Unit 5 drug regimens for pmtct
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  • 1. Drug regimes for PMTCT and their use during pregnancy, intrapartum and postpartum
  • 2. 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
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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.
  • 7. 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.
  • 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. 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
  • 10. PMTCT plus
    • The implementation of strategies to provide
    • Treatment, care and support of women
    • infected with HIV, their infants and their
    • families.
  • 11. 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