Preventing Parent To Child Transmission Of HIV

1. Preventing Parent To Child Transmission Of HIV

2. Rationale For PPTCT in India • 27 Million pregnancies per year • 108,000 infected pregnancies • Annual cohort of 32,000 infected newborns • 25,000 – 50,000 deaths within 2-5 years 0.4%prevalence 30% transmission

3. Transmission Rates Developed : 14% - 33% Developing : 21% - 43% Variations in risk factors amongst different ethnic population MTC transmission of HIV-2 is low : 1 - 3 % ( lower viral load throughout natural history )

4. Issues Concerning Obstetricians • Testing ( timing ) • Pre-pregnancy management • Management in pregnancy / labor • Preventing transmission / contraception • HIV and the health care worker

5. TODAY, IT’S A NATIONAL PROGRAM

6. Diagnosis of Perinatal Transmissionand it’s Timing • HIV antibodies passively transmitted • Negative, if loss of antibodies by 18 months Virologic Tests (HIV DNA, RNA PCR) • Antepartum infection, if tests +ve within 48 hrs. of delivery • Intrapartum, if test -ve within 48 hrs. but +ve after 1 wk. • Breast feeding, if test -ve between 2-6 mts, but infant later has HIV infection / disease

7. Timing Of Transmission • Antepartum - 30% - 50% • Intrapartum - 50% - 70% • Breast feeding- 14% - 29%

8. Without ARV drugs during pregnancy MTCT varies from 13-39% • Cases documented intrauterine, intrapartum, and postpartum by breastfeeding • In utero 25%–40% of cases • Intrapartum 60%–75% of cases • Additional risk with breastfeeding • 14%  risk with established infection • 29%  risk with primary infection Timing of Perinatal HIV Transmission Current evidence suggests most transmission occurs during the intrapartum period

9. Risk Factors for Transmission • Viral, maternal, obstetrical, foetal, and infant-related factors all influence the risk of MTCT. • The most important risk factor for MTCT is the amount of HIV virus in the mother's blood, known as the viral load. • The risk of transmission to the infant is greatest when the viral load is high — which is often the case with recent HIV infection or advanced HIV/AIDS.

10. Factors Affecting Transmission • Maternal Viral Load • Maternal Immune Status • Background Genital Tract Infections • Lifestyle & Behavioral Factors • Obstetric Factors

11. Strategies to Prevent MTC Transmission • Medical Termination of Pregnancy (MTP) • Antiretrovirals • Identification & Prevention of Risk Factors • Optimizing Obstetric Practices

12. Medical Termination of Pregnancy • Few opt for MTP • Late registrations & identification • Wish to continue pregnancy (social pressures)

13. Guidelines • U.S. - Perinatal HIV Working Group Guidelines • RCOG Guidelines • WHO Guidelines • NACO Recommendations

14. The Four Prong Model for Prevention of Mother to Child HIV Transmission: NACO Prong 1 • Primary Prevention of HIV Infection Among Women of Child Bearing Age and Young People. Prong II • Prevention of Unintended Pregnancy Among HIV Infected Women Prong III • Prevention of HIV Transmission from infected mother to her infant. Prong IV • PPTCT Plus Provide Care and Support for HIV-infected Women and their Families

15. Prevention of Primary HIV Infection Primary prevention strategies include the following components: • Safer and responsible sexual behaviour and practices. • Abstinence, Be faithful, Condom use • Early diagnosis and treatment of STIs can reduce the incidence of HIV in the general population by about 40%. • Make HIV testing and counselling widely available. • Provide suitable counselling for women who are HIV-negative.

16. Prevention of Unintended Pregnancies among Women Infected with HIV Provide • Reproductive health education to encourage them to make informed decisions • Provide safe accessible and effective contraception • Safe, legal and early termination of pregnancy

17. HIV-Related Treatment, Care And Support Services For Women Services for women include the following: • Prevention and treatment of opportunistic infections • ARV treatment • Treatment of symptoms • Palliative care • Nutritional support • Reproductive health care, including family planning and counselling • Psychosocial and community support

18. Antiretrovirals Mode of action • Reduce maternal viral load • Treatment effect is independent of viral load or CD4 counts • Pre-exposure prophylaxis of the fetus • ZDV is metabolized into the active triphosphate within the placenta

19. Antiretrovirals • Long term monotherapy with ZDV (ACTG 076) Antepartum : ZDV 100mg 5 times / day Intrapartum : IV ZDV not available ZDV 300mg 3 hrly till delivery Infant : Syr. ZDV 2mg /kg 4 times/day x 6 wks • Efficacy in preventing transmission – 67%

20. Antiretrovirals • Short term monotherapy with ZDV (Thai) Antepartum (>36wks) ZDV 300mg bd Intrapartum ZDV 300mg 3 hrly till delivery • Efficacy in preventing transmission: without BF – 51% with BF – 37%

21. Advantages Prevention of MTC – 1% Avoids EL CS if viral load < 1000 copies or undetectable Disadvantages Cost Toxicity and drug interactions (DDI & D4T, PI, anti-TB) Adherence / compliance Drug resistance Teratogenesis Specialist care Combination Antiretroviral TherapyHAART-Guidelines to prevent MTC transmission

22. Identification & Prevention of Risk Factors • Improving Nutritional Status • Search & Treat Infection (STDs & Opportunistic) • P/Sexam between 24 to 34 wks. • Tobacco Intervention (dentifrice, smoking)

23. Factors Affecting HIV Transmission During Labor And Delivery • Greater risk of MTCT of HIV during labor and delivery • The HIV is acquired due to swallowing or aspiration of maternal blood or cervical secretions • Microtransfusion due to placental bed massage with uterine contractions • High maternal viral load (new or advanced HIV/AIDS) • Long duration following rupture of membranes often in the form of ARM

24. Factors Affecting HIV Transmission During Labor And Delivery • Acute chorio-amnionitis (resulting from untreated STDs or other infections) • Invasive delivery techniques that increase the baby’s contact with maternal blood e.g., episiotomy, foetal scalp monitoring etc. • First infant in a multiple birth

25. Optimizing Labor Practices AVOID • Early rupture of membrane • Fetal scalp electrode / sampling • Difficult Labor / Instrumental delivery

26. Optimizing Obstetric Practices Elective Cesarean Section • Randomized European Mode of Delivery Trial Lancet 1999, 353: 1035 • Large Meta-analysis of 15 Prospective Cohort studies N Eng J Med 1999; 340: 977 • French Cohort Experience JAMA 1998; 280:55. Elective C.S. (done at 38 wks) confers a 50% reduction in transmission rates as compared to vaginal birth in a non breast fed population

27. Should CS Be Routine NO • Operative Morbidity & Availability • Role of HAART • Maternal HIV 1 RNA levels

28. Intrapartum Intervention Antiretrovirals • Nevirapine ( HIVNET ) Single Dose At onset of labour – 200mg single dose • Infant – Syr. Nevirapine 2mg/kg single dose within 72 hours • Efficacy in preventing transmission with breastfeeding – 47%

29. NVP Prophylaxis • Is absorbed rapidly • Crosses placenta efficiently after single oral dose of 200 mgs. • A long elimination half-life of 40 hours • In infants median half life is 45- 72 hours of elimination of maternal NVP • NVP administered to mother at least two hours before child birth • 2mg per kg single dose NVP suspension for the baby within 72 hours of birth ( Median half life 37- 46 hour )

30. NVP Prophylaxis Benefits of NVP • taken by mouth therefore easier to maintain confidentiality • inexpensive • does not require refrigeration • no significant side effect or drug resistance after single dose

31. Single-dose NVP Plus Standard ZDV to Prevent MTCT in Thailand Women: ZDV prophylaxis in 3rd trimester Infants: 1 wk ZDV + formula feeding Mother-infant pairs n = 1844 Delivery before interim analysis Final as-treated Group B: Single-dose NVP (200 mg to mother) + Placebo (to infant) + ZDVn = 721 Group A: Single-dose NVP to both mother (200 mg) and infant (6 mg) + ZDV n = 724 Group C: Placebo (to mother) + Placebo (to infant) + ZDV n = 399 P = .00026 6.3% 1.1% 2.8% NS 1.9% Lallemant M et al. N Engl J Med 2004; 351: 217-228

32. NACO Protocol for Unregistered Women • Pre-test counselling • Informed written consent • Single HIV rapid test (bed side performed by any HCW) • If positive NVP as prescribed to mother and baby • Fresh sample of mother to be collected and sent for testing to VCTC. • Report to mother with proper post-test counselling • Encourage mother to follow-up with DIC / VCTC • Follow-up of baby upto 18 months.

33. HIV Transmission through Breastfeeding Approx 14% risk of transmission Risk Factors • HIV is present in milk, although viral concentrations are significantly lower than in blood. • The pattern of breastfeeding: • babies who are exclusively breastfed have a lower risk of being infected than those who are mixed fed • Breast pathologies • mastitis • cracked nipples • bloody nipples • other breast infections

34. HIV Transmission through Breastfeeding • Breastfeeding duration • the longer it is continued, the higher the risk of transmission • Maternal viral load: • the risk is believed to double, 30% if a woman becomes infected with HIV for the first time while breastfeeding • Maternal immune status, advanced AIDS • Poor maternal nutritional status • Oral disease in the baby (eg, thrush or sores)

35. Breast Feeding • Recent WHO guidelines • Wherever alternative feeds can be provided the option to breast feed or not should be explained • Individualize depending on education, resources & understanding of safe milk substitute practices • Encourage early weaning, breast milk expression with pasteurization.

36. National HIV Infant - Feeding Protocol • Avoidance of all breastfeeding • Replacement feeding (formula milk, animal milk ) recommended if acceptable, feasible, affordable, sustainable & safe • Mixed feeding is not recommended • Otherwise –exclusive breastfeeding is recommended during first six months of life

37. Postnatal Follow-up Visit • Contraception • Condom use

38. Care And Support Of The Infant And Child Who Are HIV-exposed • Nutritional support • Support the mother’s infant-feeding choice • Provide education on hydration and early reporting of diarrhoea • Monitor for growth and development • Monitor for signs of infection that can alter feeding patterns • Regular follow-up care, especially during the first 2 years of life including immunisations and HIV testing

39. Immunization Children-with known or suspected asymptomatic HIV infection should receive all EPI vaccines according to national schedules. • Adult HIV positive individuals should not receive live bacteria or live virus vaccines (eg- oral polio virus, measles, varicella, mumps, and yellow fever vaccines) • Pneumococcal, hepatitis B, influenza vaccines may be given to HIV positive persons.

40. Pre-pregnancy Management For Discordant Couples and Those Practicing Safe Sex • Transmission is 1 in 500 per sexual act when limiting unprotected intercourse to around ovulation • Sperm washing & IUI • ICSI

41. Partner Involvement in PPTCT • PPTCT efforts should be as comprehensive as possible and acknowledge that both mothers and fathers have an impact on transmission of HIV to the infant • Both partners need to be aware of the importance of safer sex throughout pregnancy and breastfeeding. • Both partners should be tested and counselled for HIV. • Both partners should be made aware of and provided with PMTCT interventions.

42. Take Home Message ANC Visit (Enrollment)  Pre-test group Counseling including partner counseling  Informed Consent for HIV testing ( Opt-out strategy)  ANC Check up and Blood collection  HIV testing by 3 different antigenic principles  Post-test Counseling (infant feeding)  Positive mothers

43. PPTCT FLOW CHART Positive mothers  Counseled for MTP / mode of delivery / Infant feeding / STI / TB / Risk reduction Strategies  Nevirapine prophylaxis to mother during labour  Neonate Monitoring  Nevirapine to the new born (within 72 hrs)  Follow up (PNC OPD, well baby clinic)  HIV testing Baby 18 months  Continuum, Care and Support (ART / OIs, Diet / nutrition, referrals NGO / CBOs)

44. Take Home Message • HIV testing and counselling Identifies women infected with HIV • ARV prophylaxis decreases risk of MTCT by • reducing viral load in mother • preventing the virus from fixing itself in the infant • Optimizing the obstetric practices to decrease viral exposure at birth • avoid prolonged ROM, episiotomy, forceps application, fetal blood sample, fetal electrodes may use various methods of vaginal lavage before and after delivery. • Consider Elective CS at 38 weeks of pregnancy before onset of labor or ROM

45. Take Home Message • Changing life style and dietary habits • Improve nutritional status of mother • Provide vitamin and mineral supplementation • Use of tobacco and other hard drugs to be stopped • Reducing exposure to the virus through breast feeding • WHO recommendation in developed world is not to breast feed but in developing countries, choice of BF can be offered after proper counseling

46. Concept – Dr. Duru Shah • Editors Dr. Sangeeta Agrawal Dr. Reena Wani • Contributors Dr. Kaizad R Damania NACO, MDACS Guidelines

47. We acknowledge the efforts of our : Coordinators : • Dr. Sangeeta Agrawal - Central • Dr. Narendra Malhotra - North • Dr. Hema Divakar - South • Dr. P. C. Mahapatra - East • Dr. Uday Thanawala - West In bringing the FOGSI YOUTH EXPRESS to your city.

48. This Youth Express has been possible through an educational grant from : • Charak Pharma Pvt. Ltd • CIPLA Ltd. • Emcure Pharmaceuticals Ltd • GlaxoSmithKline Pharmaceuticals Limited • Glenmark Pharmaceuticals Ltd. • Metropolis Health Services (India) Pvt.Ltd. • Organon India Ltd • Roche Pharmaceuticals Ltd. • Sandoz Private Limited • USV Limited • Wyeth Limited