Unit 5 drug regimens for pmtct


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Unit 5 drug regimens for pmtct

  1. 1. Drug regimes for PMTCT and their use during pregnancy, intrapartum and postpartum
  2. 2. Session Objective and content <ul><li>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 </li></ul><ul><li>Content </li></ul><ul><ul><ul><li>Use of antiretroviral drugs and pregnancy </li></ul></ul></ul><ul><ul><ul><li>Selection of short course ART regimens for PMTCT-- efficacy, toxicity, timing of initiation and cessation </li></ul></ul></ul><ul><ul><ul><li>Use of HAART for PMTCT </li></ul></ul></ul>
  3. 3. Antiretrovirals in PMTCT <ul><li>ARV therapy </li></ul><ul><ul><li>Long-term use of antiretroviral drugs to manage maternal HIV/AIDS and prevent PMTCT. </li></ul></ul><ul><li>ARV prophylaxis </li></ul><ul><ul><li>Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant. </li></ul></ul><ul><ul><ul><li>Prophylaxis with nevirapine </li></ul></ul></ul><ul><ul><ul><li>Prophylaxis with AZT and nevirapine </li></ul></ul></ul><ul><ul><ul><li>Post exposure prophylaxis </li></ul></ul></ul><ul><ul><ul><li>Prophylaxis with HAART </li></ul></ul></ul>
  4. 4. Antiretrovirals and pregnancy <ul><li>Nucleoside analogue drugs are known to induce mitochondrial dysfunction, </li></ul><ul><ul><li>highest for zalcitabine (ddC), didanosine (ddI), stavudine (d4T). </li></ul></ul><ul><ul><li>Present as neuropathy, myopathy, cardiomyopathy, pancreatitis, </li></ul></ul><ul><li>Efavirenz: birth defects with first trimester exposure (polydactaly, hydronephrosis; bilateral hip dislocation, umbilical hernia, urinary obstruction and neural tube defects) </li></ul><ul><li>Hyperglycemia, and diabetic ketoacidosis reported with protease inhibitor. </li></ul><ul><li>increased risk of preterm delivery for infants exposed to combination therapy with or without protease particularly started before pregnancy </li></ul><ul><li>CP450 inhibition by Protease inhibitors can lead to ergortism with administration of ergometrine </li></ul>
  5. 5. Interaction of Nevirapine for PMCT and for ART <ul><li>NNRTI based HAART, often with NVP, is the first line treatment regimen in resource limited settings based on WHO recommendations </li></ul><ul><ul><li>Based on cost, efficacy, full awareness of toxicities </li></ul></ul><ul><li>NVP alone or in combination with other ARVs is the most commonly used drug for PMTCT in developing countries </li></ul><ul><li>Concerns </li></ul><ul><ul><li>safety concerns higher risk of liver and cutaneous adverse events among women with>250 CD4 count with chronic (non single dose) NVP </li></ul></ul><ul><ul><li>Resistance even with single dose </li></ul></ul>
  6. 6. Prophylaxis with Nevirapine (NVP) <ul><li>A single 200 mg tablet for the mother to take at the onset of labour </li></ul><ul><li>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. </li></ul>
  7. 7. Prophylaxis with AZT and NVP <ul><li>Antenatal </li></ul><ul><ul><li>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. </li></ul></ul><ul><li>Intrapartum </li></ul><ul><ul><li>Mother: AZT 300 mg at onset of labour and every 3 hours until delivery and single-dose NVP 200 mg at onset of labour. </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>AZT 600 mg at onset of labour AND single-dose NVP 200 mg at onset of labour. </li></ul></ul><ul><li>Postpartum </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>OR </li></ul></ul><ul><ul><li>NVP 2 mg/kg oral suspension immediately after birth or within 72 hours of delivery. </li></ul></ul>
  8. 8. 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
  9. 9. HAART for PMTCT <ul><li>Avoid NVP </li></ul><ul><li>Avoid EFV unless in late pregnancy </li></ul><ul><li>Defer in 1 st trimester </li></ul><ul><li>Monitor as with HAART treatment </li></ul><ul><li>Most experience with </li></ul><ul><ul><li>AZT/3TC/Kaletra </li></ul></ul><ul><ul><li>AZT/3TC/NFV </li></ul></ul>
  10. 10. PMTCT plus <ul><li>The implementation of strategies to provide </li></ul><ul><li>Treatment, care and support of women </li></ul><ul><li>infected with HIV, their infants and their </li></ul><ul><li>families. </li></ul>
  11. 11. PMTCT-Plus Strategies <ul><li>Child </li></ul><ul><ul><li>Monitoring the growth and development of the HIV-exposed child including immunisations </li></ul></ul><ul><ul><li>Prevention and treatment of opportunistic infections </li></ul></ul><ul><ul><li>Diagnosis of HIV </li></ul></ul><ul><li>Mother and partner </li></ul><ul><ul><li>Nutritional counseling </li></ul></ul><ul><ul><li>Psychosocial support </li></ul></ul><ul><ul><li>Support for implementation of safer infant-feeding practices </li></ul></ul><ul><ul><li>Counselling in family planning </li></ul></ul><ul><li>Family </li></ul><ul><ul><li>Assessment and initiation of ARV therapy </li></ul></ul><ul><ul><li>Linkage to related community service organisations and agencies to promote continuity of care </li></ul></ul>