of HIV-positive status
◦ Symptoms of AIDS as per WHO Clinical Staging
◦ HIV and health status of other children, if any, and partner
◦ Partner testing/management and disclosure
◦ Any potential factor that can hamper the adherence to HAART (such as
alcohol or substance use, stigma
◦ Non-communicable diseases (NCD)
◦ Nutritional status (MUAC and Weight
Antiretroviral therapy:

The ideal ART regimen should be

durable virologic suppression with immunologic and clinical improvement,
well tolerated with a simple dosage regimen,
effective in pregnancy in terms of reducing perinatal HIV transmission.
HIV treatment reduces maternal disease progression, and both ART and
viral load at delivery are independent risk factors for HIV transmission;
ART is recommended for all women, independent of viral load suppression
Cont..
strategy to suppress viral load and minimize vertical HIV
transmission includes
1. Pre conception ART,
2. antepartum ART,
3. intrapartum continuation of the antepartum oral ART regimen plus IV
zidovudine, and
4. newborn ART prophylaxis
Treatment reduces the risk of perinatal transmission regardless of
CD4 T-cell count or HIV RNA level
Cont…
Pregnant women are treated with at least three antiretroviral (ARV)
agents.
The current recommended regimen for newly HIV positive are TDF,
3TC and DTG).
There are four different scenarios during pregnancy are
• On ART
• Naïve for ART
• Prior ART but not currently
• No ART use and present in labor
Rationale for using TDF/3TC/EFV in HIV
positive pregnant women
NVP containing regimen can cause severe toxicity in patients with
high CD4 count.
TDF is more suitable for HIV+ pregnant women than AZT because it
does not cause anemia which is common during pregnancy; and is
less likely to cause long term side effects.
TDF/3TC also treats Hepatitis B virus co-infection
TDF and 3TC can be given once a day.
Intrapartum care: Labor and Delivery
Most pediatrics HIV infection occurs through transmission from the
mother during pregnancy, labor and delivery and breastfeeding and is a
critical period for prevention of MTCT.
During labor, every effort should be made to avoid instrumentation
that increases the neonate’s exposure to infected maternal blood and
secretions
Recommendations include:
• limit vaginal examinations during labor
• Treat acute chorioamnionitis promptly
Cont..
• the fetal membranes intact as long as possible,
• avoiding fetal scalp sampling and fetal scalp electrode placement, and
• reserving episiotomy and assisted vaginal delivery for select
circumstances.
• If SROM occurs, augmentation and/or induction of labor with pitocin
should not be delayed
• For intrapartum patients with viral loads greater than 1000, IV ZDV
should be given
Cont..
• If she is a newly diagnosed RVI patient and not started on ART it
should be started intrapartum and continued post-partum
irrespective of the CD4 count
Mode of Delivery
The mode of delivery of HIV positive women is determined based
viral load and status (VAGINAL Vs ELECTIVE C/S
DELIVERY)
AOCG (2020c) suggests that scheduled cesarean delivery be
discussed and recommended for HIV -infected women with HIV -1
RNA load >1000 copies/mL
ELECTIVE C/S DELIVERY
Scheduled delivery is recommended at 38 weeks’ gestation in these women to
avoid spontaneous labor.
Management of women with either HIV -1 RNA load >1000 copies/mL or
unknown viral load who present in labor or with ruptured membranes is
individualized
Patients should receive IV ZDV for 3 hours prior to surgery, and prophylactic
antibiotics should be administered.
CD is not indicated if viral copies is < 1000/ml , because the transmission rate in
this group of women is 1.0% or less
In recent study women showed that the perinatal HIV transmission rate in women
who received at least 14 days of ART was 0.8% regardless of the mode of delivery
Spontaneous Rupture of Membranes
 Increasing duration of ruptured membranes is associated with
perinatal HIV transmission increment but related to viral load
After ROM the rate increases by 2% per hour over the baseline
a patient on ART with an undetectable viral load has a baseline
perinatal HIV transmission rate of 2%, the risk of transmission after 1
hour of ruptured membranes would be 2.04%, and after 8 hours, the
risk of HIV transmission would be 2.32%
Postpartum Care of Women with HIV
For the neonate
Give NVP + AZT syrup for the first 6 weeks and continue NVP syrup
only for the next 6 weeks for all HIV exposed infants
For mothers who fulfill Acceptable, Feasible, Affordable, Sustainable
and Safe (AFASS) criteria, formula feeding should be considered after
thorough discussion with the family
Cont..
Educate mothers on the importance of exposed infant follow-up, Co-
trimoxazole preventive therapy and early infant diagnosis
DBS for DNA/PCR –done at 6wk
if negative followed as HIV Exposed Infant and do rapid HIV antibody
test after cessation of breastfeeding
Positive linked to pediatric ART for HIV/AIDS follow up
Thank u