HIV IN PREGNANCY

Facilitator : Dr Kopila Rai Interns:

1.Dr Aakrit Dahal
2.Dr Aashik Jha
3.Dr Aashish Baniya
4.Dr Abin Adhikari
HISTORY
Introduction
VIROLOGY
Transmission
Transmission
PATHOGENSIS
EDIPEMIOLOGY
CLINICAL FEATURE
DIAGNOSIS
Anti retroviral therapy
1. Nucleoside reverse transcriptase inhibitors (NRTIs)
2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
3. Protease inhibitors
4. Fusion inhibitors
5. Integrase inhibitors
6. Entry inhibitors
1.NRTIs

• Zidovudine (AZT) • Didanosine (ddI)

• Lamivudine (3TC) • Zalcitabine (ddC)

• Emtricitabine (FTC) • Abacavir (ABC)

• Stavudine (d4T) • Tenofovir (TDF)

2.NNRTI: efavirenz, nevirapine

3.Integrase inhibitors: raltegravir, eltegravir

4.Fusion inhibitor: enfuvirtide

5.Entry inhibitors(ccr5): maraviroc

6.Protease inhibitors

• Indinavir (IDV) • Fos-Amprenavir

• Saquinavir (SQV) • Lopinavir-Ritonavir

• Ritonavir (RTV) • Atazanavir

• Nelfinavir (NFV) • Tiprinavir

 Target sites of ART
Fusion Inhibitor
Enfuvirtide
Entry Inhibitors
CCR5, MRV
Protease
RNA RNA Inhibitors
Reverse Proteins
transcriptase RT
Inhibitors RNA
RNA
DNA
RT

DNA
DNA Provirus Integrase
Inhibitos
 Benefits of ART
Prevention of mother to child transmission

Post exposure prophylaxis (PEP)

Secondary prevention of HIV transmission

Primary prevention (PrEP)

Clinical management of patients with HIV

Principles of therapy
Zidovudine
or NNRTI
Stavudine
+ Or
Lamivudine/emtricitabine or
Didanosine
or + PI (boosted) or
Tenofovir Nelfinavir
or
Abacavir (not ritonavir)
Principles of HAART
• Suppress viral multiplication maximally
• Reduces perinatal transmission
• Reduce the risk of drug resistance

• Stavudine, didanosine, ritonavir are contraindicated in early

pregnancy
• Dolutegravir, elvitegravir, tenofovir should be avoided in HIV infected
pregnant women who have never taken ART
When to start ART
• Symptomatic patients should be started on ART
irrespective of their CD4+ counts

• For asymptomatic persons

CD4+ < 200 : start
CD4+ 201 – 350 : many would start
CD4+ 351- 500: some would start if VL > 55,000
Factors Affecting Decision on When to Initiate Therapy
• More effective regimens • Lack of data supporting Rx
• More convenient regimens
• Better tolerated therapy • Potential drug toxicity
• Less long-term toxicity
• Better immune recovery • Drug and monitoring cost
• Lower rates of resistance
• More treatment options • Potential negative impact on
• Concerns for uncontrolled viremia QOL
• Decrease HIV transmission
Nepal recommendations
• 1st line regimen:
• 2 NRTIs + 1 NNRTI

Tenofovir (TDF) + Lamivudine (3TC) + Efavirenz (EFV)

• Stavudine(d4T) discontinued due to metabolic toxicities

Nepal recommendations
• 2nd line regimen

Nevirapine (NVP)
Zidovudine (AZT)
+ Lamivudine (3TC) + Or
Efavirenz (EFV)

Tenofovir (TDF) + Lamivudine (3TC) + Nevirapine (NVP)

Nepal recommendations
• When to start
• WHO stage III or IV irrespective of CD4+ count
or
• WHO stage II with CD4+ count of < 200 or if CD4+ count is not available
Absolute lymphocyte count of < 1200
Initial monitoring
• After start of therapy (1st line)

• Monitor for side effects

• Patient asked to contact ARV center in case of any problems
• 2 week follow up – look to see if there is any S/E
• 1 month follow up LFTs
• If on AZT look for anemia
• After 1st month then call for monthly visit

• CD4+ monitoring every 4-6 months

HAART
• Other conditions when ART may be needed

• Post-exposure prophylaxis

• Maternal to child transmission

• Acute retroviral syndrome

 POST-EXPOSURE PROPHYLAXIS
 Risk 0.3% after an exposure to a hollow needle containing
blood

 Risk 0.09% after mucous membrane exposure

 Advise immediate post-exposure prophylaxis, preferably within

1 hour of injury
 Discuss
 Regimen to be used
 Toxicities
 Protection
 RISK ASSESSMENT
 Assess risk category of source patient

 High risk:
 Symptomatic HIV / AIDS
 High likelihood of HIV / AIDS
 High viral load

 Low risk:
 Asymptomatic HIV
 Low likelihood of HIV / AIDS
 Low viral load
 RISK ASSESSMENT
 Assess exposure category

 High-risk exposure:
 Percutaneous needle-stick
 Sharp injury
 High volume mucous membrane exposure
 Exposure of abraded skin
 Exposure to blood or fluid contaminated with blood

 Low-risk exposure:
 Low volume mucous membrane
 Intact skin exposure
 Exposure to fluid not containing blood
 IMMEDIATE MEASURES

 Do not squeeze the site of injury, allow blood to flow and wash in a
stream of water

 Wash well with soap and water

 If mucous membrane exposure, wash well with water

POST-EXPOSURE PROPHYLAXIS

 Recommended regimen is:

Basic
Zidovudine 300 mg BID + Lamivudine 150 mg BID
Or
Stavudine 40 mg (or 30 mg if BW <60 kg) + lamivudine

Extended
Nelfinavir 1250 mg BID / Indinavir 800 mg TID/ Efavirenz 600
mg OD
 PEP FOR PERCUTANEOUS EXPOSURE

High-risk patient Low-risk patient

High-risk exposure 3 drug regimen 3 drug regimen

Low-risk exposure 3 drug regimen 2 drug regimen

PREVENTION OF HIV
• Education
• Safe practices
• Voluntary counseling and testing
• PMTCT
Effects of HIV on Pregnancy
1. Studies have shown no additional effect of HIV on
pregnancy.

2. Increased perinatal mortality related to HIV infection has

been reported in infants in developing countries due to
increase in co morbid conditions

3. No increase in malformations related to HIV

Effects of pregnancy on HIV
• Studies have shown pregnancy has no effect on progression of
disease.
• Absolute CD4 counts fall in all pregnant women & rebound by 50-100
cells/mm3 after child birth.
• Plasma HIV RNA levels tend to remain stable during pregnancy
Factors which affect MTCT
Maternal Factors

1.CD4 count
2.Viral Load
3.Viral resistance
4.HIV subtype
5.Concurrent infections
6.STDs & genital infections
7.Maternal malnutrition
8.Sexual Practices
9.Antiretroviral treatment
Obstetrical factors

1. Ruptured membranes (>4 hours) Each hr. of ROM increases MTCT by 2%.
2. Chorioamnionitis : STI
3. Vaginal delivery
4. Intrapartum hemorrhage
5. Uterine manipulation
6. Invasive procedures
7. Prematurity, LBW.
8. Instrumental deliveries
Breast Feeding factors

1. Duration of breast feeding

2. Mixed feeding (top feeds + breast milk)
3. Breast abscess, nipple fissures, mastitis
4. Oral disease in infant (thrush, sores..)
HIV Screening in Pregnancy
• All Pregnant women should be given voluntary counseling &
testing (VCT) with confidentiality.

• Opt out approach is preferable – HIV testing as routine ANC

Care (WHO, ACOG)

• Repeat testing in third trimester is indicated if there is :H/o

STDs, illicit drug use, multiple sexual partners.
 HIV Screening in Pregnancy
• ACOG recommends :
• Routine HIV screening for woman aged 19-64 years
• All pregnant woman should have their HIV serostatus evaluated when
they first present for ANC
• Women should have right to refuse testing after being informed but this
should be documented in maternity notes, her reasons should be
explored and screening offered again at 28 weeks
• In case of HIV negative where there is risk of transmision ,the test
should be repeated
INVESTIGATIONS
1. ELISA
2. Western Blot
3. Blood counts
4. Viral Loads
5. Lipid profile
6. USG
7. Hepatitis and other STI testing
8. Opportunistic Infection testing
WHY DO THE TEST?
1.Parent to child transmission (PTCT) or Vertical transmission or perinatal
transmission is the second most common mode of transmission of HIV

2.90% of infections in children are due to MTCT.

3.Women diagnosed HIV positive during pregnancy should be informed that

interventions (such as antiretroviral therapy, caesarean section) can reduce the risk of
PTCT from 30 -45% to less than 2%.

4. 15% of new HIV infections each year are caused by MTCT

Antenatal care

Special Initial assessment:

1. Screen for TB
2. Women Taking HAART should be screened for GDM
3. Screen for STI
4. Cotrimoxazole prophylaxis therapy if CD4 <
250cells/mm3
5. ART/ARV prophylaxis
6. Test for progression(in every 3 month interval)
CD4 count
HIV RNA
Vaccination
• During pregnancy, live attenuated vaccines should be avoided
• Inactivated annual influenza, H1N1 and tetanus vaccines should be
administered to all pregnant women, including women who are HIV
positive
• Hepatitis A and B vaccines ( if non immune ) and pneumococcal
vaccines should be administered to HIV positive pregnant women
 CRITERIA FOR ART : ART to be started if,

a. CD4 count <350cells/cu.mm, irrespective of the WHO staging

b. WHO stage 3 or 4 disease, irrespective of CD4

cell count

Criteria for ARV prophylaxis

a. CD4 >350 cells/mm3
b. WHO stage 1 or 2
Scenario 2
Women with known HIV infection who are already
receiving HIV care, but not on ART, who get
pregnant,
a. Repeat CD4 cell count, if done 3 months back, to
determine ART eligibility.
b. Assess WHO clinical staging
c. Initiate ART/ARV prophylaxis at 14 weeks-28 weeks and then
continue throughout the Pregnency,labor,and post pArtum
period
Scenario 3
• Women with known HIV infection already on ART, who gets
pregnant
a. Evaluate current ART regimen and make necessary
substitutes
b. Undertake CD4 testing
I trimester- Evaluate the present regimen for the safety of
the mother and fetus
If she is on nevirapine based regimen, same has to be
continued
If she is on efavirenz based regimen,
a. <28days- stop and start new regimen with NVP
b.>28days- continue same, not an indication for MTP
sen4
• Pregnant women with unknown HIV status in active
labour or detected to be HIV positive through
whole blood finger prick test
a. Provide intra-partum PPTCT prophylaxis
b. Do confirmatory HIV testing and undertake CD4
cell count, after delivery
c. WHO clinical stage, if HIV is confirmed
PPTCT
GOALS:
• Primary prevention of HIV in women of child bearing age
• Prevention of unintended pregnancies in HIV+ women
• Prevention of transmission to the child
• Care and support to the mother, children and family.
I) Prevention of Primary infection :
1) Provide Access to Condoms.
2) Behavior change communication (BCC) and social mobilization
campaigns
3) Provide early diagnosis & treatment of STDs.
4) Make HIV testing & counseling widely available.
5) Provide suitable counseling for HIV negative women
II) Prevention on Unintended Pregnancies
among HIV women :
• Effective Family planning services can help prevent unintended
pregnancies in HIV infected women.
• Providing safe & effective contraception & high quality reproductive
health counseling helps to make informed decisions about
pregnancies
Mode of Delivery
HIV in Pregnency is not an
indication for Caeserian Section
Elective caesarean section
Delivery by elective CS at 38 weeks to prevent labor and/or ruptured
membrane recommended for

1.Women taking HAART who have a plasma viral load >50 copies/ml
2. Women taking zidovudine monotherapy as an alternative to HAART
3. Women with HIV and hepatitis co-virus infection
• Delivery by elective CS for obstretical indication or maternal request
should be delayed until after 30 completed weeks of gestation in
women with plasma viral loads of <50 copies/ml, to reduce the risk of
transient tachypnea of newborn
Elective caesarean section
• Zidovudine is given via the IV infusion which should be started 4 hrs
before CS and should be continue until the umbilical cord has been
clamped.

• Loading Dose=2mg/kg/hr
• Maintenance dose=1mg/kg/hr;

• Avoid rupturing the membrane until head is delivered

• Peri partum antibiotics
• Women who are HIV positive who have a detectable plasma viral load
and / or who are not taking HAART should be offered a planned
caesarean section to reduce peri-natal transmission
• Further research is needed to evaluate the effect on perinatal
transmission and maternal health of planned caesarean section for
women who are taking HAART or who have very low viral loads
Precautions during LSCS in HIV +ve
• Blood-less Cesarean with intact membranes is the key.
• Use HIV Kit with all protective gears
• Surgery should be slow, steady, Keep the field blood less by using constant
suction & cautery
• Deliver infant with intact membranes & slowly suction out amniotic fluid
• Clamp the umbilical cord immediately
• Avoid Manual removal of Placenta.
• Good surgical practices like use of forceps, avoiding using fingers, be
careful while transferring sharps to assistants.
Vaginal delivery
• Indications of Vaginal delivery are:
1.Women’s choice
2.Cesarean section deliveries not possible or safe
3.Women on HAART with undetectable viral load
4.Viral load <50 copies/ml
Planned Vaginal delivery
• HAART should be prescribed and administered throughout the labor
• Invasive procedures such as fetal blood sampling and fetal scalp
electrodes are contraindicated
• If labour progress is normal, amniotomy should be avoided
• Amniotomy and possible use of oxytocin may considered for
augmentation of labour
• If instrumental delivery is indicated, low cavity forceps are preferable
Precautions during Delivery
• Follow Universal Safety Precautions.
• Minimal Cervical examinations
• Asepsis to be mantained.
• Avoid Prolonged Labor.
• Avoid Prolonged rupture of membranes.
• Avoid Routine ARM. (Delay ARM till 7cm or more dilatation).
• Avoid Invasive fetal monitoring.
• Avoid routine Episotomy.
• Avoid Instrumental delivery, if necessary use forceps over vaccum
• Avoid use of Methergin due to interactions with various ARV drugs.
Prelabor rupture of membrane at term
• In PROM at term, delivery should be expedited
• If viral load is less than 5o copies/ml and there is no obstetric
cpmplications, augmentation may be considered
• Broad spectrum intravenous antibiotics should be administered
Prolonged pregnancy
• For women on HAART with plasma viral load of less than 50
copies/ml, the decision regarding induction of labour for pregnancy
should be individualized
• There is no contradiction to membrane sweep to use of
prostaglandins
HIV diagnosed in labour
• For women diagnosed HIV positive during labour, the pediatricians
should be informed and urgent advice should be sought from the HIV
physicians regarding optimum HAART
• Delivery should be by caeseraen section and where possible this
should be timed with respect to anti retroviral administration
Post exposure prophylaxis
• Reduces the risk of seroconversion by 80%
• Zidovudine(200mg tds)
• Lamivudine(150mg bd)
• Indinavir(800mg tds)
Postpartum management
• Advice about formula feeding
• Immediate dose of oral carbegoline should be given to suppress lactation
• Women taking HAART should have their medication prescribed and
admistered
• Guidance about contraception should be given in the immediate
postpartum period(condom or female condom)
• MMR and varicella zoster immunization may be indicated, according to
lymphocyte count
• Breastfeeding doubles the risk of MTCT from 14-25%
Management of neonate
• All neonate should be treated with anti retroviral within 4 hrs of birth
• Most should be managed with Zidovudine monotherapy but those at
high risk of HIV infection should be treated with HAART
• Prophylaxis against PCP is only for neonates at high risk of infection
• Infants should be tested at 1 day, 6 wks and 12 wks of age
• If all tests are negative then the child as not HIV infected A
• Confirmatory HIV antibody test is performed at 18 months of age
Infant ART prophylaxis
• All HIV exposed infants should receive zidovudine for first 6 weeks
• <30wks gestation: 2mg/kg po bid; after the age pof 4 wks, advance to 3
mg/kg po bid
• >30-<35:2mg/kg po bid;after age of 2 wks,advance to 3mg/kgpobid
• >35 wks gestation:4mg/kg
• Initiate as soon after delivery(6-12)hrs and continue through age 6 wks and
administer birth through 6 wks
• If infant unable to tolerate iv dose then iv dose is maintained 75% of oral
Additional prophylaxis with nevirapine
• Nevirapine is needed for HIV-exposed infants of women who did not
receive antepartum ART at the following weights and dosage
• Birth weight 1.5-2kg: 8mg/dose po
• Birth weight >2kg:12 mg/dose po
• Administer 3 doses in the first wk of life
• 1st dose 48 hrs birth 2nd dose 48 hrs after 1st dose 3rd dose 96 hrs after
2nd dose
ART DURING LABOUR
• Already on ART/ARV prophylaxis- continue same regimen and
schedule
• For planned elective cases- continue same
• For emergency cases who are not on any treatment or prophylaxis-
single dose of nevirapine + AZT + 3TC prophylaxis
• Standard antibiotic prophylaxis to be given in all cesearean patients
False labour pains- repeat sd.nevirapine , if last dose was given more
than 48hrs before
POST- PARTUM PERIOD
• WITHIN ONE HOUR OF DELIVERY

a. Administer nevirapine to the infant

b. Place infant on mother’s abdomen
c. Encourage exclusive breast-feeding
Postnatal period

• a. Continue ART/ARV prophylaxis

• b. Support daily nevirapine administration to the infant
• c. Ensure maternal well-being and rule out post-partum infections
• d. Counsel family members to provide constant support and care
• e. Nutritious diet, adequate rest and supplements
Follow up
• At 6 weeks, Check for
• Pallor
• Breast engorgement or mass
• Ceasarean and Episiotomy wound
• See for any features of opportunistic infections .
• Counsel her for insertion of IUCD and educate about DUAL
CONTRACEPTION
THERAPY- HOW LONG
• ON ART- Life-long
• On ARV prophylaxis- depends on feeding pattern,
a. on exclusive replacement feeds- stop after delivery
b. on exclusive breast-feeding- continue for the duration of breast-
feeding and for one week after cessation of breast-feeding
Women who directly came in labour- continue AZT/3TC drugs for
7days irrespective of feeding practices