Can Pregnancy With HIV Have Healthy Outcome?

There is always a big question can women with HIV have healthy pregnancy? And the answer is yes. Women with good medical care can have healthy pregnancy with HIV negative babies.

WHAT IS HIV AND ITS INCIDENCE? HOW IT LEADS TO AIDS?

HIV is a DNA Retrovirus belonging to subfamily of Lentivirus. HIV is an incurable infection and it leads to AIDS. 25-30% of infected patients are women and 90% are between 20-49 years of age.There are five known human retroviruses (HIV-1,HIV-2, HIV-I,HIV-II &HIV-IV)and three of these are associated with Human disease. HIV viruses are Retro virus having the enzyme reverse trascriptase which permits genomic RNA to be transcribed into double stranded DNA. HIV mainly targets lymphocytes, monocytes,macrophages expressing CD4 molecule whose action in immune system is to combat viruses, bacteria and certain malignancies. Once the virus is in genome of host,it produces multiple copies of itself, which will eventually cause host cell damage. There is gradual depletion of CD4 cells and there is also failure of B lymphocytes to produce antibodies to HIV. This events lead to progressive loss of host immune defense and development of AIDS. There is primary infection which is between 3-6 weeks. It leads to acute syndrome (1 week -3 months) followed by immune response to HIV (1-2 weeks) leading to clinical latency (10 years)followed by AIDS.

HOW DOES HIV SPREAD?

Main mode of transmission is:

Sexual Contact Tran placental Exposure to infected blood or tissue fluid.

Through breast milk

Perinatal transmission of HIV:Vertical transmission to neonate is about 14-25%.

Tran placental transmission occurs 20% before 36 weeks over 80 % transmission occurs around time of labor and delivery.

Vertical transmission is more in cases with preterm birth and prolonged rupture of membrane, Risk of vertical transmission is directly related to maternal viral load ( measured by HIV RNA) and inversely to maternal immune status (CD4 count).Maternal anti-retroviral therapy reduces the risk of vertical transmission by 70%. Breastfeeding doubles the risk of MTCT transmission (14-28%).

SIGNS AND SYMPTOMS OF HIV

Initial presentation may be fever,malaise, headache, sore throat, lymphadenoptahy and maculopapular rash. Primary illness may be followed by asymptomatic panel. Progress of disease may lead to multiple opportunistic infections. There must be associated constitutional symptoms like weight loss, lympadenopathy or protracted diarrhoea. Median time from infection to AIDS is about 10 years.

WHAT ARE TESTS TO CONFIRM HIV?

HIV tests done by detecting HIV viral RNA in blood by PCR testing  ( HIV RNA PCR) or by detecting antibodies to HIV. Enzyme immunoassay is used as screening tests for HIV antibodies. It is extremely sensitive, inexpensive but less specific. An initial EIA test is confirmed by western blot or HIV RNA PCR or Immunoflouresence assay.

HOW CAN YOU PROTECT YOURSELF FROM HIV?IS IT TREATABLE?

HIV is treatable disease but complete cure is never possible. Taking drugs for HIV helps person to stay healthy and reduce the chance of passing virus to other person. HIV cannot be prevented by vaccination.  You can protect yourself from HIV infection by avoiding:

Having multiple sex partners

Using condom during intercourse

Not sharing needles, syringes, razor things which come in contact with other person’s blood.

Taking pre exposure prophylaxis for people who are at increased risk of HIV.

In case you are exposed to HIV within last 3 days then you should take post exposure prophylaxis as it reduces the risk of getting infection but it must be started within 72 hrs of exposure.

HOW DOES HIV/AIDS AFFECT PREGNANCY?CAN IT BE PASSED TO BABY?

In most cases HIV does not cross the placenta to affect the fetus. There can be some factors which affect placenta from protecting the fetus like malnutrition, infection or advanced infections.If women are not on treatment than chance of baby getting infected is 25%. Baby can be affected during delivery or breastfeeding.

WHAT IS VIRAL LOAD AND CD4 COUNT AND WHY IT SHOULD BE MONITORED ON REGULAR BASIS?

CD4 count and viral load are very important when HIV is diagnosed. These value tell us about the health of immune system and progression of HIV in the body and it also tells us how the body is responding to HIV treatment and how this HIV treatment has effect on virus. CD4 cells are white blood cells and they play a vital role in body’s immune system. When a person has HIV the virus will attack CD4 cells and damage them, which reduced the infection fighting capacity of body. CD4 counts normal range is 500-1600 cells per cubic millimetre of blood (cells/mm3). CD4 count less than 200 cell/mm3 is diagnostic of AIDS.Viral load measured HIV particles in millimetre of blood. This test will assess progression of HIV in body.Increased viral load indicates recent HIV transmission or untreated or uncontrolled HIV. Low count will indicate persons HIV treatment is effective.There is no relationship between CD4 count and viral load. But higher CD4 count will generally have lower viral load. Mostly tests are done often when HIV therapy is started and then 3-4 months after that.

ART REGIMEN 

In India Regimen included in pregnancy:

Tenofovir (TDF) 300mg+ Lamivudine 300mg+ Efavirenz 600mg

PRENATAL AND ANTENATAL 

Proper counselling should be given to pregnant patient.Additional tests should be done for STD’s like Hepatitis B &C , Syphillis,Chlamydia, Herpes & Rubella

Testing for cytomegalovirus ,toxoplasmosis and tuberculosis, fungal opportunistic infection.

Husband should be offered serological testing for HIV

Prognosis of disease will be assessed by CD4 count and T lymphocytes counts and HIV RNA load.

Assessment is done at 3-4 months interval. T lymphocytes should be assessed in each trimester and if count falls less than 200 cells/mm3 than prophylaxis against Pnemocystis Carinii and other opportunistic infection should be started. HAART should be continued throughout pregnancy, labour and postpartum. It reduces viral multiplication, perinatal transmission,risk of drug resistance.

Efavirenz is avoided in first trimester due to teratogenic risk of NTD’s.

During antenatal period screening to be done for opportunistic infection.  Aneuploidy scan should be done. Monitoring of CD4 count and viral load and vaccination against HPV and pneumococcal infection should be done.

WHAT SHOULD BE THE MODE OF DELIVERY IN HIV INFECTED WOMEN?

(ACCORDING TO BHIVA GUIDELINES)

For women with plasma viral load less than 50 HIV RNA copies / ml at 36 weeks and in absence of obstetric contraindication vaginal delivery should be done.

For women with plasma load between 50-399 HIV RNA  copies/ml at 36 weeks,pre labour  caesarean section should be considered, taking into account the actual viral load, the trajectory of the viral load, length of the time on treatment ,obstetric factors and woman’s view.Where the viral load is more than 400 HIV RNA copies /ml at 36 weeks, PLCS is recommended.

Vaginal birth after CS (VBAC) can be offered to women with viral load load less than 50 HIV RNA copies/ml.

In case of rupture of membranes:

≤ 50 HIV RNA copies -delivery should be done within 24 hrs

50-399 HIV RNA copies- CS is recommended

≥ 400 HIV RNA copies-Immediate CS

WHAT SHOULD BE THE FOLLOW UP OF NEWBORN POST DELIVERY?

Infant PEP should be started within 4hrs of delivery.

Post delivery infant is tested at day 1, weeks 6, 12, 18 months of age.

Zidovudine syrup is given to infants with birth weight more than 2.5 kg in dose of 15 mg twice and those less than 2.5 kg 10 mg twice daily until 4-6 weeks of age.

Alternately Nevirapine can also be given to infants in same dose.

They can be further divided into:

Very low risk 

Two weeks of zidovudine monotherapy is recommended if:

The woman has been on ART for longer than 10 weeks

Two documented maternal HIV viral load less than 50 HIV RNA copies/ml or after 36 weeks

 Low Risk:

4 weeks of zidovudine monothrapy.

If very low risk is not fulfilled but maternal HIV viral load is less than 50 HIV RNA copies/ml or after 36 weeks. If the infant born prematurely (≤34 weeks) but most react HIV viral load is <50 HIV RNA copies/ml.

High Risk

Use combination PEP . HIV viral load is likely to be > 50 HIV RNA copies/ml. Neonatal PEP should commenced as soon as possible after birth or at least 4 hrs within birth.

TO DIAGNOSE HIV STATUS OF INFANT:

Non –Breast feeding:

During the first 48 hrs prior to hospital discharge

At 6weeks

At 12 weeks

Breast feeding:  

During the first 48 hours prior to hospital discharge

At 2 weeks age

Monthly for duration of breast feeding

At 4 & 8 weeks after cessation of breastfeeding

MANAGEMENT OF INFANT DIAGNOSED WITH HIV:

Infants with HIV positive status should be started on clotrimazole prophylaxis from 4 weeks of age.

They should be referred to specialist center for further management

IS BREASTFEEDING ALLOWED?

Antireteroviral therapy should be given in all neonates within 4 hrs of birth. Usually ZDV or Lamivudine monotherapy is started and when all tests are negative and baby is not breastfeeding than HIV test done at 18 months and if it is negative baby is said to be HIV free.

Breastfeeding increases mother to child transmission by 14-28% but when no other form of nutrition is not available than breastfeeding can be accepted.Women who is not breastfeeding infant by choice or whose viral load is more than 50 HIV RNA copies/ml should be given Cabergoline to suppress lactation. Women whose infant  are at low risk because of short duration of  ART and viral suppression because of prematurity should be counselled that transmission may be higher because of higher risk of transient viral expression in plasma and breast milk because of immature neonatal gut.

POSTNATAL FOLLOWUP OF MOTHER

Women should continue the HAART therapy with regular follow up of CD4 count .

Formula feed or breast feed according to informed consent .Contraceptive counselling and care should be given to women.Barrier method, IUCDs, Implants and inject-able can be suggested. However condom should be continued regardless of other method of contraception to prevent the transmission of disease.