HIV & TB are serious pandemics affecting millions worldwide. Both can severely weaken the immune system and lead to opportunistic infections. When contracted during pregnancy, they pose risks like preterm birth, low birthweight, growth restriction, and mother-to-child transmission. Treatment involves comprehensive care and antiretroviral therapy to suppress the virus and prevent transmission. Close monitoring of the mother's viral load and CD4 count along with delivery planning and neonatal prophylaxis are important to reduce transmission risk.

1. HIV & TB IN PREGNANCY
Moderator- Brig Aruna Menon ,Prof & HOD
Presenter- Maj Anuradha M Sawant
1

2. Severely weakens immune system
Susceptible to opportunistic infections
Certain death
No vaccine till date!
MOST FEARED PANDEMIC IN THE WORLD
2

3. MOST FEARED PANDEMIC IN THE WORLD
Globally 37.7 million people are living with HIV- 70%Africa/20%
Asia
Approximately 2million cases die & 2 million new cases arise
every year
Out of 29 million pregnancies every year, an estimated 22000
occur in HIV infected women
A total of 61,000 children (0 to 14 years) living with HIV in
India
40%- 85% of newborns infected with HIV are born to mothers with unknown HIV
status
3

4. VIROLOGY
• Known – Human RETROVIRUS (RNA )
• HIV 1- M/c affects humans
• HIV 2 – Slow / less transmission
• HIV I
• HIV II
• HIV IV
4

5. RETROVIRUS?
CENTRAL DOGMA
5

6. STRUCTURE OF THE VIRUS
6

7. REPRODUCTIVE LIFE CYCLE OF HIV VIRUS
7

8. ACTION OF ANTI-RETROVIRAL DRUGS
8

9. DO ALL WHO GET HIV PROGRESS TO AIDS?
9

10. 1% NORTHERN
EUROPEAN POPULATION
HOMOZYGOUS
MUTATION - GENE
EXPRESSING CCR5
RECEPTOR
NO PRIMARY
ATTACHMENT- NO
INFECT
10

11. RAPID GENE
MUTATION-
GP120
11
WHY NO VACCINE AGAINST HIV?

12. CLINICAL COURSE
INITIAL
INFECTION
• Initial
Viremia-
Asymptotic
carrier phase
(Most
pregnant
women)
Shed viruses :
blood /fluids
- INFECTIVE
2-8
WEEKS
TO
6
MONTHS
• Window
period -
Serology
positive
ARC
(AIDS
RELATED
COMLEX)
• LN
enlargement
Fever
Unusual
recurrent
infections
(Herpes &
Candidiasis)
AIDS
• Severe
dysfunction of
immune
system
• Opportunistic
infections
12

13. TESTS & DIAGNOSIS OF HIV
SEROLOGY- ELISA /WESTERN BLOT
VIRAL CULTURES- Rarely used/laborious/expensive/less sensitive
PCR(Polymerase chain reaction)- Detects viral antigen- (Potential
to become test of choice for HIV)
RAPID HIV TESTING- 100% sensitive and specific- Results within
hours
13

14. SCREENING TEST
1. ELISA - Higher false positives (Detects antibodies against P24)
2. WESTERN BLOT ANALYSIS -
confirmatory
(Detects antibodies
P24/P31/gp41/gp160)
14

15. CONFIRMATORY TEST- WESTERN BLOT
POSITIVE
2 X ELISA + 1 X WB
R/o false positive
CD4 cell count
Viral load
Negative
Rules out infection
Indeterminate
Viral load
Retest later in
Pregnancy
15

16. HIV & PREGNANCY
(i) Preterm births (ii) FGR
(iii) Craniofacial
anomalies
(iv) Microcephaly
(v) HIV in neonates
16

17. VERTICAL TRANSMISSION ROUTES
1. Antepartum(20%)
Trans-placental maternal–foetal microtransfusion of blood during uterine contractions
2. During labour/delivery(60-80%)
Cervico-vaginal secretions and blood
3. Breast Feeding
17

18. PREDICTORS OF HIGHER RISK OF VERTICAL TRANSMISSION
I. Severity of maternal infection- CD4 CELL COUNT/ VIRAL RNA COPIES
II. Prolonged duration of rupture of membranes
III. Cesarean/Normal delivery- Cesarean protective
IV. Maternal therapy -HAART / Intrapartum treatment
18

19. National Techincal Guidelines on ART
William Obstetrics 25 th edition
Arias’ practical guide to high risk pregnancy 5th edition
ACOG Committee Opinion No. 751
19
PPTCT & ART IN PREGNANT WOMEN

20. ISSUE DETECTION
20

21. FOUR PRONG STRATEGY
21
HIV negative
general
population
HIV positive
non pregnant
HIV positive
+pregnant
HIV positive
mother and
child
Prong I:
Primary
prevention of
HIV
Prong II:
Prevent
unintended
pregnancies
Prong III:
Prevention of
MTCT
Prong IV:
Care support
& treatment

22. MULTIDISCIPLINARY
CARE
PEDIATRICIAN
HIV SPECIALIST
OBSTETRICIAN
SOCIAL
&
22

23. PRENATAL HIV SCREENING
CDC (2006b) and ACOG recommend
 Prenatal HIV screening using an opt-out approach
Repeat testing before 36 weeks
Retesting for - At risk - Injection drug use
Prostitution
Suspected or known HIV infected sexual partner
Multiple sexual partners
Another STD(ACOG)
23

24. ANTEPARTUM CARE IN A HIV POSITIVE PREGNANCY
 Complete blood count
 LFT/RFT
 Urine test for bacteruria
 Viral load & CD4 cell count
 Anti retroviral resistance testing
 Montoux test
 Testing for opportunistic infections- HSV1/HSV2, CMV , Toxoplasmosis, Hep B & c
 Chest x-ray
 Ultrasonography to ascertain growth
 Vaccination for – Pneumococcal/Hep A/ Hep B/ TdaP/ Influenza vaccine
24

25. USG FINDINGS IN A FETUS OF HIV POSITIVE MOTHER
NONSPECIFIC FINDINGS
I. IUGR
II. Microcephaly
III. Craniofacial anomalies – Hypertelorism
Prominent forehead
Flat nasal bridge
(Only indicates any concomitant infection/drug abuse / poor nutrition)
25

26. ANTEPARTUM INVASIVE PROCEDURAL RISK
AVOID GOING THROUGH THE PLACENTA
26
AMNIOCENTESIS
No increased risk- if
on HAART
2 fold risk if not on
treatment

27. MONITORING IN ANTEPARTUM
(i) Initial prenatal visit
(ii) 2–4 weeks after initiating (or changing) cART drug regimens
(iii) Monthly until RNA levels are undetectable
(iv) Every 3 months during pregnancy
27
VIRAL LOAD AND CD4 CELL COUNT

28. HAART
28

29. WHATS DIFFERENT IN THERAPY IN PREGNANCY
SAME AS NON PREGNANT but threshold to initiate therapy is low
Earlier, If CD4 count < 500 /mm3 / If Viral load > 10000 copies/ml
Treat all infected regardless of viral load/CD4 count/breastfeeding/in labour
29

30. RISK STATISTICS OF MOTHER TO CHILD TRANSMISSION
VIRAL LOAD(PCR ASSAY) UNTREATED TREATED WITH HAART
Undetectable-<50 copies + Negligible risk
< 1000 Copies/ml 0-10% 1%
1000 – 10,000 copies/ml 17% 6%
>10000 copies/ml 33% 13%
30

31. ART DRUG THERAPY –IDEAL STRATEGY
I. Preconception ART
II. Antepartum ART
III. Intrapartum continuation of antepartum oral ART regimen with intravenous Zidovudine
IV. Newborn ART prophylaxis(6-12 weeks)
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32. 32
Women
detected
during routine
ANC
Women who are
registered in pre
ART care
Women who
are on ART
Women who
come directly in
labour
Women
detected post
partum
Ensure
linkage to
ART centre
@ART-CD4
testing &start
ART
regardless
Ensure
institutional
delivery
&F/U
Follow treat
all policy
Perform
CD4 & start
ART
regardless
Continue
same ART
regimen
Do confirmatory
HIV testing&
sample for CD4
Initiate HRT
regardless of CD4
Ensure linkage
to ART centre
post partum
Link
immediately to
ART centre
CD4 count
and start ART
regardless
Evaluating Pregnant &Breastfeeding women with HIV

33. WHY DRUG DECISION BE IN HANDS OF HIV SPECIALIST?
Overlapping toxicities of these drugs
Reduced efficacy in few drug combinations
Serious side effects – Lactic acidosis/ Mitochondrial toxicity
Monotherapy not recommended – Resistance/ multiple strains
Co-infection with Hepatitis B and Tuberculosis
33

34. RECOMMENDATIONS
CLINICAL SCENARIO RECOMMENDATIONS
Taking ART & becomes pregnant Continue
ART NAIVE 2 NRTI+ RITONAVIR boosted PI OR INTEGRASE
INHIBITOR
(FDC of TDF(300mg) +3TC(300 mg)+EFV(600mg)
Prior ART use- not currently Start ART- Prior therapy/Resistance testing
No ART & presents in labour IV ZIDOVUDINE
TDF-Tenofovir, 3TC – Lmivudine , EFV- Efaverinze , ZDV/AZT- Zidovudine
34

35. STARTING CO-TRIMOXAZOLE IN PREGNANCY
Start If CD4 count is ≤ 250 cells/mm3
Continued through pregnancy, delivery
Ensure folate supplements regularly
35

36. SIDE EFFECTS OF ART
36
NRTI-
 Peripheral
neuropathy
 Pancreatitis
 Lipoatrophy
 Hepatitis
 Lactic acidosis
 Mitochondrial
toxicity
PIs-
 Lipodystrophy
 GI intolerance
 Hyperglycemia
 Lipid
abnormality
NNRTI-
 Rash
 Fever
 Nausea
 Diarrhea
 Hepatotoxicity
Individual drug side effects-
 Zidpvudine- Hematotoxicity
 Nevirapine- Hepatotoxicity
& skin rash
 Efaverinze – CNS
disturbances
 Abacavir- Hypersensitivity

37. PREGNANCY SAFETY DRUG CLASS
37
Category C-
 Lamivudine
 Zidovudine
 Lopinavir/Ritonavir
Category B-
Tenofovir
Atazanavir
Emtricitabine
Efaverinz- no category assigned
NTD?

38. LATEST RECOMMENDATIONS ON ART
RECOMMENDS: DOLUTEGRAVIR throughout pregnancy and in those trying to conceive
Reason?- Less evidence of NTD/Single dosage/ Rapid &durable viral load suppression
NOT RECOMMENDED: Lopinavir/Ritonavir (former alternate regimen)
Reason? – Twice daily dose/Risk of preterm & SGA
INSTEAD RECOMMEND- TAF(Tenofovir Alafenamide) as alternate regimen
PrEP(Pre-exposure prophylaxis)- Oral combination of TDF/FTC (TENOFOVIR & Emtricitabine)
Ref:https://clinicalinfo.hiv.gov/en/table/table-10
38

39. DELIVERY PLAN?
If viral load <1000
copies/ml
2% risk of mother to
child transmission in
both the modes of
delivery
Patient autonomy-
NVD/CESAREAN
DELIVERY(39 weeks)
39

40. IF CHOOSES VAGINAL DELIVERY
Minimal vaginal
examinations
Avoid prolonged labour
Avoid using fetal scalp
electrode
Avoid episiotomy
/forceps/vaccum
Augment with oxytocin Avoid ARM
Early cord clamping
( DCC if preterm)
Neuraxial analgesia
suitable
If PPH- AVOID
METHERGIN- interacts
with RT/PI – severe
vasoconstriction
40

41. WHEN GOES IN ACTIVE LABOUR
Start zidovudine
(ZDV)-
loading dose- 3
hours intrapartum
@(2 mg/kg) for 1
hr
Infusion over 2
hours (1 mg/kg/hr)
until delivery
If already on ART –
take with sips of
water
41

42. DELIVERY PLAN ?
If viral loads >1,000
copies/mL at or near
delivery/levels
unknown
Independent of
antepartum
antiretroviral therapy
Plan- scheduled
prelabor cesarean
delivery at 38 0/7 weeks
42
ZDV with Cesarean reduces the risk to 2%

43. RISK OF HIV TRANSMISSION WITH ARV
43

44. RECOMMENDED ARV PROPHYLAXIS FOR HIV
EXPOSED INFANTS
44

45. HIV-2 INFECTION
Slow progress
to AIDS
Less vertical
transmission
NNRTI ( NVP
& EFV) – not
effective
Infant receives-
AZT(ZIDOVUDINE) from birth till
6 weeks
Birth weight>2.5 kg – 15 mg/dose
BD
Birth weight<2.5 kg – 10 mg/dose
BD
45

46. POST PARTUM CARE
Breast feeding contraindicated if formula feed easily available
Poor countries- Breast feeding 6 months(higher mortality /morbidity with malnourishment and other infections)
Do not discontinue ART post partum
Inter-pregnancy viral load suppression- less chances of vertical transmission in next pregnancy
46

47. IF MOTHER NEGATIVE BUT PARTNER IS
POSITIVE?
1.HAART to
infected partner
2. Pre-exposure
prophylaxis in
mother
3. IF pregnancy
desired- Pre-
ovulatory
condom less
intercourse/
uterine
insemination/IVF
after sperm
washing
4. If pregnancy
not desired –
Effective
contraception
47

48. TUBERCULOSIS AND PREGNANCY
Ref:Williams obstetrics 25th
48

49. TUBERCULOSIS
Incidence- 1/3 population is infected
Infection is via inhalation of
Mycobacterium tuberculosis
• immunocompromised - reactivated - clinical disease
90 percent - dormant for long periods
49

50. SYMPTOMS
cough with minimal sputum
production
low-grade fever
hemoptysis
weight loss
50

51. HOW DOES TUBERCULOSIS AFFECT PREGNANCY
(i) the site of
infection
(ii) gestational age
at diagnosis
(iii) incomplete or
irregular treatment
(iv) advanced
pulmonary lesions
Outcome depends on:
51

52. RISKS ASSOCIATED WITH ACTIVE TUBERCULOSIS
Preterm delivery
Low birth weight
Fetal growth restriction
Perinatal mortality
52

53. EXTRA PULMONARY TUBERCULOSIS
Spinal tuberculosis -paraplegia / Psoas abscess
Intraperitoneal tuberculosis simulate ovarian
carcinomatosis and degenerating leiomyoma
Tubercular meningitis – Hyperemesis gravidarum
53

54. EVALUATION
CBNAAT(Cartridge Based Nucleic Acid
Amplification Test)/ Gene Xpert MTB
Assay-
Early and quick diagnosis – 2 hrs
54

55. EVALUATION
• ELISA/ELISPOT
• IGRAs- measure interferon-gamma release in
response to antigens present in M tuberculosis, but
not (BCG)vaccine
Rapid diagnostic
methods-
55

56. EVALUATION
CHEST XRAY- Various infiltrative
patterns-cavitation or mediastinal
lymphadenopathy
SPUTUMSMEAR- Acid-fast bacilli are
seen on ZN stained smears
56

57. EVALUATION
Fluorescent microscopy
Culture – LJ
medium(slow-6-8weeks)
Polymerase chain
reaction
• NON SPECIFIC - Tuberculin skin
test (TST)- Montoux test
57

58. TREATMENT IN LATENT INFECTION
Non-pregnant
Tuberculin-positive
Younger than 35 years
No evidence of active disease
Treatment:
Isoniazid, 300 mg orally daily, is given for 9 months(safe in pregnancy)
Isoniazid-induced hepatitis risk in postpartum – recommend delay Rx until 3-6 months post delivery
58

59. • Known recent skin-test convertors are treated
• Skin-test-positive women exposed to active
• HIV-positive women -10-percent annual risk of active disease
59
EXCEPTIONS TO DELAYED TREATMENT

60. TREATMENT IN ACTIVE INFECTION
Tab Isoniazid- 300 mg OD
Tab Rifampicin – 600 mg OD
Tab Ethambutol- 1200 mg OD
Tab Pyrazinamide – 2000 mg OD
along with Tab pyridoxine50-100 mg OD
Tab Levofloxacin 800 mg OD added if meningitis
60

61. TREATMENT IN ACTIVE INFECTION
In the first 2-month
phase, all four drugs
given— bactericidal
phase
This is followed by a 4-
month phase of
Isoniazid and Rifampin
— continuation phase
Breastfeeding is not
prohibited during
antituberculous
61

62. PREGNANT WOMEN WITH ACTIVE TB & HIV
Intensified Case Finding (ICF)
HIV with c/o cough, fever, night sweats and weight loss- evaluate
for TB
HIV positive + active tuberculosis = start ART irrespective of CD4
cell
concomitant therapy -Immune reconstitution inflammatory
syndrome (IRIS) #Start ATT first followed by ART ( after 2 weeks)
62

63. ATT
63

64. PREGNANCY SAFETY CATEGORY
Rifampicin- Category C
Ethambutol- Category A
Pyrazinamide – Category B2
Isoniazid – Category A
Fluorquinolones0- Category C
Aminoglycosides – Category D
64

65. ATT & ART
Rifampicin –adverse interaction with NVP
(EFV is the preferred NNRTI)
HIV infected women- resistance to rifabutin or rifampicin
( pyrazinamide given)
Second-line regimens- CONTRAINDICATED-aminoglycosides—OTOTXIC
65

66. NEONATAL TUBERCULOSIS- (50%) RISK
congenital tuberculosis- also includes infection by aspiration of infected secretions at delivery
Manifests with hepatosplenomegaly, respiratory distress, fever
Unlikely if the mother with active disease is treated before delivery or if her sputum culture is negative
Isolation of neonate – If mother (active disease)
66

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