This is a lecture on HIV in pregnancy presented to medicine students from Cebu Institute of Medicine on July 6, 2017.

2. HIV IN PREGNANCY
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Institute of Medicine
6 July 2017

3. OBJECTIVES
• To discuss the principles of HIV
transmission and management
• To emphasize HIV screening,
counselling and testing during
pregnancy
• To identify the available
resources in the management of
HIV/AIDS in pregnancy
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4. UNAIDS 2016 Estimates
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Philippines is one of nine countries with
increasing prevalence >25%.
Others are Bangladesh, Guinea-Bissaue, Georgia, Indonesia, Kazakhstan, Kyrgyzstan, Republic of Moldova, and Sri Lanka.

5. PHILIPPINES NOW
•  MSM
•  IV drug use
•  gender-based violence
•  teenage pregnancy
•  single mothers
•  new cases of HIV
•  AIDS-related deaths
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6. HIV 101
HIV is a virus that attacks the
immune system.
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7. HIV 101
2. As the viral load increases, the
CD4 lymphocyte count decreases.
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8. HIV 101
3. When CD4 count <200 cells,
presence of opportunistic infections
and diseases signal AIDS
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9. HVMADAMBA2017
http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

10. HVMADAMBA2017
http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

11. HVMADAMBA2017
In April 2017
= 629 new cases
• 95% were male
• Median age 27
years old
• >50% 25-34 year
age group
• 30% were youth
aged 15-24 years`
http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

12. PLHIV on ART
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In April 2017 = 561
• Median CD4 152 cells/mm3
• 3 died within the same month
Total = 19,563 PLHIV on ART
• 97% males
• Median age 31 years
• 95% first line regimen
• 4% second line regimen
http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

13. The age group with the biggest proportion
of cases has become younger!
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• 28% in 2011-
2017 in the
15024 year
age group
http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

14. HIV among Females
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http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

15. HIV+ Pregnant Patients
• In April 2017, 6
cases of pregnant
women with HIV
were reported. 3
cases from Region 7.
• Median age was 22
years old
• Age Range: 17-27
years old
• Since 2011 ~170
cases, 90 from age
group 15-24 years
old.
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16. • Primary prevention of HIV infection
for key populations has to start in
adolescence mainly because
infections now occur at a younger
age.
• On average, the initiation to sex and
drug use is between 14 and 19 years
old.
http://www.unicef.org/philippines/hivaids.html
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17. HIV Modes of Transmission
25-40%
the risk of perinatal acquisition is without intervention
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18. HIV/AIDS EPIDEMIC TRENDS IN THE PHILIPPINES
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http://www.aidsdatahub.org/hivaids-and-art-registry-philippines-april-2017-epidemiology-bureau-department-health-2017

19. HIV in 6 PH cities may reach
'uncontrollable' rates – DOH
Prevalence rate among males who have sex with males
http://www.rappler.com/nation/89412-hiv-6-philippine-cities-uncontrollable-rates
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20. PREVENTION OF MOTHER TO CHILD
TRANSMISSION OF HIV
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21. PREVENTION OF MOTHER TO CHILD
TRANSMISSION OF HIV
• Prong 1. Primary prevention of HIV among women
of child-bearing age.
• Prong 2. Preventing unintended pregnancies
among women living with HIV.
• Prong 3. Preventing HIV transmission among
women living with HIV to her infant.
• Prong 4. Providing treatment, care and support to
women living with HIV, their children and their
families.
https://www.hsph.harvard.edu/population/aids/philippines.aids.09.pdf
HVMADAMBA 2016 HVMADAMBA2017

22. Prong 1. Primary prevention of HIV
among women of child-bearing age.
• A – abstinence
• B – be faithful
• C – check your status
• D – don’t do drugs
• E – educate yourself and
others
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23. Prong 1. Primary prevention of HIV among women of child-bearing age.
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24. Contraception
• Best protection obtained by:
– Choosing sexual activities that do not allow
semen, fluid from the vagina, or blood to
enter the mouth, vagina or anus of the
partner
– Correct and consistent use of condoms
during every sexual act
– Reducing the number of partners
POGS Clinical Practice Recommendations on PMTCT
Prong 2. Preventing unintended pregnancies among women living with HIV.
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25. Philippine Obstetrical and Gynecological
Society (Foundation) Inc
Clinical Practice Recommendation on Prevention of
Mother to Child Transmission of HIV Infection
• HIV Screening
• Antiretroviral Drugs
• Management of Delivery
• Infant Feeding
• Contraception
POGS Clinical Practice Recommendations on PMTCT
Prong 3. Preventing HIV transmission among women living
with HIV to her infant.
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26. CEBU NOW
pregnant women living with HIV
*since 2010 to April 2017
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27. HIV Screening
Preliminary Counselling Dialogue
Providers of obstetric care should
inform the patient that an HIV
screening test will be performed as
part of the recommended routine
antenatal package of tests of
infections (HBsAg, RPR/VDRL,
rubella IgG, papsmear, urine
culture)
POGS Clinical Practice Recommendations on PMTCT
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28. 5%
• Only five per cent of HIV-positive
pregnant women have received
antiretroviral medicines to prevent
mother-to-child transmission.
• Very few of those at-risk have taken an
HIV test, with the number at zero for
those under 18 years.
http://www.unicef.org/philippines/hivaids.html#.V2yW-_l95rQ
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29. HIV Screening
Preliminary Counselling Dialogue
Key Message:
The fact that you are pregnant is an
evidence of unprotected penetrative
sexual contact which is a mode of
transmission for HIV.
POGS Clinical Practice Recommendations on PMTCT
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30. HIV Screening
Preliminary Counselling Dialogue
• Part of thorough assessment of her status
in relation to her pregnancy
• Routine interview + standard counselling
about HIV
• Strictly confidential
• Opt out - and still receive
the same standard care
POGS Clinical Practice Recommendations on PMTCT
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31. Anti-retroviral (ARV) Drugs
Different Clinical Scenarios
1. Woman already receiving ARV
treatment for her own health –
continue.
2. ARV-naïve HIV-infected pregnant
woman with indication for own
health, start ARV regardless of AOG
3. ARV-naïve HIV-infected pregnant
woman, ARV prophylaxis started at
14 weeks AOG
POGS Clinical Practice Recommendations on PMTCT
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32. Anti-retroviral (ARV) Drugs
Eligibility for ARV Prophylaxis
• Option A: maternal AZT + infant ARV
prophylaxis
• Option B: maternal triple ARV prophylaxis
until delivery or if breastfeeding, until 1
week after all exposure to breast milk
ended
• Option B+: start triple ARVs as soon as
diagnosed and continued for life
POGS Clinical Practice Recommendations on PMTCT
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33. Anti-retroviral (ARV) Drugs
Advantages of Option B+
• PMTCT program : simplify
requirements
• Child : extended protection against
mother-to-child transmission
• Partners : prevention benefit against
sexual transmission in sero-
discordant couples
POGS Clinical Practice Recommendations on PMTCT
HVMADAMBA2017

34. Anti-retroviral (ARV) Drugs
Advantages of Option B+
• Earlier treatment for woman’s health and
avoiding risks of stopping and starting
triple ARVs especially in settings of high
fertility
• Simple message to communities
“once ARV started, it is
taken for life.”
POGS Clinical Practice Recommendations on PMTCT
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35. VSMMC 254-4155 loc 102
or refer to
Dr. Helen Madamba
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36. Management of Delivery
POGS Clinical Guidelines on HIV 2015
 An elective cesarean delivery is
scheduled at 38 weeks AOG
 Emergency CS is done for those in
labor and with ruptured membranes <4
hours unless delivery is imminent
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.
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37. Management of Delivery
POGS Clinical Guidelines on HIV 2015
Vaginal delivery maybe done when the
risk of maternal to child transmission is
low:
- those who had ARV treatment
- HIV viral load <1000 copies/ml
- if with ruptured membranes, the time
elapsed should be <4 hours to delivery
POGS Clinical Practice Recommendation on
PMTCT of HIV Infection. November 2015.
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38. Management of Delivery
Essential Intrapartum Newborn Care (EINC)
 Thoroughly dry newborn infant
× vigorous suctioning
 Skin to skin bonding should be encouraged
× Delayed clamping of umbilical cord is NOT
recommended.
 Latching on is done ONLY IF breastfeeding
has been chosen.
POGS Clinical Practice Recommendations on PMTCT
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39. Infant Feeding
INFORMED CONSENT
NO MIXED FEEDING
EXCLUSIVE breastfeeding
or
AFASS replacement feeding
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40. Infant Feeding
• continuing ARV medications
• replacement feeding: acceptable,
feasible, affordable, sustainable
and safe (AFASS)
• risks, follow up and other options for
replacement feeding
• relieve breast engorgement
POGS Clinical Practice Recommendations on PMTCT
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41. Prevention of HIV Infection of
Health Care Workers
• Standard
precautions
• Post-exposure
prophylaxis
• Hospital infection
control
POGS Clinical Practice Recommendations on PMTCT
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42. Prong 1. Primary prevention of HIV
among women of child-bearing age.
• A – abstinence
• B – be faithful
• C – check your status
• D – don’t do drugs
• E – educate yourself and
others
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43. Prong 4. Providing treatment, care and support to
women living with HIV, their children and their families.
• Immunization
• Healthy Lifestyle
• STI & Cancer Screening
• Opportunistic Infections
• Support Groups
• Livelihood Skills Training
• Advocacy to reduce Stigma and
Discrimination
• HIV Awareness Campaigns
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44. HVMADAMBA2017

45. “HIV will end with me!”
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46. These slides are available at
http://www.slideshare.net/HelenMadamba
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47. HIV IN PREGNANCY
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Institute of Medicine
5 July 2017