Every pregnant woman during her first visit should be counseled for voluntary HIV testing at an ICTC to know her HIV status.
Let’s Discuss HIV in Pregnancy, HIV Treatment of Mother & Newborn, HIV in Pregnancy, Treatment of Women and Baby, Care during pregnancy, Care during delivery, Care of HIV Exposed Infant, HIV Testing of Newborn.
Care of HIV positive pregnant woman during pregnancy
Points to be noted in history:-
- High-risk behavior of herself and her spouse
- Pregnancy duration, number of previous pregnancies, live children, receipt of any antiretroviral medicines earlier.
- If pregnancy is unwanted and is < 20 weeks refer her to MTP Centre.
- If she wishes to continue current pregnancy, refer her to PPTCT Centre soon after confirmation of pregnancy to start the antiretroviral medicines for reducing the risk of vertical transmission. ART Centre will be initiating anti-retroviral medicines from 14 weeks and will be doing CD4 testing and other evaluations.
- Screen for TB and STI at every visit.
Specific education & counseling regarding:-
- A nutritious diet, consumption of micronutrient supplements.
- Safe sex practices for preventing new STIs and other strains of HIV which could harm the baby.
- Adherence to HIV medicines.
- Follow up at ART & PPTCT centers as instructed.
- Institutional delivery.
- Safe infant feeding practices, infant care.
Care during delivery
Insist on institutional delivery at a PPTCT Centre as she requires ARV medicines during labour which need to be continued postpartum. C. section is performed only for obstetric indications. If she is in advanced labour, conduct delivery by following principles:
- Follow universal safety precautions
- Minimum number of vaginal examinations
- Do not rupture membranes unless indicated.
- Avoid Routine Episiotomy, perineal injuries, vacuum delivery.
- Avoid suctioning the baby unless there is meconium staining
- Give ARV medicines as per protocol.
- Clean the baby of the maternal blood and body fluids before handing over to the relatives.
Care of mother after delivery
- Refer to the PPTCT center for the care of mother and baby.
- Watch for signs of sepsis.
- A nutritious diet, nutrient supplements.
- Encourage to use of reliable contraception; safe sex practices.
Treatment at PPTCT/ART Centre
- The new protocol consists of giving triple ART to pregnant women and extended Nevirapinetherapy for the exposed infant.
- Triple antiretroviral therapy (ART) initiated from 14 weeks irrespective of CD4 count and continued lifelong. Refer to the table below.
- If there is no prior exposure to EFV/NVP, a triple ARV regime consisting of Tenofovir, Lamivudine and Efavirenz is started from 14 weeks onwards to be continued throughout pregnancy, labour, postpartum period and thereafter.
- If there is H/O prior exposure to NVP/EFV then EFV is not given and a protease inhibitor is given (Lopinavir/Ritonavir).
- Baseline investigations: Hb, urine, VDRL, screening for hepatitis B and C, ALT, CD4, urea/creatinine, blood sugar, lipid profile.
- If CD4 is < 250 Cotrimoxazole (CPT) 1 ds tab daily.Laboratory tests:
- After 2 weeks of initiating ARV ==> Hb, ALT.
- At 4,8,12 weeks ==> Hb testing.
- Every 6 months ==> BUN, Sr. Creatinine, ALT, CD4, Urine analysis (imp in TDF based regimes).
- If on PI based treatment: BSL & Lipid profile every 6 months
Dosage Schedule and Associated Side Effects of ARV Medicines
|Name of ARV||Dose||Major Side Effects|
|Tenofovir (TDF)||300 mg Once a day||Nephrotoxicity, hypophosphatemia|
|Lamivudine (3 TC)||300mg Once a day||Very few. Hypersensitivity, rarely pancreatitis|
|Efavirenz (EFV)||600 mg Once a day||Neuropsychiatric symptoms (hallucinations, suicidal ideation, nightmare)|
|*Lopinavir/Ritonavir (LPV/r)||400/100 mg BD||GI disturbance, glucose intolerance, lipodystrophy & hyperlipidemia|
Care of HIV Exposed Infant
- The infant is given Nevirapine (NVP) syrup for 6 or 12 weeks as advised by PPTCT Centredepending on the duration of ART received by the mother.
- Appropriate infant feeding is initiated as per informed choice following AFASS counseling: Up to 6 months: Exclusive breastfeeding (preferred option) or exclusive replacement feeding. No mixed feeding.
- At 6 weeks:
- Start Cotrimoxazole (CPT) prophylaxis,
- Early infant diagnosis (EID) by dry blood spot test (DBS); if DBS +ve Whole blood spot (WBS) confirmatory testing.
- EID +ve babies are started on ART at pediatric ART Centre irrespective of CD4
- After 6 months:
- if breastfeeding option has been chosen, breastfeeding is continued as per EID status:
- EID –ve babies: Continue BF up to 1 year + Complementary feeding; No abrupt stopping of breastfeeding
- EID +ve baby on ART: Breastfeeding continued up to 2 years
Growth & nutrition monitoring, immunization as per schedule.
Confirm HIV status:
Repeat HIV testing at 6, 12 months and 6 weeks after stoppage of breast feeding; (If rapid test + ve DBS followed by WBS).
At 18 months: Confirmation of HIV status by 3 rapid antibody tests.
- Counsel for adherence to ARV and AKT if co-infected with tuberculosis.
- Encourage safe infant feeding practices.