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Prevention of Parent-to-Child Transmission HIV.P

  2. INTRODUCTION  Human immunodeficiency virus(HIV) causes an incurable infection that leads ultimately to a terminal disease called acquired immunodeficiency syndrome(AIDS).  Worldwide 25-30% of infected patients are women and 90% of them are 20-49year of age.
  3. INCIDENCE OF HIV • This disease alarmingly increasing both in the developed and in developing countries.  The prevalence even in low risk population in America is close to 1 in 1000. • The seropositivity rate among US pregnant women is 1-2 per 1000. • In most Asian countries the infection rate is less than 0.5%.
  4. NACO’S 4-PRONGED PPTCT STRATEGY  Primary prevention of HIV among women of childbearing age  Preventing unintended pregnancies among women living with HIV  Preventing HIV transmission from a woman living with HIV to her infant  Providing appropriate treatment, care and support to women living with HIV and their children and families
  5. Maternal Risk Factors Influencing PTCT  High viral load  HIV subtype  Resistant strains  Advanced clinical stage  Concurrent STI  Recent infection  Viral, bacterial and parasitic (esp. malaria) placental infection  Malnourishment
  6. OBSTETRICAL RISK FACTORS INFLUENCING PTCT  Uterine manipulation (amnio, external cephalic version)  Prolonged rupture of the membranes (>4 hours)  Placental Disruption (abruption, chorioamnionitis)  Intrapartum haemorrhage  Invasive foetal monitoring (scalp electrode/scalp blood sampling)  Invasive delivery techniques: episiotomies, forceps, use of metal cups for vacuum deliveries
  7. INFANT RISK FACTORS INFLUENCING PTCT  Immature Immune System – Preterm baby  Low birth weight (<2.5kg)  First infant of multiple birth  Altered skin integrity  Immature GI tract  Genetic susceptibility – HLA genotype – CCR5 karyotype deletion
  8. INTERVENTIONS DURING PREGNANCY  Primary prevention of HIV in childbearing women  Provide HIV information to ALL pregnant women  Antenatal visits are opportunity for PPTCT  Prevention of unwanted pregnancy in HIV-positive women  Prevention of PTCT through ART (to mother and baby)  Safe obstetric practices
  9. INTERVENTIONS DURING LABOUR AND DELIVERY  Minimise vaginal examinations  Avoid prolonged labour – Consider using oxytocin to shorten labour when appropriate  Avoid premature rupture of membranes – Use Partogram to measure labour – Avoid artificial rupture of membranes (unless necessary)  Avoid unnecessary trauma during delivery – Use non-invasive foetal monitoring – Avoid invasive procedures, such as using scalp electrodes or scalp sampling – Avoid routine episiotomy – Minimise the use of forceps or vacuum extractors – Uterine manipulation - amnio, external cephalic version (ECV)
  10.  Do not use suction unless absolutely necessary – If suction is a must, use either mechanical suction at <100 mm Hg pressure or bulb suction, rather than mouth-operated suction  Clamp cord after it stops pulsating and after giving the mother oxytocin.  For all infants: – When head is delivered wipe infant’s face with gauze or cloth – After infant is completely delivered, thoroughly wipe dry with a towel and transfer to the mother
  11. CONSIDERATIONS REGARDING MODE OF DELIVERY  Caesarean section performed before the onset of labour or membrane rupture has been associated with reduced HIV Transmission from Mother to Child  The risk of elective Caesarean for PMTCT should be assessed carefully in the context of factors such as: – Risk of post-operative complications – Safety of the blood supply – Cost  In India, normal vaginal delivery is recommended unless the woman has obstetric reasons (like foetal distress, obstructed labour, etc) for a C-section  Use of ART can reduce risk of PTCT better and with less risk than a C-section
  12. INTERVENTIONS DURING INFANCY  Observe for signs and symptoms of HIV infection  All HIV exposed infants should receive cotrimoxazole at 4-6 weeks of age.  Follow standard immunization schedule  Routine well baby visits  DNA PCR  18-month visit for HIV testing
  13. INTERVENTIONS FOR SAFER INFANT FEEDING  Exclusive breastfeeding  Support good breast health and hygiene  Replacement feeding – if Affordable, Feasible, Acceptable, Sustainable and Safe (AFASS)  Avoiding addition of supplements or mixed feeding which enhance HIV transmission Discussions with mothers about the above must consider personal, familial and cultural concerns
  14.  ARV prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother-to- infant.  ARV therapy: Long-term use of antiretroviral drugs to treat maternal HIV and for PPTCT.  ARVs during pregnancy decrease the HIV viral load in the mother’s blood, thus lowering the chance of her infant to get exposed to the virus.
  15. ANTIREROVIRAL PROPHYLAXIS MONOTHERAPY Nevirapine (NACO Guidelines) – Mother - Single dose NVP 200mg onset of labour – Baby - Syrup NVP 2mg/kg within 72 hours of delivery Zidovudine syrup- infant less than 2.5kg/ 15mg/ twice day. Revised NACO Guidelines will be in place shortly
  16. ARV PROPHYLAXIS DURING LABOUR & DELIVERY FOR HIV-INFECTED WOMEN  Administer ARV therapy or ARV prophylaxis during labour according to national guidelines to reduce maternal viral load and provide protection to the infant  Avoid repeat dosing of single-dose NEVIRAPINE (e.g., in the case of false labour), as this can cause viral resistance – Ensure that a woman is in true labour before administering a single- dose of NVP – Document NVP administration clearly on a patient’s Partogram or medical record to avoid accidental repeat dosing PPTCT