Women, HIV and PMTCT

Unit 11
HIV Care and ART:
A Course for Physicians

Learning Objectives
Part 1: Women and HIV
List womens risk factors for HIV and identify
strategies to reduce risk
Identify gynecological conditions associated with
HIV in women
Describe gender differences in ARV treatment

Learning Objectives
Part 2: HIV and PMTCT
List the factors that affect HIV transmission
during pregnancy, labor, delivery and
breastfeeding
Identify how to prescribe ART appropriately for
pregnant women and exposed newborns
Describe labor, delivery and postpartum care for
HIV+ women and their infants

Part 1:
Women and HIV

Global Facts
Of 40 million people living with HIV/AIDS
worldwide, 17.5 are women (2005)
77% of all women living with HIV are in subSaharan Africa (2005)
Among HIV positive adults, women account for
57% in sub-Saharan Africa, 26% in southeast
Asia, 27% in Europe, and 25% in the US (2005)

Source: UNAIDS/WHO 2004

Source: UNAIDS/WHO 2004

Vulnerability Factors

Biological
Economic
Social
Cultural
Women are most vulnerable to HIV infection,
given the social and economic disadvantages
they face in their day to day lives.
Dr. Nafis Sadik, Executive Director of the
United Nations Population Fund
8

Gender Differences

Viral load
Disease progression
Drug pharmocokinetics
Lipodystrophy
Lactic acidosis
Contraceptives
Adherence
Gynecological issues
9

Viral Load and Disease

Progression
Women may have lower viral loads than men in
early disease
Low viral load may NOT truly reflect low risk for
progression
Women and men progress at similar rates
Gender is not significantly associated with time
to AIDS or survival time

10

Drug Pharmacokinetics
Differences in weight and body mass
Fat to muscle distribution
Concentration of enzymes needed for drug
metabolism is different
Hormonal effects
Pregnancy
Hormonal replacement therapy
Oral contraceptives

11

Lipodystrophy
Fat accumulation more common in women; fat
depletion more common in men
Accumulation and depletion in different body
areas of same person occurs equally in men and
women
Lipid abnormalities: triglyceride and cholesterol
level elevations more common in men

12

Lactic Acidosis
The FDA has received 60 reports of lactic
acidosis associated with dual nucleosides, with
55% mortality
83% in women; 50% >175lbs
Presented with nonspecific symptoms
Link between mitochondrial dysfunction and
lactic acidosis?
Occurs in women with high CD4
13

Contraception and ART

Because Efavirenz is contraindicated during
pregnancy, dual methods of contraception are
highly recommended for sexually active EFV
users: barriers plus
Progestins (Depo-Provera)
IUCD

Nelfinavir, Nevirapine and Ritonavir

Associated with decreased levels of ethinyl estradiol,
resulting in decreased contraceptive effectiveness
Do not combine
14

Contraception and ART (2)

NNRTIs and PIs interfere with blood levels of
combination oral contraceptives
Additional barrier methods are recommended to
prevent pregnancy and transmission of HIV and
STIs

15

Women and Adherence

Adherence issues are more complicated for
women who need special attention and support:
Often dont disclose HIV status due to stigma
May feel isolated
Caregivers
Challenges in accessing and maintaining care include
child care, transportation, inexperienced providers,
etc.

16

Optimal Adherence for Women

Evaluate for mental health, substance abuse
and other adherence interruptus problems
Assess HAART readiness
Develop a mutually agreeable HAART regimen
specific to her lifestyle
Prepare for side effects
Encourage atmosphere of communication and
trust
Be accessible and available
17

Gynecological Issues
Conditions causing inflammation or infection increase
the likelihood a woman will acquire or transmit HIV
Bacterial vaginosis
Cervicitis
Herpes ulcers
Genital warts
Condyloma

Recurrent candidiasis
Prevalent in 25-30% of women with HIV
Risk increases 20-fold with CD4<100

HPV genital warts associated with increased incidence

of cervical cancer
18

Care for HIV+ Women

Regular gynecologic care
Pap smear (yearly and as needed)
Detects cervical dysplasia (human papillomavirus)
and sexually transmitted diseases
Untreated HIV disease is associated with increased
risk of cervical abnormalities

Reproductive counseling

19

Care for HIV+ Women

Desiring Pregnancy
Give accurate information on MTCT
Maintain good health and nutrition status
Provide ARVs to eligible women, or consider
delaying until after the first trimester

20

Ongoing Care for Women with

HIV Infection
Psychological support
Social support
Medical support
Nutritional advice
Prophylaxis of TB, PCP, malaria, other infections
Physical examination that includes gynecologic exam
and cervical smears

21

Treatment Guidelines for

Women
Guidelines are the same for women and men
Women and men have similar responses to
initial ART
Because many women weigh less than men, it is
important to monitor for toxicity

22

Part 2:
HIV, Pregnancy and
Preventing Maternal to Child
Transmission

Introduction
HIV is a family infection
Mothers and fathers have an impact on
transmission of HIV to the baby
There is increased chance of transmission to the
baby when a woman becomes infected with HIV
when she is pregnant or breastfeeding
Partners should have safer sex throughout
pregnancy and while breastfeeding

24

Pregnancy Outcome: Goals

Uncomplicated pregnancy
Healthy, uninfected infant
Healthy mother who has not compromised her
future options for HIV therapy

25

HIV and Pregnancy

Pregnancy does not
accelerate the
progression of HIV
disease to AIDS
Patients with AIDS
are more likely to
suffer from
pregnancy-related
complications
26

Effect of Advanced HIV on

Pregnancy
Decreased fertility
Spontaneous abortion
Infections (opportunistic, GU, postpartum, postsurgical)
Preterm labor
Premature rupture of membranes
Low birth weight babies
Stillbirths
27

Current Status of Mother-to-Child

Transmission
Estimates of HIV transmission rates from
women to children are about 20-40%
MTCT is by far the largest source of HIV
infection in children under 15

28

Estimated Risk of MTCT

(Adapted from De Cock KM et al, 2000)
Timing

Transmission Rate
Without Any
Interventions

During pregnancy

5-10%

During labor and delivery

10-15%

During breastfeeding

5-20%

Overall without breastfeeding

15-25%

Overall with breastfeeding to six months

20-35%

Overall with breastfeeding to 18-24 months

30-45%

Note: Rates vary because of differences in population characteristics such as maternal

CD4+ cell counts, RNA viral load and duration of breastfeeding.
HIV transmission through breastfeeding: A review of available evidence. Marie Louise
Newell; endorsed by UNICEF, UNFPA, WHO, UNAIDS. 2004 (adapted from De Cock
KM et al., 2000).

29

Of 100 Babies Born to HIV- Infected

Mothers Not on Treatment
11 infected during breastfeeding
17 infected
during birth

67 not
infected*

5 infected
in utero

*without treatment for parents, most will be orphaned

30

Factors Influencing MTCT

Viral Load
The higher the viral load, the higher the risk of MTCT

Lower risk through:

Use of ART during pregnancy and postpartum to
mother and newborn
Adequate nutrition, particularly vitamin A

31

Factors Influencing MTCT (2)

Maternal factors increasing risk:
Viral or parasitic placental infection (especially
malaria)
Becoming infected with HIV during pregnancy
Severe immune deficiency
Advanced clinical and immunological state
Maternal malnutrition

32

Factors Influencing MTCT (3)

Labor and delivery factors increasing risk:
Prolonged rupture of membranes (>4 hours)
Injury to birth canal during child birth
Antepartum procedures
Acute chorioamnionitis
Invasive fetal monitoring
Instrumental delivery
Mixing of maternal and fetal body fluids
Delayed infant cleaning and eye care
Routine infant airway suctioning
33

Factors Influencing MTCT (4)

Fetal Conditions increasing risk:
Premature delivery
Low birth weight
Immature immune status
First infant in a multiple birth
Oral diseases

34

National Strategies for PMTCT

Primary prevention of HIV in childbearing
women
Prevention of unintended pregnancy in HIVpositive women
Prevention of transmission from HIV+ women to
their infants
Treatment, care and support of women infected
with HIV, their infants and their families

35

Antenatal Care
Primary prevention during pregnancy
Education about safer sex with use of condoms for
mother and father
Early treatment of STIs
Safer sex during pregnancy and lactation

Offer VCT to all pregnant women

Antenatal visits are vital opportunities for
PMTCT for both HIV-positive and HIV-negative
women
36

Initial Examination
All pregnant women
Syphilis test
Hgb
HIV counseling and consent
HIV test (rapid, if available)
Rule out active TB

If HIV positive:
Baseline TLC
CD4 and CD8 counts
CD4/CD8 ratio and all other baseline tests (CBC, LFT, etc.)
Viral load screening
37

Initial Examination (2)

Additionally, if HIV+:
Duration of known HIV+ status
Past history of HIV-related illness and HAART
WHO Staging
Status of other children, partner, and partner
disclosure and referral
Any medications taken for HIV-related illness since
beginning of pregnancy

38

Assess Maternal Psychosocial

Status

Generalities and pains

Headaches
Anxiety
General malaise

Depression
Palpitations
Insomnia
Irritability

39

Care of the HIV+ Pregnant Woman

Treatment:
OIs
STI
UTI
Vaginal candidiasis
ARV
Vitamin supplements

Prophylaxis:
Anemia
Tetanus (Toxic-TT)
Vitamin deficiency
Malaria
Pneumonia (PCP)
TB

40

PMTCT Clinical Scenarios

Six possible clinical scenarios of a pregnant
woman:
On ART and become pregnant
Pregnant and eligible for ART
Pregnant and not requiring ART
Pregnant and presenting after 34 weeks
Pregnant and presenting in labor
Woman and child presenting postpartum

41

Scenario 1: On ART and

Become Pregnant
Woman on efavirenz
Counsel about potential
teratogenicity
Stop EFV and start NVP if in
first trimester

Woman on
D4T/3TC/nevirapine

Women on ZDV/DDI/LPV/r
Continue treatment
Full blood count monthly
Monitor blood glucose levels
as appropriate

Continue treatment or change

D4T to ZDV
ALT monthly & when indicated
Monthly full blood count if on
ZDV

42

Scenario 2: Pregnant and

Eligible for ART
Begin first line therapy:
ZDV 300 mg bid or D4T 40 mg every 12 hours (or 30 mg q
12 hours if <60 kg)
and
3TC 150 mg q12 hrs
and
NVP 200 mg qd for 2 weeks, then 200 mg q12 hrs

If unable to use NVP, PI options include NFV, LPV/r or

SQV/r
ALT q 2 weeks for 1 month, then q month and then as
indicated
43

Scenario 3: Pregnant and Not

Requiring ART
Early stage HIV (WHO Stage I or II disease with
CD4 >200)
Follow the national PMTCT guidelines

44

Scenario 4: Pregnant Woman

Presenting After 34 Weeks
Defer ART
Provide PMTCT
Review need for ART after delivery

45

Scenario 5: Pregnant Woman

Presenting in Labor
NVP single dose given at the onset of labor and
post delivery to the infant or
AZT & 3TC to the mother during labor and infant
post delivery or
IV AZT (alone or with NVP) to the mother and
AZT syrup to the infant post partum for six
weeks, in addition to a single dose of Nevirapine

46

Scenario 6: Woman and Child

Presenting Post Partum
Initiate 6 week neonatal AZT protocol, preferably
within 6-12 hours of delivery or
Single dose Nevirapine plus AZT for the infant
for four weeks
Mother should be evaluated for HAART

47

Four Options for PMTCT

(Scenarios 3-5)
Nevirapine monotherapy to mother and infant
Zidovudine monotherapy to mother and infant
Nevirapine + zidovudine to mother and infant
Zidovudine + lamivudine to mother and infant

48

National PMTCT
Drug

Regimen to the Mother

Antepartum

1)
Nevirapine
2)
Zidovudine

300 mg po
BID from
36 weeks
onwards

Regimen to the Baby

Intrapartum
200 mg po at
onset of labor

^^2 mg/kg po single

dose within 72 hours
postpartum x1

300 mg po
every 3 hours

4 mg/kg BID po for 7

days beginning at 8-12
hours postpartum

600 mg at onset
of labor then
300 mg every 3
hours**

Same as above

3) Combination of zidovudine and nevirapine as above

49

National PMTCT (2)

Drug

4) Zidovudine
&

Lamivudine

Regimen to the Mother

Regimen to the
Baby

Antepartum

Intrapartum

300 mg po BID
from 36 weeks
onwards
&

600 mg po at
onset of labor,
then 300 po mg
every 3 hours
&

4 mg/kg po BID
for 7 days

150 mg po BID
from 36 weeks
onwards

150 mg at onset
of labor then 150
mg every 12
hours

2 mg/kg po BID
for 7 days, both
beginning within
72 hours
postpartum

&

50

Nevirapine Reduces Transmission

During Birth by 41%
No intervention

Single dose NVP to

mother and baby*

17 infected during birth

5 infected in utero
11 infected during BF
67 not infected

10 infected during birth*

5 infected in utero
11 infected during BF
74 not infected
Source: Adapted from Lancet 2003;362:859-68

51

Intrapartum Nevirapine
Single dose (200 mg) to mother in labor
Rapidly absorbed
May rapidly reduce mothers viral load in blood and
birth canal
NVP crosses placenta and enters baby
NVP provides prophylaxis to the baby during the birth
No side effects with single dose (hepatotoxicity or
rash)

52

Postpartum Nevirapine
Single dose (2 mg/kg, 0.2 ml/kg) to newborn 4872 hours after birth
Maintains therapeutic levels in babys bloodstream for
the first week of life
Acts as post-exposure prophylaxis
No side effects with single dose
If mother received her dose of NVP less than 2 hours
prior to delivery, give one dose of NVP to baby at birth
and a second dose at 48-72 hrs

53

Antiretroviral Resistance with

Nevirapine
Following single-dose NVP, resistance mutations
present 6 weeks postpartum in
20-30% of women
46% of infants

No longer detectable 12 months postpartum

(due to reappearance of wild type virus). Mutant
virus archived indefinitely

54

Antiretroviral Resistance with

Nevirapine (2)
Following single-dose intrapartum NVP, some
mothers have a decreased response to NVPbased HAART
Problem is the greatest if HAART is given within a few
months of single-dose NVP

Risk of NVP resistance appears greatly

increased with second maternal dose

55

Postpartum NVP levels (HPLC)

NVP (ng/ml)
250

200
150
100

50

(NVP IC50 =3-30 ng/ml)

Undetectable

10

15

Days post dose

20

Source: G. Jourdain et al. 11th CROI, San Francisco, CA, 2004. Abstract 41LB

56

3 and 6 Month Responders (50 copies/mL)

Copyright 1998 Massachusetts Medical Society. All rights reserved. Source:

Jordain et al., NEJM 2004; 351: 229-240

57

Addition of Short-course ZDV/3TC to

Single-dose NVP for MTCT Prophylaxis
Interim analysis of 61 mothers (target = 300)
with 6 weeks of resistance data
No NNRTI resistance at baseline in any group
NVP resistance at Week 6
NVP alone
60%
NVP plus combivir

10%

NVP + ZDV/3TC x 4 d
NVP + ZDV/3TC x 7 d

12.0%
10%

No 184V or NRTI resistance detected

McIntyre J, et al. XV IAC, Bangkok 2004,
#LBOrB09

58

ARV Therapy: HAART

Results in the lowest risk of transmission to the
infant (<2%)
Reduces the risk of the mother developing
resistance, thereby preserving her future
treatment options
Improves maternal immune status, improving
survival
Risks to infant appear to be minimal for most
regimens
59

Safety of NRTI Drugs in

Pregnancy
Balance between PMTCT and therapy for
mother vs. potential teratogenicity, toxicity, and
drug resistance
Human pregnancy data only for AZT, 3TC, ddI,
d4T
No increase in birth defects have been observed
NRTIs and mitochondrial toxicity: symptomatic
lactic acidosis and hepatic steatosis may have a
female preponderance
60

Safety of NRTI Drugs in

Pregnancy (2)
Fatal lactic acidosis described in pregnant
women receiving ddI/d4T along with other ART
ddI/d4T SHOULD NOT BE USED
IN PREGNANT WOMEN

61

Safety of NNRTIs in
Pregnancy
Single dose nevirapine has not been associated
with adverse side effects in women and children
Nevirapine resistance risk as above
Nevirapine elimination may be accelerated in infants
whose mother received chronic nevirapine as part of
ART. Significance?
No human pregnancy data on long term use of
NNRTIs

62

Safety of NNRTIs in
Pregnancy (2)
Efavirenz causes birth defects in exposed
newborns
Significant birth defects in 15% of newborn monkeys
Birth defects reported in newborn humans

Efavirenz should never be used in the first

trimester
Efavirenz is best avoided entirely during
pregnancy

63

Safety of PIs in Pregnancy

Studies of blood levels and safety during
pregnancy in progress for:
Indinavir
Ritonavir
Saquinavir
Nelfinavir

Studies in progress for

Lopinavir/ritonavir (Kaletra)
Amprenavir or fosamprenavir
Atazanavir
64

Combination ART and

Pregnancy Outcome
Development of typical adverse symptoms is
common
May increase risk of pre-term deliveries
Combination therapy started before pregnancy
may carry a higher risk of teratogenicity than
starting in the 2nd or 3rd trimester
Until more information is known, HIV-infected
pregnant women who are receiving a successful
combination ART regimen should continue (unless
on efavirenz or ddI/d4T)
65

Labor and Delivery Care

Labor and Delivery Care

To facilitate an opportunity for PMTCT:
Offer HIV testing for women in labor
If a woman accepts an HIV test, provide counseling
and rapid test

67

Labor and Delivery Care (2)

Critical issues during labor
Emotional support
Confidentiality
Secrecy, disclosure
Fear and concern about transmission

68

Labor and Delivery Care (3)

Do:
Use partogram
Perform vaginal cleansing
with 0.25% chlorhexidine
Follow universal precautions
to avoid occupational
exposure
Limit vaginal examinations
during labor
Treat acute chorioamnionitis
Perform early infant eye and
cord care

Dont:
Isolate
Shave pubic area
Perform routine episiotomy
Rupture membranes
Use vacuum extraction
and forceps if not indicated

69

Cesarean Section (CS)

Reduces the risk of MTCT
Not available and safe in many settings
Not routinely performed for women with HIV
infection in developing countries
Risks of morbidity associated with CS needs to
be carefully balanced with risk of MTCT

70

Postnatal Care of Mother

Routine postnatal care
Infant follow-up
Close monitoring for secondary postpartum
hemorrhage
Early recognition and treatment of infections
Continue on HAART if patient is eligible (if on
HAART while pregnant)
Commence on HAART if patient is eligible (if
HAART was not started while pregnant)
71

Postnatal Care of Mother (2)

Extra nutrition and micronutrient support
Counseling about safe disposal of infectious
soiled pads or other garments
Family planning counseling
Infant feeding counseling
Social support

72

Family Planning
Discuss family planning BEFORE discharge
Assess risk behaviors and counsel on suitable
and effective methods
Review birth control and infection control
Dual protection to prevent and reduce further HIV
infection, STIs and pregnancy
Data suggests hormonal contraception is less
effective with ARVs

Access to emergency contraception

73

Infant Follow-up Schedule

Follow-up at 6 hours, 6 days, 6 weeks, and
every 3 months
Do full reassessment, and reclassification for
HIV at each visit
Virological testing after 6 weeks
Cotrimoxazole prophylaxis to all exposed infants

74

Case Studies: PMTCT

Case 1 Introduction
A pregnant 22-year-old woman with previously
diagnosed HIV infection comes for her first
antenatal clinic visit. She is in her first trimester
of her first pregnancy. No other complaints.

76

Case 1 Questions
1. What information do you need from her history
and physical, in addition to the usual
information collected in the antenatal clinic?
2. What laboratory tests will you request?
3. What education and counseling will you provide
while you wait for the results of the laboratory
tests?

77

Answers: Case 1, Q1
1. What information do you need from her history
and physical, in addition to the usual
information collected in the antenatal clinic?
Why did she have an HIV test initially?
Has she disclosed her HIV status to anyone?
Has she had any HIV-related illness or
treatment?

78

Answers: Case 1, Q1 (2)

Do a review of HIV-related symptoms and OIs
Perform a full physical exam including
assessment for STIs
Do gynecological and obstetric evaluation
Stage the patient and decide on ART eligibility

79

Answers: Case 1, Q2
2.

What laboratory tests will you request?

Confirm or repeat HIV test
If available, measure CD4+ count and VL
RPR and other assessment for STI
Other usual antenatal testing
Other ARV-related testing if otherwise eligible
for combination ARV treatment (CBC, AST, ALT)

80

Answers: Case 1, Q3
3. What education and counseling will you provide
while you wait for the results of the laboratory
tests?
Education and counseling on safe sex
practices during pregnancy
You, or the counselor in clinic, may discuss with
her issues about disclosure of her status to her
husband/sexual partner. Ask what kind of
support she has
81

Answers: Case 1, Q3 (2)

Counsel on risk of MTCT. Explain about use of
ARVs to reduce the risk for her newborn. Explain
you will do blood tests to see if she needs ART
for her own health
Educate on adequate nutrition and prenatal care
Counseling regarding infant feeding options
should begin during antenatal care

82

Case 2 Introduction
A 29-year-old woman in her third pregnancy,
delivered a healthy 3.5 kg baby girl an hour after
she arrived at the maternity.
After the birth, she told the staff she had a
positive HIV test done in clinic, but did not take
the tablet given her before rushing to the
maternity because she did not want her family to
know about her HIV infection

83

Case 2 Questions
1. What treatment does she require now?
2. What treatment does her baby require?

84

Answers: Case 2, Q1
1. What treatment does she require now?
Treating Sara so as to reduce the risk of
intrapartum HIV transmission is no longer an
option
Sara will need a follow-up visit to assess her
immunologic status and to determine if she
needs HAART for her own health
Needs counseling on disclosure issues
Needs counseling on family planning
85

Answers: Case 2, Q2
2. What treatment does her baby require?
The infant has not had any nevirapine exposure, as
Rosa did not take nevirapine at least 2 hours prior to
delivery
The infant requires nevirapine 2 mg/kg:
First dose within 6 hours post-partum
Second dose 48-72 hours post-partum

OR NVP one dose plus AZT syrup for 6 weeks

86

Case 3 Introduction
A 21 year-old woman presents to the clinic with
pain in her mouth and chest upon swallowing.
She has had night sweats and diarrhea for one
month. Her usual weight was 58 kg
On exam she weighed 51 kg, had no palpable
lymph nodes, and had oral candidiasis. She was
diagnosed with presumed esophageal
candidiasis and treated with oral fluconazole for
3 weeks. Her pain subsided and she began to
eat
87

Case 3 Introduction (2)

Based on the esophageal candidiasis, she had
WHO Stage IV disease, although no CD4 count
was available.
She began daily cotrimoxazole for opportunistic
infection prophylaxis. She was started on first
line HAART with stavudine 30 mg bid,
lamivudine 150 mg bid, and nevirapine with the
usual dose escalation over 2 weeks.
She has been adherent with her medications.
The night sweats and diarrhea have stopped, her
appetite has increased, and she gained 6 kg
88

Case 3 Introduction (3)

At her 6-month follow-up visit she reports that
her menstrual period is 2 months late. A
pregnancy test is positive

89

Case 3 Questions
1.
2.
3.
4.

Should she continue her antiretroviral therapy?

How will you manage her intrapartum care?
How will you treat her after her delivery?
How will you treat her newborn?

90

Answers: Case 3, Q1
1. Should she continue her ART?
She is doing well on a standard ARV regimen,
which is safe in pregnancy
Does not include efavirenz or ddI+d4T

She is still in her first trimester of pregnancy, so

risks to her fetus are uncertain
Options:
Discontinue ARV until 10-12 weeks
Continue current ART

91

Answers: Case 3, Q2
2. How will you manage her intrapartum care?
Practice safe obstetric procedures
ART Option 1: (most practical)
Continue stavudine, lamivudine, nevirapine as usual

ART Option 2:
Give zidovudine, lamivudine, nevirapine at standard
doses

92

Answers: Case 3, Q2 (2)

ART Option 3
Zidovudine 600 mg loading dose by mouth followed
by 300 mg by mouth every 3 hours till delivery
Lamivudine 150 mg by mouth every 12 hours
Nevirapine 200 mg twelve hours daily as she used to
take it

93

Answers: Case 3, Q3
3. How will you treat her after her delivery?
She can resume her usual antiretroviral
combination after delivery
She should be counseled on infant feeding
There is no information so far on the effects of
maternal ART on risks of HIV transmission through
breast milk

94

Answers: Case 3, Q4
4. How will you treat her newborn?
Nevirapine syrup 2 mg/kg at 48-72 hours of life
as usual for HIV-exposed infants plus AZT syrup
for 4- 6 weeks
Infant starts cotrimoxazole at 6 weeks
Explain testing of infant at 18 months

95

Key Points
Women are more vulnerable to HIV due to
biological, economic, social, and cultural factors
Women with HIV have special gynecological
needs and concerns
Women and men with HIV progress at similar
rates; ART guidelines are not gender specific

96

Key Points (2)

All pregnant women should know their HIV
status in order to protect their children and
themselves
Women with AIDS are more likely to suffer from
pregnancy-related complications
Pregnant women who present with CD4
<200/mm3 irrespective of WHO stage should be
started on first line treatment: AZT, 3TC, NVP

97

Key Points (3)

Pregnant women should not receive efavirenz or
ddI/d4T
Effective strategies are available for reducing the
risk of MTCT
Nevirapine can reduce the risk of MTCT by 41%
Use of HAART can reduce MTCT to less than
2%

98