HIV IN PREGNANCY

DEFINITION
Prevention of Mother To Child Transmission (PMTCT) is the prevention of transmission of
HIV virus from the mother to the fetus and child during pregnancy, childbirth and
breastfeeding.

RISK OF MTCT
The risk of mother to child transmission varies during pregnancy, labor and delivery and
breastfeeding (see table 21 below)

Table 21. Rates of HIV transmission during pregnancy, labor and delivery, and
breastfeeding.

Estimated Risk of MTCT

Timing Transmission rate without Intervention

During pregnancy 10 - 25*
During labor and delivery 35 - 40%
Overall with breastfeeding to 6-14 months 35 - 40*
NOTE: * Rates of transmission vary because of differences in population characteristics such
as maternal CD4+ cell counts, RNA viral load, exclusivity and duration of breastfeeding

Factors that affect the rate of MTCT

Maternal Factors:- Obstetric and delivery practices:-
 High maternal viral load  Ante-partum procedures (e.g.
 New or recently acquired maternal amniocentesis, external cephalic
HIV infection version)
 Low CD4 count  Rupture of membrane for more than
 Advanced maternal disease four hours
 Viral or parasitic placental infections  Vaginal delivery compared to CS
during pregnancy, labor and childbirth  Injuries to birth canal during child
 Maternal malnutrition birth (vaginal and cervical tears)
 Nipple fissures, cracks, mastitis and  Invasive childbirth procedures (e.g.

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 breast abscess episiotomy)
 Poor ART adherence  The first twin in vaginal delivery of
 Active lower genital tract infections multiple pregnancies
like herpes simplex  Delayed infant drying with clean
Infant factors:- towels and eye care
 Routine vigorous infant airway
 First infant in multiple birth
suctioning
 Pre-maturity and low birth weight
 Instrumental deliveries (vacuum &
 Longer duration of breastfeeding
forceps)
 Mixed feeding during the first six
 Fetal birth trauma
months of life
 Internal fetal monitoring (fetal scalp
 Oral diseases in child
electrodes/sampling)

EFFECT OF HIV ON PREGNANCY

There is increased risk of Low birth weight, intrauterine growth restriction, preterm delivery
and perinatal mortality.

EFFECT OF PREGNANCY ON HIV

There is no known effect of pregnancy on HIV.

PREVENTION OF MTCT OF HIV

There are four prongs to prevent mother-to-child transmission of HIV (PMTCT).
 Prong 1: Primary prevention of HIV infection – focuses on keeping people HIV-
negative. Prevention of new infections means that fewer women and men will have
HIV and fewer infants will be exposed to HIV.
o Promote safer and responsible sexual behavior and practices through BCC
using the “ABC” approach
o Provide early diagnosis and treatment of sexually transmitted infections
o Make HTC widely available
o Provide Pretest test information
 Prong 2: Prevention of unintended pregnancies in HIV-positive women –
emphasizes reducing the number of unplanned or unwanted pregnancies.
o Effective family planning counseling and service is important to help HIV-
infected women prevent unintended pregnancies and space births. It should be
conducted sensitively, maintaining confidentiality and privacy, and must
demonstrate respect for clients’ rights.
o FP/HIV services integration is a valuable approach in reducing the unmet needs
of both family planning and HIV care services.

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 o Counseling on FP should be started in the antenatal period
 Prong 3: Prevention of HIV transmission from women living with HIV to their
infants – addresses care for HIV-positive women during pregnancy, labour and
childbirth, and breastfeeding and care for their infants.
 Prong 4: Provision of treatment, care, and support to women living with HIV, and
their infants, partner, and families – including on-going, chronic care and treatment
for HIV-positive pregnant/postpartum women and their HIV-exposed and HIV-
positive children both during and beyond the PMTCT intervention period.

DIAGNOSIS:

 All pregnant women attending maternal health services (i.e. antenatal, labour,
postpartum) should have screening for HIV with serologic tests following the national
PMTCT guideline (using the opt-out approach)
 If test result becomes positive: request laboratory tests (CD4 count & viral load)
 Clinical symptoms and signs of opportunistic infections should be thoroughly looked
for and appropriate laboratory tests should be requested & the clinical stage of the
disease assigned.
 If the test becomes negative, repeat HIV counseling and Testing in the third trimester
preferably between 28 to 36 weeks or during labor as appropriate
 All HIV positive pregnant or lactating women should be retested with a second
specimen before initiating ART.

MANAGEMENT

Preconception care
Once a patient is diagnosed to be HIV positive the following should be done:
 Counseling on the diagnosis and linkage to trained personnel for further counseling
 Baseline investigations including CD4 and viral load
 Advise on contraception use with focus on avoiding unintended pregnancy; the
preference is to give them dual contraception with one of them being condoms.
 Advise on general health including good nutrition
* Adequate caloric intake; consumption of iron rich foods (beans lentils, meat, liver);
iron and folate for three months; iodized salt
 Prevention of malaria: use of ITN for women living in malaria endemic areas.
 Screening & treatment for opportunistic infections & STIs
 Initiate ART/ Link to PMTCT unit. ART should be initiated in all pregnant and
breastfeeding women living with HIV regardless of WHO clinical stage and at any

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 CD4 cell count and continued lifelong. Discuss on future plan for pregnancy and
necessary preparations
 Provision of prophylaxis for opportunistic infections
o Cotrimoxazole for stages 2, 3, 4 HIV/AIDS and those with CD4 <=350.
 Discuss the importance of partner involvement & screening
 Avoid pregnancy for 6 months after recovery from any chronic infections (e.g Tb)
 If the patient has plan of pregnancy council on the following
o On the impact of HIV on pregnancy
o Provide accurate information on risk MTCT
o Explain available methods of reduction of MTCT
o The above mentioned counseling also apply to pregnant mothers

Antepartum care by visit and trimester of pregnancy

In addition to the focused ANC, HIV positive pregnant women need special care and should
have more visits. As soon as the patient has a missed period she should visit the antenatal
care clinic and have pregnancy test.
 Once pregnancy is confirmed, careful clinical evaluation (detailed history and
physical examination)
 All HIV positive pregnant, laboring and lactating women should be retested at the
initiation of HAART in order to ensure correct diagnosis.
 All HIV positive pregnant, laboring and lactating mothers will be initiated on
HAART for life (TDF, 3TC and DTG).
 HIV positive woman already on ART at time of pregnancy should continue and stay
on the same regimen.
 Pregnant women with WHO clinical stage 1 and 2 can safely be initiated on ART in
ANC; however, those diagnosed with advanced HIV disease at ANC (WHO stage 3
and 4) and opportunistic infections should promptly be referred to ART clinic for
diagnosis and treatment of OI and initiation of ART.
 However, following which, at the discretion of the ART clinic provider, they can be
transferred back to PMTCT unit for their on-going care and treatment.
 Monitoring and support for HAART adherence
 Early ultrasound for determination of gestational age
 Routine Laboratory screening tests like any pregnant women
(VDRL, HBSAg, CBC, Blood group and Rh, and others as needed).

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  There is no need to wait for CD4 count to initiate treatment. But CD4 count is
important to monitor response to treatment; however, viral load monitoring is more
effective to detect emergence of treatment failure
 Viral load monitoring to detect emergence of treatment failure
 Advise the mother on the importance of having strict ANC follow up with updating
investigations as needed
 Discuss with the mother the risk of MTCT and the possible complications that can
occur due to the HIV infection including (IUGR)
 Administer vaccinations like TT, pneumococcal and if HBSAg negative administer
HB vaccine.
 Nutritional supplementation like other pregnant women
 Follow the fetal growth with serial US every 3-4 weeks
 Discuss on the mode of delivery based the national PMTCT guideline (routine CD for
the prevention of MTCT is not recommended). But individualized birth plan based on
the viral load and the duration of HARRT is recommended.
 Discuss on the postpartum infant feeding plan
 Discuss on the post-partum administration of ART to the neonate for reduction of
MTCT
 Assess the patients support system and offer counseling if concerns arise

Intrapartum care
 Intra partum care and infection prevention include:
o Safe delivery practices and avoiding invasive procedures whenever possible:
 Avoid artificial rupture of membranes to shorten labour and expedite
delivery whenever there is a spontaneous rupture of the membrane.
 Avoid routine episiotomy.
 Limit use of vacuum extraction and prefer obstetric forceps whenever
instrumental delivery is indicated
 Avoid repeated vaginal examinations during labour and
 Treat chorioamnionitis with appropriate antibiotics
o Provide essential newborn care...
 Regarding mode of delivery:- For women on HAART, if the viral load is >
1000 copy/ml elective cesarean section at gestational age of 38 weeks
should be considered.

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  If the viral load is ≤ 1000copies/ml since there is no added benefit from
cesarean section, the mother should be counseled on vaginal birth
preparedness like any other pregnant mother
 In the absence of viral load, a woman adherent to HAART for at least for
one month is considered to have lower viral load. Clinical judgment of the
provider in consultation with the woman can be the way to decide the route
of delivery.
 The benefits and risks of different modes of delivery should be
discussed with women living with HIV, including vaginal delivery,
and elective and non-elective C-section.
 When indicated for other medical or obstetric reasons, C-section
should still be offered, as for all women.
 If the mother is already started on ART it should be continued intrapartum
 If she is a newly diagnosed RVI patient with no ART it should be started intrapartum
and continued post-partum irrespective of the CD4 count.
 Emergency CS is reserved for patients with obstetric indications

Post-partum care
 Continue initial ART for those who are initiated earlier. Start ART for HIV positive
mothers who are breastfeeding even if it was not started before (currently
recommended regimen TDF/3TC/ DTG )
 For mothers who fulfill Acceptable, Feasible, Affordable, Sustainable and Safe
(AFASS) feeding, formula feeding should be considered after thorough discussion
with the family.
 For those who do not fulfill AFASS, breastfeeding must be exclusive for six months
and complementary feeding should start at 6th month. Breastfeeding should be
continued until the first year of life but not more than two years.
 Give NVP + AZT syrup for the first 6 weeks and continue NVP syrup only for the
next 6 weeks for all HIV exposed infants (see table 22 below for dosing).

Table 22. Enhanced Post-natal Prophylaxis (e-PNP) for HIV Exposed Infants

Infant age / weight Formulation Dosing

NVP 10mg/ml 10 mg ( 1ml ) once daily

< 2500g + +
0-6 weeks AZT 10mg/ml 10 mg (1ml ) twice daily
NVP 10mg/ml 15mg (1.5ml) once daily
> 2500g + +
AZT 10mg/ml 15mg( 1.5ml) twice daily

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6-12 week NVP 10mg/ml 20mg (2ml) Once daily

 Educate mothers on the importance of exposed infant follow-up, Co-trimoxazole

preventive therapy and early infant diagnosis. (see table 23 below for dosing)
o DBS for DNA/PCR should be done at sixth week of life and HIV negatives should
be followed as HIV Exposed Infant (HEIs).
o DNA/PCR positive babies should be linked to pediatric ART for chronic
HIV/AIDS follow up

Table 23. Dosage of Co-trimoxazole preventive therapy in infants and children

Preparation of the Co-timaxazole suspension and tablets

Suspension per 5 Pediatric tablet Single strength adult

Age ml 200/40 mg 100/20mg tablets( 400/80 mg)

< 6 months 2.5 ml 1 tablet ½ tablet

6 months - 5 years 5ml 2 tablets ½ tablet

 Do confirmatory rapid HIV antibodies test for DNA/PCR negative HEIs six weeks
after the cessation of breastfeeding
 Discharge negative babies for follow up after rapid HIV antibody test and link the
positive babies to chronic pediatric HIV care, treatment and follow up.
 Give postpartum family planning counseling and provide mothers with family
planning method of their choice as per the PMTCT guideline and post-partum care
section of the protocol.
 Immunization and growth monitoring for the baby should be done the same way as
non HIV exposed babies
 The mother and infant should do their follow up at the MNCH clinic, where they can
get integrated MNCH and HIV care.
 After discharge link the mother with ART clinic in the following scenarios:
o If the baby is DNA/PCR positive
o If the baby is rapid HIV AB test positive
o If the baby is dead.
o If the mother develops any HIV/AIDS related complications of the disease or
its treatment

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Note: Adherence counseling and follow up is mandatory and it should be done for the
mother and infant as a pair.

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