POLICIES RELATED TO HIV

Introduction
HIV/AIDS affects fundamental rights at work, particularly with respect to discrimination and
stigmatization of workers and people living with and affected by HIV/AIDS. Stigma and
discrimination at the workplace gets reflected in the form of loss of employment and
livelihood opportunities in addition to ostracism and seclusion faced by workers either due to
known or presumed HIV status.
The threat of HIV to the Indian working population is evident from the fact that nearly 90%
of the reported HIV infections are from the most productive age group of 15-49 years.

Expanding HIV/AIDS policy and programmes in the world of work is a key component
under the mainstreaming strategy in the National AIDS Control Programme phase-III (2007-
2012).

Aim
This policy, based on principles of human rights, aims to guide the national response to
HIV/AIDS in reducing and managing the impact of the epidemic in the world of work.
Specifically the policy aims to:-
i. Prevent transmission of HIV infection amongst workers and their families;
ii. Protect rights of those who are infected and provide access to available care, support and
treatment.
iii. Protect workers from stigma and discrimination related to HIV/AIDS by assuring them
equity and dignity at the workplace;
iv. Ensure safe migration and mobility with access to information services on HIV/AIDS.

Guiding Principles
The policy adopts the key principles of the ILO Code of Practice on HIV/AIDS and the
World of Work that is in line with the Government of India’s National HIV/AIDS policy. The
ten principles are:
1. HIV/AIDS, a workplace issue
HIV/AIDS is a workplace issue because it affects workers and enterprises, increases labour
costs and reduces productivity. The workplace can play a vital role in limiting the spread and
effects of the epidemic.
2. Non-discrimination
There should be no discrimination or stigmatization of workers on the basis of real or
perceived HIV status. Discrimination and stigmatization of people living with HIV/AIDS
inhibits efforts aimed at promoting HIV/AIDS prevention.
3. Gender equality
Women are more likely to become infected and adversely affected by the HIV/AIDS
epidemic than men due to biological, socio-cultural and economic reasons. Equal gender
relations and the empowerment of women are vital to successfully preventing the spread of
HIV infection and enabling women to cope with HIV/AIDS.
4. Healthy work environment
The work environment should be healthy and safe, and adapted to the physical and mental
state of health and capability of workers.
 5. Social dialogue
A successful development and implementation of HIV/AIDS policy and programme requires
full cooperation and trust between employers, workers and governments.
6. No Screening for purpose of Employment
HIV/AIDS screening should not be required of job applicants or persons in employment or
for purposes of exclusion from employment or worker benefits. In order to assess the impact
of HIV, employers may wish to do anonymous, unlinked HIV prevalence studies in their
workplace. These studies may occur provided it is undertaken in accordance with the ethical
principles of scientific research, professional ethics and the protection of individual and
confidentiality. Where such research is done, workers should be consulted and informed that
it is occurring. Testing will not be considered anonymous if there is a reasonable possibility
that a person‟s HIV status can be deduced from the result.
7. Confidentiality
There is no justification for asking job applicants or workers to disclose HIV-related personal
information. Nor should co-workers be obliged to reveal personal information about fellow
workers.
Personal data covered by medical confidentiality should be stored only by personnel bound
by rules on medical secrecy and should be maintained apart from all other personal data.
In case of medical examination, the employer should be informed only of the conclusion
relevant to the particular employment decision. The conclusions should contain no
information of a medical nature. They might as appropriate, indicate fitness for the proposed
assignment or specify the kinds of jobs and the conditions of work which are medically
contra-indicated, either temporarily or permanently.
8. Continuation of Employment relationship
HIV infection is not a cause for termination of employment. Persons with HIV-related
illnesses should be able to work for as long as medically fit in appropriate conditions.
9. Prevention
HIV infection is preventable. The social partners are in a unique position to promote
prevention efforts through information and education, and support changes in attitudes and
behaviour
10. Care and support
Solidarity, care and support should guide the response to HIV/AIDS at the workplace. Care
and support includes the provision of voluntary testing and counselling, workplace
accommodation, employee and family assistance programmes, and access to benefits from
health insurance and occupational schemes.

KEY STRATEGIES
a) Prevention of HIV transmission
b) Provide education and training at all levels in workplaces, set up interventions for
behaviour change through peer educators, integrate HIV in the existing / to be initiated
programmes at workplaces like the training of the Human Resource Department, Welfare and
OHS programmes, Corporate Social Responsibility initiatives etc;
c) Set up interventions for unorganized/informal sector workers and migrant workers, based
on vulnerability studies and risk assessment.
d) Enhance access to condoms, treatment of STIs, universal precaution and Post Exposure
Prophylaxis (PEP).
e) Widen scope of social security coverage to include HIV in employee and family assistance
programmes, health insurance etc.
f) Undertake vulnerable studies/epidemiological surveillance at the workplace to gather
data/information for taking informed policy and programmatic decisions.
 1. Creating and ensuring an enabling environment to discourage stigma and
discrimination towards people infected and affected by HIV/AIDS through
following:-

i) Develop and implement non-discriminatory workplace policies;

ii) Integrate HIV/AIDS services in other health related services;
iii) Adapt flexibility and reasonable accommodation (make adjustments in assigned
work, as practically possible) for PLHIV;
iv) Involve PLHIV in planning and implementation; and
v) Ensure continued employment and benefits to PLHIV.

2. Provision of counselling facilities and care and support services

A) Provide counselling to infected workers/families/co-workers, either at workplaces or

by setting up partnerships with other government/civil society services.
B) Ensure provision of ART treatment services and establish adequate referrals and/or
linkages.
3. Strengthening Public-Private Partnerships in HIV/AIDS Prevention and care

4. Strengthen partnership of private sector with the SACS/ILO/other expert agencies to

offer technical assistance for setting up workplace policy and programmes;
1) Expand coverage of Corporate Social Responsibility efforts to include HIV/AIDS;
2) Set up integrated counselling and testing facilities/ART centres for workers and
nearby communities;
3) Develop insurance policies/products that are inclusive of PLHIV;
4) Develop partnership with pharmaceutical companies to offer ART at affordable costs;
and
5) Mobilize resources from the private sector to complement the National AIDS Control
Programme.

SPECIFIC PROVISIONS
HIV/AIDS policy and programmes should be established in all constituents – Ministries
and their key institutions, employers‟ and workers‟ organisations, public and private
sector enterprises / multi-national companies and civil society organisations, based on the
principles and implementation guidelines. However, specific provisions in these
constituents allow broadening of the opportunity to address the HIV vulnerability and its
impact within its own context.

IMPLEMENTATION AND MONITORING

1 At the national and state levels
a) National AIDS Control Organisation proposes to form a Steering Committee on
HIV/AIDS and the World of Work comprising of employers‟ and workers‟ organizations,
development agencies, NACO, MOL&E and PLHIV to oversee/facilitate implementation of
broad policy guidelines and take strategic decisions related to HIV/AIDS programmes in the
world of work in India. Members of Parliaments‟ Forum on HIV/AIDS (PFA) and
representatives of international organizations dealing with labour and HIV/AIDS shall be
associated with the Committee.
b) MOL&E and NACO will also take up issues necessary for action at the level of National
Council on AIDS, chaired by the Prime Minister.

c) State Council on AIDS are proposed to be set up at the state levels by SACS under the
NACP-III. They will have adequate representation of the state labour departments,
employers‟ and workers‟ organizations, Members of Legislators Forum on HIV/AIDS (LFA)
and will plan and review implementation of the policy at the state levels.

d) MOLE and NACO as part of their steering role will also facilitate implementation of
regular surveys and risks assessments, especially in labour intensive areas to map the
vulnerable populations, migrants, working conditions and other related issues. These studies
undertaken on a regular basis will facilitate identification of gaps in the policy and
implementation, inform appropriate changes in the policy, facilitate identification of work
areas requiring focus from the MOLE and NACO and also facilitate the monitoring of
implementation of the policy guidelines and impact on the HIV vulnerabilities of the work
force.

2 At the workplace
I. Every workplace – organization, institution, businesses, company etc. – should establish an
HIV/AIDS Committee to coordinate and implement the HIV/AIDS workplace policy and
programme. For multinational companies, an HIV/AIDS Committee at corporate level should
be responsible in collaboration with a small team at each plant/location. Alternatively, a team
with representation from concerned departments and led by a senior executive should be
formed to perform this function.

II. The scope and content of the policy and programme will depend on the
organization‟s/company‟s size, needs and resources.
III. A checklist for planning and implementing a workplace policy on HIV/AIDS
IV. Periodic reviewing and monitoring of the policy will allow the organization or the
company to keep up with and adjust to a constantly changing internal and external situation.
V. Regular review of the workplace programme will ensure that it is managed efficiently,
producing the expected results and meeting the needs of the employees.

3 Budgetary and Financial Provisions

All the stakeholders viz. Central/State Governments Ministries/Departments,
employers/workers organizations, public and private sector enterprises, key national
organizations and civil societies etc. who are responsible for implementing the workplace
policy on HIV/AIDS shall make suitable allocation in their budgets to ensure regular flow of
finances for the various HIV prevention, care and support programmes to be undertaken by
them.(1)

GUIDELINE FOR PREVENTION OF PARENT TO

CHILDTRANSMISSION (PPTCT) OF HIV IN INDIA

INTRODUCTION:-
There are an estimated 2.1 million (2011) People Living with HIV (PLHIV) in India, with
National adult HIV prevalence of 0.27% (2011). Of these, women constitute 39% of all
PLHIV while children less than 15 years of age constitute 7% of all infections. Between 2004
and 2013, the number of pregnant women tested annually under the Prevention of Parent-To-
Child –Transmission (PPTCT) programme increased from 0.8 million to 8.83 million and
reach of the services has expandedto the rural areas to a large extent. Mother-to-child-
transmission of HIV is a major route of HIV infection in children.
Statistics in india (2017) 2.1million living with hiv. 0.2% adult hiv prevalence (age 15- 49,
88000 new hiv infections. 69,000 aids related deaths, 56% are in antiretroviral treatment.
Source( UNAIDS DATA 2018)
India has the third largest HIV epidemic in world. In 2017, hiv prevalence among adult ( aged
15-45) was estimated 0,2%. This figure is smallcompaired to most other middle income
countaries bit because if india’s huge population (1.3 billion) this equates to 2.1 million
people living with HIV.
Overall, india’s HIV epidemics is slowing dowmn between 2010 AND 2107 new infections
declined by27% and AIDS related deaths more than halved, falling by 56%. However, in
2017 new infections increased to 88,000 from 80,000 and AIDS related death increased to
69,000 from 62,000. USAIDS(2017)

PPTCT AND ART IN PREGNANT WOMEN

Parent-to-child transmission of HIV is a major route of new HIV infections in children.

Children born to women living with HIV acquire HIV infection from their mother, either
during pregnancy, labour/delivery or through breast feeding which is largely preventable with
appropriate intervention, by providing Anti-retroviral therapy (ART) to mothers and Anti-
Retroviral (ARV) prophylaxis to infants. A total of 61,000 lakh children (0 to 14 years) are
estimated to be living with HIV in India. Out of 29 million pregnancies every year, an
estimated 22000 occur in HIV infected women. All these HIV infected pregnant women have
to be detected and provided with timely ART in order to reduce mother to child transmission
and ultimately to eliminate paediatric HIV. Counselling and information regarding the
outcome of pregnancy and HIV related treatment to the HIV infected women is provided
under the programme.
PPTCT Services:
The National PPTCT programme recognizes the 4 elements integral to preventing HIV
transmission among women and children. These include:
• Prong 1: Primary prevention of HIV, especially among women of childbearing age
• Prong 2: Prevention of unintended pregnancies among women living with HIV
• Prong 3: Prevention of HIV transmission from pregnant women infected with HIV to their
children
• Prong 4: Provide care, support and treatment to women living with HIV and to their
children and families

The National PPTCT programme adopts a public health approach to provide these services to
pregnant women and their children. Currently, the major activities focused under PPTCT
services have been Prong- 3 and 4. However, Prong 1 and prong 2 are also emphasized, to
achieve the overall results of the PPTCT Programme.

PPCT: Interventions during pregnancy:

• Primary prevention of HIV in childbearing women
• Provide HIV information to ALL pregnant women
• Antenatal visits are opportunity for PPTCT
• Prevention of unwanted pregnancies in HIV-positive women
• Prevention of PTCT through ART
• Safe obstetric practices
PPTCT: Interventions during labour and delivery:
• Minimize vaginal examinations
• Avoid prolonged labour; consider oxytocin to shorten labour
• Avoid artificial rupture of membranes
• Early cord clamping after it stops pulsating and after giving the mother oxytocin
• Use non-invasive foetal monitoring
 Avoid invasive procedures
 Avoid routine episiotomy / support perineum
 Minimise the use of forceps or vacuum extractors
Considerations in Mode of Delivery:
1. In India, normal vaginal delivery is recommended unless the woman has obstetric
indications (like foetal distress, obstructed labour) for a Caesarean section
2. Use of ART can reduce risk of PTCT better and with lesser risk than a C-section

Goal and Objectives of PPTCT Services in India

Vision: Women and children, alive and free from HIV
Goal: To work towards elimination of paediatric HIV and improve maternal, newborn and
child health and survival in the context of HIV infection

Objectives:
1. To detect more than 90 % HIV infected pregnant women in India
2. To provide access to comprehensive PPTCT services to more than 90 % of the detected
pregnant women
3. To provide access to early infant diagnosis to more than 90 % HIV exposed infants
4. To ensure access to anti-retroviral drug (ARVs) prophylaxis or Anti-Retroviral Therapy
(ART) to 100 % HIV exposed infants
5. To ensure more than 95 % adherence with ART in HIV infected pregnant women and
ARV/ ART in exposed children

The PPTCT services provide access to all pregnant women for HIV diagnostic, prevention,
care and treatment services. As such, the key goal is to ensure the integrated PPTCT services
delivery with existing Reproductive & Child Health (RCH) programme.

The Essential Package of PPTCT Services in India includes:

1. Routine offer of HIV counselling and testing to all pregnant women enrolled into
antenatalcare (ANC) with ‘opt out’ option
2. Ensure involvement of spouse & other family members and move from an “ANC
Centric” to a “Family Centric” approach
3. Provision of lifelong ART (TDF +3TC + EFV) to all pregnant and breastfeeding HIV
infected women regardless of CD4 count and clinical stage
4. Promote institutional deliveries of all HIV infected pregnant women
5. Provision of care for associated conditions (STI/ RTI, TB & other Opportunistic
Infections -OIs)
6. Provide nutrition counselling and psychosocial support to HIV-infected pregnant
women
7. Provide counselling and support for initiation of exclusive breastfeeds within an hour
of delivery as the preferred option; continue BF atleast for one year for those infants
 with negative HIV status (Early Infant Diagnosis Protocol) and 2 years for HIV
positive children.
8. Provide ARV prophylaxis to infants from birth upto minimum 6 weeks
9. Integrate follow-up of HIV-exposed infants into routine healthcare services including
immunization
10. Ensure initiation of Co-trimoxazole Prophylactic Therapy (CPT) and Early Infant
Diagnosis (EID) using HIV-DNA PCR at 6 weeks of age onwards as per the NACO
EID guidelines.
11. Strengthen community follow-up and outreach through local community networks to
support HIV-positive pregnant women and their families(2)

Sexually Transmitted Infections and Reproductive Tract Infections

Sexually transmitted infections and reproductive tract infections (STIs/RTIs) are important
public health problems in India. Studies suggest that around 6 per cent of the adult population
in India is infected with one or more STIs/RTIs. Individuals with STIs/RTIs have a
significantly higher chance of acquiring and transmitting HIV.

Pregnant Women and STI/ RTI Services

All pregnant women should be screened for syphilis. Syphilis is one of the easily treatable
Sexually Transmitted Infection (STI/RTI) caused by Treponema pallidum, which can be
transmitted to sexual partners as well as from infected pregnant woman to her new born child.
Untreated syphilis is responsible for multisystem complications and other sickness among
infected patients and may cause miscarriages, low birth weight and premature delivery in the
pregnant woman. Many patients of syphilis are asymptomatic and do not manifest any
symptoms of the disease. The rapid plasma regain test or veneral disease laboratoryTest
(VDRL Test) are the most commonly used screening tests to detect syphilis.
Risk of HIV transmission from Mother to Child with ARV interventions
ARV Intervention Risk of HIV Transmission from
Mother to child
No ARV; breastfeeding 30-45%
No ARV; No breastfeeding 20-25%
Short course with one ARV; breastfeeding 15-25%
Short course with one ARV; No breastfeeding 5-15%
Short course with two ARVs; breastfeeding 5%
3 ARVs (ART) with breastfeeding 2%
3 ARVs (ART) with No breastfeeding 1%

Process of Screening ANC Women

ANM at the village/subcentre level will do screening test for HIV and Syphilis using whole
blood finger prick test. If the Syphilis test is reactive then the pregnant woman would be
referred to designated STI/RTI clinics or PHC with RPR testing availability for Syphilis
confirmation.
If the HIV test is reactive then the pregnant woman will be referred to stand alone ICTC for
confirmation of HIV by rapid tests. The patient then undergoes pre-test counselling at the
ICTC by the ICTC counsellor.
The ICTC collects 5 ml blood for HIV rapid tests and RPR test.
After HIV and RPR testing, the patient returns to the ICTC counsellor for post test
counselling.(3)
All HIV infected pregnant women should have routine ante natal care for the well-being of her
baby including:
• At least 4 ANC check-ups during pregnancy (registration and 1st check-up within 12 weeks,
2nd between 14-26 weeks, 3rd between 28-32 weeks and 4th between 36-40 weeks) as per
RCH/ NACP guidelines.
• History, physical and abdominal examination.
• Antenatal routine blood screening:
o Hb, blood group & Rh typing, urine routine at 1st visit; including tests for
syphilis, Hepatitis ‘B’ and HIV.
o Urine routine to be done at all visits, and Hb% to be re-checked at the 3rd visit
at 28-32 weeks gestation.
• 2 Doses of Tetanus Toxoid (TT) to prevent maternal and newborn tetanus:
o First dose: at ANC registration.
o Second dose: 4-6 weeks after the first dose, preferably at least one month
before the expected date of delivery (EDD).
• Antenatal drug supplementation:
 IFA tablet (100mg iron + 0.5 mg folic acid) daily for 100 days, after
1st trimester to prevent anaemia.
 Double the dose if anaemia persists.

CONTINUMMM CARE UNDER PPTCT

With the revision of PPTCT guidelines that recommend use of the more efficacious Multi
Drug ART regimen,
it is important to consider Prong-3 of National PPTCT programme as a continuum of
interventions rather than a one-time activity. This requires close coordination between
various implementing components for PPTCT-ART linkage, Early Infant Diagnosis (EID),
Paediatric ART services etc.

The continuum of care involves the following steps:

1. Increasing uptake of PPTCT services by pregnant women.
2. Counselling and Testing of pregnant women as an integral part of ANC Comprehensive
Services package.
3. Detection of HIV infected pregnant women.
4. Linking HIV infected pregnant women to Care, Support and Treatment services.
5. Initiating ART for all HIV infected pregnant women regardless of CD4 count, starting it as
soon as diagnosed and continued for life. However, make sure to obtain samples for CD4 cell
count and baseline tests at the time of initiating ART or soon after initiating ART.
6. counselling on birth-planning and institutional deliveries of identified HIV infected
pregnant women.
7. Screening emergency labour room deliveries (un-booked cases) for HIV. If HIV positive,
providing ART and obtaining sample for CD4 cell count as soon as possible.
8. Linking of HIV infected pregnant women identified through emergency labour-room care
services to Care, Support and Treatment services.
9. Provision of Syrup Nevirapine for the new born infant from birth till 6 weeks of age
(minimum). At the end of 6 weeks, CPT should be initiated and baby to be linked to the EID
programme.
CPT continued to baby from 6 weeks up to 18 months or until the confirmatory test of the
baby is done using all three Rapid Antibody Tests. If baby is confirmed positive, then CPT
will be continued.
10. If the infant is detected positive in EID programme (DBS+WBS tests are positive), then
ensure initiation of Pediatric ART for the baby through ART centre as per ART guidelines as
soon as possible.
11. Follow-up of HIV infected mother and baby until breastfeeding period is over.
12. At six weeks of age of baby, do DBS test and confirm with WBS test. If the age of baby
is more than 6 months, then do antibody (rapid) test first, if found positive then only DBS
sample should be sent. If DBS comes positive then do a WBS test If WBS is positive, start
Paediatric ART as soon as possible.
13. Confirmation of diagnosis of child using 3 anti-body tests (Rapid) at ICTCs at 18 months
of age.(2)

The guiding principles for the use of ART to prevent HIV transmission from mother-to-
child are:
• HIV infected pregnant women, in need of ART for their own health should receive life-long
ART.
• Postpartum ART initiation to mother and ARV Prophylaxis to child are aimed at improving
HIVfree
child survival by reducing HIV transmission through breastfeeding.
• HIV exposed infants should be followed-up and managed as per the National Guidelines on
“Care of HIV exposed infants and children”.
In India, the PPTCT programme has been in place for many years, and recommended ARV
prophylaxis was sd of Tab Nevirapine (200mg) to mother during labour and single dose of Sy
Nevirapine to the infant at birth.

CRITERIA FOR ART INITIATION

In HIV infected pregnant women the dictum should be “do not delay ART initiation”.
The eligibilitycriteria for initiating ART in HIV positive pregnant women are as below:-

ART eligibility in pregnant women:

• Initiate lifelong ART in all pregnant women with confirmed HIV infectionregardless of
WHO clinical stage or CD4 cell count. TDF + 3TC + EFVis recommended as first-line ART
in pregnant and breastfeeding women,(including pregnant women in the first trimester of
pregnancy and womenof childbearing age)
• ART shall be initiated only at ART centre

CO-TRIMOXAZOLE IN PREGNANCY

The indications for co-trimozaxole initiation in pregnant women are same as those for other
adults (CD4≤250 cells/cmm). Co-trimoxazole prophylaxis is helpful in reducing morbidity
and mortality as it prevents Opportunistic Infections (OIs) such as Pneumocystis jiroveci
pneumonia (PCP), toxoplasmosis, diarrhoea as well as other bacterial infections.
Starting Co-trimoxazole in pregnancy
• Co-trimoxazole should be started if CD4 count is ≤ 250 cells/mm3 and continued through
pregnancy, delivery and breastfeeding as per national guidelines (Dose: Double strength
tablet – 1 tab daily).
• Ensure that pregnant women take their folate supplements regularly.

ART FOR HIV INFECTED PREGNANT WOMEN

All HIV infected pregnant women should be seen on a priority in the ARTCentre.
Choice of ART Regimen for HIV-infected Pregnant Women
There are several regimens recommended for use as first-line ART regimen for adults in
India. The recommended first-line regimen for HIV infected Pregnant Women is
Tenofovir (TDF) (300 mg) + Lamuvidine (3TC) (300 mg) + Efavirenz (EFV)
(600 mg) (if there is no prior exposure to NNRTIs (NVP/EFV) at any gestational Age

The alternate regimen if the pregnant women are unable to tolerate preferred first-line
regimen are as below:

First line ART for Preferred First-line Alternate

Regimen First-line Regimen
HIV positive TDF + 3TC+ EFV AZT+ 3TC+EFV
pregnant women AZT+3TC+NVP
TDF+ 3TC+NVP

Under the national programme, it is recommended to provide lifelong ART for all
pregnant and breastfeeding women living with HIV, in which all pregnant women living
with HIV receive a “single-pill” triple-drug ART regimen (TDF +3TC + EFV)
regardless of CD4 count or clinical stage, both for their own health and to prevent
vertical HIV transmission and for additional HIV prevention benefits.

ARV for Pregnant women and Exposed Infant

• All HIV positive pregnant women including those presenting in labour and breast feeding
should be initiated on a triple drug ART regardless of CD4 count and clinical stage (Test and
Treat), for preventing Mother-to-Child Transmission and continue lifelong ART.

• `The duration of Nevirapine prophylaxis to HIV exposed infant should be minimum of 6

weeks. However, this duration of Nevirapine prophylaxis should be extended to 12 weeks, if
the duration of ART in pregnant mother falls short 4 weeks during pregnancy and before
delivery or reporting at the time labour or after delivery, if not already on ART

Evaluating HIV Infected Pregnant Women under different case scenario

The decision tree below shows some of the steps taken as part of the evaluation process of
HIV infected and breastfeeding women at the ART Centre:

P.T.O
 Pregnant and Breastfeeding women with HIV

Women Women is Women who is Women who Women who

detected during registered in on ART came detected post- Link
routine Ensure linkage Do confirmatory Follow
Continue treat all
same
pre ART care directly in partum At ART centre
HIV test and immediately
policy to
antenatal care to ART ART regimen
initiate
perform ART
CD4
labor perform
take blood for ART centreCD4
immediately regardless
testing andof
CD4 count testing and
CD4 count
initiate ART
initiate ART
regardlessofofCD4
regardless
CD4 count
count

Ensure linkage
Ensure
to ART
institutional
immediately in
delivery and
post –partum
follow up
period

ART regieme for pregnant women having prior exposure to NNRTIs for PPTCT :-
HIV infected pregnant women who have had previous exposure to Sd NVP (or EFV) for
PPTCT prophylaxisin prior pregnancies, an NNRTI-based ART regimen such as
TDF+3TC+EFV may not be fully effectivedue to persistence of archived mutation to
NNRTIs. Thus, these women will require a protease-inhibitorbased ART regimen viz:
TDF + 3TC + LPV/r (Lopinavir/ritonavir)
The dose will be TDF+3TC (1tabletdaily)+ LPV (200mg)/r (50mg) (2 tablets BD)

Clinical And Laboratory Monitoring Of Hiv Infected Pregnant Women On ART

Should Be Done As Per National Art Guidelines For Adults And Adolescents.:-
Key points to be noted in pregnant women in monitoring ART in pregnant women are:
• Look for clinically significant anaemia among HIV-infected pregnant women, since
anaemia during pregnancy is common (usually developing around 28-34 weeks of gestation).
• WHO clinical staging will help in monitoring the patient clinically, potential disease
progression or treatment failure.
• Weight loss is one of the indicators used to determine deteriorating clinical stage, but this
can be difficult to assess during pregnancy. When defining the clinical stage of a pregnant
woman, it is necessary to take into consideration her expected weight gain in relation to the
gestational age of the pregnancy and her potential weight loss from HIV.
• ART-related side-effects may overlap with that of common pregnancy conditions eg. nausea
and vomiting. Minor symptoms should be controlled symptomatically with medicines.
Consult the Obstetrician for drugs that are safe for use in pregnancy.
• Due to pregnancy-related haemo-dilution, absolute CD4 cell count decreases during
pregnancy. After delivery, body fluid changes normalise to the non-pregnant state, and CD4
levels may rise by 50-100 cells/ul. Therefore, a decrease in absolute CD4 count in a pregnant
woman receivingART in comparison to CD4 values prior to pregnancy may not necessarily
indicate immunologicdecline and should be interpreted with caution (ref to SACEP in case of
any doubt).
The recommended clinical and laboratory follow-up schedule for pregnant women is similar
to that recommended for non-pregnant adults.
Assessments of haemoglobin or Liver Function Tests (LFT), Renal Function Tests (RFT)
should be performed when warranted by clinical signs & symptoms.
HIV care and follow-up of pregnant women should be scheduled to coincide with their
antenatal visits, as far as possible. Document all investigation results in the RCH/MCH card
(Antenatal & Child) also, so that the Obstetric team is aware of test results. Inform patient to
ensure that other health care providers in the team eg. Obstetricians & their support staff are
updated on the progress of their HIV care.
After 6 months of pregnancy, in case a pregnant woman is unable to go to the ART centre,
the ART drugs can be given to an authorised member of her family. The drug dispensing to
an authorised member can continue for 2 more months after delivery

ART in Pregnant / Breast feeding Women

The following table describes the specific groups to which the pregnant women belong and
guides the medical officer in selecting the regimen:-

ART regimens in pregnant and breastfeeding with HIV

Target Population Drug Regimen Remark

Pregnant and breastfeeding TDF + 3TC + EFV FDC of TDF (300 mg) +
women with HIV (ART 3TC (300
Naïve / mg) + EFV (600 mg)- To be
“Not-already” receiving given 2
ART) hours after low-fat or fat-
free dinner

Pregnant and breastfeeding The same ART regimen E.g. If they are already on
women with HIV already must AZT
receiving ART be continued +3TC +NVP/ EFV, continue
the
same regimen

ART regimen for pregnant
women having prior
exposure to
NNRTI for PPTCT
TDF + 3TC and LPV/r FDC of TDF (300 mg) +
3TC (300
mg) -- 1-tab OD and
FDC of LPV (200 mg)/r (50
mg) -
2-tab BD

• Abacavir + Lamivudine +Efavirenz: First line ART Regimen: for all patients with known
renal disease or who develop toxicity to Tenofovir
• As per PPTCT guidelines, all positive pregnant women exposed to NVP/EFV in past should
be initiated on Lopinavir/ritonavir (LPV/r) instead of Efavirenz (EFV).(3)

Care And Assessment For Women Presenting Directly-In-Labour

• Labour room nurse will offer bed side counselling and HIV screening test
• If the woman consents, screen using the “Whole Blood Finger Prick test” in delivery room
or labour ward
• If detected HIV positive, the medical Officer i/c will initiate TDF + 3TC + EFV and ensure
immediate linkage to ART centre Labour room nurse informs the ICTC counsellor and lab
technician for further confirmation of HIV test as per guidelines

Pregnant women presenting in active labour:

Maternal Status Intra-partum Post-partum

Presenting in active labour, Initiate TDF (300 mg) + Continue TDF (300 mg) +
no 3TC 3TC (300
prior ART (300 mg) + EFV (600 mg) mg) + EFV (600 mg)

Nevirapine prophylaxis for breastfeeding infant should be for 12 weeks, as mother did not
receive any ART during ante-natal period. However, EID should be carried out at 6 weeks as
per guidelines.
 In the case of false labour or mistaken ruptured membranes, for women taking ART
should continuewith normal dosing schedule of the combination regimen
 Caesarean section is not recommended for prevention of mother-to-child-transmission
and only if there is an Obstetric indication for the same.
Use of ARV drugs during Caesarean Sections
• For planned (elective) Caesarean sections, ART should be given prior to the operation.
• Women on life-long ART should continue their standard ART regimen.
• In case of an emergency Caesarean section in pregnant women who are not on ART, ensure
that the women receive ART prior to the procedure and continues thereafter.
All HIV-infected women who undergo Caesarean section should receive the standard
prophylactic antibiotics. Complications of Caesarean section are higher in women with HIV,
with the most frequently reported complication being post-partum fever.(3)

SAFE DELIVERY TECHNIQUE

Mother-to-child -transmission risk is increased by the prolonged rupture of membranes,
repeated P/Vexaminations, assisted instrumental delivery (vacuum or forceps), invasive foetal
monitoring procedures(scalp/foetal blood monitoring), episiotomy and prematurity. Thus,
when delivering HIV-infected women,observe:-
• Standard/Universal Work Precautions (UWP)
• Do NOT rupture membranes artificially (keep membranes intact for as long as possible).
 The membranes should be left intact as long as possible and artificial
rupture of membranereserved for cases of foetal distress or delay in
progress of labour.
• Minimize vaginal examination and use aseptic techniques.
• Avoid invasive procedures like foetal blood sampling, foetal scalp electrodes.
• Avoid instrumental delivery as much as possible.
 Unless required in cases of foetal distress or significant maternal fatigue to
shorten labour orthe duration of ruptured membranes.
  If indicated, low-cavity outlet forceps is preferable to ventouse, as it is
generally associatedwith lower rates of foetal trauma than ventouse.
• Avoid routine episiotomy as far as possible.
• Suctioning the newborn with a nasogastric tube should be avoided unless there is meconium
staining of the liquor.
 In case of infants who are born to HIV infected mothers who did not receive any
antenatal or pre-partum ART, or in cases where maternal HIV infection is detected
after the birth of the infant (home delivery):
o Infants should be started on daily Sy NVP prophylaxis at their first contact
with health services.Daily infant NVP prophylaxis can be started even if more
than 72 hours have passed since birth.
o Daily infant NVP prophylaxis should continue for atleast 12 weeks, by which
time the mother should be linked to appropriate ART services.(2)

Safer surgical techniques are useful in conducting any operative procedures such as the
Caesarean section, repairing wounds/lacerations etc.:-
Use of ‘dry’ haemostatic techniques to minimize bleeding; i.e. good observation and
following of surgical fascial planes during dissection, judicious use of electro-cautery during
Caesarean section etc.
During Caesarean section, wherever possible, the membranes are left intact until the head is
delivered through the surgical incision. The cord should be clamped as early as possible after
delivery;
• Use of round-tip blunt needles for Caesarean section
• Do not use fingers to hold the needle;
• Use forceps to receive and hold the needle
• Observe good practice when transferring sharps to surgical assistant eg. holding container
for sharps.
For disposal of tissues, placenta and other medical/infectious waste material from the
delivery of HIV-infected deliveries Standard waste disposal management guidelines should
be followed.

ARV PROPHYLAXIS FOR INFANT:

The infant should be started on Nevirapine. The duration of NVP prophylaxis will
depend on the duration of ART that has been given to the mother during her ante-natal
period.
• Infants should be started on daily NVP prophylaxis at their first encounter with the health
Services.
• Daily infant NVP prophylaxis can be started even if more than 72 hours have passed since
birth and should continue; during this period the mother should be linked to appropriate
ARTservices.
Duration of daily infant NVP prophylaxis will depend on “how long the mother was on
lifelongART [for a minimum of 4 weeks or not]”
• The duration of NVP given to infant is a minimum of 6 weeks, regardless of whether the
infant is exclusively breast fed or exclusive replacement fed
• 6 week-Nevirapine prophylaxis should be increased to 12 weeks, if ART to the mother has
been started in late pregnancy, during or after delivery and she has not been on ART for
anadequate period as to be effective to achieve optimal viral suppression (which is at least 4
• The recommendation on extended Nevirapine duration (12 weeks) applies to infants of
breast-feeding women only and not to those on exclusive replacement feeding
• Infants of women with prior exposure to NVP should get syrup Zidovudine (AZT) in place
of syrup Nevirapine
Recommended ARV Prophylaxis for HIV Exposed Infants
Infants BirthWeight NVP daily NVP daily dose (in Duration
dose ml)
(in mg) (10 mg Nevirapine in
1
ml suspension)

Infants with birth 2 mg/kg once 0.2 ml/kg once daily Upto minimum of 6 weeks of
weight < 2000 g daily age
regardless of whether
exclusively
breast fed or exclusively
replacement fed
Birth weight 2000 10 mg once 1 ml once daily Extended to 12 weeks, if the
– 2500 g daily duration of ART received by
the
Birth weight > 15 mg once 1.5 ml once daily mother is less than 24 weeks
2500 g daily and
she is breast feeding

PREGNANT WOMEN WITH CO-INFECTION:-

PREGNANT WOMEN WITH ACTIVE TB

The risk of active TB is approximately 10 times higher in HIV-infected pregnant women
compared to HIV uninfected women. Active TB in HIV-infected pregnant women can
contribute to increased risk of maternal mortality, and is also associated with prematurity,
low birth weight, and perinatal tuberculosis. A recent study in India 2 found that maternal TB
increases the risk of HIV transmission from mother-to-child by 2.5 times.
• Intensified Case Finding (ICF) as per national TB-HIV protocols must be instituted for all
HIV infected pregnant women.
• All HIV-infected pregnant women presenting with a cough, fever, night sweats and weight
loss should be evaluated for TB and started on TB treatment when indicated.
• HIV-infected pregnant women with active tuberculosis should start ART, irrespective of
CD4 cell count.
• The tuberculosis treatment should be started first, and followed by ART as soon as feasible
(usually after 2 weeks)
• Drug interactions between Rifampicin and some of the antiretroviral drugs, including NVP,
Complicate simultaneous treatment of the two diseases. EFV is the preferred NNRTI for
Pregnant women which can be used in those with concurrent TB treatment also.
• For those HIV-TB co-infected women not able to tolerate EFV, a NVP-based or a boosted
PI regimen can be considered after expert clinical consultation. With the use of a boosted PI
regimen, Rifampicin should be substituted with Rifabutin.

PREGNANT WOMEN CO-INFECTED WITH HEPATITIS

The HIV epidemic in India is driven by injecting drug use in some regions of the Country.
Hepatitis B and Hepatitis C may be a concern in these areas.

For Women Co-infected with HIV and HBV

• If treatment is required for HBV infection3, ART should be started irrespective of the CD4
cell count or the WHO clinical stage:
• The regimen preferred is TDF + 3TC + EFV.
• An elevation in liver enzymes following the initiation of ART may occur in HIV-HBV co-
infected women because of an immune-mediated flare in HBV disease secondary to immune
reconstitution (IRIS) with therapy, particularly in women with low CD4 cell counts.
• HBV infection may also increase the risk of hepatotoxicity with certain antiretroviral drugs,
specifically NVP and protease inhibitors.
• Pregnant women with HIV-HBV co-infection should be counselled about signs and
symptoms of liver toxicity.
• For women who do not require HBV treatment, ART general recommendations for HIV-
infected pregnant women should be followed.
For Women Co-infected with HIV and HCV
• No specific changes in treatment are recommended in the adult ART treatment guidelines.
• Pregnant women co-infected with HIV and HCV should receive ART according to the
general recommendations for HIV-infected pregnant women.
• Those women on ART require careful clinical and laboratory monitoring.
Co-infection with HIV and HBV or HCV is common among Injecting Drug Users (IDUs).
Hence, all women living with HIV who are recognized to be IDUs should routinely be
offered testing for Hepatitis B and Hepatitis C infections and monitored.(2)

Pregnant women with HIV-2 infection

Although the great majority of HIV infections in India are due to HIV-1, there are small foci
of HIV-2 infection as well, primarily in western India. HIV-2 also progresses to AIDS,
although the progression is generally much slower. HIV-2 has the same modes of
transmission as HIV-1 but has been shown to be much less transmissible from mother to
child (transmission risk 0-4%).
NNRTI drugs, such as NVP and EFV, are not effective against HIV-2. Follow ‘Adult ART
guidelines’ in HIV-2 infection.
If a pregnant woman is detected and confirmed to have HIV-2 alone or combined HIV-1 and
HIV-2 infection, she should receive PPTCT treatment interventions recommended for women
with HIV-2 infectionwhich consists of 2NRTIs + LPV/r.
• Prophylaxis NVP with AZT (instead of Syp NVP) to be given to babies in mothers with
HIV -2
If a pregnant woman is detected to have BOTH HIV-1 and HIV-2 infections, she
Should receive standard first ART Regimen (TDF+3TC+EFV) recommended for
women with HIV-1 infection
This maternal intervention should be coupled with daily Zidovudine (AZT) to the infant from
birth for minimum 6 weeks of age.
 All babies detected positive <2years of age are given Paediatric ART irrespective
of CD4 %
HIV Exposed Infants of HIV-2 infected mother
Start syrup AZT in place of NVP syrup, immediately after birth till 6 weeks of age
The recommended dosages are:
• Birth weight > 2.5 Kg: 15 mg per dose twice daily
• Birth weight < 2.5 Kg: 10 mg per dose twice daily
Specific Interventions during Infancy:
• Observe for signs and symptoms of HIV infection
• All HIV exposed infants should receive co-trimoxazole at 6 weeks of age
• Follow standard immunization schedule
• Routine well baby visits
• Early Infant Diagnosis: DNA PCR test
-: 18-month visit for HIV antibody testing
Safer Infant Feeding:
 Exclusive Breast feeding for first 6 months of life is recommended.
 In a situation where the mother is practicing mixed feeding, Health-care workers and
Counsellors should motivate her to exclusively breastfed.
 Exclusive breastfeeding is the preferred feeding option for HIV-exposed infants <6
months of age. However, it is recognized that for some women, breastfeeding may not
be possible – for example in situations of maternal death and severe maternal illness
in which case Exclusive Replacement Feeding should be done only when AFASS
criteria is fulfilled:
 A – Affordable F – Feasible A – Acceptable S – Sustainable S – Safe

 When exclusive breast feeding is not possible for any reason (maternal sickness,
twins), Mothers and health care workers can be reassured that maternal ART reduces
the risk of postnatal HIV transmission in the context of mixed feeding as well.

 Mothers known to be HIV-infected (and whose infants are HIV uninfected or of

unknown HIV status) should exclusively breastfeed their infants for the first six
months of life, introducing appropriate complementary foods thereafter and continue
breastfeeding.
 Breastfeeding should then only stop once a nutritionally adequate and safe diet
without breast milk can be provided.
Mothers living with HIV should breastfeed for at least 12 months and may continue
breastfeeding for up to 24 months or beyond (similar to the general population) while being
fully supported for ART adherence.
Adequate and timely ART, safe methods of delivery and good care of the mother during the
Antenatal period will help to decrease risk of transmission.
ARVs require ongoing care and monitoring and reduce risk of PTCT in the following ways:-
 Reduce viral replication and viral load
 Treat maternal infection
 Protect the HIV-exposed infant
Improve overall health of mother(2)
THE POST-PARTUM PERIOD
• Within an Hour of Delivery
 Infants born to HIV-infected mothers should receive NVP prophylaxis immediately
afterbirth.
 Infants after delivery should be put on the mother’s abdomen for skin contact to
beestablished which helps in bonding and maintenance of baby’s body temperature as
well as helps initiation of breast milk within 1 hour of birth.
 Infants should be given exclusive breastfeeds for the first six months preferably.
Exclusive replacement feeding may be done only if the mother has died or has a
terminal illness or decides not to breastfeed despite adequate counselling.
 If the mother has not made a decision about feeding yet, she should be counselled to
give exclusivebreastfeeds for the first 6 months which is the preferred option,
followed by complementary feedsafter 6 months. No abrupt weaning to be done after
6 months. The follow up guidance for babieson exclusive breast feeding.
  Counsel and support parent to give infant NVP prophylaxis using the syringe/dropper
provided.
• Emphasize on washing the equipment with clean boiled water after every use.

During the post-delivery period, it is important to continue follow-up and support the
postpartum mother, considering the fact that this is a stressful period and she has to assume
multiple roles and responisbilities as mother, wife and HIV infected person. Wherever
possible, include family counselling (of husband, in-laws, direct family members) to support
care of the HIV infected mother and HIV exposed infant. Postpartum depression & psychosis
is common in HIV infected women.

Involvement of men (husband/close male family members) is important so that the family
support to the HIV-infected mother and infant is optimal. Husband’s support to the
motherbaby pair (m-b pair) should be encouraged so as to:
 To remind the HIV positive mother to take ART regularly
 Support administration of daily infant NVP prophylaxis medications for 6 weeks to
the baby.
 Be involved in care and follow-up of the infant including clinic visits and
immunizationfollow-up; EID and CPT initiation and continuation up to 18 months at
least.
 Be involved in care of mother for ART centre visits
 Support exclusive breastfeeding for a minimum period of 6 months and continuation
ofbreastfeeds for 1 year in EID negative babies, and up to 2 years in EID positive
babies withinitiation of Paediatric ART. Weaning foods should be introduced from 6
months onwards inall babies whether breast fed or replacement feeds fed.
 Insertion of Cu-T (temporary contraceptive method) for HIV infected mother at 6
weeks if apost-partum IUD (PP-IUD) has already not been inserted within 48 hours in
addition tothe use of condoms will prevent unwanted pregnancies (dual protection)
 Encourage male sterilization in father (No Scalpel Vasectomy (NSV) between 18
monthsto 2 years when baby’s survival has been ensured).

Post-partum Follow-up and Care Extends Beyond the Six-week Postpartum Period and
Includes:
• Assessment of maternal healing after delivery and evaluation for post-partum infectious
Complications.
• Continued counselling and information on fertility choices and effective post-partum
Contraceptive methods as well as condom promotion and ensuring Cu-T IUD adoption and
Continued motivation for NSV for males at 18 months specifically, in HIV infected pregnant
Women, there should be linking of the baby to the Early Infant Diagnosis (EID) programme
And ART programme for mother/child as indicated.

COUNSEL AND FOLLOW-UP MOTHER-BABY (M-B) PAIRS AFTER

DISCHARGE
Counselling on Issues Related to the Mother:
• Counsel mothers taking ART for her own health for good adherence to life-long ART.
• The ART drugs will reduce the risk of HIV transmission through breastmilk during
breastfeeding
• Counsel mother who came directly-in-labour about the importance o f A R T.
• Counsel mother to have adequate rest, nutrition and to take iron-folate during the lactation
period, ensure enough proteins and fluids in the diet.
• Family support: involve husband and family members to help out with baby care so that she
can rest and recuperate, and to remind her of her ART and infant ARV prophylaxis.
• Counsel mother for her post-natal check-up at 6 weeks to coincide with the infant’s first
Immunization visit.
• Discuss and ensure contraception Copper -T ( Cu-T) insertion and condom use as dual
Protection at subsequent visits.4
• Arrange for the mother on ART to be followed with the ART Centre.
• ANMs/ASHAs/Counsellors/ORWs will follow-up the mother and baby within a week of
discharge for mother’s progress, support infant feeding practice, ensure adherence to infant
NVP prophylaxis at home, general counselling advice and infant follow-up.
Counselling for Issues of Infant to the Parents/ Caregivers:
• Counsel and reinforce decision on infant feeding practice whether exclusive breastfeeding
for first 6 months (preferably) or exclusive replacement feeding (for first six months if not
willing to breast-feed and resistant to doing so).
• All infants (irrespective of maternal ART in mother) must receive a minimum of 6 weeks of
infant NVP prophylaxis daily until the first visit for immunization at 6 weeks of age.
 If exclusive replacement feeding is being done, then infant NVP prophylaxis may be
stopped at 6 weeks of age.
• Infants who are diagnosed DNA/ PCR negative.
 Should continue breastfeeding and be re-evaluated as per EID protocol.
 Stop NVP prophylaxis at 6 weeks for babies given exclusive replacement feeding.
• Infants who are diagnosed DBS positive, are to be referred to the ART Centre for Whole
BloodSpecimen (WBS) collection. If WBS is also positive, then the infant will be initiated on
PaediatricART, irrespective of CD4 %.
• Final confirmation of the HIV status in the baby should be done at 18 months in ICTC by
doing all3 Rapid Tests even if the first rapid antibody test comes negative.(2)

CONCLUSION :-
As India embarks on the goal of eliminating parent to child transmission of HIV, it is evident
that good coverage with ANC, high rates of HIV testing, effective ART for pregnant and
breastfeeding mothers with ARV prophylaxis to infants will remain key factors contributing
to the success of preventing the vertical transmission.

BIBLIOGRAPHY :-
1. World THE, Work OF. National Policy on HIV / AIDS and the World of Work. :1–32.

2. Welfare F. Prevention of Parent to Child Transmission (PPTCT) of HIV using Multi

Drug Anti-retroviral Regimen in India. 2013.
3. National Technical Antiretroviral Treatment.2018.

CONTENT
ON
POLICY &
 GUIDELINE RELATED TO
HIV/AIDS

SUBMITTED TO SUBMITTED BY
MRS. DEBJANI NAYAK Mrs. Sandhya Sahoo
Assistant professior M.Sc. (N) 2nd year
O & G speciality O & G speciality