HIV /AIDS IN CHILDREN

1. HIV /AIDS IN CHILDREN

2. RISK OF HIV TRANSMISSION

3. Parent To Child Transmission

4. WHY THE TERM PTCT? • Mothers may transmit HIV/AIDS during , pregnancy labour & delivery breast feeding But, fathers are indirectly infect the foetus by transmitting infection to the mother.

5. EPIDEMIOLOGY OF PTCT 1 % - 4 % of pregnant women have HIV 3.64% of all HIV infections are due to perinatal Transmission The prevalence rate in pregnant women at Hyderabad, Mumbai, Pune, Sangli and Manipur is high. WHY?

6. Cont… • Truckers, migrant workers, CSWs, and Injecting Drug Users

7. Maternal factors that increase the risk for PTCT of HIV during pregnancy High viral load recent infection infected with HIV during pregnancy advanced HIV disease viral ,bacterial and parasitic (esp. Malaria) placental infection concurrent STI

8. Risk factors for PTCT of HIV during labour and delivery • Maternal factors • High viral load • Rupture of membranes >4 hours • Intra partum haemorrhage • Invasive procedures • Invasive fetal monitoring • ARM • Episiotomy • Vacuum cups • Forceps delivery

9. Cont… Malnourishment Drug use Alterations in the integrity of placenta,chorion. chorio-amnionitis invasive procedures on the uterus

10. Risk factors for PTCT of HIV after delivery NEWBORN FACTORS preterm birth low birth weight First infant of multiple birth Altered skin integrity RISK FACTORS IN INFANT FEEDING BREAST MILK WITH, High viral load Re-infection Primary infection Advanced disease

11. Cont… Breast pathologies Engorgement Cracked nipples Mastitis/abscess Poor maternal nutrition Mixed feeding Prolonged length of breast feeding Mouth sores in infant

12. Case scenario • An 18 year old girl comes to you. • She says she is likely to get married in a years time, but she is scared about HIV. • Her friend had got married last year and was diagnosed to be HIV + after her marriage during her antenatal checkup. • What points would you keep in mind while counselling her?

13. PPTCT STRATEGIES • Primary prevention: Educate all women before pregnancy on, -prevention and early treatment of STIs -Family planning methods HIV and importance of early testing. Refer to appropriate centers for additional support

14. Cont… • Educate and counsel the pregnant or lactating HIV negative women on HIV and early testing. WHY DO YOU THINK THIS IS NECESSARY UNDER PPTCT?

15. Case scenario • A woman who is 23 years and HIV + comes for her first antenatal check-up. • She is 6 weeks pregnant and you are there in the OPD • What points would you keep in mind while counselling her?

16. SECONDARY PREVENTION Educate the woman on the importance of, antenatal visit diet+ vitamin &iron supplements Continue to monitor CD4 counts /OIs 3 drug ART for mother after 14 to 28 weeks of gestation.

17. Cont… Avoid invasive procedures Treating any infection or STI Importance of hospital delivery Practicing Safe sex

18. Food safety and hygiene • Cook or steam the rice, vegetables and other foods but don’t overcook. • Use clean and boiled water. • Wash hands frequently after toileting, before and after eating food. 4. Wash vegetables before cooking.

19. Cont… 5. Keep the dust and insects away from the foods by having the closed food containers. 6. Do not eat spoiled food. 7. Prepare the food in a hygienic manner. 8. Avoid ingestion of raw meat.

20. WHEN IS ART REQUIRED DURING PREGNANCY?

21. Govt. Of India -PPTCT Programme When long term combination of ART is not available or not feasible short course regimens are used for pregnant women diagnosed during labour. 1. Single dose of oral NVP 200mg 4 hours before the onset of labour. 2. Zidovudine (AZT,ZDV) 300mg or Lamivudine (3TC) 150mg oral BD for 3-7 days after delivery with NVP 200mg

22. Cont… 1.Zidovudine( AZT, ZDV) 2mg/kg oral 4 times daily for 6 weeks to be started 6 hours after birth. 2.Single dose NVP drops 2mg /kg for baby within 72 hours of birth.

23. Case scenario • A woman who is 24 years HIV + comes to the hospital with labour pain since half and hour. • What will you assess and do for her if you were throughout her labour to reduce MTCT.?

24. DURING LABOUR ASSESSMENT Regular obstetrical assessment. Assess whether tested for HIV. - if not, offer pretest counseling and testing during labour -may offer an opportunity provide PPTCT If known HIV+ check whether she has, - already been put on ART - already taken the single dose of NVP (PPTCT)

25. MANAGEMENT DURING LABOUR AND DELIVERY

26. IMMEDIATE NEWBORN CARE

27. INFECTION CONTROL MEASURES DURING DELIVERY • Use personal protective equipments • Use clamps and gauze when cutting the cord

28. Cont… • Handle the baby with gloves until bathed • Soak all used linen in bleach solution for 2 hours • Use gloves during cord care and assisting to express the breast milk

29. Case Scenario • A woman who is 24 years, HIV +, and delivered her baby asks you about feeding her baby. You have not seen her in the past, during her prenatal period. • What points would you keep in mind while counseling her to MTCT?

30. CARE DURING POSTNATAL PERIOD -Inform about routine postnatal care -Evaluation to decide eligibility for ART -Needs to report any signs of infection such as chest, urinary,puerperal, episiotomy or breast infections -Assess risk factors for reinfection -Reinforce safe sex

31. Educate mother on: • Exclusive breast feeding for six months OR • Replacement feeding( formula feed) - if affordable, safe, sustainable, feasible and acceptable Avoid mixed feeding at all cost!

32. Cont… • Good hygiene • Good position during breast feed. • Giving colostrum • Duration-shorter the better • Not mixing feeds • Express feed vs. direct BF • How to stop abruptly

33. Case Scenario A woman who is 24 years, HIV + has doubts about her and her baby’s follow up care after delivery What key points would you keep in mind while counseling her to reduce the risk of PTCT?

34. Follow up care • Discuss about family planning BEFORE DISCHARGE • Review birth control and infection control - dual protection to prevent and reduce pregnancy and reinfection, STI. - hormonal contraception(OCP) is less effective with ARTs. - access to emergency contraception.

35. FOLLOW UP AT INFANCY PERIOD • DNA PCR testing for infants at 6wks and 6months. • Breast feeding infants-6-8wks after stopping breast feeding • Routine well baby visit. • Follow standard immunization schedule. • Need for immediate medical attention if infection occurs.

36. Cont… • HIV antibody testing at 12 and 18months visit. • Cotrimoxazole prophylaxis • Start for all HIV exposed infants at 4-6wks of age till detected as HIV negative

37. Care after infancy period • Monitor growth and development • Nutritious diet to support the growing needs • Prevent injuries and infections • Regular follow up • Periodical investigation to assess the CD4 count

38. Cont… • Report the signs of infections to the health team members • Long term care: Information to be given to school teachers and care takers

39. Initiating ART in children

40. Recommended Pediatric ART

41. Case Scenario • Mrs.B has been on ARV therapy for 6 months • She is feeding much better and would like to have another child • Her husband’s HIV status is unknown • She approaches you for advice • What advice will you give Mrs.B? • What are the medical implications ? • How will you proceed with your counseling?

42. Advice to Mrs. B • Discuss HER feelings and whether she really wants another child or is she getting pressure from others • Does she have concerns about disclosure of HIV status and stigma? • Will she be able to access good antenatal care and continue the ART and follow up care? • Will she be able to deliver in a hospital?

43. Cont… • As long as Mrs. B remains immunologically stable on ART, her HIV + status should not have a negative impact on pregnancy • Discuss the benefits of referring her husband for HIV testing • Review the risk of STI and the need for safe sex practice • Discuss the infant feeding options and risk of transmission • Discuss the risk of vertical transmission during pregnancy and birth if she does not stay on ART

44. TRUE OR FALSE • 1. Pregnancy makes HIV worst False • 2. HIV infected sperm can directly infect the embryo even if the mother does not have HIV False 3. If a woman is HIV +, there are medications she can take to reduce the likelihood of passing the virus to her infant True • 4. If both parents are HIV +, using condoms during pregnancy isn’t necessary False

45. TRUE OR FALSE • 5. If a woman is HIV +, all her babies will be HIV + because they share the same blood. False 6. Procedures during delivery that may cause exposure of the newborn to maternal body. True 7. If a HIV + woman has a caesarian section, the risk of having a baby with HIV is 0% False • 8. Giving Nevirapine to babies after they are born is like giving a nurse PEP after a needle stick injury. • True

46. POINTS TO REMEMBER • Disseminate correct information on PPTCT • Educate on the risk factors of PTCT • Administer ART to lower the viral load • Support safe infant feeding • Modify obstetric practice to reduce PPTC • Develop links for follow up of mother & baby

47. “It is the greatest of all mistakes to do nothing because you can only do little . Do what you can."  - Sydney Smith

48. THANK YOU