HIV and Pregnancy: Prevention of MothertoChild Transmission

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HIV and Pregnancy Prevention of Mother-to-Child
Transmission

• Advances in Maternal and Neonatal Health

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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

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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

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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

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Adverse Pregnancy Outcomes and Relationship to
HIV Infection
Anderson 2001.
6
Adverse Pregnancy Outcomes and Relationship to
HIV Infection (continued)
Anderson 2001.
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Mother-to-Child Transmission

• 2535 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.
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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.
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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

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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!

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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

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Antiretrovirals

• Zidovudine (ZDV)
• Long course
• Short course
• Nevirapine
• ZDV/lamivudine (ZDV/3TC)

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ZDV Perinatal Transmission Prophylaxis Regimen
ACTG 076 Trial
Anderson 2000.
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Intrapartum vs. Postpartum Regimens for
HIV-Infected Women in Labor with No Prior
Antiretroviral Therapy
Anderson 2001.
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Intrapartum vs. Postpartum Regimens for
HIV-Infected Women in Labor with No Prior
Antiretroviral Therapy (contd.)
Anderson 2001.
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Intrapartum vs. Postpartum Regimens for
HIV-Infected Women in Labor with No Prior
Antiretroviral Therapy (contd.)
Anderson 2001.
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Intrapartum vs. Postpartum Regimens for
HIV-Infected Women in Labor with No Prior
Antiretroviral Therapy (contd.)
Anderson 2001.
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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

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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 5080 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.
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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

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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!

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Newborn

• Wash newborn after birth, especially face
• Avoid hypothermia
• Give antiretroviral agents, if available

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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

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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

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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.
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South Africa Breastfeeding Trial Results and
Conclusion

• Risk of transmission in
• 156 newborns who were never breastfed 18.8 (95
  CI 12.624.9)
• 288 newborns who were breastfed and formula fed
  24.1 (95 CI 19.029.2)
• 103 newborns who were exclusively breastfed 14.6
  (95 CI 7.721.4)
• 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.
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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

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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 471476.
• 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) 11751182.
• Dunn D et al. 1992. Risk of HIV-1 transmission
  through breastfeeding. Lancet 340(8819) 585588.
• 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.

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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) 977987.
• 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) 661667.
• Semprini AE et al. 1995. The incidence of
  complications after cesarean section in 156
  women. AIDS 9913917.
• Shaffer N et al. 1999. Short-course ZDV for
  perinatal HIV-1 transmission in Bangkok,
  Thailand A randomized controlled trial. Lancet
  353 773780.
• 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) 16211629.
• 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.