ART, antiretroviral therapy; ARV, antiretroviral; DHHS, Department of Health and Human Services; PMTCT, prevention of mother-to-child transmission.
1. Advances in Preventing HIV Transmission Using Antiretroviral Therapy: The Role of OB/GYNsThis program is supported by an educational grant fromOriginally posted 5/9/2012 at clinicaloptions.com/ss/advances
2. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv About These Slides  Users are encouraged to use these slides in their own noncommercial presentations, but we ask that content and attribution not be changed. Users are asked to honor this intent  This abbreviated slideset was posted to SlideShare to publicize the availability of the full slideset. These slides may not be published or posted online without permission from CCO (email firstname.lastname@example.org)DisclaimerThe materials published on the Clinical Care Options Web site reflect the views of the authors of theCCO material, not those of Clinical Care Options, LLC, the CME providers, or the companies providingeducational grants. The materials may discuss uses and dosages for therapeutic products that have notbeen approved by the United States Food and Drug Administration. A qualified healthcare professionalshould be consulted before using any therapeutic product discussed. Readers should verify all informationand data before treating patients or using any therapies described in these materials.
3. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Faculty Disclosures Jean R. Anderson, MD Professor Division of Gynecologic Specialties Johns Hopkins University School of Medicine Baltimore, Maryland Jean R. Anderson, MD, has no significant financial relationships to disclose.
4. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Presentation Objectives  Review current status and continuing challenges for prevention of mother-to-child transmission (PMTCT) of HIV in the United States  Discuss new concepts in HIV prevention using antiretroviral medications – Treatment of HIV-infected persons for prevention of transmission – Pre-exposure prophylaxis (PrEP) From treatment vs prevention to treatment meets prevention
5. PMTCT: Proof of concept that HIV can be prevented using antiretroviral therapy
6. Advances in Preventing HIV Transmission Using Antiretroviral Therapy clinicaloptions.com/hiv AIDS Diagnoses Among Perinatally Infected Persons in US: 1985-2009 1000 900 Aged younger than 13 yrs 800 Aged 13 yrs or older 700Diagnoses (n) 600 500 400 300 200 100 0 85 88 89 90 93 94 01 02 04 07 08 86 87 91 92 95 96 97 98 99 00 03 05 06 09 19 19 19 20 20 20 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 Yr of Diagnosis CDC 2010.
7. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv OB/GYNs’ Knowledge and Practice of HIV Screening in Pregnant/Nonpregnant Pts Percentage of OB/GYNs Reporting That They Would Strongly Suggest HIV Testing to a Patient who is Pregnant or a Nonpregnant Patient Characteristic/Risk Factor, % Pregnant Nonpregnant Current injection drug user 99.3 97.9 Past injection drug user 98.7 92.8 Reports unprotected sex with multiple partners 96.4 85.9 History of blood transfusion between 1978 and 1985 91.9 77.6 Currently being treated for STI 85.4 72.5 Any history of blood transfusion 76.4 47.4 Negative HIV test within past 6 mos 45.8 15.1 No specific risk other than pregnancy identified 56.2 -- Planning a pregnancy -- 35.0 Sexually active with no previous HIV testing -- 34.2Gray AD, et al. Obstet Gynecol. 2007;110:1019-1026.
8. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Recommendations on HIV Testing of Pregnant and Nonpregnant Patients  ACOG, AAP, CDC, and the Institute of Medicine recommend that all pregnant women be screened for HIV as a part of routine prenatal care using an opt-out approach  In addition, CDC has recommended routine opt-out HIV screening for all patients in all healthcare settings since 2006 and ACOG endorsed these recommendations in 2008 – Patient notified that testing will be performed unless they decline – Signed consent should not be required – Prevention counseling not required – Persons at high risk for HIV should be screened at least annually1. ACOG. Obstet Gynecol. 2008;112:739-742. 2. AAP HIV Screening Guidelines; 2005. 3. Branson BM,et al. MMWR Recomm Rep. 2006;55:1-17. 4. Institute of Medicine Perinatal Transmission Guidelines.
9. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Basic Principles of Use of Antiretrovirals in Pregnancy  ARVs should be initiated in all HIV-infected pregnant women regardless of CD4+ cell count or HIV-1 RNA level  Regimens used should be effective in treatment of nonpregnant adults and should be safe and well tolerated – Regimen should consist of 2 NRTIs and either an NNRTI or a PI, most often with ritonavir boosting – Include ≥ 1 NRTI with good placental passage  Earlier initiation more effective in PMTCT  Women entering pregnancy on ART should continue on regimen, if effective and toleratedDHHS HIV Perinatal Guidelines. September 14, 2011.
10. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Current USPHS Classification of Antiretroviral Drugs in Pregnancy  Considerations: efficacy, durability, toxicity, convenience, pregnancy PK data, adverse outcomes for mother/fetus/infant Drug Class Preferred Alternative Agents Use in Special Insufficient Data Agents Circumstances Abacavir, Stavudine, Zidovudine, NRTIs Didanosine, n/a n/a Lamivudine Emtricitabine, Tenofovir NNRTIs Nevirapine n/a Efavirenz Etravirine, Rilpivirine Indinavir/ Darunavir/ritonavir, Lopinavir/ritona Atazanavir/ritonavir, PIs ritonavir, Fosamprenavir/ritonav vir Saquinavir/ritonavir Nelfinavir ir, Tipranavir/ritonavir Entry n/a n/a n/a Enfuvirtide, Maraviroc inhibitors Integrase n/a n/a n/a Raltegravir inhibitorsDHHS HIV Perinatal Guidelines. September 14, 2011.
11. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Efavirenz in Pregnancy  Preclinical primate data and retrospective reports in humans raise concerns about increased risk of neural tube defects  However, a recent meta-analysis of 1437 women in 19 studies with first trimester EFV exposure found NO increased risk of birth defects and only 1 neural tube defect (incidence: 0.07%)  Treatment change in pregnancy associated with increased risk of incomplete viral suppression at end of pregnancy  Draft 2012 BHIVA guidelines recommend that effective EFV-based antiretroviral therapy be continued in a woman presenting in the first trimester – Other guidelines expected to follow suit1. DHHS HIV Perinatal Guidelines. September 14, 2011. 2. Ford N, et al. AIDS. 2011;25:2301-2304.3. Floridia M, et al. HIV Clin Trials. 2010;11:303-311. 4. British HIV Association. Guidelines for themanagement of HIV infection in pregnant women 2012. Draft guidelines for consultation. January 17,2012.
12. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Reasons for Residual MTCT  Woman not offered HIV testing or declines  Late presentation in pregnancy  Lack of early and sustained control of HIV-1 RNA,[1-3] due to – Lack of access to most effective regimens (placental passage, pharmacokinetic considerations) – Treatment interruptions in pregnancy  Maternal genital tract infection  Acute HIV infection in pregnancy[6,7] – Pregnancy a period of increased risk for HIV acquisition[8-10]  Breastfeeding  Lack of neonatal ARV prophylaxis1.Tubiana R, et al. Clin Infect Dis. 2010;50:585-596. 2. Joao EC, et al. Int J STD AIDS. 2012;23:44-47. 3. Read PJ, et al.AIDS. 2012;[Epub ahead of print]. 4. Galli L. et al. Clin Infect Dis. 2009;48:1310-1317. 5. Taha TE, et al. Ann N Y Acad Sci.2000;918:84-98. 6. Birkhead GS, et al. Obstet Gynecol. 2010;115:1247-1255. 7. Patterson KB, et al. AIDS.2007;21:2303-2308. 8. Gray RH, et al. Lancet. 2005;366;1182-1188. 9. Bernasconi D, et al. J Clin Virol. 2010;48:180-183. 10.Moodley D, et al. AIDS. 2009;23:1255-1259.
13. Advances in Preventing HIV Transmission Using Antiretroviral Therapyclinicaloptions.com/hiv Unanswered Questions  When to start lifelong ART?  Should pregnant women stop ARV drugs after delivery? – Evidence that earlier treatment prevents harmful impact of – What is the impact of ongoing HIV replication[1-3] postpartum discontinuation of combination regimens used – New DHHS guidelines solely for PMTCT on short- and recommend starting at all CD4+ long-term maternal health? cell counts, but strength of recommendation varies – With multiple pregnancies? – < 350 cells/mm3 (AI) – Treatment interruption in nonpregnant adults assoc. with – 350-500 cells/mm3 (AII) increased morbidity/mortality[5-7] – > 500 cells/mm3 (BIII) – PROMISE study1. Sterne JA, et al. Lancet. 2009;373:1352-1363. 2. Severe P, et al. N Engl J Med. 2010;363:257-265.3. Kitahata MM, et al. N Engl J Med. 2009;360:1815-1826. 4. DHHS Adult and Adolescent Guidelines. March 27, 2012. 5.Phillips AN, et al. Antivir Ther. 2008;13:177-187. 6. Lundgren JD, et al. J Infect Dis. 2008;197:1145-1155. 7. Silverberg MJ, etal. AIDS. 2007;21:1957-1963. 8. ClinicalTrials.gov. NCT01253538.
14. For the rest of this presentation download the full PowerPoint slideset for self-study or use in your own educational presentations at: clinicaloptions.com/ss/advancesQuick-reference PDF Worksheets on Preventing HIV Transmission Using Antiretroviral Therapy: The Role of OB/GYNs: Guidance on HIV Testing in Women Guidance on the Use of Antiretroviral Therapy to Prevent Mother-to-Child HIV Transmission Guidance on Prevention of HIV Transmission in Serodiscordant CouplesMore ways to connect with CCO: