Prevention of Mother to Child Transmission (PMTCT) of HIV

1. Prevention of Mother to Child Transmission (PMTCT) of HIV HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives By the end of this session, participants should be able to: • Describe modes of mother to child transmission (MTCT) of HIV • Explain the risk factors for MTCT • Describe ways to prevent MTCT • Explain use of ARVs in pregnancy and for PMTCT

3. Overview: HIV in Women (1) • Globally, 15.9 million adult women living with HIV • 65% of PLHIV in sub-Saharan Africa are women • 43% of PLHIV in Caribbean are women • Proportion of women living with HIV in Latin America, Asia and Eastern Europe is increasing

4. Overview: HIV in Women (2) Percent of adults living with HIV who are female (1990-2007) WHO and CDC. Prevention of mother-to-child transmission of HIV Generic Training Package, Draft. January 2008.

5. Percentage of Pregnant Women Receiving an HIV Test, 2005, 2008, 2009 Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector by WHO, UNICEF, UNAIDS, 2010 17%

6. Percentage of HIV + Pregnant Women Receiving ARVs for PMTCT 2005, 2008, 2009 Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector by WHO, UNICEF, UNAIDS, 2010 32%

7. Mother to Child Transmission (MTCT) in Vietnam • National Sentinel Surveillance Data: • HIV prevalence in Vietnam 0.5% • HIV-1 prevalence in antenatal women 0.4% (0-1.9%) • 1.5-2 million births per year • 6000-7000 babies exposed to HIV at birth

8. Pathogenesis and Risk Factors for HIV MTCT

9. Question: What are the three main times that a mother can transmit HIV to her infant?

10. MTCT Overview (1) MTCT can occur during: • Pregnancy (5-10%) • Labor and delivery (10-20%) • Breastfeeding (10-15%) Without intervention, the overall MTCT rate is 25-40%

11. 10-20% 5-10% 10-15% Pregnancy Breast feeding Delivery MTCT Overview (2)

12. Pathogenesis: HIV Transmission During Pregnancy • HIV can cross from mother's blood through placenta's membrane to fetus • Thinning of membrane during later months of gestation facilitates HIV crossing over • CD4 cells containing HIV virus can also infiltrate through placenta to fetus

13. Pathogenesis: HIV TransmissionDuring Labor/Delivery • Factors facilitating transmission: • Uterine contractions and bleeding • Vaginal and cervical excoriations, ulcerative STDs  bleeding • Fetal injury or excoriations  bleeding due to episiotomy, forceps or vacuum • Baby swallows vaginal fluids containing HIV

14. Pathogenesis: HIV TransmissionDuring Breastfeeding • Transmission risk during breastfeeding depends on: • Use of safer breastfeeding practices • avoidance of mixed feeding • Duration of breastfeeding:

15. Group Brainstorm: What are Some Risk Factors for MTCT?

16. MTCT Risk Factors (1) Antepartum • Advanced maternal HIV disease • High viral load in mothers • MTCT < 1% if maternal viral load < 1000 • Viral load > 35,000 – higher in utero transmission • Viral load > 10,000 - higher intrapartum transmission

17. MTCT Risk Factors (2) Intrapartum • Prolonged rupture of membrane > 4 hours • Chorioamnionitis • Vaginal delivery compared to caesarean section when viral load > 1000 • Invasive procedures • scalp electrodes, etc

18. MTCT Risk Factors (3) Postpartum • Breastfeeding, risk is higher with: • Long duration • Mixed feeding in first 6 months • Breast infection • Infant with oral lesions • Pre-term, low birth weight infants

19. MTCT Risk Factors (4) • Other • STDs, especially ulcerative • Illicit drug use • Nutritional status

20. PMTCT Interventions

21. Small Group Activity: What are Some Ways to Prevent Mother to Child Transmission?

22. PMTCT Strategies Timely PMTCT interventions save babies

23. The Use of Caesarean Sections to Reduce MTCT • A scheduled C-section at 38 weeks decreases risk of transmission by approximately 50% • However, surgical risks may outweigh potential benefits in areas where this procedure is not performed often • Not recommended unless obstetrically indicated

24. Antiretroviral Therapy in Pregnancy and PMTCT

25. ARV in Pregnancy

26. Triple ART For Pregnant Women

27. What Are The Criteria For Starting Triple ART In A Pregnant Woman in Vietnam? The criteria to start a woman on ARV treatment are the same for pregnant and non-pregnant women

28. Criteria for ART Initiation in Pregnant Women • CD4 ≤ 350 cells/mm³ irrespective of clinical stage • Clinical stage 3 or 4 irrespective of CD4 cell count Modification and Supplement to the Guidelines for Diagnosis and Treatment of HIV/AIDS, MOH November 2011

29. ARV Drugs Used in Pregnancy

30. ART Regimens Recommended in Pregnancy Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, 2009. AZT + 3TC + NVP

31. Reminder: NVP Hypersensitivity • Most common side effects are rash and hepatic adverse events • Risk of symptomatic rash with hepatic toxicity is 9.8 times more common in women with CD4 > 250 • Unknown whether risk is increased in pregnant women, though cases have been reported

32. ARVs that Should be Avoided in Pregnancy

33. PMTCT Regimens in Vietnam

34. Viral Load and the Risk of MTCT • High maternal viral load is a major risk factor for MTCT of HIV • This supports the idea that the risk of transmission is most related to the baby’s overall exposure to virus • Therefore, reducing maternal viral load by ARVs is an effective way to prevent MTCT

35. PMTCT Regimen A: Mother

36. PMTCT Regimen A: Infant • A single dose of NVP 6 mg, immediately after birth PLUS • AZT4mg/kg twice daily for 4 weeks

37. PMTCT Regimen B: Mother

38. PMTCT Regimen B: Infant • AZT4mg/kg twice daily for 4 weeks

39. Triple ART in PMTCT Triple ARV treatment, if available, may be safely started any time after the first trimester Benefits: • Lowers VL most effectively in mother • Reduces transmission to < 2% • Decreases risk of viral resistance Downsides: • More expensive • Higher pill burden • More monitoring required

40. Single-Dose Nevirapineat Delivery Benefits • Inexpensive • Easy to implement • Effective for women who present late to care • Transmission rate reduced from 30% to 12% Downsides • Less effective than other regimens • Risk of NNRTI resistance

41. ARV Treatment in Pregnancy: Some Scenarios

42. Scenario 1 Nga has been taking ARVs for the past 6 months, and recently found out that she is pregnant. What is the appropriate course of action in this scenario?

43. Scenario 1: Action First, review her ARV regimen, then use chart below to determine course:

44. Scenario 2 Trang is pregnant and HIV positive. She is eligible for ARVs, but has not yet started to take them. What is the appropriate course of action in this scenario?

45. Scenario 2: Action: Start ART • *Contraindications to NVP: CD4 > 250 cells/mm3, allergy to NVP, or history of NVP hepatotoxicity

46. Scenario 3 • Lan Anh is pregnant and HIV positive, but is not yet eligible for ARVs. What is the appropriate course of action in this scenario?

47. Scenario 3: Answer • Follow PMTCT protocol • Prescribe ARVs for PMTCT

48. Antenatal Care Assess HIV status Mother needs ART Mother does not need ART Intrapartum AZT + 3TC + single dose NVP Antepartum AZT from 14 weeks Post partum AZT + 3TC for 7 days For newborn AZT-3TC-NVP Single dose NVP immediately Followed by AZT 4 weeks ARVs in Pregnancy: Summary

49. Key Points • Increasing number of women in Vietnam with HIV; more babies potentially exposed • MTCT can occur during: • Pregnancy • Labor and delivery • Breastfeeding • PMTCT strategies include: • HIV counseling and testing • ART • Avoid breastfeeding

50. Thank you Questions?