HIVAIDS and Pregnancy

8/12/2019 HIVAIDS and Pregnancy

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Diagnosis and Management. How can MTCTof HIV be reduced in KATH?

Presented by Group 1

Supervisor: Dr. Turpin

HIV/AIDS and Pregnancy


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Introduction

AIDS is caused by HIV.

HIV attacks and destroys WBCs

causing a defect in the bodysimmune system.

The incubation period may be

as long as 10 years or as shortas 2 years.


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Life Cycle of the HIV


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Modes of HIV transmission Sexual intercourse

Exposure to infected blood and blood products : Shared needles

Contaminated instruments

Blood transfusion

An HIV positive woman can transmit the virus to

her baby during pregnancy, labour and delivery,

and through breastfeeding. If she takes no

preventive drugs and breastfeeds then the

chance of her baby becoming infected is around

20-45%.


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Risk Factors for Vertical

Transmission

Maternal FactorsHigh viral load

Severe immunosuppression

(CD4


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Risk Factors for Vertical

Transmission (2)

Viral Factors

HIV type 1

Subtype C of type 1

Infant factors

Prematurity

Breastfeeding

Oral thrush and oral ulcers

Invasive fetal monitoring during labour


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Clinical Stages

Clinical Stage 1

Asymptomatic

Persistent generalized lymphadenopathy


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Clinical Stage 2

Moderate unexplained weight loss (


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Clinical Stage 3

Unexplained severe weight loss (>10% of presumed

or measured body weight) Unexplained chronic diarrhea for >1 month

Unexplained persistent fever for >1 month (>37.6C,

intermittent or constant)

Persistent oral candidiasis (thrush)

Oral hairy leukoplakia

Pulmonary tuberculosis (current)


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Clinical Stage 3(cont.)

Severe presumed bacterial infections (eg,

pneumonia, empyema, pyomyositis, bone or jointinfection, meningitis, bacteremia)

Acute necrotizing ulcerative stomatitis, gingivitis, or

periodontitis

Unexplained anemia (hemoglobin


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Clinical Stage 4

HIV wasting syndrome

Pneumocystispneumonia

Recurrent severe bacterial pneumonia

Chronic herpes simplex infection (orolabial, genital,

or anorectal site for >1 month or visceral herpes at

any site) Esophageal candidiasis (or candidiasis of trachea,

bronchi, or lungs)

Extrapulmonary tuberculosis

Kaposi sarcoma


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Clinical Stage 4 (cont.)

Cytomegalovirus infection (retinitis or infection of

other organs) Central nervous system toxoplasmosis

HIV encephalopathy

Cryptococcosis, extrapulmonary (including

meningitis)

Disseminated nontuberculosis Mycobacteria

infection

Progressive multifocal leukoencephalopathy


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Clinical Stage 4 (cont.)

Candida of the trachea, bronchi, or lungs

Disseminated mycosis (eg, histoplasmosis,

coccidioidomycosis, penicilliosis)

Recurrent nontyphoidal Salmonellabacteremia

Lymphoma (cerebral or B-cell non-Hodgkin) Invasive cervical carcinoma

Symptomatic HIV-associated nephropathy or

cardiomyopathy


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Effects of Pregnancy on HIV

Pregnancy does not worsen

HIV.

The absolute CD4 countdecreases regardless of the HIV

status. This is due to

haemodilution.In HIV- positive women,

percentage of CD4 cells as well


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Effects of HIV on pregnancy

Recurrent abortion

Prematurity

Preterm delivery

IUGR Stillbirths

Congenital abnormalities

Embryopathies


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Diagnosis

History

Physical

examinationInvestigations


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History Depending on the clinical stage, the patient

may be symptomatic or asymptomatic Risk factors :multiple sexual partners,

previous exposure to blood and blood

products, previous gynaecological surgeries(EOU,TOP), history of STIs History of chronic cough, unexplained

wasting, cutaneous lesions, unexplainedchronic diarrhoea, unexplained persistent

fever, night sweats, dysphagia History of recurrent abortions, previous

preterm deliveries, IUGR and still births


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Physical examination

General examination

Wasting

Pallor

Dyspnoea

White mucosal plaques or erythema in the buccal

cavity

Lymphadenopathy: cervical, axillary and inguinal

Skin lesions or rashes Genital, including anorectal, lesions

Any neurologic abnormalities


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Physical examination (2)

Respiratory system: air entry may be reduced,breath sounds may be bronchial, percussion

note may be dull

Abdominal examination: there may be

hepatosplenomegaly, SFH may be less than

expected for gestational age

Fundoscopy, whenever possible, for retinitis


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Investigations

The reasons for investigations are to:

Determine whether the patient satisfies

initiation criteria.

Determine the presence or absence ofopportunistic infections.

Determine the clinical stage.


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Investigations (2)

Initial laboratory evaluation should provide

Confirmation of HIV infection and typing.

Confirmatory HIV test (and typing 1

and/ or 2)Viral load (when available)

Done by using PCR.

Indication of the patients immune status

CD4 lymphocyte count


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Investigations (3)

There are two types of HIV test:Antibody test

ELISA

Western Blot Immunofluorescent Antibody AssayRapid HIV Test KitsAt-home HIV Test Kits

Antigen testPCRAmplicor HIV Monitor TestBranched DNA Test p24 Antigen Test


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Other Baseline Tests

Haematological

test

FBC including total lymphocyte

count and platelets

The basic minimum test for

pregnant women who are taking

ARV combination prophylaxis forPMTCT is Hb.

Biochemical

test

Blood urea and electrolytes

LFT (if on NVP, more frequent

monitoring is necessary)

FBS (if treatment includes PIs)

Fasting Cholesterol and lipids (if

treatment includes PIs)


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Other Baseline tests (2)

RoutineExaminations

Urinalysis (urine R/E), StoolR/E

Respiratory

Examinations

Sputum for AFBs, Chest X-ray

Supplementary

tests(These are

performed depending

on signs and

symptoms)

HBsAg screen,

Histology on skin and lymph

node biopsyScreening for STIs

Abdominal USG


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Management

ANC for the HIV positive pregnant womanANC is similar to the care given to HIV

negative pregnant women

HIV-positive clients are coded 279 on

their ANC cards ( 280 for HIV-negative

clients) to prevent stigmatisation.

Avoid invasive procedures unless

strongly indicated

Anomaly scan

Foetal monitoring

Monitoring for preterm delivery


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Management (2)ANC for the HIV positive pregnant woman

(cont.)

The patient is offered good nutritional

counselling.

2 uses of antiretrovirals in pregnancy

For treatment and

Prophylaxis

The antiretrovirals should be avoided in

the first trimester.


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Management (3)

ANC for the HIV positive pregnantwoman (cont.)

All HIV-positive women with CD4 count

> 350 must be put on prophylaxisstarting from 28 weeks for the purpose

of PMTCT.

All HIV-positive women with CD4 count< 350, irrespective of clinical stage,

must be treated with HAART.


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Management (4)

ANC for the HIV positive pregnantwoman (cont.)

All HIV-positive women with WHO

clinical stages 3 and 4, irrespective ofCD4 count, must be treated with

HAART.

28 weeks, AZT/3TC twice daily isgiven


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Management (5)

Labour / DeliveryRoutine ARM should be avoided.

Foetal scalp blood sampling and episiotomyshould be avoided if possible, as they increase

mother-to-child transmission.The vagina should be cleaned with

chlorhexidine before conducting delivery.

A skilled attendant should conduct the deliveryto prevent perineal tears, which are known toincrease MTCT.


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Management (6)

Labour / Delivery (cont.) If indicated, caesarean section should be

done before rupture of membranes. This is

associated with reduced risk of

transmission.

Single dose NVP + AZT/3TC every 12

hours. (ARVs given at onset of labour)

Clean face of newborn, avoid unnecessary

suction, avoid hypothermia.


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Management of the HIV-exposed

babyARV prophylaxisGive a single dose of NVP suspension,

2mg/kg within 48 hours of delivery + 1

week course of syrup AZT, 4mg/kg bd+ syrup 3TC, 2mg/kg bd

If the mother has had less than 4

weeks of ARV prophylaxis, give thebaby a 6 week course of AZT and 3TC


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Management of the HIV-exposed baby

(2)

Feeding options

Exclusive breastfeeding or artificial feedsonly

NB. Do not practice mixed feeding

If mother has not made any informed choiceas to whether to practice exclusivebreastfeeding or give artificial feeds, admitand give IV fluids till the mother has beencounselled. Identify and treat any otherproblems.


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Management of the HIV-exposed baby

(3)

Follow-upThe baby should be seen at theHIV clinic at 6 weeks of age.


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Prevention of MTCT of HIV

4-pronged approach. Prong 1:Primary prevention of HIV among women

of reproductive age within services related toreproductive health such as antenatal care,postpartum/natal care and other health and HIV

service delivery points, including working withcommunity structures.

Prong 2: Providing appropriate counselling andsupport to women living with HIV to enable them

make an informed decision about their futurereproductive life, with special attention to preventingunintended pregnancies.


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Prong 3:For pregnant women living withHIV, ensure HIV testing and access to the

antiretroviral drugs that will help mothers

own health and prevent infection being

passed on to their babies during pregnancy,

delivery and breastfeeding.

Prong 4:Better integration of HIV care,treatment and support for women found to

be positive and their families


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The PMTCT Process1. HIV testing of the pregnant woman plus

counselling at 1stANC attendance

Several testing strategies:

Provider initiated testing & counselling with the

option of opt-out Client initiated counselling & testing (opt-in)

2. Linkage of the HIV+ mother to PMTCT intervention

services ART clinic (care & support)

3. HIV+ mother is offered choice of Infant feeding

4. Linkage of the HIV-exposed baby to care & support


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The PMTCT Process (2)

For the woman who testsve, shes

counselled to stayve

For the woman who declines HIVtesting, the test is re-offered at each

ANC attendance till delivery

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VCT

Individuals voluntarily offerthemselves for HIV testing so as to

know their status

Its an important tool for reducingthe pandemic as clients are

counselled on risk reduction

behavioural lifestyles


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Components of VCT

Pre-test Counselling Clients knowledge of HIV is assessed and

knowledge gaps addressed. Clients risk of HIV by way of behavioural

practices are also assessed. The meaning of HIV test results (ie. POSITIVE

and NEGATIVE) are explained with emphasis onLIVING POSITIVELY for positive clients and

RISK REDUCTION BEHAVIOUR for negativeclients. The concept of window period is also explained

and the need for possibly repeating the test in 3months is emphasised.


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Components of VCT (2)

HIV Testing Clients blood is drawn for HIV Antibody

Testing. This is done with the STRICTEST

of CONFIDENTIALITY.

Post Test Counselling The client is told the HIV test results. If

POSITIVE, she is referred forcomprehensive care including accessing

ARVs.


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Wir bedanken uns sehrbei Euch!!!


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Group 1 Members

Ackah-Andoh, EdwinAcquah, MaxwellAdade, TitusAddai-Naami, Joshua Yaw

Addo-Sarkodie, EnochAdjei, FedousAdjei, ProsperAduse-Poku, Abena YeboahAfachao, FrederickAfrane, Joceline

HIVAIDS and Pregnancy

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