BHIVA Guidelines 2025- Management of HIV in pregnancy and the postpartum period 2025

will now be recorded. >> Welcome to class people. So today class will be on the ba guidelines because uh update has been there um in 2025 because of that you know I'm taking this class to make the things easy though it's a big guideline okay so let's start so some some basics so HIV the vertical transmission risk is 25 to 40% to uh and it increases to 40% in the breastfeeding So the vertical transmission rate is very high for HIV. Okay. In UK vertical transmission if the woman is on um art and avoid breastfeeding then it will be 1%. And the transmission rate if the woman is on a art and undetectable viral load undetectable viral load that means less than 50 then it is the lowest transmission that is 0.57%. So the this is just small certain percentages that would be necessary for part two people mo mostly but part three people also because they have to tell their role player that how art is going to reduce the risk of transmission to their baby. Now just this is a small basics. The roots of transmission is like uh infected body secretions vaginal fluid, semen, blood via pregnancy or breastfeeding. Usually what this virus causes it causes affects the CD4 cells because of if the treatment is not there then the virus will start continue reproduce and the CD4 count will drop because of that what really happens the CD4 cell count it drops if the treatment is not done so and CD4 when it becomes less than 200 100 then the person it will proceed virus will further proceed to the like imunocmpromised state and acquired immuno deficiency syndromes AIDS will happen. So but uh if the treatment is done with the art and the viral load is undetectable then there is no risk of transmission to uh uh other people by the unprotected sex. So the treat treatment and un to achieve the undetectable viral load then the risk of transmission even with the sex is not there. Because of that it is very important that virus has to be detected early and proper treatment has to be done and the people would have long and healthy lives. Now this is just from the strategy. I just put it because sometime part two people will get question that how much is the risk of transmission with what type of exposure. So nothing to explain here. Now what are the prevention strategies just a basic again use of condoms and the preventions would include like preexposure profile access. Pre-exposure profiles is usually troada that is taken before and after sex to prevent contacting HIV if a the partner is HIV positive. Apart from this TAP that is a post exposure profile accessis usually it has to be started within 72 hours. Then um medication has to be taken for 28 days. Apart from this during pregnancy screening and effective treatment this is just an basics. Now uh from here we are going to start the guideline. Now the what the guideline says the usually as we already know at the booking visit that happens according to the nice guiding less than 10 weeks of pregnancy some screening tests are done in that is done for arranged for the all women in the pregnancy but sometime what will happen the woman will decline the screening so if a woman is declining the HIV screening what to be done then face to to face appointment with the HIV team or a sexual health advisor apart to explain uh the benefits of uh um testing to the pregnant mother and their infants. If now if the mother is not tested then HIV testing HIV antibbody testing or HIV RNA DNA polymerase testing can be done for the baby. If the infant testing is also declined then GP has to be informed about it and woman has to be further followed up in the postnatal period for the again counseling. So why I have put this because sometime your questions will be like that that the woman has ref refused the HIV testing what is the next step and even the part three exam also you get a task like that that the woman has you know refused HIV testing so what to do further so this would be the sequence that helps to guide your answers now something you also know is that is there in this guideline is u uh like u uh equal to u um that that is a un that that is a sort of a marker for undetectable viral load. This is picture from the internet because it is important to understand what this sign means. There is a so bash guideline UK bash guideline PP guidelines summarize evidence for UU criteria there is undeductible viral load. So these are the criteria there should be history of good adherence to medication. Person should be taking art as prescribed. HIV viral load has to be less than 200 for six at least six month and there has to have a less than 200 uh copies within last 6 month. So these are the uyu criteria but u according to the bash guidelines. Okay. So u uyu criteria means undetectable viral load. Now preconception advice it is routine. what is there in what is given to all other women also just in folic acid application. So these are like usual dos is given that we already know it is a 400 microgram. What are the indications for five mg folic acid? This is common question for part two and also part three people also should know that. So these are the indication where highdose folic acid is required though it is not related to you know like HIV but it is mentioned in the guidelines so I put a screenshot. So, so the if the person or the partner have NTD, previous baby has NTD, their family history of NTD, the the patient has diabetes, they are on an epilepsy, BMI more than 30 or this is new that was not given prior. If a patient has an beriatric surgery then also highdose folic acid that is a 5 migram is given. Okay. So this could be an MC like spa. You guys should remember all these where the indications for um highdosese folic acid. Okay. Now anti what the guidelines says a person who is newly diagnosed or not uh engaged like previously diagnosed but they are not engaged in HIV care for last two month 12 weeks sorry two 12 months like then they should be referred within two weeks uh two uh within the within two weeks the person has to be referred to the by the maternity services. So this could be a sort of your SBA they can ask that newly diagnosed woman when it has to be referred to HIV services within 2 weeks time. Okay. Now what are who are the member all are the members of HIV MDT HIV specialist or HIV physician specialist midwife pediatrician and a peer mentor or you can say just a counselor. Now u psychological support yes there should be screening um for antiatal depression even for the postnatal depression. So these are the questions that we used for screening for the perinatal depression. That is the wool questions. Everybody knows it. Just a reminder again. So first question during past month have you been felt by um bothered by feeling low depressed? Last past months have you been bothered by taking less interest in doing thing? If she says yes then third question is uh any something she require any help. These are the wool's question. This again is an MC SBA anxiety question over last two weeks bothered by feeling nervous or an age or over last weeks. Two weeks have you been bothered by not able to stop or control your worries. So um uh these are the scores and if the woman says yes to depression question and the anxiety score is more than three on the anxiety screening questions. The name of this is the gap to screening for anxiety then the referral has to be done to the local perinatal mental health team. This you already know from your nice postnatal guideline but still you should be aware of that because these are the common things that are necessary for part two and part three people. Now about the sexual health screening. So if your person got to get diagnosed with an HIV then sexual health screening to be done as early as possible. Okay. It has to be done as early as possible and apart from this like they should be repeated 28 weeks when there is on because where there may be an ongoing risk. So it should be when a person is diagnosed there should be STD screen as early as possible and if there is any risk that continuation of any activities there or any risk factor is there then repeat at 28 weeks. If any STD infection has been diagnosed then then the treatment would be as per the bash guidelines. Okay. Apart from this uh like immunization for the pregnant woman is again the same national guidelines but people used to confuse so I put a slide on that. So uh like previously long back the there was u like RCOG guideline on uh HIV and also there was a leaflet and some additional vaccinations were given in those leaflets in the guideline and the people used to get confused with that but you have to follow all part two and part three people the like bash guidelines and this is all what the bash says about the immunization. You should be aware of that it has to be done according to the like national guidance. So what they say that influen influen vaccine to be offered to all women at any stage of pregnancy. Pertasis can be offered to all pregnant women from 16 weeks by 32 weeks of pregnancy. RSV vaccine from 28 weeks onwards up to delivery and like uh there should be in pertasis vaccine and RSV vaccine there should be at or co influenza or covid vaccines um there should be a gap of like 2 weeks for the optimal imunogenicity. Apart from this covid vaccines uh seasonal booster has to be offered as a national guid national guidance MMR or live vaccines in the pregnancy we are not offering that that is for everyone because there could be the risk of infection to the fetus because of the live vaccine and if the woman is not immune to rebella then MMR can be offered soon after delivery. If the patient has been offered MMR vaccination, they had to avoid pregnancy for one uh one one month because this is a live vaccine. Okay. So this is a update about immunization in the pregnancy. So and it is as per national guidance. There is no change if the woman get has an HIV infection in the pregnancy. So please people don't get confused only these are the routine investigation immunization that as per the like uh national guidance okay now diagnosis so diagnosis usually during pregnancy 95% of the women are screened and the blood sample is taken for HIV antibbody and P4 antigen P4 antigen can be detectable within 1 month of infection but antibbody takes longer time. We already know it is in 3 months because of that we always repeat this would be the window period. So we repeat the test after 3 months or 12 weeks time. If one confirmation if one test is done usually second confirmation test is also done and uh if the patient is like kind of increased risk of infection because of any ongoing risk then repeat test is done. There are rapid tests are also there. If the unknown stat status is there then it usually takes 20 minutes to perform. Apart from this there uh even the home kits are also available with the home kits they can order it online and you know from the drop of a blood as the routine testing is done for sugars and all. So they can do with a kit they can test um apart from this from the drop of saliva it can also done. So it can be so diagn like HIV testing can be done um by the self- testing with the online available kits also. Okay. But any test that is done by uh online ordering kits and all these are usually the rapid test they has to be repeated uh confirmed with a laboratory test. Okay. Now some basic about the art that would be necessary. So ARD has been uh okay previous guideline they used to say C but again in this new guideline they have change the terminology to art. So it is important to understand the medication the art medication they are in certain groups these are NRTI the that is a nucleotide reverse transcriptise inhibitors NNRTI nonucleotide reverse transcriptise inhibitors protease inhibitors integrase inhibitor boosters are also there apart from this there are certain other drugs uh drugs are also there these are used in the rare cases but these are so uncommon so I have not added to this uh this list. What are the NRTIs? So NRTI is usually uh you know three do three drug combination is given. So us but uh they keep changing it mostly it is like NRTI two medications are given from NRTI. So these could be any combination. These are u abacavir emissen lamodin zerodin tenophair two variants are there. These are disproxil and um tenopir alafenomhide. Okay. So these are the nrti apart from no need to remember that just reading once would be fine. These are NDI. These are like uh like non nucleotide reverse transcriptise inhibitors. What are the medication? These are the common medications but we should know the if virance and also nea pen. So these are the medication we usually we see in the art regimens. There are integras inhibitors. These are like dto uh rela uh relatia gave. So these are the two drugs usually we see because of that I have underlined that. Then there are proteus inhibitor. These are lupinavir and durina vir. Apart from the these are there are certain booster drugs. The booster drugs usually added to boost uh like um to boost uh a small dose of booster drug is added that makes liver break down the primary drug more slowly kind of boosting the effect. These are retino retronavir and these are the medications are there. Apart from this there are certain other categories of medications are also there but they as I said they are used very rarely. So I didn't put here. Now these are the again these are the uh uh use of arts in the pregnancy and the pregnancy outcome. So usually they will be using uh NRTI. So like uh nucleotide reverse transcriptise inhibitors the usually these are the it is the backbone and the anchor preferred anchoring agent or the second agent will be this there could be some alternative anchoring agent. So these are the choices um of a first line art when starting in the pregnancy. So these are the kind of like regimens. So doto gear plus micetrain or tennop dx or doto gear plus micetrain um tennop af. Okay. So these are various combinations are there but I think if you know one that would be enough. Okay. So uh either this or this one at least you should be a uh aware of otherwise too much. So uh is it is not asked in the exam also and it is difficult to remember also. Okay. So these this is the three first line three D drug combination dotoir plus and these are NRTI amitrain and tenophair DX. It is the second combination where ten field dx is uh replaced by tenovo um air. Okay. So minimum small this thing as a baseline you should be aware of rest it is too much no one can remember. Now people this I already told so people are treated with tinoid DX emitrain and dolto gear the combination I have already I have already told you okay so uh when to start art this is important whenever the person is get diagnosed then uh art should be started as early as possible or as soon as possible when the diagnosis is If the viral load is more than one lakh or CD4 count is less than 200 then it should be started in the first trimester. Okay, this is very important you know for both part two and part three people you should be aware of this. Now otherwise in first trimester usually significant nausea and vomiting is there. So ability to adhere the drug is usually reduced. So aim to be like consist it should be established by 18 to 20 weeks of pregnancy. Usually all women should start less than 24 weeks of pregnancy. Okay. So so all lines are very important. So once diagnosis is done what will be named to start as early as possible usually we want to start by 18 to 20 weeks by sure by 24 weeks there are certain indication for the first line starting that is a viral load more than more than one lakh copies and the CD4 count is less than 200 okay so this you have to remember this is very important apart from this if the like uh u patient is a laboratory monitoring of art in the pregnancy. Now it will be different for the women uh who conceive when they are on the art or when it is new diagnosis is there. So if any new diagnosis is there then the routine investigation will be done um as per the antiatal general antiatal in uh investigations. No uh other investigation is required. Now uh to see whether the stable viological suppression is there or not. If the patient is already on the art that means prior to pregnancy the patient is on art then viral load testing will be done every 2 months and like 36 weeks and delivery. So the um previous guideline here there had been a change CD4 count baseline at first trimester and uh it is only repeated if the CD4 count is less than 350. Okay, this would be the monitoring, lab monitoring, what the guideline recommends if the patient is already on art. Now like uh laboratory monitoring if the starting art in the pregnancy in that situation like viral load testing it should be 2 weeks after the start of art. So we have to see how much the effect is there. Then monthly till it becomes undetectable. Then uh twice every month at 36 weeks and at like uh a delivery. So this is again a change in this guideline very important for both part two and part three people. liver liver function test two to four weeks after starting art and at each visit of it has to be repeated at every antiatal visit. Why we are doing that? Because it art causes hippatto toxicity. There could be increased possibility of study complication such as help syndrome, preeclampsia, offstatic choleistasis, acute fatty liver of pregnancy. So this is the reason we are offering LFT and this is a frequency with which the LFT is to be done if the patient is newly started on art in the pregnancy. Apart from this HIV resistance testing has to be done prior to starting treatment. Now if standard regimen I have already told you if any non-standard regimen they are using then possibly more frequent viral load monitoring and the TDM is therapeutic drug monitoring may be required. So this is done if non-standard regimen is there. So this uh is the frequency of uh anyone asking any question? Any question? Okay. Um uh just a request please keep your mics off. If you guys have any question then you can ask me um put a question or you can write on the chat box also I would answer. Okay. So this is the frequency of monitoring of art when it is starting the pregnancy and you have to learn it because it they will ask question from here. It is fre common area of questions. Now there could be possibility that we have offer started on the art but the incomplete viological responses there in that situation like what they will do how they will define that that uh less than a one log drop at 4 week post initiation. So the viral copies are not uh viological response is not as expected and failure to suppress uh CD4 less more than 400 copies that means the medications are not working that time they may change it on a twice daily regimen or they they can um add other anchoring agent also. Okay. So apart from this the women who are presenting late in the pregnancy. So u late presenter. So again the uh like this is the regimen they are offering them. There is a misetin ten of DX and gear. So at least one first first choice you can just remember this rest the table is very big. It is hard to remember. Just remember one regime in my opinion that would be enough. So this would be the important point where part three station can come. Then the part two question women presented in the labor after spontaneous rupture of membrane summ or it could be pre-term. So usually if the patient comes and with a sor then triple art has to be started immediately and uh additional agents has to be given to preload the you fetus at any gas station. So patient has to be started with this but you know if the rupture of membrane is there then the baby fetus loading has to be done. So this these are the agents for the fetus loading that you guys should be remember aware of. These are additional oral dose of tennopir um tino uh tenopo v dx2 45 mg immediately plus oral neapine 200 mg and IV zerwoodin during the duration of labor. So if the patient is presenting in the with a term and or pre-term and she's with a rupture of membrane so triple art this is the combination the and these are the additional agents why we are offering because we have to kind of preload the fetus and these are the agents used okay you should remember that apart from this it is um IV zuruinine during the duration of labor has to be used and this is a dose so U there could be a question because this was not there in the pri previous guideline. So loading dose of 2 mg per kilogram of body weight for 1 hour. After that it is 1 mg per kilogram of body weight for whole duration of labor until the cord is clamped. So this is important to know because this is are the new additions in this guideline only. Now again they have put a flowchart the woman presenting late in the pregnancy like more than 80 weeks or 28 weeks. Then um for for term and pre-term baby they're offering this and these are the preloading uh this is to load new unit this part I have already explained. Okay, but just I added the flow charts so that you should uh think that the guideline has been fully covered. Then again the woman who is untested woman presenting in the labor. So there should be uh sample taken for urgent testing and uh like usually sample is processed immediately um maximum 24-hour time. If the test is positive then on call uh staff, ostitrician, pediatrician they should be explained about the provisional result and the treatment is done and um to the mother before the confirmatory result is done. So this is a hierarchy that you should be aware of given in the chart given in the guideline. Now uh like management of the woman with varymia in on art like for example the patient is on art but the virus load is still detectable so what to do so need to check for the uh resistance uh HIV resistance testing need to check uh compliance of the patient optimization of regime can be done like regimen what she's offer taking it should include daltu uh dalty garav okay so this medication to be there so basically um in this situation intensification to the four drug regimen and uh weekly viral load testing and directly observed therapy to be considered at 36 weeks the patient is about to deliver and the detectable viral loads what to do so this you have this has to be done intensification to four drug regimen because art contains three drug isn't it viral load weekly and directly observe therapy that means the patient has to take medication in uh in front of a health care professional okay so this is the management of vmia on art in the pregnancy apart from this like uh this uh Again the guidelines what what other thing to be done. So intensification to four do and if detectable viral load is there or in that situation aim for cesarian section and IV zuduodine during uh if the latest viral load is more than one,000 and if the patient is takingir AF then the double dose of uh tenno 4vx to 45 mg to be administered in the labor. So this is again the like uh about the labor part they have explained if the patient has vmia. So four so intensification to four drugs double dose tenuv dx and single dose neapin. Okay. Aim for cesarian ivodine if it is viral load is more than thousand copies and double dose of uh foro v-rex that the double dose will be 245 mg. So these things to be done if the patient is nearing labor in the labor and there had been detectable viral load. Now uh what the antiatal management the antiatal management what they say that the combined testing has to be done nip can be offered. Now if the um like if any invasive testing such as CVS or aminois is required it should not be performed until the HIV status of person is known. So if a patient comes for an invasive testing for high risk result then first the testing is done for HIV status then only the invasive testing would be performed. Okay. So viral that usually we see the viral markers before we do any invasive testing. If the suppression is not there then the test to be delayed till the suppression is there. Each line is important because each line is a stem of a question. Okay. And if invasive procedure require cannot be delayed then intensification of the ART regimen can be done. So triple art and plus dolu gave 50 mg. So this can be given it is put in the guidelines. So I put here but name it is very hard to remember. just intensification of art regimen with the four drug you can say. Now external capalic version it it can be offered if the viral load is less than 50 copies per ml and it was same in the previous guideline also this has been added new fetal surveillance. So patient uh like uh to be uh referred to the clinician who have interest in pre-term birth prevention if risk factors for pre-terms are there. Apart from this it is um now HIV infection is considered to be one of the moderate risk factor when the risk assessment is done for the IUGR. Okay. So in SGA guideline you know there are we uh read the factors mild moderate and high risk factors. So if a patient is having an HIV infection then for the fetal surveillance it is the moderate risk factor. Now management of term preor sorm like before labor rupture of membrane is there. This is favorite question from this slide. the people usually comes it is it is a management uh if the pre-lor SORM so delivery has to be within 24 hours within 24 hours we have to deliver the patient less than 50 copies immediate induction or augmentation okay now if it is 50 to three uh 100 copies then cesarian section if it is more than 400 copies then urgent category 2 cesarian section. If it is more than 50 copies then art regimen to be optimized to reduce the risk of vertical transmission. Viral load assessment to be done at the time of admission and immediate management has to be like based on the recent available viral load result. These are the like these are the question from this number of viral copies the many questions have come previously also and you know this will be the favorite question again. So this part you should guys should be aware of. Now they have added these two new things here that if it is like more than 50 copies then optimization of the regimen and the viral load immediate testing and the treatment is on the basis of recent available viral load testing. Till now anyone of you have got any question? Hello people any question? I think this I should proceed. So again they have added this two two uh things. So pre PROM so it is pre-term preor rupture and now it is okay it is less than 35 weeks or it is less than or equal to 35 weeks. the pre-term pre- labor rupture of membrane PPN is there then what to be done so timing and mode of delivery like less than 35 weeks what to do discussion with MDT apart from this like treatment will be same as per other PPRM treatment but if it is like 35 37 weeks then GBS profile access has to be given though all pre-terms according to GBS guideline GBS profile access is given. Now this is new identity if we want to delay the labor like uh conservative management is is being done for PPM till 37 weeks. So what will be the criteria which are the patient we can offer conservative management if the patient has taken art for more than 10 weeks. Okay. If the two recent load viral loads four weeks apart and they are less than 50 copies. If um the ariththro if conservative management is done then arythroycin has to be given as per RCG guid guideline that we already know. So this part you should be aware of that you may get a question where we can offer conservative management for PPRM. Answer art has been taken more than 10 weeks and the two viral loads within a 4 week time should have undetectable viral loads or the viral load less than 50 copy. So this is the criteria for conservative management less than 37 weeks of pregnancy. Now rupture uh management of P prom but now it is so here it is more than 35 weeks the management what we spoke and here it is less than 35 weeks. So less than 35 weeks then usually multi uh like uh multi if the viral load is more optimization of art multi-disiplinary discussion and if at 35 weeks 4 weeks is there and the patient is GBS carrier then it is beneficial to do expedition of birth. If apart from this what has to be given steroids, arythroycin and GBS profile access okay so this I'm repeating it again ppm less than 35 weeks of pregnancy if the viral load is more than optimization of art multi-disiplinary discussion if GBS carrier positive then expedition of birth at 34 weeks apart from this if the delivery is expedited Then GBS profile access that we offer for all pre-terms. Steroid we offer for all preterms. Ariththroycin we offer for PPM. Now uh pre-term labor if the patient comes with a pre-term labor what could be the management? So optimization of art if the viral load is more than 50 steroids GBS profile axis IVS IV magnesium sulfate for neurop protection and toolsis can be done u so that the steroids or antiviral can be offered till the patient is referred to the I uhos hospital with the neonatal facility so this is the management of preterm Mode of delivery, we already know this. Planned vaginal birth, less than 50 copies. Vback less than 50 copies. Planned section 50 to 399 copies and CS more than 400 equal to copies. Though this is same more than 50 copies, we are offering cesarian only. But the guideline you know have these two differently they have written. So I put the same you already know this is the same as prior previous guideline also timing of birth. Timing of birth is like if the cesarian has to be done then less than 50 copies and uh from like um from 38 weeks onwards. Okay. Now intraartum management the so the patient who have got no additional risk factor they can even can be even delivered in a midway free light care so this part is also important to know that um even the um HIV positive patient can opt for without risk factor so the low-risk women can offer midway free care delayed cord clamping what given in nice intraartum guidelines Delayed cord clamping can be supported if the viral load is less than 50 copies. Okay, new identity in this guideline. Water birth can also be allowed if the viral load is less than 50 copies. These are the indication of IV zuruine and um it has to be given during the duration of labor but it has to be discontinued following C clamping. Okay. So these are the indication you should be aware of when the viral load is more than 1,000 copies. So infusion should start 4 hour prior if it is elective cesarian section. Okay. The patient who present uh who are planning for cesarian or vaginal delivery viral load is more than 1,000 copy and the rupture of membrane is there. an untreated woman without any known viral load present in labor on SRM irrespective of mode of delivery they has to be offered uh IV zuro so this part uh like basically more than 1,000 copies um uh patient planned for cesarian then start IV infusion 4 hour prior any rupture of membrane or un unknown viral load then and the v viral load is more than thousand copies then IV ruodin uh during whole duration of labor apart till the cord is clapped. Okay. So these are indication for IVinine that may be asked in your questions. Now that is all about the maternal treatment that is given in the guideline. Any question till here? No. Okay. New needle management there certain changes are there. Previous guideline divi divides newal management into three categories. Um um but in this guideline there are only you know like previous guideline it was very low risk, low risk and high risk. But in this guideline the new management the units are divided into two parts only low risk and high risk. Okay. So now low risk. So what are the criteria for low risk? This part you guys should be aware of. If the art has been started 10 weeks prior to delivery and if viral load um prior has been there um like 6 weeks prior to delivery and all viral loads within last 10 weeks prior to delivery are less than 50 copies. So these are the criteria. If these criterias are met then usually how many why should patient to be referred for pre-term care? So if the risk factor for like pre-terms are there risk factor for predom pre-term would be like uh previous pre-term previous miscarriage history or uh like previous prom history any less procedure is there. So these are like certain risk factor for pre-term. So if any in the patient history if the any risk factor for pre-tum is there then they should be referred to the person who takes care or pre-term prevention specialist even it is written in the like cervical incompetence guideline. Okay. Uh so these are the criterias people for the low-risk baby and uh for what is the treatment for the low-risk baby would be 2 weeks of zerodine monotherapy. Okay. So 2 weeks of zeroin monotherapy for the low-risk babies. Now these are certain drugs in the charts. So lowrisk 2 weeks and combination therapy for high risk will be for 4 weeks. Okay. So it was given in the one of the ch appendix in the guideline because of that I have put the screenshot but no need to remember just one visual impression would be enough apart from this IV uh therapy is given and um for the pre-term babies usually because they can't take it oral okay dose I really don't think so it is necessary for you because how how many doses you can remember now the patient for high risk so what are the criteria for high risk, if the criteria for low risks are not met, if the viral load is more than 50 copies on the day of delivery, if we really don't know whether the patient is taking it or not or if the viral load is or not known. So these are the criteria for the high risk and what is high risk what is a treatment for that usually never for 2 weeks. This is the PNP uh that is a post-natal um prevention and three medications are given. These are nera for 2 weeks with zod zeroin and lemiodin for 4 weeks. Okay, there had been a change in this. So this you should be aware of. If the pre-term baby is there then IV art can be done can be given. um usually if uh the if the pre-term baby is there apart from this if the risk of uh necrotising entroplitis usually associated with uh pre-maturity so prenum baby we are offering IV medications usually PNP to be started within 4 hour of birth and uh testing for um like HIV RNA PCR for mother and for the baby to be available within 24 hour of the when they have taken uh um at the delivery apart. So this is again the four weeks regime that they have put I uh you can see as a screenshot but no need to remember. So this is again the same thing algorithm for infant PNP. So whatever I have discussed the same thing they have already put. So it is essential that uh infant and the birthing mother should have um quantitative RNA RNA PCR sample on the day of delivery and the result should be available within 24 hour. If now uh if the patient has taken 10 weeks of art and uh one viral load is there less than 6 weeks prior to delivery then and if it is like less than 50 copies 10 weeks prior. So these are the criterias for low-risk baby. If the low-risk baby is there then uh a low-risk treatment low-risk treatment is 2 weeks of zo zero. Okay. Other uh and the it should be started within 4 hours. Uh if these criterias are not met then escalate to the high risk category. Okay. And the high risk category again two weeks of neapin and four weeks of lamb uh zerodine and lambod lemiodine therapy is given. So this is the management for low-risk and the high-risk baby. Apart from so this part I have already explained. Now in terms of immunization in UK it is a great the like uh immunization book is a like green book. So immunization to be given as per national schedule national schedule outlined in the green book. Okay this is their immunization book. So roto virus is not contraindicated unless the infant is severely imunocmpromised infant at low risk. Now the babies who are follow the lowrisk criteria a BCG vaccine can be given at the same time but why there's so much of trouble with a BCG vaccine because we know that it is an live vaccine then the if the babies are or infants are high risk criteria then BCG vaccine should be deferred till the PCR testing is complete by 12 weeks of pregnancy and it is confirmed that and are negative for HIV. Okay, this is all updates about immunization. Then again this also have changed from the previous. So infant who are at high risk how the diagnosis molecular diagnosis for HIV infection to be done like it is as soon as possible after birth during first 24 hour prior to hospital discharge by uh HIV RNA or DNA PCR then it should be repeated at 2 weeks 6 weeks 12 weeks antibbody testing for the sero reversion that means the B it has been cleared off by the 244 months or 2 years of age. This you have to remember only there is nothing that can be explained here. So this is a criteria for diagnosis or excluding HIV for high-risk babies. Criteria for diagnosis or excluding HIV for the low-risk baby and they're not breastfed. Okay. As soon as possible after birth, first 24 hour prior to discharge that is for every uh one. After that uh 4 to 6 weeks, 4 to 6 weeks uh time that was 6 weeks will be like 2 weeks after cessation of their medication. Then 10 to 12 weeks antibbody testing at 24 weeks. 24 months. Okay. Then infants who are low risk but they are breastfed usually the breastfeed during breastfeeding the vertical transmission is like 25 to 40%. The maximum transmission occur at the breastfeeding. So usual recommendation you know is not to breastfeed but there if some some if the woman is breastfeeding then in that situation there should be more testing for the baby and these are the testing schedule. It is as soon as possible after birth during first four 24 hours and prior to hospital discharge. Then monthly dur during the duration of breastfeeding by HIV RNA PCR 4 weeks and 8 weeks after cation of breastfeeding and in 24 week 24 months of age for uh HIV antibbody testing but there should be at least 2 weeks uh uh 2 month time or 8 weeks time after cessation of breastfeeding. Okay. So this is the diagnosing or ex uh this is the criteria for a HIV test schedule if the woman choose to breastfeed. Now if the infant is diagnosed with HIV now the diagnosis is confirmed in that situation they should be referred to urgently to specialist and they should be given profile access for pneumosystus pneumosis pneumonia. This is cotime exosol or trimethoprim sulfa mythoxazol from 4 weeks onwards if the PCR testing is positive at this stage and this should be stopped if the HIV infection is subsequently excluded. So from four weeks on onwards if the diagnosis is confirmed then they should be given cautazol profile access for pneumocystic pneumonia uh neocystic uh pneumonia prevention. Now uh like HIV transmission by breast milk factors associated with increased transmission. So this you should be at least no one time detectable HIV new HIV infection short duration of art prior to breastfeeding they recommend it at least 10 weeks and low CD4 count for mother longer duration of breastfeeding nipple infection baby mouth or gut infection or inflammation or mixed feeding. I mix feeding means that the like uh breast milk is given uh along with the nonhuman milks or the formula feeding liquids or solids. So the mixed feeding you know it increases the risk of transmission for the u uh for the like um v vertical transmission. What is the why it happens? Because if the formula feeding is given usually it causes certain aberrations or you know during the in the gastrointestinal tract of the baby and if there is a breach or breaks in the gastrointestinal mucosa is there that increases the risk of HIV transmission because of that mixed feeding is not allowed. So they again same thing exclusive formula feeding remove all risk of postpartum HIV transmission. Okay. Apart from this uh these are the um circumstances where uh they should discontinue breastfeeding if the any mastitis is there. If mother having gastrointestinal symptom that means her absorption of art will not be proper. If the baby has gastrointestinal symptom the reason I have already explained it causes certain you know uh uh abrasion or uh in in it affect the integrity of gastrointestinal lining or the baby has lesions. So any break in the like mucosa is there increase risk of HIV transmission is there. So these are the criterias where the patient if on the breastfeeding it should be stopped. Now uh the patient um if the detectable viral load is there during breastfeeding in that situation the breastfeeding has to be discontinued patient should see the HIV physician and baby should be started on the post exposure profile access. Now uh for the supporting women uh mental health support there should be uh like uh the prior to delivery the all women to be seen by member of HIV MDT within 4 to 6 weeks and they should receive adequate art supply there should be assessment of the mental health also discussion uh about the contraception adherance to art feeding medical and the social issues cervical psychology technology like if uh it is scheduled as usual it can be done done 3 month post delivery as per the NHS guidance otherwise it has to be done annually testing the guideline recommends the testing for the partners and other older children if the patient is newly diagnosed HIV in the pregnancy if they have not diagnosed prior mixed feeding should not be done that the reason I have already explained why it should not be done so now some few updates about the co- infections any questions till now so now the uh HIV and hepatitis B co-infection so if new uh um hepatitis B infection is there then these These are the investigations done. This would be confirmation of vymia with a quantitative HPV DNA. Hepatitis E antigen and antigen E antigen antibbody hepatitis A virus C virus and D virus. LFTs an assessment for hippatic inflammation and fibrosis. LFT uh art to be started and LFT to be repeated two to two weeks and 4 weeks and monitored during pregnancy and the postpartum period. What is the treatment? Treatment is 10 uh 104 VDX or uh plus lamodin or emisetrain or apart from this it should be continued till postpartum management like u cesarian the patient having hiv and hepatitis B co- infection they can going they can considered going for vaginal birth cesarian section is for obstetic indication Now when the baby is born that we already know when the baby is born then you there is active and passive both ways of immunization is done that is like um uh um hepatitis B vaccine and uh imoglobiline also what is the risk what are the guidance for imunoglobiline this is the important question that usually asked in part two so you should be aware of it. So this is when the HPVDN is more than 10 to six uh six uh IU per ml at any point in the pregnancy. If the patient is positive for HB SAG and HB E A S S or B antigen pos E antigen positive if um Australia antigen positive but antid anti-HB anti- body negative if Australia antigen positive and we don't know anything about the anti- um E antibodies and the baby is like less than 1500 g so these are the rates for risk of transmission part two people can learn it. Part two people also has to know the what are the indications for giving uh like um uh this HPIG or the um heo imunoglobilence hepatitis C infection co- infection so uh uh confirmation of uh vymia by RNA genotype and assessment of uh inflammation and the liver disease LFT 2 to 4 weeks and HCV markers and other hepatitis B viruses also. Now uh antiviral treatment is like DAA that is a direct acting antiviral therapy. Um usually this is a treatment and the uh DAA include interferon and with or without ribba but usually uh interferon and ribbarin the these are not given in pregnancy. So if the patient is um if conception occurs and the patient is on riverin or um pagated interferin then usually the treatment has to be discontinued immediately. Okay. So art to be given and these are the therapies or drugs for direct DAA therapies. Okay. vaccination to be given uh uh hepatitis B vaccination to be given. Um if uh the patient is like uh hepatitis C positive so B vaccination is given and A vaccination is also given if it is negative and if the CD4 usually it is uh two doses but if the CD4 count is less than 300 then three doses are given 0 1 and six. mode of delivery like uh if the hepatitis C and HIV is positive irrespective of HCV viral load it is vaginal birth that's it anyone of you have got any question can ask me uh so this like very big guideline of 180 pages so I kind of put everything and try to simplify it so hope that helps you anyone having any question otherwise I would have kept few questions because it is important to answer the all questions from Justin kongji book no question okay so there are just a few questions okay so 32 year old woman at first antiatal visit screened for HIV and uh confident it is positive she has been informed that she's positive counled for investigation and art started. You have seen her and concerned about her state of mind. So what is the next? So you are concerned about everything has been done for her. You know she has been investigated, treatment started. Now her state of mind you are worried about. What you will do? Anyone want to guess mental health? >> Yes. >> So it is assessment of depression now four to 6 weeks post delivery and 3 to four month postpartum. So this is the answer from previous guideline. But if if we come to the new guideline also then also the answer would be same because these are the from the new guideline. So they write it um assessment of mental health and also at the 6 weeks visit but they again 3 to four month time they didn't write in this new guideline but answer will be still the same but if the same questions come then uh 3 to four month postpartum this part will not be there. Now 25 year old woman for antiatal care. HIV has been positive. She has been screened for ST counsel. Baseline investigations are done. Repeated attempt to um to convince that her partner should also be tested but she doesn't she's not able to do so. So what will you do? So what should be done? She's not telling her partner. >> We can break the confidentiality. >> Yes. So uh this uh uh this would be one of the condition where the confidentiality can be broken because otherwise she's putting her partner at risk. Now uh HIV primig gravida at 36 plus 6 weeks of gastation. She's compliant with HRT since uh 14 weeks of of her gustation. That means like uh she has taken a HRT for at least 22 weeks. Okay. And her viral load is more less than 50 at 36 weeks. So what should be the plan for her? She can be uh can have vagana delivery. Yes, we can allow her for vaginal birth. So like uh mode of delivery plans vaginal delivery if the copy is less than 52 and ideally she should have taken like uh she has already taken um like um art for 22 weeks but we see the viral load so she can go ahead with the labor. So patient at 18 weeks um patient on cart since 18 weeks antigrator visit at 36 weeks no complication she's capelic viral load quantification reported to be 500 copies what to do >> the section >> yes so that we already know cesarian section at 38 weeks onwards so this this is uh given from the new guideline even the old guideline it is the same now a 30-year-old woman 13 weeks pregnant she booked last week her HIV positive council about the result she want to start cart at 14 weeks so what next she's she's starting on the treatment so if the patient has been first started on the treatment then what to be done we have to do her some investigations >> the bar load uh should be done and the CD4 count >> and resistance testing >> resistant testing LFT >> LFT and STD screen >> STD screening >> yes so this is the answer so the patient to be so the patient to be testing for viral load testing, liver function test testing, HIV resistance testing and uh like uh an STD screen also. So these are the test that is done. Now the patient is 16 weeks on cart last week's fun liver function test are normal. So how frequently they has to be tested? >> Each visit and there had been a change in the guideline. So uh viral load testing to be done 2 week after art because it is newly started. Okay. This is newly started. So viral load testing to be done 2 week after art then monthly till undetectable then two monthly then 36 weeks then delivery. So this is not this option is not there in this um uh in the options is not there it so I put the answer from the new guideline. >> Okay ma >> yes to the patient at 37 weeks with rupture of membrane. Okay. She started C at 37 weeks. Sorry, 27 weeks. Her vir load is 80 copies. What to be done? >> Considering Cesarian considering >> yes cesarian plus zero wouldn't should also be there. So uh like uh rupture of membrane is there. So answer would be because it is 80 copies. So answer would be cesarian section and uh the world But viral her viral load is 80 copies. So in answer IV0 should not be there. >> Yes, this more than thousand. It should not be there. So the patient is 37 weeks. Rupture of membrane 14 hour ago. Viral load was 2,000. She's contracting and the cervix is 3 cm dilated. Answer. Now the patient has rupture of membrane. Yeah, IV Zodin and >> yes >> section. >> Yes, here the answer would be immediate cesarian section and IV zeroin. Now the patient with a rupture of membrane at 36 weeks. She started uh diagnosed HIV at 12 weeks. She was reluctant to start CL at 30 weeks. Her viral load 4 weeks after is 12,000. So what to be done again the answer >> this was AS plus IV and >> so this is like uh immediate cesarian IV rudine these are the indication these are here she's 36 weeks with a rupture of membrane but there is no conservative management because these are the criteria for conservative management And this is not followed here. So this is new in this guideline that you should be aware of. I put it again. Now 13 a woman diagnosed with HIV at 28 weeks of gastation. STD screen and LFTs are normal. Bloods sample has been taken for CD4 count. immediately start haron. >> Yes, start uh HRT art as early as possible because it is confirmed. Okay. Now there is a full-term baby delivered to HIV positive mother. She has a cart for 22 weeks. Viral load at 36 weeks is less than 50 copies. So what will be the neonatal management >> dominant for two weeks? >> Wonderful. Very nice. So the baby is at low risk and the criterias for low risk are met. The patient has taken 10 weeks more than 10 weeks of zero therapy and prior 10 weeks her viral loss is less than 50 copies. So 2 weeks of zero protein. So infant born at 38 weeks and the card started from 28 weeks. Viral load was less than 50 copies. Again it would be. So here the cart has been taken like less than 10 weeks not completely 10 weeks or more than 10 weeks because of that the criteria for low risk is not followed. So combination PNP postnatal um profile axis that will be neup in 2 weeks with zeroin lambd 4 weeks. Baby delivered at 32 weeks on cart started from 24 weeks. So she has taken 8 weeks. Viral load is 75. What to be done? Same she's high risk. The baby's at high risk. >> Same. But what is the catch here? Pretum baby >> treat. So IV infusion. >> Very nice. So IV uh treatment is given. >> Okay. 43 IV drug abuser at antiatal care. She's aware she's carrying a risk of baby 21 weeks. Request imosynthesis. >> What to be done? >> After never after giving reconsider. >> No. So the patient no >> HIV HIV viral load should be assessed. >> So you have to postpone it till we know her status. >> Okay. So defer IV drug abuser high-risisk patient defer uh invasive testing this is from the guideline invasive diagnostic test should not be performed until HIV status of a person is known. So answer is defer testing till the HIV status. No. >> Okay. Now the patient uh has a uh all test test come positive. She commenced HRT card given last week and a polit test is high risk. She wants corinic sampling. What to do? So viral load should be less than 50 uh to do the test till the viral load is undetected. >> So this is the again from the guideline if the viral if the patient is not virally suppressed invasive diagnostic test or procedure to be delayed until suppression is achieved. So this is the answer from the guideline. So infant delivered to HIV positive primig at 40 weeks. She was placed in zero wooden 2 weeks for 2 weeks after 2 hour the baby has to be discharged 20 hour after delivery. So what to be done? HIV RNA essay during first 20 48 hours. >> Yes. >> And then uh >> uh 6 hours pipe option and again 12 weeks of life at 18 to 24 months post delivered library. >> Yes. So catchy answer. This is the correct answer. So infant who are at high risk. So they should be uh so diagnosis this is from the new guideline. So they u testing should be done um immediately after birth first 24 hours prior to hospital discharge then 2 weeks 6 weeks and 12 weeks HIV antibbody testing at 12 months of age. So this is from the new guideline. This you have to remember. Now in front of an HIV positive mother who is compliant with the therapy HIV viral load is less than 50 she decided to breastfeed. So what to be done? So the same testing that is immediately after birth then uh during uh 24 hours and before this shot then monthly uh till the duration of breastfeeding >> breastfeeding duration of breastfeeding breastfeeding then four weeks and 8 weeks >> after stopping the breastfeeding and then 18 to 24 months. >> Yes. So as soon as after birth 24hour after discharge prior to hospital discharge then monthly during the duration of breastfeeding then 4 weeks and 8 weeks after cation of breastfeeding antibbody testing at 24 weeks. Wonderful. Very nice. Any questions? Ma'am, I have been attending your session first time and actually these questions um show how this will be asked in the exam or you are just making us the clear the points. I don't understand >> what I don't understand >> ma'am the uh because we we have been discussing this uh new guidelines so um how it is going to help us in our part three exam >> part three exam part three exam you know like uh they can give you any scenario like for example can be patient is refusing HIV testing So then the I have showed us a slide in top in the first uh starting of the class then that um answer will come from there or they will give you another >> okay okay >> another type of question that the patient is recently diagnosed with HIV positive. Now you have to break the news and you have to plan whole antiatal care, postnatal care, intrapartum care. So okay ma'am kind of questions will come. >> Okay okay okay I understood ma'am. So these each questions can come as scenarios that is >> these questions will come as scenarios. Yes. >> Okay ma'am. Okay. Thank you. >> Okay. Any other question people? >> Ma'am may I ma'am? >> Yes. Yes. >> Actually I just not went through ma'am then this new guidelines. I just read the old one only. So that uh time it was like 50 less than 50 50 to 499 we considered this LS and after that uh like 500. So is it changed ma'am? No no mode of delivery what it was there prior mode of delivery there had been no change it is same >> like that less than 49 uh like uh >> basically less than 50 less than 50 um viral load vaginal birth and back more than that all cesarian simp >> all cesarian previously it was like ma'am considering LCS and the recommending >> guideline considering and all this they are now written They have written like planned section, >> cesarian section but that consider what they have not written. >> Oh yes sorry ma'am. Planned cesarian and the likel. Yes ma'am. >> Cesarian they have written. >> Thank you ma'am. Thank you so much. >> Okay. Thank you ma'am. Thank you so much ma'am. >> It was a nice session ma'am. Thank you. >> Okay. All the best people for your part three people for your results and part two people for your exams. All the best. Bye. Thanks for joining.