HIV Prophylaxis for mother and baby OBG.

OBG nursing ppt

1. HIV PROPHYLAXIS FOR MOTHER AND BABY PRESENTED BY G. SIVAGAMI M.Sc (N) II YEAR, GCON, CUDDALORE.

2. 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.

3. 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.

4. 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

5. 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.

6. 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.

7. MODE OF TRANSMISSION OF HIV Sexual transmission Heterosexual Homosexual Exposure to blood and body fluids Blood transfusion IV drug use Occupational exposure like needle stick/splash cut Mother to child (vertical transmission) In utero During delivery breastfeeding

8. DETERMINANTS OF VERTICAL TRANSMISSION MATERNAL DETERMINANTS Viral load Biological prototype of virus Unprotected sex during pregnancy Smoking and illicit drug use in mother Maternal level of CD4 and lymphocytes count Low maternal zinc, vitamin A level Presence of RTI/STI in mother Time of rupture of membranes and chorioamnionitis more than 4hrs Episiotomy and operative vaginal delivery Presence and amount of virus in genital tract

9. FETAL DETERMINANTS Preterm fetus Fetal ingestion of virus Fetal scalp electrode, scalp blood sampling & umbilical blood sampling Duration of exposure to maternal secretions (first twin) Via breast milk depending on the immune response of the newborn and period of breastfeeding and infectivity of mother.

10. MATERNAL DETERMINANTS 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

11. 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

12. 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.

13. 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.

14. 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

15. 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.

16. 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%

17. 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; The period of breastfeeding Maternal HIV load HIV disease status (early or terminal)

18. 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.

19. RISK OF HIV TRANSMISSION

20. 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.

21. 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.

22. 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.

23. Diagnosis Cont., The absolute CD4 forms the basis for therapeutic intervention: CD4 counts of more than 500/ml – there is no clinical evidence of immunosuppression. At CD4 counts of 200 – 500/ ml – there is a greater likelihood of developing symptoms and need for medical intervention 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.

24. For children more than 18 months

25. Cont.,

26. For children less than 18 months

27. Cont.,

28. 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.

29. 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.

30. 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

31. CONT., Non- Nucleoside Reverse Transcriptase inhibitors Nevarapine C Delavirdene C Protease inhibitors Indinavir C Ritonavir B Saquinavir B Neltinavir B

32. CLASSIFICATION No risk for fetus during the first trimester of pregnancy No risk in animal studies but lack of human studies Safety inhuman pregnancy is not determined, drugs should not be used unless the potential benefits overweight the potential risk to fetus . Positive evidence of human fetal risk x. Studies in animals or reports of adverse reactions have indicated risk.

33. 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.

34. 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.

35. 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

36. 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.

37. 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.

38. WHO PREVENTING MOTHER TO CHILD TRANSMISSION Option B 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 NON- eligible (ART given to precent transmission) Imitate for all; stop 1 week after cessation of breast feeding immediate post delivery

39. 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 TDF-300mg + 3TC 300gm + EFV 600mg single OD dosage drug combination,

40. Cont., Alternative first line therapy A2T – 300 mg Bd + 3TC + EFC(NVD) TDF + 3TC ( ot FTC) + NVP 200 mg OD NNRTI: Nonnucleoside Reverse Transcriptase Inhibitor NRTI: Nucleoside reverse Transcriptase Inhibitor

41. 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.

42. 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.

43. 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.

44. RISK FACTOR FOR INCREASED PERINATEAL TRANSMISSION ARE Maternal high plasma viral load Low CD4 cell count Co-existing other STDs and opportunistic infections. Prolonged rupture of membranes Chorioamnionitis Invasive intrapartum procedures Preterm delivery Vaginal delivery and breast feeding Post exposure prophylaxis with triple therapy for 4 week, reduces the risk of seroconversion by more then 80% Triple therapy : zidovudine 200mg tid + lamivudine 150mg + Indinavir 800mg tid

45. 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.

46. Research findings for delayed cord clamp

47. 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.

48. 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

49. 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.

50. 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)

51. 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.

52. PREVENTION STRATEGIES Counselling Pre-pregnancy and early pregnancy counselling for HIV infected patient is essential. Risk recognition and appropriate counselling, testing and referral. STI management Ensure safe blood supply by mandatory screening of donated blood only rational use of blood, transfusion discouraging professional blood donation.

53. PREVENTION STRATEGIES Educated hospital and personal on standard work precaution and appropriate post exposure prophylaxis. Routine timely HIV testing in pregnancy and prevention of mother to child transmission. Voluntary and confidential counselling testing promotion and referral.

54. 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

55. SECONDARY PREVENTION The vertical transmission of HIV from mother to fetus can be done by 2 strategy: Reducing the viral load with use if antiviral drugs. Cleansing the vagina with antiviral chemicals preparations to reduce risks of infection from maternal secretions is of controversial value.

56. 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.

57. 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.

58. ASSIGNMENT Write an assignment on staging of HIV/AIDS and their specific management during pregnancy.