AIDs

HIV (Human Immunodeficiency Virus) causes acquired immunodeficiency syndrome (AIDS), which is caused by the retroviruses HIV 1 and HIV 2. T-lymphocytes are reduced by the virus, resulting in immunodeficiency. As a result, the person is vulnerable to infection from an opportunistic microorganism. The incubation period ranges from two months to four years.

Mode of Transmission

• Contact with an infected male or female.
• Using a contaminated, unsterile syringe, needle, or skin-piercing tool.
• Contaminated blood or blood products, such as a blood transfusion.
• Before, during, or after birth, from an infected mother to her infant (transplacental and through breast milk)

Mother to Child Transmission

Vertical transmission to newborns occurs in about 15-30% of seropositive mothers, with an additional 5-20% transmitting during breastfeeding. The baby may be affected in utero by transplacental transfer, during delivery by contaminated birth canal fluids and blood, and in the newborn period by breast milk. HIV antibodies acquired transplacentally are eliminated by the age of 18pmths. Nepalese mother to child Out of the predicted 9,00,000 pregnancies, 1800 are expected to be in HIV-positive women, resulting in 450-810 infected newborns. This transmission rate can be decreased to 2% or less with intensive treatment such as PMTCT, ARV therapy, and C/S at 38 weeks of pregnancy.

Effects on Pregnancy

1. Abortion, preterm, IUGR, and perinatal death have all increased.
2. The infection spread to unborn and born infants.

Comprehensive prevention from Mother to Child Transmission (PMTCT)

Comprehensive Four pronged strategies for PMTCT of HIV

Prong 1: Prevention of primary HIV Infection

• Increase HIV prevention knowledge among people of reproductive age.
  A = abstain
  B = be faithful to the partner
  C = use of condoms consistently and correctly
• Gather community leaders, teachers, and FCHVs.
• Establish partnerships and connections with NGOs and CBOs.
• Expand access to HIV testing
• Provide services for STI screening and treatment.
• Encourage male partners to participate in ANC and PMTCT.

Prong 2: Preventing Unintended Pregnancies

• Family planning saves lives and improves the health of HIV-positive women; therefore, assists the client in choosing a contraceptive technique. The most effective FP approaches for HIV-positive customers.
  • Condoms
  • Hormonal contraceptives
  • IUDs
  • LAM
  • Sterilization is effective for women with HIV. Must be voluntary.
  • Hormonal contraceptives: Injectables like Depo Provera are more reliable than OCP in women on ART.
• Family planning assists HIV-positive women by preventing unplanned pregnancies. It is critical that pregnant women use condoms to avoid new HIV infection during pregnancy and breastfeeding: a new HIV infection significantly increases the likelihood of MTCT. The majority of contraceptive techniques are safe for HIV-positive women to use.

Prong 3: Prevention of Mother and Child Transmission of HIV.

• HIV testing and counseling during prenatal care, labor and delivery, and postpartum (individual, couple, group).
• Antiretroviral (ARV) medications are given to the mother and infant.
• Putting in place safer delivery methods.
• Encourage exclusive breastfeeding during the first 6 months.

Prong 4: Treatment and Care for Positive Women and their Families

• Every HIV-positive mother needs thorough care.
• Antiretroviral (ARV) medications are given to the mother and infant.
• Safer delivery procedures are being implemented.
• Encourage exclusive breastfeeding during the first 6 months.
• All partners and children must be tested. Positive results are given comprehensive attention.
• Comprehensive HIV care covers the following:
• Enrollment in pre-ART care six times a year CD4
• WHO Staging in clinical practice
• Prophylaxis with cotrimoxazole
• Isoniazid Preventive Medicine
• Regular examinations
• OIs Diagnosis and Treatment ART
• Psychosocial, spiritual, and emotional counseling
• Nutritional assistance

The New Nepal Guidelines on PMTCT 2011

• Antiretrovirals are required for all HIV-positive pregnant women and HIV-positive moms breastfeeding children under the age of one year. They should either receive:
  • Life long antiretroviral treatment
  • Triple antiretroviral prophylaxis

Which pregnant women need life long ART?

Antiretroviral therapy (ART) should be started as soon as possible in pregnant or postpartum women with HIV infection if:

• CD4 cell count < 359, irrespective of WHO clinical staging or
• WHO clinical stage 3 or 4, irrespective of CD4 cell count.

All other HIV-infected women who are pregnant or breastfeeding but do not yet require lifelong ART should begin triple ARV prophylaxis. Both necessitate taking three ARV pills; however, individuals who do not require lifelong treatment will only take the drugs during pregnancy and breastfeeding, stopping one week after breastfeeding is discontinued.

Which regimens are recommended for life long ART?

The ideal first-line ART regimen for pregnant women in need of ART for their own health is:

AZT + 3TC or NVP or

AZT + 3TC + EFV

In the event of anemia, the following regimen is recommended:

TDF + 3TC + NCP

TDF+ 3TC + EFV

Recommended first-line life long ART Regimen for treating Pregnant and Postpartum Women and Prophylactic Regimen for Infants

This should be started as soon as possible (ASAP) in pregnancy. We need to go test woman as early as possible.

(Don’t start EFV in the first trimester)

Nevirapine Caution

• In PLHIV with greater CD4 counts, the risk of severe NVP hepatotoxicity increases.
• If CD4 is greater than 350, NVP should not be initiated.
• NVP should be used with caution in CD4 levels ranging from 250 to 350, and cautious liver monitoring is required.

If pregnant HIV-infected woman does not yet need lifelong ART, what should she take?

• ARV prophylaxis on three occasions. Like ART, it will be discontinued one week after breastfeeding ceases.
• Begin at 14 weeks or as soon as a woman presents:
• Later on in the pregnancy
• In the workplace
• Upon delivery
• While breastfeeding a baby under the age of 12 months.
• We need to treat pregnant women as early as possible as pregnancy.

What ARV’s should women triple ARV prophylaxis take?

The preferred regimen is:

• AZT + 3TC + EFV (preferred due to cost , strength and preserves 2nd line options)

Alternative includes:

• AZT + 3TC + ABC
• AZT + 3TC + LPV/ r

TDF should replace AZT when Hb < 7.5g/dl.

Triple ARV prophylaxis Regiment for Mother and Baby

Note: since all mothers in this group have CD4 > 350, maternal NVP use would be dangerous.

When should triple ARV prophylaxis be stopped?

• When a woman who does not require lifelong ART should discontinue triple ARVs one week after she has stopped breastfeeding.
• Most HIV-exposed babies should discontinue breastfeeding at the age of 12 months.
• If EFV is part of the regimen, it should be withdrawn first, followed by the other two medications for further 7 days. This "covering the tail" is intended to prevent future NNRTI resistance.

When a woman already on ART, who become pregnant

• ART should ideally be completely suppressive prior to conception and maintained throughout pregnancy, delivery, and lactation.
• If pregnancy is detected during the first trimester, ART should be continued. ART discontinuation may result in rebound viral load and CD4 reduction, as well as increased MTCT and HIV disease progression.
• Only use EFV during the first trimester if the possible benefit to the mother outweighs the potential harm to the fetus.
• If a pregnancy is planned, try discontinuing EFV several weeks before conception.
• If a woman using EFV becomes pregnant during the first 6 weeks, she should discontinue EFV and replace it with either Nevirapine or Lopinavir. There is no need to include lead in the Nevirapine dose.
• If a woman is discovered to be pregnant after 6 weeks of LMP, continue EFV until the hazardous period has passed.
• Continue ART if pregnancy is not detected until the second or third trimester.

What should be given for infant prophylaxis?

• All children born to HIV-infected mothers should receive daily NVP from birth (as soon as possible) until they are 6 weeks old.
• The NVP dosage is:
  Birth weight < 2.5 kg: 10mg (1.0ml) per day
  Birth weight > 2.5 kg: 15mg (1.5ml) per day

When a mother is diagnosed after 6 weeks postpartum, start maternal ART/ARVs and consult pediatric HIV specialist for decisions regarding infant prophylaxis.

What should be given for Infant prophylaxis?

What if a woman is already taking ART before pregnancy?

• Continue your artistic endeavors.
• NVP should be given to the newborn every day for 6 weeks.
• If a mother is taking EFV throughout the first six weeks of her pregnancy, she should switch to alternate third medicine.
• If she is taking EFV and is more than 6 weeks pregnant, she should keep taking it.
• ART should not be discontinued during pregnancy.

Adherence to ARVs

• Adherence to triple ARVs or ART is critical for the mother's health, preventing resistant viruses, and protecting the baby.
• Every antenatal and postpartum visit should encourage adherence.
• Consider making connections with and referring to community organizations to assist with medication and appointment adherence.

Repeat HIV Testing in Pregnancy

Retesting during the third trimester is advised for women who tested before in pregnancy and who:

• Have particular instances of known HIV exposure occurred during the last three months?
• Have a constant or ongoing risk of contracting HIV.
• Have a sexually transmitted disease.

Viral Load Testing in Pregnancy

• If viral load testing is available and an elective C-section for HIV PMTCT is being considered, it should be performed at 36 weeks of gestation.
• If the VL is greater than 1000 copies/ml, c section may be beneficial.
• If the VL is less than 1000 copies/ml, the mother can safely deliver vaginally.

SAFE DELIVERY PRACTICES

Labor and delivery management to limit the risk of mother-to-child transmission (MTCT)

• Immediate Newborn care for HIV exposed infants
• Evaluation and Counseling of Pregnant Women

All HIV-infected pregnant women should receive comprehensive education and counseling about the risks of perinatal transmission, prevention strategies, and the potential effects of HIV infection or HIV treatment on the course or outcomes of pregnancy.

Other procedures for evaluating and supporting pregnant women should include the following:

• Ensure that the woman receives ongoing physiological assistance during labor.
• Maintain effective infection control practices.
• Using partograph, provide regular monitoring and active labor management.
• Prevent premature, artificial membrane rupture.
• Prevent excessive labor.
• Consider utilizing oxytocin to shorten labor in HIV-positive patients.
• When necessary, prompt referral.
• Provide ARV to the mother in accordance with the national PMTCT protocol.
• Reduce vaginal examination: only perform a vaginal inspection when absolutely essential and use the proper sterile method.
• To determine the need for early intervention, use a non-invasive fetal monitoring approach.
• Use national protocol to treat the mother's indicators of infection.
• Episiotomies, tears, and instrumental delivery are reduced.
• If the conditions are appropriate, an elective cesarean delivery should be reserved for a woman with a viral load greater than 1000 despite triple ARV/ART medication at 38 weeks of gestation.
• Reduce the risk of postpartum hemorrhage by actively managing the third stage of labor by administering oxytocin within one minute of delivering a baby and confirming there is no second baby.
• Controlled cord traction is used.
• Carrying out uterine massage
• Carefully and quickly repair genital tract lacerations.
• Remove the placenta and membrane with care.
• Provide postpartum care for both the mother and the newborn, while keeping an eye out for infection.
• Maintain universal precautions during treatment and care:
• When administering shots, use gloves.
• Surgical spirits should be used to clean any injection sites.
• All needles must be disposed of in accordance with facility policy.
• When the head is delivered, use a gauge to clean the infant's mouth and nose.
• Clamp the cord as soon as possible after birth.
• To avoid fluid overload and increased HIV exposure, avoid "milking" the chord towards the baby.
• Before cutting the cord, cover it with a gloved hand or gauze.
• When meconium-stained liquid is present, utilize mechanical suction at less than 100 mmHg pressure or bulb suction rather than oral suction.
• Wipe the baby down and pat dry with a towel.
• Place the newborn on the breast of the mother.
• According to national guidelines, administer vitamin K, silver nitrate eye ointment, and the Bacillus Calmette Guerin (BCG) vaccine.
• The first dosage of infant Nevirapine should be given as soon as feasible after birth.
• The goals of therapy for pregnant women receiving ART, as with all HIV patients, are to suppress the HIV viral load as much as possible (preferably to undetectable levels), to improve quality of life, to restore or preserve immune function, and to prevent transmission to sexual (or injection drug equipment-sharing) partners. Another important goal for pregnant women is to limit the danger of perinatal transmission as much as feasible.
• Adverse consequences of therapy, including hyperglycemia, anemia, and liver toxicity, may have a severe impact on maternal and fetal health outcomes. Pregnant women should be informed about potential ARV-related side effects and should be monitored on a regular basis.
• HIV-infected women should be evaluated and given appropriate prophylaxis for opportunistic infections (OIs), as well as the immunizations recommended for HIV patients (see below).
• When taken during pregnancy, some medications, both ARVs, and other pharmaceuticals may induce fetal abnormalities or toxicity. Pregnant women, they should be avoided unless the expected benefit justifies the risk. Before providing drugs to pregnant women, consult with an HIV or obstetric expert, a pharmacist, or the drug labeling information.
• Options for a mode of delivery should be explored as early as possible. The perinatal recommendations highlight the advantages and disadvantages of vaginal vs. cesarean delivery. If the HIV viral load is greater than 1,000 copies/mL at 36 weeks of pregnancy, a planned cesarean delivery at 38 weeks is indicated to limit the risk of transmission even further.
• Other potential maternal health issues, such as diabetes and hypertension, are being screened for.
• Maternal nutritional evaluation and support, including the start of a prenatal multivitamin containing folate (0.4 mg PO QD) to reduce the risk of fetal neural tube defects; some experts recommend higher folate doses in the first trimester for women receiving trimethoprim-sulfamethoxazole; consult with an HIV-experienced obstetric specialist.
• Psychiatric and neurologic illness screening
• Counseling on the dangers of tobacco use; smoking cessation assistance as needed (see chapter Smoking Cessation).
• Counseling about the dangers of alcohol or drug use, as well as assistance in discontinuing these activities as needed
• Screening for intimate partner violence
• Medication review, including over-the-counter and nutritional supplements, and withdrawal of drugs with fetal harm potential.
• Immunizations (for example, influenza, Tdap, and hepatitis B) when needed
• Implementation of standard evaluation and management metrics (e.g., assessment of reproductive and familial genetic history, screening for infectious diseases or sexually transmitted diseases [STDs]).
• If desired or indicated, make plans for a consultation in maternal-fetal medicine.
• If desired, choose effective and suitable postpartum contraception options.

References:

• Tuitui Roshni, Dr. Suwal S.N, Manual of MIDWIFERY I, 9th edition, 2013 A.D, Vidyarthi Pustak Bhandar, Bhotahity, Kathmandu
• http://rnspeak.com/maternal-child-nursing/anemia-in-pregnancy-nursing-/
• http://emedicine.medscape.com/article/230802-treatment#d13
• http://www.healthline.com/health/rh-incompatibility#Symptoms2
• https://www.nlm.nih.gov/medlineplus/ency/article/001600.htm
• http://www.nursing-help.com/2011/02/rh-incompatibility-and-nursing-care.html
• http://aidsetc.org/guide/care-hiv-infected-pregnant-women