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 F OURTH E  DITION OF THE ALARM I  NTERNATIONAL P  ROGRAM 

 Infections Chapter 7 – Pae !

HIV AND PREGNANCY

Learning Objectives

By the end ! this sectin" the #artici#ant $i%%&

1. List the factors affecting vertical transmission of HIV.2. Summarize the strategies in the prevention of mother- to-child transmission of HIV.

Intrd'ctin

In 2004 the !orld Health "rganization reported that 40 million people #ere infected #ith HIV$%I&S 1'.( million

#omen 2.' million children and 1) million orphans #orld#ide. In 200* '00000 children +ecame infected #ith

HIV #ith appro,imatel */ arising from mother-to-child transmission 3. 0/ of ne# infections in

children occur in %frica due to the fact that 3 interventions are almost non-e,istent.

3 is the vertical transmission of HIV from mother to child that occurs during pregnanc child+irth and

 +reastfeeding. he most pro+a+le point of transmission occurs in the late third trimester and even more so during the

intrapartum period.

In some areas of the #orld 3 has +een virtuall eliminated than5s to the availa+ilit of specific interventions to

reduce the ris5 of transmission. hese interventions include6 effective voluntar and confidential testing and

counseling access to antiretroviral therap safe deliver practices and the availa+ilit and safe use of +reast-mil5

su+stitutes.

E!!ects ! Pregnancy n HIV& C'rse and O'tc(e

he clinical course of HIV disease is not altered in pregnanc. here is no significant difference in the death rate or

in the progression of %I&S-related illness.

E!!ect ! HIV n Pregnancy& C'rse and O'tc(e

a+le 1 summarizes the evidence availa+le from current research a+out the effect of HIV on adverse pregnanc

outcomes.

)ab%e *+ E!!ect ! HIV n adverse #regnancy 'tc(es

Adverse Pregnancy O'tc(e Re%atinshi# t HIV In!ectin

Spontaneous a+ortions Limited data evidence of possi+le increase

7etal malformation 8o increased ris5  

9renatal mortalit 8o association in developed countries

Increased ris5 in lo#-resource countries

Intrauterine gro#th retardation :vidence of possi+le increased ris5  

9reterm deliver :vidence of possi+le increased ris5  

Lo# +irth #eight :vidence of increased ris5  

ore fre;uent and severe episodes of malaria attac5s :vidence of increased ris5 

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,actrs A!!ecting Perinata% )rans(issin

HIV+re%ated !actrs

HIV-related ratio is associated #ith increased ris5 of 

transmission.

-aterna% and bstetric !actrs

3linical stage6 9rimar infection #ith greater viraemia is associated #ith increased ris5.

S&s6 here is increased HIV shedding in genital tract epithelial disruption associated #ith an increased ris5 of 

transmission.

Se,ual +ehaviour6 ?nprotected se, #ith multiple se,ual partners associated #ith increased ris5.

9lacental a+ruption6 &isruption of fetal-placental +arrier increases e,posure to the fetus.

&uration of mem+rane rupture6 he transmission rate is directl proportional to the increased duration of rupture of mem+ranes #ith a 2/ increase for each hour increment.

@estational age at deliver. 9rematurit is associated #ith increased ris5.

Invasive procedure in la+our such as episiotom vacuum deliver forceps artificial rupture of mem+ranes

%

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9rimar prevention of HIV among prospective parents.

9revention of un#anted pregnanc among HIV-infected #omen.

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  9revention of 3 among HIV-infected mothers through provision of voluntar confidential counseling andtesting antiretroviral agents safe deliver practices and safe infant feeding practices.

  Support for the affected famil and the communit at large. :ducation and counseling services ma help the

#omanAs famil understand the issues and thus support the #oman #ith her choices to prevent transmission of

HIV to her +a+.

C(#nents ! a C(#rehensive Preventin Prgra(

Health education provision of information counseling on HIV preventative care including 3

Voluntar confidential counseling and testing services that are accepta+le and accessi+le

Cualit and focused antenatal care

Safe deliver practice

Support and counseling on infant feeding practice

7amil planning services

3ommunit mo+ilization and education to decrease the stigma and discrimination against as #ell as to

increase support for HIV-positive clients

Interventins t Prevent -ther+t+Chi%d )rans(issin ! HIV

*/ Antiretrvira% treat(ent 0ante+" intra+" and #st#art'( interventins1

 Efficacy

he 9ediatric %I&S 3linical rial @roup in 14 demonstrated a (>/ reduction in 3 #hen zidovudine

#as administered from 14 #ee5sA gestation intrapartum and to the neonate in the postpartum in the a+sence of 

 +reastfeeding.

Su+se;uent trials using short-course antiretroviral drugs done in lo#-resource countries have sho#n a *0/

reduction in vertical transmission. In terms of polic implementation and costs the follo#ing regimens aremore realistic in lo#-resource settings.

 Regimens

  9ediatric %I&S 3linical rial @roup 0'(6 Didovudine given antepartum intrapartum + intravenous

infusion and to the neonate for ( #ee5s reduces ris5 of vertical transmission + (>/.

  Short-course Didovudine hai stud6 Didovudine given )00 mg t#ice dail +eginning at )( #ee5sAgestation and )00 mg ) hourl in la+our reduces transmission + *0/ in a non-+reastfeeding population.

  % +reastfeeding population in !est %frica6 Short-course Didovudine given )00 mg t#ice dail +eginning at

)( #ee5sA gestation )00mg ) hourl in la+our and )00 mg t#ice dail to the mother for 1 #ee5 after

deliver reduces transmission + 2>/ at 1> months.

  8evirapine HIV8:0126 8evirapine 200 mg given at onset of la+our and to the neonate 2 mg$5g #ithin'2 hours is associated #ith a 4'/ reduction in vertical transmission at > #ee5sA gestation. It is the onlsingle dose drug availa+le and it is relativel cheap and eas to admininster.

  8evirapine is most effective #hen administered in com+ination #ith azidothmidine %D and )3.

Ho#ever this regime can +e difficult to provide in lo#-resource settings +ecause it is more e,pensive and

difficult to implement.

  he one concern a+out the single dose nevirapine is that it can ma5e su+se;uent treatment of nevirapine or

efavirenz a similar drug less effective. his drug resistance is tpicall short lived lasting a+out (

months. %fter ( months treatment #ith nevirapine or efavirenz is usuall successful. &ue to these

concerns a single dose of nevirapine should onl +e used #hen the com+ination of drugs to prevent HIV

resistance pro+lems are not availa+le.

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Health care providers should use the +est drug therap availa+le to them. a+le 2 outlines the !orld Health

"rganization guidelines for the prevention of 3 of HIV in lo#- resource settings #here #omen have had

no previous antiretroviral therap. hese are general guidelines and consideration of national guidelines for the

 prevention of 3 of HIV should +e considered as #ell. See %ppendi, 4 for recommendations on

antiretroviral therap for specific clinical situations.

)ab%e 2 + 3r%d Hea%th Organi4atin g'ide%ines !r #reventin ! -)C) ! HIV in %$+res'rce settings

$here $(en have had n #revi's antiretrvira% thera#y !H" 200(

Pregnancy Lab'r A!ter birth& (ther A!ter birth& in!ant

#ee5s

Single dose nevirapineE%D F )3

%DF )3 for 'das

Single dose nevirapineE%D for ' das

%lternative higher

ris5 of drug resistance

%D after 2>

#ee5sSingle dose nevirapine -----

Single dose nevirapineE

%D for ' das

inimum lesseffective

----- Single dose nevirapineE%DF )3

%DF )3 for 'das

Single dose nevirapine

inimum less

effectiveE higher ris5 of drug resistance

----- Single dose nevirapine ----- Single dose nevirapine

2/ .a!e de%ivery #ractices

3esarean section is recommended for #omen #ith a high viral load. his option protects the +a+ from coming

into direct contact #ith the motherAs +odil fluids. Ho#ever in regions #ith a high HIV prevalence caesarean

section surger ma not +e a safe option for #omen. In these areas #omen are li5el to have man +a+ies thus

e,posing them to the ris5 of uterine rupture #ith su+se;uent deliveries. hese #omen are also at a higher ris5 of

infectious complications from the surger.

In lo#-resource settings it is therefore important to emphasize the need for6

?niversal precautions

odified o+stetrical practiceGdela artificial rupture of mem+rane avoid invasive fetal monitoring

 procedures avoid the use of episiotom and avoid instrumental vaginal deliveries

  &iscussion #ith the parents a+out the +enefits and ris5 of caesarean section surger.

If the mother is alread ta5ing com+ination antiretroviral therap during pregnanc and has a lo# viral load an

elective cesarean section ma not +e recommended +ecause the chance of infection is alread lo#.

5/ Breast!eeding

HIV is transmitted through +reast mil5. !hen there is no intervention to reduce infection the rate of

transmission of HIV through +reast mil5 ranges +et#een *20/. he ris5 of infection is increased #hen a

mother has a high viral load a lo# 3&4 cell count su+clinical mastitis a+scesses crac5ed nipples or #hen

an infant has oral infections sores or damaged intestinal epithelium.

Su+clinical mastitis and +reast a+scesses increase the viral load of HIV in +reast mil5. 3o#As mil5 and solid

foods create damage to a +a+As intestinal mucosa and allo#s for eas entr of the HIV virus into the +lood

stream.

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 Recommendations for breastfeeding in low-resource settings

here is no eas ans#er to #hether a #oman should +reastfeed her child or not. In high- resource settings

#omen are recommended not to +reastfeed their +a+. In lo#-resource settings there are other varia+les that

need to +e ta5en into consideration.

  !omen infected #ith HIV and all #omen should have access to information a+out ho# to +est feed her 

 +a+. 9eople #ho counsel in regard to HIV and +reastfeeding need to provide clear impartial messages to

#omen that e,plore the availa+ilit and feasi+ilit of infant feeding methods. 3ounselors need to +e #ell

trained and supported.

he !H" states6 "#hen rep$ace%ent fee&in is accepta'$e( feasi'$e( affor&a'$e( s)staina'$e an& safe(

a*oi&ance of a$$ 'reastfee&in '+ HI,-infecte& %others is reco%%en&e&. Other/ise( e0c$)si*e 'reastfee&in isreco%%en&e& &)rin the first %onths of $ife.‖

  7or #omen to ma5e a choice essential information includes the greater ris5 of infant mortalit from

diarrhea and respirator infections related to replacement feeding in areas #here access to clean #ater and

fuel is limited vs. the ris5 of HIV infection in +reastfeeding. "ne stud revealed that the ris5 of death from

diarrhea in +a+ies #ho receive replacement feeding #as dou+le that of e,clusivel +reastfed +a+ies

3oovadia et al. 200'.

  3(en $h are HIV #sitive and $h breast!eed their +a+ies should receive information a+out ho# to

ensure health +reasts and nipples to reduce vertical transmission. 3ounseling includes proper latch and

hold changing the +a+As position #hile at the +reast 5eeping the +a+ close during +reastfeeding to

ensure ade;uate empting of the +reast and avoiding mil5 stasis full +reasts. !omen should also receive

information a+out #hen to see5 health care for +reast ailments. he should also +e informed to #atch for 

an oral sores in their +a+ and to see5 medical attention if and #hen this does occur.

- !hen it is time to #ean it is recommended to stop +reastfeeding over a period of a fe# das to

shorten this period to lessen the amount of time #here the +a+ #ould receive mi,edfeedings.

- !omen #ho +reastfeed need to 5eep their viral load lo# and 3&4 count high as much as possi+le

to decrease transmission of HIV to their +a+. ?se of antiretrovirals clinical care to prevent co-infections and good nutrition should +e availa+le to these #omen.

  3(en $h are HIV #sitive and #rvide re#%ace(ent !eeding to their +a+ies need to understand ho#

to prevent infection respirator and diarrhea and to ensure ade;uate nutrition to their +a+ies i.e. teaching

 proper preparation and cleaning of +ottles nipples or cups. 9art of the teaching includes the #omen

demonstrating their ne#l ac;uired 5no#ledge. !omen #ho choose this method also need to have home

support to ensure clean feeding to prevent infection.

  3(en need t be in!r(ed ab't the dangers ! (i6ed !eeding. It has +een sho#n that HIV

transmission is higher in +a+ies #ho receive a mi,ture of replacement feeding and +reastfeeding. he most

recent good ;ualit stud on this phenomena reported that +a+ies #ho received a mi,ture of feeding #erefour times more li5el to +e infected #ith HIV than +a+ies #ho #ere e,clusivel +reastfed 1(/

compared #ith 4/ 3oovadia et al. 200'. 3(en need t be s'##rted in their decisin t

breast!eed r re#%ace(ent !eed s that they stic7 t that decisin and d nt (i6 !eed their chi%d.

  HIV-infected #omen as #ell as all #omen should have access to information follo#-up clinical care and

support including famil planning services and nutritional support.

  !omen #ho are HIV negative or #ho do not 5no# their status should +e encouraged to e,clusivel

 +reastfeed and +e supported to continue for ( months.

8/ Care ! (ther and in!ant

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3ontinuous counseling and support of the mother and her famil com+ined #ith the provision of long-term

antiretroviral therapies to the mother and$or her child are re;uired. o reduce the stigma associated #ith

infection strong lin5ages +et#een communities and HIV$%I&S support groups should +e priorities as #ell as

communit mo+ilization and education on the topics of HIV$%I&S prevention infection and care.

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9/ ,a(i%y #%anning (ethds

:ffective contraception provides #omen and their partners an opportunit to decide #hether the #ant to have

children and control the num+er and fre;uenc of children. Ho#ever famil planning is not ust a+out

regulating the num+er of childrenE it is also a+out preventing infections. 3ounseling to couples should include

the concept of dual contraception. his means that although a couple ma choose use a hormonal method to

 prevent conception the should +e educated a+out the +enefits of using a +arrier method in particular a

condom to prevent re-infection #ith another strain of the HIV. ?se of condoms during pregnanc #ill prevent

 primar HIV infection. 9rimar HIV infection in pregnanc is a greater ris5 to the fetus.

Cnc%'sin

9revention of 3 can +e reduced. @overnments families communities and health care providers should

endeavour to provide ;ualit antenatal care voluntar confidential counseling and testing provision of antiretroviral

treatment particularl at the crucial time of deliver and ade;uate support after deliver in order to improve ;ualit

of life to child and mother. %voidance of +reastfeeding and planned caesarean section in prevention of 3 is still

an open de+ate. It should +e addressed according to the local and specific conte,t of the #oman. he prevention of

the spread of HIV infection is not ust one simple intervention. It involves a multidisciplinar colla+orative approach

among communit regional and national care providers. he international communit also has a rolein the

contri+ution of the needed resources.

:ey -essages

1. Health care providers have a responsi+ilit to minimize vertical transmission at time of deliver and to usetheir national HIV guidelines.

2. Health care providers should +e familiar #ith antiretroviral treatment options for prevention of 3

and treatment of mothers.

). !omen deserve to +e provided #ith the +est availa+le treatment educated and supported #ith respect to infantfeeding.

Res'rces&

  %nderson J :d. A )i&e to the c$inica$ care of /o%en /ith HI, .

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  !H". %ntiretroviral drugs for treating pregnant #omen and prevention HIV infection in infants6 guidelines on

care treatment and support for #omen living #ith HIV$%I&S and their children in resource-constrained

settings. !H". @eneva 2004.

!H". HIV transmission through +reastfeedingG%

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