HIV Infection and Pregnancy Managing Mother and Baby - PowerPoint PPT Presentation

1 / 53
About This Presentation
Title:

HIV Infection and Pregnancy Managing Mother and Baby

Description:

Breastfeeding and HIV Infection. Women with HIV infection in the U.S. should not breastfeed ... Husband has AIDS. This is a planned pregnancy. ... – PowerPoint PPT presentation

Number of Views:3676
Avg rating:5.0/5.0
Slides: 54
Provided by: elaine93
Category:

less

Transcript and Presenter's Notes

Title: HIV Infection and Pregnancy Managing Mother and Baby


1
  • HIV Infection and Pregnancy Managing
    Mother and Baby

The National Pediatric Family HIV Resource
Center University of Medicine Dentistry of New
Jersey
2
  • In collaboration with regional AIDS Education
    Training Centers
  • With support from the U.S. Centers for Disease
    Control and Prevention, Cooperative Agreement
    R62/CCR217856-02


3
  • Scope of the Epidemic Among Women and Children
  • 125,000 AIDS cases in women reported through June
    1999
  • AIDS in women has risen from 7 early in the
    epidemic to 24 of adult cases today
  • 263 new AIDS cases reported in children in 1999
  • 10,000 20,000 estimated children living with
    HIV infection
  • 300 400 babies continue to be born with HIV
    infection each year in the U.S.

4
  • Perinatal Transmission of HIV
  • Without antiretroviral drugs during pregnancy,
    mother-to-child transmission has ranged from
    1625 in North America and Europe
  • 21 transmission rate in the U.S. in 1994 before
    the standard recommendations of zidovudine (ZDV)
    in pregnancy
  • In 1995, transmission rate was 11 after the
    change in practice

5
  • USPHS Guidelines for the Use of Antiretroviral
    Drugs in Pregnant Women for Maternal Health
    Prevention of HIV Transmission
  • Developed in 1994 in response to ACTG 076
  • Working Group reconvened in December 1999 and
    meets monthly
  • Updated recommendations available online at
    HIV/AIDS Treatment Information Service web site
    (www.hivatis.org)

6
  • Impact of PHS Guidelines for Reducing Perinatal
    HIV Transmission
  • Perinatal HIV transmission has declined sharply
    since the USPHS issued guidelines in 1994,
    resulting in a dramatic decrease in pediatric
    AIDS cases
  • 4-State Study Louisiana, Michigan, New Jersey
    and South Carolina (CDC, 1998)
  • Women diagnosed before giving birth
  • Women offered prenatal ZDV
  • Women offered intrapartum ZDV
  • Infants offered neonatal ZDV

1993 1996
68 ? 81 27 ? 85 5 ? 75 5 ?
76
7
  • National Recommendations for HIV Testing of
    Pregnant Women
  • Universal testing with patient notification as a
    routine component of prenatal care
  • Institute of Medicine (IOM)Reducing the
    Odds1998
  • American Academy of Pediatrics the American
    College of Obstetricians GynecologistsJoint
    Statement1999
  • USPHS recommendations are under revision (coming
    soon)
  • Important Regulations, laws, policies about
    HIV screening of pregnant women vary state to
    state

8
  • Routine Counseling and Voluntary HIV Testing of
    All Pregnant Women
  • Provider Role
  • Include HIV prevention education as part of
    routine antenatal care
  • Offer HIV testing to all pregnant women
  • Provide information on HIV/AIDS
  • Consider womans age, culture, education, and
    language

9
  • Routine Counseling and Voluntary HIV Testing of
    All Pregnant Women
  • Provider Role
  • Document consent /or decision NOT to test
  • Address reasons for not testing and offer again
  • Offer the test again for clinical indications
  • Provide/refer women with risk behaviors for more
    intensive client-centered prevention counseling

10
  • Routine Education/Counseling about the HIV Test
    for Pregnant Women
  • Content individual counseling, or by brochures,
    videos, group classes
  • Cause of HIV/AIDS and how it is spread
  • Highly effective treatment is available for the
    womans health and to protect the fetus from
    acquiring HIV
  • HIV testing is recommended for all pregnant women
  • Services are available to help women from
    becoming infected and to provide medical care and
    other assistance to those who are infected

11
  • Prenatal Messages for Counseling Pregnant Women
    About the HIV Test
  • Anyone can get HIV infection. Women especially
    may not know they are at risk
  • HIV is treatable. Treatment can prolong a womans
    life and prevent HIV transmission to her infant
    during pregnancy
  • Most women who get the HIV test do not have the
    virus
  • If a woman is HIV during pregnancy, she can get
    treatment immediately

12
  • Prenatal Messages (continued)
  • If a woman is HIV negative during pregnancy, she
    can learn ways to prevent getting the infection
    in the future
  • All information about HIV testing and the results
    are kept confidential to the extent allowed by
    law. Results may be reportable in your state
  • Federal and state laws protect women with HIV
    from discrimination
  • Experts recommend that all pregnant women receive
    an HIV test regardless of whether a woman thinks
    she is at risk

13
  • Counseling the Pregnant Woman with a Positive HIV
    Test Result
  • Meaning of the positive test results
  • Need for medical management
  • Treatment options for her and/or to reduce
    perinatal transmission
  • Importance of social support
  • Referral for social services
  • Collaboration between OB, HIV specialist, and the
    pregnant woman

14
  • Counseling the Pregnant Woman with a Negative HIV
    Test Result
  • Explain the meaning of the negative test results
  • Discuss and reinforce risk reduction strategies
  • Teach safer sexual practices to help assure she
    continues to be HIV negative

15
  • Acceptance of HIV Testing among Pregnant Women
  • IOM reported 7586 of pregnant women accepted
    voluntary HIV testing
  • The IOM reported that evidence demonstrates that
    pregnant women are likely to accept HIV testing
    when it is offered

16
  • Barriers and Supports to Universal Prenatal HIV
    Testing
  • Providers recommendation about testing
  • 92.8 were tested if strongly recommended
  • 42 if clinician had not recommended
  • Private insurance associated with not being
    tested
  • Reasons for not being tested
  • Not perceiving herself at risk (55.3)
  • Having been tested recently (39)
  • Test not offered or recommended (11)
  • Adverse consequences rarely mentioned

17
  • Interpreting HIV Test Results
  • Standard HIV Serology
  • ELISA enzyme immunoassay (EIA)
  • Initial screening
  • If repeatedly reactive, confirmed by supplemental
    test (Western blot)
  • Western Blot confirmatory test
  • Optional Testing
  • Rapid/Expedited Testing
  • Reactive rapid test MUST be confirmed by a
    supplemental test

18
  • Timing of Perinatal HIV Transmission
  • Cases documented intrauterine, intrapartum, and
    postpartum by breastfeeding
  • In utero 2540 of cases
  • Intrapartum 6075 of cases
  • Addition risk with breastfeeding
  • 14 ? risk with established infection
  • 29 ? risk with primary infection
  • Current evidence suggests most transmission
    occurs during the intrapartum period

19
  • Breastfeeding and HIV Infection
  • Women with HIV infection in the U.S. should not
    breastfeed
  • Women considering breastfeeding should know their
    HIV status

20
  • Factors Influencing Perinatal Transmission
  • Maternal Factors
  • HIV-1 RNA levels (viral load)
  • Low CD4 lymphocyte count
  • Other infections, Hepatitis C, CMV, Bacterial
    Vaginosis
  • Maternal injection drug use
  • Lack of ZDV during pregnancy
  • Obstetrical Factors
  • Length of ruptured membranes/chorioamnionitis
  • Vaginal delivery
  • Invasive procedures
  • Infant Factors
  • Prematurity

21
  • Maternal Viral Load and Risk of Transmission
    Women Infants Transmission Study (WITS)

HIV-1 RNA
Transmission
N
0 16.6 21.3 30.9 40.6
lt1000 1000 - 10,000 10,001- 50,000 50,001-100,00
0 gt100,000
0/57 32/193 39/183 17/54 26/64
22
  • Maternal Viral Load (VL), ZDV Treatment and the
    Risk of Perinatal HIV Transmission
  • Correlation between high maternal VL and
    transmission
  • Transmission observed at every VL level,
    including undetectable levels
  • No HIV RNA threshold below which there was no
    risk of transmission
  • ZDV decreases transmission regardless of HIV RNA
    level
  • Recommendation Initiate maternal ZDV regardless
    of plasma HIV RNA or CD4 counts

23
What have we learned?
  • Interrupting Perinatal HIV Transmission
  • Study Results

24
  • ACTG 076
  • A phase III randomized placebo-controlled trial
    of zidovudine (ZDV) for the prevention of
    maternal-fetal HIV transmission
  • Treatment Regimen
  • Antepartum 100 mg ZDV po 5x day, started at 14
    34 weeks gestation
  • IntrapartumDuring labor, 1- hour initial dose 2
    mg/kg IV followed by continuous infusion of 1
    mg/kg until delivery
  • Postpartum/Infant Regimen2 mg/kg po q 6 hr for 6
    weeks, to start 8 12 hours after birth

25
Results of ACTG 076
30
This represents a 66 reduction in risk for
transmission (P lt0.001) Efficacy was observed
in all subgroups
20
22.6
Transmission Rate ()
10
7.6
ZDV Group
Placebo
26
  • Follow-up of Uninfected Infants in ACTG 076 ZDV
    versus Placebo
  • No significant difference in growth
  • No difference in CD4 and CD8 counts between
    groups
  • No other safety abnormalities have been
    identified
  • No differences in Bayley developmental scores in
    uninfected infants in ACTG 219
  • Follow-up of infants with exposure to nucleoside
    analogues is ongoing due to the potential for
    mitochondrial toxicity
  • In the U.S. no cases of mitochondrial toxicity
    have been identified

27
  • Follow-Up of Women in ACTG 076
  • Median follow-up 4.2 years
  • No substantial differences in CD4 count, time to
    progression to AIDS, or death in women who
    received ZDV compared to those who received
    placebo

28
  • Reducing Intrapartum HIV Transmission
  • Studies of Short Course Therapy
  • Oral ZDV in a non-breastfeeding population
    (Thailand) from 36 weeks and during labor
  • Transmission rate 9.4 ZDV vs 18.9 placebo
  • Petra study intrapartum/postpartum oral ZDV/3TC
    in a breast-feeding population (Uganda, S.
    Africa,Tanzania)
  • Transmission rate 10 ZDV/3TC vs 17 placebo
  • HIVNet 012 intrapartum/postpartum/neonatal
    nevirapine (NVP) vs short course/neonatal ZDV in
    a breast-feeding population (Uganda)
  • Transmission rate 12 NVP vs 21 ZDV

29
  • Reducing HIV Transmission with
  • Suboptimal Regimens
  • Partial ZDV regimens (New York cohort)
  • Transmission rates
  • 6.1 with prenatal, intrapartum, and infant ZDV
  • 10 with only intrapartum ZDV
  • 9.3 if only infant ZDV started within first 48
    hours
  • 26.6 with no ZDV

30
Treating Women with HIV Infection in Pregnancy

31
  • Goals of Antiretroviral Therapy
  • To prolong life and improve quality of life
  • To suppress HIV to below the limits of detection
    or as low as possible, for as long as possible
  • To preserve or restore immune function

32
  • When Should an Adult be Treated?

Clinical Category CD4 count HIV RNA
Recommendations
Symptomatic Asymptomatic Asymptomatic
Any value CD4 T cells lt200/mm3 HIV RNA any
value CD4 T cells gt200/mm3 but lt350 /mm3, HIV
RNA any value CD4 T cells gt350/mm3, HIV RNA
gt30,000 (bDNA) or gt55,000 (RT-PCR) CD4 T cells
gt350/mm3, HIV RNA lt30,000(bDNA) or lt55,000
(RT-PCR)
Treat Treat Offer treatment if pt willing to
accept Some experts would treat Many experts
would delay therapy observe
33
  • Guidelines for Care of All Pregnant Women with
    HIV Infection
  • Provide standard clinical evaluation HIV
    disease stage
  • Provide standard immunologic evaluation
    absolute CD4, CD4
  • Provide standard virologic evaluation HIV-RNA
    copy number (viral load)
  • Discuss known or unknown risks/benefits of
    therapy during pregnancy
  • Develop strategy for long term evaluation and
    management of mother/infant

34
  • Guidelines for Antiretroviral Drugs in Pregnancy
    Concepts
  • Use optimal ARV for the womans health
  • Add ZDV regimen for reducing perinatal HIV
    transmission
  • Discuss preventable risk factors for perinatal
    transmission
  • Counsel on cesarean delivery
  • Support decision-making by woman following
    discussion of known and unknown benefits and
    risks
  • Acceptance or refusal of ARV or ZDV should not
    result in denial of care or punitive action

35
  • Guidelines for Antiretroviral Drugs in
    Pregnancy Clinical Scenario 1

Women without prior antiretroviral therapy
  • Recommend
  • Standard combination therapy for women with high
    viral load, low CD4 count
  • Combination therapy for women with viral load
    ?1,000 regardless of clinical or immunologic
    status
  • 3-part ZDV regimen to reduce perinatal
    transmission for all HIV-infected pregnant
    women, regardless of antenatal viral load
  • Consider delaying therapy until completion of
    first trimester
  • Offer scheduled cesarean delivery for women with
    viral loads gt1000 (based on most recent VL
    results)

36
  • Clinical Scenario 2

Women currently on antiretroviral therapy
  • Discuss benefits and potential risks of her
    current regimen during pregnancy
  • Add or substitute ZDV at ?14 weeks
  • Recommend intrapartum and neonatal ZDV
  • Discontinue teratogenic drugs
  • Consider continuing or stopping current therapy
    based on gestational age (lt14 weeks)
  • If therapy is stopped, stop and restart all ARV
    simultaneously
  • Resistance testing for suboptimal viral
    suppression or failure

37
  • Clinical Scenario 3

Women with HIV infection and present in labor
with no previous treatment
  • Discuss benefits of treatment during intrapartum
    and neonatal period
  • Four treatment options
  • Single dose nevirapine for mother at onset of
    labor followed by single dose of nevirapine for
    the newborn at age 4872 hrs
  • Oral ZDV/3TC for mother during labor followed by
    one week oral ZDV/3TC to the newborn
  • Intrapartum IV ZDV followed by six weeks ZDV for
    the newborn
  • The two-dose nevirapine regimen as above combined
    with intrapartum IV ZDV and six week ZDV for the
    newborn

38
  • Clinical Scenario 4

Infant whose mother did not receive prenatal or
intrapartum ZDV
  • Offer the six-week neonatal ZDV component
  • Initiate therapy as soon as possible after
    maternal consent (preferably within 6 12 hours
    of birth)
  • Begin diagnostic testing of the infant
  • Refer to pediatric HIV specialist for long-term
    care

39
  • Assessment of the Pregnant Woman with HIV
    Infection

Initial Assessment Desires
Antiretroviral Therapy
Yes
No
Treat according to clinical immunologic status
Monitor for HIV disease progression
Recommend ZDV Recommend combination therapy if VL
gt1000 Discuss C/S
Wants to ? perinatal transmission
40
  • Follow-Up Assessment of Pregnant Woman with HIV

4 weeks after initiation of treatment, then q 3
months if viral load stable
  • Fetal assessment based on gestational age
  • CD4 and viral load response
  • New onset of symptoms
  • Side effects or toxicities
  • Adherence to therapy
  • Long-range planning for continuity of medical
    care

41
  • Changing HIV Therapy During Pregnancy
  • Poor CD4 response
  • Drugs with potential teratogenicity
  • Poor viral load response
  • Poor adherence to regimen
  • Evidence of viral resistance

42
  • Cesarean Section to Reduce Perinatal HIV
    Transmission
  • Pregnant women with VL gt1000 should be counseled
    re potential benefit of scheduled C/S to reduce
    perinatal transmission
  • Unknown whether scheduled C/S offers any benefit
    to women on HAART with low or undetectable VL
    given the low transmission rate
  • Complications of C/S similar to HIV uninfected
    women
  • Patients decision should be respected and honored

43
  • Preterm Labor and the Use of Combination
    Antiretroviral Therapy
  • A Swiss study reported a possible association
    between combination ARV therapy and preterm
    births
  • Preliminary review of U.S. cohorts has not
    supported the association
  • Patients should be educated and cautioned about
    signs of preterm labor

44
  • Antiretroviral Pregnancy Registry
  • A collaborative project managed by PharmaResearch
    Corporation on behalf of an advisory committee
    (specialists in OB/Gyn, ID, teratology,
    epidemiology, and CDC and NIH members) and
    sponsored by
  • Abbott Laboratories, Agouron Pharmaceuticals,
    Inc., Boehringer Ingelheim Company, Bristol-Myers
    Squibb, Co., DuPont Pharmaceuticals Company,
    GlaxoSmithKline, F. Hoffmann-LaRoche Ltd., Merck
    Co., Inc.
  • Purpose To assess safety of antiretroviral
    drugs during pregnancy
  • Telephone (800) 258-4263 Fax (800) 800-1052

45
  • Comprehensive Care of Women Postpartum
  • Primary and HIV specialty care
  • Ob/gyn and family planning services
  • Mental health and substance abuse treatment as
    needed
  • Coordination of care through case management for
    the woman and her family
  • Support services for the family

46
  • Evaluation and Follow up of Infants
  • HIV diagnostic testing to establish or rule-out
    HIV infection as early as possible
  • Referral to an HIV specialist
  • PCP prophylaxis initiated at 6 weeks of age
  • Long-term follow-up of HIV- and ARV-exposed
    infants
  • Support services for the family

47
Case Studies
48
Case Study 1
  • Angela, 41 y.o., first prenatal visit,
    approximately 19 weeks gestation, tested HIV 2
    months ago. CD4 725, HIV-1 RNA 600 copies/ml.
    This is her 4th pregnancy, she has no children.
  • What recommendations for antiretroviral therapy
    apply in this case?
  • What questions will you ask what options to
    present?
  • What OB condition may complicate this case?
  • Follow-up after delivery for the woman and infant

49
Case Study 2
  • Maria, 27 y.o., at 35 weeks gestation, requested
    HIV test. Former boyfriend died of AIDS. Test is
    positive, CD4 350, HIV-1 RNA 120,000 husband
    and child test negative. Refuses ZDV. It made
    my boyfriend worse. Wants the cocktail that
    Magic Johnson uses.
  • What are the recommendations for this woman?
  • Psychological issues? Related to community
    beliefs?
  • What counseling will you do?

50
Case Study 3
  • Ellen, 32 y.o., 9 10 weeks gestation, tested
    positive on voluntary prenatal screening. A
    former heroin user, she is now on methadone. CD4
    198. HIV-1 RNA is 100,000. Under stress. Wants
    HAART therapy and aC-section. Wants to know what
    else she can do to stay well. Heard that
    ritonavir is a good drug.
  • What are the recommendations for this woman?
  • Screening for other infectious complications?
  • Options for reducing perinatal transmission?
  • What management issues does this case present?

51
Case Study 4
  • Heather, 14 weeks gestation, HIV for 5 years,
    stage B2 (mild dysplasia), CD4 220 HIV-1 RNA is
    5,000. Shes on ZDV, ddI and nelfinavir. Shes
    anemic. Husband has AIDS. This is a planned
    pregnancy. Office staff feel this couple is
    irresponsible for having a baby.
  • What are the recommendations for this woman?
  • What information does this couple need?
  • What are other options for this woman? Should she
    be referred?
  • How are you going to deal with the office staff?

52
Case Study 5
  • Joan, G8P3222, HIV for 3 years, admitted with
    ruptured membranes. No prenatal care. Lost 2
    children to HIV. Urine for cocaine, GB strep
    (urine, cervix), other STDs negative. CD4 845.
  • What are the recommendations for this mother and
    infant?
  • How will you present the 076 regimen to this
    woman?
  • What alternative therapies can she choose to
    decrease perinatal transmission?
  • What should follow-up care include?

53
Case Study 6
  • Twelve hours after the birth of her infant,
    Angela Gs HIV test comes back positive. She
    tested negative early in her pregnancy but the
    test was repeated on admission to L D because
    she reported that her husband was back to using
    IV drugs. She did not have any antenatal or
    intrapartum antiretroviral therapy.
  • What are the recommendations for this mother and
    infant?
  • How will you present the 076 regimen to this
    woman and what are the options ?
  • What follow-up care is needed for Angela and her
    baby?
Write a Comment
User Comments (0)
About PowerShow.com