Download HIV IN PREGNANCY: AN UPDATE

HIV In Mothers and
Children
What Is HIV/AIDS?
• Acquired immunodeficiency syndrome (AIDS) is caused
by the human immunodeficiency virus (HIV).
• HIV attacks and destroys white blood cells, causing a
defect in the body’s immune system.
2
What Is HIV/AIDS?
• The immune system of an HIV-infected person becomes
so weakened that it cannot protect itself from serious
infections. When this happens, the person clinically has
AIDS.
• AIDS may manifest as early as 2 years or as late as 10
years after infection with HIV.
3
Number of People with
HIV/AIDS by Region
North America
890,000
Caribbean
330,000
Latin
America
1.4 million
Source: UNAIDS/WHO 1998.
Western Europe
500,000
North Africa &
Middle East
210,000
Sub-Saharan
Africa
22.5 million
Eastern Europe &
Central Asia
270,000
East Asia
& Pacific
560,000
South and
South East Asia
6.7 million
Australia and New Zealand
12,000
4
HIV Transmission Through Sexual Contact
• Of every 100 HIV infected adults, 75-85 have been
infected through unprotected intercourse
– 70% of these infections are from heterosexual intercourse
• STDs, especially ulcerative lesions in genitalia, increase
risk of transmission
Source: UNAIDS/WHO 1996.
5
Modes of HIV Transmission
• Sexual intercourse
• Accidental exposure to blood/blood products (e.g.,
blood transfusions, shared needles, contaminated
instruments)
• Mother to child during:
– pregnancy
– birth
– breastfeeding
6
Women and HIV
Social Risk Factors
– Illiteracy
– Lack of awareness of preventive measures
Biological risk factors
– Twice as easy for women to contract HIV from men
– Physiology of women (e.g., menstruation, intercourse)
– Pregnancy-associated conditions (e.g., anemia, menorrhagia and
hemorrhage) increase the need for blood transfusion
7
HIV and Contraception
• Contraception with protection
– Male condom (latex and vinyl)
– Female condom
– Nonoxynol-9 (antiviral spermicidal cream)1
– Diaphragm1
• Methods appropriate for use by women with HIV. They should
use a condom for their partner’s protection.
– Hormonals (COCs, Implants, PICs)
– Voluntary sterilization
1Partial
protection if used without condom
8
Effect of AIDS on Pregnancy
•
•
•
•
•
•
•
Infertility
Repeated abortions
Prematurity
Intrauterine growth retardation
Stillbirths
Congenital abnormalities
Embryopathies
9
HIV Transmission from Mother to Infant
• Antenatal
– In utero by transplacental passage
• Intranatal
– Exposure to maternal blood and vaginal secretions during labor
and delivery
• Postnatal
– Postpartum through breastfeeding
Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998.
10
HIV Transmission from Mother to Infant
• 25-35% of all infants born to HIV-infected women in
developing countries become infected
• 90% of HIV-infected infants and children were infected by
mother
Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998.
11
• approximately 600,000 HIV-infected infants
are born every year–at least 1,600 every
day–in resource-constrained countries.
• Transmission occurs during pregnancy,
labor and delivery, and breastfeeding.
• The rate of mother to child transmission has
been reduced to less than 5 percent
among the limited number of HIV-infected
women in developed countries.
• high rates are largely due to
the lack of access to:
–HIV voluntary counseling and
testing
– replacement feeding
–selective caesarean section
–antiretroviral drug therapy
HIV Transmission
HIV cannot be transmitted by:
– Casual person to person contact at home or work or in social or
public places
– Food, air, water
– Insect/mosquito bites
– Coughing, sneezing, spitting
– Shaking hands, touching, dry kissing or hugging
– Swimming pools, toilets, etc.
14
AIDS and Infants
• Symptoms generally develop by 6 months of age
– Diarrhea
– Failure to thrive
• Most of these children die before their second birthday
• Children born to HIV-infected parents are likely to become
orphans
15
Reducing pediatric HIV infection
and disease involves three
stages:
• preventing HIV infection among women of
childbearing age
• preventing unwanted pregnancy among
HIV-positive women
• preventing mother to child transmission
during pregnancy, labor and delivery, and
breastfeeding
BENEFITS TO HIV TESTING
• EARLY COUNSELING AND
TREATMENT OF HIV INFECTION
• ABILITY TO MAKE DECISIONS
REGARDING PREGNANCY
• IMPLEMENTATION OF STRATEGIES
TO ATTEMPT TO PREVENT
TRANSMISSION TO FETUS
WHO SHOULD WE
SCREEN?
• ALL PREGNANT WOMEN
• TARGETED TESTING FAILS TO
IDENTIFY A SUBSTANTIAL
PROPORTION OF HIV POSITIVE
WOMEN
Anti-Retroviral Based Prevention Strategies
• zidovudine (AZT) administered to the
mother from 14 weeks of gestation and
to the child during the first seven days
after birth, reduced the risk of mother to
child transmission among nonbreastfeeding mothers by two-thirds.
• Two similar studies conducted in Côte
d’Ivoire and Burkina Faso among
breastfeeding mothers demonstrated a
37 percent reduction in mother to child
transmission.
Anti-Retroviral Based Prevention Strategies
• A study in Uganda demonstrated a 47
percent reduction in mother to child
transmission following the
administration of a single dose of
nevirapine to the mother at onset of
labor and to the baby within 72 hours
after birth.
• The combination of AZT and lamivudine
in a short-course regimen also has been
shown to reduce mother to child
transmission.
Protecting Health Care Workers During Labor
and Delivery
• Precautions during labor:
– Protection from blood and amniotic fluids
– Protection from sharp instruments
• Resuscitation of baby:
– No mouth to mouth suction
– No mouth to mouth breathing
• Precautions following labor:
– Proper disinfection of instruments
– Proper disposal of placenta and other items
21
PRETEST COUNSELING
• TAKE RISK HISTORY AND COUNCIL
REGARDING RISK REDUCTION
• DISCUSS REASONS FOR TEST
• PROVIDE INFORMATION TO WOMEN
REGARDING TESTING & ILLNESS
• RISKS & BENEFITS OF TESTING
• CONFIDENTIALITY OF RESULTS
• ASSESS WINDOW PERIOD
• PERSON HAS RIGHT TO REFUSE
TESTING
POST-TEST COUNSELING
• HIV RESULTS SHOULD BE GIVEN IN
PERSON
• ASSESS PATIENT’S UNDERSTANDING
• ENCOURAGE PATIENT TO EXPRESS
FEELINGS AND ASK QUESTIONS
• NEGATIVE AND INDETERMINATE
RESULTS: DISCUSS NEED FOR REPEAT
TESTING
POSITIVE RESULT
•
•
•
•
IDENTIFY IMMEDIATE CONCERNS
IDENTIFY SUPPORTS
EFFECT OF HIV ON PREGNANCY
RISK OF TRANSMISSION TO FETUS
DURING PREGNANCY, L&D, BF
• MEASURES TO DECREASE HIV
TRANSMISSION
CONCLUSIONS
• ALL PREGNANT WOMEN SHOULD BE
OFFERRED HIV TESTING
• PRE- & POST- TEST COUNSELING FOR
ALL PREGNANT WOMEN
• TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED
ANTENATAL CARE
INTRODUCTION
• MULTIDISCIPLINARY TEAM
APPROACH
• MEDICAL NEEDS
• SOCIAL AND PSYCHOLOGICAL
NEEDS
ANTENATAL CARE
• SIMILAR TO CARE FOR HIV NEGATIVE
WOMEN
• PREGNANCY NOT HIGH RISK
• SAME NUMBER OF ANTENATAL VISITS
• AVOID INVASIVE ANTENATAL TESTS OR
PROCEDURES
FIRST VISIT
• PATIENT HISTORY
•
•
•
•
•
•
•
DATES OF 1ST POSITIVE HIV TEST
HIV RISK FACTORS
HIV CARE AT TIME OF CONCEPTION
SEROLOGIC STATUS OF PARTNER
OTHER STD’S
OPPORTUNISTIC INFECTIONS
DRUG HISTORY
FIRST VISIT
• INVESTIGATIONS
• CBC & DIFFERENTIAL
• LYTES, GLUCOSE, RFT’S, LFT’S, LIVER
ENZYMES
• CD4+ COUNT, CD8 COUNT, CD4/CD8
• VIRAL LOAD
• SEROLOGY FOR HEP A, B, C, SYPHILIS,
RUBELLA, TOXO, CMV
• TB SKIN TEST
FOLLOW UP VISITS
• STANDARD OBSTETRICAL ROUTINE
• INCREASE SURVEILLANCE ONLY IF
WARRANTED
• LABS EVERY 3 MONTHS
• CD4+ COUNT
• VIRAL LOAD
• SEROLOGY FOR TOXOPLASMOSIS AND
SYPHILIS
OPPORTUNISTIC
INFECTIONS
• PROPHYLAXIS SHOULD BE
OFFERED IN PREGNANCY FOR THE
FOLLOWING
•
•
•
•
•
•
PNEUMOCYSTIS CARINII PNEUMONIA
TOXOPLASMOSIS
TUBERCULOSIS
MYCOBACTERIUM AVIUM COMPLEX
VARICELLA ZOSTER
HEPATITIS A, B
CONCLUSION
• HIV IN PREGNANCY SHOULD BE
MANAGED BY MULTIDISCIPLINARY
TEAM
• ANTENATAL CARE IS SIMILAR TO
THAT OF HIV POSITIVE WOMEN
• PREGNANCY NOT CONSIDERED
HIGH RISK SIMPLY BY VIRTUE OF
HIV INFECTION
ANTIRETROVIRAL USE
ANTEPARTUM
ANTIRETROVIRAL USE
• GOALS:
– CONTROL DISEASE IN MOTHER
– REDUCE PERINATAL TRANSMISSION
• VERY LITTLE DATA AVAILABLE ON
EFFECTS IN PREGNANCY
• MOST DATA ASSESSES ZIDOVUDINE
• LITTLE DATA ON OTHER DRUGS
CONCLUSIONS
• ZIDOVUDINE REDUCES PERINATAL
TRANSMISSION IN WOMEN AT
DIFFERENT STAGES OF DISEASE
• LONG AS WELL AS SHORTER
REGIMENS EFFECTIVE
• STILL EFFECTIVE IN
BREASTFEEDING POPULATIONS
• USE OF OTHER ANTIRETROVIRALS
IN COMBINATION WITH ZDV
PROMISING, STILL
IN UTERO
EXPOSURE
IN UTERO EXPOSURE
Drug
NRTI’s
Teratogenicity
In animals
(rodents)
Lamivudine Not
teratogenic
Stavudine
Not
teratogenic
Didanosine Not
teratogenic
Zalcitabine Hydrocephalu
s
Abacavir
Skeletal
Carcinogenicity FDA
in animals
Pregnancy
Category
C
Liver and
C
urinary tumours
Not
B
carcinogenic
C
C
IN UTERO EXPOSURE
Drug
PI’s
Teratogenicity in
Animals
Ritonavir
Slight incr. in
cryptorchidism
Non Teratogenic
Effects
B
Saquinav Not teratogenic
ir
Indinavir
Incr.
supranumery &
cervical ribs
Nelfinavir Not teratogenic
FDA
Pregnancy
Category
B
Increased
hyperbilirubinemia
in monkeys neonatal
C
B
ANTIRETROVIRAL
THERAPY DURING LABOR &
DELIVERY
IV ZIDOVUDINE
• ZDV LOADING DOSE AT ONSET OF
LABOR 2MG/KG OVER 1 HR
• CONTINUOUS INFUSION WHILE IN
LABOR 1MG/KG/HR
• INCREASING EVIDENCE THAT MOST
PERINATAL TRANSMISSION
OCCURS NEAR TIME OF OR DURING
DELIVERY
• REDUCTION OF PERINATAL
TRANSMISSION DUE TO SYSTEMIC
ANTIRETROVIRAL DRUG LEVELS IN
NEONATE AT TIME OF DELIVERY
IV ZIDOVUDINE
• ZDV READILY CROSSES PLACENTA
• INITIAL IV DOSE RESULTS IN
VIRUCIDAL LEVELS IN MOM &
INFANT
• CONTINUOUS INFUSION ENSURES
STABLE DRUG LEVELS IN INFANT
DURING BIRTH
ORAL ZIDOVUDINE
• IF IV ZDV NOT AVAILABLE, ORAL ZDV
MAY BE USED INTRAPARTUM
• ZDV 600MG PO @ ONSET OF LABOR
• 300MG PO Q3H IN LABOR
BANGKOK, LANCET 1999
• RANDOMIZED PLACEBO
CONTROLLED
• ZDV 300MG PO BID FROM 36WKS GA
UNTIL ONSET OF LABOR
• 300MG PO Q3H WHILE IN LABOR
• ALL WOMEN ADVISED NOT TO
BREASTFEED
• TRANSMISSION RATES: 9.4% IN RX
GROUP; 18.9% IN CONTROL GROUP
ABIDJAN, LANCET 1999
• SIMILAR TRIAL TO BANGKOK, BUT IN
BREASTFEEDING WOMEN
ZDV
PLACEBO
EFFICACY
6 MONTHS
16.5%
26.1%
37%
4.5 YEARS
21%
31%
30%
COTE D’IVOIRE & BURKINA
FASO, LANCET 1999
• PLACEBO VS ZDV STARTED @ 36-38
WKS GA
• 300MG PO DAILY
• 600MG PO AT ONSET OF LABOR
• 300MG PO BID UNTIL 7 DAYS PP
• >85% OF INFANTS BREASTFED
>3MOS
• 18% VS 27.5 % TRANSMISSION @
6MOS (38% EFFICACY)
• RESULTS SHOW SHORT-COURSE
PO ZDV SAFE & EFFECTIVE IN ING
RISK OF MOTHER-TO-CHILD
TRANSMISSION
• PREVENTION RATES NOT AS HIGH
AS WITH IV ZDV
ORAL NEVIRAPINE
• NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITOR
• VERY LONG HALF-LIFE
• RAPID DEV’T OF DRUG RESISTANCE
HIVNET 012 STUDY
GUAY ET AL - 1999
• 13626  RANDOMIZED - NVP VS ZDV
• NVP REGIMEN
• 200MG PO AT ONSET OF LABOR
• 2MG/KG PO DOSE TO BABY 72HR
DEL’Y
• ZDV REGIMEN
• 600MG PO AT ONSET OF LABOR
• 300MG PO Q3H DURING LABOR
• 4MG/KG BID x7 DAYS TO INFANTS
HIVNET 012 - RESULTS
3 DAYS
6-8 WKS
14-16 WKS
ZDV
10.4%
21.3%
25.1%
NVP
8.2%
11.9%
13.1%
SO WHAT?
• EFFICACY OF SHORT-COURSE NVP
47% GREATER THAN SHORT
COURSE ZDV
• CURRENTLY SHORT-COURSE PO
NVP NOT COMPARED TO IV ZDV
FOR TRANSMISSION PREVENTION
CONCLUSIONS
• DURING LABOR - ZDV 2MG/KG IV
LOADING DOSE, THEN 1MG/KG/HR
• IF IV ZDV NOT AVAILABLE CONSIDER
PO REGIMEN
• MAY CONSIDER ADDITION OF
NVP 200MG PO TO IV ZDV @ ONSET
OF LABOR
OBSTETRICAL
PRACTICE
OBSTETRICAL PRACTICE
• 70 % OF HIV TRANSMISSION
OCCURS INTRAPARTUM.
• THE GOAL OF OBSTETRICAL
MANAGEMENT OF THE HIV PATIENT
IS TO AVOID THOSE PRACTICES
THAT INCREASE RISK OF
TRANSMISSION.
OBSTETRICAL PRACTICE
RUPTURE OF MEMBRANES
LANDESMAN ET AL., 1996
• RUPTURED MEMBRANES ONE OF
MANY VARIABLES EXAMINED
• 281 MOTHER-CHILD PAIRS WITH
MEMBRANES RUPTURED LESS
THAN 4 HOURS
• 206 MOTHER-CHILD PAIRS WITH
MEMBRANES RUPTURED MORE
THAN 4 HOURS
RUPTURE OF MEMBRANES
LANDESMAN ET AL., 1996
25
20
15
less than 4 h
greater than 4 h
10
5
0
% Infants Infected
OBSTETRICAL PRACTICE
MODE OF DELIVERY - VAGINAL
• ARTIFICIAL RUPTURE OF MEMBRANES
SHOULD BE AVOIDED
• RUPTURE OF MEMBRANES PAST 4
HOURS SHOULD BE AVOIDED
• FETAL SCALP SAMPLING AND THE USE
OF SCALP ELECTRODES SHOULD BE
AVOIDED
MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
• RANDOMIZED CLINICAL TRIAL
• 370 MOTHER-CHILD PAIRS
ANALYZED
• 203 DELIVERED BY C-S
• 167 DELIVERED VAGINALLY
MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
12
10
8
C-S
Vag.
6
4
2
0
% INFANTS INFECTED
MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
• 203 C-S PERFORMED
• 165 WERE PERFORMED
ELECTIVELY
• 31 WERE PERFORMED
EMERGENTLY
MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
9
8
7
6
5
4
3
2
1
0
Elective
Emergency
% Infected Infants
MODE OF DELIVERY: META-ANALYSIS
THE INTERNATIONAL PERINATAL HIV
GROUP, APRIL 1999
• 15 PROSPECTIVE COHORT STUDIES
• 8533 MOTHER-CHILD PAIRS
• REDUCTION OF TRANSMISSION 50% (OR
0.43, 95% CI, 0.33 – 0.56) WITH ELECTIVE
C-S VS. OTHER MODES OF DELIVERY
• REDUCTION OF TRANSMISSION 87% (OR
0.13, 95% CI, 0.09 – 0.19) WITH ELECTIVE
C-S & PACTG 076
MODE OF DELIVERY – CAESAREAN
SECTION
• HIV INFECTED WOMEN SHOULD BE
COUNSELLED ABOUT ELECTIVE C-S
• VERTICAL TRANSMISSION IS REDUCED TO 2%
WITH PACTG 076 THERAPY AND ELECTIVE C-S
• WOMEN WITH HIGH VIRAL LOADS MAY BENEFIT
MOST FROM C-S
• TO AVOID SROM & ONSET OF LABOUR, ELECTIVE
C-S IS PERFORMED AT 38 WEEKS
• AFTER SROM OR ONSET OF LABOUR C-S IS
LESS PROTECTIVE
• TO AVOID C-S MORBIDITY, ANTIBIOTIC
PROPHYLAXIS SHOULD BE CONSIDERED
VIRAL LOAD
HIV IN PREGNANCY – VIRAL LOAD
WOMEN AND INFANTS TRANSMISSION STUDY (WITS): GARCIA ET
AL., 1999
HIV Viral Load
(Copies per mL)
Less than 1,000
Number of HIV
Transmissions
0 of 57
1,000 – 10,000
32 of 193
10,001 – 50,000
39 of 183
50,001 – 100,000
17 of 54
Greater than
100,000
26 of 64
HIV IN PREGNANCY – VIRAL LOAD
WOMEN AND INFANTS TRANSMISSION STUDY (WITS): GARCIA ET
AL., 1999
45
40
35
30
less than 1,000
1,001-10,000
10,001-50,000
50,001-100,000
more than 100,000
25
20
15
10
5
0
% INFANTS INFECTED
BREASTFEEDING IN HIV
POSITIVE WOMEN
INTRODUCTION
• HIV DNA PRESENT IN BREAST MILK
• HIV TRANSMISSION CAN OCCUR
THROUGH BREASTFEEDING
• BREASTFEEDING IS AN
INDEPENDENT RISK FACTOR FOR
HIV TRANSMISSION
EVIDENCE TO SUPPORT
TRANSMISSION
• ISOLATION OF HIV-1 FROM
CELLULAR & NON-CELLULAR
FRACTIONS OF BREAST MILK
• CASE REPORTS OF INFECTED
CHILDREN BREASTFED BY
MOTHERS WHO ACQUIRED HIV
POSTPARTUM
EVIDENCE TO SUPPORT
TRANSMISSION
• DOCUMENTATION OF OTHER
RETROVIRUSES TRANSMITTED
THROUGH BREAST MILK
• CASE REPORTS OF BREAST FED
CHILDREN WHO WERE INITIALLY
HIV NEGATIVE BUT SEROCONVERTED
DURING BREASTFEEDING
POLICIES
• AVOIDANCE OF BREASTFEEDING IS
CONTROVERSIAL AND DEPENDS ON
INTERNAL MILIEU
• DEVELOPING COUNTRIES VS
INDUSTRIALIZED COUNTRIES
POLICIES
• UNAIDS REVISED STATEMENT 1998:
WOMEN SHOULD BE OFFERED HIV
COUNSELING AND TESTING, BE
INFORMED OF RISKS AND BENEFITS
OF BREASTFEEDING IF THE
MOTHER IS HIV POSITIVE, AND
SHOULD MAKE A DECISION THAT
TAKES INTO ACCOUNT THE
INDIVIDUAL &FAMILY SITUATIONS
MECHANISM OF
TRANSMISSION
• EXACT MECHANISM OF
TRANSMISSION THROUGH BREAST
MILK STILL NOT WELL
UNDERSTOOD
• INFECTION VIA CELL-FREE HIV IN
BREAST MILK OR VIA HIV-INFECTED
CELLS
• SUSCEPTIBILITY OF IMMATURE
NEONATAL GI TRACT TO VIRUS
• GI TRACT MUCOSAL DAMAGE
DURATION OF
BREASTFEEDING
• STUDIES -  IN TRANSMISSION WITH
INCREASING DURATION OF
BREASTFEEDING
MALAWI, JAMA 1999
• CUMULATIVE INFECTION RISK
WHILE BREASTFEEDING
•
•
•
•
•
3.5% AT END OF 5 MONTHS
7.0% AT END OF 11 MONTHS
8.9% AT END OF 17 MONTHS
10.3% AT END OF 23 MONTHS
NO FURTHER TRANSMISSION AFTER
BREASTFEEDING STOPPED
MULTICENTER STUDY,
LANCET 1998
• CUMULATIVE INFECTION RISK
WHILE BREASTFEEDING
•
•
•
•
•
•
0.7% AT END OF 6 MONTHS
0.95% AT END OF 9 MONTHS
2.5% AT END OF 12 MONTHS
6.3% AT END OF 18 MONTHS
7.4% AT END OF 24 MONTHS
9.2% AT END OF 36 MONTHS
DURATION OF
BREASTFEEDING
• ? EARLY WEANING POLICY
• PROBLEMS WITH EARLY WEANING
• ADVERSE NEONATAL EFFECTS
• COLOSTRUM HIGHLY INFECTIOUS
EXCLUSIVITY OF
BRESTFEEDING
• STUDIES - INFANTS EXCLUSIVELY
BREAST FED AT LOWER RISK OF
ACQUIRING HIV THAN THOSE FED
WITH OTHER TYPES OF MILK, TEA,
OR JUICE WHILE BEING BREAST
FED
BRAZIL STUDY, 1998
• CHILDREN FED WITH OTHER TYPES
OF MILK WHILE BEING BREASTFED
WERE AT 2.2-FOLD GREATER RISK
OF HIV INFECTION THAN THOSE
EXCLUSIVELY BREASTFED
• CHILDREN FED WITH TEA OR FRUIT
JUICE WHLE BEING BREASTFED
WERE AT 2.6-FOLD GREATER RISK
OF INFECTION
DURBAN (SOUTH AFRICA),
LANCET 1999
• 3 GROUPS OF CHILDREN - NEVER
BREASTFED, EXCLUSIVELY
BREASTFED, MIXED FEEDING
• NO SIGNIFICANT DIFFERENCE IN
TRANSMISSION BETWEEN NEVER
AND EXCLUSIVELY BREASTFED
GROUPS
• SIGNIFICANTLY INCREASED RISK
OF TRANSMISSION FOR MIXED
INTERPRETATION
• IMMUNE FACTORS IN BREAST MILK
• GROWTH FACTORS IN BREAST MILK
• MUCOSAL DAMAGE WITH MIXED
FEEDING
MATERNAL FACTORS
• CRACKED NIPPLES
• BLEEDING NIPPLES
• PARITY
CONCLUSION
• PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION
STILL NOT WELL UNDERSTOOD
• WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
• WOMEN WHO BREASTFEED
SHOULD BE INFORMED THAT
TRANSMISSION CAN OCCUR
SUMMARY
HIV SCREENING
• ALL PREGNANT WOMEN SHOULD
BE OFFERRED HIV TESTING
• PRE- & POST- TEST COUNSELING
FOR ALL PREGNANT WOMEN
• TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED
ANTENATAL CARE
• HIV IN PREGNANCY REQUIRES
MULTIDISCIPLINARY APPROACH
• ANTENATAL CARE IS SIMILAR TO THAT OF
HIV -VE WOMEN
• PREGNANCY NOT HIGH RISK
• AVOID INVASIVE PROCEDURES
• MONITOR CD4+ AND VIRAL LOAD AT
LEAST EVERY 3 MONTHS IF ABLE TO
PROVIDE ANTIRETROVIRAL THERAPY
ANTIRETROVIRAL USE
• Zidovudine reduces perinatal
transmission in women at different
stages of disease
• long (ante, peri, and postnatal) as well
as shorter regimens effective
• still effective in breastfeeding
populations
• Use of other antiretrovirals in
combination with ZDV promising, still
investigational
INTRAPARTUM
ANTIRETROVIRAL
THERAPY
• DURING LABOR - ZDV 2MG/KG IV
LOADING DOSE, THEN 1MG/KG/HR
• IF IV ZDV NOT AVAILABLE CONSIDER
PO REGIMEN
• MAY CONSIDER ADDITION OF
NVP 200MG PO TO IV ZDV @ ONSET
OF LABOR
BREASTFEEDING
• PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION
STILL NOT WELL UNDERSTOOD
• WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
• WOMEN WHO BREASTFEED
SHOULD BE INFORMED THAT
TRANSMISSION CAN OCCUR