Lecture on HIV in Pregnancy given to PBL III students at the Cebu Institute of Medicine, sharing HARP statistics for April 2019

1. PREVENTION OF MOTHER
TO CHILD TRANSMISSION
OF HIV INFECTION
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
July 18, 2019
Cebu Institute of Medicine

2. OBJECTIVES
At the end of the lecture, the
learner should be able to explain:
• the basic knowledge about HIV,
• its epidemiology,
• mode of transmission, and
• means of prevention, especially
during pregnancy, labor and
delivery and postpartum

3. BASIC HIV KNOWLEDGE
easy as…

4. WHAT IS HIV?

5. What is HIV?
H – Human
I - Immunodeficiency
V – Virus
Usa ka kagaw (virus) nga gikan sa lain
nga tawo (human) na moatake sa
natural na depensa sa lawas
(immunodeficiency)

6. WHAT ARE THE STAGES
OF HIV INFECTION?

7. WHO CLINICAL STAGING OF HIV
Asymptomatic
Persistent
generalized
lymphadenopathy
Average 10
years
Antibodies
are
detectable in
the blood
The immune
system
deteriorates
Opportunistic
infections start
to appear
Rapid decline
in number of
CD4 T cells
Opportunistic
infections
become severe
and cancer
may develop

8. WHO CLINICAL STAGING OF HIV

9. How is HIV different
from AIDS?
AIDS is an acronym for Acquired Immune
Deficiency Syndrome
• Acquired – transmitted from person to
person
• Immune – the body’s system of defense
• Deficiency – lack of
• Syndrome – a group of signs and
symptoms

10. The Immune System
• HIV infects T-lymphocytes that carry CD4 receptors
• As T-cells are destroyed, the immune system is weakened
and the person is more likely to develop opportunistic
infections.

11. WHAT ARE THE THREE
MODES OF
TRANSMISION
OF HIV INFECTION?

12. Principles of HIV Transmission

13. WHAT ARE THE FOUR BODY
FLUIDS THAT TRANSMIT
HIV INFECTION?

14. •Semen
•Vaginal fluids
•Blood
•Breastmilk
Four Body Fluids
that Transmit HIV

15. •EXIT
•SURVIVAL
•SUFFICIENT
•ENTER
Principles of HIV
Transmission

16. •Temperature
•Atmosphere
•Moisture
•Acidity
Survival of HIV
(TAMA)

17. Principles of HIV
Transmission

18. HOW DO WE PREVENT
HIV INFECTION?

19. ABCDE of HIV
Prevention
A – abstinence
B – be mutually faithful
C – check your status
D – don’t inject drugs
E – educate yourself and
others

20. “HIV stigma will end with me!”

22. HIV EPIDEMIOLOGY
The Philippine HIV Epidemic
April 2019

23. OBJECTIVES
• To provide insights on the
current status of the Philippine
HIV Epidemic

24. number of reported cases since 1984
66,303

26. male

27. reproductive
age

28. 1 36
2008 2019

33. most data
on PWIDs
come from
Cebu
51% MSM

34. needle
exchange
condom
use
PMTCT

36. adolescents <19 years old are
sexually active
getting pregnant
getting infected with HIV
males having sex with males
males having sex with both males
and females
transmitting HIV to their child

40. sex workers
clients

42. prevalence of teenage
pregnancy is increasing

43. PROGRAM FOR YOUNG PARENTS
FACILITY BASED DELIVERIES
Total Number of Deliveries 905
Deliveries to Women <19 years old 158 17.45%
(Women <19yo/Total delivery)
NORMAL SPONTANEOUS DELIVERY
Total Number of NSVD 577
NSVD to Women <19 years old 128 22.18%
(Women <19yo/Total NSVD)
CESAREAN SECTION
Total Number of CS Deliveries 328
CS to Women <19 years old 30 9.15%
(Women <19yo/Total CS)
FAMILY PLANNING
BTL/PP BTL 0
IUD/PP IUD 17
CS+IUD 11
Subdermal Implant 23
DR. REQUILLO/DR. DE LEON

46. The Philippine HIV Epidemic
is fast and furious!
#GetTested
#LinktoCare
#ARVforLife
#Undetectable=Untransmissible

47. • Primary prevention of HIV
infection for key populations
has to start in adolescence
mainly because infections now
occur at a younger age.
• On average, the initiation to
sex and drug use is between
14 and 19 years old.
http://www.unicef.org/philippines/hivaids.html

48. 2015: HIV in 6 PH cities may reach
'uncontrollable' rates – DOH
Prevalence rate among males who have sex with males
http://www.rappler.com/nation/89412-hiv-6-philippine-cities-uncontrollable-rates

49. PREVENTION OF MOTHER TO CHILD
TRANSMISSION (PMTCT) OF HIV

50. PREVENTION OF MOTHER TO CHILD
TRANSMISSION OF HIV
• Prong 1. Primary prevention of HIV among women of child-
bearing age.
• Prong 2. Preventing unintended pregnancies among women
living with HIV.
• Prong 3. Preventing HIV transmission among women living with
HIV to her infant.
• Prong 4. Providing treatment, care and support to women living
with HIV, their children and their families.
https://www.hsph.harvard.edu/population/aids/philippines.aids.09.pdf

51. Prong 1. Primary prevention of HIV among women of child-bearing age.

52. Contraception
• Best protection obtained by:
–Choosing sexual activities that do not allow
semen, fluid from the vagina, or blood to
enter the mouth, vagina or anus of the
partner
–Correct and consistent use of condoms
during every sexual act
–Reducing the number of partners
POGS Clinical Practice Recommendations on PMTCT
Prong 2. Preventing unintended pregnancies among women living with HIV.

53. Philippine Obstetrical and Gynecological Society
(Foundation) Inc
Clinical Practice Recommendation on Prevention of Mother to
Child Transmission of HIV Infection
• HIV Screening
• Antiretroviral Drugs
• Management of Delivery
• Infant Feeding
• Contraception
POGS Clinical Practice Recommendations on PMTCT
Prong 3. Preventing HIV transmission among women living with HIV to her infant.

54. CEBU NOW
pregnant women living with HIV
+6 pregnant women on 2nd pregnancy
since HIV diagnosis
*only 58 alive on ART
*since 2010 to present

55. HIV Screening
Preliminary Counselling Dialogue
Providers of obstetric care should inform
the patient that an HIV screening test will
be performed as part of the
recommended routine antenatal package
of tests of infections (HBsAg, RPR/VDRL,
rubella IgG, papsmear, urine culture)
POGS Clinical Practice Recommendations on PMTCT

56. 5%
• Only five per cent of HIV-positive pregnant
women have received antiretroviral
medicines to prevent mother-to-child
transmission.
• Very few of those at-risk have taken an HIV
test, with the number at zero for those
under 18 years.
http://www.unicef.org/philippines/hivaids.html#.V2yW-_l95rQ
HVMADAMBA 2016

57. HIV Screening
Preliminary Counselling Dialogue
Key Message:
The fact that you are pregnant is
an evidence of unprotected
penetrative sexual contact
which is a mode of transmission
for HIV.
POGS Clinical Practice Recommendations on PMTCT

58. HIV Screening
Preliminary Counselling Dialogue
• Part of thorough assessment of
her status in relation to her
pregnancy
• Routine interview + standard
counselling about HIV
• Strictly confidential
• Opt out - and still receive
the same standard care
POGS Clinical Practice Recommendations on PMTCT

59. Anti-retroviral (ARV) Drugs
Different Clinical Scenarios
1. Woman already receiving ARV treatment
for her own health – continue.
2. ARV-naïve HIV-infected pregnant woman
with indication for own health, start ARV
regardless of AOG
3. ARV-naïve HIV-infected pregnant
woman, ARV prophylaxis started at 14
weeks AOG
POGS Clinical Practice Recommendations on PMTCT

60. Anti-retroviral (ARV) Drugs
Eligibility for ARV Prophylaxis
• Option A: maternal AZT + infant ARV
prophylaxis
• Option B: maternal triple ARV
prophylaxis until delivery or if
breastfeeding, until 1 week after all
exposure to breast milk ended
• Option B+: start triple ARVs as soon
as diagnosed and continued for life
POGS Clinical Practice Recommendations on PMTCT

61. Anti-retroviral (ARV) Drugs
Advantages of Option B+
• PMTCT program : simplify requirements
• Child : extended protection against mother-
to-child transmission
• Partners : prevention benefit against sexual
transmission in sero-discordant couples
POGS Clinical Practice Recommendations on PMTCT

62. Anti-retroviral (ARV) Drugs
Advantages of Option B+
• Earlier treatment for woman’s health and avoiding
risks of stopping and starting triple ARVs especially
in settings of high fertility
• Simple message to communities
“once ARV started, it is taken
for life.”
POGS Clinical Practice Recommendations on PMTCT

63. Vicente Sotto Memorial Medical Center
09561273994
or refer to Dr. Helen Madamba
(09228936749) at VSMMC

64. Management of Delivery
POGS Clinical Guidelines on HIV 2015
 An elective cesarean delivery is
scheduled at 38 weeks AOG
 Emergency CS is done for those in
labor and with ruptured membranes <4
hours unless delivery is imminent
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.

65. Management of Delivery
POGS Clinical Guidelines on HIV 2015
Vaginal delivery maybe done when the
risk of maternal to child transmission is
low:
- those who had ARV treatment
- HIV viral load <1000 copies/ml
- if with ruptured membranes, the time
elapsed should be <4 hours to delivery
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.

66. Management of Delivery
Essential Intrapartum Newborn Care (EINC)
Thoroughly dry newborn infant
×vigorous suctioning
Skin to skin bonding should be encouraged
X Delayed clamping of umbilical cord is NOT recommended.
Latching on is done ONLY IF breastfeeding has been
chosen.
POGS Clinical Practice Recommendations on PMTCT

67. Infant Feeding
INFORMED
CONSENT
NO MIXED FEEDING
EXCLUSIVE breastfeeding
or
AFASS replacement feeding

68. Infant Feeding
• continuing ARV medications
• replacement feeding: acceptable,
feasible, affordable, sustainable
and safe (AFASS)
• risks, follow up and other options
for replacement feeding
• relieve breast engorgement
POGS Clinical Practice Recommendations on PMTCT

70. Prong 4. Providing treatment, care and support to
women living with HIV, their children and their families.
• Immunization
• Healthy Lifestyle
• STI & Cancer Screening
• Opportunistic Infections
• Support Groups
• Livelihood Skills Training
• Advocacy to reduce Stigma and
Discrimination
• HIV Awareness Campaigns

71. “HIV stigma will end with me!”

72. #HealthXPH tweetchat
Healthcare Conversations on Twitter
Saturdays 9:00 p.m. to 10:00 p.m.
@helenvmadamba
https://www.facebook.com/Helen-V-Madamba
http://helenvmadamba.blogspot.com/
These slides are available on
http://www.slideshare.net/HelenMadamba

73. VISIT US!
VSMMC HIV Treatment Hub
KAAMBAG Clinic, Annex B 3rd floor
Vicente Sotto Memorial Medical Center
B. Rodriguez Street, Cebu City
Cellphone: 0956-1273-994
Email: vsmmctreatmenthub@gmail.com

74. PREVENTION OF MOTHER
TO CHILD TRANSMISSION
OF HIV INFECTION
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
July 18, 2019
Cebu Institute of Medicine