06/07/09 Dr.Sujnanendra Mishra Dr.Sujnanendra Mishra. M.D.(O&G)  Sub Divisional Hospital.  PATNAGARH.  BOLANGIR. PMTCT - -...
06/07/09 Dr.Sujnanendra Mishra Welcome you  to this  brain storming session on HIV. CHIEF DISTRICT MEDICAL OFFICER & ASSOC...
06/07/09 Dr.Sujnanendra Mishra HIV  in INDIA
06/07/09 Dr.Sujnanendra Mishra
06/07/09 Dr.Sujnanendra Mishra Expanding Disease Burden 1986 to 2005
Mothers are always Targeted : 06/07/09 Dr.Sujnanendra Mishra “ Men Think  females Bring The Disease”
06/07/09 Dr.Sujnanendra Mishra Prevention of Parent- to- Child  Transmission   (“PPTCT”) (   generally known as “ PMTCT”) ...
06/07/09 Dr.Sujnanendra Mishra Rationale for PPTCT in India 27 million pregnancies per year 1,89,000 infected pregnancies ...
HIV antibody Quantitative viral load Qualitative HIV DNA Absolute CD4+ cell count  High risk of progression Moderate risk ...
Transmission during Pregnancy Perinatal & Breastfeeding 06/07/09 Dr.Sujnanendra Mishra 0% 20% 40% 60% 80% 100% Early Anten...
The route by which children  are infected with HIV <ul><li>In countries in which blood products are monitored, and where t...
The  frequency  of  perinatal HIV transmission <ul><li>In the natural course of  HIV infection  and in the absence of meas...
The  frequency  of  perinatal HIV transmission <ul><li>Perinatal HIV transmission  is greater in countries where: </li></u...
The  frequency  of  perinatal HIV transmission <ul><li>Data on the true level of  perinatal HIV transmission can be distor...
Perinatal HIV transmission risk factors <ul><li>HIV transmission take place :  </li></ul><ul><ul><li>in 25–40% before birt...
Routes of mother-to-child transmission of HIV   in utero and  during  delivery   <ul><li>Transplacental (hematogenous) </l...
Perinatal HIV transmission risk factors <ul><li>Maternal  factors : </li></ul><ul><ul><li>viral load </li></ul></ul><ul><u...
Perinatal HIV transmission risk factors <ul><li>Obstetric al   factors : </li></ul><ul><ul><li>prolonged interval between ...
Perinatal HIV transmission risk factors <ul><li>Fetal (infant)  factors : </li></ul><ul><ul><li>prematurity </li></ul></ul...
Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the  WHO protocol for th...
Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the  WHO protocol for th...
Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the  WHO protocol for th...
Core provisions of the section  &quot; Prevention  of Mother-to-Child Transmission of HIV &quot; of the  WHO protocol for ...
Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the  WHO protocol for th...
The strategy for the prevention of mother-to-child transmission of HIV . <ul><li>Primary prevention of HIV infection in wo...
Components of the prevention of mother-to-child transmission of HIV <ul><li>Prevention using ARV drugs </li></ul><ul><li>S...
  PMTCT  Feasibility Study    AZT: March 2000 - August 2001 <ul><li>Total new ANC attendance : 192,474 </li></ul><ul><li>N...
HIV Glossary <ul><li>pMTCT – Prevention of Mother-to-Child Transmission </li></ul><ul><li>BF – Breastfeeding </li></ul><ul...
06/07/09 Dr.Sujnanendra Mishra Four classes of ARV drugs approved
HIV REPLICATION 06/07/09 Dr.Sujnanendra Mishra
Overview of antiretroviral drugs <ul><li>Nucleoside reverse transcriptase inhibitors (NRTI) </li></ul><ul><ul><li>mode of ...
Other ARVs for pMTCT? <ul><li>3TC – Lamivudine </li></ul><ul><li>d4T – Stavudine </li></ul><ul><li>ddI – Didanosine </li><...
The three-part regimen of prevention of perinatal HIV   transmission  by  zidovudine (PACTG Protocol 076  [ Pediatric AIDS...
The short-course zidovudine regimen of prevention of perinatal HIV transmission <ul><li>Before  delivery : 100 mg 5 times ...
The  regimen of prevention of perinatal HIV   transmission  by  nevirapine <ul><li>For the woman in  labor/ delivery: in t...
The  PETRA  regimen of prevention of perinatal HIV transmission <ul><li>Zidovudine   +  lamivudine: </li></ul><ul><li>For ...
Prevention  regimen s using ARV drugs with a rate of  perinatal transmission below 2% <ul><li>HAART (USA)   –  0 . 9% </li...
Prevention of perinatal HIV transmission in the management of labor/delivery <ul><li>Planned  c esarean section performed ...
Prevention of perinatal HIV transmission in the management of labor/delivery <ul><li>Amniotomy and episiotomy should not b...
Clinical scenarios  for  prevention of  mother-to-child transmission of HIV (WHO  recommendations , March 2004) <ul><li>Wo...
Clinical scenarios  for  prevention of  mother-to-child transmission of HIV (WHO  recommendations , March 2004) <ul><li>Wo...
Clinical scenarios  for  prevention of  mother-to-child transmission of HIV (WHO  recommendations , March 2004) <ul><li>Wo...
HAART  during   pregnancy <ul><li>It is desirable to start ART at the end of trimester I of  pregnancy ; if the woman is s...
Clinical scenarios  for  prevention of  mother-to-child transmission of HIV (WHO  recommendations , March 2004) <ul><li>A ...
Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital   <ul><li>F...
Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital   <ul><li>F...
Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital   <ul><li>F...
Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital   <ul><li>I...
Contraindications to the prescription  of perinatal HIV prevention medicines <ul><li>Contraindications to the  prescriptio...
Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital   <ul><li>P...
Prevention of perinatal HIV   transmission  in  newborns <ul><li>The umbilical cord should be treated with a solution of c...
Strategy for the  prevention of transmission of HIV  from nursing mother to child <ul><li>The  strategy includes : </li></...
HIV Testing for Infants <ul><li>HIV antibody tests reflect maternal antibody!!! </li></ul><ul><ul><li>Stays positive for 1...
HIV Testing for Infants <ul><li>Current recommendation:   </li></ul><ul><li>HIV proviral DNA PCR test </li></ul><ul><ul><l...
HIV Testing for Infants <ul><li>To rule  OUT  HIV: </li></ul><ul><ul><li>Need two negative viral tests </li></ul></ul><ul>...
HIV Testing for Infants <ul><li>To rule  IN  HIV: </li></ul><ul><ul><li>Confirm a positive virologic test on a second spec...
Rapid Testing in Labor <ul><li>CDC recommends routine rapid HIV testing for women in labor without documented HIV test </l...
Rapid Testing in Labor <ul><li>Positive Tests </li></ul><ul><li>Positive predictive value ~50% (depending on local prevale...
Rapid Testing in Labor <ul><li>Sounds great but implementation can be difficult </li></ul><ul><li>Requires coordination of...
The Costs <ul><ul><li>SD NVP </li></ul></ul><ul><ul><ul><li>Maternal concerns </li></ul></ul></ul><ul><ul><ul><ul><li>NVP ...
Conclusions <ul><li>PMTCT among BF women in resource-limited Indian settings remains major challenge </li></ul><ul><ul><li...
06/07/09 Dr.Sujnanendra Mishra Thanks  for  Saving  me  Let The FUTURE say ;
06/07/09 Dr.Sujnanendra Mishra PPTCT  HELPS  PROTECT  THE   FUTURE
06/07/09 Dr.Sujnanendra Mishra THANK YOU
Upcoming SlideShare
Loading in...5
×

Pmtct A Thing Of Past

1,982

Published on

Mother /parent to child transmission of HIV is a real threat to the continuance of human race.We must have to fight and look forward for a HIV free world .

Published in: Education, Health & Medicine
1 Comment
4 Likes
Statistics
Notes
  • hiv
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
1,982
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
1
Comments
1
Likes
4
Embeds 0
No embeds

No notes for slide

Transcript of "Pmtct A Thing Of Past"

  1. 1. 06/07/09 Dr.Sujnanendra Mishra Dr.Sujnanendra Mishra. M.D.(O&G) Sub Divisional Hospital. PATNAGARH. BOLANGIR. PMTCT - - - CAN IT BE A THING OF PAST ?
  2. 2. 06/07/09 Dr.Sujnanendra Mishra Welcome you to this brain storming session on HIV. CHIEF DISTRICT MEDICAL OFFICER & ASSOCIATES BOLANGIR
  3. 3. 06/07/09 Dr.Sujnanendra Mishra HIV in INDIA
  4. 4. 06/07/09 Dr.Sujnanendra Mishra
  5. 5. 06/07/09 Dr.Sujnanendra Mishra Expanding Disease Burden 1986 to 2005
  6. 6. Mothers are always Targeted : 06/07/09 Dr.Sujnanendra Mishra “ Men Think females Bring The Disease”
  7. 7. 06/07/09 Dr.Sujnanendra Mishra Prevention of Parent- to- Child Transmission (“PPTCT”) ( generally known as “ PMTCT”) To be REPLACED BY
  8. 8. 06/07/09 Dr.Sujnanendra Mishra Rationale for PPTCT in India 27 million pregnancies per year 1,89,000 infected pregnancies per year Cohort of 56,700-60,000 infected newborns per year 0.7% prevalence 30% transmission
  9. 9. HIV antibody Quantitative viral load Qualitative HIV DNA Absolute CD4+ cell count High risk of progression Moderate risk of progression Low risk of progression Weeks of Infection 0 1 2 3 4 5 6 7 8 9 10 11 12 14 26 SCHEMATIC OF LABORATORY FINDINGS IN PRIMARY HIV INFECTION ACUTE RETROVIRAL SYNDROME
  10. 10. Transmission during Pregnancy Perinatal & Breastfeeding 06/07/09 Dr.Sujnanendra Mishra 0% 20% 40% 60% 80% 100% Early Antenatal (<36 wks) Late Antenatal (36 wks to labor) Labor and Delivery Late Postpartum (6-24 months) Early Postpartum (0-6 months) Proportion of infections
  11. 11. The route by which children are infected with HIV <ul><li>In countries in which blood products are monitored, and where there is a sufficient supply of sterile syringes and needles, transmission of the pathogen from an HIV-infected mother is the main route by which children are infected with the human immuno deficiency virus (HIV). </li></ul><ul><li>HIV can be transmitted from mother to child during pregnancy, delivery, and breastfeeding. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  12. 12. The frequency of perinatal HIV transmission <ul><li>In the natural course of HIV infection and in the absence of measures to prevent transmission, it is: </li></ul><ul><ul><li>15–30% - in the economically developed countries </li></ul></ul><ul><ul><li>40–50% - in the countries of Africa </li></ul></ul><ul><ul><li>25–27% - in INDIA </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  13. 13. The frequency of perinatal HIV transmission <ul><li>Perinatal HIV transmission is greater in countries where: </li></ul><ul><ul><li>the epidemic is spreading rapidly </li></ul></ul><ul><ul><li>there is a low level of medical care </li></ul></ul><ul><ul><li>prolonged breastfeeding of children by HIV-infected mothers is practiced </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  14. 14. The frequency of perinatal HIV transmission <ul><li>Data on the true level of perinatal HIV transmission can be distorted if early diagnosis of HIV infection in children is not established by means of the polymerase chain reaction (PCR) in a country with high infant mortality. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  15. 15. Perinatal HIV transmission risk factors <ul><li>HIV transmission take place : </li></ul><ul><ul><li>in 25–40% before birth </li></ul></ul><ul><ul><li>in 60–75% during delivery </li></ul></ul><ul><ul><li>In 7–22% during breastfeeding ; if the mother has an acute HIV infection at the time of breastfeeding , the risk of transmission is 29%. </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  16. 16. Routes of mother-to-child transmission of HIV in utero and during delivery <ul><li>Transplacental (hematogenous) </li></ul><ul><li>Across the amniotic membranes or via the amniotic fluid </li></ul><ul><li>Via contact of the maternal blood and the secretions of the maternal passages with the mucous membranes of the fetus </li></ul><ul><li>During diagnostic manipulations </li></ul>06/07/09 Dr.Sujnanendra Mishra
  17. 17. Perinatal HIV transmission risk factors <ul><li>Maternal factors : </li></ul><ul><ul><li>viral load </li></ul></ul><ul><ul><li>degree of immunosuppression </li></ul></ul><ul><ul><li>presence of other infectious diseases </li></ul></ul><ul><ul><li>drug use and smoking </li></ul></ul><ul><ul><li>vitamin A deficiency and poor nutrition </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  18. 18. Perinatal HIV transmission risk factors <ul><li>Obstetric al factors : </li></ul><ul><ul><li>prolonged interval between rupture of membranes and birth (more than 4 hours) </li></ul></ul><ul><ul><li>delivery through natural maternal passages </li></ul></ul><ul><ul><li>invasive interventions during pregnancy and delivery </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  19. 19. Perinatal HIV transmission risk factors <ul><li>Fetal (infant) factors : </li></ul><ul><ul><li>prematurity </li></ul></ul><ul><ul><li>low birth weight </li></ul></ul><ul><ul><li>first of twins </li></ul></ul><ul><ul><li>matching (concordance) of maternal and fetal HLA </li></ul></ul><ul><ul><li>infant's diseases in the period of breast or mixed feeding </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  20. 20. Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the WHO protocol for the CIS countries, March, 2004 . <ul><li>The campaign against HIV infection in newborns in each country is a policy obligation of the government. </li></ul><ul><li>The following should be reduced by the end of 2010: </li></ul><ul><ul><li>the prevalence of HIV infection among newborns down to 1 case per 100,000 live births </li></ul></ul><ul><ul><li>the rate of mother-to-child transmission of HIV - down to 2% or less. </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  21. 21. Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the WHO protocol for the CIS countries, March, 2004. <ul><li>Discrimination against HIV-infected women in medical facilities and in society must be eradicated. </li></ul><ul><li>The rights of HIV-infected women and their children must be protected </li></ul><ul><li>Every medical document, regardless of the presence in it of information on HIV status, is an object of medical secrecy . </li></ul>06/07/09 Dr.Sujnanendra Mishra
  22. 22. Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the WHO protocol for the CIS countries, March, 2004. <ul><li>The prevention of mother-to-child transmission (PMTCT) of HIV is an integral part of the comprehensive care of the HIV-infected woman and her children . </li></ul><ul><li>PMTCT measures must be carried out by all relevant governmental and non-governmental services (centers for the prevention and control of AIDS, facilities providing care to mothers and children , psychoso cial aid services ). </li></ul>06/07/09 Dr.Sujnanendra Mishra
  23. 23. Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the WHO protocol for the CIS countries, March, 2004. <ul><li>HIV testing in women's clinics must be voluntary. The provision of complete information and help in understanding it are obligatory components of the procedure for obtaining informed consent. </li></ul><ul><li>HIV-infected pregnant women must be afforded the opportunity to consciously decide the fate of her pregnancy , for which she must be provided full information on the risk of transmission of HIV to the infant and on the existing PMTCT measures. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  24. 24. Core provisions of the section &quot; Prevention of Mother-to-Child Transmission of HIV &quot; of the WHO protocol for the CIS countries, March, 2004. <ul><li>It is impermissible to dispose the HIV-infected pregnant woman to the interruption of her pregnancy . </li></ul><ul><li>Each pregnant woman must be provided antiretroviral drugs in accordance with the most effective regimen. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  25. 25. The strategy for the prevention of mother-to-child transmission of HIV . <ul><li>Primary prevention of HIV infection in women of child-bearing age </li></ul><ul><li>Prevention of unwanted pregnancies in HIV-infected women </li></ul><ul><li>Drug-based prevention of mother-to-child transmission of HIV during pregnancy and rational delivery of HIV-infected women </li></ul><ul><li>Introduction of contemporary methods for the diagnosis of HIV infection in children and optimization of their management </li></ul>06/07/09 Dr.Sujnanendra Mishra
  26. 26. Components of the prevention of mother-to-child transmission of HIV <ul><li>Prevention using ARV drugs </li></ul><ul><li>Safe obstetrics, including planned cesarean section at the 38th week of pregnancy </li></ul><ul><li>Safe feeding of the child (when possible , artificial feeding) </li></ul>06/07/09 Dr.Sujnanendra Mishra
  27. 27. PMTCT Feasibility Study AZT: March 2000 - August 2001 <ul><li>Total new ANC attendance : 192,474 </li></ul><ul><li>No. of pregnant mothers counseled : 171,471 (89.1%) </li></ul><ul><li>No. of pregnant mothers accepted HIV tests : 103,681 (60.5%) </li></ul><ul><li>No. of pregnant mothers detected HIV positive : 1,724 (1.7%) </li></ul><ul><li>No. delivered with AZT : 726 (42.1%) </li></ul><ul><li>No. of PCR samples at 48 hrs. tested : 427 </li></ul><ul><li>No. of samples tested (+) positive : 34/427 (8.0%) </li></ul><ul><li>No. of additional tested (+) at 2 months : 9 </li></ul><ul><li>(adding a 2% transmission rate) </li></ul><ul><li>No. of women who opted for breastfeeding : 22% </li></ul>06/07/09 Dr.Sujnanendra Mishra
  28. 28. HIV Glossary <ul><li>pMTCT – Prevention of Mother-to-Child Transmission </li></ul><ul><li>BF – Breastfeeding </li></ul><ul><li>ARV – Antiretroviral (medication) </li></ul><ul><li>HAART – Highly Active Antiretroviral Therapy </li></ul><ul><li>AZT – Zidovudine </li></ul><ul><li>NVP – Nevirapine </li></ul><ul><li>SD NVP – Single Dose Nevirapine </li></ul><ul><li>AP – Antepartum </li></ul><ul><li>IP – Intrapartum </li></ul><ul><li>PP – Postpartum </li></ul>06/07/09 Dr.Sujnanendra Mishra
  29. 29. 06/07/09 Dr.Sujnanendra Mishra Four classes of ARV drugs approved
  30. 30. HIV REPLICATION 06/07/09 Dr.Sujnanendra Mishra
  31. 31. Overview of antiretroviral drugs <ul><li>Nucleoside reverse transcriptase inhibitors (NRTI) </li></ul><ul><ul><li>mode of action: Nucleoside analog (“wrong module”), requires intracellular activation </li></ul></ul><ul><ul><li>7 drugs currently approved </li></ul></ul><ul><li>Non- nucleoside reverse transcriptase inhibitors (NNRTI) </li></ul><ul><ul><li>mode of action: non-competitive inhibition of viral RT </li></ul></ul><ul><ul><li>3 drugs currently approved </li></ul></ul><ul><li>Protease Inhibitors (PI) </li></ul><ul><ul><li>mode of action: inhibition of the viral protease </li></ul></ul><ul><ul><li>7 drugs currently approved </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  32. 32. Other ARVs for pMTCT? <ul><li>3TC – Lamivudine </li></ul><ul><li>d4T – Stavudine </li></ul><ul><li>ddI – Didanosine </li></ul><ul><li>TNF – Tenofovir </li></ul><ul><li>Nelfinavir </li></ul><ul><li>Saquinavir </li></ul><ul><li>Indinavir </li></ul><ul><li>Lopinavir/ritonavir </li></ul>06/07/09 Dr.Sujnanendra Mishra NRTIs Nucleotide RTI Protease Inhibitors
  33. 33. The three-part regimen of prevention of perinatal HIV transmission by zidovudine (PACTG Protocol 076 [ Pediatric AIDS Clinical Trials Group] ) <ul><li>Before delivery : 100 mg 5 times a day orally (or 250-300 mg 2 times a day) starting from the 14th-34th week of pregnancy. </li></ul><ul><li>During labor/ delivery : Intravenous injection in the first hour of delivery, 2 mg/kg, then 1 mg/kg per hour until the birth of the infant. </li></ul><ul><li>For the newborn: starting 8-12 hours after birth, as syrup orally, 2 mg/kg every 6 hours over the first 6 weeks (if oral administration of the drug is not possible, it is used intravenously, 1.5 mg/kg every 6 hours ) </li></ul><ul><li>Thi s regimen makes it possible to reduce perinatal HIV transmission by 68% (provided that the mother does not breastfeed the baby), i.e., the rate of HIV transmission to newborns falls to 7-8%. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  34. 34. The short-course zidovudine regimen of prevention of perinatal HIV transmission <ul><li>Before delivery : 100 mg 5 times a day orally (or 250-300 mg 2 times a day) starting from the 34th-36th week </li></ul><ul><li>During labor/ delivery : orally 250-300 mg every 3 hours until the birth of the infant </li></ul><ul><li>For the newborn: the drug is not prescribed, artificial feeding is recommended </li></ul><ul><li>Thi s prevention regimen reduces perinatal transmission by 30 - 50% </li></ul>06/07/09 Dr.Sujnanendra Mishra
  35. 35. The regimen of prevention of perinatal HIV transmission by nevirapine <ul><li>For the woman in labor/ delivery: in the initial period of labor, 200 mg orally once </li></ul><ul><li>For the newborn: as syrup orally, 2 mg/kg in the period between 48 and 72 hours after birth </li></ul><ul><li>Thi s prevention regimen reduces perinatal transmission by 47% </li></ul>06/07/09 Dr.Sujnanendra Mishra
  36. 36. The PETRA regimen of prevention of perinatal HIV transmission <ul><li>Zidovudine + lamivudine: </li></ul><ul><li>For the woman from week 36 of pregnancy + during labor/delivery + 1 week for the mother and infant after birth </li></ul><ul><li>reduction of perinatal transmission by 50% </li></ul><ul><li>For the woman from week 36 of pregnancy + during labor/delivery </li></ul><ul><li>reduction of perinatal HIV transmission by 37% . </li></ul>06/07/09 Dr.Sujnanendra Mishra
  37. 37. Prevention regimen s using ARV drugs with a rate of perinatal transmission below 2% <ul><li>HAART (USA) – 0 . 9% </li></ul><ul><li>(Rate of planned cesarean section <40%) </li></ul><ul><li>Zidovudine + lamivudine ( France ) – 1 . 6% </li></ul><ul><li>(Rate of planned cesarean section >60%) </li></ul>06/07/09 Dr.Sujnanendra Mishra
  38. 38. Prevention of perinatal HIV transmission in the management of labor/delivery <ul><li>Planned c esarean section performed before the onset of labor and the rupture of membranes; reduces the risk of HIV infection for the fetus. </li></ul><ul><li>Surgical delivery, performed for emergency indications, is not a measure for the prevention of perinatal HIV transmission. </li></ul><ul><li>Hemostatic cesarean section, a modification of planned surgical delivery that prevents contact of the skin and mucous membranes of the fetus with maternal blood and cervical/vaginal secretions, most effectively reduces the risk of HIV transmission. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  39. 39. Prevention of perinatal HIV transmission in the management of labor/delivery <ul><li>Amniotomy and episiotomy should not be done during the management of delivery via the natural maternal passages; the application of obstetrical forceps and vacuum extractor should be avoided; it is not desirable to carr y out induction and stimulation of labor. </li></ul><ul><li>It is desirable to avoid all procedures which impair the integrity of the skin of the fetus or increase the possibility of contact of the fetus with the mother's blood (invasive monitoring). </li></ul>06/07/09 Dr.Sujnanendra Mishra
  40. 40. Clinical scenarios for prevention of mother-to-child transmission of HIV (WHO recommendations , March 2004) <ul><li>Woman does not need treatment (asymptomatic HIV infection) </li></ul><ul><li>For the mother - starting from the 28th week of pregnancy and during l abor/delivery : </li></ul><ul><ul><li>1) zidovudine + lamivudine +(saquinavir/ritonavir or nelfinavir), if these drugs are available </li></ul></ul><ul><ul><li>2) zidovudine during pregnancy and labor/delivery, 300 mg orally twice daily + nevirapine at the beginning of labor /delivery , 200 mg once. </li></ul></ul><ul><ul><li>+ planned cesarean section at 38 weeks </li></ul></ul><ul><li>For the infant : </li></ul><ul><ul><li>zidovudine syrup, 4 mg/kg every 12 hours for 1 week </li></ul></ul><ul><ul><li>OR nevirapine , 2 mg/kg once </li></ul></ul><ul><ul><li>OR both drugs. </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  41. 41. Clinical scenarios for prevention of mother-to-child transmission of HIV (WHO recommendations , March 2004) <ul><li>Woman does not need treatment (asymptomatic HIV infection) , alternative regimens without nevirapine </li></ul><ul><li>1) For the woman : zidovudine from the 28th week of pregnancy and during l abor/delivery </li></ul><ul><li>For the infant : zidovudine syrup, 4 mg/kg orally every 12 hours for 1 week (if the woman has been provided prophylaxis for less than 4 weeks - the syrup is given to the infant longer up to 4 weeks) </li></ul><ul><li>2) For the woman zidovudine 300 mg + lamivudine 150 mg orally 2 times a day from the 34th–36th week of pregnancy and during l abor/delivery </li></ul><ul><li>For the infant : zidovudine syrup 4 mg/kg + lamivudine syrup 2 mg/kg every 12 hours for 1 week . </li></ul>06/07/09 Dr.Sujnanendra Mishra
  42. 42. Clinical scenarios for prevention of mother-to-child transmission of HIV (WHO recommendations , March 2004) <ul><li>Woman needs treatment for her health: </li></ul><ul><li>If HAART is unavailable - the same scenarios as for the case of absence of indications for treatment </li></ul><ul><li>If HAART is available: </li></ul><ul><li># For the woman: ( zidovudine or stavudine) + lamivudine + nevirapine </li></ul><ul><li># For the infant : zidovudine or nevirapine or both drugs </li></ul>06/07/09 Dr.Sujnanendra Mishra
  43. 43. HAART during pregnancy <ul><li>It is desirable to start ART at the end of trimester I of pregnancy ; if the woman is severely ill, start treatment immediately. </li></ul><ul><li>At the beginning of pregnancy - continue prior ART regimen (exception: in trimesters II and III of pregnancy, switch from ifavirenz to nevirapine or PI [protease inhibitor]. </li></ul><ul><li>Stavudine + didanosine are not advisable during pregnancy (the risk of lactic acidosis is increased ). They can be prescribed only if there is no other choice. </li></ul><ul><li>Nevirapine can cause hepatic toxicity and severe rash. The risk of these side effects is higher in women with a high CD4 lymphocyte count (> 250/ µL ) . </li></ul>06/07/09 Dr.Sujnanendra Mishra
  44. 44. Clinical scenarios for prevention of mother-to-child transmission of HIV (WHO recommendations , March 2004) <ul><li>A woman has not received prophylaxis , has arrived with labor pains; the diagnosis of HIV infection is established, or a positive express test result has been obtained in the labor ward: </li></ul><ul><li>The woman is given 200 mg nevirapine once; delivery via the natural maternal passages </li></ul><ul><li>The infant is given zidovudine syrup, 4 mg/kg every 12 hours for 4 weeks + nevirapine 2 mg/kg 1 time 72 hours after birth. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  45. 45. Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital <ul><li>For pregnant women who come in before week 28 of pregnancy : </li></ul><ul><li>Starting week 28 – zidovudine 300 mg orally twice daily up to the beginning of labor/delivery . </li></ul><ul><li>During labor/delivery – zidovudine 300 mg orally every 3 hours until the birth of the infant. </li></ul><ul><li>For the newborn: zidovudine as syrup orally, 4 mg/kg every 12 hours for 7 days. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  46. 46. Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital <ul><li>For pregnant women who come in after week 28 of pregnancy: up to the beginning of labor/delivery : </li></ul><ul><li>Before labor/delivery – zidovudine 300 mg orally twice daily . </li></ul><ul><li>During labor/delivery – zidovudine 300 mg orally twice daily until the birth of the infant + nevirapine 200 mg the beginning of labor/delivery. </li></ul><ul><li>For the newborn: zidovudine as syrup, 4 mg/kg every 12 hours for 7 days + nevirapine 2 mg/kg for the first 72 hours. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  47. 47. Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital <ul><li>For women in labor who have not undergone PMTCT with antiretroviral drugs during pregnancy : </li></ul><ul><li>Nevirapine 2 00 mg orally once at the beginning of labor/delivery </li></ul><ul><li>For the newborn: nevirapine as syrup orally, 2 mg/kg once at age 72 hours + retrovir syrup 4 mg/kg every 12 hours for 4 weeks </li></ul>06/07/09 Dr.Sujnanendra Mishra
  48. 48. Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital <ul><li>If labor/delivery have taken place outside of a patient care facility: </li></ul><ul><li>Prophylaxis is not prescribed for the woman. </li></ul><ul><li>For the newborn: nevirapine as syrup orally, 2 mg/kg once at age 72 hours + retrovir syrup 4 mg/kg every 12 hours for 4 weeks </li></ul>06/07/09 Dr.Sujnanendra Mishra
  49. 49. Contraindications to the prescription of perinatal HIV prevention medicines <ul><li>Contraindications to the prescription of r etrovir : </li></ul><ul><ul><li>Granulocytopenia (below 0.75 thous/L) </li></ul></ul><ul><ul><li>Anemia ( hemoglobin below 75 g/L) </li></ul></ul><ul><ul><li>Thrombocytopenia (below 100 thous/L) </li></ul></ul><ul><ul><li>ALAT and ASAT exceed the norm by a factor of 2.5 </li></ul></ul><ul><ul><li>Creatinine exceeds the norm by a factor of 1.4 </li></ul></ul><ul><ul><li>Contraindications to the prescription of nevirapine : </li></ul></ul><ul><ul><li>Duration of pregnancy less than 28 weeks </li></ul></ul><ul><ul><li>The woman has previously received nevirapine or NNRTIs [non-nucleoside reverse transcriptase inhibitors] </li></ul></ul><ul><ul><li>Hypersensitivity to the drug </li></ul></ul><ul><ul><li>Impaired liver function or ALAT exceeds the norm by a factor of 10 </li></ul></ul><ul><ul><li>Impossibility of providing enteral nutrition </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  50. 50. Prophylaxis in relation to the time of an HIV-infected woman's visit to a women's clinic or maternity hospital <ul><li>Planned (elective) cesarean section is performed as a method of PMTCT provided the pregnant woman’s viral load is greater than 1000 HIV copies in 1 mL of blood plasma at week 38 of pregnancy before the onset of labor and before the rupture of membranes. </li></ul><ul><li>In this case, the woman receives antiretroviral drugs according to one of the prophylaxis regimens . </li></ul>06/07/09 Dr.Sujnanendra Mishra
  51. 51. Prevention of perinatal HIV transmission in newborns <ul><li>The umbilical cord should be treated with a solution of chlorhexidine (aqueous or alcohol) before it is cut. </li></ul><ul><li>The contents of the oral cavity, nose, and stomach of the infant should be suctioned carefully and meticulously. </li></ul><ul><li>The initial cleansing of the infant is done very cautiously, in order not to injure the skin and to preclude rubbing secretions of the maternal birth passages into it. The infant should be submerged in a warm soapy solution, it should be washed off, and then rinsed with warm water. </li></ul><ul><li>When abrasions are present on the newborn‘s skin, they are treated with a 3% solution of hydrogen peroxide, then with an alcohol solution of chlorhexidine; abrasions on the mucous membranes should be treated with an aqueous solution of chlorhexidine. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  52. 52. Strategy for the prevention of transmission of HIV from nursing mother to child <ul><li>The strategy includes : </li></ul><ul><ul><li>counseling the HIV-infected woman on issues relating to infant feeding </li></ul></ul><ul><ul><li>the recommendation of artificial feeding </li></ul></ul><ul><ul><li>free and continuous provision of high-quality adapted milk mixtures </li></ul></ul><ul><ul><li>provision of safe water for the preparation of the milk mixture . </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  53. 53. HIV Testing for Infants <ul><li>HIV antibody tests reflect maternal antibody!!! </li></ul><ul><ul><li>Stays positive for 12-18 months </li></ul></ul><ul><ul><li>Negative antibody test at 18 months definitively rules out MTCT </li></ul></ul><ul><ul><li>Don’t use cord blood: may be contaminated with maternal blood </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  54. 54. HIV Testing for Infants <ul><li>Current recommendation: </li></ul><ul><li>HIV proviral DNA PCR test </li></ul><ul><ul><li>Sens/spec are excellent </li></ul></ul><ul><ul><ul><li>Specificity close to 100% at all time points </li></ul></ul></ul><ul><ul><li>Testing recommended at: </li></ul></ul><ul><ul><ul><li>48 hours (sens 38%) </li></ul></ul></ul><ul><ul><ul><li>14 days (optional for high risk patients; sens 90%) </li></ul></ul></ul><ul><ul><ul><li>1-2 months (sen 96%) </li></ul></ul></ul><ul><ul><ul><li>3-6 months (99.9% sens) </li></ul></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  55. 55. HIV Testing for Infants <ul><li>To rule OUT HIV: </li></ul><ul><ul><li>Need two negative viral tests </li></ul></ul><ul><ul><ul><li>One at 1 month or older </li></ul></ul></ul><ul><ul><ul><li>One at 4 months or older </li></ul></ul></ul><ul><ul><li>Confirm with negative ab test at 18 months </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  56. 56. HIV Testing for Infants <ul><li>To rule IN HIV: </li></ul><ul><ul><li>Confirm a positive virologic test on a second specimen ASAP </li></ul></ul><ul><ul><li>HIV infection diagnosed by </li></ul></ul><ul><ul><ul><li>two positive virologic tests on separate samples drawn at any age; or </li></ul></ul></ul><ul><ul><ul><li>HIVab+ after 18 months </li></ul></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  57. 57. Rapid Testing in Labor <ul><li>CDC recommends routine rapid HIV testing for women in labor without documented HIV test </li></ul><ul><ul><li>EIA screening test </li></ul></ul><ul><ul><li>Results in < 1hr </li></ul></ul><ul><ul><li>99-100% sensitive and specific </li></ul></ul><ul><ul><li>Needs confirmatory Western blot </li></ul></ul><ul><li>It’s not too late to intervene! </li></ul>06/07/09 Dr.Sujnanendra Mishra
  58. 58. Rapid Testing in Labor <ul><li>Positive Tests </li></ul><ul><li>Positive predictive value ~50% (depending on local prevalence) </li></ul><ul><li>Act on all positive rapid tests as true positives (until confirmatory test) </li></ul><ul><li>Initiate meds in mom ASAP </li></ul><ul><li>Consider using expanded regimen for mom and infant </li></ul><ul><li>Consult local perinatal HIV experts or call the Perinatal Hotline 888 448-8765 </li></ul>06/07/09 Dr.Sujnanendra Mishra
  59. 59. Rapid Testing in Labor <ul><li>Sounds great but implementation can be difficult </li></ul><ul><li>Requires coordination of health care providers, L&D, laboratory, hospital administration, risk management etc.. </li></ul>06/07/09 Dr.Sujnanendra Mishra
  60. 60. The Costs <ul><ul><li>SD NVP </li></ul></ul><ul><ul><ul><li>Maternal concerns </li></ul></ul></ul><ul><ul><ul><ul><li>NVP resistance in up to 75% women after single dose </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Less likely to achieve maximal response to ARV therapy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>But if respond to ARV therapy, long term response good </li></ul></ul></ul></ul><ul><ul><ul><ul><li>May be more likely to respond if wait > 6 months </li></ul></ul></ul></ul><ul><ul><ul><li>Infant concerns </li></ul></ul></ul><ul><ul><ul><ul><li>NVP resistance up to 50% after single infant dose </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Resistance higher if mother also received dose </li></ul></ul></ul></ul><ul><ul><ul><ul><li>But transmission in subsequent pregnancies equivalent </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Unknown how this impacts infant response to ARV </li></ul></ul></ul></ul><ul><ul><li>HAART </li></ul></ul><ul><ul><ul><li>Women on HAART 5x more likely to have LBW infant even when adjusted for HIV severity </li></ul></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  61. 61. Conclusions <ul><li>PMTCT among BF women in resource-limited Indian settings remains major challenge </li></ul><ul><ul><li>BF assoc. with major reductions in infant mortality </li></ul></ul><ul><ul><li>But accounts for over 1/3 HIV transmissions among BF women </li></ul></ul><ul><ul><li>Early weaning (@4-6 mo.) currently recommended, but some data suggesting increased: </li></ul></ul><ul><ul><ul><li>Hospitalizations for gastroenteritis </li></ul></ul></ul><ul><ul><ul><li>Growth faltering after weaning </li></ul></ul></ul><ul><ul><li>Resistance to NVP may complicate maternal/infant care & treatment </li></ul></ul><ul><ul><li>Many studies ongoing to evaluate pMTCT interventions during BF </li></ul></ul>06/07/09 Dr.Sujnanendra Mishra
  62. 62. 06/07/09 Dr.Sujnanendra Mishra Thanks for Saving me Let The FUTURE say ;
  63. 63. 06/07/09 Dr.Sujnanendra Mishra PPTCT HELPS PROTECT THE FUTURE
  64. 64. 06/07/09 Dr.Sujnanendra Mishra THANK YOU

×