HIV and Pregnancy: Prevention of Mother-to-Child Transmission

1. HIV and Pregnancy: Prevention of Mother-to-Child Transmission Advances in Maternal and Neonatal Health

2. Session Objectives • To discuss best practice for antenatal, intrapartum and postpartum care of the HIV-positive mother to reduce mother-to-child transmission • To review the evidence supporting these practices HIV and Pregnancy

3. HIV-Related Counseling Issues During Pregnancy • Educate/counsel regarding HIV and pregnancy before pregnancy: • Impact of HIV on pregnancy and pregnancy on HIV • Maternal health • Long-term health of mother and care for children • Perinatal transmission • Use of antiretrovirals and other drugs in pregnancy HIV and Pregnancy

4. Pregnancy Effects on HIV • In all women, the absolute CD4 count decreases no matter whether HIV-positive or negative (pregnancy does not make HIV worse) • In HIV-positive women, percentage of CD4 cells should not change and viral load should not change because of pregnancy HIV and Pregnancy

5. Adverse Pregnancy Outcomes and Relationship to HIV Infection HIV and Pregnancy Anderson 2001.

6. Adverse Pregnancy Outcomes and Relationship to HIV Infection (continued) HIV and Pregnancy Anderson 2001.

7. Mother-to-Child Transmission • 25–35% of HIV positive pregnant mothers will pass HIV to their newborns • In the absence of breastfeeding: • 30% of transmission in utero • 70% of transmission during the delivery • Meta-analysis showed 14% transmission with breastfeeding and 29% transmission with acute maternal HIV infection or recent seroconversion DeCock et al 2000; Dunn et al 1992; WHO/UNAIDS 1999. HIV and Pregnancy

8. Viral load (HIV-RNA level) Genital tract viral load CD4 cell count Clinical stage of HIV Unprotected sex with multiple partners Smoking cigarettes Substance abuse Vitamin A deficiency STDs and other coinfections Antiretroviral agents Preterm delivery Placental disruption Invasive fetal monitoring Duration of membrane rupture Vaginal delivery vs. cesarean section Breastfeeding Risk Factors for Mother-to-Child Transmission HIV and Pregnancy Anderson 2001.

9. Interventions to Reduce Mother-to-Child Transmission • HIV testing in pregnancy • Antenatal care • Antiretroviral agents • Obstetric interventions • Avoid amniotomy • Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood sampling • Restrict episiotomy • Elective cesarean section • Remember infection prevention practices • Newborn feeding: Breastmilk vs. formula HIV and Pregnancy

10. HIV Testing during Pregnancy • Advantages: • Possible treatment of mother • Reduce risk of mother-to-child transmission • Future family planning issues • Precautions against further spread • If negative, advise about HIV prevention Counseling is important! HIV and Pregnancy

11. Antenatal Care • Most HIV-infected women will be asymptomatic • Watch for signs/symptoms of AIDS and pregnancy-related complications • Unless complication develops, no need to increase number of visits • Treat STDs and other coinfections • Counsel against unprotected intercourse • Avoid invasive procedures and external cephalic version • Give antiretroviral agents, if available • Counsel about nutrition HIV and Pregnancy

12. Antiretrovirals • Zidovudine (ZDV): • Long course • Short course • Nevirapine • ZDV/lamivudine (ZDV/3TC) HIV and Pregnancy

13. ZDV Perinatal Transmission Prophylaxis Regimen: ACTG 076 Trial HIV and Pregnancy Anderson 2000.

14. Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy HIV and Pregnancy Anderson 2001.

15. Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy (cont’d.) HIV and Pregnancy Anderson 2001.

16. Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy (cont’d.) Anderson 2001. HIV and Pregnancy

17. Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with No Prior Antiretroviral Therapy (cont’d.) HIV and Pregnancy Anderson 2001.

18. Obstetric Procedures Because of increased fetal exposure to infected maternal blood and secretions, increased transmission may come from: • Amniotomy • Fetal scalp electrode/sampling • Forceps/vacuum extractor • Episiotomy • Vaginal tears HIV and Pregnancy

19. Delivery: Cesarean vs. Vaginal Birth • Risk of mother-to-child transmission increased 2% each hour after membranes have been ruptured • Cesarean section before labor and/or rupture of membranes reduces risk of mother-to-child transmission by 50–80% compared with other modes of delivery in women on no antiretroviral therapy or on ZDV alone • No evidence of benefit with cesarean section after onset of labor or membranes have been ruptured • Cesarean section, however, increases morbidity and possible mortality to mother • Give antibiotic prophylaxis for cesarean section in HIV-infected women International Perinatal HIV Group 1999; Semprini 1995. HIV and Pregnancy

20. Recommended Infection Prevention Practices • Needles: • Take care! Minimal use • Suturing: Use appropriate needle and holder • Care with recapping and disposal • Wear gloves, wash hands with soap immediately after contact with blood and body fluids • Cover incisions with watertight dressings for first 24 hours HIV and Pregnancy

21. Recommended Infection Prevention Practices (continued) • Use: • Plastic aprons for delivery • Goggles and gloves for delivery and surgery • Long gloves for placenta removal • Dispose of blood, placenta and waste safely • PROTECT YOURSELF! HIV and Pregnancy

22. Newborn • Wash newborn after birth, especially face • Avoid hypothermia • Give antiretroviral agents, if available HIV and Pregnancy

23. Breasfeeding Issues • Warmth for newborn • Nutrition for newborn • Protection against other infections • Safety – unclean water, diarrheal diseases • Risk of HIV transmission • Contraception for mother • Cost HIV and Pregnancy

24. Breastfeeding Recommendations If the woman is: • HIV-negative or does not know her HIV status, promote exclusive breastfeeding for 6 months • HIV-positive and chooses to use replacements feedings, counsel on the safe and appropriate use of formula • HIV-positive and chooses to breastfeed, promote exclusive breastfeeding for 6 months HIV and Pregnancy

25. South Africa Breastfeeding Trial: Objective and Design • Objective: To assess whether pattern of breastfeeding is a critical determinant of early mother-to-child transmission of HIV • 549 HIV-infected women studied • Compared newborns at 3 months that had been: • Exclusively breastfed • Breastfed and formula-fed • Never breastfed Coutsoudis et al 1999. HIV and Pregnancy

26. South Africa Breastfeeding Trial: Results and Conclusion • Risk of transmission in: • 156 newborns who were never breastfed: 18.8% (95% CI 12.6–24.9) • 288 newborns who were breastfed and formula fed: 24.1% (95% CI 19.0–29.2) • 103 newborns who were exclusively breastfed: 14.6 (95% CI 7.7–21.4) • Conclusion: Newborns who were exclusively breastfed for at least 3 months did not have any excess risk of HIV infection compared to newborns who were not breastfed Coutsoudis et al 1999. HIV and Pregnancy

27. Conclusion • Voluntary counseling and testing • Antenatal, intrapartum and postpartum care to mother can decrease risk of mother-to-child transmission • Antiretroviral therapy can also reduce risk of transmission • Newborn care: Feeding HIV and Pregnancy

28. References Anderson J (ed). 2001. A Guide to the Clinical Care of Women with HIV, 2nd ed. U.S. Department of Health and Human Services, Health Resources and Services Administration: Rockville, Maryland. Coutsoudis A et al. 1999. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: A prospective cohort study. Lancet 354: 471–476. DeCock K et al. 2000. Prevention of mother-to-child transmission in resource-poor countries: Translating research into policy and practice. J Am Med Assoc 283(9): 1175–1182. Dunn D et al. 1992. Risk of HIV-1 transmission through breastfeeding. Lancet 340(8819): 585–588. Gray G. 2000. The PETRA study: Early and late efficacy of three short ZDV/3TC combinations regimens to prevent mother-to-child transmission of HIV-1. XIII International AIDS Conference, Durban, South Africa. HIV and Pregnancy

29. References (continued) International Perinatal HIV Group. 1999. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1. N Engl J Med 340(14): 977–987. Mandelbrot L et al. 1996. Obstetric factors and mother-to-child transmission of human immunodeficiency virus type 1: The French perinatal cohorts. Amer J Obstet Gynecol 175(3 pt 1): 661–667. Semprini AE et al. 1995. The incidence of complications after cesarean section in 156 women. AIDS 9:913–917. Shaffer N et al. 1999. Short-course ZDV for perinatal HIV-1 transmission in Bangkok, Thailand: A randomized controlled trial. Lancet 353: 773–780. Sperling RS et al. 1996. Maternal viral load, ZDV treatment, and the risk of transmission of HIV type 1 from mother to infant. N Engl J Med 335(22): 1621–1629. UNICEF/UNAIDS/WHO Technical Consultation on HIV and Infant Feeding. 1998. HIV and Infant Feeding: Implementation of Guidelines. WHO: Geneva. World Health Organization (WHO)/Joint United Nations Programme on HIV/AIDS (UNAIDS). 1999. HIV In Pregnancy: A Review. WHO/UNAIDS: Geneva. HIV and Pregnancy