PERSALINAN BAGI WANITA HAMIL YANG TERINFEKSI HIV

1. PERSALINAN BAGI WANITA HAMIL YANG TERINFEKSI HIV dr. Anita Rachmawati, SpOG Bagian Obstetri Ginekologi FK UNPAD/RS Hasan Sadikin Bandung

2. Risikopenularan HIV dariibukebayitanpaintervensi PMTCT Risiko tertinggi

3. Risiko penularan masa persalinan • His  tekanan pada plasenta meningkat • Terjadi sedikit pencampuran antara darah ibu dengan darah bayi • Lebih sering terjadi jika plasenta meradang/ terinfeksi • Bayi terpapar darah dan lendir serviks pada saat melewati jalan lahir • Bayi kemungkinan terinfeksi karena menelan darah dan lendir serviks pada saat resusitasi

4. Konsep dasar intervensi PMTCT • Kurangi jumlah ibu hamil dengan HIV positif • Turunkan Viral Load serendah-rendahnya • Meminimalkan paparan janin/bayi dengan cairan tubuh ibu HIV positif • Optimalkan kesehatan ibudengan HIV positif

5. SC elektifmenurunkanrisikotransmisivertikal • hingga 50% padawanitaterinfeksi HIV tanpa ARV • hingga 87% padawanitaterinfeksi HIV dengan ARV (ZDV) Read JS. Preventing mother to child transmission of HIV: the role of cesarean section. Sex TransmInf 2000;76;231-232 International Perinatal HIV group, 1999

6. Konsep dasar intervensi PMTCT • Kurangi jumlah ibu hamil dengan HIV positif • Turunkan Viral Load serendah-rendahnya • Meminimalkan paparan janin/bayi dengan cairan tubuh ibu HIV positif • Optimalkan kesehatan ibudengan HIV positif

7. WHO RHL • The benefit of elective CS delivery among women who either received, or did not receive,ZDV. • Unfortunately, the data are insufficient to evaluate the potential benefit of CS delivery for neonates of ARV-treated women with plasma HIV-RNA levels < 1000 copies/ml. • It is unlikely that scheduled CSdelivery would confer additional benefit in reduction of HIV-1 transmission among this group.

8. PACTG 367 (Shapiro, 2004) In almost 2900 pregnancies found that in all subgroups of VL • combination ARV therapy was associated with the lowest rates of transmission and with VL <1000 c/Ml • MTCT rates were significantly lower with multiagent vs single-agent ARV (0.6% vs 2.2%) but did not differ by mode of delivery

9. The European Collaborative Study • Among 4500 women with undetectable VL and after adjusting for ARV therapy during pregnancy, scheduled CS was not associated with additional benefit in reduction of transmission

10. REKOMENDASI • Perlu dilakukan konseling kepada ibu dan pasangan mengenai manfaat dan risiko persalinan pervaginam dan persalinan dengan SC elektif • Persyaratan untuk persalinan pervaginam: - Ibu minum ARV teratur, atau - Muatan Virus/ Viral Load tidak terdeteksi • Dianjurkan untuk melakukan pemeriksaan muatan virus/ viral load pada usia kehamilan 36 minggu ke atas

11. Kewaspadaanuniversal (misalnyacucitangandanpemakaianalatperlindungandiri) perludilakukanpadasemuatindakanobstetri. • PadadasarnyapersalinanOdhadapatdilakukandisemuafasilitaskesehatan. • Pemilihankontrasepsipascapersalinanbertujuanuntukmencegahpenularan HIV padakehamilanberikutnya, namunsterilisasibukanmerupakanindikasiabsolutpadaibudengan HIV

12. SOGC Clinical Practice Guidelines(No. 101, April 2001) The available evidence regarding the prophylactic role of CS applies only to women • who have not received optimal ARV therapy. • Elective CS (38 weeks gestation) should be offered to HIV-positive women in these specific situations:

13. SOGC Clinical Practice Guidelines • Women who have not received ARV therapy regardless of the antepartum viral load determination. These patients should be offered appropriate therapy as soon as HIV is recognized. (I) • Women receiving ARV monotherapy regardless of the viral load. Intensification of therapy should be undertaken if time permits. (II-2)

14. SOGC Clinical Practice Guidelines • Patients with detectable viral load regardless of the received therapy. (II-2) • Women in whom the viral load determination is not available or has not been done. (II-2) • Women with unknown prenatal care

15. In HIV-infected women, the higher the plasma viral load, the more likely that HIV will be found in cervicovaginal secretions. However, in many women with undetectable plasma loads, HIV is still often found in such secretions, as reported in an article in the October 17 issue of AIDS (AIDS 2003;17:2169-2176) by , the lead author , Dr Jose Ramon (University of Bati, Italy).

16. a high CD4 cell count, even in the absence of plasma HIV-1 RNA (as shown in group C), does not necessarily imply the absence of HIV in the cervicovaginal secretions. • Women under HAART treatment were more likely to reach undetectable viral levels in the vagina, even if HIV RNA was detected in the plasma, whereas women under non-HAART treatment were more likely to shed HIV in genital secretions even in the absence of plasma viraemia

17. An increased CD4 cell count and HAART treatment were significantly associated with non-detectable viral loads both in plasma and in vagina. • Non-HAART treatment was significantly associated with HIV-1 RNA absence in plasma viraemia but not in vaginal secretions

18. TERIMA KASIH