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Unit 5 drug regimens for pmtct
 

Unit 5 drug regimens for pmtct

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    Unit 5 drug regimens for pmtct Unit 5 drug regimens for pmtct Presentation Transcript

    • Drug regimes for PMTCT and their use during pregnancy, intrapartum and postpartum
    • Session Objective and content
      • Objective: At the end of the session the participant should be able Describe the various drug regimes for PMTCT used during pregnancy, intrapartum and postpartum including short course ART
      • Content
          • Use of antiretroviral drugs and pregnancy
          • Selection of short course ART regimens for PMTCT-- efficacy, toxicity, timing of initiation and cessation
          • Use of HAART for PMTCT
    • Antiretrovirals in PMTCT
      • ARV therapy
        • Long-term use of antiretroviral drugs to manage maternal HIV/AIDS and prevent PMTCT.
      • ARV prophylaxis
        • Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant.
          • Prophylaxis with nevirapine
          • Prophylaxis with AZT and nevirapine
          • Post exposure prophylaxis
          • Prophylaxis with HAART
    • Antiretrovirals and pregnancy
      • Nucleoside analogue drugs are known to induce mitochondrial dysfunction,
        • highest for zalcitabine (ddC), didanosine (ddI), stavudine (d4T).
        • Present as neuropathy, myopathy, cardiomyopathy, pancreatitis,
      • Efavirenz: birth defects with first trimester exposure (polydactaly, hydronephrosis; bilateral hip dislocation, umbilical hernia, urinary obstruction and neural tube defects)
      • Hyperglycemia, and diabetic ketoacidosis reported with protease inhibitor.
      • increased risk of preterm delivery for infants exposed to combination therapy with or without protease particularly started before pregnancy
      • CP450 inhibition by Protease inhibitors can lead to ergortism with administration of ergometrine
    • Interaction of Nevirapine for PMCT and for ART
      • NNRTI based HAART, often with NVP, is the first line treatment regimen in resource limited settings based on WHO recommendations
        • Based on cost, efficacy, full awareness of toxicities
      • NVP alone or in combination with other ARVs is the most commonly used drug for PMTCT in developing countries
      • Concerns
        • safety concerns higher risk of liver and cutaneous adverse events among women with>250 CD4 count with chronic (non single dose) NVP
        • Resistance even with single dose
    • Prophylaxis with Nevirapine (NVP)
      • A single 200 mg tablet for the mother to take at the onset of labour
      • A single dose of oral suspension (standard dosage = 2 mg/kg) to be given to the infant immediately after birth or within 72 hours of delivery.
    • Prophylaxis with AZT and NVP
      • Antenatal
        • Mother: AZT 300 mg twice daily starting at 28 weeks or as soon thereafter as possible. AZT may be started as late as 36 weeks.
      • Intrapartum
        • Mother: AZT 300 mg at onset of labour and every 3 hours until delivery and single-dose NVP 200 mg at onset of labour.
        • OR
        • AZT 600 mg at onset of labour AND single-dose NVP 200 mg at onset of labour.
      • Postpartum
        • Infant: NVP 2 mg/kg oral suspension immediately after birth or within 72 hours of delivery and AZT 4 mg/kg twice a day for 7 days.
        • OR
        • NVP 2 mg/kg oral suspension immediately after birth or within 72 hours of delivery.
    • Post exposure prophylaxis 13.4% Vs 17% difference NS 16.2% NVP stat Vs AZT 6 weeks South Africa (secure future) 22% 39% difference 14% NVP stat vs NVP stat + 7 day AZT Malawi Forgarty TX and efficacy Infant Regimen
    • HAART for PMTCT
      • Avoid NVP
      • Avoid EFV unless in late pregnancy
      • Defer in 1 st trimester
      • Monitor as with HAART treatment
      • Most experience with
        • AZT/3TC/Kaletra
        • AZT/3TC/NFV
    • PMTCT plus
      • The implementation of strategies to provide
      • Treatment, care and support of women
      • infected with HIV, their infants and their
      • families.
    • PMTCT-Plus Strategies
      • Child
        • Monitoring the growth and development of the HIV-exposed child including immunisations
        • Prevention and treatment of opportunistic infections
        • Diagnosis of HIV
      • Mother and partner
        • Nutritional counseling
        • Psychosocial support
        • Support for implementation of safer infant-feeding practices
        • Counselling in family planning
      • Family
        • Assessment and initiation of ARV therapy
        • Linkage to related community service organisations and agencies to promote continuity of care