Yes Alabama, We Still Have Perinatal HIV Transmission

1. Yes Alabama, We Still Have Perinatal HIV Transmission 3 Cases In The Past Year 2011

2. Goals and objectives • How to test all pregnant women for HIV . • How to preventing HIV transmission from mother to child • How to treat HIV exposed infants

3. DIAGNOSING HIV • Adults and children older than 2 years old • HIV ELISA-repeatedly reactive • HIV WESTERN BLOT-Positive • Positive tests tells that one has antibodies to HIV Virus

4. ELISA • ELISA-Tests for antibodies • If the specimen does not react to the EIA [ENZYME IMMUNOASSAY] it is reported as negative • If it is reactive- a second EIA is done on the same sample-if it is also reactive –it is reported as repeatedly reactive • CONFIRMATORY TEST WESTERN BLOT • WESTERN BLOT TEST is the confirmatory test • Western blot looks for the HIV Virus Antigen Bands • The test must have 2 of the HIV Virus Bands to be reactive

5. REACTIVE TEST REPEATEDLY REACTIVE ELISA POSITIVE WESTERN BLOT 2 OR MORE BANDS ARE PRESENT • INDETERMINATE • REPEATERLY REACTIVE ELISA • ONLY A SINGLE BAND BY WESTERN BLOT

6. CAUSES OF INDETERMINATE WESTERN BLOT • NO SEROCONVERSION • Advanced HIV with <Titers of p24 • HIV2—Common in WEST AFRICA • HIV subtype O , NON-CLADE B • Autoibodies due to collagen-vascular or auto-immune disease • Cross-reactive alloantibodies from pregnancy,blood transfusions or organ transplants • Receipt of HIV Vaccine • Child losing it mother HIV antibodies

7. HIV TESTING • HIV Virus causes lymphocyte count to go down • CD4 [T lymphocyte] is the main target of the HIV virus • HIV testing looks for immunsuppression • HIV causes antibodies to be created by attaching antigens to CD4 cells • HVI RNA PCR and HIV DNA PCR measure the amount of virus that is present in the blood

8. CHILDREN LESS THAN 2 YEARS OLD • Children born to HIV Positive mothers will test positive to their mother’s antibodies[at time of birth] • They are HIV exposed but not always infected with the HIV Virus Usually the antibodies are gone by age 18 months

9. HIV Polymerase Chain Reaction • HIV DNA PCR • HIV RNA PCR • Measures the amount of Viral Replication • HIV DNA PCR the amount of viral replication present or not • HIV RNA PCR measure to amount of viral replication

10. Natural History of HIV Infection • Viral Transmission • Primary HIV Infection: Acute retroviral Syndrome [2-4 weeks] • Seroconversion [95.5% within 6 months] • Early asymptomatic HIV infection [5-8 years] • Early symptomatic HIV Infection

11. How Infants Become Infected • IN Utero before Delivery • At birth during Delivery • Infected after birth by Breast Feeding • Studies Demonstrate that Children diagnosed less than 1 year and an AIDS diagnosis do not survive as long as those who are diagnosis later

12. HIV Positive Mothers • Opt-out HIV Testing, they will not know that they are HIV + if they are not tested • Risk Assessment : Don’t use it to decide who test • Offer HIV specialty Perinatal Care including Antiretrovirals • Rapid Testing in Labor and Delivery if HIV status is not known or recent STD

13. How to Prevent Perinatal Transmission? • 1. Prevent Women from Becoming HIV Infected!! • 2. Offer All Pregnant Women at the Perinatal Medical Visits HIV Testing • 3. Opt Out testing • 4. Educated Women to be Aware of HIV Infection Risk • 5. Rapid HIV Testing if unknown at L&D

14. Goals of ARV Therapy • To prolong life and improve quality of life • To suppress HIV to below the limits of detection or as low as possible, for as long as possible • To preserve or restore immune function

15. RAPID TESTING • Oral quick=Rapid ELISA testing in 10 to 30 minutes • Oral Quick can be done on children as young as 13 years of age • Can be done by finger stick or oral swab • Positive test needs to be confirmed

16. Case One • Mother thought she was going thru Menopause. • She had not had any menstrual periods in about 6 months. • She goes to the GYN and found that not only was she pregnant she was also HIV positive. • Start on HIV Antiretroviral at 32 weeks.

17. Case Two • Mom got into OB early around 8 weeks. HIV OPT-OUT testing was negative. • Around week 26 mom had STD and was treated • At L&D, Mom had rapid HIV test which was positive. • Mom delivered vaginally no AZT • Baby tested HIV Positive in the hospital

18. Case Three • Mom lived in rural Alabama • No transportation to Obstetrical care • Mom goes into labor called ambulance and delivered in the ambulance. • Mom tested positive for HIV at the Hospital

19. What do these Sentinel Cases have in common ? • Lack of repeat HIV testing • Lack of education in the Medical community • Lack of transportation • Lack of knowledge in the general population

20. How to prevent further Cases • Communication: • ADPH website on HIV and pregancy • Availability of HIV Information: aidsifo.nih.gov/guild lines • Public awareness • Test all patients

21. Postpartum ManagementInfant Antiretroviral Prophylaxis (Last updated:9/14/2011) • Panel’s Recommendations:The 6-week neonatal component of the zidovudine chemoprophylaxis regimen is recommended for all HIV-exposed neonates to reduce perinatal transmission of HIV (AI). • Zidovudine should be initiated as close to the time of birth as possible, preferably within 6–12 hours of delivery (AII). • The 6-week zidovudine prophylaxis regimen is recommended at gestational age-appropriate doses; zidovudine should be dosed differently for premature infants less than 35 weeks than for infants at least 35 weeks of age (see Zidovudine Dosing and Table 8) (AII).

22. In the United States, the use of antiretroviral (ARV) drugs other than zidovudine cannot be recommended in premature infants because of lack of dosing and safety data (BIII). • The use of intrapartum/neonatal zidovudine is recommended regardless of maternal history of zidovudine resistance (BIII).

23. Infants born to HIV-infected women who have not received antepartum ARV drugs • should receive prophylaxis with a combination ARV drug regimen, begun as soon after birth as possible (AI). • A randomized, controlled trial has shown that a 2 drug regimen of zidovudine given for 6 weeks combined with three doses of nevirapine in the first week of life (at birth, 48 hours later, and 96 hours after the second dose) is as effective as but less toxic than a 3 drug regimen of zidovudine, nelfinavir and lamivudine. •  The 2-drug regimen is preferred due to lower toxicity and because nelfinavir powder is no longer available in the United States.  (see General Considerations for Choice of Infant Prophylaxis  and Table 9) (AI).

24. Table 8.  Recommended Intrapartum Maternal and Neonatal Zidovudine Dosing for Prevention of Mother to Child Transmission of HIV • Maternal IntrapartumZidovudine (ZDV)DosingDuration ZDV 2 mg per kg body weight intravenously over 1 hour, followed by continuous infusion of 1 mg per kg body weight per hour Onset of labor until delivery of infant

25. NeonatalZidovudine (ZDV)DosingDuration • ZDV ≥35 weeks gestation:4 mg per kg body weight per dose given orally twice daily, started as soon after birth as possible and preferably within 6-12 hours of delivery (or, if unable to tolerate oral agents, 1.5 mg per kg body weight per dose intravenously, beginning within 6–12 hours of delivery, then every 6 hours) Birth through 6 weeks

26. ZDV <35 to ≥30 weeks gestation: • 2 mg per kg body weight per dose given orally (or 1.5 mg per kg body weight per dose intravenously), started as soon after birth as possible and preferably within 6-12 hours of delivery, then every 12 hours, advanced to every 8 hours at age 2 weeks Birth through 6 weeks

27. ZDV <30 weeks gestation: • 2 mg per kg body weight per dose given orally (or 1.5 mg/kg/dose intravenously) started as soon after birth as possible and preferably within 6-12 hours of delivery, then every 12 hours, advanced to every 8 hours at 4 weeks of age Birth through 6 weeks

28. General Considerations for Choice of Infant Prophylaxis • Infants born to mothers who have received standard antepartum and intrapartum ARV prophylaxis and have undetectable viral loads are at very low risk of HIV transmission. • However, the risk of transmission is increased when maternal viral load at delivery is high or maternal antepartum and/or intrapartum prophylaxis was not received. Most experts feel that the potential benefit of combining zidovudine infant prophylaxis with additional • ARV drugs may exceed the risk of multiple drug exposure to infants born to:    a. mothers who received antepartum and intrapartum ARV drugs but who had suboptimal viral suppression at delivery, particularly if delivery was vaginal;    b. mothers who received only intrapartum ARV drugs;    c. mothers who received no antepartum or intrapartum ARV drugs; and    d. mothers with known ARV drug-resistant virus.

29. All pregnant women who are HIV positive or who test HIV positive should be referred to • an HIV specialist • An infant that is born to mother who has a positive HIV test should be referred to an HIV specialist for children for evaluation

30. The Family Clinic/ UAB @ Children’s Hospital of Alabama Barbara Corley, CRNP 205-939-9400 DR. Marsha Sturdevant 205-939-9400 Department of OB/GYN UAB School of Medicine Maternal Fetal Medicine Physician on call 205-934-mist Gail Williams, OBCC, RN 205-934-2170 MAO: Dr. Dill 1-334-280-3388( Montgomery) MAO Dothan: 334-836-0830 St. George’s Clinic Cooper Green Hospital Jane Mobley, MD 205-930-3287 1917 Clinic UAB Truus H Delfos-Broner CNM 205-934-6684 Davis Clinic 256-536-4700 Mary E Marr Family Clinic /UAB Montgomery Lucia Robinson 1 888 467 0765 The Family Clinic

31. The National Perinatal HIV Hotline (1-888-448-8765) • The National Perinatal HIV Hotline is a federally funded service providing free clinical consultation to providers caring for HIV-infected pregnant women and their infants.