AIDS(ACQUIRED IMMUNO DEFICIENCY SYNDROME)

INTRODUCTION

India’s 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 year’s estimate of more than 5 million. The country’s 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.     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.

2.     Pre-test counselling and the patient’s decision about testing should be documented in the patient’s chart.

3.     Women who decline screening should still have concerns discussed and should continue to receive optimum antenatal care.

4.     Women should be offered HIV screening at their first prenatal visit.

5.     Women who test negative for HIV and continue to engage in high-risk behaviour should be retested in each trimester.

6.     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 TEST-

HIV 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 3–6 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	FINDINGS IN  HIV INFECTION
ELISA(enzyme linked immunosorbant assay)	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 mother’s 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 government’s AIDS control programme

• 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)

• Parent-To Child Transmission (PTCT) of HIV can occur during pregnancy, at the time of delivery or through breastfeeding.

•           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

o   27 million pregnancies per year

o   1,62,000 infected pregnancies

o   Cohort of 48,600 infected newborns per year

o   0.6% prevalence

o   30% transmission

o   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 anti-retroviral (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

o   Decrease viral load (ARV prophylaxis and treatment)

o   Monitor and treat infections

o   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.

Ø  ANTIVIRAL AGENTS

HIV contains enzyme ,’reverse transcriptase, which is necessary for  viral replication.

COMMON  MEDICATIONS 

Drug	Actions	Interventions
NUCLEOSIDE REVERSE  TRANSCRIPTASE INHIBITORS (NRTis)
Zidovudine (AZT, ZOV) Retrovir	Nucleoside analog, Prevents the initial step in which HIV turns its RNA into DNA and integrates itself  into human genes. Drugs acts as decoy preventing  the replication of HIV	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.
Didanosine (ddl) Videx	Nucleoside analog. Prevents the replications of HIV	Monitor  for drug associated  pancreatitis, 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) Zerit	Nucleoside analog. Prevents replication of HIV.	Monitor  for peripheral neuropathy Monitor  for drug effectives. Teach patient/significant  other regarding drug dose schedule and possible adverse effects.
Lamivudine (3TC) Epivir	Nucleoside  analog. Prevents replication of HIV	Minimal toxicity noted. 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 protecting  non HIV infected cells	Monitor for rash. Monitor  drug effectiveness. Drug interactions rifampin, rifabutin, oral contraceptives  protease inhibitors .
Delavirudine Rescriptor	Blocks  HIV replications	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.

Drug		Actions	Interventions
PROTEASE INHIBITORS
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		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.
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, 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 non- infected 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  marked”antigenic 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 life—such 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 emotionally-laden 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 employer’s 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 one’s 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 10-20 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

How does HIV transmission during breastfeeding occur?

•                  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.

Ø  Long ARV regimen during breastfeeding period for either mother and/or infant

Ø  Exclusive breastfeeding for 6 months

Ø  Gradually wean from breast milk

Ø  Mixed (complementary) feed after 6 months

Ø  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.

Will the mother need treatment 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.

1. 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). 

3. 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.     Mental Health

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

2.     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 women’s economic security and rights and empowering women to enjoy secure livelihoods.

   Engendering governance and peace building to increase women’s leadership in the decision-making processes that shape their lives.

   Promoting women’s 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.   Women’s Empowerment: Take action to promote women’s 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; women’s 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:

Ø  Understand when to refer women for ARV therapy and start co-trimoxazole prophylaxis

Ø  Recognize:

Ø  Common infections in HIV-infected persons

Ø  Common side effects of ARV therapy & advise patients accordingly

Ø  Understand importance of ARV adherence and provide adherence support 

Ø  Establish effective communication and linkages between MCH services and centres for HIV treatment, care and support

Ø  Participate in ongoing problem-solving as a part of a comprehensive care delivery team

Ø  Prevention of Common Infections in HIV-infected mothers

–                   Wash daily

–                   Eat nutritious foods

–                   Take supplemental multivitamins and essential minerals

–                   Keep mouth clean

–                   Re-hydrate promptly in case of diarrhoea

–                   Use safe drinking water

–                   Obtain adequate rest

–                   Use condoms to prevent STIs

–                   Apply a long-acting insecticide to inside walls, roof of home and domestic animal shelters 

–                   Use insecticide-treated bed nets

–                   Consider immunization against hepatitis A, B and flu

–                   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

o   Maximize comfort

o    Help for peaceful death

o   Help the family to cope with grief and bereavement

Post-delivery Care of the Mother with HIV Infection

o   nurses  should ensure that all  mothers — regardless of place of delivery — attend postpartum care with their infants or are visited at home

o   Mothers and their HIV-exposed infants should be evaluated at approximately 1 week after birth and again at 6 weeks

o   Subsequent visits for HIV-exposed infants should be scheduled according to a country’s immunization schedule

o   Screening, prevention & treatment of common infections, including Opprtunistic Infections

Infant feeding: information, counselling and support

o   Nutritional counselling

o   Psychosocial support

o   Safer sex and family planning counselling

o   Physical assessment, clinical staging and referral for ARV therapy according to national guidelines

o   Adherence counselling for self and infant

o   Palliative care, where indicated

o   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:

o     Ages 6, 10 and 14 weeks

o     Once a month from 14 weeks to 1 year

o      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

·       Pilliteri A. Maternal and child health nursing. Philadelphia: Lippincott  Williams and Wilkins; 1999

·       Fraser DM, Cooper MA. Myles textbook for midwives. 14th edition. London: Churchill  Livingstone; 2003

·       Dutta DC. Textbook of obstetrics. 6th edition. Kolkata: New Central Book Agency; 2004

·       Jacob Annamma . A Comprehensive Textbook of Midwifery . 2nd edition . New Delhi : Jaypee

·       Brothers Medical Publishers Pvt Ltd ;2008

·       Lewis, et.al, Medical Surgical Nursing Assessment and Management of clinical problems. 7^th edition.   New Delhi: Published by Elsevier ; 2000 page no: 840-870

·       Daniels Rick. Nosek Laura. contemporary medical surgical nursing. I edition, Thomson publishers 2007.

·       Joyce M. Black. Jane Hokanson Hewks Medical Surgical Nursing.volume 2 7^th edition     New Delhi: Elsevier publishers ;2005

·       Smeltzer, Brenda G. Bave Brunner and Sudharths text book of Medical surgical nursing.10^th edition.   Philadelphia: Lippincott Williams and Wilkins publishers ;2004.

·       http://en .Wikipedia.Org/Wiki/AIDS http://hyper.  Ahajournal.  Org/

·       http://www.Medicine  net.  Com/AIDS article.  Com

·       http://www. n/m .  nih.goul medline  plus/AIDS.  Htm

·       http://en.  Wikepedia.  Org/Wiki/ AIDS

·       http://www.Cancer.  Gov /Cancer  topic/types/AIDS http;www.Webindia  123.com/health/disease/AIDS