This document provides guidelines for managing HIV infection in pregnancy. It discusses counseling pregnant women who test positive for HIV, antenatal care including investigations and treatment with antiretroviral therapy, preventing mother-to-child transmission through medication and delivery methods, care during labor and delivery, testing and treatment for infants, and postpartum care of both mother and baby. The goal is to reduce the risk of transmitting HIV from mother to child to less than 2% through screening, testing, antiretroviral treatment, and modifying delivery and infant feeding practices.

1. HIV INFECTION IN PREGNANCY
• Dr pjca Mbizi
• Dr Ndwambi
• June /2018

2. 1. introduction
2. Overview
3. Counselling a pregnant woman about being
HIV positive
4. Antenatal care
5. Investigations
6. Treatment
7. Labour and delivery
8. HIV prevention and testing for infants
9. Postpartum care
10.References

3. infection with human immunodeficiency virus (hiv) results in acquired immune deficiency syndrome
(aids), and has a high risk of transmission of the virus from an infected pregnant or breastfeeding
woman to her baby.
all women who book for antenatal care should be offered hiv testing,
according to the principles of provider-initiated hiv counseling & testing.
only women who have a documented positive hiv status, and are on antiretroviral therapy (art) are
not offered an hiv test. rapid antibody tests are used.
a positive test is confirmed using another rapid hiv test kit.
if one result is positive and the other is negative, the results are indeterminate and an ELISA must be
done to confirm the hiv status.
Introduction

4. OVERVIEW
• The reduction in mother-to-child transmission of human immunodeficiency virus
(HIV) is regarded as one of the most effective public health initiatives in the
United States. In the absence of treatment, the risk of vertical transmission of HIV
is as high as 25-30%. With the implementation of HIV testing, counseling,
antiretroviral medication, delivery by cesarean section prior to onset of labor, and
discouraging breastfeeding, the mother-to-infant transmission has decreased to
less than 2% in the United States.
• an exact mechanism of mother-to-child transmission of HIV remains unknown.
Transmission may occur during intrauterine life, delivery, or breastfeeding. The
greatest risk factor for vertical transmission is thought to be advanced maternal
disease, likely due to a high maternal HIV viral load.

5. EPIDEMIOLOGY
• International statistics
• The Joint United Nations Programme on HIV/AIDS (UNAIDS) has estimated that in
2017, approximately 36.7 million people worldwide (1% of the global adult
population aged 15-49 y) were infected with HIV, of which 1.8 million people were
newly infected; 64% of all people living with HIV worldwide live in sub-Saharan
Africa. New HIV infection rates are declining globally as a result of efforts to
strengthen HIV prevention and treatment programs.

6. • 2. Establish what the woman knows about HIV
• 3. Give information on how the virus is transmitted
• 4. Discuss the symptoms, signs and progression of the disease
• 5. Explain the importance of CD4 count & viral load (VL) monitoring
• 6. Discuss the benefits and potential side-effects of ART
• 7. Explain the risk of mother-to-child transmission of HIV and how this may be reduced: safe infant
feeding choice and antiretrovirals (ARVs)
• 8. Discuss who the woman may want to tell about the result – disclosure is associated with better
treatment adherence
• 9. Discuss condom use and other safe sex practices to prevent transmission to and from the partner,
and also discuss partner testing
• 10. Discuss future fertility plans, and further contraception
Counselling a pregnant woman about being HIV positive

7. ANTENATAL CARE
Clinical assessment:
• Ask about chronic illnesses in the past, and about current health
• Ask about the presence of any psychiatric illness
• Screen for TB: ask about cough, weight loss, night sweats and fever
• On physical examination, look for evidence of opportunistic infections: oral candidiasis, herpes zoster, and
pulmonary TB
• Look for evidence of sexually transmitted infections and treat appropriately
• Stage the woman according to the World Health Organization staging system

8. • All women who test HIV negative in early pregnancy should be offered a repeat test every 3 months, at the onset of
labour, at 6 weeks postpartum, and every 3 months during breastfeeding.
• Women on ART should have VL monitoring every 3 months throughout pregnancy, then 6-monthly during
breastfeeding
• Creatinine is repeated at 3 months, 6 months, 12 months, then annually while on TDF
• If there is a need for antenatal invasive procedures, initiating ART 6 weeks before the procedure gives some
reassurance of viral suppression to allow the procedure to be done
• Consider elective caesarean section for women likely to require an emergency caesarean section in labour, e.g.
previous caesarean section
• HIV infection alone is not a valid indication for Caesarean section.

9. INVESTIGATIONS:
1. Take blood for CD4 count, Hb and creatinine at ART
initiation, and follow up in one week for results
2. Once on ART, do a VL every 3 months during pregnancy
3. Investigate for TB if screen positive

10. TREATMENT:
Initiate ART, preferably on the day of diagnosis
• Give the usual antenatal supplements, such as folate, iron and calcium
• Give isoniazid preventive therapy (IPT) 300 mg with pyridoxine 25 mg daily for 12 months to all women initiated
on ART who screen TB-negative
• Give cotrimoxazole 2 tablets orally daily to women with CD4 cell count <200/mm3
• Do a serum cryptococcal antigen (CRAG) on asymptomatic women with CD4 <100 cells/mm3. If positive, start oral
fluconazole pre-emptive therapy
• Fluconazole 800 mg daily for 2 weeks
• Then 400 mg daily for 8 weeks
• Then 200 mg daily, until her CD4 cell count has risen above 200 cells/mm3
• Note: fluconazole should not be used in the first trimester, unless it is used for the treatment of cryptococcal
meningitis.

11. ART AND PREVENTION OF MOTHER-TO-CHILD TRANSMISSION (PMTCT)
• All HIV-infected pregnant women are offered lifelong ART, irrespective of CD4 count or HIV disease stage.
• ART regimens
1. The first-line regimen comprises a fixed dose combination (FDC) tablet containing:
2. Tenofovir (TDF) 300 mg, Emtricitabine (FTC) 200 mg, and Efavirenz (EFV) 600 mg, taken once at night
3. Alternative ART regimens include Abacavir (ABC) in place of TDF for women with renal dysfunction (serum
creatinine >85 μmol/L)
4. Nevirapine (NVP) in place of EFV for women with active psychiatric illness, provided her CD4 <250 cells/mm3 OR
5. Lopinavir/ritonavir (LPV/r) if her CD4 ≥250 cells/mm3
6. While NVP is rarely initiated in pregnancy because of the risk of life-threatening toxicity, women who become
pregnant on NVP and are stable on treatment may continue with NVP.

12. LABOUR AND DELIVERY
During labour for women who are unbooked & diagnosed HIV positive:
1. Give single-dose NVP 200 mg orally at onset of labour
2. Give single-dose TDF 300 mg with FTC 200 mg orally at onset of labour
3. Give AZT 300 mg 3 hourly orally
4. Commence lifelong ART within 24 hours after delivery

13. HIV PREVENTION AND TESTING FOR INFANTS
• All HIV-exposed infants, regardless of infant feeding method
and whether the mother is on ART or not, should receive
daily NVP syrup for the first 6 weeks of life.
• NVP syrup is stopped at 6 weeks in formula fed infants. It is
also stopped at 6 weeks if the infant is breastfed and the
mother is on ART.
• All HIV-exposed infants must have an HIV PCR test done at
birth, and again at 10 weeks of age, and, if positive, must be
referred for ART initiation immediately.
• . All HIV-exposed infants who tested negative previously
must have an HIV antibody test at 18 months.
Infant’s age Nevirapine syrup dose
Birth to weeks Birthweight <2500 g: 1.0 mL (10 mg) daily
Birthweight ≥2500 g: 1.5 mL (15 mg) daily

14. ANTI-RETROVIRALS AND COMMON SIDE-EFFECTS
• Tenofovir (TDF): renal dysfunction, only use if serum creatinine <85 μmol/L
• Lamivudine (3TC) and Emtricitabine (FTC): side-effects not common, generally well-
tolerated
• Efavirenz (EFV): central nervous system effects – dizziness, insomnia, bad dreams, also
rash, hepatitis
• Abacavir (ABC): drug-induced hypersensitivity reaction (uncommon)
• Nevirapine (NVP): rash including Stevens-Johnson syndrome, hepatitis. Avoid NVP in
women with CD4 cell count >250 cells/mm3
• Lopinavir/ritonavir (LPV/r): diarrhea, nausea, dyslipidaemia

15. LABOUR AND DELIVERY
Labour is generally managed in the same way as for women who are HIV-negative.
1. Do not rupture membranes for poor progress unless her VL is undetectable
2. Avoid using penetrating fetal scalp electrodes for heart rate monitoring
3. Avoid episiotomy wherever possible

16. POSTPARTUM CARE
1. Give normal postpartum care, irrespective of mode of delivery
2. Inform the woman about handling and disposal of soiled pads and linen
3. Treat infections promptly and aggressively
4. Give information about advantages and disadvantages of breast and formula
feeding – strongly discourage mixed feeding
5. All HIV-positive women should be encouraged to exclusively breastfeed for the
first 6 months, with complementary feeding only from 6 months and
breastfeeding continued until 12 months, unless contraindicated
6. Give contraceptive advice and discuss sterilization if appropriate

17. WOMEN WITH ADVANCED HIV DISEASE
The following problems may be expected:
1. Opportunistic infections, e.g. meningitis, pneumonia, TB, chronic diarrhoea
2. Severe puerperal sepsis
3. Spontaneous preterm labour with or without chorio-amnionitis
4. The need for preterm elective delivery in a terminally ill pregnant woman – requires a
discussion with the family
5. Rapid deterioration and death after delivery, especially after spontaneous preterm labour
6. Possible need for disclosure of the illness to the relatives
7. Treatment is individualized according to each patient’s specific disease profile and family
circumstances.

18. HIV INFECTED NOT ON ART
WHO STAGING, SCREEN FOR TB,
TAKE BLOOD FOR CD4,
CREATININE
• No history of psychiatric
or renal disease
Start FDC the same day
(TDF/FTC/EFV)
One week later
CD4 and creatinine
results
History of renal disease
Creatinine ≤85 Creatinine >85 ABC + 3TC + EFV
Investigate for renal disease
Continue FDC as lifelong ART
LIFELONG ART FOR ALL HIV-INFECTED PREGNANT & BREASTFEEDING WOMEN

19. RFERENCES
1. Latest obstetrics 2017 protocol book , p 129-135
2. Brinkman K, ter Hofstede HJ, Burger DM, Smeitink JA, Koopmans PP. Adverse
effects of reverse transcriptase inhibitors: mitochondrial toxicity as common
pathway. AIDS. 1998 Oct 1. 12(14):1735-44
3. French R, Brocklehurst P. The effect of pregnancy on survival in women
infected with HIV: a systematic review of the literature and meta-analysis. Br J
Obstet Gynaecol. 1998 Aug. 105(8):827-35

20. • Thank you
• Merci
• Gracias
• Ndolivhuwa