Vertical transmission is major contributor- HIV among children No intervention – as high as 45% With interventions – as low as less than 5% Minimal manipulation NVD vs. C-section Anti retroviral prophylaxis vs. anti retroviral therapy Exclusive breastfeeding vs. exclusive replacement feeding Follow-up and care.

1. STRATEGIES TO
PREVENT VERTICAL
TRANSMISSION OF HIV
BY DR PRABHAKAR, 1ST YEAR PG
DEPT OF PEDIATRICS,
SRI VENKATESWARA MEDICAL COLLEGE,
TIRUPATI.

2. OVERVIEW
• Introduction
• WHO’s Four prong strategy
• Primary prevention
• Avoiding unintended pregnancies
• Risk factors
• Interventions for Preventing mother to child transmission
• ART for HIV infected pregnant women
• Infant ARV prophylaxis
• Breastfeeding practices
• Care and follow-up

3. INTRODUCTION
There are an estimated 2.1 million (2011) People Living with HIV
(PLHIV) in India, with National adult HIV prevalence of 0.27%
(2011). Of these, women constitute 39% of all PLHIV while
children less than 15 years of age constitute 7% of all infections.
HIV prevalence among adult population - 0.4% in the year 2000
to 0.27%
in 2011.
New HIV infections among adults from about 2.7 lakh in the year
2000 to 1.17 lakh in 2011, a drop of about 57.
On the contrary, reduction in new HIV infections among children
is only about 35% which indicates continued and high level of
transmission of HIV from infected mothers to their children.

4. A total of 1.42 lakh children (0 to14 years) are estimated to be
living with HIV in India with about 14,000 new HIV infections
annually.
Mother-to-child transmission of HIV is the primary route of
transmission for HIV among children.
This transmission is known to occur during pregnancy,
delivery and breast-feeding period.
It is estimated that without any intervention the risk of
transmission of HIV from infected mother to her child is
between 20 to 45%. However, with effective use of Anti-
retroviral (ARV) drugs, this risk reduces significantly.

5. ROUTES OF
TRANSMISSION OF HIV
NACO Annual Report 2009-2010

6. FOUR PRONGS
Prong 1: Primary prevention of HIV, especially among women of
child bearing age.
Prong 2: Preventing unintended pregnancies among women
living with HIV.
Prong 3: Prevent HIV transmission from pregnant women
infected with HIV to their child.
Prong 4: Provide care, support and treatment to women living
with HIV, her children and family in
women in child bearing age.

8. PRONG 1:
PRIMARY PREVENTION OF HIV

9. PRIMARY
PREVENTION OF HIV
• Promoting condoms through social marketing and
community-based distribution system
• Behaviour change communication (BCC) and social
mobilisation campaigns
• Prevention, diagnosis, and treatment of sexually
transmitted infections (STIs)

11. PRONG 2:
PREVENTING UNINTENDED
PREGNANCIES

12. PREVENTING UNINTENDED
PREGNANCIES
• Pre-conception counselling–HIV infected pregnant women are similar to
non-HIV infected pregnant women. The goals are improve the health of
the woman before conception and to identify risk factors for adverse
maternal and foetal outcomes. These include:
• Safe sex practice
• Prevent test and treat STI.
• Reproductive history including numbers of pregnancies and outcomes
• of pregnancies.
• Length of relationship with current partner, HIV status of partner and
couple’s sexual history including condom use and sexual decision-
making or control of reproductive choices.
• Patient’s and partners reproductive desires and discussion of options.
• Reduce/avoid risky behaviour eg. smoking, substance abuse.

13. • Information about effective contraceptive methods to prevent
pregnancy, dual protection; the effects of progression of HIV
disease on the woman’s health
• The importance of family planning and birth planning;
• The risk of HIV transmission to an uninfected partner while
having unprotected intercourse (for instance, when trying to
become pregnant);
• The risk of transmission of HIV to the infant and the risks and
benefits of Antiretroviral prophylaxis in reducing
transmission; and
• Information on the interactions between HIV and pregnancy,
including a possible increase in certain adverse pregnancy
outcomes
FAMILY PLANNING COUNSELLING
INFORMATION INCLUDES:

15. PRONG 3:
PREVENT HIV TRANSMISSION

16. PREVENT HIV TRANSMISSION
FROM MOTHER TO CHILD
• Provide HIV information to ALL pregnant women
• Antenatal visits are opportunity for PPTCT
• Safe obstetric practices
• Prevention of PTCT through ART (to mother and baby)
• Safer Infant Feeding

18. RISK OF HIV TRANSMISSION
What are the factors that influence mother-to-
child transmission risk ?

19. RISK FACTORS
• Maternal risk factors
• Obstetrical risk factors
• Infant risk factor
• Feeding risk factors

20. • High viral load
• HIV subtype
• Resistant strains
• Advanced clinical stage
• Concurrent STI
• Recent infection
• Viral, bacterial and parasitic (esp. malaria) placental infection
• Malnourishment
MATERNAL RISK FACTORS

21. OBSTETRICAL RISK FACTORS
• Uterine manipulation
(amnio, external cephalic version)
• Prolonged rupture of the membranes
(>4 hours)
• Placental Disruption (abruption, chorioamnionitis)
• Intrapartum haemorrhage
• Invasive foetal monitoring (scalp electrode/scalp blood
sampling)
• Invasive delivery techniques: episiotomies, forceps, use of
metal cups for vacuum deliveries
• Vaginal delivery vs. caesarean section

22. INFANT RISK FACTORS
• Immature Immune System
• Preterm baby
• Low birth weight (<2.5kg)
• First infant of multiple birth
• Altered skin integrity
• Immature GI tract
• Genetic susceptibility
• HLA genotype
• CCR5 karyotype deletion

23. INFANT FEEDING RISK
FACTORS
• Mother is infected with HIV while breastfeeding
• Breast pathologies (cracked nipples, mastitis, or
engorgement)
• Advanced HIV disease in the mother
• Poor maternal nutrition
• Mouth sores or an inflamed GI tract in baby
• Mixed feeding: Breast milk along with other
foods
• Prolonged breast feeding (6-18 months)

24. INTERVENTIONS

25. INTERVENTIONS DURING
LABOUR AND DELIVERY
1. Minimise vaginal examinations
2. Avoid prolonged labour
– Consider using oxytocin to shorten labour when appropriate
3. Avoid premature rupture of membranes
– Use partogram to measure labour
– Avoid artificial rupture of membranes (unless necessary)
4. Avoid unnecessary trauma during delivery
– Use non-invasive foetal monitoring
– Avoid invasive procedures, such as using scalp
electrodes or scalp sampling
– Avoid routine episiotomy
– Minimise the use of forceps or vacuum extractors
– Uterine manipulation - amnio, external cephalic version
(ECV)

26. • Do not use suction unless absolutely necessary
• Clamp cord after it stops pulsating and after giving the
mother oxytocin
• For all infants:
• When head is delivered wipe infant’s face with gauze or
cloth
• After infant is completely delivered, thoroughly wipe dry
with a towel and transfer to the mother

27. CONSIDERATIONS
REGARDING MODE OF DELIVERY
• Caesarean section performed before the onset of labour or
membrane rupture has been associated with reduced HIV
Transmission from Mother to Child
• The risk of elective Caesarean for PMTCT should be
assessed carefully in the context of factors such as:
• Risk of post-operative complications
• Safety of the blood supply
• Cost
• In India, normal vaginal delivery is recommended unless the
woman has obstetric reasons (like foetal distress, obstructed
labour, etc) for a C-section
• Use of ART can reduce risk of PTCT better and with less risk
than a C-section

28. ANTI RETROVIRAL PROPHYLAXIS
VS.
ANTI RETROVIRAL THERAPY
ARV prophylaxis: Short-term use of antiretroviral
drugs to reduce HIV transmission from mother-to-
infant
ARV therapy: Long-term use of antiretroviral drugs to
treat maternal HIV and for PPTCT
ARVs during pregnancy decrease the HIV viral
load in the mother’s blood, thus lowering the
chance of her infant to get exposed to the virus

29. ARV INTERVENTIONS

30. ANTIRETROVIRAL
PROPHYLAXIS: MONOTHERAPY
Nevirapine (NACO Guidelines)
• Mother - Single dose NVP 200mg onset of
labour
• Baby - Syrup NVP 2mg/kg within 72 hours
of delivery

31. WHAT ARE THE CHALLENGES OF
USING SINGLE DOSE NEVIRAPINE
FOR PROPHYLAXIS ?
• Resistance can occur even with single dose of Nevirapine,
which makes it difficult to treat mother subsequently if she
needs ART for her own health in the immediate future with
a NVP based combination ART regimen.
• Increased risk of treatment failure
• Baby may get infected with Nevirapine resistant strains.
• Still 10 % risk of transmission

32. WHO new guidelines (June 2013) recommend two options:
1. Providing lifelong ART to all the pregnant and
breastfeeding women living with HIV regardless of CD4
count or clinical stage
OR
2. Providing ART (ARV drugs) for pregnant and breastfeeding
women with HIV during the mother-to-child transmission risk
period and then continuing life-long ART for those women
eligible for treatment for their own health.

33. Department of AIDS Control has decided to provide life-long
ART (triple drug regimen) for all pregnant and breast feeding
women living with HIV, in which all pregnant women living
with HIV receive a triple drug ART regimen regardless of CD4
count or WHO clinical stage, both for their own health and to
prevent vertical HIV transmission from mother-to-child.

34. WHY LIFELONG ART FOR ALL PREGNANT
AND BREAST FEEDING WOMEN LIVING
WITH HIV?
• Ease of implementation
• Increased coverage of ART.
• Vertical transmission benefit
• Maternal health benefit:
• Acceptability: preference and acceptability for this
approach.
• Sexual prevention benefit

35. ART FOR HIV INFECTED
PREGNANT WOMEN

36. PRINCIPLES OF
MANAGEMENT
All HIV-infected Pregnant Women should Start ART
• Start ART as soon as possible and continue ART throughout
pregnancy, delivery, breast feeding period and thereafter lifelong.
• Even if the pregnant women presents very late in pregnancy
(including those who present after 36 weeks of gestation), ART
should be initiated promptly.
Choice of ART Regimen for HIV-infected Pregnant Women
• There are several regimens recommended for use as first-line
ART regimen for adults in India.
• However, in case of HIV infected pregnant women requiring ART,
the recommended first-line regimen is
• Tenofovir (TDF) (300 mgs) +
• Lamuvidine (3TC) (300 mg) +
• Efavirenz (EFV) (600 mg).

41. INTERVENTIONS FOR
SAFER INFANT FEEDING
• Exclusive breastfeeding
• Support good breast health and hygiene
• Replacement feeding – if Affordable, Feasible, Acceptable,
Sustainable and Safe (AFASS)
• Avoiding addition of supplements or mixed feeding which
enhance HIV transmission

44. PRINCIPLES OF INFANT
FEEDING FOR HIV INFECTED
PREGNANT WOMEN

46. PRONG 4:
PROVIDE CARE, SUPPORT AND
TREATMENT

48. CARE AND FOLLOW-UP OF HIV
INFECTED PREGNANT WOMEN

49. CARE AND FOLLOW-UP OF
HIV EXPOSED INFANTS
Any intervention or ARV prophylaxis given to the HIV
exposed newborn should be documented in the child health
card before discharge. The following should be noted in the
card:
• Whether the infant had received ARV prophylaxis and the
duration received/advice
• What feeding choice the mother has made? Whether EBF or
ERF?
• Date of next follow-up.

50. WHAT ARE OTHER INTERVENTIONS
AND CARE ISSUES FOR A BABY BORN
TO AN HIV POSITIVE MOTHER?
• Infants exposed to HIV should start cotrimoxazole at 6
weeks (starting earlier may interfere with bilirubin
conjugation). Cotrimoxazole is continued until the baby is
one year old or till the baby is detected as uninfected.
• Infants who may be HIV infected are at high risk of
acquiring PCP.
• Cotrimoxazole prevents PCP, which has the highest
morbidity and mortality for children with HIV.
• The highest incidence is 3 to 6 months of age, before the
baby is accurately diagnosed.

51. • Give all standard immunisations as per schedule.
• Sick children born to an HIV-positive mother should be
evaluated immediately for diagnosis and treatment.
• Diagnosis difficult because maternal antibodies cross
placenta.
• Perform HIV-antibody test at 18 months.
• HIV DNA PCR (viral load) is more accurate in newborns.
• If baby is HIV negative, discontinue cotrimoxazole PCP
prophylaxis.
• Carefully monitor and document care.

52. • Infant is considered indeterminate status until 15-18
months.
• If HIV-DNA PCR is available:
• A positive test at 6-12 weeks of age means infection.
• A negative test 6 weeks after stopping breastfeeding
means infection very unlikely.
• The goal is to diagnose babies who are HIV positive in
order to provide timely treatment.

54. WHAT ARE SIGNS AND SYMPTOMS
OF HIV INFECTION IN THE INFANT?
• Fever
• Failure to gain weight (may suggest HIV and/or
malnutrition)
• Lymphadenopathy
• Loss of milestones
• Hepatosplenomegaly
• Recurrent/recalcitrant infections
• Otitis media
• Candidiasis (Most infants have thrush, so this is not a
reliable indicator of HIV infection)
• Parotid enlargement

58. CHALLENGES TO IMPLEMENTING
INTERVENTIONS TO PREVENT
VERTICAL TRANSMISSION
• A significant proportion of deliveries continue to be
unsupervised Home deliveries in many states
• Many of the hospital deliveries still remain uncovered by
PPTCT for different reasons
• Most of the private institutional deliveries are not covered
by PPTCT
• Gaps in initiating early ART for the eligible HIV positive
pregnant mothers
• Infant feeding practices / options for HIV exposed infants:
varied perceptions, opinions and advices

59. SUMMARY
• Vertical transmission is major contributor- HIV among
children
• No intervention – as high as 45%
• With interventions – as low as less than 5%
• Minimal manipulation
• NVD vs. C-section
• Anti retroviral prophylaxis vs. anti retroviral therapy
• Exclusive breastfeeding vs. exclusive replacement feeding
• Follow-up and care.

60. REFERENCES
• National Guidelines For PPTCT 2013
• National strategic plan PPTCT 2013