SUMANDEEP COLLEGE OF

NURSING
SUBJECT:- OBSTETRICS AND GYNAECOLOGY NURSING
TOPIC:- seminar on HIV/AIDS

SUBMITTED TO:BY:-

SUBMITTED

MS. RITA THAPA

TIGGA

ROJLIN

ASSO. PROFESSOR
M.Sc
SCON, VADODARA
SCON, VADODARA

2nd YEAR

AIDS(ACQUIRED IMMUNO DEFICIENCY SYNDROME)

INTRODUCTION
Indias first known HIV infection was diagnosed in a female sex worker in Chennai in
February 1986. It is highly probable that HIV had been circulating for some years before that,
since screening during 1986-87 found as many as 3%-4% of sex workers infected in Vellore
and Madurai, and 1% of STD patients infected in Mumbai. As there were already over 20,000
cases in the world before any case was identified in India, screening for HIV infections began
in India in 1985, almost as soon as tests for the HIV antibody were available. In India, too,
for the first time in 2006, HIV testing was a part of the National Family Health Survey
(NFHS).
DEFINITION
Acquired
immune
deficiency
syndrome or acquired
immunodeficiency
syndrome (AIDS) is a disease of the human immune system caused by the human
immunodeficiency virus (HIV)
HIV POSITIVE MOTHER AND HER BABY
Women who are infected with HIV are at risk of passing the infection on to their babies.
Approximately 25% of all babies born to HIV-positive pregnant women are infected with the
virus. HIV can be transmitted from an HIV-positive woman to her child either during
pregnancy, or during labour and delivery, or by breast-feeding. In Europe and the USA, about
15 to 20%of babies born to HIV-positive women who are not taking anti-HIV drugs are
infected. In most cases, HIV is thought to be transmitted during the last weeks of pregnancy
or during delivery.
However, the risks of mother-to-child transmission of HIV can be
reduced to below 1% by the appropriate use of anti-HIV drugs during pregnancy and labour;
by having a caesarean delivery if you have a detectable viral load; and (when safe alternatives
are available) by not breastfeeding. In 2010, a study showed that there were no cases of
mother-to-child transmission when guidelines to prevent this were properly followed.
EPIDEMIOLOGY OF AIDS IN INDIA
*

In India there is an estimated 2-5 million people infected with HIV in India today. The most
rapid and well-documented spread of infection has occurred in Bombay and the State of
Tamil Nadu.

In Bombay, HIV prevalence has reached 50% in sex workers, 36% in STD patients, and
2.5% in women seen in antenatal clinics.
* The infection affects both urban and rural areas.
*

In Bombay, seroprevalence rose from 2-3% in patients seen in STD clinics in 1990 to 36% in
1994 and in rural areas 3-4% of some populations have an STD.

In India, there are an estimated 1-2 million cases of tuberculosis every year. TB is the most
prevalent form of POI (opportunistic infection) in over 60% of AIDS cases. In Bombay
alone, 10% of the patients with TB are HIV-positive.

The epidemiology of HIV infections and AIDS is quite different in children (diagnosed
when younger than 13 year of age). About 1% of all AIDS cases occur in population and the
vast majority (about 90% results from vertical transmission of virus from infected motler to
the fetus or newborn.

Mother To Infant Transmission Mother to infant vertical transmission is the major cause of
pediatric AIDS. Three routes are involved in utero, by transplacental spread intrapartum,
during delivery and via ingestion of HIV contaminated breast milk. Of these the
transplacental and intrapartum routes account for most cases. Vertical transmission rates
world side vary from 25% . Vertical transmission rates world side vary from 25% to 35%
with a 15% to 25% rate reported in the United States, higher rates of infection occur with
high maternal viral load and or the presence of presumably by increasing placental
accumulation of inflammatory cells.
NATIONAL FAMILY HEALTH SURVEY-III
According to NFHS-II figures, India had an estimated 2.5 million people (range 2 and 3.1
million) between the ages of 15 and 49 years living with HIV in 2006 less than half the
previous years estimate of more than 5 million. The countrys adult HIV prevalence is
halved as well, and is now estimated to be approximately 0.36%. HIV prevalence among
adult women is 0.29%; for men it is 0.43%. This puts India behind South Africa and Nigeria
in numbers living with HIV.

HIV prevalence was highest among women whose spouses were employed in the transport
industry. In Manipur and Nagaland, HIV prevalence was the highest among women whose
spouses were industry/factory workers.

In 2006, HIV prevalence among mothers attending antenatal clinics is more than 1% in 118
districts. Eighty-one districts have an HIV prevalence of more than 5% in one or more of the
high risk groups.

The HIV epidemic in the north-eastern states of Manipur, Mizoram and Nagaland continues
unabated. In 2006, HIV seropositivity among pregnant women was 1.39%, 1.36% and 0.94%

in Manipur, Nagaland and Mizoram respectively. In addition, HIV prevalence among sex
workers appears to be increasing in Nagaland and Mizoram.
* Further, there has been a rise in HIV prevalence in the northern and eastern regions: 26
districts -- mostly in Madhya Pradesh, Uttar Pradesh, West Bengal, Orissa, Rajasthan and
Bihar are high prevalence districts. In West Bengal, prevalence has gone up from 0.21% in
2005, to 0.30% in 2006. In some districts of West Bengal high HIV transmission is seen
among sex workers and IDUs. Among migrants at one site in Orissa, HIV prevalence was
5%. In Rajasthan, HIV prevalence has gone from 0.12% in 2005 to 0.17% in 2006.
*

Karnataka: HIV prevalence at antenatal clinics in Karnataka has been over 1% for some
years. A 2005-2006 survey found that 0.69% of the general population was infected. The
average HIV prevalence among female sex workers in Karnataka was 18% in 2005.
HIV SCREENING IN PREGNANCY
In many countries across the world, women are tested for HIV during pregnancy. There are a
number of important reasons for this:

HIV infection can be passed on to a baby during pregnancy, labour and delivery,
and breastfeeding.
In areas where antiretroviral therapy is available, a pregnant woman can receive these
drugs if she tests HIV positive during pregnancy.
For many women, especially in resource-poor areas, pregnancy will be the only time
in their young adult lives when they access healthcare services on a regular basis. It
therefore presents an excellent opportunity not only to screen for HIV, but also to
educate and advise about the dangers of the virus.

RECOMMENDATIONS
1.

2.
3.
4.
5.
6.

All pregnant women should be offered HIV screening with appropriate counselling. This
testing must be voluntary. Screening should be considered a standard of care, although
women must be informed of the policy, its risks and benefits, and the right of refusal. Women
must not be tested without their knowledge.
Pre-test counselling and the patients decision about testing should be documented in the
patients chart.
Women who decline screening should still have concerns discussed and should continue to
receive optimum antenatal care.
Women should be offered HIV screening at their first prenatal visit.
Women who test negative for HIV and continue to engage in high-risk behaviour should be
retested in each trimester.
Women with no prenatal care and unknown HIV status should be offered testing when
admitted to hospital for labour and delivery. Women at high risk for HIV and with unknown
status should be offered HIV prophylaxis in labour, and HIV prophylaxis should be given to
the infant post partum.

7.

Women who test positive for HIV should be followed by practitioners who are
knowledgeable in the care of HIV-positive women.
HIGH-RISK BEHAVIOURS
Sharing needles or any other components during intravenous drug use
Unprotected sex with multiple partners
Unprotected sex with a known HIV-positive individual
Unprotected sex with a partner who is from an HIV-endemic area.
Unprotected sex with a partner participating in known high-risk behaviour
HIV TESTHIV tests are usually performed on venous blood. Many laboratories use fourth
generation screening tests which detect anti-HIV antibody (IgG and IgM) and the HIV p24
antigen. The detection of HIV antibody or antigen in a patient previously known to be
negative is evidence of HIV infection. Individuals whose first specimen indicates evidence of
HIV infection will have a repeat test on a second blood sample to confirm the results.
The window period (the time between initial infection and the development of
detectable antibodies against the infection) can vary since it can take 36 months to
seroconvert and to test positive. Detection of the virus using polymerase chain reaction (PCR)
during the window period is possible, and evidence suggests that an infection may often be
detected earlier than when using a fourth generation EIA screening test.
Positive results obtained by PCR are confirmed by antibody tests.[ Routinely used
HIV tests for infection in neonates and infants (ie, patients younger than 2 years), born to
HIV-positive mothers, have no value because of the presence of maternal antibody to HIV in
the child's blood. HIV infection can only be diagnosed by PCR, testing for HIV pro-viral
DNA in the children's lymphocytes
LABORATORY TEST FOR DIAGNOSING AND TRACKING HIV AND ASSESSING
IMMUNE STATUS

TESTS
ELISA(enzyme
assay)

linked

FINDINGS IN HIV INFECTION

immunosorbant Antibodies are detected, resulting in positive

results and making the end of the window
period.
WESTERN BLOT
Detects antibodies to HIV; used to confirm
ELISA
VIRAL LOAD
Measures HIV RNA in the plasma
CD4-CD8 RATIO
These are lymphocytes; HIV kills CD4 cells,
which results in a significant impaired immune
system.
ELISA AND WESTERN BLOT TEST

Blood samples are tested with two different blood test to determine the presence of antibodies
to HIV.ELISA identifies antibodies against HIV. The western blot test is used to confirm
seropositivity when the ELISA is positive. People whose blood contain antibodies for HIV
are seropositive. Saliva can also be tested using the ELISA antibody test.
VIRAL LOAD TESTS
It measures plasma HIV RNA level. Currently these test are used to track viral load and
response to treatment to HIV infection.HIV culture or quantitative plasma culture and
plasma viremia are additional test that measure viral burden but they are used infrequently.
The lower the viral load, the longer the time to AIDS diagnosis and the longer the survival
time.

PARENT TO CHILD TRANSMISSION

Without interventions the risk of MTCT is 25-40% . The change of PMCTC to PPTCT is to
involve the father in the prevention of transmission of HIV infection to the child
Combination interventions can reduce MTCT rate by up to 40% in breastfeeding populations
Because ARV prophylaxis alone does not treat the mothers infection, ongoing care and
support is needed. MCH services can act as an entry point to the range of services that can
provide care and support to the HIV-positive women and affected family members. Linkages
to community services can provide enhanced care and support. An important component of
the Indian governments AIDS control programme.
o Parent-to-child transmission (PTCT) of HIV, or perinatal transmission, accounts for
2.72 percent of the total HIV infection load in the country.(India)
o Parent-To Child Transmission (PTCT) of HIV can occur during pregnancy, at the time
of delivery or through breastfeeding.
o If an HIV positive woman becomes pregnant, there is a 25-30% chance that the baby
will also be infected.
Rationale for PPTCT in India
27 million pregnancies per year
1,62,000 infected pregnancies
Cohort of 48,600 infected newborns per year
0.6% prevalence
30% transmission
Most of these children die within 2-5 years
The Terminology of HIV/AIDS
MTCT mother-to-child transmission
PMTCT prevention of MTCT
PTCT parent-to-child transmission
PPTCT prevention of PTCT
PLWHA people living with HIV/AIDS
Estimated MTCT Rates
Without intervention
During pregnancy 5 - 10%
During labour and delivery 15- 20 %
During breastfeeding 5 - 15%
Total 25 - 45%

Elements of the PPTCT programme:

Primary prevention of HIV infection in young people & women of child bearing age
through promotion and provision of free, subsidized or commercially marketed
condoms, provide diagnosis for treatment of sexually transmitted diseases, and
behaviour change communication efforts to reduce behaviour that place individuals at
risk, and information about risks of PTCT during pregnancy, delivery, breastfeeding
& encouragement to see VCT counselor or health provider for information on how to
prevent HIV/AIDS among infants & young children.

Prevention of unintended pregnancies in HIV positive women through reproductive

health services, which include family planning.

Prevention of transmission from an HIV positive women to her infant through antiretroviral (ARV) prophylaxis and safer delivery practices

Care and support services to HIV-infected women who are enrolled with the
programme and to their children and families, including counselling on infant feeding.

Comprehensive PPTCT services include 4 prongs:

Prong 1 Primary prevention of HIV infection

Prong 2 Prevention of unintended pregnancies among HIV-infected women
Prong 3 Prevention of HIV transmission from HIV-infected women to their infants.
Prong 4 Provision of care and support to HIV-infected women, their infants, and their
families

PPTCT: Interventions to Decrease Risk of HIV Transmission to Infant

During pregnancy

Decrease viral load (ARV prophylaxis and treatment)

Monitor and treat infections
Support optimal nutrition

PPTCT: Interventions to Decrease Risk During labour and delivery

Avoid

Premature rupture of membranes

Invasive delivery techniques
Unresolved infections such as STIs

Provide
Elective caesarean section when safe and feasible
PPTCT: Interventions to Decrease Risk
Promote safer infant feeding
Replacement feeding

Exclusive breastfeeding for limited time

Avoidance of mixed feeding
Reporting breast problems
Support for optimal nutrition

For parents-to-be . . . the ABCs

A = Abstinence
B = Be faithful to one HIV-uninfected partner
C = Condoms use consistently and correctly
PROPHYLAXIS
MEDICAL TREATMENT
Effective treatment would require both the destruction or inactivation of the virus in the
body and the restimulation of the immunesystem.
ANTIVIRAL AGENTS
HIV contains enzyme ,reverse transcriptase, which is necessary for viral replication.
COMMON MEDICATIONS
DRUG

ACTIONS

INTERVENTIONS

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTis)

Zidovudine
Nucleoside analog, Prevents
(AZT,
ZOV) the initial step in which HIV
Retrovir
turns its RNA into DNA and
integrates itself into human
genes. Drugs acts as decoy
preventing the replication of
HIV

Didanosine
(ddl) Videx

Monitor for bone marrow suppression

anemia or neutropenia
Monitor for GI intolerance, headache,
insomia, asthemia.
Monitor for drug effectiveness
Teach patients/significant other regarding
drug dose schedule,a nd possible adverse
effects.

Nucleoside analog. Prevents Monitor for drug associated pancreatitis,

the replications of HIV
peripheral neuropathy nausea, diarrhea.
Monitor CD4 cell counts for drug
effectiveness Teach patient significant other
regarding drug dose schedule and possible
adverse effects.

Zalcitabine
(ddc) Hivid

Nucleoside analog. Prevents

replication of HIV

Monitor
for
peripheral
neuropathy,
stomatitis.
Monitor for drug effectiveness.
Teach patient/significant other regarding
drug dose schedule, and possible adverse
effects.

Stavudine (d4T) Nucleoside analog. Prevents Monitor for peripheral neuropathy

Zerit
replication of HIV.
Monitor for drug effectives.
Teach patient/significant other regarding
drug dose schedule and possible adverse
effects.
Lamivudine
(3TC) Epivir

Nucleoside analog. Prevents Minimal toxicity noted.

replication of HIV
Monitor for drug effectiveness.
Teach patient significant other regarding
drug dose schedule and possible adverse
effects.

NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIs)

Nevirapine
Viramune

Blocks HIV replication by Monitor for rash.

protecting non HIV infected Monitor drug effectiveness.
cells
Drug interactions rifampin, rifabutin, oral
contraceptives protease inhibitors .

Delavirudine
Rescriptor

Blocks HIV replications

DRUG

ACTIONS

PROTEASE INHIBITORS

Monitor for rash

Do not administer within 1 hour of antacids.
Drug interactions : terfenadine, astemizole
alprazolam midazolam, cisapride, rifabutin,
rifampin.
Drugs that decrease drug effectiveness
phenytoin, carbamazepine Phenobarbital.
Increases drug levels of calrithromycin,
dapsone.
Rifabutin
ergot
alkaloids,
dihydropyrides
quinidine,
warfarin,
indinaviro, saquinavir.
INTERVENTIONS

Indinavir
Crixivan

Protease inhibitors interfere

with the step of HIV replication
in which the virus makes the
long protein chains necessary to
reproduce itself from DNA. The
long protein chains must be cut
by a protease enzyme in order
to turn the proteins into the
correct length to create HIV.
Protease inhibitors interfere
with this step of the process,
rendering
the
virus
non
infections. The defective viruses
are not able to infect or destroy
immune cells.

Monitor CD4 cells and viral load for

drugs effectiveness.
Teach patient/significant other about
drug dose, schedule, and potential side
effects.
Monitor
for nephrolithiasis, GI
intolerance headache, asthenia, blurred
vision, dizziness, rash, metallic taste,
thrombocytopenia.
Drug
interactions
rifampin
terfenadine,
astemizole
cisapride
triazolam,
ergot
alkaloids
ketoconazole rifabutin, midazolam.

Ritonavir Norvir

Protease inhibitor

Saquinavir
Invirase

Protease inhibitor

Monitor CD4 cells and viral load for

drug effectiveness
Teach patient/significant other about
drug dose, schedule, and potential side
effects.
Monitor for GI intolerance nausea,
vomiting diarrhea.
Must be kept refrigerated
Drug
interactions,
meperidine
piroxicam,
flecainde
quinidine
rifampin,
bepridil,
terfenadine
cisapride
bupropion,
clozapine,
diazepam,
alprazolam,
dihydroergotamine, ergotamine.
Monitor CD4 cells and viral load for
drug effectiveness
Teach patient significant other about
drug dose, schedule and potential side
effects.
Monitor for GI intolerance nausea,
diarrhea,
headache,
elevated
transaminase enzymes.
Drug interactions rifampin , rifabutin
astemizole, terfenadine, cisapride.

Nelfinavir
Viracept

Protease inhibitor

Monitor for diarrhea.

Monitor CD4 celsl and viral load for
drug effectiveness.
Teach patient significant other about
drug dose, schedule and potential side
effects.
Drug
interactions
rifampin,
astemiozole terfenadine, cisapride,
midazolam, triazolam.

Risks and Benefits of Early Antiretroviral Therapy for the Asymptomatic HIV
infected Person
POTENTIAL BENEFITS
Potential reduction of viral load
Control of viral replication and mutation
Prevention of progressive immunodeficiency
Delayed progression from HIV infection to AIDS
Decreased risk of resistance
Decreased risk of drug toxicity
POTENTIAL RISKS
Reduction in quality of life from side effects of drug therapy
Earlier development of drug resistance
Limited choice of antiretroviral agents for future use
Risk of dissemination of drug resistant virus
Unknown long term toxicity
Unknown duration of drug effectiveness.
IMMUNOSUPPRESANT THERAPY
HIV infects some but certainly not all T4-nhelper cells.When these cells are
stimulated,infected T4 helper cells may provoke an autoimmune disease.Each time T4helper
cells are stimulated,there is a further autoimmune destruction of both infected and noninfected T4 cells.Immunosuppressive drugs ,such as cyclosporine A are being investigated as
one means of controlling this possible autoimmune mechanism.
IMMUNE STIMULATION OR RECONSTRUCTION
As the primary defect in patients with HIV related illness is a depressed immne
system,investigators have explored the role of immunostimulants such as interleukin2 and
interferone.As they stimulate T4 helper cells ,viral replication and disease progression is
accelerated.
A VACCINE AGAINST HIV INFECTION
Researchers in the USA have recently been successful in inserting one of the genes
from HIV into the Vaccinia virus .When the altered vaccinia virus is injected into mice and

rhesus monkeys , they produce antibodies against the outer envelope of HIV without
developing AIDS.Approaches using recombinant DNA anti- idiotype antibodies and
immunostimulating complexes are also being explored.The chief difficulty in producing a
vaccine against HIV is that this retrovirus shows markedantigenic drift.
Postexposure Prophylaxis
For Health Care Providers
If you sustain a needle stick injury take the following actions immediately
Wash the area with soap and water.
Alert your supervisor and initiate the injury reporting system used in the setting.
Identify the source patient, who may need to be rested for HIV, hepatitis, B an
Hepatitis C. (state laws will determine if written informed consent must be obtained
from the source patient prior to his or her testing.
Report to the employee health services the emergency department or other designated
treatment facility
Give consent for baseline testing for HIV, hepatitis B and Hepatitis C.
Get post exposure prophylaxis for HIV in accordance with CDC guidelines. Start
the prophylaxis medications within 2 hours after exposure . Make sure that you are
being monitored for symptoms of toxicity. Practice safer sex until follow up testing
is complete.
Follow up with post exposure testing at 6 weeks, 3 months and 6 months and
perhaps 1 year.
Document the exposure in detail for your own records as well as for the employer.

STANDARD SAFETY PRECAUTIONS

The following guidelines were developed to prevent the transmission of infection during
patient care for all patients, regardless of known or unknown infectious status.
Hand Washing/Hand Hygiene
Wash hands/perform hand hygiene after touching blood body fluids, secretions,
excretions, and contaminated items whether or not gloves are worn

Wash hands perform hand hygiene immediately gloves are removed, between
patient contacts and when other wise indicated to avoid transfer of microorganisms
to other patient or environments.

Wash hand/perform hand hygiene between tasks and procedures on the same patient
to prevent cross contamination of different body sites.

Use a plain (non antimicrobial) soap or alcohol base hand rub for routine hand
washing.

Use an antimicrobial agent or waterless antiseptic agent for specific circumstances

(control of outbreaks or hyperendemic infections)

Gloves
Wear clean, nonsterile gloves when touching blood, body fluids secretions,
excretions, and contaminated items.

Put on clean gloves just before touching mucous membranes and nonintact skin

Change gloves between tasks and procedures on the same patient after contact with
materials that may contain a high concentration of microorganisms.

Remove gloves promptly after use, before touching noncontraminated items and
environmental surfaces, and before going to another patient.

Wash hands/perform hand hygiene immediately after removing gloves.

Mask, Eye Protection, Face Shield

Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes,
and mouth during procedures and patient care activities that are likely to generate splashers
or sprays of blood, body fluids secretions, or excretions.

Gown
Wear a clear nonsterile, gown to protect skin and prevent soiling of clothing during
procedures and patient care activities that are likely to generate splashers or sprays of
blood body fluids secretions or secretions .

Select a gown that is appropriate for the activity and amount of fluid likely to be
encountered.

Remove a soiled as promptly as possible and wash hands/perform hand hygiene to

prevent he transfer of microorganisms to other patients or environments.

Patient Care Equipment

Handle used patient care equipment soiled with blood, body fluids, secretions and
excretions in a manner that prevents skin and mucous membrane exposures,
contamination of clothing and transfer of microorganisms to other patients and
environments.

Ensure that reusable equipment is not used for the care of another patient until has
been cleaned and reprocessed appropriately.

Ensure that single use items are discarded properly.

Environmental Control
Ensure that the hospital has adequate procedures for the routine care, cleaning and
disinfection of environmental surfaces, beds, bed rails, bedside equipment and other
frequently touched surfaces.

Ensure that procedures are being followed.

Linen
Handle transport, and process used linen soiled with blood body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposure and
contamination of clothing and that avoids transfer of microorganisms to other patients and
environments.
Occupational Health and Bloodborne Pathogens
Take care to prevent injuries when using needles scalpels and other sharp instruments
or devices. When handling sharp instruments after procedures. When cleaning used
instruments. When disposing of used needles.

Never recap used needles or otherwise manipulate them by using both hands or use
any technique that involves directing the point of the needle toward any part of the
body.
Use either a one handed scoop technique or a mechanical device designed for
holding the needle sheath.

Do not remove used needles from disposable syringes by hand and do not bend
break otherwise manipulate used needles by hand.

Place used disposable syringes and needles, scalpel blades, and other sharp items in
a appropriate puncture resistant containers as close as practical to the area in which
the items were used.

Place reusable syringes and needles in a puncture resistant container for transport to
the reprocessing area.

Use mouthpieces resuscitation bags, or other ventilation devices as an alternative to

mouth to mouth to resuscitation methods in areas where needs for resuscitation is
predictable.

Patient Placement- Place a patient who contaminates the environment or who does
not or cannot be expected to assist in maintaining appropriate hygiene or
environmental control in a private room.

If a private room is not available consult with infection control professionals

regarding patient placement or other alternatives.

HIV COUNSELING

Counselling in HIV and AIDS has become a core element in a holistic model of health care,
in which psychological issues are recognised as integral to patient management.
HIV and AIDS counselling has two general aims:
(1) the prevention of HIV transmission and
(2) the support of those affected directly and indirectly by HIV.
It is vital that HIV counselling should have these dual aims because the spread of HIV can be
prevented by changes in behaviour. One to one prevention counselling has a particular
contribution in that it enables frank discussion of sensitive aspects of a patient's lifesuch
discussion may be hampered in other settings by the patient's concern for confidentiality or
anxiety about a judgmental response. Also, when patients know that they have HIV infection
or disease, they may suffer great psychosocial and psychological stresses through a fear of
rejection, social stigma, disease progression, and the uncertainties associated with future
management of HIV. Good clinical management requires that such issues be managed with
consistency and professionalism, and counselling can both minimise morbidity and reduce its
occurrence. All counsellors in this field should have formal counselling training and receive
regular clinical supervision as part of adherence to good standards of clinical practice.
Factors that affect Voluntary Counselling and HIV Testing among antenatal pregnant
women
Factors that affect voluntary counselling and HIV testing among antenatal pregnant
women revolve primarily around stigma and discrimination. Stigma and discrimination fuel
the HIV & AIDS epidemic, with the adverse effects extending beyond the infected
individuals into the broad society. Stigma is predominantly fuelled by domestic and societal
pressures, as well as some cultural and religious ethos. Another factor is the emotionallyladen disclosure of status, especially as it affects children. Relevant factors that determine
whether or not an individual will disclose his or her status include:

Adverse reaction from relatives and the fear of hurting the parents: relatives of the
subject including the parents might not take the news easily, especially as the
condition is regarded as a terminal situation. For adults, it will be taken that the
affected is/was promiscuous.

Apprehension of an employers reaction: the subject might be worried about the way
the employer will take the news, including the possibility of severance. This is
predominant in organisations that subject their employees to HIV & AIDS tests.

Loss of acquaintances: friends and associates of the affected might reduce interaction
with the infect individual.
Feeling of guilt, especially for members of same cultural community: this situation
arises when such cultural affiliations attach much value to subjects revolving around
sexual ethics, etc.

The likelihood of having the integrity of ones sexual relationship questioned or of

losing a relationship: when one sexual partner tests positive, this might lead to
questioning the sexual fidelity of the infected.

The probability of being subjected to prejudice and stigma: this is very common
especially in developing countries / societies. This is fuelled by ignorance about HIV
& AIDS issues.
The prospect of being labelled an unfit parent: this is also predominantly propelled by
ignorance. There is the tendency to label the affected as being sick with HIV.

Vulnerability to violence, and in this context a woman intending to disclose to her

partner. The difficulty here is that the woman needs to be supported and shielded from
physical and emotional abuses as well as to prevent being re-infected or infecting her
partner if sero-discordant. These are ultimately the responsibility of the partner to
provide for, including economic support.

All of these factors highlight the necessity of social support in advocating for and
implementing voluntary testing and counselling of antenatal pregnant women and preventing
mother-to-child transmission of HIV.

BREAST FEEDING
HIV transmission from mothers to infants occurs during pregnancy, at the time of labor and
delivery, and postnatal through breastfeeding. In the absence of any interventions to prevent

or reduce transmission, about 5-10 percent of HIV infected mothers pass the virus to their
infants during pregnancy; between 10-20 percent during labor and delivery; and another 1020 percent postnatally through breastfeeding to 24 months.

Labor and delivery is the single time point of greatest risk with as much infection
occurring within 24 hours as occurs postnatally within 24 months of breastfeeding. Most
ARV prophylaxis regimens aim to reduce HIV transmission during this time.
BREAST FEEDING ISSUES
Warmth for newborn
Nutrition for newborn
Protection against other infections
Safety unclean water, diarrheal diseases
Risk of HIV transmission
Contraception for mother
Cost
Risk factors for postnatal transmission
Prolonged breastfeeding
Mixed breastfeeding
High plasma viral load, low CD4
Seroconversion during lactation
Mastitis
Cracked bleeding nipples, abscesses
Sub-clinical mastitis (raised Na/K ratio)
High viral load in breast milk
Oral thrush in infant

HIV transmission during breastfeeding

Exact mechanisms unknown

HIV virus in blood passes to breast milk
cell-associated, cell-free virus observed
Virus shed intermittently (undetectable ~ 25-35%)
levels vary between breasts in samples taken at same time
Virus may also come directly from infected cells in mammary gland
produced locally in mammary macrophages, lymphocytes, epithelial cells

Making breastfeeding safer in terms of HIV transmission with the current knowledge
we have
Exclusive breastfeeding up to 6 mths
Shorter duration 6 months??
Encourage condom use during lactation period
Good lactation management (attachment, positioning) to avoid mastitiS
No feeding from breast with cracked bleeding nipples or abscesses (express milk from
affected side and continue feeding from unaffected side)
Prompt treatment of oral thrush
Heat treatment of expressed breast milk
Anti-retrovirals to infant during breastfeeding period
2010 WHO Infant Feeding Guidelines
Mother takes ARVs from 14th week of pregnancy until 1 week after labor or for an indefinite
amount of time if the mother is taking ARVs for their own health.
Long ARV regimen during breastfeeding period for either mother and/or infant
Exclusive breastfeeding for 6 months
Gradually wean from breast milk
Mixed (complementary) feed after 6 months
Recommended to breastfeed and mix feed in conjunction with ARVs

LEGAL AND ETHICAL ISSUES

1.

Planned Pregnancy
A woman who knows that she or her partner is HIV positive before she becomes
pregnant should consider effective contraception. This may help to protect her, her partner
and her baby. Being pregnant may cause her CD4 count to drop slightly, but it should return
to its pre-pregnancy level soon after her baby is born.

2.

Protection at conception
An HIV positive woman with an HIV negative partner can become pregnant without
endangering her partner; by using artificial insemination (the process by which sperm is
placed into a female's genital tract using artificial means rather than by natural sexual
intercourse). This simple technique provides total protection for the man, but does nothing to
reduce the risk of HIV transmission to the baby.
If the man has HIV then the only effective way to prevent transmission is sperm
washing. This involves separating sperm cells from seminal fluid, and then testing these for
HIV before artificial insemination or in vitro fertilisation.
When both partners are HIV positive, it might still be sensible for them not to engage
in frequent unprotected sex, because there might be a small risk of one re-infecting the other
with a different strain of HIV

3.

Benefit of being tested during pregnancy

By knowing the HIV status, one can decide on the best treatment for her and the baby
and can take steps to prevent mother-to-child transmission of HIV.

4.

Benefit of baby being tested for HIV

Health care providers recommend that all babies born to HIV positive mothers be
tested for HIV. Some states require that babies receive a mandatory HIV test if the status of
the mother is unknown. Some states are only required to offer an HIV test to pregnant women
(not their babies), which they can either accept or refuse.

5.

HIV positive mother taking anti-HIV medications

If the woman is HIV positive and pregnant, it is recommended that she take anti-HIV
medications to prevent her baby from becoming infected with HIV and for own health. These
medications are recommended for all infected pregnant women regardless of CD4 count and
viral load.
6.

The best HIV treatment regimen

It depends on many factors include: risk that the HIV infection may become worse,
risks and benefits of delaying treatment, potential drug toxicities and interactions with other
drugs she is taking.

7.

Treatment Regimen During Pregnancy For The First Time Diagnosed Mother
The best treatment options depend on when mother is diagnosed with HIV, when she
found out were pregnant, and whether she need treatment for own health. Women who are in
the first trimester of pregnancy and who do not have symptoms of HIV disease may consider
delaying treatment until after 10 to 12 weeks into their pregnancies. After the first trimester,
pregnant women with HIV should receive at least AZT (Retrovir or zidovudine); The doctor
may recommend additional medications depending on your CD4 count, viral load, and drug
resistance testing.

8.

Drug effect on the baby

The long-term effects of babies exposure to anti- HIV medications in utero are
unknown. In general, protease inhibitors (PIs) are associated with increased levels of blood
sugar (hyperglycemia), development of diabetes mellitus or worsening of diabetes mellitus
symptoms and diabetic ketoacidosis. Two non-nucleoside reverse transcriptase inhibitors
(NNRTIs), Rescriptor (delavirdine) and Sustiva (efavirenz), are not recommended for the
treatment of HIV-infected pregnant women. Use of these medications during pregnancy may
lead to birth defects. Another NNRTI, Viramune (nevirapine), may be part of your HIV
treatment regimen.
Treatment Needed Mother During Labour And Delivery
Most mother-to-child transmission of HIV occurs around the time of labour and
delivery. Therefore, HIV treatment during this time is very important for protecting baby
from HIV infection. Several treatments can be used together to reduce the risk of
transmission to the baby.
Highly active antiretroviral therapy (HAART) is recommended even for HIV-infected
pregnant women who do not need treatment for their own health. HAART should include
Intravenous AZT (Retrovir or zidovudine). The baby should take AZT (in liquid form) every
6 hours for 6 weeks after birth.

9.

Delivery options for a HIV positive mother

Depending on the health and treatment status, plan either a caesarean or a vaginal
delivery. Cesarean delivery is recommended for an HIV positive mother when, her viral load
is unknown or is greater than 1,000 copies/mL at 36 weeks of pregnancy, she has not taken

any anti-HIV medications or has only taken AZT (Retrovir or zidovudine) during her
pregnancy. For preventing transmission, the caesarean should be scheduled at 38 weeks or
should be done before the rupture of membranes. Vaginal delivery is recommended for an
HIV positive mother when, she has been receiving prenatal care throughout her pregnancy,
she has a viral load less than 1,000 copies/mL at 36 weeks, and Vaginal delivery may also be
recommended if a mother has ruptured membranes and labor is progressing rapidly.
10. Preliminaries of labour and delivery
Intravenous AZT should be started 3 hours before a scheduled caesarean/vaginal
delivery and should be continued until delivery. It is also important to minimize the baby's
exposure to the mother's blood. This can be done by avoiding any invasive monitoring and
forceps- or vacuum-assisted delivery.
11. Testing baby for HIV infection
Babies born to HIV positive mothers are tested for HIV differently than adults.
Adults are tested by looking for antibodies to HIV in their blood. A baby keeps antibodies
from its mother, including antibodies to HIV, for many months after birth. Therefore, an
antibody test given before the baby is 18 months old may be positive even if the baby does
not have HIV infection. For the first 18 months, babies are tested for HIV directly, and not by
looking for antibodies to HIV. When babies are more than 18 months old, they no longer have
their mother's antibodies and can be tested for HIV using the antibody test. Preliminary HIV
tests for babies are usually performed at three time points, they are; birth to 14 days, at 1 to 2
months of age, and at 3 to 6 months of age. If babies test negative on two of these preliminary
tests and negative for HIV antibodies at 12 18 months are not HIV infected. Babies are
considered HIV positive if they test positive on two of these preliminary HIV tests and are
need to be retested at 15 to 18 months. A positive HIV antibody test given after 18 months of
age confirms HIV infection in children.
Babies born to HIV positive mothers should have a complete blood count (CBC) for
signs of anemia, which is the main negative side effect caused by the 6-week AZT (Retrovir,
or zidovudine) regimen. They may also undergo other routine blood tests and vaccinations for
babies.
12. HIV Policies of Different State
The U.S. Department of Health and Human Services (HHS) can provide with HIV
testing information for each state.
PSYCHOSOCIAL ISSUES
1.

2.

Mental Health
There are high rates of mental health problems, ranging from distress to suicidal ideation,
among women living with HIV/AIDS.
Violence & Abuse

66% of HIV-positive women found that had experienced some form of domestic violence in
their lifetime and 31% had been sexually abused as children. Interventions to help women
with HIV is reduce the abuse and violence in their lives to improving their mental health,
increasing their access to antiretrovirals and building their ability to negotiate safer sex
practices, including condom use.
3.

Substance Use
There is a need for substance abuse treatment programs that specifically target HIVpositive
women.

4.

Family & Children

Family can be a strong source of psychosocial support for women living with HIV.

5.

Sexuality/Prevention for Positives

Relationships with sexual partners are another key psychosocial issue for HIV-positive
women. As with family, disclosure is a major issue in sexual relationships. The need to create
culturally appropriate, on-going risk reduction counselling programs for HIV-positive women
and their partners that take into account the impact of HAART, sterilization, housing
instability, drug use and poverty on condom use.
REHABILITATION OF HIV INFECTED WOMEN
The aims are;
Strengthening womens economic security and rights and empowering women to
enjoy secure livelihoods.
Engendering governance and peace building to increase womens leadership in the
decision-making processes that shape their lives.
Promoting womens human rights and eliminating all forms of violence against
women to transform development into a more equitable and sustainable process.

1. HIV/AIDS Prevention: Making sure young people know how to avoid infection and have
access to services like ensure that condoms are readily available and are used consistently
and correctly.
2. helping pregnant women protect against infection
3. Young People: To ensure that adolescents and young people have accurate information as
well as non-judgmental counselling, and comprehensive and affordable services to prevent
unwanted pregnancy and STIs including HIV/AIDS.
4. Safe Motherhood: To help reduce the 500,000 preventable maternal deaths in developing
countries. To promote wider access to skilled delivery assistance and emergency obstetric
care.

5. Reproductive Health Supplies: To provide logistic support and commodities to help

countries improve access to high quality and affordable means of contraception and STI
prevention, including condoms.
6. Response to Emergencies: Have lifesaving services such as assisted delivery, and prenatal
and post-partum care; and it works to reduce their vulnerability to HIV infection, sexual
exploitation and violence.

7. Womens Empowerment: Take action to promote womens rights and prevent gender-based
violence including female genital cutting.
8. Population and Development: To support for data collection and analysis, and for policy
formulation, to help countries meet the needs of growing populations.
9. Advocacy: Regarding reproductive health and rights; lower infant and maternal mortality;
closing the gender gap in education; gender equality and equity; womens empowerment; and
increasing resources for population and development initiatives.
ROLE OF NURSE
Caring for a women who is positive during pregnancy and childbirth calls for a great
sensitivity to respect the women as a patient with a baffling yet fatal disease but to encourage
her to continue with prenatal care.Nurses need to remain current on recommendations for
therapy as well as prevention.The role of nurse is explained under various headings.
Role of nurse in HIV Care & Treatment
The specific role of nurses in HIV care and treatment can vary by country, region or facility
In general, nurses should:
Understand when to refer women for ARV therapy and start co-trimoxazole prophylaxis
Recognize:
Common infections in HIV-infected persons
Common side effects of ARV therapy & advise patients accordingly
Understand importance of ARV adherence and provide adherence support
Establish effective communication and linkages between MCH services and centres
for HIV treatment, care and support
Participate in ongoing problem-solving as a part of a comprehensive care delivery
team
Prevention of Common Infections in HIV-infected mothers
o Wash daily
o Eat nutritious foods
o Take supplemental multivitamins and essential minerals
o Keep mouth clean
o Re-hydrate promptly in case of diarrhoea
o Use safe drinking water

o Obtain adequate rest

o Use condoms to prevent STIs
o Apply a long-acting insecticide to inside walls, roof of home and domestic
animal shelters
o Use insecticide-treated bed nets
o Consider immunization against hepatitis A, B and flu
o Take medications that prevent common infections (e.g., co-trimoxazole,
INH)HIV-infected pregnant women should be evaluated for TB and offered
preventive therapy with INH
All HIV-infected pregnant women (except those on co-trimoxazole prophylaxis) should
receive at least 3 doses of sulfadoxine-pyrimethamine (SP) as intermittent preventive
treatment (IPT) against malaria during the last 6 months of pregnancy
1st dose of SP should be given during 2nd trimester after quickening
SP should be given during routine ANC visits, under HCW observation
Educate all women about malaria prevention
Education of mothers
Review ARV drug regimen; ensure patient knows ARVs are not a cure
Assist in planning dosage schedule
Remind about food/beverage restrictions
Remind about ARV drugs only work if taken every day at the correct time.
Encourage patients to disclose HIV status to at least one friend or family member who
can remind her to take the medication
Prevention of Viral Resistance
Promotion of all safety precautions to the mother ,family and among health
professionals
Social & Psychosocial Support
HIV-infected women may need assistance adjusting to diagnosis, managing illness
and/ or addressing concerns of stigma and discrimination
Nurses should be familiar with community-based services available and make
referrals as appropriate to help families access necessary service:
Peer group counselling & clubs
Referrals to other services
Provides mothers who are HIV-infected with spiritual and psychosocial support
May also provide an important sense of belonging to a larger community that offers
them compassionate care
Nurses should refer patients in need of ongoing home-based care to local programmes
where available
Palliative Care
Maximize comfort
Help for peaceful death
Help the family to cope with grief and bereavement
Post-delivery Care of the Mother with HIV Infection

nurses should ensure that all mothers regardless of place of delivery attend
postpartum care with their infants or are visited at home
Mothers and their HIV-exposed infants should be evaluated at approximately 1 week
after birth and again at 6 weeks
Subsequent visits for HIV-exposed infants should be scheduled according to a
countrys immunization schedule
Screening, prevention & treatment of common infections, including Opprtunistic
Infections

Infant feeding: information, counselling and support

Nutritional counselling
Psychosocial support
Safer sex and family planning counselling
Physical assessment, clinical staging and referral for ARV therapy according to
national guidelines
Adherence counselling for self and infant
Palliative care, where indicated
Co-trimoxazole prophylaxis
Comprehensive Treatment, Care & Support: HIV-exposed Infant
Prevention and treatment of common infections, including OIs
Diagnosis of HIV by laboratory measurements and/or clinical symptoms
Immunizations
Growth, nutritional status and development monitoring
Assessment and referral for ARV therapy
Co-trimoxazole prophylaxis and adherence support
Comprehensive Treatment, Care & Support: Family
Links and relationships with community service organizations and agencies to promote
continuity of care
Follow-up Care for HIV-exposed Infants

PMTCT interventions reduce, but do not eliminate, risk of MTCT

HIV increases risk of illness and failure to thrive

Regardless of whether ARV prophylaxis was administered to mother and/or infant

because HIV disease can progress extremely rapidly in perinatally-infected
infants close monitoring and regular follow-up care is critical

Follow-up care facilitates early diagnosis and allows infant to be started on ARV
therapy

Infant should be seen in the clinic or at home within two weeks to monitor feeding
progress

Schedule subsequent visits according to the immunization schedule. Recommended visit

schedule:
Ages 6, 10 and 14 weeks
Once a month from 14 weeks to 1 year
Every 3 months from the ages of 1 to 2 years

PREVENTION OF HIV

PPTCT- Education
Prevent medical transmission use of sterile medical equipment and screened
blood products
Education to avoid risk behaviours
Folllow safety precautions

CONCLUSION
Creating an enabling environment for the better living of the HIV victims - is a key
role of the nurse. Stigmatization can be broken down through education and discussion. We
have to Educate family members, teachers, peers and other community members on the needs
of persons affected by HIV/AIDS. Mass media, health professionals, NGOs play a major
role in creating awareness to people. Though we are not able to cure the disease we are able
to provide quality care to the persons thus to extend a better living.
BIBLIOGRAPHY
1. Pilliteri A. Maternal and child health nursing. Philadelphia: Lippincott Williams and
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Livingstone; 2003
3. Dutta DC. Textbook of obstetrics. 6th edition. Kolkata: New Central Book Agency; 2004
4. Jacob Annamma . A Comprehensive Textbook of Midwifery . 2nd edition . New Delhi :
Jaypee
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6. Lewis, et.al, Medical Surgical Nursing Assessment and Management of clinical problems.
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