This is a lecture given to medical students of Cebu Institute of Medicine under the reproductive module. It contains a discussion of principles of HIV infection screening, diagnosis, staging and management, especially during pregnancy.

1. HIV IN PREGNANCY
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Institute of Medicine
July 5, 2016

2. Objectives
1. To review the principles of HIV
infection and management
2. To emphasize the goals of HIV
screening and counseling during
pregnancy
3. To identify the available resources
in the management of HIV/AIDS in
pregnancy
HVMADAMBA 2016

3. HIV 101
1. HIV is a virus that attacks the
immune system
2. As the viral load increases, the CD4
lymphocyte count decreases.
3. When CD4 count <200 cells,
presence of opportunistic infections
and diseases signal AIDS
HVMADAMBA 2016

4. CDC Classification of HIV-infected Adults
*PGL = persistent generalized lymphadenopathy
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

5. # Category C AIDS-Indicator
Conditions
• Bacterial pneumonia, recurrent (two or more episodes in 12 months)
• Candidiasis of the bronchi, trachea, or lungs
• Candidiasis, esophageal
• Cervical carcinoma, invasive, confirmed by biopsy
• Coccidioidomycosis, disseminated or extrapulmonary
• Cryptococcosis, extrapulmonary
• Cryptosporidiosis, chronic intestinal (>1 month in duration)
• Cytomegalovirus disease (other than liver, spleen, or nodes)
• Encephalopathy, HIV-related
• Herpes simplex: chronic ulcers (>1 month in duration), or bronchitis,
pneumonitis, or esophagitis
• Histoplasmosis, disseminated or extrapulmonary
• Isosporiasis, chronic intestinal (>1-month in duration)
• Kaposi sarcoma
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

6. # Category C AIDS-Indicator
Conditions
• Lymphoma, Burkitt, immunoblastic, or primary central nervous
system
• Mycobacterium avium complex (MAC) or Mycobacterium kansasii,
disseminated or extrapulmonary
• Mycobacterium tuberculosis, pulmonary or extrapulmonary
• Mycobacterium, other species or unidentified species, disseminated
or extrapulmonary
• Pneumocystis jiroveci (formerly carinii) pneumonia (PCP)
• Progressive multifocal leukoencephalopathy (PML)
• Salmonella septicemia, recurrent (nontyphoid)
• Toxoplasmosis of brain
• Wasting syndrome caused by HIV (involuntary weight loss >10% of
baseline body weight) associated with either chronic diarrhea (two or
more loose stools per day for ≥1 month) or chronic weakness and
documented fever for ≥1 month
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

7. WHO Clinical Staging of HIV/AIDS
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

8. WHO Clinical Staging of HIV/AIDS
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

9. WHO Clinical Staging of HIV/AIDS
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

10. Clinical Stage 4
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

11. Clinical Stage 4
http://aidsetc.org/guide/hiv-classification-cdc-and-who-staging-systems
HVMADAMBA 2016

12. Changes in the incidence rate of HIV infection
among adults, 2001–2011
Increasing
>25%
Stable Decreasing
26-49%
Decreasing >50%
Bangladesh Angola Burundi Bahamas
Georgia Congo Jamaica Central Africa
Indonesia France Kenya Cambodia
Kazakhstan Gambia Malaysia Ethiopia
Kyrgyzstan Nigeria Mexico Ghana
Philippines Uganda Sierra Leone Haiti
Republic of
Moldova
Tanzania South Africa India
Sri Lanka USA Swaziland Thailand
HVMADAMBA 2016

13. HVMADAMBA 2016

14. • New infections are largely
concentrated among key populations
with specific risk behaviors, such as
unprotected male-to-male sex,
transactional sex and intravenous drug
use
• On average, the initiation to sex and
drug use is between 14 and 19 years
old.
http://www.unicef.org/philippines/hivaids.html#.V2yW-_l95rQ
HVMADAMBA 2016

15. • 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
HVMADAMBA 2016

16. HVMADAMBA 2016HVMADAMBA 2016

17. MODES OF TRANSMISSION
• Unprotected penetrative sexual
contact
• Exchange of infected bodily fluids
• From an infected mother to her
unborn child
HVMADAMBA 2016

18. A total of 81 children (less than 10 years old) and 6 adolescents were reported to
have acquired HIV through mother-to-child transmission
HVMADAMBA 2016

19. The age group of new reported HIV cases is
getting younger!
• 2001 to 2005: 35-49 years
• 2006 to 2010: 25-34 years
• 2011 to 2016: 20-29 years
• Notably, the proportion of
People Living with HIV
(PLHIV) in the 15-24 year
age group increased from
25% in 2006-2010 to 28% in
2011-2016.
HVMADAMBA 2016

20. HIV in 6 PH cities may reach
'uncontrollable' rates – DOH
http://www.rappler.com/nation/89412-hiv-6-philippine-cities-uncontrollable-rates
HVMADAMBA 2016

21. PREVENTION OF MOTHER TO CHILD
TRANSMISSION OF HIV
HVMADAMBA 2016

22. 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

23. 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
HVMADAMBA 2016

24. 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
HVMADAMBA 2016

25. 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
HVMADAMBA 2016

26. 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
HVMADAMBA 2016

27. Post-test Counseling
 it takes 3-6 months for
a person to develop
antibodies against HIV
HVMADAMBA 2016
POGS Clinical Practice Recommendations on PMTCT
Pretest counselling  informed consent 
blood extraction  post test counselling

28. Anti-retroviral (ARV) Drugs
• Determine whether patient requires ARV
treatment or just prophylaxis using the
eligibility criteria based on WHO clinical
stage and CD4 cell count.
POGS Clinical Practice Recommendations on PMTCT
HVMADAMBA 2016

29. 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
HVMADAMBA 2016

30. 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
HVMADAMBA 2016

31. 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
HVMADAMBA 2016

32. 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
HVMADAMBA 2016

33. (032) 254-4155 / 0933-1336163
or refer to Dr. Helen Madamba
HVMADAMBA 2016

34. Cebu Social Hygiene Clinic
(032) 233-0987
HVMADAMBA 2016

35. Management of Delivery
• 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 Recommendations on PMTCT
HVMADAMBA 2016

36. Management of Delivery
• 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 Recommendations on PMTCT
HVMADAMBA 2016

37. 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
HVMADAMBA 2016

38. Infant Feeding
Avoid breastfeeding in women you
are HIV positive.
Even when no breastfeeding is the
chosen strategy, explain to the HIV+
mother the importance of continuing
the ARVs prescribed for her and her
infant.
POGS Clinical Practice Recommendations on PMTCT
HVMADAMBA 2016

39. Infant Feeding
• avoid breastfeeding, danger of mixed 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
HVMADAMBA 2016

40. 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
HVMADAMBA 2016

41. Prevention of HIV Infection of
Health Care Workers
• Standard precautions
• Post-exposure prophylaxis
• Hospital infection control
POGS Clinical Practice Recommendations on PMTCT
HVMADAMBA 2016

42. Summary
1. We reviewed the principles of HIV
infection and management
2. We emphasized the goals of HIV
screening and counseling during
pregnancy
3. We identifed the available resources
in the management of HIV/AIDS in
pregnancy
HVMADAMBA 2016

43. “HIV will end with me!”
HVMADAMBA 2016

44. #HealthXPH tweetchat
Healthcare Conversations on Twitter
Saturdays 9:00 p.m. to 10:00 p.m.
@helenvmadamba
https://www.facebook.com/helenvmadamba
http://helenvmadamba.blogspot.com
These slides are available on
http://www.slideshare.net/HelenMadamba/

45. HIV IN PREGNANCY
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Cebu Institute of Medicine
July 5, 2016