Care of Women with HIV Living in

Limited-Resource Settings

HIV and Pregnancy

Jean R. Anderson, MD
Director
Johns Hopkins HIV Women’s Health Program

1
 Objectives

❚ Review significance of HIV during pregnancy and

magnitude of the problem
❚ Review HIV-related issues to be considered prior to
pregnancy
❚ Discuss effects of pregnancy on HIV infection and
effects of HIV infection on pregnancy course and
outcome
❚ Discuss mother-to-child transmission (MTCT) and its
prevention
❚ Discuss care of pregnant woman with HIV

2
 HIV and Pregnancy – Why Is It
Important?

❚ HIV may have adverse effect on pregnancy course or

outcome
❚ More than 90% of pediatric HIV/AIDS cases are caused
by MTCT
❚ Most children born to HIV-positive mothers in limited-
resource settings will be orphaned when one or both
parents die
❚ Women without HIV may place themselves at risk for
infection while trying to get pregnant
❚ Majority of women with HIV are of childbearing age

3
 Prevalence of HIV (Type-1) among
Pregnant Women

Haiti
Latin Honduras
America
Brazil
Cambodia
Asia
Thailand
Botswana
Rwanda
Malawi
Africa South Africa
Kenya
Uganda
Nigeria

0% 10% 20% 30% 40% 50%

% Positive

Source: DeCock et al 2000. 4

 C
ar
le
to HIV prevalence (%)
n vi
M lle
ut ,S
as ou
a

0
10
20
30
40
50
60
70
di 199 th
st A
K ric 8 (u fri
is t, r ca
um Zi ban ,

Source: UNAIDS June 2000.

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K 9 a
Lu en 8 (r bw
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C er 97
ot o
Various African Studies, 1995–1998

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Po en
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96
(r
ur
Women, 20-24
Women, 15-19

al
)
HIV Prevalence among Women Age 15–24

5
 Effect of HIV on Fertility

❚ Prior STIs or pelvic inflammatory disease

❚ Direct effects of HIV
❙ Decreased fertility seen after adjustment for age, lactation,
illness, STIs
❙ Worsened fertility in women with symptomatic HIV or co-
infected with syphilis
❙ Pregnancy loss more common with HIV infection
❙ Decreased sexual activity with advanced HIV

6
Source: Lancet 1998.
 Voluntary Counseling and Testing
(VCT) in Women of Childbearing Age

❚ Information about HIV and pregnancy

❚ Risk assessment
❚ Prevention of HIV transmission or acquisition
❚ Prevention of unintended pregnancy
❙ Dual protection with condoms

Need to involve men in VCT!

7
 Goals of VCT in Antenatal Care

❚ Educate about HIV

❚ Reduce stigma
❚ Prevent new HIV infections in pregnancy
❚ Identify women with HIV
❙ Stabilize and maintain maternal health
❙ Prevent HIV transmission to uninfected sexual or drug
using partners
❙ Reduce risk of MTCT
❙ Plan for future

8
 Special Counseling Issues for HIV-Positive Women
Who Are Pregnant or Considering Pregnancy

❚ Effect of HIV on fertility

❚ Effect of HIV on pregnancy and pregnancy on HIV
❚ Potential for MTCT
❙ Risk
❙ Timing
❙ Prevention
❚ Use of antiretroviral (ARV) agents and other drugs
during pregnancy, if available

9
 Special Counseling Issues for HIV-Positive Women
Who Are Pregnant or Considering Pregnancy
continued

❚ Newborn feeding options

❚ Disclosure issues – concerns about stigma and violence
❚ Use of condoms
❚ Long-term health of mother and care for children
❚ Pregnancy termination option – if legal and safe

10
 Effect of Pregnancy on HIV

❚ CD4 count decreases in all pregnancies due to dilutional

effect; CD4% remains stable in HIV-positive women
❚ HIV-RNA levels (viral load) remain stable during
pregnancy in absence of treatment
❚ No significant differences in HIV progression or survival
between pregnant and nonpregnant women with HIV
infection

Source: Alliegro 1997 Brocklehurst 1998 Burns 1998. 11

 Effect of HIV on Pregnancy

Pregnancy Outcome Relationship to HIV Infection

Spontaneous abortion Limited data, but evidence of possible increased risk
Stillbirth Evidence of increased risk in developing countries
Perinatal mortality Evidence of increased risk in developing countries
Infant mortality Evidence of increased risk in developing countries
IUGR Evidence of possible increased risk
Low birth weight (<2500g) Evidence of possible increased risk
Preterm delivery Evidence of possible increased risk, especially with
more advanced disease
Pre-eclampsia No data
Gestational diabetes No data
Chorioamnionitis Limited data; more recent studies do not suggest an
increased risk
Oligohydramnios Minimal data
Fetal malformation No evidence of increased risk
12
Source: Brocklehurst 1998.
 Estimated Number of Children (< 15 years)
Newly Infected with HIV during 2000

Eastern
Western Europe &
North Europe Central Asia
America
<North
500 600 East Asia &
< 500 Pacific
Caribbean Africa South &
4,200 2,600
& Middle South-East
East Asia
Latin 11,000
Sub-
Saharan 65,000
America Australia &
Africa
7,300 520,0 New
Zealand
00
< 100

Total: 600,000
13
Source: UNAIDS December 2000.
 Estimated Timing and Risk of MTCT of
HIV (Absolute Rates)

Breastfeeding Breastfeeding
No through 6 through 18–24
Breastfeeding Months Months

Intrauterine 5 to 10% 5 to 10% 5 to 10%

Intrapartum 10 to 20% 10 to 20% 10 to 20%

Postpartum

Early (first 2 months) 5 to 10% 5 to 10%

Late (after 2 months) 1 to 5% 5 to 10%

Overall 15 to 30% 25 to 35% 30 to 45%

Source: DeCock et al 2000. 14

 Factors Affecting MTCT of HIV/AIDS

❚ Viral load (HIV-RNA level)

❚ Genital tract viral load
❚ CD4 cell count
❚ Clinical stage of HIV
❚ Unprotected sex with
multiple partners
❚ Smoking cigarettes
❚ Substance abuse
❚ Vitamin A deficiency

Photo: Nelson, Zambia 2000.

15
 Factors Affecting MTCT of HIV/AIDS
continued

❚ STIs and other co-infections

❚ ARV agents
❚ Preterm childbirth
❚ Placental disruption
❚ Invasive fetal monitoring
❚ Duration of membrane
rupture
❚ Vaginal childbirth versus
cesarean section
❚ Breastfeeding
Photo: Nelson, Zambia 2000.

16
 MTCT Prevention in Low-Resource
Settings

❚ Change behavioral factors

❙ Encourage consistent condom use during pregnancy and
postpartum
❙ Discourage use of drugs, alcohol and cigarettes
❚ Identify and treat modifiable risk factors
❙ Screen and treat STIs and co-infections
❙ Provide vitamin A supplementation, if available (?)
❙ Recommend treatment for substance abuse

17
 MTCT Prevention in Low-Resource
Settings continued

❚ Reduce viral exposure

❙ Avoid:
❘ Artificial membrane rupture
❘ Transfusion (use only in life-threatening situations)
❙ Shorten duration of ruptured membranes
❙ Cleanse vaginal area with disinfectant (?)
❚ Reduce viral load before childbirth
❙ Administer ARV agents
❙ Treat STIs

18
 MTCT Transmission with Short Course
Oral ARV Regimens

MTCT
Site Regimen Reduction
No Breastfeeding
Thailand ZDV: 36 weeks, labor 50%
Breastfeeding
Cote d’Ivoire ZDV: 36 weeks, labor 37%
(3 months)
ZDV: 36 weeks, labor, 34%
postpartum (mother) (18 months)
Uganda, Tanzania, ZDV/3TC: 36 weeks, labor, 52%
South Africa postpartum (mother & newborn) (6 weeks)

ZDV/3TC: labor, 38%

postpartum (mother & newborn) (6 weeks)
Uganda NVP (single dose): labor, postpartum 41%
(newborn) (18 months)
19
 Recommendations for Antenatal Care

❚ Basic antenatal care

❚ Prevent and treat common opportunistic infections
❚ Recommend nutritional interventions
❚ Screen and treat STIs and other co-infections
❚ Monitor for signs and symptoms of progressive
HIV/AIDS
❚ Counsel on safe sex practices

20
 Recommendations for Antenatal Care
continued

❚ Avoid invasive procedures

❙ Amniocentesis
❙ External cephalic version
❚ Consider administering ARV agents, if available
❚ Plan for future
❙ Newborn feeding
❙ Family planning
❙ Long-term care needs for mother, newborn and other
children
❚ Provide emotional support

21
 Recommendations for Labor and
Childbirth

❚ Avoid invasive procedures

❙ Artificial membrane rupture
❙ Fetal scalp electrode or sampling
❙ Forceps or vacuum extractor
❙ Episiotomy
❚ Administer ARV agents, if available
❚ Consider issues related to type of delivery — cesarean
section versus vaginal childbirth
❚ Wipe newborn quickly and thoroughly with a dry cloth to
remove maternal blood and secretions

22
 Recommendations for Labor and
Childbirth continued

❚ Follow recommended infection prevention practices

❙ Wash hands thoroughly before and after each procedure
and examination
❙ Wear hand and eye protection
❙ Handle needles and other sharp instruments safely
❙ Dispose placenta and other waste materials and supplies
properly
❙ Process instruments, gloves and other items by
decontamination, cleaning and either sterilization or high-
level disinfection

23
 MTCT and Cesarean Section

❚ Cesarean section before onset of labor and membrane

rupture decreases risk of MTCT 50–80%
❚ Additional benefit in women not using ARV agents or on
ZDV alone
❚ No evidence of benefit after onset of labor or membrane
rupture

24
 MTCT and Cesarean Section continued

❚ Special concerns with cesarean section in limited-

resource settings
❙ Increased maternal morbidity and possible mortality
❙ Availability of blood and blood safety
❙ Iatrogenic prematurity
❙ Antibiotic prophylaxis
❙ Anesthesia availability
❙ Limited human resources — nursing care time

25
 Postpartum Care

❚ Assess healing
❚ Review newborn feeding, growth and development
❚ Reinforce safer sexual practices
❚ Discuss contraception options
❚ Refer mother and newborn for ongoing care

26
 Recommendations for Breastfeeding

❚ Avoid all breastfeeding when replacement feeding is

acceptable, feasible, affordable, sustainable and safe
❙ Provide guidance and support to HIV-positive mothers who
choose not to breastfeed to ensure adequate nutrition
❚ If breastfeeding chosen, encourage exclusive
breastfeeding up to 6 months of infant’s life
❙ Teach proper attachment of newborn to nipples and
frequent breast emptying
❙ Teach prevention and recognition and encourage prompt
treatment of mastitis, breast abscess, cracked nipples and
oral thrush or other oral lesions in newborns

27
 Estimated Impact of AIDS On Under-5 Child
Mortality Rates Selected African Countries, 2010

250
Deaths per 1000 live births

200 Without AIDS

With AIDS
150

100

50

0
Botswana Kenya Malawi Tanzania Zambia Zimbabwe

28
Source: UNAIDS June 2000.
 Estimated Number of Children (< 15
years) Orphaned by AIDS* by End of 1999

Eastern
Western Europe &
North Europe Central Asia
America
70,00 9,000
North
500 East Asia &
Caribbean Africa South &Pacific
085,00 & Middle 5,600
South-East
East Asia
0 15,000
Sub-Saharan 850,000
Latin Africa
America Australia
110,0 12.1 & New
Zealand
00 million < 500

Total: 13.2 million

* HIV-negative children who have lost their mother or both parents to AIDS before the age of 15 years
29
Source: UNAIDS December 2000.
 Summary

❚ Prevent HIV infection in women in their childbearing

years
❚ Prevent unintended pregnancies in HIV-positive women
❚ Identify HIV infection in pregnant women
❙ To provide effective antenatal, labor and childbirth, and
postpartum care can be provided
❙ To reduce risk of MTCT

30