Managing HIV-Positive Pregnant Mothers Narendra Malhotra, Jaideep Malhotra, Nidhi Gupta, Bharti Malhotra
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IntroductionCHAPTER 1

Nidhi Gupta
Bharti Malhotra
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HIV IN PREGNANCY
  • Most of the thirty-three million people living with HIV are in the developing world.
  • The prevalence of HIV infection in women is now increasing at a rate faster than men.
  • HIV infection is no longer confined to drug users, blood recipients and homosexuals.
  • More than 70% of all the HIV infections are a result of heterosexual transmission.
  • Over 90% of infection in children result from mother to child transmission.
  • Almost, 600,000 children are infected annually (1,600 each day).
  • Thus, women and children form more than 50% of HIV-infected individuals and this has formed a global health crisis.
  • So, maternity facilities have several responsibilities:
    1. To enable the women to be tested.
    2. To reduce mother-to-child transmission and
    3. To train the staff and provide the necessary equip­ment to prevent infection.
 
VIROLOGY
 
Discovery
Acquired Immunodeficiency Syndrome (AIDS) is a pandemic disease caused by human immunodeficiency virus (HIV). AIDS was first recognised in the United States in 1981, when the US Center for Disease Control and Prevention reported the unexplained occurrence 3of Pneumocystis carinii pneumonia and Kaposi’s sarcoma in few previously healthy homosexual men in New York and Los Angeles. In 1983, Luc Montaigner and his colleagues discovered the virus and named it lymphadenopathy-associated virus (LAV). In 1984, Robert Gallo and coworkers of the National Institute of Health, USA reported the same virus but called it human T-lymphocyte virus III. In 1985, a sensitive enzyme-linked immunosorbent assay (ELISA) was developed for HIV infection and the International Committee on Virus nomenclature named the virus “human immunodeficiency virus (HIV)”.
 
The Virus
  • HIV is a class of Retrovirus belonging to Lentivirinae family. It is an enveloped RNA virus is isosahedral shaped and 120 mm in size (Figs 1.1A and 1.1B).
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Fig. 1.1B: HIV structure
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Fig. 1.1B: Structure of HIV virus with antigen structure
  • Comprises of an outer lipid bilayer enveloped with uniformly arranged 72 knobs (gp120 and gp41).
  • Inside there is a protein core surrounding 2 copies of RNA.
  • 5 Core contains viral enzymes essential for viral replication and maturation.
  • It is a thermolabile virus, killed in 10 minutes, at 60ºC and in seconds at 100ºC.
  • Readily inactivated by chemical germicides like 0.5-1% sodium hypochlorite, 70% ethanol, 2% glutaral­dehyde, acetone and ether.
  • Relatively, resistant to ionizing radiation.
 
Antigenic Variation
HIV-1 is the most common, causing majority of HIV infections worldwide. It is subdivided into groups; M (10 subtypes), O (9 subtypes) and N, based on sequence analysis for their gag and env genes.
HIV-2 is subdivided into 5 subtypes.
 
EPIDEMIOLOGY OF HIV/AIDS
 
Global Status (Table 1.1) Indian Scenario
  • First few cases of HIV in India were detected in 1986 in Chennai and parts of Tamil Nadu.
  • First AIDS case was detected in Mumbai in 1987.
  • As on 30th December 2003, 57, 781 AIDS cases were reported to NACO.
  • Out of 1,200 new infections estimated in our country, 200 are children.
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Table 1.1   Global Status
No. of people HIV in 2004
Newly infected HIV in 2004
AIDS deaths in 2004
Total
39.4 million
4.9 million
3.1 million
Adults
37.2 million
4.3 million
2.6 million
Women
17.6 million
—
—
Children
2.2 million
640,000
510,000
  • With a prevalence of HIV of around 1% in antenatal mothers—25,000 children may be born/year with HIV infection (Table 1.2).
 
Trends in India
  • HIV infection is spreading from high-risk behaviour groups to general population, from urban to rural areas.
Table 1.2   HIV prevalence in India
High
Moderate
Low
(HIV present in > 1% of antenatal women)
(HIV present in < 1% of antenatal women;> 5% of high risk persons)
(HIV present in < 1% of antenatal women; < 5% of high risk persons)
  • Maharashtra
  • Tamil Nadu
  • Karnataka
  • Andhra Pradesh
  • Manipur
  • Gujarat
  • Goa
  • Kerala
  • West Bengal
  • Nagaland
  • Remaining states
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  • Males account for 78.5% of AIDS cases, female 1.5% ((ratio 3 : 1), but more women are being infected now.
  • The major opportunistic infection in AIDS patient is tuberculosis (65%).
  • The major presenting signs and symptoms in AIDS are:
    • Weight loss (89%)
    • Fever (88%)
    • Diarrhoea (86%).
 
Epidemiological Factors
 
Agent
  • HIV as described above.
 
Reservoir of Infection
  • Cases and carriers
  • More infectious in window period
  • Once infected, virus remains in the body life long
  • Risk of developing AIDS increases with time.
 
Source of Infection
  1. Greatest concentration in:
    • Blood
    • Semen
    • CSF
  2. Lower concentration in:
    • Tears
    • Saliva
    • 8 Milk
    • Urine and vaginal secretion.
 
Host Factors
  1. Age
    • Maximum cases occur in sexually active persons aged 20 to 49 years.
    • Children < 15 years account for < 3% of the cases.
  2. Race
    • More common in black race.
  3. High-risk group
    • Population receiving blood, e.g. haemophilics
    • IV drug abusers
    • Promiscuous behaviour
    • Clients of STDs
    • Homosexuality
    • Social unacceptability of condoms in certain population.
  4. Economic status
    • Low literacy
    • Urbanisation and migration of people to cities away from homes.
    • Occupation, e.g. truck drivers.
 
SUSCEPTIBILITY OF WOMEN TO HIV INFECTION
Women in the developing world are at higher risk of HIV infection than their male counterparts for a number of reasons—biological and sociocultural.
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Biological Factors
The rate of transmission of HIV from male to female is two to three times higher than that from female to male due to the following reasons:
  • The Langerhans’ cells of the cervix may provide a portal of entry for HIV and it has been suggested that some HIV serotypes may have higher affinity for these, and therefore to be more efficient in heterosexual transmission.
  • Vulval and vaginal inflammation or ulceration may facilitate entry of the virus.
  • Inadequately treated STD or “silent” disease may be a major factor in facilitating HIV infection.
  • Chlamydial infection and other sexually trans­mitted diseases may act as co-factors for trans­mission.
 
Sociocultural Factors
Women are often blamed incorrectly as the source of HIV infection and carry the dual burden of infection and of caring for infected family members. This is due to:
  • Gender inequalities
  • Poverty
  • Less access to education
  • Lack of employment opportunities force many women into commercial sex work in order to survive.
  • 10Usually, women are monogamous, but are at high risk due to the sexual behaviour of their male partner.
  • Traditional practices and customs such as “dry sex” practices, vaginal douching with non-antiseptic compounds, female circumcision and “widow cleansing”.
  • Cultural practices and pressures often prevent women from taking the necessary precautions to guard against infection.
  • Use of male condoms is low in many developing countries.
  • The desire and the societal pressure to reproduce make it difficult for women to practice protected sex.
  • There are no methods available for women to use to prevent HIV transmission, independent of the male partner, with the possible exception of the female condom.
  • Female barrier methods remain expensive or unavailable in most developing countries.
 
MODE OF HIV TRANSMISSION (Table 1.3)
 
Sexual Intercourse
  • Unprotected acts of sexual penetration.
  • Both homosexuals and heterosexuals carry risk of HIV transmission.
  • “Receptive” partners are at greater risk than “Insertive” partners.
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Table 1.3   Efficiency of different routes of HIV transmission and their contribution to total number of cases
Exposure route
Percent efficiency (World over)
Percentage (World over)
of total (India)
Blood transfusion
90-95
5
7.05
Perinatal
20-40
10
Sexual intercourse
0.1 to 1
75
74.15
(heterosexuals)
0.58 (homosexuals)
i. Vaginal
(60)
ii. Anal
(15)
Injecting drugs use
0.5-1.0
10
7.3
Needle stick exposure
< 0.5
0.1
0
Others
10.92
 
Blood Borne
HIV infected:
  • Blood/blood products
  • Transplanted tissue/organs.
 
Mother-to-Child Transmission
Can occur:
  • Before, during or after birth of the child.
 
PATHOGENESIS (Figs 1.2 and 1.3A)
Hallmark of HIV disease is a profound immunodeficiency resulting primarily from a progressive quantitative and 12qualitative deficiency of the subset of T lymphocytes referred to as helper T cells or inducer T cells.
The sequence of events whereby HIV-1 infects a CD4 cell is (Fig. 1.3B):
 
Course of HIV Infection [(Figs 1.4A and B) Table 1.4]
Three patterns are seen:
  1. Typical progression with a median survival time of 10 years (80-90% of patients)
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    Fig. 1.2: Life cycle of HIV
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    Fig. 1.3A: Pathogenesis of HIV. HIV causes lytic and latent infec­tion of CD4 lymphocytes, whereas the virus causes persistent (pro­ductive) infection of the cells of monocyte/macrophage line­age and disrupts neurons
  2. Rapid progression with a survival time of 3 to 4 years (5-10% of patients)
  3. Non-progressers (5% of patients) (Fig. 1.4).
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Fig. 1.3B:
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Fig. 1.3B: The sequence of events whereby 
HIV-1 infects a CD4 cell
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Fig. 1.4A: The course of HIV infection
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Fig. 1.4B: The course and stages of HIV infection
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Table 1.4   Natural history of HIV infection in adults
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