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1. HIV and Pregnancy
Sunil Kumar Daha
Dhanusha, Nepal 1

2. HIV
•Human Immuno-Deficiency Viruses (HIV-1 and HIV-2 ) is the retrovirus
having the enzyme reverse transcriptase which permits genomic RNA to be
transcribed into double stranded DNA.
•Most of the worldwide cases are caused by HIV-1.
2

3. Virus Structure
3

4. Modes of transmission
1. Sexual Contact
- homosexual and heterosexual activity is common mechanism of
transmission.
- women are 20 times more likely to get HIV with vaginal
intercourse.
2. Trans-placental
3. Blood product transfusion
4. Intravenous drug use with needle sharing
5. Through breast milk
4

5. Perinatal Transmission of HIV
• Vertical transmission to the neonates is 14-25%
• Transplacental transmission occurs 20% before 36 weeks
50% before delivery and 30% during labor
• Vertical transmission is more in case of preterm births and prolonged
rupture of the membranes
• Risk of the vertical transmission is directly related to the maternal viral
load and inversely to the maternal immune status (CD4+)
• Maternal anti-retroviral therapy reduces the risk of the vertical
transmission by 70%
5

6. Etiopathogenesis
• The virus attaches to the T lymphocytes known as CD4+
cells whose main function in the immune system is to
combat viruses,bacteria and other pathogens.
• Once the virus is in the genome of the host then it gets
multiplied which will eventually cause the host cell
damage.
• There is now gradual depletion of the CD4+ cells as well as
the failure of the B lymphocytes to produce antibodies to
HIV.
• These events lead to progressive loss of host immune
defense and leads to AIDS. 6

7. Clinical Course
Primary Infection
3-6 weeks
Acute Syndrome(3-6 weeks)
Immune response to HIV (1-2 weeks)
Clinical Latency
About 10 years
AIDS
7

8. Effects of the HIV infection
•Although maternal mortality and morbidity rates are not
increased in seropositive asymptomatic women but it appears that
the adverse fetal outcomes may be increased, like:
-increased incidence of abortion
- Prematurity
- Intra uterine restriction growth (IUGR)
- Perinatal mortality
8

9. Clinical Presentation
• Initial presentation may be malise,fever,headache,sore throat,
lymphadenotathy,and maculopapular rash.
• Progression of disease may lead to the multiple opportunistic
infection such as candidiasis, tuberculosis, pneumocystis
• Patient may also have neoplasm such as cervical carcinoma,
lymphomas, and Kaposi sarcoma
• Generalized lymphadenopathy, oral hairy leukoplakia, aphthous
ulcers, and thrombocytopenia are common.
• Weight loss, lymphadenopathy or protracted diarrhea may be
associated with the constitunal symptoms
• CD4+ count<200 cells/mm3 is a diagnostic of AIDS 9

10. Higher levels of inflammatory cytokines and a decrease in regulatory T cells in
late pregnancy may contribute to maternal and fetal morbidity 10

11. Diagnosis
• Enzyme immunoassay is used as a screening test for HIV antibodies.
-This is extremely sensitive but is less specific.
• Polymerase chain reaction is also done for early diagnosis
-This is the technique of amplifying viral DNA.
• This method is confirmed by Western blot test or by the
immuno-fluorescence assay
-Western blot detects specific viral antigens
p24(capsid),GP41(envelope) and GP120/60.
11

12. Management
12

13. 1.PRENATAL CARE
• voluntary serological testing- to all pregnant women
• In seropositive cases- additional test for STDS, such as
hepatitis B virus, syphilis,chlamydia,herpes and rubella
• counselling about the risk of HIV transmission of the fetus
and neonates.
• progression of disease is accessed by: CD4+ count, viral load,
and the assessment is done every 3-4 months.
• Women with CD4+ count(≤350 cells/mm3) or HIV RNA level
≥ 50,000 copies/mm3 should be initiated with HAART.
13

14. •Stages of HIV infection:
•Stage - I (HIV infection): CD4+ T-lymphocyte ≥500/mm3;
• Stage-2 (HIV Infection):CD4+ T-lymphocyte count of 200-
499/mm3;
•Stage-3 (AIDS): CD4+ T-lymphocyte count of ≤200/mm3
•T lymphocyte count in each trimester. If the count falls to less
than 200 cells/mm3,the patient should receive prophylaxis
against Pneumocystis carinii and other opportunistic infections
14

15. f) Highly Active Antiretroviral Therapy(HAART) to all HIV-1 positive
women
-triple therapy is preferred as the first line defense and to be
started any time between 14- 28 weeks.
principles of highly active antiretroviral therapy:
- suppress viral multiplication
- to reduce perinatal transmission
- reduce the risk of drug resistance
g) Prophylactic antibiotics should be started when there is
opportunistic infection.
(sulfamethaoxazole –trimethoprim or dapsone)
15

16. Antiretroviral Therapy
a) Nucleoside reverse transcriptase inhibitor
zidovudine, zalcitabine, lamivudine, Abacavir
b) Non-nucleoside reverse transcriptase inhibitors
nevirapine,delavirdine,efavirenz
c) Protease inhibitors
indinavir,saquinavir,ritonavir,Atazanavir
d) Entry inhibitors
enfurvirtide
• WHO recommends first line ART regimen to include:
Zidovudine (ZDV), + Lamivudine (3 TC), + Nevirapine (NVP) or
ZDV + 3 TC + EFV (Efavirenz).
16

17. 2. INTRAPARTUM CARE
a)zidovudine given IV infusion at the onset of labor(vaginal
delivery) or 4 hours before cesarean delivery.
- loading dose 2mg/kg/hr. ,maintenance dose 1mg/kg/hr. until the
cord clamping is done.
b) a single dose of nevirapine at the onset of labor and a single dose
of it to the newborn at age 48 hours is an alternative requirement for
women who had no prior therapy.
c) elective cesarian delivery reduces the risk of vertical transmission
by about 50%.
d) high viral load (>10000 copies/ml) lower CD4 count, rupture of
membrane >4 hours, and breast feeding double the risk of MTCT.
18

18. e) Mechanical suctioning devices should be used to remove secretions
from the neonates airways.
f) Factors for increased perinatal transmission: previous child with HIV
infection, mother with AIDS, preterm delivery, decreased maternal
CD4+ count, high maternal viral load.
g) Post exposure prophylaxis with triple therapy for 4 weeks ,reduces
risk of seroconversion by more than 80%. ( zidovudine 200 mg TID
+lamivudine 150 mg BID+ 800 mg TID+ indinavir 800 mg TID)
19

19. 3. POSTPARTUM CARE
a) breastfeeding
doubles the risk but if the alternative methods are not available
for infant nutrition then the risks associated with the
breastfeeding may be accepted
b) zidovudine SYRUP
2mg/kg is given to the neonates 4 times daily for first 6 weeks
of the life. High risk neonate should be treated with the
HAART. The infant is tested at D1, weeks 6,12 and 18 months of age.
c) Neonatal care
• Antiretroviral therapy (ARV) i.e. ZDV monotherapy should be given to all neonates within 4
hours of birth.
• When all these tests are negative and the baby is not breastfed a confirmatory HIV antibody
test is done at 18 months. Once this test is negative, the child is declared to be free of HIV
20

20. 4. Contraception
-barrier methods of contraception is effective in preventing
transmission of the virus. IUCD is found safe and effective. Condoms,
should be used regardless of using other devices.
5. Counselling
-pre-pregnancy and early pregnancy counselling for HIV infected
patient is essential.
21

21. Breast feeding and HIV transmission
• Vertical transmission is increased by breast feeding
• Breastfeeding increases transmission by 30-40%.
• the probability of HIV transmission per liter of breast milk ingested is
estimated to be similar to heterosexual transmission with unsafe sex in adults.
• Most transmission occurs in first 6 months
• The risk of infant transmission increases with increased levels of maternal HIV
RNA in plasma or breast milk.
• The who has recommended continuing breast feeding promotion with early
weaning by 6 months for women living in developing countries in which the
infectious disease and malnutrition are the primary causes of the infant
deaths.
22

22. • Maternal and infant antiretroviral prophylaxis strategies during the
breastfeeding period are comparably effective in reducing the rate of
transmission, but antiretroviral therapy (ART) is the preferred
strategy.
• The WHO recommends that ART be initiated in all pregnant and
breastfeeding women,as soon as there is a risk of mother-to-child
transmission of HIV in order to minimize this risk
• Infant antiretroviral use remains important as postexposure
prophylaxis after delivery and in settings in which maternal
antiretroviral use is delayed or interrupted during breastfeeding
23

23. • Exclusive breastfeeding, in combination with antiretroviral
interventions, is recommended for the first six months of life as it
leads to nutritional and immunologic benefits for the infant.
• Subsequently, breastfeeding, along with antiretroviral prophylaxis
and appropriate complementary feeding, should continue for another
six months given the increased infant morbidity associated with
earlier weaning
24

24. References
1. Williams Obstetrics, 24th Edition
2. DC Dutta’s Textbook of Obstetrics, 7th Edition