HIV POSITIVE PREGNANT
WOMEN
Dr.
Anjalakshi Chandrasekar, M.D.,
D.G.O., Ph.D.,
Addl.
Prof. Ofae& Gynae.
IOG
& Govt. Hospital for Women Children
Madras
Medical College,
Chennai
Prevention of HIV in young
people and women of childbearing age
Prevention of unintended
pregnancies in HIV-positive women
Prevention of transmission from an
HIV-positive women to her infant.
Care & support for the mother and her family.
Global
estimates for adults
and children end 2004
People
living with HIV
New HIV
infections in 2004
Deaths due
to AIDS in 2004
Antenatal
Sentinel Surveillance
Tamil
Nadu
HIV
Virus Structure
Cont
AIDS first
described in 1981
HIV-1 isolated in 1984, and HIV-2 in
1986
Belong to the lentivirus subfamily of
the retroviridae
Enveloped RNA virus, 120nm in diameter
HIV-2 shares 40% nucleotide homology with
HIV-1
Genome consists of 9200 nucleotides (HIV-1):
SUSCEPTIBILITY OF HIV
HIV virus is thermo-labile and
delicate, which cannot tolerate high temperature.
In an aqua (fluid) state HIV can survive under normal environmental conditions at room
temperature up to 7days.
At 37ฐC
the virus survives for 11days.
At 23ฐC
to 27ฐC it survives up to 15days.
This virus is inactivated with in 30minutes at temperature above 55ฐC.
Mechanisms
of Mother-Infant HIV Transmission
HIV
ON PREGNANCY
Obstetric
abortions , ectopic, preterm, PROM
Abruption,
post partum endometritis
l
PIH, GDM no data
Maternal
l l
STI
l
CD4 < 200 pueumocystis carinii
l
CD4 < 100 Toxoplasma
l <CD4 50 Mycobactrium Avium
Fetal
l
LBW babies,
Pre maturity
OPPURTUNISTIC INFECTIONS
HEP B
HEP C
Toxoplasmosis
CMV
Syphilis
HPV
HSV
Bacterial
Vaginosis
Candidiasis
Basic Principle in Pregnancy
Avoid mono therapy
Multi drug regimen is mandatory
Strict adherence and follow up
CD4 count is important
STRICTLY AVOIDED
DURING PREGNANCY
Family Planning for the HIV Positive
women
The aim is to prevent
unwanted pregnancies
To check the viral
load.
Dual contraception is Ideal
BREAST FEEDING TRANSMISSION IS THE FRONTIER IN HIV
MTCT PREVENTION
BREAST
MILK TRANSMISSION
12-14%
HIV IN HUMAN BREAST MILK
Cellular part
Cell free part
Cellular part:
Mono nuclear cells, Histiocytes of b.m.
High titers colostrum & b.m. first 4 days
Vit
A deficiency เ
แ
HIV in b.m.
Breast
abscess/mastitis/sore nipples เ
แHIV
in b.m.
Free
HIV infects CD4 cells lining
GIT
Infected maternal mononuclear cells in b.f. pass thr mucous membranes & infect baby.
PROTECTIVE
FACTORS IN B.M.
Presence of glyco proteins
Muscin, lysozymes, lactoferrins
T cells, completements
Secretary leucocyte protease
inhibitor (SLIP)
Prevent binding of pathogenic organisms.
Transmission of HIV thr ough
Breast Milk
can take
place at any point during lactation.
EARLY POST PARTUM TRANSMISSION
First
few weeks เdifficult
to determine mode of Tr. of infection A.P./ I.P/colostrum
Maternal Antibodies
Window period maternal
Timing of infants sampling.
Common around 6 weeks
2-3 months of age.
LATE POSTPARTUM TRANSMISSION
At birth--negative PCR Test positivity is estimated from No.of b.f. children who have
subsequent +ve PCR or, persistent
Antibodies beyond 15 month.
3. Breast Health
Addressed
during AN period itself.
Mastitis and poor
breast health increase risk
Mastitis
associated with a 3.9 fold increased risk
Optimal breast feeding practices reduce the risk of mastitis
and other breast problems
Maternal Vit. A
def.
- < 20 g/dl ฎ HIV DNA
in B.M.
-
fissured nipples
INFLUENCES
cont
4.
Infant Health
Infant
oral health-thrush or ulcers increase risk
Pattern of feeding-mixed feeding
likely to increase risk
Prematurity
WHAT IS OUR AIM B.F.?
BREASTFEEDING IS IMPORTANT FOR
CHILD
HEALTH
Optimal nutrients for health &
growth
Protects against
infections, diseases.
child
spacing
Warmth and closeness
Convenient and cheap
Boosts IQ
NO BREAST FEEDS
Sickness & death of babies
Financial costs to families
Stigma bad mother, HIV status
identified
Guilt
ฏ
birth intervals
Rapid return of menses
BREAST FEEDS
Exclusive breast feeds.
Short duration 4 to 6
months.
No mixed feeds.
When to cease exclusive breastfeed?
Little evidence
to guide decisions
Depends on the baby & other circumstances-availability of milk, other
weaning foods, time to feed the baby & health of baby.
Avoid very abrupt weaning may result in breast engorgement, distressed baby
- a return to b.f. then the baby is at higher risk of HIV.
Trained counsellors and support with replacement feeding helps to reduce problems.
Alternatives to breastfeeding-expressed
breastmilk
Heat treatment of expressed breast milk - kills virus
Heat destroys some of the anti-infective factors in breast
milk, but the nutrients remain the same
HIV is killed at 56
.C, but EBM should be boiled and
then cooled immediately
Pasteurisation - milk heated at
62.5.C
for 30 minutes.
But can women continue to express for six months without the stimulation
of suckling?
UNIVERSAL
PRECAUTIONS
Applies to HIV,
HBV, HCV etc.,
Body fluids
Blood, fluids
containing visible blood
Amniotic fluid
Semen, Vaginal
fluids
CSF
Synovial fluids
Pleural,
Pericardial, Peritonial fluids
Do not apply toF
Feces
Urine
Vomitus
Sputum
, Nasal secretions
Sweat
Tears
GOALS OF THE WORLD
COMMUNITY
By 2010, reduce by 50% the No. of
babies infected by HIV
100% Pregnant women in ANC receive info.on HIV,
counselling & prevention services.
Continuum of Care
holistic and comprehensive approach.