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Hiv infection in pregnancy

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This document provides guidelines for managing HIV infection in pregnancy. It discusses counseling pregnant women who test positive for HIV, antenatal care including investigations and treatment with antiretroviral therapy, preventing mother-to-child transmission through medication and delivery methods, care during labor and delivery, testing and treatment for infants, and postpartum care of both mother and baby. The goal is to reduce the risk of transmitting HIV from mother to child to less than 2% through screening, testing, antiretroviral treatment, and modifying delivery and infant feeding practices.

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HIV INFECTION IN PREGNANCY Dr pjca Mbizi Dr Ndwambi June /2018
1. introduction 2. Overview 3. Counselling a pregnant woman about being HIV positive 4. Antenatal care 5. Investigations 6. Treatment 7. Labour and delivery 8. HIV prevention and testing for infants 9. Postpartum care 10.References
infection with human immunodeficiency virus (hiv) results in acquired immune deficiency syndrome (aids), and has a high risk of transmission of the virus from an infected pregnant or breastfeeding woman to her baby. all women who book for antenatal care should be offered hiv testing, according to the principles of provider-initiated hiv counseling & testing. only women who have a documented positive hiv status, and are on antiretroviral therapy (art) are not offered an hiv test. rapid antibody tests are used. a positive test is confirmed using another rapid hiv test kit. if one result is positive and the other is negative, the results are indeterminate and an ELISA must be done to confirm the hiv status. Introduction
OVERVIEW The reduction in mother-to-child transmission of human immunodeficiency virus (HIV) is regarded as one of the most effective public health initiatives in the United States. In the absence of treatment, the risk of vertical transmission of HIV is as high as 25-30%. With the implementation of HIV testing, counseling, antiretroviral medication, delivery by cesarean section prior to onset of labor, and discouraging breastfeeding, the mother-to-infant transmission has decreased to less than 2% in the United States. an exact mechanism of mother-to-child transmission of HIV remains unknown. Transmission may occur during intrauterine life, delivery, or breastfeeding. The greatest risk factor for vertical transmission is thought to be advanced maternal disease, likely due to a high maternal HIV viral load.
EPIDEMIOLOGY International statistics The Joint United Nations Programme on HIV/AIDS (UNAIDS) has estimated that in 2017, approximately 36.7 million people worldwide (1% of the global adult population aged 15-49 y) were infected with HIV, of which 1.8 million people were newly infected; 64% of all people living with HIV worldwide live in sub-Saharan Africa. New HIV infection rates are declining globally as a result of efforts to strengthen HIV prevention and treatment programs.
2. Establish what the woman knows about HIV 3. Give information on how the virus is transmitted 4. Discuss the symptoms, signs and progression of the disease 5. Explain the importance of CD4 count & viral load (VL) monitoring 6. Discuss the benefits and potential side-effects of ART 7. Explain the risk of mother-to-child transmission of HIV and how this may be reduced: safe infant feeding choice and antiretrovirals (ARVs) 8. Discuss who the woman may want to tell about the result disclosure is associated with better treatment adherence 9. Discuss condom use and other safe sex practices to prevent transmission to and from the partner, and also discuss partner testing 10. Discuss future fertility plans, and further contraception Counselling a pregnant woman about being HIV positive
ANTENATAL CARE Clinical assessment: Ask about chronic illnesses in the past, and about current health Ask about the presence of any psychiatric illness Screen for TB: ask about cough, weight loss, night sweats and fever On physical examination, look for evidence of opportunistic infections: oral candidiasis, herpes zoster, and pulmonary TB Look for evidence of sexually transmitted infections and treat appropriately Stage the woman according to the World Health Organization staging system
All women who test HIV negative in early pregnancy should be offered a repeat test every 3 months, at the onset of labour, at 6 weeks postpartum, and every 3 months during breastfeeding. Women on ART should have VL monitoring every 3 months throughout pregnancy, then 6-monthly during breastfeeding Creatinine is repeated at 3 months, 6 months, 12 months, then annually while on TDF If there is a need for antenatal invasive procedures, initiating ART 6 weeks before the procedure gives some reassurance of viral suppression to allow the procedure to be done Consider elective caesarean section for women likely to require an emergency caesarean section in labour, e.g. previous caesarean section HIV infection alone is not a valid indication for Caesarean section.
INVESTIGATIONS: 1. Take blood for CD4 count, Hb and creatinine at ART initiation, and follow up in one week for results 2. Once on ART, do a VL every 3 months during pregnancy 3. Investigate for TB if screen positive
TREATMENT: Initiate ART, preferably on the day of diagnosis Give the usual antenatal supplements, such as folate, iron and calcium Give isoniazid preventive therapy (IPT) 300 mg with pyridoxine 25 mg daily for 12 months to all women initiated on ART who screen TB-negative Give cotrimoxazole 2 tablets orally daily to women with CD4 cell count <200/mm3 Do a serum cryptococcal antigen (CRAG) on asymptomatic women with CD4 <100 cells/mm3. If positive, start oral fluconazole pre-emptive therapy Fluconazole 800 mg daily for 2 weeks Then 400 mg daily for 8 weeks Then 200 mg daily, until her CD4 cell count has risen above 200 cells/mm3 Note: fluconazole should not be used in the first trimester, unless it is used for the treatment of cryptococcal meningitis.
ART AND PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) All HIV-infected pregnant women are offered lifelong ART, irrespective of CD4 count or HIV disease stage. ART regimens 1. The first-line regimen comprises a fixed dose combination (FDC) tablet containing: 2. Tenofovir (TDF) 300 mg, Emtricitabine (FTC) 200 mg, and Efavirenz (EFV) 600 mg, taken once at night 3. Alternative ART regimens include Abacavir (ABC) in place of TDF for women with renal dysfunction (serum creatinine >85 亮mol/L) 4. Nevirapine (NVP) in place of EFV for women with active psychiatric illness, provided her CD4 <250 cells/mm3 OR 5. Lopinavir/ritonavir (LPV/r) if her CD4 250 cells/mm3 6. While NVP is rarely initiated in pregnancy because of the risk of life-threatening toxicity, women who become pregnant on NVP and are stable on treatment may continue with NVP.
LABOUR AND DELIVERY During labour for women who are unbooked & diagnosed HIV positive: 1. Give single-dose NVP 200 mg orally at onset of labour 2. Give single-dose TDF 300 mg with FTC 200 mg orally at onset of labour 3. Give AZT 300 mg 3 hourly orally 4. Commence lifelong ART within 24 hours after delivery
HIV PREVENTION AND TESTING FOR INFANTS All HIV-exposed infants, regardless of infant feeding method and whether the mother is on ART or not, should receive daily NVP syrup for the first 6 weeks of life. NVP syrup is stopped at 6 weeks in formula fed infants. It is also stopped at 6 weeks if the infant is breastfed and the mother is on ART. All HIV-exposed infants must have an HIV PCR test done at birth, and again at 10 weeks of age, and, if positive, must be referred for ART initiation immediately. . All HIV-exposed infants who tested negative previously must have an HIV antibody test at 18 months. Infants age Nevirapine syrup dose Birth to weeks Birthweight <2500 g: 1.0 mL (10 mg) daily Birthweight 2500 g: 1.5 mL (15 mg) daily
ANTI-RETROVIRALS AND COMMON SIDE-EFFECTS Tenofovir (TDF): renal dysfunction, only use if serum creatinine <85 亮mol/L Lamivudine (3TC) and Emtricitabine (FTC): side-effects not common, generally well- tolerated Efavirenz (EFV): central nervous system effects dizziness, insomnia, bad dreams, also rash, hepatitis Abacavir (ABC): drug-induced hypersensitivity reaction (uncommon) Nevirapine (NVP): rash including Stevens-Johnson syndrome, hepatitis. Avoid NVP in women with CD4 cell count >250 cells/mm3 Lopinavir/ritonavir (LPV/r): diarrhea, nausea, dyslipidaemia
LABOUR AND DELIVERY Labour is generally managed in the same way as for women who are HIV-negative. 1. Do not rupture membranes for poor progress unless her VL is undetectable 2. Avoid using penetrating fetal scalp electrodes for heart rate monitoring 3. Avoid episiotomy wherever possible
POSTPARTUM CARE 1. Give normal postpartum care, irrespective of mode of delivery 2. Inform the woman about handling and disposal of soiled pads and linen 3. Treat infections promptly and aggressively 4. Give information about advantages and disadvantages of breast and formula feeding strongly discourage mixed feeding 5. All HIV-positive women should be encouraged to exclusively breastfeed for the first 6 months, with complementary feeding only from 6 months and breastfeeding continued until 12 months, unless contraindicated 6. Give contraceptive advice and discuss sterilization if appropriate
WOMEN WITH ADVANCED HIV DISEASE The following problems may be expected: 1. Opportunistic infections, e.g. meningitis, pneumonia, TB, chronic diarrhoea 2. Severe puerperal sepsis 3. Spontaneous preterm labour with or without chorio-amnionitis 4. The need for preterm elective delivery in a terminally ill pregnant woman requires a discussion with the family 5. Rapid deterioration and death after delivery, especially after spontaneous preterm labour 6. Possible need for disclosure of the illness to the relatives 7. Treatment is individualized according to each patients specific disease profile and family circumstances.
HIV INFECTED NOT ON ART WHO STAGING, SCREEN FOR TB, TAKE BLOOD FOR CD4, CREATININE No history of psychiatric or renal disease Start FDC the same day (TDF/FTC/EFV) One week later CD4 and creatinine results History of renal disease Creatinine 85 Creatinine >85 ABC + 3TC + EFV Investigate for renal disease Continue FDC as lifelong ART LIFELONG ART FOR ALL HIV-INFECTED PREGNANT & BREASTFEEDING WOMEN
RFERENCES 1. Latest obstetrics 2017 protocol book , p 129-135 2. Brinkman K, ter Hofstede HJ, Burger DM, Smeitink JA, Koopmans PP. Adverse effects of reverse transcriptase inhibitors: mitochondrial toxicity as common pathway. AIDS. 1998 Oct 1. 12(14):1735-44 3. French R, Brocklehurst P. The effect of pregnancy on survival in women infected with HIV: a systematic review of the literature and meta-analysis. Br J Obstet Gynaecol. 1998 Aug. 105(8):827-35
Thank you Merci Gracias Ndolivhuwa

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Hiv infection in pregnancy

  • 1. HIV INFECTION IN PREGNANCY Dr pjca Mbizi Dr Ndwambi June /2018
  • 2. 1. introduction 2. Overview 3. Counselling a pregnant woman about being HIV positive 4. Antenatal care 5. Investigations 6. Treatment 7. Labour and delivery 8. HIV prevention and testing for infants 9. Postpartum care 10.References
  • 3. infection with human immunodeficiency virus (hiv) results in acquired immune deficiency syndrome (aids), and has a high risk of transmission of the virus from an infected pregnant or breastfeeding woman to her baby. all women who book for antenatal care should be offered hiv testing, according to the principles of provider-initiated hiv counseling & testing. only women who have a documented positive hiv status, and are on antiretroviral therapy (art) are not offered an hiv test. rapid antibody tests are used. a positive test is confirmed using another rapid hiv test kit. if one result is positive and the other is negative, the results are indeterminate and an ELISA must be done to confirm the hiv status. Introduction
  • 4. OVERVIEW The reduction in mother-to-child transmission of human immunodeficiency virus (HIV) is regarded as one of the most effective public health initiatives in the United States. In the absence of treatment, the risk of vertical transmission of HIV is as high as 25-30%. With the implementation of HIV testing, counseling, antiretroviral medication, delivery by cesarean section prior to onset of labor, and discouraging breastfeeding, the mother-to-infant transmission has decreased to less than 2% in the United States. an exact mechanism of mother-to-child transmission of HIV remains unknown. Transmission may occur during intrauterine life, delivery, or breastfeeding. The greatest risk factor for vertical transmission is thought to be advanced maternal disease, likely due to a high maternal HIV viral load.
  • 5. EPIDEMIOLOGY International statistics The Joint United Nations Programme on HIV/AIDS (UNAIDS) has estimated that in 2017, approximately 36.7 million people worldwide (1% of the global adult population aged 15-49 y) were infected with HIV, of which 1.8 million people were newly infected; 64% of all people living with HIV worldwide live in sub-Saharan Africa. New HIV infection rates are declining globally as a result of efforts to strengthen HIV prevention and treatment programs.
  • 6. 2. Establish what the woman knows about HIV 3. Give information on how the virus is transmitted 4. Discuss the symptoms, signs and progression of the disease 5. Explain the importance of CD4 count & viral load (VL) monitoring 6. Discuss the benefits and potential side-effects of ART 7. Explain the risk of mother-to-child transmission of HIV and how this may be reduced: safe infant feeding choice and antiretrovirals (ARVs) 8. Discuss who the woman may want to tell about the result disclosure is associated with better treatment adherence 9. Discuss condom use and other safe sex practices to prevent transmission to and from the partner, and also discuss partner testing 10. Discuss future fertility plans, and further contraception Counselling a pregnant woman about being HIV positive
  • 7. ANTENATAL CARE Clinical assessment: Ask about chronic illnesses in the past, and about current health Ask about the presence of any psychiatric illness Screen for TB: ask about cough, weight loss, night sweats and fever On physical examination, look for evidence of opportunistic infections: oral candidiasis, herpes zoster, and pulmonary TB Look for evidence of sexually transmitted infections and treat appropriately Stage the woman according to the World Health Organization staging system
  • 8. All women who test HIV negative in early pregnancy should be offered a repeat test every 3 months, at the onset of labour, at 6 weeks postpartum, and every 3 months during breastfeeding. Women on ART should have VL monitoring every 3 months throughout pregnancy, then 6-monthly during breastfeeding Creatinine is repeated at 3 months, 6 months, 12 months, then annually while on TDF If there is a need for antenatal invasive procedures, initiating ART 6 weeks before the procedure gives some reassurance of viral suppression to allow the procedure to be done Consider elective caesarean section for women likely to require an emergency caesarean section in labour, e.g. previous caesarean section HIV infection alone is not a valid indication for Caesarean section.
  • 9. INVESTIGATIONS: 1. Take blood for CD4 count, Hb and creatinine at ART initiation, and follow up in one week for results 2. Once on ART, do a VL every 3 months during pregnancy 3. Investigate for TB if screen positive
  • 10. TREATMENT: Initiate ART, preferably on the day of diagnosis Give the usual antenatal supplements, such as folate, iron and calcium Give isoniazid preventive therapy (IPT) 300 mg with pyridoxine 25 mg daily for 12 months to all women initiated on ART who screen TB-negative Give cotrimoxazole 2 tablets orally daily to women with CD4 cell count <200/mm3 Do a serum cryptococcal antigen (CRAG) on asymptomatic women with CD4 <100 cells/mm3. If positive, start oral fluconazole pre-emptive therapy Fluconazole 800 mg daily for 2 weeks Then 400 mg daily for 8 weeks Then 200 mg daily, until her CD4 cell count has risen above 200 cells/mm3 Note: fluconazole should not be used in the first trimester, unless it is used for the treatment of cryptococcal meningitis.
  • 11. ART AND PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT) All HIV-infected pregnant women are offered lifelong ART, irrespective of CD4 count or HIV disease stage. ART regimens 1. The first-line regimen comprises a fixed dose combination (FDC) tablet containing: 2. Tenofovir (TDF) 300 mg, Emtricitabine (FTC) 200 mg, and Efavirenz (EFV) 600 mg, taken once at night 3. Alternative ART regimens include Abacavir (ABC) in place of TDF for women with renal dysfunction (serum creatinine >85 亮mol/L) 4. Nevirapine (NVP) in place of EFV for women with active psychiatric illness, provided her CD4 <250 cells/mm3 OR 5. Lopinavir/ritonavir (LPV/r) if her CD4 250 cells/mm3 6. While NVP is rarely initiated in pregnancy because of the risk of life-threatening toxicity, women who become pregnant on NVP and are stable on treatment may continue with NVP.
  • 12. LABOUR AND DELIVERY During labour for women who are unbooked & diagnosed HIV positive: 1. Give single-dose NVP 200 mg orally at onset of labour 2. Give single-dose TDF 300 mg with FTC 200 mg orally at onset of labour 3. Give AZT 300 mg 3 hourly orally 4. Commence lifelong ART within 24 hours after delivery
  • 13. HIV PREVENTION AND TESTING FOR INFANTS All HIV-exposed infants, regardless of infant feeding method and whether the mother is on ART or not, should receive daily NVP syrup for the first 6 weeks of life. NVP syrup is stopped at 6 weeks in formula fed infants. It is also stopped at 6 weeks if the infant is breastfed and the mother is on ART. All HIV-exposed infants must have an HIV PCR test done at birth, and again at 10 weeks of age, and, if positive, must be referred for ART initiation immediately. . All HIV-exposed infants who tested negative previously must have an HIV antibody test at 18 months. Infants age Nevirapine syrup dose Birth to weeks Birthweight <2500 g: 1.0 mL (10 mg) daily Birthweight 2500 g: 1.5 mL (15 mg) daily
  • 14. ANTI-RETROVIRALS AND COMMON SIDE-EFFECTS Tenofovir (TDF): renal dysfunction, only use if serum creatinine <85 亮mol/L Lamivudine (3TC) and Emtricitabine (FTC): side-effects not common, generally well- tolerated Efavirenz (EFV): central nervous system effects dizziness, insomnia, bad dreams, also rash, hepatitis Abacavir (ABC): drug-induced hypersensitivity reaction (uncommon) Nevirapine (NVP): rash including Stevens-Johnson syndrome, hepatitis. Avoid NVP in women with CD4 cell count >250 cells/mm3 Lopinavir/ritonavir (LPV/r): diarrhea, nausea, dyslipidaemia
  • 15. LABOUR AND DELIVERY Labour is generally managed in the same way as for women who are HIV-negative. 1. Do not rupture membranes for poor progress unless her VL is undetectable 2. Avoid using penetrating fetal scalp electrodes for heart rate monitoring 3. Avoid episiotomy wherever possible
  • 16. POSTPARTUM CARE 1. Give normal postpartum care, irrespective of mode of delivery 2. Inform the woman about handling and disposal of soiled pads and linen 3. Treat infections promptly and aggressively 4. Give information about advantages and disadvantages of breast and formula feeding strongly discourage mixed feeding 5. All HIV-positive women should be encouraged to exclusively breastfeed for the first 6 months, with complementary feeding only from 6 months and breastfeeding continued until 12 months, unless contraindicated 6. Give contraceptive advice and discuss sterilization if appropriate
  • 17. WOMEN WITH ADVANCED HIV DISEASE The following problems may be expected: 1. Opportunistic infections, e.g. meningitis, pneumonia, TB, chronic diarrhoea 2. Severe puerperal sepsis 3. Spontaneous preterm labour with or without chorio-amnionitis 4. The need for preterm elective delivery in a terminally ill pregnant woman requires a discussion with the family 5. Rapid deterioration and death after delivery, especially after spontaneous preterm labour 6. Possible need for disclosure of the illness to the relatives 7. Treatment is individualized according to each patients specific disease profile and family circumstances.
  • 18. HIV INFECTED NOT ON ART WHO STAGING, SCREEN FOR TB, TAKE BLOOD FOR CD4, CREATININE No history of psychiatric or renal disease Start FDC the same day (TDF/FTC/EFV) One week later CD4 and creatinine results History of renal disease Creatinine 85 Creatinine >85 ABC + 3TC + EFV Investigate for renal disease Continue FDC as lifelong ART LIFELONG ART FOR ALL HIV-INFECTED PREGNANT & BREASTFEEDING WOMEN
  • 19. RFERENCES 1. Latest obstetrics 2017 protocol book , p 129-135 2. Brinkman K, ter Hofstede HJ, Burger DM, Smeitink JA, Koopmans PP. Adverse effects of reverse transcriptase inhibitors: mitochondrial toxicity as common pathway. AIDS. 1998 Oct 1. 12(14):1735-44 3. French R, Brocklehurst P. The effect of pregnancy on survival in women infected with HIV: a systematic review of the literature and meta-analysis. Br J Obstet Gynaecol. 1998 Aug. 105(8):827-35
  • 20. Thank you Merci Gracias Ndolivhuwa