HIV In Mothers and

Children
 What Is HIV/AIDS?
Acquired immunodeficiency
syndrome (AIDS) is caused by the
human immunodeficiency virus
(HIV).

HIV attacks and destroys white

blood cells, causing a defect in the
bodys immune system.
2
 Number of People with
HIV/AIDS by Region
Western Europe Eastern Europe &
North America 500,000 Central Asia
890,000 270,000 East Asia
North Africa & & Pacific
Caribbean Middle East 560,000
330,000 210,000
South and
Sub-Saharan South East Asia
Africa 6.7 million
Latin 22.5 million
America
1.4 million
Australia and New Zealand
12,000

Source: UNAIDS/WHO 1998. 3

 HIV Transmission Through
Sexual Contact
Of every 100 HIV infected adults, 75-85 have been
infected through unprotected intercourse
70% of these infections are from heterosexual intercourse

STDs,
STDs especially ulcerative lesions in genitalia,
increase risk of transmission

Source: UNAIDS/WHO 1996. 5

Modes of HIV Transmission
Sexual intercourse
Accidental exposure to blood/blood products (e.g., blood transfusions,
shared needles, contaminated instruments)
Mother to child during:
pregnancy
birth
breastfeeding

6
 Women and HIV
Social Risk Factors
Illiteracy
Lack of awareness of preventive measures
Biological risk factors
Twice as easy for women to contract HIV from
men
Physiology of women (e.g., menstruation,
intercourse)
Pregnancy-associated conditions (e.g., anemia,
menorrhagia and hemorrhage) increase the need
for blood transfusion
8
 HIV and Contraception
Contraception with protection
Male condom (latex and vinyl)
Female condom
Nonoxynol-9 (antiviral spermicidal cream) 1
Diaphragm1
Methods appropriate for use by women
with HIV. They should use a condom for
their partners protection.
Hormonals (COCs, Implants, PICs)
Voluntary sterilization
1
Partial protection if used without condom 9
 Effect of AIDS on
Pregnancy
Infertility
Repeated abortions
Prematurity
Intrauterine growth retardation
Stillbirths
Congenital abnormalities
Embryopathies
10
HIV Transmission from Mother
to Infant
Antenatal
In utero by transplacental passage

Intranatal
Exposure to maternal blood and vaginal
secretions during labor and delivery

Postnatal
Postpartum through breastfeeding
Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998. 11
HIV Transmission from Mother
to Infant

25-35% of all infants born to HIV-

infected women in developing
countries become infected

90% of HIV-infected infants and

children were infected by mother

Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998. 12

 approximately 600,000 HIV-infected infants
are born every yearat least 1,600 every
dayin resource-constrained countries.

Transmission occurs during pregnancy,

labor and delivery, and breastfeeding.

The rate of mother to child transmission

has been reduced to less than 5
percent among the limited number of HIV-
infected women in developed countries.
high rates are largely due
to the lack of access to:
HIV voluntary counseling and
testing
replacement feeding
selective caesarean section
antiretroviral drug therapy
 HIV Transmission
HIV cannot be transmitted by:
Casual person to person contact at home
or work or in social or public places
Food, air, water
Insect/mosquito bites
Coughing, sneezing, spitting
Shaking hands, touching, dry kissing or
hugging
Swimming pools, toilets, etc.
15
 AIDS and Infants
Symptoms generally develop by 6
months of age
Diarrhea
Failure to thrive
Most of these children die before
their second birthday
Children born to HIV-infected parents
are likely to become orphans
16
Reducing pediatric HIV
infection and disease involves
three stages:
preventing HIV infection among
women of childbearing age
preventing unwanted pregnancy
among HIV-positive women
preventing mother to child
transmission during pregnancy, labor
and delivery, and breastfeeding
BENEFITS TO HIV TESTING
EARLY COUNSELING AND
TREATMENT OF HIV INFECTION
ABILITY TO MAKE DECISIONS
REGARDING PREGNANCY
IMPLEMENTATION OF STRATEGIES
TO ATTEMPT TO PREVENT
TRANSMISSION TO FETUS
 WHO SHOULD WE
SCREEN?
ALL PREGNANT WOMEN

TARGETED TESTING FAILS TO

IDENTIFY A SUBSTANTIAL
PROPORTION OF HIV POSITIVE
WOMEN
Anti-Retroviral Based Prevention
Strategies
zidovudine (AZT) administered to the
mother from 14 weeks of gestation and
to the child during the first seven days
after birth, reduced the risk of mother to
child transmission among non-
breastfeeding mothers by two-thirds.
two-thirds
Two similar studies conducted in Cte
dIvoire and Burkina Faso among
breastfeeding mothers demonstrated a
37 percent reduction in mother to
child transmission.
Anti-Retroviral Based Prevention
Strategies
A study in Uganda demonstrated a 47
percent reduction in mother to child
transmission following the
administration of a single dose of
nevirapine to the mother at onset of
labor and to the baby within 72 hours
after birth.
The combination of AZT and lamivudine
in a short-course regimen also has been
shown to reduce mother to
child transmission.
Protecting Health Care
Workers During Labor and
Delivery
Precautions during labor:
Protection from blood and amniotic fluids
Protection from sharp instruments
Resuscitation of baby:
No mouth to mouth suction
No mouth to mouth breathing
Precautions following labor:
Proper disinfection of instruments
Proper disposal of placenta and other items
22
 PRETEST COUNSELING
TAKE RISK HISTORY AND COUNCIL REGARDING RISK REDUCTION
DISCUSS REASONS FOR TEST
PROVIDE INFORMATION TO WOMEN REGARDING TESTING &
ILLNESS
RISKS & BENEFITS OF TESTING
CONFIDENTIALITY OF RESULTS
ASSESS WINDOW PERIOD
PERSON HAS RIGHT TO REFUSE TESTING
 CONCLUSIONS
ALL PREGNANT WOMEN SHOULD BE
OFFERRED HIV TESTING
PRE- & POST- TEST COUNSELING FOR
ALL PREGNANT WOMEN
TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED
ANTENATAL CARE
 INTRODUCTION
MULTIDISCIPLINARY TEAM
APPROACH

MEDICAL NEEDS

SOCIAL AND PSYCHOLOGICAL

NEEDS
 ANTENATAL CARE
SIMILAR TO CARE FOR HIV NEGATIVE
WOMEN

PREGNANCY NOT HIGH RISK

SAME NUMBER OF ANTENATAL VISITS

AVOID INVASIVE ANTENATAL TESTS OR

PROCEDURES
ANTIRETROVIRAL USE
IN UTERO
EXPOSURE
 IN UTERO EXPOSURE

Drug Teratogenici Carcinogenici FDA

NRTIs ty ty in animals Pregnanc
In animals y
Lamivudin (rodents)
Not Category
C
e teratogenic
Stavudine Not Liver and C
teratogenic urinary
Didanosin Not tumours
Not B
e teratogenic carcinogenic
Zalcitabin Hydrocephal C
e us
Abacavir Skeletal C
 IN UTERO EXPOSURE
Drug Teratogenicity Non Teratogenic FDA
PIs in Animals Effects Pregnanc
y
Ritonavi Slight incr. in Category
B
r cryptorchidism

Saquina Not B
vir teratogenic
Indinavir Incr. Increased C
supranumery hyperbilirubinemi
& cervical ribs a in monkeys
Nelfinav Not -neonatal B
ir teratogenic
ANTIRETROVIRAL THERAPY
DURING LABOR &
DELIVERY
 IV ZIDOVUDINE
ZDV LOADING DOSE AT ONSET OF
LABOR 2MG/KG OVER 1 HR
CONTINUOUS INFUSION WHILE IN
LABOR 1MG/KG/HR
 INCREASING EVIDENCE THAT MOST
PERINATAL TRANSMISSION OCCURS
NEAR TIME OF OR DURING
DELIVERY
REDUCTION OF PERINATAL
TRANSMISSION DUE TO SYSTEMIC
ANTIRETROVIRAL DRUG LEVELS IN
NEONATE AT TIME OF DELIVERY
BREASTFEEDING IN HIV
POSITIVE WOMEN
 INTRODUCTION
HIV DNA PRESENT IN BREAST MILK
HIV TRANSMISSION CAN OCCUR
THROUGH BREASTFEEDING
BREASTFEEDING IS AN
INDEPENDENT RISK FACTOR FOR
HIV TRANSMISSION
 CONCLUSION
PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION STILL
NOT WELL UNDERSTOOD
WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
WOMEN WHO BREASTFEED SHOULD BE
INFORMED THAT TRANSMISSION CAN
OCCUR
SUMMARY
 HIV SCREENING
ALL PREGNANT WOMEN SHOULD
BE OFFERRED HIV TESTING
PRE- & POST- TEST COUNSELING
FOR ALL PREGNANT WOMEN
TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED
 ANTENATAL CARE
HIV IN PREGNANCY REQUIRES
MULTIDISCIPLINARY APPROACH
ANTENATAL CARE IS SIMILAR TO THAT OF HIV
-VE WOMEN
PREGNANCY NOT HIGH RISK
AVOID INVASIVE PROCEDURES
MONITOR CD4+ AND VIRAL LOAD AT LEAST
EVERY 3 MONTHS IF ABLE TO PROVIDE
ANTIRETROVIRAL THERAPY
 ANTIRETROVIRAL USE
Zidovudine reduces perinatal
transmission in women at different
stages of disease
long (ante, peri, and postnatal) as
well as shorter regimens effective
still effective in breastfeeding
populations
Use of other antiretrovirals in
combination with ZDV promising,
still investigational
 BREASTFEEDING
PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION STILL
NOT WELL UNDERSTOOD
WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
WOMEN WHO BREASTFEED SHOULD BE
INFORMED THAT TRANSMISSION CAN
OCCUR