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Prevention of Perinatal HIV Transmission

Prevention of Perinatal HIV Transmission. Cyril K. Goshima, M. D. Director Hawaii AIDS Education and Training Center Pohnpei, FSM June 16, 2006. Objectives. Why treatment is essential to prevent Maternal to Child Transmission (MTCT).

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Prevention of Perinatal HIV Transmission

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  1. Prevention of Perinatal HIV Transmission Cyril K. Goshima, M. D. Director Hawaii AIDS Education and Training Center Pohnpei, FSM June 16, 2006

  2. Objectives • Why treatment is essential to prevent Maternal to Child Transmission (MTCT). • What are some maternal factors to consider in HIV treatment. • What regimens can be used to prevent MTCT. • What may be a potential HIV medication formulary.

  3. HIV Testing in Pregnancy • Standard serologic test recommended for all pregnant women. • In HIV negative pregnant women, repeat test should be done at 28 weeks or third trimester. • HIV rapid test recommended in untested women presenting in labor. • If syx. of acute HIV in 3rd trimester, HIV RNA tests should be done.

  4. Why Treat? • Pregnancy has no clear effect on HIV progression. • Data from developing countries show HIV associated with increase rates of preterm delivery, low birth weights, and stillbirth. • Higher viral loads at the time of delivery probably incr. risk of HIV transmission.

  5. Why Treat? • Women and Infants Transmission Study • U.S. Group 1542 patients • 18.1% perinatal transmission w/o Rx. • 1.6% perinatal transmission with Rx • AIDS Clinical Trial Group Study 076 • AZT significantly reduced perinatal transmission even when the baseline viral load <1,000 c/mL

  6. Maternal Factors • Maternal Health is key to a healthy infant. • Evaluate and if necessary treat mother first • Basic PE, health screening labs

  7. Maternal Factors • Highly Active Antiretroviral Therapy (HAART) should be recommended to all women regardless of pregnancy status based on general guidelines. • HAART should be recommended to prevent MTCT in pregnant women with viral load >1000. • If the VL is <1000, AZT monotherapy may be acceptable.

  8. Maternal Factors • Drugs to avoid in pregnancy • Hydroxyurea, Efavirenz, Tenofovir, Stavudine+Didanosine • Preferred Regimens • WHO: 2 NRTIs + Nevirapine (NVP)* or Nelfinavir (NFV) • DHHS: Retrovir (AZT) + Epivir (3TC) + Nelfinavir or Saquinavir boosted with Ritonavir • Nevirapine should be avoided in women with CD4 > 250 due to hepatotoxicity (not single dose NVP to prevent MTCT)

  9. Maternal Factors • C-Section • Efficacy in reducing MTCT if maternal VL >1000 • C-Section at time of labor or with premature rupture of membranes no benefit in reducing MTCT, increases risk of infections • Breast Feeding • Risk of HIV transmission 10 – 16%, incr. with mastitis, cracked nipples, prolonged breast feeding • In developing countries, breastfeeding may be critical for infant nutrition and survival

  10. Maternal Factors • Counseling • HIV treatable • Prevention of transmission to infant is possible • Need for close follow-up pre and post delivery for both pt. and infant • Treatment of STI • Use of condoms to prevent acquiring STI during pregnancy • Look for an treat all STI esp. ulcerative ones • Discuss options for mode of delivery and feeding of infant

  11. Regimens to Prevent MTCT • If possible delay Rx till after 1st Trimester • ACTG 076 Protocol (3 Part AZT Protocol) • Antepartum: AZT 300 mg. BID or 200 mg. TID from week 14 to delivery • Intrapartum: AZT IV 2 mg/kg 1st hr., then 1 mg/kg/hr until delivery • Postpartum: for the infant AZT syrup 2 mg/kg Q 6 hr (or 1.5 mg/kg Q 6 hr IV) x 6 weeks

  12. Regimens to Prevent MTCT • Other Regimens (Presenting in Labor & Un-Rx) • Single dose NVP for mother and infant • AZT/3TC • Mother: AZT 600 mg po onset of labor, then 300 mg Q 3 hrs., 3TC 150 mg po onset of labor, then 150 mg po Q 12 hrs till delivery • Infant: AZT 4 mg/kg Q 12 hrs + 3TC 2 mg/kg Q 12 hrs x 7 days • AZT/NVP • Mother: AZT 2 mg/kg IV bolus, then 1 mg/kg/hr till delivery + NVP 200 mg. at onset of labor • Infant: AZT 2 mg/kg po Q 6 hrs x 6 wks + NVP 2 mg/kg po at 48-72 hrs x 1 dose

  13. Regimens to Prevent MTCT • If infant presents postpartum start AZT therapy ASAP for 6 weeks.

  14. Regimens • Considerations of medications • Availability • Sustainability • Tolerance, side effects • Resistance

  15. HIV Medication Formulary • Based on the need to prevent MTCT the following medications may be considered as part of a basic HIV formulary • Retrovir (AZT): tab/capsule, IV, Syrup • Epivir (3TC): tab, liquid • Nevirapine (NVP) • Efavirenz (EFV) • Nelfinavir (NVP)

  16. Summary • Prevention of MTCT of HIV is possible. • An HIV pregnant woman should be treated based on current guidelines for all patients with a few considerations. • Knowledge of what is needed to prevent MTCT may shape your formulary.

  17. Thank You Questions?

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