HIV AIDS in pregnancy

1. HIV AIDS IN PREGNANCY
Ephrem Yohannes (MSc in maternity and Neonatology)
4/12/2016 Ephrem Yo 1

2. • Learning objectives:
Describe the four prongs of PMTCT
List components of PMTCT
Describe option B+
List the benefits of Option B+
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3. Epidemiology
• HIV / AIDS is one of the public health problem caused by infection with the
human immunodeficiency virus.
• First recognized in 1981 from the unusual cluster of PCP & Kaposi sarcoma in
homosexuals.
• In 1983- identification of a cytopathic retrovirus
• 1985- development of a diagnostic serologic test for HIV-1
• Since it’s recognition there is increased morbidity & mortality.
• To decrease this morbidity & mortality there is increased technology for
diagnosis & treatment of the disease.
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• People living with HIV(PLHIV):(December,2009 (UNAIDS/WHO)
Total: 33.4 million [31.1 – 35.8 million]
 Adults: 31.3 million [29.2 – 33.7 million]
 Women: 15.7 million [14.2 – 17.2 million]
 Children under 15 years: 2.1 million [1.2 – 2.9 million] - 6.3%

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• People newly infected with HIV annually:
2.7 million [2.4 - 3.0 million] in 2008
Adults: 2.3 million [2.0 – 2.5 million]
<15 years: 430, 000 [240 000-610 000]-15.9%
• There are 34.2 million peoples living with HIV, PEPFAR 2012
• Rate of new infection is decreasing, but millions of people infected each year

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• AIDS related deaths in 2008:
 2.0 million [1.7 – 2.4 million]
 Adults: 1.7 million [1.4 – 2.1 million]
Children under 15 years: 280 000 [150 000 –
410 000]- 14%

7. Current epidemiologic assessment findings
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• Global prevalence of HIV is remaining at the same level
• There are localized reductions in prevalence in specific countries
• A reduction in HIV-associated deaths
• A decline in the number of annual new HIV infections

8. Historical Overview of HIV/AIDS in Ethiopia
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• 1984: The first evidence of HIV infection in Ethiopia
• 1985: National HIV/AIDS Taskforce was established .
• 1986: The first two AIDS cases reported to the Ministry of Health.
• 1987: National AIDS Control Program (NACP) was formed at the MOH.
• 1989: HIV surveillance activities were started.
• At present there are 115 HIV sentinel surveillance sites
 Urban: 40
 Rural: 75
• Government of Ethiopia issued an HIV/AIDS Policy in 1998 and
subsequently established the National AIDS Council (NAC).

9. Impact of HIV on different aspects
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Social:
Increased number of orphans
 Old men remaining with out support
 Economic: HIV more affects the productive age group
Impact at rural house-hold level:
 Loss of income (50 % or more)
 Loss of labour
 Loss of skilled manpower and knowledge
 Reduction in savings and investment
 Expenses for treatment, funeral, teskar
 Need to sell livestock to meet expenses

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Impacts on industry:
Loss of workers
 Expenses for recruiting and training replacements
 Reduced productivity in cases of skilled workers or managers
 Lost work days due to sickness
 30 - 240 days per year
 Lost work days due to funeral leave
 Increased health care costs
 50% illness due to AIDS
 Loss of skilled professionals

11. HIV prevalence and current status of the epidemic in Ethiopia
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• National HIV prevalence (single point estimate): 2.4% for 2010.
 Female: 2.9%
 Male: 1.9%
• Urban HIV prevalence : 7.7%
• Rural HIV prevalence : 0.9%
• HIV prevalence in Addis : 9.2%; Male: 7.3 %, Female: 11%.
• Highest prevalence HIV in Ethiopia occurs in the age group 15-24

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• Estimated number of PLHIV in 2010 : 1,216,908
41 % males and
59 % females (2:3)
• Of which, 79,871 (6.6%) are children (<15 years)
• 137,494 new infections estimated to occur in 2010
• 44,751 deaths occurred due to AIDS in 2009.
• Total AIDS Orphans (2010): 804,184
• Total ART Need in 2010: 397,818 (26,053 children)

13. Gynecological Issues
• Conditions causing inflammation or infection increase the
likelihood a woman will acquire or transmit HIV.
• Bacteral vaginosis
• Cervicitis
• Herpes ulcers
• Genital warts
• Condyloma.
• Recurrent candidiasis
• Prevalent in 25 – 30% of women with HIV
• Risk increases 20 fold with CD4 <100.
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14. HIV and Pregnancy
• Pregnancy does not accelerate the progression of HIV disease to AIDS.
• Cd4 count may decrease up to 50 cell/mm3 but return to its pre pregnancy
state.
• Patients with AIDS are more likely to suffer from pregnancy related
complications.
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15. Strategies for PMTCT
• UN General Assembly High-level Meeting on AIDS in June 2011, UN Secretary-
General launched:
Global Plan towards the elimination of new HIV infections among
children by 2015 & keeping their mothers alive.
• Two high level targets of the Global Plan:
Reducing number of children newly infected with HIV by 90%
Reducing number of mothers dying from AIDS related causes by 50%.
• Global Plan which incorporates the four prongs
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17. WHO’s 4-prong approach to PMTCT
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1. Primary prevention of HIV infection
2. Prevention of unintended pregnancy
3. Prevention of mother to child transmission
4. Linkage to care & support

18. PRONG 1: Preventing HIV infection among
women of reproductive age
• 50% reduction in the number of women 15–49 years old acquiring HIV
infection by 2015.
• Primary prevention during pregnancy.
• Education about safer sex with use of condoms.
• Early treatment of STIs.
• Safer sex during pregnancy and lactation.
• PICT
• Ensuring comprehensive, correct knowledge about how to prevent HIV
transmission.
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19. Prong 2: Preventing unintended pregnancies
among women living with HIV
• By providing family planning services
• Decreasing the level of unmet need
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20. Prong 3: PMTCT
• Providing ART for the mother
• Safe labor and delivery
• Providing ARV for the neonate
• Exclusive breast feeding up to 6 months
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21. Effect of HIV on pregnancy
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• Spontaneous abortion
• IUGR
• Preterm delivery
• Low birth weight
• Still birth
• Perinatal mortality
• New born mortality
• Decreased fertility

22. Timing of mother to child transmission
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During pregnancy
(5-10%)
During labor and delivery (10-20%)
During breastfeeding
(5-10%)

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Timing Transmission Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
Overall without breastfeeding 15-25%
Overall with breastfeeding to six months 20-35%
Overall with breastfeeding to 18-24 months 30-45%

24. Factors that increase MTCT
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Viral
Viral load (the higher the viral load, the greater the risk of HIV
transmission)
Viral genotype and phenotype
Viral resistance
Maternal
Maternal immunological status
Maternal nutritional status
New infection with HIV during pregnancy
Maternal clinical status (including co-infection with an STI)
Behavioral factors
Antiretroviral treatment

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Obstetrical
Prolonged rupture of membrane (longer than 4 hours)
Mode of delivery
Intrapartum hemorrhage
Obstetrical procedures
Invasive fetal monitoring
Chorioamnionitis
Fetal
Prematurity
Genetic
Multiple pregnancy

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Infant
Breastfeeding
Gastrointestinal tract factors
Immature immune system

27. Option of ARV

28. Evolution of option B+
•November 2009
WHO issued ‘Rapid advice’ for PMTCT and ART
•January 2010:
Joint meetings for PMTCT and ART
Realization that access to reliable CD4 count is critical for these PMTCT
policies and that this would be a major bottleneck.
•February 2010:
Can we scale up PMTCT without CD4 count testing?
Should we stop ART (option B) after end of breastfeeding period?
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29. What is option B+
“Test and treat” strategy in which triple ARVs are started as soon as
HIV is detected in a pregnant woman irrespective of CD4 count and
gestational age
• Treatment (ART) intended to be given for life
• Specific ART regimen that requires just once a day dosing (either
with one or two tablets), which will result in convenience for the
patient and good drug adherence
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30. • Care of both mother (including provision of ART) and infant stays at
the PMTCT clinic from antenatal diagnosis to cessation of breast
feeding at 18-24 months
• Improving retention of both mother and infant in care.
• Bringing ART, PMTCT, and MNCH services together for fuller
integration
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31. What are the Benefits of Option B+
• Requires just one/two pills taken once daily
• No need for CD4 test to initiate ART
• Makes breast feeding safer
• Avoids the need for extended infant ARV prophylaxis (Option A)
• Mothers start treatment early, so quality of life and survival are better
• Maintains continuity of care: ANC to post-weaning so improves infant
testing as well as post-partum uptake of FP services.
• Minimize HIV transmission among discordant partnership
• Ongoing treatment of mother will protect future pregnancies from
moment of conception.
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34. EFV IN PREGNACY
• Better long term viral suppression
• Less adverse effect
• Less risk of resistance

36. Period HIV testing approach/PMTCT
regimen
Eligibility criteria for ART for Life
2001-2007 Vertical with Opt-in approach
Single dose ARV drugs (SdNVP)
≤ 200 CD4
2008-2011 Integration with MNCH and Opt-
out approach
Combined ARV regimen
AZT/3TC/NVP starting at 28wks
WHO Stage IV
WHO Stage III CD4 < 350
WHO Stages I or II with a CD4 <
200
January 2012 Option A
AZT/3TC/NVP starting at 14 wks
Daily NVP if breastfeeding
WHO stage III and IV
≤ 350 CD4
August 2012 Option B+ (FMOH approval for
adoption)
All HIV + pregnant women
Evolution of the PMTCT in Ethiopia

37. Initiating ART at ANC for HIV positive pregnant/
lactating women
• ART requires 3 different ARVs that act differently in order to
avoid development of drug resistant HIV
• Use standard ARV drugs that are recommended for pregnant
women for Option B+.
• The ART regimen is easy to prescribe and easy to take since it is
available as a once a day single pill

38. • LEAST side effects and requires minimal laboratory monitoring
• If switching regimens is indicated for other reasons, you must refer to
ART clinic for decision
• If regimen is changed, you will still provide ANC and PNC, but ART
management will be transferred to ART Clinic.
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39. Ethiopia’s 1st Line ART Regimen for HIV
positive pregnant & lactating women
1. Women diagnosed at ANC, labor, or post-partum should started
TDF/3TC/EFV as soon as diagnosed.
2. Women started on TDF/3TC/EFV prior to pregnancy can transfer their ART
care to the PMTCT service provider integrated into MNCH care.
3. Women who get pregnant while on an ART regimen other than
TDF/3TC/EFV should continue the same regimen
4. If woman on a non-TDF/3TC/EFV regimen wishes to have ART managed at
PMTCT site, her ART Clinic provider must determine it is safe to switch
regimens to TDF/3TC/EFV and agree to do so
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40. Why TDF & 3TC? Why EFV?
• TDF and 3TC can be given once a day.
• TDF is safe drug with rare side effect and toxicity than other ARVs.
• TDF and 3TC are rarely discontinued due to side effects or toxicity, compared to
the other NRTIs.
• Why EFV? Choice is between EFV and NVP.
NVP can cause severe liver & skin toxicity especially in pregnant women with
high CD4 count.
EFV recently found to be safe in 1st trimester & is dosed once daily.
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41. Detailed option B+: Recommendations
1. During pregnancy:
o TDF/3TC/EFV if for the first time
o Continue same ART regimen if already initiated (unless ART provider
agrees to switch to TDF/3TC/EFV)
o If on AZT prophylaxis; Shift to TDF/3TC/EVF
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42. 2. During labor and Delivery:
o If on ART continue same regimen of ART
o For women presenting for the first time initiate TDF/3TC/EFV
o If on AZT prophylaxis; Shift to TDF/3TC/EVF
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43. 3. Lactating or post partum.
o Continue ART if started
o Initiate TDF/3TC/EVF if on no treatment
4. Infant regimen: NVP for six weeks post partum
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By 2020
HIV Free
New Generation