HIV and Pregnancy: Prevention

of Mother-to-Child Transmission
Advances in Maternal and Neonatal Health
 Session Objectives

l To discuss best practice for antenatal,

intrapartum and postpartum care of the HIV-
positive mother to reduce mother-to-child
transmission
l To review the evidence supporting these
practices

HIV and Pregnancy 2

 The Facts On PMTCT
In 2009:
l About 1,000 babies were infected with HIV every
day during pregnancy, birth or breastfeeding.
l Globally, there are approximately 1.4 million
pregnant women living with HIV in low- & middle-
income countries.
l Only 26% of pregnant women living in these
countries received HIV tests.
l In Eastern & Southern Africa, the region hit
hardest by the epidemic, only half of pregnant
women were tested for HIV.

HIV and Pregnancy 3

 The Facts On PMTCT
l An estimated 53% of pregnant women living with
HIV in the developing world received ARV drugs to
prevent them from transmitting the virus to their
babies.
l In Eastern & Southern Africa, 68% of pregnant
women living with HIV received ARV treatment.
l PMTCT has been implemented in Indonesia since
2007, especially in areas with high levels of HIV
epidemic. Until the end of 2011 the new service is
available 90 PMTCT, reaching about 8% of the
estimated number of women who need the service

HIV and Pregnancy 4

Four Critical Elements or “Prong”
1. Primary prevention of HIV among women of
reproductive age within services related to
reproductive health (15-49 yo) such as ANC,
postpartum care & other health & HIV service
delivery points, including working with
community structures.
2. Providing appropriate counseling & support to
women living with HIV to enable them make an
informed decision about their future
reproductive life, with special attention to
preventing unintended pregnancies.

HIV and Pregnancy 5

Four Critical Elements or “Prong”…..

3. For pregnant women living with HIV,

ensure HIV testing and access to the
antiretroviral drugs that will help mothers’
own health and prevent infection being
passed on to their babies during
pregnancy, delivery and breastfeeding.
4. Better integration of HIV care, treatment
and support for women found to be
positive and their families.

HIV and Pregnancy 6

 PMTCT PROGRAMMES
l HIV testing and counseling during ANC, labour and
delivery and postpartum
l Provision of antiretroviral (ARV) drugs to mother
and infant
l Safer delivery practices
l Infant feeding information, counseling and support
l Referrals to comprehensive treatment, care and
social support for mothers and families with HIV
infection

HIV and Pregnancy 7

HIV and Pregnancy 8
 HIV-Related Counseling Issues
During Pregnancy
l Educate/counsel regarding HIV & pregnancy
before pregnancy:
l Impact of HIV on pregnancy and pregnancy on HIV
l Maternal health
l Long-term health of mother & care for children
l Perinatal transmission
l Use of antiretrovirals & other drugs in pregnancy

HIV and Pregnancy 9

 Pregnancy Effects on HIV
l In all women, the absolute CD4 count
decreases no matter whether HIV-positive or
negative (pregnancy does not make HIV worse)
l In HIV-positive women, percentage of CD4 cells
should not change & viral load should not
change because of pregnancy

HIV and Pregnancy 10

 Adverse Pregnancy Outcomes &
Relationship to HIV Infection
Pregnancy Outcome Relationship to HIV Infection
Spontaneous Limited data, but evidence of possible
abortion increased risk
Stillbirth No association noted in developed countries;
evidence of increased risk in developing
countries
Perinatal mortality No association noted in developed countries,
but data limited; evidence of increased risk in
developing countries
Newborn mortality Limited data in developed countries; evidence
of increased risk in developing countries
Intra-uterine growth Evidence of possible increased risk
retardation

Anderson 2001. HIV and Pregnancy 11

 Adverse Pregnancy Outcomes &
Relationship to HIV Infection (continued)
Pregnancy Outcome Relationship to HIV Infection

Low birth weight Evidence of possible increased risk

Preterm delivery Evidence of possible increased risk, especially w/
more advanced disease
Pre-eclampsia No data
Gestational diabetes No data
Amnionitis Limited data; more recent studies do not suggest
an increased risk; some earlier studies found
increased histologic placental inflammation,
particularly in those with preterm deliveries
Oligohydramnios Minimal data
Fetal malformation No evidence of increased risk
Anderson 2001. HIV and Pregnancy 12
 Mother-to-Child Transmission

l 25–35% of HIV positive pregnant mothers will

pass HIV to their newborns
l In the absence of breastfeeding:
l 30% of transmission in utero
l 70% of transmission during the delivery
l Meta-analysis showed 14% transmission with
breastfeeding & 29% transmission with acute maternal
HIV infection or recent seroconversion

DeCock et al 2000; Dunn et al 1992; WHO/UNAIDS 1999.

HIV and Pregnancy 13
HIV outcomes of infants born to women
infected with HIV

HIV and Pregnancy 14

 Risk Factors for Mother-to-Child
Transmission
Mother Infants
l Viral load (HIV-RNA level)/ l Breastfeeding duration
Genital tract viral load l Preterm delivery & birth
l CD4 cell count weight
l Clinical stage of HIV l Sores at mouth
l Unprotected sex with multiple Obstetric
partners l Placental disruption
l Smoking cigarettes/ Substance l Invasive fetal monitoring
abuse l Duration of membrane
l Nutritional status/ Vitamin A rupture
deficiency l Vaginal delivery vs. cesarean
l STDs & other co infections section
l Breast problems during BF l Labor duration
Anderson 2001. HIV and Pregnancy 15
Maternal & neonatal factors that may
increase the risk of HIV transmission

HIV and Pregnancy 16

 Interventions to Reduce Mother-to-
Child Transmission
l HIV testing in pregnancy
l Antenatal care
l Antiretroviral agents
l Obstetric interventions
l Avoid amniotomy
l Avoid procedures: Forceps/vacuum extractor, scalp electrode,
scalp blood sampling
l Restrict episiotomy
l Elective cesarean section
l Remember infection prevention practices
l Newborn feeding: Breastmilk vs. formula

HIV and Pregnancy 17

 Other Programs
l Feeding management for infants
l Pregnancy planning (contraception)
l Prophylactic ARV treatment for newborn
l Immunization for children
l Diagnostic screening for children

HIV and Pregnancy 18

 HIV Testing during Pregnancy
l Provider Initiated Test & Counseling (PITC)
approach à mother offered HIV test when ANC
visiting after explanation (informed consent), if
agree à pre test counseling (volunteer HIV test
l Advantages of HIV testing:
l Possible treatment of mother
l Reduce risk of mother-to-child transmission
l Future family planning issues
l Precautions against further spread
l If negative, advise about HIV prevention

Counseling is important!
HIV and Pregnancy 19
 Antenatal Care
l Most HIV-infected women will be asymptomatic
l Watch for signs/symptoms of AIDS & pregnancy-
related complications
l Unless complication develops, no need to increase
number of visits
l Treat STDs and other coinfections
l Counsel against unprotected intercourse
l Avoid invasive procedures & external cephalic
version
l Give antiretroviral agents, if available
l Counsel about nutrition

HIV and Pregnancy 20

 Antiretrovirals
l Zidovudine (ZDV):
l Long course

l Short course

l Nevirapine
l ZDV/lamivudine (ZDV/3TC)

HIV and Pregnancy 21

 Pemberian obat antiretroviral (ARV)
untuk ibu hamil dengan HIV:
l Status HIV-nya diketahui sebelum
kehamilan, & pasien sdh mendapatkan ART
à ART tetap diteruskan dgn rejimen yg
sama spt saat sebelum hamil.
l Status HIV-nya diketahui sblm umur
kehamilannya 14 minggu, jika
§ ada indikasi untuk segera diberikan ART, à
berikan ART.
§ tidak ada indikasi à pemberian ART ditunggu
hingga umur kehamilannya 14 minggu.

HIV and Pregnancy 22

Pemberian obat antiretroviral (ARV) untuk
ibu hamil dengan HIV…………

l Status HIV-nya diketahui pada umur

kehamilan ≥ 14 minggu à segera diberikan
ART berapapun nilai CD4 & stadium
klinisnya.
l Status HIV-nya diketahui sesaat menjelang
persalinan à segera diberikan ART sesuai
kondisi klinis ibu.

HIV and Pregnancy 23

 Hal-hal yang perlu diperhatikan dlm
pengobatan ARV pada ibu hamil
1. Pemberian ART disesuaikan dgn kondisi klinis ibu.
2. Pilihan terapi yg direkomendasikan utk ibu hamil
HIV (+): paduan tiga obat ARV (2 NRTI & 1 NNRTI).
3. Pemantauan thdp kemajuan pengobatan (scr klinis
& laboratorium), tmsk pemantauan jml sel CD4,
gejala/ tanda & pengobatan IO
4. Pemantauan efek samping, toksisitas & interaksi
obat ARV & tanda kegagalan terapi
Pemerintah menyediakan ARV utk ibu hamil HIV à me↓
risiko penularan HIV dari ibu ke anak, termasuk utk
tujuan pengobatan jangka panjang.
HIV and Pregnancy 24
 Pemberian Obat ARV pada ibu Hamil
Situasi Klinis Rekomendasi pengobatan
(paduan untuk ibu)
ODHA dengan • AZT + 3TC + NVP atau
indikasi Terapi ARV • TDF + 3TC (atau FTC) + NVP*
dan kemungkinan
hamil atau sedang Hindari EFV pada trimester pertama:
hamil • AZT + 3TC + EFV** atau
• TDF + 3TC (atau FTC) + EFV**
ODHA sedang terapi • Lanjutkan paduan (ganti dengan NVP atau
ARV, kemudian hamil golongan PI jika sdng menggunakan EFV pd
trimester I)
• Lanjutkan dgn paduan ARV yg sama selama
dan sesudah persalinan
ODHA hamil dgn jmlh Mulai ARV pada minggu ke-14 kehamilan
CD4 >350/mm3 atau Paduan sesuai dengan butir 1
dlm stadium klinis 1

HIV and Pregnancy 25

Pemberian Obat ARV pada ibu Hamil ......
Situasi Klinis Rekomendasi pengobatan
(paduan untuk ibu)
ODHA hamil dengan Segera mulai terapi ARV
jumlah CD4 <350/mm3
atau stadium klinis 2,3, 4
ODHA hamil dengan • OAT yang sesuai tetap diberikan
tuberkulosis aktif • Paduan untuk ibu, bila pengobatan
mulai trimester II dan III: AZT (TDF) +
3TC + EFV
Ibu hamil dalam masa • Tawarkan tes HIV dalam masa
persalinan dan status HIV persalinan; atau tes setelah persalinan
tidak diketahui • Jika hasil tes reaktif, dapat diberikan
paduan pada butir 1
ODHA datang pada masa Paduan pada butir 1
persalinan dan belum
mendapat Terapi ARV

HIV and Pregnancy 26

 ZDV Perinatal Transmission
Prophylaxis Regimen: ACTG 076 Trial

Antepartum Initiation at 14–34 weeks gestation and

continued throughout pregnancy
l PACTG 076 regimen: ZDV 5 times daily
l Acceptable alternative regimen: ZDV 2 or 3
times daily (depending on dose)
Intrapartum During labor, ZDV IV over 1 hour, followed by a
continuous infusion of IV until delivery
Postpartum Oral administration of ZDV to newborn for first
6 weeks of life, beginning at 8–12 hours after
birth

Anderson 2000. HIV and Pregnancy 27

 Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy
Drug Maternal Newborn Data on
Regimen Intrapartum Postpartum Transmission
Nevirapine One oral dose One oral dose at Transmission at 6
at onset of age 48–72 hours (if weeks 12% with
labor mother received nevirapine
nevirapine < 1 hour compared to 21%
before delivery, with ZDV, a 47%
newborn given oral (95% CI, 20–64%)
nevirapine as soon reduction
as possible after
birth and at 48–72
hours)

Anderson 2001. HIV and Pregnancy 28

 Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy (cont’d.)
Drug Maternal Newborn Data on
Regimen Intrapartum Postpartum Transmission
ZDV/3TC ZDV orally at ZDV orally every Transmission at
onset of labor 12 hours 6 weeks 10%
followed by with ZDV/3TC
AND
dose orally compared to
every 3 hours 3TC orally every 17% with
until delivery 12 hours for 7 placebo, a 38%
AND days reduction
3TC orally at
onset of labor,
followed by
dose orally
every 12 hours
Anderson 2001. HIV and Pregnancy 29
 Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy (cont’d.)
Drug Maternal Newborn Data on
Regimen Intrapartum Postpartum Transmission
ZDV IV bolus, Orally every 6 Transmission
followed by hours for 6 10% with ZDV
continuous weeks compared to
infusion of every 27% with no
hour until ZDV treatment,
delivery a 62% (95% CI,
19-82%)
reduction

Anderson 2001.

HIV and Pregnancy 30

 Intrapartum vs. Postpartum Regimens
for HIV-Infected Women in Labor with
No Prior Antiretroviral Therapy (cont’d.)
Drug Maternal Newborn Data on
Regimen Intrapartum Postpartum Transmission
ZDV and IV bolus, then Orally every 6 No data
Nevirapine continuous hours for 6
infusion until weeks
delivery AND
AND Nevirapine single
Nevirapine single oral dose at age
oral dose at 48–72 hours
onset of labor

Anderson 2001. HIV and Pregnancy 31

 Obstetric Procedures
Because of increased fetal exposure to infected
maternal blood and secretions, increased
transmission may come from:
l Amniotomy
l Fetal scalp electrode/sampling
l Forceps/vacuum extractor
l Episiotomy
l Vaginal tears

HIV and Pregnancy 32

 Delivery: Cesarean vs. Vaginal Birth
l Risk of mother-to-child transmission increased 2%
each hour after membranes have been ruptured
l Cesarean section before labor &/or rupture of
membranes reduces risk of mother-to-child
transmission by 50–80% compared with other modes of
delivery in women on no antiretroviral therapy or on
ZDV alone
l No evidence of benefit with cesarean section after
onset of labor or membranes have been ruptured
l Cesarean section, however, increases morbidity &
possible mortality to mother
l Give antibiotic prophylaxis for cesarean section in HIV-
infected women

International Perinatal HIV Group 1999;

Semprini 1995. HIV and Pregnancy 33
 Recommended Infection
Prevention Practices
l Needles:
l Take care! Minimal use
l Suturing: Use appropriate needle and holder
l Care with recapping and disposal
l Wear gloves, wash hands with soap
immediately after contact with blood & body
fluids
l Cover incisions with watertight dressings for
first 24 hours

HIV and Pregnancy 34

 Recommended Infection
Prevention Practices (continued)

l Use:
l Plastic aprons for delivery
l Goggles and gloves for delivery and surgery
l Long gloves for placenta removal
l Dispose of blood, placenta and waste safely
l PROTECT YOURSELF!

HIV and Pregnancy 35

 Newborn

l Wash newborn after birth,

especially face
l Avoid hypothermia
l Give antiretroviral
agents, if available

HIV and Pregnancy 36

 Breasfeeding Issues
l Warmth for newborn
l Nutrition for newborn
l Protection against other
infections
l Safety – unclean water, diarrheal
diseases
l Risk of HIV transmission
l Contraception for mother
l Cost

HIV and Pregnancy 37

 Breastfeeding Recommendations
If the woman is:
l HIV-negative or does not know her HIV status,
promote exclusive breastfeeding for 6 months
l HIV-positive & chooses to use replacements
feedings, counsel on the safe and appropriate use of
formula
l HIV-positive & chooses to breastfeed, promote
exclusive breastfeeding for 6 months

HIV and Pregnancy 38

AFASS Principles for Feeding Replacement
AFASS means the mother/family:
l Accept not to breastfeed & thus use exclusive replacement
feeding through Breast Milk Substitute (BMS).
l Consider the Breast Milk Substitute Feasible given the
extended family/community but also nature of work and
lifestyle of the mother/ family.
l Can Afford to supply enough Breast Milk Substitute feeds
for the duration the child needs the alternative e.g. 6
months + other 12-18 months when on complementary
foods.
l Can Sustain the supply of the Breast Milk Substitute &
sustain support from the family.
l Will maintain Safe conditions for the feeds, e.g. in that they
have water, storage facilities & sanitation standards.
HIV and Pregnancy 39
 AFASS Assessment Table
Replacement
Question Breastfeeding
feeding
Piped water at home
Where do you get your River, stream, pond, or
or can buy clean
drinking water? well
water
What kind of latrine/toilet do Waterborne latrine or
None or pit latrine
you have? flush toilet
How much money could you Less than minimum
afford for formula each Minimum amount
required amount
month? required for formula
available for formula
ps: calculate the amount based every month
each month
on the local costs
Do you have a refrigerator No, or irregular power
Yes
with reliable power? supply
Can you prepare each feed
with boiled water & clean No Yes
utensils?
HIV and Pregnancy 40
 AFASS Assessment Table…contd

Replacement
Question Breastfeeding
feeding
Preparation of
How would you arrange Preparation of milk
milk feeds at night
night feeds? feeds at night difficult
possible.
Does your family know
that you are HIV No Yes
positive?
Family not
Is your family supportive supportive & not
Family supportive
of milk feeding & are they willing to help, or
& willing to help
willing to help? don’t know- can’t
discuss?

HIV and Pregnancy 41

 AFASS Criteria
l Acceptable: The mother perceives no problem in
replacement feeding. Potential problems may be cultural,
social, or due to fear of stigma & discrimination.
l Feasible: The mother (or family) has adequate time,
knowledge, skills, resources & support to correctly mix
formula or milk & feed the infant up to 12 times in 24 hours.
l Affordable: The mother & family, with community or health
system support if necessary, can pay the cost of
replacement feeding without harming the health or nutrition
status of the family.
l Sustainable: Availability of a continuous supply of all
ingredients needed for safe replacement feeding for up to
one year of age/ longer.
l Safe: Replacement foods are correctly & hygienically
prepared & stored, & fed preferably by cup.
Source: IMCI Complementary Course on HIV/AIDS; Module 3; Counseling the HIV Positive Mother. WHO 2007
35
HIV and Pregnancy
 South Africa Breastfeeding Trial:
Objective & Design

l Objective: To assess whether pattern of

breastfeeding is a critical determinant of early
mother-to-child transmission of HIV
l 549 HIV-infected women studied
l Compared newborns at 3 months that had
been:
q Exclusively breastfed
q Breastfed and formula-fed
q Never breastfed

Coutsoudis et al 1999.
HIV and Pregnancy 43
 South Africa Breastfeeding Trial:
Results and Conclusion
l Risk of transmission in:
l 156 newborns who were never breastfed: 18.8%
(95% CI 12.6–24.9)
l 288 newborns who were breastfed and formula fed:
24.1% (95% CI 19.0–29.2)
l 103 newborns who were exclusively breastfed: 14.6
(95% CI 7.7–21.4)
l Conclusion: Newborns who were exclusively
breastfed for at least 3 months did not have any
excess risk of HIV infection compared to newborns
who were not breastfed

Coutsoudis et al 1999.
HIV and Pregnancy 44
 Reminder!
l Bila AFASS bisa dipenuhi à makanan bayi dari ibu
HIV (+): pemberian susu formula.
l Bila AFASS tidak bisa dipenuhi maka ASI boleh
diberikan dgn ketentuan:
q ASI Eksklusif selama 6 bulan,
q sudah mendapatkan konseling managemen laktasi,
q ibu sudah minum ARV minimal 4 - 6 minggu & tdk
ada kontra indikasi lain utk pemberian ASI.

Sangat tidak dianjurkan menyusui campur à memiliki risiko paling

tinggi penularan virus HIV pada anak. Hal ini disebabkan pemberian
susu formula yg merupakan benda asing dpt menimbulkan perubahan
mukosa dinding usus yg mempermudah masuknya HIV dalam ASI ke
peredaran darah
HIV and Pregnancy 45
Alur Proses PMTCT

HIV and Pregnancy 46

 Nursing Care
General goals:
l Recognize the risk population
l Recognize the signs & symptoms
l Teach the client about the infection
l Teach the client how to prevent infection
l Teach the client about medications & other
treatments
l Stress the importance of compliance with the
medication regimen & other treatments
l Emphasize the importance of follow-up visits to
ensure that the infection is controlled
HIV and Pregnancy 47
 Nursing Care: Assessment
l Health history l Physical assessment
q Reason for seeking care l Diagnostic test
q Menstrual history l Blood test
q Contraceptive history – CBC
q Genitourinary problems – ELISA/Quick test
q Additional medical history l Urine test
q Surgical history l Others
q Allergies
q Personal habits
q Sleep & rest patterns
q Stress
q Sexuality patterns
q Social support patterns
HIV and Pregnancy 48
 Nursing Care: Nursing diagnoses
l Altered nutrition: less than l Hopelessness r/ to lack of a
body requirements, r/ to cure for AIDS
nausea l Powerlessness r/ to AIDS
l Risk for infection r/ to l Self esteem disturbance r/
AIDS to physical changes caused
l Impaired tissue integrity r/ by AIDS
to OI l Non compliance r/ to dislike
l Fatigue r/ to altered the treatment regimen
immune response l Sexual dysfunction r/ to
l Anxiety r/ to stigma concerns about
associated with AIDS transmitting HIV infection to
l Ineffective individual partner
coping r/ to denial of AIDS
l Fear r/ to impending death
HIV and Pregnancy 49
Nursing Care: Planning & implementation
l Teach about the infection
l Teach about treatments
l Teach about the infection prevention
l Take infection control measures
l Provide support
l Make referrals
l Care of the family
l Promote compliance

EVALUATION

HIV and Pregnancy 50

 Primary Prevention
l A (Abstinence): Absen berhubungan seks
atau sama sekali tidak melakukan hubungan
seks bagi orang yang belum menikah;
l B (Be Faithful): Bersikap saling setia kepada
satu pasangan seks (tidak berganti-ganti
pasangan);
l C (Condom): Cegah penularan HIV melalui
hubungan seksual dgn menggunakan
kondom;
l D (Drug No): Dilarang menggunakan napza.

HIV and Pregnancy 51

 CONTRACEPTION

Kontrasepsi pada ibu/perempuan HIV

positif (dual protection):
l Menunda/mengatur kehamilan =
kontrasepsi jangka pendek + kondom
l Menunda/mengatur kehamilan =
kontrasepsi jangka panjang + kondom
l Memutuskan tidak punya anak lagi =
kontrasepsi mantap + kondom

HIV and Pregnancy 52

 Conclusion
l Voluntary counseling & testing
l Antenatal, intrapartum & postpartum care to
mother can decrease risk of mother-to-child
transmission
l Antiretroviral therapy can also reduce risk of

transmission
l Newborn care: Feeding

HIV and Pregnancy 53

Conclusion…….
l Voluntary counseling & testing
l Antenatal, intrapartum &
postpartum care to mother can
decrease risk of mother-to-child
transmission
l Antiretroviral therapy can also
reduce risk of transmission
l Newborn care: Feeding

HIV and Pregnancy 54

 References
Anderson J (ed). 2001. A Guide to the Clinical Care of Women with HIV,
2nd ed. U.S. Department of Health and Human Services, Health
Resources and Services Administration: Rockville, Maryland.
Coutsoudis A et al. 1999. Influence of infant-feeding patterns on early
mother-to-child transmission of HIV-1 in Durban, South Africa: A
prospective cohort study. Lancet 354: 471–476.
DeCock K et al. 2000. Prevention of mother-to-child transmission in
resource-poor countries: Translating research into policy & practice. J
Am Med Assoc 283(9): 1175–1182.
Dunn D et al. 1992. Risk of HIV-1 transmission through breastfeeding.
Lancet 340(8819): 585–588.
Gray G. 2000. The PETRA study: Early & late efficacy of three short
ZDV/3TC combinations regimens to prevent mother-to-child
transmission of HIV-1. XIII International AIDS Conference, Durban,
South Africa.
International Perinatal HIV Group. 1999. The mode of delivery and the
risk of vertical transmission of human immunodeficiency virus type 1.
N Engl J Med 340(14): 977–987.
HIV and Pregnancy 55
 References (continued)
Mandelbrot L et al. 1996. Obstetric factors and mother-to-child transmission
of human immunodeficiency virus type 1: The French perinatal cohorts. Amer
J Obstet Gynecol 175(3 pt 1): 661–667.
Semprini AE et al. 1995. The incidence of complications after cesarean
section in 156 women. AIDS 9:913–917.
Shaffer N et al. 1999. Short-course ZDV for perinatal HIV-1 transmission in
Bangkok, Thailand: A randomized controlled trial. Lancet 353: 773–780.
Sperling RS et al. 1996. Maternal viral load, ZDV treatment, and the risk of
transmission of HIV type 1 from mother to infant. N Engl J Med 335(22): 1621–
1629.
UNICEF/UNAIDS/WHO Technical Consultation on HIV and Infant Feeding.
1998. HIV and Infant Feeding: Implementation of Guidelines. WHO: Geneva.
World Health Organization (WHO)/Joint United Nations Programme on
HIV/AIDS (UNAIDS). 1999. HIV In Pregnancy: A Review. WHO/UNAIDS:
Geneva.

HIV and Pregnancy 56