English Case Hiv In Pregnancy Arde .doc

CHAPTER I INTRODUCTION

Human Immunodeficiency Virus is a type of virus that attacks human’s immune system and can cause AIDS. Attacking one type of white blood cells in charge of against infection, particularly lymphocytes that have CD4 as a marker located on the lymphocyte cells’s surface. Reduced CD4 in human body indicates a decrease in white blood cells or lymphocytes that should play a role in resolve the infections that enter human body. (KPA, 2007). Approximately 95% of HIV-infected patients live in developing countries, about 12% of patients infected with HIV are women and 85% at reproductive age. HIV / AIDS cases in children in Indonesia increased 700% from 2006 to 2010. HIV cases in children are most often found due to transmission from HIV-positive mothers to their children. Over 90% of mother-to-child HIV transmission occurs during pregnancy, labor, and breastfeeding. (CDC 2009; WHO 2009; KEMENKES RI, 2012). In USA, reported by The Center for Disease Control (CDC), in 2009 there were only 7 new cases of HIV because of perinatal transmission. This is evidence that HIV transmission due to perinatal transmission can be prevented. From the data presented above, then control / prevention of HIV and AIDS transmission to women, children and families is becoming increasingly important and inseparable from HIV and AIDS prevention programs in general. The risk of infants acquiring HIV can be reduced to 90%, if the mother gets antiretroviral therapy during pregnancy. Thus prevention of mother-to-child transmission of HIV or PMTCT is important, as most HIV-positive women are of child-bearing age and more than 90% of HIV cases are transmitted from mothers. (McFarland, Elizabeth 2003; Yunihastuti E et al., 2003; PMCT MOH 2008). Most HIV transmission to the fetus/infant occurs during labor, then the current treatment and appropiate labor of childbirth are essensial for the protection of infant’s HIV infection (Perinatal HIV Guidelines Working Group) Here is reported a case about HIV in pregnancy, a 35 years old woman pregnant with a first child from a second husband. Refered from regional Hospital with opportunistic infection , Rapid test Reactive.

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CHAPTER II CASE REPORT IDENTITY Name

: Ny. M

Age

: 35 years old

MR

: 01 01 59 55

Address

: Jorong Ranah Baru Abai Siat, Dharmasraya

Admitted

: 12th May 2018

Husband

: Mr. P

Age

: 39 years old

Address

: Jorong Ranah Baru Abai Siat, Dharmasraya

Occupation : Farmer ANAMNESIS A 35 years old patient was admitted to the Ward Room of Dr. M. Djamil Central General Hospital on May, 12th 2018 at 06.00 am. refered from Sungai dareh Regional Hospital with diagnose G6P3A2L3 term pregnancy + first stage of laten phase + Opportunistic infections Suspected. PRESENT ILLNESS HISTORY -

Previously patient was control pregnancy to primary health care at Dharmasraya a month ago and do screening for HIV and the result was positive. Patient given information and consultation about the result and referred to VCT polyclinic at Sungai dareh Regional Hospital but she didn’t come because of transportation.

-

Patien came to primary health care at Dharmasraya 12 hours ago with chief complain fluid leakage from vagina, smelled fishy, greenish color and wetting one piece of cloth,

-

Patient was referred to Sungai dareh Regional Hospital, patient was recheck and the result was negative and then the patient was referred to Dr. M. Djamil Central General Hospital with IV line access due to there hasn’t prepare facilities

-

fluid leakage from the vagina since 12 hours ago, smelled fishy, greenish color and wetting one piece of cloth,

2

-

Feeling of pain from waist region which referred to the groin since 6 hours ago, more frequent and increase

-

Bloody show from the vagina since 6 hours ago

-

Massive bleeding from the vagina was absent

-

Amenorrhea since 9 months ago.

-

First date of last menstrual period forgot

-

Estimation date of delivery difficult to determine

-

Fetal movement was felt since 5 months ago

-

There is no complain of nausea, vomiting and vaginal bleeding either during early pregnancy or late pregnancy.

-

Prenatal care with midwife 3 times (3,4 and 7 month of pregnancy), and control to primary health care when 8 month of pregnancy , and do screening for HIV and the result was positive. Never control to the obstetrician.

-

Menstrual history : menarche at 13 years old, irregular menstrual cycle once in a month, which last for 4-6 days each cycle with the amount of 2-3 times pad change/day without menstrual pain.

-

History of frequent fever and chronic diarrhea are dinied

-

History of drastic weight loss is denied

PREVIOUS ILLNESS HISTORY There was no previous history of heart, lung, liver, kidney, DM, hypertension and allergy FAMILY ILLNESS HISTORY -

There was no history of hereditary disease, contagious and physiological illness in the family

OCCUPATION, SOCIOECONOMICS, PSYCHIATRY, AND HABITUAL HISTORY Marriage history

:

- first marriage on 2006, second marriage on 2017 - Patien is housewife, ex-husband died 4 years ago due to illness and she didn’t know the illness, ex husband was a trader in Batam, 3

-

The patient is the fifth wife 0fthe present husband and another wife not divorced

History of pregnancy/abortion/delivery: 6/2/3 1. 2006/male/2800 gr/spontaneous/aterm/ dukun /live 2. 2007/female/2900 gr/spontaneous/aterm/midwife/live 3. 2012/female/4100 gr/spontaneous/aterm/midwife/live 4. 2013 abortus/ no curettage 5. 2014 abortus/ no curettage 6. present Present History of family planning

: (-)

History of immunization

: (-)

History of education

: did not finish primary school

History of habits

: There is no history of smoking, drinking and drugs

PHYSICAL EXAMINATION General Record: GA

Cons

BP

HR

RR

T

Mdt

CMC

120/70

84

20

36,8

Body weight : Before pregnancy Present

: 56 kg : 65 kg

Body Height

: 160 cm

BMI

: 21,87 kg/m2 (normoweight)

Upper arm circumference

: 25 cm

Eyes

: Conjunctiva wasn’t anemic, sclera wasn’t icteric

Neck

: JVP 5-2 cmH2O, thyroid gland no enlargement

Chest

: H/L normal, enlargement of breast. 4

Abdomen

: obstetrical record

Genitalia

: obstetrical record

Extremity

: Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obsetric Examination Abdomen : I

: Abdomen seem enlarg to term pregnancy, striae gravidarum (+), cicatrix (-), linea mediana hyperpigmentation (+)

Pa : L1 fundal uterine was palpable at 3 finger below proc.xyphoideus. a large nodular mass was palpated L2 a hard and resistance structure was felt on the left side, numerous small part of the baby was felt on the right side L3 a hard round mass was palpable and it was fixated L4 parallel Uterine fundal height : 35 cm

EFW : 3565 grams

Uterine contraction : 2-3 times/35 second/moderate Pe : Tympani Au : Peristaltic sound was normal, FHR :132-142 x/minutes Genitalia : Inspection : V/U normal, vaginal bleeding (-) VT : dilatation of servix 5-6 cm, amnion membrane (-) Greenish residue, nitrazine test (+) Small fontanel was palpable left anterior, Hodge II-III

5

USG

Fetal Alive singleton intra uterin head presentation Fetus movement normal Biometric : BPD

: 95,6 mm

AC

: 383 mm 6

FL

: 77,5 mm

Amnion fluid index /SDP : 18 mm EFW

: 3400-3500 gr

Plasenta Implanted at anterior corpus grade III Impresion : 39-40 weeks of pregnancy , fetal alive head presentation CTG

Base line

: 145

Variabilitas

: 5-15

Acceleration

: (+)

Deseleration

: (-)

Contraction

: (+)

Fetal Movement : (+) Impression

: Reactive CTG (first category)

LABORATORY

Result

Normal value

Hemoglobine

10,9 gr/dl

9,5-15,0

Leucocyte

8700 /mm3

5.9–16.9

Hematocrit

32 %

28.0–40.0

7

Trombocyte

225.000/mm3

146–429

PT

9,9

10,0-13,6

APTT

31,9

29,2-39,4

HbsAg

Non reactive

HIV Rapid test

Non reactive

DIAGNOSIS G6P3A2L3 term pregnancy first stage of laten phase + history 12 hours PROM + HIV (+) Suspected. Fetal alive singleton intrauterin head presentation, Small fontanel was palpable left anterior, Hodge II-III TREATMENTS Control,VS,HIS,FHR. Informed consent Reevaluations 4 hours later Cosult perinatology IVFD RL gtt XX/ mnt Inj. Ceftriaxon 1 gr IV (skin test) Plan : vaginal delivery Follow Up at 10.00 am S / sense of wanting to push (+) O/

GA

Cons

BP

HR

RR

T

Mdt

CMC

120/70

84

20

36,8

8

Abdomen : Uterine contraction : 4-5 times/50 second/strong, FHR 140-150 x/min Genitalia : Inspection : V/U normal, vaginal bleeding (-) VT : full of dilatation , amnion membrane (-) Greenish residue Small fontanel was palpable anterior, Hodge III-IV A/ G6P3A2L3 term pregnancy second stage Fetal alive, singleton, intra uterine, head presentation occiput anterior HIII-IV P/ Control,VS,HIS,FHR Normal vaginal delivery At 10.15 AM Vaginal delivery was performed a male baby was born, 3600 gr in weight, 53 cm in height, A/S : 7/8 placenta was born spontaneously, complete, size 17x16x2 cm, weight 500 gr. umbilical cord 45 cm long, paracentralis insertion Bleeding during procedure was ± 50 cc Diagnose: P4A2L4 post term vaginal delivery + HIV (+) Suspected Mother and child rooming in Treatments : Observe after procedure (VS, Vaginal bleeding, Contraction) IVFD RL + Oxytosin 10 iu Gtt XX/ mnt Inj. Ceftriaxon 2x1 gr (IV) Mefenamic acid 3 x 500 mg (oral) Sulfas ferrosus 2 x 300 mg (oral) Vit C 3x50 mg (oral) Plan : check laboratory 6 hours post procedure . 9

CHAPTER III LITERATURE VIEW A. Definition HIV is type of RNA virus from Retrovirus family and Lentiriviridae subfamily. Until now only two known HIV serotypes are HIV-1 and HIV-2, also called as lymphadenopathy associated virus type-2 (LAV-2) which until now only found in AIDS or healthy person in Africa. Spectrum of diseases that have caused it is not widely known. HIV-1, the most common cause of immune deficiency syndrome, was formerly known as Human T-Cell Lymph tropic Virus Type III (HTLV-III), Lymphadenipathy-Associated Virus (LAV) and AIDS-Associated Virus. ( Zein, 2006). The most frequent cause of AIDS worldwide is HIV-1 because it is more infectious than HIV-2. HIV primarily infects vital components from immune systems such as CD+ T cells, macrofage, and dendritic cells. CD4+ T cells derived from Tymus are lymphocyte derivates that act as HIV receptors. As is known CD4 + T cells are indispensable for the implementation of immune function, and when CD4 + T cell counts are greatly decreased will result in the appearance of clinical manifestations or AIDS. AIDS is a accumulation of symptoms or syndrome due to decreased immunity caused by HIV virus infection. The human body has the immunity to protect itself from outside attack such as bacteries or viruses and AID diseases weaken or damage immune system, so that various types of other diseases come.(Orphans, 2006) B. Epidemiology On June 18, 1981, the first recorded AIDS epidemic appeared when the CDC (Center for Disease Control and Prevention) reported a group of patients with Pneumocystis Carinii Pneumonia in 5 gay men in Los Angeles USA in the early

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1980s. In 1982, CDC introduced the term AIDS to describe the collection of symptoms this disease (Wikipedia, 2010). Based on Ministry of Health, until December 2011 there were 21.031 cases of Human

Immunodeficiency

Virus

(HIV)

and

4.162

cases

of

Acquired

immunodeficiency syndrome (AIDS). Until 31 December 2011, HIV and AIDS cases who reported since 1978 ammounted to 76.879 dan 29.879 cases, respectively, with 5.430 deaths. According to data collected until Desember 2011, West Sumatera ranks 12th after Papua, DKI Jakarta, Riau Islands, and North Sumatera, with 568 HIV cases and 428 AIDS cases. (Ministry of Health, 2012) There is difference transmission patterns of HIV / AIDS between industrialized and developing countries, where in industrialized countries the largest transmission is found in the homosexual group, followed by the compactor, and the last is the perinatal transmission. For Indonesia, based on data from Ministry of Health until December 2011, largest transmission is heterosexual group as many as 14,775 cases, homosexual 807 cases, 9392 drug abuse, blood transfusion 51 cases, perinatal transmission 730 cases and unknown 940 cases. (CDC, 2009; Ministry of Health, 2012) Approximately 95% of HIV patients live in developing countries, about 12% of HIV patients are woman, which 85% are at reproductive age. HIV / AIDS cases in Indonesian children increased 70 percent in the last four years (2006-2010). HIV cases in children are most commonly found due to transmission from mothers who already have HIV to their children. If the birth rate in Indonesia is 2.5%, then every year there will be 2,250 - 3,250 babies born to HIV positive mothers. Over 90% of mother-to-child HIV transmission occurs during pregnancy, labor, and breastfeeding. In the United States, as reported by the Centers for Disease Control (CDC), in 2009 there were only 7 new cases of HIV because of perinatal transmission. This is evidence that HIV transmission due to perinatal transmission can be prevented. (CDC 2009; WHO 2009; KEMENKES RI, 2012). HIV transmission to children from HIV positive mothers is referred to as Mother to Child Transmission (MTCT). Transmission from mother to child / infant occurs through transmission in utero, at birth / peripartum and through breastfeeding. The risk of infants acquiring HIV can be reduced to 98%, if the mother gets antiretroviral (ARV) therapy during pregnancy. (CDC 2009; WHO 2009; KEMENKES RI, 2012) 11

C. HIV in Pregnancy Planned and non-planned pregnancies can occur in HIV positive women. HIV infected patients’s desire to get pregnant needs attention. After obtaining correct information about the effect of HIV on pregnancy, as well as the risk of transmission to infants, we need to respect the decisions taken by HIV infected patients. The effects of HIV infection on pregnancy are related to abortion, prematurity, IUGR (Intra Uterine Growth Restriction), IUFD (Intra Uterine Fetal Death), transmission to the fetus, and increased maternal mortality. In contrast, pregnancy has little effect on HIV infection, a decrease in CD4 due to increased body fluid volume during pregnancy, in addition HIV levels are stable and do not affect the risk of death or progression to AIDS. Pregnancy monitoring on CD4 <500 cells / mm3 is recommended every 3 weeks to 28 weeks and every 2 weeks until 36 weeks' gestation, then once a week until labor. Additional examination include complete blood laboratory examination, as well as CD4 count, and ultrasound if the facility is possible at 16, 28 and 36 weeks gestational age in pregnant women taking either antiretroviral or CD4 <200 cells/ mm3. 1. Perinatal transmission Perinatal transmission is transmitted from the mother living with HIV to the fetus during the perinatal period. Pregnancy transmission rate is about 5 - 10%, when labor about 10-20%, and when breastfeeding about 10-20% if feeding until 2 years. Transmission during breastfeeding primarily occurs in the first weeks of breastfeeding, especially when new mothers are infected while breastfeeding. If the mother living with HIV is not breastfeeding her baby, the baby may be infected by HIV infection of 15-30%, if breastfeeding up to 6 months may be infected 25-35%,

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and if breastfeeding period is extended to 18-24 months then the risk of infection will increase to 30-45%. In most women infected with HIV, transmission can not pass through the placenta. Generally, maternal blood does not mix with infant blood, so not all babies conceived by HIV positive mothers are infected with HIV in the womb. Placenta even protects the fetus from HIV, but this protection can be damaged if there is a viral, bacterial, or parasitic infection of the placenta, or in situations where mother's immunity is very low. In labor process, there is contact between the mother's blood, as well as maternal and infant mucus, so that HIV virus can enter the baby's body. Longer the labor process, the contact between the baby and the mother's body fluids gets longer, risk of transmission be higher. Breast milk from HIV-infected mothers contains HIV in concentrations lower than those found in the blood. Transmission occurs in about 10 - 20% of infants who are breastfed for 18 months or more. Based on that basis, women with HIV infection are advised not to breastfeed their babies and be replaced with milk substitute breast milk. Frequency of mother-to-child transmission in developed countries is about 15 25%, while in developing countries 25-45%, is associated with high breastfeeding habits in developing countries. With the development of understanding about pathogenesis of perinatal HIV-1 transmission, it is known that most occur at the time of labor. Additional data, have demonstrated that short-term safety of ZDV regimens, on monitoring of infants and women with PACTG 076 treatment. Data from animal studies, indicating the potential of transplacental carcinogens from ZDV use, therefore further monitoring of children with antiretroviral exposure in-utero . 2. Factors that affect mother-to-child transmission of HIV Transmission of HIV from mother to baby is generally associated with immune system, and virulence of germs. a. Mother factors:

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1) Newly infected mother is easy to infect her baby. This is due to the amount of virus in the mother's body is very high compared to the number of viruses in mothers who contracted HIV before or during pregnancy. 2) Mothers with HIV-related diseases such as cough, persistent diarrhea, weight loss, this is also due to the amount of virus in the mother's body is high. 3) Infection in pregnancy, especially sexually transmitted infections or placental infections 4) Malnutrition during pregnancy, especially lack of micronutrients 5) Mastitis 6) KPD, prolonged partus, and interventions during labor such as amniotomy, episiotomy. b. Baby factors 1) The baby is born prematurely 2) Breastfeeding to mothers with HIV 3) Lesions in the baby's mouth increase the risk of contracting HIV, especially in infants under 6 months of age D. Prevention of HIV Transmission in Infants and Children In the book Prevention of Mother to Child Transmission of HIV, the World Health Organization states that PMTCT (Programmes of the Prevention of Mother to Child Transmission), can reduce vertical transmission of HIV, also connects women with HIV infection, children, and their families, to get treatment , care, and support. PMTCT is a comprehensive program and follows national protocol and policy. (CDC 2009; WHO 2009; KEMENKES RI, 2012) PMTCT Interventions: 1. HIV examination and counseling 2.Aniretroviral 3. More secure labor 4. Breastfeeding is safer

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Couple involvement in PMTCT: 1. Both partners should know the importance of safe sex during labor and breastfeeding 2. Both partners should undergo HIV examination and counseling 3. Both partners should know and do PMTCT Risk factors for MTCT during pregnancy: 1.High maternal viral load (new HIV / AIDS or advanced) 2.Infection of viruses, bacteria, or parasites through the placenta (especially malaria) 3.Sexually transmitted infections 4.Maternal malnutrition (indirectly) Risk factors for MTCT during labor: 1.High maternal viral load (new HIV / AIDS or advanced) 2. Rupture of membranes > 4 hours before labor begins 3. Invasive labor procedure 4.First infant in multiple pregnancies 3. Chorioamnionitis Risk factors for MTCT during breastfeeding: 1.High maternal viral load (new HIV / AIDS or advanced) 2.Long breastfeeding 3.Breastfeeding with early replacement feeding 4.Breast abcess/ nipples are infected 5.Maternal malnutrition 6.Baby oral disease (eg, trust or mouth sores) WHO launched four strategies for prevention of HIV transmission in infants and children: 15

1. Primary prevention, by preventing all women from becoming infected with HIV The most important thing is that a healthy mother should not be infected with HIV, for that especially change sexual behavior, loyal to partner, avoid sexual intercourse with changing partner, if this is violated, use condom. Sexually transmitted diseases should be prevented and treated promptly. Do not be an injection drug user, especially with the use of a syringe alternately. For health workers to follow the standard universal precautions rules. Doctors, nurses and other health workers treating patients with HIV / AIDS (HIV infected patients) do not belong to high-risk groups who are infected with HIV, especially when applying universal precautionary procedures for infection prevention. All blood or body fluids should be considered to transmit HIV or other diseases contained in the blood. Blood transfusions should use blood or blood components that have been declared free of HIV and for surgery plans to seek autologous blood transfusions. In couples wishing to conceive, HIV testing should be performed before pregnancy, and for those who have been pregnant, HIV testing is done at the first visit. Key to the success of this program is VCT (Voluntary Counseling and Testing), namely counseling and readiness to undergo HIV testing. The targets are young women and their partners, as well as pregnant and lactating mothers. (CDC 2009; WHO 2009; KEMENKES RI, 2012) 2.Prevention of unwanted pregnancy in women with HIV positive There are three strategies that are proclaimed: 1. Prevent unwanted pregnancy Most women with HIV infection in developing countries are unaware of their serological status, so VCT plays an important role. Family planning services need to be extended to all women, including those infected, receiving support and services to prevent unknown pregnancies. For women who are already infected with HIV to get essential services and support including family planning and reproductive health so they can make decisions about their reproductive lives. 16

2. Delay the next pregnancy If the mother still wants the child, WHO recommend at least 2 years distance between pregnancy. To delay pregnancy: 1) Not allowed to use IUDs because it can spread the infection upwards causing pelvic infection. Women who use IUDs have a tendency to have bleeding that can cause transmission more easily. 2) The recommended contraceptive is condom, because it can prevent the transmission of HIV and sexually transmitted infections, but does not have the same success rate with other contraceptives such as oral contraceptives or noorplant. 3) Oral contraceptives and long-term hormonal contraceptives such as noorplant and depo provera do not constitute a contraindication in HIV-infected women. Studies are underway to determine the effect of hormonal contraceptive use on HIV disease travel. 4) Sponges and diaphragms are less effective in preventing pregnancy and preventing HIV transmission. 5) For mothers who do not want to have more children, the most appropriate contraception is sterilization (tubectomy or vasectomy). 6) If the mother chooses contraception other than condom to prevent pregnancy, then condom use must be done to prevent HIV transmission. 3. Replace the effects of breastfeeding contraception Non-breastfeeding to prevent mother-to-child transmission of HIV cause the effects of lactation contraception to be lost, for which a contraceptive is necessary to prevent pregnancy. 3. Prevention of HIV transmission from mother to fetus Prevention interventions from mother to fetus / baby include four things, from pregnancy, labor, and after birth:

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1. Use of ARVs during pregnancy (PMTCT plus project) 2. Use of ARVs during labor and newborns 3. Obstetric care during labor 4.Treatments during breastfeeding

4. Treatment, care and support for women with HIV, infants, and their families 1. Provide HIV-related treatments, care and support for women 2. Provide early diagnosis, care, and support for infants and children with HIVpositive infections 3. Encourage relationships among community services for integrated family services WHO proposed AFASS criteria for PASI in infants born to HIV positive mothers: Acceptable (accepted) Mothers have no sociocultural barriers to choosing alternative foods or there is no fear of stigma and discrimination Feasible (executed) Mother or family has enough time, knowledge, skills and other to prepare and feed the baby. Mothers get support when there is family, community and social pressure. Affordable (affordable) Mothers and families are able to purchase, manufacture and prepare selected foods, including groceries, fuel and clean water. Not using funds for family health and nutrition. Sustainable (continuous) Substitute foods given to infants should be daily and or evening (every 3 hours) and in fresh form. Distribution of the food must be sustainable as long as the baby needs it. 18

Safe (safe, clean quality) Food replacement must be stored properly, hygienic with adequate quantity of nutrients. In general, infant feeding from HIV positive mothers can be described as follows: When the mother chooses to continue breastfeeding, breast milk is given for only 6 months and then stopped. Breast milk is warmed and warmed to 56 Celcius degree for 30 minutes.  When the mother chooses to give formula milk, formula must be given by fulfilling 5 AFAS criteria, not to give breast milk simultaneously with formula milk. Babies and mothers are in emergency situations (natural disasters, wars) In emergency situations, infants are still encouraged to get breast milk with some control: - Monitoring and control of infant feeding by National Coordinator of Disaster. - Breastfeeding remains the first and best choice in emergency situations. Poor hygiene conditions, lack of clean water and fuel are risk factors for infection in infant formula feeding. - Counseling should be given to breastfeeding mothers by trained PP-ASI teams. need Shelter / special tents and breastfeeding materials should be provided. Breastfeeding production disorders in times of disaster are generally due to psychic trauma so it needs to be emphasized that the situation is temporary. - Formula milk, including skim milk should not be part of the food rations. - Not receiving help for formula milk from formula producers / distributors, the use of formula only for the right one obviously requires with medical indication and orphaned baby. Providing this formula with purchase. - Formula milk may be dispensed when given not as a single food, but mixed with ground food. - Product labels meet International code requirements for PASI marketing, including instructional use, health hazards, in Indonesian 19

- If the infant formula is distributed by the donor, then distribution, use, and health effects of infants should be monitored by trained personnel - Available MP-ASI for babies over 6 months Although some of these controls are sometimes difficult to implement in the field, but with cooperation of all parties, it can gradually be implemented. Makes every baby breastfed and enables every mother to breastfeed her baby. Breastfeeding rights are defined as breastfeeding in accordance with WHA Resolution (2001), that is, the infant is exclusively breastfed from birth to 6 months, then MP-ASI is given and breastfeeding continues until the infant is 2 years or older. A breastfeeding mother to be able and successfully carry out breastfeeding completely. A mother needs comprehensive protection, information, and assistance while eliminating barriers to her environment, including: - Environment / family and community support - Communication, information and education to all levels of society to cultivate the culture of breast milk, for example the provision of lactating space in public service. - The entire healthcare system applies 10 Steps to Breastfeeding Success or apply Baby's affection - Mother gets information or counseling about the benefits of breastfeeding and how to breastfeed - Mother gets breastfeeding counseling especially when faced with problems - Mother not exposed / affected by marketing PASI or mother should be able to refuse giving PASI - Working mother gets protection, policies, tools and assistance to implement optimal breastfeeding - Mothers who are HIV positive require knowledge of infant feeding - When the mother-baby is in emergency situations assisted to keep breastfeeding. E. HIV / AIDS Management in Indonesia At present less than 5% of HIV infected patients in developing countries needing ARVs can be affordable. Antiretroviral treatment guidelines provide information about 4S: starting, substituting, switching, and stopping, which is a good time to start therapy, choosing a drug that must be continued when replacing a substitute regimen 20

(substitution), the reason for replacing the entire regimen (switching ), and when stopping antiretroviral (stopping). 1. Precondition Administration of antiretroviral (ARV) therapy according to the National Guidelines for Care, Support and Treatment for HIV infected patients, Directorate General of Communicable Disease Eradication and Environmental Health Ministry of the Republic of Indonesia in 2003 generally has certain requirements, such as CD4 cell count <200 cells / mm3, but administration of ART in HIV infected patients’s pregnant with the aim of preventing HIV transmission from mother to fetus / baby does not pay attention to the above requirements. In general, before starting antiretroviral treatment, special services and facilities should be available, because of complex and costly therapies, and also require intensive monitoring. These services consist of: Voluntary Counseling and Testing (VCT) to find cases requiring treatment and follow-up counseling services to provide ongoing psychosocial support. b. Compliance counseling services to ensure patient readiness to receive treatment by trained counselors and continue treatment (may be provided through counseling or peer support). c. Medical services that are able to diagnose and treat diseases that are often associated with HIV as opportunistic infections. d. Laboratory services capable of performing routine laboratory tests such as complete blood tests and blood chemistry. Access to a referral laboratory capable of performing CD4 examinations is useful for monitoring treatment. e. Availability of ARVs and other opportunistic infections and other related diseases are effective, quality, affordable and sustainable. (CDC 2009; WHO 2009; KEMENKES RI, 2012) 2. Clinical Assessment Before starting treatment, it is necessary to: a.Complete history of the disease b.Complete physical examination 21

c. Routine laboratory examination d. Calculate total lymphocytes (Total Lymphocyte Count / TLC) e. CD4 count examination whenever possible Need a detailed clinical assessment: a. Assessing clinical stages of HIV infection b. Identify past HIV-related illnesses c. Identify current HIV-related illnesses that require treatment d. Identify other treatments underway that may affect the choice of therapy

Disease history: a. When and where HIV diagnosis is enforced b. Possible source of HIV infection c. Current symptoms and complaints of the patient d.Previous history of disease, diagnosis and treatment received, including opportunistic infections e.Historical disease and treatment of tuberculosis (TB) including possible contact with previous TB f. History of Possible Sexually Transmitted Infections (STIs) g. History and possible pregnancy h. History of ARV use includes a history of the regimen for previous PMTCT i.Rescription history and use of oral contraceptives in women j. Daily habits and sexual behavior history k.Historical use of injecting narcotics drug Physical examination includes: a. Weight b. Vital signs c. Skin: herpes zoster, Kaposi’s sarcoma, HIV dermatitis, pruritic papular eruption (PPE), severe seborrheic dermatitis, needle track, or incision lesion. d.Lymphadenopathy e.Oropharyngeal

mucous

membranes:

candidiasis,

leukoplakia, HSV 22

Kaposi's

sarcoma,

hairy

f. Examination of the heart, lungs, abdomen g.Check the nervous system and skeletal muscle: psychiatric state, reduced motor function and sensory h.Examination of the eye fundus: retinitis and papillary edema i.Examination of the genital tract / uterus Psychological examination: a. To know mental status b. Assessing readiness to receive long-term or lifelong treatment Laboratory examination: a. Serological examination for HIV using strategy 2 or strategy 3 according to guidelines b. Lymphocyte total or CD4 (if available) c. Complete blood test (mainly Hb) and blood chemistry (especially liver function) and kidney function d.Pregnancy examination Additional examination required according to disease history and clinical examination: a. Thorax Photo b. Routine urine and microscopic examination c. Serology of hepatitis C virus (HCV) and hepatitis B virus (HBV) depends on the examination and resources If possible, blood chemistry examination did includes: a. Serum creatinine and / or blood urea to assess renal function at baseline b. Glucose blood c. SGOT / SGPT to determine the possibility of hepatitis and monitor the presence of drug poisoning d. Other tests as necessary, such as: serum bilirubin, serum lipids, and serum amylases

23

HIV examination should be performed by a trained technician in a laboratory who runs a quality watch program. The results of the examination should also mention the type of examination used to establish a diagnosis based on the WHO guidelines. If any doubt arises, the examination shall be repeated in the reference laboratory. (CDC 2009; WHO 2009; KEMENKES RI, 2012)

Table 1. Clinical Classificaition of Adult HIV infection (WHO) Stage I

II

CLinical Manifestations Asymptomatic

Activities Scale Asymptomatic,normal

Generalized lymphadenopathy Weight loss < 10%

activities Symptomatic,normal

Skin and mild mucosa disorders such as seborroic

activities

dermatitis, prurigo, onychomicosis, recurrent oral ulcers, angular chilitis Herpes zoster in the last 5 years

III

ISPA (URTI) like bacterialis sinusitis Weight loss > 10%

Commonly weakness,

Chronic diarrhea > 1 month

activities on the bed <

Prolonged fever > 1 month

50%

Orofaryngeal Candidiasis Oral hairy leukoplakia Pulmonary TB in the last year Severe bacterial infections like pneumonia,

IV

pyomyositis HIV wasting syndrome like who defined CDC

Pada umumnya sangat

Pneumonia Pneumocytis carinii

lemah, aktivitas di tempat

Brain Toxoplasmosis otak

tidur > 50%

Cryptoporidiosis diarrhea > 1 month Extrapulmonal cryptokokosis Cytomegalo Retinitis Mucocutaneous Herpes simpleks > 1 month Progressive Multifocal Leucoensephalophaty Disseminated Mycosis like histoplasmosis Candidiasis in esophagus, trachea, bronchus, and pulmo Disseminated atypical mycobacteriosis Salmonelosis Septisemia non typhoid Tuberculosis outside the pulmo 24

Limphoma Caposy Sarcoma HIV Ensephalophaty

Explanation : HIV wasting syndrome: weight loss > 10% plus chronis diarrhea > 1 month or fever > 1 month who is not caused by the other diseases. HIV Encephalopathy: cognitive disorders and or motoric disfunction which is disturbe daily activities and getting worse in few weeks or months not accompanied with other diseases except HIV. Table 2. CLinical Classification HIV Infections in Children Stage I

Clinical Manifestations Asymptomatic Generalized Limphadenopathy Chronic diarrhea > 30 days, without any known aetiology Severe Persistent Candidiasis or recurrent at the time of neonate

II.

Weight loss or failure to thrive without any known aetiology Persistent fever > 30 days without any known aetiology Recurrent severe bacterial infections bacterial pneummonia non TB, abses) Oppurtunistic infection AIDS-defining Failure to thrive or weight loss without any known aetiology

III

Progressuve Encepalophaty Malignancy Septicemia or Recurrent Meningitis

Explanation: Weight loss >10% if baseline or less than fifth percentile from weight graphic at twice measurements with distance more than one moth without any known aetiology or the others diasease. 3. Others Requirements

25

Before receiving ARV treatment, patients should be well prepared with standardized adherence counseling, so that patient understands the benefits, ways of use, drug side effects, hazards, etc. associated with ARV. Patients receiving ARV treatment should undergo reguler clinical monitoring examination. 4. Indication of Antiretroviral Treatment ARV treatment in adult HIV infected patients should start immediately when HIV infections has been established in a laboratory with one of the following: a. Advanced clinical stage of HIV infections 1) HIV infection stage IV regardless of CD4 count 2) HIV infection stage III with CD4 < 350 cells/mm3 b. HIV infection stage I or II with CD4 < 200 cells/mm3 If there is not CD4 examination’s device, total lymphocytes ≤ 1200/mm3 used as indicator ARV treatment in HIV infection symptomatic, and on asymptomatic patient total lymhocytes count is less correlated with CD4 count. Viral load examination (for example with RNA HIV-1 levels in plasma) is not considered necessary before administraion of ARV and not recommended WHO as rutine action in decision making action. Table 3. ARV Treatment in Adult HIV infected patients CD4 Examination is Available Stage IV regardeless of CD4 count Stage III wtih CD4 < 350 cells/mm3 Stage I or II with CD4 < 200 cells/mm3 Device of CD4 Examination is not Available Stage IV regardeless of total lymphocyte count Stage III regardeless of total lymphocyte count Stage II with total lymphocyte < 1200 /mm3

Table 4. Dose of Antiretroviral for Adult HIV infected patients

26

Category/ Drugs Name Nucleoside RTI Abicavir (ABC)

Dose 300 mg every 12 hours 400 mg once a days

Didanosine (ddl)

(250 mg once a days if weight < 60 kg)

Lamivudine (3TC)

(250 mg once a day if given with TDF) 150 mg every 12 hours or 300 mg once a days 40 mg every 12 hours

Stavudine (d4T) Zidovudine (ZDV atau AZT) Nucleotide RTI Tenofovir (TDF) Non Nucleoside RTIs Evafirenz (EFV) Nevirapine (NVP) Protease Inhibitors Indinavir/ritonavir (IDV/r) Lopinavir/ritonavir (LPV/r) Nelfinavir (NFV) Saquinavir/ritonavir (SQV/r) Ritonavir (RTV/r)

(30 mg every 12 hours if weight < 60 kg) 300 mg every 12 hours 300 mg once a days (Drug interaction with ddl, need to reduce the ddl dose) 600 mg once a days 200 mg once a days for 14 days, then 200 mg every 12 hours 800 mg / 100 mg every 12 hours 400 mg / 100 mg every 12 hours (533 mg / 133 mg every 12 hours if combined with EVP or NVP) 1250 mg every 12 hours 1000 mg / 100 mg every 12 hours or 1600 mg / 200 mg once a days Capsule 100 mg, oral solution 400 mg / 5 ml

F. Antiretroviral in Pregnancy According to recommendations on the use of antiretroviral treatment in pregnant women with HIV-1 positive for maternal health, as well as interventions to reduce perinatal HIV-1 transmission in the United States, revised on 24 February 2005 by the Perinatal HIV Guidelines Working Group stated, treatment for pregnant women with HIV -1 is positive based on the belief that treatment has a usefulness that is known to women during pregnancy, unless there is an effect known to both mother and fetus. ARV treatment in pregnant women is given when: 1. Have severe symptoms of HIV or with an AIDS diagnosis 2.CD4 <200 cells / mm3 3.Viral load> 1000 / ml ARV treatment is also needed to prevent transmission of HIV to the fetus. AntiHIV treatment is an important part of maintaining maternal health, as well as 27

preventing HIV transmission to the fetus. The decision to start therapy depends on several factors, which should also be known by non-pregnant women: 1. The risk of HIV infection becomes severe 2.Risk and usefulness delay treatment 3.Toxicity of treatment, drug interactions with other drugs taken 4.The need to adhere to a drug regimen closely In addition, for pregnant women with HIV, must consider: 1. Benefits reduce the number of viruses, reduce the risk of HIV transmission from mother to fetus 2. Long-term effects that have not been known to the baby when using antiretroviral drugs during pregnancy 3.Information available about use of anti-HIV drugs during pregnancy Pregnant women with HIV in the first trimester without symptoms of HIV, may delay treatment until 10-12 weeks gestation. After the first trimester, HIV infected patients’s woman should receive treatment at least with zidovudine (also known as ZDV or AZT). Additional treatment may be considered, according to CD4 count and viral load. Combination of antiretroviral therapy usually consists of two nucleoside analog reserve transcriptase inhibitors (NRTIs) with protease inhibitor (PI), a standard treatment recommended for adults with non-pregnant HIV-1 infection. In pregnancy it is not permitted to use this treatment regimen.

Selection of antiretroviral treatment in HIV-positive pregnant women, depends on several thoughts:

28

1. Possibility of changing the dose of need corresponds to the physiological changes associated with pregnancy. 2. Potential effects of antiretroviral drugs in pregnant women 3. Short-term and long-term potential effects of antiretroviral drugs on fetuses and infants, which may not be known for all antiretroviral drugs Decisions of use of antiretroviral medications during pregnancy should be made by pregnant women after discussing with the health worker regarding both known and unknown uses, as well as risks for the woman and her baby. Physiological changes during pregnancy may affect the kinetic absorption, distribution, biotransformation, and elimination of the drug, thus also affecting the dose of the drug required, as well as the possibility of toxicity. During pregnancy, transit time in the digestive tract extends, water content and body fat increases, followed by increased cardiac output, ventilation, and liver and renal blood flow, decreased plasma protein concentration, increased renal sodium reabsorption, and altered metabolic pathways of enzymes in the liver . Drug transport on the placenta, drug compartmentalization of the embryo / fetus and placenta, biotransformation of drugs by the fetus and placenta, and elimination of the drug by the fetus, also result in pharmacokinetics of drugs in pregnant women. Additional consideration of drug use in pregnant women: (CDC 2009; WHO 2009; KEMENKES RI, 2012) 1. Effects of drugs on the fetus and newborn, including teratogenic potential, metagenity, and carcinogenicity 2. Pharmacokinetic as well as drug toxicity transported through the placenta. The consequences that arise in the fetus of the mother for a particular drug, depend not only on the drug itself, but also on the dose of the drug, the age of pregnancy when the fetus is exposed, duration of exposure, interactions with other drugs also exposed to the fetus, and genetics of the mother and fetus.

In the Prevention of Mother to Child Transmission of HIV book, World Health Organization says that ARV treatment decreases viral replication and viral load in

29

mothers, and protects the fetus against HIV exposure. Antiretroviral drugs effectively treat maternal HIV infection and prevent vertical transmission. Treatment should not be equated with prevention (prophylaxis). ARV treatment is a long-term antiretroviral use for treating maternal HIV / AIDS infection, as well as preventing MTCT. While ARV prophylaxis is a short-term antiretroviral use to reduce mother-to-child transmission of HIV to the fetus. Antiretroviral treatment during pregnancy, if indicated, will improve women's health, and reduce the risk of HIV transmission to the fetus, and is recommended in the following situations: 1.If CD4 examination is available, it is recommended to record CD4 cell counts, and offer ARV treatment to patients with: a. Stage IV WHO, regardless of CD4 count b. Stadium III WHO with CD4 < 350/mm3 c.Stadium I or II WHO with CD4 ≤ 200 / mm3 2. If there is no available CD4 examination, it is recommended to offer antiretroviral treatment in patients with: a.Stadium IV WHO, regardless of total lymphocyte count b.Stadium III WHO, regardless of total lymphocyte count c.Stadium II WHO with total lymphocytes ≤1200 / mm3 If antiretroviral treatment is indicated in pregnancy, it should be done immediately. Sometimes treatment is delayed until after the first trimester. Pregnant women receiving ARV treatment require ongoing care and monitoring between local HIV / AIDS programs. If coinfection with TB occured, additional treatment and clinical management are needed to minimize side effects. Principle of antiretroviral treatment in women of childbearing age or pregnant women should be based on the needs and requirements of antiretrovirals as already mentioned. Pregnancy and breastfeeding provide additional problems in maternal and child toxicity, antiretroviral drug selection, and prevention of mother-to-child HIV transmission. First-line regimens recommended for this group are:

30

(d4T atau AZT) + 3TC + NVP

ARV options for HIV infected patients who may still be pregnant, or an unpredictable pregnancy or young pregnancy, then antiretroviral drugs given should be safe for the first trimester of pregnancy. For that group should be avoided giving EFV because it is teratogenic. Women who receive ARV treatment but do not want to become pregnant should use effective and appropriate methods of contraception to prevent unwanted pregnancies, while EFV may remain an NNRTI of choice. Women who have taken ART treatment and then become pregnant must continue treatment with antiretrovirals, but when using EFV, it should be discontinued and replaced by NVP. Hepatotoxicity with symptoms associated with NVP or severe skin rash is uncommon, and tends to occur in women with high CD4 cell counts (> 250 cells / mm3). Toxicity has been reported from a group of pregnant women, but it is not known why pregnancy predisposes to the toxicity. HIV infected patients’s women who have had single-dose prophylactic NVP or 3TC PMTCT should be considered eligible for NNRTI-containing regimens and should have access to lifetime ARVs until there is definite data on this problem. Many countries have considered the use of short-term triple-drug therapy for PMTCT in HIV infected patients’s women who do not need antiretrovirals for themselves, and postpartum therapy is discontinued if it does not meet the clinical criteria for ARV administration. Use a highly active combination is expected to prevent perinatal transmission to the infant. However, this intervention also give the risk of drug toxicity to the mother and baby in condition of still healthy mothers and does not require antiretroviral drugs. In a condition where it is necessary to select a protease inhibitor during pregnancy, SQV / r or NFV is the best choice because it is safe enough for pregnant women. Antiretroviral drugs have potential to increase or decrease the bioavailability of steroid hormones and hormonal contraceptives. Limited data show an interraction between some ARV drugs (especially some NNRTIs and PI) with hormonal contraceptives and may alter the safety of both contraceptive and antiretroviral hormones. It is not known whether contraceptives containing only injectable progesterone (eg, medroxyprogesterone acetetate and norethisterone enentate) are also 31

threatened its effecacy, because this method provides higher levels of hormones in the blood than other progesterone contraceptives as well as combined oral contraceptives. So, if women with ARV treatment will initiate or continue hormonal contraceptives, it is always advisable to always use condoms to prevent HIV transmission and also to maintain the possibility of decreasing the effectiveness of hormonal contraception used. In developing countries there are several antiretroviral regimens to prevent transmission from mother to fetus / baby recommended: 1. Nevirapine Mothers received nevirapine 200 mg single dose at labor. Baby 2 mg / kgBB before the age of 3 days (within the first 72 hours after birth). This regimen is an option because it is easy to its administer, does not need repeat therapy and effectively prevents mother-to-child transmission up to 13%, and is economical. Economic factors are noticed because ARV cost are relatively expensive and its principle ARVs should be given for longlife. Nevirapine can cause skin rashes, Steven-Johnson syndrome, increased serum aminotransferase, and hepatitis. 2. AZT Pregnant women with 36 weeks gestation were given AZT 2 x 300 mg / day, and 300 mg every 3 hours during labor. This regimen is more effective to reduce the risk of mother-to-child transmission (9%), but more expensive, because it requires recurrent therapy with duration of therapy until 1 month. Given the relative cost of the drug, then most regimens are used according to local conditions. Side effects are common in pregnant women who consume AZT is anemia, therefore it is necessary to screen for anemia and its treatment if anemia occured. Other side effects of zidovudine are netropenia, gastrointestinal intolerance, headache, insomnia, myopathy, lactic acidosis. Administration of antiretrovirals in pregnant women does not cause resistance of antiretroviral therapy, because its administration is short-lived,less than 3 months. Although it is known there is the possibility of single therapy with nevirapine may cause rapid resitance, however so far there is no evidence for that. 32

Table 4. Guideliness of ARV Treatment in PMTCT

CLinical condition 1.

HIV infected patient with pregnancy

2.

Regiment for Mother (dose according to table 3) - Make sure that aren’t pregnancy before starting ARV

probability who

- Avoid use EFV

ARV-indicated

- AZT + 3TC + NVP or

HIV infected

- d4T + 3TC + NVP - Continue ARV regiment were

patients with ARV, then pregnancy

using - If get treatment with EFV trimester pregnancy. - Continue same ARV treatment

Pregnant infected

- AZT (4mg/kgBB every 12 hours) for 1 week or

changed with NVP or PI in first

3.

Regiment for baby

during labor and post labor - Delay ARV until after first

- NVP (2mg/kgBB) single dose or - NVP single dose + AZT for 1 week - NVP single dose for first

HIV patients with

trisemester if possible. In bad

72 hours + AZT for 1

ARV indication

condition need considered about

week or

advantage-disadvantage of ART

- AZT for 1 week or

use.

- NVP single dose for first

- ARV like in usual HIV infected

72 hours

patients - First line ARV: AZT + 3TC + NVP or - d4T + 3TC + NVP - EFV may not given in first 4.

Pregnant infected

trisemester pregnancy - AZT started at 28 weeks

- NVP single dose in first

HIV patients, but

gestation or soon after that, then

72 hours + AZT for 1

there isn’t ARV

continue during labor +

week

indication yet

- NVP single dose in the beginning of labor

33

Alternative regiments:

- AZT for 1 week

- AZT started at 28 weeks gestation or soon after that, continued during labor - AZT + 3TC: since 28 weeks gestation or soon after that,

- AZT + 3TC (2mg/kgBB) for 1 week

continued during labor period until one week post labor - NVP single dose intrapartum

- NVP single dose in 72 hours

5.

Pregnant infected

- According to 4th point, but it is

HIV patients with

better to use most effective

ARV indication but

regiments

haven’t started the 6.

therapy yet Pregnant infected

If considered to use ARV:

HIV patients with

- AZT + 3TC + SQV/r or

active TB

- D4T + 3TC + SQV/r

The appropiate of

If treatment started in trimester III:

antiTB drugs for

- AZT + 3TC + EFV or d4T +

pregnant woman

7.

3TC + EFV

still given.

- If you’re not using ARV therapy,

Pregnant mother in

follow point 4 Bila sempat tawarkan pemeriksaan dan konseling pada ibu yang

labor period with

belum diketahui status HIV-nya, bila tidak, lakukan pemeriksaan dan

unknown HIV status

konseling segera setelah persalinan (dengan persetujuan) dan ikuti

Or

butir 8 If positive:

HIV infected patients who visite when labor but don’t get ARV therapy yet

- Give NVP single dose - If the labor happened, don’t give NVP, but follow point 8, or

- NVP single dose in first 72 hours - AZT + 3TC during 1 week

- AZT + 3TC in labor until 1 week post labor

8.

Baby from HIV

NVP single dose as soon as

infected patients

possible + AZT for 1 week. If

who never get ARV

given after > 2 days it’s less

therapy yet

benefit

* From: ”Recommendation on ARVs and MTCT Prevention 2004”. WHO July 2004 G. Safety and Toxicity of Anti HIV Treatment during Pregnancy

34

Information about anti HIV treatment for pregnant women is limited compared with nonpregnant adult women, but it is well known to recommend the suitable treatments for both mother and baby. However, according to the Perinatal HIV Guidlines Working Group in 2005 the long-term effects of ARV treatment on in-utero fetus are still unknown. One of the treatment regimens that can be used is non-nucleoside reverse transcriptase inhibitors (NNRTIs) niverapine (NVP). Long-term use of NVP may cause some negative side effects such as fatigue or weakness, nausea, loss of appetite, yellowing of eyes or skin, or signs of liver toxicity such as liver hardening or enlarging or enhancing liver enzymes. These effects have not been found in the shortterm (one or two dose) NVPs during pregnancy. The condition of the patient during treatment with NVP should be monitored because, pregnancy may cause some early symptoms of liver toxicity. The use of NVP also requires attention in women who have never received anti-HIV treatment as well as in women with CD4> 250 cells / mm3. Liver toxicity is more common in these patients. Delavirdine and efavirenz, are NDA-approved NNRTIs, but are not recommended for use in HIV-positive pregnant women. Use of this drug during pregnancy can lead to birth defects. Nucleoside reverse transcriptase inhibitors (NRTIs) can cause mitochondrial toxicity, which can lead to accumulation of lactic acid in the blood. This toxicity is known as hyperlactemia or lactic acidosis. This toxicity may be considered for pregnant women and their infants who will be exposed to NRTIs in-utero. Protease Inhibitors (PIs) are associated with elevated blood sugar or hyperglycemia, onset of diabetes mellitus, or onset of symptoms of diabetes mellitus, and diabetic ketoacidosis. Pregnancy is also a risk factor for hyperglycemia, but it is not known whether the use of protease inhibitors increases the risk of hyperglycemia associated with pregnancy or gestational diabetes. Enfuvirtide (T-20) is the only FDA-approved Fusion Inhibitor, very little is known about its use during pregnancy.

H. Handling of Labor 35

Most HIV transmission to the fetus / infant occurs during labor, so the current treatment is very important to protect against infant HIV infection. According to the Perinatal HIV Guidlines Working Group in 2005, there are several treatment regimens that can reduce the risk of transmission to infants. Regimens commonly used are three part ZDV regimens: 1.Pregnant woman with HIV ZDV begins at 14 to 34 weeks pregnancy with dose 5 x 100 mg, or 3 x 200 mg, or 2 x 300 mg 2.Labor At the time of labor, intravenous administration of ZDV is administered 3.Baby Babies delivered are given ZDV in liquid form every 6 hours for 6 weeks after birth. If during pregnancy, an HIV-positive pregnant woman has received other antiHIV medications, then the treatment is continued as scheduled during labor. The choice of labor for pregnant women with HIV is positive, depending on their health and treatment. Labor may be vaginal or operative with cesarean section. Selection of labor should be discussed first during pregnancy, as early as possible. Caesarean section is recommended for HIV-positive pregnant women with: 1. Number of unknown virus or > 1000 / mL at 36 weeks gestation 2. Have not received anti-HIV treatment or just received zidovudine during pregnancy 3. Have never received prenatal care until 36 weeks of gestation or more To be more effective in preventing transmission, cesarean section should be scheduled at 38 weeks gestation, and should be performed before rupture of membranes. Vaginal delivery is preferred choice of labor for HIV-positive pregnant women by: 1. Have obtained prenatal care during pregnancy 2. Viral load <1000 / mL at 36 weeks gestation 3. Get ZDV treatment with or without other anti-HIV drugs.

36

Vaginal delivery can also be performed in HIV-positive pregnant women when the membranes are ruptured, and labor is rapid. All labor methods are at risk, but the risk of HIV transmission from HIV-positive pregnant women to their babies is higher in vaginal delivery than in planned cesarean section. For the mother, cesarean section increases the risk of infection, problems associated with anesthesia, and other risks associated with operative action. For infants, cesarean section increases the risk of infant respiratory distress. Intravenous administration of ZDV (i.v) begins 3 hours before cesarean section, and resumes after the baby is born. ZDV i.v should be given during labor and after the baby is born in vaginal labor. It is also important to do is to minimize the baby's contact to the mother's blood. This can be done by avoiding invasive examination, as well as vacuum or forceps labor. All babies have born from HIV positive women should receive anti-HIV treatment to prevent HIV transmission. Treatment is minimal with the administration of ZDV for 6 weeks, sometimes also with additional other drug. If it has been decided to perform scheduled cesarean section to avoid transmission of HIV virus, ACOG recommends doing it at 38 weeks' gestation, judging by the best-presumed clinical condition and avoiding rupture of membranes. In women not infected with the HIV virus, cesarean section management without knowing fetal lung maturity, according to ACOG, is delayed until 39 weeks of gestation, or at the time of entering labor, to reduce possibility complications in the fetus. Cesarean section between 38 and 39 weeks' gestation has little difference in possibility of increased infant respiratory distress, which requires mechanical ventilation. This increased risk was matched by the incidence of labor risks and rupture of membranes before reaching 39 weeks' gestation. In women who have been scheduled for cesarean section, ZDV administration should be started 3 hours before the operative, in accordance with standard recommendation dosage. Other antiretroviral treatments used during pregnancy should be continued at the time of labor, and during labor. With increased maternal morbidity due to infection, consideration should also be given to perioperative prophylactic antibiotics, although there has been no research on their efficiency. Rupture of amniotic fluid, increased incidence of perinatal transmission, in women not receiving antiretroviral treatment. In women receiving ZDV treatment, studies have shown increased risk of transmission of ruptured membranes 4 hours or 37

more before labor. Obstetric procedures increase the risk of fetal exposure to maternal blood, such as amniocentesis, as well as invasive monitoring should be avoided. This procedure should be performed only if indicated. If premature rupture of the membranes occurs,before labor, action should be taken to shorten the labor time, such as oxytocin,can be thought. Recommended prevention of vertical HIV transmission to the fetus: 1. Efforts to maximize the health of pregnant women, give the combination antiretroviral therapy, is expected to reduce the number of viruses as well as rates of vertical transmission. The minimum reduction in HIV transmission, recommended by ZDV regimen of prophylaxis according to PACTG 076. 2. HIV-1 RNA plasma levels should be monitored during pregnancy according to standards of HIV infection in adults. 3. Perinatal HIV transmission may be decreased by planned cesarean section, in women with unknown HIV-1 RNA levels, who are not receiving antiretroviral treatment, or simply obtain ZDV prophylaxis. 4. Women with HIV-1 RNA levels> 1000 / ml, should be consulted to discuss the planned cesarean section action to reduce the risk of vertical transmission. 5. The management of women who have planned for cesarean section and come with ruptured membranes, or come into labor, should be based on the length of time of ruptured membranes, the course of delivery, the level of plasma HIV-1 RNA, previous antiretroviral treatment, and other clinical factors. It remains unclear whether the benefit of cesarean section after rupture of membranes, or after labor is present. 6. The woman should also obtain an explanation of the risks associated with cesarean section. Risks that arise must be balanced with the benefits gained for the fetus. 7. The woman should also be consulted on limited data. Decisions about delivery to be performed should be respected. I. Labor for Pregnant Women with HIV Positive in Indonesia Directorate

General

of

Communicable

Disease

Eradication

and

Environmental Health Ministry of Health of Republic of Indonesia said in 2003, in developed countries, cesarean section before start of labor can reduce the risk of mother to child transmission until 80% (1.8% compared with 10.5%). A study of 8533 38

mother and child pairs in North America and Europe found that elective cesarean section before inpartu and before rupture of membranes could reduce the risk of mother-to-child HIV transmission by 50% compared with vaginal labor. When elective cesarean section is accompanied by use of antiretroviral treatment, then risk can be reduced to 87%. When cesarean section is compared with antiretroviral treatment with a vaginal labor accompanied by antiretroviral treatment, the incidence of transmission becomes 2% in elective cesarean section and 7.3% in the vaginal section. However, cesarean section is not an operation without risk, especially in people living with HIV where the immunity is very weak. In Zambia it was reported that 75% of HIV infected patients delays in wound healing with increased risk of infection. In Ruwanda, cesarean section even causes death of people living with HIV / AIDS increased. WHO does not recommend for cesarean section, but it also does not prohibit considering conditions in each different area, it should consider the cost of surgery, facilities for the action, complications that can result from low maternal immunity. (CDC 2009; WHO 2009; KEMENKES RI, 2012) Unacceptable action as it increases the risk of mother-to-child transmission of HIV is unnecessary invasive obstetric action, and can be a pathway to HIV transmission, such as: 1. Routine episiotomy 2. Vacuum extraction 3. Cunam extraction 4. Precomplete opening of amniotic membranes rupture 5. Internal examination frequently 6. Monitor fetal blood gas analysis during labor where blood samples are taken from the scalp of the fetus.

39

Table 5. Protective Equipment for Medical Personnel

Type of Action

Hand

Gloves

Mask

+

-

-

+

+

+

Glasse

Hat

Apron

Dress

Boots

-

-

-

-

-

-

-

-

-

-

-

+

-

-

-

-

-

-

+

+

-

-

-

-

-

-

+

+

-

-

-

-

-

-

+

+

-

-

-

-

-

-

+

+

-

-

-

-

-

-

toucher) Help in labor Bathing the

+

+

+

+

+

+

+

+

baby Clean the room Wash the

+

+

-

-

-

-

-

-

+

+

-

-

-

+/-

-

+/-

+

+

-

-

-

+/-

-

-

+

+

+/-

+/-

+/-

+

+/-

+

Washing

s

Physical examination of intac skin Physical examination of wound skin Take blood sample Inject intravena Clean the wound/ venasection Urine catheteritation Pelvic examination (vaginal

dishes/ cutlery Washing clothes

J. Postpartum for HIV Positive Women and their infants Treatment for postpartum women with HIV should, as far as possible, be discussed during pregnancy or shortly after delivery. Perinatal HIV Guidlines Working Group in 2005 said, babies born from women with HIV positive, received different HIV examination from adults. In adults examination is performed to look for HIV antibodies in the blood. Babies store maternal antibodies in their blood, including HIV antibodies, for several months after birth. Thus, antibody tests given before a 1year-old baby will get a positive result even if the baby is not HIV-infected. For the first year, infants are screened for HIV directly, not to look for HIV antibodies. Infants

40

aged > 1 year, no longer have antibodies from their mothers, so they can be tested for HIV antibodies. Preliminary HIV examination for infants is usually performed on: 1. Between 48 hours after birth 2.Between 1 - 2 months 3. Between 3 - 6 months Infants are suspected of being infected with HIV if the results are positive on two of the above examination. At 12 months of age, infants who have preliminary positive results should be screened for HIV antibodies to ensure infection. Infants with HIV negative antibody examination, currently uninfected with HIV. Infants with HIV positive antibody examination should be reexamined at 15 to 18 months of age. Infants born from HIV positive women should be screened for Complete Blood Count (CBC) after birth. Infants should also be monitored for signs of anemia, which is a negative side effect of ZDV treatment for 6 weeks given to infants. The baby should also have routine blood examination, as well as other immunizations. All infants born from HIV positive women are recommended to receive oral ZDV treatment for 6 weeks to prevent HIV transmission from their mother. This oral ZDV regimen should start 6 to 12 hours after the baby is born. Giving ZDV can also be combined with other ARVs. In addition to antiretroviral treatment, infants should also receive treatment to prevent P. carinii / jiroveci pneumonia (PCP). The recommended treatment is with a combination of sulfamethoxazole and trimethoprim. This treatment should be started when the baby is 4-6 weeks old and continued until the baby is HIV negative. When the results of the HIV positive infant, then the treatment continues. Give the explanation to the patient to be able to obtain appropriate health care and other support services for mother and baby: 1.Health care routine 2. Special care for HIV 3. Family plan 41

4. Physchiatry services 5. Substance abuse treatment 6. Case management HIV positive women are not expected to breastfeed their babies to prevent HIV transmission through breast milk. During postpartum period, physical and emotional changes can occur, along with the pressure and responsibility for caring the baby, it can be difficult in continuing the ARV regimen treatment. It should also be discussed to the patient regarding: 1.It is not understood about the regimen of medication and good treatment 2. Depression (many women who experience it after childbirth) 3. Long-term plan to continue health care and antiretroviral treatment for mother and baby. K. Postpartum Handling in Indonesia In accordance with the Directorate General of Communicable Disease Eradication and Environmental Health of the Ministry of Health of the Republic of Indonesia in 2003, there are several things that should be considered postpartum, among others: 1.Contraceptives If the baby is not breastfed, the contraceptive effects of lactation will be lost, so the couple should use contraception to avoid or delay the next pregnancy. HIV infected patients already have to use contraceptives no later than 4 weeks post partum. 2. Breastfeeding For mothers with no known serologic status, breastfeeding is recommended exclusively for 6 months, and may be continued for up to 2 years or more. Alternative food is given since the baby is 6 months old. For HIV-positive women, it is not advisable to breastfeed their babies, since HIV can occur between 10-20%, especially if there is a blister on the breast, or mastitis. 42

Conversely if not breastfeeding, infants will be at risk for malnutrition and susceptible to infectious diseases including HIV. In situations where mothers can not buy formula, unlikely environments such as unavailability of clean water and sociocultural , when formula feeding is unacceptable, unfavorable, unreachable, unsustainable, insecure, infants may be exclusively breastfed until age 4 - 6 months, then immediately weaned. Approximately 50 - 75% of infants breastfed by HIV-infected mothers are infected with HIV in the first 6 months of life, but infants who are exclusively breastfed for 6 months are at lower risk than infants who receive additional food. In infants receiving supplementary foods at <6 months of age, early immunologic stimulation from premature food may result digestive disorders resulting in increased intestinal permeability, which may be the site for entry of HIV. Exclusive breastfeeding for 4-6 months reduces morbidity and mortality from non-HIV infections. Supplementary feeding is also associated with the risk of mastitis, due to breast milk accumulated in the mother's breast. Another way to avoid transmission of HIV, by warming milk above 66 C to kill the HIV virus and breastfeeding only done in the first months only. PASI (Breast Milk Substitute) can be prepared from animal milk such as cow, buffalo, goat. Pure animal milk contains too much protein, so it can damage the kidneys and disrupt the baby's intestines, then milk should be diluted with water, and added sugar to energy. PASI should be given with a cup, because it is easier to clean than bottles. Giving mixed foods such as milk, food, juice, and water is not permitted because it can increase the risk of transmission and increased infant mortality. If possible, formula milk is given, otherwise breastfeeding may be exclusively administered for 6 full months, then immediately weaned. Before receiving antiretroviral treatment, mothers need counseling. As per the ARV protocol, at least 6 months should check CD4. Antiretroviral treatment is increasingly important after the mother gives birth, because the mother must take care of her child until quite large. Without antiretroviral treatment it is feared maternal age is not long enough.Baby should get immunization like a healthy baby. HIV testing should be done when the baby is 12 months old, and if positive is repeated at age 18 month. There are various ways to stop breastmilk production in HIV mothers such as drugs containing bromocryptine mesylate, estrogen or natural preparations such as

43

breast bacilli, the principle also does not stimulate the nipple that can stimulate milk production.

CHAPTER IV DISCUSSION

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A case has been discussed about HIV in pregnancy. A 35-year-old female patient is pregnant with a fourth child form sixth pregnancy. Patients are known rapid test reactive in the first screening and referred to VCT policlinic at Sungai Dareh Regional Hospital, the patient did not come. Patien came to primary health care at Dharmasraya with chief complain fluid leakage from vagina, and Patient was referred to Sungai dareh Regional Hospital, patient was recheck and the result was negative and then the patient was referred to Dr. M. Djamil Central General Hospital with IV line access due to there hasn’t prepare facilities. Rapid test for HIV was performed in Dr. M Djamil Central General Hospital and the result was non Reaktive and was planned to take vaginal delivery. As a guide to the discussion on target academically comprehensive scientific then we will discusss some of the reference questions are as follows : 1. Whether the diagnose of this patient was right ? 2. Whether the management of this patient was appropriate ? 1. Whether the diagnose of this patient was right ? Discussion based on the questions are : Known by anamnese this patient was a multiparous, haven't had menstrual since 9 months ago but forgot the first day of last menstrual period. On physical examination, abdomen was enlarge equal to term pregnancy, fundus uterine was felt 3 fingers below processus xyphoideus, uterine fundal height was 35 cm. From the ultrasound examination, confirmed by biometry, placental grading that this patient have reached term pregnancy. From the anamnese, we found that patient was control pregnancy to primary health care at Dharmasraya a month ago and do screening for HIV and the result was positive. Patient given information and consultation about the result and referred to VCT polyclinic at Sungai dareh Regional Hospital but she didn’t come because of transportation.

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Patien came to primary health care at Dharmasraya 12 hours ago with chief complain fluid leakage from vagina, smelled fishy, greenish color and wetting one piece of cloth, Patient was referred to Sungai dareh Regional Hospital, patient was recheck and the result was negative and then the patient was referred to Dr. M. Djamil Central General Hospital with IV line access due to there hasn’t prepare facilities

On physical examination, found that uterine contraction was adequate which last 23x/35”/moderate, then from vaginal toucher we have got that cervical dilatation is 5-6 cm, amnion membrane negative and Nitrazine test (+). This mean that the patient occured in progression of labor, which is the first stage of active phase. Laboratory result for HIV rapid test non reactive. Based on anamnese, physical and assisted examination, the diagnose of this patient was correct, a G6P3A2L3 term pregnancy first stage of laten phase + history 12 hours PROM + HIV (+) Suspected. Fetal alive singleton intrauterin head presentation, Small fontanel was palpable left anterior, Hodge II-III

2. Whether the management of this patient was appropriate ? This patient pregnancy was planned to be terminated by Vaginal Delivery . the patient not met the HIV criteria by rapid test. HIV positive if examination A1,A2 and A3 show reactive results. A1 result maybe positive because this test use for screening procedure and the reagent has high sensitivity, and but not high specificity. In this case, there is no information on the type of reagent has been used. Based on the HIV diagnosis algorithm was recommended by health ministry of Indonesia Republic, result of first A1 examination can be used as a consideration for examination reagent A2. If the result of A2 reagent examination is also non reactive then it can be said that this patien is HIV negative, and vaginal delivery is the proper choice for this patient.

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CHAPTER V CONCLUSION

1.

The diagnose of this patient was correct, a G6P3A2L3 term pregnancy first stage of laten phase + history 12 hours PROM + HIV (+) Suspected. Fetal alive singleton intrauterin head presentation, Small fontanel was palpable left anterior, Hodge II-III

2.

The management on this case was correct by doing the vaginal delivery was the best choice for this patient.

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REFERENCES Direktorat Jendral Pemberantasan Penyakit Menular dan Penyehatan Lingkungan Departemen Kesehatan Republik Indonesia : Pedoman Nasional Perawatan, Dukungan, dan Pengobatan bagi ODHA. Jakarta. 2008 AIDS info : HIV During Pregnancy, Labor, and Delivery, and After Birth. http://aidsinfo.nih.gov. 2010 Perinatal HIV Guidelines Working Group : Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Helath and Intervensions to Reduce Perinatal HIV-1 Transmission in the United States. http://aidsinfo.nih.gov. 2010 Direktorat Jendral Pemberantasan Penyakit Menular dan Penyehatan Lingkungan Departemen Kesehatan Republik Indonesia : Pedoman Nasional Terapi Antiretroviral. Jakarta. 2009 WHO : Prevention of Mother to Child Transmission of HIV, Generic Training Package, Pocket Guide. http://www.who.int/hiv/en. 2009 Komisi Penanggulangan AIDS.2007 McFarland, Elizabeth 2003; Yunihastuti E dkk, 2003 PMTCT Depkes. 2008 Perinatal HIV guideline Working Group.2012. www.google.com

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