CHAPTER I

INTRODUCTION

Human Immunodeficiency Virus is a type of virus that attacks human’s immune

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

1
 CHAPTER II
CASE REPORT

IDENTITY
Name : Ny. M
Age : 35 years old
MR : 01 01 59 55
Address : Jorong Ranah Baru Abai Siat, Dharmasraya
Admitted : 12th May 2018
Husband : Mr. P
Age : 39 years old
Address : Jorong Ranah Baru Abai Siat, Dharmasraya
Occupation : Farmer

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

PRESENT ILLNESS HISTORY

- Previously patient was control pregnancy to primary health care at Dharmasraya a
month ago and do screening for HIV and the result was positive. Patient given
information and consultation about the result and referred to VCT polyclinic at
Sungai dareh Regional Hospital but she didn’t come because of transportation.
- Patien came to primary health care at Dharmasraya 12 hours ago with chief
complain fluid leakage from vagina, smelled fishy, greenish color and wetting one
piece of cloth,
- Patient was referred to Sungai dareh Regional Hospital, patient was recheck and
the result was negative and then the patient was referred to Dr. M. Djamil Central
General Hospital with IV line access due to there hasn’t prepare facilities
- fluid leakage from the vagina since 12 hours ago, smelled fishy, greenish color
and wetting one piece of cloth,

2
- Feeling of pain from waist region which referred to the groin since 6 hours ago,
more frequent and increase
- Bloody show from the vagina since 6 hours ago
- Massive bleeding from the vagina was absent
- Amenorrhea since 9 months ago.
- First date of last menstrual period forgot
- Estimation date of delivery difficult to determine
- Fetal movement was felt since 5 months ago
- There is no complain of nausea, vomiting and vaginal bleeding either during early
pregnancy or late pregnancy.
- Prenatal care with midwife 3 times (3,4 and 7 month of pregnancy), and control to
primary health care when 8 month of pregnancy , and do screening for HIV and
the result was positive. Never control to the obstetrician.
- Menstrual history : menarche at 13 years old, irregular menstrual cycle once in a
month, which last for 4-6 days each cycle with the amount of 2-3 times pad
change/day without menstrual pain.
- History of frequent fever and chronic diarrhea are dinied
- History of drastic weight loss is denied

PREVIOUS ILLNESS HISTORY

There was no previous history of heart, lung, liver, kidney, DM, hypertension and
allergy

FAMILY ILLNESS HISTORY

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

OCCUPATION, SOCIOECONOMICS, PSYCHIATRY, AND HABITUAL

HISTORY

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

3
 - The patient is the fifth wife 0fthe present husband and another wife not
divorced
History of pregnancy/abortion/delivery: 6/2/3
1. 2006/male/2800 gr/spontaneous/aterm/ dukun /live
2. 2007/female/2900 gr/spontaneous/aterm/midwife/live
3. 2012/female/4100 gr/spontaneous/aterm/midwife/live
4. 2013 abortus/ no curettage
5. 2014 abortus/ no curettage
6. present
Present
History of family planning : (-)
History of immunization : (-)
History of education : did not finish primary school
History of habits : There is no history of smoking, drinking and
drugs

PHYSICAL EXAMINATION
General Record:

GA Cons BP HR RR T

Mdt CMC 120/70 84 20 36,8

Body weight :
Before pregnancy : 56 kg
Present : 65 kg
Body Height : 160 cm
BMI : 21,87 kg/m2 (normoweight)
Upper arm circumference : 25 cm
Eyes : Conjunctiva wasn’t anemic, sclera wasn’t icteric
Neck : JVP 5-2 cmH2O, thyroid gland no enlargement
Chest : H/L normal, enlargement of breast.

4
Abdomen : obstetrical record
Genitalia : obstetrical record
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex -/-

Obsetric Examination

Abdomen :
I : Abdomen seem enlarg to term pregnancy, striae gravidarum (+), cicatrix (-),
linea mediana hyperpigmentation (+)
Pa :
L1 fundal uterine was palpable at 3 finger below proc.xyphoideus. a large
nodular mass was palpated
L2 a hard and resistance structure was felt on the left side, numerous small part
of the baby was felt on the right side
L3 a hard round mass was palpable and it was fixated
L4 parallel
Uterine fundal height : 35 cm EFW : 3565 grams
Uterine contraction : 2-3 times/35 second/moderate
Pe : Tympani
Au : Peristaltic sound was normal, FHR :132-142 x/minutes

Genitalia :
Inspection : V/U normal, vaginal bleeding (-)
VT : dilatation of servix 5-6 cm, amnion membrane (-)
Greenish residue, nitrazine test (+)
Small fontanel was palpable left anterior, Hodge II-III

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USG

Fetal Alive singleton intra uterin head presentation

Fetus movement normal
Biometric :
BPD : 95,6 mm
AC : 383 mm

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FL : 77,5 mm
Amnion fluid index /SDP : 18 mm
EFW : 3400-3500 gr
Plasenta Implanted at anterior corpus grade III
Impresion :
39-40 weeks of pregnancy , fetal alive head presentation

CTG

Base line : 145

Variabilitas : 5-15
Acceleration : (+)
Deseleration : (-)
Contraction : (+)
Fetal Movement : (+)
Impression : Reactive CTG (first category)

LABORATORY

Result Normal value

Hemoglobine 10,9 gr/dl 9,5-15,0

Leucocyte 8700 /mm3 5.9–16.9

Hematocrit 32 % 28.0–40.0

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 Trombocyte 225.000/mm3 146–429

PT 9,9 10,0-13,6

APTT 31,9 29,2-39,4

HbsAg Non reactive

HIV Rapid test Non reactive

DIAGNOSIS

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

TREATMENTS

Control,VS,HIS,FHR.
Informed consent
Reevaluations 4 hours later
Cosult perinatology
IVFD RL gtt XX/ mnt
Inj. Ceftriaxon 1 gr IV (skin test)
Plan : vaginal delivery

Follow Up at 10.00 am

S / sense of wanting to push (+)

O/

GA Cons BP HR RR T

Mdt CMC 120/70 84 20 36,8

8
Abdomen : Uterine contraction : 4-5 times/50 second/strong, FHR 140-150 x/min
Genitalia :
Inspection : V/U normal, vaginal bleeding (-)
VT : full of dilatation , amnion membrane (-)
Greenish residue
Small fontanel was palpable anterior, Hodge III-IV
A/ G6P3A2L3 term pregnancy second stage
Fetal alive, singleton, intra uterine, head presentation occiput anterior HIII-IV
P/ Control,VS,HIS,FHR
Normal vaginal delivery

At 10.15 AM

Vaginal delivery was performed

a male baby was born, 3600 gr in weight, 53 cm in height, A/S : 7/8
placenta was born spontaneously, complete, size 17x16x2 cm, weight 500 gr.
umbilical cord 45 cm long, paracentralis insertion
Bleeding during procedure was ± 50 cc

Diagnose:
P4A2L4 post term vaginal delivery + HIV (+) Suspected
Mother and child rooming in

Treatments :

Observe after procedure (VS, Vaginal bleeding, Contraction)

IVFD RL + Oxytosin 10 iu Gtt XX/ mnt
Inj. Ceftriaxon 2x1 gr (IV)
Mefenamic acid 3 x 500 mg (oral)
Sulfas ferrosus 2 x 300 mg (oral)
Vit C 3x50 mg (oral)

Plan : check laboratory 6 hours post procedure .

9
 CHAPTER III
LITERATURE VIEW

A. Definition

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

B. Epidemiology

On June 18, 1981, the first recorded AIDS epidemic appeared when the CDC
(Center for Disease Control and Prevention) reported a group of patients with
Pneumocystis Carinii Pneumonia in 5 gay men in Los Angeles USA in the early

10
1980s. In 1982, CDC introduced the term AIDS to describe the collection of
symptoms this disease (Wikipedia, 2010).
Based on Ministry of Health, until December 2011 there were 21.031 cases of
Human Immunodeficiency Virus (HIV) and 4.162 cases of Acquired
immunodeficiency syndrome (AIDS). Until 31 December 2011, HIV and AIDS cases
who reported since 1978 ammounted to 76.879 dan 29.879 cases, respectively, with
5.430 deaths. According to data collected until Desember 2011, West Sumatera ranks
12th after Papua, DKI Jakarta, Riau Islands, and North Sumatera, with 568 HIV cases
and 428 AIDS cases. (Ministry of Health, 2012)
There is difference transmission patterns of HIV / AIDS between industrialized
and developing countries, where in industrialized countries the largest transmission is
found in the homosexual group, followed by the compactor, and the last is the
perinatal transmission. For Indonesia, based on data from Ministry of Health until
December 2011, largest transmission is heterosexual group as many as 14,775 cases,
homosexual 807 cases, 9392 drug abuse, blood transfusion 51 cases, perinatal
transmission 730 cases and unknown 940 cases. (CDC, 2009; Ministry of Health,
2012)
Approximately 95% of HIV patients live in developing countries, about 12% of
HIV patients are woman, which 85% are at reproductive age. HIV / AIDS cases in
Indonesian children increased 70 percent in the last four years (2006-2010). HIV
cases in children are most commonly found due to transmission from mothers who
already have HIV to their children.
If the birth rate in Indonesia is 2.5%, then every year there will be 2,250 - 3,250
babies born to HIV positive mothers. Over 90% of mother-to-child HIV transmission
occurs during pregnancy, labor, and breastfeeding. In the United States, as reported by
the Centers for Disease Control (CDC), in 2009 there were only 7 new cases of HIV
because of perinatal transmission. This is evidence that HIV transmission due to
perinatal transmission can be prevented. (CDC 2009; WHO 2009; KEMENKES RI,
2012).
HIV transmission to children from HIV positive mothers is referred to as Mother
to Child Transmission (MTCT). Transmission from mother to child / infant occurs
through transmission in utero, at birth / peripartum and through breastfeeding. The
risk of infants acquiring HIV can be reduced to 98%, if the mother gets antiretroviral
(ARV) therapy during pregnancy. (CDC 2009; WHO 2009; KEMENKES RI, 2012)

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C. HIV in Pregnancy

Planned and non-planned pregnancies can occur in HIV positive women. HIV
infected patients’s desire to get pregnant needs attention. After obtaining correct
information about the effect of HIV on pregnancy, as well as the risk of transmission
to infants, we need to respect the decisions taken by HIV infected patients.
The effects of HIV infection on pregnancy are related to abortion, prematurity,
IUGR (Intra Uterine Growth Restriction), IUFD (Intra Uterine Fetal Death),
transmission to the fetus, and increased maternal mortality.
In contrast, pregnancy has little effect on HIV infection, a decrease in CD4 due to
increased body fluid volume during pregnancy, in addition HIV levels are stable and
do not affect the risk of death or progression to AIDS.
Pregnancy monitoring on CD4 <500 cells / mm3 is recommended every 3 weeks
to 28 weeks and every 2 weeks until 36 weeks' gestation, then once a week until
labor. Additional examination include complete blood laboratory examination, as well
as CD4 count, and ultrasound if the facility is possible at 16, 28 and 36 weeks
gestational age in pregnant women taking either antiretroviral or CD4 <200 cells/
mm3.

1. Perinatal transmission

Perinatal transmission is transmitted from the mother living with HIV to the fetus
during the perinatal period. Pregnancy transmission rate is about 5 - 10%, when labor
about 10-20%, and when breastfeeding about 10-20% if feeding until 2 years.
Transmission during breastfeeding primarily occurs in the first weeks of
breastfeeding, especially when new mothers are infected while breastfeeding. If the
mother living with HIV is not breastfeeding her baby, the baby may be infected by
HIV infection of 15-30%, if breastfeeding up to 6 months may be infected 25-35%,

12
and if breastfeeding period is extended to 18-24 months then the risk of infection will
increase to 30-45%.
In most women infected with HIV, transmission can not pass through the
placenta. Generally, maternal blood does not mix with infant blood, so not all babies
conceived by HIV positive mothers are infected with HIV in the womb. Placenta even
protects the fetus from HIV, but this protection can be damaged if there is a viral,
bacterial, or parasitic infection of the placenta, or in situations where mother's
immunity is very low.
In labor process, there is contact between the mother's blood, as well as maternal
and infant mucus, so that HIV virus can enter the baby's body. Longer the labor
process, the contact between the baby and the mother's body fluids gets longer, risk of
transmission be higher.
Breast milk from HIV-infected mothers contains HIV in concentrations lower
than those found in the blood. Transmission occurs in about 10 - 20% of infants who
are breastfed for 18 months or more. Based on that basis, women with HIV infection
are advised not to breastfeed their babies and be replaced with milk substitute breast
milk. Frequency of mother-to-child transmission in developed countries is about 15 -
25%, while in developing countries 25-45%, is associated with high breastfeeding
habits in developing countries.
With the development of understanding about pathogenesis of perinatal HIV-1
transmission, it is known that most occur at the time of labor. Additional data, have
demonstrated that short-term safety of ZDV regimens, on monitoring of infants and
women with PACTG 076 treatment. Data from animal studies, indicating the potential
of transplacental carcinogens from ZDV use, therefore further monitoring of children
with antiretroviral exposure in-utero .

2. Factors that affect mother-to-child transmission of HIV

Transmission of HIV from mother to baby is generally associated with immune

system, and virulence of germs.

a. Mother factors:

13
1) Newly infected mother is easy to infect her baby. This is due to the amount of virus
in the mother's body is very high compared to the number of viruses in mothers who
contracted HIV before or during pregnancy.
2) Mothers with HIV-related diseases such as cough, persistent diarrhea, weight loss,
this is also due to the amount of virus in the mother's body is high.
3) Infection in pregnancy, especially sexually transmitted infections or placental
infections
4) Malnutrition during pregnancy, especially lack of micronutrients
5) Mastitis
6) KPD, prolonged partus, and interventions during labor such as amniotomy,
episiotomy.

b. Baby factors

1) The baby is born prematurely

2) Breastfeeding to mothers with HIV
3) Lesions in the baby's mouth increase the risk of contracting HIV, especially in
infants under 6 months of age

D. Prevention of HIV Transmission in Infants and Children

In the book Prevention of Mother to Child Transmission of HIV, the World Health
Organization states that PMTCT (Programmes of the Prevention of Mother to Child
Transmission), can reduce vertical transmission of HIV, also connects women with
HIV infection, children, and their families, to get treatment , care, and support.
PMTCT is a comprehensive program and follows national protocol and policy. (CDC
2009; WHO 2009; KEMENKES RI, 2012)

PMTCT Interventions:
1. HIV examination and counseling
2.Aniretroviral
3. More secure labor
4. Breastfeeding is safer

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Couple involvement in PMTCT:

1. Both partners should know the importance of safe sex during labor and
breastfeeding
2. Both partners should undergo HIV examination and counseling
3. Both partners should know and do PMTCT

Risk factors for MTCT during pregnancy:

1.High maternal viral load (new HIV / AIDS or advanced)

2.Infection of viruses, bacteria, or parasites through the placenta (especially malaria)
3.Sexually transmitted infections
4.Maternal malnutrition (indirectly)

Risk factors for MTCT during labor:

1.High maternal viral load (new HIV / AIDS or advanced)

2. Rupture of membranes > 4 hours before labor begins
3. Invasive labor procedure
4.First infant in multiple pregnancies
3. Chorioamnionitis

Risk factors for MTCT during breastfeeding:

1.High maternal viral load (new HIV / AIDS or advanced)

2.Long breastfeeding
3.Breastfeeding with early replacement feeding
4.Breast abcess/ nipples are infected
5.Maternal malnutrition
6.Baby oral disease (eg, trust or mouth sores)

WHO launched four strategies for prevention of HIV transmission in infants and
children:

15
1. Primary prevention, by preventing all women from becoming infected with
HIV
The most important thing is that a healthy mother should not be infected with
HIV, for that especially change sexual behavior, loyal to partner, avoid sexual
intercourse with changing partner, if this is violated, use condom. Sexually
transmitted diseases should be prevented and treated promptly. Do not be an injection
drug user, especially with the use of a syringe alternately.
For health workers to follow the standard universal precautions rules. Doctors,
nurses and other health workers treating patients with HIV / AIDS (HIV infected
patients) do not belong to high-risk groups who are infected with HIV, especially
when applying universal precautionary procedures for infection prevention. All blood
or body fluids should be considered to transmit HIV or other diseases contained in the
blood.
Blood transfusions should use blood or blood components that have been
declared free of HIV and for surgery plans to seek autologous blood transfusions.
In couples wishing to conceive, HIV testing should be performed before
pregnancy, and for those who have been pregnant, HIV testing is done at the first
visit.
Key to the success of this program is VCT (Voluntary Counseling and Testing),
namely counseling and readiness to undergo HIV testing. The targets are young
women and their partners, as well as pregnant and lactating mothers. (CDC 2009;
WHO 2009; KEMENKES RI, 2012)
2.Prevention of unwanted pregnancy in women with HIV positive

There are three strategies that are proclaimed:

1. Prevent unwanted pregnancy

Most women with HIV infection in developing countries are unaware of their
serological status, so VCT plays an important role. Family planning services need to
be extended to all women, including those infected, receiving support and services to
prevent unknown pregnancies. For women who are already infected with HIV to get
essential services and support including family planning and reproductive health so
they can make decisions about their reproductive lives.

16
2. Delay the next pregnancy

If the mother still wants the child, WHO recommend at least 2 years distance
between pregnancy. To delay pregnancy:

1) Not allowed to use IUDs because it can spread the infection upwards causing
pelvic infection. Women who use IUDs have a tendency to have bleeding that can
cause transmission more easily.
2) The recommended contraceptive is condom, because it can prevent the
transmission of HIV and sexually transmitted infections, but does not have the
same success rate with other contraceptives such as oral contraceptives or
noorplant.
3) Oral contraceptives and long-term hormonal contraceptives such as noorplant
and depo provera do not constitute a contraindication in HIV-infected women.
Studies are underway to determine the effect of hormonal contraceptive use on
HIV disease travel.
4) Sponges and diaphragms are less effective in preventing pregnancy and
preventing HIV transmission.
5) For mothers who do not want to have more children, the most appropriate
contraception is sterilization (tubectomy or vasectomy).
6) If the mother chooses contraception other than condom to prevent pregnancy,
then condom use must be done to prevent HIV transmission.

3. Replace the effects of breastfeeding contraception

Non-breastfeeding to prevent mother-to-child transmission of HIV cause the

effects of lactation contraception to be lost, for which a contraceptive is necessary to
prevent pregnancy.

3. Prevention of HIV transmission from mother to fetus

Prevention interventions from mother to fetus / baby include four things, from
pregnancy, labor, and after birth:

17
1. Use of ARVs during pregnancy (PMTCT plus project)
2. Use of ARVs during labor and newborns
3. Obstetric care during labor
4.Treatments during breastfeeding

4. Treatment, care and support for women with HIV, infants, and their families
1. Provide HIV-related treatments, care and support for women
2. Provide early diagnosis, care, and support for infants and children with HIV-
positive infections
3. Encourage relationships among community services for integrated family services

WHO proposed AFASS criteria for PASI in infants born to HIV positive mothers:

Acceptable (accepted)
Mothers have no sociocultural barriers to choosing alternative foods or there is no
fear of stigma and discrimination

Feasible (executed)
Mother or family has enough time, knowledge, skills and other to prepare and
feed the baby. Mothers get support when there is family, community and social
pressure.

Affordable (affordable)
Mothers and families are able to purchase, manufacture and prepare selected
foods, including groceries, fuel and clean water. Not using funds for family health and
nutrition.

Sustainable (continuous)
Substitute foods given to infants should be daily and or evening (every 3 hours)
and in fresh form. Distribution of the food must be sustainable as long as the baby
needs it.

18
Safe (safe, clean quality)

Food replacement must be stored properly, hygienic with adequate quantity of

nutrients.
In general, infant feeding from HIV positive mothers can be described as follows:

When the mother chooses to continue breastfeeding, breast milk is given for only
6 months and then stopped. Breast milk is warmed and warmed to 56 Celcius
degree for 30 minutes.

When the mother chooses to give formula milk, formula must be given by
fulfilling 5 AFAS criteria, not to give breast milk simultaneously with formula
milk.

Babies and mothers are in emergency situations (natural disasters, wars)

In emergency situations, infants are still encouraged to get breast milk with some
control:
- Monitoring and control of infant feeding by National Coordinator of Disaster.
- Breastfeeding remains the first and best choice in emergency situations. Poor
hygiene conditions, lack of clean water and fuel are risk factors for infection in infant
formula feeding.
- Counseling should be given to breastfeeding mothers by trained PP-ASI teams. need
Shelter / special tents and breastfeeding materials should be provided. Breastfeeding
production disorders in times of disaster are generally due to psychic trauma so it
needs to be emphasized that the situation is temporary.
- Formula milk, including skim milk should not be part of the food rations.
- Not receiving help for formula milk from formula producers / distributors, the use of
formula only for the right one obviously requires with medical indication and
orphaned baby. Providing this formula with purchase.
- Formula milk may be dispensed when given not as a single food, but mixed with
ground food.
- Product labels meet International code requirements for PASI marketing, including
instructional use, health hazards, in Indonesian

19
- If the infant formula is distributed by the donor, then distribution, use, and health
effects of infants should be monitored by trained personnel
- Available MP-ASI for babies over 6 months

Although some of these controls are sometimes difficult to implement in the field,
but with cooperation of all parties, it can gradually be implemented.
Makes every baby breastfed and enables every mother to breastfeed her baby.
Breastfeeding rights are defined as breastfeeding in accordance with WHA
Resolution (2001), that is, the infant is exclusively breastfed from birth to 6 months,
then MP-ASI is given and breastfeeding continues until the infant is 2 years or older.
A breastfeeding mother to be able and successfully carry out breastfeeding
completely. A mother needs comprehensive protection, information, and assistance
while eliminating barriers to her environment, including:

- Environment / family and community support

- Communication, information and education to all levels of society to cultivate the
culture of breast milk, for example the provision of lactating space in public service.
- The entire healthcare system applies 10 Steps to Breastfeeding Success or apply
Baby's affection
- Mother gets information or counseling about the benefits of breastfeeding and how
to breastfeed
- Mother gets breastfeeding counseling especially when faced with problems
- Mother not exposed / affected by marketing PASI or mother should be able to refuse
giving PASI
- Working mother gets protection, policies, tools and assistance to implement optimal
breastfeeding
- Mothers who are HIV positive require knowledge of infant feeding
- When the mother-baby is in emergency situations assisted to keep breastfeeding.

E. HIV / AIDS Management in Indonesia

At present less than 5% of HIV infected patients in developing countries needing
ARVs can be affordable. Antiretroviral treatment guidelines provide information
about 4S: starting, substituting, switching, and stopping, which is a good time to start
therapy, choosing a drug that must be continued when replacing a substitute regimen

20
(substitution), the reason for replacing the entire regimen (switching ), and when
stopping antiretroviral (stopping).

1. Precondition
Administration of antiretroviral (ARV) therapy according to the National
Guidelines for Care, Support and Treatment for HIV infected patients, Directorate
General of Communicable Disease Eradication and Environmental Health Ministry of
the Republic of Indonesia in 2003 generally has certain requirements, such as CD4
cell count <200 cells / mm3, but administration of ART in HIV infected patients’s
pregnant with the aim of preventing HIV transmission from mother to fetus / baby
does not pay attention to the above requirements.
In general, before starting antiretroviral treatment, special services and facilities
should be available, because of complex and costly therapies, and also require
intensive monitoring.

These services consist of:

Voluntary Counseling and Testing (VCT) to find cases requiring treatment and
follow-up counseling services to provide ongoing psychosocial support.
b. Compliance counseling services to ensure patient readiness to receive treatment by
trained counselors and continue treatment (may be provided through counseling or
peer support).
c. Medical services that are able to diagnose and treat diseases that are often
associated with HIV as opportunistic infections.
d. Laboratory services capable of performing routine laboratory tests such as complete
blood tests and blood chemistry. Access to a referral laboratory capable of performing
CD4 examinations is useful for monitoring treatment.
e. Availability of ARVs and other opportunistic infections and other related diseases
are effective, quality, affordable and sustainable. (CDC 2009; WHO 2009;
KEMENKES RI, 2012)

2. Clinical Assessment
Before starting treatment, it is necessary to:
a.Complete history of the disease
b.Complete physical examination

21
c. Routine laboratory examination
d. Calculate total lymphocytes (Total Lymphocyte Count / TLC)
e. CD4 count examination whenever possible

Need a detailed clinical assessment:

a. Assessing clinical stages of HIV infection
b. Identify past HIV-related illnesses
c. Identify current HIV-related illnesses that require treatment
d. Identify other treatments underway that may affect the choice of therapy

Disease history:
a. When and where HIV diagnosis is enforced
b. Possible source of HIV infection
c. Current symptoms and complaints of the patient
d.Previous history of disease, diagnosis and treatment received, including
opportunistic infections
e.Historical disease and treatment of tuberculosis (TB) including possible contact with
previous TB
f. History of Possible Sexually Transmitted Infections (STIs)
g. History and possible pregnancy
h. History of ARV use includes a history of the regimen for previous PMTCT
i.Rescription history and use of oral contraceptives in women
j. Daily habits and sexual behavior history
k.Historical use of injecting narcotics drug

Physical examination includes:

a. Weight
b. Vital signs
c. Skin: herpes zoster, Kaposi’s sarcoma, HIV dermatitis, pruritic papular eruption
(PPE), severe seborrheic dermatitis, needle track, or incision lesion.
d.Lymphadenopathy
e.Oropharyngeal mucous membranes: candidiasis, Kaposi's sarcoma, hairy
leukoplakia, HSV

22
f. Examination of the heart, lungs, abdomen
g.Check the nervous system and skeletal muscle: psychiatric state, reduced motor
function and sensory
h.Examination of the eye fundus: retinitis and papillary edema
i.Examination of the genital tract / uterus

Psychological examination:
a. To know mental status
b. Assessing readiness to receive long-term or lifelong treatment

Laboratory examination:
a. Serological examination for HIV using strategy 2 or strategy 3 according to
guidelines
b. Lymphocyte total or CD4 (if available)
c. Complete blood test (mainly Hb) and blood chemistry (especially liver function)
and kidney function
d.Pregnancy examination

Additional examination required according to disease history and clinical

examination:
a. Thorax Photo
b. Routine urine and microscopic examination
c. Serology of hepatitis C virus (HCV) and hepatitis B virus (HBV) depends on the
examination and resources

If possible, blood chemistry examination did includes:

a. Serum creatinine and / or blood urea to assess renal function at baseline

b. Glucose blood
c. SGOT / SGPT to determine the possibility of hepatitis and monitor the presence of
drug poisoning
d. Other tests as necessary, such as: serum bilirubin, serum lipids, and serum amylases

23
 HIV examination should be performed by a trained technician in a laboratory
who runs a quality watch program. The results of the examination should also
mention the type of examination used to establish a diagnosis based on the WHO
guidelines. If any doubt arises, the examination shall be repeated in the reference
laboratory. (CDC 2009; WHO 2009; KEMENKES RI, 2012)

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

Stage CLinical Manifestations Activities Scale

Asymptomatic Asymptomatic,normal
I
Generalized lymphadenopathy activities
Weight loss < 10% Symptomatic,normal
Skin and mild mucosa disorders such as seborroic activities
dermatitis, prurigo, onychomicosis, recurrent oral
II
ulcers, angular chilitis
Herpes zoster in the last 5 years
ISPA (URTI) like bacterialis sinusitis
Weight loss > 10% Commonly weakness,
Chronic diarrhea > 1 month activities on the bed <
Prolonged fever > 1 month 50%
Orofaryngeal Candidiasis
III
Oral hairy leukoplakia
Pulmonary TB in the last year
Severe bacterial infections like pneumonia,
pyomyositis
IV HIV wasting syndrome like who defined CDC Pada umumnya sangat
Pneumonia Pneumocytis carinii lemah, aktivitas di tempat
Brain Toxoplasmosis otak tidur > 50%
Cryptoporidiosis diarrhea > 1 month
Extrapulmonal cryptokokosis
Cytomegalo Retinitis
Mucocutaneous Herpes simpleks > 1 month
Progressive Multifocal Leucoensephalophaty
Disseminated Mycosis like histoplasmosis
Candidiasis in esophagus, trachea, bronchus, and
pulmo
Disseminated atypical mycobacteriosis
Salmonelosis Septisemia non typhoid
Tuberculosis outside the pulmo

24
 Limphoma
Caposy Sarcoma
HIV Ensephalophaty

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

Table 2. CLinical Classification HIV Infections in Children

Stage Clinical Manifestations

Asymptomatic
I
Generalized Limphadenopathy
Chronic diarrhea > 30 days, without any known aetiology
Severe Persistent Candidiasis or recurrent at the time of neonate
II. Weight loss or failure to thrive without any known aetiology
Persistent fever > 30 days without any known aetiology
Recurrent severe bacterial infections bacterial pneummonia non TB, abses)
Oppurtunistic infection AIDS-defining
Failure to thrive or weight loss without any known aetiology
III Progressuve Encepalophaty
Malignancy
Septicemia or Recurrent Meningitis

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

3. Others Requirements

25
 Before receiving ARV treatment, patients should be well prepared with
standardized adherence counseling, so that patient understands the benefits, ways of
use, drug side effects, hazards, etc. associated with ARV.
Patients receiving ARV treatment should undergo reguler clinical monitoring
examination.

4. Indication of Antiretroviral Treatment

ARV treatment in adult HIV infected patients should start immediately when HIV
infections has been established in a laboratory with one of the following:

a. Advanced clinical stage of HIV infections

1) HIV infection stage IV regardless of CD4 count
2) HIV infection stage III with CD4 < 350 cells/mm3

b. HIV infection stage I or II with CD4 < 200 cells/mm3

If there is not CD4 examination’s device, total lymphocytes ≤ 1200/mm3 used as
indicator ARV treatment in HIV infection symptomatic, and on asymptomatic patient
total lymhocytes count is less correlated with CD4 count.
Viral load examination (for example with RNA HIV-1 levels in plasma) is not
considered necessary before administraion of ARV and not recommended WHO as
rutine action in decision making action.

Table 3. ARV Treatment in Adult HIV infected patients

CD4 Examination is Available

Stage IV regardeless of CD4 count
Stage III wtih CD4 < 350 cells/mm3
Stage I or II with CD4 < 200 cells/mm3
Device of CD4 Examination is not Available
Stage IV regardeless of total lymphocyte count
Stage III regardeless of total lymphocyte count
Stage II with total lymphocyte < 1200 /mm3

Table 4. Dose of Antiretroviral for Adult HIV infected patients

26
 Category/ Drugs Name
Nucleoside RTI
Abicavir (ABC)
Didanosine (ddl)
Lamivudine (3TC)
Stavudine (d4T)
Zidovudine (ZDV atau AZT)
Nucleotide RTI
Tenofovir (TDF)
Non Nucleoside RTIs
Evafirenz (EFV)
Nevirapine (NVP)
Protease Inhibitors
Indinavir/ritonavir (IDV/r)
Lopinavir/ritonavir (LPV/r)
Nelfinavir (NFV)
Saquinavir/ritonavir (SQV/r)
Ritonavir (RTV/r)
Dose
300 mg every 12 hours
400 mg once a days
(250 mg once a days if weight < 60 kg)
(250 mg once a day if given with TDF)
150 mg every 12 hours or 300 mg once a days
40 mg every 12 hours
(30 mg every 12 hours if weight < 60 kg)
300 mg every 12 hours
300 mg once a days
(Drug interaction with ddl, need to reduce the ddl dose)
600 mg once a days
200 mg once a days for 14 days, then 200 mg every 12 hours
800 mg / 100 mg every 12 hours
400 mg / 100 mg every 12 hours
(533 mg / 133 mg every 12 hours if combined with EVP or NVP)
1250 mg every 12 hours
1000 mg / 100 mg every 12 hours or 1600 mg / 200 mg once a
days
Capsule 100 mg, oral solution 400 mg / 5 ml

F. Antiretroviral in Pregnancy

According to recommendations on the use of antiretroviral treatment in pregnant

women with HIV-1 positive for maternal health, as well as interventions to reduce
perinatal HIV-1 transmission in the United States, revised on 24 February 2005 by the
Perinatal HIV Guidelines Working Group stated, treatment for pregnant women with
HIV -1 is positive based on the belief that treatment has a usefulness that is known to
women during pregnancy, unless there is an effect known to both mother and fetus.
ARV treatment in pregnant women is given when:

1. Have severe symptoms of HIV or with an AIDS diagnosis

2.CD4 <200 cells / mm3
3.Viral load> 1000 / ml

ARV treatment is also needed to prevent transmission of HIV to the fetus. Anti-
HIV treatment is an important part of maintaining maternal health, as well as

27
preventing HIV transmission to the fetus. The decision to start therapy depends on
several factors, which should also be known by non-pregnant women:

1. The risk of HIV infection becomes severe

2.Risk and usefulness delay treatment
3.Toxicity of treatment, drug interactions with other drugs taken
4.The need to adhere to a drug regimen closely

In addition, for pregnant women with HIV, must consider:

1. Benefits reduce the number of viruses, reduce the risk of HIV transmission from
mother to fetus
2. Long-term effects that have not been known to the baby when using antiretroviral
drugs during pregnancy
3.Information available about use of anti-HIV drugs during pregnancy

Pregnant women with HIV in the first trimester without symptoms of HIV, may
delay treatment until 10-12 weeks gestation. After the first trimester, HIV infected
patients’s woman should receive treatment at least with zidovudine (also known as
ZDV or AZT). Additional treatment may be considered, according to CD4 count and
viral load.
Combination of antiretroviral therapy usually consists of two nucleoside analog
reserve transcriptase inhibitors (NRTIs) with protease inhibitor (PI), a standard
treatment recommended for adults with non-pregnant HIV-1 infection. In pregnancy it
is not permitted to use this treatment regimen.

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

several thoughts:

28
1. Possibility of changing the dose of need corresponds to the physiological changes
associated with pregnancy.
2. Potential effects of antiretroviral drugs in pregnant women
3. Short-term and long-term potential effects of antiretroviral drugs on fetuses and
infants, which may not be known for all antiretroviral drugs

Decisions of use of antiretroviral medications during pregnancy should be made

by pregnant women after discussing with the health worker regarding both known and
unknown uses, as well as risks for the woman and her baby.
Physiological changes during pregnancy may affect the kinetic absorption,
distribution, biotransformation, and elimination of the drug, thus also affecting the
dose of the drug required, as well as the possibility of toxicity. During pregnancy,
transit time in the digestive tract extends, water content and body fat increases,
followed by increased cardiac output, ventilation, and liver and renal blood flow,
decreased plasma protein concentration, increased renal sodium reabsorption, and
altered metabolic pathways of enzymes in the liver . Drug transport on the placenta,
drug compartmentalization of the embryo / fetus and placenta, biotransformation of
drugs by the fetus and placenta, and elimination of the drug by the fetus, also result in
pharmacokinetics of drugs in pregnant women. Additional consideration of drug use
in pregnant women: (CDC 2009; WHO 2009; KEMENKES RI, 2012)

1. Effects of drugs on the fetus and newborn, including teratogenic potential,

metagenity, and carcinogenicity
2. Pharmacokinetic as well as drug toxicity transported through the placenta.

The consequences that arise in the fetus of the mother for a particular drug,
depend not only on the drug itself, but also on the dose of the drug, the age of
pregnancy when the fetus is exposed, duration of exposure, interactions with other
drugs also exposed to the fetus, and genetics of the mother and fetus.

In the Prevention of Mother to Child Transmission of HIV book, World Health

Organization says that ARV treatment decreases viral replication and viral load in

29
mothers, and protects the fetus against HIV exposure. Antiretroviral drugs effectively
treat maternal HIV infection and prevent vertical transmission.
Treatment should not be equated with prevention (prophylaxis). ARV treatment is
a long-term antiretroviral use for treating maternal HIV / AIDS infection, as well as
preventing MTCT. While ARV prophylaxis is a short-term antiretroviral use to reduce
mother-to-child transmission of HIV to the fetus.
Antiretroviral treatment during pregnancy, if indicated, will improve women's
health, and reduce the risk of HIV transmission to the fetus, and is recommended in
the following situations:
1.If CD4 examination is available, it is recommended to record CD4 cell counts, and
offer ARV treatment to patients with:

a. Stage IV WHO, regardless of CD4 count

b. Stadium III WHO with CD4 < 350/mm3
c.Stadium I or II WHO with CD4 ≤ 200 / mm3

2. If there is no available CD4 examination, it is recommended to offer antiretroviral

treatment in patients with:

a.Stadium IV WHO, regardless of total lymphocyte count

b.Stadium III WHO, regardless of total lymphocyte count
c.Stadium II WHO with total lymphocytes ≤1200 / mm3
If antiretroviral treatment is indicated in pregnancy, it should be done
immediately. Sometimes treatment is delayed until after the first trimester. Pregnant
women receiving ARV treatment require ongoing care and monitoring between local
HIV / AIDS programs. If coinfection with TB occured, additional treatment and
clinical management are needed to minimize side effects.

Principle of antiretroviral treatment in women of childbearing age or pregnant

women should be based on the needs and requirements of antiretrovirals as already
mentioned. Pregnancy and breastfeeding provide additional problems in maternal and
child toxicity, antiretroviral drug selection, and prevention of mother-to-child HIV
transmission. First-line regimens recommended for this group are:

30
 (d4T atau AZT) + 3TC + NVP

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

31
threatened its effecacy, because this method provides higher levels of hormones in the
blood than other progesterone contraceptives as well as combined oral contraceptives.
So, if women with ARV treatment will initiate or continue hormonal contraceptives, it
is always advisable to always use condoms to prevent HIV transmission and also to
maintain the possibility of decreasing the effectiveness of hormonal contraception
used.
In developing countries there are several antiretroviral regimens to prevent
transmission from mother to fetus / baby recommended:

1. Nevirapine
Mothers received nevirapine 200 mg single dose at labor. Baby 2 mg / kgBB
before the age of 3 days (within the first 72 hours after birth).
This regimen is an option because it is easy to its administer, does not need repeat
therapy and effectively prevents mother-to-child transmission up to 13%, and is
economical. Economic factors are noticed because ARV cost are relatively expensive
and its principle ARVs should be given for longlife.
Nevirapine can cause skin rashes, Steven-Johnson syndrome, increased serum
aminotransferase, and hepatitis.

2. AZT
Pregnant women with 36 weeks gestation were given AZT 2 x 300 mg / day, and
300 mg every 3 hours during labor. This regimen is more effective to reduce the risk
of mother-to-child transmission (9%), but more expensive, because it requires
recurrent therapy with duration of therapy until 1 month. Given the relative cost of the
drug, then most regimens are used according to local conditions.
Side effects are common in pregnant women who consume AZT is anemia,
therefore it is necessary to screen for anemia and its treatment if anemia occured.
Other side effects of zidovudine are netropenia, gastrointestinal intolerance, headache,
insomnia, myopathy, lactic acidosis.

Administration of antiretrovirals in pregnant women does not cause

resistance of antiretroviral therapy, because its administration is short-lived,less than 3
months. Although it is known there is the possibility of single therapy with nevirapine
may cause rapid resitance, however so far there is no evidence for that.

32
 Table 4. Guideliness of ARV Treatment in PMTCT

Regiment for Mother (dose

CLinical condition Regiment for baby
according to table 3)
1. HIV infected patient - Make sure that aren’t pregnancy
with pregnancy before starting ARV
probability who - Avoid use EFV
ARV-indicated - AZT + 3TC + NVP or
- d4T + 3TC + NVP
2. HIV infected - Continue ARV regiment were - AZT (4mg/kgBB every 12
patients with ARV, using hours) for 1 week or
then pregnancy - If get treatment with EFV - NVP (2mg/kgBB) single
changed with NVP or PI in first dose or
trimester pregnancy. - NVP single dose + AZT
- Continue same ARV treatment for 1 week
during labor and post labor
3. Pregnant infected - Delay ARV until after first - NVP single dose for first
HIV patients with trisemester if possible. In bad 72 hours + AZT for 1
ARV indication condition need considered about week or
advantage-disadvantage of ART - AZT for 1 week or
use. - NVP single dose for first
- ARV like in usual HIV infected 72 hours
patients
- First line ARV: AZT + 3TC +
NVP or
- d4T + 3TC + NVP
- EFV may not given in first
trisemester pregnancy
4. Pregnant infected - AZT started at 28 weeks - NVP single dose in first
HIV patients, but gestation or soon after that, then 72 hours + AZT for 1
there isn’t ARV continue during labor + week
indication yet - NVP single dose in the
beginning of labor

33
 Alternative regiments: - AZT for 1 week
- AZT started at 28 weeks
gestation or soon after that,
continued during labor
- AZT + 3TC: since 28 weeks - AZT + 3TC (2mg/kgBB)
gestation or soon after that, for 1 week
continued during labor period
until one week post labor
- NVP single dose intrapartum - NVP single dose in 72
hours
5. Pregnant infected - According to 4th point, but it is
HIV patients with better to use most effective
ARV indication but regiments
haven’t started the
therapy yet
6. Pregnant infected If considered to use ARV:
HIV patients with - AZT + 3TC + SQV/r or
active TB - D4T + 3TC + SQV/r
The appropiate of If treatment started in trimester III:
antiTB drugs for - AZT + 3TC + EFV or d4T +
pregnant woman 3TC + EFV
still given. - If you’re not using ARV therapy,
follow point 4
7. Pregnant mother in Bila sempat tawarkan pemeriksaan dan konseling pada ibu yang
labor period with belum diketahui status HIV-nya, bila tidak, lakukan pemeriksaan dan
unknown HIV status konseling segera setelah persalinan (dengan persetujuan) dan ikuti
Or butir 8
If positive:
HIV infected
- Give NVP single dose - NVP single dose in first
patients who visite
- If the labor happened, don’t give 72 hours
when labor but
NVP, but follow point 8, or - AZT + 3TC during 1 week
don’t get ARV
- AZT + 3TC in labor until 1
therapy yet
week post labor
8. Baby from HIV NVP single dose as soon as
infected patients possible + AZT for 1 week. If
who never get ARV given after > 2 days it’s less
therapy yet benefit
* From: ”Recommendation on ARVs and MTCT Prevention 2004”. WHO July 2004
G. Safety and Toxicity of Anti HIV Treatment during Pregnancy

34
 Information about anti HIV treatment for pregnant women is limited compared
with nonpregnant adult women, but it is well known to recommend the suitable
treatments for both mother and baby.
However, according to the Perinatal HIV Guidlines Working Group in 2005 the
long-term effects of ARV treatment on in-utero fetus are still unknown.
One of the treatment regimens that can be used is non-nucleoside reverse
transcriptase inhibitors (NNRTIs) niverapine (NVP). Long-term use of NVP may
cause some negative side effects such as fatigue or weakness, nausea, loss of appetite,
yellowing of eyes or skin, or signs of liver toxicity such as liver hardening or
enlarging or enhancing liver enzymes. These effects have not been found in the short-
term (one or two dose) NVPs during pregnancy. The condition of the patient during
treatment with NVP should be monitored because, pregnancy may cause some early
symptoms of liver toxicity. The use of NVP also requires attention in women who
have never received anti-HIV treatment as well as in women with CD4> 250 cells /
mm3. Liver toxicity is more common in these patients.
Delavirdine and efavirenz, are NDA-approved NNRTIs, but are not
recommended for use in HIV-positive pregnant women. Use of this drug during
pregnancy can lead to birth defects.
Nucleoside reverse transcriptase inhibitors (NRTIs) can cause mitochondrial
toxicity, which can lead to accumulation of lactic acid in the blood. This toxicity is
known as hyperlactemia or lactic acidosis. This toxicity may be considered for
pregnant women and their infants who will be exposed to NRTIs in-utero.
Protease Inhibitors (PIs) are associated with elevated blood sugar or
hyperglycemia, onset of diabetes mellitus, or onset of symptoms of diabetes mellitus,
and diabetic ketoacidosis. Pregnancy is also a risk factor for hyperglycemia, but it is
not known whether the use of protease inhibitors increases the risk of hyperglycemia
associated with pregnancy or gestational diabetes.
Enfuvirtide (T-20) is the only FDA-approved Fusion Inhibitor, very little is
known about its use during pregnancy.

H. Handling of Labor

35
 Most HIV transmission to the fetus / infant occurs during labor, so the current
treatment is very important to protect against infant HIV infection. According to the
Perinatal HIV Guidlines Working Group in 2005, there are several treatment regimens
that can reduce the risk of transmission to infants. Regimens commonly used are three
part ZDV regimens:

1.Pregnant woman with HIV

ZDV begins at 14 to 34 weeks pregnancy with dose 5 x 100 mg, or 3 x 200 mg,
or 2 x 300 mg
2.Labor
At the time of labor, intravenous administration of ZDV is administered
3.Baby
Babies delivered are given ZDV in liquid form every 6 hours for 6 weeks after
birth.
If during pregnancy, an HIV-positive pregnant woman has received other anti-
HIV medications, then the treatment is continued as scheduled during labor.
The choice of labor for pregnant women with HIV is positive, depending on their
health and treatment. Labor may be vaginal or operative with cesarean section.
Selection of labor should be discussed first during pregnancy, as early as possible.

Caesarean section is recommended for HIV-positive pregnant women with:

1. Number of unknown virus or > 1000 / mL at 36 weeks gestation
2. Have not received anti-HIV treatment or just received zidovudine during pregnancy
3. Have never received prenatal care until 36 weeks of gestation or more

To be more effective in preventing transmission, cesarean section should be scheduled

at 38 weeks gestation, and should be performed before rupture of membranes.

Vaginal delivery is preferred choice of labor for HIV-positive pregnant women by:
1. Have obtained prenatal care during pregnancy
2. Viral load <1000 / mL at 36 weeks gestation
3. Get ZDV treatment with or without other anti-HIV drugs.

36
 Vaginal delivery can also be performed in HIV-positive pregnant women when
the membranes are ruptured, and labor is rapid.
All labor methods are at risk, but the risk of HIV transmission from HIV-positive
pregnant women to their babies is higher in vaginal delivery than in planned cesarean
section. For the mother, cesarean section increases the risk of infection, problems
associated with anesthesia, and other risks associated with operative action. For
infants, cesarean section increases the risk of infant respiratory distress.
Intravenous administration of ZDV (i.v) begins 3 hours before cesarean section,
and resumes after the baby is born. ZDV i.v should be given during labor and after the
baby is born in vaginal labor. It is also important to do is to minimize the baby's
contact to the mother's blood. This can be done by avoiding invasive examination, as
well as vacuum or forceps labor.
All babies have born from HIV positive women should receive anti-HIV
treatment to prevent HIV transmission. Treatment is minimal with the administration
of ZDV for 6 weeks, sometimes also with additional other drug.
If it has been decided to perform scheduled cesarean section to avoid
transmission of HIV virus, ACOG recommends doing it at 38 weeks' gestation,
judging by the best-presumed clinical condition and avoiding rupture of membranes.
In women not infected with the HIV virus, cesarean section management without
knowing fetal lung maturity, according to ACOG, is delayed until 39 weeks of
gestation, or at the time of entering labor, to reduce possibility complications in the
fetus. Cesarean section between 38 and 39 weeks' gestation has little difference in
possibility of increased infant respiratory distress, which requires mechanical
ventilation. This increased risk was matched by the incidence of labor risks and
rupture of membranes before reaching 39 weeks' gestation.
In women who have been scheduled for cesarean section, ZDV administration
should be started 3 hours before the operative, in accordance with standard
recommendation dosage. Other antiretroviral treatments used during pregnancy
should be continued at the time of labor, and during labor. With increased maternal
morbidity due to infection, consideration should also be given to perioperative
prophylactic antibiotics, although there has been no research on their efficiency.
Rupture of amniotic fluid, increased incidence of perinatal transmission, in
women not receiving antiretroviral treatment. In women receiving ZDV treatment,
studies have shown increased risk of transmission of ruptured membranes 4 hours or

37
more before labor. Obstetric procedures increase the risk of fetal exposure to maternal
blood, such as amniocentesis, as well as invasive monitoring should be avoided. This
procedure should be performed only if indicated. If premature rupture of the
membranes occurs,before labor, action should be taken to shorten the labor time, such
as oxytocin,can be thought.
Recommended prevention of vertical HIV transmission to the fetus:

1. Efforts to maximize the health of pregnant women, give the combination

antiretroviral therapy, is expected to reduce the number of viruses as well as rates of
vertical transmission. The minimum reduction in HIV transmission, recommended by
ZDV regimen of prophylaxis according to PACTG 076.
2. HIV-1 RNA plasma levels should be monitored during pregnancy according to
standards of HIV infection in adults.
3. Perinatal HIV transmission may be decreased by planned cesarean section, in
women with unknown HIV-1 RNA levels, who are not receiving antiretroviral
treatment, or simply obtain ZDV prophylaxis.
4. Women with HIV-1 RNA levels> 1000 / ml, should be consulted to discuss the
planned cesarean section action to reduce the risk of vertical transmission.
5. The management of women who have planned for cesarean section and come with
ruptured membranes, or come into labor, should be based on the length of time of
ruptured membranes, the course of delivery, the level of plasma HIV-1 RNA, previous
antiretroviral treatment, and other clinical factors. It remains unclear whether the
benefit of cesarean section after rupture of membranes, or after labor is present.
6. The woman should also obtain an explanation of the risks associated with cesarean
section. Risks that arise must be balanced with the benefits gained for the fetus.
7. The woman should also be consulted on limited data. Decisions about delivery to
be performed should be respected.

I. Labor for Pregnant Women with HIV Positive in Indonesia

Directorate General of Communicable Disease Eradication and

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

38
mother and child pairs in North America and Europe found that elective cesarean
section before inpartu and before rupture of membranes could reduce the risk of
mother-to-child HIV transmission by 50% compared with vaginal labor. When
elective cesarean section is accompanied by use of antiretroviral treatment, then risk
can be reduced to 87%. When cesarean section is compared with antiretroviral
treatment with a vaginal labor accompanied by antiretroviral treatment, the incidence
of transmission becomes 2% in elective cesarean section and 7.3% in the vaginal
section. However, cesarean section is not an operation without risk, especially in
people living with HIV where the immunity is very weak. In Zambia it was reported
that 75% of HIV infected patients delays in wound healing with increased risk of
infection. In Ruwanda, cesarean section even causes death of people living with HIV /
AIDS increased.
WHO does not recommend for cesarean section, but it also does not prohibit
considering conditions in each different area, it should consider the cost of surgery,
facilities for the action, complications that can result from low maternal immunity.
(CDC 2009; WHO 2009; KEMENKES RI, 2012)

Unacceptable action as it increases the risk of mother-to-child transmission of HIV is

unnecessary invasive obstetric action, and can be a pathway to HIV transmission,
such as:
1. Routine episiotomy
2. Vacuum extraction
3. Cunam extraction
4. Precomplete opening of amniotic membranes rupture
5. Internal examination frequently
6. Monitor fetal blood gas analysis during labor where blood samples are taken from
the scalp of the fetus.

39
 Table 5. Protective Equipment for Medical Personnel

Hand Glasse
Type of Action Gloves Mask Hat Apron Dress Boots
Washing s
Physical
examination of + - - - - - - -
intac skin
Physical
examination of + + - - - - - -
wound skin
Take blood
+ + - - - - - -
sample
Inject intravena + + - - - - - -
Clean the
wound/ + + - - - - - -
venasection
Urine
+ + - - - - - -
catheteritation
Pelvic
examination
+ + - - - - - -
(vaginal
toucher)
Help in labor + + + + + + + +
Bathing the
+ + - - - - - -
baby
Clean the room + + - - - +/- - +/-
Wash the
+ + - - - +/- - -
dishes/ cutlery
Washing
+ + +/- +/- +/- + +/- +
clothes

J. Postpartum for HIV Positive Women and their infants

Treatment for postpartum women with HIV should, as far as possible, be

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

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aged > 1 year, no longer have antibodies from their mothers, so they can be tested for
HIV antibodies.
Preliminary HIV examination for infants is usually performed on:

1. Between 48 hours after birth

2.Between 1 - 2 months
3. Between 3 - 6 months

Infants are suspected of being infected with HIV if the results are positive on two
of the above examination.
At 12 months of age, infants who have preliminary positive results should be
screened for HIV antibodies to ensure infection. Infants with HIV negative antibody
examination, currently uninfected with HIV. Infants with HIV positive antibody
examination should be reexamined at 15 to 18 months of age.

Infants born from HIV positive women should be screened for Complete Blood Count
(CBC) after birth. Infants should also be monitored for signs of anemia, which is a
negative side effect of ZDV treatment for 6 weeks given to infants. The baby should
also have routine blood examination, as well as other immunizations.
All infants born from HIV positive women are recommended to receive oral ZDV
treatment for 6 weeks to prevent HIV transmission from their mother. This oral ZDV
regimen should start 6 to 12 hours after the baby is born. Giving ZDV can also be
combined with other ARVs.
In addition to antiretroviral treatment, infants should also receive treatment to
prevent P. carinii / jiroveci pneumonia (PCP). The recommended treatment is with a
combination of sulfamethoxazole and trimethoprim. This treatment should be started
when the baby is 4-6 weeks old and continued until the baby is HIV negative. When
the results of the HIV positive infant, then the treatment continues.
Give the explanation to the patient to be able to obtain appropriate health care and
other support services for mother and baby:

1.Health care routine

2. Special care for HIV
3. Family plan

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4. Physchiatry services
5. Substance abuse treatment
6. Case management

HIV positive women are not expected to breastfeed their babies to prevent HIV
transmission through breast milk.
During postpartum period, physical and emotional changes can occur, along with
the pressure and responsibility for caring the baby, it can be difficult in continuing the
ARV regimen treatment.

It should also be discussed to the patient regarding:

1.It is not understood about the regimen of medication and good treatment
2. Depression (many women who experience it after childbirth)
3. Long-term plan to continue health care and antiretroviral treatment for mother and
baby.

K. Postpartum Handling in Indonesia

In accordance with the Directorate General of Communicable Disease

Eradication and Environmental Health of the Ministry of Health of the Republic of
Indonesia in 2003, there are several things that should be considered postpartum,
among others:

1.Contraceptives
If the baby is not breastfed, the contraceptive effects of lactation will be lost, so
the couple should use contraception to avoid or delay the next pregnancy. HIV
infected patients already have to use contraceptives no later than 4 weeks post partum.

2. Breastfeeding
For mothers with no known serologic status, breastfeeding is recommended
exclusively for 6 months, and may be continued for up to 2 years or more. Alternative
food is given since the baby is 6 months old.
For HIV-positive women, it is not advisable to breastfeed their babies, since HIV
can occur between 10-20%, especially if there is a blister on the breast, or mastitis.

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

43
breast bacilli, the principle also does not stimulate the nipple that can stimulate milk
production.

CHAPTER IV
DISCUSSION

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 A case has been discussed about HIV in pregnancy. A 35-year-old female
patient is pregnant with a fourth child form sixth pregnancy. Patients are known rapid
test reactive in the first screening and referred to VCT policlinic at Sungai Dareh
Regional Hospital, the patient did not come.

Patien came to primary health care at Dharmasraya with chief complain fluid leakage
from vagina, and Patient was referred to Sungai dareh Regional Hospital, patient was
recheck and the result was negative and then the patient was referred to Dr. M. Djamil
Central General Hospital with IV line access due to there hasn’t prepare facilities.
Rapid test for HIV was performed in Dr. M Djamil Central General Hospital and the
result was non Reaktive and was planned to take vaginal delivery. As a guide to the
discussion on target academically comprehensive scientific then we will discusss
some of the reference questions are as follows :

1. Whether the diagnose of this patient was right ?

2. Whether the management of this patient was appropriate ?

1. Whether the diagnose of this patient was right ?

Discussion based on the questions are :

Known by anamnese this patient was a multiparous, haven't had menstrual
since 9 months ago but forgot the first day of last menstrual period. On physical
examination, abdomen was enlarge equal to term pregnancy, fundus uterine was felt 3
fingers below processus xyphoideus, uterine fundal height was 35 cm. From the
ultrasound examination, confirmed by biometry, placental grading that this patient
have reached term pregnancy.

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

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

On physical examination, found that uterine contraction was adequate which last 2-
3x/35”/moderate, then from vaginal toucher we have got that cervical dilatation is 5-6
cm, amnion membrane negative and Nitrazine test (+). This mean that the patient
occured in progression of labor, which is the first stage of active phase. Laboratory
result for HIV rapid test non reactive. Based on anamnese, physical and assisted
examination, the diagnose of this patient was correct, a G6P3A2L3 term pregnancy
first stage of laten phase + history 12 hours PROM + HIV (+) Suspected.
Fetal alive singleton intrauterin head presentation, Small fontanel was palpable
left anterior, Hodge II-III

2. Whether the management of this patient was appropriate ?

This patient pregnancy was planned to be terminated by Vaginal Delivery . the

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

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 CHAPTER V
CONCLUSION

1. The diagnose of this patient was correct, a G6P3A2L3 term pregnancy first stage
of laten phase + history 12 hours PROM + HIV (+) Suspected. Fetal alive
singleton intrauterin head presentation, Small fontanel was palpable
left anterior, Hodge II-III
2. The management on this case was correct by doing the vaginal delivery was the
best choice for this patient.

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 REFERENCES

Direktorat Jendral Pemberantasan Penyakit Menular dan Penyehatan

Lingkungan Departemen Kesehatan Republik Indonesia : Pedoman
Nasional Perawatan, Dukungan, dan Pengobatan bagi ODHA.
Jakarta. 2008

AIDS info : HIV During Pregnancy, Labor, and Delivery, and After Birth.
http://aidsinfo.nih.gov. 2010

Perinatal HIV Guidelines Working Group : Recommendations for Use of

Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal
Helath and Intervensions to Reduce Perinatal HIV-1 Transmission in
the United States. http://aidsinfo.nih.gov. 2010

Direktorat Jendral Pemberantasan Penyakit Menular dan Penyehatan

Lingkungan Departemen Kesehatan Republik Indonesia : Pedoman
Nasional Terapi Antiretroviral. Jakarta. 2009

WHO : Prevention of Mother to Child Transmission of HIV, Generic Training

Package, Pocket Guide. http://www.who.int/hiv/en. 2009

Komisi Penanggulangan AIDS.2007

McFarland, Elizabeth 2003; Yunihastuti E dkk, 2003
PMTCT Depkes. 2008
Perinatal HIV guideline Working Group.2012.
www.google.com

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