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1. HIV IN PREGNANCY
DR AHMAD ZHARIF BIN HUSSEIN

3. HIV
(HIV) Human immunodeficiency virus is a lentivirus (a member of the
retrovirus family) that causes Acquired Immunodeficiency Syndrome (AIDS)
Discovered in 1983
HIV has been divided into two primary strains
HIV-1 and HIV-2
HIV is a retrovirus that is believed to have evolved from a simian
immunodeficiency virus.
Group - Group VI (-ssRNA)
Family - Retroviridae
Genus - Lentivirus
It is composed of two copies of positive single-stranded RNA.

4. STRUCTURE HIV
HIV is different in structure
from other retroviruses.

5. ETIOLOGY
The 3 main route of transmission is via;
o blood, blood products
o sexual contact
o mother to child in intrauterine infection, perinatal transmission, or
the mother’s milk.

6. GUIDELINES FOR HIV IN
PREGNANCY
 RCOG –GREEN TOP NO 39 MANAGEMENT OF HIV IN PREGNANCY
2010
 British HIV Association guidelines for the management of
HIV infection in pregnant women 2012(NICE)

7. Guidelines
 Objectives
 to increase in the proportion of vaginal deliveries and a reduction in the
number of emergency CS.
 To reduce the risk of MTCT
 Contents
 Antenatal HIV management
 Intrapartum HIV management
 Postpartum HIV management
 Neonatal HIV management

8. Antenatal management
 Recommended to have screening for HIV infection in every
pregnancy at their booking antenatal visit. - can prevent mother-to-
child transmission and significantly improve their own health.
 women who are HIV positive should be referred promptly for
assessment and for their pregnancies to be management within a
multidisciplinary team.
 If a woman declines screening, her reasons should be explored
sensitively to ensure that she has received accurate information on
which to base her decision.
 Involvement of a senior health professional should be considered.
The decision to decline screening should be documented in the
maternity notes and screening offered again at around 28 weeks

9. Multidisciplinary team
HIV positive patients should be managed by a multidisciplinary team.
 HIV physician
 an Obstetrician
 a Midwife
 a Paediatrician
 a Psychiatric team
 support groups
“Confidentiality is important.& an early assessment of their social
circumstances.”

10. HIV test
 Rapid HIV tests are recommended for women with unknown HIV
status who present in labour and a reactive result should be acted
on immediately
 HIV screening test at 26 weeks of gestation or later, an urgent
request should be made and the result issued by the laboratory with
24 hours.

11. ADVICE
 Safer sex practice-use condom
 Appropriate support
 To screen others children and partners who unknown HIV status

13. Antenatal care
 Screening for Down syndrome and fetal anomalies should be
offered.
 A detailed ultrasound scan for fetal anomalies is important after first-
trimester exposure to HAART(exposed to potentially teratogenic
drugs)- between 18 + 0 and 20 + 6 weeks’ gestation ,In past
theoretical increased risk of anomaly due to first trimester ART
exposure.
 The combined screening (the ‘triple test’+ NT scan)for trisomy 21 is
recommended as this has the best sensitivity and specificity and will
minimize the number of women who may need invasive testing

14. Invasive prenatal diagnosis
 The risk of mother-to-child transmission with chorionic villus sampling
or second-trimester amniocentesis hasn’t been estabilished.
 If invasive prenatal diagnosis is contemplated, the advice of the
fetal medicine specialist and HIV physician should be seeked and
prophylaxis with HAART considered.
 Invasive prenatal diagnostic testing should not be performed until
after HIV status of the mother is known and should be ideally
deferred until HIV VL has been adequately suppressed
 Where possible, amniocentesis should be deferred until VL is <50 HIV
RNA copies/mL

15. Recommended
• All pregnant women who are HIV positive
should be screened for syphilis, hepatitis B,C
& other genital infection
• When to do ?
• This should be done as early as possible in pregnancy
• repeated at around 28 weeks.
• Bacterial vaginosis is associated with around a
two-fold increased risk of preterm delivery & have
been shown to stimulate HIV in vitro.
• HIV positive taking HAART at the time of
booking should be screened for gestational
diabetes.

16. Antiretroviral therapy
 Aims:
 prevention of mother-to-child transmission
 treatment of the mother to prevent maternal disease progression
 The decision to start,modify or stop anti-retroviral therapy
 should be undertaken by an HIV physician
 in close liaison with other health professionals
 obstetrician
 paediatrician.

17.  All pregnant HIV positive women should be advised to take
antiretroviral therapy:
 a) For women who require HIV treatment for their own health, their
prescribed HAART regimen should be continued throughout pregnancy
and postpartum.
 b) For women who do not require HIV treatment for their own health,
HAART should be initiated between 20 and 28 weeks and discontinued
at delivery.
 c) For women who do not require HIV treatment for their own health,
have a viral load less than 10 000 copies/ml and are prepared to be
delivered by elective caesarean section, an acceptable alternative to
HAART is zidovudine monotherapy initiated between 20 and 28 weeks,
given orally twice daily, intravenously at delivery and discontinued
immediately thereafter

18.  Timing
 Antenatally
 Intrapartum
 Neonatal period(4-6 weeks)
 Choice of antiretroviral therapy & Timing is decided by HIV physician.
 Plasma viral load & CD4 counts regularly monitored.
 Patients on antiretroviral therapy should be monitored for toxicity
 full blood count
 urea and electrolytes
 liver function tests- Hepatoxicity
 Lactate –(Lactic acidosis)
 blood glucose-GDM

19.  In women who commence HAART in pregnancy a VL should be
performed 2–4 weeks after commencing HAART, at least once every
trimester, at 36 weeks and at delivery
 presented with an opportunistic infection, initiation of HAART should
not be delayed.
 Treatment is indicated based on CD4 cell count only,
 Treatment to the start of the second trimester is reasonable,
particularly if the patient is experiencing nausea and/or vomiting of
pregnancy

20. Type of ARV drug
 Nucleoside reverse transcriptase inhibitors (NRTI) and nucleotide
reverse transcriptase inhibitors (NtRTI)
 deoxythymidine, zidovudine, stavudine, didanosine, zalcitabine,
abacavir, lamivudine, emtricitabine, and tenofovir.[6]
 Non-Nucleoside reverse transcriptase inhibitors (NNRTI)
 nevirapine, delavirdine, efavirenz, and rilpivirine.[6]
 Integrase inhibitors
 Raltegravir &Elvitegravir.[3]
 Protease inhibitors
 Lopinavir, Indinavir,Nelfinavir, Amprenavir and Ritonavir. Maturation
inhibitors

21. Nucleoside reverse transcriptase
inhibitors (NRTI) and nucleotide reverse
transcriptase inhibitors (NtRTI)
 nucleoside and nucleotide analogues which inhibit reverse
transcription. NRTIs are chain terminators such that once
incorporated, work by preventing other nucleosides from also being
incorporated because of the absence of a 3’ OH group. ; they both
act as competitive substrate inhibitors
 Zidovudine monotherapy can be used in women planning a CS who
have a baseline VL <10 000 HIV RNAcopies/mL and CD4 cell count
>350 cells/mL.
 Emtricitabine is structurally similar to lamivudine but has a longer
half-life

22. Non-Nucleoside reverse
transcriptase inhibitors (NNRTI)
 inhibit reverse transcriptase by binding to an allosteric site of the
enzyme; NNRTIs act as non-competitive inhibitors of reverse
transcriptase. NNRTIs affect the handling of substrate (nucleotides)
by reverse transcriptase by binding near the active site and causing
“molecular arthritis”
 Efavirenz-earlier it contraindication in pregnancy
 Report:{3 offspring of 20 the first trimester had significant abnormalities
at birth: one had anencephaly and unilateral anophthalmia; the
second microphthalmia; and the third a cleft palate}
 On current evidence, that efavirenz can be used in pregnancy.

23. Integrase inhibitors
 Inhibit the enzyme integrase, which is responsible for integration of
viral DNA into the DNA of the infected cel

24. Protease inhibitors
 block the viral protease enzyme necessary to produce mature
virions upon budding from the host membrane. Particularly, these
drugs prevent the cleavage of gag and gag/pol precursor proteins
 Is are highly protein-bound and placental transfer in humans
appears to be limited

25. HAART
 regimens consist of three(3) drugs: 2 NRTIs + 1 PI/NNRTI/II
 UK are now rarely prescribed zidovudine as part of HAART
 zidovudine plus lamivudine, tenofovirplus emtricitabine or abacavir
plus lamivudine are acceptable nucleoside backbones
 the efficacy of HAART in pregnancy are based on a three/four-drug
combination, including a zidovudine/lamivudine backbone
 In the absence of specific contraindications, it is recommended that
the third agent in HAART should be efavirenz or nevirapine (if the
CD4 cell count is <250 cells/mL) or a boosted PI

26. Zidovudine Vs START
Zidovudine START
may allow the emergence of
resistant virus
maternal plasma viraemia is more
likely to be suppressed to
undetectable levels
exposure of the mother and fetus
to larger numbers of potentially
toxic drugs

27.  No routine dose alterations are recommended for ARVs during
pregnancy if used at adult licensed doses
 third-trimester TDM if combining tenofovir and atazanavir
 should have commenced ART by week 24 of pregnancy
 combination of zidovudine, lamivudine and abacavir can be used if
the baseline VL is <100 000 HIV RNA copies/mL plasma
 If the VL is unknown or >100 000 copies/mL a three- or four-drug
regimen that includes raltegravir is suggested

28. HBV infection
 All HBV/HIV coinfected women should receive HAART
containing tenofovir with emtricitabine or lamivudine unless
contraindicated
 Combining lamivudine/emtricitabine with tenofovir may also reduce
the risk of breakthrough HBV viraemia
 CD4 cell count is <500 cells/mL, HAART should be continued postpartum
 CD4 cell count is >500 cells/mL and there is no other indication to treat
HBV, consideration should be given to continuing anti-HBV treatment
postpartum with HAART incorporating tenofovir and emtricitabine
 If a decision is taken to discontinue therapy,careful monitoring of liver
function is imperative, there is HBV viraemia and evidence of liver
inflammationor fibrosis, HAART containing tenofovir and emtricitabine
should be continued

29.  In the absence of obstetric complications, normal vaginal delivery
can be recommended if the mother has fully suppressed HIV VL on
HAART
 Neonatal immunization with or without HBIG should commence
within 24 h of delivery

30. HCV
 On diagnosis of new HCV infection, confirmation of HCV viraemia with
quantitative VL and genotype,assessment of hepatic inflammation and
function and concomitant liver disease should be performed.
 LFTs should be repeated at 2 weeks after commencingHAART to detect
evidence of hepatotoxicity
 Coinfected mothers with HCV should not be treated for HCV with
pegylated interferon with or without ribavirin and all women who
discover they are pregnant while receiving treatment should
discontinue both pegylated interferon and ribavirin immediately.
 HCV antiviral therapy is contraindicated in pregnant women due to possible
teratogenicity
 In all non-immune HCV coinfected women after the first trimester,
vaccination against HBV is recommended

31. Failure to suppress
 Treatment of HAART during pregnancy has not achieved a plasma
VL of <50 copies/mL at 36 weeks the following interventions
are recommended:
• Review adherence and concomitant medication.
• Perform resistance test if appropriate.
• Consider TDM.
• Optimize to best regimen.
• Consider intensification.
 these interventions should be undertaken as soon as possible

32. Intrapartum management
 Mode of delivery
 Elective caesarean section at 38 weeks to prevent labour and/or ruptured
membranes is recommended for:
women taking HAART who have a plasma viral load greater than 50 copies/ml.
women taking ZDV monotherapy as an alternative to HAART.
women with VL >400 HIV RNA copies/mL regardless of ART
 Vaginal delivery
can be offered to women taking HAART with plasma viral loads of less than 50
copies/ml.
 Elective caesarean section for obstetric indications or maternal request should be
delayed till 39-40 completed weeks of gestation in women with plasma viral loads of
less than 50 copies/ml, to reduce the risk of transient tachypnoea of the newborn.
“A plan regarding mode of delivery should be made at around 36 weeks following
detailed discussion with the mother”

33. LSCS
 A zidovudine infusion
 should be started four hours before beginning the caesarean section
 Should continue until the umbilical cord has been clamped.
 A maternal sample for plasma viral load and CD 4 should be taken
at delivery.
 The cord should be clamped as early as possible after delivery and
the baby should be bathed immediately after the birth.
 a technique of ‘bloodless’ caesarean section may further reduce
the risk of mother-tochild transmission.
 opening the uterus with a staple gun,which simultaneously cuts and
giveshaemostasis.

34.  This should be sheduled at 38 weeks to reduce the risk of spontaneus
labour or membrane rupture.
 Contamination of the baby with maternal blood should be avoided
 Secure the bleeding points
 Cord clamped as soon as possible
 Not to rupture membrane till fetal head out
 Drainage should be used and they should be used to closed
suction system
 Universal precautions :gloves, aprons & face protection should be
employed.

35. VBAC
 VBAC should be offered to women with a VL <50 HIV RNA copies/Ml

36. In Labour
 planned vaginal delivery should have their membranes left intact for
as long as possible (ARM if have indication)
 Use of fetal scalp electrodes and fetal blood sampling should be
avoided.
 Women should continue their HAART regimen throughout labour .
 If an intravenous infusion of zidovudine is required it should be
commenced at the onset of labour and continued until the umbilical
cord has been clamped.
 A maternal sample for plasma viral load should be taken at
delivery.
 The cord should be clamped as early as possible after delivery and
the baby should be bathed immediately after the birth.

37. Vaginal delivery
 Forceps preferred to Vacuum
 Remove maternal blood stain with alcohol wipe prior to Vitamin K injection
 Universal precautions :gloves, aprons & face protection should be employed.
 Amniotomy and possible use of oxytocin may be considered for augmentation of
labour.

38. Preterm delivery
 Initial assessment
 The multidisciplinary team should be involved so that a clear plan of care
 indications for steroids apply.
 A genital infection screen should be undertaken.
 Tocolysis may be initiated as appropriate.
 Urgent advice-from the HIV physicians and paediatricians about the choice of
anti-retroviral therapy. Infants born below 32 weeks of gestation are at
increased risk of HIV but may be unable to tolerate oral medication.
 Anti-retroviral therapy administered to the mother just before and during
delivery will provide prophylaxis for the neonate
 a single dose of oral nevirapine (200 mg) given at least 2 hours before delivery,
 a double dose of oral tenofovir (600 mg) and intravenous ZDV.

39. SROM in HIV
 SROM-spontaneus rupture of Membranes
 ruptured membranes for more than four hours , associated with double
the risk of HIV transmission.
 These studies also demonstrated a 2% incremental increase in
transmission risk for every hour of rupturedmembranes up to 24 hours.
 The relevance of these studies for women taking HAART who have
undetectable viral loads is uncertain.
 delivery should be expedited.
 should be given to startingintravenous broad-spectrum antibiotics.

40. PPROM in HIV
 PPROM-preterm prelabour rupture of membranes
 If there is preterm rupture of membranes, with or without labour, the risk of
HIV transmission should be set against the risk of preterm delivery.
 Preterm infants are more likely to be infected with HIV.
 To the use of short-term steroids to promote fetal lung maturation.
 Oral erythromycin -accordance with national guidelines and consideration
should be given to starting intravenous broad-spectrum antibiotics.
 Evidence of chorioamnionitis and fetal distress are indications for prompt
delivery.
 Less 34/52 – multidiscipline team involvement and obstetric indication for
decision time of delivery
 After 34/52- delivery expedited

41. ECV
 ECV can be performed in women with HIV
ECV should be offered to women with a VL <50 copies/mL and
breech presentation at >36 + 0 weeks in the absence of obstetric
contraindications

42. Induction
 previously been avoided as there were concerns about the
duration of ruptured membranes and risk of MTCT but recent
evidence would appear to be reassuring on this point

43. Late diagnose & unknown HIV
status
 Rapid multidisciplinary team assessment and HAART should be
commenced ASAP
 vaginal delivery if she commences HAART and achieves a viral load of less
than 50 copies/ml by 36 weeks.
 elective caesarean section at 38/52 -If the viral load is greater than 50
copies/ml at 36 weeks
 Diagnosed during labour, urgent advice should be sought from the HIV
physicians regarding optimum HAART; delivery should be by caesarean
section and, wherepossible, should be timed with respect to anti-
retroviral administration.
 HAART regimen(intravenous ZDV and oral nevirapine (an anti-retroviral with
rapid placental transfer and of proven benefit in reducing transmission)
 delivery should be timed to be at least 2 hours after administration of
nevirapine

44.  An untreated woman presenting in labour at term should be given a
stat dose of nevirapine 200 mg and commence fixed-dose
zidovudine with lamivudine and raltegravir.
 It is suggested that intravenous zidovudine be infused for the
duration of labour and delivery.

45. Postpartum management
 women with HIV advised not to breast feed
 Neonate infections.
 PCR is done as maternal antibodies cross the placenta
 Typically, tests are carried out at birth, then at three weeks, six weeks
and six months.
 definitive test is the HIV antibody test: a negative result at 18 months of
age confirms that the child is uninfected.
 should receive guidance about contraception in the immediate
postpartum period.

46. Management of the neonate
 All infants born to women who are HIV positive should be treated
with anti-retroviral therapy from birth.
 Usually treatment is discontinued after four to six weeks
 Zidovudine monotherapy is recommended if maternal VL is <50 HIV
RNA copies/mL at 36 weeks’ gestation or thereafter before delivery
(or mother delivered by CS while on zidovudine monotherapy).

47.  There are two situations where triple combination ART for neonates is
advised:
(i) Post-delivery infant-only prophylaxis: mother found to be HIV positive
after delivery, which is only effective if given within 48–72 h of birth
 (ii) Detectable maternal viraemia (>50 HIV RNA copies/mL) at delivery,
mother may be on HAART or not:
• delivery before complete viral suppression is achieved (e.g. starting
HAART late or delivery premature);
• viral rebound with or without resistance, with or without poor
adherence;
• unplanned delivery ( e.g. premature delivery before starting ART or
late presentation when maternal HIV parameters may be unknown).
 Infants <72 h old, born to untreated HIV-positive mothers

48. Recommendation for for HIV-infected
mother in labor who had no prior
therapy
1. Single dose Nevirapine during labor and a single dose to
the neonate at age 48h.
2. Intrapartum AZT, the 6 weeks of AZT to the
neonate.(2mg/kg 4 times daily)
3. The two dose Nevirapine combined with the intrapartum
and 6 weeks AZT regimen.

49.  IN case of maternal HIV antiretroviral resistance:
AZT is still recommended to the infant, plus other medications
based on maternal HIV resistance pattern.

50. Neonatal care
 HIV DNA PCR (or HIV RNA testing) should be performed on the
following occasions:
 _ During the first 48 h and before hospital discharge.
 _ 2 weeks post infant prophylaxis (6 weeks of age).
 _ 2 months post infant prophylaxis (12 weeks of age).
 _ On other occasions if additional risk (e.g.breastfeeding).
 HIV antibody testing for seroreversion should be checked at age 18
months.

51. PCP
 PCP prophylaxis, with co-trimoxazole, should be initiated from age
4 weeks in:
• All HIV-positive infants
• In infants with an initial positive HIV DNA/RNA test result (and
continued until HIV infection has been excluded).
• Infants whose mother’s VL at 36 weeks’ gestational
age or at delivery is >1000 HIV RNA copies/mL despite
HAART or unknown (and continued until HIV infection
has been excluded).

52. Immunization
 Hepatitis B, pneumococcus and influenza immunisation are
recommended for all individuals who are HIV positive; these
immunisations can be safely administered in pregnancy.
 Varicella zoster and measles, mumps and rubella vaccines are
contraindicated in pregnancy. Women testing immunoglobulin G
negative for these infections should be considered for immunisation
postpartum, depending on their CD4 count

53. Continuation of ARV
 ARV therapy should be continued in all pregnant
women who commenced HAART with a history of an AIDS-defining
illness or with a CD4 cell count <350 cells/mL
 ART should be continued in all women who commenced HAART for
PMTCT with a CD4 cell count of between 350 and 500 cells/mL
during pregnancy who are coinfected with HBV or HCV
 ART should be discontinued in all women who commenced HAART
for PMTCT with a CD4 cell count >500 cells/mL unless there is
discordance with her partner or co-morbidity

54. Prepregnancy management
 Couples who are serodiscordant for HIV infection and who choose to
have sexual intercourse should be advised to use condoms.
 Serodiscordant couples 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 are recommended to delay conception until plasma viraemia
is suppressed, prophylaxis against PCP is no longer required and any
opportunistic infections have been treated.
 Folate supplementation should be administered in accordance with
national guidelines. For women taking cotrimoxazole, higher dose folate
(5 mg) should be administered.
 All women who are HIV positive are recommended to have yearly
cervical cytology.

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