Human immunodeficiency virus in pregnancy

HIV in pregnancy

1. HIV IN PREGNANCY

2. Human immunodeficiency virus (HIV) infection is a major global epidemic, which has emerged in the last century. However, the number of women affected has risen to 50%, of which 80% are in their reproductive years. Antenatal positivity has been estimated to be more than 1%. This reveals the magnitude of the obstetric problem. Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh, Manipur and Nagaland were detected to have prevalence rates of more than 1% among the general population and more than 5% among the high-risk group. India's ART programme is the second largest globaily and has been acclaimed as one of the best public health programmes providing HIV care services. There is direct access to free diagnostic facilities, free first-line therapy, second and third-line ART, prevention of parent to child transmission of HIV (PPTCT) services, prevention, diagnosis and management of opportunistic infections including management of TB with daily anti-TB treatment through a single window approach. The national progra-mme provides psychosocial support and follow-up services, individualised counselling and positive prevention services with appropriate referral linkages to various social

3. EPIDEMIOLOGY HIV is a retrovirus containing reverse transcriptase. enzyme allows the virus to transcribe its RNA genome into DNA, which then integrates into host cell DNA Exist in 2 forms HIV 1 and HIV 2 HIV 1 more common Targets lymphocytes expressing CD4 molecules – CD4 lymphocytes MODE OF TRANSMISSION Sexual route 86% Mother to child 3.6% Injecting drugs 2.4% Transfusion of blood and blood products 2% Others 6%

4. DIAGNOSIS ELISA is used as screening test for HIV antibody Test usually become positive within 3 weeks to 3 months after exposure PCR detects viral DNA and RNA CD4 count decline indicate the degree of immunosuppression Viral load predicts disease progression Two positive ELISA tests are taken as evidence of infection

5. EFFECT OF HIV ON PREGNANCY In advanced disease there may be an increased risk of miscarriage, preterm delivery and fetal growth restriction. In developing countries, the perinatal mortality is increased. The main concern is the risk of vertical transmission to the fetus. Teratogenicity of the drugs is also a problem although there is not enough evidence at the moment. Birth defects like anencephaly, cleft palate and micropthalmia were seen associated with efavirenz in the first trimester. Hypospadias and congenital heart defects have been linked to zidovudine.Another emerging concern is mitochondrial toxicity.

6. VERTICAL TRANSMISSION Means mother to child transmission 30% risk for vertical transmission in india Two thirds of vertical transmission occurs at deliveryif breastfeeding is not practised .

7. FACTORS AFFECTING VERTICAL TRANSMISSION DISEASE FACTORS Maternal viral load is the important risk factor ,highest in recent infection advanced maternal disease low CD4 count seroconversion in pregnancy or early disease

8. OBSTETRIC FACTORS Vaginal delivery Prolonged rupture of membrane Preterm delivery Chorioamnionitis Coexistent sexually transmitted infections and syphilitic infection of placenta Low birth weight Antepartum invasive procedure (instrumental delivery,episiotomy,scalp electrodes) Breastfeeding is another important risk factor

9. PARENT TO CHILD TRANSMISSION Major route of new HIV infections in children HIV infected pregnant women have to be detected and provided with timely ART in order to reduce mother-to ado child transmission and ultimately to eliminate paediatric HIV Counselling and information regarding the outcome of pregnancy and HIV related treatment to the HIV-infected women is provided under the programme This programme for prevention of vertical transmission called PPTCT

10. PPTCT prevention of parent to child transmission Objectives of PPTCT 1. To detect more than 90% HIV-infected pregnant women in India. 2. To provide access to comprehensive PPTCT services to more than 90% of the detected pregnant women. 3. To provide access to early infant diagnosis to more than90% HIV-exposed infants. 4. To ensure access to ARVs prophylaxis or ART to 100%HIV exposed infants. 5. To ensure more than 95% adherence with ART in HIV infected pregnant women and ARV/ART in exposed children

11. COMPONENTS OF PPTCT – 4 PRONGED STRATEGY Prong 1 Primary prevention of HIV Prong 2 Prevent unintended pregnancies among HIV positive women Prong 3 Prevention of MTCT among HIV positive mothers Prong 4 Provide care, support and treatment to HIV

12. RISK OF HIV TRANSMISSION 2006 WHO ARV intervention Risk of transmission from mother to child No ARV; breastfeeding 30-45% No ARV; no breastfeeding 20-25% Short course with one ARV; breast feeding 15-25% Short course with one ARV; no breastfeeding 5-15% Short course with 2 ARVs; breastfeeding 5% 3 ARVs (ART) with breastfeeding 2% 3 ARVs (ART) with no breastfeeding 1%

13. PRECONCEPTIONAL MANAGEMENT Couples who are serodiscordant , choosing to have intercourse should be advised to use condoms. Couples who are serodiscordant (where the female partner is HIV negative), should be advised that assisted conception with either donor insemination or sperm washing is significantly safer than unprotected inter-course. Couples should be advised to delay conception until plasma viraemia is suppressed, prophylaxis against Pneumocystis carinii pneumonia is no longer required and any opportunistic infections have been treated. All women who are HIV-positive are recommended to have annual cervical cytology

14. ANTEPARTUM MANAGEMENT HIV positive women should be managed by a multidisciplinary team comprising a HIV specialist obstetrician and a paediatrician Women should be reassured that her confidentiality will be respected All pregnant women should be offered screening for HIV in early pregnancy Screening offered again at around 28 weeks Prenatal care should be given Plasma viral load , CD4 count , RFT,LFT should be done and repeated every 3 months Hepatitis B , pneumococcal vaccination recommended for all hiv positive patients , can safely administered in pregnancy

15. SCREENING FOR HIV All pregnant women should be offered screening for HIV in early pregnancy because appropriate maternal interventions can reduce vertical transmission Pretest and posttest counselling are mandatory. If a woman declines HIV test, this should be documented in the maternity notes, her reasons should be sensitively explored and screening offered again at around 28 weeks

16. PRENATAL CARE The option of termination of pregnancy should be discussed at the earliest. HIV-positive mothers should be counselled a de regarding nutrition, hygiene, safe sex and avoiding substance abuse as they are at high risk for infections. Screening for genital infections/ should be done early on and repeated at 28 weeks /Syphilis and hepatitis B are screened at booking. Varicella zoster and measles, mumps and rubella vaccines are contraindicated in pregnancy.Prophylaxis for Pneumocystis carinii pneumonia is indicatedWhen the CD4 count is < 200/mm'.

17. INTRAPARTUM MANAGEMENT Normal vaginal delivery recommended unless having an obstetric indication for caesarean section Elective cs at 38 w may be better choice who not received ART,high viral load,or received zidovudine alone Early cord clamping to be done .If instrumental delivery indicated, vacuum preferable. No ARM Avoid episiotomy if possible Avoid fetal scalp electrodes and scalp bood sampling Universal precautions to be followed by health care professionals Placenta to be placed in a cover containing 10% sodium hypochlorite (bleach) solution for atleast 20 mints prior to disposal

18. PREGNANT WOMEN PRESENTING IN ACTIVE LABOUR Bedside counselling is done and HIV testing offered. IF detected to be HIV-positive, initiate FDC of 300 mg Tenofovir + 300 mg Lamivudine + 50mg Dolutegravir and ensure linkage to an ART centre . As the mother has not received ARV prophylaxis in the antenatal period, Nevirapine prophylaxis for the breastfeeding infant should be 12 weeks

19. POSTPARTUM CARE ART should be continued The choice of breastfeeding left to mother after proper information and counselling regarding the risk of breastfeeding If partner hiv negative ,use condoms as contraceptive methods

20. ART regimen in pregnant $ breastfeeding women with HIV 2021 National guidelines Target Population Preferred ART Regimen pregnant or breast feeding women with HIV Dolutegravir+Tenofovir + Lamivudine • FDC of TDF (300 mg) + 3TC (300 mg) +DTG (50 mg) To be given once daily Including HIV-1, HIV-2, HIV-1 & 2, women exposed to single-dose NVP in the past and co infected with TB or hepatitis

21. NEONATAL CARE Nevirapine prophylaxis started for 6 weeks If mother having high viral load/ART taken less than 24 weeks , then nevirapine for 12 weeks Zidovudine will be added if high viral load for mother Maternal antibody will be present in baby till 18months so after 18 months baby tested for HIV

22. HIV STATUS OF INFANT Maternal antibodies cross the placenta and may be detected in most babies of HIV-positive mothers. Therefore, accurate diagnosis of infant HIV at birth can only be through PCR and DNA analysis. Dried blood spot and whole blood in EDTA are the specimens used to perform HIV DNA PCR testing. The level of maternal antibody falls below the limit of detection by 18 months. Antibody test can identify potentially uninfected infants 6-18 months of age if they are not breastfed. A negative HIV antibody test at 18 months confirms that the child is not infected. Children with known or suspected asymptomatic HIV infection should receive vaccines according to national immunisation schedule.

23. UNIVERSAL PRECAUTIONS Wear protective eyewear and mask, if spatter with blood or body fluids is a possibility. Also wear gowns and protective leg wear. Wear double gloves. Handle all linen soiled with blood or fluid as potentially infectious. Process all lab specimens as potentially infectious, including blood. Wash hands before and after all patient or specimen contact. Place all used syringes immediately in a nearby impermeable container. Do not recap or manipulate needle in anyway.