3. Seminar on
HIV Positive mother andher baby andepidemiology
PRESENTED BY
M.R.ABISHA
M.SC(N)- II YEAR
GCON
CUDDALORE
4. INTRODUCTION:
HIV is a critical public health problem
affecting the lives of millions of women. In recent years
HIV infection has become a rising concern and a
leading cause of mortality among woman throughout
the world. As more and more women HIV positive
there is increase in number of pregnant woman with
HIV and its complication.
5. HIV presents as an challenge to safe motherhood and
aggressive HIV prevention is an essential part of safe
motherhood.
6. Human Immuno Deficiency virus that causes
acquired immuno deficiency syndrome. It attacks
the immune system of the body.
DEFINITION OF HIV:
7. DEFINITION OF AIDS:
AIDS is the name given to a group of disorders
related to immunodeficiency produced as a result of
the infection by the human immunodeficiency virus.
9. EPIDEMIOLOGY OF HIV:
In the United states infections in women have
increased from 5% of the total in 19802 about 20%.
Now WHO prediction that by the ‘2000’ 3 million
women worldwide would have died from aids.
10 million would have occurred perinatal HIV
infection.
10 million children are punished as a result of aids
10. NACO estimates show that that number of Indians living
with HIV increased by half million in ‘2003’
By the end of may ‘2005’ the total number of AIDS cases
reported in India was 1.09 million of woman 31982.
According to the WHO by ‘2023’ HIV/AIDS had killed
approximately 40.4 million people
11. Approximately 39 million people were infected with
HIV globally.
Of these 29.8 million people 75% dates are received anti
retroviral therapy treatment.
The transmission rate of HIV from mother to child is
20 percentage to 25 percentage for HIV-I versus about 5
percentage for HIV-2
12. WHO continues to work in this area supporting
countries to improve and better monitor interventions
towards ending the aids epidemic as a public health
threat by ‘2030’.
14. Mode of transmission of HIV:
sexual contact:
male to male
male to female
female to male
recently female to female
Blood exposure:
Injecting drug use using needles
Occupational exposure
Transfusion of blood products
15. Occupational transmission :
Hospital staff
Laboratory worker
Perinatal transmission
Transmission from mother to baby :
Breastfeeding
other routes:
organ transplantation
artificial insemination
needle brick
17. • VERTICAL TRANSMISSION OF INFECTION:
HIV transmission from mother to child can occur,
Antinatally (in utero)
Intrapartum (during labor and delivery)
Postpartum (breastfeeding) intrauterine infections
intrapartum vertical transmission postpartum
transmission
20. INTRA UTERINE INFECTIONS:
Fetus exposed to HIV infected maternal blood at
10 to 12 weeks.
Human immunodeficiency virus-1 has been
isolated from amniotic fluid and cells as well as
from cord blood indicating intrauterine fetal cells.
The prevalence of HIV infection is higher in
abortuses than in full term pregnancies suggesting
that,
21. Intrauterine infection may lead to ‘fetal demise’
Intrauterine infections occur 25% of babies born
to woman with HIV will be infected by the virus
25 percentage intra uterine infections 2023
22. INTRAPARTUM VERTICAL TRANSMISSION:
Intrapartum events are crucial factors governing mother
to child transmission since this is the period where the
risk is highest
Duration of membrane rupture more than four hours
Preterm births
Corioamniotis
Invasive procedures during labour and delivery
23. have all been associated with an increased risk of
perinatal transmission.
The ratio of intrapartum transmission of HIV is
15 % to 45%
24. POSTPARTUM TRANSMISSION:
Cell associated virus has been detected in human
breast milk. The viral concentration is highest in
coloustrum.
HIV RNA deducted both breast milk and coloustrum.
Infected maternal CD4 cells isolated in breast milk
Complete elimination of HIV from breast milk has
not been achieved
25. Major maternal risk factors of breast milk HIV
transmission were,
Low CD4 counts,low hemoglobin level, high plasma
level.
Increased risk of postpartum transmission of HIV
to the infant by 14 %.
27. Immune status:
The CD 4 cell count is a commonly obtained laboratory
test in the evaluation of those with HIV infection; it is
used as a marker of host immune status.
There is an inverse linear relationship between low CD4
plus cell count and increased risk of transmission.
28. Viral strain virulence:
Characteristics of the virus itself also may influence
maternal transmission of HIV.
HIV-1 can be classified into multiple subtypes which
show different geographic distribution .
29. Viral load:
Transmission is more likely in persons with
peripheral blood CD4 plus lymphocyte depletion.
The risk of transmission seems to be very high if
seroconversion occurs during pregnancy.
Probably because the viral load is very high in
primary infection, before the development of anti HIV
immunity
30. Nutritional factors:
May affect viral transmission maternal vitamin A
deficiency promoted disease transmission and
increased infant mortality.
Maternal vitamin A deficiency was strongly
associated with the presence of retroviral DNA in
breast milk.
31.
32.
33. Placental barriers:
Evidence of infected placental cells, especially
placental macrophages has been reported.
Placental inflammation facilities transmission.
34. Obstetric factors:
In twins, the first-born has a higher likelihood of being
infected than the second.
Cultures of gastric aspirates in newborns have detected
the virus. The risk of infection is also related to the
duration of ruptured membranes and is particularly
increased when this duration is more than four hours.
35. LABORATORY IN EVALUATION:
Pretest counseling
Informed consent
Post test counseling
ELIZA
CD4 lymphocyte count
Quantitative viral load assay
Other test that are routinely performed
CDC guidelines for HIV testing in pregnancy
36. Pretest counseling:
It allows healthcare providers to educate all
antenatal patients about HIV infection.
The major issues covered in counseling session
Include;
Rationale for antibody testing
Explanation of the antibody test
Discussion of risk reduction strategies
37. Discussion of major modes of viral transmission
Discussion of risk of perinatal transmission
It can be a group counselling or one to one
counselling session.
38. Informed consent:
At the completion of pre test counseling, an informed written
consent is obtained from woman desiring antibody testing.
3 basic types of written consent employed for antenatal HIV
antibody testing::
Consent for HIV antibody testing only
Blanket consent for all antenatal test including HIV antibody
testing
Consent if HIV testing is not desired
39.
40. Post test counselling:
Major issues to be addressed in this session include,,
Partner notification
Interaction of HIV infection and pregnancy
The risk of big peri natal transmission
Risk and benefits of zidovudine therapy
Contraception
Long term maternal and infant follow up
41. ELISA:
It depends on the sero prevalence of HIV in the
patient population.
Western blot test:
It is used for confirmation of HIV infection.
Woman with intermediate results should be
reassured and have follow-up testing.
42. CD4 lymphocyte count:
HIV infects CD4 cells and in untreated woman, will
result in a progressive decrease in number of CD4
cells
This leads to decreasing immunity and consequently
increasing risk of opportunistic infection
43. Quantitative viral load assay:
It indicates degree of viral activity and can predict the
rate of disease progression.
Other tests :
CBC with DC
LFT
RFT and serological test
44. CDC guidelines for HIV testing in pregnancy:
Woman with evidence of HIV infection
Intravenous drug users
Woman born in countries with a high rates of
heterosexual transmission
Woman who engages in prostitution
45. Woman whose sexual partners are,
IV drug users
Bi sexual men
Men with hemophilia
Men born in countries with high rates of
heterosexual transmission
Men with evidence of HIV infection
46. MANAGEMENT
MATERNAL THERAPY FOR HIV INPREGNANCY:
Therapy for the HIV infected woman during
pregnancy is directed at both maximizing maternal
health and reducing the risk of potential
transmission.
47. The benefits of therapy in improving maternal
health, minimizing viral replication to prevent
resistance and decreasing the risk of vertical
transmission must be balanced against the
potential toxicity, teratogenicity and uncertain long
term effects.
48.
49. HAART
Highly active anti retroviral therapy, the mode of
action of anti retro virals in preventing vertical
transmission lies in their ability to reduce maternal
viral load and thereby decreasing the viral
exposure to that fetus.
HAART for pregnant woman is recommend with
CD4 counts lower than 200 to 300/ml or when
HIV-1 RNA copy number exceeds 1000 / ml.
50. The goal of ART for HIV is maximal and durable
suppression of viral load to allow preservation or
restoration of immune system function and
reduction of HIV related motility and morbidity
53. PRENATAL CARE
voluntary counseling and testing center:
At the antenatal clinic to all pregnant women with an
OPT out approach is offered
In sero positive cases:
Additional test should be done
Test for other STD’s
Fungal opportunities infections
Husband should be offered serological test for HIV
54. Antenatal care:
Woman’s need screening against opportunistic
infection.
screening for aneuploidy anomaly scan.
woman and HAART should be screened for GDM
55. INTRA PARTUM CARE:
Woman presenting in labour, need to check her
recent viral load to plan mode of delivery.
Zidovudine is given iv infusion starting at the onset
of labor or 4 hours before cesarean section.
Loading dose 2mg/kg/hour maintenance dose
1mg/kg/hour until cord clamping is done.
56. COUNSELLING WITH EDUCATION
to the patient is done about the impact of
HIV infection on pregnancy, perinatal
transmission, side effects of medications and mode
of delivery, pregnancy does not affect the
progression of HIV disease.
57. Progression of the disease assessed by,
diagnostic evaluations
HAART
is effective in reducing the viral load
Woman taking heart can have planned vaginal
delivery plasma viral load is <50 copies/ ml
Elective cesarean section is recommended at 38
weeks for women taking HAART who have plasma
viral load > 50 copies /ml
58. Elective cesarean delivery reduces the risk of
vertical HIV transmission by about 50 p%.
Avoidance of breastfeeding HAART therapy and
appropriate mode of delivery has reduced MTCT
rates from 25 to 30 % < 1% .
Baby should be bath immediately.
59. Peri operative or peri partum broad spectrum
antibiotics should be given as per hospital protocol.
invasive procedures that might result in break in
the skin or mucous membrane of the infants are
contraindicated
amniotomy and oxytocin augmentation should be
avoided
Place of cesarean delivery to reduce MTCT
60. PPE must
Mechanical suctioning devices should be used to
remove secretions.
Blend tipped needles should be used.
Healthcare workers should be protected from contact
potentially infected body fluids.
Post exposure prophylaxis with triple therapy 5-4
weeks .
Disposable syringes and needles should be used .
61. Postpartum care:
Woman should continue HAART with CD4 count
Formula feeding or breastfeeding to be started
with counseling and informed consent
Neonatal care, ART should be given to all neonates
with this folder
62. Usually zidovudine or lamivudine monotherapy is
started. Once this test is negative the child, the
child is declared to be free of HIV
Breastfeeding:
WHO recommends exclusive breastfeeding with an
ARV intervention, in the developing countries for
the first six months
63. Zidovudine syrup :
Infant birthweight more than 2.5 kg are given
15mg per dose twice daily, less than 2.5 kg 4 to 6
weeks of age
Nevirapine:
15mg once daily more than 2.5 kg
10 mg once daily less than 2.5 kg
64. Obstetric precautions:
Cell free HIV can be isolated from vaginal
secretions in 32% of infected woman
Delivery by cesarean section :
Elective cesarean delivery for prevention of HIV-1
transmission poses a higher risk than vaginal
delivery but less than that of emergency cesarean
delivery
65. Vaginal in disinfection:
With benzalkonium chloride or other
virucidal agents before delivery and washing the
newborn with benzalkonium chloride may be
helpful but are of unproven efficacy .
66. Breast feeding
Breastfeeding is not recommended for women at
high risk for HIV infection because of the lack of
universal testing and possible transmission despite
man initially negative HIV test, resulting from
subsequent maternal postpartum infection.
67. Prevention of vertical transmission of HIV
Antivirultherapy:
Monotherapy:
Zidovudine markedly diminishes the risk of
vertical transmission. zidovudine causes little
fetal toxicity other than reversible anemia
68. Therapeutic regimen
Before delivery zidovudine 300 mg BD 200 mg
TDS or 100mg 5 times day until onset of Labor.
During labor zidovudine 2mg per kg as continuous
IV infusion during first hour then 1mg /kg/hour
until delivery.
Newborn infant zidovudine syrup 2mg/kg orally
every 6 hours for 6weeks beginning 8 to 12 hours
after birth
69. Thai study
Regimen
Before delivery: oral ZDV 300 mg BD beginning
at 36 weeks of gestation
At the onset of Labor: oral ZDV 300 mg every 3
hours from onset of Labor until delivery
70. Combination therapy:
The combination of lamivudine and zidovudine as
well as nevirapine, the later administrator as single
dose, also reduces vertical transmission.
71. Summary
Every pregnant woman should know her zero
status as early in gestation as possible routine
testing of all women with an informed right of
refusal should be a standard component of
prenatal care.
72. Conclusion
Through this seminar I have learned about HIV
positive mother and her baby.
I would like to thank our OG faculty
Dr.S.kalaivani MSC(N) ph.D for given this golden
opportunity
75. Journal presentation:
Kulkarni.s(2022) conducted a study of HIV in pregnancy a
study of 30 cases in a tertiary care center in department of
obstetrics and gynecology at Maharashtra. A sample of 30
ANC mothers were participated in the study by using non
probability sampling technique. The researcher collected
data via collecting history. The findings showed that
appropriate antiretroviral therapy should be given to all
HIV positive mothers to reduce the burden of the infection.
