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HIV In Mothers and Children

HIV In Mothers and Children

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HIV In Mothers and Children

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  1. HIV In Mothers and Children

  2. 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.

  3. 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.

  4. Number of People with HIV/AIDS by Region Western Europe 500,000 Eastern Europe & Central Asia 270,000 North America 890,000 East Asia & Pacific 560,000 North Africa & Middle East 210,000 Caribbean 330,000 South and South East Asia 6.7 million Sub-Saharan Africa 22.5 million Latin America 1.4 million Australia and New Zealand 12,000 Source: UNAIDS/WHO 1998.

  5. 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, increaserisk of transmission Source: UNAIDS/WHO 1996.

  6. 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

  7. 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

  8. 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

  9. Effect of AIDS on Pregnancy • Infertility • Repeated abortions • Prematurity • Intrauterine growth retardation • Stillbirths • Congenital abnormalities • Embryopathies

  10. 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.

  11. 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.

  12. 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.

  13. high rates are largely due to the lack of access to: • HIV voluntary counseling and testing • replacement feeding • selective caesarean section • antiretroviral drug therapy

  14. 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.

  15. 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

  16. 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

  17. 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

  18. WHO SHOULD WE SCREEN? • ALL PREGNANT WOMEN • TARGETED TESTING FAILS TO IDENTIFY A SUBSTANTIAL PROPORTION OF HIV POSITIVE WOMEN

  19. 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 non-breastfeeding 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.

  20. 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.

  21. 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

  22. 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

  23. 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

  24. 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

  25. ANTENATAL CARE

  26. INTRODUCTION • MULTIDISCIPLINARY TEAM APPROACH • MEDICAL NEEDS • SOCIAL AND PSYCHOLOGICAL NEEDS

  27. ANTENATAL CARE • SIMILAR TO CARE FOR HIV NEGATIVE WOMEN • PREGNANCY NOT HIGH RISK • SAME NUMBER OF ANTENATAL VISITS • AVOID INVASIVE ANTENATAL TESTS OR PROCEDURES

  28. 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

  29. 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

  30. FOLLOW UP VISITS • STANDARD OBSTETRICAL ROUTINE • INCREASE SURVEILLANCE ONLY IF WARRANTED • LABS EVERY 3 MONTHS • CD4+ COUNT • VIRAL LOAD • SEROLOGY FOR TOXOPLASMOSIS AND SYPHILIS

  31. OPPORTUNISTIC INFECTIONS • PROPHYLAXIS SHOULD BE OFFERED IN PREGNANCY FOR THE FOLLOWING • PNEUMOCYSTIS CARINII PNEUMONIA • TOXOPLASMOSIS • TUBERCULOSIS • MYCOBACTERIUM AVIUM COMPLEX • VARICELLA ZOSTER • HEPATITIS A, B

  32. 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

  33. ANTIRETROVIRAL USE

  34. 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

  35. 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 INVESTIGATIONAL

  36. IN UTERO EXPOSURE

  37. Drug NRTI’s Teratogenicity In animals (rodents) Carcinogenicity in animals FDA Pregnancy Category Lamivudine Not teratogenic C Stavudine Not teratogenic Liver and urinary tumours C Didanosine Not teratogenic Not carcinogenic B Zalcitabine Hydrocephalus C Abacavir Skeletal C IN UTERO EXPOSURE

  38. Drug PI’s Teratogenicity in Animals Non Teratogenic Effects FDA Pregnancy Category Ritonavir Slight incr. in cryptorchidism B Saquinavir Not teratogenic B Indinavir Incr. supranumery & cervical ribs Increased hyperbilirubinemia in monkeys -neonatal C Nelfinavir Not teratogenic B IN UTERO EXPOSURE

  39. ANTIRETROVIRAL THERAPY DURING LABOR & DELIVERY

  40. IV ZIDOVUDINE • ZDV LOADING DOSE AT ONSET OF LABOR 2MG/KG OVER 1 HR • CONTINUOUS INFUSION WHILE IN LABOR 1MG/KG/HR

  41. 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

  42. 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

  43. ORAL ZIDOVUDINE • IF IV ZDV NOT AVAILABLE, ORAL ZDV MAY BE USED INTRAPARTUM • ZDV 600MG PO @ ONSET OF LABOR • 300MG PO Q3H IN LABOR

  44. 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

  45. ABIDJAN, LANCET 1999 • SIMILAR TRIAL TO BANGKOK, BUT IN BREASTFEEDING WOMEN

  46. 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)

  47. 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

  48. ORAL NEVIRAPINE • NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR • VERY LONG HALF-LIFE • RAPID DEV’T OF DRUG RESISTANCE

  49. 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