Prevention of Mother-to-Child HIV Transmission and Management of HIV Positive Pregnant Women

Department of Health

Directorate: HIV and AIDS and STDs

Launched October 2000

TABLE OF CONTENTS

Acronyms

1. Summary

2. Introduction

3. Background

4. Risk factors for Mother-to-child HIV Transmission

5. Interventions to reduce Mother-to-child HIV Transmission

6. Management of HIV Positive Pregnant Women

7. Antenatal Care

8. Management of Labour

9. Post- Delivery

10. Termination of Pregnancy

11. Other Considerations

ACRONYMS

1. SUMMARY

Mother-to-child transmission (MTCT) is the overwhelming source of HIV infection in young children. In the absence of preventive intervention, the probability that an HIV-positive woman’s baby will become infected is approximately 25% to 35%. HIV may be transmitted during pregnancy, labour, delivery, or after the child’s birth during breastfeeding.

The introduction of MTCT prevention procedures will require expanded voluntary counselling and HIV testing for women; strengthening prenatal, delivery and postnatal care programmes; and, developing care and support services for HIV positive persons.

Even in the absence of therapeutic interventions, voluntary HIV testing and counselling offers benefits for HIV-positive women, and their sex partners. It permits them to make informed decisions regarding sexual activity, contraception, termination of pregnancy and methods of infant feeding, and gives them the opportunity of seeking early access to care.

Breastfeeding is important contributor to improved infant health. Breastfeeding however has been shown to contribute to mother-to-child transmission. Appropriate alternatives to breastfeeding should be made available and affordable for HIV positive women. Breastfeeding should be supported in women who are HIV-negative or of unknown HIV status.

2. INTRODUCTION

This document provides recommendations to prevent the transmission of HIV from mothers to children during pregnancy and childbirth and medical management of HIV positive pregnant women. It is intended to complement the Department of Health Guidelines for Maternity Care.

Nationally and internationally there is ongoing research in the field of HIV and AIDS related prevention and treatment modalities. This research will provide new therapeutic interventions for reduction of MTCT of HIV.

This document will be continually reviewed and updated as new therapies emerge.

3. BACKGROUND

Epidemiology of HIV Infection

At the end of 1999 it was estimated that there were approximately 4.2 million HIV positive South Africans, almost half of whom were women in their reproductive years. It is estimated that there are 50 000 HIV positive children whose HIV transmission was contracted primarily through transmission from their mothers. Over 90% of HIV infection in children are acquired by transmission from mothers to their infants. Most infected infants acquire their infection close to delivery or by breastfeeding. The risk of a baby acquiring the virus from an infected mother ranges from 25% to 35%.

4. RISK FACTORS FOR MOTHER-TO-CHILD HIV TRANSMISSION (MTCT)

The following factors have been shown to increase the risk of MTCT.

4.1 Maternal Factors

1. Immune status:

The risk for MTCT is increased with the severity of immune deficiency. Women with low CD4 counts (<200 cells/ml or less) are more likely to transmit HIV to their infants.

2. Vitamin A deficiency:

Studies on MTCT have suggested an association between Vitamin A deficiency in the mother and risk of MTCT. Vitamin A deficiency in HIV- infected mothers is associated with a higher risk of HIV transmission from mother to child. Ongoing trials in Malawi, South Africa, Tanzania and Zimbabwe are currently studying whether adding vitamin supplements to pregnant women’s diet will affect the risk of MCTC.

4.2 Behavioural factors

Cigarette smoking, drug use, and unprotected sexual intercourse during pregnancy has been associated with an increased risk of MTCT.

4.3 Obstetrical Factors

1. Placental infection:

Infection of the chorion or the amnion may increase the chance of MTCT. Genital infections and especially sexually transmitted diseases (STD’s) may result in chorioamnionitis. Prolonged rupture of membranes during labour is another common cause of infection.

There is a relatively high risk of transmission during delivery due to presence of the virus in blood and mucus in the birth canal. Therefore, various methods of vaginal washing (lavage) before and during delivery are being investigated in several developing countries. In a trial performed in Malawi, lavage-using chlorhexidine showed no overall difference in rates of MTCT, but did show a significant reduction in cases where membranes were ruptured for more than four hours. It also resulted in significant reduction of infant mortality and morbidity.

2. Mode of delivery:

The mode of delivery may also influence the risk of MTCT. Elective Caesarean section births has been shown to reduce the risk of MTCT.

4.4 Infant Factors

1. Breastfeeding:

HIV is transmissible through breastmilk. Subsequently breastfeeding is associated with at least one-third all MTCT.

2. Foetal trauma:

Traumatic births and births where the foetal skin is traumatised from obstetrical procedures increase the risk of MTCT.

3. Prematurity:

Pre term births tend to place the infant at higher risk for MTCT as compared to full term births.

4.5 Viral Factors

1. HIV Viral load:

A high level of circulating HIV virus (viral load) is an important contributor to MTCT. The higher the viral load the more likelihood that MTCT will occur. There is a higher risk of MTCT in women with advanced HIV disease (AIDS) or documented high viral loads (e.g. >50,000 HIV viral particles or more/ml).

5. INTERVENTIONS TO PREVENT MOTHER-TO-CHILD HIV TRANSMISSION

There are a variety of interventions that have been shown or suggested to reduce MTCT. These include the following.

5.1 Behavioural Interventions

1. Primary Prevention of HIV:

Preventing HIV infection among women, and men, of childbearing age is the best method to reduce the possibility of MTCT.

2. Preventing new HIV infections:

New HIV infection during pregnancy (and breast-feeding) may increase HIV viraemia which will increase the risk of MTCT. Pregnant women should be advised on safer sexual practices, including the importance of correct and consistent condom use.

3. Treatment of sexually transmitted diseases (STDs):

Effective treatment of any STD and of any other genital infection will reduce the likelihood of placental infection (Chorio-amnionitis) and reduce the risk for MTCT.

5.2 Therapeutic Interventions

1. Nutritional supplementation:

Nutritional supplements (iron, folate, multivitamins and vitamin A) should be routinely given from the initial diagnosis of pregnancy until delivery. These supplements have been shown to result in improved pregnancy outcomes, including reducing the incidence of still birth, prematurity and low birthweight.

5.3 Obstetric Interventions

1. Vaginal cleansing:

MTCT may occur during delivery due to the presence of blood and mucus in the birth canal. Studies have shown that vaginal cleansing with an antiseptic solution is associated with reduced MTCT and improved perinatal outcome^123,,.

2. Artificial rupture of membranes (AROM)

Rupture of membranes for longer than 4 hours prior to delivery is associated with increased MTCT⁴. Routine AROM should be avoided in both HIV positive or negative women. AROM should only be done if there are specific obstetric indications and as late as possible. In HIV-positive women other methods of augmenting labour should be considered (e.g. oxytocin augmentation).

5.3 Trauma

1. Foetal trauma:

Trauma to the foetus should be avoided. Vigorous suctioning of the infant is not recommended as this may cause trauma to the mucous membranes.

Controlled suctioning is only indicated in the presence of meconium stained liquor. Care must be taken to remove maternal body fluids from the foetus.

2. Maternal trauma:

Routine episiotomies must be avoided. Episiotomy should only be performed for recognised obstetric indications e.g. prolonged second stage, assisted delivery.

3. Mode of delivery:

Although elective caesarean section has been shown to reduce the risk of MTCT in resource constrained settings it has been found to be costly and impractical with an increased risk of post-operative complications. Routine elective caesarean sections are therefore not recommended.

5.4 Modification of Infant Feeding

1. Consider alternatives to breast-feeding:

Breast-feeding by HIV positive women is an established risk factor for MTCT and should be avoided if a safe and adequate alternative is possible. Readers should refer to the Department of Health South African Breastfeeding Guidelines for Health Workers for more detailed information.

6. MANAGEMENT OF HIV POSITIVE PREGNANT WOMEN

Pregnant women who are HIV positive pose special and unique management challenges. These include expanded voluntary counselling services and HIV testing for pregnant women, and strengthening of antenatal, intrapartum and post-delivery care programmes. There is also a need to develop a supportive environment for HIV positive persons, as well as for children orphaned by the epidemic.

The strategies for the optimum management of HIV positive pregnant women therefore require the following:

• Supportive health and social environment

• Non-discrimination and non-stigmatisation

• Ongoing counselling

• Adequate laboratory support services for monitoring

7. ANTENATAL CARE

The essential components of antenatal care provided to HIV negative women should be provided to HIV positive women as well. These include complete physical examinations, assessment for high-risk obstetric factors, and antepartum foetal surveillance.

7.1 Voluntary HIV counselling and testing:

Voluntary counselling and testing must be available to all pregnant women. The benefits to a women of knowing her HIV status include the ability to make informed choices about infant feeding options, earlier access to care for both mother and child, the opportunity to terminate pregnancy where desired and legal, and the ability to make informed decisions about sexual practises and future fertility. VCT can also promote openness and acceptance of HIV as an important social issue.

1. Components of pre-test counselling

• Privacy

• Confidentiality

• Explain or determine reasons for testing

• Provide information about HIV and AIDS, and pregnancy

• Provide information on HIV tests, including the concept of "window period"

• Review implications of positive and negative test results

• Information about testing procedures

• Informed consent

2. Components of Post-Test Counselling

• Personal interaction with clients (not over the phone)

• Providing HIV test results as soon after testing as possible

• Deal with feelings arising from negative and positive results

• Explore prevention of infection and the "window period"

• Identify and help with woman’s immediate concerns

• Discuss what support the woman has and needs

• Discuss who the client may want to share the results with

• Identify what difficulties the client foresees and how to deal with them

• Encourage the woman to ask questions

• Provide information on healthy lifestyle, medical follow-up, local support systems

• Continue follow-up and counselling

3. Issues to consider when counselling HIV positive women

• Effects of pregnancy on HIV infection

• Effect of HIV infection on pregnancy – risk of adverse pregnancy events

• Risk of transmission of HIV to foetus and new-born

• Option of termination of pregnancy

• Options for treatment in pregnancy

• Options for infant feeding: advantages and disadvantages of breastfeeding

• Disclosure of results to male partner and family: advantages and risks

• Need for follow-up of both woman and her child

• Future fertility management

7.2 Nutritional Interventions

Vitamin supplementation must be started at the first antenatal care visit. Multivitamins and Vitamin A in particular has been shown to be effective in improving immunity.

1. Recommendations:

• Multivitamin 1 three times a day

• Vitamin A 200 000 units daily (?)

• Ferrous sulfate 1 two times a day

• Folic acid 1 daily

7.3 Medical Interventions

Specific Infections

1. Urinary tract infection (mild uncomplicated)

Treatment

• Amoxil 500 mg three times a day or

• Cotrimoxazole (for use in the second and third trimester only - 80/400 mg) two tablets three times a day over 7-10 days.

2. Pneumocystis carinii pneumonia

Prophylaxis:

Prophylaxis should be commenced when the CD4 count is below 200/ml, or when there are clinical signs of advanced immune deficiency.

• Trimethoprim/sulfamethoxazole (cotrimoxazole) (80/400mg) two tablets daily, or

• Dapsone 100 mg three times a week, for women hypersensitive to cotrimoxazole

Treatment:

The following should be given, preferably through the oral route:

Trimethoprim/sulfamethoxazole 20/100 mg/kg/day in 4 divided doses over 14-20 days. If the woman is unable to swallow, this must be administered intravenously. In those who are hypoxic, prednisone 40 mg per day must be given for 10-14 days initially.

3. Cervicitis

Treatment:

• Ampicillin 500 mg four times a day

• Metronidazole 400 mg three times a day over 5 days.

4. Candidiasis

Vaginal or vulval candidiasis

Treatment:

• Antifungal preparations Canesten, Canstat or Nystatin pessaries over 7 days

• Vinegar solution 1 teaspoon in 250 ml of water for douching and vaginal cleansing two times a day, or

• Paint with gentian violet twice a day as well over 7-10 days.

Systemic candidiasis

Treatment:

• Ketoconazole 200 – 400 mg orally daily for 5 – 7 days

• Clotrimazole 100 mg pessaries one every night for 7-10 nights. For severely immuno-compromised women, treat for longer periods of time.

Diarrhoea

Treat early and vigorously in order to maintain circulatory integrity and electrolyte stability and balance.

Treatment:

If infective, give Cotrimoxazole (trimethoprim/sulfamethoxazole 80/400 mg) orally 2 tablets twice daily for 5 days.

8. MANAGEMENT OF LABOUR

The mode of delivery should be planned and discussed beforehand. The following principles should be followed:

1. Labour and delivery should be as natural as possible

2. Avoid artificial rupture of membranes

3. Shorten length of ruptured membranes to less than 4 hours; augment labour if there is any evidence of slow progress

4. Administer prophylactic antibiotics in women with CD4 counts of less than 200/ml; where there are signs of AIDS or severe immune deficiency; or rupture of membranes for more than 4 hours

5. Avoid episiotomy, invasive monitoring and other procedures

6. Observe aseptic techniques throughout labour. Use Chlorhexidine 0.25% for vulval and vaginal toilet when performing internal digital examination.

7. Check for and manage urinary tract infection at the start of labour

8.1 Technique for vaginal cleansing

Prior to vaginal examination in labour, cleanse vulva area with the chlorhexidine solution using a spray bottle or swabs. The vaginal canal is cleansed with 0.25% chlorhexidine solution during vaginal examinations. Adding 12.5ml chlorhexidine with 5 litres of water makes a 0.25% chlorhexidene preparation.

Wrap a thick or double gauze swab around the two examining fingertips, securely pinching the free edges between the two fingers. Soak the swabs with chlorhexidene solution by dipping in galley pot, pouring over swabs or by thoroughly spraying the swabs with a swab bottle.

Part the vulvae with gloved left hand and carefully clean whole vaginal surface with soaked swabs.

Discard the swabs and keep the vulva area parted while inserting examining fingers, preferably using chlorhexidene obstetric cream, for vaginal examination

8.2 Caesarean section

Discuss the option of elective caesarean section with pregnant women with the following conditions: 1) previous caesarean section; 2) gross fetopelvic disproportion; or, 3) any other contra-indication to vaginal delivery.

Prophylaxis for:

• Caesarean section

• Rupture of membranes for more than 4 hours

• Other interventions, e.g. assisted delivery

Following caesarean section, prophylaxis consists of the following:

• Cefazolin 1 – 2 g intravenously at induction of general anaesthesia. It may be repeated after completion of surgery, OR

• Ampicillin 1 g IV at induction of general anaesthesia, and

• Metronidazole 400 mg orally three times a day over 5 days or 500mg suppository every 12 hours for three days.

9. POST-DELIVERY

The third stage of labour must be managed actively. Use of syntometrine, if not contra-indicated, is encouraged to prevent haemorrhage after delivery. HIV positive women in the postpartum period must be closely monitored. Women with AIDS or severe immune deficiency must be given antibiotics over 7-10 days.

9.1 Infant Feeding Options

• Exclusive breastfeeding

• Formula feeding

• Expressed and heat-treated breastmilk

1. Expressed and heat-treated breast milk

Heat treatment of expressed breast milk from an HIV positive woman kills the virus in the breast milk. To pasteurise the milk, in hospitals it should be treated to 62.5 C for 30 minutes. At home, it can be heated and then cooled immediately by putting it in a refrigerator or standing the container in cold water. To minimise contamination, heat treated breast milk should be put in a sterilised or very clean container and kept in a refrigerator or in a cool place before and after heat treatment.

2. Wet Nursing

In some cultures, wet nursing is considered a traditional practice, however there is a risk of HIV transmission to the infant through breastfeeding if the wet nurse is HIV positive. There is also a potential risk of infection from the infant to the wet nurse is she has cracked nipples.

3. Recommended medications in HIV positive pregnant women postpartum:

• Multivitamin tablets 1 twice a day

• Vitamin A gel capsule 200 000

• Ferrous sulfate 1 twice a day

• Ergometrine 1 tablet twice a day if necessary

• Amoxycillin 500 mg three times a day for 5 – 7 days

• Metronidazole 400 mg three times a day

9.2 Prevention of STDs and Family Planning

It is recommended to provide barrier methods for the prevention of genital infections and future pregnancies, after comprehensive counselling. Discuss other forms of contraception, including permanent sterilisation, both male (vasectomy) and female (tubal ligation).

10. TERMINATION OF PREGNANCY

HIV positive pregnant women who have undergone termination of pregnancy must receive antibiotics. Treatment of any obvious genital infection is mandatory before the procedure is undertaken.

Recommendation

• Cefazolin 1 – 2 g intravenously at induction of general anaesthesia. It may be repeated after completion of surgery, OR

• Ampicillin 1 g IV at induction of general anaesthesia, and

• Metronidazole 400 mg orally three times a day over 5 days or 500mg suppository every 12 hours for three days.

11. OTHER CONSIDERATIONS

Community Involvement and The Reduction of Stigma

Successful implementation of programmes to reduce MTCT of HIV requires not only improvements within health services but also a climate of social support and community involvement. A package of care tailored to the needs of the mother must include ongoing support for the mother, her infant and the family.

Human rights, including reproductive rights and the rights to informed choices and confidentiality, should be respected. This means that the social environment must enable women and families to make informed choices and cope with the choices they make.

Annexure A

Table 1. Summary of factors affecting mother-to-child transmission of HIV

Table 2. Possible uses of AROM and recommendations to reduce the risk of MTCT

Table 3. Summary of Interventions to Prevent Mother-to-child HIV Transmissions

Footnote

[1] Biggar RJ, Miotti PG, Taha TE et al .perinatal intervention trial in Afirca: effect of  birth canal cleansing intervention to prevent HIV transmission. Lancet 1996;347:1647-1650

[2] Taha TE, Biggar RJ Broadhead RL et al. Birth canal cleansing with an antiseptic solution reduces maternal and new born morbidity and mortality: Clinical trial. Br Med J 1997;315:216-219

[3] Hofemeyr GJ, McIntyre J. Preventing perinatal infections. Br Med J 1997;315:199-200

[4] Minkoff H, Burns DN, Landesman S et al. The relationship o f the duration of ruptured membranes to vertical transmission of HIV. Am J Obstet Gynecol 1995; 173:585-589