1 / 95

HIV / AIDS 2005

HIV / AIDS 2005. Mother To Child Transmission. - Sky R. Blue, MD. Number of people living with HIV/AIDS Total 40 million (34 - 46 million) Adults 37 million (31 - 43 million) Children under 15 years 2.5 million (2.1 - 2.9 million) People newly infected with HIV in 2003

beverlyadams
Télécharger la présentation

HIV / AIDS 2005

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. HIV / AIDS2005 Mother To Child Transmission - Sky R. Blue, MD

  2. Number of people living with HIV/AIDS Total 40 million (34 - 46 million) Adults 37 million (31 - 43 million) Children under 15 years 2.5 million (2.1 - 2.9 million) People newly infected with HIV in 2003 Total 5 million (4.2 - 5.8 million) Adults 4.2 million (3.6 - 4.8 million) Children under 15 years 700 000 (590 000 - 810 000) AIDS deaths in 2003 Total 3 million (2.5 - 3.5 million) Adults 2.5 million (2.1 - 2.9 million) Children under 15 years 500 000 (420 000 - 580 000 HIV - The Numbers

  3. Australia & New Zealand 15,000 Adults and Children Living with HIV/AIDS 2003 Eastern Europe 1 million Western Europe 550,000 N. America 950,000 210,000 21,000 44,000 Asia & Pacific 6.6 million North Africa 500,000 Caribbean 420,000 92,000 1,800,000 53,000 Sub-Saharan Africa 28.5 million Latin America 1.5 million 240,000 3,100,000 5,000 Total: 40 million Data from UNAIDS New Cases

  4. Prevalence 15 – 30 % 5.0 - 15 % 1.0 – 5.0 % 0.5 – 1.0 % 0.1 – 0.5 % 0.0 – 0.1 % Not Available HIV Prevalence Worldwide

  5. Men to Women Ratios • US • 14 : 1 • Haiti • 3 : 1 • Africa • 1 : 1

  6. Estimated Incidence of AIDS, Deaths, and Prevalence by Quarter-Year of Diagnosis/Death, United States, 1985-1999* 25,000 350,000 1993 definition AIDS implementation Deaths 300,000 Prevalence 20,000 250,000 15,000 200,000 Number of Cases/Deaths Prevalence 150,000 10,000 100,000 5,000 50,000 0 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Quarter-Year *Adjusted for reporting delays

  7. Epidemiology • Distribution of AIDS/HIV status1 950K 1000K 280K Undiagnosed 800K 600K 200K HIV+ but not in care 130K HIV+ 400K 200K 340K AIDS

  8. HIV in Idaho – Prevalence HIV AIDS • District 1 50 40 • District 2 32 15 • District 3 60 36 • District 4 214 113 • District 5 48 23 • District 6 44 18 • District 7 26 15 • Total 478 260 738 (As of Dec 2003)

  9. HIV Services Clinic – Family Medicine Residency of Idaho (FMRI) • Gender • Male 78% • Female 22% • Ethnicity • White 79% • Black 5% • Hispanic 14% • Asian 1% • Native Am 1% • Other <1%

  10. HIV Services Clinic - FMRI % AGE

  11. HIV and Pregnancy • AIDS in women has risen from 7% of adult cases early in the epidemic to 27% today • 7,000-10,000 babies are born each year to HIV infected mothers • 2,000-3,000 would be born with HIV • Universal screening and perinatal treatment could reduce this to <500

  12. HIV Testing in Pregnancy • National Recommendations • Universal voluntary testing with patient notification as a routine component of prenatal care • American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Human Immunodeficiency Virus screening: joint statement of the AAP and ACOG. Pediatrics 1999;104:128. • Institute of Medicine. Reducing the odds: preventing perinatal transmission of HIV in the United States. Washington, DC: National Academy Press, 1999

  13. HIV Testing in Pregnancy • CDC (USPHS) recommendations for HIV screening of pregnant women • Prenatal: routine HIV screening for all pregnant women using the “opt out” approach — women will be notified that they will be tested unless they decline • Labor and delivery: routine rapid testing for women whose HIV status is unknown • Postnatal: rapid testing for all infants whose mother’s status is unknown. • MMWR November 15, 2002 • Regulations, laws, & policies about HIV screening of pregnant women vary state to state

  14. Untreated Populations • 15% of women with HIV infection have no prenatal care compared to 2% of all pregnant women (MMWR, 1998) • Risk of HIV infection at least 2- to 4-fold higher among women presenting for delivery without prenatal care E Aaron, CRNP. Presented at Clinical Pathway, August 2002.

  15. Missed Opportunities • Women who do not receive prenatal care • Pregnant women who seek prenatal care erratically • Non-legal residents • Injection drug users • Homeless • Women who receive prenatal care but are not offered testing E Aaron, CRNP. Presented at Clinical Pathway, August 2002.

  16. 3rd Trimester Testing • Retesting in the third trimester, preferably before 36 weeks of gestation, is recommended for women known to be at high risk for acquiring HIV: • who have a history of sexually transmitted diseases, • who exchange sex for money or drugs, • who have multiple sex partners during pregnancy, • who use illicit drugs, • who have sex partner(s) known to be HIV-positive or at high risk • who have signs and symptoms of seroconversion. CDC. Revised US Public Health Service recommendations for human immunodeficiency virus screening of pregnant women. MMWR 2001;50(No. RR-19):59--86.

  17. Rapid Testing at Delivery • High risk of perinatal transmission in women without antenatal care and without HIV counseling and testing • Rapid testing during labor can make it possible to initiate ART prophylaxis and to refer the woman for care • ART prophylaxis should be initiated as soon as possible after a positive rapid HIV test (before confirmatory test results are available)

  18. HIV Antibody Tests • Serum antibody (EIA) • Saliva and urine antibody tests (EIA) • Rapid tests • SUDS (Microfiltration EIA) • Laboratory-based • OraQuick • Point of care • Western blot assay • Confirmatory test

  19. CDC criteria 1 p160, p120 AND p41 CDC criteria 2 p160, p120 OR p41 PLUS p24 p160 p120 p41 p68 p53 p32 p55 p40 p24 p18 Western Blot GAG POL ENV

  20. HIV Direct Tests • Viral Load • Qualitative / quantitative • RNA through bDNA or PCR • p24 antigen tests

  21. HIV care During Pregnancy • Use optimal ART for the woman’s health • Add ZDV to regimen to reduce perinatal HIV transmission • Discuss preventable risk factors • Counsel on cesarean delivery • Support decision-making by woman following discussion of known and unknown benefits and risks • Acceptance or refusal of ART or ZDV should not result in denial of care or punitive action

  22. Pregnancy Effects on HIV • In all women, the absolute CD4 count decreases no matter whether HIV-positive or negative (pregnancy does not make HIV worse) • In HIV-positive women, percentage of CD4 cells should not change and viral load should not change because of pregnancy

  23. Adult Treatment Guidelines Clinical Category CD4+ count HIV RNA Recommendations Any value Any value CD4+ T cells Any value <200/mm3 CD4+ T cells Any value >200/mm3 but <350 /mm3 CD4+ T cells >100,000 >350/mm3 CD4+ T cells <100,000 >350/mm3 Treat Treat Treatment should be offered Most recommend deferring treatment, but some would treat. Defer therapy Symptomatic Asymptomatic, AIDS Asymptomatic Asymptomatic Asymptomatic

  24. Nucleoside / nucleotide analogues (NRTIs) ABC ddI FTC 3TC d4T TDF ddC ZDV/ AZT C – No studies. Concern for hypersensitivity B – Concern for lactic acidosis (do not use w/ d4T) B – No studies. C– Well tolerated. Widely used. C – Concern for lactic acidosis (do not use w/ ddI) B – No studies. Animal reports of bone abnls C – No studies. Teratogenic in animals. C – Well tolerated. The most experience. Antiretroviral Agents - 1

  25. Non-nucleoside RT inhibitors (NNRTIs) DLV EFV NVP C – No studies. D – Teratogenic. 4/142 birth defects. Avoid in 1st trimester C – Well tolerated. Avoid initiating if CD4 >250 cells/mm3. Used as single-dose Rx in labor to prevent perinatal transmission (consider adding ZDV/3TC for 3-7 days to reduce risk of NVP resistance) . Antiretroviral Agents - 2

  26. Protease inhibitors (PIs) APV ATV FPV IDV LP/r NFV RTV SQV TPV C – No studies. Oral solution contraindicated. B – No studies. Concern hyperbilirubinemia C – No studies C– Unboosted: poor blood levels in preg C – No studies B – Registry data shows no incr in birth def B –Not used alone due to GI side effects B – Well tolerated, used boosted C – No studies Antiretroviral Agents - 3

  27. ART in Pregnant Women: NRTIs

  28. ART in Pregnant Women: NRTIs

  29. ART in Pregnant Women: NNRTIs

  30. ART in Pregnant Women: PIs

  31. ART in Pregnant Women: PIs

  32. ART in Pregnant Women: PIs

  33. ART in Pregnant Women: Fusion Inhibitors

  34. NRTI Toxicity • Bone marrow suppression ZDV (AZT) • Anemia(1%- severe, 50%-mild) • Mitochondrial toxicity • Related to inhibition of DNA polymerase  • ddC > ddI > d4T > ZDV > 3TC > ABC > TDF • Peripheral neuropathy(15-35%) • ddC > ddI > d4T • Pancreatitis (6-10%) • ddI > ddC > 3TC • Hypersensitivity rash (3-5%) • Abacavir • Not related to mitochondria

  35. NRTI Toxicity During Pregnancy • Symptoms may be subtle, insidious, and non-specific • Fatigue, nausea, anorexia, abdominal pain, weakness • May be synergistic with maternal changes seen during pregnancy • Overlaps with other complications of pregnancy • Acute fatty liver of pregnancy • HELLP syndrome

  36. Lactic Acidosis • Lactic acidosis is a rare life-threatening complication of antiretroviral therapy • Nucleoside analogue therapy-induced mitochondrial toxicity appears to be the cause of this syndrome • Diagnosis is difficult because symptoms are vague and non-specific • Routine monitoring of lactate levels is not recommended in asymptomatic patients; however, lactate should be measured in patients with unexplained weight loss, nausea, or abdominal pain • Treatment includes discontinuing NRTIs, followed by supportive care measures

  37. Symptoms Nausea and vomiting Abdominal pain Weight loss Malaise Dyspnea/tachypnea Laboratory Findings Increased anion gap Increased lactic acid levels Increased lactate/pyruvate Lactic Acidosis Adapted from: Boxwell DE, Styrt BA. 39th ICAAC, San Francisco, CA, 1999. Abstract 1284.

  38. NNRTI Toxicities • Rash 5-20% • Delavirdine > nevirapine > efavirenz • CNS 5% • Dizziness, vivid dreams, psychiatric • Efavirenz >> nevirapine • Nausea/diarrhea • Any • Liver toxicity 2-5% • Nevirapine (400mg QD > 200mg BID; risk greater if CD4 count before initiation of NVP in women is >250 cells/mm3) • Fetal abnormalities • Efavirenz

  39. PI Toxicities • Lipodystrophy (up to 84%, severe in 12%) • Glucose intolerance (up to 23%) • Dyslipidemia (up to 90%) • Cutaneous changes, e.g., dry skin

  40. Glucose Metabolism • Abnormalities of glucose homeostasis (primarily insulin resistance) are common in patients on ART • Higher incidence in patients receiving PIs • Mechanisms remain unclear at this time • Treatment with insulin-sensitizing agents may be beneficial

  41. Insulin Resistance • Increased insulin levels found • Blood sugars normal • State of compensated insulin resistance

  42. Antiretroviral Pregnancy Registry • Collaborative project managed by PharmaResearch Corporation on behalf of an advisory committee (specialists in OB/GYN, ID, teratology, epidemiology, and CDC and NIH members) and sponsored by: • Abbott Laboratories, Agouron Pharmaceuticals, Inc., Boehringer Ingelheim Company, Bristol-Myers Squibb, Co., Gilead Sciences, Inc., GlaxoSmithKline, F. Hoffmann-LaRoche Ltd., Merck & Co., Inc. and PharmaResearch. • Purpose: To assess safety of ARVs during pregnancy • Telephone: (800) 258-4263 Fax: (800) 800-1052 available at http://www.apregistry.com

  43. Antiretroviral Pregnancy Registry • Through January 31, 2004 there were 5010 voluntarily reported prospective cases  www.apregistry.com

More Related