HIV &

HEPATITIS IN
PREGNANCY:
THE
CONCEPT OF
PMTCT

LECTURES FOR MEDICAL

STUDENTS
DR. OMEKE CHIDIMMA A.
MBBS, MSC (PHARM),FWACS
INTRODUCTION
Acquired immunodeficiency syndrome (AIDS) was
first reported in the US in 1981 amongst
homosexuals.
Human immunodeficiency virus (HIV), its
causative agent was identified in 1983.
Since then, HIV infection has been reported in
every country.
It is a global epidemics that has remained
unabated with associated morbidity and mortality
in all age groups and gender especially in sub-
Saharan Africa.
HIV infection is a common medical condition in
pregnancy.
HIV-1 VS HIV-2
Transmitted through the same routes
Associated with similar opportunistic infections
HIV-1 is more common worldwide.
HIV-2 is found predominantly in West Africa,
Angola and Mozambique.
Differences between HIV-1 and HIV-2
HIV-2 is less easily transmitted.
HIV-2 develops more slowly.
MTCT is relatively rare with HIV-2.
Some ARV drugs (NNRTIs) are ineffective
against HIV-2
EPIDEMIOLOGY OF HIV IN
NIGERIA
Nigeria reported the first case of AIDS in 1986.
Since then, the National HIV prevalence increased exponentially from 1.8% in 1991 peaking at 5.8% in 2001
and progressively declining through 4.4% in 2005, 3% in 2014.
Based on the report from National AIDS Indicator and Impact Survey (NAIIS), the current prevalence of
individuals aged 15 - 64 is 1.4%.
As at 2019, Nigeria had an estimated HIV burden of 1.9 million people, the fourth largest in the world.
The incidence of HIV in 2018 was estimated at 8 per 10,000 persons (NAIIS).
The prevalence varied across Regions and States with the highest prevalence being in the South-South (3.1%)
while the North-West had the lowest prevalence (0.6%).
Akwa Ibom state had the highest prevalence (5.5%) while Katsina had the lowest prevalence (0.3%).
Although the current HIV prevalence of 1.4% in Nigerian adults and 0.2% among children (NAIIS 2018) suggest
a low MTCT, two findings in the report have an ominous outcome;
a) Women (1.3%) have almost 4 times the prevalence of men (0.4%) in the same age group.
b) This gender disparity was greatest among females of age 20-24 years, the age when most Nigerian women
bear children.
HIV
TRANSMISSION
HIV is transmitted by:
Sexual contact:
 Unprotected sex (anal, vaginal, or oral)
 Direct contact with HIV-infected body fluids such as
semen and vaginal secretions
Blood to Blood transmission:
 Transfusion with HIV-infected blood
 Direct contact with HIV-infected blood
 Re-use of unsterilized sharps (needles, surgical
blades, razors used in scarification practices)
 Needle stick injury
Injection of drugs with needles or syringes
contaminated with HIV
Mothers infected with HIV to infants during pregnancy,
delivery and breastfeeding
SEROPREVALENCE OF
HIV IN PREGNANCY
Variable depending on site of study
HIV in pregnancy in Nigeria [5.7%,
Eleje et al, 2020 national pilot
data]
In one recent study in GHANA, 1·6%
tested positive to HIV —higher than the
country’s national HIV incidence for all
ages of 0·70 per 1000 population,
according to UNAIDS estimates for
2018
 In pregnancy, immune function is suppressed in
both HIV-infected and uninfected women.
There is a decrease in immunoglobulin and
complement levels in early pregnancy and a more
NATURAL significant decrease in cell-mediated immunity.

HISTORY Studies have shown that pregnancy may however

not affect the progression of HIV or the rate of

OF HIV IN death.
On the other hand, HIV infected pregnant women
PREGNAN are more likely to develop early pregnancy
complications such as bacterial pneumonia,
CY urinary tract infections, spontaneous abortion,
higher rates of ectopic pregnancy and increased
stillbirth rates, especially from areas where the
epidemic has been present for a long time.
The risk appears to be lower in asymptomatic HIV
positive pregnant women.
 No significant differences in HIV progression or survival
between women who had been pregnant and those who

Natural had not experienced pregnancy. – except in advanced

disease.

History of
Maternal HIV infection is associated with relative infertility –
PID, poor sperm function, condom use and prolonged ill
health etc

HIV in
Adverse pregnancy outcome in HIV infected persons (some
are due to effect of treatment) – spontaneous abortion,
preterm delivery, IUGR, LBW

Pregnanc
Maternal mortality – from co-morbidities, poor nutrition etc
Adversely affects the frequency, natural history, and
presentation of many infections – vulvovaginal candidiasis,

y bacteria vaginosis, genital herpes simplex, syphilis, HBV,

HCV, UTI, Pneumonia.
Opportunistic infections are more common – Tb,

(Cont’d) pneumocystis jerovecii pneumonia

Risk of MTCT - More than 90% of paediatric HIV/AIDS cases
are caused by MTCT
WHAT IS MOTHER-TO-
CHILD TRANSMISSION
(MTCT) OF HIV?
MTCT of HIV occurs when an HIV-positive woman passes
the virus to the baby during pregnancy, labour and
delivery, or after delivery through breastfeeding.
Without interventions, the risk of MTCT is estimated to
range from 15 to 25% in developed countries and 25 to
45% in developing countries.
The differences in MTCT rates between the developed and
developing countries is partly attributed to postnatal
transmission – breastfeeding.
Other factors contributing to the high burden of MTCT in
sub-saharan Africa are
higher prevalence of HIV in women of reproductive age,
high total fertility rate and
poor access to PMTCT interventions.
Estimated Timing and Risk of
MTCT of HIV
Breastfeeding through Breastfeeding through
No 6 Months 18–24 Months
Breastfeeding
Intrauterine 5 to 10% 5 to 10% 5 to 10%
Intrapartum 10 to 20% 10 to 20% 10 to 20%
Postpartum
Early (first 2 5 to 10% 5 to 10%
months)
Late (after 2 months) 1 to 5% 5 to 10%
Overall 15 to 30% 25 to 35% 30 to 45%
FACTORS ASSOCIATED WITH MTCT
OF HIV-1
1. VIRAL Factors

• Viral load
• Viral genotype
• Viral phenotype
• Viral resistance

2. MATERNAL

• Maternal immunological status – Low CD4 count, low CD4/CD8 ratio

• Maternal nutritional status – Vit A def
• STIs – especially those associated with ulcers e.g syphilis
• Behavioural factors (Smoking, Alcohol, Injection drug use, non-use of condoms)
• HIV infection acquired during pregnancy or breastfeeding
 3. OBSTETRICS
Invasive Obstetrics procedures

FACTORS Chorionic villus sampling

Amniocentesis, Cordocentesis, Amnioscopy
ASSOCIA Intrauterine pressure catheters

TED penetrating scalp electrode

WITH Fetal scalp blood sampling

Instrumental deliveries – vacuum and forceps
MTCT OF Episiotomy, External cephalic version in breech
presentation
HIV-1 Prolonged labour
Prolonged rupture of fetal membranes
Placental seperation – abruptio placenta
 4. MODE OF DELIVERY
Caesarean section prior to rupture of
membranes is associated with 50%
FACTORS reduction in risk of MTCT in the absence
of viral suppression
ASSOCIAT
ED WITH 5. FETAL / NEONATAL
MTCT OF Prematurity
HIV-1 Genetic susceptibility
Multiple pregnancy
6. BREASTFEEDING
Time of high maternal plasma / Breast
milk viral load – new infection, advance
disease
Vit. A deficiency
Prolonged breastfeeding
Mixed feeding (Doing both breast feeding
and infant formulae
Cracked nipples, breast abscess, mastitis,
Oral thrush in baby
Risk Factors for MTCT
Pregnancy Labour and Breastfeeding
•High maternal Delivery •High maternal
viral load •High maternal viral load
•Infection viral load •Duration
•Prolonged rupture
•STIs •Early mixed
of membranes
•Malnutrition feeding
•Invasive delivery
•Breast fissures,
•Haemorrhage procedures
infections
•Chorioamnionitis
•Poor maternal
nutrition
•Oral disease in
infant
REASONS FOR FOCUS
ON PMTCT /eMTCT OF
HIV/AIDS
About 360,000 children are infected globally every
year through MTCT
MTCT accounts for over 90% of Paediatric
(Children Less than 15 years) HIV/AIDS
An important contributor to the HIV/AIDS burden
(10%) in the country
HIV infected children cannot survive long without
effective care
MTCT threaten future generation of our society
MTCT is largely preventable
MTCT rate is < 2 when properly managed
PREVENTION /
ELIMINATION OF MTCT –
PMTCT/eMTCT
There is a strategic shift from PMTCT to eMTCT
MTCT has been eliminated in some countries
including Cuba and Thailand, Belarus
Global and National targets of ending HIV as a
public health problem
The 90-90-90 targets specify that by 2020,
90% of all people living with HIV will know
their HIV status; by 2020, 90% of people with
diagnosed HIV infection will receive sustained
antiretroviral therapy; and by 2020, 90% of all
people receiving ART will have viral
suppression
ENDING HIV/AIDS EPIDEMIC BY
2030
The 95-95-95 targets specify that by
2030, 95% of all people living with HIV
will know their HIV status; by 2030, 95%
of people with diagnosed HIV infection will
receive sustained antiretroviral therapy;
and by 2030, 95% of all people receiving
ART will have viral suppression
Also referred to as 90-90-90 and 95-
95-95 by the year 2020 and 2030
respectively
WHO/UN Comprehensive Approach/Strategies to
Prevent/Eliminate HIV Infection in Infants and
Young Children

A 4-prong approach has been recommended for eMTCT globally. These

include :
Prevention of new HIV infections in young people;
Prevention of unintended pregnancies in HIV-infected women;
Prevention of transmission of HIV from infected pregnant mothers to
their children; and
Provision of treatment, care and support to infected mothers, their
husband/partners and children
PREVENTION OF NEW
INFECTIONS IN YOUNG
WOMEN
Promotion of safer sex (ABC of primary HIV
prevention):
A = Abstain
B = Be faithful to one HIV-uninfected partner
C = Condom use – use condoms consistently
and correctly
Adequate treatment of STIs
Improvement in status of women
Information, Education and Communication (IEC)
activities to create and / or improve awareness
about HIV/AIDS and its prevention
Prevention Of New Infections In
Young Women (Cont’d)
Lifestyle
Reduction in Reduction in
changes –
frequency of the number of
avoiding use of
unprotected sex sexual partners
hard drugs and
during during
smoking during
pregnancy pregnancy
pregnancy
Post-exposure Pre-exposure Male
prophylactic prophylactic circumcision,
antiretroviral antiretroviral safe blood
therapy therapy transfusion etc
PREVENTION OF UNINTENDED PREGNANCIES
IN WOMEN INFECTED WITH HIV

Access to counselling and referral for family planning

Safe, consistent, effective contraception services.
Dual contraception
PREVENTION OF HIV TRANSMISSION FROM
INFECTED WOMEN TO THEIR INFANTS – CORE
INTERVENTION

HIV testing and counselling

Antiretroviral treatment during pregnancy and breastfeeding period
Safer delivery practices / caesarean section
Safer infant-feeding practices and antiretroviral prophylaxis for the baby.
TREATMENT, CARE AND SUPPORT
FOR WOMEN INFECTED WITH HIV
AND THEIR FAMILIES
Prevention and
treatment of Treatment of
ARV treatment Palliative care
opportunistic symptoms
infections (OIs)

Psychosocial
Nutritional Reproductive
and community
support healthcare
support
MANAGEMENT OF
HIV IN PREGNANCY
The management of HIV in pregnancy is aimed at
optimizing the health of the mother during
pregnancy, labour and delivery in order to
have a healthy baby who is not HIV infected.
It involves provision of well supervised and
professional preconception, antenatal, delivery and
postnatal care for the mother and expert care of the
infant.
It involves appropriate treatment including use of
combination ART and opportunistic infections (OIs)
prophylaxis and treatment.
It should be multidisciplinary, involving the
obstetrician, General Practitioner, physician,
counsellor, paediatrician, nutritionist etc
HIV TESTING SERVICES
IN PREGNANCY
The recommended approach during pregnancy is the
Routine approach (Opt-out approach) where HIV
testing is offered as part of routine tests in ANC
The pregnant woman reserves the right to refuse the
test
Women should be encouraged to start antenatal care
early and HIV testing should be provided during the
first ANC visit
Retesting for HIV in late pregnancy or labour is
recommended in women who tested negative in early
pregnancy
Testing in labour (or after delivery) is recommended
for women seen for the first time in labour or after
delivery (unbooked cases)
HIV TESTING
SERVICES (HTS)
HTS consists of a range of services that are used in diagnosis
of HIV, including testing methods, counselling (pre-test
information and post-test counselling), linkage to HIV
prevention, treatment and care and other clinical services;
and coordination with laboratory services for quality
assurance and the delivery of accurate results
All forms of HIV testings should conform to WHO five C’s –
- Consent
- Confidentiality
- Counselling
- Correct test results
- Connection – linkages to prevention, treatment and
care
ESSENTIAL COMPONENT OF HIV
TESTING SERVICES IN PREGNANCY

Pre-test Routine offer of Testing Post test Follow-up

information HIV testing algorithm using counselling counselling
(group) (with same day 2 Serial Rapid
result) with tests and a tie
option to opt breaker to
out. confirm positive
cases. Note that
Parallel testing
algorithm is not
recommended
in-the National
Determine,
HIV programme
Unigold and
Statpak are the
main test kits
used
Use of Antiretroviral
Therapy for PMTCT
Pregnancy in HIV positive women is an absolute
indication for ART.
ART should be initiated in all HIV pregnant and
breast-feeding women regardless of gestational
age, WHO clinical stage and at any CD4+ cell
count and continued for life.
ART should be initiated urgently in all pregnant
and breastfeeding women, even if they are
identified late in pregnancy or postpartum. This is
the most effective way to prevent MTCT of HIV
through the reduction of maternal viral load.
Same day initiation of ART is preferred except in
patients with Advanced HIV Disease.
Recommended first-line regimen for pregnant and breastfeeding women

In line with National recommendations, DTG- based regimen is the

preferred first-line ART for HIV positive pregnant women.
The first-line ART consist of two nucleotide/nucleoside reverse-
transcriptase inhibitors (NRTIs) backbone plus an integrase
strand inhibitor (INSTI) or non-nucleoside reverse-transcriptase
inhibitor (NNRTI).

Target Population Preferred first-line Alternative first-

regimens line regimens
Pregnant or TDF + 3TC + DTG TDF + 3TC (or FTC) +
breastfeeding women EFV400
AZT + 3TC + EFV400
TDF + 3TC (or FTC) +
EFV400
AZT + 3TC + NVP
TDF + 3TC (or FTC) +
NVP
ABC + 3TC + DTG.
Recommended first-line regimen for
pregnant and breastfeeding women

AS at TODAY, TDF + 3TC + DTG 300:300:50 as fixed dose

combination is the preferred first line regimen for initiating ART
in treatment naive adults.
In order to serve this preferred 1st line regimen, all women of
reproductive age who can potentially be on DTG- based
regimen during the 1st trimester of pregnancy should receive
intensive counselling on the benefits and potential risks. This
includes those already on the DTG-based regimen and those
newly diagnosed.
OTHER REGIMENS
The second-line ART consists of two nucleotide/nucleoside reverse-
transcriptase inhibitors (NRTIs) backbone plus a ritonavir-boosted protease
inhibitor (PI).

Preferred AZT+ 3TC (or FTC) + LPV/r (or ATV/r)

Alternative TDF + 3TC (or FTC) + LPV/r (or ATV/r)
TDF + 3TC (or FTC) + DRV/r
ATV=Atazanavir
The third-line regimens include newer drugs with
minimal risk of cross resistance to the previous
drugs used. Such as integrase strand inhibitor
(INSTIs), second generation NNRTIs and PIs.
DRV/r + DTG (or RAL) + 1-2 NRTIs
DRV=Darunavir
The Non-nucleoside reverse transcriptase
inhibitors are ineffective in management of
HIV-2 infections.
The PIs are therefore used in combination with
the 2 NRTI (backbone drugs) as the first line
regimen
ABBREVIATIONS
ART: antiretroviral therapy;
TDF: Tenofovir disoproxil fumarate 300mg OD;
3TC: Lamivudine 300mg OD;
FTC: Emtricitabine 200mg OD;
EFV: Efavirenz 600mg OD;
AZT: azidothymidine or zidovudine –ZDV 300mg BD;
NVP: Nevirapine 200mg OD for 14 days then 200mg BD;
LPV/r: Lopinavir/ritonavir 400mg + 100mg;
ATV/r: Atazanavir/ritonavir 300mg + 100mg;
DRV/r: Darunavir + ritonavir 800mg +100m OD ;
DTG: Dolutegravir 50mg OD;
RAL: Raltegravir400mg OD;
NRTIs: Nucleoside reverse transcriptase inhibitors
SPECIAL NOTE ON
DOLUTEGRAVIR
Dolutegravir is an integrase strand transfer inhibitor
(INSTI)
Has clinical advantages over NNRTIs and PIs in
antiretroviral therapy .
In late 2017, WHO emphasized the usefulness of
DTG-based regimen in first line ART for adults and
adolescents but advised as follows –
Women who can become pregnant could be placed
on DTG-based therapy, but must use effective long-
acting reversible contraception throughout treatment
Where this is not feasible, alternative ARV-based
therapy such as efavirenz based therapy should be
considered.
DTG
If a woman becomes pregnant while taking DTG based therapy
and pregnancy is confirmed in the first trimester, it is
recommended that the antiretroviral therapy should be changed
from DTG based therapy to other antiretroviral based therapy.
-- Initiation of DTG in pregnancy in ARV naïve pregnant
women should be started after the first trimester.
---These recommendations were based on studies which reported
higher risk of neural tube defect in dolutegravir combinations.
ADVANTAGES OF
DOLUTEGRAVIR
Updated data are available from the Tsepamo birth outcomes surveillance study
in Botswana of neural tube defect risks with dolutegravir

Additionally, the NAMSAL and ADVANCE randomized trials have been fully
published, which compared dolutegravir-based and efavirenz-based initial first-
line ART in Africa

The ADVANCE trial gave rise to concern over substantial weight gain possibly
caused by dolutegravir, particularly in women, for whom there was an average
gain in weight of over 6 kg in 48 weeks in one dolutegravir group.

No recommendation currently exists for people who are already on a first-line

efavirenz-based regimen as to whether a switch should be made to a
dolutegravir-based regimen.

A higher genetic barrier to developing HIV drug resistance

DTG is active against HIV 2 infection, which is naturally resistant to EFV

Although DTG is associated with higher risk of sleep disorders and weight gain.

(NAMSAL = The New Antiretroviral and Monitoring Strategies in HIV-Infected

Adults in Low-income countries)
ANTENATAL CARE FOR HIV
POSITIVE WOMAN -1
A comprehensive and quality antenatal care provides the opportunity to diagnose
women who are HIV positive and who would benefit from expert care to optimize
their heath condition and reduction in the risk of vertical and sexual transmission of
HIV.

In a situation where the life of the woman is seriously threatened by the

continuation of the pregnancy, termination of pregnancy should be in accordance
with the provision of the prevailing laws. HIV infection is not an indication for
termination of pregnancy.
ANC
Most HIV-infected women will be asymptomatic hence the
need to Follow usual ANC protocol
Unless complication develops, no need to increase
number of visits
Watch for signs/symptoms of AIDS and pregnancy-related
complications
Treat STDs and other coinfections
Counsel on behavioral changes that can reduce the risk of
MTCT e.g cigarette smoking, unprotected intercourse
ANC
Avoid invasive procedures and external cephalic version
Give antiretroviral agents.
Ensure proper nutrition, haematinics and at least 3 doses
of IPT for malaria
Ensure on-going counselling including infant feeding,
partner notification, need for hospital delivery and mode
of delivery
Chemoprophylasis for Tb and Pneumocystis jerovicii
pneumonia using INH and cotrimoxaxole when CD4 count
is less than 350cells/mm
INTRAPARTUM CARE
Patient should not be isolated, discriminated or treated differently from other women in
labour.
Supportive measures, empathy and caring attitudes by the health care providers are
necessary to boost her morale.
Universal safety precautions are essential, and labour management should follow standard
labour and delivery guidelines with a few modifications and avoiding unnecessary trauma or
prolongation of the second stage.
Intrapartum ART treatment is dictated by the ART regimen a pregnant woman received
during the antenatal period and the degree of viral suppression that has been achieved
Women who had been on an effective ART with viral load less than 1000 copies/mL should
be allowed to continue their established drug regimen as much as possible during labour or
prior to having an elective or scheduled caesarean section.
Women who had not commenced antiretroviral, should be started on combination ART in
labour.
MODE OF DELIVERY
With the current recommendation and use of ART in all HIV positive pregnant women, vaginal delivery IS RECOMMENDED
except for obstetric indications for Caesarean section.

However, if viral load is high (>1,000 copies/mL) at about 36 weeks’ gestation, caesarean section remains an option for delivery.

Hence the mode of delivery decisions to prevent HIV transmission should be individualized and take into account factors such as
type and duration of ART regimen used,

viral load,

duration of membrane rupture,

amount of time expected until vaginal delivery is accomplished, and

patient’s preference
DELIVERY
When vaginal delivery is the accepted option, some modifications to standard
obstetric practice is associated with reduction in the risk of perinatal
transmission.
Avoidance of prolonged rupture of membrane (>4 hours) and Avoidance of
prolonged labour.
Regular swabbing of the vagina with 0.25% chlorhexidine, especially before
every vaginal examination.
Avoidance of invasive procedures such as intrauterine pressure catheters,
penetrating scalp electrodes or scalp blood sampling.
Avoidance of instrumental deliveries and routine episiotomy
Mode of delivery (cont’d)
Available evidence shows that when elective CS is performed before the onset of
labour or rupture of membranes, it reduces the risk of MTCT by greater than 50%
as compared to vaginal delivery among women not on ART or with high viral load.
The benefits of CS in reducing transmission in women on antiretroviral and with low
viral load, would be of small magnitude.
CS is also associated with several fold increased risk of
postpartum infections, including uterine infections and pneumonia, anesthesia
risks, and surgical complications.
When Caesarean section is the choice, it should be undertaken at 38 weeks, before
the onset of labour (elective or schedule) and prior to rupture of membranes.
The use of prophylactic antibiotics is essential to prevent infections which tend to be
common in situations of immune-deficiency.
POSTNATAL CARE
Issues to be addressed in the postpartum period includes –
Review and support for the infant feeding method chosen by the mother
Good perineal hygiene and proper handling of body fluids
Discussion about issues of partner testing, sexual activity and protection of sexual partners against HIV infection
Need for contraception and use of condom, and other RH services including cervical screening
Continuation or commencement of maternal antiretroviral therapy or prophylaxis.
Prophylaxis for opportunistic infections and TB management if indicated
Infant ARV prophylaxis
Infection prevention and prompt medical treatment
Importance of early infant diagnosis at 6 weeks
Schedule postnatal visits at 2, 4 and 6 weeks and baby immunization.
Need for referral to adult ART clinic after postnatal period
MANAGEMENT OF HIV-
EXPOSED BABY
The immediate care of the newborn includes:
Mouth and nostrils should be wiped with gauze at delivery of the head
Clamp cord immediately after baby is delivered and avoid milking.
Cut cord under cover of lightly-wrapped gauze swab to avoid blood spurts.
Keep baby warm by placing infant on mother’s body for skin-to-skin contact
Wiped dry with a towel or surgical cloth to remove maternal blood and body fluids
If indicated, use mechanical/electrical suction unit at a pressure below 100mmHg or
bulb suction.
Mouth -operated suction should be avoided.
Give vitamin K injection after baby has been properly cleaned, ensuring injection
safety.
ARV prophylaxis for the HIV
exposed infant
All HIV exposed infants should receive ARV prophylaxis.
Infants at low risk of acquiring HIV from their mothers should
receive NVP only once daily for 6 weeks.
Infants born to mothers with HIV who are at high risk of acquiring
HIV should receive dual prophylaxis with AZT (twice daily) and NVP
(once daily) for the first 12 weeks of life, whether they are breastfed
or formula-fed.
Antiretroviral prophylaxis should commence within 72 hours of
birth.
ARV Prophylaxis for Low-Risk
Infants with NVP
Birth to 6 weeks:
Birth weight <2.5kg 10 mg (1 ml) once daily

Birth weight ≥2.5kg 15 mg (1.5 ml) once daily

ARV prophylaxis for high-risk
Infants
High-risk infants are defined as those:
Born to women with established HIV infection who have received less than four weeks
of ART at the time of delivery
OR
Born to women with established HIV infection with viral load >1000 copies/mL in the
four weeks before delivery;
OR
Born to women with incident HIV infection during pregnancy (this includes women
diagnosed in labour) or breastfeeding;
OR
Identified for the first time during the postpartum period, with or without a negative
HIV test prenatally.
ARV prophylaxis for High-risk
Infants with NVP and AZT
Infant Age Nevirapine daily dosing Zidovudine daily dosing
Birth to 6 weeks (dual
prophylaxis):
Birth weight <2.5kg 10mg (1ml) once daily 10mg (1ml) twice daily
Birth weight >2.5kg 15mg (1.5ml) once daily 15mg (1.5ml) twice daily
6 weeks to 12 weeks 20mg (2ml) once daily 60 mg (6ml) twice daily
Cotrimoxazole prophylaxis is recommended for HIV exposed infants
from 6 wks HIV infection has been excluded by an age-appropriate
HIV test 12 weeks after complete cessation of breastfeeding
All HIV –exposed infants should have initial DNA PCR testing at 6
weeks of age (or earliest opportunity thereafter) and 12 wks after
complete cessation of breastfeeding.
INFANT FEEDING IN THE
CONTEXT OF HIV
Appropriate infant feeding is critical to child survival because the
natural food for infants is breast milk.
In the context of maternal HIV infection, infant feeding can become
complex.
HIV infection may be transmitted through breast milk from mother
to child and this risk approaches 5%-15% in the absence of any
intervention.
Breast milk substitute has the benefit of zero HIV transmission but
carries with it the risk of increased morbidity and mortality from
malnutrition, diarrhoea and pneumonia.
RECOMMENDATIONS
Mothers of HIV exposed infants should breastfeed their babies exclusively for the
first six (6) months of life.
Adequate complementary feeds should be introduced at 6 months in addition to
breastmilk
Breastfeeding complemented by adequate complementary and household foods
should
be continued till 12 months of age.
Mothers who breastfeed should be aware that:
Mixed feeding (breast milk plus substitutes or foods) increases the risk of MTCT
of HIV.
ARV provided during labour and to the mother/infant pair throughout
breastfeeding protects the infant from MTCT of HIV
The risk of transmitting HIV to her infant during breastfeeding is
higher in certain conditions such as:
o When the woman is severely ill (by clinical or laboratory
measures)
o When she has mastitis, breast abscess, or other similar
conditions
o When the child has ulcers in the mouth
o When breastfeeding is prolonged beyond 12 months of age
PRECONCEPTION CARE
The main goal of Preconception care is to provide services for
health promotion, counselling, screening and interventions for
women of reproductive age before pregnancy to reduce risk factors
that might affect subsequent pregnancies.
In the context of HIV infection, preconception care services include:
Selection of effective and appropriate contraceptive options to
reduce the chance of unwanted pregnancy and until the optimal
maternal health status for pregnancy is achieved.
Ensure appropriate therapy to maximally reduce viral load and
optimize immune function before pregnancy.
Preconception care (cont’d)
Means of achieving safe conception especially in a sero-discordant
relationship, minimizing both horizontal (sexual) and perinatal
transmission of HIV
Available options ranged from
timed unprotected intercourse,
pre-exposure prophylaxis,
insemination with donor semen and sperm wash combined
with assisted reproductive technology-intrauterine
insemination (IUI),
in-vitro fertilization (IVF) and intracytoplasmic sperm
injection (ICSI).
Preconception care (cont’d)
Modification of ART regimen that has potential for teratogenicity and
adverse side effects.
ART adherence promotion
Diagnosis, prophylaxis and treatment of opportunistic infections such as
tuberculosis
Diagnosis and treatment of STIs
Optimization of maternal nutritional status
Recommendation for safe sexual practices
A discussion of the effects of HIV infection on pregnancy and PMTCT
strategies
PREVENTION OF MOTHER-TO
CHILD TRANSMISSION OF
HEPATITIS B VIRUS
HBV INFECTION
Acute HBV infection is transmitted by HBV, a DNA-containing virus of
the Hepadnaviridae family with an incubation period of six weeks to
six months
HBV can be transmitted by parenteral, sexual, and vertical routes
The sources of the virus include blood, saliva, tears, breast milk,
pathological effusions, vaginal secretions, and semen
The virus is present in all physiological and pathological body fluids
except in stool.
HBV Seroprevalence in pregnancy in Nigeria was 8.8%
[Eleje et al, 2020 pilot data]
OBJECTIVES
The fundamental goal of the prevention of mother to child transmission
(PMTCT) of Hepatitis B virus is identification of pregnant women who are
hepatitis B surface-antigen (HBsAg) positive and ensuring proper
immunoprophylaxis of their infants.
To accomplish this, the primary functions of the obstetrician are to
ensure that all women who book at the facility for ANC are screened for
hepatitis B Virus (HBV) infection.
Provide education to women positive for HBsAg regarding disease
management during pregnancy, the intrapartum and the postpartum period.
Provide information to HBsAg positive women about strategies to prevent
transmission of the HBV.
Ensure postnatal follow-up for the mother and the neonate.
ANTENATAL MANAGEMENT
All pregnant women should be offered HBsAg screening for HBV and
hepatitis C antibody at booking.
If the woman is HBsAg positive, inform the woman that it is
recommended that her husband/sexual partners be screened for
HBV.
All women who are HBsAg positive should be requested to do a
Panel Testing and referral to a hepatology (Gastroentorology) clinic
as early as possible in pregnancy.
PANEL TEST
A Hepatitis B panel is a blood test used to find markers of hepatitis
B infection
Hepatitis causes inflammation of the liver.
There are different hepatitis panels.
Some tests look for proteins (Antibodies) that the body makes to
fight the infection
Other tests look for antigens or the genetic material (DNA) of
the viruses that cause hepatitis.
A common panel checks for:
Hepatitis B surface antigen (HBsAg).
Hepatitis B surface antibody (HBsAb).
Hepatitis B IgM core antibody (HBcAb-IgM) and IgG core antibody
(HBcAb-IgG).
Hepatitis B type e antigen (HBeAg).
In some hospitals, Panel testing involves altogether testing for
HBsAg, HBsAb, HBeAg, HBeAb, and HBcAb.
HBeAg testing checks for infectivity status while HBsAb, HBeAb, and
HBcAb check for antibody/protective immunity status.
 All women who are Where possible or
HBsAg positive on available, viral loads for
repeat testing should be HBV should be checked
referred to a hepatology at 28 weeks gestation
(Gastroentorology) as a high viral load
clinic as early as increases the risk for
possible in pregnancy. perinatal transmission.
 INTERPRETATION OF HEPATITIS B SEROLOGIC TEST RESULTS
TEST INTERPRETATION
 HBsAg negative SUSCEPTIBLE
 anti-HBc negative
 anti-HBs negative

 HBsAg negative Immune due to natural infection

 anti-HBc positive
 anti-HBs positive

 HBsAg negative Immune due to hepatitis B vaccination

 anti-HBc negative
 anti-HBs positive

 HBsAg positive Acutely infected

 anti-HBc positive
 IgM anti-HBc positive
 anti-HBs negative

 HBsAg positive Chronically infected

 anti-HBc positive
 IgM anti-HBc negative
 anti-HBs negative

 HBsAg negative Interpretation unclear; 4 possibilities: 1. Resolved

 anti-HBc positive infection (most common) 2. False-positive anti-HBc, thus
 anti-HBs negative susceptible 3. “Low level” chronic infection 4. Resolving
Hepatitis B surface
antigen (HBsAg):
A protein on the surface of hepatitis B
virus; it can be detected in high levels in
serum during acute or chronic hepatitis B
virus infection
The presence of HBsAg indicates that the
person is infectious.
The body normally produces antibodies
to HBsAg as part of the normal immune
response to infection.
HBsAg is the antigen used to make
hepatitis B vaccine.
Hepatitis B surface
antibody (anti-HBs)
The presence of anti-HBs is generally
interpreted as indicating recovery and
immunity from hepatitis B virus
infection
Anti-HBs also develops in a person who
has been successfully vaccinated
against hepatitis B.
Total hepatitis B core
antibody (anti-HBc)
Appears at the onset of symptoms in
acute hepatitis B and persists for life
The presence of anti-HBc indicates
previous or ongoing infection with
hepatitis B virus in an undefined time
frame.
IgM antibody to hepatitis B core
antigen (IgM anti-HBc)

POSITIVITY INDICATES RECENT ITS PRESENCE INDICATES

INFECTION WITH HEPATITIS B ACUTE INFECTION
VIRUS (≤6 MONTHS)
IgM and IgG antibody to
hepatitis B core antigen
Anti-HBc is the first detectable antibody
in the course of HBV disease
IgM anti-HBc indicates acute infection
and is the only serologic marker
detectable during the “window
period,” when neither HbsAg nor anti-
HBs is detectable
Once IgG anti-HBc appears in the serum,
it persists for life
Detection of IgG anti-HBc indicates
previous or ongoing infection
 Hepatitis B e antigen (HBeAg) is a small
polypeptide that exists in a free form in
the serum of individuals during the early
phase of hepatitis B infection, soon after
hepatitis B surface antigen (HBsAg)
Hepatitis becomes detectable.
Serum levels of both HBeAg and HBsAg
Be rise rapidly during the period of viral
replication

antigen The presence of HBeAg in serum

correlates
with hepatitis B virus (HBV)
infectivity, the number of infectious
virions, and the presence of HBV
core antigen in the infected
hepatocytes.
HBeAg testing is indicated primarily during
follow-up of chronic infection rather than acute
infection because of its variable level during the
acute phase.
HBV can be present in hepatocytes in two
forms: as replicating virus, leading to
production of infectious particles, or as a
nonreplicative form after integrating into the
host DNA.
Since HBeAg is produced only during replication
of the virus, it can also be used to indirectly
determine the state of HBV in the hepatocyte
The presence of HBeAg indicates the degree of
infectivity of the person.
The higher the concentration of HBeAg, the
higher the degree of infectivity
The risk of vertical transmission of HBV increases with the
gestational age at which the mother is infected.
Vertical transmission occurs in up to 10% of neonates when the
mother is infected during the first trimester, and in 60% to
90% of babies when acute infection occurs when the mother is
infected during the third trimester.
Over 60% of pregnant women who acquire acute hepatitis B
infection at or near term transmit HBV to their offspring.
The commonly used markers to determine chronic infection
with HBV are hepatitis B surface antigen (HBsAg),HBV-DNA, and
hepatitis B core antibody (HBcAb).
Prophylaxis (postexposure prophylaxis) of infants from all
HBsAg-positive mothers is recommended, regardless of the
mother’s HBeAg or HBeAb status
ANTENATAL
MANAGEMENT
If at 30-32 weeks gestation a high viral load
(>106copies/ml) is found the woman may be considered
suitable for anti-viral therapy after consultation with the
gastroenterologists.
Lamivudine, telbivudine and tenofovir are currently
available options for pregnant mothers with HBV infection.
It should be given daily (eg Lamivudine 100 mg or
Telbivudine 600 mg) from 32 weeks to 4 weeks postpartum.
Ensure that HBsAg positive pregnant woman should
prepare for their upcoming childbirth by having HBIG on
hand or stored in hospital pharmacy.
This will ensure that HBIG and the first dose of hepatitis B
vaccine are given within 12 hours of birth to the
neonate
INTRAPARTUM
MANAGEMENT
Intra-partum transmission refers to transmission
occurring during childbirth, and it is recognized
as the most important route of HBV MTCT.
During the process of delivery, newborns may
have the chance to be exposed to maternal
body fluids or blood that contains HBV at the
time when they pass the maternal genital tract.
Similar to HIV, avoid procedures that may
increase risk of vertical transmission of HBV
including:
fetal blood sampling
fetal scalp electrode use.
There is not enough evidence to support
that caesarean section is
better in avoiding MTCT of HBV
compared with vaginal delivery
Caesarean delivery is therefore
not recommended in HBsAg-positive
mothers
Elective caesarean delivery (if indicated
from other obstetrics reasons) is
suggested to be started
before
the onset of labor and
ROM if it has to be chosen for other
reasons to avoid possibility of
transmission.
Early and quick cleaning of the respiratory
tract, mouth and skin of the newborns
after delivery.
This process will decrease exposure
chance of fetus to their maternal amniotic
fluid, serum and vaginal discharges.
POSTPARTUM MANAGEMENT
Many studies including Cochrane systematic reviews indicate that
vaccination alone is insufficient to prevent MTCT of HBV in these HBsAg positive
mothers, while combination of Hepatitis B vaccine with HBIG in the newborn
has been proved to be more efficient in reducing MTCT prevalence than vaccine
or HBIG alone.
Know the HBsAg status of the mothers of all infants for whom you provide care.
Help ensure that no babies are infected by HBV due to a medical error.
Make sure that all newborns under your care receive the first dose of hepatitis B
vaccine prior to discharge.
Postpartum, appropriate prophylactic HBV vaccination [for
active immunity] and HBV immunoglobulin (HBIG)
[passive immunity] administration should be implemented
for the neonate (Joint immunoprophylaxis).
HBIG (0.5 mL or 1 ml, depending on birth weight) should be
given intramuscularly (IM), preferably within 12 hours of
birth.
HBIG given at birth does not interfere with the
administration of other vaccines administered at 2 months
of age.
All infants in both arms received 200 IU (0.5ml or 1ml) of
HBIG within 12 hours postpartum and recombinant HBV
vaccine of 10 or 20 μg at 0, 1, and 6 months.
Know that the usual schedule consists of 3
intramuscular doses of hepatitis B vaccine
at 0, 1 to 2 months, and 6 to 18
months.
Infants whose mothers are HBsAg-positive
should receive the last (3rd or 4th) dose
by 6 months of age
Post-vaccination testing is recommended 3
to 12 months after completion of at least
3 doses of the hepatitis B vaccine series,
but no earlier than 9 months of age.
Hepatitis B and
Breastfeeding
HBV-positive mothers do NOT need to be
separated from their infants nor should their
infants be placed in special isolation.
Breastfeeding does not increase the risk of
HBV transmission provided the neonate receives
HBV vaccination and HBIG at birth (Joint
immune-prophylaxis)
HBV-positive mothers can breastfeed their infant
unless there is significant breast pathology
Although HBsAg has been detected in some
samples of breast milk, special concentration
techniques were needed in most studies.
HEPATITIS
C VIRUS
INFECTIO
N
INTRODUCTION
The worldwide prevalence of hepatitis C virus (HCV) infection in
pregnant women is estimated to be between 1 and 8%.
In Nigeria, 1.3% pilot Nigeria National study [Eleje et al]
7.7% in Asante Akim North Municipality, in the Ashanti region
of GHANA
8.07% by Dabsu and Ejeta in Ethiopia
While parenteral transmission is still common in children living
in low- and middle-income countries,
perinatal transmission is now the leading cause of
HCV transmission in high income countries.
The absence of an HCV vaccine or approved therapy during
pregnancy means that prevention of vertical transmission is
still not possible.
Introduction
(cont’d)
However, a low vertical transmission rate of 3-5%, a high rate of
spontaneous clearance (25-50%) and delayed morbidity have
resulted in HCV being overlooked in pregnant women and their
infants.
Factors known to increase the risk of perinatal transmission
include
HIV coinfection and higher maternal viral loads, while
elective C-section and withholding breastfeeding have
not been demonstrated to reduce vertical transmission.
Current guidelines for the diagnosis of persistent perinatal
infection requires a positive anti-HCV test in infants born to
infected mothers after 12 months or two positive HCV RNA tests
at least 6 months apart.
Current HCV treatment options using pegylated interferon
and ribavirin are both unsuitable for use in pregnancy and
infancy.
All women with confirmed HCV should be offered
referral to a gastroenterology/hepatology clinic
for ongoing monitoring and assessment for
suitability of antiviral treatment options if RNA
positive.
CONCLUSION
Viral infections (HIV, HBV and HCV) occur
worldwide with the highest prevalence in Africa
To improve public health, universal screening of
pregnant women for HIV, HBV, HCV infection
should be performed.
All pregnant women testing positive for HIV and
HBV should receive appropriate imterventions in
line with current recommendations.
Pregnant women infected with HCV carry an
approximately 5% risk of transmission from mother
to infant.
There is no vaccine to prevent HCV infection, the
clinical focus is primarily on treatment
REFERENCES
Ugwu EO, Eleje GU, Ugwu AO, Nwagha UI,
Ikechebelu JI, Umeh UA, Okafor HU. Antivirals for
prevention of hepatitis B virus mother-to-child
transmission in human immunodeficiency virus
positive pregnant women co-infected with hepatitis B
virus (Protocol).Cochrane Database of Systematic
Reviews 2020, Issue 6. Art. No.: CD013653
Eleje GU. PMTCT Of HIV And Hepatitis. WACS update
2021
Agboghoroma OC. HIV In Pregnancy & PMTCT
Protocol. WACS update 2019.
Federal Ministry of Health, Nigeria. National
Guidelines for HIV Prevention Treatment and Care,
Abuja, NASCP, Federal Ministry of Health, 2020.
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