HIV and Pregnancy : Dr Ruby Bansal HIV and Pregnancy Why is this important

1. HIV and Pregnancy
Dr Ruby Bansal
MD, Fellowship HIV
Medicine(MAMC)
Observership HIV&ID (USA)

2. Why is this important
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3. 21,00,000
People living with HIV
3
880 000
(41.9%) are women
60%
of pregnant women living
with HIV have accessed ART
Preventing
3500
new HIV infections among
newborns
Only 23% infants were early diagnosed before eight
weeks of age.
https://www.unaids.org/en/regionscountries/countries/india

4. Routes of HIV Transmission, 2014-15
94%
1%
0.1%
0.9%
3% 1%
*Source : SIMS data 2014-15
Hetero sexual
Homo/Bisexual
Blood & blood
products
Infected syringe and
needles
Parent to child is Transmission rate
Decreased from 5% to 3% during 2012-13 to 2014-15
MTCT

5. My personal experience
▫ 26 HIV positive couple delivered healthy
baby
▫ Non of the child is HIV positive
▫ God ‘s blessings

6. Parent-to-child transmission
▫ In the absence of any intervention, transmission rates range from 15% to 45%.
▫ If neither mother nor baby are on HIV treatment, there is around a 20% chance of the
child acquiring HIV after two years of breastfeeding.
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NACO Guidelines. 2018.; https://www.aidsmap.com/about-hiv/how-likely-mother-child-transmission-hiv
1,20000 children (0 to 19 years) living with HIV in India
Out of 29 million pregnancies/year - 22,000 occur in HIV infected women.

7. Risk of HIV transmission from Mother to Child
with ARV interventions
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NACO Guidelines. 2018.; https://www.aidsmap.com/about-hiv/how-likely-mother-child-transmission-hiv
ARV Intervention Risk of HIV Transmission from
mother to child
No ARV; breastfeeding 30-45%
No ARV; No breastfeeding 20-25%
Short course with one ARV; breastfeeding 15-25%
Short course with one ARV; No breastfeeding 5-15%
Short course with two ARVs; breastfeeding 5%
3 ARVs (ART) with breastfeeding 2%
3 ARVs (ART) with No breastfeeding 1%
A recent study in which women were taking treatment estimated
the risk of transmission at..
0.3% if a woman breastfeeds for six months and
0.6% if she breastfeeds for one year.

8. Maternal factors
▫ Low CD4+ lymphocyte count
▫ High viral load
▫ Advanced AIDS
▫ Preterm delivery
▫ Placental membrane inflammation
▫ Maternal p24 HIV core
antigenemia at birth
Factors That Increase the Risk of Vertical
Transmission of HIV
Intrapartum events
▫ Events that increase fetal exposure
to maternal blood (artificial rupture
of membranes, use of fetal scalp
monitors, instrumental deliveries,
scalp pH testing, DeLee suctioning)
▫ Rupture of membranes more than
four hours before delivery
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American Family Physician; Volume 63, Number 1, Jan 1, 2001

9. ▫ Reducing perinatal transmission
▫ Assessing future risks
▫ Reinforcing HIV risk-reduction behaviors
▫ Allowing referral to prevention services
▫ Making an early diagnosis
▫ Starting treatment early
▫ Informing patients about reproductive decisions
▫ Preventing transmission to others
▫ Obtaining psychologic and social support services
Reasons to Screen Pregnant Patients for HIV
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American Family Physician; Volume 63, Number 1, Jan 1, 2001

10. Different Case Scenarios
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11. HIV Infected Pregnant Women under different case
scenario
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Pregnant and Breastfeeding women with HIV
Women
detected
during routine
antenatal care
Women who
is registered
in preART care
Women who
is on ART
Women who
came directly
in labour and
delivery
Women
detected post-
partum
NACO Guidelines. 2018.

12. 12
Women detected during routine antenatal care
???
 Patient panic…
 Gynecologist ?????
 Patient –Gynecologist what to ? do how it happen ? Now ?
DHHS Perinatal Guidelines. 2020.

13. “Termination is not the solution in
women living with HIV
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14. 14
Women detected during routine antenatal care
Role of HIV physician is must here
Let we work together for……
 Optimizes maternal health
 Minimizes risk of perinatal HIV transmission
 Prevents of sexual transmission to partner without HIV
DHHS Perinatal Guidelines. 2020.

15. Role of HIV Physician
▫ Confirm the diagnosis with 3 different tests
▫ Spouse testing for HIV
▫ Counselling about disease facts & fear
▫ Supportive test to start treatment
▫ ART at earliest
▫ Regular follow up counselling consulting and
physical as well mental management
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16. Ethical Considerations
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▫ Distinguishing between women who might become pregnant and women
trying to conceive
▫ Counseling and informed decision-making critical with all ARV regimens
▫ Give medical guidance in a noncoercive manner, respect her autonomy in
decision-making
▫ Use caution in unilaterally restricting choice of ART regimen in women of
childbearing age or changing fully suppressive ART regimens in women who
present in pregnancy
▫ May impact likelihood of achieving sustained viral suppression
▫ Remember difference between absence of data and evidence of harm
DHHS Perinatal Guidelines. 2020.

17. Role of Gynecologist
▫ Antenatal care is same in HIV positive as well
non HIV
▫ Avoid invasive testing /procedure
▫ Regular psychological counselling
▫ Preparedness for mode of delivery & child
care
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18. 18
Women in preART care Women who is on ART
Primary prevention of HIV in childbearing women
Provide HIV information to ALL pregnant women
Antenatal visits are opportunity for PPTCT
Prevention of unwanted pregnancies in HIV-positive women
Prevention of PTCT through ART
Safe obstetric practices
NACO Guidelines. 2018.

19. After 36-38 weeks
Happy moment for me /
Gynecologist and parent
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20. 20
Women who came directly in labour
Call from lab HIV test “Reactive “
 In labour room/OT Panic……… staff fear
 Gynecologist OMG ab kya karoon
 Patient relative –Gynecologist what to ? do how it happen ?
Now ?
DHHS Perinatal Guidelines. 2020.

21. 21
Women who came directly in labour and delivery
Minimize vaginal
examinations
Avoid invasive procedures
Avoid routine episiotomy / support perineum
Minimise the use of forceps or vacuum extractors
Avoid prolonged
labour; consider
oxytocin to
shorten labour
Avoid artificial
rupture of
membranes
Early cord clamping
after it stops pulsating
and after giving the
mother oxytocin
Use non-invasive
foetal monitoring
NACO Guidelines. 2018.

22. Care and Assessment for Women presenting Directly-in-
labour
In governement hospital :
▫ Labour room nurse will offer bed side counselling and HIV screening test
▫ If the woman consents, screen using the “Whole Blood Finger Prick test”
in delivery room or labour ward
▫ If detected HIV positive, the HIV physician i/c will initiate TDF + 3TC + EFV
and ensure immediate linkage to ART centre
▫ Labour room nurse informs the counsellor and lab technician for further
confirmation of HIV test as per guidelines
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NACO Guidelines. 2018.

23. 23
Pregnant and Breastfeeding women with HIV
Women
detected during
routine
antenatal care
Women who is
registered in
preART care
with
HIVphysician
Women who is
on ART
Women who
came directly in
labour and
delivery
Women
detected post-
partum
Link to HIV
physician
Follow treat to
care policy
Continue the
ART
Confirm HIV and
perform CD4 test
Link to ART care
CD4 /VLand start
ART
CD4 /VLand start
ART
Continue the
ART
Start ART
CD4 and start
ART
Ensure drug
delivery and
follow up
Link to ART care
post partum

24. Considerations in Mode of Delivery
▫ In India, normal vaginal delivery is recommended unless the woman has
obstetric indications (like foetal distress, obstructed labour) for a
Caesarean section
▫ Use of ART can reduce risk of PTCT better and with lesser risk than a C-
section
▫ *Planned LSCS has shown extreme reduction of HIV in new born (depend
on patient as well obstetrician) European data
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NACO Guidelines. 2018.

25. ARV Categories
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26. Ideal combination of ARV drugs, consider the following
▫ Teratogenicity
▫ Toxicity to maternal health
▫ Impact on obstetric outcomes such as preterm birth (PTB), low birth
weight (LBW) and stillbirth
▫ Hepatitis B coinfection/hep C coinfection
▫ Assessment of resistance testing, if available
▫ Prior ARV regimens
▫ Minimizing pill burden to optimize compliance
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https://www.contemporaryobgyn.net/view/obs-role-hiv-management-pregnancy

27. NACO recommendations
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28. ART regimens in pregnant and breastfeeding with HIV
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NACO Guidelines. 2018.
Target Population Drug Regimen Remark
Pregnant and breastfeeding women
with HIV (ART Naïve / “Not-already”
receiving ART)
TDF + 3TC + EFV FDC of TDF (300 mg) + 3TC (300 mg)
+ EFV (600 mg) - To be given 2 hours
after low-fat or fat-free dinner
Pregnant and breastfeeding women
with HIV already receiving ART
The same ART
regimen must be
continued
E.g. If they are already on AZT + 3TC
+ NVP/ EFV, continue the same
regimen
ART regimen for pregnant women
having prior exposure to NNRTI for
PPTCT
TDF + 3TC and
LPV/r
FDC of TDF (300 mg) + 3TC (300 mg)
– 1 tab OD and
FDC of LPV (200 mg)/r (50 mg) – 2
tab BD
ABC+3TC+EFV: 1st line ART Regimen, for all patients with known renal disease or who develop toxicity to TDF
As per PPTCT guidelines, all positive pregnant women exposed to NVP/EFV in past should be initiated on
Lopinavir/ritonavir (LPV/r) instead of Efavirenz (EFV).

29. Pregnant women presenting in active labour
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NACO Guidelines. 2018.
Maternal Status Intra-partum Post-partum
Presenting in active labour, no
prior ART
Initiate TDF (300 mg) +
3TC (300 mg) + EFV (600
mg)
Continue TDF (300 mg) + 3TC (300
mg) + EFV (600 mg)
Nevirapine prophylaxis for breastfeeding infant should be for 12 weeks, as mother did not
receive any ART during ante-natal period

30. ARV Prophylaxis for Infant
The infant should be started on Nevirapine. The duration of NVP prophylaxis
will depend on the duration of ART that has been given to the mother during
her ante-natal period.
▫ Infants should be started on daily NVP prophylaxis at their first encounter
with the health services
▫ Daily infant NVP prophylaxis can be started even if more than 72 hours
have passed since birth and should continue; during this period the
mother should be linked to appropriate ART services
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NACO Guidelines. 2018.

31. Recommended ARV Prophylaxis for HIV Exposed Infants
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NACO Guidelines. 2018.
Infants Birth
Weight
NVP daily dose
(in mg)
NVP daily dose (in ml) (10 mg
Nevirapine in 1 ml suspension)
Duration
Infants with birth
weight < 2000 g
2 mg/kg once daily 0.2 ml/kg once daily Upto minimum of 6 weeks of
age regardless of whether
exclusively breast fed or
exclusively replacement fed
Extended to 12 weeks, if the
duration of ART received by
the mother is less than 24
weeks and she is breast
feeding
Birth weight 2000
– 2500 g
10 mg once daily 1 ml once daily
Birth weight >
2500 g
15 mg once daily 1.5 ml once daily

32. DHHS recommendations
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33. DHHS Recommendations for Initial ART During
Pregnancy
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Guideline Status NRTIs INSTIs PIs NNRTIs
Preferred
3TC/ABC*
FTC/TDF
3TC + TDF
DTG†
RAL
ATV/RTV
DRV/RTV‡
Alternative 3TC/ZDV LPV/RTV‡ EFV
RPV§
Insufficient data to recommend TAF BIC DOR
Not recommended EVG/COBI
ATV/COBI
DRV/COBI
*Only if HLA-B*5701 negative. †Use of DTG at conception/very early pregnancy has been associated with small
but statistically significant increase in the risk of NTDs; this information should be discussed with patients to
ensure informed decision-making. ‡Must be used twice daily in pregnancy. §Only if pretreatment HIV-1 RNA ≤
100,000 copies/mL and CD4+ cell count ≥ 200 cells/mm3
DHHS Perinatal Guidelines. 2020.

34. Summary
Both Gynecologist & HIV physician to work together
▫ Aim is have a healthy and HIV negative offspring
▫ Counselling is important
▫ Diagnosis and immediate initiation of treatment
▫ Choose the right regimen for the mother
▫ Prophylaxis to the infant
▫ Monitor and follow up
▫ Fast diagnosis and fast referral will play a key role
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35. Thank You!
Any questions?
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