hiv in pregnancy

1. HIV In Mothers and
Children

2. 2
What Is HIV/AIDS?
• Acquired immunodeficiencysyndrome (AIDS) is caused
by the humanimmunodeficiencyvirus (HIV).
• HIV attacks and destroys whiteblood cells, causinga
defect in thebody’s immunesystem.

3. 3
What Is HIV/AIDS?
• The immunesystem of an HIV-infectedperson becomes
so weakenedthatit cannotprotect itself from serious
infections. Whenthishappens, theperson clinically has
AIDS.
• AIDS may manifestas early as 2 years or as late as 10
years after infectionwith HIV.

4. 4
Number ofPeoplewith
HIV/AIDSby Region
North America
890,000
Caribbean
330,000
Latin
America
1.4 million
Western Europe
500,000
Sub-Saharan
Africa
22.5 million
Eastern Europe &
Central Asia
270,000 East Asia
& Pacific
560,000
South and
South East Asia
6.7 million
Australia and New Zealand
12,000
North Africa &
Middle East
210,000
Source: UNAIDS/WHO 1998.

5. 5
HIV Transmission Through SexualContact
• Of every 100 HIV infectedadults, 75-85 have been
infectedthrough unprotected intercourse
– 70% of these infections are from heterosexual intercourse
• STDs, especially ulcerative lesions in genitalia,increase
risk of transmission
Source: UNAIDS/WHO 1996.

6. 6
Modesof HIV Transmission
• Sexualintercourse
• Accidental exposure to blood/blood products (e.g.,
blood transfusions,shared needles, contaminated
instruments)
• Mother to childduring:
– pregnancy
– birth
– breastfeeding

7. 7
Womenand HIV
Social Risk Factors
– Illiteracy
– Lackof awarenessof preventive measures
Biological risk factors
– Twiceas easy for women to contract HIVfrom men
– Physiology of women (e.g., menstruation, intercourse)
– Pregnancy-associated conditions (e.g., anemia, menorrhagia and
hemorrhage) increase the need for blood transfusion

8. 8
HIV andContraception
• Contraception withprotection
– Male condom (latex and vinyl)
– Female condom
– Nonoxynol-9 (antiviralspermicidal cream)1
– Diaphragm1
• Methods appropriate for use by womenwith HIV. They should
use a condom for their partner’s protection.
– Hormonals (COCs, Implants, PICs)
– Voluntary sterilization
1Partial protection if used without condom

9. 9
Effectof AIDSon Pregnancy
• Infertility
• Repeated abortions
• Prematurity
• Intrauterinegrowth retardation
• Stillbirths
• Congenitalabnormalities
• Embryopathies

10. 10
HIV Transmission from Mother toInfant
• Antenatal
– In utero bytransplacentalpassage
• Intranatal
– Exposure to maternal blood and vaginalsecretions during labor
and delivery
• Postnatal
– Postpartum through breastfeeding
Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998.

11. 11
HIV Transmission from Mother toInfant
• 25-35% of all infantsborn to HIV-infected womenin
developing countriesbecome infected
• 90% of HIV-infectedinfantsand children were infectedby
mother
Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998.

12. • approximately 600,000 HIV-infected infants
are born every year–at least 1,600 every
day–in resource-constrained countries.
• Transmission occurs during pregnancy,
labor and delivery, and breastfeeding.
• The rate of mother to child transmission has
been reduced to less than 5 percent
among the limited number of HIV-infected
women in developed countries.

13. • high rates are largely due to
the lack of access to:
–HIV voluntary counseling and
testing
– replacement feeding
–selective caesarean section
–antiretroviral drug therapy

14. 14
HIV Transmission
HIV cannot be transmittedby:
– Casualperson to person contact at home or work or in socialor
public places
– Food, air, water
– Insect/mosquito bites
– Coughing, sneezing, spitting
– Shakinghands, touching, dry kissingor hugging
– Swimming pools, toilets, etc.

15. 15
AIDSand Infants
• Symptoms generallydevelop by 6 monthsof age
– Diarrhea
– Failure to thrive
• Most of thesechildren diebefore their second birthday
• Children born to HIV-infected parents are likely to become
orphans

16. Reducing pediatric HIV infection
and disease involves three
stages:
• preventing HIV infection among women of
childbearing age
• preventing unwanted pregnancy among
HIV-positive women
• preventing mother to child transmission
during pregnancy, labor and delivery, and
breastfeeding

17. BENEFITS TO HIV TESTING
• EARLY COUNSELING AND
TREATMENT OF HIV INFECTION
• ABILITY TO MAKE DECISIONS
REGARDING PREGNANCY
• IMPLEMENTATION OF STRATEGIES
TO ATTEMPT TO PREVENT
TRANSMISSION TO FETUS

18. WHO SHOULD WE
SCREEN?
• ALL PREGNANT WOMEN
• TARGETED TESTING FAILS TO
IDENTIFY A SUBSTANTIAL
PROPORTION OF HIV POSITIVE
WOMEN

19. • zidovudine (AZT) administered to the
mother from 14 weeks of gestation and
to the child during the first seven days
after birth, reduced the risk of mother to
child transmission among non-
breastfeeding mothers by two-thirds.
• Two similar studies conducted in Côte
d’Ivoire and Burkina Faso among
breastfeeding mothers demonstrated a
37 percent reduction in mother to child
transmission.
Anti-Retroviral Based Prevention Strategies

20. • A study in Uganda demonstrated a 47
percent reduction in mother to child
transmission following the
administration of a single dose of
nevirapine to the mother at onset of
labor and to the baby within 72 hours
after birth.
• The combination of AZT and lamivudine
in a short-course regimen also has been
shown to reduce mother to child
transmission.
Anti-Retroviral Based Prevention Strategies

21. 21
Protecting HealthCareWorkersDuring Labor
and Delivery
• Precautionsduringlabor:
– Protection from blood and amniotic fluids
– Protection from sharp instruments
• Resuscitationof baby:
– Nomouth to mouth suction
– Nomouth to mouth breathing
• Precautionsfollowinglabor:
– Proper disinfection of instruments
– Proper disposal of placenta and other items

22. PRETEST COUNSELING
• TAKE RISK HISTORY AND COUNCIL
REGARDING RISK REDUCTION
• DISCUSS REASONS FOR TEST
• PROVIDE INFORMATION TO WOMEN
REGARDING TESTING & ILLNESS
• RISKS & BENEFITS OF TESTING
• CONFIDENTIALITY OF RESULTS
• ASSESS WINDOW PERIOD
• PERSON HAS RIGHT TO REFUSE
TESTING

23. POST-TEST COUNSELING
• HIV RESULTS SHOULD BE GIVEN IN
PERSON
• ASSESS PATIENT’S UNDERSTANDING
• ENCOURAGE PATIENT TO EXPRESS
FEELINGS AND ASK QUESTIONS
• NEGATIVE AND INDETERMINATE
RESULTS: DISCUSS NEED FOR REPEAT
TESTING

24. POSITIVE RESULT
• IDENTIFY IMMEDIATE CONCERNS
• IDENTIFY SUPPORTS
• EFFECT OF HIV ON PREGNANCY
• RISK OF TRANSMISSION TO FETUS
DURING PREGNANCY, L&D, BF
• MEASURES TO DECREASE HIV
TRANSMISSION

25. CONCLUSIONS
• ALLPREGNANTWOMEN SHOULD BE
OFFERRED HIV TESTING
• PRE- & POST- TEST COUNSELING FOR
ALL PREGNANTWOMEN
• TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED

26. ANTENATAL CARE

27. INTRODUCTION
• MULTIDISCIPLINARY TEAM
APPROACH
• MEDICAL NEEDS
• SOCIAL AND PSYCHOLOGICAL
NEEDS

28. ANTENATAL CARE
• SIMILAR TO CARE FOR HIV NEGATIVE
WOMEN
• PREGNANCY NOT HIGH RISK
• SAME NUMBER OF ANTENATAL VISITS
• AVOID INVASIVE ANTENATAL TESTS OR
PROCEDURES

29. FIRST VISIT
• PATIENT HISTORY
• DATES OF 1ST POSITIVE HIV TEST
• HIV RISK FACTORS
• HIV CARE AT TIME OF CONCEPTION
• SEROLOGIC STATUS OF PARTNER
• OTHER STD’S
• OPPORTUNISTIC INFECTIONS
• DRUG HISTORY

30. FIRST VISIT
• INVESTIGATIONS
• CBC & DIFFERENTIAL
• LYTES, GLUCOSE, RFT’S, LFT’S, LIVER
ENZYMES
• CD4+ COUNT, CD8 COUNT, CD4/CD8
• VIRAL LOAD
• SEROLOGY FOR HEP A, B, C, SYPHILIS,
RUBELLA, TOXO, CMV
• TB SKIN TEST

31. FOLLOW UP VISITS
• STANDARD OBSTETRICAL ROUTINE
• INCREASE SURVEILLANCE ONLY IF
WARRANTED
• LABS EVERY 3 MONTHS
• CD4+ COUNT
• VIRAL LOAD
• SEROLOGY FOR TOXOPLASMOSIS AND
SYPHILIS

32. OPPORTUNISTIC
INFECTIONS
• PROPHYLAXIS SHOULD BE
OFFERED IN PREGNANCY FOR THE
FOLLOWING
• PNEUMOCYSTIS CARINII PNEUMONIA
• TOXOPLASMOSIS
• TUBERCULOSIS
• MYCOBACTERIUM AVIUM COMPLEX
• VARICELLA ZOSTER
• HEPATITIS A, B

33. CONCLUSION
• HIV IN PREGNANCY SHOULD BE
MANAGED BY MULTIDISCIPLINARY
TEAM
• ANTENATAL CARE IS SIMILAR TO
THAT OF HIV POSITIVE WOMEN
• PREGNANCY NOT CONSIDERED
HIGH RISK SIMPLY BY VIRTUE OF
HIV INFECTION

34. ANTIRETROVIRAL USE

35. ANTEPARTUM
ANTIRETROVIRAL USE
• GOALS:
– CONTROL DISEASE IN MOTHER
– REDUCE PERINATAL TRANSMISSION
• VERY LITTLE DATA AVAILABLE ON
EFFECTS IN PREGNANCY
• MOST DATA ASSESSES ZIDOVUDINE
• LITTLE DATA ON OTHER DRUGS

36. CONCLUSIONS
• ZIDOVUDINE REDUCES PERINATAL
TRANSMISSION IN WOMEN AT
DIFFERENT STAGES OF DISEASE
• LONG AS WELL AS SHORTER
REGIMENS EFFECTIVE
• STILL EFFECTIVE IN
BREASTFEEDING POPULATIONS
• USE OF OTHER ANTIRETROVIRALS
IN COMBINATION WITH ZDV
PROMISING, STILL

37. IN UTERO
EXPOSURE

38. IN UTERO EXPOSURE
C
Skeletal
Abacavir
C
Hydrocephalu
s
Zalcitabine
B
Not
carcinogenic
Not
teratogenic
Didanosine
C
Liver and
urinary tumours
Not
teratogenic
Stavudine
C
Not
teratogenic
Lamivudine
FDA
Pregnancy
Category
Carcinogenicity
in animals
Teratogenicity
In animals
(rodents)
Drug
NRTI’s

39. IN UTERO EXPOSURE
B
Not teratogenic
Nelfinavir
C
Increased
hyperbilirubinemia
in monkeys -
neonatal
Incr.
supranumery &
cervical ribs
Indinavir
B
Not teratogenic
Saquinav
ir
B
Slight incr. in
cryptorchidism
Ritonavir
FDA
Pregnancy
Category
Non Teratogenic
Effects
Teratogenicity in
Animals
Drug
PI’s

40. ANTIRETROVIRAL
THERAPY DURING LABOR &
DELIVERY

41. IV ZIDOVUDINE
• ZDV LOADING DOSE AT ONSET OF
LABOR 2MG/KG OVER 1 HR
• CONTINUOUS INFUSION WHILE IN
LABOR 1MG/KG/HR

42. • INCREASING EVIDENCE THAT MOST
PERINATAL TRANSMISSION
OCCURS NEAR TIME OF OR DURING
DELIVERY
• REDUCTION OF PERINATAL
TRANSMISSION DUE TO SYSTEMIC
ANTIRETROVIRAL DRUG LEVELS IN
NEONATE AT TIME OF DELIVERY

43. IV ZIDOVUDINE
• ZDV READILY CROSSES PLACENTA
• INITIAL IV DOSE RESULTS IN
VIRUCIDAL LEVELS IN MOM &
INFANT
• CONTINUOUS INFUSION ENSURES
STABLE DRUG LEVELS IN INFANT
DURING BIRTH

44. ORAL ZIDOVUDINE
• IF IV ZDV NOT AVAILABLE, ORAL ZDV
MAY BE USED INTRAPARTUM
• ZDV 600MG PO @ ONSET OF LABOR
• 300MG PO Q3H IN LABOR

45. BANGKOK, LANCET 1999
• RANDOMIZED PLACEBO
CONTROLLED
• ZDV 300MG PO BID FROM 36WKS GA
UNTIL ONSET OF LABOR
• 300MG PO Q3H WHILE IN LABOR
• ALL WOMEN ADVISED NOT TO
BREASTFEED
• TRANSMISSION RATES: 9.4% IN RX
GROUP; 18.9% IN CONTROL GROUP

46. ABIDJAN, LANCET 1999
• SIMILAR TRIAL TO BANGKOK, BUT IN
BREASTFEEDING WOMEN
6 MONTHS 4.5 YEARS
ZDV 16.5% 21%
PLACEBO 26.1% 31%
EFFICACY 37% 30%

47. COTE D’IVOIRE & BURKINA
FASO, LANCET 1999
• PLACEBO VS ZDV STARTED @ 36-38
WKS GA
• 300MG PO DAILY
• 600MG PO AT ONSET OF LABOR
• 300MG PO BID UNTIL 7 DAYS PP
• >85% OF INFANTS BREASTFED
>3MOS
• 18% VS 27.5 % TRANSMISSION @
6MOS (38% EFFICACY)

48. • RESULTS SHOW SHORT-COURSE
PO ZDV SAFE & EFFECTIVE IN ING
RISK OF MOTHER-TO-CHILD
TRANSMISSION
• PREVENTION RATES NOT AS HIGH
AS WITH IV ZDV

49. ORAL NEVIRAPINE
• NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITOR
• VERY LONG HALF-LIFE
• RAPID DEV’T OF DRUG RESISTANCE

50. HIVNET 012 STUDY
GUAY ET AL - 1999
• 13626  RANDOMIZED - NVP VS ZDV
• NVP REGIMEN
• 200MG PO AT ONSET OF LABOR
• 2MG/KG PO DOSE TO BABY 72HR
DEL’Y
• ZDV REGIMEN
• 600MG PO AT ONSET OF LABOR
• 300MG PO Q3H DURING LABOR
• 4MG/KG BID x7 DAYS TO INFANTS

51. HIVNET 012 - RESULTS
ZDV NVP
3 DAYS 10.4% 8.2%
6-8 WKS 21.3% 11.9%
14-16 WKS 25.1% 13.1%

52. SO WHAT?
• EFFICACY OF SHORT-COURSE NVP
47% GREATER THAN SHORT
COURSE ZDV
• CURRENTLY SHORT-COURSE PO
NVP NOT COMPARED TO IV ZDV
FOR TRANSMISSION PREVENTION

53. CONCLUSIONS
• DURING LABOR - ZDV 2MG/KG IV
LOADING DOSE, THEN 1MG/KG/HR
• IF IV ZDV NOT AVAILABLE CONSIDER
PO REGIMEN
• MAY CONSIDER ADDITION OF
NVP 200MG PO TO IV ZDV @ ONSET
OF LABOR

54. OBSTETRICAL
PRACTICE

55. OBSTETRICAL PRACTICE
• 70 % OF HIV TRANSMISSION
OCCURS INTRAPARTUM.
• THE GOAL OF OBSTETRICAL
MANAGEMENT OF THE HIV PATIENT
IS TO AVOID THOSE PRACTICES
THAT INCREASE RISK OF
TRANSMISSION.

56. OBSTETRICAL PRACTICE
RUPTURE OF MEMBRANES
LANDESMAN ET AL., 1996
• RUPTURED MEMBRANES ONE OF
MANY VARIABLES EXAMINED
• 281 MOTHER-CHILD PAIRS WITH
MEMBRANES RUPTURED LESS
THAN 4 HOURS
• 206 MOTHER-CHILD PAIRS WITH
MEMBRANES RUPTURED MORE
THAN 4 HOURS

57. RUPTURE OF MEMBRANES
LANDESMAN ET AL., 1996
0
5
10
15
20
25
% Infants Infected
less than 4 h
greater than 4 h

58. OBSTETRICAL PRACTICE
MODE OF DELIVERY - VAGINAL
• ARTIFICIAL RUPTURE OF MEMBRANES
SHOULD BE AVOIDED
• RUPTURE OF MEMBRANES PAST 4
HOURS SHOULD BE AVOIDED
• FETAL SCALP SAMPLING AND THE USE
OF SCALP ELECTRODES SHOULD BE
AVOIDED

59. MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
• RANDOMIZED CLINICAL TRIAL
• 370 MOTHER-CHILD PAIRS
ANALYZED
• 203 DELIVERED BY C-S
• 167 DELIVERED VAGINALLY

60. MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
0
2
4
6
8
10
12
% INFANTS INFECTED
C-S
Vag.

61. MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
• 203 C-S PERFORMED
• 165 WERE PERFORMED
ELECTIVELY
• 31 WERE PERFORMED
EMERGENTLY

62. MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
0
1
2
3
4
5
6
7
8
9
% Infected Infants
Elective
Emergency

63. MODE OF DELIVERY: META-ANALYSIS
THE INTERNATIONAL PERINATAL HIV
GROUP, APRIL 1999
• 15 PROSPECTIVE COHORT STUDIES
• 8533 MOTHER-CHILD PAIRS
• REDUCTION OF TRANSMISSION 50% (OR
0.43, 95% CI, 0.33 – 0.56) WITH ELECTIVE
C-S VS. OTHER MODES OF DELIVERY
• REDUCTION OF TRANSMISSION 87% (OR
0.13, 95% CI, 0.09 – 0.19) WITH ELECTIVE
C-S & PACTG 076

64. MODE OF DELIVERY – CAESAREAN
SECTION
• HIV INFECTED WOMEN SHOULD BE
COUNSELLED ABOUT ELECTIVE C-S
• VERTICAL TRANSMISSION IS REDUCED TO 2%
WITH PACTG 076 THERAPY AND ELECTIVE C-S
• WOMEN WITH HIGH VIRAL LOADS MAY BENEFIT
MOST FROM C-S
• TO AVOID SROM & ONSET OF LABOUR, ELECTIVE
C-S IS PERFORMED AT 38 WEEKS
• AFTER SROM OR ONSET OF LABOUR C-S IS
LESS PROTECTIVE
• TO AVOID C-S MORBIDITY, ANTIBIOTIC
PROPHYLAXIS SHOULD BE CONSIDERED

65. VIRAL LOAD

66. HIV IN PREGNANCY – VIRAL LOAD
WOMEN AND INFANTS TRANSMISSION STUDY (WITS): GARCIA ET
AL., 1999
26 of 64
Greater than
100,000
17 of 54
50,001 – 100,000
39 of 183
10,001 – 50,000
32 of 193
1,000 – 10,000
0 of 57
Less than 1,000
Number of HIV
Transmissions
HIV Viral Load
(Copies per mL)

67. HIV IN PREGNANCY – VIRAL LOAD
WOMEN AND INFANTS TRANSMISSION STUDY (WITS): GARCIA ET
AL., 1999
0
5
10
15
20
25
30
35
40
45
% INFANTS INFECTED
less than 1,000
1,001-10,000
10,001-50,000
50,001-100,000
more than 100,000

68. BREASTFEEDING IN HIV
POSITIVE WOMEN

69. INTRODUCTION
• HIV DNA PRESENT IN BREAST MILK
• HIV TRANSMISSION CAN OCCUR
THROUGH BREASTFEEDING
• BREASTFEEDING IS AN
INDEPENDENT RISK FACTOR FOR
HIV TRANSMISSION

70. EVIDENCE TO SUPPORT
TRANSMISSION
• ISOLATION OF HIV-1 FROM
CELLULAR & NON-CELLULAR
FRACTIONS OF BREAST MILK
• CASE REPORTS OF INFECTED
CHILDREN BREASTFED BY
MOTHERS WHO ACQUIRED HIV
POSTPARTUM

71. EVIDENCE TO SUPPORT
TRANSMISSION
• DOCUMENTATION OF OTHER
RETROVIRUSES TRANSMITTED
THROUGH BREAST MILK
• CASE REPORTS OF BREAST FED
CHILDREN WHO WERE INITIALLY
HIV NEGATIVE BUT SEROCONVERTED
DURING BREASTFEEDING

72. POLICIES
• AVOIDANCE OF BREASTFEEDING IS
CONTROVERSIAL AND DEPENDS ON
INTERNAL MILIEU
• DEVELOPING COUNTRIES VS
INDUSTRIALIZED COUNTRIES

73. POLICIES
• UNAIDS REVISED STATEMENT 1998:
WOMEN SHOULD BE OFFERED HIV
COUNSELING AND TESTING, BE
INFORMED OF RISKS AND BENEFITS
OF BREASTFEEDING IF THE
MOTHER IS HIV POSITIVE, AND
SHOULD MAKE A DECISION THAT
TAKES INTO ACCOUNT THE
INDIVIDUAL &FAMILY SITUATIONS

74. MECHANISM OF
TRANSMISSION
• EXACT MECHANISM OF
TRANSMISSION THROUGH BREAST
MILK STILL NOT WELL
UNDERSTOOD
• INFECTION VIA CELL-FREE HIV IN
BREAST MILK OR VIA HIV-INFECTED
CELLS
• SUSCEPTIBILITY OF IMMATURE
NEONATAL GI TRACT TO VIRUS
• GI TRACT MUCOSAL DAMAGE

75. DURATION OF
BREASTFEEDING
• STUDIES -  IN TRANSMISSION WITH
INCREASING DURATION OF
BREASTFEEDING

76. MALAWI, JAMA 1999
• CUMULATIVE INFECTION RISK
WHILE BREASTFEEDING
• 3.5% AT END OF 5 MONTHS
• 7.0% AT END OF 11 MONTHS
• 8.9% AT END OF 17 MONTHS
• 10.3% AT END OF 23 MONTHS
• NO FURTHER TRANSMISSION AFTER
BREASTFEEDING STOPPED

77. MULTICENTER STUDY,
LANCET 1998
• CUMULATIVE INFECTION RISK
WHILE BREASTFEEDING
• 0.7% AT END OF 6 MONTHS
• 0.95% AT END OF 9 MONTHS
• 2.5% AT END OF 12 MONTHS
• 6.3% AT END OF 18 MONTHS
• 7.4% AT END OF 24 MONTHS
• 9.2% AT END OF 36 MONTHS

78. DURATION OF
BREASTFEEDING
• ? EARLY WEANING POLICY
• PROBLEMS WITH EARLY WEANING
• ADVERSE NEONATAL EFFECTS
• COLOSTRUM HIGHLY INFECTIOUS

79. EXCLUSIVITY OF
BRESTFEEDING
• STUDIES - INFANTS EXCLUSIVELY
BREAST FED AT LOWER RISK OF
ACQUIRING HIV THAN THOSE FED
WITH OTHER TYPES OF MILK, TEA,
OR JUICE WHILE BEING BREAST
FED

80. BRAZIL STUDY, 1998
• CHILDREN FED WITH OTHER TYPES
OF MILK WHILE BEING BREASTFED
WERE AT 2.2-FOLD GREATER RISK
OF HIV INFECTION THAN THOSE
EXCLUSIVELY BREASTFED
• CHILDREN FED WITH TEA OR FRUIT
JUICE WHLE BEING BREASTFED
WERE AT 2.6-FOLD GREATER RISK
OF INFECTION

81. DURBAN (SOUTH AFRICA),
LANCET 1999
• 3 GROUPS OF CHILDREN - NEVER
BREASTFED, EXCLUSIVELY
BREASTFED, MIXED FEEDING
• NO SIGNIFICANT DIFFERENCE IN
TRANSMISSION BETWEEN NEVER
AND EXCLUSIVELY BREASTFED
GROUPS
• SIGNIFICANTLY INCREASED RISK
OF TRANSMISSION FOR MIXED

82. INTERPRETATION
• IMMUNE FACTORS IN BREAST MILK
• GROWTH FACTORS IN BREAST MILK
• MUCOSAL DAMAGE WITH MIXED
FEEDING

83. MATERNAL FACTORS
• CRACKED NIPPLES
• BLEEDING NIPPLES
• PARITY

84. CONCLUSION
• PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION
STILL NOT WELL UNDERSTOOD
• WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
• WOMEN WHO BREASTFEED
SHOULD BE INFORMED THAT
TRANSMISSION CAN OCCUR

85. SUMMARY

86. HIV SCREENING
• ALL PREGNANT WOMEN SHOULD
BE OFFERRED HIV TESTING
• PRE- & POST- TEST COUNSELING
FOR ALL PREGNANT WOMEN
• TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED

87. ANTENATAL CARE
• HIV IN PREGNANCY REQUIRES
MULTIDISCIPLINARY APPROACH
• ANTENATAL CARE IS SIMILAR TO THAT OF
HIV -VE WOMEN
• PREGNANCY NOT HIGH RISK
• AVOID INVASIVE PROCEDURES
• MONITOR CD4+ AND VIRAL LOAD AT
LEAST EVERY 3 MONTHS IF ABLE TO
PROVIDE ANTIRETROVIRAL THERAPY

88. ANTIRETROVIRAL USE
• Zidovudine reduces perinatal
transmission in women at different
stages of disease
• long (ante, peri, and postnatal) as well
as shorter regimens effective
• still effective in breastfeeding
populations
• Use of other antiretrovirals in
combination with ZDV promising, still
investigational

89. INTRAPARTUM
ANTIRETROVIRAL
THERAPY
• DURING LABOR - ZDV 2MG/KG IV
LOADING DOSE, THEN 1MG/KG/HR
• IF IV ZDV NOT AVAILABLE CONSIDER
PO REGIMEN
• MAY CONSIDER ADDITION OF
NVP 200MG PO TO IV ZDV @ ONSET
OF LABOR

90. BREASTFEEDING
• PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION
STILL NOT WELL UNDERSTOOD
• WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
• WOMEN WHO BREASTFEED
SHOULD BE INFORMED THAT
TRANSMISSION CAN OCCUR