This document discusses HIV infection in pregnancy and strategies to reduce mother-to-child transmission of HIV. It covers antepartum, intrapartum, and postpartum care for HIV-infected women including antiretroviral regimens, monitoring, testing protocols, and delivery methods. The goal is to reduce the risk of perinatal HIV transmission to less than 2% through highly effective antiretroviral therapy, elective cesarean section when appropriate, and avoiding breastfeeding.
This is a lecture given to medical students of Cebu Institute of Medicine under the reproductive module. It contains a discussion of principles of HIV infection screening, diagnosis, staging and management, especially during pregnancy.
HIV infects and damages cells that help the body fight infection and disease. It can be transmitted from mother to child during pregnancy, childbirth, or breastfeeding. To prevent mother-to-child transmission, pregnant women should receive counseling and voluntary testing for HIV. If infected, antiretroviral treatment is recommended during pregnancy and delivery, and avoidance of breastfeeding if safe alternatives are available. Planned c-section or antiretroviral prophylaxis can further reduce the risk of transmission.
Premature Rupture of Membranes (PROM) refers to rupture of membranes before the onset of labor. It occurs in 10% of term pregnancies and more commonly in preterm labor. PROM can be diagnosed through various tests including a nitrazine paper test, fern test, sterile speculum exam, or ultrasound. Complications of PROM include preterm labor, infection, and fetal deformities or distress. Management depends on gestational age - expectant management is common above 34 weeks while induction or C-section may be recommended below 36 weeks to prevent complications.
The document provides an overview of HIV in pregnancy including:
1. The history, virology, global scenario, burden in India, routes of transmission, testing and management during the ante-natal, intra-partum, and post-natal periods are discussed.
2. Guidelines for prevention of mother-to-child transmission through antiretroviral therapy, delivery method, feeding options and infant prophylaxis and care are provided.
3. Staging of HIV disease and treatment criteria including when to start antiretroviral therapy during pregnancy based on CD4 count and clinical stage are outlined.
The document discusses HIV in pregnancy and strategies to prevent mother-to-child transmission. It recommends screening all pregnant women for HIV early in pregnancy and managing positive cases with a multidisciplinary team. Antiretroviral therapy is recommended for HIV-positive mothers during pregnancy and delivery to reduce transmission risk below 2%. Mode of delivery depends on the mother's viral load and treatment, with elective c-section beneficial for untreated or high viral load women.
This document discusses HIV/AIDS, including transmission, signs and symptoms, stages of infection, treatment and prevention of mother-to-child transmission. It notes that HIV can be transmitted sexually, through infected body fluids or from mother to child. The stages of infection are acute infection, clinical latency and AIDS. Signs may include flu-like symptoms during acute infection and infections over time as immunity declines. Prevention of mother-to-child transmission is important, as without intervention up to 45% of babies may be infected, but can be reduced to less than 5% with antiretroviral treatment and safe delivery practices.
HIV DURING PREGNANCY, this is very common and very dangerous disease during pregnancy. this is for medical and nursing student. i tried to make understand of students.
This is a lecture given to medical students of Cebu Institute of Medicine under the reproductive module. It contains a discussion of principles of HIV infection screening, diagnosis, staging and management, especially during pregnancy.
HIV infects and damages cells that help the body fight infection and disease. It can be transmitted from mother to child during pregnancy, childbirth, or breastfeeding. To prevent mother-to-child transmission, pregnant women should receive counseling and voluntary testing for HIV. If infected, antiretroviral treatment is recommended during pregnancy and delivery, and avoidance of breastfeeding if safe alternatives are available. Planned c-section or antiretroviral prophylaxis can further reduce the risk of transmission.
Premature Rupture of Membranes (PROM) refers to rupture of membranes before the onset of labor. It occurs in 10% of term pregnancies and more commonly in preterm labor. PROM can be diagnosed through various tests including a nitrazine paper test, fern test, sterile speculum exam, or ultrasound. Complications of PROM include preterm labor, infection, and fetal deformities or distress. Management depends on gestational age - expectant management is common above 34 weeks while induction or C-section may be recommended below 36 weeks to prevent complications.
The document provides an overview of HIV in pregnancy including:
1. The history, virology, global scenario, burden in India, routes of transmission, testing and management during the ante-natal, intra-partum, and post-natal periods are discussed.
2. Guidelines for prevention of mother-to-child transmission through antiretroviral therapy, delivery method, feeding options and infant prophylaxis and care are provided.
3. Staging of HIV disease and treatment criteria including when to start antiretroviral therapy during pregnancy based on CD4 count and clinical stage are outlined.
The document discusses HIV in pregnancy and strategies to prevent mother-to-child transmission. It recommends screening all pregnant women for HIV early in pregnancy and managing positive cases with a multidisciplinary team. Antiretroviral therapy is recommended for HIV-positive mothers during pregnancy and delivery to reduce transmission risk below 2%. Mode of delivery depends on the mother's viral load and treatment, with elective c-section beneficial for untreated or high viral load women.
This document discusses HIV/AIDS, including transmission, signs and symptoms, stages of infection, treatment and prevention of mother-to-child transmission. It notes that HIV can be transmitted sexually, through infected body fluids or from mother to child. The stages of infection are acute infection, clinical latency and AIDS. Signs may include flu-like symptoms during acute infection and infections over time as immunity declines. Prevention of mother-to-child transmission is important, as without intervention up to 45% of babies may be infected, but can be reduced to less than 5% with antiretroviral treatment and safe delivery practices.
HIV DURING PREGNANCY, this is very common and very dangerous disease during pregnancy. this is for medical and nursing student. i tried to make understand of students.
HIV stands for Human Immunodeficiency Virus and can be transmitted through sexual contact, blood transmission, or from mother to child. There are two types of HIV, HIV-1 being more prevalent. HIV progresses to AIDS by weakening the immune system over time. Prevention of mother-to-child transmission (PMTCT) aims to prevent HIV transmission from mother to child during pregnancy, birth, or breastfeeding through testing, treatment, and replacement feeding. Antiretroviral therapy can suppress HIV and slow disease progression.
*I hope its help you all for preparation part 1 exam for MRCOG & MOG and your daily job.Good Luck May ALLAH bless our work and study,Good luck to all.dont forget to pray to ALLAH.if i wrong please correct me..process of learning..
This document summarizes various viral and protozoal infections that can occur during pregnancy including rubella, measles, influenza, chickenpox, cytomegalovirus, parvovirus, mumps, herpes simplex virus, and HIV. For each infection, the document discusses the causative virus, clinical features, effects on pregnancy, methods of diagnosis, and management approaches. Complications of congenital infections are also outlined. The management of HIV positive pregnancies including antiretroviral therapy and approaches to reduce mother-to-child transmission are described in detail.
The document discusses prevention of parent-to-child transmission (PPTCT) of HIV. It outlines NACO's four-pronged strategy for PPTCT, which includes primary prevention of HIV among women, preventing unintended pregnancies in HIV+ women, preventing transmission from mother to child, and treatment/care for women and children living with HIV. It then discusses factors influencing transmission risk and interventions to reduce risk during pregnancy, delivery, and infancy including antiretroviral prophylaxis and therapy.
Sexually transmitted disease in pregnancyDR MUKESH SAH
An STI during pregnancy can pose serious health risks for you and your baby. As a result, screening for STIs , such as human immunodeficiency virus (HIV), hepatitis B, chlamydia and syphilis, generally takes place at the first prenatal visit for all pregnant women.
Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.
The TORCH complex refers to a group of perinatal infections - Toxoplasmosis, Other (syphilis, varicella, parvo virus), Rubella, Cytomegalovirus, and Herpes simplex virus type 2. These infections can cross the placenta and infect the fetus, potentially causing severe anomalies or death. Toxoplasmosis is caused by the protozoan Toxoplasma gondii which can infect fetuses during acute maternal infection via the placenta. Rubella virus infection during pregnancy increases risks of fetal anomalies, especially in the first trimester. Cytomegalovirus is a herpes virus that commonly infects fetuses, with 30
Vertical transmission is major contributor- HIV among children
No intervention – as high as 45%
With interventions – as low as less than 5%
Minimal manipulation
NVD vs. C-section
Anti retroviral prophylaxis vs. anti retroviral therapy
Exclusive breastfeeding vs. exclusive replacement feeding
Follow-up and care.
1) Prevention of Mother to Child Transmission (PMTCT) programs provide antiretroviral drugs, counseling, and support to pregnant women living with HIV to reduce the risk of transmitting the virus to their babies during pregnancy, childbirth, and breastfeeding.
2) Key interventions include antiretroviral prophylaxis for pregnant and breastfeeding women and their infants, safer delivery and infant feeding practices, and treatment, care and support for women and families.
3) In Tanzania, the national PMTCT program incorporates antiretroviral prophylaxis including various combination drug regimens during antenatal, intrapartum, postpartum, and infant periods, depending on when
Post-term pregnancy is defined as exceeding 40 weeks of gestation. It occurs in 5-10% of pregnancies, often due to inaccurate gestational age calculation. Both mother and baby are at increased risk of complications like dystocia, meconium aspiration, stillbirth. Management includes assessing gestational age accurately, monitoring the fetus, and inducing labor between 41-42 weeks to prevent risks of post-term pregnancy. Intrauterine fetal death is the death of a fetus before delivery. It can result from maternal, fetal or obstetric complications. Evaluation includes detailed history, examinations, and tests to determine the cause to help counsel patients and prevent future recurrence.
urinary tract infection during pregnancySrikutty Devu
Urinary tract infections (UTIs) are more common during pregnancy due to anatomical and physiological changes that cause incomplete bladder emptying and a less acidic urine. There are different types of UTIs including asymptomatic bacteriuria, acute cystitis, and pyelonephritis. Common symptoms are urges to urinate, painful urination, and fever. Left untreated, UTIs can cause serious complications for both mother and baby like preterm labor. Diagnosis involves urine and blood tests and treatment consists of hospitalization, IV fluids and antibiotics. Prevention focuses on drinking fluids, urinating frequently, and good genital hygiene.
Please find the power point on Gestational Diabetes Mellitus (GDM) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
This document provides guidelines for managing HIV in pregnancy. It discusses screening all pregnant women for HIV and other infections. For HIV-positive mothers, it recommends prompt referral to a multidisciplinary team and starting combination antiretroviral therapy (cART) by 14 weeks of pregnancy to prevent mother-to-child transmission. The guidelines cover antenatal care, immunization, labor and delivery recommendations depending on viral load, and neonatal and postpartum management of HIV-positive mothers and exposed infants. The overall aim is to optimize care and reduce risk of HIV transmission through comprehensive antenatal and delivery protocols.
The document discusses the care of HIV-infected mothers during pregnancy, labor, delivery, and postpartum, including the use of antiretroviral therapy (ART). It covers pre-pregnancy counseling, antenatal care, intrapartum care during delivery, and postpartum care of both mother and baby. The goal is to reduce mother-to-child transmission of HIV through various interventions during these stages, including ART, treatment of other infections, modified obstetric practices, and post-exposure prophylaxis for the newborn.
Hydatidiform Mole (HM) is a rare mass or growth that forms inside the uterus at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD).
When a normal sperm cell fertilizes one of these oocytes, the resulting embryo has only one set of chromosomes. Because the embryo has no genes from the mother, the pregnancy cannot develop normally, resulting in a hydatidiform mole.
Preconception counseling involves obtaining medical histories from both parents and performing physical exams on prospective mothers. This aims to minimize health risks for mothers and fetuses by identifying preexisting conditions and providing counseling. Counseling covers topics like folic acid supplementation to prevent neural tube defects, maintaining control of chronic conditions like diabetes before pregnancy, vaccinations, genetic screening, lifestyle factors, and nutritional needs. The goal is to optimize women's health before conception and promote healthy pregnancies.
Prevention of Mother to Child Transmission of HIV 2017Helen Madamba
This is a lecture delivered during the Integrated Orientation on HIV/AIDS and TBHIV Collaboration by the Department of Health Region 7 at Bohol Tropics Resort, Tagbilaran City, Bohol
Puerperal infection is an infection of the genital tract that occurs after delivery. It is commonly caused by bacteria like Doderlein bacillus. Risk factors include prolonged rupture of membranes, traumatic delivery, and anemia. Symptoms range from local infection to sepsis. Diagnosis involves examinations, tests, and cultures to identify the site and cause of infection. Treatment involves antibiotics, surgery if needed to drain abscesses, and supportive care. Prevention focuses on clean delivery techniques, prompt repair of lacerations, and prophylactic antibiotics in high risk cases.
Perinatal HIV and Addressing Missed Opportunities through the Texas Consortiu...ElviaLedezma
This document summarizes perinatal HIV in Texas and efforts through the Texas Consortium for Perinatal HIV Prevention (TCPHP) to address missed opportunities. Key points include:
- Perinatal HIV rates in Texas have decreased from 2000-2008 due to prenatal care, earlier HIV diagnosis, and antiretroviral therapy.
- Missed opportunities still exist, as some infected infants were born to women with no prenatal care or incomplete antiretroviral regimens.
- TCPHP aims to reduce perinatal transmission through improved standards of care, education, and outreach. Work groups have developed guidelines, testing recommendations, and identified gaps in hospital pharmacies.
- Case examples
This document discusses HIV infection in pregnancy and factors affecting mother-to-child transmission. It notes that over 600,000 children are infected with HIV annually through mother-to-child transmission. The transmission rate can be affected by viral load, stage of infection, use of antiretroviral therapy, and duration of rupture of membranes during delivery. Proper prenatal care, treatment of opportunistic infections, nutrition support, and antiretroviral therapy for the mother can help reduce transmission risk from mother to child.
HIV stands for Human Immunodeficiency Virus and can be transmitted through sexual contact, blood transmission, or from mother to child. There are two types of HIV, HIV-1 being more prevalent. HIV progresses to AIDS by weakening the immune system over time. Prevention of mother-to-child transmission (PMTCT) aims to prevent HIV transmission from mother to child during pregnancy, birth, or breastfeeding through testing, treatment, and replacement feeding. Antiretroviral therapy can suppress HIV and slow disease progression.
*I hope its help you all for preparation part 1 exam for MRCOG & MOG and your daily job.Good Luck May ALLAH bless our work and study,Good luck to all.dont forget to pray to ALLAH.if i wrong please correct me..process of learning..
This document summarizes various viral and protozoal infections that can occur during pregnancy including rubella, measles, influenza, chickenpox, cytomegalovirus, parvovirus, mumps, herpes simplex virus, and HIV. For each infection, the document discusses the causative virus, clinical features, effects on pregnancy, methods of diagnosis, and management approaches. Complications of congenital infections are also outlined. The management of HIV positive pregnancies including antiretroviral therapy and approaches to reduce mother-to-child transmission are described in detail.
The document discusses prevention of parent-to-child transmission (PPTCT) of HIV. It outlines NACO's four-pronged strategy for PPTCT, which includes primary prevention of HIV among women, preventing unintended pregnancies in HIV+ women, preventing transmission from mother to child, and treatment/care for women and children living with HIV. It then discusses factors influencing transmission risk and interventions to reduce risk during pregnancy, delivery, and infancy including antiretroviral prophylaxis and therapy.
Sexually transmitted disease in pregnancyDR MUKESH SAH
An STI during pregnancy can pose serious health risks for you and your baby. As a result, screening for STIs , such as human immunodeficiency virus (HIV), hepatitis B, chlamydia and syphilis, generally takes place at the first prenatal visit for all pregnant women.
Shoulder dystocia occurs when the baby's shoulders become stuck after delivery of the head. It has a low incidence rate of 0.2-1% and risk factors include fetal macrosomia, obesity, diabetes and others. Diagnosis is made when normal maneuvers by the midwife fail to deliver the baby. Management involves calling for help, clearing the baby's airways, and performing maneuvers like McRoberts and Rubin's to rotate the shoulders and decrease their diameter in order to allow delivery. More invasive maneuvers like cleidotomy may be needed if these fail to deliver the anterior shoulder.
The TORCH complex refers to a group of perinatal infections - Toxoplasmosis, Other (syphilis, varicella, parvo virus), Rubella, Cytomegalovirus, and Herpes simplex virus type 2. These infections can cross the placenta and infect the fetus, potentially causing severe anomalies or death. Toxoplasmosis is caused by the protozoan Toxoplasma gondii which can infect fetuses during acute maternal infection via the placenta. Rubella virus infection during pregnancy increases risks of fetal anomalies, especially in the first trimester. Cytomegalovirus is a herpes virus that commonly infects fetuses, with 30
Vertical transmission is major contributor- HIV among children
No intervention – as high as 45%
With interventions – as low as less than 5%
Minimal manipulation
NVD vs. C-section
Anti retroviral prophylaxis vs. anti retroviral therapy
Exclusive breastfeeding vs. exclusive replacement feeding
Follow-up and care.
1) Prevention of Mother to Child Transmission (PMTCT) programs provide antiretroviral drugs, counseling, and support to pregnant women living with HIV to reduce the risk of transmitting the virus to their babies during pregnancy, childbirth, and breastfeeding.
2) Key interventions include antiretroviral prophylaxis for pregnant and breastfeeding women and their infants, safer delivery and infant feeding practices, and treatment, care and support for women and families.
3) In Tanzania, the national PMTCT program incorporates antiretroviral prophylaxis including various combination drug regimens during antenatal, intrapartum, postpartum, and infant periods, depending on when
Post-term pregnancy is defined as exceeding 40 weeks of gestation. It occurs in 5-10% of pregnancies, often due to inaccurate gestational age calculation. Both mother and baby are at increased risk of complications like dystocia, meconium aspiration, stillbirth. Management includes assessing gestational age accurately, monitoring the fetus, and inducing labor between 41-42 weeks to prevent risks of post-term pregnancy. Intrauterine fetal death is the death of a fetus before delivery. It can result from maternal, fetal or obstetric complications. Evaluation includes detailed history, examinations, and tests to determine the cause to help counsel patients and prevent future recurrence.
urinary tract infection during pregnancySrikutty Devu
Urinary tract infections (UTIs) are more common during pregnancy due to anatomical and physiological changes that cause incomplete bladder emptying and a less acidic urine. There are different types of UTIs including asymptomatic bacteriuria, acute cystitis, and pyelonephritis. Common symptoms are urges to urinate, painful urination, and fever. Left untreated, UTIs can cause serious complications for both mother and baby like preterm labor. Diagnosis involves urine and blood tests and treatment consists of hospitalization, IV fluids and antibiotics. Prevention focuses on drinking fluids, urinating frequently, and good genital hygiene.
Please find the power point on Gestational Diabetes Mellitus (GDM) . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
This document provides guidelines for managing HIV in pregnancy. It discusses screening all pregnant women for HIV and other infections. For HIV-positive mothers, it recommends prompt referral to a multidisciplinary team and starting combination antiretroviral therapy (cART) by 14 weeks of pregnancy to prevent mother-to-child transmission. The guidelines cover antenatal care, immunization, labor and delivery recommendations depending on viral load, and neonatal and postpartum management of HIV-positive mothers and exposed infants. The overall aim is to optimize care and reduce risk of HIV transmission through comprehensive antenatal and delivery protocols.
The document discusses the care of HIV-infected mothers during pregnancy, labor, delivery, and postpartum, including the use of antiretroviral therapy (ART). It covers pre-pregnancy counseling, antenatal care, intrapartum care during delivery, and postpartum care of both mother and baby. The goal is to reduce mother-to-child transmission of HIV through various interventions during these stages, including ART, treatment of other infections, modified obstetric practices, and post-exposure prophylaxis for the newborn.
Hydatidiform Mole (HM) is a rare mass or growth that forms inside the uterus at the beginning of a pregnancy. It is a type of gestational trophoblastic disease (GTD).
When a normal sperm cell fertilizes one of these oocytes, the resulting embryo has only one set of chromosomes. Because the embryo has no genes from the mother, the pregnancy cannot develop normally, resulting in a hydatidiform mole.
Preconception counseling involves obtaining medical histories from both parents and performing physical exams on prospective mothers. This aims to minimize health risks for mothers and fetuses by identifying preexisting conditions and providing counseling. Counseling covers topics like folic acid supplementation to prevent neural tube defects, maintaining control of chronic conditions like diabetes before pregnancy, vaccinations, genetic screening, lifestyle factors, and nutritional needs. The goal is to optimize women's health before conception and promote healthy pregnancies.
Prevention of Mother to Child Transmission of HIV 2017Helen Madamba
This is a lecture delivered during the Integrated Orientation on HIV/AIDS and TBHIV Collaboration by the Department of Health Region 7 at Bohol Tropics Resort, Tagbilaran City, Bohol
Puerperal infection is an infection of the genital tract that occurs after delivery. It is commonly caused by bacteria like Doderlein bacillus. Risk factors include prolonged rupture of membranes, traumatic delivery, and anemia. Symptoms range from local infection to sepsis. Diagnosis involves examinations, tests, and cultures to identify the site and cause of infection. Treatment involves antibiotics, surgery if needed to drain abscesses, and supportive care. Prevention focuses on clean delivery techniques, prompt repair of lacerations, and prophylactic antibiotics in high risk cases.
Perinatal HIV and Addressing Missed Opportunities through the Texas Consortiu...ElviaLedezma
This document summarizes perinatal HIV in Texas and efforts through the Texas Consortium for Perinatal HIV Prevention (TCPHP) to address missed opportunities. Key points include:
- Perinatal HIV rates in Texas have decreased from 2000-2008 due to prenatal care, earlier HIV diagnosis, and antiretroviral therapy.
- Missed opportunities still exist, as some infected infants were born to women with no prenatal care or incomplete antiretroviral regimens.
- TCPHP aims to reduce perinatal transmission through improved standards of care, education, and outreach. Work groups have developed guidelines, testing recommendations, and identified gaps in hospital pharmacies.
- Case examples
This document discusses HIV infection in pregnancy and factors affecting mother-to-child transmission. It notes that over 600,000 children are infected with HIV annually through mother-to-child transmission. The transmission rate can be affected by viral load, stage of infection, use of antiretroviral therapy, and duration of rupture of membranes during delivery. Proper prenatal care, treatment of opportunistic infections, nutrition support, and antiretroviral therapy for the mother can help reduce transmission risk from mother to child.
Perinatal Hiv Ledezma Addressing Missed Opp Patel Final HandoutsElviaLedezma
The document summarizes perinatal HIV transmission in Texas and efforts by the Texas Consortium for Perinatal HIV Prevention (TCPHP) to address missed opportunities. Key points:
- Perinatal HIV transmission in Texas decreased 57% from 2000-2008, however missed opportunities still occur for timely diagnosis, treatment, and care of HIV-positive pregnant women.
- TCPHP aims to reduce perinatal HIV transmission through improved standards of care, education, and outreach. It is a collaborative of various health organizations and experts.
- TCPHP has developed guidelines to improve access to antiretroviral therapy and standardized testing recommendations. The group's work seeks to enhance communication and cultural competency
TrioMarkets is an online trading platform regulated by CySEC and FCA that offers forex, CFDs, indices and commodities trading. It was founded by three financial professionals with over 15 years experience. Key features include advanced technology like MT4 platforms, education resources through Trio Academy, and a focus on security including encrypted servers and segregated client funds. The company aims for a win-win relationship with clients through competitive pricing and a variety of tradable assets.
Via La Moda was founded in 1989 in Johannesburg, South Africa by Hanspeter Winklmayr and Walter Hauser. It manufactures luxury leather goods using traditional craftsmanship techniques passed down over generations combined with modern machinery. The company produces high-quality leather handbags and accessories under various brand names like Via La Moda, 1691 Collection, and Via Veneta Provoque, distributing them globally through a network of stockists.
La ciudadanía digital se refiere a la aplicación de los derechos humanos y derechos de ciudadanía a la sociedad de la información. Ser ciudadano digital ofrece beneficios como periodismo ciudadano y facilita la vida cotidiana. Es importante ser ciudadano digital para desarrollarse con la tecnología y participar en la sociedad digital, y para estar informado sobre el uso adecuado de las TIC. La huella digital es un mecanismo para proteger los derechos de autor mediante la introducción de bits imperceptibles que permiten detectar copias ilegales.
EOI · 04/04/2014 · http://a.eoi.es/5t24
El Taller “Aprender emprendiendo y controlando” impartido por Jon Icazurriaga, ha sido recibido con una excelente acogida, ya que asistieron más de 20 profesionales a esta actividad.
En el taller, se trataron los nuevos modelos de emprendimiento y de análisis estratégico de las empresas, haciendo énfasis en el análisis delentorno empresarial actual, los elementos comunes en las estrategias potenciales, las herramientas de análisis estratégico, la planificación empresarial, lanzamiento de nuevas ideas y modelos de negocio, el emprendimiento como un proceso de aprendizaje y el compromiso y conocimiento.
Este taller ha sido desarrollado en colaboración entre la EOI, la Agencia Local de Desarrollo del Ayuntamiento de Alicante y Jovempa. Esta actividad forma parte del Proyecto Acompañarte, proyecto cofinanciado por FEDER.
Jon Icazurriaga es profesor, consultor, asesor y consejero de diferentes empresas y organizaciones nacionales e internacionales.
Este documento resume una reunión de padres sobre el curso escolar 2013-2014 para niños de 4 años en el Colegio Fray Albino. El objetivo principal es que los niños sean felices en la escuela y aprendan y se desarrollen de forma global. Se enfatiza la importancia de la colaboración de las familias y se proporcionan detalles sobre las normas, estrategias de enseñanza y objetivos del curso.
TDD Mini Workshop @ Bucharest JUG 2014 04 24Adi Bolboaca
This document introduces Test-Driven Development (TDD) as an incremental approach to software design that involves writing tests before code. TDD follows three main steps - write a test, add minimum code to pass the test, and refactor code and tests. It allows requirements to change more easily by starting with examples and extracting abstractions based on patterns rather than predefining all designs upfront. The document notes two main difficulties with TDD as thinking at the problem level rather than solution and using proof-based rather than assumption-based design, and provides guidance on getting started with TDD by focusing on the next test and design direction.
Este documento discute como as geografias da comunicação estão se tornando plurais devido à natureza multifacetada, online e intercultural da realidade atual, onde o acesso à Internet está presente no cotidiano de muitas pessoas. A mídia portátil está em todos os lugares constituindo fluxos de informação, conhecimento e intercâmbios entre territórios diversos. Com a aceleração do tempo, o espaço deixou de ser uma variável dependente e se tornou um fator determinante para estudos que abrangem política, economia, sociologia,
This document contains two comments responding to the paper "Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries".
The first comment criticizes the paper for proposing "selective primary health care" as an alternative to the comprehensive primary health care strategy endorsed at the Alma Ata conference. The comment argues that the paper fails to appreciate shifts away from viewing economic growth alone as development, and that a healthy population is necessary for true development. The comment also notes three key issues with the arguments in the paper: it introduces a term not used at Alma Ata, it slips between "health care" and "health services", and it cites an estimate about costs of basic rather than comprehensive services
This document provides instructions for setting up and using a new Sagemcom telephone. It includes recommendations for safety, an overview of the phone and base features, instructions for connecting the base and charging the handset batteries, and guides for navigating menus and making calls. The document also outlines how to customize settings, view call logs, set up alarms, and pair additional handsets.
(Gerard Gassol). This work will focus in how climate change will affect the city of Schiedam. We will study the main consequences of climate change in the Netherlands and we will focus in flood. How floods will affect the City at mid and long term. In order to do an accurate approach, we will consult various studies but specially the last KNMI’14 study, developed by the Royal Netherlands Meteorological Institute.
Risks of search engine dependency and its influence on data qualityNanor
This document is Ronan Chardonneau's master's thesis submitted in 2009 for the European Master in Business Studies degree. The thesis examines the risks of search engine dependency and its influence on data quality. It contains four chapters that introduce the topic, define data quality concepts, describe search engines and their market, and analyze how search engine dependency can influence data quality and potential solutions. The thesis was supervised by professors from universities in Italy, France, Germany, and Spain as part of Ronan's two-year business studies program.
Este documento anuncia los eventos que se celebrarán el 4 de diciembre de 2013 en Zaragoza para conmemorar el Día Internacional del Voluntariado. Incluye un torneo de trivial solidario a las 16:30, la lectura del manifiesto a las 18:15 y una gala del voluntariado a las 18:30 con diferentes actuaciones. También habrá una exposición de arte y una conferencia por la mañana sobre el impacto del voluntariado.
This document provides guidelines for managing HIV infection in pregnancy. It discusses counseling pregnant women who test positive for HIV, antenatal care including investigations and treatment with antiretroviral therapy, preventing mother-to-child transmission through medication and delivery methods, care during labor and delivery, testing and treatment for infants, and postpartum care of both mother and baby. The goal is to reduce the risk of transmitting HIV from mother to child to less than 2% through screening, testing, antiretroviral treatment, and modifying delivery and infant feeding practices.
This document provides guidelines for preventing mother-to-child transmission of HIV (PMTCT) in antenatal care settings. There are four key elements of PMTCT care: primary HIV prevention, preventing unintended pregnancies among HIV+ women, preventing transmission from mother to child, and treatment/support for HIV+ women and their families. The goals of PMTCT in antenatal care are to identify all HIV+ women, provide same-day ART to optimize health and prevent transmission, and ensure viral suppression through treatment. All pregnant women should be tested for HIV and receive counseling. HIV+ women initiate lifelong ART regardless of CD4 count or clinical stage, while HIV- women receive repeat testing during pregnancy and breastfeeding.
1) The document discusses pharmacological principles for treating HIV in pregnant women to reduce mother-to-child transmission.
2) Updated perinatal guidelines from 2007 recommend initiating HAART after 14 weeks of gestation and continuing treatment throughout pregnancy, labor, and delivery.
3) Clinical scenarios provide examples of applying the guidelines, such as recommending HAART, scheduled C-sections if viral load is high, and 6 weeks of infant ZDV treatment starting within hours of birth.
This document provides guidance on the management of HIV in pregnancy. It recommends screening all pregnant women for HIV and other infections. For women who test positive, it recommends a multidisciplinary care team and interventions to prevent transmission to the child and disease progression in the mother, including antiretroviral therapy. It provides guidance on antenatal care, delivery, postpartum care, and management of the neonate to reduce risk of transmission to less than 1%.
This document provides guidance on the management of HIV in pregnancy. It recommends screening all pregnant women for HIV and other infections. For women who test positive, it recommends a multidisciplinary care team and interventions to prevent transmission to the child and disease progression in the mother, including antiretroviral therapy. It provides guidance on antenatal care, delivery, postpartum care, and management of the neonate to reduce risk of transmission to less than 1%.
Management of perinatal infections and exposures was discussed. Congenital CMV is a leading cause of hearing loss and malformations. Treatment is recommended for moderate-severe cases while treatment for mild cases or isolated hearing loss is controversial. Congenital syphilis evaluation involves interpreting maternal tests and infant titers to determine treatment. HIV testing is recommended for all pregnant women and antiretroviral prophylaxis is given to exposed infants based on maternal viral load and treatment. Hepatitis C transmission risk is low but testing exposed infants allows early identification and monitoring. HSV exposed asymptomatic neonates do not require treatment but should be monitored for symptoms.
HAART, or highly active antiretroviral therapy, involves using a combination of antiretroviral drugs to treat HIV. The goals of ART include increased survival, improved quality of life, reduction of viral load, immune reconstitution, and limiting drug toxicity while maintaining treatment options and adherence. Commonly used drug classes include NRTIs, NNRTIs, integrase inhibitors, and protease inhibitors. Treatment involves monitoring viral load, CD4 count, adverse effects, and potential treatment failure or immune reconstitution inflammatory syndrome. Guidelines provide recommendations on treatment initiation and first, second, and third-line regimens for both adults and children.
1) HIV infection during pregnancy poses risks for both mother and baby, with around 13,000 babies born to HIV+ mothers becoming infected each year in India.
2) Strategies to prevent mother-to-child transmission include antiretroviral therapy for the mother during pregnancy and delivery, and for 6 weeks postpartum. Caesarean delivery and avoiding breastfeeding can further reduce risks of transmission.
3) Proper prenatal counseling, treatment, and testing of the newborn are important for management of HIV infection during pregnancy.
This document summarizes recommendations for prenatal care and delivery of a 28-year-old HIV-positive pregnant woman. The plan includes monitoring the woman's CD4 count and viral load during pregnancy, referring her to an HIV specialist, providing antiretroviral therapy to reduce transmission risk, counseling on transmission risks and prevention, and treating the newborn after delivery to further reduce transmission risk. Mode of delivery will depend on the woman's viral load at delivery, with C-section recommended if her viral load is over 1,000 copies/mL to lower transmission risk.
This document provides recommendations for evidence-based practice in managing foetal and neonatal alloimmune thrombocytopenia (FNAIT). FNAIT is caused by maternal alloantibodies against platelet antigens inherited by the fetus. It can cause thrombocytopenia and intracranial hemorrhage in neonates. The document outlines recommendations for postnatal and antenatal management including platelet transfusions, IVIG administration, corticosteroid use, fetal testing and monitoring, and delivery planning to improve outcomes for at-risk pregnancies and neonates. It also discusses screening approaches and the role of HLA and antibody level testing to determine risk of FNAIT.
HIV and Pregnancy : Dr Ruby Bansal (1st Session of DGF HIV Committee on 10th ...Lifecare Centre
This document discusses HIV and pregnancy in India. Some key points:
- Over 21 million people live with HIV in India, including 880,000 women. 60% of pregnant women with HIV access antiretroviral therapy (ART).
- ART and other interventions can reduce the risk of parent-to-child HIV transmission to under 2%. Without treatment, transmission rates range from 15-45%.
- Timely diagnosis and treatment of HIV-positive pregnant women is important to prevent transmission to infants. Options include different ART regimens starting during pregnancy, delivery, or breastfeeding depending on when the woman is diagnosed.
- Close coordination between HIV physicians, gynecologists, and other care providers is
1) Tuberculosis (TB) is a major cause of maternal mortality in South Africa. All pregnant women, especially those with HIV, should be screened for TB at antenatal visits.
2) Symptom screening involves asking about cough, fever, night sweats, and weight loss. A TB test (GeneXpert) is also required for pregnant women with new HIV diagnoses or known HIV.
3) If TB is diagnosed, treatment should begin promptly according to national guidelines. For drug-resistant TB, consultation with infectious disease specialists is recommended due to high mortality risk.
Hyperemesis Gravidarum (HG) is diagnosed when there is intractable nausea and vomiting of pregnancy associated with weight loss, dehydration, and electrolyte imbalance. Guidelines recommend outpatient management for mild cases using antihistamines and phenothiazines as first-line antiemetics. Hospitalization is indicated for HG with continued vomiting and signs of dehydration or ketosis. Inpatient treatment involves IV hydration with normal saline and potassium, supplementation with thiamine, and thromboprophylaxis with low molecular weight heparin. Second-line therapies include metoclopramide, ondansetron, corticosteroids, and ginger may be used as complementary therapy.
This document provides guidance on the management of Hepatitis C in pregnancy. It recommends screening all pregnant women for HCV at their first prenatal visit and retesting those at high risk. For HCV-positive patients, it advises monitoring liver enzymes during pregnancy, discussing transmission risks and treatment with the patient, and considering referral to a hepatology clinic. It also provides guidance on intrapartum care, postpartum management including breastfeeding, neonatal follow-up testing, and contraception during and after antiviral therapy.
Care of HIV positive Pregnant and breastfeeding women_Feb_1_2023.pptxyakemichael
The document provides an overview of prevention of mother-to-child transmission (PMTCT) of HIV, describing its 4 prongs and continuum of services from antenatal care to postnatal care. It aims to eliminate new HIV infections in children and reduce mortality and morbidity in HIV-positive women and their exposed infants. Key interventions discussed include lifelong antiretroviral therapy (ART) for positive mothers, cotrimoxazole prophylaxis, nutrition support, safe delivery practices, early infant diagnosis, and viral load monitoring throughout pregnancy and breastfeeding.
NACO's 4-pronged strategy aims to prevent parent-to-child transmission of HIV through primary prevention of HIV among women, preventing unintended pregnancies in HIV-positive women, preventing transmission from mother to child, and providing treatment, care and support. Risk of transmission is influenced by maternal, obstetrical, and infant factors. Interventions include antiretroviral prophylaxis and therapy for the mother and infant, safer delivery practices, and guidance on infant feeding options. Challenges to implementation include unsupervised home deliveries and gaps in early antiretroviral therapy initiation for eligible pregnant women.
Dr k prabha devi new pptct guidelines-1(1)Ratan Yadav
The document outlines new guidelines for initiating ART for HIV-infected pregnant women in India. It recommends providing lifelong ART to all pregnant and breastfeeding women living with HIV, regardless of CD4 count or clinical stage, to prevent mother-to-child transmission. This includes initiating a regimen of TDF+3TC+EFV and continuing it throughout pregnancy, delivery, and breastfeeding. It also details protocols for providing antiretroviral prophylaxis to newborns to reduce HIV transmission and the durations of prophylaxis depending on the mother's ART history.
Overview & Whats New _Kenya Treatment and Prevention Guidelines, 2022_LM.26.0...nelliusmutindi
This document provides an overview and outline of the updated 2022 Kenya HIV Prevention & Treatment Guidelines. Key points include:
- Shifting to a 3-test HIV testing algorithm to increase positive predictive value with lower prevalence. Dual HIV/syphilis testing is now recommended for all pregnant women.
- Initial evaluation of PLHIV includes medical history, exam, screening for advanced HIV disease and opportunistic infections. CD4 testing criteria are outlined.
- The standard package of care covers ART, prevention education, screening and management of opportunistic infections, reproductive health services, nutrition support, and prevention of other infections like COVID-19.
- Adherence preparation, monitoring and support are emphasized throughout
Rhesus factor is a protein found on red blood cells. If present, one is Rh positive; if absent, Rh negative. Rh factor is inherited from parents. Rh incompatibility occurs when an Rh negative mother is exposed to Rh positive blood, risking complications for her Rh positive baby like hydrops fetalis or jaundice. Management includes screening, anti-D immunoglobulin, monitoring, and timing delivery to prevent baby anemia. Sensitized mothers require additional monitoring and may need intrauterine transfusions or early delivery.
The document discusses various staining techniques used to visualize bacteria under the microscope, including simple staining, Gram staining, acid-fast staining, and Albert staining. Different staining methods are used to differentiate bacteria based on cell wall structure and composition, with Gram staining distinguishing between Gram-positive and Gram-negative bacteria and acid-fast staining identifying Mycobacteria. Proper staining enhances contrast and visibility of bacterial cells and structures.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help alleviate symptoms of mental illness and boost overall mental well-being.
This document discusses three case scenarios involving pregnant women with reactive syphilis serology. It provides information on interpreting syphilis serology tests, the stages of syphilis infection, and treatment recommendations. The key points are: syphilis should be suspected in pregnant women who are sexually active or have partners with risk factors; reactive nontreponemal and treponemal tests indicate current or past untreated syphilis; and pregnant women with reactive tests should be treated with penicillin to prevent transmission to the fetus.
Solid organ transplant recipients have a higher risk of developing TB compared to the general population. The majority of post-transplant TB cases are due to reactivation of latent TB infections in recipients. Donor-derived TB may occur if the donor was from a TB endemic area or had untreated TB. For living donors, a TST or IGRA is used for screening and treatment of latent TB is considered. For recipients, treatment of latent TB is indicated if they have a risk factor such as a positive PPD or history of TB exposure. Recommended regimens include 9 months of INH or 4 months of rifampin plus other drugs. Treatment duration of at least 12 months is important to prevent TB recurrence.
Treatment of HCV in HIV-infected patients has historically been challenging with low response rates and side effects. However, recent developments in direct-acting antiviral agents now offer highly effective interferon-free regimens. Studies show sofosbuvir-based combinations achieving over 90% cure rates in HIV/HCV coinfected individuals, including those on antiretroviral therapy. Daclatasvir is being studied in phase III trials and may be co-administered with many antiretrovirals. These developments promise to greatly improve outcomes for people living with HIV/HCV coinfection.
Treatment of HCV in HIV-infected patients has historically been challenging with low response rates and side effects. However, recent developments in direct-acting antiviral agents now offer highly effective interferon-free regimens. Studies show sofosbuvir-based combinations achieving over 90% cure rates in HIV/HCV coinfected individuals, including those on antiretroviral therapy. Daclatasvir is being studied in phase III trials and may be co-administered with many antiretrovirals. These developments promise to greatly improve outcomes for people living with HIV/HCV coinfection.
Antimicrob. agents chemother. 2015-lee-aac.01477-15NAIF AL SAGLAN
This document summarizes a study comparing clinical outcomes of patients with Enterobacter cloacae bacteremia treated definitively with cefepime or carbapenems. The study found:
1) Among 144 patients receiving definitive cefepime or carbapenem therapy, 30-day mortality rates were similar at 26.4% for cefepime and 22.2% for carbapenems.
2) However, for the 18 patients infected with cefepime susceptible-dose dependent (SDD) isolates, those treated with cefepime had a higher 30-day mortality rate than those treated with carbapenems (71.4% vs 18.2%).
3
This patient likely has chronic Chagas disease based on their symptoms, physical exam findings, and risk factors from living in rural Mexico. Chronic Chagas disease involves biventricular systolic dysfunction and is diagnosed through serum testing for Trypanosoma cruzi antibodies. Given the presentation, right heart catheterization could help evaluate cardiac pressures and output, but serum T. cruzi IgG antibody testing would be most likely to reveal the diagnosis.
This document summarizes various methods for detecting methicillin-resistant Staphylococcus aureus (MRSA) in the laboratory, including challenges, considerations, and mechanisms of resistance. It discusses culture-based detection methods like selective media, enrichment broths, and chromogenic agar. It also covers rapid detection tests like PBP2a latex agglutination and molecular methods. The document explores MRSA characteristics like pathogenicity, limited treatment options, and transmissibility. It discusses vancomycin-intermediate S. aureus (VISA), vancomycin-resistant S. aureus (VRSA), and their mechanisms of reduced susceptibility. The importance of accurate and timely MRSA detection is highlighted.
This document lists resources for infectious diseases, including textbooks, journals, websites, and resources for residents. It provides textbooks such as Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases and Hospital Epidemiology and Infection Control. Journals mentioned include Clinical Infectious Diseases and Lancet Infectious Diseases. Websites include Journal Watch, Medscape, and various sites for HIV/AIDS, hepatitis, and emerging diseases. Resources for residents include textbooks, MKSAP, Red Book, and reviewing major infectious disease syndromes through articles.
This document discusses the case of a 21-year-old female patient with a history of acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) who developed a skin lesion on her arm during chemotherapy treatment for AML relapse. Skin biopsy revealed infection with Aspergillus fumigatus. She was diagnosed with cutaneous aspergillosis and treated intravenously with voriconazole. Cutaneous aspergillosis is a rare manifestation of disseminated infection most commonly caused by A. fumigatus in immunocompromised patients, with skin lesions occurring in 5-10% of cases. Treatment involves intravenous antifungal drugs such as amphotericin B
A 41-year-old woman with aplastic anemia was admitted with fever. Blood cultures grew E. coli resistant to ampicillin and narrow-spectrum cephalosporins. Despite treatment with multiple antimicrobials over 4 weeks, the patient's fever and bacteremia persisted. The microbiology lab was contacted to help determine why standard therapies were failing to clear the infection.
Board review course badreddine- june 2015 idNAIF AL SAGLAN
This document contains a series of clinical case scenarios and questions related to infectious diseases and hospital infection control. The cases cover topics like tuberculosis, hepatitis from anti-TB drugs, rifampin interaction with oral contraceptives, multidrug resistant tuberculosis, central line-associated bloodstream infections, catheter-associated urinary tract infections, MERS, and ventilator-associated pneumonia. The questions test knowledge of appropriate diagnostic testing, treatment regimens, transmission-based precautions, and measures to prevent hospital-acquired infections.
The most likely diagnosis based on the information provided is viral meningitis (B). A CSF with cloudy appearance, lymphocytic predominance, and glucose greater than half the serum level is characteristic of viral meningitis. Bacterial meningitis would show a higher white count with neutrophil predominance. Tuberculous meningitis typically has a lower glucose. Cryptococcal meningitis would have a very low glucose.
1. The document contains questions and answers related to internal medicine board review topics such as infectious diseases, antibiotics treatment, and hospital-acquired infections.
2. Many questions focus on determining the most appropriate antibiotic therapy or treatment duration for various bacterial infections and hospitalized patients.
3. Other topics addressed include risk factors for ventilator-associated pneumonia, Clostridium difficile infection treatment, HACEK gram-negative bacilli, and antifungal therapy for invasive fungal infections.
A woman presents for a pre-employment physical. She received the hepatitis B vaccine in medical school. Her hepatitis B serologic profile would be hepatitis B surface antigen negative, core antibody positive, and surface antibody positive, indicating past infection that resolved.
A man with a history of blood transfusions 10 years ago has elevated liver enzymes and tests positive for hepatitis C antibodies. A liver biopsy shows portal inflammation, indicating he has chronic hepatitis C. The incidence of this complication from HCV infection is 20%.
Dengue fever is the only viral haemorrhagic fever listed that has not been reported in Saudi Arabia.
This document provides guidance on preventing ventilator-associated pneumonia (VAP) in adult and pediatric patients. It outlines the adult VAP bundle, which consists of 5 evidence-based practices: elevating the head of the bed, daily readiness-to-extubate evaluations, use of endotracheal tubes with subglottic secretion drainage, oral care with chlorhexidine, and early enteral nutrition. Additional recommended practices include hand hygiene, promoting patient mobility and autonomy, and VTE prophylaxis. For children, key practices are head elevation, proper tube positioning, and oral care. The document aims to help healthcare teams reduce VAP through a quality improvement approach.
Treatment of HCV in HIV-infected patients has historically been challenging with low response rates and side effects. However, recent developments in direct-acting antiviral agents now offer highly effective interferon-free regimens. Studies show sofosbuvir-based combinations achieving over 90% cure rates in HIV/HCV coinfected individuals, including those on antiretroviral therapy. Daclatasvir is being studied in phase III trials and may be co-administered with many antiretrovirals. These developments promise to greatly improve outcomes for people living with HIV/HCV coinfection.
The document discusses three case scenarios involving pregnant women with reactive syphilis serology. It provides details on interpreting syphilis serology, the stages of syphilis infection, and recommendations for treatment and follow up after treatment. The key points are: syphilis should be suspected in pregnant women who are sexually active or have partners with risk factors; reactive nontreponemal and treponemal tests indicate current or past untreated syphilis; and pregnant women with reactive tests should be treated with penicillin to prevent transmission to the fetus.
HIV infection is caused by a retrovirus that can lead to AIDS if not treated. It is transmitted through bodily fluids and can be diagnosed through viral load tests, p24 antigen tests, HIV antibody tests, and Western blot. If left untreated, it progresses from acute infection to asymptomatic infection and eventually symptomatic infection and AIDS. Antiretroviral therapy is recommended for all infected individuals to suppress the virus and preserve immune function. The goals of treatment are to durably suppress the virus, restore immune function, and prevent transmission. Response is monitored through clinical, virologic, and immunologic measures.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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2. Table of Contents
● Perinatal HIV Epidemic: Situation Analysis
● Reducing Perinatal HIV Transmission
● Antepartum Care
● Intrapartum Care
● Postpartum/Newborn Care and Testing
● HIV-Infected Women of Childbearing Age
● Resources
1
4. Perinatal HIV Transmission
● Without ARV drugs during pregnancy, risk of transmission
from mother to infant is 1 in 4
● Pediatric AIDS Clinical Trials Group (PACTG) 076 found that
by giving zidovudine (ZDV) to the pregnant woman during
pregnancy, labor, and delivery, and to her newborn,
transmission could be reduced to 8%
● The risk of perinatal transmission can now be less than 2%
(1 in 50) with:
● Highly effective ARV therapy (HAART)
● Elective Cesarean section as appropriate
● Formula feeding
13
5. Timing of Perinatal HIV Transmission:
Non-Breastfeeding Women
● Intrauterine (before 36 weeks) ~20% of cases
● Virologic detection of HIV in newborn at 1–2 days of life
● Peripartum ~80% of cases
● Onset of placental separation
● Mother-to-fetus microtransfusions
● Labor and rupture of membranes
● Most transmission occurs close to or during labor and delivery
(L&D)
14
6. Factors Influencing Perinatal
Transmission
● Maternal Factors
● High HIV-1 RNA levels (viral load [VL])
● Low CD4+ lymphocyte count (“T-cells”)
● Co-infections: Hepatitis C, cytomegalovirus (CMV)
bacterial vaginosis
● Maternal injection drug use
● No ARV therapy or prophylaxis
15
8. Mechanisms to Reduce Perinatal
HIV Transmission
● ARV drugs
● Lower maternal antepartum viral load
● Provide pre- and post-exposure prophylaxis for the
infant
● Prophylaxis is recommended
● Antepartum
● Intrapartum
● Neonatal
17
9. National Recommendations for HIV Testing of
Pregnant Women CDC (USPHS) and ACOG
• Prenatal: routine, universal HIV screening with the right to
decline
• 3rd trimester: repeat if woman has risk factors, is in area of
high prevalence, or has previously refused
• Labor and delivery: routine rapid testing for women with
unknown HIV status
• Postnatal: rapid testing for infants whose mother’s status is
unknown
18
10. Recommendations for 3rd
Trimester Repeat HIV Testing
● In jurisdictions with an elevated incidence of HIV/AIDS
among women
● Women known to be at high risk for HIV
● Facilities that identify HIV infection in at least 1/1,000 women
screened
● Women who have signs or symptoms of acute HIV infection
(acute retroviral syndrome)
19
11. Acute HIV Infection
● Can present like mononucleosis
● Symptoms include
● Fever
● Rash, often erythematous
maculopapular
● Fatigue
● Pharyngitis
● Generalized lymphadenopathy
● Use a plasma RNA PCR test as well as HIV antibody to
diagnose
● Urticaria
● Myalgia/arthralgia
● Anorexia
● Mucocutaneous ulceration
● Headache, retroorbital pain
● Neurologic symptoms (e.g., aseptic
meningitis, radiculitis, myelitis)
20
12. Acute HIV Infection in Pregnancy
● Increased risk of transmission to the fetus during gestational
acute retroviral syndrome is hypothesized due to:
● High viral titers in plasma and genital fluid
● Absence of immune factors that may neutralize infection
● Treatment should include interventions to reduce perinatal
HIV transmission
● Appropriate ARV prophylaxis
● Consideration of elective Cesarean delivery
● Consult with HIV expert
21
13. Interpreting HIV Test Results
● EIA (enzyme-linked immunosorbent assay, ELISA) is a
standard HIV-antibody screening blood test
● Rapid HIV screening tests detect HIV antibody
● A positive (reactive) ELISA or a rapid HIV test is always
confirmed with a Western blot (WB) test
● A positive WB can usually confirm HIV infection
● During pregnancy, there may be a lower predictive value
of a positive EIA
27
15. Review: Goals of ARV Therapy
● Suppress HIV to below the limits of detection or as low as
possible for as long as possible
● Prolong life and improve quality of life
● Preserve or restore immune function
● Reduce risk of perinatal transmission
41
16. Guidelines for ARV Drugs in
Pregnancy
● Use optimal ARVs for woman’s health; consider potential
impact on fetus/infant
● Include 3-part ZDV regimen to reduce perinatal transmission
as part of 3-drug ARV regimen
● Use of ZDV alone is controversial but may be considered
when HIV RNA levels are <1000 copies/mL
43
17. Guidelines for ARV Drugs in
Pregnancy (continued)
● Discuss preventable risk factors for perinatal transmission
● Support woman’s decision
● Acceptance or refusal of ARVs should not negatively affect
care
44
18. General Principles: Use of ARVs
During Pregnancy
● Initial evaluation should include:
● Assessment of HIV disease status
● Recommendations for ARV therapy or assessment of
current ARV regimen
● Recommend ARV therapy/prophylaxis to all pregnant
women with HIV infection
● Discuss known benefits and potential risks of ARVs during
pregnancy
45
19. General Principles: Use of ARVs
During Pregnancy (continued)
● Treatment is complex: Consult with an HIV expert
● If HIV RNA is detectable, do resistance testing before
starting/modifying therapy
● If HIV is diagnosed during second half of pregnancy, initiate
ARV regimen without waiting for results of resistance test
● Individualize ARV treatment
● Emphasize the importance of adherence to treatment and
prophylaxis
● Assure coordination of comprehensive services 46
20. Special Considerations: ARV Use
by Pregnant Women and Infants
● Pregnancy may alter ARV absorption, distribution,
and metabolism
● Dosing and toxicity risk may be affected
● Limited data to guide treatment in pregnancy
47
21. Special Considerations for ARV
in Pregnancy (continued)
● Potential adverse effects during pregnancy, including
teratogenicity
● During pregnancy avoid:
● Combination of stavudine (d4T) + didanosine (ddI):
increased risk of lactic acidosis and hepatic steatosis
48
22. ARVs to Use With Caution
During Pregnancy
● Nevirapine (NVP) – increased risk of hepatotoxicity
● Do not start NVP in women with CD4 counts of >250
cells/µL unless benefits clearly outweigh risks
● Nucleoside Reverse Transcriptase Inhibitors (NRTIs) –
risk of lactic acidosis/hepatic steatosis; monitor liver
enzymes, electrolytes monthly in 3rd trimester; assess
often for new symptoms
49
23. Hyperglycemia and Protease
Inhibitor (PI)-based ARV Therapy
● Potential for hyperglycemia
● Screening for hyperglycemia:
● Standard glucose loading test at 24–28 weeks
● Consider earlier screening if on chronic PI-based
therapy
50
24. Types of ARV Regimens
● Non-nucleoside Reverse Transcriptase Inhibitor
(NNRTI)-based
(1 NNRTI + 2 NRTI backbone)
● PI-based
(1 or 2 PIs + 2 NRTI backbone)
● NRTI-based
(3 NRTIs: inferior virologic efficacy; consider if
NNRTI- or PI-based regimen is not appropriate)
51
25. HIV-Infected, Pregnant, ARV Naive
● If patient meets criteria for treatment, potent
combination therapy is the standard of care
● In consultation with an HIV expert, start as soon as
possible, including in 1st trimester
● Consult data on specific ARVs in pregnancy
● If patient does not require treatment for her own health:
3-drug combination ARV regimen for perinatal
prophylaxis
● Consider delay until after 1st trimester in women
with high CD4 cell counts and low HIV RNA levels
● ZDV monotherapy for prophylaxis not
recommended, but may
be considered if VL <1,000 copies/mL 52
26. HIV-Infected Pregnant Women
Currently on ARVs
● Continue ARVs, if possible; avoid treatment interruption
● Continue efavirenz in women receiving efavirenz-based ART
who present in 1st trimester of HIV RNA is suppressed
● Order ARV resistance tests if detectable viremia (>500–1000
copies/mL)
● If on NVP with suppressed VL and tolerating it, continue NVP
● Include ZDV, unless contraindicated
53
27. Women with Past History of ARVs
But Not Currently on Treatment
● Obtain history of prior ARV regimens and results of resistance
testing
● Get drug resistance testing before starting ARVs
● Consult an HIV specialist regarding choice of regimen
● Select ARVs based on ARV history and resistance testing;
monitor virologic response closely
● Repeat resistance testing and consult experts if poor virologic
response
54
28. Stopping ARV Therapy During
Pregnancy
● Avoid interruption of therapy, if possible
● Interruption is likely to increase risk of ARV resistance
● If discontinuation required, stop and reinitiate all drugs at
the same time, except:
● If on NNRTI, if possible stop NNRTI first, continue
others for approximately 7 days
● If restarting NVP after interruption of >2 weeks, restart with
standard 2-week dosage escalation
55
29. Prenatal Monitoring
● Monitor CD4 cell count at initial visit and every 3 months
thereafter
● Monitor plasma HIV RNA levels to assess rapid and
sustained decrease
● At initial visit
● 2–4 weeks after starting/changing ARV regimen
● Monthly until RNA levels undetectable
● At least every 3 months during pregnancy
● At 34–36 weeks for decision on mode of delivery
56
30. Prenatal Monitoring
(continued)
● Obtain resistance testing for women with suboptimal VL
suppression or rebound
● Monitor for ARV drug complications
● Assess and support ARV adherence
57
31. Monitoring Women and Fetus:
Ultrasound Recommendations
● 1st trimester: confirmation of gestational age
● Potential timing for Cesarean delivery, if needed,
performed at 38 weeks
● 2nd trimester: assess fetal anatomy for women on
combination ARVs
58
32. Failure of Viral Suppression
● Assess resistance, adherence, dosing and problems with
absorption
● Consider modification of ARV regimen
● Consult with an HIV expert
● Scheduled Cesarean delivery recommended if HIV RNA
>1,000 copies/mL near time of delivery
59
33. ARV Resistance in Pregnancy
Resistance to ARVs may:
● Decrease efficacy of perinatal prophylaxis
● Limit future maternal treatment options
● Limit treatment options in infected infants
60
34. ZDV Resistance in Pregnancy
● Women with ZDV resistance should receive IV ZDV
during labor (if they have an HIV RNA >400 copies/mL
near delivery), along with their ARV regimen
● The optimal prophylactic regimen for newborns of women
with ARV resistance is unknown
● Consult pediatric HIV specialist
61
35. ARV Therapy and Pregnancy
Outcome
● Preterm delivery—conflicting data
● Most US data do not demonstrate increased risk
● Mitochondrial dysfunction in neonates due to in utero ARV
exposure
● Conflicting data: appears to occur very rarely
● HIV-infected women should receive combination ARVs
according to current USPHS guidelines
62
37. Which Pregnant Women Will Need
Rapid HIV Testing in Labor?
Women:
● With no or limited prenatal care
● Who were not offered testing
● Whose results are unavailable
● Who declined testing previously
● Who live in high-incidence areas, are at risk,
and have not had a repeat test in 3rd trimester
64
38. Rapid HIV Tests
● Six tests currently FDA approved for blood/serum
● Four point-of-care tests (CLIA waived)
● One test available for oral fluid
● All are very specific and sensitive
65
39. Rapid HIV Testing in Labor
and Delivery
● Provides results quickly; if positive, treatment can be started
to reduce transmission to infant
● Message:
● It is a screening test
● If negative, no further testing is necessary at this time
● If positive, results are “preliminary,” a confirmatory test
is always done
66
40. Giving Positive Rapid HIV Results
in Labor
● “Your preliminary HIV test was positive…this means that you
may have HIV infection. We always do another test to confirm
a positive rapid test.”
● “It is best that we start medicine to reduce the risk to your
baby while we wait for the confirmatory results.”
● Treatment to reduce transmission to her baby
● Need to postpone breastfeeding until results of
confirmatory test
67
41. Intrapartum ARV Prophylaxis
with a Positive Rapid Test
● If test is positive, give maternal IV ZDV and initiate infant
combination ARV prophylaxis (that includes ZDV)
● Maternal confirmatory HIV test done postpartum
● If positive, continue infant combination ARV
prophylaxis (that includes ZDV) for 6 weeks
● If negative, stop infant ARV therapy
68
42. Caring for the Woman Newly
Diagnosed with HIV in Labor
● Psychosocial support during labor and postpartum follow-up
for mother and baby
● Confidentiality of results and treatment for mother and infant
● Communication and documentation of preliminary positive
results
● Delivery and newborn records
● Communication with pediatrician
● Plan for follow-up of confirmatory results
69
43. Intrapartum ARV Management for
Women on ARVs in Pregnancy
● At onset of labor, IV ZDV is recommended for all HIV-positive
women with HIV RNA ≥400 copies/mL (or unknown HIV
RNA) near delivery, regardless of antepartum regimen or mode
of delivery
● 2 mg/kg body weight over 1 hour followed by continuous
infusion of 1mg/kg/body weight per hour until delivery of infant
● IV AZT is not required if woman is receiving combination
ARV regimens and HIV RNA < 400 copies/mL near delivery
● Continue other ARVs orally on schedule as possible
● When administering ZDV, discontinue d4T
70
44. HIV Transmission and
Cesarean Delivery
● Cesarean section recommended:
● For women with HIV RNA levels >1,000 near time
of delivery
● For women with unknown HIV RNA levels
● Schedule at 38 weeks
● Benefits of Cesarean unclear after ROM or onset of
labor: base decision on clinical factors
● Benefits of Cesarean unclear for women with HIV RNA
levels <1,000 on combination ARVs 71
45. Maternal Risks by Mode of Delivery
● Counsel women about potential risks/benefits of Cesarean
versus vaginal delivery
● Cesarean associated with somewhat greater risk of
obstetrical complications in HIV-infected women
● Complications do not outweigh benefits of reduced HIV
transmission for those at increased risk
● Prophylactic narrow-spectrum antibiotic generally
recommended
72
46. Management of Membrane Rupture
● Risk of transmission with rupture of membranes (ROM)
increases with time
● If labor is progressing and membranes are intact, avoid
artificial ROM and invasive monitoring
● Women scheduled for Cesarean who present with
premature rupture of membranes (PROM): individualize
management
● Duration of rupture, progress of labor
● HIV RNA level, current ARV regimen
73
47. Other Intrapartum Issues
● Avoid artificial ROM or invasive monitoring unless
obstetrically indicated and duration is expected to be
short
● Use forceps or vacuum extractor only in select
circumstances
● Avoid use of methergine for postpartum hemorrhage in
women receiving PIs, efavirenz, or delavirdine
● Risk of exaggerated vasoconstrictive response
● Use if no other alternative, at low dosage, and for
short duration
74
49. Breastfeeding and Transmission
● An additional 15–29% of infants will be infected if there is
breastfeeding
● HIV is found in breast milk, both cell-associated and
cell-free
● Recommendations:
● Women with HIV infection in the United States should not
breastfeed
● Women considering breastfeeding should know their HIV
status
● Consider cultural norms in supporting the non-breastfeeding
woman with HIV
95
50. Follow-Up Care for the Mother
● Refer mother for specialty HIV care
● Possible changes in mother’s ARV therapy
● Monitor for adherence and postpartum depression: consider
first follow-up visit at 2 weeks, then at 6 and 12 weeks
● HIV testing and follow-up of older children
● Follow-up of sexual/needle-sharing partners
96
51. Follow-Up Care for the Mother
(continued)
● Primary, gynecologic/obstetric, and family planning services
● Mental health services
● Substance abuse treatment
● Coordination of care through case management for the
woman, her children, and other family members
97
52. Clinical Management of the
Perinatally HIV-Exposed Infant
● 6-week neonatal component of the ZDV chemoprophylaxis
regimen is recommended for all HIV-exposed neonates
● Initiate ZDV for neonate (at gestational age-appropriate doses), as
close to the time of birth as possible
● If mother has not received antepartum ARV, infant should receive
ZDV for 6 weeks combined with three doses of nevirapine in the
first week of life (at birth, 48 hours later, and 96 hours after the
second dose)
● Decision to combine other drugs with the 6-week ZDV regimen
should be made in consultation with a pediatric HIV specialist
98
53. ZDV Dosing in the Perinatally
HIV-Exposed Infant
● Administration of neonatal ZDV
● Oral: 2mg/kg/dose every 6 hours for 6 weeks
● Give first dose as soon as possible after delivery: within 6–
12 hours
● IV dose for full-term infant is 1.5 mg/kg every 6 hours
● Dose is adjusted for preterm infants
● Consult a pediatric HIV specialist
● For ZDV dosing for premature infants
● For additional ARV drugs for prophylaxis in infants
99
54. Evaluation and Follow-up of HIV-
Exposed Infants
● Referral to a pediatric HIV specialist
● Support for ZDV prophylaxis for 6 weeks
● Diagnostic testing to establish or rule out HIV infection as
early as possible
● PCP prophylaxis initiated at 6 weeks of age until HIV
presumptively excluded
● Long-term follow-up of HIV- and ARV-exposed infants
● Support services for the family
100
55. Resources for Clinicians
• Offering information on AIDS treatment, prevention, and
research
• Clinical guidelines for ARV treatment
• Perinatal/Mother-to-Child Transmission
• Pediatrics
• Adults and Adolescents
• http://www.aidsinfo.nih.gov
107
56. Information Resources
• CDC’s One Test. Two Lives.™ program
http://www.cdc.gov/actagainstaids/ottl
1-800-CDC-INFO
(800-232-4636)
• National HIV Testing Resources
http://hivtest.cdc.gov
• Act Against AIDS
http://www.cdc.gov/actagainstaids
111
Editor's Notes
This curriculum is sponsored by the Centers for Disease Control and Prevention’s (CDC’s) One Test. Two Lives. program. The goals of the curriculum are perinatal HIV prevention and promotion of the health of pregnant women infected with HIV in the United States.
[Note to speaker: Add any additional introductory notes based on the audience/purpose of meeting. Students can reference full sources on the One Test. Two Lives. curriculum website.]
This curriculum is based on the most current recommendations of the United States Public Health Service Perinatal Guidelines, the CDC Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings, and the American College of Obstetricians and Gynecologists (ACOG), ACOG Committee on Obstetric Practice. Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations.1,2,3
Sources:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
2. Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR Morb Mortal Wkly Rep. 2006 Sept 22; [cited 2009 Sep 29]; 55 (RR14):1-17. Available from: http://www.cdc.gov/mmwr/PDF/rr/rr5514.pdf.
3. American College of Obstetricians and Gynecologists (ACOG), ACOG Committee on Obstetric Practice. Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Washington, DC: ACOG; 2004;304:1119-1124. Committee opinion no. 418.
Talking Points:
The listed “chapters” will be covered in this presentation:
Situation Analysis – A Landscape View of HIV and its Impact on Women
What We Know About Reducing Perinatal HIV Transmission
Lessons from Clinical Trials – Antiretroviral (ARV) Interventions to Reduce Perinatal HIV Transmission
Antepartum Care for HIV-Infected Women
Intrapartum Care for HIV-Infected Women
Postpartum/Newborn Care and Testing
Psychosocial, Legal, and Ethical Issues
HIV-Infected Women of Childbearing Age
Case Discussions
Resources
[Note to speaker: If desired, you may choose to cover only applicable chapter topics. To receive Continuing Education credit, please note that listeners/students will be tested on full curriculum content.]
Chapter title slide; no notes.
Talking Points:
In 1994, a landmark clinical trial—PACTG 076—demonstrated that the risk of perinatal HIV transmission could be cut by 2/3 if the mother and newborn were prophylaxed with zidovudine (ZDV).
With appropriate management, the risk or perinatal transmission can now be less than 2%.
Supporting Information:
In February 1994, a clinical trial examining a strategy to decrease perinatal HIV transmission, PACTG 076, was halted when interim results showed a significant difference in transmission rates between the intervention and placebo groups.
In the trial of more than 477 pregnant women with HIV infection, women in the intervention group received ZDV during pregnancy from 34-weeks gestation, during labor and delivery, and their infants received oral ZDV for 6 weeks after birth.
Interim results showed a significant difference in transmission rate between ZDV (8%) and the placebo group (26%).1
1995: Transmission rate was 11% after adoption of “076” ZDV regimen into practice.2
In a longitudinal epidemiologic United States study since 1990, transmission was:3
・ 20% in women receiving no ARV treatment in pregnancy
・ 10.4% in women on ZDV alone
・ 3.8% in women receiving combination therapy without protease inhibitors (PIs)
・ 1.2% in women on combination therapy with Pis
Sources:
1. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med. 1994;331:1173-1180.
2. Bertolli, J. (1996). Estimating the timing of mother-to-child transmission of human immunodeficiency virus in a breast-feeding population in Kinshasa, Zaire. J Infect Dis. 174(4):722.
3. Cooper ER, Charurat M, Mofenson LM, et al. Combination antiretroviral strategies for the treatment of pregnant HIV-1 infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr Hum Retrovirol. 2002;29(5):484-94.
Talking points:
Transmission can occur at multiple points during pregnancy, peripartum and postpartum.
Most transmission occurs around the time of labor and delivery.
Supporting Information:
Using highly sensitive diagnostic tests, HIV culture or polymerase chain reaction (PCR) helps determine when infection occurs in a fetus/infant.
・ In-utero transmission is presumed if specimen taken in first 48 hours after birth is positive for HIV.
・ Intrapartum transmission is presumed if specimen taken in the first week of life in non-breastfed infant is negative and later sample is positive.
Mechanisms of transmission in-utero:
・ Most likely transplacental, possibly due to placental membrane inflammation through maternofetal transfusion (placental disruption).
・ Much of this transmission happens relatively late in gestation; although in some cases, rapid disease progression in infants points to infection earlier in gestation.
・ Early trimester transmission may result in early fetal loss.
・ There is an increased risk of transmission if a woman becomes HIV infected during pregnancy, possibly in-utero or during intrapartum.
Mechanisms of transmission intrapartum:
・ Through maternofetal transfusion of blood during labor
・ Infant skin or mucous membranes coming in contact with infected blood or other maternal secretions during delivery
Important risk factors:
・ Increased duration of membrane rupture
・ Vaginal delivery (in a woman with viral load (VL) >1000)
Sources:
1. Kourtis AP, Bulterys M, Nesheim SR, Lee FK. Understanding the timing of HIV transmission from mother to infant. JAMA. 2001;285:709-712.
2. American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. Scheduled cesarean delivery and the prevention of vertical transmission of HIV infection. Washington, DC: ACOG; 2000 May. ACOG committee opinion no. 234.
Talking Point:
The maternal factors listed can influence whether transmission occurs: clinical status with HIV infection, co-morbidity, and behavioral factors such as non-prescription injection drug use or noncompliance with recommended treatment.
Supporting Information:
The viral load level provides important information that is used to monitor the status of HIV disease and to guide recommendations for therapy.
Evidence shows that maintaining the viral load level as low as possible for as long as possible decreases the complications of HIV disease and prolongs life.
The higher the maternal viral load or HIV-RNA level, the higher the risk is of perinatal HIV transmission.
Other maternal factors correlated with increased risk of transmission:
・ Frequent, unprotected sex with multiple partners (possibly leading to increased risk of sexually transmitted diseases (STDs), other inflammatory processes
・ Smoking
・ Illicit drug use
Source:
1. Centers for Disease Control and Prevention (CDC). US Public Health Service Task Force recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV-1 transmission in the United States. MMWR Morb Mortal Wkly Rep. 2002;51(RR18):1-38.
Talking Points:
The obstetrical and infant factors listed can increase the risk of HIV transmission.
OB factors include rupture of membranes-timing and increased risk with women diagnosed with AIDS infection.
・ Each hour increase in duration of rupture of membrane (ROM) has a small but high statistically significant and stable association with perinatal transmission.
Supporting Information:
Meta-analysis of 15 prospective cohort studies (4,721 mother-infant pairs) suggests that an elective Cesarean section reduces the risk of perinatal transmission; the meta-analysis also found that perinatal transmission increased with increasing duration of ruptured membranes. Association remained after adjusting for mode of delivery, ARVs (generally the 3-part zidovudine prophylaxis), or maternal CD4 count and infant birth weight.1
・ Each hour increase in duration of rupture of membrane (ROM) has a small but high statistically significant and stable association with perinatal transmission.
・ Greatest risk with duration of rupture was in women with AIDS.
・ Several studies reported that women with clinical chorioamnionitis had an increased transmission risk.2
・ Amniocentesis and fetal scalp electrodes should be avoided in women with HIV infection.3
・ In a study to assess amniotic fluid as a marker of intrauterine infection and evaluate amniocentesis as a risk factor in vertical transmission, amniotic fluid VL was undetectable, and no perinatal transmission was found in HIV-infected women on HAART with undetectable maternal blood samples.4
Infant factors:
・ Skin integrity of preterm infants is more fragile, less of a barrier.
・ Gastric acid secretion is lower in preterm and newborn infants and is less protective against swallowed organisms.
・ Functional immune responsiveness is decreased.
Sources:
1. The International Perinatal HIV Group. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1—a meta-analysis of 15 prospective cohort studies. N Engl J Med. 1999;340(13):977-87.
2. Heyward WL, Batter VL, Malulu M, St. Louis ME, et al. Impact of HIV counseling and testing among child-bearing women in Kinshasa, Zaire. AIDS. 1993;7(12):1633-1637.
3. Mofenson LM. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. N Engl J Med. 1999;341(6):385.
4. Maiques V, Garca-Tejedor A, Perales A, Cordoba J, Esteban RJ. HIV detection in amniotic fluid samples—amniocentesis can be performed in HIV pregnant women? Eur J Obstet Gynecol Reprod Biol. 2003;108;137-141.
5. American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. Scheduled cesarean delivery and the prevention of vertical transmission of HIV infection. Washington, DC: ACOG; 2000 May. ACOG committee opinion no. 234.
6. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
There are a number of mechanisms through which ZDV or other ARV drugs can reduce perinatal transmission.
・ One important mechanism is by decreasing maternal viral load in the blood and genital secretions via antenatal drug administration, particularly in women with high viral loads.
・ Another is pre-exposure infant prophylaxis by administration of ARV drugs that cross the placenta during labor, resulting in adequate systemic drug levels in the infant at a time of intensive exposure to the maternal genital tract virus during passage through the birth canal.
Post-exposure infant prophylaxis is provided through administration of drug to the infant after birth; this would protect against cell-free or cell-associated virus that might have obtained access to the fetal/infant systemic circulation through maternal-fetal transfusion during uterine contractions in labor or through systemic dissemination of virus swallowed by the infant during passage through the birth canal.
Supporting Information:
For prophylaxis recommendations, see notes for slides 35 and 43.
Source:
1. Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR Morb Mortal Wkly Rep. 2006 Sept 22; [cited 2009 Sep 29]; 55 (RR14):1-17. Available from: http://www.cdc.gov/mmwr/PDF/rr/rr5514.pdf.
Talking Points:
In September 2006, CDC revised their recommendations for testing in pregnancy as listed in the slide.
American College of Obstetrics and Gynecology (ACOG) and AAP is the American Academy of Pediatrics (AAP) (1999) support routine HIV testing in pregnancy and encourage counseling.
In a “Dear Colleague” letter of April 22, 2003, CDC cited data on HIV prenatal testing rates utilizing three different methods and changed their recommendations for HIV screening in pregnancy to “opt-out” screening.
Health care providers should be familiar with and adhere to state and local laws, regulations, and policies concerning HIV screening of pregnant women and newborns. Many current state laws require HIV counseling and informed consent and would prevent implementing “opt-out” HIV testing in pregnancy.
Supporting Information:
In 1998, the Institute of Medicine recommended universal HIV testing of pregnant women.
For 3rd-trimester retesting, see the listing of geographic areas of elevated incidence for HIV or AIDS among women aged 15–45 (slide 7), see speaker notes on slide 19.
Retesting also is recommended for women who receive health care in facilities in which prenatal screening identifies at least one HIV-infected pregnant woman per 1,000 women screened.1
Sources:
1. Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR Morb Mortal Wkly Rep. 2006 Sept 22; [cited 2009 Sep 29]; 55 (RR14):1-17. Available from: http://www.cdc.gov/mmwr/PDF/rr/rr5514.pdf.
2. American College of Obstetricians and Gynecologists (ACOG), ACOG Committee on Obstetric Practice. Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Washington, DC: ACOG; 2004;304:1119-1124. Committee opinion no. 418.
3. American Academy of Pediatrics (AAP), American College of Obstetricians and Gynecologists. Joint statement on human immunodeficiency virus screening. Elk Grove Village (IL): AAP; Washington (DC): ACOG; 1999; reaffirmed 2006.
Talking Point:
In the 2006 revised recommendations, CDC described who should be retested in the third trimester as detailed on the slide.
Supporting Information:
Identified jurisdictions with an elevated incidence of HIV/AIDS in 2004: Alabama, Connecticut, Delaware, Washington, D.C., Florida, Georgia, Illinois, Louisiana, Maryland, Massachusetts, Mississippi, Nevada, New Jersey, New York, North Carolina, Pennsylvania, Puerto Rico, Rhode Island, South Carolina, Tennessee, Texas, Virginia.
A second HIV test in the 3rd trimester is as cost-effective as other common health interventions when HIV incidence among women of childbearing age is greater than or equal to 17 HIV cases per 100,000 person-years.
Women at high risk: injection drug users, their sex partners, women who exchange sex for money or drugs, women who are sex partners of HIV-positive persons, women who have had a new or more than one sex partner during this pregnancy, other risk factors.
Signs or symptoms of acute retroviral syndrome – see slide 20.
Source:
1. Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. MMWR Morb Mortal Wkly Rep. 2006 Sept 22; [cited 2009 Sep 29]; 55 (RR14):1-17. Available from: http://www.cdc.gov/mmwr/PDF/rr/rr5514.pdf.
Talking Points:
Acute HIV infection should be considered when a patient presents with mononucleosis symptoms.
When acute retroviral syndrome is a possibility, a plasma RNA test is recommended in addition to an HIV antibody test to diagnose acute HIV infection.
Plasma RNA (PCR) is more sensitive than antibody tests because standard HIV enzyme-linked immunoassay (ELISA) testing determines the presence of HIV antibodies.
・ The body may take 10 days to 4 weeks to develop antibodies to HIV after exposure (the “window period” between transmission and seroconversion).
・ Standard testing often misses patients with acute infection who typically have extremely high levels of circulating virus.
・ HIV-RNA (PCR) testing is more likely to detect acute or early infection.
Source:
1. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Washington, DC: Department of Health and Human Services; 2008 Nov 3 [cited 2009 Sep 29]. Available from: http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.
Talking Points:
Increased risk of transmission to the fetus during gestational acute retroviral syndrome is hypothesized due to high viral titers and absence of immune factors.
The risk of transmission from an individual with primary HIV infection may be 20-fold greater per exposure than the risk of transmission from someone with chronic infection.
Supporting Information:
An HIV expert can be an obstetrician/gynecologist (OB/GYN) specializing in infectious diseases or maternal-fetal medicine. An expert could also be a specialist in infectious diseases.
The professional organizations representing these specialties are: The Infectious Diseases Society for Obstetrics and Gynecology (IDSOG), The Society of Maternal Fetal Medicine (SMFM), and The Infectious Disease Society of America (IDSA).
Source:
1. Weintrob AC, Giner J, Menezes P, et al. Infrequent diagnosis of primary human immunodeficiency virus infection. Arch Intern Med. 2003;163:2097-2100.
Talking Points:
ELISA and rapid HIV tests both detect the presence of HIV antibodies. Some of the rapid tests detect antibody at an earlier time after infection.
Laboratories generally report a positive HIV antibody test only after it has been confirmed by a WB.
Supporting Information:
Resource on HIV testing: http://www.cdc.gov/hiv/topics/testing.
False positive ELISA test results can be caused by alloantibodies resulting from transfusions, transplantation, pregnancy, autoimmune disorders, malignancies, alcoholic liver disease, or for reasons that are unclear.
Source:
1. Doran TI, Parra E. False positive and indeterminate human immunodeficiency virus test results in pregnant women. Arch Fam Med. 2000;9:924-929.
Chapter title slide; no notes.
Talking Points:
The primary goals of ARV treatment are the same for a pregnant woman as for any person living with HIV.
An added benefit/goal of ARV treatment for a pregnant woman is the unique opportunity to reduce the risk of transmission to the baby.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Therapies with known benefit should not be withheld during pregnancy unless there are adverse effects for mother, fetus, or infant, and unless adverse effects outweigh benefit to the woman.
Unique considerations for treating pregnant women include:
・ Potential changes in dosing due to physiologic changes in pregnancy
・ Potential short- and long-term effects of drugs on the fetus and newborn, which may not be known for many ARVs
Supporting Information:
Discussion regarding use of ARV in pregnancy should include:
・ Known and unknown effects of drugs on the woman, on the fetus and newborn, and lack of data on long-term effects
・ Recommended treatment for woman’s health
・ Known ZDV efficacy for reducing perinatal transmission
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Decisions regarding the use and choice of ARV drugs during pregnancy are complex and should be made by the woman in consultation with her healthcare provider.
Coercive or punitive policies are potentially counterproductive in that they may undermine provider-patient trust and could discourage women from seeking prenatal care and adopting health care behaviors that optimize fetal and neonatal well-being.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
In addition to the standard antenatal assessments, the initial evaluation should include an assessment of HIV disease status and recommendations regarding ARV treatment or alteration of her current ARV regimen:
・ Evaluation of the degree of existing immunodeficiency determined by past and current CD4 count
・ Evaluation of the risk for disease progression and perinatal HIV transmission as determined by current plasma HIV RNA copy number
・ Assessment of the need for prophylaxis against opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP) or Mycobacterium avium complex (MAC)
・ Baseline evaluation with complete blood cell count, and renal and liver function testing
Supporting Information:
History of prior and current ARV therapy
History of prior ARV drug use for prevention
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Medical care of HIV-infected pregnant women requires coordination and communication between HIV specialists and obstetrical providers.
In general, if plasma HIV RNA is detectable, ARV drug resistance studies should be performed before starting ARV therapy or prophylaxis; however, if HIV is diagnosed late in pregnancy, therapy should be initiated while awaiting results of resistance testing.
A pregnant woman may need additional services in her community and should be referred to a social worker.
Sources:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Recommendations regarding the choice of ARV drugs for treatment of HIV-infected pregnant women are subject to unique considerations. These include:
・ Possible changes in dosing requirements resulting from physiologic changes associated with pregnancy
・ Possible toxicities of ARV drugs that may be magnified in the pregnant woman
・ Potential short- and long-term effects of the ARV drug on the fetus and newborn, including the potential for teratogenicity, mutagenicity, or carcinogenicity, which may not be known for certain ARV drugs
・ Pharmacokinetics and toxicity of transplacentally transferred drugs; some protease inhibitors may require altered dosing.
Supporting Information:
Treatment recommendations for pregnant women infected with HIV are based on the concept that therapies of known benefit to women should not be withheld during pregnancy unless there are known adverse effects on the mother, fetus, or infant and unless these adverse effects outweigh the benefit to the woman.1
Pregnancy should not preclude the use of optimal therapeutic regimens. The decision to use any ARV drug during pregnancy should be made by the woman after discussing with her healthcare provider the known and potential benefits and risks to her and her fetus.
The Antiretroviral Pregnancy Registry is intended to provide an early signal of any major teratogenic effect associated with a prenatal exposure to the products monitored through the Registry. The Registry is a voluntary prospective, exposure-registration, observational study designed to collect and evaluate data on the outcomes of pregnancy exposures to ARV products. Telephone: (800) 258-4263 Fax: (800) 800-1052 Internet: www.apregistry.com.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Didanosine should be used with stavudine only if no other alternatives are available. Cases of lactic acidosis, some fatal, have been reported in pregnant women receiving didanosine and stavudine together.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Some ARVS as outlined on the slide should only be used with caution during pregnancy.
Women initiating NVP with CD4 counts >250 cells/mm3, including pregnant women receiving ARV drugs solely for prevention of transmission, have an increased risk of developing symptomatic, often rash-associated, NVP-related hepatotoxicity, which can be severe, life-threatening, and in some cases fatal. NVP should therefore be used as a component of a combination regimen only if the benefit clearly outweighs the risk. Regardless of maternal CD4 count, if NVP is used, providers should do frequent, careful monitoring of symptoms and hepatic transaminases (i.e., ALT and AST), particularly during the first 18 weeks of therapy. Some clinicians do serum transaminases at baseline, every 2 weeks for the first month, monthly through month 4, and every 1 to 3 months thereafter.
Supporting Information:
Increases in hepatic transaminase levels (ALT and AST) associated with rash or systemic symptoms may be observed during the first 18 weeks of treatment with Nevirapine (NVP). Signs and symptoms of systemic toxicity may be nonspecific: fatigue, malaise, anorexia, nausea, jaundice, liver tenderness, or hepatomegaly, with/without initially abnormal hepatic transaminases.
Nucleoside Reverse Transcriptase Inhibitor (NRTI) drugs are known to induce mitochondrial dysfunction. Mitochondrial toxicity has been reported in patients on long-term treatment with NRTI drugs and generally resolved with discontinuation of the drug(s). These toxicities may be of concern for pregnant women and infants with in-utero exposure to NRTI drugs.
Clinical disorders linked to mitochondrial toxicity include neuropathy, myopathy, cardiomyopathy, pancreatitis, hepatic steatosis, and lactic acidosis. These syndromes have similarities to rare life-threatening syndromes that occur during pregnancy, most often during the 3rd trimester: acute fatty liver, the syndrome of hemolysis, elevated liver enzymes, and low platelets (the HELLP syndrome). The frequency in pregnant HIV-infected women receiving NRTI drugs is unknown. Because pregnancy can mimic some of the early symptoms of the lactic acidosis/hepatic steatosis syndrome or be associated with other disorders of liver metabolism, physicians caring for HIV-infected pregnant women receiving NRTI drugs need to be alert for early signs of this syndrome.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Hyperglycemia, new onset diabetes mellitus, exacerbation of existing diabetes mellitus, and diabetic ketoacidosis have been reported in patients treated with PI ARV drugs.
・ Pregnancy itself is a risk factor for hyperglycemia.
・ Majority of data to date have not shown an increased risk of glucose intolerance with PI therapy in pregnancy.
HIV-infected women receiving ARV therapy during pregnancy should receive standard glucose screening with a standard 1-hour, 50-gram glucose loading test at 24–28 weeks of gestation.
Supporting Information:
Some experts would perform earlier glucose screening in women on ongoing PI-based therapy started before pregnancy similar to women with high-risk factors for glucose intolerance.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
There are three primary types of ARV regimens:
・ Non-nucleoside reverse transcriptor (NNRTI) in combination with a “backbone” of two NRTIs.
・ PI-based: one or two PIs in combination with a “backbone” of two NRTIs.
・ NRTI-based: 3 NRTIs have inferior virologic efficacy and should only be considered if NNRTI- or PI-based regimen is not appropriate.
Supporting Information:
Any HIV-infected pregnant woman who meets standard criteria for ARV therapy as per adult ARV guidelines should receive potent combination ARV therapy, generally consisting of two NRTIs plus a NNRTI or PI(s), with continuation of therapy postpartum.
ARV prophylaxis is recommended for all pregnant women regardless of viral load.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Pregnant women with HIV should receive standard clinical, immunologic, and virologic evaluation.
Decisions about the need for ARV therapy should be based on standard guidelines in non-pregnant adults.
Supporting Information:
A pregnant woman who meets criteria for treatment should be started on a potent standard regimen.
A pregnant woman who does not need treatment for her own health should receive a 3-drug combination ARV regimen for prophylaxis.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
In general, women who have been on ARV treatment should continue during pregnancy. Discontinuing therapy could lead to an increase in viral load, which could result in a decline in immune status and disease progression as well as adverse consequences for the fetus/newborn and the woman, including increased risk of HIV transmission.
Counsel women on ARVs who present during the first trimester regarding the benefits and potential risks of ARVs during this period, but continuation of therapy should be recommended if HIV RNA is suppressed.
Order ARV resistance tests if detectable viremia (>500-1000 mL).
Supporting Information:
While ZDV should be a component of the ARV regimen, there may be circumstances, such as severe ZDV-related toxicity or documented ZDV resistance, when this is not possible. Women receiving an ARV regimen that does not contain ZDV but who have HIV undetectable RNA levels have a very low risk of perinatal transmission. Substituting ZDV for another drug or the addition of ZDV could compromise adherence. In such cases, continuing a non-ZDV-containing regimen that is fully suppressive is reasonable.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Appropriate choice of ARVs will vary according to the history of ARV use, the indication for stopping therapy, whether the drugs are currently needed for treatment or prophylaxis, and results of resistance testing.
In addition to obtaining genotypic resistance testing consult, specialists in the treatment of HIV infection about the choice of ARV therapy for these women.
Selection of an appropriate ARV regimen for women with advanced HIV disease, a history of extensive prior ARV therapy, or history of significant toxicity to ARV drugs in the past may be challenging even for health care providers experienced in HIV care.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Interruption of therapy should be avoided if possible.
If therapy must be stopped, all drugs should be stopped and re-intitiated at the same time except that an NNRTI should be stopped first and the others continued for 7 days.
NNRTIs have a long half-life; the optimal interval between stopping NNRTI and other ARV drugs not known.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
CD4 cell count and plasma HIV RNA levels should be monitored regularly as outlined on the slide.
Due to physiologic changes such as hemodilution during pregnancy, CD4 percentage may be more stable than absolute CD4 count during pregnancy.
Since parameters for initiating therapy are based primarily on absolute CD4 count, most clinicians still rely on CD4 count to evaluate immune status during pregnancy.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Resistance testing should be done if VL rebounds or is not optimally suppressed.
Monitoring for potential complications of ARV drugs during pregnancy should be based on what is known about the side effects of the drugs the woman is receiving.
Adherence should be assessed and supported at each visit.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
First-trimester ultrasound is recommended for confirmation of gestational age and to guide timing of scheduled Cesarean delivery, if needed, since scheduled Cesarean deliveries for prevention of perinatal HIV transmission should be performed at 38 weeks gestation.
・ First-trimester ultrasound has been shown in research studies and is recommended by ACOG as most accurate for dating of pregnancy.
If the patient is not seen until later in gestation, then second-trimester ultrasound can be used for anatomy scanning and gestational age.
Because less is known about the effect of combination ARV therapy on the fetus during pregnancy, some experts consider more intensive fetal assessment for these mothers.
Supporting Information:
Most experts would recommend second-trimester ultrasound assessment of fetal anatomy in women who are on combination ARVs during the first trimester, particularly if the regimen included EFV. Some experts would also recommend ultrasound assessment of fetal growth and well-being during the third trimester in addition to standard clinical monitoring, if the woman was receiving an ARV regimen for which there is limited experience with use in pregnancy.
Additional assessments such as non-stress testing should be determined based on ultrasound findings and any maternal co-morbidities.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Management of women on chronic ARV therapy who have suboptimal suppression of HIV RNA (i.e., detectable virus at any time during pregnancy) should include evaluation for resistant virus, assessment of adherence, incorrect dosing or potential problems with absorption (e.g., with nausea/vomiting or lack of attention to food requirements), and consideration of modification of ARV therapy.
Experts in the care of ARV-experienced adults should be consulted, in particular when a change in drug regimen is necessary.
If VL is >1000, a scheduled Cesarean delivery is recommended.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
2. American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetric Practice. Scheduled cesarean delivery and the prevention of vertical transmission of HIV infection. Washington, DC: ACOG; 2000 May. ACOG committee opinion no. 234.
Talking Points:
Antiretroviral resistance may:
・ Decrease the efficacy of perinatal prophylaxis
・ Limit the woman’s future treatment options
・ Limit treatment options if the infant is infected
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Women who have documented ZDV resistance should still receive IV ZDV during labor.
Some experts would give additional ARVs to these infants, so a pediatric HIV specialist should be consulted.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Data are conflicted on whether ARV exposure has an influence of pregnancy outcome.
Until more information is known, HIV-infected pregnant women who are receiving combination therapy for their HIV infection should continue their provider-recommended regimen. They should receive careful, regular monitoring for pregnancy complications and for potential toxicities.
Supporting Information:
Some European studies found an increased incidence of preterm pregnancy in women with HIV infection. In contrast, the majority of data from the United States and Latin America do not suggest an increased risk of preterm birth associated with HAART during pregnancy.
In a meta-analysis of seven clinical studies that included 2,123 HIV-infected pregnant women who delivered infants during 1990–1998 and had received antenatal ARV therapy and 1,143 women who did not receive antenatal ARV therapy, use of multiple ARV drugs as compared with no treatment or treatment with one drug was not associated with increased rates of preterm labor.
Until more information is known, HIV-infected pregnant women who are receiving combination therapy for their HIV infection should continue their provider-recommended regimen. They should receive careful, regular monitoring for pregnancy complications and for potential toxicities.
Some European data suggested that mitochondrial dysfunction might develop in infants exposed to NRTIs in-utero, however a review of >16,000 infants born to HIV-infected women with and without ARV drug exposure found no deaths similar to those in the European studies or with clinical findings attributable to mitochondrial dysfunction. Most infants had been exposed to ZDV alone and few had been exposed to ZDV/3TC.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Chapter title slide; no notes.
Talking Points:
Some women may need rapid HIV testing in labor including:
Women with no or limited prenatal care.
・ There are many reasons why women do not access prenatal care. Women with more prenatal visits have a greater likelihood of being offered HIV counseling and testing. Royce, et al. (2001) found that entering care in the 3rd trimester was a predictor for NOT being tested.
・Ask all women with no prenatal/limited prenatal care or no documented
HIV status on their chart “if they know if they have HIV infection.” A woman
is more likely to tell you her HIV+ status if asked directly.
Women whose results aren’t available: administrative “red tape” or tested late.
Women who declined testing:
・ Thought they weren’t at risk
・ Provider didn’t recommend to them
・ Know they are HIV positive and are fearful to disclose
Women who should have had a 3rd trimester test but did not.
Sources:
1. Royce R. et al. Barriers to universal prenatal HIV testing in 4 US locations in 1997. Am J Public Health. 2001;92:727-733.
2. Gross EG, Burr CK. HIV counseling and testing in pregnancy. N J Med. 2003;Suppl 100:21-26.
Talking Points:
HIV testing on blood specimens is preferred; of the currently approved CLIA-waived rapid tests, rapid tests performed on blood are slightly better (have greater sensitivity) than oral fluid tests at detecting true positives.
Oral fluid testing continues to play an important role in HIV testing and prevention where blood testing is not practical, or where oral fluid is preferred. It allows more people to be tested and receive their test results.
Persons tested with any rapid test need to be informed before testing that the results are preliminary only and need to be confirmed.
All reactive screening tests (oral fluid or blood) should be followed by a confirmatory test using serum specimens.
Source:
1. http://www.hret.org/disparities/projects/resources/rpd1.pdf
2. American College of Obstetricians and Gynecologists (ACOG), ACOG Committee on Obstetric Practice. Prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Washington, DC: ACOG; 2004;304:1119-1124. Committee opinion no. 418.
Talking Points:
HIV testing in labor gives results quickly. It is recommended for all women who have not had a test in prenatal care, it is voluntary, and a woman can decline testing or consent to it.
The messages to the pregnant woman should include:
・ HIV can be passed from mother to baby during pregnancy, delivery, and through breastfeeding.
・ HIV is spread by unprotected sexual intercourse; therefore, all pregnant women may be at risk for HIV infection.
・ If test is positive, ARVs during labor and delivery can reduce risk of transmission to baby.
・ A pregnant woman with HIV has a 1in 4 chance of passing HIV to her baby if she is not treated.
・ If a woman with HIV takes ARVs during labor and delivery and her baby takes the medicine after birth, the chance of passing HIV to her baby is 1 in 10.
Supporting Information:
Explain when she can expect results.
・ Results should be given while maintaining confidentiality. Some women request that positive results be given to them after the infant is born.
・ Positive preliminary tests will be confirmed. Obtain consent for prophylactic treatment based on preliminary test results.
Talking Points:
Explain that a positive HIV test means that she may (or is likely to) have HIV infection, but the test is preliminary and another test will be done to confirm the first test to be sure.
Describe the available interventions to reduce the risk of transmission to her baby.
Discuss delaying/postponing breastfeeding until after results of confirmatory test are available.
Supporting Information:
If she planned to breastfeed, explain how you will support her (breast-milk pumping, etc.) until the results of the confirmatory test are available. Engage a lactation specialist to assist the new mother with her pumping options for breast milk until the confirmatory results are received; this will allow her the option to breastfeed if she is HIV-negative.
Tell her when to expect the confirmatory results.
Explain the resources you will have for her in postpartum after the baby is born.
Talking Points:
All women with a positive rapid HIV test in labor should have intravenous ZDV started immediately to prevent perinatal HIV transmission and begin infant combination ARV prophylaxis.
Whether the addition of other ARV drugs to the intravenous intrapartum/newborn ZDV regimen when no maternal antepartum drugs have been received increases efficacy in preventing perinatal transmission has not been directly studied.
Supporting Information:
Several intrapartum/neonatal prophylaxis regimens have been found to be effective in international studies. None of these regimens has been compared to intravenous ZDV. These include oral ZDV/3TC during labor followed by one week of oral ZDV/3TC to the infant single-dose intrapartum/newborn NVP.
Consult with an OB and/or pediatric HIV specialist.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Comprehensive care and support services are very important for women with HIV infection and their families who often face multiple social and medical challenges.
Women with a positive rapid antibody test should be presumed to be infected until confirmatory testing clarifies their status.
The woman should have appropriate assessments (e.g., CD4 count and HIV RNA copy number) in the immediate postpartum period to determine maternal health status and whether ARV therapy is recommended for her own health.
Arrangements for establishing HIV care and providing ongoing psychosocial support after discharge should also be provided. Most states have laws governing the confidentiality of HIV diagnosis and treatment. Often, specific written consent is required to share a patient’s HIV information with others outside the healthcare team.
Supporting Information:
The State HIV Testing Laws Compendium available from the National HIV/AIDS Clinicians’ Consultation Center (www.nccc.ucsf.edu) describes key HIV testing laws and policies by state. Each state’s HIV testing laws are unique and many have been revised since the release of the CDC’s 2006 HIV testing guidelines. The Compendium is designed to help clinicians understand HIV testing laws and to implement sound HIV testing policies.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
HIV-positive women who are receiving an antepartum ARV regimen should continue the regimen on schedule as much as possible during the intrapartum period, regardless of route of delivery, to provide maximal virologic effect and to minimize the chance of development of drug resistance.
If a woman is receiving combination ARV regimens and HIV RNA < 400 copies/mL near delivery, IV AZT is not required.
When Cesarean delivery is planned, oral medications may be continued preoperatively with sips of water.
Supporting Information:
Medications requiring food ingestion for absorption could be taken with liquid dietary supplements, but consultation with the attending anesthesiologist should be obtained before administering in the preoperative period.
If maternal ARVs must be interrupted temporarily (i.e., for less than 24 hours) in the peripartum period, all drugs (except for intrapartum intravenous ZDV) should be stopped and reinstituted simultaneously to minimize the chance of developing resistance.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
ACOG’s Committee on Obstetric Practice Committee Opinion (2000) recommended consideration of scheduled Cesarean delivery (prior to labor and rupture of membranes) for HIV-infected pregnant women with HIV RNA levels >1,000 copies/mL near the time of delivery.
For women with HIV RNA <1,000 copies/mL, the data regarding the benefit of scheduled Cesarean are insufficient to draw definitive conclusions; therefore, decisions regarding mode of delivery should be individualized.
Supporting Information:
HIV-infected women who present late in pregnancy and are not on ARVs may not have HIV RNA results available before delivery. Without current ARV therapy, HIV viral load levels are unlikely to be <1000 copies/mL. Scheduled Cesarean is likely to provide additional benefit in reducing perinatal transmission risk.
Pregnant women on combination ARV with VL of <1,000 near the time of delivery have transmission rates of 1.2–1.5%. Given this very low rate of transmission, the benefit of scheduled Cesarean is difficult to evaluate in this group of women. Scheduled Cesarean may not further reduce risk of transmission.
Sources:
1. American College of Obstetrics and Gynecology (ACOG) Committee on Obstetric Practice. ACOG Committee Opinion No. 234 Scheduled Cesarean Delivery and the Prevention of Vertical Transmission of HIV infection. Int J Gynaecol Obstet. 2000;234;73(3);279-281.
2. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Data indicate that Cesarean delivery is associated with a somewhat greater risk of complications among HIV-infected women than observed among uninfected women, the difference is most notable among women with more advanced disease.
Scheduled Cesarean delivery for prevention of HIV transmission poses a risk of obstetrical complications greater than that of vaginal delivery and less than that of urgent or emergent Cesarean delivery.
Complication rates in most studies were within the range reported in populations of HIV-uninfected women with similar risk factors and were not of sufficient frequency or severity to outweigh the potential benefit of reduced transmission among women at heightened risk of transmission.
Supporting Information:
Complications included endometritis, postpartum fever, wound infections, mild anemia, and pneumonia.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
ROM increases the risk of HIV transmission over time.
If spontaneous rupture of membranes occurs before or early during the course of labor, interventions to decrease the time to delivery, such as administration of oxytocin, may be considered.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Obstetric procedures increasing the risk of fetal exposure to maternal blood, such as amniocentesis and invasive monitoring, have been implicated in increasing vertical transmission rates by some, but not all, investigators. None of the studies assessing these risks has controlled for VL or have been in women on potent combination ARV therapy.
Delivery with forceps or vacuum extractor may increase the risk of transmission and should be avoided if possible. May be considered to shorten time to delivery or for firm obstetric indications.
If labor is progressing and membranes are intact, artificial rupture of membranes (AROM) and use of fetal scalp electrodes should be considered only when obstetrically indicated and time of ruptured membranes or monitoring is expected to be short.
Supporting Information:
Methergine should not be co-administered with drugs that are potent CYP3A4 enzyme inhibitors, including PI and the NNRTI drugs efavirenz (EFV) and delavirdine.
・ The concomitant use of ergotamines and PIs has been associated with exaggerated vasoconstrictive responses.
When uterine atony results in excessive postpartum bleeding in women with HIV infection receiving PIs or EFV or delavirdine as a component of an ARV regimen, methergine should not be used unless alternative treatments (e.g., prostaglandin F2 alpha, misoprostol, or oxytocin) are not available.
・ If there are no alternative medications available and the need for pharmacologic treatment outweighs the risks, methergine should be used in as low a dosage and for as short a duration as possible.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Chapter title slide; no notes.
Talking Points:
Worldwide, HIV transmission through breastfeeding accounts for about 1/3–1/2 of all transmissions from mothers to their infants.1
Women in the United States who have HIV should not breastfeed, and every breastfeeding woman should know her HIV status.
Decisions NOT to breastfeed may raise issues related to confidentiality and disclosure of a mother’s HIV diagnosis and require sensitive and supportive interventions.
Women who are in a discordant relationship and are breastfeeding should use protective measures while breastfeeding.
Supporting Information:
In resource-limited settings, where safe water is not readily available, the risks of breastfeeding must be weighed against the risk of replacement feeding. A meta-analysis suggested a constant risk of HIV transmission through breastfeeding of about 0.9% per month after the first month of life.2
There are ongoing international studies investigating the role of ARVs in HIV-infected breastfeeding women in reducing HIV transmission.
In the United States, breastfeeding is the norm among many cultural groups, particularly among recent immigrants from resource-limited countries.
Sources:
1. The Breastfeeding and HIV International Transmission Study Group. Late postnatal transmission of HIV-1 in breast-fed children: an individual patient data meta-analysis. J Infect Dis. 2004;15; 189:2154-66.
2. Fowler, MG, Newell, ML. Breast-feeding and HIV-1 transmission in resource-limited settings. J Acquir Immune Defic Syndr. 2002;30:230-239.
3. Fowler MG, Lampe MA, Jamieson DJ, Kourtis AP, Rogers MF. Reducing the risk of mother-to-child human immunodeficiency virus transmission: past successes, current progress and challenges, and future directions. Am J Obstet Gynecol. 2007;197 Suppl 3:S3-S9.
4. Miotti PG, Taha T, Kumwenda NI, Broadhead R, et al. HIV transmission through breastfeeding: a study in Malawi. JAMA. 1999:282:744-749.
Talking Points:
A woman should be referred for HIV specialty care postpartum, if she has not been receiving it, since she may need her ARV regimen modified.
Maternal medical services during the postpartum period must be coordinated between obstetric care providers and HIV specialists. Continuity of ARV treatment when such treatment is required for the woman’s HIV infection is especially critical and must be ensured.
The decision to continue or stop ARV therapy after delivery depends on the nadir CD4 counts, clinical symptoms, presence of other indications for ARV therapy, and patient and provider preference.
The immediate postpartum period poses unique challenges for adherence: new or continued supportive services should be assured before the mother and infant are discharged from the hospital.
If the mother is newly diagnosed, older children need to have HIV testing if that has not been done. Her sexual and needle-sharing partners will also need to be referred for testing.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
All women with HIV infection need to be referred for ongoing OB/GYN services and interconception care.
Contraceptive counseling is a critical aspect of postpartum care. Although condoms are universally recommended for prevention of STD/HIV transmission, the unintended pregnancy rate with condom use alone is high.
The postpartum period provides an opportunity to review and optimize women’s health care, including cervical cancer screening, routine immunizations, mental health and substance abuse treatment as indicated, and assessment for signs of postpartum depression.
Care coordination services and case management are available in most communities through HIV services funded through the Ryan White Program. See slide 112.
Supporting Information:
Support services should be tailored to the individual woman’s needs and may include case management, child care, respite care, assistance with basic life needs (e.g., housing, food, and transportation), peer counseling, and legal and advocacy services. Ideally, this care should begin before pregnancy and should be continued throughout pregnancy and postpartum.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
6-week neonatal component of ZDV regimen is recommended for all HIV-exposed neonates.
Start ZDV at age-appropriate doses as close as possible to birth.
If mother has not received antepartum ARV, give the infant ZDV for 6 weeks combined with doses of nevirapine noted.
Consult a pediatric HIV specialist about combining a ZDV regimen with other drugs.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
The first dose of neonatal ZDV should be administered as soon as possible after delivery and within 6-12 hours.
Consult a pediatric HIV specialist for ZDV dosage in premature infants and for recommendations regarding the use of additional ARVs for infants whose mothers were diagnosed late in pregnancy.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
Refer the mother and infant to a pediatric HIV specialist for diagnostic follow-up and monitoring.
Arrange follow-up to support the family’s adherence to infant’s prophylactic ARV regimen.
For newborns, before beginning ZDV, perform a CBC and differential as a baseline.
Supporting Information:
HIV DNA PCR or HIV RNA assays are the preferred virologic assays.
・ Testing is recommended at 14–21 days, 1–2 months, and 3–6 months.
・ HIV is diagnosed by two positive virologic tests on separate blood samples regardless of age.
Start prophylaxis for P. carinii pneumonia for all infants exposed to HIV and continue until HIV is ruled out or to age 1 year. HIV can be presumptively excluded in a non-breast fed infant with two or more negative tests: one at >14 days and one at >1 month.
Data are currently insufficient to address the effect of exposure to ZDV or other ARVs in utero. Educate families to include child’s exposure to HIV and to ARVs in utero as an important element of child’s medical history.
Continue to follow children exposed to ARVs into adulthood because of the theoretical concerns regarding potential for carcinogenicity of nucleoside analogue ARVs. Long-term follow-up should include yearly physical exams and for adolescent females, gynecologic evaluation with Pap smears.
Source:
1. Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available from: http://aidsinfo.nih.gov/contentfiles/lvguidelines/PerinatalGL.pdf. Last updated July 31, 2012. Accessed February 8, 2013.
Talking Points:
AIDSinfo is a federally-sponsored web site that provides the most current guidelines for the treatment of HIV/AIDS which are reviewed and updated regularly by experts in the field.
Talking Points:
The One Test. Two Lives. program from the Centers for Disease Control and Prevention (CDC) gives obstetric providers new tools to help ensure all patients get tested for HIV early in their pregnancy.
One Test. Two Lives. provides a variety of resources for providers—as well as materials for their patients—to help encourage universal prenatal testing for HIV.