HIV infection in pregnancy

1. HIV IN
PREGNANCY

2. HIV stands for Human
Immunodeficiency
Virus.
• Human: Infecting human beings
• Immunodeficiency: Decrease or weakness in
the body’s ability to fight off infections and
illnesses
• Virus: A pathogen having the ability to
replicate only Inside a living cell

3. Types of HIV Virus
There are two types of HIV virus:
• HIV 1 is most common in Sub-Saharan Africa and
throughout the world. HIV 1 can be divided into groups M,
N, and O.
The pandemic is dominated by Group M, which is
composed of subtypes A – J.
• HIV 2 is most often found in West Central Africa, parts of
Europe and India.
Both produce the same pattern of illness.
Both are RNA viruses with single strand of genetic materials.
HIV 2 causes a slower progression of disease than HIV 1.

4. Historical Events
 June 5 1981 – Centre for Disease Control & Prevention –
Reported 5 homosexual men with PCP – Gay Related Immune
deficiency
 1982 – CDC Reported – also seen in non-homosexuals – AIDS .
 1982 – Luc Montagnier et al, Pasteur Institute – Discovered the
virus & named it Lymphadenopathy associated virus (LAV).
 1983 – Robert , US – confirmed the virus – called it – Human T
Lymphotropic Virus type III (HTLV – III).
 1986 – Renamed as Human Immunodeficiency Virus (HIV).

6. VIROLOGY
p24Capsule protein
p17Matrix protein
Single stranded RNA (2 Copies).
Family :- Retroviridae ; Sub-family :- Lentiviridae
RNA genome has 9 genes :-
: 3 Structural (gag, pol, env)
: 6 Regulatory genes .

9. Disease Progression

10. WHO CLINICAL
STAGING OF
ADOLOSCENTS /
YOUNG ADULTS

11. CLINICAL STAGE 1
•Asymptomatic
•Persistent generalized lymphadenopathy
CLINICAL STAGE 2
•Moderate unexplained weight loss (under 10% presumed or
measured body weight)
•Recurrent respiratory tract infection
(sinusitis, tonsillitis, otitis media, pharyngitis)
•Herpes zoster
•Angular cheilitis
•Recurrent oral ulceration
•Papular pruitic eruptions, Seborrhoeic dermatitis, Fungal nail
infections

12. CLINICAL STAGE 3
• Unexplained severe weight loss (over 10% of presumed or
measured body weight)
• Unexplained chronic diarrhoea for longer than one month
• Unexplained persistent fever (intermittent or constant for
longer than one month)
• Persistent oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis

13. • Severe bacterial infections (e.g. pneumonia, empyema,
pyomyositis, bone or joint infection, meningitis, bacteraemia)
• Acute necrotizing ulcerative stomatitis, gingivitis or
periodontitis
• Unexplained anaemia (below 8 g/dl ), neutropenia (below 0.5
x 100/1) and/or chronic thrombocytopenia(below 50 x 100 /1)

14. CLINICAL STAGE 4
• HIV wasting syndrome
• Pneumocystis jeroveci pneumonia (PCP)
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (oro-labial, genital or ano-
rectal of more than one month’s duration or visceral at any
site)
• Oesophageal candidiasis (or candidiasis of trachea, bronchi or
lungs)
• Extrapulmonary tuberculosis

15. • Kaposi sarcoma
• Cytomegalovirus infection (retinitis or infection of other
organs)
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Extrapulmonary cryptococcosis including meningitis,
Disseminated non-tuberculous mycobacterial infection ,
Progressive multifocal leukoencephalopathy
• Chronic cryptosporidiosis
• Chronic isosporiasis

16. • Disseminated mycosis (extrapulmonary histoplasmosis,
coccidiomycosis) Recurrent septicaemia (including non-
typhoidal Salmonella)
• Lymphoma (cerebral or B cell non-Hodgkin)
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy or HIV-associated
cardiomyopathy

17. • Globally, 35.3 million (0.8%) people infected with
HIV/AIDS in 2012 with 50.14% women.
• Prevalence of HIV in pregnant women is 0.3%
• INDIA has the highest population of HIV infected
persons next to AFRICA!
• Overall prevalence is 0.4% in INDIA.
• High risk areas like MAHARASHTRA, MANIPUR,
NAGALAND, TAMIL NADU, ANDHRA PRADESH and
KARNATAKA account for 1%.

18. RISK FACTORS FOR HIV
• Higher (2-17%) male to female transmission.
• Larger surface area of contact in women.
• Less recognition of RTI/STIs in women making
them more susceptible.
• Illicit drug use.
• Intravenous drug sharing needles, waxing,
piercings.
• Higher need of blood transfusion in women.
• Promiscuous behaviour of either partner.
• Occupation involving frequent travel.
• Adolescents indulging in unsafe sexual practices.

19. MODES OF TRANSMISSION OF
HIV
• SEXUAL
 Homosexual
Heterosexual (most common)

20. • PARENTERAL
 Transplacental transmission
 Exposure to infected blood and blood
products (most potent). Blood transfusion
with infected blood (90-95%)
Exposure to infected tissue fluids
Injectable drug users

21. • VERTICAL
Intrauterine
transplacental before 36
weeks
Intrapartum
Postpartum
breastfeeding
30%
20%
50%

22. DIAGNOSIS
• ELISA test with a sensitivity of >99.5 percent.
• Western blot or immuno fluorescence assay (IFA),
both of which have high specificity.
• According to the Center for Disease Control and
Prevention, antibody can be detected in most patients
within 1 month of infection, and thus, antibody
serotesting may not exclude early infection.
• For acute primary HIV infection, identification of viral
p24 core antigen or viral RNA or DNA is possible. False-
positive confirmatory results are rare.

24. • “rapid” HIV test is performed to women with
limited prenatal care or with undocumented HIV
status.
These tests can detect HIV antibody in 60
minutes or less and have sensitivities and
specificities comparable with those of
conventional ELISAs.
A negative rapid test result does not need to be
confirmed.
A positive rapid test result should be confirmed
with a Western blot or IFA test.

25. All Pregnant women should be given voluntary counselling & testing
(VCT) with confidentiality.
Both partners should be counseled & tested for HIV in pregnancy
(NACO).
Opt out approach is preferable – HIV testing as routine
Repeat testing in third trimester is indicated if there is :-
H/o STDs, illicit drug use, multiple sexual partners.
Symptoms of acute HIV infection at any time during pregnancy.
In areas of high prevalence (5/1000).

26. Maternal Factors :-
CD4 count
Viral Load
Viral resistance
HIV subtype
Concurrent infections
STDs & genital
infections
Malnutrition
Sexual Practices
 Antiretroviral treatment
Factors which affect MTCT

27. Obstetrical Factors :
Ruptured membranes
(>4 hrs) Each hour of ROM increases MTCT by
2%.
Chorio-amnionitis
Vaginal delivery
Intrapartum hemorrhage
Uterine manipulation
Invasive procedures
Prematurity, Low birth weight infants
Instrumental deliveries

28.  Breast Feeding factors :-
 Duration of breast feeding
Mixed feeding (top feeds + breast milk)
 Breast abscess, nipple fissures, mastitis.
 Oral disease in infant (thrush, sores)

29. Preterm birth
Stillbirth
Intra uterine growth restriction
Pre eclampsia
Effects of HIV on pregnancy

30. 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
Effects of pregnancy on HIV

31. PPTCT (NACO)

32. Antenatal care in HIV Patients
• Regular ANC visits
• Antenatal investigations (CBC, urine examination,
blood group, ultrasound for fetal well being)
• 2 doses of TT
• Iron and Folic acid supplementation
• Screen for TB
• Screen for STI
• Assess CD4 counts at initial visit and repeat in
each trimester
• Serological tests for CMV, toxoplasmosis

33. • Serological tests for husband for HIV should be
offered
• Liver function tests, serum electrolytes, G 6PD
test
• HIV viral load at initial visit and repeated in
each trimester
• Aneuploidy anomaly scan
• Vaccination against Hep B virus and
pneumococcus
• Antiretroviral therapy

34. Summary of Maternal
ART (Life Long) and
Infant ARV Prophylaxis

37. Replication Cycle Of HIV :-
NRTI/ NNRTI
FI
PI
Drug Category
Nucleoside reverse transcriptase inhibitors
Abacavir
Didanosine
Emtricitabine
Lamivudine
Stavudine
Tenofovir
Zalcitabine
Zidovudine
Non-nucleoside reverse transcriptase inhibitors
Delavirdine
Efavirenz
Nevirapine
Protease inhibitors
Amprenavir
Atazanavir
Fosaprenavir
Indinavir
Lopinavir/ritonavir
Nelfinavir
Ritonavir
Saquinavir
Fusion inhibitors
Enfuvirtide
Maraviroc
Integrase inhibitor- Raltegravir, Elvitegravir
C
B
B
C
C
B
C
C
C
D
B
C
B
C
C
C
B
B
B
B
B
C

38. “Option B”

39. Rationale: Shift from Option A to B+ or B
Major issue now is not “when to start” or “what to start” but “whether to stop”
BENEFITS FOR MOTHER AND CHILD BENEFITS FOR PROGRAM DELIVERY &
PUBLIC HEALTH
Ensures all ART eligible women initiate
treatment
Reduction in number of steps along PMTCT
cascade
Prevents MTCT in future pregnancies Same regimen for all adults (including
pregnant women)
Potential health benefits of early ART for
non-eligible women
Simplification of services for all adults
Reduces potential risks from treatment
interruption
Simplification of messaging
Improves adherence with once daily, single
pill regimen
Protects against transmission in discordant
couples
Reduces sexual transmission of HIV Cost effective

40. Regimen of choice
1. Tenofovir(TDF,300mg)
Lamuvidine(3TC,300mg)
Efavirenz (EFV, 600mg)
2. Tenofovir(TDF,300mg)
Emtricitabine(FTC,200mg)
Efavirenz (EFV, 600mg)
ART – HAART (NACO
GUIDELINES 2013)

41. • Alternative first line therapy
1. Zidovudine (300mg ; BD)
Lamivudine
Efavirenz/Nevirapine
2. Tenofovir
Lamivudine/Emtricitabine
Nevirapine (200mg;OD)

42. Starting Co-trimoxazole in
pregnancy
• Co-trimoxazole should be started if CD4 count is
≤250 cells/mm3 and continued through pregnancy,
delivery and breastfeeding as per national
guidelines
(Dose: Double strength tablet – 1 tab daily).
• Ensure that pregnant women take their folate
supplements regularly.

43. British HIV Association Guidelines
(BHIVA 2014)
• Combination of Zidovudine, Lamivudine, and
Abacavir used in baseline viral load is
< 1,00,000 HIV RNA copies/ml.
• Zidovudine monotherapy if VL <10,000
copies/ml and CD4 count of 350 cells/µL.

44. MODES OF DELIVERY

45. RCOG (2010) and ACOG (2000)
 Planned caesarean section :- AT 38 COMPLETED WEEKS
 LSCS after onset of labour or after rupture of
membranes (for more than 4 hours) - NOT BENEFICIAL
 Vaginal delivery can be allowed if viral load < 50 copies/ml.

46. Vaginal delivery unless the woman has obstetric reasons
for LSCS.
Elective LSCS is NOT considered a standard PPTCT
intervention.
 Consider :-
 LSCS facilities.
Stage of disease & viral load in mother.
 Presence of Labor or rupture of membranes.
Though LSCS reduces PTCT it may not be feasible in rural
settings & may increase the risk of infectious
complications.
NACO Recommendation

47. BHIVA 2014
• Viral load at 36 weeks.
• If VL < 50 copies/mL, vaginal delivery
recommended.
• If VL >50 copies/mL, a planned LSCS preferred
• Planned LSCS should be undertaken between
38-39 weeks of gestation.

48.  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.
Precautions during LSCS in HIV
+ve

49.  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.
Precautions during Delivery

50. Zidovudine as a loading dose of
2mg/kg/hour by intravenous infusion may be
given 4 hours prior to caesarean section or
at the onset of labour for vaginal delivery
followed by maintenance dose of
1mg/kg/hour until cord clamping.

51. According to WHO, providing an optimized
lifelong ART to all pregnant and breastfeeding
women with HIV is essential due to :
• Ease of implementation
• Increased coverage
• Reduced vertical transmission
• Delay in disease progression
• Better acceptability
• Reduced sexual transmission
• Avoids development of resistance
THERAPY- HOW LONG?

52. FEEDING PRACTICES:
RCOG :-
Women who are HIV positive should be advised
not to breastfeed their babies.
Breastfeeding increases the overall MTCT rate by
14% for women infected with HIV before birth and
by 30% in mothers infected post natally.
HIV EXPOSED INFANTS

53. UN Infant recommendations (2003) :-
 Avoid all breast feeding if replacement feeding is
acceptable, feasible, affordable, sustainable, &
safe ; otherwise exclusive breast feeding with
abrupt weaning at 4-6 months of life.

54. • EXCLUSIVE BREAST FEEEDING- 6 MONTHS
• Maternal death, severe maternal infection or mother’s
choice- exclusive replacement feeds may be considered
• EXCLUSIVE REPLACEMENT FEEDS- AFASS criteria,
a. Affordability
b. Feasible
c. Acceptable
d. Safe
e. Sustainable
Start weaning after 6 months and gradually start
complementary feeds irrespective of HIV status of the infant
NO MIXED FEEDING UNDER ANY CIRCUMSTANCES
NACO RECOMMENDATIONS

55. Avoid mixed feeding !
56
Exclusive
breast
Feeding
Exclusive
formula
Feeding
“A little bit of this and a little bit of
that is not best for the baby! ”
Feeding options for the HIV exposed infant

56. HIV negative Breast-feed infants HIV positive
Continue BF till 12months of age continue BF till 2years
irrespective of whether or not mother age along with pediatric
Is on ART/ARV prophylaxis ART
After 6 weeks of stopping BF, repeat EID
Confirmation at 18 months using 3 rapid tests
HOW LONG?

57. Nevirapine prophylaxis

58. • Oral contraceptive pills :
a. Not on any treatment- WHO category 1- no
restriction for the use of the method
b. On ART- dose adjustment may be needed as
drug interactions are known to occur,
ex. Ritonavir and Nevirapine reduce the efficacy
of OCPs.
Family planning and birth
spacing

59. • Injectable contraceptives- WHO category 1- no
restriction.
• Intra-uterine contraceptive devices- WHO
category 1, can be within 48hrs after delivery.
• Permanent sterilisation-
Best, but should continue to use condoms
a. Motivate men at every mother-baby pair follow-
up
b. Can be done after 18 months irrespective of HIV
status of the infant

60. Wash the wound & exposed sites with soap & water.
 Rapid HIV testing on patient & health care worker.
 Start PEP within 2 hrs. of exposure.
Discontinue PEP if confirmed that patient’s HIV test is negative.
Regimens:
 AZT+ 3TC for 4 wks, add protease inhibitor if exposure is severe.
Repeat test after 3 and 6 months .
In pregnant individuals, Nelfinavir/ lopinavir is a better.
Post Exposure Prophylaxis
Guidelines

61. Opportunistic
Infections
Prophylaxis
indicated below
CD4 count
Prophylaxis in Pregnancy.
Pneumocystis
Carini
Pneumonia (PCP)
200 TMP-SMX double strength tablet
daily or Pentamidine 300 mg once
a month
Toxoplasmosis 100 TMP-SMX double strength tablet
daily .
Disseminated
MAC
50 Azithromycin 1200 mg weekly.
Prophylaxis for OI’s in
Pregnancy

62.  For frequent or recurrent infections of :-
Herpes Simplex :- Acyclovir 200 mg tid PO.
 Candidiasis :- Fluconazole 100-200 mg/d PO.
 Recommended Immunizations for :-
Hepatitis B Virus.
Hepatitis A Virus.
Influenza Virus.
Pneumococcus.
Prophylaxis for OI’s in
Pregnancy

63. a. 10 times more in HIV positive women
b. Risk of MTCT transmission increases by 2.5
times
c. Intensified case finding has to be initiated
d. Anti-tubercular drugs have to be started first,
followed by ART as soon as possible, start ART
irrespective of CD4 cell count
Positive women with active TB

64. a. Less progressive and less incidence of
MTCT(0-4%)
b. NNRTI are not effective against HIV-2, hence
regimen includes
2 NRTI + LPV/r
HIV -2 INFECTION

65. a. Common among IV drug abusers
b. Require treatment for HBV infection- Regimen
TDF+3TC+EFV, to be started irrespective of CD4
count and WHO staging as it is effective against
both.
c. If treatment is not required- follow general
recommendations for ART/ARV prophylaxis
d.HCV co-infection- follow general
recommendations for ART/ARV prophylaxis
Hepatitis B or C co-infection

66.  Women with indications for ART with Hb <9g/dl
should be on a non-AZT regimen and receive
treatment for anemia.
 Alternatives to AZT are Stavudine (d4T) or Abacavir.
Pregnancy in HIV Positive who
have anaemia