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1. Perinatal
Transmission
Of HIV
Nishitha A
8th Term

2. Objectives
• Introduction
• Statistics
• Factors affecting Perinatal Transmission
• Prevention
• Treatment
• PPTCT

3. Introduction
• HIV transmission from mother to child during
pregnancy, labour and delivery, or
breastfeeding is known as perinatal
transmission
• Most common route of HIV infection in
children.

4. Statistics
2.08 million living with HIV/AIDS in India (2011)
• More than 3,70,000 children were newly
infected with HIV in 20091.
• Route of infection in 9/10 HIV children - PTCT2.
• PTCT accounts for 5.4 per cent of the newly
infected cases3
• Out of 27 million annual pregnancies in India,
34,675 occur in HIV positive pregnant women.

5. Factors affecting Perinatal
Transmission
Factors
Maternal Viral Foetal Obstetrical
Breast milk
factors

6. Factors affecting Perinatal
Transmission

7. Need for Control of PTCT
Why ?
• Benefit to the Mother
• Benefit to the Child
• Benefit to the community

8. Control Of PTCT
• Prevention
• Anti-Retroviral Therapy(ART)
• Post- Exposure Prophylaxis
• Primary Health Care

9. Prevention
• Risk in non-
breastfeeding women –
15-30%
• Risk in breastfeeding
infected women- 20-
45%
• Risk with appropriate
Intervention - <2%

10. Prevention Challenges
• Lack of appropriate prenatal care & Testing Facilities
• HIV testing
• Substance abuse
• Socioeconomic issues
• Lack of awareness
• Unintended pregnancies
• Enhanced primary HIV prevention strategies for
women and girls

11. Anti-Retroviral Treatment(ART)
• From 1st January 2014, HIV+ve pregnant
women are initiated on lifelong ART
(irrespective of CD4 count and WHO clinical
Staging).
• HIV exposed babies are initiated on 6 weeks of
Syrup Nevirapine immediately after birth
• 12 weeks of Syrup Nevirapine if the duration
of the ART of mother is less than 24 weeks.

12. ART-WHO Regimen (2013)
First-Line ART
Mothers
TDF+3TC+EFV
(OD)
Infants of ART
receiving
mothers
Nevirapine
daily for 6
weeks

13. Nevirapine Prophylaxis and Dosage
Birth Weight (g) NVP daily dose(mg/kg) NVP daily dose(ml/kg)
<2000 2 0.2
2000-2500 10 1
>2500 15 1.5

14. ART-WHO Regimen (2013)
Second-line ART
( 2NRTI +1 ritonavir based PI)- daily dose
• Failure of TDF+3TC, use AZT+3TC as NRTI
backbone
• Failure of AZT, use TDF+3TC as NRTI backbone
• PI – FDC of ATV/r & LPV/r Key:
TDF- Tenofovir
3TC- Lamivudine
AZT- Zidovudine
ATV/r- Atazanavir+Ritonavir
LPV/r- Lopinavir+ Ritonavir

15. Monitoring ART response
• Viral Load – recommended to monitor
response and diagnose treatment failure
• Other ways to monitor efficacy:
1. Clinical improvement
2. Increase in Total Lymphocyte Count
3. Improvement in biological markers of HIV
(CD4 & viral load)

16. Breastfeeding In HIV-mothers
• Replacement Feeding (Infant formula
milk) should be ideally given-
EARLIER concept
• Exclusive Breastfeeding for first 6
months and continue till 12 months
of age and mother on regular ART
and infant on exposure prophylaxis.
[WHO recommendation]

17. Model on Safe Breastfeeding
Mother On
lifelong ART
Infant on
exposure
Prophylaxis
Education-
Breastfeeding
advantages

18. Immunization
• HIV exposed children / infected but
asymptomatic – ALL standard vaccines (UIP
schedule)
• HIV infected with symptoms /immune
suppression – ALL standard vaccines except
BCG, OPV and Varicella

19. Post-Exposure Prophylaxis
• Should be initiated ideally within 72 hours
• In infants who are exposed to HIV infection
either during delivery , breast-feeding
• Consists of :
1. Preferred ART regimen: AZT+3TC
2. Counselling & Risk Assessment
3. HIV testing & counselling
4. Support & follow-up

20. Co-Trimoxazole Prophylaxis
Lifelong ART if positive in the second testing also
If positive – Repeat testing through whole blood sample
Tested for HIV DNA PCR by DBS (Dry Blood Spot)
Exposed baby initiated on Co-trimoxazole prophylaxis at 6 weeks

21. Co-trimoxazole Prophylaxis and
Dosage
Birth Weight (g) Syrup (ml)
(40mg TMP/200mg SMX)
Dispersible Tablet
(20mg TMP/100mg SMX)
<5 2.5 1 tablet
5-10 5 2 tablets
10-15 7.5 3 tablets
15-22 10 4 tablets

22. PPTCT
• PPTCT – Prevention of Parent to Child Transmission
• National Programme (2002)
• Aims:
1. To offer HIV testing to every pregnant woman in India- 100%
Coverage
2. To prevent the perinatal transmission of HIV .
• It works toward achievement of global target of “Elimination
of new HIV infections among children” by 2015.

23. PPTCT Essential Services
• Routine HIV counselling & testing to all
pregnant women
• Family-Centric Approach
• Provision of lifelong ART
• Provision of institutional delivery facilities
• Provision of nutrition, psychosocial support
• Provision of ARV prophylaxis
• Provision of support of initiating breastfeeding

24. PPTCT
• Estimated that around 35,000 HIV-positive pregnant women
needed PPTCT services in 2015.
• The PPTCT services cover about 37% annual estimated
pregnancies in the country.
• In the year 2013-14, nearly 10 million pregnant women
accessed this service. Of these, 12008 pregnant women were
HIV positive.

25. References
1. www.naco.gov.in
2. www.who.int
3. www.googleimages.com
4. www.unaids.org
5. Park’s Textbook of Preventive & Social
medicine- 23rd edition
6. OP Ghai Essential Paediatrics – 8th edition