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Jean R. Anderson, MD
DirectorJohns Hopkins HIV Womens Health Program
Care of Women with HIV Living in
Limited-Resource Settings
HIV and Pregnancy
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Objectives
Review significance of HIV during pregnancy and
magnitude of the problem
Review HIV-related issues to be considered prior to
pregnancy
Discuss effects of pregnancy on HIV infection and
effects of HIV infection on pregnancy course and
outcome
Discuss mother-to-child transmission (MTCT) and itsprevention
Discuss care of pregnant woman with HIV
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HIV and Pregnancy Why Is It
Important?
HIV may have adverse effect on pregnancy course or
outcome
More than 90% of pediatric HIV/AIDS cases are caused
by MTCT
Most children born to HIV-positive mothers in limited-
resource settings will be orphaned when one or both
parents die
Women without HIV may place themselves at risk forinfection while trying to get pregnant
Majority of women with HIV are of childbearing age
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Prevalence of HIV (Type-1) among
Pregnant Women
0% 10% 20% 30% 40% 50%
Nigeria
Uganda
Kenya
South Africa
Malawi
Rwanda
Botswana
ThailandCambodia
Brazil
Honduras
Haiti
% Positive
Source: DeCock et al 2000.
Latin
America
Asia
Africa
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0
10
20
30
40
50
60
70
Carletonville,SouthAfrica
,
1998(urban)
Mutasadistrict,Zimbabwe
,
1998(rural)
Kisumu,Kenya,1997(urb
an)
Lusaka,Zam
bia,1995(urba
n)
Mposhi,Zambia,1996(rur
al)
Ndola,Zam
bia1997(urba
n)
Kisesa,Tanzania,1997(ru
ral)
Yaounde,Cam
eroon1997(urb
an)
Cotonou,Benin1997(urba
n)
FortPortal,Uganda1995(urb
an)
Masaka,Uganda1996(rur
al)
Women, 15-19
Women, 20-24
HIVprevalence(%
)
HIV Prevalence among Women Age 1524Various African Studies, 19951998
Source: UNAIDS June 2000.
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Effect of HIV on Fertility
Prior STIs or pelvic inflammatory disease
Direct effects of HIV
Decreased fertility seen after adjustment for age, lactation,
illness, STIs
Worsened fertility in women with symptomatic HIV or co-
infected with syphilis
Pregnancy loss more common with HIV infection
Decreased sexual activity with advanced HIV
Source: Lancet 1998.
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Voluntary Counseling and Testing
(VCT) in Women of Childbearing Age
Information about HIV and pregnancy
Risk assessment
Prevention of HIV transmission or acquisition
Prevention of unintended pregnancy
Dual protection with condoms
Need to involve men in VCT!
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Goals of VCT in Antenatal Care
Educate about HIV
Reduce stigma
Prevent new HIV infections in pregnancy
Identify women with HIV
Stabilize and maintain maternal health
Prevent HIV transmission to uninfected sexual or drug
using partners
Reduce risk of MTCT Plan for future
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Special Counseling Issues for HIV-Positive Women
Who Are Pregnant or Considering Pregnancy
Effect of HIV on fertility
Effect of HIV on pregnancy and pregnancy on HIV
Potential for MTCT
Risk
Timing
Prevention
Use of antiretroviral (ARV) agents and other drugs
during pregnancy, if available
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Special Counseling Issues for HIV-Positive Women
Who Are Pregnant or Considering Pregnancycontinued
Newborn feeding options
Disclosure issues concerns about stigma and violence
Use of condoms
Long-term health of mother and care for children
Pregnancy termination option if legal and safe
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Effect of Pregnancy on HIV
CD4 count decreases in all pregnancies due to dilutional
effect; CD4% remains stable in HIV-positive women
HIV-RNA levels (viral load) remain stable during
pregnancy in absence of treatment
No significant differences in HIV progression or survival
between pregnant and nonpregnant women with HIV
infection
Source: Alliegro 1997 Brocklehurst 1998 Burns 1998.
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Effect of HIV on Pregnancy
Pregnancy Outcome Relationship to HIV Infection
Spontaneous abortion Limited data, but evidence of possible increased risk
Stillbirth Evidence of increased risk in developing countries
Perinatal mortality Evidence of increased risk in developing countries
Infant mortality Evidence of increased risk in developing countries
IUGR Evidence of possible increased risk
Low birth weight (
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Estimated Number of Children (< 15 years)
Newly Infected with HIV during 2000
WesternEurope
< 500< 500North
Africa& MiddleEast
11,00011,000Sub-SaharanAfrica
520,0520,0
0000
EasternEurope &
Central Asia
600600East Asia &Pacific
2,6002,600South &South-EastAsia
65,00065,000Australia &
NewZealand
< 100< 100
NorthAmerica
< 500< 500Caribbean4,2004,200
LatinAmerica
7,3007,300
Total: 600,000Total: 600,000Source: UNAIDS December 2000.
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Estimated Timing and Risk of MTCT of
HIV (Absolute Rates)
NoBreastfeeding
Breastfeedingthrough 6Months
Breastfeedingthrough 1824
Months
Intrauterine 5 to 10% 5 to 10% 5 to 10%
Intrapartum 10 to 20% 10 to 20% 10 to 20%
Postpartum
Early (first 2 months) 5 to 10% 5 to 10%
Late (after 2 months) 1 to 5% 5 to 10%
Overall 15 to 30% 25 to 35% 30 to 45%
Source: DeCock et al 2000.
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Factors Affecting MTCT of HIV/AIDS
Viral load (HIV-RNA level)
Genital tract viral load
CD4 cell count
Clinical stage of HIV
Unprotected sex with
multiple partners
Smoking cigarettes
Substance abuse
Vitamin A deficiency
Photo: Nelson, Zambia 2000.
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STIs and other co-infections
ARV agents
Preterm childbirth
Placental disruption
Invasive fetal monitoring
Duration of membrane
rupture
Vaginal childbirth versus
cesarean section
Breastfeeding
Factors Affecting MTCT of HIV/AIDScontinued
Photo: Nelson, Zambia 2000.
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MTCT Prevention in Low-Resource
Settings
Change behavioral factors
Encourage consistent condom use during pregnancy and
postpartum
Discourage use of drugs, alcohol and cigarettes
Identify and treat modifiable risk factors
Screen and treat STIs and co-infections
Provide vitamin A supplementation, if available (?)
Recommend treatment for substance abuse
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MTCT Prevention in Low-Resource
Settings continued
Reduce viral exposure
Avoid:
Artificial membrane rupture
Transfusion (use only in life-threatening situations)
Shorten duration of ruptured membranes
Cleanse vaginal area with disinfectant (?)
Reduce viral load before childbirth
Administer ARV agents
Treat STIs
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MTCT Transmission with Short Course
Oral ARV Regimens
Site Regimen
MTCTReduction
No Breastfeeding
Thailand ZDV: 36 weeks, labor 50%
Breastfeeding
Cote dIvoire ZDV: 36 weeks, labor 37%(3 months)
ZDV: 36 weeks, labor,postpartum (mother)
34%(18 months)
Uganda, Tanzania,South Africa ZDV/3TC: 36 weeks, labor,postpartum (mother & newborn) 52%(6 weeks)
ZDV/3TC: labor,postpartum (mother & newborn)
38%(6 weeks)
Uganda NVP (single dose): labor, postpartum(newborn)
41%(18 months)
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Recommendations for Antenatal Care
Basic antenatal care
Prevent and treat common opportunistic infections
Recommend nutritional interventions
Screen and treat STIs and other co-infections
Monitor for signs and symptoms of progressive
HIV/AIDS
Counsel on safe sex practices
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Recommendations for Antenatal Carecontinued
Avoid invasive procedures
Amniocentesis
External cephalic version
Consider administering ARV agents, if available
Plan for future
Newborn feeding
Family planning
Long-term care needs for mother, newborn and otherchildren
Provide emotional support
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Recommendations for Labor and
Childbirth
Avoid invasive procedures
Artificial membrane rupture
Fetal scalp electrode or sampling
Forceps or vacuum extractor
Episiotomy
Administer ARV agents, if available
Consider issues related to type of delivery cesarean
section versus vaginal childbirth Wipe newborn quickly and thoroughly with a dry cloth to
remove maternal blood and secretions
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Recommendations for Labor and
Childbirth continued
Follow recommended infection prevention practices
Wash hands thoroughly before and after each procedure
and examination
Wear hand and eye protection Handle needles and other sharp instruments safely
Dispose placenta and other waste materials and supplies
properly
Process instruments, gloves and other items by
decontamination, cleaning and either sterilization or high-
level disinfection
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MTCT and Cesarean Section
Cesarean section before onset of labor and membrane
rupture decreases risk of MTCT 5080%
Additional benefit in women not using ARV agents or on
ZDV alone No evidence of benefit after onset of labor or membrane
rupture
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MTCT and Cesarean Section continued
Special concerns with cesarean section in limited-
resource settings
Increased maternal morbidity and possible mortality
Availability of blood and blood safety Iatrogenic prematurity
Antibiotic prophylaxis
Anesthesia availability
Limited human resources nursing care time
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Postpartum Care
Assess healing
Review newborn feeding, growth and development
Reinforce safer sexual practices
Discuss contraception options
Refer mother and newborn for ongoing care
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Recommendations for Breastfeeding
Avoid all breastfeeding when replacement feeding is
acceptable, feasible, affordable, sustainable and safe
Provide guidance and support to HIV-positive mothers who
choose not to breastfeed to ensure adequate nutrition If breastfeeding chosen, encourage exclusive
breastfeeding up to 6 months of infants life
Teach proper attachment of newborn to nipples and
frequent breast emptying
Teach prevention and recognition and encourage prompt
treatment of mastitis, breast abscess, cracked nipples and
oral thrush or other oral lesions in newborns
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Botswana Kenya Malawi Tanzania Zambia Zimbabwe
0
50
100
150
200
250Deaths per 1000 live births
WithoutAIDS
WithAIDS
Estimated Impact of AIDS On Under-5 Child
Mortality Rates Selected African Countries, 2010
Source: UNAIDS June 2000.
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WesternEurope
9,0009,000North
Africa& MiddleEast
15,00015,000Sub-SaharanAfrica
12.112.1millionmillion
EasternEurope &
Central Asia
500500East Asia &Pacific
5,6005,600South &
South-EastAsia
850,000850,000Australia
& NewZealand
< 500< 500
NorthAmerica
70,0070,00
00Caribbean85,0085,0000Latin
America
110,0110,0
0000
Total: 13.2 millionTotal: 13.2 million* HIV-negative children who have lost their mother or both parents to AIDS before the age of 15 years
Estimated Number of Children (< 15
years) Orphaned by AIDS* by End of 1999
Source: UNAIDS December 2000.
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Summary
Prevent HIV infection in women in their childbearing
years
Prevent unintended pregnancies in HIV-positive women
Identify HIV infection in pregnant women
To provide effective antenatal, labor and childbirth, and
postpartum care can be provided
To reduce risk of MTCT