This document discusses HIV in pregnancy, including how HIV affects pregnancy and vice versa. It covers mother-to-child transmission of HIV, the importance of antiretroviral treatment during pregnancy to prevent transmission, and recommendations for care during pre-pregnancy, antenatal, intrapartum, and postpartum periods. Key points include initiating ART for all HIV+ pregnant women, close monitoring for drug side effects, modes of delivery depending on viral load, and continuing ART after delivery to reduce risk of mother-to-child HIV transmission to less than 2%.

1. Dr Ahmad Zharif Bin Hussein
O&G Specialist HSIJB
FB page: drzharif
Youtube channel: drzharifhussein
HIV in Pregnancy

2. contents
Understanding HIV in pregnancy:
1.HIV → pregnancy
2.Pregnancy → HIV
PMTCT
ART drug in pregnancy
Pre-pregnancy care
Antenatal care
Intrapartum care
Postpartum care
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3. Introduction
• WHO AIM ≤ 50 case for livebirth peryear in every country
Rate < 5% baby among Breastfeeding HIV mother & < 2% bayi
Nonbreastfeeding HIV mother
2011-2015,Malaysia show reducing newcase from 11.7 to 0.39 for
100,000 livebirth.
2011- WHO campaign “no Child born with HIV”
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4. Understanding HIV in pregnancy
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5. HIV → pregnancy
Maternal
Miscarriage
Risk of chorioamnitis & BV.
Poor nutritional status.
Risk of GDM (ARV)
Risk of Pre-eclampsia
Fetus
Risk of preterm labour.
risk of FGR (IUGR)
MTCT risk.
ARV drug risk (teratogenic).
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6. Pregnancy → HIV
NO adverse effect on HIV progression/survival.
Not compliance to ARV drug :
Nausea & vomiting (1st trimester)
Anxious teratogenicity effect
Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based
Algorithms (pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013
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7. MTCT
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8. MTCT (Mother to Child Transmission)
3 Way of MTCT Reduce risk of MTCT
Antepartum (in utero ) ARV(HAART)
Intrapartum period ( during labour &
delivery)
Mode of delivery ( LSCS ) & ARV
intrapartum.
Post partum period ( Breastfeeding ) Avoid Breastfeeding
Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In
Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge: Cambridge
University Press. doi:10.1017/CBO9781107338876.013
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9. Obstetric factors associated with transmission are:
* Mode of delivery.
* Duration of membrane rupture.
* Delivery before 32 weeks of gestation.
* Presence of other STI(Hep B,C & syphillis).
* Chorioamnionitis.
• Breastfeeding doubles the risk from 14 to 28%.
Principal risk factors for transmission:
* High plasma viraemia at delivery.
* Short duration of HAART / not on HAART.
* Delivery at <32 weeks of gestation.
Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus.
In Obstetrics: Evidence-based Algorithms (pp. 48-53). Cambridge:
Obstetric factors
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10. Neonatal factors
• Duration of breastfeeding (more longer more risk)
• Mixed feeding,Non-exclusive BF
• Condition of the breasts-ulcer/lesion
• Condition of the baby’s mouth(lesion in mouth)
• Pre-maturity, low birth weight
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11. ARV in pregnancy
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12. when to intiate in newly diagnosed/ naive
ART pregnant women?
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13. ART counselling
First line HAART offers the best opportunity for effective viral suppression and
immune recovery. It also improves mortality
• To educate patient about the expected clinical, immunological and
virological response
• To ensure that patient knows the correct dosage and management of
potential adverse effects
• To develop an individualized medication schedule (Link to patient’s daily
social activities and lifestyle)
• To plan follow up sessions and provide contact details if urgent consultation
is required due to adverse effects
• To discuss the possible occurrence of IRIS after starting HAART
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17. ARV Drug
(Nucleoside or nucleotide reverse transcriptase inhibitors (NRTI) )
Zidovudine (AZT)
Lamivudine (3TC)
Tenofovir disoproxil fumarate (TDF)
Emtricitabine (FTC)
*risk of congenital malformation(about 2.8%).
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18. Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Nevirapine (NVP)
Efavirenz (EFV )
safe-no teratogenicity
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19. Protease Inhibitors (PI)
Lopinavir / ritonavir (LPV/r)
Integrase Inhibitors
Raltegravir (RAL)
Dolutegravir (after 6 weeks’ gestation)-risk of NTD
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20. January 2018, the APR report for infants exposed to antiretrovirals
includes the following.
• Abacavir, atazanavir, lamivudine, emtricitabine, lopinavir, nevirapine, ritonavir,
tenofovir DF and zidovudine: there are now more than 200 prospective reports of
first-trimester exposure with no signal of increased risk, and a greater than two-fold
higher rate than in the general population has been excluded.
• Darunavir, efavirenz, indinavir, raltegravir and rilpivirine have been shown to have
congenital malformation rates within the expected range, and a congenital
malformation rate greater than 1.5-fold higher than in the general population has
been excluded.
• For newer agents (cobicistat, dolutegravir, elvitegravir and tenofovir alafenamide)
and a number of less commonly prescribed older compounds (saquinavir,
fosamprenavir, enfuvirtide, tipranavir, maraviroc and etravirine) there have been
insufficient reported outcomes of first-trimester exposure to exclude such risk.
Ref: British HIV Association guidelines for the management of HIV in
pregnancy and postpartum 2018 (2019 second interim update)
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21. Regime ART in pregnant women
ART used during pregnancy must consist of 2 NRTIs plus either a NNRTI
or a boosted PI or an integrase strand transfer inhibitors
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22. Raltegravir in late presenting HIV mother?
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23. Intrapartum Zidovudine
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24. Adherence to ART
ART adherence is the key to successful HIV treatment ART adherence is
the key to successful HIV treatment.
Current data shows that to maintain successful viral suppression, 95% or more
adherences to ART is required.
Specific group at risk of poor adherence includes:
• Poor family support
• Intravenous drug users
• Adolescence and
• Pregnant mothers
• Underlying psychiatric illness
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25. Pre-pregnancy
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26. Serodiscordant couples
• The risk of transmission for each act of sexual intercourse is 0.001% –
0.03%. This risk is significantly reduced, if the male partner has a viral
load of <50 copies/ml and is taking HAART.
The risk can be further reduced by limiting exposure to the fertile
period of the cycle and ensuring that all genital infections have been
treated.
• Couples who are serodiscordant choosing to have intercourse should
use condoms as it is associated with an 80% reduction in transmission.
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27. Serodiscordant couples
References 1. Cohen MS, Chen YQ, McCauley M, et al. and the HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral
therapy. N Engl J Med. 2011;365:493–505. 2. Dunkle KL et al. New heterosexually transmitted HIV infections in married or cohabiting
couples in urban Zambia and Rwanda: an analysis of survey and clinical data. The Lancet, 2008, 371(9631):2183–2191.
2.British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018 (2019 second interim update).
3.Malaysian Consensus Guidelines on Antiretroviral Therapy 2017
• Assisted conception with either donor insemination or sperm
washing is significantly safer than timed unprotected intercourse.
• Sperm washing is simple and is significantly safer than timed
unprotected intercourse, with no case of seroconversion in either
female partner or child born in over 3000 cycles of sperm washing
combined with IUI, IVF or ICSI reported in the literature.
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28. HIV mother
• To optimize health of mother and baby – advise to delay conception
until:
* HAART regimen is optimised and is effectively suppressing viraemia.
* Any opportunistic infections are treated.
• Folate supplementation – higher dose folate (5 mg) for women taking
cotrimoxazole.
• Yearly cervical cytology because of the association of HIV,
immunosuppression, and cervical neoplasia.
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29. Counselling prepregnancy
** MDT approach
Counselling couple:
1.About antenatal,intrapartum and postpartum care.
2.Effective and appropriate contraceptive methods to reduce the likelihood of
unplanned pregnancy.
3.Provide information on safe sex and encourage the elimination of alcohol, tobacco,
and other drugs of abuse.
4.ARV drugs compliance,safety of drug,teratogenicity effect & regime.
5.provide information complication HIV towards pregnancy and pregnancy towards HIV.
6.Assess the pshycosocial issue.
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Ref : 1. https://aidsinfo.nih.gov/contentfiles/glchunk/glchunk_152.pdf
2. https://www.bhiva.org/file/5bfd30be95deb/BHIVA-guidelines-for-the-
management-of-HIV-in-pregnancy.pdf

30. Antenatal
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31. Antenatal care
Ref: Garis Panduan Pencegahan Jangkitan HIV/Sifilis Dari Ibu-ke-Anak
(Prevention of Mother-To-Child Transmission HIV/Syphilis) 2020
all pregnant women- screening
1.screening (RDT/EIA) reactive →
confirmatory test.
2.screening (RDT/EIA) non reactive :
Low risk mother- no need to repeat.
High risk pregnant women if negative to
screening (RDT/EIA) before 36 week
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32. High-risk mother:
1. Women whose past or present sexual partners were HIV infected,
bisexual or injecting drug use
2. Women seeking treatment for sexually transmitted infections (STI)
3. Commercial sex worker
4. Women with past or present history of injecting drug
5. Women with history of blood transfusion before 1986
6. Unprotected vaginal or anal intercourse with more than one sex
partner
.
Ref: Garis Panduan Pencegahan Jangkitan HIV/Sifilis Dari Ibu-ke-Anak
(Prevention of Mother-To-Child Transmission HIV/Syphilis) 2020
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33. Antenatal care
All infective screening
MDT management (ID physician,FMS,Obstetrician,& paediatrician)
Confidentiality
safer sex practice-Condom
Ix- MOGTT- on HAART
Detail scan for fetal anomaly.
Aneuploidy screening (recommended)
invasive prenatal diagnostic- limited data safety.
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34. Antenatal monitoring
Monitor for drug toxicities – FBC, urea and electrolytes and liver
function tests regularly.
Pregnant women with advanced HIV are at increased risk of
opportunistic infections, particularly PCP.
• Adverse effects of HAART – gastrointestinal disturbances, skin
rashes, and hepatotoxicity.
• Presentation with symptoms suggestive of PET, cholestasis or
other signs of liver dysfunction may indicate drug toxicity
therefore seek early liaison with HIV physicians.
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35. Newly diagnosed/HAART Naive
counselling
start HAART regardless of CD4 level
diagnosed >> 28 week of gestation→ consider RAL(refer ID)
Do viral load at 32-36 week → decide mode of delivery
continue ART post delivery
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36. Diagnosed in Labour/not on HAART
LSCS is recommended
IV AZT (2mg/kg for 1 hour followed by 1mg/kg/h)
start 2 NRTI+ Raltegravir (RAL)
or 2NRTI + EFV/NVP
switch to 1st line regime post delivery
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37. On HAART
Stable on HAART (VL < 50 copies before pregnant)
- counselling
- continue HAART
- do viral load at 32-36 weeks
- Continue HAART post delivery
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38. Failing HAART (VL> 1000 copies after treatment iniated for 3 months)
-Refer ID physician
-Alert ID paediatrician
-Resistance testing if available
-LSCS at 38 weeks
- during delivery- intrapartum AZT
-Cont HAART post delivery
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39. Intrapartum
Mode of delivery depend on viral load at 32-36 weeks.
ELLSCS : between 38 and 39 weeks’ gestation
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40. Intrapartum Intravenous Zidovudine Infusion
Intrapartum IV Zidovudine (AZT) infusion (2 mg/kg for the 1st hour
followed by 1 mg/kg/h subsequently) is recommended for women with
a viral load of >1000 copies/mL who present in labour or with ruptured
membranes or who are admitted for planned PLCS.
Current evidence suggests that intrapartum IV AZT has no additional
benefit in prevention of vertical transmission in pregnant women on
ART with viral load ≤1000 copies/mL during late pregnancy and near
delivery .
Ref : Consensus MALAYSIA /HIVGuideline_2017
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41. SVD (VL < 50)
1. continue HAART
2. No invasive procedure
3. ARM if indicated
4. Augmentation of labour (pitocin & ARM)-Safe
5. Instrumental delivery-if indicated only (low cavity forcep preferable
to ventous)
6. Avoid mid-cavity and rotational instrumental deliveries.
Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms
(pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013
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42. LSCS
Time : 38-39 weeks
1. Early cord clamping.
2. Keep surgical field as haemostatic as possible and take care to avoid
rupturing the membranes until the head is delivered through the
surgical incision.
3. Peripartum antibiotics in accordance with national guidelines.
4. If IV ZDV is indicated, start the infusion 4 hours before beginning the
CS and continue until the umbilical cord is clamped.
5. Take a maternal sample for plasma viral load and CD4 lymphocyte
count at delivery.
Ref: Pundir, J., & Coomarasamy, A. (2016). Human immunodeficiency virus. In Obstetrics: Evidence-based Algorithms
(pp. 48-53). Cambridge: Cambridge University Press. doi:10.1017/CBO9781107338876.013 O&G Tutorial by
DrZharifHussein

43. PROM
Mode of delivery must consider of the maternal viral load, duration of
ROM and the expected time of delivery.
After ROM, there is an increased risk of perinatal HIV transmission of
2% per hour .
Chorioamnionitis → associated with perinatal transmission of HIV.
Delivery should be expedited for women with PROM at term, either
with induction of labour or Caesarean section.
There should be a low threshold to start antibiotics if signs suggestive
of chorioamnionitis are present.
Ref : Consensus MALAYSIA /HIVGuideline_2017
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44. PPROM
When premature rupture of membrane (PPROM) occurs at < 34
weeks, intramuscular steroids should be administered in accordance to
national guidelines.
There should be multidisciplinary discussion between Obstetrician,
Paediatrician and ID Physician about the timing and mode of delivery
after PPROM.
Ref : Consensus MALAYSIA /HIVGuideline_2017
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45. Postpartum
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46. Breastfeeding
Breast-Feeding Breast-feeding is not recommended as it is associated
with risk of transmission up to 14%.
Replacement feeding (AFASS).
For women on ART, compliance must be stressed if they insist on
breast-feeding their baby.
Ref : Consensus MALAYSIA /HIVGuideline_2017
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47. AFASS
• Acceptable
– Perceive no barrier to replacement feeding
• Feasible
– Has adequate time,knowlege,skills and resources to prepare replacement food
• Affordable
– Able to pay for the cost of purchasing/producing, preparing replacement feed
• Sustainable
– Available in continuous and uninterrupted supply
• Safe
– Correctly and hygenically prepared ,stored and fed to baby
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48. Thank You
Fbpages: Drzharif ,
Youtube channel :drzharifhussein.