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HUMAN IMMUNODEFICIENCY VIRUS

HUMAN IMMUNODEFICIENCY VIRUS. In pregnancy. I ntroduction. Global epidemic UNAIDS 2010 – there is 19% reduction in HIV infected people. 20% reduction in AIDS related death Number of women affected has risen to 50%.

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HUMAN IMMUNODEFICIENCY VIRUS

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  1. HUMAN IMMUNODEFICIENCY VIRUS In pregnancy

  2. Introduction • Global epidemic • UNAIDS 2010 – there is 19% reduction in HIV infected people. • 20% reduction in AIDS related death • Number of women affected has risen to 50%

  3. Millennium development goal 6 aims to decrease new pediatric HIV infection and improve HIV-free child survival • India has the second highest population of HIV infected people • HIV is a retrovirus containing reverse transcriptase enzyme, which allows the virus to transcribe its RNA genome into DNA, then integrates into host cell DNA

  4. RNA virus – sub gp of lentivirus • exists in two forms HIV-1 Common HIV-2 • HIV preferentially targets lymphocytes expressing CD4 molecule, causing progressive immunosuppression • Main problem in clinical illness with AIDs is profound immunosuppression rendering patient susceptible to opportunistic infections and neoplasia.

  5. Modes of HIV transmission • Sexual route 8.6% • Mother to child 3.6% • Injection drugs 2.4% • Transfusion of blood 2% • Others 6%

  6. DIAGNOSIS : • Elisa test is used for screening test – becomes +ve within 3 weeks to 3 months after exposure. • Previously a +ve test needed confirmation with either western blot / immuno fluorescence • PCR detects viral DNA / RNA • CD4 counts decline indicates degree of Immuno suppression • Viral load (HIV – RNA) predicts disease progression

  7. Effect of pregnancy on HIV • Does not increase the risk of progression of HIV. • Women with advanced disease may deteriorate • Opportunistic infections may be less aggressively investigated

  8. Effect of HIV on pregnancy : • In advanced disease, increased risk of miscarriage, PTL, IUGR • Main concern is vertical transmission

  9. Vertical transmission Varies between 15-20% in non BF women Europe 25-40% in African population India 30% Antepartum 0-14wk 1% 14-36wk 4% >36wk 12% Intrapartum 8% Postpartum established 14% priinf 29%

  10. Factors increasing vertical transmission • H/O previus child with HIV • Maternal viral load • Seroconversion in pregnancy • Advanced maternal disease • Low CD4 count • Prolonged ROM • First born twin

  11. Factors increasing vertical transmission • PTL • Chorioamnionitis • Coexistent STD • Antepartum invasive procedures • Intrapartum invasive produces • Episiotomy,lacertions, • Forceps delivery • Breast feeding

  12. Preconceptional management • Couples who are serodiscordant – use condom • Female partner (HIV –ve) should be advised that assisted conception with either donor inseminate or sperm washing • Couples should be advised to delay conception until viraemia is suppressed • All women who are HIV +ve are recommended to have annual cervical cytology cytology

  13. ANTEPARTUM MANAGEMENT • Multidisciplinary team management • PPTCT was commenced in 2002 • Screening offered to all pregnant mothers. • Pretest and post test counselling are mandatory • Women who decline HIV test – are eligible to receive all ANC benefits are known as ‘opt out’.

  14. Screening all pregnant mother in early pregnancy • Screening offered again at round 28 weeks • ART should be offered to all pregnant women who test +ve for HIV infection (maternal health/vertical transmission

  15. ANC : Termination should be discussed at the earliest • counselled regarding nutrition, hygiene, safe sex, avoid substance abuse. RFT, LFT, viral load. CD4 count – Rpt 3mnths • Screening for genital infection done early Rpt at 28 wks. . Hepatitis and pneunococcal vaccines is recommended

  16. NACO revised guidelines • All HIV infected pregnant women should be initiated on life long ART regardless of WHO clinical stage or CD4 count/ gestational age. • HIV infected pregnant mothers should preferably be initiated on ART at ART centres and should not be delayed for want of CD4 cell count report.

  17. NACO revised guidelines • The three drug option recommended are tenofovir(TDF)+ lamivudine(3TC) + efavirenz (EFV) Zidovidine(AZT) +3TC +nevirapine(NVP) AZT +3TC +EFV TDF +3TC +NVP • Mode of delivery should be vaginal, cs are done for obstetric reasons • Avoid ROM, Ergometrine , early cord clamping

  18. NACO revised guidelines • Breast feeding – is discouraged • Bottle feeding may be more harmful in certain SE condition • Risk of neonate dying of diarrhoea has to be weighed against transmission of infection.

  19. ARV • HAART : Benefits outweigh the risks • Deferred until 1st trimester • Include 2 nucleoside RTI with either one/non PI or non NRTI • Efavirenz is C/I as it can cause cong. Abnormalities

  20. Regimen to continue after delivery • Women who conceive while on HAART should continue the same.

  21. Neonatal care • All babies are Rx with ARV from birth (Zidovdine10 mg in 1ml suspension) is give for 6 weeks in non Breast fed babies. • In B Feed neonates – continues until one week after stopping B feeding. • Diagnose of infant HIV at birth can thro’ PCR/DNA analysis dried blood spot / blood in EDTA are specimens used to perform PCR

  22. Care of HIV exposed infant • Exclusive breast feeding for six months • NVP prophylaxis from birth till 6 weeks • Cotrimoxazole prophylaxis from 6 weeks till 18 months • Early infant diagnosis (EID) of HIV – DNA – PCR testing (6 weeks, 6 months, 12 months or 5 weeks after stopping breast feeding and confirmation with antibody test at 18 months ) • Level of maternal antibody falls below the limit of detection by 18 months.

  23. Regular immunization as per national schedule • Continued breast feeding and growth monitoring • Follow-up of child till 18 months for confirmation of HIV status

  24. Antibody test can identify potentially uninfected infants 6-18 months of age if they are not breast fed. • A negative HIV antibody test at 18 months confirms that the child is not infected. • Children with known/suspected asymptomatic HIV infection should receive vaccines according to national immunization schedule.

  25. Contraception • Barrier method

  26. Universal precaution • Staff should adhere to universal precaution during delivery • Wear protective eye wear, mask, wear double gloves • Wear gown and protective leg wear

  27. Universal precaution • Handle all linen soiled with blood fluid as potentially infections. • Process all lab specimen as PI • Wash hands before and after all patient or specimen contact • Place all used syringes immediate in nearby impermeable contained don’t recap or manipulate.

  28. Measures to reduce vertical transmission • Universal screening • ARV in pregnancy • Exclusive formula feeding

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