History

Fact Explanation
Fever, malaise [8] Acute seroconversion of the virus may manifests as fever, malaise, which is mistaken for a simple viral infection. [8]
Rash [6] Acute seroconversion of the virus may manifests as flu like illness with a rash similar to viral exanthum, which is mistaken for a simple viral infection. [6]
Generalized lymph node enlargement [5] This is a common sign and generalized widespread lymph node enlargement is seen. [5]
Oral lesions [9] Due to immunosuppression, opportunistic infections such as candidiasis can occur as well as patients infected with HIV are likely to have other STDs. Therefore oral Herpes lesions can also present. [9]
Genital ulcers, itching, discharge [12] patients infected with HIV are likely to have other STDs. Therefore Herpes, Syphilis lesions can also present. [12]
Prolonged and recurrent cough, diarrhea in the mother [7] Their immune system is suppressed therefore recurrent unusual bacterial and viral infections occur. They are prolonged in course too. Also there can be reactivation of infections such as Tuberculosis. [7]
Weight loss [10] [11] They experience chronic diarrhea which causes weight loss [10] [11]
Rash, fever, oral lesions, eye lesions in the baby [13] [16] Immune system of the babies is also suppressed therefore recurrent unusual bacterial and viral infections occur. They are prolonged in course too. Oral thrush is due to candidiasis commonly and eye lesions suggest cytomegalo virus retinitis [13] [16]
Development delay, Failure to thrive in children [14] [15] [17] HIV infected children are likely to have impairment in growth, with development delay and especially language impairment. [14] [15] [17]
References
  1. DRAKE ALISON L., WAGNER ANJULI, RICHARDSON BARBRA, JOHN-STEWART GRACE, MOFENSON LYNNE MERYL. Incident HIV during Pregnancy and Postpartum and Risk of Mother-to-Child HIV Transmission: A Systematic Review and Meta-Analysis. PLoS Med [online] 2014 February [viewed 07 September 2014] Available from: doi:10.1371/journal.pmed.1001608
  2. LOCKMAN SHAHIN, CREEK TRACY. Acute Maternal HIV Infection during Pregnancy and Breast‐Feeding: Substantial Risk to Infants. J INFECT DIS [online] 2009 September, 200(5):667-669 [viewed 29 August 2014] Available from: doi:10.1086/605124
  3. KEATING MARIA A., HAMELA GLORIA, MILLER WILLIAM C., MOSES AGNES, HOFFMAN IRVING F., HOSSEINIPOUR MINA C., MYER LANDON. High HIV Incidence and Sexual Behavior Change among Pregnant Women in Lilongwe, Malawi: Implications for the Risk of HIV Acquisition. PLoS ONE [online] 2012 June [viewed 29 August 2014] Available from: doi:10.1371/journal.pone.0039109
  4. HUANG YEN-FANG, YANG JYH-YUAN, NELSON KENRAD E., KUO HSU-SUNG, LEW-TING CHIN-YIN, YANG CHIN-HUI, CHEN CHANG-HSUN, CHANG FENG-YEE, LIU HUI-RONG, COFFIN PHILLIP. Changes in HIV Incidence among People Who Inject Drugs in Taiwan following Introduction of a Harm Reduction Program: A Study of Two Cohorts. PLoS Med [online] 2014 April [viewed 29 August 2014] Available from: doi:10.1371/journal.pmed.1001625
  5. SHOBHANA A, GUHA S K, MITRA K, DASGUPTA A, NEOGI D K, HAZRA S C. People living with HIV infection / AIDS - A study on lymph node FNAC and CD4 count. Indian J Med Microbiol [online] 2002, ;20:99-101 [viewed on 29 Aug 2014] Available from: http://www.ijmm.org/text.asp?2002/20/2/99/8359
  6. MACKOWIAK P. A., VAN HAL S. J., KOTSIOU G.. An HIV-Positive Man with Generalized Rash. Clinical Infectious Diseases [online] 2005 January, 40(1):182-183 [viewed 29 August 2014] Available from: doi:10.1086/426553
  7. STERLING TIMOTHY R., PHAM PAUL A., CHAISSON RICHARD E.. HIV Infection–Related Tuberculosis: Clinical Manifestations and Treatment. CLIN INFECT DIS [online] 2010 May, 50(s3):S223-S230 [viewed 29 August 2014] Available from: doi:10.1086/651495
  8. LOCKMAN SHAHIN, CREEK TRACY. Acute Maternal HIV Infection during Pregnancy and Breast‐Feeding: Substantial Risk to Infants. J INFECT DIS [online] 2009 September, 200(5):667-669 [viewed 07 September 2014] Available from: doi:10.1086/605124
  9. SHETTI ARVIND, GUPTA ISHITA, CHARANTIMATH SHIVYOGI M.. Oral Candidiasis: Aiding in the Diagnosis of HIV—A Case Report. Case Reports in Dentistry [online] 2011 December, 2011:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2011/929616
  10. CHHIN SENYA, HARWELL JOSEPH I., BELL JOANNA D., ROZYCKI GREGORY, ELLMAN TOM, BARNETT J. MARK, WARD HONORINE, REINERT STEVEN E., PUGATCH DAVID. Etiology of Chronic Diarrhea in Antiretroviral‐Naive Patients with HIV Infection Admitted to Norodom Sihanouk Hospital, Phnom Penh, Cambodia. CLIN INFECT DIS [online] 2006 October, 43(7):925-932 [viewed 07 September 2014] Available from: doi:10.1086/507531
  11. CáRCAMO CéSAR, HOOTON THOMAS, WENER MARK H., WEISS NOEL S., GILMAN ROBERT, AREVALO JORGE, CARRASCO JUAN, SEAS CARLOS, CABALLERO MARTIN, HOLMES KING K.. Etiologies and Manifestations of Persistent Diarrhea in Adults with HIV‐1 Infection: A Case‐Control Study in Lima, Peru. J INFECT DIS [online] 2005 January, 191(1):11-19 [viewed 07 September 2014] Available from: doi:10.1086/426508
  12. LOGIE C. H., NAVIA D., RWIGEMA M.-J., THARAO W., ESTE D., LOUTFY M. R.. A group-based HIV and sexually transmitted infections prevention intervention for lesbian, bisexual, queer and other women who have sex with women in Calgary and Toronto, Canada: study protocol for a non-randomised cohort pilot study. BMJ Open [online] December, 4(4):e005190-e005190 [viewed 07 September 2014] Available from: doi:10.1136/bmjopen-2014-005190
  13. RICHARDSON B. A., NDUATI R., MBORI-NGACHA D., OVERBAUGH J., JOHN-STEWART G. C.. Acute HIV Infection among Kenyan Infants. Clinical Infectious Diseases [online] 2008 January, 46(2):289-295 [viewed 07 September 2014] Available from: doi:10.1086/524748
  14. VAN ARNHEM LOTUS A., BUNDERS MADELEINE J., SCHERPBIER HENRIETTE J., MAJOIE CHARLES B. L. M., RENEMAN LIESBETH, FRINKING OLIVIER, POLL-THE BWEE TIEN, KUIJPERS TACO W., PAJKRT DASJA, BUCH SHILPA J.. Neurologic Abnormalities in HIV-1 Infected Children in the Era of Combination Antiretroviral Therapy. PLoS ONE [online] 2013 May [viewed 07 September 2014] Available from: doi:10.1371/journal.pone.0064398
  15. RICE ML, BUCHANAN AL, SIBERRY GK, MALEE KM, ZELDOW B, FREDERICK T, PURSWANI MU, HOFFMAN HJ, SIROIS PA, SMITH R, TORRE P III, ALLISON SM, WILLIAMS PL. Language Impairment in Children Perinatally Infected with HIV Compared to Children Who Were HIV-Exposed and Uninfected J Dev Behav Pediatr [online] 2012 Feb, 33(2):112-123 [viewed 07 September 2014] Available from: doi:10.1097/DBP.0b013e318241ed23
  16. WREN S M E, FIELDER A R, BETHELL D, LYALL E G H, TUDOR-WILLIAMS G, COCKER K D, MITCHELL S M. Cytomegalovirus Retinitis in infancy. Eye [online] 2004 April, 18(4):389-392 [viewed 07 September 2014] Available from: doi:10.1038/sj.eye.6700696
  17. ROSE A. M., HALL C. S., MARTINEZ-ALIER N.. Aetiology and management of malnutrition in HIV-positive children. Archives of Disease in Childhood [online] December, 99(6):546-551 [viewed 07 September 2014] Available from: doi:10.1136/archdischild-2012-303348

Examination

Fact Explanation
Febrile [2] Acute seroconversion of the virus may manifests as fever, malaise, which is mistaken for a simple viral infection. [2]
Rash [6] Acute seroconversion of the virus may manifests as flu like illness with a rash similar to viral exanthum, which is mistaken for a simple viral infection. [6]
Generalized lymph node enlargement [5] This is a common sign and generalized widespread lymph node enlargement is see. Epitrochlear node enlargement is characteristic. [5]
Oral lesions [1] [2] [3] Due to immunosuppression, opportunistic infections such as candidiasis can occur as well as patients infected with HIV are likely to have other STDs. Therefore oral Herpes lesions can also present. [1] [2] [3]
Cachexic [2] Rapid weight loss is seen therefore patients appear cachexic. [2]
Dullness on percussion, Crepitations, reduced breath sounds on auscultation of the respiratory system [7] [8] [9] Recurrent opportunistic infections of the respiratory system is common, particularly Tuberculosis. Therefore respiratory signs can occur. Pneumonic signs and signs of pleural effusion are likely. [7] [8] [9]
Genital ulcers, discharge. [1] [2] [3] patients infected with HIV are likely to have other STDs. Therefore Herpes, Syphilis lesions can also present. [1] [2] [3]
Needle marks [4] HIV is commonly seen in patients with IV drug abuse, therefore needle marks in the skin can be seen [4]
No signs in the mother [1] [2] Sometimes patient can appear apparently healthy with no signs on examination at all [1] [2]
Unusual rashes in the neonate [10] Unusual rashes such as erythematous, papular rash due to HIV dermatitis, Varicella shingles rash, candidal dermatitis can be seen. Rarely HIV-induced thrombocytopenia can cause petechial rash as well. [10]
Oral lesions in the neonate [12] Large tonsils, oral aphthous ulcers, oral/pharyngeal plaques due to candidiasis or leukoplakia can be present. Sometimes parotid enlargement can occur [12]
Eye lesions in the neonate [11] Due to Cytomegalovirus retinitis. [11]
Peripheral oedema in the neonate [14] Due to hypoalbuminaemia due to HIV induced nephropathy or malnutrition due to gastrointestinal dysfunction. [14]
Cardiomegaly, tachypnoea, tachycardia, scalp sweating suggestive of cardiac failure [13] These signs of congestive cardiac failure due to cardiomyopathy can occur. [13]
Hepatomegaly and splenomegaly [15] These are relatively common findings in HIV-infected children. [15]
References
  1. DRAKE ALISON L., WAGNER ANJULI, RICHARDSON BARBRA, JOHN-STEWART GRACE, MOFENSON LYNNE MERYL. Incident HIV during Pregnancy and Postpartum and Risk of Mother-to-Child HIV Transmission: A Systematic Review and Meta-Analysis. PLoS Med [online] 2014 February [viewed 29 August 2014] Available from: doi:10.1371/journal.pmed.1001608
  2. LOCKMAN SHAHIN, CREEK TRACY. Acute Maternal HIV Infection during Pregnancy and Breast‐Feeding: Substantial Risk to Infants. J INFECT DIS [online] 2009 September, 200(5):667-669 [viewed 29 August 2014] Available from: doi:10.1086/605124
  3. KEATING MARIA A., HAMELA GLORIA, MILLER WILLIAM C., MOSES AGNES, HOFFMAN IRVING F., HOSSEINIPOUR MINA C., MYER LANDON. High HIV Incidence and Sexual Behavior Change among Pregnant Women in Lilongwe, Malawi: Implications for the Risk of HIV Acquisition. PLoS ONE [online] 2012 June [viewed 29 August 2014] Available from: doi:10.1371/journal.pone.0039109
  4. HUANG YEN-FANG, YANG JYH-YUAN, NELSON KENRAD E., KUO HSU-SUNG, LEW-TING CHIN-YIN, YANG CHIN-HUI, CHEN CHANG-HSUN, CHANG FENG-YEE, LIU HUI-RONG, COFFIN PHILLIP. Changes in HIV Incidence among People Who Inject Drugs in Taiwan following Introduction of a Harm Reduction Program: A Study of Two Cohorts. PLoS Med [online] 2014 April [viewed 29 August 2014] Available from: doi:10.1371/journal.pmed.1001625
  5. SHOBHANA A, GUHA S K, MITRA K, DASGUPTA A, NEOGI D K, HAZRA S C. People living with HIV infection / AIDS - A study on lymph node FNAC and CD4 count. Indian J Med Microbiol [online] 2002, ;20:99-101 [viewed on 29 Aug 2014] Available from: http://www.ijmm.org/text.asp?2002/20/2/99/8359
  6. MACKOWIAK P. A., VAN HAL S. J., KOTSIOU G.. An HIV-Positive Man with Generalized Rash. Clinical Infectious Diseases [online] 2005 January, 40(1):182-183 [viewed 29 August 2014] Available from: doi:10.1086/426553
  7. STERLING TIMOTHY R., PHAM PAUL A., CHAISSON RICHARD E.. HIV Infection–Related Tuberculosis: Clinical Manifestations and Treatment. CLIN INFECT DIS [online] 2010 May, 50(s3):S223-S230 [viewed 29 August 2014] Available from: doi:10.1086/651495
  8. VENTURINI ELISABETTA, TURKOVA ANNA, CHIAPPINI ELENA, GALLI LUISA, DE MARTINO MAURIZIO, THORNE CLAIRE. Tuberculosis and HIV co-infection in children. Array [online] 2014 December [viewed 29 August 2014] Available from: doi:10.1186/1471-2334-14-S1-S5
  9. NARAYANAN SUJATHA, SWAMINATHAN SOUMYA, SUPPLY PHILIP, SHANMUGAM SIVAKUMAR, NARENDRAN GOPALAN, HARI LALITHA, RAMACHANDRAN RANJANI, LOCHT CAMILLE, JAWAHAR MOHIDEEN SHAHEED, NARAYANAN PARANJI RAMAN. Impact of HIV Infection on the Recurrence of Tuberculosis in South India. J INFECT DIS [online] 2010 March, 201(5):691-703 [viewed 29 August 2014] Available from: doi:10.1086/650528
  10. RICHARDSON B. A., NDUATI R., MBORI-NGACHA D., OVERBAUGH J., JOHN-STEWART G. C.. Acute HIV Infection among Kenyan Infants. Clinical Infectious Diseases [online] 2008 January, 46(2):289-295 [viewed 07 September 2014] Available from: doi:10.1086/524748
  11. WREN S M E, FIELDER A R, BETHELL D, LYALL E G H, TUDOR-WILLIAMS G, COCKER K D, MITCHELL S M. Cytomegalovirus Retinitis in infancy. Eye [online] 2004 April, 18(4):389-392 [viewed 07 September 2014] Available from: doi:10.1038/sj.eye.6700696
  12. SHETTI ARVIND, GUPTA ISHITA, CHARANTIMATH SHIVYOGI M.. Oral Candidiasis: Aiding in the Diagnosis of HIV—A Case Report. Case Reports in Dentistry [online] 2011 December, 2011:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2011/929616
  13. BARBARO G.. Cardiovascular Manifestations of HIV Infection. [online] 2002 September, 106(11):1420-1425 [viewed 07 September 2014] Available from: doi:10.1161/01.CIR.0000031704.78200.59
  14. ROSE A. M., HALL C. S., MARTINEZ-ALIER N.. Aetiology and management of malnutrition in HIV-positive children. Archives of Disease in Childhood [online] December, 99(6):546-551 [viewed 07 September 2014] Available from: doi:10.1136/archdischild-2012-303348
  15. JASPAN HEATHER B, MYER LANDON, MADHI SHABIR A, VIOLARI AVY, GIBB DIANA M, STEVENS WENDY S, DOBBELS ELS, COTTON MARK F. Utility of clinical parameters to identify HIV infection in infants below ten weeks of age in South Africa: a prospective cohort study. Array [online] 2011 December [viewed 07 September 2014] Available from: doi:10.1186/1471-2431-11-104

Differential Diagnoses

Fact Explanation
Infectious mononucleosis (IMN) [3] Clinical features seen in IMN are pharyngitis, splenomegaly, hepatomegaly, jaundice, rash, and myalgia and can be mistaken for HIV infection [3]
Toxoplasmosis [1] [2] This is difficult to differentiate clinically but positive serologic tests for antibodies to Toxoplasma gondii confirm the diagnosis of Toxoplasmosis. [1] [2]
Viral hepatitis [4] [5] This causes right hypochondrial pain, fever, malaise and jaundice and Aminotransferases (ALT/AST) elevated, Hepatitis serology positive. [4] [5]
Morbilliform drug eruption [6] This presents as a maculopapular rash But this rash usually spares the palms and soles. [6]
Viral exanthems (enterovirus) [7] Acute febrile illness and rash can occur. Diagnosis is usually clinical depending on the associated symptoms. [7]
Parvovirus B19 infection [8] Patients are typically asymptomatic. but "slapped cheek" rash on the face is characteristic. Pain and swelling of the wrist joint, joints of the hands and knee joints will be seen. Infection in pregnancy can result in first trimester abortions, or hemolysis in the older fetus which can cause fetal anemia, hypoxia, heart failure, and edema (Hydrops fetalis) [8]
Idiopathic thrmobocytopenia in pregnancy [9] This also presents with a rash, bruises in an otherwise healthy pregnant patient and can be mistaken for HIV [9]
References
  1. MONTOYA JOSE G., REMINGTON JACK S.. Clinical Practice: Management of Infection during Pregnancy . CLIN INFECT DIS [online] 2008 August, 47(4):554-566 [viewed 29 August 2014] Available from: doi:10.1086/590149
  2. COSTA FABIANNE, SOARES GONDIM ANA, DE LIMA MARY, BRAGA JOSE, DE SOUZA VIEIRA LUIZA JANE, LEITE ARAúJO MARIA. Preventive behavior for toxoplasmosis in pregnant adolescents in the state of Ceara, Brazil. Array [online] 2012 December [viewed 29 August 2014] Available from: doi:10.1186/1471-2458-12-73
  3. LUZURIAGA KATHERINE, SULLIVAN JOHN L.. Infectious Mononucleosis. N Engl J Med [online] 2010 May, 362(21):1993-2000 [viewed 29 August 2014] Available from: doi:10.1056/NEJMcp1001116
  4. TRAN T. T.. Management of hepatitis B in pregnancy: Weighing the options. Cleveland Clinic Journal of Medicine [online] December, 76(Suppl_3):S25-S29 [viewed 29 August 2014] Available from: doi:10.3949/ccjm.76.s3.06
  5. CHAN OI KA, LAO TERENCE T., SUEN STEPHEN S. H., LEUNG TAK YEUNG. Deficient Knowledge on Hepatitis B Infection in Pregnant Women and Prevalence of Hepatitis B Surface Antigen Carriage in an Endemic Area: A Review. Hepatitis Research and Treatment [online] 2012 December, 2012:1-8 [viewed 29 August 2014] Available from: doi:10.1155/2012/317451
  6. RAMSAY M. Causes of morbilliform rash in a highly immunised English population. [online] 2002 September, 87(3):202-206 [viewed 29 August 2014] Available from: doi:10.1136/adc.87.3.202
  7. VILLAGRA E., DELGADO L. V., OLEA A.. Enhanced Surveillance for Congenital Rubella Syndrome Following Mass Rubella Vaccination of Girls and Reproductive-Aged Women. Journal of Infectious Diseases [online] December, 204(suppl 2):S642-S646 [viewed 29 August 2014] Available from: doi:10.1093/infdis/jir481
  8. BASSOLS A. C.. Parvovirus B19 and the New Century. Clinical Infectious Diseases [online] 2008 February, 46(4):537-539 [viewed 29 August 2014] Available from: doi:10.1086/526523
  9. CINES D. B.. ITP and pregnancy. Blood [online] 2003 December, 102(13):4250-4251 [viewed 29 August 2014] Available from: doi:10.1182/blood-2003-09-3304

Investigations - for Diagnosis

Fact Explanation
Enzyme-linked immunosorbent assay (ELISA), for HIV antibodies [1] [6] [7] ELIZA is done as a screening test in all pregnant women at their first visit. It detects antibodies with a high sensitivity. False-negative results may occur early in the disease due to sero-conversion therefore repeat testing is needed at several months later(At 1 month and 6 months). A positive test is sent for Western blot for confirmation. [1] [6] [7]
Western blot [1] [6] [7] This is the confirmatory test and used for protein detection and also it allows to quantify the protein expression as well. [1] [6] [7]
Full blood count [1] [6] [7] This is done to assess anemia and white blood cell count [1] [6] [7]
CD4+ counts [1] [6] [7] This helps determine the degree of immunodeficiency. [1] [6] [7]
Viral load, determined by plasma HIV RNA copy number (copies/mL) [8] Baseline values are helpful before starting treatment to measure the efficacy of the treatment. But in pregnancy even a very viral load is sufficient to cause infection in the neonate therefore, viral load assessment before starting treatment is usually not necessary [8]
HIV DNA PCR / HIV RNA PCR in newborns [2] [3] [4] [5] This is performed in HIV exposed infants 48 hours within birth, between 1 to 2 months, and between 3 to 6 months. If two or more tests performed at age ≥1 month become as negative, with one of those performed at age ≥4 months, HIV can be excluded in a non breast fed infant. [2] [3] [4] [5]
Viral culture in newborns [2] [3] [4] [5] This is performed in HIV exposed infants 48 hours within birth, between 1 to 2 months, and between 3 to 6 months. If two or more tests performed at age ≥1 month become as negative, with one of those performed at age ≥4 months, HIV can be excluded in a non breast fed infant. [2] [3] [4] [5]
HIV IgG antibody tests in newborns [2] [3] [4] [5] Because of transplacental passage of maternal HIV antibodies this test can be positive up to 18 months in a baby. Therefore two negative results of the tests performed at least one month apart after months of age will exclude infection in infants without any symptoms [2] [3] [4] [5]
References
  1. GRAY G. E, MCINTYRE J. A. HIV and pregnancy. BMJ [online] 2007 May, 334(7600):950-953 [viewed 29 August 2014] Available from: doi:10.1136/bmj.39176.674977.AD
  2. HAMPANDA KAREN. Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT. ISRN Infectious Diseases [online] 2013 December, 2013:1-5 [viewed 29 August 2014] Available from: doi:10.5402/2013/420361
  3. HIV Testing and Prophylaxis to Prevent Mother-to-Child Transmission in the United States. PEDIATRICS [online] December, 122(5):1127-1134 [viewed 29 August 2014] Available from: doi:10.1542/peds.2008-2175
  4. KOYE DIGSU NEGESE, ZELEKE BERIHUN MEGABIAW. Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at a PMTCT clinic in northwest Ethiopia. Array [online] 2013 December [viewed 29 August 2014] Available from: doi:10.1186/1471-2458-13-398
  5. EZEANOLUE ECHEZONA E, OBIEFUNE MICHAEL C, YANG WEI, OBARO STEPHEN K, EZEANOLUE CHINENYE O, OGEDEGBE GBENGA G. Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: study protocol for a cluster randomized controlled trial. Array [online] 2013 December [viewed 29 August 2014] Available from: doi:10.1186/1748-5908-8-62
  6. LOCKMAN SHAHIN, CREEK TRACY. Acute Maternal HIV Infection during Pregnancy and Breast‐Feeding: Substantial Risk to Infants. J INFECT DIS [online] 2009 September, 200(5):667-669 [viewed 29 August 2014] Available from: doi:10.1086/605124
  7. WALENSKY ROCHELLE P., ROSENBERG ERIC S., FERRARO MARY JANE, LOSINA ELENA, WALKER BRUCE D., FREEDBERG KENNETH A.. Investigation of Primary Human Immunodeficiency Virus Infection in Patients Who Test Positive for Heterophile Antibody. CLIN INFECT DIS [online] 2001 August, 33(4):570-572 [viewed 29 August 2014] Available from: doi:10.1086/321903
  8. CALMY ALEXANDRA, FORD NATHAN, HIRSCHEL BERNARD, REYNOLDS STEVEN J., LYNEN LUT, GOEMAERE ERIC, DE LA VEGA FELIPE GARCIA, PERRIN LUC, RODRIGUEZ WILLIAM. HIV Viral Load Monitoring in Resource‐Limited Regions: Optional or Necessary?. CLIN INFECT DIS [online] 2007 January, 44(1):128-134 [viewed 04 September 2014] Available from: doi:10.1086/510073

Investigations - Fitness for Management

Fact Explanation
Lipid profile [5] Certain medications used in HIV is known to cause various lipid abnormalities. Protease inhibitors, particularly indinavir and lopinavir, are associated with hypercholesterolemia and some nucleoside reverse-transcriptase inhibitors (didanosine, stavudine, and zidovudine) causes lipoatrophy and hypertriglyceridemia, whereas abacavir increased the risk of cardiovascular diseases even without abnormalities in the lipid profile. Even though non-nucleoside reverse-transcriptase inhibitors predisposed to hypertriglyceridemia and hypercholesterolemia, nevirapine causes high HDL-c. [5]
Full blood count [1] [2] To exclude any anemia prior to surgery (caesarian section) [1] [2]
Renal function tests- Serum Creatinine, Estimated GFR, Blood urea nitrogen [1] [2] [4] To exclude any renal dysfunction prior to anesthesia as well as certain medication are likely to cause renal dysfunction [1] [2] [4]
Coagulation studies [1] [2] To exclude any coagulopathy prior to surgery (caesarian section) [1] [2]
Liver function tests [3] certain medication are likely to cause liver dysfunction [3]
Obstetric ultrasonography [6] Dating is important by ultrasound scan for further management of pregnancy and to plan the delivery. Teratogenicity is highest during the first trimester, therefore treatment could be delayed during this time. [6]
References
  1. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 29 August 2014] Available from: doi:10.4103/0970-9185.81824
  2. SHULMAN M. A., THOMPSON B. R.. I. Not fit for a haircut ... how should we assess fitness and stratify risk for surgery?. British Journal of Anaesthesia [online] December, 112(6):955-957 [viewed 29 August 2014] Available from: doi:10.1093/bja/aeu003
  3. BONACINI M.. Liver Injury during Highly Active Antiretroviral Therapy: The Effect of Hepatitis C Coinfection. Clinical Infectious Diseases [online] 2004 March, 38(Supplement 2):S104-S108 [viewed 30 August 2014] Available from: doi:10.1086/381453
  4. WINSTON JONATHAN, DERAY GILBERT, HAWKINS TREVOR, SZCZECH LYNDA, WYATT CHRISTINA, YOUNG BENJAMIN. Kidney Disease in Patients with HIV Infection and AIDS. CLIN INFECT DIS [online] 2008 December, 47(11):1449-1457 [viewed 30 August 2014] Available from: doi:10.1086/593099
  5. WOHL DAVID A., WATERS DAVID, SIMPSON ROSS J., RICHARD SUSAN, SCHNELL AMANDA, NAPRAVNIK SONIA, KEYS JESSICA, ERON J. JOSEPH, HSUE PRISCILLA. Ezetimibe Alone Reduces Low‐Density Lipoprotein Cholesterol in HIV‐Infected Patients Receiving Combination Antiretroviral Therapy. CLIN INFECT DIS [online] 2008 October, 47(8):1105-1108 [viewed 30 August 2014] Available from: doi:10.1086/592116
  6. MARTIN F., TAYLOR G. P.. The safety of highly active antiretroviral therapy for the HIV-positive pregnant mother and her baby: is 'the more the merrier'?. Journal of Antimicrobial Chemotherapy [online] December, 64(5):895-900 [viewed 30 August 2014] Available from: doi:10.1093/jac/dkp303

Investigations - Followup

Fact Explanation
CD4 counts [1] [2] CD4 count is important for monitoring for progression of disease, to determine the initiation of Anti Retro Viral Therapy (ART), to stage the HIV disease and the need for prophylaxis against opportunistic infections. CD4 cell counts <200 cells/mm3 defines the progression to AIDS. [1] [2]
Viral Load Assays [3] This is important to measure the efficacy of treatment. [3]
Drug resistance tests [5] Resistance testing could be done in patients who have never received ART before initiation of ART or in failure of treatment. Genotyping, Phenotyping, Co-receptor tropism analysis are several tests to determine drug resistance [5]
Human Leukocyte Antigen Testing [4] This is mainly done before abacavir-based therapy because some HLA classes are at high risk of hypersensitivity to this drug. [4]
References
  1. WILLIAMS BRIAN G., KORENROMP ELINE L., GOUWS ELEANOR, SCHMID GEORGE P., AUVERT BERTRAN, DYE CHRISTOPHER. HIV Infection, Antiretroviral Therapy, and CD4 Cell Count Distributions in African Populations . J INFECT DIS [online] 2006 November, 194(10):1450-1458 [viewed 30 August 2014] Available from: doi:10.1086/508206
  2. RABI S. ALIREZA, LAIRD GREGORY M., DURAND CHRISTINE M., LASKEY SARAH, SHAN LIANG, BAILEY JUSTIN R., CHIOMA STANLEY, MOORE RICHARD D., SILICIANO ROBERT F.. Multi-step inhibition explains HIV-1 protease inhibitor pharmacodynamics and resistance. J. Clin. Invest. [online] December, 123(9):3848-3860 [viewed 30 August 2014] Available from: doi:10.1172/JCI67399
  3. BARLETTA JANET M., EDELMAN DANIEL C., CONSTANTINE NIEL T.. Lowering the Detection Limits of HIV-1 Viral Load Using Real-Time Immuno-PCR for HIV-1 p24 Antigen. American Journal of Clinical Pathology [online] December, 122(1):20-27 [viewed 30 August 2014] Available from: doi:10.1309/529T2WDNEB6X8VUN
  4. MALLAL S, NOLAN D, WITT C, MASEL G, MARTIN AM, MOORE C, SAYER D, CASTLEY A, MAMOTTE C, MAXWELL D, JAMES I, CHRISTIANSEN FT. Association between presence of HLA-B*5701, HLA-DR7, and HLA-DQ3 and hypersensitivity to HIV-1 reverse-transcriptase inhibitor abacavir. The Lancet [online] 2002 March, 359(9308):727-732 [viewed 30 August 2014] Available from: doi:10.1016/S0140-6736(02)07873-X
  5. VAN VAERENBERGH K. Study of the impact of HIV genotypic drug resistance testing on therapy efficacy. Verh K Acad Geneeskd Belg [online] 2001, 63(5):447-73 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11813503

Investigations - Screening/Staging

Fact Explanation
CD4 counts [1] CD4 cell count is important to stage the disease and CD4 cell counts <200 cells/mm3 defines the progression to AIDS. [1]
Hepatitis testing [2] This is also done as a screening test in the first antenatal visit and when there's co-infection with Hep B management may be differed. [2]
Testing for Syphilis with Fluorescent Treponemal Antibody Absorption Test (FTA-ABS), Treponema pallidum Particle Agglutination Assay; (TPPA) [4] Maternal syphilis is thought to increase the risk of mother-to-child transmission of HIV [4]
Cervical cytology for Gonorrhoea, Chlamydia [5] Cervical cytology smear and assays are done for gonorrhea and chlamydia and all sexually transmitted diseases should be treated. [5]
Tuberculosis testing with Mantoux testing and Chest x-ray [3] Immunosuppression from HIV infection contributes to tuberculosis reactivation. When the Mantoux test is more than 5-mm it's interpreted as positive. If positive, chest radiography may be performed. Additionally co-infection of both is common in developing countries [3]
Pap smear [6] Genital warts ,vulvar intraepithelial neoplasia and cervical dysplasia are more common among HIV infected women. [6]
Antibodies for Cytomegalovirus [7] Evaluation for these opportunistic infections are important and presence of these indicates the progression to AIDS [7]
Antibodies for Toxoplasmosis [7] Evaluation for these opportunistic infections are important and presence of these indicates the progression to AIDS [7]
ELIZA for HIV antibody testing [8] This may be done as a routine test to screen for HIV in all pregnant women. [8]
References
  1. WILLIAMS BRIAN G., KORENROMP ELINE L., GOUWS ELEANOR, SCHMID GEORGE P., AUVERT BERTRAN, DYE CHRISTOPHER. HIV Infection, Antiretroviral Therapy, and CD4 Cell Count Distributions in African Populations . J INFECT DIS [online] 2006 November, 194(10):1450-1458 [viewed 30 August 2014] Available from: doi:10.1086/508206
  2. JASUJA SUPRIYA, THOMPSON NICOLA D., PETERS PHILIP J., KHUDYAKOV YURY E., PATEL MEGAN T., LINCHANGCO PURISIMA, THAI HONG T., SWITZER WILLIAM M., SHANKAR ANUPAMA, HENEINE WALID, HU DALE J., MOORMAN ANNE C., GERBER SUSAN I., LAMA JAVIER R.. Investigation of Hepatitis B Virus and Human Immunodeficiency Virus Transmission among Severely Mentally Ill Residents at a Long Term Care Facility. PLoS ONE [online] 2012 August [viewed 30 August 2014] Available from: doi:10.1371/journal.pone.0043252
  3. VENTURINI ELISABETTA, TURKOVA ANNA, CHIAPPINI ELENA, GALLI LUISA, DE MARTINO MAURIZIO, THORNE CLAIRE. Tuberculosis and HIV co-infection in children. Array [online] 2014 December [viewed 30 August 2014] Available from: doi:10.1186/1471-2334-14-S1-S5
  4. HO EMILY L., LUKEHART SHEILA A.. Syphilis: using modern approaches to understand an old disease. J. Clin. Invest. [online] 2011 December, 121(12):4584-4592 [viewed 30 August 2014] Available from: doi:10.1172/JCI57173
  5. ROMOREN MARIA, SUNDBY JOHANNE, VELAUTHAPILLAI MANONMANY, RAHMAN MAFIZUR, KLOUMAN ELISE, HJORTDAHL PER. Chlamydia and gonorrhoea in pregnant Batswana women: time to discard the syndromic approach?. BMC Infect Dis [online] 2007 December [viewed 30 August 2014] Available from: doi:10.1186/1471-2334-7-27
  6. DAL MASO LUIGINO, FRANCESCHI SILVIA, LISE MAURO, DE' BIANCHI PRISCILLA, POLESEL JERRY, GHINELLI FLORIO, FALCINI FABIO, FINARELLI ALBA C. Self-reported history of Pap-smear in HIV-positive women in Northern Italy: a cross-sectional study. BMC Cancer [online] 2010 December [viewed 30 August 2014] Available from: doi:10.1186/1471-2407-10-310
  7. WESTER C. W., BUSSMANN H., MOYO S., AVALOS A., GAOLATHE T., NDWAPI N., ESSEX M., MACGREGOR R. R., MARLINK R. G.. Serological Evidence of HIV-Associated Infection among HIV-1--Infected Adults in Botswana. Clinical Infectious Diseases [online] 2006 December, 43(12):1612-1615 [viewed 30 August 2014] Available from: doi:10.1086/508865
  8. GRAY G. E, MCINTYRE J. A. HIV and pregnancy. BMJ [online] 2007 May, 334(7600):950-953 [viewed 29 August 2014] Available from: doi:10.1136/bmj.39176.674977.AD

Management - General Measures

Fact Explanation
Patient education and counseling [1] [2] [3] [7] Patients should be educated on the course of the disease, available treatment options, importance of anti retroviral therapy, importance of follow up. Reassurance and counseling plays an important role as well and sometimes psychiatric referral may be needed. Cigarette smoking, concurrent use of drugs and unprotected intercourse are thought to increase risk of perinatal transmission therefore patients should be advised to avoid these. [1] [2] [3] [7]
Diet and activity [4] [9] During pregnancy, a healthy, well-balanced diet and normal exercise is recommended as for a normal pregnancy. Vitamin A deficiency has been noted in HIV infected mothers therefore supplementation during pregnancy might help to improve birth weight in these babies [4] [9]
Avoidance of breast feeding [8] Breastfeeding is not recommended in patients infected with HIV and also patients on antiretroviral therapy as passage of antiretrovirals into breast milk has been shown. [8]
Regular follow up [4] [5] [6] Regular follow up of the pregnancy is needed similar to a normal pregnancy but carefully should be looked into certain investigations such as CD 4 counts, appearance of opportunistic infections. [4] [5] [6]
Awareness programmes for population [4] [5] [6] It's important to avoid the AIDS associated stigma in the general population. Safe sexual practices, avoidance of needle prick injuries, harms of intravenous drug abuse, Proper screening of blood products for HIV should be emphasized. [4] [5] [6]
References
  1. FENTON K. A.. Changing Epidemiology of HIV/AIDS in the United States: Implications for Enhancing and Promoting HIV Testing Strategies. Clinical Infectious Diseases [online] 2007 December, 45(Supplement 4):S213-S220 [viewed 30 August 2014] Available from: doi:10.1086/522615
  2. MAHAJAN AP, SAYLES JN, PATEL VA, REMIEN RH, ORTIZ D, SZEKERES G, COATES TJ. Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward AIDS [online] 2008 Aug, 22(Suppl 2):S67-S79 [viewed 30 August 2014] Available from: doi:10.1097/01.aids.0000327438.13291.62
  3. WARE NORMA C., WYATT MONIQUE A., GENG ELVIN H., KAAYA SYLVIA F., AGBAJI OCHE O., MUYINDIKE WINNIE R., CHALAMILLA GUERINO, AGABA PATRICIA A., PARSONS JANET. Toward an Understanding of Disengagement from HIV Treatment and Care in Sub-Saharan Africa: A Qualitative Study. PLoS Med [online] 2013 January [viewed 30 August 2014] Available from: doi:10.1371/journal.pmed.1001369
  4. ANDERSON BRENNA L., CU‐UVIN SUSAN. Pregnancy and Optimal Care of HIV‐Infected Patients. CLIN INFECT DIS [online] 2009 February, 48(4):449-455 [viewed 30 August 2014] Available from: doi:10.1086/596477
  5. MADHIVANAN PURNIMA, et al. Increasing Antenatal Care and HIV Testing among Rural Pregnant Women with Conditional Cash Transfers to Self-Help Groups: An Evaluation Study in Rural Mysore, India. Journal of Sexually Transmitted Diseases [online] 2013 December, 2013:1-6 [viewed 30 August 2014] Available from: doi:10.1155/2013/971458
  6. TURAN JANET M, et al. The Study of HIV and Antenatal Care Integration in Pregnancy in Kenya: Design, Methods, and Baseline Results of a Cluster-Randomized Controlled Trial. PLoS ONE [online] 2012 September [viewed 30 August 2014] Available from: doi:10.1371/journal.pone.0044181
  7. RUJUMBA JOSEPH, NEEMA STELLA, TUMWINE JAMES K, TYLLESKäR THORKILD, HEGGENHOUGEN HARALD K. Pregnant women’s experiences of routine counselling and testing for HIV in Eastern Uganda: a qualitative study. Array [online] 2013 December [viewed 30 August 2014] Available from: doi:10.1186/1472-6963-13-189
  8. MOFENSON LYNNE M.. Prevention in Neglected Subpopulations: Prevention of Mother‐to‐Child Transmission of HIV Infection. CLIN INFECT DIS [online] 2010 May, 50(s3):S130-S148 [viewed 30 August 2014] Available from: doi:10.1086/651484
  9. MULU ANDARGACHEW, KASSU AFEWORK, HURUY KAHSAY, TEGENE BIRHANEMESKEL, YITAYAW GASHAW, NAKAMORI MASAYO, VAN NHIEN NGUYEN, BEKELE ASSEGEDECH, WONDIMHUN YARED, YAMAMOTO SHIGERU, OTA FUSAO. Vitamin A deficiency during pregnancy of HIV infected and non-infected women in tropical settings of Northwest Ethiopia. Array [online] 2011 December [viewed 07 September 2014] Available from: doi:10.1186/1471-2458-11-569

Management - Specific Treatments

Fact Explanation
Antepartum treatment of Antiretroviral therapy (ART) [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] This plays a major role as tretament can effectively reduce the vertical transmission. Zidovudine (ZDV) is the only agent shown to reduce perinatal transmission therefore used in combination therapy in highly active antiretroviral therapy (HAART) regimen. protease inhibitors (PIs), Nucleosides and nucleotide analogue reverse transcriptase inhibitors (NRTIs) and Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are the classes of drugs which are used. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]
Peripartum treatment of Antiretroviral therapy (ART) [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] intravenous zidovudine (ZDV) during labor, may be helpful in the peripartum management. Nevirapine, Lamivudine can be used after this. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10]
Newborn Antietroviral Therapy (ART) [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [13] [14] Zidovudine is Initiated as soon after delivery in all HIV infected infants. Nevirapine maybe helpful as well for babies of mothers who did not receive antepartum ART. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [13] [14]
Co-infection with Hepatitis B [11] Tenofovir and lamivudine or emtricitabine are the currrent recommended drugs used when there's co-infection. [11]
Elective Cesarean delivery [1] [2] [3] [4] [5] [6] [7] [8] [12] This should be discussed with mother as elective cesarean delivery is shown to reduce the risk of vertical transmission. [1] [2] [3] [4] [5] [6] [7] [8] [12]
References
  1. MOFENSON LYNNE M.. Prevention in Neglected Subpopulations: Prevention of Mother‐to‐Child Transmission of HIV Infection. CLIN INFECT DIS [online] 2010 May, 50(s3):S130-S148 [viewed 30 August 2014] Available from: doi:10.1086/651484
  2. MARTIN F., TAYLOR G. P.. The safety of highly active antiretroviral therapy for the HIV-positive pregnant mother and her baby: is 'the more the merrier'?. Journal of Antimicrobial Chemotherapy [online] December, 64(5):895-900 [viewed 30 August 2014] Available from: doi:10.1093/jac/dkp303
  3. RABI S. ALIREZA, LAIRD GREGORY M., DURAND CHRISTINE M., LASKEY SARAH, SHAN LIANG, BAILEY JUSTIN R., CHIOMA STANLEY, MOORE RICHARD D., SILICIANO ROBERT F.. Multi-step inhibition explains HIV-1 protease inhibitor pharmacodynamics and resistance. J. Clin. Invest. [online] December, 123(9):3848-3860 [viewed 30 August 2014] Available from: doi:10.1172/JCI67399
  4. GRAY G. E, MCINTYRE J. A. HIV and pregnancy. BMJ [online] 2007 May, 334(7600):950-953 [viewed 30 August 2014] Available from: doi:10.1136/bmj.39176.674977.AD
  5. HAMPANDA KAREN. Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT. ISRN Infectious Diseases [online] 2013 December, 2013:1-5 [viewed 30 August 2014] Available from: doi:10.5402/2013/420361
  6. HIV Testing and Prophylaxis to Prevent Mother-to-Child Transmission in the United States. PEDIATRICS [online] December, 122(5):1127-1134 [viewed 30 August 2014] Available from: doi:10.1542/peds.2008-2175
  7. KOYE DIGSU NEGESE, ZELEKE BERIHUN MEGABIAW. Mother-to-child transmission of HIV and its predictors among HIV-exposed infants at a PMTCT clinic in northwest Ethiopia. Array [online] 2013 December [viewed 30 August 2014] Available from: doi:10.1186/1471-2458-13-398
  8. EZEANOLUE ECHEZONA E, OBIEFUNE MICHAEL C, YANG WEI, OBARO STEPHEN K, EZEANOLUE CHINENYE O, OGEDEGBE GBENGA G. Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: study protocol for a cluster randomized controlled trial. Array [online] 2013 December [viewed 30 August 2014] Available from: doi:10.1186/1748-5908-8-62
  9. MCGOWAN J. P.. Prevention of perinatal HIV transmission during pregnancy. [online] 2000 November, 46(5):657-668 [viewed 30 August 2014] Available from: doi:10.1093/jac/46.5.657
  10. DRAKE ALISON L., WAGNER ANJULI, RICHARDSON BARBRA, JOHN-STEWART GRACE, MOFENSON LYNNE MERYL. Incident HIV during Pregnancy and Postpartum and Risk of Mother-to-Child HIV Transmission: A Systematic Review and Meta-Analysis. PLoS Med [online] 2014 February [viewed 30 August 2014] Available from: doi:10.1371/journal.pmed.1001608
  11. ANDERSON BRENNA L., CU‐UVIN SUSAN. Pregnancy and Optimal Care of HIV‐Infected Patients. CLIN INFECT DIS [online] 2009 February, 48(4):449-455 [viewed 30 August 2014] Available from: doi:10.1086/596477
  12. MUULA AS. Ethical and Practical Consideration of Women Choosing Cesarean Section Deliveries without "Medical Indication" in Developing Countries Croat Med J [online] 2007 Feb, 48(1):94-102 [viewed 30 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2080500
  13. TRICCO ANDREA C, ANTONY JESMIN, ANGELIKI VERONIKI A, ASHOOR HUDA, HUTTON BRIAN, HEMMELGARN BRENDA R, MOHER DAVID, FINKELSTEIN YARON, GOUGH KEVIN, STRAUS SHARON E. Safety and effectiveness of antiretroviral therapies for HIV-infected women and their infants and children: protocol for a systematic review and network meta-analysis. Array [online] 2014 December [viewed 30 August 2014] Available from: doi:10.1186/2046-4053-3-51
  14. HSIAO NEI-YUAN, STINSON KATHRYN, MYER LANDON, JOHN-STEWART GRACE C.. Linkage of HIV-Infected Infants from Diagnosis to Antiretroviral Therapy Services across the Western Cape, South Africa. PLoS ONE [online] 2013 February [viewed 30 August 2014] Available from: doi:10.1371/journal.pone.0055308