HIV IN PREGNANCY

Human immunodeficiency virus (HIV) is a virus that affects the cells of immune system of
body.

HIV causes acquired immunodeficiency syndrome (AIDS).

The global fight against HIV/AIDS is far from over. In 2020, out of 33.7 million people
living with HIV, 1.5 million were newly infected persons and 680,000 HIV related deaths
occurred.

9% of the global new infections were attributed to vertical transmission and over 90% of HIV
infections in children less than 15 years of age are attributed to mother-to-child transmission
(MTCT).

Much as the global rollout of antiretroviral (ARVs) has resulted in to 47% decline in AIDS-
related deaths since 2010, over two thirds of the HIV burden is in the African region.

In South Sudan, the overall prevalence of HIV is estimated at 2.7%. Children born to HIV
positive mothers contribute to 15.7% of the overall prevalence.

All pregnant women should be encouraged to know their HIV status

All HIV services for pregnant mothers are offered in the MCH clinic.

All pregnant mothers and partners should receive routine counselling and testing for HIV.

Mode of transmission

 Sexual intercourse with an infected person

 Sharing of sharp objections
 Vertical transmission-mother to child

Investigations

 Determine strip
 Startpack strip
 Polymerase chain reaction (PCR)

Key Interventions for eMTCT

 Routine HIV Counseling and Testing during ANC

 ART in pregnancy, labour and post-partum, and for life – Option B+

If mother tests negative:

 Counsel on HIV prevention

 Repeat test in third trimester/during labour and delivery
If mother tests positive or is already known positive but not yet on ART

 Enroll mother on HIV care (eMTCT).

If mother is already positive and already on ART:

 Continue on their existing regimen; may not be switched to Option B+ regimens

 Perform viral load at first contact

After delivery, mother and baby will remain in the MCH postnatal clinic until HIV status of
the child is confirmed, and then they will be transferred to the general ART clinic.

Care for HIV Positive mother (eMTCT)

Ensure the care is provided during pregnancy, labour, delivery, and postpartum period for all
HIV+ women

Find out what she has told her partner (degree of disclosure), labour companion, and family
support. Respect her choice and desired confidentiality

During labour: safe obstetric practices

– Avoid episiotomy

– Avoid artificial rupture of membranes

– Avoid instrumental delivery (vacuum)

– Avoid frequent vaginal examination

– Do not milk umbilical cord before cutting

– Actively manage third stage of labour

Baby

Give infants daily Nevirapine (NVP) for for 6 weeks (12 weeks for high risk infants)

Give Cotrimoxazole beginning at 6 weeks; continue until final HIV status is confirmed
negative

Offer DNA PCR test at 6 weeks, and again 6 weeks after cessation of breastfeeding

WHO staging for HIV infection and disease in adults and adolescents

Clinical Stage I:

1. Asymptomatic
2. Persistent generalized lymphadenopathy

Performance Scale 1: Asymptomatic, normal activity

Clinical Stage II:

1. Moderate weight loss (less than 10% of presumed or measured body weight)

2. Minor mucocutaneous manifestations (seborrhoeic dermatitis (scaly patche on face, side of

nose, eye brows, ears, etc), prurigo (intensively itchy spot on the skin), fungal nail infections,
recurrent oral ulcerations, angular stomatitis)

3. Herpes zoster within the last five years

4. Recurrent upper respiratory tract infections, e.g., bacterial sinusitis, tonsillitis, otitis media
and pharyngitis

Performance Scale 2: Symptomatic but normal activity

Clinical Stage III:

1. Severe weight loss (more than 10% of presumed or measured body weight)

2. Unexplained chronic diarrhoea for more than one month

3. Unexplained prolonged fever, intermittent or constant, for more than one month

4. Oral candidiasis

5. Oral hairy leukoplakia (condition in which white patches or spots form in the mouth)

6. Pulmonary tuberculosis (current)

7. Severe bacterial infections such as pneumonia, pyomyositis (rare bacterial infection that
cause muscle abscess), empyema/pyothorax, bacteremia or meningitis 8. Acute necrotizing
ulcerative stomatitis, gingivitis or periodontitis (infection that damages the gum soft tissue)

9. Unexplained anemia (<8g/dl), neutropenia (low neutrophils count), or chronic

thrombocytopenia (low platelets count)

Performance Scale 3: Bed-ridden for less than 50% of the day during the last month

Clinical Stage IV:

1. HIV wasting syndrome – weight loss of more than 10%, and either unexplained chronic
diarrhoea for more than one month or chronic weakness or unexplained prolonged fever for
more than one month
2. Pneumocystis pneumonia (PCP) (fungal infection in the lungs caused by pneumocystis
jirovecii)

3. Recurrent severe bacterial pneumonia

4. Toxoplasmosis of the brain

5. Cryptosporidiosis with diarrhoea for more than one month (caused by cryptosporidium
parasites)

6. Chronic Isosporiasis, watery diarrhoea caused by coccidian parasite, cystoisospora

7. Extrapulmonary Cryptococcosis including meningitis

8. Cytomegalovirus infection (retinitis or infection of other organs)

9. Herpes simplex virus (HSV) infection, mucocutaneous for more than one month

10. Progressive multifocal leukoencephalopathy (PML) (deteriotion of CNS’s white matter)

11. Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis (fungal

infection that causes fatigue, cough, shortness of breath, headache, night sweats)

12. Candidiasis of the oesophagus, trachea, bronchi or lungs

13. Atypical mycobacteriosis, disseminated

14. Recurrent non-typhoid salmonella septicemia

15. Extrapulmonary tuberculosis

16. Lymphoma

17. Invasive cancer of the cervix

18. Kaposi’s sarcoma

19. HIV encephalopathy – disabling cognitive and/or motor dysfunction interfering with
activities of daily living, progressing slowly over weeks or months, in the absence of
concurrent illness or condition other than HIV infection that could account for the findings

20. Atypical disseminated leishmaniasis caused by leishmanial parasites

21. Symptomatic HIV-associated nephropathy or symptomatic HIV-associated

cardiomyopathy

Performance Scale 4: Bed-ridden for more than 50% of the day during the last month

Management

Recommended ARV for option B+

One Fixed Dose Combination (FDC) pill daily, containing TDF(Tenofovir Disoproxil
Fumarate) + 3TC(Lamivudine) + EFV(Efavirenz) is started early in pregnancy irrespective of
the CD4 cell count and continued during labour and delivery, and for life

The consolidated HIV treatment guidelines, 2020 version recommends using

Dolutegravir(DTG)-based regimens as preferred first- and second-line ART for all eligible
PHLIV including pregnant and breastfeeding women.

 These guidelines emphasize the importance of Pharmacovigilance (PV) and describe

the procedures for identifying, investigating, reporting and management of adverse
effects of ART, anti-TB and other medications.

Alternative regimens for women who may not tolerate the recommended option are:

If TDF contraindicated: AZT(Zidovudine)+3TC+EFV

If EFV contraindicated: TDF + 3TC + LPV/r(Lopinavir/ritonavir)

Prophylaxis for opportunistic infections

 Cotrimoxazole 960 mg 1 tablet daily during pregnancy and postpartum. Mothers on

cotrimoxazole (sulfamethaxazole and trimethoprim) DO NOT NEED IPT with
Sulfadoxine-pyrimethamine (SP) for malaria
 Those newly diagnosed during labour will receive single dose Niverapine (sdNVP)
tablet and begin HAART for life after deliver

Benefits of Option B +

 Reduction of new HIV infection in children, by minimizing the risk of HIV

transmission from infected pregnant and lactating women, to less than 5% in
breastfeeding populations, and to less than 2% in non-breastfeeding populations
 Improved health, and reduced maternal mortality and morbidity of HIV-infected
mothers through lifelong ART
 Reduction of the risk of HIV transmission to non-HIVinfected sexual partner in
discordant relationship
 Reduction in the number of HIV/AIDS orphans y Contribution to the achievement of
the 90/90/90 goals by 2020 though it was 75/79/81 in 2017 and 84/87/90 in 2020.
 Contributes to achievement of the Sustainable Development Goals by 2030 that states
the end of HIV endemic.

Counselling for HIV Positive Mothers

 Give psychosocial support, encourage mothers to enroll in Family Support Groups

(FSG) for peer support
 Advise on the importance of good nutrition – Talk to family members to encourage
the woman to eat enough and help her avoid hard physical work – Micronutrient
supplementation during pregnancy and breastfeeding; iron + folic acid and
multivitamins
  Advise her that she is more liable to infections, and to seek medical help as soon as
possible
 Review the birth plan
– Advise her to continue attending ANC
– Advise her to deliver in a health facility where appropriate care can be
provided for her and the baby
– Advise her to go to the health facility as soon as labour starts or membranes
rupture

During postpartum period

 Advise her on the infectiousness of lochia and blood- stained sanitary pads, and how
to dispose them off safely according to local facilities
 Advise her to use a family planning method immediately to prevent unwanted
pregnancy
 Linkage of mother-baby pair and her family, for on-going care beyond puerperium
 Breast care: If not breastfeeding, advise that:
-The breasts may be uncomfortable for a while
-She should avoid expressing the breast to remove milk (the more you remove the
more it forms)
-She should support her breasts with a firm, well-fitting bra or cloth, and give her
paracetamol for painful breasts

-Advise her to seek care if breasts become painful, swollen, red; if she feels ill; or
has fever

Counselling on infant feeding choice

 Begin infant feeding counselling before birth when the pregnant mother has been
identified to be HIV positive.
 The decision on how she will feed the baby should be made before delivery. The
mother should then be supported to implement the feeding option she has chosen
 All mothers are encouraged to breastfeed their babies exclusively for 6 months and
then introduce complimentary feeding until 1 year
 The mother has to continue her ARVs all through breastfeeding
 The child should continue cotrimoxazole prophylaxis, until status confirmed negative
with a PCR at 6 weeks after stopping breastfeeding
 If a mother chooses to feed the newborn on replacement feeding from the beginning,
the choice of replacement feeds should fulfil the AFASS Criteria (Affordable,
Feasible, Available, Sustainable and Safe).

TUBERCULOSIS IN PREGNANCY

TUBERCULOSIS
TB is an ancient disease that persists as a result of poverty and unhealthy living conditions. It
is also a disease that carries a heavy burden of stigma.

In 2020, WHO reported an estimate of 10 million people fell ill of TB, around 1.5 million
deaths including 214,000 persons living with HIV of which pregnant mothers were inclusive.

A chronic bacterial infection caused by Mycobacterium tuberculosis complex. It commonly

affects lungs but can affect any organ (lymph nodes, bones, meninges, abdomen and
kidneys).

Mycobacterium tuberculosis complex group include M. tuberculosis, M. bovis, M. africanum,

M. microti and M. Canetti .They all can cause tuberculosis in humans.

The vast majority of tuberculosis is cause by M. tuberculosis.

The bovine bacillus (Mycobacterium bovis) caused much infection in cattle. Infection was
often passed on to man through contaminated milk. Bovine TB in milk can be killed by
boiling the milk. Mycobacterium leprae causes leprosy.

TB is treatable with antimicrobials though TB resistance to antimicrobials is increasing.

Women of childbearing age should be asked about current or planned pregnancy before
starting TB treatment.

The bacilli Calmette-Guerin (BCG) vaccine protects TB meningitis and disseminated TB in

children. It does not prevent primary infection and reactivation of latent pulmonary
infection.

Classification of TB by site of infection

Pulmonary TB is a bacteriologically confirmed or clinically diagnosed case, affecting lung

parechyma or tracheobronchial tree. Isolated TB pleural effusion and mediastinal
lymphadenopathy without lung tissue involvement is considered extra-pulmonary TB

Extra-pulmonary TB is any other case of TB not involving the lungs. If the patient has
pulmonary and extra-pulmonary involvement, he/ she will be classified as pulmonary

Classification of TB by Drug resistance

Rifampicin resistant: any case of rifampicin resistance (isolated or in combination with

other resistance) (RR-TB)

Mono resistant: resistant to only one first line anti-TB drug

Poly drug resistant: resistant to more than one first line anti TB other than both rifampicin
and isoniazid

Multi drug resistant: resistant to rifampicin and isoniazid (MDR –TB)

Extensive drug resistance: resistant to rifampicin, isoniazid and any fluoroquinolone
(moxifloxacin, levofloxacin) and at least one of the 3 second line injectable drugs
(capreomycin, kanamycin, amikacin) (XDR-TB)

Causes of TB

Transmission by droplet inhalation (cough from a patient with open pulmonary TB)

It can also be transmitted through drinking unpasteurised milk, especially M.bovis

M. tuberculosis is strictly aerobic bacterium it there for multiplies well in pulmonary tissue
(in particular at the apex where oxygen concentration is higher).

Pathogenesis of tuberculosis

Primary infection. After transmission M. tuberculosis multiply slowly, in most cases in the
terminal alveoli of the lung (primary focus) and lymph nodes of corresponding drainage
areas. This represents the primary infection.

In one to two month due to action of lymphocyte and macrophage (cellular immunity) the
primary focus will be contained and encapsulated with a central zone of parenchymal
necrosis (caseous necrosis). At this moment specific TB immunity appear and a positive skin
reaction to tuberculin is observed .this stage is usually a symptomatic, however in some rare
cases hypersensitivity reaction may occur.

Active TB or Post primary TB. Post-primary TB is the pattern of disease that occurs in a
previously sensitized host. It occurs after a latent period of months or years after primary
infection. It may occur either by reactivation of latent bacilli or by re-infection.

Reactivation occurs when dormant bacilli, persisting in tissues for months or years after
primary infection, start to multiply. This may be in response to a trigger such as weakening of
the immune system by HIV infection or re-infection occurs when a person who previously
had a primary infection is exposed to an infectious contact. In a small number of cases it
occurs as a progression of primary infection. Following primary infection, rapid progression
to intra-thoracic disease is more common in children than in adults. Chest X-rays may show
intra-thoracic lymphadenopathy and lung infiltrates. Postprimary TB usually affects the lungs
but can involve any part of the body.

Sputum smears are usually positive. Pulmonary tuberculosis is the infectious and most
common form of TB disease, occurring in over 80% of cases.

Tuberculosis may, however, affect any part of the body. Extra-pulmonary tuberculosis is a
result of the spread of mycobacteria to other organs.

Risk factor for developing TB

The risk depend on number of factors include those that lead to weakened immune system,
damaged lungs, or the intensity and duration of exposure. The followings are the risk factors:

 HIV infection
 Diabetes mellitus
 Malnutrition
 Prolong therapy with corticosteroid and other immunosuppressant therapy
 Severe kidney disease
 Age - Young children under 5 have twice the risk and higher risk are observe those
under 6 month - Person over 60 years has 5 times the risk of developing TB
 Pregnancy
 Alcoholism and substance abuse Condition
 Tobacco smoking
 Intensity of exposure
 Contagiousness of the source

Clinical presentation of TB

Pulmonary TB

The main symptoms of pulmonary tuberculosis are:

 Persistent cough for 2 weeks or more (however, in HIV settings, cough of any
duration)
 Fever for more than 2 weeks or more
 Night sweats
 Unexplained weight loss
 purulent sputum occasionally blood-stained

These symptoms may be accompanied by:

Shortness of breath, chest pains, haemoptysis, loss of appetite and fatigue

Advanced course of PTB include:

 Respiratory insufficiency due to extensive lesion and destroyed lung

 Massive haemoptysis due to large cavities with hypervasculrisation and erosion of vessels

 Pneumothorax due to rupture of cavity in the pleural space

Finger clubbing may occur, particularly in a patient with extensive disease. Remember that
clubbing is more common with lung cancer, lung abscess or bronchiectasis.

On the Chest

Often there are no abnormal signs. The commonest sign is:

 Fine crepitations (crackles): In the upper part of one or both lungs. These are heard
particularly on taking a deep breath after coughing.

Dullness to percussion in the upper part of both lungs.

Localized wheeze that is due to local tuberculous bronchitis or pressure by a lymph node on
a bronchus. In chronic tuberculosis with much fibrosis (scarring), the scarring may pull the
trachea or the heart over to one side. At any stage the physical signs of pleural effusion may
be present.

Extra-pulmonary TB

 Lymph node TB: Localized enlargement of lymph nodes depending on the site
affected (commonly neck)
 Pleural or pericardial effusion
 Abdominal TB: ascites and abdominal pain
 TB meningitis: subacute meningitis (headache, alteration of consciousness)
 Bone or joint TB: swelling and deformity

NB: Pulmonary TB should be considered when there is persistent cough for 2 weeks or more
(however, in HIV settings, cough of any duration)

Investigations/Diagnosis

 Sputum smear microscopy

 GeneXpert
 Sputum culture and Drug susceptibility test
 Tuberculin skin test
 Chest x-ray

In Sudan since the availability of the Chest x-ray test is limited to the capital city in high cost
it is recommended to start TB investigation with Sputum testing (Microscopy or GeneXpert)
as it is provided free to the patients.

Treatment

The aims of the treatment are

1. to cure patients with minimal toxic drugs and without interruption of usual life patterns

2. to prevent death of seriously ill patients

3. to prevent extensive damage to the lungs

4. to avoid recurrence of the disease

5. to prevent the emergence of resistant TB (acquired resistance)

6. to protect the family and community of the patient from infection. Standardized regimen
First line Anti TB drugs are:

 Isoniazid (H)
 Rifampicin (R)
 Pyrazinamide (Z)
 Ethambutol (E)
 Streptomycin (S)

Second line drugs

 capreomycin
 kanamycin
 amikacin

Treatment is divided into 2 phases:

 an initial(intensive) phase of 2 months

 a continuation phase

Treatment regimen

Millary TB- 2HRZE/6HR and if CNS is involved, then 2HRZE/HR is used

TB Meningitis- 2HRZES/10HR

Bone and Joint TB- 2HRZES/1OHR

All other forms of TB- 2HRZE/4HR

In Uganda, treatment regimen is as followed,

All forms of TB in adults and children but excluding TB meningitis and Bone TB)
2RHZE/4RH

TB meningitis and Bone TB- 2RHZE/10RH

A pregnant woman can have successful treatment of TB with the standard regimen for
successful outcome of pregnancy. With the exception of streptomycin, the first line anti-TB
drugs are safe for use in pregnancy; streptomycin is ototoxic to the foetus and should not be
used during pregnancy. Streptomycin is contraindicated in pregnant women and should be
omitted in retreatment cases.

A breastfeeding woman who has TB should receive a full course of TB treatment. Timely
and properly applied chemotherapy is the best way to prevent transmission of tubercle bacilli
to the baby. Mother and baby should stay together and the baby should continue to
breastfeed. After active TB in the baby is ruled out, the baby should be given 6 months of
isoniazid preventive therapy, followed by BCG vaccination Pyridoxine supplementation is
recommended for all pregnant or breastfeeding women taking isoniazid.
Complications

 Massive haemoptysis - coughing up >250 mL blood per episode

 Spontaneous pneumothorax and pleural effusion
 TB pericarditis, TB meningitis, TB peritonitis
 Bone TB: can be TB spine with gibbus, TB joints with deformity)
 Respiratory failure

Prevention of TB

 early diagnose of TB patients

 completion of a standardized treatment
 Isoniazid (H) preventive treatment to persons living with HIV/AIDS
 Bacillus Calmette-Guerin vaccine