The document provides an overview of HIV in pregnancy including: 1. The history, virology, global scenario, burden in India, routes of transmission, testing and management during the ante-natal, intra-partum, and post-natal periods are discussed. 2. Guidelines for prevention of mother-to-child transmission through antiretroviral therapy, delivery method, feeding options and infant prophylaxis and care are provided. 3. Staging of HIV disease and treatment criteria including when to start antiretroviral therapy during pregnancy based on CD4 count and clinical stage are outlined.

1. Dr. Babitha
Dr. Manvi
Moderator:
Dr. Lakshmikanth
HIV IN PREGNANCY

2. REFERENCES
 NACO guidelines for ART- 2012
 Williams obstetrics- 23rd edition
 Practical guidelines to high risk pregnancy and
delivery- 3rd edition..Fernando Arias, Shirish
daftary
 Practical obtetric problems- Ian donald, 6th edition
 WHO- consolidated guidelines for use of ART
drugs n treating and preventing HIV infection,
2013

3.  History
 Virology
 Global scenario
 Burden of the disease in india
 Routes of transmission and progression of the disease
 Testing and management in the ante-natal period
 Intra-partum management
 Post-natal care of the mother and follow-up of the infant
 Contraception
 Post exposure prophylaxis
 Special situations
OVERVIEW

4. Historical Events
 June 5 1981 – Centre for Disease Control & Prevention –
Reported 5 homosexual men with PCP – Gay Related
Immune deficiency
 1982 – CDC Reported – also seen in non-homosexuals –
AIDS .
 1982 – Luc Montagnier et al, Pasteur Institute – Discovered
the virus & named it Lymphadenopathy associated virus
(LAV).
 1983 – Robert , US – confirmed the virus – called it – Human
T Lymphotropic Virus type III (HTLV – III).
 1986 – Renamed as Human Immunodeficiency Virus (HIV).

5. VIROLOGY
p24Capsule protein
p17Matrix protein
Single stranded RNA (2 Copies).
Family :- Retroviridae ; Sub-family :- Lentiviridae
RNA genome has 9 genes :-
: 3 Structural (gag, pol, env)
: 6 Regulatory genes .
Two Types of Virus :-
-: HIV I – More Virulent,
global, easily Transmitted
-: HIV II – Less
Transmittable,confined to
Africa.

6. Replication Cycle Of HIV :-

7. Global Pandemic
 33.4 million adult individuals infected(2008)
 2.1 million children are infected (2008).
 15.7 million women are infected.
 1.4 million HIV+ pregnant women
Global Scenario

8.  Negligible number in year 1986 to 5.5 million in year 2006.
 Second highest in the world because of the large size of
the population.
 About 2.4 million AIDS cases in India were documented in
our country
 Over 39% i.e 93600 are women of reproductive age
groups.
 4.4% children are infected
(NACO 2010.)
Indian Scenario - EPIDEMIC

9. HIV/AIDS – India’s Response
• 1986: 1st case of HIV detected in Chennai
• 1990: HIV/AIDS Cell set up in MoHFW
• 1992: NACP-I launched with a outlay of US$ 84 m
• 1992: National AIDS Control Organisation (NACO)
established within MoHFW
• 1999-2006: NACP-II
• 2007-2012: NACP-III
• NACP IV (2012-2017) on the anvil with projected outlay of
more than US$ 2 billion

10. Categor
y
NACP-III Definition
A > 1% ANC prevalence in any of the sites in the
last 3 years
B < 1% ANC prevalence in all the sites during last
3 years with > 5% prevalence in any HRG site
(STD/FSW/MSM/IDU)
C < 1% ANC prevalence in all sites during last 3
years with < 5% in all STD clinic attendees or
any HRG, with known hot spots
D < 1% ANC prevalence in all sites during last 3
years with < 5% in all STD clinic attendees or
any HRG OR no or poor HIV data with no known
hot spots

11. Routes of HIV Transmission, 2012-13

12. HIV Concentrated in HRG & Bridge Pop.
Source: HIV Sentinel Surveillance 2010-11 – A Technical Brief, NACO

13.  Acute retroviral syndrome ; fever, night sweats, fatigue,
rash, headache, lymphadenophathy, pharyngitis,
myalgias, arthralgias, nausea, vomiting, diarrhea ; lasts <
10 days
 After symptoms abate ; chronic viremia
COURSE OF THE DISEASE

14.  Median time = 10 years --- AIDS
 AIDS; generalized lymphadenopathy, oral hairy
leukoplakia, aphthous ulcer, thrombocytopenia,
opportunistic infections ( candida, HSV, TB, CMV,
HPV, PCP, toxoplamosis), Kaposi sarcoma, non-
Hodgkin lymphoma

15.  Stage I :-
 Asymptomatic or with Persistent generalized
Lymphadenopathy.
 Performance Scale 1 :- Asymptomatic normal activity .
 Stage II :-
Wt.loss < 10% of body wt.
 Minor muco-cutaneous lesions
Herpes zoster within last 5yrs.
 Recurrent URTIs .
 Performance Scale 2 :- Symptomatic, normal activity.
WHO Staging System.

16.  Stage III :-
 Wt. Loss > 10 % body wt.
 Unexplained chronic diarrhea / persistent fever for > 1month.
Oral candidiasis / hairy Leukoplakia.
 Pulmonary TB within past 1 yr.
Performance Scale 3 :- Bedridden for < 50% of day in last
month.

17. Stage IV :-
 HIV wasting syndrome.
PCP / CNS Toxplasmosis / Extrapulmonary
cryptococcosis
Cryptosporidiosis / Kaposis Sarcoma / Lymphoma
Extrapulmonary TB / HIV Encephalopathy
Performance Scale 4 :- Bedridden for > 50% of day in
last month.

18. Screening –
ELISA
Rapid antibody tests.
Dot blot tests
Particle agglutination
HIV spot and comb test
Immunochromatography
Dipstick and comb’s test
Negative if the first test result is negative.
(Revised Training Curriculum Trainer Manual, NACO)
Establishing diagnosis of HIV

19. Positive results - re-checked by a 2nd & confirmed by an
3rd Rapid test using different antigen or using different
principle & using the same serum/plasma sample as used
in the first test.
In-determinate results are confirmed by ELISA
ELISA + - Declared positive
ELISA – Declared negative

20. All Pregnant women should be given voluntary counseling &
testing (VCT) with confidentiality. Both partners should be
counseled & tested for HIV in pregnancy.
(NACO).
 Opt out approach is preferable – HIV testing as routine
ANC Care (WHO, ACOG)
 Repeat testing in third trimester is indicated if there is :-
 H/o STDs, illicit drug use, multiple sexual partners.
 Symptoms of acute HIV infection at any time during
pregnancy.
 In areas of high prevalence (5/1000).
HIV Screening in Pregnancy

21. Agree to test Offer HIV test Opt out
HIV –ve HIV +ve repeat counseling
Post-test offer HIV test at
Counseling subsequent visit
Support
referred to ART centre

22. MOTHER TO CHILD TRANSMISSION
Parent to child transmission (PTCT) or Vertical transmission or
perinatal transmission is the second most common mode of
transmission of HIV infection in India.
 90% of infections in children are due to MTCT.
Women diagnosed HIV positive during pregnancy should be
informed that interventions (such as antiretroviral therapy,
caesarean section) can reduce the risk of PTCT from 30 -45%
to less than 2%.
15% of new HIV infections each year are caused
by MTCT
WHY DO THE TEST?

23. Timing Transmission rate
During Pregnancy 20-25 %
During Labour & Delivery 60 – 70 %
During Breastfeeding 15 – 20 %
Overall Without Breastfeeding 15 – 25 %
Overall with Breastfeeding upto 6 mths 20 – 25 %
Overall with Breastfeeding upto 18-24mths 30 – 45 %.
Estimated Risk of PTCT in absence of
interventions

24. Maternal Factors :-
 CD4 count
 Viral Load
 Viral resistance
 HIV subtype
 Concurrent infections
 STDs & genital
infections
 Maternal malnutrition
 Sexual Practices
 Antiretroviral treatment
Factors which affect MTCT -

26. Obstetrical Factors :--
 Ruptured membranes
(>4 hrs) Each hr. of ROM increases MTCT by 2%.
 Chorio-amnionitis : STI
 Vaginal delivery
 Intrapartum hemorrhage
 Uterine manipulation
 Invasive procedures
 Prematurity, LBW.
 Instrumental deliveries

27.  Breast Feeding factors :-
 Duration of breast feeding
Mixed feeding (top feeds + breast milk)
 Breast abscess, nipple fissures, mastitis.
 Oral disease in infant (thrush, sores..)
Factors which affect MTCT

29. Studies have shown no effect of HIV on
pregnancy.
Increased perinatal mortality related to HIV infection
has been reported in infants in developing countries
due to increase in co morbid conditions
No increase in malformations related to HIV
infection.
Effects of HIV on pregnancy

30.  Studies have shown pregnancy has no effect
on progression of disease.
 Absolute CD4 counts fall in all pregnant women &
rebound by 50-100 cells/mm3 after child birth.
 Plasma HIV RNA levels tend to remain stable during
pregnancy
Effects of pregnancy on HIV

31. PPTCT
 Prevention of Parent To Child Transmission
GOALS:
 Primary prevention of HIV in women of child
bearing age
 Prevention of unintended pregnancies in HIV+
women
 Prevention of transmission to the child
 Care and support to the mother, children and
family.

32. I) Prevention of Primary infection :-
1) Provide Access to Condoms.
2) Behavior change communication (BCC) and social
mobilization campaigns
3) Provide early diagnosis & treatment of STDs.
4) Make HIV testing & counseling widely available.
5) Provide suitable counseling for HIV negative women.

33. II) Prevention on Unintended Pregnancies
among HIV women :-
 Effective Family planning services can help
prevent unintended pregnancies in HIV infected
women.
 Providing safe & effective contraception & high
quality reproductive health counseling helps to
make informed decisions about pregnancies.

34.  Goals- improve health and identify risk factors
causing adverse maternal and fetal outcome,
Safe sexual practices
Prevent and manage STD’s
Eliminating alcohol, illicit drug use, tobacco chewing,
cigarette smoking.
Available reproductive options such as IUI, IVF or
ICSI, in sero-discordant couples.
 Educate women about risk factors for peri-natal HIV
transmission, & strategies to reduce those risks.
 Assess indications for antiretroviral regimens
Preconception counseling

35.  Attain a stable, maximally suppressed maternal viral load.
 Evaluate and treat :-
ARV therapy-associated side effects (e.g. lactic acidosis,
hepatotoxicity)
 Evaluate for appropriate prophylaxis for opportunistic infections
and administration of vaccines (e.g., influenza, pneumococcal,
or hepatitis)
 Encourage sexual partners to receive HIV testing and
counseling.
 Educate about Balanced diet, Folic acid & Iron prophylaxis.
Preconception Care

36. Antenatal care
 Initial assesment:
 Regular ANC visits
 Antenatal inestigations
 2 doses of TT
 Iron and Folic acid supplementation
 Screen for TB
 Screen for STI
 Assess CD4 counts
 Cotrimoxozole prophlyaxis therapy if CD4 <
250cells/mm3
 ART/ARV prophylaxis

37. 1. Assess WHO clinical stage
2. Evaluate CD4 cell count
3. Initiate ART/ ARV prophylaxis without waiting
for results.
ART/ ARV PROPHYLAXIS

38. CRITERIA FOR ART : ART to be started if,
a. CD4 count <350cells/cu.mm, irrespective of the
WHO staging
b. WHO stage 3 or 4 disease, irrespective of CD4
cell count
Criteria for ARV prophylaxis
a. CD4 >350 cells/mm3
b. WHO stage 1 or 2

39. ANTI RETROVIRAL
THERAPY

40. Replication Cycle Of HIV :-
NRTI/ NNRTI
FI
PI
Drug Category
Nucleoside reverse transcriptase inhibitors
Abacavir
Didanosine
Emtricitabine
Lamivudine
Stavudine
Tenofovir
Zalcitabine
Zidovudine
Non-nucleoside reverse transcriptase inhibitors
Delavirdine
Efavirenz
Nevirapine
Protease inhibitors
Amprenavir
Atazanavir
Fosaprenavir
Indinavir
Lopinavir/ritonavir
Nelfinavir
Ritonavir
Saquinavir
Fusion inhibitors
Enfuvirtide
Maraviroc ( receptor CCR5 Co)
Integrase inhibitor- Raltegravir
C
B
B
C
C
B
C
C
C
D
B
C
B
C
C
C
B
B
B
B
B
C

41. Regimen of choice
Tenofovir(TDF,300mg)
Lamuvidine(3TC,300mg)
Efavirenz (EFV, 600mg)
--If exposed to NNRTI earlier- protease inhibitor based
regimen,
Tenofovir(tdf,300mg)
Lamuvidine(3tc,300mg)
Lopinavir/ritonavir(lpv/r, 100mg)
ART - HAART

42. Women with known HIV infection who are already
receiving HIV care, but not on ART, who get
pregnant,
a. Repeat CD4 cell count, if done 3 months back, to
determine ART eligibility.
b. Assess WHO clinical staging
c. Initiate ART/ARV prophylaxis at 14 weeks
SCENARIO 2

43. Women with known HIV infection already on ART, who gets
pregnant
a. Evaluate current ART regimen and make necessary
substitutes
b. Undertake CD4 testing
I trimester- Evaluate the present regimen for the safety of
the mother and fetus
If she is on nevirapine based regimen, same has to be
continued
If she is on efavirenz based regimen,
a. <28days- stop and start new regimen with NVP
b.>28days- continue same, not an indication for MTP
SCENARIO 3

44. Pregnant women with unknown HIV status in active
labour or detected to be HIV positive through
whole blood finger prick test
a. Provide intra-partum PPTCT prophylaxis
b. Do confirmatory HIV testing and undertake CD4
cell count, after delivery
c. WHO clinical stage, if HIV is confirmed
SCENARIO 4

45.  Single dose 200mg nevirapine +Zidovudine, 300mg(
after ensuring Hb>9g/dl) + Lamiuvidine(150mg) every
12hrs during labour and delivery
 Confirm HIV status and evaluate CD4 cell count
 Continue AZT+3TC, BD for 7 days after delivery
Later on link her to any ART center, to assess
eligibility to ART or ARV prophylaxis
Intra-partum PPTCT prophylaxis

46. Post-partum women detected to be HIV positive
after delivery,
a. Assess WHO clinical stage, undertake CD4 cell
count , decision about starting therapy
b. Infant prophylaxis and its care.
CASE 5

47. MODE OF DELIVERY

48. RCOG and ACOG
Planned caesarean section :- AT 38 COMPLETED
WEEKS
 LSCS after onset of labour or after rupture of
members- NOT BENEFICIAL
Mode of Delivery :-

49. The European Collaboration
 Controlled trial of C-section versus vaginal delivery
The European Mode of Delivery Collaboration.
Lancet.1999;353:35–39
Mode of Delivery
C-section Vaginal delivery
3/170 (1.8%) 21/200 (10.5%)
50-80% decrease in transmission with C-section
as the mode of delivery

50. Women who are HIV positive who have a
detectable plasma viral load and / or who are
not taking HAART should be offered a planned
caesarean section to reduce peri-natal
transmission
Further research is needed to evaluate the
effect on perinatal transmission and maternal
health of planned caesarean section for
women who are taking HAART or who have
very low viral loads

51. Indications of Vaginal delivery are:-
 Women’s choice.
 Cesarean section deliveries not
possible or safe.
 Women on HAART with undetectable
viral load.

52. Vaginal delivery unless the woman has obstetric reasons for
LSCS.
Elective LSCS is NOT considered a standard PPTCT
intervention.
 Consider :-
 LSCS facilities.
 Stage of disease & viral load in mother.
 Presence of Labor or rupture of membranes.
Though LSCS reduces PTCT it may not be feasible in rural
settings & may increase the risk of infectious
complications.
NACO Recommendation

53.  Already on ART/ARV prophylaxis- continue same
regimen and schedule
 For planned elective cases- continue same
 For emergency cases who are not on any
treatment or prophylaxis- single dose of
nevirapine + AZT + 3TC prophylaxis
 Standard antibiotic prophylaxis to be given in all
cesearean patients
 False labour pains- repeat sd.nevirapine , if last
dose was given more than 48hrs before
ART DURING LABOUR

54.  Blood-less Cesarean with intact membranes is
the key.
 Use HIV Kit with all protective gears.
 Surgery should be slow, steady, Keep the field
blood less by using constant suction & cautery.
 Deliver infant with intact membranes & slowly
suction out amniotic fluid.
 Clamp the umbilical cord immediately.
 Avoid Manual removal of Placenta.
 Good surgical practices like use of forceps,
avoiding using fingers, be careful while
transferring sharps to assistants.
Precautions during LSCS in HIV +ve

55.  Follow Universal Safety Precautions.
 Minimal Cervical examinations
 Asepsis to be mantained.
 Avoid Prolonged Labor.
 Avoid Prolonged rupture of membranes.
 Avoid Routine ARM. (Delay ARM till 7cm or more dilatation).
 Avoid Invasive fetal monitoring.
 Avoid routine Episotomy.
 Avoid Instrumental delivery, if necessary use forceps over
vaccum
 Avoid use of Methergin due to interactions with various ARV
drugs.
Precautions during Delivery

56. WITHIN ONE HOUR OF DELIVERY,
a. Administer nevirapine to the infant
b. Place infant on mother’s abdomen
c. Encourage exclusive breast-feeding
POST-NATAL PERIOD,
a. Continue ART/ARV prophylaxis
b. Support daily nevirapine administration to the infant
c. Ensure maternal well-being and rule out post-partum
infections
d. Counsel family members to provide constant support and
care.
e. Nutritious diet, adequate rest and supplements
POST- PARTUM PERIOD

57. At 6 weeks,
 See for pallor, any breast engorgement or mass,
cesearean and episiotomy wound
 See for any features of opportunistic infections
 Counsel her for insertion of IUCD and educate
about DUAL CONTRACEPTION
FOLLOW-UP

58.  ON ART- Life-long
 On ARV prophylaxis- depends on feeding pattern,
a. on exclusive replacement feeds- stop after
delivery
b. on exclusive breast-feeding- continue for the
duration of breast-feeding and for one week after
cessation of breast-feeding.
 Women who directly came in labour- continue
AZT/3TC drugs for 7days irrespective of feeding
practices.
THERAPY- HOW LONG?

59. SUMMARY

60. WHO RECOMMENDATIONS

62. Rationale: Shift from Option A to B+ or
B
Major issue now is not “when to start” or “what to start” but “whether to
stop”
BENEFITS FOR MOTHER AND CHILD BENEFITS FOR PROGRAM DELIVERY
& PUBLIC HEALTH
Ensures all ART eligible women initiate
treatment
Reduction in number of steps along
PMTCT cascade
Prevents MTCT in future pregnancies Same regimen for all adults (including
pregnant women)
Potential health benefits of early ART for
non-eligible women
Simplification of services for all adults
Reduces potential risks from treatment
interruption
Simplification of messaging
Improves adherence with once daily,
single pill regimen
Protects against transmission in
discordant couples
Reduces sexual transmission of HIV Cost effective

63. Programmatic considerations for
B+
 Initiate all HIV+ pregnant and breastfeeding women on ART
 Operational and programmatic advantages to lifelong ART for
pregnant and breastfeeding women (“B+”), particularly in
settings with:
 Generalized epidemics
 High fertility (though need to strengthen FP)
 Long duration of breastfeeding
 Limited access to CD4 to determine ART eligibility
 High partner serodiscordance rates
 National programmes need to decide B or B+

64. HIV EXPOSED INFANTS

69. FEEDING PRACTICES:
RCOG :-
Women who are HIV positive should be advised
not to breastfeed their babies .
Breastfeeding increases the overall MTCT rate by
14% for women infected with HIV before birth and
by 30% in mothers infected postnatally.
HIV EXPOSED INFANTS

70. UN Infant recommendations (2003) :-
 Avoid all breast feeding if replacement feeding
is acceptable, feasible, affordable, sustainable,
& safe ; otherwise exclusive breast feeding with
abrupt weaning at 4-6 months of life.

71.  EXCLUSIVE BREAST FEEEDING- 6 MONTHS
 Maternal death, severe maternal infection or mother’s choice-
exclusive replacement feeds may be considered
 EXCLUSIVE REPLACEMENT FEEDS- AFASS criteria,
a. Affordability
b. Feasible
c. Acceptable
d. Safe
e. Sustainable
Start weaning after 6 months and gradually start complementary
feeds irrespective of HIV status of the infant
NO MIXED FEEDING UNDER ANY CIRCUMSTANCES
NACO RECOMMENDATIONS

72. HIV negative Breast-feed infants HIV positive
Continue BF till 12months of age continue BF til 2years
irrespective of whether or not mother age along with pediatric
Is on ART/ARV prophylaxis ART
After 6 weeks of stopping BF, repeat EID
Rapid test–- DBs– WBS
WBS +--- pediatric ART
Confirmation t 18 months using 3 rapid tests
HOW LONG?

73. BIRTH WEIGHT DOSE/mg DOSE/ml DURATION
< 2KGS 8mg/kg OD 0.2ml/kg OD 6 WEEKS
2-2.5KGS 10mg/kg OD 1 ml/kg 0D 6 WEEKS
> 2.5KGS 15mg/ kg OD 1.5 ml/ kg OD 6 WEEKS
NVP prophylaxis

74.  Oral contraceptive pills,
a. Not on any treatment- WHO category 1- no restriction for
the use of the method
b. On ART- dose adjustment many be needed as drug
interactions are known to occur, ritonavir and nevirapine
reduce the efficacy of OCP’s
 Injectable contraceptives- WHO category 1- no restriction
 Intra-uterine contraceptive devices- WHO category 1, can
be within 48hrs after delivery also
 Permanent sterilisation- Best, but should continue to use
condoms
a. Motivate men at every mother-baby pair follow-up
b. Can be done after 18 months irrespective of HIV status of
the infant
Family planning and birth spacing

75.  Wash the wound & exposed sites with soap & water.
 Rapid HIV testing on patient & health care worker.
 Start PEP within 2 hrs. of exposure.
 Discontinue PEP if confirmed that pts HIV test is
negative
Regimens:
 AZT+ 3TC for 4 wks, add protease inhibitor if exposure
is severe.
 Repeat test after 3 and 6 months
 In pregnant individuals, Nelfinavir/ lopinavir is a better
Post Exposure Prophylaxis Guidelines

76. Opportunistic
Infections
Prophylaxis
indicated
below CD4
count
Prophylaxis in Pregnancy.
Pneumocystis
Carini
Pneumonia
(PCP)
200 TMP-SMX 1 double strength
tablet daily or Pentamidine 300
mg once a month
Toxoplasmosis 100 TMP-SMX 1 double strength
tablet daily .
Disseminated
MAC
50 Azithromycin 1200 mg weekly.
Prophylaxis for OI’s in Pregnancy

77.  For frequent or recurrent infections of :-
 Herpes Simplex :- Acyclovir 200 mg tid PO.
 Candidiasis :- Fluconazole 100-200 mg/d PO.
 Recommended Immunizations for :-
 Hepatitis B Virus.
 Hepatitis A Virus.
 Influenza Virus.
 Pneumococcus.
(NIH/CDC 2008 guidelines for
OIs)
Prophylaxis for OI’s in Pregnancy

78. a. 10 times more in HIV positive women
b. Risk of MTCT transmission increases by 2.5
times
c. Intensified case finding has to be initiated
d. Anti-tubercular drugs have to be started first,
followed by ART as soon as possible, start ART
irrespective of CD4cell count
Positive women with active TB

79. a. Less progressive and less incidence of MTCT(0-
4%)
b. NNRTI are not effective against HIV-2, hence
regimen includes
2 NRTI + LPV/r
HIV -2 INFECTION

80. a. Common among IV drug abusers
b. Require treatment for HBV infection- Regimen
TDF+3TC+EFV, to be started irrespective of CD4
count and WHO staging as it is effective against
both.
c. If treatment is not required- follow general
recommendations for ART/ARV prophylaxis
d.HCV co-infection- follow general
recommendations for ART/ARV prophylaxis
Hepatitis B or C co-infection

81. Women with indications for ART with Hb
<9g/dl should be on a non-AZT regimen and
receive treatment for anemia.
Alternatives to AZT are Stavudine(d4T) or
Abacavir.
Pregnancy in HIV +ve who have
anaemia

82.  Primary prevention of HIV in women of childbearing age
 Voluntary Counseling(VCT) & Testing in Pregnancy.
 Proper Counseling & education of HIV+ve Pregnant
couples.
 Multidisciplinary approach.
 Screen for genital tract & opportunistic infections.
 ARV Prophylaxis/ ART reduces MTCT regardless of CD4
cell count and HIV-RNA levels.
Take Home Message :-

83.  Vaginal delivery with utmost precautions can
reduce MTCT by only 2 percent.
 Elective LSCS can reduce MTCT by 50%.
 Exclusive breast feeding for 6 months as this
provides adequate nutrition and also protects the
baby from hazardous infection which is
responsible for majority of neo-natal morbidity
and mortality.

84. 