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Recognition and Management of Perinatal HIV

Recognition and Management of Perinatal HIV. Elwyn M. Grimes, M.D.,F.A.C.O.G Cook County Hospital Chicago, Illinois. Adults and children estimated to be living with HIV/AIDS, 12/2000. North Africa & Middle East 400 000. Eastern Europe & Central Asia 700 000. Western Europe 540 000.

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Recognition and Management of Perinatal HIV

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  1. Recognition and Management of Perinatal HIV Elwyn M. Grimes, M.D.,F.A.C.O.G Cook County Hospital Chicago, Illinois

  2. Adults and children estimated to be living with HIV/AIDS, 12/2000 North Africa & Middle East 400 000 Eastern Europe & Central Asia 700 000 Western Europe 540 000 North America 920 000 East Asia & Pacific 640 000 South & South-East Asia 5.8 million Caribbean 390 000 Sub-Saharan Africa 25.3million Latin America 1.4 million Australia & New Zealand 15 000 Total: 36.1 million

  3. AIDS Cases, January 1986 - June 1999, U.S. 25 6,000 20 Number of Cases Percent of Cases 4,000 15 10 2,000 5 0 0 1989 1990 1993 1986 1987 1988 1991 1992 1994 1995 1996 1997 1998 1999 Year of Diagnosis* *Adjusted for reporting delay

  4. AIDS Rates per 100,000 Women Reported in 1999 2.1 * 2.0 * * 1.8 1.7 1.2 1.2 NH 1.3 30.0 1.6 14.8 MA 2.5 3.4 RI 7.2 9.2 1.2 CT 13.0 1.9 1.8 4.6 19.6 NJ 2.0 2.1 5.5 2.1 0.9 14.1 DE 2.5 7.4 5.2 MD 21.0 2.7 3.6 93.4 DC 6.7 5.9 1.5 0.9 4.7 3.0 15.0 Rate per 100,000 <5 6.3 9.1 13.4 _ 7.4 5 9.9 11.0 10+ 23.2 * <5 cases VI 30.1 PR 21.3 1.6 US rate: 9.3 N=10,780 *

  5. AIDS in Women, by ExposureCategory Reported in 1999, United States Sex with men of Sex with other or injection drug user Heterosexual † unspecified risk 11% transmission 29% 40% Other/ not identified* Injection drug use 32% 27% Transfusion recipient 1% *Includes patients whose medical record review is pending; patients who died, were lost to follow-up, or declined interview; and patients with other or undetermined modes of exposure † Includes sex with a bisexual male, a person with hemophilia, a transfusion recipient with HIV infection, or an HIV-infected person with an unspecified risk

  6. US Pediatric AIDS Incidence

  7. HIV Prevalence among Childbearing Women in Chicago: 1989-1997

  8. Perinatal HIV Transmission • Perinatal AIDS cases peaked in 1992; then declined 67% from 1992-97. • AIDS rates/100,000 births declined 69% (22.8 in 1992 to 6.2 in 1996) • HIV-infected women giving birth declined 17% (6990 in 1992 to 5579 in 1996) • Perinatally exposed children receiving ZDV increased from 7% in 1993 to 91% in 1997. Lindegren ML, et al. JAMA 1999;283(6):44531-8

  9. Maternal HIV Quantification and Perinatal Transmission • Transmission Reported at All Levels • Correlation of RNA Levels with T. Risk • No threshold for zero or 100% Transmission • Discordance between Plasma and Genital Tract HIV (Compartmentalization)

  10. Mother-to-child transmission Take home messages ART reduces transmission regardless of setting Multiple factors found to influence rate Increase transmission Decrease transmission Low birth weight ART Prematurity Elective C-sectionHigh maternal VL Lower maternal VLHIV-specific T helper cellsBreast feeding PROM (hourly) Maternal AIDSPossibly ART resistance

  11. ACOG Guidelines For Pregnant Women with HIV • HIV + pregnant women should be offered scheduled cesarean delivery at 38 weeks • Women should be informed of the risks of cesarean delivery, and physicians should consider prophylactic antibiotics • If viral load <1000, cesarean delivery many not offer additional benefit. • Plasma viral load should be monitored every 3 months during pregnancy ACOG Committee Opinion, August 19/99

  12. Ongoing Studies:Cook County Hospital • WITS—WOMEN AND INFANTS TRANSMISSION STUDY • WIHS—WOMEN’S INTERAGENCY HIV STUDY • ACTG—AIDS CLINICAL TRIALS GROUP • MIRIAD

  13. The MIRIAD Project • Mother Infant Rapid Intervention At Delivery • A 5 year, multi-site, CDC-sponsored project • Atlanta, GA • Chicago, IL • Miami, FL • New Orleans, LA • New York City, NY

  14. MIRIAD Study Aims 1) Assess innovative approaches to 24-hour counseling and voluntary rapid HIV testing program among women who present late to care or in labor with unknown HIV status 2) Assess the feasibility of obtaining informed consent during labor or soon after birth 3) Determine barriers to prenatal care and to HIV testing 4) Assess ART givenat labor and delivery or to the neonate 5) Assess adherence to neonatal therapy 6) Determine subsequent receipt of ART and other services, as indicated, for women and their children.

  15. Antiretroviral Treatment Options Scenario #3 (HIV+ women in labor/ no prior therapy) 1) Single dose nevirapine at the onset of labor followed by a single dose of nevirapine for the newborn at 48 hours 2) Oral ZDV and 3TC during labor, followed by one week of oral ZDV/3TC for the newborn; 3) Intrapartum intravenous ZDV followed by six weeks of ZDV for the newborn; 4) Two-dose nevirapine regimen combined with intrapartum intravenous ZDV and six week ZDV for newborn.

  16. Antiretroviral Treatment Options Scenario #4 (Infants born to mothers without ART during pregnancy or intrapartum: The six-week neonatal ZDV component of the ZDV chemoprophylactic regimen should be discussed with the mother and offered for the newborn. ZDV should be initiated as soon as possible after delivery -preferably within 6-12 hours of birth. Some clinicians may choose to use ZDV in combination with other antiretroviral drugs, particularly if the mother is known or suspected to have ZDV-resistant virus.

  17. Background • CORE Center sees one third of pregnant women with HIV in Chicago • Most women enroll during their second or third trimester; a few are seen after they have delivered their infant. • Through coordinated care and research efforts, we’ve learned important information about these women and children, even those seen after the infant is born.

  18. Annual Enrollment of Pregnant and Postpartum Women

  19. Summary • For the past 4 years there have been 1-3 infants born infected in the WCHP. • In 2000, for the first time, there was no HIV transmission to newborns of women in WCHP. • All mother/infant pairs, seen in WCHP, took ZDV and other anti-retrovirals during the perinatal period. • One HIV+ infant was born at CCH in 12/00; mother (2 months in this country) not seen at CORE Center prior to delivery. (?MIRIAD candidate in the future)

  20. Perinatal Transmission 1996-2000 Amy Berrios, Marcia Katz, Linda Powell, Ken Boyer, Kathy Jennings, Dorothy Regok, Helen Cejtin, Sandy Micci, Lucretia Rios, Mardge Cohen, Lashawna Moore, Julie Schmidt, Sheila Cooper, Nikki Mourikes, Janie Sewar Conigan, Jim McAuley, Audrey Stillerman, Renee Flores, Ella Orange,Kim Stieglitz, Kimberly Harris, Renee Pearson, Calvine Thompson

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