HIV and Pregnancy:

Prevention of
Mother-to-Child Transmission

Part A: Module A3
Session 1

Part A /Module A3/Session 1

 Objectives

1. Understand the effects of HIV on pregnancy

2. Discuss MTCT transmission, factors that may

increase transmission, and measures that reduce
transmission

3. Describe how ART is used for the prevention of

MTCT

Part A /Module A3/Session 1

 Objectives, continued

4. Describe the various drug regimens for PMTCT that

are used during pregnancy, intrapartum, and
postpartum, including short course ART
5. Discuss issues related to breastfeeding, PMTCT,
ART and WHO recommendations
6. Discuss national guidelines on infant feeding

Part A /Module A3/Session 1

 HIV and Pregnancy:
Prevention of Mother-to-Child Transmission

 Worldwide, each year, two million HIV infected

women become pregnant, most of them in
poor countries
 Between 1/4 and 1/3 transmit the disease to
their newborns either during labor, during
delivery, or while breast-feeding (2,000 new
AIDS-infected infants each day)
 HIV infected children whose mothers die are
left orphaned and harder to care for than the
HIV negative infant

Part A /Module A3/Session 1

 HIV and Pregnancy: Prevention
of Mother-to-Child Transmission, continued

 In [participants’ country] % of women are HIV

positive. Prevalence is higher in areas
 HIV presentation is the same in both sexes, but the
disease has greater implications on a woman’s
reproductive health in terms of her ability to cope with
pregnancy and transmission of the virus to her unborn
and newborn child
 During the asymptomatic phase of HIV, most women
are unaware of their infection until the disease is
diagnosed in their infants. This may cause conflict
within the family and the woman might be blamed for
bringing the infection into the family

Part A /Module A3/Session 1

 Effects of HIV on Pregnancy

 Some studies in Africa suggest that HIV may have

an adverse affect on fertility in both symptomatic
and asymptomatic women
 When comparing changes in CD4 count/percentage
over time, there is no difference between HIV-
positive women who are pregnant and HIV-positive
women who are not pregnant
 HIV does not seem to significantly cause congenital
abnormalities or an increase in spontaneous
abortion

Part A /Module A3/Session 1

 Effects of HIV on Pregnancy, continued

 During the early stages of HIV infection, pregnancy

does not accelerate disease progression
 Late HIV disease may affect the outcome of
pregnancy, i.e., poor fetal growth, preterm delivery,
low birth weight, prenatal and neonatal death
 With regard to common HIV-related problems, there
is no difference between pregnant and non-
pregnant women and they should be managed the
same (except for drug management)

Part A /Module A3/Session 1

Mother-to-Child Transmission of HIV

 Transmission
• Factors which may increase risk of transmission
• Measures to reduce MTCT

 ARV Therapy and MTCT

• Prevention of prenatal • ART and breastfeeding
transmission • Treatment postpartum
• Women first diagnosed • Adherence to therapy
with HIV infection during
pregnancy • Recommendations
• HIV-infected women on
ART who become pregnant

Part A /Module A3/Session 1

 Transmission

 HIV may be transmitted to the infant during

pregnancy, at the time of delivery, and through
breastfeeding; most transmission is thought to
take place during delivery
 For a mother known to be HIV-infected
prenatally, the additional risk of transmission of
HIV to her infant through breastfeeding has
been estimated at 14%
 The risk is as high as 29% for mothers who
acquire HIV post-natally

Part A /Module A3/Session 1

 Transmission, continued

 Many studies indicate that the risk of breast milk

transmission is higher in the first few months of
life, with a subsequent tapering off of risk
 The risk persists as long as the infant is
breastfed
 HIV transmission is also higher if the mother has
mastitis

Part A /Module A3/Session 1

Factors Which May Increase the
Risk of Transmission
 High maternal viral load: >5-10,000 copies/ml
(e.g., at time of seroconversion and during late
HIV disease: CD4 cell counts <100 cells/mm)
 Recurrent STDs
 Malaria interferes with placental functions and
eases viral transmission across the placenta
 Vitamin A deficiency
 Preterm delivery
 Infected amniotic fluid (chorioamnionitis) (limited
data; recent studies do not suggest increased
risk)

Part A /Module A3/Session 1

 Factors Which May Increase the Risk
of Transmission, continued

 Vaginal delivery
 Duration of rupture of membranes is longer than 4
hours
 Placental disruption
 Invasive procedures during delivery (e.g., vacuum
extraction, episiotomy, use of forceps, fetal scalp
monitoring)
 Mechanical nasal suction after delivery
 Breastfeeding and especially mixed feeding

Part A /Module A3/Session 1

 Measures to Reduce MTCT
During pregnancy:
 Provide voluntary counseling and HIV testing plus
psychosocial support
 Diagnose and provide aggressive treatment of
malaria, STDs and other infections as early as
possible
 Provide basic antenatal care including:
• Iron Supplementation
• Education about MTCT and infant feeding
options
• ART for MTCT
• Risk reduction/safer sex measures

Part A /Module A3/Session 1

 Measures to Reduce MTCT
During Labor and Delivery:
 Delay rupturing of membranes (ROM)
 Do only minimal digital examinations after ROM
 Cleanse the vagina with hibitane or other viricides
if available
 Reduce use of assisted delivery with forceps,
 Reduce use of episiotomy
 Elective caesarean section has a more protective
effect against MTCT than vaginal delivery
 If not already on ART, give NVP

Part A /Module A3/Session 1

 Measures to Reduce MTCT
After Delivery:
 Avoid mechanical nasal suction
 Clean the newborn immediately of all maternal
secretions and blood
 Support safer infant feeding (according to national
guidelines re: mother’s choice to put the infant to
breast within 30 minutes of birth)
 If breastfeeding is chosen as an option: encourage
exclusive breastfeeding and advise early cessation
(up to 6 months) or breast milk substitute
 Advise giving milk substitutes where conditions are
suitable and no breastfeeding after 6 months

Part A /Module A3/Session 1

 Risks and Benefits:
Breastfeeding vs. Replacement Feeding

 Current WHO/UNAIDS/UNICEF guidelines

recommend that women with HIV infection be fully
informed of both risks and benefits of breastfeeding
and be supported in their decision about feeding
practices
 Safe alternatives may not be available in some
resource-limited settings, in which case exclusive
breastfeeding for the first six months of life is
recommended

Part A /Module A3/Session 1

Breastfeeding by HIV Positive Mothers:
Risks to the Infant

 HIV infection
 Infection risk persists for as long as the infant is
breastfeeding
 Children who receive mixed feeding seem to be at
higher risk of HIV infection during the first months of
life than children who receive exclusive breastfeeding
or exclusive replacement feeding
 Shortening the period of breastfeeding may reduce
the risk of HIV transmission and mixed feeding should
be discouraged
 The alternative of exclusively giving replacement
feeding also has considerable risks

Part A /Module A3/Session 1

 Breastfeeding: Benefits to the Infant

 The immunological, nutritional, psychosocial,

and child-spacing benefits are well recognized
 Breast milk plays an important role in
preventing the infections that accelerate
progression of HIV-related diseases in already
infected children

Part A /Module A3/Session 1

 ARV Therapy and MTCT
Prevention of Prenatal Transmission
ARV therapy can produce a significant reduction in
mother to child transmission of HIV
 Studies showed that administration of AZT to
women from 14th week of pregnancy and during
labor to the newborn decreased the risk of MTCT
by nearly 70% in the absence of breastfeeding
 A shorter AZT alone regimen starting from the 36th
week of pregnancy was shown to reduce the risk of
transmission of HIV at 6 months by 50% in non-
breastfeeding population and by 37% in those
breastfeeding

Part A /Module A3/Session 1

 ARV Therapy and MTCT, continued

 Short course of NVP (HIVNET 012) has been shown

to reduce the risk of transmission by 47%

 This protocol is the most commonly used one

because of its
 demonstrated efficacy in clinical trials in
reducing MTCT
 low cost
 ease of use in MTCT programs

Women on treatment with ARVs for HIV infection have

very low transmission if their viral load is <1000 copies/ml

Part A /Module A3/Session 1

 Women First Diagnosed with
HIV Infection During Pregnancy

 Women in the first trimester may consider delaying

initiation of ART
 Consider severity of maternal HIV disease and
potential benefits and risks of delaying ART until
after first trimester
 For women who are severely ill, the benefit of early
initiation may outweigh theoretical risk to fetus; in
these cases, recommend initiating with drugs such
as AZT, 3TC, NVP, or NFV

Part A /Module A3/Session 1

 HIV-infected Women on ART
Who Become Pregnant
 Options are:
• Suspend therapy temporarily during first
trimester
• Continue same therapy
• Change to a different regimen
 Issues to consider:
• Gestational stage of the pregnancy
• Severity of maternal disease
• Tolerance of regimen in pregnancy
• Potential for adverse fetal effects

Part A /Module A3/Session 1

 ART and Breastfeeding

 Women who require ART and are

breastfeeding should continue their ongoing
ART regimen

 Efficacy of a potent ART being given to the

mother solely to prevent postnatal
transmission of HIV through breast milk is
unknown, but is currently being studied

Part A /Module A3/Session 1

Short-Course ARV prophylaxis and
Treatment Postpartum

 Short-course ARV regimens, that do not fully

suppress viral replication, may be associated
with the development of ARV drug resistance

The Ugandan HIVNET 012 study of single

dose intrapartum/newborn NVP for prevention
of MTCT found that 19% of the women
developed resistance to the drug. This was
associated with delivery, HIV viral load and
CD4 cell count

Part A /Module A3/Session 1

 Short-Course ARV Prophylaxis
and Treatment Postpartum,
continued

 Based on current information (until further

research is done), prior administration of short-
course AZT/3TC or single dose NVP for
prevention of MTCT should not preclude use of
these agents as part of a combination ARV drug
regimen initiated for treatment of these women

Part A /Module A3/Session 1

 Adherence to Therapy
in Pregnancy and Postpartum
 Difficulty of adherence is greater in pregnant and
postpartum women

 Obstacles to adherence: morning sickness, GI upset,

fears about ARV harming the fetus

 If need to temporarily discontinue therapy during

pregnancy, stop all drugs and then re-start
simultaneously
• This reduces the potential for emergence of
resistance

Part A /Module A3/Session 1

 Adherence to Therapy
in Pregnancy and Postpartum, continued

 Treatment adherence difficult postpartum

• Physical changes of postpartum period

coupled with stresses and demands of caring
for a newborn infant

 Important to provide additional supports for

maintaining adherence to therapy during ante-
and post-partum periods

Part A /Module A3/Session 1

 Recommendations
 Exclusive breastfeeding for the first 6 months
generally promoted and supported ---
• serostatus of most mothers unknown
• benefits to infants outweigh the risks
regardless of their HIV status
 The mother should make final choice about the
feeding method
• Whatever her choice may be, health staff
should provide support to ensure optimal
nutrition of mother and child
[Refer to national HIV and infant feeding guidelines]

Part A /Module A3/Session 1