Part A: Module A3

1

• HIV and Pregnancy
• Prevention of
• Mother-to-Child Transmission

• Part A Module A3
• Session 1

2
Objectives

• Understand the effects of HIV on pregnancy
• Discuss MTCT transmission, factors that may
  increase transmission, and measures that reduce
  transmission
• Describe how ART is used for the prevention of
  MTCT

3
Objectives, continued

• Describe the various drug regimens for PMTCT that
  are used during pregnancy, intrapartum, and
  postpartum, including short course ART
• Discuss issues related to breastfeeding, PMTCT,
  ART and WHO recommendations
• Discuss national guidelines on infant feeding

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HIV and Pregnancy Prevention of Mother-to-Child
Transmission

• Worldwide, each year, two million HIV infected
  women become pregnant, most of them in poor
  countries
• Between 1/4 and 1/3 transmit the disease to their
  newborns either during labor, during delivery, or
  while breast-feeding (2,000 new AIDS-infected
  infants each day)
• HIV infected children whose mothers die are left
  orphaned and harder to care for than the HIV
  negative infant

5
HIV and Pregnancy Prevention of Mother-to-Child
Transmission, continued

• In participants country of women are HIV
  positive. Prevalence is higher in areas
• HIV presentation is the same in both sexes, but
  the disease has greater implications on a womans
  reproductive health in terms of her ability to
  cope with pregnancy and transmission of the virus
  to her unborn and newborn child
• During the asymptomatic phase of HIV, most women
  are unaware of their infection until the disease
  is diagnosed in their infants. This may cause
  conflict within the family and the woman might be
  blamed for bringing the infection into the family

6
Effects of HIV on Pregnancy

• Some studies in Africa suggest that HIV may have
  an adverse affect on fertility in both
  symptomatic and asymptomatic women
• When comparing changes in CD4 count/percentage
  over time, there is no difference between
  HIV-positive women who are pregnant and
  HIV-positive women who are not pregnant
• HIV does not seem to significantly cause
  congenital abnormalities or an increase in
  spontaneous abortion

7
Effects of HIV on Pregnancy, continued

• During the early stages of HIV infection,
  pregnancy does not accelerate disease progression
• Late HIV disease may affect the outcome of
  pregnancy, i.e., poor fetal growth, preterm
  delivery, low birth weight, prenatal and neonatal
  death
• With regard to common HIV-related problems, there
  is no difference between pregnant and
  non-pregnant women and they should be managed the
  same (except for drug management)

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Mother-to-Child Transmission of HIV

• Transmission
• Factors which may increase risk of transmission
• Measures to reduce MTCT
• ARV Therapy and MTCT

• Prevention of prenatal transmission
• Women first diagnosed with HIV infection during
  pregnancy
• HIV-infected women on ART who become pregnant

• ART and breastfeeding
• Treatment postpartum
• Adherence to therapy
• Recommendations

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Transmission

• HIV may be transmitted to the infant during
  pregnancy, at the time of delivery, and through
  breastfeeding most transmission is thought to
  take place during delivery
• For a mother known to be HIV-infected prenatally,
  the additional risk of transmission of HIV to her
  infant through breastfeeding has been estimated
  at 14
• The risk is as high as 29 for mothers who
  acquire HIV post-natally

10
Transmission, continued

• Many studies indicate that the risk of breast
  milk transmission is higher in the first few
  months of life, with a subsequent tapering off of
  risk
• The risk persists as long as the infant is
  breastfed
• HIV transmission is also higher if the mother has
  mastitis

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Factors Which May Increase the Risk of
Transmission

• High maternal viral load gt5-10,000 copies/ml
  (e.g., at time of seroconversion and during late
  HIV disease CD4 cell counts lt100 cells/mm)
• Recurrent STDs
• Malaria interferes with placental functions and
  eases viral transmission across the placenta
• Vitamin A deficiency
• Preterm delivery
• Infected amniotic fluid (chorioamnionitis)
  (limited data recent studies do not suggest
  increased risk)

12
Factors Which May Increase the Risk of
Transmission, continued

• Vaginal delivery
• Duration of rupture of membranes is longer than 4
  hours
• Placental disruption
• Invasive procedures during delivery (e.g., vacuum
  extraction, episiotomy, use of forceps, fetal
  scalp monitoring)
• Mechanical nasal suction after delivery
• Breastfeeding and especially mixed feeding

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Measures to Reduce MTCT

• During pregnancy
• Provide voluntary counseling and HIV testing plus
  psychosocial support
• Diagnose and provide aggressive treatment of
  malaria, STDs and other infections as early as
  possible
• Provide basic antenatal care including
• Iron Supplementation
• Education about MTCT and infant feeding options
• ART for MTCT
• Risk reduction/safer sex measures

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Measures to Reduce MTCT

• During Labor and Delivery
• Delay rupturing of membranes (ROM)
• Do only minimal digital examinations after ROM
• Cleanse the vagina with hibitane or other
  viricides if available
• Reduce use of assisted delivery with forceps,
• Reduce use of episiotomy
• Elective caesarean section has a more protective
  effect against MTCT than vaginal delivery
• If not already on ART, give NVP

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Measures to Reduce MTCT

• After Delivery
• Avoid mechanical nasal suction
• Clean the newborn immediately of all maternal
  secretions and blood
• Support safer infant feeding (according to
  national guidelines re mothers choice to put
  the infant to breast within 30 minutes of birth)
• If breastfeeding is chosen as an option
  encourage exclusive breastfeeding and advise
  early cessation (up to 6 months) or breast milk
  substitute
• Advise giving milk substitutes where conditions
  are suitable and no breastfeeding after 6 months

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Risks and Benefits Breastfeeding vs.
Replacement Feeding

• Current WHO/UNAIDS/UNICEF guidelines recommend
  that women with HIV infection be fully informed
  of both risks and benefits of breastfeeding and
  be supported in their decision about feeding
  practices
• Safe alternatives may not be available in some
  resource-limited settings, in which case
  exclusive breastfeeding for the first six months
  of life is recommended

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Breastfeeding by HIV Positive MothersRisks to
the Infant

• HIV infection
• Infection risk persists for as long as the infant
  is breastfeeding
• Children who receive mixed feeding seem to be at
  higher risk of HIV infection during the first
  months of life than children who receive
  exclusive breastfeeding or exclusive replacement
  feeding
• Shortening the period of breastfeeding may reduce
  the risk of HIV transmission and mixed feeding
  should be discouraged
• The alternative of exclusively giving replacement
  feeding also has considerable risks

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Breastfeeding Benefits to the Infant

• The immunological, nutritional, psychosocial, and
  child-spacing benefits are well recognized
• Breast milk plays an important role in preventing
  the infections that accelerate progression of
  HIV-related diseases in already infected children

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ARV Therapy and MTCT

• Prevention of Prenatal Transmission
• ARV therapy can produce a significant reduction
  in mother to child transmission of HIV
• Studies showed that administration of AZT to
  women from 14th week of pregnancy and during
  labor to the newborn decreased the risk of MTCT
  by nearly 70 in the absence of breastfeeding
• A shorter AZT alone regimen starting from the
  36th week of pregnancy was shown to reduce the
  risk of transmission of HIV at 6 months by 50 in
  non-breastfeeding population and by 37 in those
  breastfeeding

20
ARV Therapy and MTCT, continued

• Short course of NVP (HIVNET 012) has been shown
  to reduce the risk of transmission by 47
• This protocol is the most commonly used one
  because of its
• demonstrated efficacy in clinical trials in
  reducing MTCT
• low cost
• ease of use in MTCT programs
• Women on treatment with ARVs for HIV infection
  have very low transmission if their viral load is
  lt1000 copies/ml

21
Women First Diagnosed with HIV Infection During
Pregnancy

• Women in the first trimester may consider
  delaying initiation of ART
• Consider severity of maternal HIV disease and
  potential benefits and risks of delaying ART
  until after first trimester
• For women who are severely ill, the benefit of
  early initiation may outweigh theoretical risk to
  fetus in these cases, recommend initiating with
  drugs such as AZT, 3TC, NVP, or NFV

22
HIV-infected Women on ART Who Become Pregnant

• Options are
• Suspend therapy temporarily during first
  trimester
• Continue same therapy
• Change to a different regimen
• Issues to consider
• Gestational stage of the pregnancy
• Severity of maternal disease
• Tolerance of regimen in pregnancy
• Potential for adverse fetal effects

23
ART and Breastfeeding

• Women who require ART and are breastfeeding
  should continue their ongoing ART regimen
• Efficacy of a potent ART being given to the
  mother solely to prevent postnatal transmission
  of HIV through breast milk is unknown, but is
  currently being studied

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Short-Course ARV prophylaxis and Treatment
Postpartum

• Short-course ARV regimens, that do not fully
  suppress viral replication, may be associated
  with the development of ARV drug resistance
• The Ugandan HIVNET 012 study of single dose
  intrapartum/newborn NVP for prevention of MTCT
  found that 19 of the women developed resistance
  to the drug. This was associated with delivery,
  HIV viral load and CD4 cell count

25
Short-Course ARV Prophylaxis and Treatment
Postpartum, continued

• Based on current information (until further
  research is done), prior administration of
  short-course AZT/3TC or single dose NVP for
  prevention of MTCT should not preclude use of
  these agents as part of a combination ARV drug
  regimen initiated for treatment of these women

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Adherence to Therapy in Pregnancy and Postpartum

• Difficulty of adherence is greater in pregnant
  and postpartum women
• Obstacles to adherence morning sickness, GI
  upset, fears about ARV harming the fetus
• If need to temporarily discontinue therapy during
  pregnancy, stop all drugs and then re-start
  simultaneously
• This reduces the potential for emergence of
  resistance

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Adherence to Therapy in Pregnancy and
Postpartum, continued

• Treatment adherence difficult postpartum
• Physical changes of postpartum period coupled
  with stresses and demands of caring for a newborn
  infant
• Important to provide additional supports for
  maintaining adherence to therapy during ante- and
  post-partum periods

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Recommendations

• Exclusive breastfeeding for the first 6 months
  generally promoted and supported ---
• serostatus of most mothers unknown
• benefits to infants outweigh the risks regardless
  of their HIV status
• The mother should make final choice about the
  feeding method
• Whatever her choice may be, health staff should
  provide support to ensure optimal nutrition of
  mother and child
• Refer to national HIV and infant feeding
  guidelines