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  1. 1. 1. MANAGEMENT OF THE HIV POSITIVE MOTHER AND PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV / PREGNANCY AND ARV1.1 Counselling and Voluntary testing for HIV in pregnant women.The effectiveness of a program for the reduction of parent to child transmission ofHIV infection depends on the mother’s HIV status being known so that she canreceive antiretroviral therapy and counseling regarding infant feeding and otherimportant issues. With the availability of ARV, the woman herself also potentiallyderives benefit from knowing her HIV status as, if positive, she can enter theprogram of monitoring and when necessary, receive ARV.Since the start of the MTCT pilot program in South Africa, testing rates havevaried widely between different centers. A recent study has shown that provinceswhere all women receive individual pre-test counseling before making a decisionregarding HIV testing have a much higher HIV test uptake rate than provinceswhere women receive group information and then may choose to have individualcounseling().1.1.1 Counselling and voluntary testing.All women attending antenatal clinic must receive individual counseling aboutHIV testing before making a decision regarding the test. Group information maybe provided but should not replace individual pre-test counseling. Pre-testcounseling is not optional – it is a standard part of management for each womanattending antenatal clinic, just as blood pressure measurement is. Counsellingshould be performed in a private room by lay counselors who have been trainedfor this purpose. All women need to give consent before undergoing HIV testing.Couples testing is to be strongly encouraged, with the couple receiving their pre-test counseling together and making the decision about HIV testing together.Provisions need to be made for partner testing at antenatal clinics. Couples
  2. 2. testing may be facilitated by offering antenatal clinic services at times when menmay more easily attend clinic with their wife/partner, eg in the evenings orweekends.For all individuals agreeing to HIV testing, the test is to be done on site with rapidtesting. For positive tests a second rapid test is performed. For negative tests,no further HIV testing is performed. If women leave the clinic before beinginformed of their HIV test result, some will not return to that clinic to receive theresult, thus missing the potential benefit which can be provided to themselvesand their infants. In order to avoid this situation, all women should be stronglyadvised to receive their result at the same visit. HIV test results should never begiven telephonically. Women must be post test counselled after receiving theresult of their HIV test. For HIV negative women this will be a brief sessionaimed at behaviour modification to reduce risk of HIV infection. For HIV positivewomen, post test counseling is not confined to the session after receiving theirresult - conselling and support is ongoing, and is particularly important foradherence to therapy.1.1.2 CounsellorsThe quality of counselling can be improved by strengthening the system. Morelay counsellors need to be trained and employed in antenatal clinics. Existingcounselors should receive regular refresher courses and a mechanism ofpsychological support for counselors needs to be put in place. A standardremuneration structure for lay counselors should be established and theremuneration process needs to be streamlined.
  3. 3. 1.2 ARV IN PREGNANCY AND POSTPARTUM / HIV POSITIVE PREGNANT WOMENThe seroprevalence of HIV infection amongst women in the reproductive agegroup is variable by province throughout the country, and has only beenestablished amongst the ante-natal attendees in sentinel site surveys. Thecomprehensive operational plan for HIV/AIDS care, treatment and managementshould ensure thati) the great majority of the population who are currently not infected with HIV remain uninfected;ii) that availability and access to post exposure prophylaxis (PEP) for women who suffer sexual violence must be improved.iii) widespread coverage of contraception and family planning services, such that pregnancies occuring in HIV infected women should be planned, and not accidental,iv) women diagnosed of HIV infection during early pregnancy should be offered the option of termination of pregnancy, (access to and the availability of such services should be improved),v) enhanced efforts in the prophylaxis and treatment of opportunistic infections, improved nutrition and lifestyle choices be put into placevi) effective management by suitable palliative and terminal care of those HIV infected individuals who have developed AIDS defining illness and where treatment has run its course.1.2.1 Care of Pregnant Women
  4. 4. Further significant reductions in mother-to-child transmission can be made by strengthening the provision of the package of prenatal HIV counseling and testing in antenatal structures, ensuring that appropriate measures are taken predelivery, during labour and the immediate post delivery and by improving access to infant formula feeds. In making available appropriate ARV regimen as indicated by the clinical condition of the women should be instituted.1.2.2 General Measuresi) Offer VCT and detailed information about testing and results and the options in respect of these to all women at point of first contact.ii) Provide detailed information on safe sexual practices, early presentation in circumstances of medical and obstetric problems to all women.iii) Ensure universal precautions against vertical transmission during pregnancy, labour, delivery of the baby and in the puerperium.iv) Encourage contraception, in particular the access and availability of barrier methods. Women particularly those above 35 years and parity 5 or more, should be fully informed about tubal ligation.v) Ensure screening for STI’s (always do a RPR and in those with a history of vaginal discharge or who have a discharge present on speculum examination, take microbiology and treat syndromically) a Pap Encourage adherence to iron, folic acid and multivitamin preparations, and information about “healthy eating habits”vii) Perform routine antenatal blood investigations, history taking and examination. Remember to enquire about TB in the past or positive contact.viii) The offer and provision of appropriate contraception for women living with HIV should be an integral part of their care. Contraceptive choices will have to take into consideration the potential interactions with antiretroviral treatment.
  5. 5. ix) The prevention of new infections in women remains an important goal of South Africa’s HIV AIDS management. Antenatal care and gynaecological service provide and important opportunity counseling and testing, and risk reduction education activities.1.2.3 Principles of ARVs in Pregnancyi) The eligibility criteria for pregnant women to start antiretroviral treatment should be similar to those in non-pregnant adults, but consideration should be given to any potential effects on the fetus.ii) The selection of antiretroviral drugs should take into account the special circumstances of pregnancy. Where therapy is indicated, it should comprise of a combination of 3 drugs. In particular stavudine and didanosine should not be used together in pregnant women, and the use of efavirenz should be avoided in pregnancy, due to its potential to cause fetal abnormalities. Pharmacovigilance will be essential to monitor for any adverse events associated with the more widespread use of these drugs in women of childbearing potential.iii) All pregnant women with a CD4< 200 cells/mm 3 should be started on antiretrovirals after the first trimester. Pregnant women with CD4 counts between 200 and 350 CD4 cells/mm 3 should be strongly considered for initiation of antiretroviral therapy after the first trimester, with therapy to be continued for life.iv) Nutritional supplements, pneumonia prophylaxis (with co-trimoxazole) and INH (isoniazide) prophylaxis against tuberculosis should be included in the enhanced care package.1.2.4 Evaluation of pregnant women with HIV infectionThe following provide a checklist to facilitate evaluation and decision for provisionof ARV. i) provide standard clinical evauation - HIV disease stage
  6. 6. ii) evaluate degree of immunodeficiency - CD 4 count iii) document history of prior or current ARV use iv) assess goal of ARV therapy - maternal health versus PMTCT v) discuss known and unknown risks and benefits of ARV in pregnancy vi) develop strategy for long term evaluation and management of mother and infant1.2.5 Specific scenarios: Women already receiving highly active antiretroviral treatment(HAART) Those women who are treated with antiretroviral drugs before becoming pregnant, should continue on their medication, even in the first trimester. A second trimester fetal anomaly scan is usually reassuring. Where indicated, invasive procedures such as amniocentesis may be considered. If the woman is receiving efivarenz, this should be discontinued, and replaced with nevirapine as part of the combination therapy. Women receiving prophylactic medication (eg against TB, and PCP) should continue these in pregnancy Monitoring will follow guidelines set out as for adult management. Because of viral suppression achieved by combination therapy, there is no need for additional medication to reduce vertical transmission during delivery. Women not on antiretroviral therapy / antiretroviral naïveFor the majority of women who learn of their HIV status during antenatal care, adecision has to be made whether there is maternal indication for initiation oftherapy, or antiretroviral treatment is used for the sole purpose of reducingvertical transmission.
  7. 7. ι) Initiation of therapy for maternal benefit will follow the same guidelines as for adult women who are not pregnant – CD4< /= 200 cells/mm3 or clinical stage 4 (AIDS defining illness). Same routine will be followed as amongst adults regarding education and counselling towards treatment readiness. (argument to start therapy at a higher CD4 during pregnancy is not supported since CD4 tend to show a slight decline anyway during pregnancy, and pregnant women by argument will be started on treatment earlier than if not pregnant). Treatment should be initiated after the end of the first trimester. In select cases where mothers book in the first trimester with a very low CD 4 counts (<50 cells/mm 3), early initiation of treatment could be considered after discussion with the mother.ii) Where reduction of vertical transmission is the goal – (in a mother who has no clinical / laboratory indication for initiation of triple therapy), women should be managed according to the existing programme which includes the two dose administration of nevirapine to the mother during labour and neonate within 72 hours. In the event that nevirapine cannot be used, other short course regimen should be utilized. Unbooked women:Majority who fall in this category will not have received any medical attention inthe recent past, therefore with unknown HIV statusWomen presenting unbooked for the first time during labour should receivepretest counselling. If they test positive, baby should receive 2 doses ofnevirapine – one given immediately following delivery, and second within 48hours. Post-test counseling to the mother can be delayed until after the deliveryprocess. Assessment regarding maternal indication for ARV should be made
  8. 8. postpartum, bearing in mind the possibility of poor compliance in women who do not present for free antenatal care. Delivery All women should be delivered vaginally where possible, with caesarean section reserved for known obstetric indications Universal precautions and modified obstetric practices shown to reduce intrapartum transmission should be observed. In the event of a caesarean section, prophylactic antibiotics should be administered to reduce the risk of postpartum sepsis (there is no evidence in the literature that the same should be implemented in women undergoing vaginal delivery). Post delivery Signs of infection should be observed before discharge, and arrangement for follow-up within the next 1 – 2 weeks made to exclude this. Women who are not on antiretroviral therapy should be reviewed at 6 weeks for clinical staging, and repeat CD4 count to determine indications for initiation of antiretroviral therapy, after which they are referred to the general adult clinicPostpartum 1. Rational for staging in 6 weeks and not earlier not clear. WHO recommends initiation of treatment as soon as possible including the postpartum period 2. HIV-positive postpartum women with CD4 count > 350 should be followed up according to current guidelines. Guidelines need to be developed for postpartum women on HAART 3. Newly diagnosed women would need to be diagnosed much faster 4. Unbooked woman HIV positive with CD4 count >350 in pregnancy refer for follow- up 5. Consider adopting WHO follow-up schedule of 6 hours, 6 days and 6 weeks recommended – needs to be coordinated with PMTCT follow-up schedule 6. Site for receiving HAART – easy if one site, if other sites may be a problem Principle decision of where to look after the patients still to be taken e.g. KZN ARV clinic currently not universal1.3 ARV and Breastfeeding.
  9. 9. 1.3.1 Postnatal HIV transmissionIt is well known that HIV is excreted in breast milk. In breastfed infants there isan ongoing risk of mother to child transmission of HIV via breastmilk for theduration of breastfeeding. This is probably highest in the first 6 months but thereis an ongoing risk after six months of age of between 3.2 and 6.9 new infectionsper 100 child years of breastfeeding 1. In developed countries almost all HIVinfected women formula feed their infants. In South Africa exclusive formulafeeding may not always be possible. Women living in informal settlements andrural areas frequently do not have adequate facilities for safe reconstitution offormula feeds. A second consideration is the loss of the immunological benefitsof breast milk, particularly in areas where there is a high infant mortality rate fromdiarrhoea and other infectious causes. The factor, however, which is probablymore important that any of those above is that of family and communityexpectations and fear of stigmatization related to HIV/AIDS. Women may beexpected to at least partially breast-feed their infant and may do so despite therisks, because of fear of revealing their HIV status. Many women will havediscovered their HIV status for the first time during the pregnancy and may notyet have disclosed their status to family members.The exclusive use of formula feeding for infants of HIV positive mothers indeveloped countries means that there has been very little experience of theeffect of maternal ARV on the breastfed infant and HIV transmission viabreastmilk.1.3.2 Factors contributing to breastfeeding transmission of HIV.
  10. 10. i) Maternal viral load: There is some correlation between maternal stage of disease or viral load and breastfeeding transmission. ii) Mastitis: several studies have shown that mastitis significantly increases the amount of HIV excreted in breast milk. This is also true for other breast conditions such as cracked nipples. iii) Exclusive breastfeeding vs mixed feeding: One study has shown that breastfeeding transmission of HIV is lower in women using exclusive breastfeeding as opposed to those using mixed infant feeding. Further studies are underway to investigate this finding. iv) Vitamin A deficiency: The rate of postnatal transmission of HIV is higher in women who are vitamin A deficient. There is no evidence, however that vitamin A supplementation reduces transmission at any stage.1.3.3 Safety of ARV for breastfeeding infantFew of the ARV have been studied in lactating women, and for many, littleinformation is available on breast milk excretion.ARV Excreted in breast Effects on infant milk?Abacavir Excreted into milk of rats. No data on breastmilk No human data. exposureddI Excreted into milk of rats No data on breastmilk No human data exposure3TC Excreted into human Well tolerated in breastmilk neonates, but clearance slower than that of older childrenD4T Excreted into milk of rats. No data on breastmilk No human data exposureZidovudine Excreted into human Well tolerated in the breastmilk neonate
  11. 11. Efavirenz No human dataNevirapine Excreted in to human Potential for skin breastmilk. Median reactions, but no concentration is 76% of breastmilk exposure data. maternal serum levels.Lopinavir/Ritonavir Excreted into milk of rats. No human data1.3.4 General considerations:All HIV positive pregnant women must receive information about infant feedingchoices during the antenatal period. Each woman needs to understand whatoptions are available to her and what the pros and cons of each option would be.She then needs to make an informed choice of infant feeding method best suitedto her own circumstances.Factors to be taken into account are: • Whether she is currently on ARV • What the stage of her HIV disease is • Her socioeconomic circumstances and ability to obtain (for at least the first 9 months of the infant’s live) an adequate supply of formula milk • Her access to facilities to reconstitute the milk safely. • She also needs to consider whether the expectations of her partner or family are likely to impact on her ability to use a chosen method. If disclosure has not yet taken place, she must be encouraged to disclose to a trusted family member who will also be able to support her in maintaining her chosen feeding method.1.3.5 Options and important factors to consider:
  12. 12. Exclusive formula feeding.The woman needs to be able to obtain infant formula for at least the first 6months of the infant’s life. In addition she must have access to facilities for safereconstitution of the formula, including a source of clean water and facilities forthe sterilization of bottles. Unicef and the National Department of Healthrecommend cup feeding instead of bottles with teats. Healthcare workers needto ensure that the woman knows how to make up the infant feeds beforedischarge home after delivery. The impact of family expectations need to betaken into account and if there are likely to be questions as to why the woman isnot breastfeeding, she should decide beforehand what she will tell herfamily/friends.Where a woman has chosen to formula feed, healthcare workers need to assisther and support her with strategies to enable her to continue using the method. Exclusive breastfeeding with or without early weaning.The concept of exclusive breastfeeding needs to be understood by the mother –the infant is to receive only breastmilk and no other food or fluids (not evenwater). The only other substances which the infant may consume by mouth aremedicines.The woman needs to be counseled regarding good breastfeeding techniques andmethods to maintain adequate production of breastmilk. Weaning shouldpreferably take place at 3 or 4 months of age and must occur abruptly with noperiod of mixed feeding. If early weaning is to take place, the woman needs tobe able to obtain suitable infant foods. Other factors to be considered arewhether there will be family or community expectations for the infant to receiveadditional foods which are traditionally given, and how the mother will deal withthese expectations. Wet Nursing
  13. 13. The HIV status of the wet-nurse needs to be considered as well as the fact thateven if she is HIV negative initially, it is possible for her to become infectedduring the period of wet-nursing and HIV seroconversion while breastfeeding isassociated with rates of transmission to the infant as high as 29%. The responseof the family and community to such an arrangement also needs to beconsidered. Heat treatment of expressed breast milkPasteurisation of expressed breast milk has been shown to effectively inactivateHIV in the milk. The method has been effectively implemented in an institutionalsetting for the feeding of preterm neonates born to HIV positive mothers. Thefeasibility of use of the method in a domestic setting after discharge from hospitalhas not yet been assessed and for this reason, the method cannot yet berecommended as an option on a wide scale.HIV positive women who choose to breastfeed, whether using ARV or not shouldbe advised and assisted with a number of general measures which can affectbreastmilk transmission; i) Maternal nutrition – Advice should be given on nutrition and where necessary additional nutrition supplied. The mother should be on a multivitamin supplement which includes vitamin A. ii) Protected sex – the mother should continue to use condoms in order not to unnecessarily increase her viral load by repeated re-exposure. iii) Breast-care – correct breastfeeding technique to avoid mastitis or damaged nipples. If a breast problem arises, it is to be treated promptly and do not feed from affected breast until the problem has resolved.
  14. 14. Antiretroviral use during lactationi) Scenario 1: Woman who is on ARV for her own health • For the woman who meets the eligibility criteria for ARV therapy, this should be commenced whether during pregnancy or in the postpartum period. • After delivery, the woman should be on the regimen which is the best for her health. • Infant feeding should be changed to suit the woman’s ARV needs and not the other way around. Maternal survival influences infant survival, thus maternal ARV is beneficial to the infant. • Because the effect on infants of breast-milk exposure to ARV is not known, the general recommendation is that women on ARV should formula feed if possible. Concerns for the infant would be side effects from breast milk consumption of ARV, drug interactions between ARV and other medications which the infant may receive, and transmission of resistant virus to the infant if mother has treatment failure. There is no data on what the effect of low doses of ARV will have on infants that have been infected perinatally – there is a theoretical possibility that it could lead to resistance, thereby making ARV therapy ineffective for the child. • The woman on ARV should be advised to use exclusive formula feeding where possible. • If breastfeeding is not avoidable, the infant should be assessed at each visit for possible side effects of the ARV. • Where medication is prescribed to the infant, care needs to be taken to review whether there is a known interaction between the medication and any of the ARV to which he/she is exposed.
  15. 15. ii) Scenario 2: ARV for reduction of postnatal MTCT.ARV to infants during breast feeding to reduce breastfeeding transmissionStudies of ARV as post exposure prophylaxis to infants up to six weeks of lifeindicate some reduction in perinatal transmission. Data on the effect ofcontinuing courses of ARV for the duration of breastfeeding are very limited. Thepotential adverse effects of ARV on the infant need to be considered as well asthe effect it will have on the child’s options for treatment, should he or shebecome infected despite ARV prophylaxis. In the absence of any evidence ofclear benefit and concerns about safety, there is currently no indication for theadministration of ARV to infants to reduce postnatal transmission of HIV. Thisrecommendation will be reviewed as further information becomes available.iii) ARV to mothers during breastfeeding to reduce breastfeeding transmissionTheoretically the use of ARV by mothers during breastfeeding will reducebreastfeeding transmission by reducing maternal viral load, but there is noclinical evidence to support this. Use of ARV for the purpose of reducingbreastfeeding transmission may affect the effectiveness of ARV therapy for themother later. If breastfeeding transmission occurs despite ARV therapy, there isa risk of transmission of resistant virus to infant. ARV also have potentiallyserious side effects for mother, and adherence may be particularly difficult whenthe therapy is not directly benefiting the woman. There is no place for ARVadministration to the mother solely for reducing breastfeedingtransmission.1.4 HIV and TB in Pregnancy
  16. 16. Globally tuberculosis is the most important opportunistic infection complicatingHIV.1 Among communicable diseases, tuberculosis is the second leading causeof death worldwide, killing nearly 2 million people each year 2 It is the leadingcause of death in HIV-infected individuals.31.4.1 Interaction between HIV, TB and PregnancyIn the general population the interaction between TB and HIV infection is bi-directional. HIV is the most potent known risk factor for the reactivation of latentTB.4 HIV also increases the risk of developing symptomatic primary TB infection.The patient’s defense against the progression of TB infection to active disease iscompromised proportional to the degree of immunosuppression related to HIV. 5With immunosuppression, the clinical and radiological features of TB may bealtered. These include a delayed hypersensitivity response resulting in false-negative tuberculin skin tests. There is also more involvement of extrapulmonarysites of TB disease in these infected with HIV especially if the CD4 + cell count isvery low.On the other hand, there is also evidence that TB affects the course of HIVinfection by enhancing its replication, which, in turn, results in a higher risk ofother opportunistic infections other than TB.The lifetime risk of developing TB in HIV-negative individuals is 5-10%, and 50%in HIV-infected individuals6. In other words, an individual infected with HIV has10 times increased risk of developing TB compared to an individual who is notinfected with HIV.The outcome of pregnancy is not altered in pregnant women on anti-tuberculosisdrugs. Maternal TB and HIV coinfection increases the risk of the baby acquiringcongenital TB infection. It has been presumed in the past that congenital TB wasrare, however, there is now evidence suggesting that congenital or newborn TB
  17. 17. is an underestimated emergent disease. 7,8,9 The caseload of culture confirmedcases of TB in neonates and young infants increase by about two-fold when thepregnant mother is infected by both HIV and TB1.4.2 Diagnosis of TB in pregnancyTB attributable to HIV in pregnancy is about 70%, which is very high. 10 In thoseareas where the prevalence of TB and HIV are high, efforts to improve maternalhealth must include detection of TB in pregnancy. However, the diagnosis of TBin pregnancy is usually difficult and delayed. 11 This is because the symptomsmay be confused with pregnancy symptoms by both the patient and the healthcare worker. It may also be due to the fact that extra-pulmonary TB is morecommon in HIV-infected individuals, both pregnant and non-pregnant ones.Diagnosis of TB, according to the NTCP guidelines, should be confirmed bymicroscopic examination of sputa. When the sputum is smear positive, itsuggests that the patient has an infectious TB and should be started on anti-TBtherapy without delay.1.4.3 Treatment of TB in HIV-infected Pregnancy womanThe use of anti-TB drugs and anti-retrovirals in pregnancy is complicated by thedrug-drug interactions between these two groups of drugs as well as theirpotential teratogenicty. The following clinical management issues should beconsidered:Efavirenz, (EFZ) an antiretroviral drug, is contraindicated in pregnancy,especially during the first trimester, because of its potential for birth defects of theStreptomycin, an anti-TB drug is contraindicated in pregnancy because it cancause permanent deafness to the unborn babyNevirapine (NVP) and Rifampicin should not be used together, becauserifampicin is a potent inducer of liver enzymes (cytochrome P450 3A4) These
  18. 18. enzymes reduce the expose to NVP by 31% and unfortunately dose adjustmentsfor NVP coadministered with Rifampicin have not been established.There is also a concern about the hepatotoxicity of both the NVP and anti-TBdrugs when used together. Nevirapine, therefore, is not used in patients receiving a rifampicin -based anti-TB regimen.TB treatment with DOTS should be initiated immediately in a pregnant woman,irrespective of whether she is on antiretroviral or not.If a pregnant woman receives both the anti-TB treatment as well as antiretroviral,all drugs should be reviewed for potential drug interactions and safety inpregnancy.The WHO recommended first line regimen for a pregnant woman receiving bothanti-TB drugs as well as antiretroviral is (AZT or d4T) + 3TC + SQV1.4.4 Scenarios1.4.4.1 Patients who become pregnant while on TB treatmentNot receiving ARV’s and not eligible for themMust complete TB therapy like non- HIV infected patientsMonitor patient and start ARV’s when indicatedMonitor patient and start ARV’s when indicated1.4.4.2 Not receiving ARV’s but eligibleMust complete TB therapyStart ARV’s using the recommended regimen. Prevention of MTCT must betaken into consideration when choosing a regimen.Consider all drugs used for their safety in pregnancy and for drug-interactions
  19. 19. Receiving ARV’sReview all medication (TB and HIV) for potential drug interactions andteratogenicity and manage accordingly1.4.5 New TB cases during pregnancy1.4.5.1 No ARV’s and not eligible for ARV’sStart TB therapy immediatelyFollow the NTCP protocol (DOTS) No ARV’s, but eligibleStart TB therapy immediatelyFollow NTCP protocol (DOTS)If CD4 count <50 or if there is extrapulmonary TB, start ARV’s as soon as patienttolerates TB therapyIf CD4 count 50-200, start ARV’s after two months1.4.5.2 On ARV’sPatient must continue using ARV’s, but must start TB therapy immediately.Review patient’s HIV treatment. If a patient is on nevirapine, change to SQVprovided there is no contraindication.Follow NTCP protocol (DOTS)1.4.6 Patient requiring re-treatment (failure, relapse or return after default) No ARV’s and not eligible for ARV’sStart TB therapy immediately (Retreatment option)Streptomycin must not be used in pregnancyFollow the NTCP protocol (DOTS)
  20. 20. No ARV’s, but eligibleStart TB therapy immediately (Retreatment option)Follow NTCP protocol (DOTS)Start ARV’s as soon as patient tolerates TB therapyStreptomycin must not be used in pregnancy1.4.6.3 On ARV’sPatient must continue using ARV’s, but must start TB therapy immediately.Review patient’s HIV treatment. If a patient is on nevirapine, change to SQVprovided there is no contraindication.Follow NTCP protocol (DOTS) for retreatmentStreptomycin must not be used in pregnancy1.4.7 Multi-Drug Resistance TB (MDR-TB) in PregnancyMDR-TB refers to TB, which is resistant to at least INH and Rifampicin. Currentlythe cure rate of MDR-TB patients is less than 50% in the general population inour country. Treating all TB patients adequately with appropriate TB regimenscan prevent resistance.Suspect MDR-TB when:Retreatment patients remain sputum smear positive after three months oftherapyClose contacts of MDR-TB casesTreatment failure and interruption casesDiagnosis can only be done by TB culture and susceptibility testing1.4.7.1 TreatmentTreat according to guidelines for management of MDR-TB patients in SA. It mustbe based on the medication history as well as susceptibility results.1.4.8 Latent TB
  21. 21. Latent TB or infection with M.Tuberculosis without an active disease. Because ofthe high incidence of progression of latent TB to active TB in HIV-infectedindividuals, WHO recommends preventive therapy for latent TB with INH.Currently the preventive therapy is not given widely as part of the NTCP.1.7 ETHICS GUIDELINES: PREGNANT HIV INFECTED PATIENTSREQUIRING EMERGENCY MEDICAL AND / OR SURGICAL INTERVENTIONSIt is important to bear in mind that with HIV disease, the unpredictable andepisodic course of the illness makes it difficult to estimate exact prognosis.However, when treating these women, the clinician must be able to recognise thepoint at which quality of life is more important than quantity and hence changethe course of treatment from aggressive curative care to palliative management.The availability of antiretrovirals must not be allowed to obscure this point andinterfere with sound medical judgement. This has particular bearing in poorlyresourced settings where acute emergency situations are common andantiretroviral treatments scarce or not available. Moreover, currently, there is noconclusive evidence that the initiation of antiretroviral treatment during an acuteemergency results in an improvement in the course of recovery from theemergency. Accordingly, at present antiretroviral treatment should not becommenced during an acute emergency. However, this does not precludeinstitution of antiretroviral treatment where appropriate once the patient recoversfrom the emergency. All health care provision must take into consideration theprinciples of respect for persons, acting in the best interests of the patient,minimising harm and fair and justified treatment. Health professionals arereminded that although HIV / AIDS is incurable at present, it is considered achronic condition which is manageable despite being life-threatening.These guidelines are specific to the critically ill HIV infected patient requiringemergency medical and / or surgical care. The scope does not extend to cover
  22. 22. the asymptomatic patient who requires a caesarean section as standard obstetricmanagement.1.7.1 Definitions:i) Emergency: a sudden catastrophe calling for immediate treatment that is necessary and available to avert harm.ii) Terminal illness: an illness, injury, or other physical or mental condition that- (a) in reasonable medical judgement, will inevitably cause the death of the patient concerned; or (b) causes a persistent and irreversible vegetative condition with the result that no meaningful existence is possible for the patient The diagnosis of terminal illness must be made by at least two health professionals. ιι) Terminal state: has a corresponding meaning as terminal illness.iv) Intractable and unbearable illness: an illness, injury or other physical or mental condition, but excluding terminal illness, that- (a) offers no reasonable prospect of being cured; and (b) causes severe physical or mental suffering of a nature and degree not reasonable of being enduredv) Palliative care: treatment and care with the object of relieving physical, emotional and psychosocial suffering, in addition to providing basic needs.
  23. 23. 1.7.2 GUIDELINESi) • All decisions regarding medical and surgical procedures will have to satisfy the ethical and legal requirements of informed consent and the medical criteria with regards to the patient’s ability to withstand medical or surgical interventions • Health professionals managing these pregnant women are reminded that the pregnant women’s life is of paramount importance and takes precedence over that of the fetus. • Any deviations from standard management should only occur if determined to be in the patient’s best interests.ii) Symptomatic HIV+ patient requiring emergency care where CD4 count is available – • Where the condition is not terminal, proceed with standard, appropriate management for the particular emergency. • Where the patient has terminal disease, palliative care should be instituted as first-line treatment. • Where condition is perceived to be, but not conclusive of terminal disease, institute resuscitation. If, in reasonable medical judgement, there is no response, a diagnosis of terminal disease should be made, and the management should be changed to palliative care. • Where the condition is intractable and unbearable, proceed with management as in bullet 3 above.
  24. 24. iii) Symptomatic HIV+ patient requiring emergency care where CD4 count is not available – • Institute resuscitation. • Perform standard blood tests including CD4 counts. Manage according to section 1 once blood results available. (The HPCSA cautions HCWs that HIV diagnosis without further examination such as CD4 and viral load, provides no information about prognosis and actual state of health and unilateral decisions not to resuscitate these patients could result in disciplinary action. It therefore follows that withholding or withdrawing of treatment should only occur once a definitive diagnosis of terminal disease is made.)iv) Where the patient is not in a position to make an informed decision and proxy consent is unavailable, the health professional should institute emergency management in accordance to the institution’s management procedures. The following criteria must be satisfied where treatment is initiated without informed consent: • There is a real emergency; • The patient is unable to communicate; • The treatment is not against the patient’s prior wishes; and • The treatment is in the best interests of the patient.v) Any decision regarding peri-mortem delivery will have to take into consideration the patient’s prior wishes or be made in consultation with the patient’s family. The decision will be made by a health professional after consultation with a colleague. This applies only for the perimortem delivery in an emergency situation.
  25. 25. vi) For further advice on the ethical issues pertaining to the management of the HIV infected patient from a woman’s health perspective, contact the National Department of Health at this number ……… .ANNEXURESSCHEMA 1: PT ON ARV ARV + Pregnancy Review medication - if 3TC, d4T, NVP , change d4T and Add AZT - do baseline CD4 - monitor as per adult protocol Term: - do viral loads - delivery - according to obstetric indications Postdelivery - watch for sepsis - contraception - - baby - if maternal viral load was >1000 at term- give NVP (2mg / kg body weight within 24 to 72 hrs)
  26. 26. - continue same regimen until 6weeks, and consider changing to Std adult therapy at 6 weeksSCHEMA 2 = ARV naïve (Tshidi c- VCT - (-)ve - posttest counselling, promote condom use, screen for STIs, contraception including condoms postdelivery- (+)ve - CD 4 count, clinical staging, pap, screen for STIs, supplements(iron, folate and MVT)>200 <200stages 1 / 2 stages 3 or 4 ARV (3TC, NVP, AZT)NVP at 28 weeks baseline FBC, LFT and U&E PCP proph(bactrim), exclude TB, and if -ve, INH proph monitor FBC, LFT, U&E monthly CD4 and viral loads at 3 or 6 months Viral loads at termDelivery - NVD delivery - NVD,Modified obs practices modified obs practices
  27. 27. C/s for obstetric reasons C/s for obst indications, with with proph antibiotics proph antibiotics Baby=NVP within 48-72 hrs- baby - if maternal viral at term >1000, give NVP syrup (2mg/kg within 24to 72 hrs) *because of slight decline of CD4 in pregnancy, these to be repeated in all women postdelivery, esp those not on ARV SCHEMA 3; patient received single dose NVP in previous pregnancy (,12 months) Take blood for resistance testing No resistance Resistance Stage 1/2, CD4 >200 CD 4 >200 CD4 <200 Stages 1/2 stages 3/4 NVP AZT/ 3TC HAART- substitute NVP For rotinavir
  28. 28. Monitor as usual