1 / 27

What We Know About Perinatal HIV Transmission

What We Know About Perinatal HIV Transmission. François-Xavier Bagnoud Center at UMDNJ. Scope of the Epidemic Among Women and Children. 130,000 AIDS cases in women reported through December 2000 AIDS in women has risen from 7% early in the epidemic to 24% of adult cases today

donar
Download Presentation

What We Know About Perinatal HIV Transmission

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. What We Know About Perinatal HIV Transmission François-Xavier Bagnoud Center at UMDNJ

  2. Scope of the Epidemic Among Women and Children • 130,000 AIDS cases in women reported through December 2000 • AIDS in women has risen from 7% early in the epidemic to 24% of adult cases today • 196 new AIDS cases reported in children in 2000 • 10,000 – 20,000 estimated children living with HIV infection • 300 – 400 babies continue to be born with HIV infection each year in the U.S. François-Xavier Bagnoud Center, UMDNJ, 2003

  3. Scope of the Epidemic Among Women and Children in New Jersey • NJ is 5th in the U.S. in AIDS cases — 49,000 • Women are 28% — highest proportion in U.S. • 91% of pregnant women know their HIV status • ART use in pregnant women rose from 7% in 1993 to 70% in 1999 • Perinatal transmission fell from 21% in ’93 to 5.0% in ‘99 • But . . . 25% of HIV+ pregnant women have no prenatal care François-Xavier Bagnoud Center, UMDNJ, 2003

  4. Perinatal Transmission of HIV • Without antiretroviral drugs during pregnancy, mother-to-child transmission has ranged from 16%–25% in North America and Europe • 21% transmission rate in the U.S. in 1994 before the standard recommendations of zidovudine (ZDV) in pregnancy • In 1995, transmission rate was 11% after the change in practice François-Xavier Bagnoud Center, UMDNJ, 2003

  5. USPHS Guidelines for the Use of Antiretroviral Drugs in Pregnant Women for Maternal Health & Prevention of HIV Transmission • Developed in 1994 in response to ACTG 076 • Working Group reconvened in December 1999 and meets monthly • Updated recommendations available online at HIV/AIDS Treatment Information Service web site (www.hivatis.org) François-Xavier Bagnoud Center, UMDNJ, 2003

  6. Timing of Perinatal HIV Transmission • Cases documented intrauterine, intrapartum, and postpartum by breastfeeding • In utero 25%–40% of cases • Intrapartum 60%–75% of cases • Addition risk with breastfeeding • 14%  risk with established infection • 29%  risk with primary infection • Current evidence suggests most transmission occurs during the intrapartum period François-Xavier Bagnoud Center, UMDNJ, 2003

  7. Breastfeeding and HIV Infection • Women with HIV infection in the U.S. should not breastfeed • Women considering breastfeeding should know their HIV status François-Xavier Bagnoud Center, UMDNJ, 2003

  8. Influences on Perinatal Transmission: Maternal Factors • HIV-1 RNA levels (viral load) • Low CD4 lymphocyte count • Other infections, Hepatitis C, CMV, Bacterial Vaginosis • Maternal injection drug use • Lack of ZDV during pregnancy François-Xavier Bagnoud Center, UMDNJ, 2003

  9. Influences on Perinatal Transmission: Obstetric and Infant Factors • Obstetrical Factors • Length of ruptured membranes/chorioamnionitis • Vaginal delivery • Invasive procedures • Infant Factors • Prematurity François-Xavier Bagnoud Center, UMDNJ, 2003

  10. Maternal Viral Load (VL), ZDV Treatment and the Risk of Perinatal HIV Transmission • Correlation between high maternal VL and transmission • Transmission observed at every VL level, including undetectable levels • No HIV RNA threshold below which there was no risk of transmission • ZDV decreases transmission regardless of HIV RNA level • Recommendation: Initiate maternal ZDV regardless of plasma HIV RNA or CD4 counts François-Xavier Bagnoud Center, UMDNJ, 2003

  11. What have we learned? Interrupting Perinatal HIV Transmission: Study Results

  12. PACTG 076 • A phase III randomized placebo-controlled trial of zidovudine (ZDV) for the prevention of maternal-fetal HIV transmission • Treatment Regimen • Antepartum 100 mg ZDV po 5x day, started at 14 – 34 weeks gestation • IntrapartumDuring labor, 1- hour initial dose 2 mg/kg IV followed by continuous infusion of 1 mg/kg until delivery • Postpartum/Infant Regimen2 mg/kg po q 6 hr for 6 weeks, to start 8 – 12 hours after birth François-Xavier Bagnoud Center, UMDNJ, 2003

  13. Results of PACTG 076 30 This represents a 66% reduction in risk for transmission (P = <0.001) Efficacy was observed in all subgroups 20 22.6% Transmission Rate (%) 10 7.6% Placebo ZDV group François-Xavier Bagnoud Center, UMDNJ, 2003

  14. Follow-up of Uninfected Infants and of Mothers in PACTG 076 • No significant differences in infant growth, development, or immune function in placebo v. ZDV. • No other safety abnormalities have been identified in infants • Follow-up of infants with exposure to nucleoside analogues is ongoing due to the potential for mitochondrial toxicity • In the U.S. no cases of mitochondrial toxicity have been identified • For mothers, no substantial differences in CD4 count, time to progression to AIDS, or death in women who received ZDV compared to those who received placebo François-Xavier Bagnoud Center, UMDNJ, 2003

  15. Reducing Intrapartum HIV Transmission: Studies of Short Course Therapy • Oral ZDV in a non-breastfeeding population (Thailand) from 36 weeks and during labor • Transmission rate: 9.4 % ZDV vs 18.9 % placebo • Petra study – intrapartum/postpartum oral ZDV/3TC in a breast-feeding population (Uganda, S. Africa, Tanzania) • Transmission rate: 10% ZDV/3TC vs 17% placebo • HIVNet 012 – intrapartum/postpartum/neonatal nevirapine (NVP) vs short course/neonatal ZDV in a breast-feeding population (Uganda) • Transmission rate: 12% NVP vs 21% ZDV François-Xavier Bagnoud Center, UMDNJ, 2003

  16. Reducing Intrapartum HIV Transmission:Studies of Short Course ARV Therapy François-Xavier Bagnoud Center, UMDNJ, 2003

  17. Reducing HIV Transmission with Suboptimal Regimens • HIV transmission rates with partial ZDV regimens (New York cohort): • 6.1% with prenatal, intrapartum, and infant ZDV • 10% with only intrapartum ZDV • 9.3% with only infant ZDV started within first 48 hours • 26.6% with no ZDV François-Xavier Bagnoud Center, UMDNJ, 2003

  18. Reducing HIV Transmission with Suboptimal Regimens: The New York Cohort François-Xavier Bagnoud Center, UMDNJ, 2003

  19. Treating Women with HIV Infection in Pregnancy

  20. Goals of Antiretroviral 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 François-Xavier Bagnoud Center, UMDNJ, 2003

  21. Guidelines for Antiretroviral Drugs During Pregnancy • Use optimal ARV for the woman’s health • Add ZDV regimen for reducing perinatal HIV transmission • Discuss preventable risk factors for perinatal transmission • Counsel on cesarean delivery • Support decision-making by woman following discussion of known and unknown benefits and risks • Acceptance or refusal of ARV or ZDV should not result in denial of care or punitive action François-Xavier Bagnoud Center, UMDNJ, 2003

  22. Women without prior antiretroviral therapy: Guidelines for Antiretroviral Drugs in Pregnancy:Clinical Scenario 1 • Recommend: • Standard combination therapy for women with high viral load, low CD4 count • Combination therapy for women with viral load 1,000 regardless of clinical or immunologic status • 3-part ZDV regimen to reduce perinatal transmission for all HIV-infected pregnant women, regardless of antenatal VL • Consider delaying therapy until completion of first trimester • Offer scheduled cesarean delivery for women with viral loads >1000 (based on most recent VL results) François-Xavier Bagnoud Center, UMDNJ, 2003

  23. Clinical Scenario 2: Women currently on antiretroviral therapy: • Discuss benefits and potential risks of her current regimen during pregnancy • Add or substitute ZDV at 14 weeks • Recommend intrapartum and neonatal ZDV • Discontinue teratogenic drugs • Consider continuing or stopping current therapy based on gestational age (<14 weeks) • If therapy is stopped, stop and restart all ARV simultaneously • Resistance testing for suboptimal viral suppression or failure François-Xavier Bagnoud Center, UMDNJ, 2003

  24. Clinical Scenario 3: Women with HIV infection who present in labor with no previous treatment • Discuss benefits of treatment during intrapartum and neonatal period • Four treatment options • Single dose nevirapine for mother at onset of labor followed by single dose of nevirapine for the newborn at age 48–72 hrs • Oral ZDV/3TC for mother during labor followed by one week oral ZDV/3TC to the newborn • Intrapartum IV ZDV followed by six weeks ZDV for the newborn • The two-dose nevirapine regimen as above combined with intrapartum IV ZDV and six week ZDV for the newborn François-Xavier Bagnoud Center, UMDNJ, 2003

  25. Clinical Scenario 4: Infant whose mother did not receive prenatal or intrapartum ZDV • Offer the six-week neonatal ZDV component • Initiate therapy as soon as possible after maternal consent (preferably within 6 – 12 hours of birth) • Begin diagnostic testing of the infant • Refer to pediatric HIV specialist for long-term care François-Xavier Bagnoud Center, UMDNJ, 2003

  26. Cesarean Section to Reduce Perinatal HIV Transmission • Scheduled C/S offers potential benefit to reduce perinatal transmission for pregnant women with VL >1000 • Unknown whether scheduled C/S offers any benefit to women on HAART with low or undetectable VL given the low transmission rate • Complications of C/S similar to HIV uninfected women • Patient’s decision should be respected and honored • No known benefit of C/S if labor has begun François-Xavier Bagnoud Center, UMDNJ, 2003

  27. Postpartum Follow-up of the Woman with HIV Infection • Referral for medical management • Referral for psychosocial care and case management • Refer infant to experienced pediatric HIV providers for follow-up • Educate mom about newborn’s need for • Prophylactic ARV (ZDV x 6 weeks) • Diagnostic testing and follow-up • PCP prophylaxis at 6 wks of age François-Xavier Bagnoud Center, UMDNJ, 2003

More Related