Human Immunodeficiency Virus (HIV) is a ribonucleic acid (RNA) retrovirus that explicitly attacks the human immune system, making it easy to be infected with various other diseases. A collection of clinical symptoms and signs in people with HIV due to an opportunistic infection due to a decrease in the immune system is called Acquired Immune Deficiency Syndrome (AIDS). HIV infection is not only found in adults but also infants. Transmission of HIV from mother to baby is called a vertical transmission and can occur during pregnancy, during delivery, and during breastfeeding [1].

HIV and AIDS can have a devastating impact on public health and countries globally. Until now, no country has been free from HIV and AIDS. Based on WHO data in 2019, 78% of new HIV infections in the Asia Pacific region. The United Nations Program on HIV and AIDS (UNAIDS) states that the largest HIV-infected population in the world is on the African continent (25.7 million people), then in Southeast Asia (3.8 million), and America (3.5 million people). While the lowest was in the Western Pacific with 1.9 million people. It is reported that 1.8 million children in the age range 0-14 years worldwide are infected with HIV, with 150,000 new cases of infection in the same age range. The 2012 UNAIDS Global HIV Epidemic Report shows that 34 million people are living with HIV in the world, 50% of whom are women and 2.1 million children aged less than 15 years. Until 2013, HIV and AIDS cases in Indonesia had spread to 368 of the world's population. Four hundred ninety-seven districts / cities (72%) in all provinces. The number of new HIV cases every year reaches about 20,000 cases. In 2013 there were 29,037 new cases, with 26,527 (90.9%) of reproductive age (15-49 years) and 12,279 women. UNAIDS [2] reports that in 2017 antiretroviral therapy (ART) was only accessible to 26% of children and 41% of adults in West andCentral Africa, as well as 59% of children and 66% of adults who had access to ART in Eastern and Southern Africa. The high population of people infected with HIV Southeast Asia requires Indonesia to be more aware of the spread and transmission of this virus. Although it tends to fluctuate, data on HIV AIDS cases in Indonesia continues to increase yearly; during the last eleven years, the number of HIV cases in Indonesia peaked in 2019 at 50,282 cases and in 2013 at 12,214 cases. Based on data from the [1], the highest proportion of new HIV cases was in the productive age group of 25-49 years, 70.4%. Meanwhile, HIV transmission was still found from mother to child, as indicated by discovering HIV and AIDS cases in the age group under four years as much as 1.8%.

According to the Indonesian Health Profile 2020, the estimated number of people living with HIV in Indonesia in 2020 is 543,100 people with 29,557 new infections and 30,137 deaths. The number of reported HIV positive cases from year to year tends to increase. However, in 2020 the number of HIV positive cases was the lowest since the last four years, which was reported as many as 41,987 cases. On the contrary, compared to the average of the previous 8 years, the number of new AIDS cases tends to decrease but has increased compared to the previous year, in 2020 reported as many as 8,639 cases [3].

Vertical transmission of HIV from mother to baby can occur during pregnancy (5%-10%), during delivery (10%-20%), and during breastfeeding (10%-15%). HIV infection in mothers and babies can cause illness, disability, and death, harming mothers and children's survival and quality of life. The purpose of HIV testing in pregnant women is to prevent cases of HIV in babies born to mothers with HIV. In 2019, 2,370,473 pregnant women were tested for HIV. From this examination, 6,439 (0.27%) pregnant women were HIV positive. The risk of HIV transmission from mother to child without prevention or intervention efforts ranges from 20 to 50% [3].

The mother-to-child transmission prevention program in Indonesia is a very effective intervention to prevent vertical HIV transmission. The basic concept is to reduce the Viral Load as low as possible, minimize the exposure of the fetus or baby to the body fluids of an HIV-positive mother, and optimize the health of the baby from an HIV-positive mother. The prevention of mother-to-child transmission of HIV policy is integrated with integrated Antenatal Care (ANC) package where all pregnant women are triple-eliminated against HIV, syphilis, and hepatitis B transmission. 51 of 2013 concerning Guidelines for the Prevention of Mother to Child Transmission of HIV [3].

Implementing a vertical HIV transmission prevention strategy program must be carried out comprehensively to reduce the risk of transmission to a minimum. The strategy includes integrated services such as offering HIV testing as an effort to determine the HIV status of pregnant, maternity, and breastfeeding women. It also includes immediate ARV provision for mothers diagnosed as HIV positive, safe delivery, management of infant feeding, and immediate ARV provision to mothers with HIV infection and prophylaxis in children.

Those strategies are certainly not without challenges. Based on data from the [4] from 70,995 pregnant women who underwent HIV tests, 61,736 people were found, and 288 newly pregnant women with HIV cases were found. Data on visits by high-risk pregnant women at the Wangaya Hospital in 2020 with 324 people, of which 166 were pregnant women with HIV with 44 new cases. Based on the postpartum room register data at Wangaya Hospital, Denpasar City, the number of postpartum mothers with HIV from 2015 to 2019 has increased, namely 22 people in 2015, 28 people in 2016, 32 people in 2017, 47 people in 2018, and 63 people in 2019. In 2020 there were 58 postpartum mothers with HIV with 58 babies born to mothers with HIV at the Wangaya Hospital, Denpasar City. Standard Operating Procedures (SOP) at Wangaya Hospital for all pregnant patients with HIV indicate abdominal delivery or Sectio Caesarea (SC) and elective SC performed at a minimum gestational age of 38 weeks. Based on the description and the lack of data and information related to postpartum mothers with HIV, it is necessary to conduct more in-depth research to obtain data about the characteristics of postpartum mothers with HIV and babies born at Wangaya Regional General Hospital. 

This research is a descriptive observational study with a cross-sectional approach carried out at Wangaya Hospital, Denpasar City. The sample used was 58 postpartum mothers with HIV and their babies born at the Wangaya Hospital, Denpasar City, in 2020, using a non-probability sampling technique with the total sampling method.

The population in this study was 58 postpartum mothers with HIV in Wangaya Hospital in 2020. The sample in this study were all postpartum mothers with HIV and babies born at Wangaya Hospital in 2020 who met the inclusion criteria. The criteria for selecting the sample for this study were the inclusion criteria, namely all postpartum mothers with HIV and their babies. Their data were recorded in the patient's medical record. The sampling technique was conducted by non-probability sampling technique. Samples were obtained by the total sampling method. The data for this study were obtained from registers in the Comprehensive Emergency Neonatal Obstetric Service Room, obstetric polyclinic registers, delivery room registers, postpartum room registers, pigeon clinic registers, and medical records of postpartum mothers with HIV their babies born at Wangaya Hospital in 2020. The univariate analysis used the SPSS computer software program, presented in distribution and percentage tables with explanations arranged in narrative form.

This research has obtained a statement of ethical clearance with the number 071/XI.11/KEP/RSW/2021 dated 23 November 2021 from the Health Research Ethics Committee of Wangaya Hospital Denpasar City.

Description of Respondents' Characteristics of Postpartum Mothers with HIV: The Table 1 shows a description of the characteristics of respondents based on age, education, occupation, marital history, parity, gestational age, prevention of mother-to-child transmission of HIV examination status, duration of HIV infection, antiretroviral treatment status, type of delivery, breastfeeding status, and opportunistic infection status of postpartum mothers with HIV at Wangaya Hospital. Denpasar City. Most of the respondents aged between 20-35 years were 48 people (82.8%), and most of the respondents had high school/vocational education, namely 50 people (86.2%). A total of 29 people (50%) of respondents work as entrepreneurs. Moreover, 53 people (91.4%) of respondents have a history of marriage in their marital status. This study was dominated by multiparas, namely 44 people (75.9%) with a gestation period of as many as 54 people (93.1%). Data obtained from the prevention of mother-to-child transmission of HIV examination status of 'during pregnancy' was 37 people (63.8%), most of them with 'HIV infection duration of fewer than six months as many as 52 people (89.7%). Furthermore, those with an antiretroviral treatment status of fewer than six months and 55 people (94.8%) had no opportunistic infection. Fifty-seven people (98.3%) gave birth by cesarean section, and 58 people (100%) chose not to breastfeed their babies.

Table 1: Characteristics of Respondents (n=58)

Description of Respondents' Babies Characteristics Born to HIV Mothers

The Table 2 shows a description of the characteristics of the respondents based on the APGAR score, birth weight, birth weight for gestational mass, and prophylactic treatment status in infants born to HIV-infected mothers. In this study, most of the babies born, as many as 57 people (98.3%) had an APGAR score of 7-10, which included mild asphyxia, and most of the 53 people (91.4%) had moderate birth weight (2500-4000 grams). The data obtained were 55 people (94.8%) according to the gestational mass, and 58 infants (100%) received prophylactic treatment.

Table 2: The Characteristics of Respondents' APGAR Scores in The First Minute, Birth Weight, Birth Weight to Gestational Mass, And Prophylactic Treatment Status (n=58)

Characteristics of Postpartum mothers with HIV

The results of the study on 58 postpartum women with HIV at the Wangaya Regional General Hospital in 2020 showed that the age group of pregnant women with HIV infection was mainly in the age group of 20-35 years, as many as 48 people (82.8%), age group >35 years. As many as eight people (13.8%) and <20 years as many as two people (3.4%). This fact follows research conducted [5] at the Midwifery Polyclinic of Sanglah Hospital Denpasar, which also showed that most pregnant women with HIV were in the age group 20-35 years (85.71%). These results are based on active sexual activity found in the age range of 20-35 years, and this group is the optimal reproductive age. The 2019 Indonesia Health Profile data also support this, the highest proportion of new HIV cases in the productive age group 25-49 years, namely 70.4%.

This research was conducted in urban areas that have relatively good access to education. Most of the samples took high school/vocational education with a percentage of 86.2%, 6.9% graduated from junior high school, 5.2% took education up to Diploma/Bachelor, and only 1.7% finished elementary school. The level of education obtained from this study showed the same results as the results of research conducted [5]. Denpasar at the high school education level of 85 people (54.11%) and the study [6] where the sample with senior high education school (SMA/ equivalent) the most, namely 39.4% and 40.5%. Based on the level of education, the higher a person's education, the easier it is to receive information. Hence, the knowledge they have will be more and more appropriate in taking attitudes. This fact indicates a person's ability to absorb information is strongly influenced by the level of education. The higher the level of education undertaken, the better the ability to absorb information related to increasing understanding of the dangers of HIV transmission. Hence, mothers have good awareness to carry out routine checks.

In this study, most postpartum mothers with HIV worked as entrepreneurs (50%) and as merchants, laborers, and farmers (6.9%). Only 43.1% are housewives. The results of this study are different from the research conducted by [7], which reported that the majority of pregnant women with HIV were housewives/not working, as many as 66.7%, and the research conducted [5]. where the most work was pregnant women with HIV/AIDS. AIDS is IRT as many as 95 people (60.50%).

Working outside the home provides opportunities for mothers to socialize and communicate with the outside environment, thereby increasing access to information. The more often someone contacts, the source of information can increase one's knowledge. In this study, most postpartum mothers were workers. Hence the opportunity to get information and socialization about HIV knowledge was open. This data is beneficial in increasing the knowledge and enthusiasm of postpartum mothers to carry out HIV tests and treatment.

In this study, the majority of postpartum mothers with HIV showed that 91.4% had married status, 5.2% had widowed status, and 3.4% were unmarried [8]. Thailand also reported pregnant women with HIV with the majority of marital status 60.16%, and [7] with 94.11% of pregnant women with HIV infection being married. These results indicate the importance of family counseling on how to transmit HIV and preventive efforts, which would be better if given early, considering that most pregnant women who are HIV positive are of reproductive age and are married. Counseling and preventive and treatment efforts can be carried out in HIV-infected families.

A total of 75.9% (N=44) were multiparous mothers, 19% (N=11) were primiparous, and 5.2% (N=3) were grand multiparous. This data is not following previous research conducted [5], where the highest number was found in parity 1 (primipara), with as many as 73 people (46.49%). This discrepancy may occur due to differences in the place, time and research conditions

In this study, most mothers' gestational age was a term, namely 37-42 weeks gestational age, 93.1% (N=54) and 6.9% (N=3) preterm pregnancies. This finding supports research at Dr. Kariadi General Hospital Semarang. The data obtained that in the study, there were only a few cases of prematurity (8.7%). There were no cases of neonatal asphyxia. Most of the babies were born with sufficient birth weight (78.3%) there were no cases of neonatal death in mothers. They were giving birth to HIV infection, where most of the respondents in this study were aged 20-35 years and had received antiretroviral treatment [9].

The results showed that the participation of mothers in the prevention of mother-to-child transmission of HIV program while pregnant was 63.8% and 36.2% before birth. This data makes it easier to counsel and early screen HIV-infected pregnant women and their families. Hence, the prevention of HIV transmission in the family can be carried out so that patients can be exposed to the prevention of mother-to-child transmission of HIV program in early pregnancy and immediately receive ARV treatment. The risk of HIV transmission from mother to child without prevention or intervention efforts ranges from 20 to 50% [1].

Implementing a vertical HIV transmission prevention strategy program must be carried out comprehensively to reduce the risk of transmission to a minimum. The strategy includes integrated services such as offering HIV testing as an effort to determine the HIV status of pregnant, maternity, and breastfeeding women. Moreover, its immediate ARV provision for mothers who have been diagnosed as HIV positive, safe delivery, management of infant feeding, and immediate ARV provision for mothers with HIV infection. HIV and prophylaxis in children. In this study, most postpartum mothers were infected with HIV for less than six months, as many as 52 people (89.7%), 8.6% were infected with postpartum >24 months, and only 1.7% were infected with HIV for 12-24 months. This case illustrates that the prevention of mother-to-child transmission of HIV program is running well.

Opportunistic Infection (OI) is caused by microorganisms that attack the immune system both in normal and weak conditions that attack a person. There are many bacteria, fungi, and viruses in the human body. But the human immune system can control these germs. In someone infected with HIV, OI will attack when the CD4 count is less than 200 cells/mm. In this study, 94.8% (N=55) of the patients did not have an opportunistic infection, and only 5.2% (N=3) had opportunistic syphilis infection and had received therapy. This case is probably caused by a CD4 count below 200 cells/mm, poor nutrition, being sexually active, and changing partners without a condom. In line with this, [10] support the current recommendations to screen all adults and adolescents who have a CD4 cell count of 100 cells/μL for CrAg and give preemptive fluconazole treatment for those who test positive. It is also necessary to consider screening for people who have a CD4 cell count higher than 200 cells/μL if possible.

Pregnant women whose HIV status is known during pregnancy, childbirth, or the puerperium, should immediately give antiretroviral treatment. This study found that all postpartum women with HIV received ARV treatment where as many as 89.7% (N=52) had received antiretroviral treatment for less than six months, and 10.3% (N=6) had received ARV treatment for more than six months. Effective antiretroviral therapy (ART) has prevented progression to AIDS and reduced HIV-related morbidity and mortality for the majority of infected individuals [11].

The goal of safe delivery for mothers with HIV is to reduce the risk of HIV transmission from mother to baby and the risk to the mother, the rescue team (medical/non-medical), and other patients. Delivery by cesarean section is less risky for transmission to the baby but adds another risk to the mother. The risk of transmission during vaginal delivery can be minimized and is relatively safe if the mother receives antiretroviral treatment for at least six months and a viral load of fewer than 1000 copies/mm3 at 36 weeks [1]. This study found that most mothers with HIV gave birth by section Caesarea method as much as 98.3% (N=57). In comparison, only 1.7% (N=1) with the vaginal method because the mother came to Wangaya Hospital after the opening was complete. Following medical procedures that give birth to mothers with HIV should be carried out with a cesarean operation procedure to reduce vertical transmission to their babies. [12] showed that elective routine caesarean section for all mothers with HIV may not be appropriate. The risks and benefits depend on the underlying risk of complications and vertical transmission during labor. 

If the mother's viral load is known, it can be used to determine the method of delivery in case the mother's viral load is less than 1000 copies/mL. Exclusive Breastfeeding (EBF) among women with HIV remains the gold standard in resource-limited areas. However, in industrialized countries where safe alternatives to infant formula are available, breastfeeding not recommended due to increased risk of viral MCTs. Infected infants should follow up carefully throughout infancy and childhood by appropriately qualified personnel. In an effort to prevent HIV MCTs, screening is essential including increasing access to ARV therapy, and providing education to improve adherence to cART for all individuals living with HIV [13].

An increased risk of HIV transmission by 10-20% can occur during the puerperium and breastfeeding. If the mother does not breastfeed, the risk of HIV transmission becomes 20-30% and will decrease if the mother receives antiretroviral (ARV) treatment. Short-term ARV and exclusive breastfeeding have a 15-25% risk of HIV transmission and a 5-15% risk of transmission if the mother does not breastfeed for a long time. The risk of mother-to-child transmission of HIV can be reduced again to 1-5%, and mothers who breastfeed exclusively have the same risk of transmitting HIV to their children as mothers who do not breastfeed. With good implementation, the transmission rate can be reduced to less than 2%. The Indonesian Pediatrician Association recommendation for nutrition for infants born to HIV-infected mothers is formula milk to prevent transmission. Formula Milk Meets AFASS requirements, namely Acceptable: acceptable, Feasible: can be done (knowledge, availability of formula milk), Affordable: affordable, Sustainable: available sustainably, and Safe: safe (available clean water facilities). Suppose one of the AFASS is not fulfilled, and after counselling, the mother still wants to breastfeed. In that case, breast milk can be given with the following conditions: exclusive breastfeeding for six months, reducing viral load by giving ARV or pasteurizing breast milk, preventing or treating injuries to the breast or baby's mouth, repairing the general condition of the baby to prevent infection and AFASS is still being pursued. All postpartum mothers in this study 100% chose not to breastfeed their babies. This case follows Indonesian Pediatrician Associations’ recommendations and reflects that the prevention of mother-to-child transmission of HIV program is running well. The insight and awareness of patients and families are increased, and they understand the dangers of HIV transmission, perform antiretroviral treatment obediently, and follow the advice not to breastfeed.

Characteristics of Respondents Babies Born to HIV-infected Mothers

Maternal HIV infection is associated with the birth of babies in poor conditions, namely premature birth, low birth weight, and intrauterine growth retardation. HIV-positive pregnant women have the potential to give birth to babies with low APGAR due to asphyxia due to maternal infection that causes synthesis and secretion of pulmonary surfactant. – reduced fetal lungs [14]. In this study, the APGAR score in the first minute was 1.7% of infants with an APGAR score of 4-6. The APGAR score is an essential indicator of the condition and prognosis of a newborn and requires medical attention. [15] found that infants born to HIV-positive mothers had a higher prevalence of low APGAR scores. The majority of 98.3% of newborns born to HIV mothers in this study with an APGAR score of 7-10 was because 89.7% of postpartum mothers had received ARV treatment during pregnancy and did not have opportunistic infections during pregnancy until delivery.

Mothers with HIV who gave birth to babies with low birth weight were 6.9%. The lowest birth weight in the sample was 2100 grams, and the largest was 4100 grams. Maternal HIV infection was independently associated with LBW, with a 1.9-fold increased risk in [15] study. The research results [16] stated that there was a relationship between HIV infection in pregnant women and the incidence of LBW and prematurity. Low birth weight and HIV-associated preterm delivery may be associated with a compromised human immune system, particularly CD4 cell depletion, T cells, and immunosuppression. The altered immune response of the mother to the infant is a fundamental reason for this relationship. Mechanisms in maternal HIV infection may increase proinflammatory cytokines in maternal placental cells, which is an indicator of the immune response to infection. These changes interfere with the normal development of the baby's immune system, which can interfere with the normal development of the fetus. Decreased birth weight is often found in births to HIV-infected mothers compared to those who are not infected with HIV.

Most babies of HIV mothers were born with birth weight in the 10th to 90th percentile of body weight for gestational age on the Lubchenco curve or birth weight according to gestational age, namely 55 people (94.8%), born less than the 10th percentile or small for gestational age. Two people (3.4%) and one baby (1.7%) were born with a birth weight of more than the 90th percentile or gestational age. Another meta-analysis found a higher proportion of preterm births and small for gestational age (SGA) among the HIV-infected cohort without ARV treatment than in the uninfected cohort. Compared with the term-AGA (appropriate for gestational age) group, infants born prematurely and SGA had a greater risk of neonatal death than infants born prematurely-AGA and term infants-SGA. Maternal HIV infection causes the risk of infant mortality associated with preterm birth or low birth weight to be relatively higher than infants born to women who are not infected with HIV. Increased coverage of prenatal antiretroviral treatment resulted in a decrease in adverse birth outcomes [17].

Study conducted by [18] at National Taiwan University Hospital (NTUH) did not find any babies born with HIV-positive to HIV-infected mothers. Provision of ARV to infants follows the 2019 National Guidelines for Medical Services for HIV Management. All infants born to HIV mothers are required to receive prophylactic ARV. Prophylactic ARV administration of zidovudine according to body weight in newborns aged 6-12 hours after birth or at least less than 72 hours of age. Giving ARV to babies born to HIV mothers aims to prevent HIV transmission, especially during childbirth and breastfeeding. The principle of giving prophylactic ARVs to infants born to HIV mothers is post-exposure prevention which aims to reduce the risk of HIV infection after a potential exposure [1]. In this study, 100% of infants born to HIV mothers received prophylactic treatment.

Suggestion

Referring to the process of completing this research, can be expressed some suggestions that may be useful for all parties who play a role in this research. Optimizing the implementation of the prevention of mother-to-child transmission of HIV program in early pregnancy can perform early detection of HIV in pregnant women, maternity, postpartum, and everyone at risk of contracting HIV. Therefore, HIV status can be known early; hence, early intervention can reduce the risk of falling into the advanced stage of HIV (AIDS). Improving mentoring programs for HIV patients with a routine follow-up system and constantly monitoring adherence to ARV consumption to reduce the incidence of drug withdrawal (lost follow-up) in HIV patients. Reporting, Monitoring and Evaluation) to be carried out more optimally in the national system with a network system on an ongoing basis and access to all health facilities making it easier to provide care. For further researchers who conducted the same study can guide further research by expanding other variables such as data variables from Viral Load, CD4 examination results, and Early Infant Diagnosis (EID), namely HIV examination in infants born to HIV mothers. Multiply the sample and research coverage area.

1. Ministry of Health of the Republic of Indonesia. Indonesian Health Profile 2018, 2019.

2. UNAIDS. Global AIDS Update 2018: Miles to Go—Closing Gaps, Breaking Barriers, Righting Injustices. 2018, pp. 6.
   www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf.

3. Ministry of Health of the Republic of Indonesia. Indonesian Health Profile 2020. Ministry of Health of the Republic of Indonesia, 2021.

4. Bali Provincial Health Office. Bali Province Health Profile 2019, 2020.

5. Putu, S. Prevalensi dan Karakteristik Ibu Hamil dengan HIV di RSUP Sanglah Denpasar Periode 2010–2013, 2015.

6. Suherlim, R. “Karakteristik penderita HIV pada Ibu hamil di klinik prevention mother to child transmission (pmtct) poli kebidanan rsup sanglah denpasar periode juli 2013–juni 2014.” Jurnal Mahasiswa PSPD FK Universitas Tanjungpura, vol. 1, no. 3, 2015.

7. Putra, R.A. et al. “Characteristics of pregnant women with hiv/aids in dr. hasan sadikin bandung period 2014–2016.” Indonesian Journal of Obstetrics & Gynecology Science, vol. 1, no. 2, 2018, pp. 125–130.

8. Areechokchai, D. et al. “Pregnancy outcomes among HIV-infected women undergoing antiretroviral therapy.” The Open AIDS Journal, vol. 3, 2009, pp. 8–12.

9. Junnisa, S.D. et al. Luaran Maternal dan Neonatal pada Ibu Bersalin dengan Infeksi HIV (Analisis Faktor Jumlah Sel CD4). Doctoral dissertation, Faculty of Medicine, 2015.

10. Ford, N. et al. “CD4 cell count threshold for cryptococcal antigen screening of hiv-infected individuals: A systematic review and meta-analysis.” Clinical Infectious Diseases, vol. 66, suppl. 2, 2018, pp. S152–S159. https://doi.org/10.1093/cid/cix1143.

11. Aid, M. et al. “Follicular cd4 t helper cells as a major hiv reservoir compartment: A molecular perspective.” Frontiers in Immunology, vol. 9, 2018, pp. 895. https://doi.org/10.3389/fimmu.2018.00895.

12. Kennedy, C.E. et al. “Elective cesarean section for women living with HIV: A systematic review of risks and benefits.” AIDS, vol. 31, no. 11, 2017, pp. 1579–1588. https://doi.org/10.1097/QAD.0000000000001535.

13. Lynch, N. G., and A. K. Johnson. “Congenital HIV: Prevention of Maternal to Child Transmission.” Advances in Neonatal Care, vol. 18, no. 5, 2018, pp. 330–340. https://doi.org/10.1097/ANC.0000000000000559.

14. Purwaningsih, N.A. Relationship of HIV/AIDS Positive Pregnant Mothers with APGAR Score Babies in RSD dr. Soebandi Jember, 2018.

15. Yang, M. et al. “Impact of maternal hiv infection on pregnancy outcomes in southwestern China: A hospital registry-based study.” Epidemiology & Infection, vol. 147, 2019.

16. Xiao, P.L. et al. “Association between maternal hiv infection and low birth weight and prematurity: A meta-analysis of cohort studies.” BMC Pregnancy and Childbirth, vol. 15, no. 1, 2015, pp. 1–11.

17. Sania, A. et al. “Neonatal and infant mortality risk associated with preterm and small for gestational age births in Tanzania: Individual level pooled analysis using the intergrowth standard.” The Journal of Pediatrics, vol. 192, 2018, pp. 66–72.

18. Huang, K.Y. et al. “Mother-to-child transmission of HIV: An 11-year experience in a single center and hiv prevention effectiveness in Taiwan.” Journal of the Formosan Medical Association, vol. 118, no. 8, 2019, pp. 1211–1217. https://doi.org/10.1016/j.jfma.2019.05.001.