HIV in Pregnancy

Introduction
HIV

Natural history
The principal target = T lymphocytes Specific at CD4 surface antigen (receptor for the virus) Monocyte-macrophages may be infected Incubation period days to weeks

Acute retroviral syndrome

Fever Night sweats Fatigue Rash Headache Lymphadenophathy Pharyngitis Myalgias Arthralgias Nausea and vomiting Diarrhea lasts < 10 days

Natural history
After symptoms abate chronic viremia Median time = 10 years AIDS AIDS; generalized lymphadenopathy, oral hairy leukoplakia, aphthous ulcer, thrombocytopenia, opportunistic infections (candida, HSV, TB, CMV, HPV, PCP, toxo), Kaposi sarcoma, non-Hodgkin lymphoma

Number of People with HIV/AIDS by Region

Western Europe 500,000 North Africa & Middle East 210,000 Sub-Saharan Africa 22.5 million Eastern Europe & Central Asia 270,000 East Asia & Pacific 560,000 South and South East Asia 6.7 million

North America 890,000 Caribbean 330,000

Latin America 1.4 million

Australia and New Zealand 12,000

6

Source: UNAIDS/WHO 1998.

HIV in Pregnancy

Pregnancy on HIV infection

Pregnancy : slightly immunosuppressive : minimal effect on CD4 count : minimal effect on HIV RNA level : does not have significant effect on the clinical or immunological course of HIV infection (Minkoff 2003) Maternal morbidity and mortality : not increased

HIV infection on pregnancy

Slightly increase rate of -preterm birth -IUGR -PROM

Fetal and neonatal infection

varies from 25-40 percent

Adverse Pregnancy Outcomes and Relationship to HIV Infection

Pregnancy Outcome Spontaneous abortion Stillbirth Perinatal mortality Relationship to HIV Infection Limited data, but evidence of possible increased risk No association noted in developed countries; evidence of increased risk in developing countries No association noted in developed countries, but data limited; evidence of increased risk in developing countries Limited data in developed countries; evidence of increased risk in developing countries

Newborn mortality

Intra-uterine growth Evidence of possible increased risk retardation

Anderson 2001.

Adverse Pregnancy Outcomes and Relationship to HIV Infection (continued)

Pregnancy Outcome Low birth weight Preterm delivery Pre-eclampsia Gestational diabetes Amnionitis Relationship to HIV Infection Evidence of possible increased risk Evidence of possible increased risk, especially w/ more advanced disease No data No data Limited data; more recent studies do not suggest an increased risk; some earlier studies found increased histologic placental inflammation, particularly in those with preterm deliveries Minimal data

Oligohydramnios

Fetal malformation

No evidence of increased risk

Anderson 2001.

Maternal and Perinatal Transmission

Maternal and Perinatal Transmission

Antenatal In utero by transplacental passage Intranatal Exposure to maternal blood and vaginal secretions during labor and delivery Postnatal Postpartum through breastfeeding

Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998.

Risk factors for vertical transmission

1. Preterm birth 2. Prolonged membrane rupture increase rate from 15 to 25% in ROM > 4 hr 3. Placental inflammation, chorioamnionitis, concurrent syphylis

4. Maternal plasma HIV RNA level

35 30 25 20 15 10 5 0 1st Qtr 400-3000 3000-40000 40000100000
Most important factor, HIV RNA viral load > 100000 copies/ml : risk > 30 % HIV RNA viral load < 400 copies/ml : risk 1 %

>100000

5. Stage of disease 6. CD4+ T-cell count 7. Mode of delivery cesarean section vs vaginal delivery 8. Breast feeding (risk 30-40%)

Prevention mother to child

Prevention mother to child

Antepartum Antenatal HIV screening Antiretroviral therapy Intrapartum Elective Caesarean section Post partum Avoiding breast feeding

Reduced from 25-30% to less than 2 %

Transmission rate
No ARV AZT alone HAART HAART+C/S Transmission rate 20% 10.4% 2% <2%

Monitoring CD4 count at initiation then CD4 count every 3 months HIV RNA levels at 4 weeks after initiation of treatment then HIV RNA levels monthly until undetectable, then every 3 months HIV RNA level at GA 36 weeks

ARV

Antiretroviral therapy

Drug Nucleoside reverse transcriptase inhibitors Abacavir Didanosine Emtricitabine Lamivudine Stavudine Tenofovir Zalcitabine Zidovudine Non-nucleoside reverse transcriptase inhibitors Delavirdine Efavirenz Nevirapine Protease inhibitors Amprenavir Atazanavir Fosaprenavir Indinavir Lopinavir/ritonavir Nelfinavir Ritonavir Saquinavir Fusion inhibitors Enfuvirtide

Category C B B C C B C C C C C

C B C C C B B B
B

Antepartum

Antepartum care
History taking +Physical examination
Oral health, Ophthalmic,PV

Investigation
CBC with Platelet, BUN/Cr ,LFT, CD4, Viral load Syphilis , hepatitis B C, rubella , TB CXR ,U/S

Screen DM ARV hyperglycemia Immunization

Hepatitis B , Pneumococal , Influenza C/I : live vacc. MMR , varicella , JE

Prevention of opportunistic infection Anteretroviral administration Nutrition support / vitamin supplementation

Antenatal HIV screening

All pregnancy Screening is performed using an ELISA test
Positive, is confirmed with either a Western blot or immunofluorescence assay (IFA)

Rapid HIV test can detect HIV antibody in 60 minutes

Negative rapid test does not need to be confirmed. Positive rapid test should be confirmed with a Western blot or IFA test

women at high risk for acquiring HIV during pregnancy, repeat testing in the 3rd trimester

Intrapartum

Intrapartum care
ARV during labor periodminimum viral load Mode of delivery Labor augmentation is used when needed to shorten the interval to delivery / but avoid ARM Avoid methergin Minimize obstetrics procedure
No fetal scalp blood sampling Forceps extraction Vacuum extraction Avoid episiotomy

Intrapartum care
Cesarean section
decrease vertical transmission one-half compared with vaginal delivery No ANC , No ARV or on ARV< 4 wk. Poor ARV adherance

Combined cesarean section with ARV reduced the risk 87 % Scheduled C/S is recommended at 38 wk viral load > 1000 copies/ml recommended C/S viral load < 1000 copies/mldata insufficient to estimate benefit of C/S (ACOG 2000)

Postpartum

Postpartum care
ARV Mother: AIDS, HIV infection with CD4<200 ; continue ARV treatment CD4 200-350 ; controversial for ARV CD4 > 350 ; stop ARV , monitoring CD4 Baby: ARV 1 / 6 weeks If delivery occurs before treatment is given, the newborn can receive prophylaxis for 6 weeks with zidovudine, or in some cases combination antiretroviral treatment

Postpartum care
Infant regimen ANC
GA>35wk : AZT syrup 4 mg/kg/dose 12 . 4 GA 30-35wk : AZT syrup 2 mg/kg/dose 12 . 2 8 . 2 GA <30wk : AZT syrup 2 mg/kg/dose 12 . 4

Postpartum care
Infant regimen No ANC
NVP syrup 4 mg/kg 24 . 2-4 AZT syrup 4 mg/kg/dose 12 . 3TC syrup 2 mg/kg/dose 12 . 4-6

AZT + 3TC NVP 2 ARV 48 hr.

Postpartum management of infants born to HIV infected women

Wear gloves while exposed to blood or body secretions. Clamp and cut umbilical cord carefully to reduce blood splash contamination. Dry and clean infants skin with a warm cloth to reduce contamination with maternal blood or secretions before transferring to the nursery. Avoid unnecessary use of gastric tube to prevent mucosal trauma. Give infant formula and completely avoid breastfeeding or mixed feeding. Start ARV drug(s) Give vitamin K and routine vaccinations for infants, including BCG vaccine and HBV vaccine.

Breast feeding Not recommended (Infant formula is provided without charge for 18 months by Thai MOPH.)

HIV diagnosis for infants born to HIV-infected mothers and comprehensive care for HIV-infected
infants 1) ARV drugs for infants need to be provided as recommended 2) HIV-infected mothers need to receive counseling on infant formula feeding. Infant formula is provided without charge for 18 months by ThaiMOPH. 3) Infants need to be assessed for signs and symptoms of HIV infection and side effects from ARV drug(s). 4) Infants need to receive appropriate vaccination.

Diagnosis of HIV in children younger than 18 months of age

PCR 1-2 PCR 2 4 2 anti-HIV PCR 18 anti-HIV anti-HIV 12 5-10 antibody anti-HIV 12 anti-HIV 18

PCP prophylaxis
HIV PCP 2-3 CD4 co-trimoxazole (TMP-SMX) 150 mg/m2 TMP 1-2 3 HIV 6 12

Comprehensive care for HIV-infected women and family during the postpartum period
Medical care during the postpartum period 1) Standard postpartum care pay attention on puerperal infection, side effects from ARV drugs, provision of medication to inhibit lactation and prevent breast engorgement or mastitis, postpartum check up at 4-6weeks after delivery, including cervical Pap smear (annually) 2) General health promotion Nutritional support and exercise, should also be provided. 3) All postpartum women should be referred to internists for standard HIV treatment and care

Psychological management postpartum depression, psychosocial support for child rearing, and long-term family care. Caring for male partner Assess HIV status of male partner Voluntary HIV counseling and testing should be offered Refer infected-male partner for standard HIV treatment and care health promotion including: Promotion of safer sex practices Advice on how to live happily with an HIV-infected partner. repeat HIV testing every 6 months.

Family planning services and contraceptive counseling The aim is to prevent unintended pregnancy and HIV transmission to HIVuninfected partner. assess future pregnancy wishes in HIV-infected women and partners and provide family planning services. 1) planning to have children receive pre-conceptual counseling on MTCT risks their long-term health and possible effects of ARV drugs on the fetus. Couples should carefully weigh risks and benefits. Couples who decide to have children should be advised on ways to reduce risk of HIV transmission to infants and partners HIV discordant couples in which -the woman + refer to obstetrician for intrauterine insemination -the man + sperm wash HIV concordant couple long-term HAART unprotected SI at ovulation

2) planning not to have children contraception counseling using dual methods of contraception which include consistent condom use plus others Advice about interactions between oral contraceptive pills and ARV, e.g. NVP or some PI drugs that may reduce the efficacy of birth control pills.