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Lecture 1

Lecture 1. Human Immunodeficiency Infection HIV Acquired Immunodeficiency Syndrome AIDS/SIDA. HIV/SIDA/AIDS. Have you heard of this What have you heard Do you know anyone who has this What causes this infection Can it be cured. HIV/SIDA/AIDS. Can it be cured

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Lecture 1

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  1. Lecture 1

  2. Human Immunodeficiency Infection HIV Acquired Immunodeficiency Syndrome AIDS/SIDA

  3. HIV/SIDA/AIDS Have you heard of this What have you heard Do you know anyone who has this What causes this infection Can it be cured

  4. HIV/SIDA/AIDS Can it be cured Can this infection be prevented If so how can it be prevented Does everyone who has it have symptoms

  5. HIV and the DRC • 1 of 20 nations-the highest risk HIV/AIDS • Over 1 million infected persons • Estimated infection incidence 2-4% • Treatment rate <5% • Lack of an infrastructure • Lack of health services • Lack testing and prevention strategy • Problems getting the meds to the people • Costs $5/mo and $15 for a CD4 test

  6. HIV and the DRCAntenatal surveillance data Rates of HIV infection in pregnant women • Urban Kisangai (Orientale) 3-9.5% • Mwene Ditu (Kasai Orientale) 6.9 • Matadi (Bas Congo P) 4.3 • Rural Neisu and Buta >5.0

  7. HIV does not come from Being in the same room Hugging Touching Eating together Sharing clothes Shopping or working together Eating at the same table

  8. HIV/SIDA/AIDSPrevention Do not share razors, toothbrushes Condoms are not totally preventive; avoid sex with an infected person Where possible adequate treatment to lessen risk Male circumcision Always wear gloves when touching any body fluids of another

  9. HIV/SIDA/AIDSPrevention In the hospital or any treatment facility All needles, surgical instruments, must be sterilized Be careful handling any blood or bodily fluids Blood to be transfused should be tested if possible Lab has the ability to test blood Lab has the ability to test patients

  10. HIV/SIDA/AIDS Where the test is available,all pregnant women should be tested to prevent MTCT Positive women should receive meds to prevent MTCT Educate on prevention of transmission to partner Discuss breastfeeding options-now can have meds but this is dependent on med accessibility Teach not to chew food then give to children Educate community re stigmatization

  11. What is HIV/AIDS Chronic viral infection- causing progressive immune system deterioration leading to opportunistic infections, cancers, multiple organ system failure, neurologic manifestations and wasting. Two types of virus • HIV-1 most common • HIV-2 West Africa

  12. What is HIV? • Retrovirus leads to AIDS • NO CURE • Prevention-only option • Treatment prolongs quality of life-a chronic disease • Transmitted sexually (most common) & body fluid contact • Pediatric most commonly MTCT

  13. HIV Infection Symptoms • Acute infection-similar to any viral infection • Incubation: 6-8 wks • Symptoms last 3 wks

  14. Symptoms Fever Joint/muscle pain Malaise Sore throat Headache Photophobia Signs Swollen lymph nodes Mucosal ulcers Maculopapular rash Acute HIV Infectionsigns and symptoms

  15. HIV Latent PeriodMonths to Years (10-12) Signs and Symptoms • Generalized lymphadenopathy • Recurrent vaginal yeast infections • Asymptomatic

  16. Candidiasis (oesaphagus,respiratory system) Invasive cervix cancer Severe infections often called opportunistic Protozoa (toxo), viruses (CMV, herpes), bacteria(Tb, MAI), fungi/yeast(PCP,as-pergillus) Extra Pulmonary TB Chronic herpes Any disseminated mycosis Wasting Pneumocystis pneumonia Chronic diarrhea Lymphomas Kaposi’s sarcoma Kidney and heart failure Blindness Encephalitis Meningitis Dementia AIDS/SIDASome manifestations

  17. HIV Diagnosis • Rapid test for HIV antibody usually 2 HIV Monitoring the infection-special lab • HIV RNA levels (viral load) • CD4 counts Additional co-infections • Hepatitis A,B and C • Sex transmitted infections

  18. Other lab tests • CBC, differential • Biochemistries-liver and kidney function, lipid profile, glucose • Hepatitis A, B and C • Cytomegalovirus and Toxoplasmosis antibodies • Syphilis and other STD’s • Cervical cytology

  19. HIV Lab • Virus levels-very high before symptoms, then decline, rise again as disease progresses (months to years) • CD4 count declines with progressive destruction of the immune system (months to years)

  20. HIV/AIDS-SIDATreatment Antiretroviral drugs in combination (HAART) • Virus may become resistant requiring changes • Lifelong adherence to drugs is essential • Aim to obtain a non-detectable viral load and CD4 count >250cells/mm3 • Prevent opportunistic infections • Requires care by HIV specialists

  21. HIV Prevention • Universal precautions • Gloves-handling body fluids • Proper disposal of all body tissues and fluid • Clean blood spills with proper fluids – chlorine solutions • Proper blood bank testing

  22. HIV Prevention • Everyone knowing their infection status • Testing all pregnant women (and their partners and or children if +) prevent MTCT • Decreases risk taking • Monogamy • Safer sex • +/-condom use (at best 70% effective)

  23. Consenting Options • OPT IN • Discuss HIV • Sign consent • Discuss ARV & confirmatory tests • OPT OUT • Routine care-mention all labs being done • Discuss ARV prophylaxis & confirmatory tests if probably infected (first test +) • Sign only if refusal

  24. Lecture 2

  25. Prevention HIV MTCT

  26. HIV in Pregnancy How does virus get to the baby? • Crosses the placenta-maternal blood enters fetal blood • May be in vaginal secretions • Maternal blood present in vaginal secretions during labor

  27. Possible Routes of Transmission In-utero At Birth During Breastfeeding

  28. Timing HIV MTCT • 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 • Most transmission occurs intrapartum

  29. PACTG 076 Trial Targeted 3 Potential Time Points of MTCT Pregnancy Labor and delivery Infant Antepartum Intrapartum Postpartum AZT IV AZT AZT ___________________________________ Result: 67% reduction in MTCT 25.5% placebo arm 8.3% AZT arm

  30. Infant AZT Within 24 Hours Reduced MTCT without Maternal AP/IP AZT AP+IP+PP IP+PP PP<24 hr PP>48 hr No AZT Importance of Infant Pre- +/or Post-Exposure Prophylaxis

  31. MTCT HIV Transmission in the U.S.

  32. Preventing HIV MTCT • Early identification • Test for HIV as early as possible and treat • Pregnancy management • Proper prenatal care • Monitor fetal growth • Decide on mode of delivery • Maternal medical management • Serial labs to follow CBC, glucose, kidney and liver function, viral load and CD4 counts

  33. Preventing HIV MTCT Maternal medical management • Treat all infections • Vaginal, urine, respiratory • Decreases challenges to immune system • Serial labs to follow disease status and effect of HIV meds • CBC, glucose, kidney and liver function, viral load and CD4 counts

  34. Preventing MTCT • Delivery & postpartum management • If undelivered at 40 weeks consider induction • DO NOT rupture membranes if possible • Avoid episiotomy • HIV meds in labor • If breastfeeding continue meds

  35. Preventing MTCT • Neonatal prophylaxis/treatment • Initiate HIV meds as soon as possible after delivery • Notify a pediatric provider of potential HIV infection for care • Ideally get HIV RNA viral load or better DNA viral load at 2-4 wks of age and at 12 weeks if not BF* • BF then same 6-12 weeks after all exposure to breast milk stops • Infant should be tested if abnormal growth and development *breastfeeding

  36. Maternal HIV-1 RNA levels Low CD4 count Other infections(hepatitis C, CMV, bacterial vaginosis) Maternal injection drug use Lack of ARV during pregnancy Obstetric Length of ruptured membranes?? chorioamnionitis Vaginal delivery Invasive procedures Infant Prematurity Factors Influencing MTCT

  37. Lecture 3 ANTIRETROVIRAL DRUGS IN PREGNANCY

  38. Antiretroviral Drugs in Pregnancy • Viral Load (VL) affects rate of MTCT • Although rare, transmission can occur despite a non-detectable (ND) VL and adequate therapy • Combination drugs better than single • Adherence to drug is essential

  39. Delivery VL & MTCT

  40. Potent regimens lower MTCT Women & Infants Transmission Study, 1990-1999

  41. Antiretroviral Therapy in Pregnancy

  42. ARV in Pregnancy ROLE • Reduce perinatal transmission • Improve maternal health

  43. Classification of ARV Drugs All are inhibitors of viral action • Nucleoside reverse transcriptase -NRTI • Non-nucleoside NNRTI • Protease PI • Integrase Inhibitor • Entry Inhibitor

  44. Effects of ARV in Pregnancy • Pregnant woman • Fetus • Newborn

  45. ARV and Birth Defects • Rate same as in the general population not taking ARV’s 1.5-3% • EFV has a small but increased risk of neural tube defects • Ideally initiation avoided in the first trimester

  46. ARV concerns • Multi drug resistance • Lactic acidosis (ddl + d4T you are unlikely to use these) • Efavirenz • Gestational DM (protease inhibitors) • May affect other drugs due to interference with enzyme activity

  47. Use optimal ARV for the woman’s health • Consider potential fetal/infant impact • Discuss preventable risk factors for MTCT • Support decision-making by the woman following discussion of known and unknown benefits and risks • Acceptance or refusal of ARV should not result in denial of care or punitive action Guidelines for ART in Pregnancy

  48. Lecture 4 WHO HIV/AIDS Guidelines

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