HIV AIDS in Pregnancy

1
HIV AIDS in Pregnancy

• DV, Michael Wanjara, MD, M Med
• Consultant Gynecologist
• Arusha Hospital for women
• Arusha Tanzania

2
HIV AND AIDS IN PREGNANCY
3
Summary

• Introduction
• Mother to child Transmission of HIV (MTCT)
• Prevention of mother to child transmission of HIV
• Antanatal care of women with HIV and AIDS
• Care during labour and delivery
• Postnatal care of women with HIV and AIDS
• Follow up for HIV exposed child
• Use of prophylactic antiretroviral (ARU) drugs
  during pregnancy
• The adverse effect of HIV/AIDS on the outcome of
  pregnancy.
• The adverse effect of pregnancy in HIV/AIDS

4
Introduction

• A. Why is HIV/AIDS of special concern in
  pregnancy?
• HIV/AIDS is a major medical problem complicating
  pregnancy in Tanzania
• HIV/AIDS has major adverse effects with outcome
  of pregnancy
• Pregnancy may adversely affect the course of AIDS
  in advanced stages
• B. Prevalence
• Prevalence of HIV in pregnancy in Tanzania varies
  from 4 -32 .

5
Mother to child transmission of HIV (MTCT)

• The risk of MTCT is estimated at 15-40 in
  developing world.
• MTCT (vertical transmission) is cause of over 90
  of all HIV infected children aged below 15 years.
• MTCT is estimated to be the cause of about
  72.000 infected children's in Tanzania annually
  (year 2000 data).
• In Tanzania MTCT is about 40 distributed as
  follows
• 10 In Utero
• 20 During labour and delivery
• 10 Through breast feeding

6
Estimated risk of MTCT in the absence of
intervations (including risks during pregnancy
labour and delivery
7
Factors associated with increased MTCT of HIV,
viral factors

• Viral load
• High levels of Maternal
• Subtypes of HIV virus Subtypes is associated
  with higher MTCT than A, B, and D.
• B. Maternal factors
• Primary HIV infection during pregnancy
• Poor maternal nutrition
• Presence of abruption or chorioamnionities
• Maternal disease stage Advanced stage MTCT
• Presence of other maternal infections in
  pregnancy and delivery STI, syphilis, vaginosis,
  etc.

8
Factors associated with increased MTCT of HIV

• C. Foetal factors
• Prematurity
• Genetic susceptibility
• Twin pregnancy
• D. Postnatal factors
• Breast conditions (mastitis, abscess, nipple
  cracks)
• Pattern of infant feeding - prolonged breast
  feeding
• - mixed feeding
• Infant infection (e.g., oral thrush, gastritis)

9
Prevention of MTCT of HIV (PMTCT)

• Promotion of access to counseling and testing in
  FP, MCH clinics, antenatal words etc.
• Promotion of male involvement in PMTCT
• General information, education, and communication
  in the general population
• Promote HIV education during pregnancy

10
Prevention of MTCT can be achieved through

• FP in FP clinics and comprehensive ANC
• Provision of prophylactic ARV to HIV infected
  pregnant women
• Provision of comprehensive ANC
• Provision of appropriate obstetric car
• Modification of infant feeding practices
• Exclusive breast feeding or exclusive replacement
  feeding
• Avoid invasive procedures during ANC, ECV, do C/S
  when feasible

11
Antenatal care of women with HIV/AIDS

• Give similar obstetric ANC to both HIV negative
  and positive.
• No need for increased ANC visits to those who are
  HIV positive of have AIDS unless there are
  complications
• Provide integrated ANC/Medical care to HIV
  related conditions
• Provide social and psychological support
• Provide counseling to include Potential modes of
  transmission esp. delivery method and infant
  feeding
• Encourage to involve partner
• Provide continued support
• Teach as HIV related programs e.. Wt loss,
  diarrhea
• Teach self care nutrition

12
Care during labour and delivery

• Follow outline
• Avoid repeated VE during labour
• Avoid prolonged rapture of membranes
• Avoid ARM if progress of labour is adequate
• Avoid unnecessary episiotomies
• Avoid suction of the newborn unless it is
  absolutely necessary

13
Postnatal car of a woman with HIV/AIDS

• Stress and anxiety of the postnatal period are
  likely to be intensified
• Elements to be addressed in postnatal care
  include
• Continued care at MCH/postpartum clinic and
  addressing HIV related emotional land clinical
  issues
• Provide adequate emotional support
• Elicit early sings and symptoms of physical and
  emotional stress and help accordingly
• Gloves should be worn when examining the perineum
  C/S wound, cord care, changing baby diaper, etc.
• Mother should be encourage to care for baby if
  conditions allow
• Plan for ongoing care by Community Health worker
  prior to discharge
• Decision to inform other care givers of her HIV
  status should be left of the women herself
• Information on contraception should be offered
  before discharge.

14
Postnatal care of HIV/AIDS patients (continue)

• Teach on early signs of HIV infection and
  encourage to report to clinic
• Discuss with pt. feeding options and the
  additional risk of breast feeding
• Discuss option for replacement feeding
• Promote access to FP
• Plan with the woman for early regular follow up
  at the nearest care and treatment clinic (CTC).

15
Follow up for the HIV exposed child

• Babies born in Health care facilities should
  receive MCH card with NVP (Nevirapine)
  prophylaxis dose must be indicated if given.
• Routine follow up (monthly to one year, than
  three monthly to 5 years)
• Do a full clinical reassessment at each follow up
  visit including growth and development
  assessment.
• Counsel about feeding practices. Avoid giving
  both breast milk and formula milk (limited
  feeding) in the first 6 months of life.
• Start Contrimoxazole prophylaxis from 6 weeks
  onwards
• Perform an antibody test for HIV infection at 18
  months, and if the child is breast feeding at 6
  weeks after stopping breast feeding

16
Use of prophylactic antiretroviral (ARV) drugs
during pregnancy

• Use of ARV have been shown to reduce MTCT
• All pregnant HIV positive women should be
  prescribed Nevirapine and advised to take it when
  labour starts.
• Women who deliver at home should be advised to
  bring their babies for Nevirapine administration
  within 72 hours of delivery
• A single dose of 200 mg orally is given to the
  mother at onset of labour combined with a single
  2 mg/kg oral dose given to her infant within 72
  hours after delivery
• If a pregnant women is on ARV (first or second
  line the rapy) then the baby still needs to be
  given a single dose of NVP and the mother needs
  counseling on breastfeeding options exclusive
  breast feeding or formula milk

17
Cotrimoxazole prophylaxis for the HIV exposed
child