hiv and pregnancy: prevention of mother-to-child transmission advances in maternal and neonatal...

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

Advances in Maternal and Neonatal Health

2 HIV and Pregnancy

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

3 HIV and Pregnancy

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

4 HIV and Pregnancy

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

5 HIV and Pregnancy

Adverse Pregnancy Outcomes and Relationship to HIV Infection

Pregnancy Outcome Relationship to HIV Infection

Spontaneous abortion Limited data, but evidence of possible increased risk

Stillbirth No association noted in developed countries; evidence of increased risk in developing countries

Perinatal mortality No association noted in developed countries, but data limited; evidence of increased risk in developing countries

Newborn mortality Limited data in developed countries; evidence of increased risk in developing countries

Intra-uterine growth retardation

Evidence of possible increased risk

Anderson 2001.

6 HIV and Pregnancy

Adverse Pregnancy Outcomes and Relationship to HIV Infection (continued)

Pregnancy Outcome Relationship to HIV Infection

Low birth weight Evidence of possible increased risk

Preterm delivery Evidence of possible increased risk, especially w/ more advanced disease

Pre-eclampsia No data

Gestational diabetes No data

Amnionitis Limited data; more recent studies do not suggest an increased risk; some earlier studies found increased histologic placental inflammation, particularly in those with preterm deliveries

Oligohydramnios Minimal data

Fetal malformation No evidence of increased risk

Anderson 2001.

7 HIV and Pregnancy

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.

8 HIV and Pregnancy

Risk Factors for Mother-to-Child Transmission

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

Anderson 2001.

9 HIV and Pregnancy

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

10 HIV and Pregnancy

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!


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


Antiretrovirals

Zidovudine (ZDV):

Long course Short course

Nevirapine

ZDV/lamivudine (ZDV/3TC)


ZDV Perinatal Transmission Prophylaxis Regimen: ACTG 076 Trial

Antepartum Initiation at 14–34 weeks gestation and continued throughout pregnancy

PACTG 076 regimen: ZDV 5 times dailyAcceptable alternative regimen: ZDV 2 or 3 times

daily (depending on dose)

Intrapartum During labor, ZDV IV over 1 hour, followed by a continuous infusion of IV until delivery

Postpartum Oral administration of ZDV to newborn for first 6 weeks of life, beginning at 8–12 hours after birth

Anderson 2000.


Intrapartum vs. Postpartum Regimens for HIV-Infected Women in Labor with

No Prior Antiretroviral Therapy

Drug Regimen

Maternal Intrapartum

Newborn Postpartum

Data on Transmission

Nevirapine One oral dose at onset of labor

One oral dose at age 48–72 hours (if mother received nevirapine < 1 hour before delivery, newborn given oral nevirapine as soon as possible after birth and at 48–72 hours)

Transmission at 6 weeks 12% with nevirapine compared to 21% with ZDV, a 47% (95% CI, 20–64%) reduction

Anderson 2001.



No Prior Antiretroviral Therapy (cont’d.)

Drug Regimen


Newborn Postpartum


ZDV/3TC ZDV orally at onset of labor followed by dose orally every 3 hours until delivery AND

3TC orally at onset of labor, followed by dose orally every 12 hours

ZDV orally every 12 hours

AND

3TC orally every 12 hours for 7 days

Transmission at 6 weeks 10% with ZDV/3TC compared to 17% with placebo, a 38% reduction

Anderson 2001.




Drug Regimen


Newborn Postpartum


ZDV IV bolus, followed by continuous infusion of every hour until delivery

Orally every 6 hours for 6 weeks

Transmission 10% with ZDV compared to 27% with no ZDV treatment, a 62% (95% CI, 19-82%) reduction

Anderson 2001.




Drug Regimen


Newborn Postpartum


ZDV and Nevirapine

IV bolus, then continuous infusion until deliveryANDNevirapine single oral dose at onset of labor

Orally every 6 hours for 6 weeksANDNevirapine single oral dose at age 48–72 hours

No data

Anderson 2001.


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


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.


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


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!


Newborn

Wash newborn after birth, especially face

Avoid hypothermia

Give antiretroviral agents, if available


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


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


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.


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.


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


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.


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.

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