Hrsa Hiv Pregncy

8/7/2019 Hrsa Hiv Pregncy

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Jean R. Anderson, MD

DirectorJohns Hopkins HIV Womens Health Program

Care of Women with HIV Living in

Limited-Resource Settings

HIV and Pregnancy


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Objectives

Review significance of HIV during pregnancy and

magnitude of the problem

Review HIV-related issues to be considered prior to

pregnancy

Discuss effects of pregnancy on HIV infection and

effects of HIV infection on pregnancy course and

outcome

Discuss mother-to-child transmission (MTCT) and itsprevention

Discuss care of pregnant woman with HIV


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HIV and Pregnancy Why Is It

Important?

HIV may have adverse effect on pregnancy course or

outcome

More than 90% of pediatric HIV/AIDS cases are caused

by MTCT

Most children born to HIV-positive mothers in limited-

resource settings will be orphaned when one or both

parents die

Women without HIV may place themselves at risk forinfection while trying to get pregnant

Majority of women with HIV are of childbearing age


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Prevalence of HIV (Type-1) among

Pregnant Women

0% 10% 20% 30% 40% 50%

Nigeria

Uganda

Kenya

South Africa

Malawi

Rwanda

Botswana

ThailandCambodia

Brazil

Honduras

Haiti

% Positive

Source: DeCock et al 2000.

Latin

America

Asia

Africa


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0

10

20

30

40

50

60

70

Carletonville,SouthAfrica

,

1998(urban)

Mutasadistrict,Zimbabwe

,

1998(rural)

Kisumu,Kenya,1997(urb

an)

Lusaka,Zam

bia,1995(urba

n)

Mposhi,Zambia,1996(rur

al)

Ndola,Zam

bia1997(urba

n)

Kisesa,Tanzania,1997(ru

ral)

Yaounde,Cam

eroon1997(urb

an)

Cotonou,Benin1997(urba

n)

FortPortal,Uganda1995(urb

an)

Masaka,Uganda1996(rur

al)

Women, 15-19

Women, 20-24

HIVprevalence(%

)

HIV Prevalence among Women Age 1524Various African Studies, 19951998

Source: UNAIDS June 2000.


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Effect of HIV on Fertility

Prior STIs or pelvic inflammatory disease

Direct effects of HIV

Decreased fertility seen after adjustment for age, lactation,

illness, STIs

Worsened fertility in women with symptomatic HIV or co-

infected with syphilis

Pregnancy loss more common with HIV infection

Decreased sexual activity with advanced HIV

Source: Lancet 1998.


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Voluntary Counseling and Testing

(VCT) in Women of Childbearing Age

Information about HIV and pregnancy

Risk assessment

Prevention of HIV transmission or acquisition

Prevention of unintended pregnancy

Dual protection with condoms

Need to involve men in VCT!


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Goals of VCT in Antenatal Care

Educate about HIV

Reduce stigma

Prevent new HIV infections in pregnancy

Identify women with HIV

Stabilize and maintain maternal health

Prevent HIV transmission to uninfected sexual or drug

using partners

Reduce risk of MTCT Plan for future


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Special Counseling Issues for HIV-Positive Women

Who Are Pregnant or Considering Pregnancy

Effect of HIV on fertility

Effect of HIV on pregnancy and pregnancy on HIV

Potential for MTCT

Risk

Timing

Prevention

Use of antiretroviral (ARV) agents and other drugs

during pregnancy, if available


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Special Counseling Issues for HIV-Positive Women

Who Are Pregnant or Considering Pregnancycontinued

Newborn feeding options

Disclosure issues concerns about stigma and violence

Use of condoms

Long-term health of mother and care for children

Pregnancy termination option if legal and safe


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Effect of Pregnancy on HIV

CD4 count decreases in all pregnancies due to dilutional

effect; CD4% remains stable in HIV-positive women

HIV-RNA levels (viral load) remain stable during

pregnancy in absence of treatment

No significant differences in HIV progression or survival

between pregnant and nonpregnant women with HIV

infection

Source: Alliegro 1997 Brocklehurst 1998 Burns 1998.


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Effect of HIV on Pregnancy

Pregnancy Outcome Relationship to HIV Infection

Spontaneous abortion Limited data, but evidence of possible increased risk

Stillbirth Evidence of increased risk in developing countries

Perinatal mortality Evidence of increased risk in developing countries

Infant mortality Evidence of increased risk in developing countries

IUGR Evidence of possible increased risk

Low birth weight (


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Estimated Number of Children (< 15 years)

Newly Infected with HIV during 2000

WesternEurope

< 500< 500North

Africa& MiddleEast

11,00011,000Sub-SaharanAfrica

520,0520,0

0000

EasternEurope &

Central Asia

600600East Asia &Pacific

2,6002,600South &South-EastAsia

65,00065,000Australia &

NewZealand

< 100< 100

NorthAmerica

< 500< 500Caribbean4,2004,200

LatinAmerica

7,3007,300

Total: 600,000Total: 600,000Source: UNAIDS December 2000.


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Estimated Timing and Risk of MTCT of

HIV (Absolute Rates)

NoBreastfeeding

Breastfeedingthrough 6Months

Breastfeedingthrough 1824

Months

Intrauterine 5 to 10% 5 to 10% 5 to 10%

Intrapartum 10 to 20% 10 to 20% 10 to 20%

Postpartum

Early (first 2 months) 5 to 10% 5 to 10%

Late (after 2 months) 1 to 5% 5 to 10%

Overall 15 to 30% 25 to 35% 30 to 45%

Source: DeCock et al 2000.


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Factors Affecting MTCT of HIV/AIDS

Viral load (HIV-RNA level)

Genital tract viral load

CD4 cell count

Clinical stage of HIV

Unprotected sex with

multiple partners

Smoking cigarettes

Substance abuse

Vitamin A deficiency

Photo: Nelson, Zambia 2000.


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STIs and other co-infections

ARV agents

Preterm childbirth

Placental disruption

Invasive fetal monitoring

Duration of membrane

rupture

Vaginal childbirth versus

cesarean section

Breastfeeding

Factors Affecting MTCT of HIV/AIDScontinued

Photo: Nelson, Zambia 2000.


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MTCT Prevention in Low-Resource

Settings

Change behavioral factors

Encourage consistent condom use during pregnancy and

postpartum

Discourage use of drugs, alcohol and cigarettes

Identify and treat modifiable risk factors

Screen and treat STIs and co-infections

Provide vitamin A supplementation, if available (?)

Recommend treatment for substance abuse


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MTCT Prevention in Low-Resource

Settings continued

Reduce viral exposure

Avoid:

Artificial membrane rupture

Transfusion (use only in life-threatening situations)

Shorten duration of ruptured membranes

Cleanse vaginal area with disinfectant (?)

Reduce viral load before childbirth

Administer ARV agents

Treat STIs


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MTCT Transmission with Short Course

Oral ARV Regimens

Site Regimen

MTCTReduction

No Breastfeeding

Thailand ZDV: 36 weeks, labor 50%

Breastfeeding

Cote dIvoire ZDV: 36 weeks, labor 37%(3 months)

ZDV: 36 weeks, labor,postpartum (mother)

34%(18 months)

Uganda, Tanzania,South Africa ZDV/3TC: 36 weeks, labor,postpartum (mother & newborn) 52%(6 weeks)

ZDV/3TC: labor,postpartum (mother & newborn)

38%(6 weeks)

Uganda NVP (single dose): labor, postpartum(newborn)

41%(18 months)


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Recommendations for Antenatal Care

Basic antenatal care

Prevent and treat common opportunistic infections

Recommend nutritional interventions

Screen and treat STIs and other co-infections

Monitor for signs and symptoms of progressive

HIV/AIDS

Counsel on safe sex practices


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Recommendations for Antenatal Carecontinued

Avoid invasive procedures

Amniocentesis

External cephalic version

Consider administering ARV agents, if available

Plan for future

Newborn feeding

Family planning

Long-term care needs for mother, newborn and otherchildren

Provide emotional support


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Recommendations for Labor and

Childbirth

Avoid invasive procedures

Artificial membrane rupture

Fetal scalp electrode or sampling

Forceps or vacuum extractor

Episiotomy

Administer ARV agents, if available

Consider issues related to type of delivery cesarean

section versus vaginal childbirth Wipe newborn quickly and thoroughly with a dry cloth to

remove maternal blood and secretions


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Recommendations for Labor and

Childbirth continued

Follow recommended infection prevention practices

Wash hands thoroughly before and after each procedure

and examination

Wear hand and eye protection Handle needles and other sharp instruments safely

Dispose placenta and other waste materials and supplies

properly

Process instruments, gloves and other items by

decontamination, cleaning and either sterilization or high-

level disinfection


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MTCT and Cesarean Section

Cesarean section before onset of labor and membrane

rupture decreases risk of MTCT 5080%

Additional benefit in women not using ARV agents or on

ZDV alone No evidence of benefit after onset of labor or membrane

rupture


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MTCT and Cesarean Section continued

Special concerns with cesarean section in limited-

resource settings

Increased maternal morbidity and possible mortality

Availability of blood and blood safety Iatrogenic prematurity

Antibiotic prophylaxis

Anesthesia availability

Limited human resources nursing care time


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Postpartum Care

Assess healing

Review newborn feeding, growth and development

Reinforce safer sexual practices

Discuss contraception options

Refer mother and newborn for ongoing care


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Recommendations for Breastfeeding

Avoid all breastfeeding when replacement feeding is

acceptable, feasible, affordable, sustainable and safe

Provide guidance and support to HIV-positive mothers who

choose not to breastfeed to ensure adequate nutrition If breastfeeding chosen, encourage exclusive

breastfeeding up to 6 months of infants life

Teach proper attachment of newborn to nipples and

frequent breast emptying

Teach prevention and recognition and encourage prompt

treatment of mastitis, breast abscess, cracked nipples and

oral thrush or other oral lesions in newborns


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Botswana Kenya Malawi Tanzania Zambia Zimbabwe

0

50

100

150

200

250Deaths per 1000 live births

WithoutAIDS

WithAIDS

Estimated Impact of AIDS On Under-5 Child

Mortality Rates Selected African Countries, 2010

Source: UNAIDS June 2000.


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WesternEurope

9,0009,000North

Africa& MiddleEast

15,00015,000Sub-SaharanAfrica

12.112.1millionmillion

EasternEurope &

Central Asia

500500East Asia &Pacific

5,6005,600South &

South-EastAsia

850,000850,000Australia

& NewZealand

< 500< 500

NorthAmerica

70,0070,00

00Caribbean85,0085,0000Latin

America

110,0110,0

0000

Total: 13.2 millionTotal: 13.2 million* HIV-negative children who have lost their mother or both parents to AIDS before the age of 15 years

Estimated Number of Children (< 15

years) Orphaned by AIDS* by End of 1999

Source: UNAIDS December 2000.


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Summary

Prevent HIV infection in women in their childbearing

years

Prevent unintended pregnancies in HIV-positive women

Identify HIV infection in pregnant women

To provide effective antenatal, labor and childbirth, and

postpartum care can be provided

To reduce risk of MTCT

Hrsa Hiv Pregncy

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