HIV in pregnancy

HIV IN PREGNANCY

Prof. Urmila Singh

Dept. of Obstetrics & Gynaecology

King George Medical University, Lucknow

Presentation is for educational purposes only not for commercial activity

Human Immunodeficiency Virus

• RNA Retrovirus

• Type : HIV 1-India ,

HIV 2-more in Africa

slow & mild in initial stages.

• Very fragile Virus

• Susceptible to heat,

boiling for few seconds kills virus.

1% Na Hypochlorite inactivate virus.

Pathogenesis

Main targets of the Virus are Human CD4` helper’ Lymphocytes

Start Producing new virus particle

Significant fall in CD4 cells

Inability of ß- Lymphocytes to produce antibody to HIV

Causes Progressive Immunosuppression

Ultimately development of AIDS—takes 8 to 10 yrs

HIV Infection

• Incubation period is 1-3 weeks

• After exposure to HIV infection there is a

window period of 12 weeks

in which antibody titre is not detectable .

Routes of Transmission of HIV

• Sexual Route

– Male-to-Female; Female-to-Male

– Male-to-Male

• Parenteral Route

– Transmission of infected blood

– Sharing of infected needles

• Parental Route

– Mother-to-Child

Heterosexual

88.2%

MSM

1.5%

Parent to

Child

5.0%

IDU

1.7%

Blood

Products

Unknown

3.3%

What is the magnitude of problem?

NACO Annual Report 2011-12

Prevention Methods

Sexual Route

– Sexual abstinence

– Being Faithful to sexual partner

– Reducing number of sexual partners

– Correct and consistent use of Condoms

– Less risky sexual practices

Parenteral Route

– Safe blood

– Safe injecting

Parental Route - Mother to Child transmission

- PPTCT

Parent to Child Transmission-PTCT

• Known as vertical or Perinatal Transmission

• In most other countries known as Mother to Child

transmission (MTCT)

• Prevalence of HIV in pregnant women 0.3%

• Vertical transmission rate to fetus is about 30%

• There are proven interventions to reduce likelihood

of PTCT.

PTCT of HIV

Is the main cause of HIV infection in

children

Can occur during

• Pregnancy

• Labour and delivery

• Breast feeding

Estimated Risk of Mother to Child transmission

in absence of any intervention

PPTCT Overview

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%

Source: WHO

Maternal risk factors influencing- PTCT

• High viral load (lower the CD4 count , greater the risk

of transmission)

• HIV subtype (HIV – 2 is less pathogenic)

• Advanced clinical stage of HIV disease

• Concurrent STI

• Recent infection

• Viral, bacterial & parasitic (esp malaria) placental

infection

• Malnourishment

Obstetric risk factors influencing- PTCT

• Uterine manipulations (ECV)

• Prolonged rupture of membrane >4 hrs

• Placental disruption (Abruptio, Chorioamnionitis)

• Intrapartum Haemorrhage

• Invasive fetal monitoring, scalp blood sampling

• Invasive delivery techniques (episiotomy,forceps,

metal cup in Vacuum delivery)

Why PPTCT Programme

Parent to Child –Major route for transmission.

If diagnosed / Untreated

• 35% mortality by 1year

• 50% mortality by 2year

• 60% mortality by age 3 year.

PPTCT Service

Intervention during pregnancy

• Provide HIV information to all pregnant women

attending ANC OPD (Pretest Counseling)

• Voluntary confidential counseling & testing (VCT) to

be given to all pregnant women

• Post test counseling

• Counseling and enable to her to make decision either

to continue or termination of pregnancy

• Availability of safe abortion services & sterilization

HIV positive who wants to continue the

pregnancy

• Ensure Hospital delivery

• Provide similar antenatal care to HIV positive

women as for HIV negative women

• Counseling about infant feeding

• They should have the same number of antenatal

visits and investigations

• Refer to ART center & CD4 count

National Guidelines 2010

HIV Infected

pregnant

women

Clinical stage I,II

&CD4 count ≤ 350

cells/mm2 or

stage III &IV

Yes

Initiate ART

No :ARV prophylaxis

Single dose 200mg

of NVP at onset of

labor

Already on Life

long ART

Continue

ART

There have been major changes in

recommendation for ART during pregnancy

WHO (2013)

Which has been accepted by NACO (Jan.2014)

National PPTCT Algorithm 2013

HIV infected

pregnant

women

Initiate ART

Already on

Life long ART

Continue ART

Initiation of ART

in PLHIV with Pregnancy

(India-New PPTCT National guidelines 2013)

WHO

Clinical Staging

CD4 (cells/cu.mm)

I , II, III & IV

(regardless

of clinical

stage)

Start ART irrespective of CD4 Count -

ART lifelong

What is ART?

• Anti-retroviral therapy (ART) is a combination of certain medicines

given to people living with HIV

• This is a combination of at least three drugs from different groups

• It works to control HIV replication in the body and prevent the

destruction of CD

Cells

• However, it cannot cure HIV/AIDS

• It is a life long therapy, similar to treatment taken for high BP and

diabetes

• There are certain side-effects, but these are mostly manageable

• ART is given after proper evaluation of patients for eligibility and

counseling for adherence

Nucleoside Reverse

Transcriptase

Inhibitors

(NsRTI)

NNRTI

Protease Inhibitor

(PI)

Azidothymidine (AZT),

Zidovudine

Nevirapine (NVP)* Lopinavir (LPV)

Stavudine (d4t) Efavirenz (EFV) Ritonavir (RTV)

Lamivudine (3TC) Atazanavir (ATZ)

Didanosine (ddI)

Abacavir (ABC)

NtRTI:

Tenofovir (TDF)

ARV Drugs under National programme

Guidelines for Antiretroviral Therapy

HAART: Highly Active Antiretroviral Therapy

Human Immunodeficiency virus (HIV) infection is currently treated with

combination therapy using at least three drugs from NRTI & NNRTI/PIs

over an indefinite period.

Possible combinations

1. 2 NRTI's + 1 NNRTI

2. 2 NRTI's + 1 PI

3. 2 NRTI's + 1 More NRTI

No MONOTHERAPY or DUAL THERAPY

PPTCT Scenarios

• Pregnant women newly - initiating ART

• Pregnant women already receiving ART

• ART regimen for pregnant women having prior

exposure to NNRTI for PPTCT

• Women presenting Directly-in-labour

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 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

centers

All pregnant women at ART centre shall be seen on priority

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:

– Should be continued. DO NOT STOP

– There is no indication for abortion/termination of pregnancy in

women exposed to EFV in the first trimester of pregnancy.

ART regimen for pregnant women having prior

exposure to NNRTI for PPTCT

• A small number of HIV-positive pregnant women have had

previous exposure to Single Dose NVP 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.

Tenofovir(TDF) 300mg +Lamivudine (3TC) 300mg -- 1 tab OD

LPV(Lopinavir) (400mg)/r(Ritonavir) (100mg)----------1 tab BD

Women presenting Directly-in-labour

NEW PPTCT Prophylactic Regimen

• Women on life long ART should continue to receive

ART as per the usual schedule including during labour

and delivery. Women do not require any other

additional ARV dosing

• HIV status – not known-Whole blood finger prick test-

if negative no further test. If positive give 3drugs ART &

ref. to PPTCT Centre for rapid test

Dosage schedule and side effects with ARV drugs

Name of ARV Dose Schedule Side-effects

Tenofovir (TDF)

NRTI

300mg OD Nephrotoxicity, hypophosphetemia

Lamivudine (3TC)

NRTI

300mg OD Rarely pancreatitis

Efavirenz (EFV)

NNRTI

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)

Lopinavir/Ritonavir

(LPV/r) PI

400/100 mg BD

Gastro intestinal disturbance, glucose

intolerance, Lipo dystrophy, dyslipdemia

Cotrimaxazole prophylactic therapy (CPT)

for Pregnant Women

• 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

• Cotrimoxazole prophylaxis therapy (CPT) prevents Opportunistic

Infections (OIs) such as

Pneumocystis pneumonia ,

toxoplasmosis, diarrhea

bacterial infections

Considerations

Regarding Mode of Delivery

• Caesarean section can decrease the risk of vertical

transmission when performed before the onset of labour

and rupture of the membrane

• In India Recommendation by WHO & NACO (2013),

cesarean delivery is to be done only for obstetric

indications, otherwise vaginal delivery can be allowed

• Use of ART can reduce risk of PTCT better and with less

risk than a C-section

Interventions during Labor & Delivery for

reducing MTCT

• Safe delivery practices / Universal Precaution

• Vaginal cleaning with 0.25% chlorhexidine

• Minimize cervical examination

• Always use clean technique

• Avoid

– Routine rupture of membrane

– Prolonged labour

– Instrumental deliveries if instrumental delivery is necessary then

forceps are better than vacuum

– Episiotomy, unnecessary trauma during child birth

• Active management of third stage.

Interventions for Newborn

• Don’t milk the cord

• Cut cord under cover of light gauge

• Do not use suction unless absolutely necessary

• Handle infant with gloves

• Clean inj site with spirit before any inj

• Determine mother’s feeding choice before attaching

the baby to breast

Intervention for safe feeding practices

• Infant feeding as per mother’s choice

• Replacement feeding only when it is acceptable,

affordable, feasible sustainable & safe

• According to 2013 National Guidelines

exclusive breast feeding for 6 months, continue feeding

till 12 months if possible.

• Infectious diseases and malnutrition are the primary

causes of infant deaths in developing countries.

• Avoiding addition of supplements or mixed feeding which

enhances HIV transmission

ARV Prophylaxis for infants born to

HIV +VE Women

• All infants born to HIV +VE pregnant women will receive

Nevirapine syrup once daily for 6 weeks- irrespective of

infant feeding option,

• if ART to mother was started in late pregnancy, during or after

delivery and has not been on adequate period of ART as to be

effective to achieve optimal viral suppression (which is at least

24 weeks), and opt for breast feeding then the infant NVP

should be increased to 12 weeks. ( Extended NVP Regimen )

• This recommendation not applies to those on exclusive

replacement feeding

Dose & duration of NVP prophylaxis for HIV

Exposed Infant

(1ml of NVP suspension =10mg NVP)

Infants Birth Weight

(gm)

NVP daily dose (mg) NVP daily dose (ml) Duration

Birth weight less than

2000 gm 2 mg /kg. once daily

0.2 ml /kg. once

daily

Up to 6

weeks*

irrespective

of exclusive

breast

feeding or

exclusive

replacement

feeding

Birth weight between

2000 – 2500 gm

10 mg. once daily 1 ml once a day

Birth weight more

than 2500 gm

15 mg. once daily 1.5 ml once a day

*Extended NVP duration up to 12weeks to infant of exclusive breast feeding , mother

has been < 24 weeks duration of ART

ARV prophylaxis for Infant of HIV +VE pregnant

women -Received Single Dose NVP for PPTCT

prophylaxis in prev. pregnancies

Zidovudine (2.5ml) 25mg/day

• Up to 6 weeks irrespective of exclusive breast

feeding or exclusive replacement feeding

• Up to 12 weeks if mother has received ART for <24

weeks duration and infant on breast feeding .

Mother and Infant follow up schedule

• Routine follow up for mother and infant

• Follow up at 6 wks, assess and record status of mother &

infant.

• All HIV exposed infants should receive cotrimaxazole

prophylactic therapy (CPT)

• Follow standard immunization schedule

• DBS- Direct Blood Spot for HIV-1 DNA PCR of child

between 6weeks & < 6 month of age

• Follow up at 6 months HIV test & CPT

• Follow up at 12months HIV test & CPT

• Follow up at 18 months HIV test & CPT

CPT Starting & Stopping criteria for HIV

exposed infants and children

Group Start

Cotrimoxazole

Stop

Cotrimoxazole

All HIV exposed

infants &

children

<18 months

Any time from 6

weeks

of age

at 18 months of age

When HIV infection

has been excluded

Infants &

children

<18 months

diagnosed

HIV+ve

HIV DNA PCR / HIV

rapid test at 18

months of age

As above, and

any time afterwards

if not already on

Cotrimoxazole

Continue CPT

till 5

yrs of age

CPT Dosage

Cotrimoxazole

once a day

Weight ( kg) Syrup 5ml

(40mg

trimethoprim &

200mg

sulphamethoxazole

)

1 tablet

(20mg of trimethoprim &

100mg

sulphamethoxazole

)

<5 2.5ml 1 tablet

5-10 5ml 2 tablets

10-15 7.5ml 3 tablets

15-22 10ml 4 tablets

Evidence based newer initiatives

• Initiation of ART

• Exclusive Breast feeding

• Whole blood finger prick test- if negative no further test. If

positive give ART & ref. to PPTCT centre for rapid test

• CPT-Cotrimoxazole prophylactic therapy

• Extended PPTCT regimen

• DBS- Direct Blood Spot for HIV-1 DNA PCR of child between

6weeks & < 6 month of age confirmation by whole blood DNA

PCR

• HIV testing of HIV exposed baby at 6 , 12, and 18 months

Contraception for HIV +ve women

• HIV +ve women are strongly advised to use

dual contrception

• Barrier method to reduce the risk of sexual

transmission of the virus to the partner

In combination with

• Combined oral pills, progestogen only pill and DMPA

can be given in HIV and AIDS (category 1 WHO)

• IUCD is category 2 for HIV infected and

category 3 for AIDS

An HIV Free Generation

THANK YOU