HIV/AIDS and Pregnancy

Diagnosis and Management. How can MTCT of HIV be reduced in KATH?

Presented by Group 1 Supervisor: Dr. Turpin

Introduction AIDS is caused by HIV. HIV attacks and destroys WBCs causing a defect in the bodys immune system. The incubation period may be as long as 10 years or as short as 2 years.

Life Cycle of the HIV

Modes of HIV transmission

Sexual intercourse
Exposure to infected blood and blood products :
Shared needles Contaminated instruments Blood transfusion

An HIV positive woman can transmit the virus to

her baby during pregnancy, labour and delivery, and through breastfeeding. If she takes no preventive drugs and breastfeeds then the chance of her baby becoming infected is around 20-45%.

Risk Factors for Vertical Transmission

Maternal Factors High viral load Severe immunosuppression

(CD4<200) Advanced maternal disease Maternal micronutrient deficiencies PROM STIs Cracked nipples and breast abscesses in breastfeeding mothers.

Risk Factors for Vertical Transmission (2)

Viral Factors

HIV type 1
Subtype C of type 1 Infant factors Prematurity Breastfeeding Oral thrush and oral ulcers Invasive fetal monitoring during labour

Clinical Stages
Clinical Stage 1 Asymptomatic Persistent generalized lymphadenopathy

Clinical Stage 2 Moderate unexplained weight loss (<10% of presumed or measured body weight) Recurrent respiratory infections (sinusitis, tonsillitis, otitis media, and pharyngitis) Herpes zoster Angular cheilitis Recurrent oral ulceration Papular pruritic eruptions Seborrheic dermatitis Fungal nail infections

Clinical Stage 3 Unexplained severe weight loss (>10% of presumed or measured body weight) Unexplained chronic diarrhea for >1 month Unexplained persistent fever for >1 month (>37.6C, intermittent or constant) Persistent oral candidiasis (thrush) Oral hairy leukoplakia Pulmonary tuberculosis (current)

Clinical Stage 3 (cont.) Severe presumed bacterial infections (eg, pneumonia, empyema, pyomyositis, bone or joint infection, meningitis, bacteremia) Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis Unexplained anemia (hemoglobin <8 g/dL) Neutropenia (neutrophils <500 cells/L) Chronic thrombocytopenia (platelets <50,000 cells/L)

Clinical Stage 4 HIV wasting syndrome Pneumocystis pneumonia Recurrent severe bacterial pneumonia Chronic herpes simplex infection (orolabial, genital, or anorectal site for >1 month or visceral herpes at any site) Esophageal candidiasis (or candidiasis of trachea, bronchi, or lungs) Extrapulmonary tuberculosis Kaposi sarcoma

Clinical Stage 4 (cont.) Cytomegalovirus infection (retinitis or infection of other organs) Central nervous system toxoplasmosis HIV encephalopathy Cryptococcosis, extrapulmonary (including meningitis) Disseminated nontuberculosis Mycobacteria infection Progressive multifocal leukoencephalopathy

Clinical Stage 4 (cont.) Candida of the trachea, bronchi, or lungs Disseminated mycosis (eg, histoplasmosis, coccidioidomycosis, penicilliosis) Recurrent nontyphoidal Salmonella bacteremia Lymphoma (cerebral or B-cell non-Hodgkin) Invasive cervical carcinoma Symptomatic HIV-associated nephropathy or cardiomyopathy

Effects of Pregnancy on HIV

Pregnancy does not worsen

HIV. The absolute CD4 count decreases regardless of the HIV status. This is due to haemodilution. In HIV- positive women, percentage of CD4 cells as well

Effects of HIV on pregnancy

Recurrent abortion

Prematurity
Preterm delivery IUGR Stillbirths Congenital abnormalities Embryopathies

Diagnosis

History
Physical

examination Investigations

History
Depending on the clinical stage, the patient

may be symptomatic or asymptomatic Risk factors :multiple sexual partners, previous exposure to blood and blood products, previous gynaecological surgeries (EOU,TOP), history of STIs History of chronic cough, unexplained wasting, cutaneous lesions, unexplained chronic diarrhoea, unexplained persistent fever, night sweats, dysphagia History of recurrent abortions, previous preterm deliveries, IUGR and still births

Physical examination
General examination Wasting Pallor Dyspnoea White mucosal plaques or erythema in the buccal cavity Lymphadenopathy: cervical, axillary and inguinal Skin lesions or rashes Genital, including anorectal, lesions Any neurologic abnormalities

Physical examination (2)

Respiratory system: air entry may be reduced,

breath sounds may be bronchial, percussion note may be dull

Abdominal examination: there may be

hepatosplenomegaly, SFH may be less than expected for gestational age

Fundoscopy, whenever possible, for retinitis

Investigations
The reasons for investigations are to: Determine whether the patient satisfies initiation criteria. Determine the presence or absence of opportunistic infections. Determine the clinical stage.

Investigations (2)
Initial laboratory evaluation should provide Confirmation of HIV infection and typing. Confirmatory HIV test (and typing 1 and/ or 2) Viral load (when available) Done by using PCR. Indication of the patients immune status CD4 lymphocyte count

Investigations (3)
There are two types of HIV test: Antibody test ELISA Western Blot Immunofluorescent Antibody Assay Rapid HIV Test Kits At-home HIV Test Kits Antigen test PCR Amplicor HIV Monitor Test Branched DNA Test p24 Antigen Test

Other Baseline Tests

Haematological FBC including total lymphocyte test count and platelets The basic minimum test for pregnant women who are taking ARV combination prophylaxis for PMTCT is Hb. Biochemical Blood urea and electrolytes test LFT (if on NVP, more frequent monitoring is necessary) FBS (if treatment includes PIs) Fasting Cholesterol and lipids (if treatment includes PIs)

Other Baseline tests (2)

Routine Examinations Respiratory Examinations Urinalysis (urine R/E), Stool R/E Sputum for AFBs, Chest X-ray

Supplementary HBsAg screen, tests Histology on skin and lymph (These are node biopsy performed depending on signs and Screening for STIs symptoms) Abdominal USG

Management
ANC for the HIV positive pregnant woman ANC is similar to the care given to HIV

negative pregnant women HIV-positive clients are coded 279 on their ANC cards ( 280 for HIV-negative clients) to prevent stigmatisation. Avoid invasive procedures unless strongly indicated Anomaly scan Foetal monitoring Monitoring for preterm delivery

Management (2)
ANC for the HIV positive pregnant woman

(cont.) The patient is offered good nutritional counselling. 2 uses of antiretrovirals in pregnancy For treatment and Prophylaxis The antiretrovirals should be avoided in the first trimester.

Management (3)
ANC for the HIV positive pregnant

woman (cont.) All HIV-positive women with CD4 count > 350 must be put on prophylaxis starting from 28 weeks for the purpose of PMTCT. All HIV-positive women with CD4 count < 350, irrespective of clinical stage, must be treated with HAART.

Management (4)
ANC for the HIV positive pregnant

woman (cont.) All HIV-positive women with WHO clinical stages 3 and 4, irrespective of CD4 count, must be treated with HAART. 28 weeks, AZT/3TC twice daily is given

Management (5)
Labour / Delivery Routine ARM should be avoided. Foetal scalp blood sampling and episiotomy

should be avoided if possible, as they increase mother-to-child transmission. The vagina should be cleaned with chlorhexidine before conducting delivery. A skilled attendant should conduct the delivery to prevent perineal tears, which are known to increase MTCT.

Management (6)
Labour / Delivery (cont.) If indicated, caesarean section should be

done before rupture of membranes. This is associated with reduced risk of transmission.
Single dose NVP + AZT/3TC every 12

hours. (ARVs given at onset of labour)

Clean face of newborn, avoid unnecessary

suction, avoid hypothermia.

Management of the HIV-exposed baby

ARV prophylaxis Give a single dose of NVP suspension,

2mg/kg within 48 hours of delivery + 1 week course of syrup AZT, 4mg/kg bd + syrup 3TC, 2mg/kg bd
If the mother has had less than 4

weeks of ARV prophylaxis, give the baby a 6 week course of AZT and 3TC

Management of the HIV-exposed baby (2)

Feeding options Exclusive breastfeeding or artificial feeds

only NB. Do not practice mixed feeding

If mother has not made any informed choice

as to whether to practice exclusive breastfeeding or give artificial feeds, admit and give IV fluids till the mother has been counselled. Identify and treat any other problems.

Management of the HIV-exposed baby (3) Follow-up The baby should be seen at the HIV clinic at 6 weeks of age.

Prevention of MTCT of HIV

4-pronged approach. Prong 1: Primary prevention of HIV among women of reproductive age within services related to reproductive health such as antenatal care, postpartum/natal care and other health and HIV service delivery points, including working with community structures.
Prong 2: Providing appropriate counselling and

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.

 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.
Prong 4: Better integration of HIV care,

treatment and support for women found to be positive and their families

The PMTCT Process

HIV testing of the pregnant woman plus counselling at 1st ANC attendance Several testing strategies: Provider initiated testing & counselling with the option of opt-out Client initiated counselling & testing (opt-in) 2. Linkage of the HIV+ mother to PMTCT intervention services ART clinic (care & support) 3. HIV+ mother is offered choice of Infant feeding 4. Linkage of the HIV-exposed baby to care & support
1.

The PMTCT Process (2)

For the woman who tests ve, shes

counselled to stay ve For the woman who declines HIV testing, the test is re-offered at each ANC attendance till delivery

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VCT
Individuals voluntarily offer

themselves for HIV testing so as to know their status

Its an important tool for reducing

the pandemic as clients are counselled on risk reduction behavioural lifestyles

Components of VCT
Pre-test Counselling Clients knowledge of HIV is assessed and knowledge gaps addressed. Clients risk of HIV by way of behavioural practices are also assessed. The meaning of HIV test results (ie. POSITIVE and NEGATIVE) are explained with emphasis on LIVING POSITIVELY for positive clients and RISK REDUCTION BEHAVIOUR for negative clients. The concept of window period is also explained and the need for possibly repeating the test in 3 months is emphasised.

Components of VCT (2)

HIV Testing Clients blood is drawn for HIV Antibody Testing. This is done with the STRICTEST of CONFIDENTIALITY.

Post Test Counselling The client is told the HIV test results. If POSITIVE, she is referred for comprehensive care including accessing ARVs.

Wir bedanken uns sehr bei Euch!!!

Group 1 Members

Ackah-Andoh, Edwin Acquah, Maxwell Adade, Titus Addai-Naami, Joshua Yaw Addo-Sarkodie, Enoch Adjei, Fedous Adjei, Prosper Aduse-Poku, Abena Yeboah Afachao, Frederick Afrane, Joceline