The document describes various drug regimens used for the prevention of mother-to-child transmission (PMTCT) of HIV during pregnancy, childbirth, and postpartum. It discusses the use of antiretroviral therapy (ART) and prophylaxis with drugs like nevirapine and AZT to reduce transmission. Common regimens involve mothers taking antiretrovirals during late pregnancy and labor, and giving the infant prophylaxis after birth. The risks and benefits of different drug options are considered, as well as monitoring treatment to support both mother and child.

1. Drug regimes for PMTCT and their use during pregnancy, intrapartum and postpartum

2. Session Objective and content Objective: At the end of the session the participant should be able Describe the various drug regimes for PMTCT used during pregnancy, intrapartum and postpartum including short course ART Content Use of antiretroviral drugs and pregnancy Selection of short course ART regimens for PMTCT-- efficacy, toxicity, timing of initiation and cessation Use of HAART for PMTCT

3. Antiretrovirals in PMTCT ARV therapy Long-term use of antiretroviral drugs to manage maternal HIV/AIDS and prevent PMTCT. ARV prophylaxis Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant. Prophylaxis with nevirapine Prophylaxis with AZT and nevirapine Post exposure prophylaxis Prophylaxis with HAART

4. Antiretrovirals and pregnancy Nucleoside analogue drugs are known to induce mitochondrial dysfunction, highest for zalcitabine (ddC), didanosine (ddI), stavudine (d4T). Present as neuropathy, myopathy, cardiomyopathy, pancreatitis, Efavirenz: birth defects with first trimester exposure (polydactaly, hydronephrosis; bilateral hip dislocation, umbilical hernia, urinary obstruction and neural tube defects) Hyperglycemia, and diabetic ketoacidosis reported with protease inhibitor. increased risk of preterm delivery for infants exposed to combination therapy with or without protease particularly started before pregnancy CP450 inhibition by Protease inhibitors can lead to ergortism with administration of ergometrine

5. Interaction of Nevirapine for PMCT and for ART NNRTI based HAART, often with NVP, is the first line treatment regimen in resource limited settings based on WHO recommendations Based on cost, efficacy, full awareness of toxicities NVP alone or in combination with other ARVs is the most commonly used drug for PMTCT in developing countries Concerns safety concerns higher risk of liver and cutaneous adverse events among women with>250 CD4 count with chronic (non single dose) NVP Resistance even with single dose

6. Prophylaxis with Nevirapine (NVP) A single 200 mg tablet for the mother to take at the onset of labour A single dose of oral suspension (standard dosage = 2 mg/kg) to be given to the infant immediately after birth or within 72 hours of delivery.

7. Prophylaxis with AZT and NVP Antenatal Mother: AZT 300 mg twice daily starting at 28 weeks or as soon thereafter as possible. AZT may be started as late as 36 weeks. Intrapartum Mother: AZT 300 mg at onset of labour and every 3 hours until delivery and single-dose NVP 200 mg at onset of labour. OR AZT 600 mg at onset of labour AND single-dose NVP 200 mg at onset of labour. Postpartum Infant: NVP 2 mg/kg oral suspension immediately after birth or within 72 hours of delivery and AZT 4 mg/kg twice a day for 7 days. OR NVP 2 mg/kg oral suspension immediately after birth or within 72 hours of delivery.

8. Post exposure prophylaxis 13.4% Vs 17% difference NS 16.2% NVP stat Vs AZT 6 weeks South Africa (secure future) 22% 39% difference 14% NVP stat vs NVP stat + 7 day AZT Malawi Forgarty TX and efficacy Infant Regimen

9. HAART for PMTCT Avoid NVP Avoid EFV unless in late pregnancy Defer in 1 st trimester Monitor as with HAART treatment Most experience with AZT/3TC/Kaletra AZT/3TC/NFV

10. PMTCT plus The implementation of strategies to provide Treatment, care and support of women infected with HIV, their infants and their families.

11. PMTCT-Plus Strategies Child Monitoring the growth and development of the HIV-exposed child including immunisations Prevention and treatment of opportunistic infections Diagnosis of HIV Mother and partner Nutritional counseling Psychosocial support Support for implementation of safer infant-feeding practices Counselling in family planning Family Assessment and initiation of ARV therapy Linkage to related community service organisations and agencies to promote continuity of care