"HIV" AND "pregnancy" AND "antiretroviral"

HIV in pregnancy 2024 2025 guidelines PMTCT antiretroviral updates WHO

https://pmc.ncbi.nlm.nih.gov/articles/PMC12711239

mkdir -p /home/daytona/workspace/hiv-pregnancy-ppt && ls /home/daytona/workspace…

~/hiv-pregnancy-ppt/create_ppt.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Medical Education";
pres.title = "HIV in Pregnancy";

// ─── COLOR PALETTE ───────────────────────────────────────────────────────────
const C = {
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  gold:       "F5A623",   // key facts / warnings
  red:        "C0392B",   // alerts / danger
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  midGray:    "D0D9E3",
  textDark:   "1A2B3C",
  textMid:    "2C3E50",
};

// ─── HELPER FUNCTIONS ─────────────────────────────────────────────────────────
function addSlideHeader(slide, title, subtitle = "") {
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function addSlideFooter(slide, slideNum) {
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  slide.addText("HIV in Pregnancy | MBBS Undergraduate Teaching | 2025–2026 Updates", {
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function bulletSlide(slideNum, title, subtitle, bullets, noteText = "") {
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function twoColSlide(slideNum, title, subtitle, leftTitle, leftBullets, rightTitle, rightBullets) {
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function tableSlide(slideNum, title, subtitle, headers, rows) {
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    rowH: 0.42,
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  addSlideFooter(slide, slideNum);
  return slide;
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 1 — TITLE SLIDE
// ════════════════════════════════════════════════════════════════
{
  const slide = pres.addSlide();

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    x: 0, y: 4.6, w: "100%", h: 0.08,
    fill: { color: C.teal }, line: { color: C.teal },
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  slide.addText("HIV IN PREGNANCY", {
    x: 0.5, y: 1.2, w: 9.0, h: 0.95,
    fontSize: 44, bold: true, color: C.white, fontFace: "Calibri",
    align: "left", charSpacing: 3,
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  slide.addText("A Comprehensive Guide with 2025–2026 Updates", {
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    fontSize: 20, color: C.tealLight, italic: true, fontFace: "Calibri", align: "left",
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  slide.addText("For MBBS Undergraduates | Department of Obstetrics & Gynaecology", {
    x: 0.5, y: 2.85, w: 9.0, h: 0.38,
    fontSize: 14, color: C.midGray, fontFace: "Calibri", align: "left",
  });

  // Key stat boxes
  const stats = [
    ["1.3 M", "Pregnant women\nliving with HIV\nglobally (2023)"],
    ["94%", "Coverage of ART\namong HIV+ pregnant\nwomen (2023)"],
    ["< 1%", "MTCT rate with\noptimal ART &\nundetectable VL"],
  ];
  stats.forEach(([val, label], i) => {
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  slide.addText("Sources: WHO Global HIV Report 2024 | US Perinatal Guidelines 2025 | BHIVA Guidelines 2025", {
    x: 0.5, y: 4.8, w: 9.0, h: 0.3,
    fontSize: 8, color: C.midGray, fontFace: "Calibri", align: "left",
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}

// ════════════════════════════════════════════════════════════════
//  SLIDE 2 — LEARNING OBJECTIVES
// ════════════════════════════════════════════════════════════════
bulletSlide(2, "Learning Objectives", "By the end of this session, the student will be able to:",
  [
    "Describe the epidemiology of HIV in pregnancy globally and in India",
    "Explain the pathophysiology of HIV and mother-to-child transmission (MTCT)",
    "Outline the screening protocols and diagnostic testing in pregnancy",
    "Enumerate the preferred ART regimens in pregnancy (2025 updates)",
    "Discuss obstetric management, mode of delivery, and intrapartum care",
    "Describe postnatal prophylaxis for the neonate and infant feeding guidelines",
    "Recognize complications of HIV and ART in pregnancy",
    "Apply PrEP and prevention strategies for serodiscordant couples",
    "Counsel a pregnant woman living with HIV using current evidence",
  ], "Aligns with MCI competency OG 18.1 | Revised per 2025 US Perinatal & BHIVA Guidelines");

// ════════════════════════════════════════════════════════════════
//  SLIDE 3 — EPIDEMIOLOGY
// ════════════════════════════════════════════════════════════════
{
  const slide = pres.addSlide();
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  addSlideHeader(slide, "Epidemiology", "HIV in Pregnancy — Global & Indian Scenario");

  const boxes = [
    { label: "Pregnant women\nwith HIV (global)", val: "1.3 M", sub: "2023 estimate", col: C.navy },
    { label: "ART coverage\n(pregnant women)", val: "94%", sub: "Up from 47% in 2010", col: C.teal },
    { label: "MTCT infections\n(global, 2023)", val: "130 K", sub: "↓ 78% since 2010", col: C.red },
    { label: "India PPTCT\nprogramme", val: "NACO", sub: "~37,000 HIV+ deliveries/yr", col: C.textMid },
  ];

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      fill: { color: b.col }, line: { color: b.col },
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  addSlideFooter(slide, 3);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 4 — HIV VIROLOGY BASICS
// ════════════════════════════════════════════════════════════════
twoColSlide(4, "HIV Virology — Basics", "Essential background for understanding MTCT & ART",
  "HIV Structure & Types",
  [
    "RNA retrovirus — HIV-1 (global) & HIV-2 (West Africa)",
    "Enveloped; gp120/gp41 surface glycoproteins",
    "Core: p24 antigen (diagnostic marker)",
    "Carries reverse transcriptase, integrase, protease",
    "HIV-1: more virulent, responsible for pandemic",
    "HIV-2: lower transmission, slower progression",
  ],
  "Lifecycle (Drug Targets)",
  [
    "1. Attachment — gp120 binds CD4 + CCR5/CXCR4",
    "2. Fusion — gp41 (target: enfuvirtide)",
    "3. Reverse transcription — RNA→DNA (NRTIs/NNRTIs)",
    "4. Integration — into host genome (INSTIs: DTG, BIC)",
    "5. Transcription & translation",
    "6. Protease cleavage (PIs: darunavir)",
    "7. Budding & release",
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 5 — ROUTES OF MTCT
// ════════════════════════════════════════════════════════════════
{
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  addSlideHeader(slide, "Mother-to-Child Transmission (MTCT)", "Routes, Timing & Risk Factors");

  const rows = [
    { route: "In Utero\n(Transplacental)", timing: "1st trimester (rare)\nLate pregnancy ↑", risk: "5–10% of MTCT", mech: "Placental microabrasions;\ncell-to-cell spread" },
    { route: "Intrapartum\n(During Labour)", timing: "Most common route", risk: "10–20% (↑ if VL >1000)", mech: "Exposure to blood/\ncervicovaginal secretions" },
    { route: "Postnatal\n(Breastfeeding)", timing: "Throughout lactation", risk: "10–15% (cumulative)", mech: "HIV in breast milk;\ncompartment reservoir" },
  ];

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    const colW = [2.2, 2.1, 2.1, 3.1];
    const colX = [0.25, 2.45, 4.55, 6.65];
    const vals = [r.route, r.timing, r.risk, r.mech];
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        line: { color: C.midGray, pt: 1 },
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        color: i === 0 ? C.white : (j === 0 ? C.white : C.textDark),
        fontFace: "Calibri", align: "center", valign: "middle",
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  // Headers
  const hdrs = ["ROUTE", "TIMING", "RISK", "MECHANISM"];
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  const colX2 = [0.25, 2.45, 4.55, 6.65];
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      x: colX2[j], y: 1.08, w: colW2[j], h: 0.3,
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    slide.addText(h, {
      x: colX2[j], y: 1.08, w: colW2[j], h: 0.3,
      fontSize: 10, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
    });
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  slide.addText("⚠  Without ART: overall MTCT risk 15–45% | With optimal ART + undetectable VL: < 1%", {
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    fontSize: 11, bold: true, color: C.red, fontFace: "Calibri", align: "center",
    fill: { color: "FFF5F5" },
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  addSlideFooter(slide, 5);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 6 — RISK FACTORS FOR MTCT
// ════════════════════════════════════════════════════════════════
twoColSlide(6, "Risk Factors for MTCT", "Maternal, Obstetric & Infant Factors",
  "Maternal Factors",
  [
    { text: "High viral load — most important predictor", bold: true, color: C.red },
    "Low CD4+ T-cell count (< 200 cells/µL)",
    "Primary/acute HIV infection during pregnancy",
    "Advanced HIV disease (AIDS)",
    "Co-infections: TB, STIs, chorioamnionitis",
    "Absence of or late initiation of ART",
    "Breastfeeding duration & exclusivity",
    "Nutritional deficiencies (vitamin A)",
  ],
  "Obstetric & Infant Factors",
  [
    "Prolonged rupture of membranes (> 4 hrs)",
    "Vaginal delivery with VL > 1000 copies/mL",
    "Preterm birth (< 34 weeks)",
    "Chorioamnionitis / placental inflammation",
    "Invasive obstetric procedures (amniocentesis, fetal scalp electrode)",
    "Infant prematurity / low birth weight",
    "Infant HLA type (genetic susceptibility)",
    "Mixed feeding practices",
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 7 — SCREENING IN PREGNANCY
// ════════════════════════════════════════════════════════════════
{
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: "100%", h: "100%",
    fill: { color: C.lightGray }, line: { color: C.lightGray },
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  addSlideHeader(slide, "HIV Screening in Pregnancy", "Universal Opt-Out Strategy | India PPTCT Programme");

  // Timeline-style
  const steps = [
    { num: "1ST", title: "First Antenatal Visit", detail: "Opt-out HIV testing offered to ALL pregnant women\nRapid HIV test (ELISA/Ag-Ab combo)\nIndia: free at all PHC/CHC/DH under PPTCT", color: C.navy },
    { num: "3RD\nTRI", title: "Third Trimester Retest", detail: "Recommended for high-risk women (serodiscordant couple,\nSTI, IDU, sex workers)\nAim: detect new infections before delivery", color: C.teal },
    { num: "LABOR", title: "Intrapartum Testing", detail: "Rapid test if status unknown or high-risk\nResult within 20–30 minutes\nAllows prophylaxis even if first test missed", color: C.red },
    { num: "POST\nPARTUM", title: "Post-Exposure Testing", detail: "Infant HIV DNA PCR at 6 weeks, 6 months, 18 months\nHIV antibody test at 18 months (maternal antibody wanes)", color: C.textMid },
  ];

  steps.forEach((s, i) => {
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      x, y: 1.15, w: 2.2, h: 0.6,
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      fontSize: 15, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle",
    });
    // Arrow
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      slide.addShape(pres.ShapeType.rightArrow, {
        x: x + 2.2, y: 1.3, w: 0.2, h: 0.3,
        fill: { color: C.tealLight }, line: { color: C.tealLight },
      });
    }
    slide.addShape(pres.ShapeType.rect, {
      x, y: 1.75, w: 2.2, h: 0.52,
      fill: { color: C.white }, line: { color: s.color, pt: 1 },
    });
    slide.addText(s.title, {
      x, y: 1.75, w: 2.2, h: 0.52,
      fontSize: 11, bold: true, color: s.color, fontFace: "Calibri", align: "center", valign: "middle",
    });
    slide.addShape(pres.ShapeType.rect, {
      x, y: 2.27, w: 2.2, h: 2.8,
      fill: { color: C.white }, line: { color: C.midGray, pt: 1 },
    });
    slide.addText(s.detail, {
      x: x + 0.05, y: 2.32, w: 2.1, h: 2.7,
      fontSize: 10, color: C.textDark, fontFace: "Calibri", valign: "top",
    });
  });

  slide.addText("Algorithm: Reactive Rapid Test → Confirmatory Western Blot / Line Immunoassay / 2nd Rapid Test → Positive = Start ART", {
    x: 0.25, y: 5.1, w: 9.5, h: 0.28,
    fontSize: 10, bold: true, color: C.navy, fontFace: "Calibri", align: "center",
  });

  addSlideFooter(slide, 7);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 8 — DIAGNOSIS & MONITORING
// ════════════════════════════════════════════════════════════════
tableSlide(8, "Diagnostic Tests & Monitoring Parameters",
  "Initial evaluation and monitoring of HIV-positive pregnant women",
  ["Test", "When to Perform", "Significance / Action"],
  [
    ["HIV Ag/Ab Combo (4th gen)", "1st ANC visit", "Detects acute HIV (p24 Ag); window period 18 days"],
    ["CD4+ T-cell count", "1st visit, then 3-monthly", "Guides OI prophylaxis; target > 500 cells/µL"],
    ["HIV Viral Load (HIV RNA PCR)", "1st visit, 2–4 wks after ART start, 34 wks gestation", "Key MTCT predictor; guides mode of delivery"],
    ["HIV Genotype / Resistance test", "1st visit (if VL detectable)", "Select effective ART; avoid ineffective drugs"],
    ["FBC, LFT, RFT, fasting glucose", "Baseline & each trimester", "ART toxicity monitoring (TDF → renal, ZDV → anaemia)"],
    ["HBsAg, HCV Ab, VDRL/RPR", "1st visit", "Co-infection screening; affects ART choice"],
    ["TB screening (symptom screen ± GeneXpert)", "Every visit", "TB-HIV co-infection — start ART within 2 weeks of ATT"],
    ["Cervical cytology (Pap smear)", "1st visit", "HPV / CIN risk increased in HIV; annual in HIV+"],
    ["TORCH screen, anomaly scan (18–20 wks)", "As per ANC protocol", "Teratogenicity monitoring if ART started in 1st trimester"],
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 9 — ART IN PREGNANCY — PRINCIPLES
// ════════════════════════════════════════════════════════════════
bulletSlide(9, "ART in Pregnancy — Core Principles", "Starting, Continuing & Optimising Treatment",
  [
    { text: "ALL HIV-positive pregnant women should receive ART regardless of CD4 count or viral load (WHO/NACO)", bold: true, color: C.red },
    "Goals of ART in pregnancy:",
    { text: "  → Maximal viral suppression (VL < 50 copies/mL)", indent: 20, size: 14, color: C.teal },
    { text: "  → Prevent perinatal transmission (MTCT)", indent: 20, size: 14, color: C.teal },
    { text: "  → Preserve maternal immune function", indent: 20, size: 14, color: C.teal },
    { text: "  → Minimise drug toxicity to mother and fetus", indent: 20, size: 14, color: C.teal },
    "ART should NOT be withheld or delayed in 1st trimester to avoid preterm birth (updated 2025 US guidelines)",
    "Women already on ART before pregnancy: continue the same regimen if virologically suppressed",
    "Women diagnosed in pregnancy: start ART immediately (same day if possible)",
    "3-drug regimen: 2 NRTIs + 1 INSTI (preferred) OR 2 NRTIs + 1 PI (alternative)",
    "Drug choice must balance: teratogenicity, pharmacokinetics, resistance, tolerability",
  ], "US Perinatal Guidelines June 2025 | WHO Consolidated Guidelines 2024");

// ════════════════════════════════════════════════════════════════
//  SLIDE 10 — PREFERRED ART REGIMENS (2025 UPDATE)
// ════════════════════════════════════════════════════════════════
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  addSlideHeader(slide, "Preferred ART Regimens in Pregnancy (2025 Update)", "US Perinatal Guidelines | June 2025");

  // NEW 2025 highlight box
  slide.addShape(pres.ShapeType.rect, {
    x: 0.3, y: 1.0, w: 9.4, h: 0.52,
    fill: { color: C.gold }, line: { color: C.gold },
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  slide.addText("⭐  NEW 2025: BIC/TAF/FTC (Biktarvy®) now designated PREFERRED for pregnancy — first INSTI single-tablet regimen with this status", {
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    fontSize: 12, bold: true, color: C.deepNavy, fontFace: "Calibri", valign: "middle", margin: 4,
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    { status: "PREFERRED", color: C.navy, drugs: [
      "BIC/TAF/FTC (Bictarvy®) — NEW 2025",
      "DTG + (TDF or TAF) + (FTC or 3TC)",
      "DTG/3TC/TDF (Symtuza equivalent combinations)",
    ]},
    { status: "ALTERNATIVE", color: C.teal, drugs: [
      "RAL 400mg BD + TDF + FTC",
      "EFV/TDF/FTC (if INSTI not available)",
      "ATV/r + TDF + FTC",
      "ABC/3TC + DTG (if HLA-B*5701 negative)",
    ]},
    { status: "USE WITH\nCAUTION", color: "#E67E22", drugs: [
      "ABC-containing regimens — reclassified to Alternative (↑ CVD risk, 2025)",
      "ZDV/3TC — only if preferred unavailable",
      "EFV — teratogenicity concern in 1st trimester (historical)",
    ]},
    { status: "AVOID", color: C.red, drugs: [
      "ddI + d4T (mitochondrial toxicity)",
      "Full-dose ritonavir monotherapy",
      "Cabotegravir LA as PrEP if ART not established (risk of resistance on breakthrough infection)",
    ]},
  ];

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    const x = 0.3 + (i % 2) * 4.8;
    const y = 1.65 + Math.floor(i / 2) * 1.75;
    slide.addShape(pres.ShapeType.rect, {
      x, y, w: 4.4, h: 0.32,
      fill: { color: r.color }, line: { color: r.color },
    });
    slide.addText(r.status, {
      x, y, w: 4.4, h: 0.32,
      fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
    });
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      text: d,
      options: { bullet: { type: "bullet" }, fontSize: 11, color: C.textDark, fontFace: "Calibri", breakLine: di < r.drugs.length - 1 },
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      x, y: y + 0.32, w: 4.4, h: 1.38,
      fill: { color: C.white }, line: { color: r.color, pt: 1 },
    });
    slide.addText(items, {
      x: x + 0.05, y: y + 0.35, w: 4.3, h: 1.28, valign: "top",
    });
  });

  addSlideFooter(slide, 10);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 11 — DTG SAFETY UPDATE & NTD RISK
// ════════════════════════════════════════════════════════════════
bulletSlide(11, "Dolutegravir (DTG) Safety in Pregnancy", "Neural Tube Defects — Updated Evidence 2024–2025",
  [
    { text: "2018 Botswana Tsepamo Study: Initial signal of 0.3% NTD risk with periconceptional DTG", bold: true, color: C.red },
    "Subsequent large-scale studies and meta-analyses (2024): NTD risk NOT significantly elevated over background",
    { text: "Payra et al. 2024 (Systematic Review & Meta-analysis): DTG-based ART — no significant increase in congenital anomalies overall", bold: false, color: C.teal },
    "WHO 2019: Updated to support DTG as preferred INSTI in all settings including at conception",
    "Folic acid 5 mg/day (not just 0.4 mg) recommended periconceptionally for all women on DTG",
    "Current consensus (2025): DTG benefits far outweigh theoretical NTD risk",
    { text: "BIC (Bictegravir) — 2025 Preferred: No increased congenital anomalies in Antiretroviral Pregnancy Registry data", bold: true, color: C.navy },
    "RAL (Raltegravir): Established safety data; now Alternative (less PK data than DTG/BIC)",
    { text: "Key message: Do NOT withhold INSTIs in pregnancy; ensure adequate folic acid supplementation", bold: true, color: C.red },
  ], "Payra S et al. Clin Drug Investig 2024 [PMID 39302585] | WHO Consolidated Guidelines 2024");

// ════════════════════════════════════════════════════════════════
//  SLIDE 12 — ART MONITORING & ADHERENCE
// ════════════════════════════════════════════════════════════════
twoColSlide(12, "ART Monitoring & Adherence in Pregnancy", "Pharmacokinetics change — close monitoring essential",
  "Monitoring Schedule",
  [
    "Viral load: baseline, 2–4 wks after start/change, 34 wks",
    "CD4 count: baseline, every 3 months",
    "LFT / RFT: baseline, 4 weeks, each trimester",
    "FBC: monthly if on ZDV-containing regimen",
    "Fasting glucose: baseline + 28 wks (PI use → GDM risk)",
    "Lipids: baseline (PI and some NRTIs → dyslipidaemia)",
    "Urinalysis + creatinine: TDF nephrotoxicity monitoring",
    "Fetal growth scans: 28 wks, 34 wks (PK changes may reduce efficacy late in pregnancy)",
  ],
  "Adherence Support",
  [
    "Adherence > 95% required for sustained viral suppression",
    "Common barriers in pregnancy: nausea, pill burden, stigma",
    "Strategies: adherence counselling, pill organizers, SMS reminders",
    "Involve partner and family in counselling (serodiscordant couple support)",
    "Address mental health — depression associated with non-adherence",
    "Directly observe therapy (DOT) in resource-limited settings",
    "Peer support groups for pregnant women living with HIV",
    "Never stop ART abruptly — risk of viral rebound, IRIS, resistance",
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 13 — OBSTETRIC COMPLICATIONS
// ════════════════════════════════════════════════════════════════
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  addSlideHeader(slide, "Obstetric Complications in HIV-Positive Pregnancy", "Both HIV disease and ART contribute to adverse outcomes");

  const comp = [
    { title: "Spontaneous Abortion", detail: "Increased in untreated HIV\n↑ immune activation, placental dysfunction", icon: "⚠" },
    { title: "Preterm Birth", detail: "Risk: HIV disease + some ARV combinations\nART should NOT be stopped to prevent PTB (2025)", icon: "⏰" },
    { title: "Low Birth Weight / FGR", detail: "Multifactorial: malnutrition, anaemia, HIV viremia\nMonitor with serial scans", icon: "📉" },
    { title: "Gestational Diabetes", detail: "PI-based ART (lopinavir/r, darunavir/r) → insulin resistance\nScreen at 24–28 wks with GCT", icon: "🩸" },
    { title: "Pre-eclampsia", detail: "Modest increase in HIV-infected women\nRenal disease from TDF can confound diagnosis", icon: "💊" },
    { title: "Anaemia", detail: "AZT/ZDV → macrocytic anaemia\nHIV-related anaemia of chronic disease\nFolic acid + iron supplementation", icon: "💉" },
  ];

  comp.forEach((c, i) => {
    const x = 0.3 + (i % 3) * 3.2;
    const y = 1.15 + Math.floor(i / 3) * 2.0;
    slide.addShape(pres.ShapeType.rect, {
      x, y, w: 3.0, h: 1.8,
      fill: { color: C.white }, line: { color: C.teal, pt: 1.5 },
      shadow: { type: "outer", blur: 4, offset: 2, angle: 45, color: "AAAAAA", opacity: 0.2 },
    });
    slide.addText(c.icon + "  " + c.title, {
      x: x + 0.08, y: y + 0.05, w: 2.84, h: 0.42,
      fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri", valign: "middle",
    });
    slide.addShape(pres.ShapeType.line, {
      x: x + 0.08, y: y + 0.48, w: 2.84, h: 0,
      line: { color: C.teal, pt: 1 },
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      x: x + 0.08, y: y + 0.53, w: 2.84, h: 1.2,
      fontSize: 11, color: C.textDark, fontFace: "Calibri", valign: "top",
    });
  });

  addSlideFooter(slide, 13);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 14 — ANTENATAL CARE OVERVIEW
// ════════════════════════════════════════════════════════════════
tableSlide(14, "Antenatal Care Schedule for HIV-Positive Women",
  "Key investigations and actions at each visit",
  ["Trimester / Timing", "Actions", "Special Considerations"],
  [
    ["Booking Visit\n(ASAP on diagnosis)", "HIV Ag/Ab test, CD4, VL, genotype, FBC, LFT, RFT, VDRL, HBsAg, HCV, TB screen, Pap smear, Anomaly dating scan", "Start ART same day if possible; folic acid 5 mg; cotrimoxazole prophylaxis if CD4 < 200"],
    ["11–13 Weeks", "Nuchal translucency scan, first trimester screen, confirm ART tolerance", "Avoid invasive procedures (amniocentesis) if VL detectable; counsel on MTCT"],
    ["18–20 Weeks", "Anomaly scan, VL check 2–4 wks after ART start, FBC", "Assess fetal growth; rule out ART-associated anomalies"],
    ["28 Weeks", "GCT (PI-based ART), growth scan, CD4, FBC, anaemia screen", "Anti-D if Rh –ve; influenza vaccine; COVID-19 vaccine"],
    ["34 Weeks", "Viral load — critical for delivery planning\nCD4, LFT, RFT, FBC", "VL < 50: aim for vaginal delivery; VL > 1000: LSCS at 38 wks\nRefer to specialist if VL not suppressed"],
    ["36–38 Weeks", "Birth plan discussion, neonatal team notification, IV ZDV availability if needed", "Discuss infant feeding (avoid breastfeeding if formula accessible & safe); postnatal prophylaxis plan"],
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 15 — INTRAPARTUM MANAGEMENT
// ════════════════════════════════════════════════════════════════
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  addSlideHeader(slide, "Intrapartum Management", "Mode of Delivery & Labour Care");

  // Two decision branches
  const branches = [
    {
      title: "VL < 50 copies/mL at 36–38 wks",
      color: C.teal,
      points: [
        "Aim for vaginal delivery — no added benefit from elective LSCS",
        "Continue oral ART throughout labour (do not skip doses)",
        "IV ZDV NOT required if VL undetectable",
        "Avoid fetal scalp electrode, fetal blood sampling, prolonged ROM",
        "Active management of 3rd stage (↑ PPH risk in HIV+)",
        "Avoid episiotomy unless necessary",
      ],
    },
    {
      title: "VL > 1000 copies/mL or VL Unknown",
      color: C.red,
      points: [
        "Elective LSCS at 38 weeks of gestation (ACOG/BHIVA 2025)",
        "IV Zidovudine (ZDV) infusion: 2 mg/kg loading over 1 hr → 1 mg/kg/hr until cord clamped",
        "Continue oral ART — do NOT discontinue perioperatively",
        "Minimise maternal blood exposure; double gloves, eye protection",
        "Prolonged ROM (> 4 hrs): ↑ MTCT — expedite delivery",
        "Preterm with PROM: weigh MTCT risk vs prematurity risk carefully",
      ],
    },
  ];

  branches.forEach((b, i) => {
    const x = 0.3 + i * 4.8;
    slide.addShape(pres.ShapeType.rect, {
      x, y: 1.1, w: 4.4, h: 0.42,
      fill: { color: b.color }, line: { color: b.color },
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    slide.addText(b.title, {
      x, y: 1.1, w: 4.4, h: 0.42,
      fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
    });
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      text: p,
      options: { bullet: { type: "bullet" }, fontSize: 12, color: C.textDark, fontFace: "Calibri", breakLine: pi < b.points.length - 1 },
    }));
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      x, y: 1.52, w: 4.4, h: 3.55,
      fill: { color: C.white }, line: { color: b.color, pt: 1 },
    });
    slide.addText(items, {
      x: x + 0.08, y: 1.57, w: 4.25, h: 3.45, valign: "top",
    });
  });

  addSlideFooter(slide, 15);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 16 — POSTPARTUM MANAGEMENT: MOTHER
// ════════════════════════════════════════════════════════════════
bulletSlide(16, "Postpartum Management — Mother", "Continued care after delivery",
  [
    { text: "Continue ART lifelong — do NOT stop postpartum (\"Treatment for Life\" policy)", bold: true, color: C.red },
    "Monitor for immune reconstitution inflammatory syndrome (IRIS) if CD4 was very low",
    "Postnatal review: VL at 4–6 weeks postpartum; CD4 count",
    "Contraception counselling:",
    { text: "  → IUCD: safe and effective; insert post-placental delivery", indent: 20, size: 14, color: C.teal },
    { text: "  → Progestogen implants/injectables: check ART interaction (EFV ↓ progestogen levels)", indent: 20, size: 14, color: C.teal },
    { text: "  → COC: avoid in advanced disease; enzyme-inducing ARVs (NVP, EFV) reduce efficacy", indent: 20, size: 14, color: C.teal },
    { text: "  → Condoms: always recommended regardless of contraceptive choice", indent: 20, size: 14, color: C.teal },
    "Inhibit lactation (if breastfeeding contraindicated): cabergoline 0.5 mg × 2 tablets single dose at delivery",
    "Mental health screening: postpartum depression more common in HIV+ women",
    "Family planning — partner HIV testing, PrEP for seronegative partners",
    "Spermicides & diaphragm: CONTRAINDICATED (mucosal microabrasions ↑ HIV transmission risk)",
  ], "BHIVA 2025 | Brazil Ministry of Health Guidelines 2025");

// ════════════════════════════════════════════════════════════════
//  SLIDE 17 — INFANT PROPHYLAXIS & POSTNATAL CARE
// ════════════════════════════════════════════════════════════════
{
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  slide.addShape(pres.ShapeType.rect, {
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  addSlideHeader(slide, "Neonatal / Infant Prophylaxis", "Based on Maternal Viral Load at Delivery | 2025 US Guidelines");

  const regimens = [
    {
      risk: "LOW RISK\nMaternal VL < 50\nat delivery",
      color: C.teal,
      regimen: "ZDV 4 mg/kg/dose BD × 4 weeks\nOR\nNVP 12 mg/dose OD × 4 weeks",
      note: "Single drug prophylaxis sufficient\nif maternal VL undetectable",
    },
    {
      risk: "HIGHER RISK\nVL 50–999 or\nsuboptimal ART",
      color: "#E67E22",
      regimen: "ZDV 4 mg/kg/dose BD × 6 weeks\n+ 3TC 2 mg/kg/dose BD × 6 weeks",
      note: "Consider adding NVP\nInitiate within 6–12 hours of birth",
    },
    {
      risk: "HIGH RISK\nVL ≥ 1000 or\nunknown at delivery",
      color: C.red,
      regimen: "ZDV 4 mg/kg BD × 6 wks\n+ 3TC 2 mg/kg BD × 6 wks\n+ NVP 12 mg OD × 6 wks\n(or first 2 weeks then BD)",
      note: "Triple prophylaxis\nInfant ARV Pregnancy Registry\nmonitoring applies",
    },
    {
      risk: "HIV-2 EXPOSED\n(new 2025)",
      color: C.navy,
      regimen: "Use drugs active against HIV-2\nAvoid NVP/EFV (HIV-2 inherently resistant)\nPrefer ZDV + 3TC + LPV/r or DTG",
      note: "NEW 2025 recommendation:\nmanage same as HIV-1 exposed\nwith HIV-2 active drugs",
    },
  ];

  regimens.forEach((r, i) => {
    const x = 0.25 + (i % 2) * 4.9;
    const y = 1.15 + Math.floor(i / 2) * 2.15;
    slide.addShape(pres.ShapeType.rect, {
      x, y, w: 4.5, h: 0.42,
      fill: { color: r.color }, line: { color: r.color },
    });
    slide.addText(r.risk, {
      x, y, w: 4.5, h: 0.42,
      fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
    });
    slide.addShape(pres.ShapeType.rect, {
      x, y: y + 0.42, w: 4.5, h: 1.7,
      fill: { color: C.white }, line: { color: r.color, pt: 1 },
    });
    slide.addText(r.regimen, {
      x: x + 0.08, y: y + 0.48, w: 4.3, h: 0.95,
      fontSize: 12, bold: true, color: r.color, fontFace: "Calibri", valign: "top",
    });
    slide.addText(r.note, {
      x: x + 0.08, y: y + 1.45, w: 4.3, h: 0.65,
      fontSize: 10, italic: true, color: C.textMid, fontFace: "Calibri", valign: "top",
    });
  });

  slide.addText("Start prophylaxis within 6 hours of birth (within 12 hours at most) | Preterm dosing adjustments required", {
    x: 0.25, y: 5.1, w: 9.5, h: 0.28,
    fontSize: 10, bold: true, color: C.navy, fontFace: "Calibri", align: "center",
  });

  addSlideFooter(slide, 17);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 18 — INFANT FEEDING
// ════════════════════════════════════════════════════════════════
twoColSlide(18, "Infant Feeding in HIV-Positive Mothers", "Context-Specific Recommendations",
  "High-Resource Settings\n(Safe water, formula available)",
  [
    { text: "Breastfeeding is CONTRAINDICATED", bold: true, color: C.red },
    "Formula feeding exclusively for 6 months, then complementary",
    "Provide formula free of charge (NACO / government scheme in India)",
    "Suppress lactation: cabergoline 1 mg single dose at delivery",
    "Avoid mixed feeding — increases gut permeability, ↑ HIV risk",
    "Avoid home pasteurisation — not reliably effective",
    "Cross-nursing (wet nursing) ABSOLUTELY CONTRAINDICATED",
  ],
  "Low-Resource Settings\n(WHO AFASS criteria not met)",
  [
    "Exclusive breastfeeding (EBF) for 6 months if formula not safe, accessible, feasible",
    "Mother must be on ART with good adherence",
    "Infant must receive NVP prophylaxis throughout breastfeeding",
    "Abrupt weaning at 6 months (transition to complementary food)",
    "Any breast disease (mastitis, cracked nipples) — temporarily avoid BF",
    "Monitor infant VL/HIV DNA PCR regularly during breastfeeding",
    { text: "WHO 2022: Countries may support breastfeeding if maternal VL undetectable — context specific", bold: true, color: C.teal },
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 19 — INFANT HIV TESTING
// ════════════════════════════════════════════════════════════════
tableSlide(19, "Infant HIV Testing Algorithm",
  "Early Infant Diagnosis (EID) — India PPTCT Programme",
  ["Age / Timing", "Test", "Interpretation & Action"],
  [
    ["Birth (if high-risk exposure)", "HIV DNA PCR (qualitative DBS)", "Positive: begin infant ART; Negative: repeat at 6 wks"],
    ["6 Weeks of Age", "HIV DNA PCR — STANDARD for all HIV-exposed infants", "Negative: continue prophylaxis; Positive: confirmatory VL + start ART"],
    ["3 Months", "HIV DNA PCR (if 6-wk equivocal or high-risk)", "Allows detection of intrapartum infections"],
    ["9 Months", "HIV DNA PCR (breastfeeding infant)", "Post-weaning testing if recently weaned"],
    ["18 Months", "HIV Ab test (ELISA/Rapid)", "Maternal antibody waned; Positive = infant infected"],
    ["Any time — symptomatic", "HIV DNA PCR + CD4 + clinical assessment", "Do not wait for scheduled testing if symptomatic"],
    ["Post-breastfeeding weaning (+6 wks)", "HIV DNA PCR", "Detect late postnatal acquisition during breastfeeding"],
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 20 — OI PROPHYLAXIS & VACCINATIONS
// ════════════════════════════════════════════════════════════════
twoColSlide(20, "OI Prophylaxis & Vaccinations in Pregnancy", "Immune Compromise Requires Special Attention",
  "Opportunistic Infection Prophylaxis",
  [
    { text: "Cotrimoxazole (TMP-SMX) prophylaxis:", bold: true, color: C.navy },
    { text: "  → CD4 < 200 cells/µL: start PCP prophylaxis", indent: 20, size: 13 },
    { text: "  → Avoid in 1st trimester (folate antagonism) + near term (neonatal jaundice)", indent: 20, size: 13, color: C.red },
    { text: "TB Prophylaxis (IPT — Isoniazid Preventive Therapy):", bold: true, color: C.navy },
    { text: "  → After active TB excluded; INH 300 mg + B6 25 mg daily × 6 months", indent: 20, size: 13 },
    { text: "  → Can be given in pregnancy if high TB burden setting", indent: 20, size: 13 },
    "Fluconazole: recurrent oropharyngeal candidiasis (avoid systemic in 1st trimester)",
    "Azithromycin: MAC prophylaxis if CD4 < 50 (consult specialist)",
  ],
  "Vaccinations in HIV+ Pregnancy",
  [
    { text: "SAFE & RECOMMENDED (inactivated):", bold: true, color: C.teal },
    { text: "  → Influenza (inactivated) — annual", indent: 20, size: 13, color: C.teal },
    { text: "  → COVID-19 mRNA vaccine — recommended", indent: 20, size: 13, color: C.teal },
    { text: "  → Tdap (28–32 wks) — whooping cough protection", indent: 20, size: 13, color: C.teal },
    { text: "  → Hepatitis B (if non-immune)", indent: 20, size: 13, color: C.teal },
    { text: "  → Pneumococcal (if CD4 < 200)", indent: 20, size: 13, color: C.teal },
    { text: "CONTRAINDICATED (live vaccines):", bold: true, color: C.red },
    { text: "  → BCG, MMR, Varicella, Yellow fever (if CD4 < 200)", indent: 20, size: 13, color: C.red },
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 21 — PrEP & PREVENTION
// ════════════════════════════════════════════════════════════════
bulletSlide(21, "PrEP & HIV Prevention in Pregnancy", "For Seronegative Pregnant Women at Risk",
  [
    { text: "Pre-Exposure Prophylaxis (PrEP) — SAFE in pregnancy and breastfeeding (WHO 2022)", bold: true, color: C.teal },
    "Indications in pregnancy: serodiscordant couple (partner VL detectable), high-risk sexual behaviour, IDU",
    { text: "TDF/FTC (Truvada®): Daily oral PrEP — preferred regimen in pregnancy", bold: false, color: C.navy },
    { text: "  → Start ≥ 7 days before exposure; continue ≥ 7 days after last exposure", indent: 20, size: 14 },
    { text: "  → Efficacy requires > 6–7 tablets/week adherence", indent: 20, size: 14 },
    { text: "CAB-LA (Long-acting injectable Cabotegravir): NOT recommended in pregnancy as standard PrEP", bold: true, color: C.red },
    { text: "  → Risk: pharmacokinetic tail → functional monotherapy → INSTI resistance if HIV acquired", indent: 20, size: 14, color: C.red },
    "Post-Exposure Prophylaxis (PEP): TDF/FTC + RAL or DTG × 28 days (within 72 hrs of exposure)",
    "Serodiscordant couple ANC: offer HIV testing to male partner; PrEP + condoms if partner VL detectable",
    "U = U (Undetectable = Untransmittable): partner on ART with VL < 200 has effectively zero sexual transmission risk",
    { text: "WHO 2024: 94% of countries have incorporated PrEP into national guidelines", bold: false, color: C.teal },
  ], "WHO Global HIV Report 2024 | IAS-USA Panel Guidelines 2025 (PMID 39616604)");

// ════════════════════════════════════════════════════════════════
//  SLIDE 22 — TB-HIV CO-INFECTION IN PREGNANCY
// ════════════════════════════════════════════════════════════════
twoColSlide(22, "TB-HIV Co-Infection in Pregnancy", "The Deadly Duo — Requires Specialist Co-Management",
  "Diagnosis",
  [
    { text: "Screen ALL HIV+ pregnant women for TB at every visit", bold: true, color: C.red },
    "Symptom screen: cough > 2 wks, fever, night sweats, weight loss",
    "Sputum GeneXpert MTB/RIF if symptomatic",
    "CXR: perform if clinically indicated (shield abdomen)",
    "IGRA (QuantiFERON): preferred over Mantoux in pregnancy",
    "Extrapulmonary TB more common in advanced HIV (CD4 < 200)",
    "Miliary TB & TB meningitis — life-threatening in pregnancy",
  ],
  "Treatment",
  [
    { text: "Start ATT immediately — do NOT wait for ART", bold: true, color: C.teal },
    "Start ART within 2 weeks of ATT initiation (CD4-independent)",
    "Standard RHEZ × 2 months + RH × 4–7 months",
    "Rifampicin interactions: reduces levels of NVP, most PIs",
    { text: "DTG-based ART: double dose DTG 50 mg BD when on Rifampicin", bold: true, color: C.navy },
    "EFV: acceptable alternative with Rifampicin — standard dose",
    "Avoid streptomycin (ototoxicity to fetus)",
    "IRIS risk: monitor closely after ART initiation with active TB",
  ]
);

// ════════════════════════════════════════════════════════════════
//  SLIDE 23 — INDIA PPTCT PROGRAMME
// ════════════════════════════════════════════════════════════════
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  addSlideHeader(slide, "India PPTCT Programme — NACO", "Prevention of Parent-to-Child Transmission of HIV");

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    { title: "Universal Testing", detail: "HIV testing offered to ALL pregnant women at every ANC visit (opt-out)\nFree Rapid HIV test at PHC/CHC/district hospitals", color: C.navy },
    { title: "Free ART", detail: "Free TLE (TDF+3TC+EFV) or TLD (TDF+3TC+DTG) at all ART centres\nOption B+ strategy: lifelong ART for all HIV+ mothers", color: C.teal },
    { title: "Safe Delivery", detail: "Delivery at facility with HIV protocols\nIV ZDV available if VL not suppressed\nCaesarean section if VL > 1000", color: C.red },
    { title: "Infant Formula", detail: "Free formula feed for 6 months for all HIV-exposed infants\nCounsel against breastfeeding if formula safe", color: "#7D3C98" },
    { title: "Early Infant Diagnosis", detail: "Free HIV DNA PCR at 6 weeks at EID centres\nResult via SMS to DAPCU — Dried Blood Spot (DBS)", color: "#1E8449" },
    { title: "Follow-Up", detail: "ICTC + ART centre coordination\nHIV-exposed infant followed to 18 months\nLink to paediatric ART if infected", color: C.textMid },
  ];

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    const y = 1.15 + Math.floor(i / 3) * 1.95;
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      x, y, w: 3.0, h: 0.38,
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    });
  });

  addSlideFooter(slide, 23);
}

// ════════════════════════════════════════════════════════════════
//  SLIDE 24 — RECENT UPDATES 2024–2026 (SUMMARY)
// ════════════════════════════════════════════════════════════════
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    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri", valign: "middle", margin: 0,
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  const updates = [
    { year: "2025", update: "BIC/TAF/FTC (Bictarvy) → NOW PREFERRED ART in pregnancy (US Perinatal Guidelines June 2025)", source: "US DHHS" },
    { year: "2025", update: "ABC-containing regimens reclassified to Alternative due to updated cardiovascular risk data", source: "US DHHS" },
    { year: "2025", update: "HIV-2 exposed infants: manage same as HIV-1 with HIV-2 active drugs (new explicit recommendation)", source: "US DHHS" },
    { year: "2025", update: "ART should NOT be avoided/withheld in early pregnancy to prevent preterm birth — explicit recommendation", source: "US DHHS" },
    { year: "2025", update: "BHIVA guidelines 2025: comprehensive UK guidance update including infant feeding, PK monitoring, postnatal care", source: "BHIVA" },
    { year: "2024", update: "DTG meta-analysis: no significant increase in congenital anomalies — DTG confirmed safe in all trimesters", source: "Payra et al. Clin Drug Investig" },
    { year: "2024", update: "Dugdale CM et al. (Lancet 2025): maternal VL key predictor — undetectable VL reduces MTCT to near zero", source: "Lancet 2025" },
    { year: "2024", update: "WHO 2024: 94% countries have incorporated PrEP; CAB-LA available; TDF/FTC PrEP safe in pregnancy", source: "WHO" },
    { year: "2025", update: "Antiretroviral Pregnancy Registry: standardised reporting language added to all drug sections", source: "APR" },
  ];

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    const y = 1.0 + i * 0.47;
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      x: 0.25, y, w: 0.65, h: 0.38,
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// ════════════════════════════════════════════════════════════════
//  SLIDE 25 — SUMMARY & KEY TAKE-HOME MESSAGES
// ════════════════════════════════════════════════════════════════
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    { num: "01", msg: "Screen ALL pregnant women for HIV — universal opt-out testing at first ANC visit" },
    { num: "02", msg: "Start ART immediately in ALL HIV+ pregnant women regardless of CD4 count" },
    { num: "03", msg: "2025: BIC/TAF/FTC is now PREFERRED; DTG/TDF/3TC also preferred; ABC regimens are alternative" },
    { num: "04", msg: "Undetectable viral load is the goal — it reduces MTCT to < 1% and transmission to partners" },
    { num: "05", msg: "VL > 1000 at delivery → IV ZDV + elective LSCS at 38 weeks" },
    { num: "06", msg: "All HIV-exposed infants receive ARV prophylaxis; regimen depends on maternal VL" },
    { num: "07", msg: "Avoid breastfeeding where formula is safe, accessible, affordable, sustainable" },
    { num: "08", msg: "HIV DNA PCR at 6 weeks is standard for early infant diagnosis (not HIV antibody)" },
    { num: "09", msg: "ART is NOT stopped postpartum — lifelong treatment for maternal health and future transmission prevention" },
    { num: "10", msg: "U = U: Undetectable = Untransmittable — counsel patients on this empowering evidence" },
  ];

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  addSlideFooter(slide, 25);
}

// ════════════════════════════════════════════════════════════════
//  WRITE FILE
// ════════════════════════════════════════════════════════════════
const outputPath = "/home/daytona/workspace/hiv-pregnancy-ppt/HIV_in_Pregnancy_MBBS_2025.pptx";
pres.writeFile({ fileName: outputPath })
  .then(() => console.log("SUCCESS: " + outputPath))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

cd /home/daytona/workspace/hiv-pregnancy-ppt && node create_ppt.js

ls -lh /home/daytona/workspace/hiv-pregnancy-ppt/HIV_in_Pregnancy_MBBS_2025.pptx