1. MANAGEMENT OF THE HIV POSITIVE MOTHER AND PREVENTION OF
MOTHER-TO-CHILD TRANSMISSION OF HIV / PREGNANCY AND ARV
1.1 Counselling and Voluntary testing for HIV in pregnant women.
The effectiveness of a program for the reduction of parent to child transmission of
HIV infection depends on the mother’s HIV status being known so that she can
receive antiretroviral therapy and counseling regarding infant feeding and other
important issues. With the availability of ARV, the woman herself also potentially
derives benefit from knowing her HIV status as, if positive, she can enter the
program of monitoring and when necessary, receive ARV.
Since the start of the MTCT pilot program in South Africa, testing rates have
varied widely between different centers. A recent study has shown that provinces
where all women receive individual pre-test counseling before making a decision
regarding HIV testing have a much higher HIV test uptake rate than provinces
where women receive group information and then may choose to have individual
counseling().
1.1.1 Counselling and voluntary testing.
All women attending antenatal clinic must receive individual counseling about
HIV testing before making a decision regarding the test. Group information may
be provided but should not replace individual pre-test counseling. Pre-test
counseling is not optional – it is a standard part of management for each woman
attending antenatal clinic, just as blood pressure measurement is. Counselling
should be performed in a private room by lay counselors who have been trained
for this purpose. All women need to give consent before undergoing HIV testing.
Couples testing is to be strongly encouraged, with the couple receiving their pretest counseling together and making the decision about HIV testing together.
Provisions need to be made for partner testing at antenatal clinics. Couples
testing may be facilitated by offering antenatal clinic services at times when men
may more easily attend clinic with their wife/partner, eg in the evenings or
weekends.
For all individuals agreeing to HIV testing, the test is to be done on site with rapid
testing. For positive tests a second rapid test is performed. For negative tests,
no further HIV testing is performed.
If women leave the clinic before being
informed of their HIV test result, some will not return to that clinic to receive the
result, thus missing the potential benefit which can be provided to themselves
and their infants. In order to avoid this situation, all women should be strongly
advised to receive their result at the same visit. HIV test results should never be
given telephonically. Women must be post test counselled after receiving the
result of their HIV test. For HIV negative women this will be a brief session
aimed at behaviour modification to reduce risk of HIV infection. For HIV positive
women, post test counseling is not confined to the session after receiving their
result - conselling and support is ongoing, and is particularly important for
adherence to therapy.
1.1.2 Counsellors
The quality of counselling can be improved by strengthening the system. More
lay counsellors need to be trained and employed in antenatal clinics. Existing
counselors should receive regular refresher courses and a mechanism of
psychological support for counselors needs to be put in place.
A standard
remuneration structure for lay counselors should be established and the
remuneration process needs to be streamlined.
1.2 ARV IN PREGNANCY AND POSTPARTUM / HIV POSITIVE PREGNANT
WOMEN
The seroprevalence of HIV infection amongst women in the reproductive age
group is variable by province throughout the country, and has only been
established amongst the ante-natal attendees in sentinel site surveys. The
comprehensive operational plan for HIV/AIDS care, treatment and management
should ensure that
i)
the great majority of the population who are currently not infected with
HIV remain uninfected;
ii)
that
availability and access to post exposure prophylaxis (PEP) for
women who suffer sexual violence must be improved.
iii)
widespread coverage of contraception and family planning services, such
that pregnancies occuring in HIV infected women should be planned, and
not accidental,
iv)
women diagnosed of HIV infection during early pregnancy should be
offered the option of termination of pregnancy, (access to and
the
availability of such services should be improved),
v)
enhanced efforts in the prophylaxis and treatment of opportunistic
infections, improved nutrition and lifestyle choices be put into place
vi)
effective management by suitable palliative and terminal care of those
HIV infected individuals who have developed AIDS defining illness and
where treatment has run its course.
1.2.1 Care of Pregnant Women
Further significant reductions in mother-to-child transmission can be made by
strengthening the provision of the package of prenatal HIV counseling and
testing in antenatal structures, ensuring that appropriate measures are taken
predelivery, during labour and the immediate post delivery and by improving
access to infant formula feeds. In making available appropriate ARV regimen as
indicated by the clinical condition of the women should be instituted.
1.2.2 General Measures
i)
Offer VCT and detailed information about testing and results and the
options in respect of these to all women at point of first contact.
ii)
Provide detailed information on safe sexual practices, early presentation in
circumstances of medical and obstetric problems to all women.
iii)
Ensure universal precautions against vertical transmission during
pregnancy, labour, delivery of the baby and in the puerperium.
iv)
Encourage contraception, in particular the access and availability of
barrier methods. Women particularly those above 35 years and parity 5 or
more, should be fully informed about tubal ligation.
v)
Ensure screening for STI’s (always do a RPR and in those with a history
of vaginal discharge or who have a discharge present on speculum
examination, take microbiology and treat syndromically) a Pap smear.
vi)
Encourage adherence to iron, folic acid and multivitamin preparations, and
information about “healthy eating habits”
vii)
Perform routine antenatal blood investigations, history taking and
examination. Remember to enquire about TB in the past or positive
contact.
viii)
The offer and provision of appropriate contraception for women living with
HIV should be an integral part of their care. Contraceptive choices will
have to take into consideration the potential interactions with antiretroviral
treatment.
ix)
The prevention of new infections in women remains an important goal of
South Africa’s HIV AIDS management. Antenatal care and gynaecological
service provide and important opportunity counseling and testing, and risk
reduction education activities.
1.2.3 Principles of ARVs in Pregnancy
i)
The eligibility criteria for pregnant women to start antiretroviral treatment
should be similar to those in non-pregnant adults, but consideration should
be given to any potential effects on the fetus.
ii)
The selection of antiretroviral drugs should take into account the special
circumstances of pregnancy. Where therapy is indicated, it should
comprise of a combination of 3 drugs. In particular stavudine and
didanosine should not be used together in pregnant women, and the use
of efavirenz should be avoided in pregnancy, due to its potential to cause
fetal abnormalities. Pharmacovigilance will be essential to monitor for any
adverse events associated with the more widespread use of these drugs
in women of childbearing potential.
All pregnant women with a CD4< 200 cells/mm 3 should be started on
iii)
antiretrovirals after the first trimester. Pregnant women with CD4 counts
between 200 and 350 CD4 cells/mm3 should be strongly considered for
initiation of antiretroviral therapy after the first trimester, with therapy to be
continued for life.
iv)
Nutritional supplements, pneumonia prophylaxis (with co-trimoxazole)
and INH (isoniazide) prophylaxis against tuberculosis should be included
in the enhanced care package.
1.2.4 Evaluation of pregnant women with HIV infection
The following provide a checklist to facilitate evaluation and decision for provision
of ARV.
i)
provide standard clinical evauation - HIV disease stage
ii)
evaluate degree of immunodeficiency - CD 4 count
iii)
document history of prior or current ARV use
iv)
assess goal of ARV therapy - maternal health versus PMTCT
v)
discuss known and unknown risks and benefits of ARV in pregnancy
vi)
develop strategy for long term evaluation and management of mother
and infant
1.2.5 Specific scenarios:
1.2.5.1 Women already receiving highly active antiretroviral treatment
(HAART)
Those women who are treated with antiretroviral drugs before becoming
pregnant, should continue on their medication, even in the first trimester. A
second trimester fetal anomaly scan is usually reassuring. Where indicated,
invasive procedures such as amniocentesis may be considered. If the woman is
receiving efivarenz, this should be discontinued, and replaced with nevirapine
as part of the combination therapy. Women receiving prophylactic medication
(eg against TB, and PCP) should continue these in pregnancy Monitoring will
follow guidelines set out as for adult management. Because of viral suppression
achieved by combination therapy, there is no need for additional medication to
reduce vertical transmission during delivery.
1.2.5.2 Women not on antiretroviral therapy / antiretroviral naïve
For the majority of women who learn of their HIV status during antenatal care, a
decision has to be made whether there is maternal indication for initiation of
therapy, or antiretroviral treatment is used for the sole purpose of reducing
vertical transmission.
i)
Initiation of therapy for maternal benefit will follow the same
guidelines as for adult women who are not pregnant – CD4< /= 200
cells/mm3 or clinical stage 4 (AIDS defining illness). Same routine will be
followed as amongst adults regarding education and counselling towards
treatment readiness. (argument to start therapy at a higher CD4 during
pregnancy is not supported since CD4 tend to show a slight decline
anyway during pregnancy, and pregnant women by argument will be
started on treatment earlier than if not pregnant). Treatment should be
initiated after the end of the first trimester. In select cases where mothers
book in the first trimester with a very low CD 4 counts (<50 cells/mm3),
early initiation of treatment could be considered after discussion with the
mother.
ii)
Where reduction of vertical transmission is the goal – (in a mother
who has no clinical / laboratory indication for initiation of triple therapy),
women should be managed according to the existing programme which
includes the two dose administration of nevirapine to the mother during
labour and neonate within 72 hours. In the event that nevirapine cannot be
used, other short course regimen should be utilized.
1.2.5.3 Unbooked women:
Majority who fall in this category will not have received any medical attention in
the recent past, therefore with unknown HIV status
Women presenting unbooked for the first time during labour should receive
pretest counselling. If they test positive, baby should receive 2 doses of
nevirapine – one given immediately following delivery, and second within 48
hours. Post-test counseling to the mother can be delayed until after the delivery
process. Assessment regarding maternal indication for ARV should be made
postpartum, bearing in mind the possibility of poor compliance in women who do
not present for free antenatal care.
7.2.5.4 Delivery
All women should be delivered vaginally where possible, with caesarean section
reserved for known obstetric indications Universal precautions and modified
obstetric practices shown to reduce intrapartum transmission should be
observed. In the event of a caesarean section, prophylactic antibiotics should be
administered to reduce the risk of postpartum sepsis (there is no evidence in the
literature that the same should be implemented in women undergoing vaginal
delivery).
1.2.5.5 Post delivery
Signs of infection should be observed before discharge, and arrangement for
follow-up within the next 1 – 2 weeks made to exclude this. Women who are not
on antiretroviral therapy should be reviewed at 6 weeks for clinical staging, and
repeat CD4 count to determine indications for initiation of antiretroviral therapy,
after which they are referred to the general adult clinic
Postpartum
1. Rational for staging in 6 weeks and not earlier not clear. WHO recommends
initiation of treatment as soon as possible including the postpartum period
2. HIV-positive postpartum women with CD4 count > 350 should be followed up
according to current guidelines. Guidelines need to be developed for postpartum
women on HAART
3. Newly diagnosed women would need to be diagnosed much faster
4. Unbooked woman HIV positive with CD4 count >350 in pregnancy refer for followup
5. Consider adopting WHO follow-up schedule of 6 hours, 6 days and 6 weeks
recommended – needs to be coordinated with PMTCT follow-up schedule
6. Site for receiving HAART – easy if one site, if other sites may be a problem
Principle decision of where to look after the patients still to be taken e.g. KZN ARV
clinic currently not universal
1.3 ARV and Breastfeeding.
1.3.1 Postnatal HIV transmission
It is well known that HIV is excreted in breast milk. In breastfed infants there is
an ongoing risk of mother to child transmission of HIV via breastmilk for the
duration of breastfeeding. This is probably highest in the first 6 months but there
is an ongoing risk after six months of age of between 3.2 and 6.9 new infections
per 100 child years of breastfeeding1.
In developed countries almost all HIV
infected women formula feed their infants. In South Africa exclusive formula
feeding may not always be possible.
Women living in informal settlements and
rural areas frequently do not have adequate facilities for safe reconstitution of
formula feeds. A second consideration is the loss of the immunological benefits
of breast milk, particularly in areas where there is a high infant mortality rate from
diarrhoea and other infectious causes. The factor, however, which is probably
more important that any of those above is that of family and community
expectations and fear of stigmatization related to HIV/AIDS. Women may be
expected to at least partially breast-feed their infant and may do so despite the
risks, because of fear of revealing their HIV status.
Many women will have
discovered their HIV status for the first time during the pregnancy and may not
yet have disclosed their status to family members.
The exclusive use of formula feeding for infants of HIV positive mothers in
developed countries means that there has been very little experience of the
effect of maternal ARV on the breastfed infant and HIV transmission via
breastmilk.
1.3.2 Factors contributing to breastfeeding transmission of HIV.
i)
Maternal viral load: There is some correlation between maternal stage
of disease or viral load and breastfeeding transmission.
ii)
Mastitis: several studies have shown that mastitis significantly
increases the amount of HIV excreted in breast milk. This is also true
for other breast conditions such as cracked nipples.
iii)
Exclusive breastfeeding vs mixed feeding: One study has shown that
breastfeeding transmission of HIV is lower in women using exclusive
breastfeeding as opposed to those using mixed infant feeding. Further
studies are underway to investigate this finding.
iv)
Vitamin A deficiency:
The rate of postnatal transmission of HIV is
higher in women who are vitamin A deficient. There is no evidence,
however that vitamin A supplementation reduces transmission at any
stage.
1.3.3 Safety of ARV for breastfeeding infant
Few of the ARV have been studied in lactating women, and for many, little
information is available on breast milk excretion.
ARV
Excreted
in
breast Effects on infant
milk?
Abacavir
ddI
3TC
Excreted into milk of rats. No data on breastmilk
No human data.
exposure
Excreted into milk of rats
No data on breastmilk
No human data
exposure
Excreted
into
breastmilk
human Well
tolerated
in
neonates, but clearance
slower than that of older
children
D4T
Excreted into milk of rats. No data on breastmilk
No human data
Zidovudine
Excreted
into
breastmilk
exposure
human Well
tolerated
the
neonate
Efavirenz
No human data
Nevirapine
Excreted in to human Potential
breastmilk.
in
Median reactions,
for
but
skin
no
concentration is 76% of breastmilk
maternal serum levels.
Lopinavir/Ritonavir
exposure
data.
Excreted into milk of rats.
No human data
1.3.4 General considerations:
All HIV positive pregnant women must receive information about infant feeding
choices during the antenatal period. Each woman needs to understand what
options are available to her and what the pros and cons of each option would be.
She then needs to make an informed choice of infant feeding method best suited
to her own circumstances.
Factors to be taken into account are:

Whether she is currently on ARV

What the stage of her HIV disease is

Her socioeconomic circumstances and ability to obtain (for at least
the first 9 months of the infant’s live) an adequate supply of formula
milk

Her access to facilities to reconstitute the milk safely.

She also needs to consider whether the expectations of her partner
or family are likely to impact on her ability to use a chosen method.
If disclosure has not yet taken place, she must be encouraged to
disclose to a trusted family member who will also be able to support
her in maintaining her chosen feeding method.
1.3.5 Options and important factors to consider:
1.3.5.1 Exclusive formula feeding.
The woman needs to be able to obtain infant formula for at least the first 6
months of the infant’s life. In addition she must have access to facilities for safe
reconstitution of the formula, including a source of clean water and facilities for
the sterilization of bottles.
Unicef and the National Department of Health
recommend cup feeding instead of bottles with teats. Healthcare workers need
to ensure that the woman knows how to make up the infant feeds before
discharge home after delivery. The impact of family expectations need to be
taken into account and if there are likely to be questions as to why the woman is
not breastfeeding, she should decide beforehand what she will tell her
family/friends.
Where a woman has chosen to formula feed, healthcare workers need to assist
her and support her with strategies to enable her to continue using the method.
1.3.5.2 Exclusive breastfeeding with or without early weaning.
The concept of exclusive breastfeeding needs to be understood by the mother –
the infant is to receive only breastmilk and no other food or fluids (not even
water). The only other substances which the infant may consume by mouth are
medicines.
The woman needs to be counseled regarding good breastfeeding techniques and
methods to maintain adequate production of breastmilk.
Weaning should
preferably take place at 3 or 4 months of age and must occur abruptly with no
period of mixed feeding. If early weaning is to take place, the woman needs to
be able to obtain suitable infant foods.
Other factors to be considered are
whether there will be family or community expectations for the infant to receive
additional foods which are traditionally given, and how the mother will deal with
these expectations.
1.3.5.3 Wet Nursing
The HIV status of the wet-nurse needs to be considered as well as the fact that
even if she is HIV negative initially, it is possible for her to become infected
during the period of wet-nursing and HIV seroconversion while breastfeeding is
associated with rates of transmission to the infant as high as 29%. The response
of the family and community to such an arrangement also needs to be
considered.
1.3.5.4 Heat treatment of expressed breast milk
Pasteurisation of expressed breast milk has been shown to effectively inactivate
HIV in the milk. The method has been effectively implemented in an institutional
setting for the feeding of preterm neonates born to HIV positive mothers. The
feasibility of use of the method in a domestic setting after discharge from hospital
has not yet been assessed and for this reason, the method cannot yet be
recommended as an option on a wide scale.
HIV positive women who choose to breastfeed, whether using ARV or not should
be advised and assisted with a number of general measures which can affect
breastmilk transmission;
i)
Maternal nutrition – Advice should be given on nutrition and where
necessary additional nutrition supplied. The mother should be on a
multivitamin supplement which includes vitamin A.
ii)
Protected sex – the mother should continue to use condoms in order
not to unnecessarily increase her viral load by repeated re-exposure.
iii)
Breast-care – correct breastfeeding technique to avoid mastitis or
damaged nipples.
If a breast problem arises, it is to be treated
promptly and do not feed from affected breast until the problem has
resolved.
1.3.5.5 Antiretroviral use during lactation
i)
Scenario 1: Woman who is on ARV for her own health

For the woman who meets the eligibility criteria for ARV therapy, this
should be commenced whether during pregnancy or in the postpartum
period.

After delivery, the woman should be on the regimen which is the best for
her health.

Infant feeding should be changed to suit the woman’s ARV needs and not
the other way around. Maternal survival influences infant survival, thus
maternal ARV is beneficial to the infant.

Because the effect on infants of breast-milk exposure to ARV is not
known, the general recommendation is that women on ARV should
formula feed if possible.
Concerns for the infant would be side effects
from breast milk consumption of ARV, drug interactions between ARV and
other medications which the infant may receive, and transmission of
resistant virus to the infant if mother has treatment failure. There is no
data on what the effect of low doses of ARV will have on infants that have
been infected perinatally – there is a theoretical possibility that it could
lead to resistance, thereby making ARV therapy ineffective for the child.

The woman on ARV should be advised to use exclusive formula feeding
where possible.

If breastfeeding is not avoidable, the infant should be assessed at each
visit for possible side effects of the ARV.

Where medication is prescribed to the infant, care needs to be taken to
review whether there is a known interaction between the medication and
any of the ARV to which he/she is exposed.
ii)
Scenario 2: ARV for reduction of postnatal MTCT.
ARV to infants during breast feeding to reduce breastfeeding transmission
Studies of ARV as post exposure prophylaxis to infants up to six weeks of life
indicate some reduction in perinatal transmission.
Data on the effect of
continuing courses of ARV for the duration of breastfeeding are very limited. The
potential adverse effects of ARV on the infant need to be considered as well as
the effect it will have on the child’s options for treatment, should he or she
become infected despite ARV prophylaxis. In the absence of any evidence of
clear benefit and concerns about safety, there is currently no indication for the
administration of ARV to infants to reduce postnatal transmission of HIV. This
recommendation will be reviewed as further information becomes available.
iii)
ARV to mothers during breastfeeding to reduce breastfeeding
transmission
Theoretically the use of ARV by mothers during breastfeeding will reduce
breastfeeding transmission by reducing maternal viral load, but there is no
clinical evidence to support this.
Use of ARV for the purpose of reducing
breastfeeding transmission may affect the effectiveness of ARV therapy for the
mother later. If breastfeeding transmission occurs despite ARV therapy, there is
a risk of transmission of resistant virus to infant.
ARV also have potentially
serious side effects for mother, and adherence may be particularly difficult when
the therapy is not directly benefiting the woman. There is no place for ARV
administration
to
the
mother
solely
for
reducing
breastfeeding
transmission.
1.4 HIV and TB in Pregnancy
Globally tuberculosis is the most important opportunistic infection complicating
HIV.1 Among communicable diseases, tuberculosis is the second leading cause
of death worldwide, killing nearly 2 million people each year 2 It is the leading
cause of death in HIV-infected individuals.3
1.4.1 Interaction between HIV, TB and Pregnancy
In the general population the interaction between TB and HIV infection is bidirectional. HIV is the most potent known risk factor for the reactivation of latent
TB.4 HIV also increases the risk of developing symptomatic primary TB infection.
The patient’s defense against the progression of TB infection to active disease is
compromised proportional to the degree of immunosuppression related to HIV. 5
With immunosuppression, the clinical and radiological features of TB may be
altered. These include a delayed hypersensitivity response resulting in falsenegative tuberculin skin tests. There is also more involvement of extrapulmonary
sites of TB disease in these infected with HIV especially if the CD4 + cell count is
very low.
On the other hand, there is also evidence that TB affects the course of HIV
infection by enhancing its replication, which, in turn, results in a higher risk of
other opportunistic infections other than TB.
The lifetime risk of developing TB in HIV-negative individuals is 5-10%, and 50%
in HIV-infected individuals6. In other words, an individual infected with HIV has
10 times increased risk of developing TB compared to an individual who is not
infected with HIV.
The outcome of pregnancy is not altered in pregnant women on anti-tuberculosis
drugs. Maternal TB and HIV coinfection increases the risk of the baby acquiring
congenital TB infection. It has been presumed in the past that congenital TB was
rare, however, there is now evidence suggesting that congenital or newborn TB
is an underestimated emergent disease. 7,8,9 The caseload of culture confirmed
cases of TB in neonates and young infants increase by about two-fold when the
pregnant mother is infected by both HIV and TB
1.4.2 Diagnosis of TB in pregnancy
TB attributable to HIV in pregnancy is about 70%, which is very high.10 In those
areas where the prevalence of TB and HIV are high, efforts to improve maternal
health must include detection of TB in pregnancy. However, the diagnosis of TB
in pregnancy is usually difficult and delayed. 11 This is because the symptoms
may be confused with pregnancy symptoms by both the patient and the health
care worker. It may also be due to the fact that extra-pulmonary TB is more
common in HIV-infected individuals, both pregnant and non-pregnant ones.
Diagnosis of TB, according to the NTCP guidelines, should be confirmed by
microscopic examination of sputa. When the sputum is smear positive, it
suggests that the patient has an infectious TB and should be started on anti-TB
therapy without delay.
1.4.3 Treatment of TB in HIV-infected Pregnancy woman
The use of anti-TB drugs and anti-retrovirals in pregnancy is complicated by the
drug-drug interactions between these two groups of drugs as well as their
potential teratogenicty. The following clinical management issues should be
considered:
Efavirenz, (EFZ) an antiretroviral drug, is contraindicated in pregnancy,
especially during the first trimester, because of its potential for birth defects of the
Streptomycin, an anti-TB drug is contraindicated in pregnancy because it can
cause permanent deafness to the unborn baby
Nevirapine (NVP) and Rifampicin should not be used together, because
rifampicin is a potent inducer of liver enzymes (cytochrome P450 3A4) These
enzymes reduce the expose to NVP by 31% and unfortunately dose adjustments
for NVP coadministered with Rifampicin have not been established.
There is also a concern about the hepatotoxicity of both the NVP and anti-TB
drugs when used together.
Nevirapine, therefore, is not used in patients receiving a rifampicin
-based anti-TB regimen.
TB treatment with DOTS should be initiated immediately in a pregnant woman,
irrespective of whether she is on antiretroviral or not.
If a pregnant woman receives both the anti-TB treatment as well as antiretroviral,
all drugs should be reviewed for potential drug interactions and safety in
pregnancy.
The WHO recommended first line regimen for a pregnant woman receiving both
anti-TB drugs as well as antiretroviral is (AZT or d4T) + 3TC + SQV
1.4.4 Scenarios
1.4.4.1 Patients who become pregnant while on TB treatment
Not receiving ARV’s and not eligible for them
Must complete TB therapy like non- HIV infected patients
Monitor patient and start ARV’s when indicated
Monitor patient and start ARV’s when indicated
1.4.4.2 Not receiving ARV’s but eligible
Must complete TB therapy
Start ARV’s using the recommended regimen. Prevention of MTCT must be
taken into consideration when choosing a regimen.
Consider all drugs used for their safety in pregnancy and for drug-interactions
1.4.4.3 Receiving ARV’s
Review all medication (TB and HIV) for potential drug interactions and
teratogenicity and manage accordingly
1.4.5 New TB cases during pregnancy
1.4.5.1 No ARV’s and not eligible for ARV’s
Start TB therapy immediately
Follow the NTCP protocol (DOTS)
1.4.5.1 No ARV’s, but eligible
Start TB therapy immediately
Follow NTCP protocol (DOTS)
If CD4 count <50 or if there is extrapulmonary TB, start ARV’s as soon as patient
tolerates TB therapy
If CD4 count 50-200, start ARV’s after two months
1.4.5.2 On ARV’s
Patient must continue using ARV’s, but must start TB therapy immediately.
Review patient’s HIV treatment. If a patient is on nevirapine, change to SQV
provided there is no contraindication.
Follow NTCP protocol (DOTS)
1.4.6 Patient requiring re-treatment (failure, relapse or return after default)
1.4.6.1 No ARV’s and not eligible for ARV’s
Start TB therapy immediately (Retreatment option)
Streptomycin must not be used in pregnancy
Follow the NTCP protocol (DOTS)
1.4.6.2 No ARV’s, but eligible
Start TB therapy immediately (Retreatment option)
Follow NTCP protocol (DOTS)
Start ARV’s as soon as patient tolerates TB therapy
Streptomycin must not be used in pregnancy
1.4.6.3 On ARV’s
Patient must continue using ARV’s, but must start TB therapy immediately.
Review patient’s HIV treatment. If a patient is on nevirapine, change to SQV
provided there is no contraindication.
Follow NTCP protocol (DOTS) for retreatment
Streptomycin must not be used in pregnancy
1.4.7 Multi-Drug Resistance TB (MDR-TB) in Pregnancy
MDR-TB refers to TB, which is resistant to at least INH and Rifampicin. Currently
the cure rate of MDR-TB patients is less than 50% in the general population in
our country. Treating all TB patients adequately with appropriate TB regimens
can prevent resistance.
Suspect MDR-TB when:
Retreatment patients remain sputum smear positive after three months of
therapy
Close contacts of MDR-TB cases
Treatment failure and interruption cases
Diagnosis can only be done by TB culture and susceptibility testing
1.4.7.1 Treatment
Treat according to guidelines for management of MDR-TB patients in SA. It must
be based on the medication history as well as susceptibility results.
1.4.8 Latent TB
Latent TB or infection with M.Tuberculosis without an active disease. Because of
the high incidence of progression of latent TB to active TB in HIV-infected
individuals, WHO recommends preventive therapy for latent TB with INH.
Currently the preventive therapy is not given widely as part of the NTCP.
1.7
ETHICS
GUIDELINES:
PREGNANT
HIV
INFECTED
PATIENTS
REQUIRING EMERGENCY MEDICAL AND / OR SURGICAL INTERVENTIONS
It is important to bear in mind that with HIV disease, the unpredictable and
episodic course of the illness makes it difficult to estimate exact prognosis.
However, when treating these women, the clinician must be able to recognise the
point at which quality of life is more important than quantity and hence change
the course of treatment from aggressive curative care to palliative management.
The availability of antiretrovirals must not be allowed to obscure this point and
interfere with sound medical judgement. This has particular bearing in poorly
resourced settings where acute emergency situations are common and
antiretroviral treatments scarce or not available. Moreover, currently, there is no
conclusive evidence that the initiation of antiretroviral treatment during an acute
emergency results in an improvement in the course of recovery from the
emergency. Accordingly, at present antiretroviral treatment should not be
commenced during an acute emergency. However, this does not preclude
institution of antiretroviral treatment where appropriate once the patient recovers
from the emergency. All health care provision must take into consideration the
principles of respect for persons, acting in the best interests of the patient,
minimising harm and fair and justified treatment. Health professionals are
reminded that although HIV / AIDS is incurable at present, it is considered a
chronic condition which is manageable despite being life-threatening.
These guidelines are specific to the critically ill HIV infected patient requiring
emergency medical and / or surgical care. The scope does not extend to cover
the asymptomatic patient who requires a caesarean section as standard obstetric
management.
1.7.1 Definitions:
i)
Emergency: a sudden catastrophe calling for immediate treatment that is
necessary and available to avert harm.
ii)
Terminal illness: an illness, injury, or other physical or mental condition
that-
(a) in reasonable medical judgement, will inevitably cause the death of the
patient concerned; or
(b) causes a persistent and irreversible vegetative condition with the result
that no meaningful existence is possible for the patient
The diagnosis of terminal illness must be made by at least two health
professionals.
ii)
iv)
Terminal state: has a corresponding meaning as terminal illness.
Intractable and unbearable illness: an illness, injury or other physical or
mental condition, but excluding terminal illness, that-
(a) offers no reasonable prospect of being cured; and
(b) causes severe physical or mental suffering of a nature and degree not
reasonable of being endured
v)
Palliative care: treatment and care with the object of relieving physical,
emotional and psychosocial suffering, in addition to providing basic needs.
1.7.2 GUIDELINES
i)

All decisions regarding medical and surgical procedures will have to
satisfy the ethical and legal requirements of informed consent and the
medical criteria with regards to the patient’s ability to withstand medical or
surgical interventions

Health professionals managing these pregnant women are reminded that
the pregnant women’s life is of paramount importance and takes
precedence over that of the fetus.

Any deviations from standard management should only occur if
determined to be in the patient’s best interests.
ii)
Symptomatic HIV+ patient requiring emergency care where CD4 count is
available –

Where the condition is not terminal, proceed with standard, appropriate
management for the particular emergency.

Where the patient has terminal disease, palliative care should be
instituted as first-line treatment.

Where condition is perceived to be, but not conclusive of terminal
disease, institute resuscitation. If, in reasonable medical judgement,
there is no response, a diagnosis of terminal disease should be made,
and the management should be changed to palliative care.

Where the condition is intractable and unbearable, proceed with
management as in bullet 3 above.
iii)
Symptomatic HIV+ patient requiring emergency care where CD4 count is
not available –

Institute resuscitation.

Perform standard blood tests including CD4 counts. Manage according
to section 1 once blood results available.
(The HPCSA cautions HCWs that HIV diagnosis without further
examination such as CD4 and viral load, provides no information about
prognosis and actual state of health and unilateral decisions not to
resuscitate these patients could result in disciplinary action. It therefore
follows that withholding or withdrawing of treatment should only occur
once a definitive diagnosis of terminal disease is made.)
iv)
Where the patient is not in a position to make an informed decision and
proxy consent is unavailable, the health professional should institute
emergency management in accordance to the institution’s management
procedures. The following criteria must be satisfied where treatment is
initiated without informed consent:
v)

There is a real emergency;

The patient is unable to communicate;

The treatment is not against the patient’s prior wishes; and

The treatment is in the best interests of the patient.
Any decision regarding peri-mortem delivery will have to take into
consideration the patient’s prior wishes or be made in consultation with the
patient’s family. The decision will be made by a health professional after
consultation with a colleague. This applies only for the perimortem
delivery in an emergency situation.
vi)
For further advice on the ethical issues pertaining to the management of
the HIV infected patient from a woman’s health perspective, contact the
National Department of Health at this number ……… .
ANNEXURES
SCHEMA 1: PT ON ARV
ARV + Pregnancy
Review medication - if 3TC, d4T, NVP , change d4T and
Add AZT
- do baseline CD4
- monitor as per adult protocol
Term: - do viral loads
- delivery - according to obstetric indications
Postdelivery - watch for sepsis
- contraception
-
-
baby - if maternal viral load was
>1000 at term- give NVP (2mg / kg body weight within 24 to 72 hrs)
- continue same regimen until 6
weeks, and consider changing to Std adult therapy at 6 weeks
SCHEMA 2 = ARV naïve (Tshidi c
-
VCT - (-)ve - posttest counselling, promote condom use, screen for STI's,
contraception including condoms postdelivery
-
(+)ve
- CD 4 count, clinical staging, pap, screen for STI's,
supplements(iron, folate and MVT)
>200
stages 1 / 2
<200
stages 3 or 4
ARV (3TC, NVP, AZT)
NVP at 28 weeks
baseline FBC, LFT and U&E
PCP proph(bactrim),
exclude TB, and if -ve, INH proph
monitor FBC, LFT, U&E monthly
CD4 and viral loads at 3 or 6
months
Viral loads at term
Delivery - NVD
delivery - NVD,
Modified obs practices
modified obs practices
C/s for obstetric reasons
C/s for obst indications, with
with proph antibiotics
proph antibiotics
Baby=NVP within 48-72 hrs
- baby - if maternal viral at
to 72 hrs)
term >1000, give NVP syrup (2mg/kg within 24
*because of slight decline of CD4 in pregnancy, these to be repeated in all
women postdelivery, esp those not on ARV
SCHEMA 3; patient received single dose NVP in previous pregnancy (,12
months)
Take blood for resistance testing
No resistance
Resistance
Stage 1/2, CD4 >200
CD 4 >200
Stages 1/2
NVP
AZT/ 3TC
CD4 <200
stages 3/4
HAART- substitute
NVP
For rotinavir
Monitor as usual