1. HIV in pregnancy
ESMOE

2. World Aids Day – 1 December 2009
The Government announced improvements to ART (anti-retroviral treatment) for special groups. All HIV +ve infants, pregnant women, persons with HIV and TB and those with CD4 counts ≤ 350µl would receive ART 2.6 million people were on ART by mid- 2014
Start of our modern HIV strategy. Prior to this there was denialism and an estimated 330,000 unnecessary deaths

3. Further progress
2013 FDC introduced Jan 2015 Threshold for initiation of ART ≤ 500µl All pregnant and breastfeeding women qualify for lifelong ART June 2015 Improved infant testing

4. Fixed dose combination (FDC)
Combination of emtricitabine 200mg (FTC), tenofovir 300mg (TDF) and efavirenz 600mg (EFV)

5. Current status
HIV testing of pregnant women now close to 100% PMTCT (Prevention of Mother to Child Transmission) now offered in 98% of facilities ART uptake increased from 83% in 2009 to 87.1% in 2012 MTCT reduced to 2.7% in 2011

6. HIV - Current status in SA
SA has highest HIV burden in the world
2015 national sero-prevalence survey showed an increase in the ANC infection rate
There is a high mortality due to HIV and AIDS
SA has the largest HIV and AIDS program but morbidity and mortality remain high
There is a political commitment to increase the life expectancy of S Africans by providing ARVs
Sa has 1% of the world’s population and 17% of global HIV

7. Maternal mortality and NPRI for each triennium and for 2011-2013.
2011
2012
2013
iMMR NPRI 55
66.28
71.29
53.47
58.87
54.08
47.49
iMMR all maternal deaths
145.48
151.77
176.22
154.06
163.11
155.23
143.85
total number of deaths from NPRI
1246
1729
1969
1504
550
509
445
% of all maternal deaths
37.8
43.7
40.5
34.7
36.1
34.8
33.0

8. The bad news…..
This improvement in only in the NPRI category All the other categories remain unchanged

10. Benefits of earlier initiation of ART
Delayed ART
Early ART
Drug toxicity
Preservation of limited Rx options
Risk of resistance (and transmission of resistant virus)
↑ potency, durability, simplicity, safety of current regimens
↓ emergence of resistance
↓ toxicity with earlier therapy
↓risk of uncontrolled viremia
Near normal survival if CD4+ count > 500
↓ transmission
ART, antiretroviral therapy; Rx, prescription.
For years, HIV experts have debated whether it is better to start antiretroviral therapy early or whether treatment should be deferred until later in the course of disease. In recent years, there has been an increasing movement toward early antiretroviral therapy, given the potency, simplicity, and safety of current regimens and the significant benefit of early therapy in terms of patient health and survival and the reduction in the risk of transmission.

11. Maternal factors

12. Encourage all women to book as early as possible in pregnancy, preferably before 14 weeks gestation
Do not turn women away when trying to book
All women coming to the clinic for a pregnancy test or first antenatal booking must be seen on the same day

13. Counselling
No change
Group, individual pre-test, post-test and test refusal.
Method of testing, interpretation, treatment advantages
Prevention, condoms, breast feeding, contraception, circumcision and family spacing
Not sure how they manage all this for all pts!!

14. HCT (HIV Counselling & Testing)
Group information session to all clients Individual info session and offer to test Agree to test Test HIV –ve Post test counselling Repeat HIV in 3 months Educate re- window period

15. Tests HIV +ve
Confirm with 2nd test Positive Same day post test counselling TB screening, HIV education, support, CD4 count, creatinine, clinical staging Immediate initiation of FDC

16. Test refusal
Post refusal counselling Continuously offer PICT (Provider Initiated Counselling and Testing)

17. When to repeat HIV test
Every 3 months through pregnancy At labour/delivery At the 6 week EPI visit Every 3 months during breastfeeding Conversion rate = 4%

18. Who qualifies for life-long ART?
All pregnant, breastfeeding (even if > 1 year postpartum) or postpartum women up to 1 year post delivery

19. 1st ANC (Antenatal Clinic) visit
Start FDC If contra-indications to FDC (renal & psychiatric disease) Start AZT (zidovudine) if Hb > 7g/dl

20. 2nd ANC visit
Any CD4 count and creatinine ≤ 85 mmol/l Continue FDC ↑ creatinine or psychiatric illness Refer

21. Tests +ve in labour
Single dose (sd) NVP and Truvada + 3hourly AZT for duration of labour Caesarean section (C/S): sd NVP + sd Truvada Start FDC next day
This regimen is used as it is fastest in achieving high ARV levels to cover delivery

22. Test +ve postpartum → 1 year
Initiate lifelong FDC immediately

23. Pregnant and on ART for > 3 months
Perform viral load (VL) at same visit Review result in 2 weeks VL < 1000 copies/ml Continue ART/switch to FDC

24. VL > 1000 copies/ml
Give comprehensive adherence counselling Repeat VL 1 month later VL unchanged, < 1 log drop (10 fold) or increased Switch to 2nd line ART and infant will require prophylaxis with AZT & NVP

25. WHO clinical staging To assess risk
HIV +ve - baseline
WHO clinical staging To assess risk
Clinical staging on the CD

26. CD4 FBC Creatinine Viral load
Routine blood tests
CD4 FBC Creatinine Viral load

27. CD4 count
To identify eligibility for CTZ ( cotrimoxazole) CD4 <200 To identify eligibility for CrAg (Cryptococcus Antigen screening) CD4 <100

28. Other bloods
Do FBC To detect anaemia and neutropenia Do creatinine To assess renal function

29. Pregnant – on ART
Do VL at booking (if on ART for >3 months) To identify treatment failures and confirm suppression VL at 3, 6, 12, 18 and 24 months To monitor disease suppression ↑ in VL →↑ risk of MTCT

30. Other bloods
If on AZT: FBC at 3, 6, 12 and then annually To identify AZT toxicity If on Tenofovir (TDF): Creatinine at 3, 6, 12 and then annually To identify TDF toxicity

31. Factors ↑ risk of MTCT
Prolonged rupture of membranes Multiple PVs Invasive monitoring Episiotomy Invasive suctioning of the neonate’s nose and airway Try and avoid the above but the obstetric situation will dictate management. HIV infection, if on ARVs, should not affect Mx

32. Infant testing

33. Infant testing: HIV PCR
At birth: All babies born to HIV +ve mothers
At 10w: All HIV exposed infants
At 18w: All infants that received 12w of NVP
Breastfed infants test 6w after weaning
PCR if <18m; HIV ELISA if >18m
At 18m: ELISA/Rapid for all
Except if child known HIV+ and on ART

34. ART prophylaxis for HIV exposed infants
Mother on lifelong ART (> 4w pre-delivery) NVP at birth and for 6 weeks PCR at 10 weeks PCR 6 weeks after stopping breastfeeding

35. Mom started ART < 4 weeks before delivery (or tests HIV+ at birth)
NVP for 12 weeks Infant PCR at birth, at 10 weeks, at 18 weeks and 6 weeks after completing breastfeeding

36. Breastfeeding (BF) Mom diagnosed HIV +ve
NVP & AZT immediately PCR –ve: stop AZT, NVP until 4 weeks after cessation of BF or until Mom has been on ART for 12 weeks (VL) Repeat PCR at 18 weeks after starting NVP Infant HIV testing 6 weeks post BF

37. Uncertain HIV status and abandoned infants
Immediate NVP (within 72h of birth) Test infant with rapid HIV test If rapid +ve perform PCR If PCR –ve continue NVP for 6 weeks Repeat PCR at 10 weeks PCR +ve → ARVs ELISA –ve: discontinue NVP

38. Maternal VL > 1000 copies/ml
Dual ARV (AZT & NVP) for 6 weeks PCR at birth PCR at 10 weeks

39. Infant prophylaxis: Summary
Clinical scenario
Infant prophylaxis
Comment
Mother on lifelong ART
NVP x 6w
<4w of maternal ART
NVP x 12 w (if BF)
If no BF, then 6w NVP
Maternal VL >1,000
NVP & AZT x 6w
Unknown maternal HIV
NVP within 72h, then x 6w

40. Further maternal management

41. Isoniazid preventive therapy (IPT)
Must exclude active TB
Any 1 of the following symptoms suggest TB
Should be screened at every ANC visit
Current cough of any duration.
Fever
Night sweats
Weight loss or poor weight gain

42. TB screening
If an HIV positive patient has symptoms suggestive of TB, a sputum specimen must be collected for GeneXpert testing and the TB Xpert diagnostic algorithm followed. Although it is important to investigate patients for TB before starting ART, in most pregnant patients, initiation of ART prophylaxis or lifelong treatment should not be delayed for TB investigations.

43. IPT dosage
Isoniazid (INH): 5mg/kg/day (maximum 300mg/day) + Vit B 6 (pyridoxine) 25 mg/day to prevent peripheral neuropathy
Tuberculin Skin Testing (TST) is recommended in the Guidelines but is not done anywhere

44. Cotrimoxazole preventive therapy (CPT)
For patients with CD4 ≤ 200 cells/µl WHO stage 3 or 4 HIV/TB co-infection Prescribe 2 single strength tablets daily Discontinue when on established ART and CD4 >200 on 2 occasions

45. Cryptococcus screening (CrAg)
Done on all patients with CD4 < 100 cells/µl Cr Ag +ve (no clinical signs of meningitis) Oral fluconazole (800 mg daily for 2 weeks) CrAg +ve (with signs of meningitis) Refer for lumbar puncture and admit for 2 weeks treatment with IV amphotericin B and fluconazole

46. What has changed?

47. Maternal
3-monthly maternal HIV-testing in pregnancy & BF All pregnant, postpartum and women breastfeeding after 1 yr → lifelong ART irrespective of CD4 count Better protocol for VL testing

48. More aggressive infant screening to identify neonates for ART
Birth PCR for all babies born to HIV +ve mothers Follow-up PCR testing at 6 weeks and 6 weeks after completing breastfeeding PCR at 16 weeks: For all infants who received 12 weeks of NVP prophylaxis

49. More aggressive infant prophylaxis
Low VL → 6w NVP Recent ART initiation (high VL)→ 12w NVP Possible maternal HIV resistance (high VL on ART) → 6w AZT & NVP Regular PCR during follow-up