HIV IN PREGNANCY

1. Ms.G.Thanga Anusha Bell
M.Sc(N) II year
College of Nursing,
Madurai Medical College, Madurai

2.  HIV (Human Immunodeficiency Virus)is a
virus that causes AIDS (Acquired
Immunodeficiency Syndrome). An AIDS
infected person cannot fight off diseases as
they would normally and are more
susceptible to infections, certain cancers and
other health problems that can be life-
threatening or fatal.

3.  Acquired immunodeficiency syndrome (AIDS)
is defined in terms of either a CD4+ T cell
count below 200 cells per µL or the
occurrence of specific diseases in association
with an HIV infection.

4. Estimated Range
People living with HIV 34.2million 31.8–35.9million
New HIV infections in 2011 2.5million 2.2–2.8million
Deaths due to AIDS in 2011 1.7million 1.6–1.9million
Global estimates for Adults and Children
2011
3National AIDS Control Programme

5. Disease Burden of HIV in India
Provisional estimates place the number of people
living with HIV in India in 2011 at 20.9 lakhs with
an estimated adult HIV prevalence of 0.27 percent
Available evidence on HIV epidemic in India shows
a declining trend at national level
The epidemic is concentrated among high risk group
populations and is heterogeneous in its spread
Heterosexual route of transmission accounts for
87% of HIV cases detected
Source: HIV Estimations,2008-09
National AIDS Control Programme 4

6. Declining Trends of HIV Epidemic in India
Control Programme
Female: 39% of PLHIV; Children: 7% of PLHIV
National AIDS Source: TechnicalReport India HIV Estimates 2012, NACO & NIMS

7.  National antenatal
prevalence ranges from
0.08% to 5%
 3.64% of all HIV infections
are due to perinatal
transmission
NACO 7
Source: NACO
Level of HIV/AIDS Epidemic in 2005

9.  HIV is transmitted by three main routes:
 sexual contact
 exposure to infected body fluids or tissues
 from mother to child during pregnancy,
delivery, or breastfeeding (known as vertical
transmission)

10.  SIGNS AND SYMPTOMS
 There are three main stages of HIV infection
 acute infection,
 clinical latency
 AIDS

12.  Influenza-like illness
 fever
 large tender lymph nodes
 throat inflammation
 Macula papular rash
 Headache
 Sores of the mouth and genitals
 Nausea,
 Vomiting
 Diarrhea

13.  Fever
 weight loss
 gastrointestinal problems and muscle pains.
 persistent generalized lymphadenopathy

15.  Pneumocystis pneumonia (40%)
 Cachexia in the form of hiv wasting syndrome
(20%)
 Esophageal candidiasis
 Recurring respiratory tract infections
 Opportunistic infections
 people with aids have an increased risk of
developing various viral induced cancers
including
• Kaposi's sarcoma
• Burkitt's lymphoma
• primary central nervous system lymphoma
• cervical cancer

16.  STAGE 1 : ASYMPTOMATIC
 PERS. GEN LYMPHADENOPATHY
 STAGE 2 : UNEXPLAINED MODERATE WEIGHT
LOSS
 RECURRENT RTI
 HERPES ZOSTER
 ANGULAR CHEILITIS
 RECURRENT ORAL ULCERATION
 SEBORRHOEIC DERMATITIS
 FUNGAL NAIL INFECTIONS

17.  STAGE 3:
 UNEXPLAINED SEVERE WEIGHT LOSS MORE THAN 10%
 UNEXPLAINED CHRONIC DIARRHOEA MORE THAN ONE
MONTH
 UNEXPLAINED PERSISTENT FEVER MORE THAN ONE
MONTH
 PERSISTENT ORAL CANDIDIASIS
 Oral hairy leukoplakia
 Pulmonary TB
 SEVERE BACTERIAL INFECTIONS
 ACUTE NECROTIZING ULCERATIVE ORAL INFECTIONS
 UNEXPLAINED ANEMIA,NEUTROPENIA,
THROMBOCYTOPENIA

18.  HIV WASTING SYNDROME
 BACTERIAL PNEUMONIA
 HSV
 OESOPHAGEAL CANDIDIASIS
 EPTB
 KAPOSI SARCOMA
 CMV
 TOXO
 HIV ENCHEPALOPATHY
 CRYPTOCOCCOSIS
 CRYPTO,ISO,MYCOSIS
 SEPTICAEMIA
 LYMPHOMA
 CERVICAL CARCINOMA

19.  Stage 1: CD4 count ≥ 500 cells/µl and no
AIDS defining conditions
 Stage 2: CD4 count 200 to 500 cells/µl and
no AIDS defining conditions
 Stage 3: CD4 count ≤ 200 cells/µl or AIDS
defining conditions
 Unknown: if insufficient information is
available to make any of the above

20.  Nucleoside reverse transcriptase
inhibitors
 Nucleotide reverse transcriptase
inhibitors
 Protease inhibitors
 Non Nucleoside reverse transcriptase
inhibitors
 Entry inhibitors

21.  Nucleoside reverse transcriptase
inhibitors
 Zidovudine 600 mg
 Lamivudine 150 mg
 Stavudine 40 mg
 Didanosine 400 mg
 Abacavir 300 mg

22.  Nucleotide reverse transcriptase
inhibitors
 Tenofovir 300 mg
 Protease inhibitors
 Indinanir 800 mg
 Ritonavir 600 mg
 Entry inhibitors
 Enfuvirtide 90 mg

23.  Mother-to-child transmission (MTCT) is
when an HIV positive woman passes the
virus to her baby.
 This can occur during pregnancy, labour
and delivery, or breastfeeding.
 Without treatment, around 15-30% of
babies born to HIV positive women will
become infected with HIV during
pregnancy and delivery.
 A further 5-20% will become infected
through breastfeeding.

24.  In 2007, around 370,000 children under 15
became infected with HIV, mainly through
mother-to-child transmission.
 About 90% of these MTCT infections occurred
in Africa where AIDS is beginning to reverse
decades of steady progress in child survival.
 In high income countries MTCT has been
virtually eliminated due to effective
voluntary testing and counselling, access to
antiretroviral therapy, safe delivery
practices, and the widespread availability
and safe use of breast-milk substitutes

25. Is the main cause of HIV infection in children
It can occur during:
Pregnancy
Labour and delivery
Breastfeeding
PPTCT TOT

26. Estimated numbers – PPTCT
 Source of Data : TANSACS & NACO
Indicator & year India Tamil Nadu
Pregnancies 27 Million 1.1 Million
AN sero-positivity rate 0.3% 0.87%
Estimated HIV+ mothers 1,00,000 16,000
Transmission rate (in absence
of intervention)
30%
Estimated HIV babies 30,000 5,500

27.  Primary prevention among men and women
of childbearing age
 Prevention of unwanted pregnancies among
HIV-positive women
 Prevention of PTCT from
HIV-positive mothers

28.  Through ICTCs
 783 ICTCs through out Tamil Nadu
 Primary prevention of HIV in childbearing
women
 Provide HIV information to ALL pregnant
women
 Antenatal visits are opportunity for PPTCT
 Intensive group and pre test counselling
 Informed consent
 Post test counselling (for pos and neg)

29. 1
1.13
0.87
0.75
0.65
0.5
0.375
0.25
0
0.2
0.4
0.6
0.8
1
1.2
2000 2001 2002 2003 2004 2005 2006 2007
Year
Percent HIV Prevalence - ANC (%)

30. Option of medical termination of
pregnancy given to positive mothers
If they are willing for MTP then it
should be done

31.  TIME OF TRANSMISSION
 RISKS OF TRANSMISSION
 FACTORS INFLUENCING PTCT
 MODES OF INTERVENTION

32.  Pregnancy (Maternal
Factors)
 Labour and Delivery
(Obstetric Factors)
 Post-partum (Infant
Feeding Factors)
 Infancy (Infant Factors)
Images Courtesy HIV Basics Course for Nurses, I-TECH

33. Risk of HIV Transmission
Transmission
Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
Overall without breastfeeding 15-25%
Overall with breastfeeding up-to six months 20-35%
Overall with breastfeeding for 18-24 months 30-45%
PPTCT TOT

34.  4 possible scenarios
 Pregnant women already on ART
 Pregnant women already on ARV prophylaxis
 Women presenting directly in labour for the first
time and found HIV positive
 Women found to be positive after delivery at
home or a health care facility where HIV test was
not done in ANC or in labour
34

35.  High viral load
 HIV subtype
 Resistant strains
 Advanced clinical stage
 Concurrent STI
 Recent infection
 Viral, bacterial and parasitic (esp. malaria)
placental infection
 Malnourishment

36.  Prevention of PTCT through ART (to mother and
baby) and safe obstetric practices
 Clinical staging of positive mothers
 Baseline cd4 testing
 Treatment of concurrent STIs , recent infections-
viral,bacterial and parasitical
 Safe sex practices
 Nutritional counselling

37. 1. Lifelong ART for HIV-positive pregnant women
in need of treatment
2. Prophylaxis, or short-term provision of ARV's, to
prevent HIV transmission from mother to child
 During pregnancy
 During breastfeeding (as breastfeeding is the
prefered infant feeding option)

38. HIV infected
pregnant
women
Eligible for
Life long
ART?
Yes: Initiate
ART
No: Initiate
ARV
Prophylaxis
Already on
Life long ART
Continue ART
38
38
PPTCT TOT

39.  ART (HAART)?
 ARV Prophylaxis?
39
39
PPTCT TOT

40. • ART (HAART)
• Life long use of ARV drugs to treat HIV infected
pregnant women for her own health (also effective in
PPTCT )
• ARV Prophylaxis
• Short-term use of ARV drugs specifically for PPTCT
(when ART not indicated for mothers own health)
40
40
PPTCT TOT

41.  Reduction of maternal viral load
 Loading fetus with ARVs that prevent
transmitted virions from replicating
41
41
PPTCT TOT

42. Clinical Staging? Immune Status?
42
42
PPTCT TOT

43. Clinical Staging Immune Status
WHO Clinical
Stage 3 or 4
CD4
< 350 cells/ cmm
43
43
PPTCT TOT

44. Pregnant women newly initiating ART
 Start ART as soon as possible after proper preparedness
counseling and continue ART throughout pregnancy, delivery, and
thereafter life long
 Even if the eligible pregnant women present very late in
pregnancy (including those who present after 36 weeks of
gestation) the ART should be initiated promptly
 This ART shall be initiated at ART centers only, hence all efforts
need to be made to ensure that pregnant women reach ART
centres
All pregnant women at ART centre shall be seen on priority
44

45.  The recommended first line ART regimen
for HIV positive pregnant women
Available as a FDC in One single Pill
(If there is no prior exposure to NNRTIs
(NVP/EFV))
TCT ToT MOs
TDF(300mg) + 3TC(300mg) + EFV(600mg)

46. ART regimen for pregnant women having prior exposure to NNRTI for
PPTCT
 A small number of HIV-positive pregnant women who require
lifelong ART for their own health have had previous exposure to
sd-NVP or EVF for PPTCT prophylaxis in prior pregnancies.
Because of the risk of resistance to NNRTI drugs in this
population, an NNRTI-based ART regimen such as TDF/3TC/EFV
may not be effective. Thus, these women will require a protease
inhibitor-based ART regimen.
46

47. FDC of TDF(300mg) + 3TC(300mg)-- 1 tab OD
FDC of LPV(200mg)/r(50mg)----------2 tab BD
(Because of the risk of resistance to NNRTI drugs in this population, an NNRTI
based ART regimen such as TDF/3TC/EFV may not be effective and may be
just a 2 drug regimen—issue of archived resistance)
TCT ToT MOs
TDF + 3TC + LPV/r

48. Pregnant women already receiving ART
 Pregnant women who are already receiving a NVP-based ART
regimen should continue receiving the ART regimen
 Pregnant women who are already receiving EFV-based ART
regimens:
 If pregnancy is recognized before 28 days gestation, EFV should be
stopped and substituted with NVP ( No Lead in dose required)
 If a woman is diagnosed as pregnant after 28 days gestation, EFV should
be continued. There is no indication for abortion/termination of
pregnancy in women exposed to EFV in the first trimester of pregnancy.
48

49. 49
• The indications for co-trimozaxole initiation in pregnant women
follow that for other adults.
• Co-trimoxazole prophylaxis prevents Opportunistic Infections (OIs)
such as Pneumocystis jiroveci pneumonia (PCP), toxoplasmosis,
diarrhoea as well as bacterial infections.
• Cotrimoxazole should be started if CD4 count is < 250
cells/mm3 and continued through pregnancy, delivery
and breast-feeding as per national guidelines
• Ensure that pregnant women take their folate
supplements regularly

50. PPTCT Guidelines 2012

51. WHO Clinical Stage 1-2
with CD4 > 350 cells/cmm
WHO Clinical Stage 1-2,
awaiting CD4 reports
51
51
PPTCT TOT

52. > 14 wk gestation
52
52
PPTCT TOT

53. TDF (300mg) + 3TC (300mg) + EFV (600mg)
53
(FDC once daily pill , preferably to be taken at bedtime )
Triple drug ARV prophylaxis always initiated at ART Centre

54. 54
Don’t Wait for CD4 test report
But always collect CD4 blood sample before ARVs
initiation
This is required for decision on continuation/stopping
ART after breast feeding period is over
54
PPTCT TOT

55. Continue Regimen through pregnancy and delivery
Pregnant Women with CD4>350 cells/mm3
(i.e. not eligible for ART and requires ARV prophylaxis)
Start from 14 weeks of gestation or as soon as possible but not before 14 weeks
TDF + 3TC + EFV
Breastfeeding
Mothers: Continue regimen until 1 week after
breastfeeding has been stopped with 7 days tail of
TDF +3TC
Infants: Daily NVP from birth for 6
weeks.
Replacement feeding only
Mother: TDF + 3TC tail for 7 days
after delivery
Infants: Daily NVP from birth for 6
weeks
PPTCT TOT

56. Breastfeeding Infants
 Mothers: Continue regimen until 1 week after
breastfeeding has been stopped , then 7 days tail
of TDF +3TC
 Infants: Daily NVP from birth for 6 weeks.
56

57. Antenatal Intranatal Postnatal
TDF+3TC+EFV
57
In all scenarios: Infants get daily NVP from birth to 6 wk age
irrespective of mode of feeding
(<2kg: 2mg/kg; 2-2.5kg: 10 mg; >2.5kg: 15 mg)

58. Birth to 6 weeks *
 Birth weight 2000 – 2500
gm
 Birth weight more than
2500 gm
 Infants with birth weight <
2000 gm
10 mg once daily
15 mg once daily
2 mg/kg once
daily. In
consultation with
a pediatrician
trained in HIV
care.
1 ml once a
day
1.5 ml once a
day
0.2 ml/kg once
daily
Up to 6 weeks
irrespective of
breast feeding
or
replacement
feeding
58
58
PPTCT TOT

60. Assessment
Baseli
ne
2
week
s
4
weeks 8 weeks 12 weeks
Every 6
months
Comme
nt
CD 4 count √ Thereafter every 6 months as per guidelines
Blood Sugar* √
Blood Urea /
Sr.Creatinine
√
HBV,* HCV
screening
√
RPR/ VDRL* √
CD 4 count √ Thereafter every 6 months as per guidelines
Due to pregnancy-related haemodilution, absolute CD4 cell
count decreases during pregnancy. Therefore, a decrease in
absolute CD4 count in a pregnant woman receiving ART in
comparison to CD4 values prior to pregnancy may not
necessarily indicate immunologic decline and should be
interpreted with caution.
60

61. Name of ARV Dose Schedule Side-effects
1Tenofovir (TDF) 300mg OD Nephrotoxicity, hypophosphetemia
2Lamivudine (3TC)
150 mg BD/300mg
OD
Rarely pancreatitis
3Efavirenz (EFV) 600 mg HS
CNS toxicity: Vivid dreams, nightmare, insomnia,
dizziness, headache, impaired concentration,
depression, hallucination, exacerbation of
psychiatric disorders (usually subsides by 2-6
weeks)
4
Lopinavir/Ritonavi
r (LPV/r)
400/100 mg BD
Gastro intestinal disturbance, glucose
intolerance, Lipo –dystrophy, dyslipdemia
61
61
PPTCT TOT

62. PPTCT Regimen for women
presenting in labour & their
newborn infants

63.  Vaginal delivery vs. cesarean section
 Uterine manipulation (amnio, external cephalic
version (ECV)
 Prolonged rupture of the membranes (>4 hours)
 Placental Disruption (abruption, chorioamnionitis)
 Intrapartum haemorrhage
 Invasive fetal monitoring (scalp electrode/scalp
blood sampling)
 Invasive delivery techniques (episiotomies,
forceps, use of metal cups for vacuum deliveries)

64.  VAGINAL DELIVERY
 Vaginal cleansing with 0.25% chorhexidine
 Avoid instrumental deliveries
 Do not:
 shave the pubic area
 give an enema
 rupture membranes
 perform episiotomy

65. If the mother is taking combination
antiretroviral therapy then a
caesarean section will often not be
recommended because the risk of
HIV transmission will already be
very low.
 Caesarean delivery may be
recommended if the mother has a
high level of HIV in her blood,

66.  Antenatal
 ART
(TDF+3TC+EFV)
 ARV Prophylaxis
TDF+3TC+EFV
(Triple ARV)
• Intrapartum,
– Continue same ART
(TDF+3TC+EFV)
– Continue Triple ARVs
(TDF+3TC+EFV)
66

67.  If during ANC, the HIV
infected pregnant
women did not
receive any ART or
ARV Prophylaxis
• Intrapartum
– Mother: sd-NVP as
soon as possible
during labour and AZT
+ 3TC every 12 hour
during labour and
than twice daily for 1
week
– Infant: daily NVP from
birth until 6 weeks of
age
67

68. BREASTFEEDING INFANT REPLACEMENT FED INFANT
• Daily NVP from birth till
6 weeks (minimum)
• Mother to be linked
with ART centre and
continue infant NVP
prophylaxis until
mother has been on
effective ART/ARV
prophylactic
regimen(for minimum 6
weeks) .
 Daily NVP from
birth till 6 wks
68

69. Pregnant women coming directly in Labour
Detected HIV Positive using Whole Blood Finger Prick testing in labour / delivery ward
At onset of labour: Single dose Nevirapine once +
AZT + 3TC every 12 hours during labour and delivery
Mother: Continue AZT + 3TC for 7 days after delivery
All Infants: Daily
Nevirapine from
birth for minmum 6
weeks, (See
Advisory#)
Mother: To be linked to
ART centre for initiation
of ART/ARV
prophylactic regimen
ASAP
Intra-partumPost-partum

70.  Born premature
 Low birth weight (<2.5kg)
 First infant of multiple birth
 Altered skin integrity
 Immature GI tract
 Genetic susceptibility
 HLA genotype
 CCR5 karyotype deletion
 Immature Immune System
 Preterm baby

71.  Institute NVP to the baby within 72
hrs.
 Determine mother’s feeding choice
before attaching to breast
 Clean injection site with surgical
spirits before administering injections
 Do not use suction unless absolutely
necessary

72. Mothers with HIV are advised
not to breastfeed whenever the
use of breast milk substitutes
(formula) is
Acceptable,
Feasible,
Affordable,
Sustainable and
Safe

73.  Mother is infected with HIV while breastfeeding
 Breast pathologies (cracked nipples, mastitis, or
engorgement)
 Advanced HIV disease in the mother
 Poor maternal nutrition
 Mouth sores or an inflamed GI tract in baby
 Mixed feeding: Breast milk along with other foods
 Prolonged breast feeding (6-18 months)

74.  Replacement feeding – if affordable, safe and
sustainable
 Exclusive breastfeeding
 Avoiding addition of supplements or mixed
feeding which enhance HIV transmission
 Support good breast health and hygiene
Discussions with mothers about the above must
consider personal, familial and cultural concerns

75.  Observe for signs and symptoms of HIV infection
 All HIV exposed infants should receive
cotrimoxazole at 4-6 weeks of age
 Follow standard immunisation schedule
 Routine well baby visits
 DNA PCR if necessary and available
 18-month visit for HIV testing
Images Courtesy HIV Basics Course for Nurses, I-TECH

76.  Wash newborn after birth, especially face
 Avoid hypothermia
 Give antiretroviral agents, if available
 Breast feeding Issues
 Warmth for newborn
 Nutrition for newborn
 Protection against other infections

77.  Antibody (indirect) tests such as the ELISA
or rapid test cannot confirm HIV infection in
infants younger than 18 months of age
 The infant still carries antibodies from the
mother
 Positive results at this age indicate infection
in the mother (HIV exposure, and possible
infection, of the infant)
Introduction to early infant diagnosis 77

78. Therefore, virologic (direct) tests,
such as DNA and RNA PCR, are
necessary for definitive diagnosis
 Positive DNA or RNA PCR results confirm
the presence of the virus in the infant
Introduction to early infant diagnosis 78

79.  DNA PCR testing is the gold standard for HIV
diagnosis in infants
 Stands for Polymerase Chain Reaction
 Looks for HIV DNA, not antibody
 Extremely accurate, even in newborns
 Most accurate after 6 weeks (>99% sensitivity)
Introduction to early infant diagnosis 79

80. Introduction to early infant diagnosis 80
38
93
99
0
10
20
30
40
50
60
70
80
90
100
Percentagepositive
Birth 14 days 28 days
Age

81. Introduction to early infant diagnosis 81
Early infant diagnosis enables us to:
1. Provide care for exposed & infected infants
2. Assess effectiveness of PMTCT program

82.  HIV progresses rapidly in infants
 High mortality (~50% by age 2)
 First significant illness often ends in death
 Poor growth and development
 Treatment for infants and children now available
 Children respond well to ART; can prevent disease
progression and death
 Treating early improves outcomes
 Diagnosis can guide correct use of CTX (including
excluding unnecessary use in uninfected infants)
 Diagnosis can guide infant feeding choices
Introduction to early infant diagnosis 82

83.  National programme piloted in 2003
 PMTCT now available in most district hospitals
and some health centres
 Testing at 15-18 months cannot accurately show
effectiveness of PMTCT programme
 Many positive babies have died
 Most babies are lost to follow-up
 Poor records of what PMTCT interventions were given
 Early testing gives more accurate data on
programme effectiveness
Introduction to early infant diagnosis 83

84. National AIDS Control Programme
Goal :
Halt and reverse the epidemic in India
Objectives:
Prevention of new infections: Saturate High Risk Group
coverage and scale up of interventions for General
population
Increased proportion of PLHIV receiving care, support
and treatment
Strengthening capacities at district, state and national
levels
National AIDS Control Programme 8

85.  Imbalanced nutritional status less than body
intake
 Acute/ Chronic pain
 Impaired skin integrity
 Impaired oral mucus membranes
 Fatigue
 Anxiety and fear
 Ineffective sleeping pattern
 Disturbed thought process
 Social isolation
 Powerlessness
 Deficient knowledge
 Risk for infection
 Risk for injury
 Risk for deficient fluid volume

86. Thank you.
Are there any questions?
86
PPTCT TOT GK 26.6.12