HIV/AIDS IN PREGNANCY

Hassan I.N, MMed 4

KEY OBJECTIVES
At the end of this session, you should to be able to :

1.Describe the epidemiology of MTCT

2.Describe the effects of HIV on pregnancy

3.Describe the effects of pregnancy on HIV disease

4.DescribeMTCT , factors that may increase transmission, and

measures that reduce transmission

5.Describe how ART is used for the prevention of MTCT

6.Discuss national guidelines on infant feeding in the context of HIV

 Epidemiology
 The HIV pandemic remains a major public health problem
worldwide, with devastating effects in Sub-Saharan Africa
 In Sub-Saharan Africa, women account for almost 60% of
the adults living with HIV.(UNAIDS Global Report, 2012).
 In Tanzania, an estimated 5% of adults age 15–49 are
infected with HIV.
 Rural HIV prevalence (4.3%) is lower than that of urban
areas (7.2%).
 HIV prevalence is higher among women (6.2%) than men
(3.8%), (THMIS 2012),
Ctd…………
 It is estimated that 200,000 children under 15 years
of age are living with HIV (UNAIDS 2010), and
that 90% of them may have acquired the
infection through MTCT.
 Virological and Immunological
Goals of ART
CD4+ T cell count
Viral load

800-1200

50,000

200

Undetectabl
e
Days Years Treatment begun
Major Steps in HIV Lifecycle
1. HIV attaches to CD4 cell &
releases RNA & enzymes
2. Enzyme Reverse
Transcriptase makes a DNA
copy of viral RNA
3. New viral DNA integrated
using enzyme integrase into
CD4 cell nucleus
4. New viral components
produced, using cell’s
“machinery”
5. These are assembled together
using enzyme protease
6. Then released as new
Susceptiblity of women to HIV infection
A.Biological Factors:
1) Langerhan cells at the cervix have affinity
to HIV-1 viral subtypes e.g.subtype E.
2).Early exposure to sex predispose them to STDs
and inflamation
B.Social Cultural Factors:
1).Gender inequality
women take care of the sick; have limited acess to information &
inadequate formal education;& lack of dicision making power
2).Lack of economic power—comercial sex
3).Cultural-wife cleansig ,inheritance, and dry sex.
Effect of pregnancy on disease HIV
Progression
 In pregnancy both HIV negative and HIV infected women
there is a decline in CD4 cell counts and this is thought to
be due to hemo- dilution

 CD4 percentage remains relatively stable: there is no

difference between HIV pregnant and non pregnant women

 Therefore CD4 percentage rather than absolute count

would be a more accurate measure of immune function for
HIV infected women.
EFFECT OF PREGNANCY ON DISEASE
PROGRESSION-CONT’D

Most studies have not demonstrated pregnancy accelerating

the HIV disease progression.

Thissuggests that pregnancy does not accelerate the decline

in CD4 cells.

Pregnancy does not affect the course of HIV Infection

Effect of HIV on pregnancy course and
outcome
 Spontaneous abortion:
 Limited data but evidence of increased risk

 Stillbirth:
 evidence of increased risk

 Intrauterine growth retardation:

 Evidence of increased risk
Pregnancy course and outcome cont’d
 Low birth weight(<2500g):
 Evidence of increased risk.
 Preterm delivery:
 Evidence of possible increased risk especially
with more advanced disease
 Fetal malformation: No evidence of increased
risk
 MTCT-Acquisition of HIV infection from the
mother
Mother-to-child transmission of HIV
(MTCT)
 Mother-to-child transmission (MTCT) of HIV
refers to the transmission of HIV infection from
HIV-infected mothers to their infants.

 MTCT can occur during pregnancy, labour and

delivery, and breastfeeding.

 Without intervention, the overall risk of MTCT is

approximately 20% to 45%.
MTCT
 RISK FACTORS FOR MTCT

 There are multiple risk factors that increases the

chance of MTCT of HIV.

 These include:

1. Viral Factors
2. Maternal factors
3. Obstetric factors
4. Neonatal factors
5. Postnatal factors
VIRAL FACTORS
 Viral load:
 high maternal viral load occurs in new infection
with HIV or advanced AIDS.
 Viral strain:
 transmission is higher with HIV-1 than HIV-2.
 It is also higher with C and E subgroups.
 Viral resistance:
 pre-existing resistance to available ARV drugs
 MATERNAL FACTORS
1. Placental infections e.g malaria
2. Genital tract infections
3. APH
4. PROM and/or choriomnionitis
5. Prolonged labour
6. Complicated deliveries eg breach delivery
 OBSTETRIC FACTORS:
 Mode of deliveries: elective CS reduces the risk
 Intrapartum haemorrhage
 Obstetric procedures:
 early amniotomy,
 episiotomies,
 vacuum deliveries,
 forceps
NEONATAL FACTORS:
 Prematurity

 Neonatal infections
 oral thrush,

 gastritis
 POSTNATAL FACTORS:
 Breast conditions eg
 mastitis,
 abscess,
 nipple cracks
 Pattern of infant feeding eg
 Prolonged Breast Feeding,
 Mixed feeding
PMTCT
 Consists of 4 elements that are :
1. Primary prevention of HIV among women of
childbearing age and their partners
2. Prevention of unintended pregnancies among
women living with HIV
3. Prevention of vertical transmission of HIV from
mothers to their infants
4. Provision of treatment, care and support to women
living with HIV and their partners, infants, and
families
MEASURES TO REDUCE MTCT
During pregnancy:
 Provide voluntary counseling and HIV testing
 Diagnose and provide aggressive treatment of
malaria, STDs and other infections as early as
possible
 Provide basic antenatal care including:
 Education about MTCT and infant feeding
options
 ART for MTCT
 Risk reduction/safer sex measures
MEASURES TO REDUCE MTCT

During Labor and Delivery:

Use Standard Precautions (good infection prevention
practices) for all patient
Delay rupturing of membranes (Not more than 4 hours
before delivery)
Do only minimal digital examinations after ROM

Elective caesarean section has a more protective effect

against MTCT than vaginal delivery
 Caesarean section performed before the onset of labour
or membrane rupture
Ctd……………….
 Avoid prolonged labour.
 Consider use of oxytocic medications to shorten
labour when appropriate.
 Avoid unnecessary trauma during delivery.
 Avoid invasive procedures, including scalp electrodes
or scalp sampling.
 Avoid routine episiotomy.
 Minimise the use of instrumental vaginal delivery
such as forceps or vacuum delivery.
Ctd……………………………………
 Avoid mechanical nasal suction
 Clean the newborn immediately of all maternal
secretions and blood
MEASURES TO REDUCE MTCT
 After Delivery:
 Clamp the cord immediately after birth, and avoid
milking the cord
 Avoid mechanical nasal suction
 Clean the newborn immediately of all maternal
secretions and blood
 Place the infant on the mother’s breast if she is going to
breastfeed.
 Administer ARV prophylaxis as soon as possible
following birth.
Ctd………………………………
 Administer BCG and polio vaccines according to
national guidelines.
 For non-breastfed infants, administer vitamin A 50,000
IUs at birth or within 6 months.
 Support safer infant feeding (according to national
guidelines)
 If breastfeeding is chosen as an option: encourage
exclusive breastfeeding
 Advise giving milk substitutes where conditions are
suitable
ART for PMTCT
 ART:
 Life-long use of ARV medications to treat maternal HIV
infection in order to improve health and slow disease
progression.
 ART also reduces HIV transmission from mother to infant.
 Pregnant or breastfeeding women living with HIV should start
ART as soon as possible regardless of gestational age, CD4
count or WHO clinical stage (Option B+).

 ART should continue throughout pregnancy, childbirth,

breastfeeding and for life.
Goals of Antiretroviral Therapy (ART)
1. Maximum and long-lasting suppression of viral
load
2. Restoration and/or preservation of immune
function
3. Improvement of quality of life
4. Reduction of HIV-related morbidity (OIs) and
mortality
 Classes of Antiretroviral Drugs
1. Nucleoside/Nucleotide analogues, NRTI/NtRTI
 Stavudine (d4T), Lamivudine (3TC), Zidovudine (AZT),
Tenofovir (TDF), Didanosine (DDI), Abacavir (ABC),
Emtricitabine (FTC)
2. Non-nucleoside analogues, NNRTI
 Nevirapine (NVP), Efavirenz (EFV)
3. Protease inhibitors, PI
 Saquinavir (SQV), Lopinavir/Ritonavir(LPV/r), Atazanavir
boosted by Ritonavir (ATV/r) and Nelfinavir (NVF)
4. Fusion inhibitors
 Enfuvirtide or T-20
Where ARVs Work in HIV Lifecycle
 ARV Combinations in Tanzania
 First line treatment given as a combination

 2-NRTI/NtRTIs + 1-NNRTI
ART regimens for eligible pregnant women
 The recommended first-line ART regimen for
pregnant women is
 Tenofovir (TDF) 300 mg +Lamivudine (3TC)
300 mg + Efavirenz (EFV) 600 taken once a
day in a fixed dose combination tablet.

 Alternative first line ART regimens are:

 Zidovudine (AZT)+ 3TC+ EFV or
 AZT +3TC + Nevirapine (NVP)
Recommended First-Line Regimens

TDF 3TC EFV

Anaemia EFV
Nephropathy TB
intolerance

AZT 3TC or FTC NVP

Fixed Drug Combinations (FDC)
 FDCs are preferred when they are available because they
reduce the pill burden.
 Different brands of FDCs are available eg.
1. Combivir (AZT/3TC),
2. Duovir-N (AZT/3TC/NVP),
3. Triomune(d4T/3TC/NVP), TT-vir,
4. Truvada(TDF/FTC),
5. Atripla(TDF/FTC/EFV)
6. TLE
Why Change Drugs Within the First Line
Regimen?
 Reasons for substituting a single drug within the first line
regimen include:
 Drug specific side effects
 Anaemia

 Systemic allergic reactions

 Liver toxicity

 Neuropathy

 Lipodystrophy

 Onset of TB disease during ART

 Substitute EFV for NVP if patient is taking Rifampicin
Why Change the Entire First Line Regimen?
 Although the first combination of ART offers the
best chance of success, sometimes the entire first
line regimen needs to be stopped or switched due
to:
 Treatment failure (non responsive to 1st line) usually
after at least 6 months
 Multiple or severe side effects
Historical snapshot of PMTCT
(Fundamental Shift in Thinking)
Basic Test Used For Monitoring ARV
Drugs Toxicity

LFT – Hepatotoxicity
RFT - Renal failure
FBC - Haematological toxicity
ARV prophylaxis for infant
 Short term use of ARV medications in HIV
exposed infants to reduce HIV transmission from
mother to infant

 Infants born to women with HIV should be started

on a once daily regimen of Nevirapine (NVP)
prophylaxis from birth or as soon as possible
thereafter (preferably within 6 to 12 hours of
birth) until 6 weeks of age, regardless of mode of
infant feeding.
Infant NVP dosing recommendations
 Birth weight 2000–2499 g
 1ml (10 mg) once daily

 Birth weight ≥2500 g

 1.5ml (15 mg) once daily
Infant Feeding in the Context of HIV Infection

 Definitions
 Exclusive breastfeeding (EBF):
 Feeding an infant ONLY breast milk and no other
liquids or solids, with the exception of multivitamins,
mineral supplements or medicines prescribed by a
HCW.

 Exclusive formula feeding (FF):

 Feeding an infant, who is not receiving any breast milk,
only commercial infant formula and no other liquids or
solids.
Ctd……………………….
 Mixed feeding (MF):
 Feeding an infant breast milk and other liquids or foods
(such as water, tea, formula, animal milk, and porridge).

 NB:
 Women with HIV should be supported to feed their
infants in a manner that reduces risk of HIV
transmission
Ctd……….
 Exclusive breastfeeding
 is recommended for the first 6 months of life
unless replacement feeding is acceptable,
feasible, affordable, sustainable and safe
(AFASS) for the mother and infant.
 Ctd……………
 At 12 months:
 If the child is either HIV-uninfected or of unknown
HIV status, breastfeeding should stop gradually (over a
period of one month).

 If the child is known to be HIV infected,mothers are

strongly encouraged to continue breastfeeding as per
the recommendations for the general population, that
is, up to 24 months or beyond.