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  • 1. HIV in Pregnancy Dr. ARCHANA VERMA
  • 2. INTRODUCTION – (HIV) Human immunodeficiency virus is a lentivirus (a member of the retrovirus family) that causes Acquired Immunodeficiency Syndrome (AIDS) – Discovered in 1983 – HIV has been divided into two primary strains • HIV-1 and HIV-2 – HIV is highly a variable virus which mutates very readily.
  • 3. CHARACTERISTICS OF HIV  HIV is a retrovirus that is believed to have evolved from a simian immunodeficiency virus. Group Family Genus - Group VI (-ssRNA) Retroviridae Lentivirus  HIV can be characterized primarily by its; • Structure • Viral genome.
  • 4. STRUCTURE OF HIV • It is composed of two copies of positive single-stranded RNA. • A matrix composed of the viral protein surrounds the capsid. • It has a viral envelope • It has glycoprotein's/receptors on its envelope
  • 5. STRUCTURE OF HIV HIV is different in structure from other retroviruses.
  • 6. EPIDEMIOLOGY WHO estimated that Sub-Saharan Africa remains by far the worst-affected region, with an estimated 22.5 million people currently living with HIV (67% of the global total), and 1.8 million new infections (69% of the global total).  However, the number of new infections declined by 19% across the region between 2001 and 2009, and by more than 25% in 22 subSaharan African countries during this period.  Asia is the second-worst affected region, with 4.9 million people living with HIV (15% of the global total).
  • 7. EPIDEMIOLOGY  The first case of HIV in Ghana was reported in March 1986. HIV PREVELANCE BY REGION(%), 2009.
  • 9. ETIOLOGY The 3 main route of transmission is via; o blood, blood products o sexual contact o mother to child in intrauterine infection, perinatal transmission, or the mother’s milk.  NB. Infection via saliva or insect bite has not been confirmed.
  • 10. PATHOGENESIS  Mode of Transmission o Blood Products o Blood transfusion o Infected blood coming into contact with open wounds o Sexual contact o Mother to child o Child birth o Breast feeding
  • 11.  Entry into host cell o HIV enters macrophages and CD4+ T cells by the adsorption of glycoproteins on its surface to receptors on the target cell. o Followed by fusion of the viral envelope with the cell membrane and the release of the HIV capsid into the cell.  Replication and Transcription o On entry of the viral capsid, there is reverse transcription of the +ssRNA, into a complementary DNA molecule by the reverse transcriptase. o The enzyme integrase, integrates the viral DNA into the host cell genome. o This integrated viral DNA may then lie dormant, in the latent stage of HIV infection.
  • 12. Assembly and Release o Structural proteins, functional proteins and enzymes are packaged. o After assembly of the viral particle in the plasma membrane it buds out of the cell, thus acquiring an envelope in the process.
  • 13. Stages of Infection The stages of infection can be grouped into four. • Stage 1 – Primary • Short, flu-like illness - occurs one to six weeks after infection • no symptoms at all • Infected person can infect other people
  • 14. • Stage 2 – Asymptomatic • Lasts for an average of ten years • This stage is free from symptoms • There may be swollen glands • The level of HIV in the blood drops to very low levels • HIV antibodies are detectable in the blood
  • 15. • Stage 3 – Symptomatic • The symptoms are mild • The immune system deteriorates • emergence of opportunistic infections and cancers Stage 4 - HIV  AIDS • The immune system weakens • The illnesses become more severe leading to an AIDS diagnosis
  • 16. Laboratory Diagnosis Detection of HIV is tackled on three different fronts; o Blood o Urine o Oral
  • 17. Blood Detection Tests • Enzyme-Linked Immunosorbent Assay/Enzyme Immunoassay (ELISA/EIA) • Radio Immunoprecipitation Assay/Indirect Fluorescent Antibody Assay (RIP/IFA) • Polymerase Chain Reaction (PCR) • Western Blot Confirmatory test
  • 18. Urine Testing • Urine Western Blot – As sensitive as testing blood – Safe way to screen for HIV – Can cause false positives in certain people at high risk for HIV
  • 19. Oral Testing • Orasure – The only FDA approved HIV antibody. – As accurate as blood testing – Draws blood-derived fluids from the gum tissue. – NOT A SALIVA TEST!
  • 20. PROGNOSIS Without treatment, the net median survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV subtype, and the median survival rate after diagnosis of AIDS in resource-limited settings is 6 and 19 months. . In areas where it is widely available, the development of HAART as effective therapy for HIV infection and AIDS reduced the death rate from this disease by 80%, and raised the life expectancy for a newly diagnosed HIV-infected person to 20–50 years.
  • 21. Effect of HIV in pregnancy
  • 22. Effect of pregnancy on HIV • CD4 counts fall during pregnancy but return to pre pregnancy levels post partum. • No increased risk of accelerated immunosuppression.
  • 23. Effect of AIDS on Pregnancy • • • • • • • Infertility Repeated abortions Prematurity Intrauterine growth retardation Stillbirths Congenital abnormalities Embryopathies 23
  • 24. Antenatal management • Screening for HIV should be offered early in pregnancy because appropriate antenatal interventions can reduce maternal-to-child transmission of HIV infection. • positive HIV antibody test result should be given to the woman in person by an appropriately trained health professional.
  • 25. Confidentiality • Confidentiality is important. • Information may be disclosed to a known sexual contact of the woman
  • 26. multidisciplinary team HIV positive patients should be managed by a multidisciplinary team. • HIV physician • an Obstetrician • a Midwife • a Paediatrician • a Psychiatric team • support groups
  • 27. Booking visit • Additional tests – Lymphocyte subsets – Quantitaive RNA PCR measurement of viral load – Hepatitis B & C – Cervical & vaginal swabs to check for STDs,Bacterial vaginosis & Group B streptococcus. – CD4 count should be tested every trimester or more frequently if maternal viral load is high.
  • 28. Antenatal care • Screening for Down syndrome and fetal anomalies should be offered. • A detailed ultrasound scan for fetal anomalies is important after first-trimester exposure to HAART
  • 29. invasive prenatal diagnosis • The risk of mother-to-child transmission with chorionic villus sampling or second-trimester amniocentesis hasn’t been estabilished. • If invasive prenatal diagnosis is contemplated, the advice of the fetal medicine specialist and HIV physician should be seeked and prophylaxis with HAART considered.
  • 30. Treatment Options
  • 31. Antiretroviral therapy • 2 reasons – prevention of mother-to-child transmission (therapy usually discontinued at, or soon after, delivery) – secondly for treatment of the mother to prevent maternal disease progression (therapy continued indefinitely after delivery)
  • 32. Antiretroviral therapy • anti-retroviral therapy is recommended for all HIV positive women during pregnancy and at delivery to prevent MTCT. • The optimal regimen is determined by an HIV physician on a case-by-case basis. • The decision to start,modify or stop antiretroviral therapy – should be undertaken by an HIV physician – in close observation with other health professionals • obstetrician • paediatrician.
  • 33. Antiretroviral therapy • Women who are not on HIV treatment for their own health need anti-retroviral therapy to prevent mother-tochild transmission. • Anti-retroviral therapy is usually started between 28 and 32 weeks of gestation and should be continued intrapartum. • A maternal sample for plasma viral load is taken at delivery. • Maternal anti-retroviral therapy is usually stopped soon after delivery but the precise time of discontinuation should be discussed with the HIV physician. • Zidovudine is usually administered orally to the neonate for four to six weeks.
  • 34. Antiretroviral therapy • Timing – Antenatally – Intrapartum – Neonatal period(4-6 weeks) • Choice of antiretroviral therapy & Timing is decided by HIV physician. • Plasma viral load & CD4 counts regularly monitored.
  • 35. Antiretroviral therapy...... • Patients on antiretroviral therapy should be monitored for toxicity • • • • • full blood count urea and electrolytes liver function tests Lactate blood glucose • Patients should also have detail ultrasound scan to detect foetal anomalies.
  • 36. Drug toxicity • Presentation with symptoms or signs of • pre-eclampsia • Cholestasis • other signs of liver dysfunction during pregnancy – may indicate drug toxicity
  • 37. Lactic acidosis – is a recognised complication of certain HAART regimens. • presenting symptoms • often nonspecific • include – – – – gastrointestinal disturbance fatigue fever breathlessness.
  • 38. Types of HIV drugs • Reverse transcriptase inhibitors – Nucleoside reverse transcriptase inhibitors – Non nucleoside reverse transcriptase inhibitors • Protease inhibitors • Entry inhibitors • Integrase inhibitors
  • 39. Prophylaxis of Pneumocystis carinii • PCP prophylaxis is usually administered when the CD4 T-lymphocyte count is below 200 • The first line treatment is cotrimoxazole(a folate antagonist). • Folic acid 5 mg should also be given • Nebulised pentamidine is another alternative.
  • 40. Screening for genital infections • All pregnant women who are HIV positive should be screened for genital infections. • When to do ? • This should be done as early as possible in pregnancy • repeated at around 28 weeks. • Any infection detected should be treated.
  • 41. Mother to child transmission • Non breast feeding women in Europe 15-20% • Breast feeding mothers in Africa 25-40% • Breast feeding is associated with 2 fold increase in transmission.
  • 42. Prevention • Maternal child transmission is prevented by – Antenatal HIV screening – Antiretroviral therapy – Elective Caesarean section – Avoiding breast feeding – Reduced from 25-30% to less than 2 %
  • 43. Prevention of MTCT • 2 choices of antiretroviral therapy – Single agent-Zidovudine – START(short term antiretroviral therapy) • HAART for short duration in pregnancy and continued intrapartum
  • 44. Zidovudine Vs START Zidovudine START may allow the emergence of resistant virus maternal plasma viraemia is more likely to be suppressed to undetectable levels exposure of the mother and fetus to larger numbers of potentially toxic drugs
  • 45. advanced HIV • likely to have symptomatic HIV infection and – a falling or low CD4 T-lymphocyte count less than 350 – And / or a high viral load (greater than 10 000–20 000 copies/ml).
  • 46. advanced HIV • These women should be treated with a HAART regimen. • The start of treatment should be deferred until after the first trimester, if possible, and should be continued after delivery.
  • 47. advanced HIV • Women who conceive while taking HAART should continue their HAART regimen if it is effectively suppressing plasma viraemia. • For women whose regimen is not suppressing viraemia, a change in therapy after the first trimester may be indicated.
  • 48. Mode of delivery • Elective Caesarean section is beneficial – HIV positive women who are not taking HAART during pregnancy – for women with a detectable plasma viral load • Value of elective caesarean section is uncertain – in women taking HAART who have an undetectable plasma viral load at the time of delivery.
  • 49. LSCS in HIV women • A zidovudine infusion – should be started four hours before beginning the caesarean section – Should continue until the umbilical cord has been clamped. • A maternal sample for plasma viral load should be taken at delivery. • The cord should be clamped as early as possible after delivery and the baby should be bathed immediately after the birth.
  • 50. LSCS in HIV women.... • a technique of ‘bloodless’ caesarean section may further reduce the risk of mother-tochild transmission. – opening the uterus with a staple gun,which simultaneously cuts and giveshaemostasis.
  • 51. Casarean section • This should be sheduled at 38 weeks to reduce the risk of spontaneus labour or membrane rupture. • Contamination of the baby with maternal blood should be avoided – Secure the bleeding points • Cord clamped as soon as possible
  • 52. Casarean section • Drainage should be used and they should be used to closed suction system • Universal precautions :gloves, aprons & face protection should be employed.
  • 53. Labour in HIV woman • Women who opt for a planned vaginal delivery should have their membranes left intact for as long as possible. • Use of fetal scalp electrodes and fetal blood sampling should be avoided. • Women should continue their HAART regimen throughout labour . • If an intravenous infusion of zidovudine is required it should be commenced at the onset of labour and continued until the umbilical cord has been clamped. • A maternal sample for plasma viral load should be taken at delivery. • The cord should be clamped as early as possible after delivery and the baby should be bathed immediately after the birth.
  • 54. Vaginal delivery • Forceps preferred to Vacuum • Remove maternal blood stain with alcohol wipe prior to Vitamin K injection • Universal precautions :gloves, aprons & face protection should be employed.
  • 55. SROM in HIV • SROM-spontaneus rupture of Membranes – ruptured membranes for more than four hours , associated with double the risk of HIV transmission. – These studies also demonstrated a 2% incremental increase in transmission risk for every hour of rupturedmembranes up to 24 hours. – The relevance of these studies for women taking HAART who have undetectable viral loads is uncertain.
  • 56. PPROM in HIV • PPROM-preterm prelabour rupture of membranes – If there is preterm rupture of membranes, with or without labour, the risk of HIV transmission should be set against the risk of preterm delivery. – Preterm infants are more likely to be infected with HIV. – There is no known contraindication to the use of short-term steroids to promote fetal lung maturation.
  • 57. Postpartum • women with HIV advised not to breast feed • Neonate infections. – PCR is done as maternal antibodies cross the placenta – Typically, tests are carried out at birth, then at three weeks, six weeks and six months. – definitive test is the HIV antibody test: a negative result at 18 months of age confirms that the child is uninfected.
  • 58. Management of the neonate • All infants born to women who are HIV positive should be treated with antiretroviral therapy from birth. • Usually treatment is discontinued after four to six weeks
  • 59. Recommendation for for HIV-infected mother in labor who had no prior therapy 1. Single dose Nevirapine during labor and a single dose to the neonate at age 48h. 2. Intrapartum AZT, the 6 weeks of AZT to the neonate.(2mg/kg 4 times daily) 3. The two dose Nevirapine combined with the intrapartum and 6 weeks AZT regimen.
  • 60. • IN case of maternal HIV antiretroviral resistance: AZT is still recommended to the infant, plus other medications based on maternal HIV resistance pattern.
  • 61. THANK YOU