HIV PROPHYLAXIS

FOR MOTHER AND

BABY

PRESENTED BY
G. SIVAGAMI
M.Sc(N) II YEAR,
GCON, CUDDALORE.
 INTRODUCTION
• Acquired immune deficiency virus (AIDS) is caused by
retrovirus known as human immune deficiency virus. HIV
infection is major challenge for the obstetrics team and for
midwifery care. HIV causes incurable infection that leads
ultimately to terminal disease called AIDS. HIV was discovered
by Barre sinovursi and collegues in 1983. HIV virus (HIV 1 &
HIV 2) are retroviruses having the enzyme reverse transcriptase,
which permits genomic RNA to be transcripted into double
standard DNA.
• The virus specially reduces CD4 receptor molecules of the T-
lymphocytes, monocytes macrophages and other antigen
presenting cells leading to immunodeficiency.
 Cont.,
• Free diagnosis of HIV has been made available through
intergrated counselling and testing centers (ICTC) associated
with ANC s at most Government aided health care facilities.
• From 2016, approximately 21000 ICTCs are available to offer
free services to pregnant women, across India and most are
attached with government aided health care facilities. Objective
of the prevention of parent to child transmission of HIV/AIDS
(PPTCT) is to prevent the perinatal transmission from a pregnant
women with HIV to her newborn.
 DEFINITION

• Acquired immune deficiency syndrome has been defined

as, an acquired defect of cellular immunity associated with
infection by the human immunodeficiency virus (HIV), a
CD4 positive T- lymphocyte count under 200 cells or less
than 14% of the total lymphocytes and increased
susceptibility to opportunistic infection and malignant
neoplasms.
- Centers For Disease Control
Prevention
 INCIDENCE
• According to WHO, Globally an estimated 1.3 million
women and girls living with HIV become pregnant each
year.
• In the absence of intervention, the rate of transmission of
HIV mother living with HIV to her child during
pregnancy, labour, delivery of breastfeeding ranges from
15% to 45%.
• As such, identification of HIV infection should be
immediately followed by an offer of linkage to lifelong
treatment and care, including support to remain in care
and virally suppressed and an offer of partner services.
 RISK FACTORS FOR HIV/AIDS
• Marriage with an older man who is more likely to have
HIV or AIDS
• Economic dependence on men
• RTI/STI goes unrecognized in women making them more
susceptible to HIV/AIDS
• Illicit drugs use and cigarette smoking
• More frequent blood transfusion in women.
MODE OF TRANSMISSION OF HIV
• Sexual transmission
• Mother to child (vertical
Heterosexual transmission)
Homosexual In utero
• Exposure to blood and During delivery
body fluids breastfeeding
Blood transfusion
IV drug use
Occupational exposure
like needle stick/splash cut
 DETERMINANTS OF VERTICAL
TRANSMISSION
• MATERNAL DETERMINANTS
1. Viral load
2. Biological prototype of virus
3. Unprotected sex during pregnancy
4. Smoking and illicit drug use in mother
5. Maternal level of CD4 and lymphocytes count
6. Low maternal zinc, vitamin A level
7. Presence of RTI/STI in mother
8. Time of rupture of membranes and chorioamnionitis more than 4hrs
9. Episiotomy and operative vaginal delivery
10. Presence and amount of virus in genital tract
 FETAL DETERMINANTS
1. Preterm fetus
2. Fetal ingestion of virus
3. Fetal scalp electrode, scalp blood sampling & umbilical
blood sampling
4. Duration of exposure to maternal secretions (first twin)
5. Via breast milk depending on the immune response of the
newborn and period of breastfeeding and infectivity of
mother.
 MATERNAL DETERMINANTS
1. Viral load (the virus in blood stream)
• Viral load in the mother is maximal immediately after
infection and in the advanced stage of disease.
• Measurement of plasma HIV-1 RNA and quantitative culture
is a better predictor of vertical transmission.
Normal- 20 to 75 copies of HIV/ml of blood
2. Concurrent STI
• This is also strongly associated with vertical perinatal HIV
transmission. E.g: syphilis infection
Cont.,
3. Unprotected sexual intercourse
• An high frequency of unprotected intercourse during
pregnancy was associated with an increased risk of
transmission even after the adjustment of multiple potent
confounding variables
4. Maternal CD4 and lymphocyte count
• It is an independent predictor of prenatal transmission
risk.
• A lesser concentration causes greater transmission
 Maternal determinants Cont.,
6. Nutritional status
• Inadequate nutrition may increase the risk of vertical
transmission by influencing maternal and child factors for
transmission.
• Low level of vitamin A during pregnancy were associated
with an increased transmission of HIV
7. Rupture of membrane
A correlation between the time lapsed from rupture of
membranes to actual delivery and an increased risk of
transmission is known.
 Maternal determinants Cont.,
8. Type of virus
The viral biological phenotype may influence the
transmission risk
9. Placental barrier
Breaches in the placental barrier could lead to a mixing of
maternal and fetal cells. Conditions like chorioamniotis,
cigarette smoking and illicit drug use are known to be
associated with placental disruption and hence cause an
increased transmission risk.
Maternal determinants Cont.,
10. Presence of amount of virus in genital tract
This may affect the transmission risk. HIV1 DNA was
detected in 32% of cervical and 10% of vaginal samples.
11. Smoking and illicit drug use
Maternal use of illicit drug may increase the risk three fold
 FETAL DETERMINANTS
The susceptibility to infection could vary with gestational age
possible because of development of CD4 expression.
It is been reported that there is 3.7 times risk for intrapartum HIV
transmission during preterm delivery, perhaps because of
newborn’s immune mechanism is immature
Invasive procedures that breach the infant’s skin barriers could
provide another mechanism for viral entry.
Extensive cephalic version, episiotomy and operative vaginal
delivery also increase intrapartum transmission to the fetus
It is observed that there is a more than two fold risk of infection of
the first born twin compared to the second.
 TIMING OF VERTICAL
TRANSMISSION
• In Utero
The exact timing of HIV transmission from the mother to
fetus is not known with certainly.
Intrauterine transmission is documented by HIV infected
in placental tissue, fetal blood samples and amniotic fluid,
positive viral studies in 20 to 60% of infected in infants at
birth.
Bimodel onset of symptoms with early onset is less than
12 months in more than 30%
Cont.,
• Breastfeeding
Transmission via breast milk is supported by known
transmission of other retero viruses by milk.
There is evidence that breastfeeding increases postnatal
HIV 1 transmission by as high as 30 to 40%
The risk of transmission varies with;
1. The period of breastfeeding
2. Maternal HIV load
3. HIV disease status (early or terminal)
Cont.,
4. Associated with breast abscess
5. Cracks in nipples
6. Whether exclusive breastfeeding
7. It was found that breastfeeding beyond 15 months was
associated with 1.9 fold increased risk of infection.
It was calculated that the HIV-1 transmission risk exceeded
the potential benefits of breastfeeding after 6 months of age.
RISK OF HIV TRANSMISSION
 INTRAPARTUM
• There is evidence that intrapartum (during delivery)
transmission is the highest. This gave rise to idea of
carrying out a caesarean section in all HIV positive patients.
Effect of HIV on pregnancy
HIV infection has been reported to have little effect on
pregnancy outcomes or complications.
Adverse pregnancy outcomes have, however been reported
more common in a number of Africans studies, including
complications of both early and late pregnancy.
 CLINICAL PRESENTATION
• ACUTE INFECTION:
• Initial presentation of an infected patient may be fever, malaise, headache,
sore throat, lymphadenopathy and maculopapular rash.
• CHRONIC INFECTION:
• Progression of disease may lead to multiple opportunistic infection with
candida, tuberculosis, pneumocystis and others.
• AIDS: Patients may present with neoplasms such as cervical carcinoma,
lymphoma and Kaposi’s sarcoma.
• There may be associated constitutional symptoms like weight loss,
lymphadenopathy or protracted diarrhoea.The median time from infection to
AIDS is about 10 years.
 DIAGNOSIS OF HIV
FOR MOTHER
• Detecting DNA viral load in blood by PCR testing- HIV
RNA PCR
• ENZYMEIMMUNOASSAY is used as screening test for
HIV antibodies.
• Western blot, immunofluorescence assay is to confirm
the test and presence of antibodies.
• Clinical progression of the disease is monitored by
evaluating the CD4 cell count.
Diagnosis Cont.,
• The absolute CD4 forms the basis for therapeutic
intervention:
1. CD4 counts of more than 500/ml – there is no clinical
evidence of immunosuppression.
2. At CD4 counts of 200 – 500/ ml – there is a greater
likelihood of developing symptoms and need for medical
intervention
3. At CD4 counts of less than 200/ml- patient suffering
from persistent thrush and temperature more than 37.8 c
for 2 or more weeks are at increased risk of developing
complicated disease.
For children more than 18 months
Screening tests
Detection of
antibodies to
HIV-1 & HIV-2
Adults and Supplemental/
children >18 confirmation test
months
laboratory
P24 antigen
diagnosis Detection of detection
virus or viral
products
PCR
Cont.,
Supplemental/
Screening tests
confirmation test

ELISA (requires E/R 2nd & 3rd

equipment) kills

Rapid (point of
Western blot
care)
For children less than 18 months
Newborn <18 months

Virological based tests

only can detect HIV
infection

Detection of viral
Direct of free p24 Isolation Of Virus
nucleic acids (RNA
antigen (Rarely Done)
or DNA)

DNA – PCR used

ELISA
more often

RNA -RTPCR
Cont.,
other
s
Detection of IgM and
IgA class of
antibodies
Invitro
antibody
production
Estimation of CD4 T cells
to show progressive
decline
 MANAGEMENT
• Physical examination
HIV positive women should have a full examination at the
first visit.
The presence of any signs of HIV related infections
particularly tuberculosis, oral or vaginal thrush or
lymphadenopathy should be checked without fail.
Clinical diagnosis and treatment of vaginal or cervical
inflammation, abnormal discharge or sexually transmitted
infection should be a priority.
INVESTIGATIONS
• Invasive diagnostic procedures, such as chorionic villus
sampling, amniocentesis or cordocentesis should be
avoided where possible.
• Syphilis testing should be undertaken and repeat testing in
late pregnancy may advisable.
• Haemoglobin estimation is mandatory, a complete blood
count should be performed and T cell subset investigations
should be undertaken where possible.
FDA classification of antiretroviral drugs
for use in pregnancy
DRUG FDA CATEGORY
Nucleoside reverse transcriptase
inhibitors
Zidovudine C

Zalcitabine C

Diclanosine B

Stavudine C

Lamivudine C
CONT.,
Non- Nucleoside Reverse Transcriptase inhibitors

Nevarapine C

Delavirdene C

Protease inhibitors

Indinavir C

Ritonavir B

Saquinavir B

Neltinavir B
 CLASSIFICATION
A. No risk for fetus during the first trimester of pregnancy
B. No risk in animal studies but lack of human studies
C. Safety inhuman pregnancy is not determined, drugs
should not be used unless the potential benefits
overweight the potential risk to fetus.
D. Positive evidence of human fetal risk
x. Studies in animals or reports of adverse reactions have
indicated risk.
 Therapeutic options for women with a low plasma
viral load and a well preserved CD4 T- lymphocyte
count
Option 1: single agent zidovudine regimen
• Zidovudine is given orally twice a day during pregnancy commencing at 28 weeks
of gestation.
• Zidovudine is given intravenously intrapartum
• Zidovudine is usually discontinued immediately after delivery
• Delivery should be by elective CS.
Benefits
Exposure of the mother and fetus to layer numbers of potentially toxic drugs is
avoided. Zidovudine is usually administered orally to neonate for 4-6 weeks,
commencing as soon as possible after birth.
Option 2: short term antiretroviral therapy
regimen
• HAART is given during pregnancy, at 20 -28 weeks of gestation
• HAART may be discontinued shortly after delivery provided that
the maternal viral load is undefectable.
Benefits
 Maternal plasma viraemia is more likely to be suppressed to
undefectable levels.
 Fewer mother to infant transmission as therefore envisaged
 Risk of the mother developing resistant virus may be lower.
 CARE OF MOTHER
• Prenatal care / antenatal care
 The national AIDS control organization of India recommends that all pregnant
women irrespective of their risk factors should be counselled to undergo testing for
HIV infection unless they opt out of it rather than opt in screening in which the
patients have to opt for screening.
 In HIV positive women, the initial booking visit should include a through history
and physical examination including baseline fundus examination, neurological and
pelvic examination.
 Tests should be performed are; complete hemogram, urine examination, Blood
group, tests for other STD, Tests for toxoplansmosis, cytomegalo virus infection,
serological testing of husbands should be offered
 Liver function test, HIV viral load at initial visit and repeated each trimester
 Cont.,
 CD4 lymphocyte count at initial visit repeated in each trimester
 If the CD4 count falls to cells/mm3 the patient is given prophylaxis against pneumocystis
jiroveci and other opportunistic infection.
 The women and her partner are counselled about the risk of HIV transmission to the fetus and
neonates
 Iron, calcium and vitamin supplements are necessary to improve the general condition of the
patient.
 Invasive testing like amniocentesis should be avoided
 Antiviral therapy during pregnancy by WHO(2013) which has been accepted by NACO.
 There has been a shift from option A to option B or B +
 NACO operational guideline has decided to adopt options b + for life long ART.
 Antiretroviral therapy is highly effective in viral load and perinatal transmission.
WHO PREVENTING MOTHER TO
CHILD TRANSMISSION
Option B+
• Regardless of CD4 count or WHO clinical Stage.

• Initiate and maintain lifelong for all

• Particularly in generally epidemic settings.

• Settings with CD4 testing.

• Long duration of breast feeding

• High rates of fertility

• Limited partner testing: high partner discordancy rates.

WHO PREVENTING MOTHER TO CHILD
TRANSMISSION
Option B
1. Eligible women (ART required for mother's health)

Initiate & maintain lifelong

INDICATIONS

Stage I and II – if CD4<500

Stage III and Stage IV – irrespective of CD4
2. NON- eligible (ART given to precent transmission)

Imitate for all; stop 1 week after cessation of breast feeding immediate post delivery
Highly active antiretroviral therapy

• HAART is the best regimen as it can minimize the perinatal

transmission to less than 2%.
• The dosage and type pf ART for HIV positive mother
Preferred first line therapy
2 NRTI + INNRTI
1. TDF-300mg + 3TC 300gm + EFV 600mg single OD dosage drug
combination,
Cont.,
Alternative first line therapy
1. A2T – 300 mg Bd + 3TC + EFC(NVD)
2. TDF + 3TC (ot FTC) + NVP 200 mg OD
NNRTI: Nonnucleoside Reverse Transcriptase Inhibitor
NRTI: Nucleoside reverse Transcriptase Inhibitor
INTRAPARTUM CARE
In recent recommendation by WHO and NACO caesarean delivery
to be done only for obstetric indications, otherwise vaginal
delivery can be allowed especially if the women is on ART in
pregnancy.
Elective caesarean section reduces the risk of vertical transmission
by approximately half.
Royal college of obstetrics and gynaecology has recommended
elective cesearean delivery at 38 week HIV positive mother taking
HAART regimen
Vaginal delivery is only allowed if women is on HAART with viral
load <50copies/ml.
INTRAPARTUM CARE cont..,
The morbidity of caesarean in 5 – 7 times as compared with
vaginal delivery in HIV positive women.
Factors that increase the risk of vertical transmission of HIC like
artificial rupture of membrane, use of fetal scalp and determination
of scalp blood pH should be best avoided.
Maternal blood sample is taken for viral load and CD4 count.
Intrapartum therapy consist of zidovudine 2mg/kg during 1 st hour
of labour & 1.0mg/kg/hr in rest of labour.
Zidovudine as loading dose of 2mg/kg hour by intravenously
infusion may be given 4 hours before caesarean section followed
maintenances dose of 1mg/kg/he until cord clamping.
INTRAPARTUM CARE cont..,
The operating table should be cleared with 0.5% sodium
hypochlorite or 10% Lysol.
Universal standard precautions must be followed during delivery.
Avoidance of needle stick injuries by using blunt tipped needles,
avoiding resheating of needles and other measures.
Disposable syringes and needles should be used which are then
disposed in puncture proof containers.
RISK FACTOR FOR INCREASED
PERINATEAL TRANSMISSION ARE
 Maternal high plasma viral  Preterm delivery
load
 Vaginal delivery and breast
 Low CD4 cell count feeding
 Co-existing other STDs and  Post exposure prophylaxis with
opportunistic infections. triple therapy for 4 week,
reduces the risk of
 Prolonged rupture of
seroconversion by more then
membranes 80%
 Chorioamnionitis  Triple therapy : zidovudine
 Invasive intrapartum 200mg tid+ lamivudine 150mg +
procedures Indinavir 800mg tid
 Guidance for vaginal and caesarean section
Elective caesarean section:

• Elective LSCS Should be performed at 38 – 39 weeks.

• Commence zidovudine infusion before 4 hour of LSCS and continue until cord has been clamped.

Planned vaginal delivery

• Amniotomy should be avoided

• Avoid use of fetal scalp electrode and fetal blood sampling.

• Continue HAART regime throughout labour.

• If intravenous infusion of zidovudine is required start it at beginning of labour and continues until cord has
been clamped.

• Clamp the cord as soon as possible after birth of baby.

• Test maternal blood at delivery for plasma viral load.

• Bath baby immediately after birth.

Research findings for delayed cord clamp
 Post partum care
• Women should continue HAART with CD4 count.
• Formula feeding or breast feeding to be started with counselling
and informed consent.
• Breastfeeding doubles the risk MTCT (from14.1% to 28%) but
when alternative forms of infant.
• Zidovudine syrup 2mg/kg is given to the neonate 4 times daily for
first 6 weeks of life.
Contraception
• HIV positive women are strongly advised to use dual contraception
or double Dutch.
 WHO CATEGORY IN HIV & AIDS
Category I: Combined oral pills, progesterone only pill and
DMPA.
Category II for HIV: IUCD
Category III for AIDS
• IUCD spermicide is avoided
• Barrier method with simultaneous use of a spermicidal
agent such as nonoxynol-9 is found to improve the
efficiency
 Nursing management
While taking the care of HIV/AIDS client the nurse has to follow some
standards of care guidelines, they are
Utilize universal precautions
Protect confidentiality
Educate the patient about methos for the prevention of HIV
transmission.
Perform a psychosocial assessment
Develop adherence strategies for patient taking antiviral therapy.
Provide education and interventions for HIV symptom management.
 CARE OF NEWBORN
 All HIV exposed infants should be started with ART, preferably within
12 – 24 hours of birth, even if the mother had not taken any ART
during pregnancy.
 Commonly used regime are A2T (Zidovudine 2mg/kg 6 th hourly for 6
weeks Niverapine 2mg/kg single dose or a combination of both)
 Anaemia has been the most common complication seen in neonate
with the long term treatment of 6 weeks zidovudine to the child.
 Children should be referred to for long tern follow-up and for repeat
testing for diagnosis of HIV infection either by early PCR or by ELISA
at 15 – 18 months(because of passive transfer of IgG from mother to
fetus which persist for 18 months in the baby)
 CARE OF NEWBORN
 Avoid invasive nasogastric suctioning
 Wash away blood from newborn
 Baby should be bathed immediately
 Accordingly to 2013, guidelines breast feeding for 6 months,
continues feeding till 12 month if possible.
 Breast feeding should be avoided only when formula feed is
acceptable.
Follow up care of the baby
parent must be counselled with regard to the period of (18
months) uncertainly and doubt.
PREVENTION STRATEGIES
1. Counselling
Pre-pregnancy and early pregnancy counselling for HIV
infected patient is essential.
2. Risk recognition and appropriate counselling, testing and
referral.
3. STI management
4. Ensure safe blood supply by mandatory screening of
donated blood only rational use of blood, transfusion
discouraging professional blood donation.
PREVENTION STRATEGIES

5. Educated hospital and personal on standard work

precaution and appropriate post exposure prophylaxis.
6. Routine timely HIV testing in pregnancy and prevention
of mother to child transmission.
7. Voluntary and confidential counselling testing promotion
and referral.
 PRIMARY PREVENTION
Prevention of unintended pregnancy is primary preventive
measure.
Lobal preventive initiatives target young people by giving
message of safe sexual behaviour, promotion of condom
use, testing negotiation skills, dual protection and
diagnosis and treatment of STI & RTI
 SECONDARY PREVENTION
The vertical transmission of HIV from mother to fetus can
be done by 2 strategy:
1. Reducing the viral load with use if antiviral drugs.
2. Cleansing the vagina with antiviral chemicals
preparations to reduce risks of infection from maternal
secretions is of controversial value.
 WHO RECOMMENDED PMTCT
ARV prophylaxis to the infants immediately after birth to
6 – 12 weeks of continuation.
The duration of administration of ARV to the newborn
depends on the states of ART to the HIV infected mothers
The nevirapine prophylaxis was suggested for early 4 – 6
weeks of same ART prophylaxis for non-breastfeeding
infants.
 CONCLUSION
• Indian AIDS control program has made progress in
reducing HIV transmission from infected pregnant women
to her newborn babies though country is far away to
achieve total elimination of MTCT of HIV.
• Intervention program strengthening maternal ART,
initiation of ARV prophylaxis of born to HIV infected
mothers simultaneously institutional caesarean delivery
might help in reducing MTCT HIV risk. However, at
present more surveillance data are crucial to follow the
development of PMTCT program.
 ASSIGNMENT
• Write an assignment on staging of HIV/AIDS and their
specific management during pregnancy.