HIV in pregnancy Islamic University in Uganda.pptx

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1. H IV IN PREGNANCY AND EMTCT SSEMWOGERERE LAWRENCE

2. H IV(HUMAN IMMUNODEFICIENCY VIRUS) H IV is a retrovirus(+ssRNA-RT) that causes acquired imunodeficiency syndrome P rimarily targets helper (CD4+)t lymphocytes, macrophages and dentritic M ode of transimission T hrough unprotected sexual intercourse with an infected person exchanging infected body fluids like semen, vaginal fluid or blood B lood transimission(contaminated needles, unsafe blood transfusion) M other to child transmission(vertical)

3. S tructure and replication cycle

4. Without treatment, this illness eventually progresses to a symptomatic, life-threatening immunodeficiency disease known as AIDS. In untreated patients, the time between initial HIV infection and the development of AIDS varies significantly from a few months to many years, with an estimated median time of approximately 11 years.

5. ESSENTIALS OF DIAGNOSIS Asymptomatic Infection HIV antibody, antigen, or ribonucleic acid or culture Mononucleosis-like syndrome with weight loss, fever, night sweats Lymphadenopathy Pharyngitis Erythematous maculopapular rash Extragenital lymphadenopathy.

6. Acquired Immunodeficiency Syndrome (AIDS) Opportunistic infections(tuberculosis, candidiasis, toxoplasmosis, HSV, CMV, Cryptococcus neoformans) Cognitive difficulties or depression Kaposi’s sarcoma CD4 counts below 200 Cervical neoplasia

7. P revalence of hiv pregnancy The HIV prevalence among pregnant women in Uganda varies by location and time period, with some recent studies showing rates of around 24% in specific areas like Mbarara, while other national data from the  Uganda AIDS Commission  in 2023 indicated an overall decline.  A major challenge is the persistence of mother-to-child transmission (MTCT) of HIV, with factors like a woman stopping treatment during pregnancy and breastfeeding contributing to new infections in children . 

8. Mother-to-Child Transmission of HIV Approximately one-third of the women who are infected with HIV can pass it to their babies. Transmission droped from 20% to 2.8% Time of transmission antepartum(15-20%) During time of labour and delivery (60%-70%) Through breast feeding (15%-20%)

9. Pre-disposing factors High maternal viral load Depleted maternal immunity (e.g. very low CD4 count) Prolonged rupture of membranes Intrapartum haemorrhage and invasive obstetrical procedures If delivering twins, first twin is at higher risk of infection than second twin P remature baby is at higher risk than term baby Mixed feeding carries a higher risk than exclusive breastfeeding

10. Investigations Blood: HIV serological test HIV DNA PCR testing of babies Viral load testing every 6 month

11. Elimination of mother to child transmission(EMTCT) Aims at preventing the transmission of HIV from the mother to the child. Strategies for EMTCT Providing HTS(HIV testing services) and syphilis testing in ANC Antenatal care package for all pregnant women (regardless of HIV status) Laboratory investigations specific to HIV-positive pregnant women Comprehensive care for pregnant women with HIV Assess risk of unborn baby among pregnant women with HIV at ANC 1

12. Management All HIV services for pregnant mothers are offered in the MCH clinic. After delivery, mother and baby will remain in the MCH postnatal clinic till HIV status of the child is confirmed, then they will be transferred to the general ART clinic. The current policy aims at elimination of Mother-to-Child Transmission ( eMTCT ) through provision of a continuum of care with the following elements: -   Primary HIV prevention for men, women and adolescents  

13. Prevention of unintended pregnancies among women living with HIV. Prevention of HIV transmission from women living with HIV to their infants.   Provision of treatment, care and support to ALL women infected with HIV, their children and their families.

14. Risk reduction counselling and support Encourage consistent and correct condom use Encourage women to deliver at the health facilities Advising women that they are more prone to infections and should seek medical help she develop any medical complication

15. ANTIRETROVIRAL THERAPY All women living with HIV identified during pregnancy, labour and delivery or while breastfeeding should be started on lifelong ART ART should be initiated on the same day, and adherence counselling should be initiated and sustained intensively for the first three months then maintained for life. Initiate mother on once-daily Fixed Dose Combination of TDF+3TC+DTG(dolutegravir /lamivudine and tenofovir ) with pharmacovigilance The mothers initiated on TDF + 3TC +EFV400 shall be transitioned to TDF + 3TC + DTG at 6-9 months post-partum if VL within past 6 months is suppressed.

16. If mother is already on ART >6 months with TDF/3TC/EFV, do VL test. If she is virally suppressed, maintain her on TDF/3TC/EFV400 until 6-9 months after delivery and then substitute EFV with DTG if VL within the past 6 months is suppressed. If she is already on a DTG-based 1st-line regimen and virally suppressed, maintain on the same regimen. If she is already on ART and VL is not suppressed, manage as treatment failure and switch to DTG-based 2nd line regimen (if no previous exposure to DTG).

17. If she is on 2ndline ART with atazanavir/ritonavir ( ATV/r) or LPV/r and virally suppressed, maintain on the same regimen until 6-9 months after delivery and then substitute PI with DTG if VL within the past 6 months is suppressed and no previous exposure to DTG. All women should receive Pre-ART adherence counselling before initiating ART and ongoing adherence support after that ART should be initiated and maintained in mother-baby care point in MCH

18. O ther measures to increase emtct P roviding vit.A during ANC C orrecting anemias with iron and folic acid L imiting episiotomies to a few conditions like breech delivery D elay rupturing of membranes till patient is close to delivery C lamping code immediately ensuring strict infection prevention practices

19. DELIVERY Vaginal delivery Untreated women with a CD4 count greater or equal to 350 and a viral load of <50 copies/ml can be treated with zidovudine monotherapy or HAART and can aim for a vaginal delivery. Vaginal delivery is recommended for women on HAART with an HIV viral load <50 at 36wks. In women in whom a vaginal delivery has been recommended and labour has commenced, obstetric management should follow the same guidelines as for the uninfected population. Vaginal birth after Caesarean (VBAC) should be offered to women with a viral load <50.

20. Caesarean delivery Delivery by CS is recommended for women taking zidovudine monotherapy, irrespective of plasma viral load at the time of delivery and for women with viral load >400 regardless of ART. Where the indication for CS is the prevention of MTCT, CS should be undertaken at between 38 and 39wks gestation.

21. NEONATAL PROPHYLAXIS N evirapine is given for once daily for 6 weeks Cotrimoxazole is given beginning at 6 weeks, continue until final HIV status is confirmed negative

22. References O xford handbook of obstetrics and gynecology O bstetrics by ten teachers 20th edition U ganda clinical guidelines 2023