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Dr ankita bansal
Dr ankita bansal

This document provides information on HIV/AIDS in India, mother-to-child transmission of HIV (MTCT), and the management of HIV-infected pregnant women. Some key points: - An estimated 2.39 million people are living with HIV in India, with 0.9 million women infected. - Without intervention, the rate of MTCT is 20-45%, but can be reduced to 10-1% with proper intervention. - Triple antiretroviral therapy is recommended for all HIV-infected pregnant women in India, regardless of CD4 count, to be continued lifelong. - Elective c-section is recommended at 38 weeks for women with high viral loads (>1000 copies/mL

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India data: Estimated no. of PLW HIV =2.39 million (1.93 - 3.04) No. of women who are HIV infected =0.9 million (38%) No. of newborns born per year = 12,900 MTCT: Without any intervention, MTCT@ 20-45% With intervention @10%-1%
alp hiv 2
In India-1/3rd of the total affected population are rural Classification of Indian states Prevalence of HIV infection States High >1% in ANW Maharashtra,TN,Manipur Karnataka,AP,Nagaland Intermediate < 1% in ANW >5% among HRG Gujarat, Goa & P0ndicherry Low < 1% in ANW <5% among HRG Other states
Timing of infection(early, late pregnancy or labour) Type of disease(symptomatic/asymptomatic) Viral load,CD4 counts & immune status Duration of ART Genital tract infections
Obstetrical factors- Prematurity, PTPROM, chorioamnionitis, prolonged labour, operative interventions & blood transfusion Medical complications Tuberculosis, Hepatitis Route of delivery
Increased risk of abortion(3-6 times) IUGR(>2times) Preterm labour(>2times) Still birth Increased risk of maternal anemia & low birth weight babies
HIV infection-slightly accelerated; hastens development of AIDS Plasma HIV1RNA-unaffected in pregnancy but increases in postpartum period Due to haemo-dilution, absolute CD4 count After delivery- CD4 levels by 50-100 cells/ul Unprotected sexual intercourse enhances the viral load
Types- a)Opt out-provider initiated counselling & testing b)Opt in-client initiated counseling & testing c) Pretest counselling- informed consent for testing is obtained; in case of refusal, client is recounsiled; test report is kept confidential d) Post test counseling-information regarding Disease status Therapy Follow up Behaviour modifications Use of safe sex practices Contraception Antenatal care Mode of delievery Breastfeeding
CDC classification - based on immunological marker WHO classification - based on clinical stage
Assesses disease severity by CD4 counts & presence of specificAIDS related conditions CD4 count A Asymp, acute or PGL B Symtomatic cond. Not A / C C AIDS indicator cond > 500 cells / micro L A 1 B 1 C 1 200-499 cells/ micro L A 2 B 2 C 2 <200 cells / micro L A 3 B 3 C 3
HIV-associated symptoms WHO clinical stage Asymptomatic 1 Mild symptoms (unexpl mod wt loss, rec URTI, rec oral ulceration) 2 Advanced symptoms(unexpl severe wt loss, pulTB, chr diarrhoea, cervical dys, TO mass, persistent fever,) 3 Severe symptoms (pneumocystis, CMV, kaposi, extrapul TB, invasive Ca Cx ) 4
Care and Assessment of HIV Infected Pregnant Women
WHO clinical staging Clinical screening forTB Screen and treat any STIs ( Pap smear ,VDRL) CD4 cell count (Baseline) Additional assessments of Hb , LFTs, RFTs should be performed when warranted by clinical signs & symptom Lipid profile , RBS at baseline, 6 mths & 1 yr, if started on LPV/r based regimens
Avoid invasive tests(CVS, Amniocentesis) Iron, calcium , vitamin supplementation Folic acid intake High protein diet Monitor wt gain Start on cotrimoxazole prophylactic therapy Start on ART
alp hiv 2
Antenatal period- decreases maternal viral load in blood and genital secretions Pre exposure prophylaxis: ARV drugs that cross the placenta from mothers to infants and produce adequate systemic drug levels in the infants Post exposure prophylaxis ARV drugs to infants after birth, provide protection from virus that may have entered the fetal/infant systemic circulation during labor and delivery
Group of ARV Name of drugs Common adverse effects NRTI Zidovudine(ZDV)300mg od Lamivudine(3TC) 300mg od Tenofovir -- 300 mg od -Nausea, vomiting, anemia -Minimal side effects -Nephrotoxicity NNRTI Nevirapine(NVP)200mg od Efavirenz(EFV) -----600 mg od Liver dysfunction, hyp.reaction NTDs , Neurological problems Protease Inhibitors Lopinavir (LPV)+ Ritonavir(r) FDC- 200mg/ 50 mg 1 tab Dose- 2 tab bd Hyperglycemia, diabetic exacerbation-ketoacidosis, viral diarrhoea, deranged liver function- drug interactions
Zidovudine (300 mg) + Lamivudine (150 mg) Tenofovir (300mg) +Lamivudine (150 mg) Zidovudine(300 mg) +Lamivudine (150 mg)+Nevirapine (200 mg) Efavirenz (600 mg) Nevirapine (200 mg) Fixed-dose combinations (FDCs) are preferred Easy to use Have distribution advt (procurement and stock management) Better complaince & reduce drug resistance
NACO Dec 2013 Recommends - Lifelong Triple drug therapy for all Pregnant and Breastfeeding Women with HIV irrespective of CD4 counts & clinical stage of Disease
alp hiv 2
Principles for selecting the first-line regimen 1. Choose Lamivudine in all regimens 2. Choose one NRTI Ziduvudine / Tenofovir to combine with Lamivudine 3. Choose one NNRTI Nevirapine/ Efavirenz
Option B+Triple drug therapy lifelong Option B ARV Prophylaxis Triple drugs frm 14 wks + 1 week until BF ends OptionA Ziduvudine+ sd Nevirapine+AZT& 3TC postpartum for 1 week
Efavirenz has been classified as FDA Pregnancy Category D. Because of the potential for teratogenicity, pregnancy should be avoided in women receiving efavirenz, and treatment with efavirenz should be avoided during the first 8 weeks of pregnancy (the primary period of fetal organogenesis) whenever possible Meta-analysis including data from 21 studies reporting on 1,437 first-trimester exposures found no increased risk of overall birth defects in infants - giving an incidence of 0.07% ( incidence in general US population 0.02-0.2%) (PACTG) 219 and 219C studies -reported a higher defect rate in infants Additional data are needed on first-trimester Efavirenz exposures to be able to more conclusively determine if risk of neural tube defects or other malformations is elevated. AIDS info/ USA Guidelines march 2014
Until recently, most people receiving ART in resource-limited settings have initiated NVP-based regimens EFV has been recommended for use in pregnant women in all trimesters of pregnancy including first trimester. (Ford. N et. al, 2011, Ekouevi DK et.al2011, Use of Efavirenz during pregnancy: a public health perspective, Technical update on treatment optimisation, Geneva, World Health Organization, 2012 The use of EFV is increasing in resource-limited settings as a result of its widespread availability as part of once-daily fixed-dose combinations ,considerable reductions in drug price
Previous exposure to Single dose Nevirapine (or EFV) for PPTCT prophylaxis in prior pregnancies, first line ART regimen such asTDF+3TC+EFV may not be fully effective due to development of resistance to Nevirapine/ cross resistance with Efavirenz Tenofovir+ Lamivudine + Efavirenz Tenofovir+ Lamivudine + Lopinavir 2oomg / ritonavir 50 mg
Should continue to receive the same regimen throughout pregnancy, labour, breast- feeding period and thereafter life-long. If a woman is on an EFV based regimen, there is no need to substitute with Nevirapine (this was done as per earlier guidelines)
When CD4 count is 250 cells/mm3 Continued through pregnancy, delivery and breastfeeding as per national guidelines Dose: Double strength tablet 1 tab daily CPT-is helpful in reducing morbidity and mortality as it prevents Opportunistic Infections If CD4 count >250 for at least 6 months and If patient is on ART for at least 6 months, is asymptomatic and well , CPT should be stopped Should be continued during breastfeeding when indicated
Labour and Delivery in the HIV Infected Pregnant Women
LSCS in HIV positive pregnant women should be performed for Obstetric indications only Caesarean section is not recommended for prevention of MTCT & only if there is an Obstetric indication for the same NACO Dec 2013
Elective CS at 38 weeks gestation to minimize perinatal transmission of HIV is recommended for women with HIV RNA levels >1000 copies/mL or unknown HIV levels near the time of delivery, irrespective of administration of antepartum ART In women with HIV RNA levels 1000 copies/mL, CS performed for standard obstetrical indications should be scheduled at 39 weeks gestation. AIDS info/ USA Guidelines march 2014
Results from a large meta-analysis from 15 prospective cohort studies demonstrated the benefit of Elective CS with a 50% reduction in risk The benefits of CS included mostly women who were receiving either no ARVs or zidovudine alone Pregnant women receiving ART ( at least 3 drugs) had transmission rates of about 1%, the benefit of is difficult to evaluate.
Women on life-longART should continue their standardART regimen In case of an emergency CS in pregnant women who are not on ART, ensure that the women receiveART prior to the procedure and continues thereafter Standard prophylactic antibiotics to be given
IV zidovudine should be administered to HIV- infected women with HIV RNA >1,000 copies/mL Unknown HIV RNA status Non complaince withART IV zidovudine administration should begin 3 hours before the scheduled operative delivery AIDS info/ USA Guidelines march 2014
Standard/Universal Work Precautions ARM reserved for cases of fetal distress or delay in progress of labour. Minimize PVs and use aseptic techniques Avoid invasive procedures like fetal blood sampling, fetal scalp electrodes Avoid instrumental delivery as much as possible If indicated, low-cavity outlet forceps is preferable to ventouse, as it is generally associated with lower rates of fetal trauma than ventouse Avoid routine episiotomy as far as possible
Use of dry haemostatic techniques to minimize bleeding; i.e. good observation and following of surgical fascial planes during dissection, judicious use of electro-cautery during Caesarean section etc. Membranes are left intact until the head is delivered through the surgical incision. Early cord clamping Use of round-tip blunt needles Do not use fingers to hold the needle; Use forceps to receive and hold Observe good practice when transferring sharps to surgical assistant eg. holding container for sharps the needle
The decision Elective CS vsVaginal delivery must be individualized, taking into account: Duration of rupture or labor upon presentation( 2% risk per hour) Plasma RNA levels Current ARV drug regimen status The ARV drug regimen should be continued and IV zidovudine initiated HIV transmission rate was similar in women undergoing emergency cesarean delivery and those delivering vaginally (1.6% vs. 1.9%) Meta-analysis of HIV-infected women, most of whom were on zidovudine as a single drug or receiving no ARV medications, demonstrated a 2% INCREASED RISK PER HOUR
Care and Follow-up of HIV Exposed Infants
NACO2013 Infants should be given exclusive breastfeeds for the first 6 mths preferably. Exclusive replacement feeding(ERF) may be done only if the mother has died or has a terminal illness or decides not to breastfeed despite adequate counselling Exclusive Replacement Feeding should be done only when AFASS criteria is fulfilled: A Affordable F Feasible A Acceptable S Sustainable S Safe In US where safe infant feeding alternatives are available and free for women in need, HIV infected women should not breastfeed their infants. Maternal receipt of combination ARV regimens is likely to reduce free virus in the breast milk, but the presence of cell- associated virus (intracellular HIV DNA) remains unaffected and, therefore, may continue to pose a transmission risk
Risk of infant mortality due to diarrheal and respiratory infections Duration of maternal ART- Several weeks to months before full viral suppression in breast milk is achieved Reduced but potential risk of transmission of virus in breast milk(intracellular DNA ) Development ofARV drug resistance in infants who become infected despite prophylaxis IN INDIA >50 % of children <5 yr of age Malnutrition 57 % of women of childbearing age Anaemia 30 % of infants being born r underweight
Mixed feeding -Feeding breast-feeds and replacement feeds simultaneously in the first 6 months is contraindicated- infant gut mucosal injury Mother should be receiving ART during the whole duration of breastfeeding (ART is lifelongART for the mother) Breast-feeding should NOT be stoppedABRUPTLY Complementary feeding should be introduced gradually after 6 months irrespective of whether the infant is diagnosed HIV negative or positive BF- continued upto 1 year( Infant tested negative) BF- continued upto 2 years ( Infant tested positive) NACO Dec 2013
Infants born to HIV-infected mothers should receive NVP prophylaxis immediately after birth(Within 1 hr of delivery)
It is important to do the following for infants at 6 weeks: Do re-inforcement for EBF for the first 6 Mths (Continuation of breastfeeds with introduction of complementary feeds thereafter) Do Early Infant Diagnosis (EID) testing at 6 wks, 6 mths & 18 mths Do Immunization Do CPT initiation and continue until baby is 18 mnths old or longer if baby is confirmed positive Do stop NVP Prophylaxis for baby at 6 weeks (maternal ART is not of adequate duration continue upto 12 wks)
alp hiv 2
Dual protection refers to simultaneous protection against both unplanned pregnancy and STIs and HIV by using: Condoms together with another effective method of contraception, including emergency contraception HIV-infected women can use all available contraceptive methods, including hormonal contraception (e.g., pill, patch, ring, injection, implant) and intrauterine devices (IUDs) DMPA can be used without restriction because of its relative higher dose and studies that have shown no significant interaction between DMPA and ARV Ritonavir boosted regimens- OCPs contraindicated NVP reduces the levels of cOCPs but at present, no dosage modification are being suggested IUCD/ PPIUCD within 48hrs good contraceptive method Male partner counselled for NSV( condoms to be used still) NACO Dec 2013
NACO DEC 2013 AIDS info/ USA March 2014 1) When to start ART At diagnosis of HIV status irrespective of CD4 count Drug resistance testing advised If later in pregnancy ART started promptly 2) ART Drug regimens 2NRTI- Tenofovir+Lamivudine 1 NNRTI- Efavirenz 2 NRTI- Tenofovir+ Lamivudine Tenofovir+ Emtricitabine Tenofovir+ Abacavir PI-ritonavir boosted LPV 3) Efavirenz safety Safe To be continued in first trimester Efavirenz after 8 wks 4) Mode of delivery Vaginal delivery unless obstetrical Indication If RNA > 1000 copies/ml Elective CS @ 38 wks If RNA < 1000 copies /ml Elective CS for obs indication only @ 39 wks
NACO DEC 2013 AIDS info/ USA March 2014 5) Zid0vudine during CS ---------- IV Zidovudine ( for 3 hrs) before CS- if viral RNA copies > 1000 6) Infant feeding EBF preferred ERF 7) Infant prophylaxis Nevirapine for 6-12 wks 4-6 weeks of zidovudine + 3 doses of nevirapine in the first week of life 8)When to stop ART To be continued lifelong Depending upon Pretreatment CD4 Count RNA levels Drug complaince Partner status Pt preference etc.
TB responsible for - 25% of all deaths among HIV infected individuals. Risk of activeTB - 10 times higher in HIV ActiveTB in HIV-infected pregnant- Risk of Maternal mortality Prematurity Low BirthWeight InfantTB Risk of HIV transmission ( MTCT) by 2.5 times
Evaluation forTB- History & Exam Should be started on ART, irrespective of CD4 count ATT should be started first, and followed by ART as soon as feasible (usually after 2 wks) Drug interactions: Efavirenz preferred over Nevirapine( liver toxicity) Those not able to tolerate EFV, a boosted PI regimen - With Rifampicin(component of ATT) should be substituted with Rifabutin
Eligibility For HIV PEP 1)Timing of initiation of prophylaxis- within 72 hrs of exposure ( not to delayed awaiting HIV test results) 2)The persons HIV status-PEP for HIV negative individual 3) Nature and risk of exposure-mucous membrane or non intact skin exposed to potentially infectious body fluids 4) HIV positive status of the source of potential exposure/ status not known First line PEP: Zidovudine( 300mg) + Lamivudine ( 150mg) (BD) for 4 wks
Exposure to body fluids considered at risk Blood Semen Vaginal secretions Cerebrospinal fluid Synovial, pleural, peritoneal, pericardial fluid Amniotic fluid Other body fluids contaminated with visible blood Exposure to body fluids considered Not at risk (unless these secretions contain visible blood) Tears sweat Urine faeces saliva
Exposure which may place at risk of blood-borne infection : Percutaneous injury-needle-stick or cut with a sharp instrument(o.3%) Contact with the mucous membranes of the eye or mouth( 0.09%) Contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis) Contact with intact skin when the duration of contact is prolonged (e.g. several min or more) with blood or other potentially infectious body fluids.
TIMING after exposure TESTS 2-4 Weeks Hb, LFTs 6 weeks HIV antibody( ab) 3 months HIV antibody( ab) Anti HCV Hbsag 6 months HIV antibody( ab) Anti HCV Hbsag
PrEP- Daily- or intermittently-dosed oral or vaginally- applied ART given to an HIV-uninfected individual in order to prevent HIV acquisition during a high risk sexual encounter PrEP - More practical than post-exposure prophylaxis (PEP) - injection drug users, commercial sex workers, or women in serodiscordant heterosexual relationships Microbicides- intravaginal/intrarectal topical formulations of anti-HIV agents Tenofovir disoproxil fumarate (or in co-formulation with emtricitabine )
alp hiv 2
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alp hiv 2

  • 2. India data: Estimated no. of PLW HIV =2.39 million (1.93 - 3.04) No. of women who are HIV infected =0.9 million (38%) No. of newborns born per year = 12,900 MTCT: Without any intervention, MTCT@ 20-45% With intervention @10%-1%
  • 4. In India-1/3rd of the total affected population are rural Classification of Indian states Prevalence of HIV infection States High >1% in ANW Maharashtra,TN,Manipur Karnataka,AP,Nagaland Intermediate < 1% in ANW >5% among HRG Gujarat, Goa & P0ndicherry Low < 1% in ANW <5% among HRG Other states
  • 5. Timing of infection(early, late pregnancy or labour) Type of disease(symptomatic/asymptomatic) Viral load,CD4 counts & immune status Duration of ART Genital tract infections
  • 6. Obstetrical factors- Prematurity, PTPROM, chorioamnionitis, prolonged labour, operative interventions & blood transfusion Medical complications Tuberculosis, Hepatitis Route of delivery
  • 7. Increased risk of abortion(3-6 times) IUGR(>2times) Preterm labour(>2times) Still birth Increased risk of maternal anemia & low birth weight babies
  • 8. HIV infection-slightly accelerated; hastens development of AIDS Plasma HIV1RNA-unaffected in pregnancy but increases in postpartum period Due to haemo-dilution, absolute CD4 count After delivery- CD4 levels by 50-100 cells/ul Unprotected sexual intercourse enhances the viral load
  • 9. Types- a)Opt out-provider initiated counselling & testing b)Opt in-client initiated counseling & testing c) Pretest counselling- informed consent for testing is obtained; in case of refusal, client is recounsiled; test report is kept confidential d) Post test counseling-information regarding Disease status Therapy Follow up Behaviour modifications Use of safe sex practices Contraception Antenatal care Mode of delievery Breastfeeding
  • 10. CDC classification - based on immunological marker WHO classification - based on clinical stage
  • 11. Assesses disease severity by CD4 counts & presence of specificAIDS related conditions CD4 count A Asymp, acute or PGL B Symtomatic cond. Not A / C C AIDS indicator cond > 500 cells / micro L A 1 B 1 C 1 200-499 cells/ micro L A 2 B 2 C 2 <200 cells / micro L A 3 B 3 C 3
  • 12. HIV-associated symptoms WHO clinical stage Asymptomatic 1 Mild symptoms (unexpl mod wt loss, rec URTI, rec oral ulceration) 2 Advanced symptoms(unexpl severe wt loss, pulTB, chr diarrhoea, cervical dys, TO mass, persistent fever,) 3 Severe symptoms (pneumocystis, CMV, kaposi, extrapul TB, invasive Ca Cx ) 4
  • 13. Care and Assessment of HIV Infected Pregnant Women
  • 14. WHO clinical staging Clinical screening forTB Screen and treat any STIs ( Pap smear ,VDRL) CD4 cell count (Baseline) Additional assessments of Hb , LFTs, RFTs should be performed when warranted by clinical signs & symptom Lipid profile , RBS at baseline, 6 mths & 1 yr, if started on LPV/r based regimens
  • 15. Avoid invasive tests(CVS, Amniocentesis) Iron, calcium , vitamin supplementation Folic acid intake High protein diet Monitor wt gain Start on cotrimoxazole prophylactic therapy Start on ART
  • 17. Antenatal period- decreases maternal viral load in blood and genital secretions Pre exposure prophylaxis: ARV drugs that cross the placenta from mothers to infants and produce adequate systemic drug levels in the infants Post exposure prophylaxis ARV drugs to infants after birth, provide protection from virus that may have entered the fetal/infant systemic circulation during labor and delivery
  • 18. Group of ARV Name of drugs Common adverse effects NRTI Zidovudine(ZDV)300mg od Lamivudine(3TC) 300mg od Tenofovir -- 300 mg od -Nausea, vomiting, anemia -Minimal side effects -Nephrotoxicity NNRTI Nevirapine(NVP)200mg od Efavirenz(EFV) -----600 mg od Liver dysfunction, hyp.reaction NTDs , Neurological problems Protease Inhibitors Lopinavir (LPV)+ Ritonavir(r) FDC- 200mg/ 50 mg 1 tab Dose- 2 tab bd Hyperglycemia, diabetic exacerbation-ketoacidosis, viral diarrhoea, deranged liver function- drug interactions
  • 19. Zidovudine (300 mg) + Lamivudine (150 mg) Tenofovir (300mg) +Lamivudine (150 mg) Zidovudine(300 mg) +Lamivudine (150 mg)+Nevirapine (200 mg) Efavirenz (600 mg) Nevirapine (200 mg) Fixed-dose combinations (FDCs) are preferred Easy to use Have distribution advt (procurement and stock management) Better complaince & reduce drug resistance
  • 20. NACO Dec 2013 Recommends - Lifelong Triple drug therapy for all Pregnant and Breastfeeding Women with HIV irrespective of CD4 counts & clinical stage of Disease
  • 22. Principles for selecting the first-line regimen 1. Choose Lamivudine in all regimens 2. Choose one NRTI Ziduvudine / Tenofovir to combine with Lamivudine 3. Choose one NNRTI Nevirapine/ Efavirenz
  • 23. Option B+Triple drug therapy lifelong Option B ARV Prophylaxis Triple drugs frm 14 wks + 1 week until BF ends OptionA Ziduvudine+ sd Nevirapine+AZT& 3TC postpartum for 1 week
  • 24. Efavirenz has been classified as FDA Pregnancy Category D. Because of the potential for teratogenicity, pregnancy should be avoided in women receiving efavirenz, and treatment with efavirenz should be avoided during the first 8 weeks of pregnancy (the primary period of fetal organogenesis) whenever possible Meta-analysis including data from 21 studies reporting on 1,437 first-trimester exposures found no increased risk of overall birth defects in infants - giving an incidence of 0.07% ( incidence in general US population 0.02-0.2%) (PACTG) 219 and 219C studies -reported a higher defect rate in infants Additional data are needed on first-trimester Efavirenz exposures to be able to more conclusively determine if risk of neural tube defects or other malformations is elevated. AIDS info/ USA Guidelines march 2014
  • 25. Until recently, most people receiving ART in resource-limited settings have initiated NVP-based regimens EFV has been recommended for use in pregnant women in all trimesters of pregnancy including first trimester. (Ford. N et. al, 2011, Ekouevi DK et.al2011, Use of Efavirenz during pregnancy: a public health perspective, Technical update on treatment optimisation, Geneva, World Health Organization, 2012 The use of EFV is increasing in resource-limited settings as a result of its widespread availability as part of once-daily fixed-dose combinations ,considerable reductions in drug price
  • 26. Previous exposure to Single dose Nevirapine (or EFV) for PPTCT prophylaxis in prior pregnancies, first line ART regimen such asTDF+3TC+EFV may not be fully effective due to development of resistance to Nevirapine/ cross resistance with Efavirenz Tenofovir+ Lamivudine + Efavirenz Tenofovir+ Lamivudine + Lopinavir 2oomg / ritonavir 50 mg
  • 27. Should continue to receive the same regimen throughout pregnancy, labour, breast- feeding period and thereafter life-long. If a woman is on an EFV based regimen, there is no need to substitute with Nevirapine (this was done as per earlier guidelines)
  • 28. When CD4 count is 250 cells/mm3 Continued through pregnancy, delivery and breastfeeding as per national guidelines Dose: Double strength tablet 1 tab daily CPT-is helpful in reducing morbidity and mortality as it prevents Opportunistic Infections If CD4 count >250 for at least 6 months and If patient is on ART for at least 6 months, is asymptomatic and well , CPT should be stopped Should be continued during breastfeeding when indicated
  • 29. Labour and Delivery in the HIV Infected Pregnant Women
  • 30. LSCS in HIV positive pregnant women should be performed for Obstetric indications only Caesarean section is not recommended for prevention of MTCT & only if there is an Obstetric indication for the same NACO Dec 2013
  • 31. Elective CS at 38 weeks gestation to minimize perinatal transmission of HIV is recommended for women with HIV RNA levels >1000 copies/mL or unknown HIV levels near the time of delivery, irrespective of administration of antepartum ART In women with HIV RNA levels 1000 copies/mL, CS performed for standard obstetrical indications should be scheduled at 39 weeks gestation. AIDS info/ USA Guidelines march 2014
  • 32. Results from a large meta-analysis from 15 prospective cohort studies demonstrated the benefit of Elective CS with a 50% reduction in risk The benefits of CS included mostly women who were receiving either no ARVs or zidovudine alone Pregnant women receiving ART ( at least 3 drugs) had transmission rates of about 1%, the benefit of is difficult to evaluate.
  • 33. Women on life-longART should continue their standardART regimen In case of an emergency CS in pregnant women who are not on ART, ensure that the women receiveART prior to the procedure and continues thereafter Standard prophylactic antibiotics to be given
  • 34. IV zidovudine should be administered to HIV- infected women with HIV RNA >1,000 copies/mL Unknown HIV RNA status Non complaince withART IV zidovudine administration should begin 3 hours before the scheduled operative delivery AIDS info/ USA Guidelines march 2014
  • 35. Standard/Universal Work Precautions ARM reserved for cases of fetal distress or delay in progress of labour. Minimize PVs and use aseptic techniques Avoid invasive procedures like fetal blood sampling, fetal scalp electrodes Avoid instrumental delivery as much as possible If indicated, low-cavity outlet forceps is preferable to ventouse, as it is generally associated with lower rates of fetal trauma than ventouse Avoid routine episiotomy as far as possible
  • 36. Use of dry haemostatic techniques to minimize bleeding; i.e. good observation and following of surgical fascial planes during dissection, judicious use of electro-cautery during Caesarean section etc. Membranes are left intact until the head is delivered through the surgical incision. Early cord clamping Use of round-tip blunt needles Do not use fingers to hold the needle; Use forceps to receive and hold Observe good practice when transferring sharps to surgical assistant eg. holding container for sharps the needle
  • 37. The decision Elective CS vsVaginal delivery must be individualized, taking into account: Duration of rupture or labor upon presentation( 2% risk per hour) Plasma RNA levels Current ARV drug regimen status The ARV drug regimen should be continued and IV zidovudine initiated HIV transmission rate was similar in women undergoing emergency cesarean delivery and those delivering vaginally (1.6% vs. 1.9%) Meta-analysis of HIV-infected women, most of whom were on zidovudine as a single drug or receiving no ARV medications, demonstrated a 2% INCREASED RISK PER HOUR
  • 38. Care and Follow-up of HIV Exposed Infants
  • 39. NACO2013 Infants should be given exclusive breastfeeds for the first 6 mths preferably. Exclusive replacement feeding(ERF) may be done only if the mother has died or has a terminal illness or decides not to breastfeed despite adequate counselling Exclusive Replacement Feeding should be done only when AFASS criteria is fulfilled: A Affordable F Feasible A Acceptable S Sustainable S Safe In US where safe infant feeding alternatives are available and free for women in need, HIV infected women should not breastfeed their infants. Maternal receipt of combination ARV regimens is likely to reduce free virus in the breast milk, but the presence of cell- associated virus (intracellular HIV DNA) remains unaffected and, therefore, may continue to pose a transmission risk
  • 40. Risk of infant mortality due to diarrheal and respiratory infections Duration of maternal ART- Several weeks to months before full viral suppression in breast milk is achieved Reduced but potential risk of transmission of virus in breast milk(intracellular DNA ) Development ofARV drug resistance in infants who become infected despite prophylaxis IN INDIA >50 % of children <5 yr of age Malnutrition 57 % of women of childbearing age Anaemia 30 % of infants being born r underweight
  • 41. Mixed feeding -Feeding breast-feeds and replacement feeds simultaneously in the first 6 months is contraindicated- infant gut mucosal injury Mother should be receiving ART during the whole duration of breastfeeding (ART is lifelongART for the mother) Breast-feeding should NOT be stoppedABRUPTLY Complementary feeding should be introduced gradually after 6 months irrespective of whether the infant is diagnosed HIV negative or positive BF- continued upto 1 year( Infant tested negative) BF- continued upto 2 years ( Infant tested positive) NACO Dec 2013
  • 42. Infants born to HIV-infected mothers should receive NVP prophylaxis immediately after birth(Within 1 hr of delivery)
  • 43. It is important to do the following for infants at 6 weeks: Do re-inforcement for EBF for the first 6 Mths (Continuation of breastfeeds with introduction of complementary feeds thereafter) Do Early Infant Diagnosis (EID) testing at 6 wks, 6 mths & 18 mths Do Immunization Do CPT initiation and continue until baby is 18 mnths old or longer if baby is confirmed positive Do stop NVP Prophylaxis for baby at 6 weeks (maternal ART is not of adequate duration continue upto 12 wks)
  • 45. Dual protection refers to simultaneous protection against both unplanned pregnancy and STIs and HIV by using: Condoms together with another effective method of contraception, including emergency contraception HIV-infected women can use all available contraceptive methods, including hormonal contraception (e.g., pill, patch, ring, injection, implant) and intrauterine devices (IUDs) DMPA can be used without restriction because of its relative higher dose and studies that have shown no significant interaction between DMPA and ARV Ritonavir boosted regimens- OCPs contraindicated NVP reduces the levels of cOCPs but at present, no dosage modification are being suggested IUCD/ PPIUCD within 48hrs good contraceptive method Male partner counselled for NSV( condoms to be used still) NACO Dec 2013
  • 46. NACO DEC 2013 AIDS info/ USA March 2014 1) When to start ART At diagnosis of HIV status irrespective of CD4 count Drug resistance testing advised If later in pregnancy ART started promptly 2) ART Drug regimens 2NRTI- Tenofovir+Lamivudine 1 NNRTI- Efavirenz 2 NRTI- Tenofovir+ Lamivudine Tenofovir+ Emtricitabine Tenofovir+ Abacavir PI-ritonavir boosted LPV 3) Efavirenz safety Safe To be continued in first trimester Efavirenz after 8 wks 4) Mode of delivery Vaginal delivery unless obstetrical Indication If RNA > 1000 copies/ml Elective CS @ 38 wks If RNA < 1000 copies /ml Elective CS for obs indication only @ 39 wks
  • 47. NACO DEC 2013 AIDS info/ USA March 2014 5) Zid0vudine during CS ---------- IV Zidovudine ( for 3 hrs) before CS- if viral RNA copies > 1000 6) Infant feeding EBF preferred ERF 7) Infant prophylaxis Nevirapine for 6-12 wks 4-6 weeks of zidovudine + 3 doses of nevirapine in the first week of life 8)When to stop ART To be continued lifelong Depending upon Pretreatment CD4 Count RNA levels Drug complaince Partner status Pt preference etc.
  • 48. TB responsible for - 25% of all deaths among HIV infected individuals. Risk of activeTB - 10 times higher in HIV ActiveTB in HIV-infected pregnant- Risk of Maternal mortality Prematurity Low BirthWeight InfantTB Risk of HIV transmission ( MTCT) by 2.5 times
  • 49. Evaluation forTB- History & Exam Should be started on ART, irrespective of CD4 count ATT should be started first, and followed by ART as soon as feasible (usually after 2 wks) Drug interactions: Efavirenz preferred over Nevirapine( liver toxicity) Those not able to tolerate EFV, a boosted PI regimen - With Rifampicin(component of ATT) should be substituted with Rifabutin
  • 50. Eligibility For HIV PEP 1)Timing of initiation of prophylaxis- within 72 hrs of exposure ( not to delayed awaiting HIV test results) 2)The persons HIV status-PEP for HIV negative individual 3) Nature and risk of exposure-mucous membrane or non intact skin exposed to potentially infectious body fluids 4) HIV positive status of the source of potential exposure/ status not known First line PEP: Zidovudine( 300mg) + Lamivudine ( 150mg) (BD) for 4 wks
  • 51. Exposure to body fluids considered at risk Blood Semen Vaginal secretions Cerebrospinal fluid Synovial, pleural, peritoneal, pericardial fluid Amniotic fluid Other body fluids contaminated with visible blood Exposure to body fluids considered Not at risk (unless these secretions contain visible blood) Tears sweat Urine faeces saliva
  • 52. Exposure which may place at risk of blood-borne infection : Percutaneous injury-needle-stick or cut with a sharp instrument(o.3%) Contact with the mucous membranes of the eye or mouth( 0.09%) Contact with non-intact skin (particularly when the exposed skin is chapped, abraded, or afflicted with dermatitis) Contact with intact skin when the duration of contact is prolonged (e.g. several min or more) with blood or other potentially infectious body fluids.
  • 53. TIMING after exposure TESTS 2-4 Weeks Hb, LFTs 6 weeks HIV antibody( ab) 3 months HIV antibody( ab) Anti HCV Hbsag 6 months HIV antibody( ab) Anti HCV Hbsag
  • 54. PrEP- Daily- or intermittently-dosed oral or vaginally- applied ART given to an HIV-uninfected individual in order to prevent HIV acquisition during a high risk sexual encounter PrEP - More practical than post-exposure prophylaxis (PEP) - injection drug users, commercial sex workers, or women in serodiscordant heterosexual relationships Microbicides- intravaginal/intrarectal topical formulations of anti-HIV agents Tenofovir disoproxil fumarate (or in co-formulation with emtricitabine )