CARE DURING ANTENATAL PERIOD:

• Pregnant Women who are detected to be HIV infected during ante natal care should be initiated on ART (TDF+3TC+EFV) regardless of clinical stage or CD4 count. However, it is important to obtain sample of blood for CD4 count and for baseline tests before initiating ART. The initiation of ART should not be delayed for want of CD4 test results. Initiate Co-trimozaxole prophylactic Therapy (CPT) if CD4 ≤ 250 cells/mm3 and continued throughout the pregnancy, delivery and breast feeding as per national guidelines. All HIV infected pregnant women should start ART: 
• Start ART as soon as possible and continue ART throughout pregnancy, delivery, breast feeding period and thereafter lifelong. 
•  Even if the pregnant women presents very late in pregnancy (including those who present after 36 weeks of gestation), ART should be initiated promptly. Choice of ART Regimen for HIV-infected Pregnant Women: 

There are several regimens recommended for use as first-line ART regimen for adults in India. However, in case of HIV infected pregnant women requiring ART, the recommended first-line regimen is Tenofovir (TDF) (300 mgs) + Lamuvidine (3TC) (300 mg) + Efavirenz (EFV) (600 mg) In HIV infected pregnant women the dictum should be “do not delay ART initiation”. ART Regimen for Pregnant Women having Prior Exposure to NNRTIs for PPTCT: HIV infected pregnant women who have had previous exposure to Sd NVP (or EFV) for PPTCT prophylaxis in prior pregnancies, an NNRTI-based ART regimen such as TDF+3TC+EFV may not be fully effective due to persistence of archived mutation to NNRTIs. Thus, these women will require a proteaseinhibitor based ART regimen viz: TDF + 3TC + LPV/r (Lopinavir/ritonavir)The dose will be TDF+3TC (1tabletdaily)+ LPV (200mg)/r (50mg) (2 tablets BD) Pregnant Women Already Receiving ART: Pregnant women who are already receiving ART for their own health, should continue to receive the same regimen throughout pregnancy, labour, breastfeeding period and thereafter life-long. If a woman is on an EFV based regimen, there is no need to substitute with nevirapine (this was done as per earlier guidelines). She must continue on whatever regimen she is stabilized on and is responding to adequately HIV exposed infant: Infants of mothers who are receiving ART and are exclusively breastfeeding or doing exclusive replacement feeding should receive atleast six weeks of infant prophylaxis with daily Syp Nevirapine. Infant prophylaxis should begin at birth or when HIV exposure is known Exclusive breast feeding upto 6 Months and continued breast feeds in addition to complimentary feeds after 6 months upto 1 year Postpartum ARV prophylaxis for infant for minimum 6 weeks. Co-trimoxazole prophylaxis from 6 weeks of age Early infant diagnosis (EID) at 6 weeks of age, repeat testing at 6 months, 12 months and 6 months after cessation of breastfeeding. HIV care and pediatric ART for infants and children diagnosed as HIV positive through EID. Growth and nutrition monitoring Immunizations and routine infant care Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth and development of child. Confirmation of HIV status of all babies at 18 months using all 3 antibody rapid tests.

ARV PROPHYLAXIS FOR INFANTS BORN TO MOTHERS RECEIVING LIFE-LONG ART:

•  Infant prophylaxis is required for all infants born to HIV infected women receiving ART to further reduce pre-partum and postpartum HIV transmission, in addition to the protection received from the mother’s ART regimen. It provides added protection from early postpartum transmission, particularly in situations where women started ART late in pregnancy The infant ARV prophylaxis where mothers are receiving ART is: Daily NVP for 6 weeks (i.e. till the first immunization visit for the infant), regardless of whether the infant is exclusively breastfed or receives exclusive replacement feeding.

PREGNANT WOMEN IN LABOUR WHO ARE FOUND POSITIVE IN HIV-SCREENING TEST HOULD BE:

• Initiate on ART immediately. Blood sample for CD4 count testing Counselling by ART medical officer at the earliest Advise for exclusive breast feeding for first 6 months if she has already started on breast feeding. If not counsel on option for breast vs replacement therapy PROTOCOL FOR WOMEN PRESENTING DIRECTLY IN LABOUR (UNBOOKED CASE) Pregnant women coming directly in labour Found HIV positive while screening in labour room/ delivery ward Collect blood sample for CD4 and send sample next day to ART centre Initiate maternal ART (TDF+3TC+EFV) Next morning: counselling and confirmation of HIV status and blood sample collection for CD4 testing Infant: daily Syp Nevirapine from birth until 6 weeks (minimum) Mother: Link with ART centre to continue ART as soon as possible All infants born to women who present directly in labour and receiving intrapartum ART and thereafter, should be started on daily NVP prophylaxis at birth and continued for a minimum of 6 weeks. ARV PROPHYLAXIS FOR INFANTS BORN TO WOMEN WHO DID NOT RECEIVE ANY ART (HOME DELIVERY): Infants should be started on daily Syp NVP prophylaxis at their first contact with health services. Daily infant NVP prophylaxis can be started even if more than 72 hours have passed since birth. Daily infant NVP prophylaxis