HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.): SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN: Antenatal care: Medical treatment during pregnancy

HIV in Pregnancy: A Review (UNAIDS, 1999, 67 p.)

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EXECUTIVE SUMMARY

INTRODUCTION

SECTION A : HIV IN PREGNANCY

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Epidemiology of HIV

Susceptibility of women to HIV infection

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Biological factors

Socio-cultural factors

Effect of pregnancy on the natural history of HIV infection

Effect of HIV infection on pregnancy

Mother-to-child transmission

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Factors affecting mother-to-child transmission of HIV-1

Interventions to prevent mother-to-child transmission of HIV

Appropriate interventions to reduce mother-to-child transmission

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Antiretroviral therapy

Immune therapy

Nutritional interventions

Mode of delivery

Vaginal cleansing

Modification of infant feeding practice

Voluntary HIV counselling and testing in pregnancy

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Testing of antenatal women

Counselling before and after HIV testing in pregnancy

Counselling about pregnancy-related issues

SECTION B : MANAGEMENT OF HIV-POSITIVE PREGNANT WOMEN

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Antenatal care

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Obstetrical management

Examination and investigations

Medical treatment during pregnancy

Antiretroviral therapy

Care during labour and delivery

Postpartum care

Care of neonates

SECTION C : INFECTION CONTROL MEASURES

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Universal precautions

Risks of needlestick injuries

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Management of needlestick injuries and other accidental blood exposure

REFERENCES

Medical treatment during pregnancy

The medical care of HIV positive women should be tailored to the individual needs of the woman. In general, pregnancy is not a contraindication for the most appropriate antiretroviral therapy for a woman or for most of the medical management of HIV-related conditions, but the risk to the fetus should always be considered, and treatment modified if necessary²⁹⁰.

The value of vitamin A supplementation in reducing transmission has not been proven, but multivitamins may provide cost effective nutritional support^372,373,374. Mebendazole should be given at the first visit in areas of high hookworm prevalence.

Malaria in pregnancy causes high maternal and infant morbidity and mortality, and may be associated with increased risk of mother-to-child transmission of HIV^216.217. Current recommendations are that intermittent treatment with an effective, preferably one-dose antimalarial drug should be made available to all primigravidae and secundigravidae in highly endemic areas. This should be started from the second trimester and given at intervals of not more than one month apart.

Prophylaxis for opportunistic infections should be given in pregnancy, as indicated by the clinical stage of the HIV infection, and according to local policy. Prophylaxis and treatment for tuberculosis should be given where indicated, although streptomycin and pyrazinamide are not recommended during pregnancy. Pneumocystis carinii pneumonia (PCP) prophylaxis should continue through pregnancy: sulfamethoxazole/trimethoprim (Bactrim/Septran) or pentamidine can be used. The risk to the fetus of maternal sulphonamide administration in the third trimester is outweighed by the risk to maternal health of PCP and kernicterus has not been reported where the drug was not also used in the neonatal period⁵. Consideration should be given to pneumococcal and Hepatitis B vaccination.

Treatment for opportunistic infections during pregnancy depends on the clinical stage of the patient. Treatment regimens should follow local policy guidelines. Where a variety of treatment options are available, those with the lowest risk to the fetus should be used. Dermatological conditions are common in HIV positive women and men, and treatment may be required for prolonged periods. Acyclovir can be used safely after the first trimester. Topical imidazole antifungals or topical gentian violet can be used throughout pregnancy and oral fluconazole can be used after the first trimester, if required.