1. HIV IN PREGNANCY PANEL DISCUSSION
Moderator Dr Ashakiran
Panelist: Dr Savitha, Dr Srinivas,
Dr Ashok, Dr Radhika

2. Introduction
Transmission from HIV infected mother to baby is the key mode of HIV transmission in children
Annually about 14,000 New HIV Infections occur among children in India
HIV infection causes about 10,000 deaths annually among children in India
But
It is possible to prevent HIV infection among children
It is also possible to Minimize Mortality if children are infected –Early detection and prompt treatment
PPTCT Overview 3

3. HIV Prevalence Among Pregnant Women (ANC)
National Average (ANC): 0.42%
Estimated HIV positive Pregnant Women / year: 38,202
Higher prevalence in southern region of the country and pockets of high prevalence in rest of the country
Step 2: Parent to Child Transmission in India and Risk factors (Slide 5-10) - 9 minutes
PPTCT Overview
Source – HSS 2010 – 11, Department of AIDS Control, MOHFW/GoI

4. Brief about the virology of HIV

5. Brief about the virology of HIV
It is a spherical, enveloped, single stranded RNA virus.
The reverse transcriptase enzyme is a characteristic feature.
P24 : core antigen, which can be detected in early stages of infection
Envelop antigen gp 120, antibodies against this are present till terminal stages.
Tran membrane protein gp41
IT IS A HIGHLY MUTABLE VIRUS

6. Inactivated by the following
Temperature: 10 min at 60 degree and in seconds at 100 degree centigrade respectively
In 10 min by: 50% ethanol, 35% isopropanol, 0.5% lysol, 0.5% paraformaldehyde, 0.3% hydrogen peroxide, 10% household bleach
0.25% chlorhexidine (to be used to clean the vagina during labor)

7. What is the pathogenesis?
Receptor for the virus is CD4 antigen
Virus enters blood or tissues
Comes in contact with cells having CD4 antigen(receptor). Ex: CD4 T lymphocyte and binds with the help of gp 120
Fusion with host cell by trans membrane gp41.
Co receptors CCR5 and CCXR4 for viral entry
HIV genome in internalized
Reverse transcriptase produces DNA which is incorporated into host genome of infected cells
Cell lysis, release of virons, infection of other cells

8. Modes of spread And Risk of transmission with each route

9. Routes of Transmission of HIV
Step 2: Parent to Child Transmission in India (Slide 3-4) - 3 minutes
Trainer Notes:
The above slide reflects the various routes of transmission in our country.
The trainer here needs to stress that the primary drivers of HIV epidemic in India are unprotected paid sex/commercial female sex work, unprotected sex between men and injecting drug use and explain the definition of High risk groups (STD,IDU,MSM,FSW)
High risk groups: Female sex workers, IV Drug Users, Truck drivers, Men having sex with men, Sexually Transmitted Diseases and others are included in the high risk category.
It is estimated that there are 12.6 lakh Female Sex Workers (FSW), 3.5 lakh Men who have Sex with Men (MSM) with high risk and 1.9 lakh Injecting Drug Users (IDU) in India. Though sex workers account for 0.5 percent of adult female population, they account for seven percent of HIV infected females.
Sex work continues to act as the most important source of HIV infections in India due to the large size of clients that get infected from sex workers.
Heterosexual mode of transmission is still the predominant mode of HIV transmission in India.
Ref: National AIDS Control Organisation (Department of AIDS Control Ministry of Health & Family Welfare Government of India): Annual Report
NACO Annual Report
PPTCT Overview 3

10. Mode of spread
Risk of infection
Blood and blood product transfusion
92%
Receptive penile vaginal intercourse
0.1%
Penetrative penile vaginal intercourse
0.04%
Receptive anal intercourse
1.7%
Penetrative anal intercourse
0.08%
IV drug abuse(sharing of needles)
0.6%
Mother to child transmission
15 to 45%
Needle stick injuries
0.3%

11. Q1
Mrs A, patient living with HIV is 8 weeks pregnant. She comes to you with a query regarding the risk of transmission of HIV to her baby. What is MTCT/PTCT

12. PTCT : parent to child transmission of HIV MTCT : mother to child transmission of HIV

13. Risk of HIV Transmission
Estimated Risk of Mother to Child transmission in absence of any intervention
Risk of HIV Transmission
Transmission Rate
During pregnancy
5-10%
During labour and delivery
10-15%
During breastfeeding
5-20%
Overall without breastfeeding
15-25%
Overall with breastfeeding up-to six months
20-35%
Overall with breastfeeding for months
30-45%
Trainer Notes:
Source: WHO
PPTCT Overview 9

14. What are the risk factors which increase the risk of MTCTQ2
What are the risk factors which increase the risk of MTCT

15. Maternal Risk Factors Influencing MTCT
High viral load
HIV subtype
Resistant strains
Advanced clinical stage
Concurrent STI
Recent infection
Viral, bacterial and parasitic (esp. malaria) placental infection
Malnourishment
Trainer Notes:
The above slide discusses the antenatal factors influencing transmission. Explain each of the points to the participants and ask them to justify the reason for each of the points and facilitate a discussion among the participants.
Reader Notes:
There is a correlation between the maternal blood viral loads and the risk of transmission. There is no lower limit of viral load, below which there is absolute safety and there is no upper limit above which there will be definite HIV transmission. Studies have shown that the viral load, the phenotype and genotype of the virus found in the plasma may be different from what is present in cervicovaginal secretion. Other factors like viral resistance to Nevirapine may also influence transmission.
The lower the CD4 count, the greater risk of transmission. Women who are recently infected and those in clinical stage 3 & 4 have high viremia. Their infants are at higher risk of acquiring the infection. Any infection that induces the presence of immune mediators influences transmission. Sexually transmitted infections in the mother increases genital viral shedding.
While pregnancy does not appear to hasten HIV progression, it is clearly an important additional stress on the body above and beyond the effects of HIV and OI, and ARV side effects. Data on the impact of HIV and pregnancy are difficult to interpret, as so many factors may affect the outcome. Most pregnancy complications appear to be related to advanced HIV disease. .
PPTCT Overview 8

16. Obstetrical Risk Factors Influencing MTCT
Uterine manipulation (external cephalic version)
Prolonged rupture of the membranes (>4 hours)
Placental Disruption (abruption, chorioamnionitis)
Intrapartum haemorrhage
Invasive delivery techniques: episiotomies, forceps, use of metal cups for vacuum deliveries
Trainer Notes:
Ask participants: Consider invasive delivery techniques? Identify “breaks” in the integrity of the skin.
Answer:
This is not dissimilar to women or men with genital ulcers. In this case, it is strictly accessed by the virus to the infant’s blood.
Infant will be exposed to vaginal fluids containing HIV.
If there is haemorrhage, infant will be exposed to mother’s blood with HIV.
If there is an episiotomy, infant will be exposed to mother’s blood with HIV.
If there is invasive foetal monitoring, the skin integrity of the infant is altered, allowing a portal for infection.
Unless the mother’s viral load is suppressed, HIV transmission to baby is generally higher with vaginal delivery than C-section if C-section is performed before labour and rupture of membranes. However, maternal mortality, cost, and skill level is so much higher than vaginal delivery, that C-section is often impractical in many settings in India.
PPTCT Overview 9

17. Infant Risk Factors Influencing PTCT
Immature Immune System
Preterm baby
Low birth weight (<2.5kg)
First infant of multiple births
Altered skin integrity
Immature GI tract
Genetic susceptibility
HLA genotype
CCR5 karyotype deletion
Trainer Notes:
Ask participants the following questions:
Question 1: Why would a premature baby be at higher risk than a full term infant?
Answers:
Encourage participants to think about the biggest organ of the immune system: skin.
Remind people how the skin looks like in a premature baby –fragile, porous.
Question 2: How can low birth weight be a risk factor?
Low birth weight could mean lower resistance and therefore increased risk to HIV.
Question 3: What about first infant? Usually we consider twin A to be healthier and often larger.
Twin A is first in the birth canal, exposed to maternal fluids, bearing “brunt” of contractions.
Twin B, smaller, usually slips right through the “cleaned” birth canal in minutes rather than hours.
Question 4: What about immature GI tract?
Again, think of the newborn with fragile GI tract mucus membrane that may have swallowed infected vaginal secretions and/or amniotic fluid that has been exposed to HIV-infected vaginal secretions.
PPTCT Overview 10

18. Infant Feeding Risk Factors Influencing PTCT
Mother is infected with HIV while breastfeeding
Breast pathologies (cracked nipples, mastitis or engorgement)
Advanced HIV disease in the mother
Poor maternal nutrition
Mouth sores or an inflamed GI tract in baby
Mixed feeding: Breast milk along with other feeds
Prolonged breast feeding (6-18 months)
Trainer Notes:
Ask participants the following questions:
Question 1: Why does becoming infected with HIV while breastfeeding increases the risk of transmission?
Answer: With recent infection there is increased viral load (it will take 6-24 weeks for the body to make antibody to control the virus). The viral load may be in the millions, and transmission risk is increased.
Question 2: What about “Mixed” feeding?
Answer: Microscopic bleeds in baby’s gut could occur from foods other than breast milk (e.g. kanji (porridge), cow’s milk, etc)
This, when followed by ingestion of infected breast milk by the baby, increases its risk of acquiring HIV.
Question 3: What about breast pathologies, like cracked nipples?
Answer: It increases the risk as both breast milk and blood may be swallowed by the baby.
Question 4: What interventions would you discuss with mother in the event of mastitis or bleeding nipples?
Answer: Preferable to express breast milk and heat it slightly. This could kill the virus. Avoid feeding from the affected breast if possible. Avoid mixed feeding. Advanced disease in the mother, poor nutrition could increase the risk of transmission. Prolonged breast feeding increases the risk of HIV transmission.
Question 5: Would sores in the baby’s mouth increase the risk?
Answer: Yes, since the virus could have direct access to the baby’s blood vessels through the cuts.
Reader Notes:
The factor conferring the greatest risk is the mother becoming infected herself during pregnancy or lactation.
Advantages of exclusive breast feeding over mixed feeding need to be emphasised during infant feeding counselling sessions. When replacement feeding (infant formula) is acceptable, feasible, affordable, sustainable and clean water is available, then only the HIV-infected mothers should avoid breastfeeding completely.
Conditions to consider during feeding options counselling: Home environment refers to resources such as refrigerators, cooking facilities, fuel, electricity, etc. For example, difficulty in boiling water 8 times a day or safe storage of milk. Education on how to manage breastfeeding or prepare breast milk substitute and the importance of not mixing the feeds. Income refers to capacity to buy supplies, or taking break during work to breastfeed. Do they have resources to boil water, type of contamination during transport and to store water safely? It may also be difficult to get water.
Family and community support is very important for successful feeding of the child. Breastfeeding support groups and health worker support also play a role. Time available for child care is important. If the mother is working, who takes care of child for exclusive breastfeeding/ preparing and feeding of replacement milk? Access to counselling is especially important during the management of breastfeeding problems or artificial feeding problems.
PPTCT Overview 11

19. What is PPTCT And How can you achieve thisQ3
What is PPTCT And How can you achieve this

20. PPTCT : Prevention of parent to child transmission of HIV

21. HIV Negative general population,
PPTCT: Overall Goals
Four Pronged Strategy
HIV Negative general population,
e.g. ARSH
Prong 1:
Primary prevention of HIV
HIV +ve
Not Pregnant
Family Planning counselling in ICTC but more importantly at ART centres
Prong 2:
Prevent unintended pregnancies
HIV +ve
& Pregnant
Prong 3:
Prevention of MTCT
HIV +ve Mother
& Child
Prong 4:
Care, support and treatment
Step 3: NACO’s Goals of PPTCT (Slides 11-12) - 6 minutes
Trainer Notes: The trainer has to explain the four pronged PPTCT strategy of NACO.
 NACO has a four-pronged strategy for the PPTCT.
The first, primary prevention focuses on preventing HIV among women and men of childbearing age. This can only be achieved as part of a general population-based HIV prevention strategy as discussed in the epidemiology module. Some components of the primary prevention include:
Promoting condoms through social marketing and community-based distribution system. This strategy has helped in increasing the use of condoms in the country at large. There is greater need to ensure availability of condoms at places (hospitals and clinics) & times where they are needed.
Behaviour change communication (BCC) and social mobilisation campaigns. While there is general awareness about the disease, people are still ignorant on specific aspects like mode of transmission, method of protecting oneself from getting infected. There is an urgent need to generate appropriate programmes which stress interpersonal communication for targeted groups (e.g. students, youth, women, migrant workers and children).
Prevention, diagnosis, and treatment of sexually transmitted infections (STIs). The presence of STDs, especially with ulcers or discharge, facilitates transmission of HIV infection. The risk of transmission is 8 to 10 times higher in case of persons having STDs compared with others. Two approaches for STD control adopted by the government are: incorporate management of STDs through Syndromic approach into the general health service and the integrate services for treatment of reproductive tract infections (RTIs) and sexually transmitted infections (STIs) at all levels of health care.
The second strategy involves preventing unwanted pregnancies in HIV infected women. This strategy requires provision of VCT services and voluntary, safe, and effective contraception, sterilisation, or abortion. HIV positive women should have complete choice in making decisions regarding pregnancy and childbirth. Proper counselling should be provided to women to enable her to make an appropriate decision either to continue the pregnancy or terminate the pregnancy.
The third strategy is to promote interventions to prevent PTCT by HIV-positive mothers. PPTCT programme can reduce the risk of transmission from the mother to the child. Examples include: Comprehensive maternal and child health services (antenatal, postnatal, and child health), voluntary, confidential counselling and testing (VCT), antiretroviral (ARV) prophylaxis, counselling and support for safe infant feeding and optimal obstetrical practices.
The fourth strategy is to follow up the positive women and her infant and continue to provide care and support to both. The exposed infant need to be started on CTZ prophylaxis as early as 4-6 weeks for all exposed infants. All immunisations should be considered for these exposed children. The mother needs to be followed up closely and assessment of her eligibility for ART initiation should be done as appropriate if she is not already on ART. 11

22. Q4
Mrs. B is a primigravida with 6 weeks gestation. She underwent testing for HIV after counseling and was found to be positive.

23. What are the tests used for HIV testing

24. Tests for HIV
Screening test : ELISA (antibody) sensitivity of > 99.5%
Confirmatory test : Western blot
Additional tests : EIA (p24 antigen), RNA assay, DNA PCR
Rapid tests : on blood or plasma. Results available within 1-60 min. Sensitivity 99%.
who opt-out of HIV testing should be offered repeat counselling to explore
the reasons for opting out, address any

25. What are the interventions during antenatal period to prevent MTCT

26. 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 pregnancies in HIV-positive women
Prevention of PTCT through ART (to mother and baby)
Safe obstetric practices
Step 4: Factors Influencing Transmission and Strategies to Reduce Transmission Risk (Slides 13-19) – 12 minutes
Trainer Notes:
The trainer can explain the interventions during pregnancy that can control the transmission risk.
Primary prevention includes:
Education about safe sex with use of condoms for mother AND father.
Early treatment of STIs.
Encouraging safe sex during pregnancy and lactation.
Physicians should provide similar care to HIV-positive women as for HIV- negative women. They should have the same number of antenatal visits. Antenatal visits are vital opportunities for PPTCT for both HIV-positive and HIV- negative women. Whether positive or negative, all women should recognise the risk of initial infection, super-infection if they are already infected and STIs in terms of increased burden on the immune system.
Pregnancy is not necessarily high risk in HIV-positive women. Invasive antenatal test and procedures must be avoided and voluntary counselling and testing (VCT) to be given all pregnant women. The eventual goal is no mother-to-child transmission. While this may not be possible currently, we can greatly reduce transmission by using the practices described in this unit.
PPTCT Overview 13

27. What are the NACO guidelines for ART in Pregnancy

28. National PPTCT Algorithm
HIV infected pregnant women
Initiate ART
Already on Life long ART
Continue ART
PPTCT Overview 23

29. ART in Pregnant women with HIV
TDF (300mg) + 3TC (300mg) + EFV (600mg)
FDC once daily pill, to be taken at bedtime
Trainer Notes:
PPTCT Overview 25

30. Recommendations for HIV positive pregnant women
Pregnant Women who are detected to be HIV infected during antenatal care should be initiated on ART tenofovir, lamivudin and efavirenz (TDF+3TC+EFV) regardless of clinical stage or CD4 count.
Obtain sample for CD4 count before initiating or soon after initiating ART.
The initiation of ART should not be delayed for want of CD4 test results.
PPTCT Overview 24

31. What is the plan of antenatal follow up and management

32. Antenatal management summary
Start ART
CD4 count at initiation of ART and every 6 months
Serum hepatic transaminase levels, complete blood count and renal function test at initiation of ART and after 4 weeks.
Serological testing for Hepatitis B and C, syphilis.
Screening for STI and appropriate treatment
Evaluate the need for vaccination: Hepatitis B, pneumoccoccal, influenza, Tdap vaccines
If CD4 count less that 250/cumm pneumocystis jiroveci prophylaxis is started.

33. Q5
Mrs. C is a primigravida on ART admitted in labor room in early labor with intact membranes.
What are the interventions during labor and delivery period to prevent MTCT

34. Interventions During Labour and Delivery
Minimise vaginal examinations
Use partogram to monitor labour
Avoid prolonged labour
Consider oxytocin to shorten labour
Avoid artificial rupture of membranes
Do not use suction unless absolutely necessary
Early cord clamping.
Trainer Notes:
The trainer should explain that vaginal examinations need to be minimised so that infection can be prevented.
Long duration of rupture of membranes increase the transmission risk. It has been estimated that with every hour, the risk of transmission increases by 2%.
Studies have shown that uterine manipulations like amniocentesis and external cephalic version increase the risk of transmission of HIV.
Placental disruption and infections also adversely affect transmission.
Invasive foetal monitoring should be avoided, as should all invasive obstetric procedures.
PPTCT Overview 14

35. Interventions During Labour and Delivery
Avoid unnecessary trauma during delivery
Use non-invasive foetal monitoring
Avoid invasive procedures
Avoid routine episiotomy
Minimise the use of forceps or vacuum extractors
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
Trainer Notes:
The trainer should explain the interventions that need to be done during labour and delivery to minimize transmission risk.
Any procedure that makes mother’s blood in contact with foetus is to be avoided.
The suction should not be used unless absolutely necessary.
Before moving to the next slide the trainer may pose the question “ what is the ideal mode of delivery that can minimize transmission”
Answers:
Where facilities are available, elective LSCS should be offered. This will most likely minimize the risk of transmission as against any other mode of delivery. Where not feasible, obstetricians should learn safer ways to deliver babies of HIV positive women.
If instrumental delivery is necessary, then forceps are a better option than vacuum suction cup delivery. Emergency LSCS is associated with high transmission of mother to child transmission.
PPTCT Overview 15

36. Q6
Mrs D primigravida on ART is now 37 weeks of gestation. She was told by one of the Basic health workers that cesarean section reduces the risk of MTCT.
What is the preferred mode of delivery in HIV positive pregnancy according to WHO/NACO in developing countries
What counseling will you do to this patient.

37. Considerations Regarding Mode of Delivery
Caesarean section performed before the onset of labour and rupture of the membrane to reduce HIV transmission
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
Lscs is beneficial only if the HIV RNA is more than 1000 copies per ml.
Transmission rate is reduced only by 50%. Where as ART reduces the risk by 98 to 99%.
Trainer Notes:
Delivery can be an emotional time for pregnant women. It could be even more so for women, who have fears about disclosure, confidentiality, and transmission of HIV to the baby. The staff must be extremely sensitive and respectful in making these stressful situations less traumatic for the mother and her family.
General practice recommends that an elective C-section is NOT considered a standard PPTCT intervention. Benefits of protecting the baby from HIV are better understood than risk to mothers (i.e., infection, wound dehiscence) and risk to the health-care workers. It is a complex issue that must be discussed.
Clinical judgment and the mother’s wishes should guide the decision. It is indicated and effective in certain clinical situations such as when the viral load of mother is extremely high, and should be done before onset of labour preferably at 38 weeks & electively based on mothers wishes and facilities available, but is not standard practice. In India – normal 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.
PPTCT Overview 16

38. Q7
Primipara on the post natal day one is worried about the HIV status of her baby. She was on ART during antenatal period.
what interventions can you do to prevent transmission of HIV to the infant
What are other interventions and care issues for a baby born to an HIV positive mother

39. Interventions During Infancy
Observe for signs and symptoms of HIV infection
ARV Prophylaxis to infant
All HIV exposed infants should receive cotrimoxazole at 4-6 weeks of age
Follow standard immunization schedule
Routine well baby visits
CPT should be initiated and baby to be linked to the EID programme.
CPT continued to baby from 6 weeks up to 18 months or until the confirmatory test of the baby
is done using all three Rapid Antibody Tests. If baby is confirmed positive, then CPT will be
continued.
Question 1: What are signs and symptoms of HIV infection in the infant?
Answer:
Fever, Failure to gain weight (may suggest HIV and/or malnutrition), Lymphadenopathy, Loss of milestones, Hepatosplenomegaly, Recurrent/recalcitrant infections, Otitis media, Candidiasis (Most infants have thrush, so this is not a reliable indicator of HIV infection) & Parotid enlargement
Question 2: What are other interventions and care issues for a baby born to an HIV
positive mother?
Infants exposed to HIV should start cotrimoxazole at 4 weeks (starting earlier may interfere with bilirubin conjugation). Cotrimoxazole is continued until the baby is one year old or till the baby is detected as uninfected.
Infants who may be HIV infected are at high risk of acquiring PCP. Cotrimoxazole prevents PCP, which has the highest morbidity & mortality for children with HIV. The highest incidence is 3 to 6 months of age, before the baby is accurately diagnosed.
Give all standard immunisations as per schedule.
Sick children born to an HIV-positive mother should be evaluated immediately for diagnosis and treatment.
Diagnosis difficult because maternal antibodies cross placenta.
Perform HIV-antibody test at 18 months.
HIV DNA PCR (viral load) is more accurate in newborns.
If baby is HIV negative, discontinue cotrimoxazole PCP prophylaxis.
Carefully monitor and document care.
Infant is considered indeterminate status until months.
If HIV-DNA PCR is available:
A positive test at 6-12 weeks of age means infection.
A negative test 6 weeks after stopping breastfeeding means infection very unlikely.
The goal is to diagnose babies who are HIV positive in order to provide timely treatment.
PPTCT Overview 17

40. What tests will you do
how do you follow up the infant and
when can you tell the mother definitively about the HIV status of her child.

41. Early Infant Diagnosis: DNA PCR test at 6-12 weeks
Repeat DNA PCR at 6 months, at one year and 6 weeks after cessation of breast feeding
18-month visit for HIV antibody testing (for diagnosis of HIV in the baby)

42. ARV Prophylaxis to infant (within 6-12 hours of birth)
Short-term use of Nevirapine syrup in infant upto the age of six weeks
In infants whose mother has taken ART during pregnancy for a period of less than 24 weeks, give nevirapine syrup for 12 weeks
Infant: Daily NVP from birth until minimum 6 weeks of age,
then stop (irrespective of choice of infant feeding

43. NVP daily dose (in ml) (10 mg Nevirapine in 1 ml suspension)
Recommendations for
HIV Exposed Infants
Infants Birth Weight
NVP daily dose (in mg)
NVP daily dose (in ml) (10 mg Nevirapine in ml suspension)
Duration
Birth weight less than gm
2 mg / kg once daily. In consultation with a pediatrician trained in HIV care
0.2 ml / kg once daily
Up to 6 weeks irrespective of whether exclusively breast fed or exclusive replacement fed.
Birth weight – 2500 gm
10 mg once daily
1 ml once a day
Birth weight more than gm
15 mg once daily
1.5 ml once a day
PPTCT Overview 30

44. What advice will you give regarding infant feedingQ8
What advice will you give regarding infant feeding

45. Safer Infant Feeding
Feeding options must be explained to all the mothers and they must be allowed to select their choice
Exclusive Replacement feeding (ERF)
if Affordable, Feasible, Acceptable, Sustainable and Safe (AFASS)
Trainer Notes:
The trainer has to emphasize NACO’s Recommendations on breastfeeding.
Mother has to decide her feeding option
PPTCT Overview 18

46. Safer Infant Feeding NACO Recommendations
EID – HIV positive:
For these infants, exclusive breast feeding is to be done till 6 months. Breast feeding can be continued up to 24 months.
EID – HIV negative:
(Exclusive breast feeding is to be done till 6 months and start complimentary feeding at 6 months of age. Breastfeeding should continue up till 12 months only. Stopping of breast feeding should be done gradually over 1 month according to the comfort of the mother and child. Educate parents that HIV testing needs to be done again after cessation of breastfeeding according to the EID protocols. )
Trainer Notes:
The trainer has to emphasize NACO’s Recommendations on breastfeeding.
PPTCT Overview 19

47. What is the risk reduction with ARTQ9
What is the risk reduction with ART

48. Risk of Mother-to-Child
ARV Interventions
Intervention
Risk of Mother-to-Child
HIV Transmission
No ARV, breastfeeding
30-45%
No ARV, No breastfeeding
20-25%
Short course with 1 ARV, breastfeeding
15-25%
Short course with 1 ARV, No breastfeeding
5-15%
Short course with 2 ARVs, no breastfeeding 5%
3 ARVs (ART), no breastfeeding 1%
3 ARVs (ART), with breast feeding
<5%
Trainer Notes:
Adequate and appropriate ARV prophylaxis, safe methods of delivery and good care of the mother during the antenatal period will help to decrease risk of transmission.
This is a review of ARV interventions that summarise efforts to decrease the risk to babies. Our goal is to prevent the HIV transmission.
ARV’s require ongoing care and monitoring and reduce risk of PTCT in the following ways:
Reduces viral replication and viral load.
Treats maternal infection.
Protects the HIV-exposed infant.
Improves overall health of mother.
Advantages of ART during pregnancy:
Antiretroviral therapy reduces risk of transmission even in mothers with low baseline viral loads. Combination therapy with 3 ARVs can reduce transmission risk to <2% in many cases. Combination ART is the best way to prevent PTCT.
Remember that in developed countries vertical transmission rarely happens, especially for women on ART (less than 70 nationwide in the U.S., 2003).
ARV’s are safe, well tolerated and easy to use in a pregnant woman who is carefully monitored.
It is economical because it eliminates the need for the HIV care and treatment of infected babies (there will not be any, or they will be a few in number).
Reduces the risk of the mother developing resistance, thereby preserving her future treatment options.
GOI guidelines for PPTCT include single dose of Nevirapine for all pregnant positive women.
Risks to infant (teratogenicity, preterm labour) appear to be minimal for most regimens. EFV has a teratogenic effect and is contraindicated in pregnancy. It should be avoided in women of child-bearing age who are not on effective contraceptives.
PPTCT Overview 21
Source: WHO

49. Q10
A 23 year old G2P1L0 with 14 weeks of gestation has to be started on ART. In her previous pregnancy she had taken single dose nevirapine at the onset of labor. What ART drugs should be given to her.

50. ART regimen for pregnant women having prior exposure to NNRTI for PPTCT
Because of the risk of resistance (archived resistance) to NNRTI drugs in this population, Efavirenz in the TDF+3TC+EFV regimen may not be effective
Thus, these women will require a protease inhibitor-based ART regimen
FDC of TDF(300mg) + 3TC(300mg)-- 1 tab OD
FDC of LPV(200mg)/r(50mg) tab BD
TDF + 3TC + LPV/r
Trainer Notes:
PPTCT Overview 27

51. Q11
A primigravida with 12 weeks gestation is found to be HIV positive with a CD4 count of 250. How will you manage.

52. CPT for Pregnant Women
The indications for Cotrimoxazole initiation in pregnant women follow that for other adults
Cotrimoxazole prophylaxis prevents Opportunistic Infections (OIs) such as Pneumocystis jiroveci pneumonia (PCP), toxoplasmosis, diarrhoea as well as bacterial infections
Cotrimoxazole should be started if CD4 count is <250 cells/mm3 and continued through pregnancy, delivery and breast-feeding as per national guidelines
PPTCT Overview 29

53. Mrs. k, 31 year old HIV positive attends the antenatal clinic with 2 months amenorrhea. She has pulmonary tuberculosis and is on treatment. Which ART regimen in appropriate for her.

54. ART tenofovir, lamivudin and efavirenz (TDF+3TC+EFV)

55. Q12
Mrs. x, 25 year old un booked primigravida is admitted in labor. She is found to be HIV positive on rapid testing. Which ART regimen is appropriate for this patient.

56. ART regimen remains the same irrespective of the gestational age at which it is started
Start ART (TDF+3TC+EFV) even if she is in labor
Detailed evaluation is done after delivery.
NVP for the baby till 12 weeks

57. Q13
Mrs. A, 19 year old primigravida is admitted in second stage of labor. You have conducted her delivery. Her HIV status is not known. How will you manage this case and what precautions should you take in such situations.

58. Universal precautions to be followed for all cases.
Refer her for HIV testing and further needful
If positive then further management depends on breastfeeding status
If breast feeding : maternal ART +NVP for infant for 12 weeks
If replacement feeding : maternal ART only if eligible and no NVP required for the baby.

59. Advice on contraception
Barriers have to be used even if the women is using other contraceptives
If partner is also HIV positive? Is there a need to use barriers?
Yes to prevent super infection and other STIs
PPIUCD and Interval IUCDs can be used in women without AIDS. (WHO MEC cat 2)
Hormonal contraceptives: Efavirenz, Nevirapine and Ritonavir boosted protease inhibitors reduce the efficacy of COC. DMPA injection and LNG IUS Can be used.
Permanent sterilization

60. Key Points
Best obstetric and appropriate infant feeding practices are the effective interventions to reduce PTCT
ART initiation guidelines have been liberalised and simplified to have all the pregnant women with HIV under ART
Triple drug (Tenofovir + Lamivudine + Efavirenz) ART is the best option made available to pregnant women with HIV in India
Effective implementation of “PPTCT continuum” with the planned linkages and referrals aimed to wipe out paediatric HIV in future
Step 6: Summary & Key Points (Slide 43) - 2 minutes
Trainer Notes:
Review Key Points with participants and answer any final questions.
PPTCT Overview 43

61. Thank you

62. Nucleoside reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
Protease inhibitors (PIs)
Integrase inhibitors (INSTIs)
Fusion inhibitors (FIs)
Chemokine receptor antagonists (CCR5 antagonists