4 HIV in mother and baby
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- Basics of HIV infection
- Spread and prevention of HIV infection
- Mother to child transmission of HIV infection
- Preventing mother-to-child transmission of HIV infection
- Feeding babies born to mothers with HIV infection
- Supporting HIV positive mothers
- Case studies
When you have completed this chapter you should be able to:
- Understand the basics of HIV infection
- List the ways in which HIV is spread between adults
- Understand how HIV infection is diagnosed
- Explain how adults can prevent becoming infected with HIV
- Understand how HIV can be transmitted from mother to child
- Prevent mother to child transmission during pregnancy and labour
- Assist HIV positive mothers to choose how best to feed their newborn baby
- Support HIV positive mothers
Basics of HIV infection
4-1 What is HIV infection?
HIV stands for Human Immunodeficiency Virus. HIV is a virus (type of germ) which infects humans and causes a serious illness called HIV disease. HIV belongs to a group of viruses called retroviruses.
A person with HIV infection is called HIV positive (HIV + ve). A person without HIV infection is called HIV negative (HIV – ve).
4-2 What is AIDS?
When HIV disease becomes advanced and threatens the person’s life it is called AIDS. AIDS stands for Acquired Immunodeficiency Syndrome. People with AIDS are clinically unwell and have many health problems. Most people with HIV infection who are correctly managed will remain clinically well and will should not develop AIDS.
Most people with HIV infection will never develop AIDS if they are correctly managed.
4-3 How does HIV cause disease?
HIV weakens and damages the cells of the immune system. These are a group of special cells in the body which help to prevent many infections. These immune cells are called CD4 cells. The CD4 cells act as soldiers which fight off infections and protect the body. With early HIV infection the immune system still functions normally and the person remains clinically well.
HIV damages the immune system which then can no longer protect the body against many dangerous infections.
4-4 Why does HIV disease slowly become worse?
Once the body is infected with HIV the virus slowly multiplies. As the amount of virus in the body (called the viral load) increases over time more and more CD4 cells are killed. This progressively weakens the immune system and the person starts to become ill, first with mild infections and later with severe infections.This can be prevented with the correct treatment.
Without the correct treatment HIV infection progresses and is divided into 4 clinical stages.
4-5 What are the 4 clinical stages of HIV infection?
Stage 1 starts when the person becomes infected with HIV. The amount of virus in the body rapidly increases and the person becomes ill. This illness looks like influenza (flu) with a fever, headache and body pains. They may also have a rash and swollen lymph nodes.
Stage 2 begins a few weeks later when the body starts to produce antibodies to the virus and as a result the person feels much better. The antibodies in the body control the HIV infection for a number of years and during this time the person remains well. At this time they often do not know that they have been infected with HIV. As antibodies are produced the amount of virus in the body decreases but does not disappear completely. Stage 2 may last a number of years in adults.
Stage 3 starts when the HIV infection lowers the number of CD4 cells and the immune system can no longer protect the body from many mild infections such as chest infections, oral thrush and cold sores. The person feels unwell, loses weight, may have vomiting and diarrhoea, general body pains and swollen lymph nodes. This is called HIV disease.
Stage 4 starts when the immune system is very damaged and cannot protect the person from dangerous and life threatening infections such as tuberculosis (TB). These people now have AIDS. They are very ill as they have very few CD4 cells and they have a high viral load in their bodies. Without the correct treatment they will die.
4-6 How is HIV infection diagnosed in adults?
Testing for HIV in adults and older children is simple and fast and can be done at most health facilities. A sample of finger prick blood is needed. The rapid HIV test detects any HIV antibodies and can be done at the health facility. The result is available in a few minutes. The presence of HIV antibodies in a person’s blood indicates that they have been infected with HIV. Counselling is needed before the test to explain the importance of the test and how it is done. It is also needed after the test when the person is given the results.
HIV is diagnosed with a simple, rapid HIV test on a sample of blood.
Spread and prevention of HIV infection
4-7 Can HIV infection spread from person to person?
Yes. The virus can be spread (transmitted) from person to person. Therefore HIV is an infectious disease. Every effort must be made to prevent the spread of HIV.
4-8 Which people with HIV infection are infectious to others?
All people with HIV infection who are not on antiretroviral treatment (ARVs) are infectious to others.
People with stage 1 infection have not produced antibodies to HIV yet so they have a high viral load and are very infectious to others. Patients with stage 4 infection also have a high viral load as their immune system is too weak to produce antibodies. Therefore people with stage 4 infection are also very infectious to others. Patients with stage 2 and 3 HIV do produce antibodies to fight the HIV infection, but they are still infectious to others.
The correct use of antiretroviral treatment lowers the HIV viral load in the body and prevents the spread of HIV to others.
4-9 How is HIV spread?
There are two common ways that HIV is spread from one person to another:
- HIV in adults is usually spread by unprotected sexual intercourse (both vaginal and anal intercourse). The risk is less with oral sex.
- HIV may be transmitted from a pregnant woman to her unborn baby or through breast milk.
Less common ways to become infected with HIV are sharing unsterilised injection syringes or needles, razor blades or skin piercing instruments that are used for tattooing. Blood transfusions are safe in South Africa as all donated blood is screened for HIV. Insect bites do not spread HIV.
In adults HIV is usually spread by sexual intercourse.
4-10 What daily activities do not spread HIV?
- Holding hands, touching, hugging and social kissing
- Sharing food, plates, cups, bowls, knives, forks or spoons
- Sharing towels, telephones or clothes
- Using public toilets
4-11 How common is HIV infection in South Africa?
HIV infection is very common in South Africa. About 13% (7 million) of people in South Africa are infected with HIV. The percentage of HIV positive pregnant women in 2017 was 21% varies from 5% in the Western Cape to 30% in KwaZulu-Natal.
HIV infection is common in South Africa
4-12 Are women at high risk of becoming infected with HIV?
Yes. Four times more women than men are infected with HIV. The risk is particularly high in young women who have older or multiple sex partners. These women are often not able to negotiate safe sex.
Young women are at high risk of HIV infection.
4-13 How can women avoid getting HIV infection?
There are 3 important ways that both men and women can prevent becoming infected with HIV. This is called practising safer sex:
- Avoid sexual intercourse (abstain) if possible
- Only have sex with a partner who is HIV negative. Preferably only have sex with one faithful partner (be faithful). Avoid multiple sex partners.
- Always use a condom when having sex (condomise). Either a male or female condom can be used. It is important to know how to use a condom correctly to both protect yourself and your partner.
Abstain, be faithful and condomise to avoid HIV infection.
Other important ways of reducing the risk of HIV infection are:
- Understanding how HIV is spread and how to protect oneself against HIV infection
- Knowing one’s HIV status and that of one’s partner
- Delaying the first sexual relationship for as long as possible
- Male circumcision decreases the risk of the male getting HIV infection by 40% but does not reduce the risk of a partner becoming infected
- Taking antiretroviral medication if one is exposed to HIV.
4-14 Can people with HIV infection remain well?
Yes. Both adults and children with HIV infection can remain well for many years if they lead a healthy lifestyle and take antiretroviral medication. All children and adults with HIV infection should take ARVs for life.
4-15 What are anti-HIV medicines?
Anti-HIV medicines are called antiretrovirals or ARVs. These are a group of important medicines that act against HIV. These ARVs may be used to prevent HIV infection or control HIV infection. At present HIV infection cannot be cured.
Anti-HIV medicines are called antiretrovirals or ARVs because HIV is a specific type of virus called a retrovirus.
Anti-HIV medicines are called antiretrovirals or ARVs.
4-16 What is HIV stigma?
Many people with HIV infection suffer from stigma. Stigma means disapproval and rejection. This is a negative belief or attitude towards another person who you think is different to yourself because they have HIV. Many people incorrectly believe that someone who is HIV positive must be bad, dirty and have no morals, and as a result they should be avoided and punished.
Mother-to-child transmission of HIV infection
4-17 How can HIV spread from mother to child?
Mother-to-child transmission (MTCT) of HIV can take place at three different times:
- HIV may cross the placenta and spread from the mother to her unborn baby during pregnancy
- HIV may spread during labour from mother to baby
- HIV may spread in breast milk from mother to child.
HIV can spread from mother to child during pregnancy, delivery and breastfeeding.
4-18 What is the risk of mother to child transmission of HIV?
If an HIV positive mother and her baby are not receiving ARVs the estimated risk of the baby being infected with HIV is:
- 5% during pregnancy
- 15% during vaginal delivery
- 5% during mixed breastfeeding for 6 months
Therefore the overall risk for HIV transmission in an HIV positive mother who is not receiving ARVs and practices mixed breastfeeding for 6 months is about 25%.
The risk of transmission is higher if the mother becomes infected with HIV while she is pregnant or still breastfeeding.
Preventing mother-to-child transmission of HIV infection
4-19 Can the risk of mother-to-child transmission of HIV be reduced or prevented?
Yes. The risk of mother-to-child transmission of HIV can be reduced or prevented by:
- Not getting pregnant unless the pregnancy is wanted and planned. Prevent unwanted pregnancies with family planning.
- Managing the mother and her newborn baby correctly. Correct management will prevent or reduce the risk of mother-to-child transmission in women who are HIV positive. The risk of transmission with the correct management is less than 1%.
- Practising safer sex. It is very important that pregnant women who are HIV negative also practice safer sex to ensure that they do not become infected with HIV.
The risk of mother-to-child transmission of HIV can be reduced to less than 1%.
4-20 How should pregnant women be managed for HIV infection?
- Encourage safer sex in pregnancy and while breastfeeding.
- Screen all pregnant women for HIV infection.
- Give ARVs to all HIV positive pregnant women.
- Give ARVs to all babies born to HIV positive women.
- Encourage and support exclusive breastfeeding.
- Provide careful follow-up.
It is important that all HIV positive mothers are identified when they book for antenatal care so that they can be managed in the prevention of mother-to-child transmission (PMTCT) programme.
4-21 How should pregnant women be screened for HIV?
- All pregnant women need to book early for antenatal care. It is best if pregnant women start antenatal care before 12 weeks after their last normal menstrual period. If possible the pregnancy should be confirmed and antenatal care should start at 8 weeks after their last normal menstrual period.
- All pregnant women should be counselled and screened for HIV at their first antenatal visit with the rapid HIV test. The rapid HIV test detects HIV antibodies in the blood and is used to screen for HIV infection. The test takes less than 30 minutes and can be done at most antenatal clinics.
- If the booking HIV test is negative it should be repeated at 32 weeks of pregnancy to make sure that she has not become infected during her pregnancy.
- Community health workers can play an important role in getting pregnant women to book early for antenatal care and making sure that they are screened for HIV at their first visit.
All pregnant women must book early for antenatal care and be screened for HIV at the first visit.
4-22 How should pregnant women be managed for HIV infection?
All HIV positive pregnant women should be started on ARVs if they are not already receiving ARVs. Management with ARVs is started as soon as the diagnosis of HIV infection is made and these women must remain on ARVs for life. ARVs will reduce the risk of mother-to-child-transmission of HIV as well as control the mother’s HIV infection and keep her healthy.
4-23 What medication is given to pregnant women with HIV?
Pregnant women should take one ARV tablet every evening at bedtime. This is the fixed dose combination (FDC) tablet. The tablet contains three different ARVs. These will be prescribed at the healthcare facility. It is very important that the mother takes her medication every day during her pregnancy, labour and after delivery.
All mothers should have a 6 week postnatal check. At this time the further management of HIV positive mothers will be made. They will need routine follow up visits. All HIV positive women should continue with ARVs for life to prevent them developing HIV disease.
HIV positive pregnant women should start daily ARVs for life.
4-24 What medication is given to newborn babies born to pregnant women with HIV infection?
Babies born to mothers who are HIV positive are called HIV exposed babies. HIV exposed babies should be given a daily dose of nevirapine drops starting within one hour after they are born. The daily nevirapine drops for the baby should be continued until 6 weeks after birth. The nevirapine drops will not hurt the baby but will protect the baby from HIV infection. Some babies at high risk of HIV infection may also be given AZT drops for 6 weeks.
HIV exposed babies must be given nevirapine drops daily for 6 weeks.
4-25 What follow up is needed for babies born to HIV positive mothers?
HIV exposed babies must be closely followed up at a primary care clinic. At birth and again at 10 weeks old, HIV exposed babies will have a PCR blood test to assess whether they have been infected with HIV. The PCR test for babies is different from the rapid screening test used for children of 18 months or more and for adults.
The 10 weeks screen is usually done when immunisations are given and the mother has her postnatal visit:
- Babies who have a positive test at birth or 10 weeks have been infected with HIV. The nevirapine drops can be stopped and they should they be started on a combination of ARVs for life.
- Babies with a negative test at 10 weeks have not been infected and their nevirapine drops can be stopped if their mothers are taking ARVs. They should be screened again at 18 months.
- The PCR screening test should be repeated 6 weeks after the last feed of breast milk.
- All HIV exposed infants who have a negative PCR test at birth, 10 weeks and after the end of breastfeeding should have an adult rapid test at 18 months.
Feeding babies born to mothers with HIV infection
4-26 How should HIV positive mothers feed their newborn babies?
Women with HIV infection should be carefully counselled during pregnancy so that they can decide and plan how to feed their newborn baby. They have two options:
- Exclusive breastfeeding. This means only giving breast milk and nothing else, not even water.
- Exclusive formula feeding. This means only giving milk formula.
Mixed feeding of both breast milk and formula should NOT be used as this increases the risk of HIV crossing in the breast milk to the baby.
4-27 Which mothers should exclusively breastfeed?
Exclusive breastfeeding for 6 months is the best method of feeding a newborn baby for both HIV positive and HIV negative women. The risk of HIV passing from mother to baby is very small if both are correctly taking ARVs.
The main advantages of exclusive breastfeeding are:
- The baby receives all the food needed to grow and develop normally
- The risk of diarrhoea and chest infections is much lower
- It is cheap
- There is no need for clean water, mixing formula and cleaning bottles and teats correctly
- It promotes bonding between mother and baby.
All mothers should be encouraged to practice exclusive breastfeeding.
4-28 Which mothers should consider exclusive formula feeding?
For both HIV positive and HIV negative women exclusive formula feeding should only be considered if all the following can be met:
- Adequate amounts of formula are available at local shops
- The mother can afford to buy formula
- Safe, clean water is available
- The mother is able to measure and mix formula correctly
- The mother able to sterilise bottles and teats if they are used.
Whenever possible cups rather than bottles should be used to formula feed as cups are much easier to clean properly with soap and water.
If an HIV positive mother refuses ARVs she should exclusively formula feed her baby.
4-29 When is the risk of HIV transmission increased in breastfeeding mothers?
- If the mother also gives formula or solid foods during the first 6 months
- If the mother has cracked nipples or mastitis (breast infection)
- If the mother becomes infected with HIV when she is still breastfeeding
- If the mother and baby are not taking ARVs correctly
- If anyone other than the mother gives their own breast milk to the baby
When using ARVs the risk of HIV transmission with exclusive breastfeeding is very small.
Supporting HIV positive mothers
4-30 How can community health workers play a role in reducing the rate of HIV among women in the community?
Community health workers can prevent the spread of HIV in the community, reduce the number of deaths from HIV and improve the health of women. Community health workers can:
- Educate the community about HIV
- Make sure that every woman in the community knows her HIV status
- Encourage both HIV positive and HIV negative women to practice safer sex
- Make sure that all HIV positive women are on ARVs and are taking their medication correctly
- Encourage a healthy lifestyle with good nutrition and avoiding alcohol, cigarettes and illegal drugs
- Help women disclose their HIV status to their partners or a family member
- Help avoid HIV stigma in the community
- Promote family planning.
4-31 How can community health workers support pregnant women and young mothers with HIV?
- Encourage all pregnant women to book early for antenatal care.
- Ensure that they are screened for HIV at their first antenatal visit.
- Many women only know their HIV status for the first time during pregnancy. Therefore this is an important opportunity to educate all women on the dangers of HIV and how to protect themselves by practising safer sex.
- If a woman is HIV positive her partner should also be screened for HIV.
- Check that all HIV positive mothers are taking ARVs correctly and are attending the clinic regularly. This enables many well HIV positive women to start ARVs early so that they can remain well and not die when their children are young.
- Make sure that woman deliver at a clinic or hospital. If a mother delivers at home, she and her baby must be taken to the nearest clinic immediately.
- Check that all HIV exposed babies start on neviraoine for 6 weeks after birth.
- Support all mothers to exclusively breastfeed for 6 months. Encorage family members and friends to also support breastfeeding mothers.
- Help HIV positive mothers give ARVs to their babies correctly.
- Check that all infants born to HIV positive mothers have an PCR test at birth, 10 weeks old and 6 weeks after the last breast feed and are closely followed up at clinic with an adult rapid test at 18 months.
- Help mothers with HIV infected babies give ARVs to their babies correctly.
Community healthcare workers have an important role to play in supporting HIV positive mothers.
Case study 1
A young, unmarried woman, who is pregnant for the first time, books for antenatal care at 20 weeks after her last menstrual period. When screened for HIV she is found to be HIV positive.
1. What test is used to screen pregnant women for HIV infection?
The rapid HIV test for HIV antibodies is used to screen adults for HIV infection. This simple test can be done at the health facility on a small sample of blood. The result is available within 30 minutes.
2. Should pregnant women start antenatal care at 20 weeks gestation?
No. All pregnant women should book early for antenatal care and be screened for HIV before 12 weeks after their last normal menstrual period. This allows for the early diagnosis and management of HIV which prevents HIV crossing from the mother to her unborn baby.
3. Can a woman be infected with HIV and be clinically well?
Yes. Many people in the early stages of HIV infection are clinically well and may not even know they are infected with HIV. Only after a few years of HIV infection will the person become ill (now called HIV disease) if they are not taking ARVs. HIV disease is called AIDS when they become severely ill.
4. How does HIV infection cause illness?
HIV infection damages the immune system. As a result the number of CD4 cells in the blood drops and the person becomes at risk for a wide range of serious infections such as tuberculosis (TB).
5. How is HIV infection usually spread between adults?
By unprotected sexual intercourse. Women are at higher risk than men for infection with HIV.
6. How can the spread of HIV between adults be prevented?
By practising safer sex. This includes abstaining from sexual intercourse, being faithful to one HIV negative partner and using condoms correctly. If HIV positive people take ARVs correctly the risk of spreading HIV is greatly reduced.
Case study 2
A 32 year old mother of two children books for antenatal care at 12 weeks of gestation. She knows that both she and her husband are HIV positive. She is clinically well and not on ARVs (antiretroviral treatment) as her CD4 count is still normal.
1. Should this woman be started on antiretroviral treatment?
Yes. All pregnant women who are HIV positive must be started on ARVs even if they are clinically well with a normal CD4 count. They must continue taking ARVs for life.
2. Which antiretroviral treatment is usually used for pregnant women?
A once a day fixed dose combination (FDC) tablet which contains 3 different ARVs. The tablet should be taken every the evening before going to bed.
3. What are the benefits of antiretroviral treatment in pregnancy?
It keeps the mother well and also prevents the spread of HIV to her unborn baby and newborn baby. It will also help prevent spreading HIV to her partner or partners.
4. When can HIV spread from mother to child?
HIV may cross from the mother to her baby during pregnancy, delivery and while breastfeeding.
5. What is the risk of mother-to-child infection?
Without the correct management with ARVs, the risk of HIV transmission from a mother who has a vaginal delivery and breastfeeds her baby is about 25%. However with correct management with ARVs the risk of transmission from mother to baby is very small and can be less than 1%.
Case study 3
A woman in her last three months of pregnancy has been on ARVs since she was found to be HIV positive early in her pregnancy. When attending an antenatal visit she tells the Community Healthcare Worker that she plans to formula feed her baby as her mother says that breastfeeding is dangerous if one is HIV positive.
1. Should HIV positive women breastfeed?
Yes. If ARVs are taken correctly by mother and baby the risk of HIV crossing in the breast milk is very small. Therefore both HIV positive and HIV negative women should be encouraged to exclusively breastfeed for 6 months.
2. What factors may increase the risk of HIV transmission while breastfeeding?
- If they practice mixed instead of exclusive breastfeeding
- If they have cracked nipples or mastitis
- If they become infected with HIV during the time that they are still breastfeeding
- If mother and baby are not receiving ARVs correctly
3. What medication is usually given to HIV exposed newborn babies?
From birth the baby should receive a daily dose of nevirapine drops (an ARV). This should be continued until 6 weeks of age.
4. How should HIV exposed babies be screened for HIV infection?
If the mother is HIV positive, a PCR screening test should be done at birth and again at 10 weeks when the baby attends a clinic for immunisation. If the test is positive the baby has been infected with HIV and must be started on ARVs immediately. If the test is negative the baby has not been infected with HIV during pregnancy and delivery. The test must be repeated 6 weeks after the last breastfeed.
5. How can a Community Health Worker support an HIV positive mother?
- Encourage all pregnant women to book early for antenatal care so that they can be screened for HIV at their first antenatal visit.
- Educate all pregnant women on the dangers of HIV and how to protect themselves by practising safer sex.
- Check that all HIV positive mothers are taking ARVs correctly and are attending the antenatal clinic regularly.
- Check that all HIV exposed babies start on nevirapine after birth and help mothers to give their babies daily nevirapine correctly for 6 weeks.
- Support all mothers to exclusively breastfeed for 6 months.