1. Dr Abhimanyu Makane Aditya Birla Memorial Hospital Sterling Multispeciality Hospital

2.  HIV-1+ since 2001  Wife 33Y, Primary Teacher in Talegaon  Husband 35Y, small vendor in PCMC  Hail from traditional Punjabi family

3.  Husband taking treatment from Govt ART  On AZT/3TC/NVP  Wife on TDF/3TC/EFV from Sterling  Both virologically suppressed and doing immunologically good (CD4-500+)  Haven’t disclosed HIV status to anybody apart from doctor

5.  15-30% intrapartum  15% during breastfeeding.  Pregnancy + Delivery + Breastfeeding = 20-40% without PMTCT  Antenatal and post-natal PMTCT can decrease transmission to < 1%.

6.  The HIV-infected partner must be virologically suppressed before conception  Discordant Couples with HIV-Infected Female: ◦ Artificial insemination - Safest conception option ◦ Option of self-insemination with a partner’s sperm during the periovulatory period  Discordant Couples with HIV-Infected Male: ◦ Donor sperm from an HIV-Neg male with artificial insemination is the safest option. ◦ If donor sperm is unacceptable, the use of sperm preparation techniques coupled with either IUI or IVF

7.  May offer an additional tool to reduce the risk of sexual transmission.  The utility of PrEP has not been studied.

8.  Combined ◦ Antepartum cART ◦ Intrapartum cART, and ◦ Infant antiretroviral (ARV) prophylaxis recommended because  ARV drugs reduce perinatal transmission ◦ By lowering maternal antepartum viral load and ◦ Providing infant pre- and post-exposure prophylaxis

9.  Efavirenz- ? neural tube deffects  Particularly during 1 st trimester exposure  BHIVA and WHO don’t consider pregnancy a contraindication for EFV

10.  Mrs B was doing fine on her EFV based cART  At end of second trimester ◦ CD4 686 cell/mm3 ◦ Viral load undetectable

11.  Depends on VL at 36-38 wks gestation and general obstetrical considerations. Schedule elective Csection if ◦ VL >1000, ◦ labor has not started and ◦ ROM has not occurred, ◦ May consider C-section with VL 50-1000; although not based on evidence of reduced risk of transmission.  No HIV indication for Csection ◦ if maternal VL < 50.

12.  Unless there are clear obstetric indications following should generally be avoided : ◦ Artificial rupture of membranes ◦ Operative delivery with forceps or a vacuum extractor and/or episiotomy

13.  Mrs B was offered a C-section considering age and previous history of stillbirth by her obstetritian

14.  PI increase methargine levels  NNRTI decrease Methargine levels  misoprostol, oxytocin, and  prostaglandin F2 alpha are all safe

15.  Mrs B gave birth to a female child- 3.4kg at 38 week gestation  Advised strictly avoiding breastfeeding  Baby offered ARV prophylaxis

16.  Start AZT 6-12 hrs post-partum for 6 wks  Standard AZT dose: 4 mg/kg BID  Add NVP if mother did not have a suppressed VL at delivery ◦ Three doses 1. At Birth, Day-0 2. 48hrs after 1st dose, Day-3 3. 96hrs after 2nd dose, Day-7

17.  Nucleic acid testing required upto18 mos ◦ because of placental antibody transfer. ◦ Age >2-4 wks, HIV DNA testing >90% sensitive ◦ Age >2-3 mos, HIV RNA >90% ◦ Test (1) 14-21 days, (2) 1-2 mos, (3) 4-6 mos. ◦ Repeat any positive nucleic acid test on a separate blood sample. ◦ Dx based on  2 positive NAAT  HIV Ab reactive age >18 mos.  HIV can be excluded with ◦ 2 negative NAAT age >14 days, ◦ 1 negative NAAT, age >2 months, ◦ negative HIV Ab test,age >18 mos.

18.  Contraindicated where safe alternatives exist even if mother has HIV RNA < 50 and is receiving ART  However, formula feeding increases mortality in resource-limited settings, thus breast feeding with continued maternal ART recommended in those setting.

19.  Baby of Mrs B was tested with HIV proviral DNA at 4 weeks and 8weeks of gestation and declared negative  Was not offered TMP-SMX prophylaxis

21.  Conclusion-Effort of the government to integrate ART services with maternity care services is likely to have benefited the HIV positive mothers. HIV NegativeHIV Positive TFR2.780.84 ANC utilization78%92% Institutional delivery40%67%

22.  Risks ◦ higher maternal VL ◦ lower CD4 count ◦ severe prematurity (< 33 wks) ◦ Multiple gestation (twin A at higher risk), ◦ smoking, active HSV, genital ulcer disease.  Risk lower with ◦ Low VL ◦ effective ART ◦ Cesarean section delivery (when VL not suppressed) ◦ Intrapartum ART ◦ Formula feeding.

23.  Antenatal and post-natal PMTCT can decrease transmission to < 1%.  Pregnancy does not increase ◦ HIV progression, ◦ Risk of OIs, or ◦ HIV-related survival.