TORCH infections in pregnancy

1. Infections in
Pregnancy
+
HIV in Pregnancy
Jonathan Sookdeo
Mariyah Shah
Lee Marie Shade
Aaron Smith

2. Infections in PregnancyInfections in Pregnancy

3. Why pregnancy predisposes to infection?
Pregnancy is a state of immunocompromise due to a
high level of steroids
Anatomical changes increases the susceptibility to
infection
Fetal infection may occur following PPROM or
hematogenous spread via the placental barrier or
during parturition.
Roopnarinesingh, Syam. Textbook of Obstetrics. 3rd ed. Port of Spain,Trinidad &

4. TORCH
o Toxoplasmosis
o Other (syphilis)
o Rubella
o Cytomegalovirus (CMV)
o Herpes simplex virus (HSV)
"TORCH Syndrome." National Center for Biotechnology Information. U.S. National
Library of Medicine. Web. 11 Nov. 2014.

5. TORCH
o Indiscriminate screening for TORCH infections with
the battery of “TORCH titers” is expensive and has a
poor diagnostic yield
o An alternate approach involves testing of infants
with suspected congenital infections for specific
pathogens based upon their clinical presentation
"TORCH Syndrome." National Center for Biotechnology Information. U.S. National
Library of Medicine. Web. 11 Nov. 2014.

6. Toxoplasmosis
Most infants with congenital toxoplasmosis are
asymptomatic or without apparent abnormalities at
birth.
Can present with signs at birth
The classic triad of congenital toxoplasmosis consists
of chorioretinitis, hydrocephalus, and intracranial
calcifications
Gilbert RE. Congenital toxoplasmosis: Scientific background, clinical management and control. In: Epidemiology
of infection in pregnant women, 1st ed, Petersen E, Amboise-Thomas P (Eds), Springer-Verlag, Paris 2000

8. Treatment
If antibodies in maternal serum suggest an infection,
antiprotozoal treatment can reduce the risk of fetal
infection.
Sulphadiazine + pyrimethamine
Spiramycin or clindamycin + pyrimethamine
Roopnarinesingh, Syam. Textbook of Obstetrics. 3rd ed. Port of Spain,Trinidad &

9. Rubella
Rubella typically causes a mild, self-limited illness
In Pregnancy it is responsible for serious congenital
malformations and perinatal death
The use of MMR has led to a decrease in the number
of infants affected with congenital rubella
In the 1990s, there has been a decrease in the uptake
of MMR in Infants due to its possible link to autism
Centers for Disease Control and Prevention (CDC). Progress toward elimination of
rubella and congenital rubella syndrome--the Americas, 2003-2008. MMWR Morb
Mortal Wkly Rep 2008; 57:1176.

10. The Wakefield Scandal

11. MMR Vaccine
MMR vaccination compliance dropped sharply in the
United Kingdom, from 92% in 1996 to 84% in 2002.
In some parts of London, it was as low as 61% in
2003.
In 2005, the United Kingdom was in a mumps
epidemic with almost 5000 notifications in the first
month of 2005 alone.
Centers for Disease Control and Prevention (CDC). Progress toward elimination of
rubella and congenital rubella syndrome--the Americas, 2003-2008. MMWR Morb
Mortal Wkly Rep 2008; 57:1176.

12. What about the infants that were not
immunized?
“It is probably too soon to say whether this will
eventually lead to an increase in the prevalence of
rubella in the community and an increase in the
incidence of congenital rubella when this cohort of
non-immunized infants reaches child bearing age”

14. Diagnosis
Clinical diagnosis
Can be confirmed by a 4 fold rise in serum titre of
antibodies
Congenital rubella can be diagnosed by detection of
specific Rubella IgM in neonatal serum, which
remains positive for up to one year of age.
Rubella vaccine is not usually given in pregnancy.
Centers for Disease Control and Prevention (CDC). Progress toward elimination of
rubella and congenital rubella syndrome--the Americas, 2003-2008. MMWR Morb
Mortal Wkly Rep 2008; 57:1176.

15. Treatment
Prevention
 immunization of girls before they reach child-bearing age;
 testing pregnant women for rubella immunity
 and ensuring that caregivers of children with congenital
rubella syndrome in child care and hospital settings are rubella
immune
Centers for Disease Control and Prevention (CDC). Progress toward elimination of
rubella and congenital rubella syndrome--the Americas, 2003-2008. MMWR Morb
Mortal Wkly Rep 2008; 57:1176.

16. Cytomegalovirus
In places where rubella is uncommon, CMV can be a
major cause of congenital abnormalities
Mother’s presentation may be mild or asymptomatic,
fever with/without lymphadenopathy or sore throat
"Cytomegalovirus (CMV) and Pregnancy." Centers for Disease Control and Prevention. Centers for
Disease Control and Prevention, 1 May 2013. Web. 10 Nov. 2014

17. Transmission
o Person to person contact (such as, kissing, sexual
contact, and getting saliva or urine on your hands and
then touching your eyes, or the inside of your nose or
mouth)
o Breast milk of an infected woman who is breast feeding
o Infected pregnant women can pass the virus to their
unborn babies
o Blood transfusions and organ transplantations
"Cytomegalovirus (CMV) and Pregnancy." Centers for Disease Control and Prevention. Centers for
Disease Control and Prevention, 1 May 2013. Web. 10 Nov. 2014

18. Most babies infected with CMV may show no
symptoms.
The babies that show symptoms can be
permanent/temporary.
"Cytomegalovirus (CMV) and Pregnancy." Centers for Disease Control and Prevention. Centers for
Disease Control and Prevention, 1 May 2013. Web. 10 Nov. 2014

19. Congenital CMV in newborn
Temporary Symptoms Permanent Symptoms or disabilities
Liver problems
Spleen problems
Jaundice (yellow skin and eyes)
Purple skin splotches
Lung problems
Small size at birth
Seizures
Hearing Loss
Vision loss
Mental disability
Small head
Lack of coordination
Seizures
Death
"Cytomegalovirus (CMV) and Pregnancy." Centers for Disease Control and Prevention. Centers for
Disease Control and Prevention, 1 May 2013. Web. 10 Nov. 2014

20. SYPHILIS
Abortion: of a dead foetus after the 4th month of pregnancy
when the spirochetes can cross the placenta as the
cytotrophoblast starts to disappear.
Repeated late abortions then premature or mature
macerated still born then live born with congenital syphilis
or developing it later on.
Skin eruption- osteititis of nasal bones – saddle nose –
hepatosplenomegaly-frontal bossing -8th
nerve deafness.

21. Treatment
Mother:
Treatment should be started before 16 weeks i.e. before spirochetes cross
the placenta
(I) Penicillin:
Procaine penicillin 600.000 units IM daily for 17 days or - benzathine
penicillin (long acting) 2.4 million units IM, half the dose in each
buttock. This is repeated for 3 courses at 2 weeks interval.
(II) Erythromycin:
500 mg/ 6 hours orally for 21 days is given to patients who are allergic to
penicillin.
(B) New born:
Procaine penicillin 150.000 units IM for 10 days.
Centers for Disease Control and Prevention (CDC). Congenital syphilis - United States, 2003-2008.
MMWR Morb Mortal Wkly Rep 2010; 59:413.

22. Herpes Simplex Virus
Disseminated disease in pregnant woman - death from
hepatitis, encephalitis
Miscarriage (severe disease)
No congenital syndrome known
Intrapartum infection
 disseminated disease - chorioretinitis, meningitis, encephalitis,
mental retardation, seizures and death
 HSV II - 75%; HSV I - 25% cases

23. Gonorrhea
Symptoms: usually asymptomatic. Mucopurulent
endocervical discharge, dysuria, proctitis.
May cause perihepatitis ( Fitz -Hugh-Curtis
syndrome).
In infants: it infects conjunctiva (gonococcal
ophthalmia neonatorum, prevented by 1% silver
nitrate eye drops immediately after birth),
pharynx, respiratory tract, or anal canal.
Treatment- Infants
Benzyl penicillin 30mg/kg stat. ( cephalosporin) +
chloramphenicol eye drops

24. Other Infections
Chlamydia Throcomatis
Grp B strept

25. HIV in Pregnancy

26. •PRE- PREGNANCY MANAGEMENT
•ANTENATAL CARE
•INTRA-PARTUM CARE
•POST-PARTUM CARE
HIV in pregnancy.

27. MULTIDISCIPLINARY
APPROACH
Midwife
Obstetricians
HIV physician
Paediatrician
HIV Community Nurse
Specialist
HIV in Pregnancy; An International Perspective
Byne, et al 2012; 14:17-24
The Obstetrician and Gynaecologist
HIV Community Nurse at Mt. Hope Women’s Hospital

28. What is HIV?
HIV is a complex chronic medical condition which, if
untreated, is associated with high morbidity and
mortality.
It is a retrovirus containing reverse transcriptase.
This enzyme allows the virus to transcribe its RNA
genome into DNA, which then integrates into host cell
DNA.
HIV preferentially targets lymphocytes expressing CD4
molecules (CD4 lymphocytes), causing progressive
immunosuppression.
When CD4 lymphocytes fall below a critical level,
infected individuals become more susceptible to
opportunistic infections and malignancies.

29. How is it transmitted?
Transmission is through:
1. Sexual intercourse,
2. Injecting drug use,
3. Transfusion of blood or blood products and
4. From mother to child during pregnancy and breastfeeding.

30. Pre-pregnancy management
Couples who are serodiscordant choosing to have
intercourse should be advised to use condoms.
Couples who are serodiscordant where the female
partner is HIV negative should be advised that assisted
conception with either donor insemination or sperm
washing is significantly safer than timed unprotected
intercourse.
Couples should be advised to delay conception until
plasma viraemia is suppressed, prophylaxis against
PCP is no longer required and any opportunistic
infections have been treated.
All women who are HIV positive are recommended to
have annual cervical cytology.

31. Antenatal Care
Antenatal HIV screening
Professional approach to the antenatal care of
women who are HIV positive
Antenatal care who are HIV positive
Management of antenatal complications

32. Antenatal HIV screening
All pregnant women are recommended screening for HIV
infection, syphilis, hepatitis B and rubella in every pregnancy
at their booking antenatal visit
If a woman declines an HIV test, this should be documented
in the maternity notes, her reasons should be sensitively
explored and screening offered again at around 28 weeks.
If a woman tests HIV negative at booking but is judged by her
clinician as being at continued high risk of acquiring HIV,
offering a repeat HIV test should be considered.
Midwives and doctors reviewing women during antenatal care
should ensure that the HIV result is clearly documented.

33. Antenatal HIV screening
Where a woman books for antenatal care at 26 weeks
of gestation or later, the test should be requested
urgently and the result issued within 24 hours.
Rapid HIV tests use rapid-test devices to deliver
results within 20 minutes of the sample being taken.
These tests are recommended for all women with
unknown HIV status in labour and a reactive result
should be acted on immediately

34. Professional approach
Management should be by a multidisciplinary team,
including an HIV physician, obstetrician, specialist
midwife, health advisor and paediatrician.
All women who are newly diagnosed HIV positive should
have an early assessment of their social circumstances.
Women should be reassured that their confidentiality
will be maintained.
Women should be encouraged to disclose their HIV
status to their partner and given appropriate support.
Care should be taken to avoid inadvertent disclosure to a
woman’s partner or family members, as they may be
unaware of her HIV diagnosis, even though they may
attend antenatal visits and be present at the delivery.

35. Professional approach
Advice should be given about safer-sex practices and the
use of condoms, to prevent transmission of HIV and
other sexually transmitted infections to an uninfected
partner.
It is recommended that women with existing children of
unknown HIV status should have them tested for HIV.
In rare cases where women refuse interventions to
reduce the risk of mother-to-child transmission, despite
supportive guidance from the multidisciplinary team, a
pre-birth planning meeting should be held with social
services to discuss safeguarding issues.

36. Antenatal care who are HIV positive
Pregnant women who are HIV positive are
recommend to have screening for syphilis,
hepatitis B and rubella at their booking antenatal
visit, in line with the general population.
Pregnant women who are HIV positive should have
additional blood tests for hepatitis C, varicella
zoster, measles and toxoplasma.
Women taking HAART at the time of booking
should be screened for gestational diabetes.

37. Antenatal care who are HIV positive
Hepatitis B and pneumococcal vaccination is
recommended for all individuals who are HIV positive
and can be safely administered in pregnancy. Influenza
vaccination can also be safely administered in
pregnancy and the decision to immunise depends on
the time of year.
Varicella zoster and measles, mumps and rubella
vaccines are contraindicated in pregnancy.
Women should be screened for genital infections at
booking and again at 28 weeks. Any infection detected
should be treated according to national guidelines,
even if asymptomatic.
Screening for aneuploidy should be offered to all
women in accordance with national guidelines for the
general population.

38. Antenatal care who are HIV positive
Women who are HIV positive who are considering
invasive diagnostic testing should be counselled in a
fetal medicine unit and the advice of the HIV
physicians sought about reducing the risk of HIV
transmission.
Dating and anomaly scans should be offered to all
women in accordance with national guidelines for
the general population.
Monitoring of plasma viral load and drug toxicities
should be undertaken as directed by the HIV
physicians.

39. Antenatal care who are HIV positive
A plan of care for anti-retroviral therapy and mode of
delivery should be made at 36 weeks following detailed
discussion with the mother. Only women with plasma
viral loads of less than 50 copies/ml should be offered a
planned vaginal delivery.
This plan should be reviewed when the woman presents
in labour, after confirming that any recently performed
viral load results are less than 50 copies/ml. In the
absence of a documented mode of delivery plan or, in the
event of uncertainty about viral load results, urgent
advice should be sought from the HIV physicians.

40. Trinidad and Tobago
Pregnant women whose baseline CD4 count is 250,˃
and do not require HAART for their own infection
should start START beginning at 20 weeks gestation.
Recommended START regime:
 Combivir 150/300 mg po bd + Kaletra 333mg po bd

41. Trinidad and Tobago
Pregnant women whose baseline CD4 is 250 should˂
commence HAART ante-partum as per adult
treatment guidelines for Trinidad and Tobago.
Pregnant women who have already started
antiretroviral therapy prior to conception must
continue HAART ante-partum.

42. Trinidad and Tobago
All HIV pregnant women are to be reffered to the
HIV treatment clinic.
They should be advised of abosolutely NO
breastfeeding.
Monitoring of the viral load
Baseline :
1. 20 weeks
2. 28 weeks
3. 36 weeks (to determine the mode of delivery)

43. Management of antenatal complications
For any woman who is HIV positive who becomes
acutely unwell in pregnancy, close liaison between
the obstetricians and HIV physicians is mandatory to
avoid diagnostic error.
HIV-related complications should also be considered
as a cause of acute illness in pregnant women whose
HIV status is unknown, particularly those who are
not booked for antenatal care. In these
circumstances, a rapid HIV test should be
considered.

44. About 30% MTCT occurs during
delivery and passage through the
birth canal.
Mother-to-child Transmission of HIV-1: Timing and Implications for
prevention
Athena P. Kourtis, et al.
Lancet Infect Dis 2006; 6: 726-32

45. 1990’s before HAART, Caesarian Section was
found to reduce MTCT of HIV.
In the UK, the rate of MTCT in women on HAART
IS 0.7% with both elective Caesarian Section and
vaginal delivery.
HIV in Pregnancy; An International Perspective
Byne, et al 2012; 14:17-24
The Obstetrician and Gynaecologist

46. “PLCS may offer no additional benefit over vaginal
delivery when MTCT rates of 1% are achieved via
the use of optimal HAART and an undetectable VL
at least 4 weeks before delivery.”
Human Immunodeficiency Virus Infection in
Pregnancy
Zoe Penn, Archana Dixit
Current Obstetrics and Gynaecology (2006) 16, 191-

47. Monitoring of viral load
20 weeks
28 weeks
36 weeks (to determine mode of delivery)
 Counsel the mother about the mode of delivery. Her wishes
should be taken into account.
Ministry of Health
Prevention of Mother-To-Child Transmission (PMTCT) of HIV Policy
Trinidad and Tobago
August 2010

48. If viral load is undetectable by 36 weeks then a
vaginal delivery is planned
Royal College of Obstetrics and Gynaecology
Green-top Guideline No. 39
June 2010

49. Local Recommendations for PMTCT of
HIV
CD4 count >250 and no HAART required
for their own infection:
 Begin START at 20 weeks of gestation
 No ARVs required intrapartum
Ministry of Health
Prevention of Mother-To-Child Transmission (PMTCT)
of HIV Policy
Trinidad and Tobago
August 2010

50. CD4 count < 250:
 Commence HAART antepartum (as per adult
treatment guidelines for Trinidad and Tobago)
 Women on HAART should be counseled about the
association with pre-term labour.
 Continue normal doses during intrapartum period
Ministry of Health
Prevention of Mother-To-Child Transmission (PMTCT)
of HIV Policy
Trinidad and Tobago
August 2010

51. Pregnant women who have already started
ART before conception:
 Continue HAART antepartum
 No additional ARVs required intrapartum
Ministry of Health
Prevention of Mother-To-Child Transmission (PMTCT)
of HIV Policy
Trinidad and Tobago
August 2010

52. Viral load that is detectable prior to
delivery:
 IV AZT should be given and C-Section is highly
recommended
Ministry of Health
Prevention of Mother-To-Child Transmission (PMTCT)
of HIV Policy
Trinidad and Tobago
August 2010

53. Women who present in labour and not on
HAART or START:
 AZT 600 mg po stat + NVP 200 mg po stat + 3TC 150 mg
and every 12 hrs until delivery
Ministry of Health
Prevention of Mother-To-Child Transmission (PMTCT)
of HIV Policy
Trinidad and Tobago
August 2010

54. Indications for Elective Caesarian Section
Women not taking HAART during pregnancy
Women with a detectable viral load
Women on ZDV monotherapy
Women with HIV/Hepatitis C co-infection
Human Immunodeficiency Virus Infection in Pregnancy
Zoe Penn, Archana Dixit
Current Obstetrics and Gynaecology (2006) 16, 191-198

55. VAGINAL DELIVERY
Avoid:
 Fetal Scalp Electrodes
 Fetal Blood Sampling
 Ventouse Delivery
Human Immunodeficiency Virus Infection in
Pregnancy
Zoe Penn, Archana Dixit
Disposable Delivery Kit at MHWH

56. VAGINAL DELIVERY, cont’d
Keep membranes intact for
as long as possible.
Early cord clamping. Use
ART until the cord is
clamped.
Bathe baby immediately.
Stomach washout.
(MHWH)
Human Immunodeficiency Virus Infection in
Pregnancy
Zoe Penn, Archana Dixit
Current Obstetrics and Gynaecology (2006) 16, 191-
Protective eyewear worn by midwives at MHWH

57. PRE-TERM DELIVERY AND PRE-TERM PRELABOUR
RUPTURE OF MEMBRANES
Genital infection screen and treat as indicated.
Usual indications for steroids apply.
Royal College of Obstetrics and Gynaecology
Green-top Guideline No. 39
June 2010

58. After 34 weeks:
 Expedite delivery
 Augment delivery if viral load less than 50 copies per ml and
no contraindications
 Consider starting broad-spectrum antibiotics
Royal College of Obstetrics and Gynaecology
Green-top Guideline No. 39
June 2010

59. Before 34 weeks:
 Oral erythromycin
 Consider broad spectrum antibiotics
 Prompt delivery if
 Discuss the following with a MDT:
 Risk of neonatal morbidity and mortality associated with
prematurity
 Maternal HAART
 Viral load
 Presence of comorbidities
Royal College of Obstetrics and Gynaecology
Green-top Guideline No. 39
June 2010

60. Postpartum
After delivery, the Prevention Mother to Child
Transmission Programme aims to provide quality
treatment, care and support for HIV positive
mothers, exposed infants and their families.
ART treatment for mothers, infants and families.
All HIV positive women are encouraged to seek HIV
counselling and testing for their partners and
exposed children.
 http://hiv.health.gov.tt/site_media/media/filer_public/2013/01/21/prevention_of_mot
her_to_child_transmission_policy.pdf

61. Diagnosis of HIV infection in infants
Children born to HIV positive mothers are tested for
HIV at 6 weeks after birth by DNA PCR and at 18
months of age by HIV antibody testing.
AZT 4mg/kg twice daily for 4 weeks is commenced
within 12 hrs of birth.
 http://hiv.health.gov.tt/site_media/media/filer_public/2013/01/21/prevention_of_mother_to_child_trans
mission_policy.pdf

62. Continued infant feeding counselling and support
All HIV infected women are continuously counselled
on infant feeding and nutrition practices at each visit
to the paediatric clinic or health centre.
Breastfeeding by HIV infected mothers is prohibited.
 http://hiv.health.gov.tt/site_media/media/filer_public/2013/01/21/prevention_of_mother_t
o_child_transmission_policy.pdf

63. Postnatal Transmission via breastfeeding
Breastfeeding is a major risk factor for HIV-1
transmission in settings where safe feeding
alternatives are not available.
The postnatal transmission rate is estimated to be as
high as 15% if women engage in prolonged
breastfeeding of about 2 years.
Mother-to-child transmission of HIV-1: timing and implications for
prevention Athena P Kourtis, Francis K Lee, Elaine J Abrams, Denise J Jamieson, Marc
Bulterys

64. Risk of Breastfeeding
The Breastfeeding and HIV International
Transmission Study (BHITS) meta-analysis
calculated the risk of postnatal HIV transmission
after 4 weeks of age to be 8·9 transmissions per 100
child years of breastfeeding, with a generally constant
rate of transmission between 1 and 18 months of age.

65. Postnatal Transmission via breastfeeding
A randomised study of breastfeeding versus formula
feeding conducted in Nairobi, Kenya, showed that
the transmission rate was 36% in the breastfed
cohort (versus 20% in the formula-fed cohort).
 Mother-to-child transmission of HIV-1: timing and implications for prevention Athena P
Kourtis, Francis K Lee, Elaine J Abrams, Denise J Jamieson, Marc Bulterys

66. Postnatal Transmission via breastfeeding
Studies have indicated that HIV-1
transmission risk in infants who are
exclusively breastfed is half that of
infants who undergo mixed feeding.
Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai WY, Coovadia HM. Method of feeding and transmission of HIV-1 from mothers to
children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 2001; 15: 379–87.

67. Postnatal Transmission via breastfeeding
Data from the BHITS meta-analysis indicate that the
cumulative probability of postnatal HIV
transmission by 6 months of life is approximately 5%
lower than the probability of transmission with
prolonged breastfeeding of 18 months, currently the
practice in most African countries.

68. Postnatal Transmission via breastfeeding
If breastfeeding for only 6 months became a widely
adopted policy, the transmission risk during
breastfeeding would drop by about 5%, from 16% to
11%, and, if breastfeeding was used exclusively for
those 6 months, this risk might be further reduced to
about half (6%).
Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai WY, Coovadia HM. Method of feeding and transmission of HIV-1 from
mothers to children by 15 months of age: prospective cohort study from
Durban, South Africa. AIDS 2001; 15: 379–87.

69. Postnatal Transmission via breastfeeding
Breastfeeding for the first 6 months of life followed
by rapid weaning has been advocated as a strategy to
decrease mother-to-child HIV transmission to the
infant and is currently promoted by the World
Health Organization.
Fowler MG, Newell ML. Breastfeeding and HIV transmission in resource-
limited settings. J Acquir Immune Defi c Syndr HumRetrovirol 2002; 30:
230–39.

71. Breastfeeding Issues
Warmth for newborn
Nutrition for newborn
Protection against other infections
Safety – unclean water, diarrheal diseases
Risk of HIV transmission
Contraception for mother
Cost

72. Breast feeding reduces infant morbidity and mortality
and protects against childhood infections and promotes
child spacing.
In resource poor countries mothers oftern have limited
access to clean water and replacement feeding.
WHO only advocates replacement feeding if it is
affordable, acceptable,feasible,safe and sustainable.
World Health Organization. Guidelines on HIV and Infant Feeding.2010. Principles and Recommendations for Infant Feeding in the Context of HIV and a Summary of Evidence.
Geneva: WHO;2010 [www.who.int/child_adolescent_health/documents/9789241
599535/en/].

73. Sexual and reproductive health services, including family
planning
HIV positive mothers are counselled and
encouraged to have a PAP SMEAR examination done
at first diagnosis of HIV infection or when they first
seek prenatal care, then another PAP SMEAR 6
months later. If both tests are negative, then yearly
PAP SMEAR screening is recommended.
 http://hiv.health.gov.tt/site_media/media/filer_public/2013/01/21/prevention_of_mother_t
o_child_transmission_policy.pdf

74. Immunization and growth monitoring
All HIV exposed infants will be immunized in
accordance with the National Immunization
Guidelines. At the paediatric clinic or health
centre, the growth of all children will be
recorded and monitored at each visit.
http://hiv.health.gov.tt/site_media/media/filer_public/2013/01/21/prevention_of_mother_to_c
hild_transmission_policy.pdf

75. Psychosocial support
All HIV infected women will be referred to Medical
Social Workers for psychosocial support.
 http://hiv.health.gov.tt/site_media/media/filer_public/2013/01/21/prevention_of_mother_t
o_child_transmission_policy.pdf

76. References
1.http://hiv.health.gov.tt/site_media/media/filerpublic/2013/01/21/prevention_of_
mother_to_child_transmission_policy.pdf
2.The Breastfeeding and HIV International Transmission Study(BHITS) Group. Late
postnatal transmission of HIV-1 in breast-fedchildren: an individual patient data meta-
analysis. J Infect Dis 2004;189: 2154–66.
3.Coutsoudis A, Pillay K, Kuhn L, Spooner E, Tsai WY, Coovadia HM. Method of
feeding and transmission of HIV-1 from mothers to children by 15 months of age:
prospective cohort study from
Durban, South Africa. AIDS 2001; 15: 379–87.
4.Fowler MG, Newell ML. Breastfeeding and HIV transmission in resource-limited
settings. J Acquir Immune Defi c Syndr HumRetrovirol 2002; 30: 230–39.
5 World Health Organization. Guidelines on HIV and Infant Feeding.2010. Principles
and Recommendations for Infant Feeding in the Context of HIV and a Summary of
Evidence. Geneva: WHO;2010
[www.who.int/child_adolescent_health/documents/9789241
599535/en/].

77. ThankYou