The Pregnancy Journey Open discussion

HIV and AIDS 2013 Romania Cumulative number people diagnosed with HIV since ,261 (of which 9,946 diagnosed as children) Adults aged 15 to 49 prevalence rate % (% - 0.2%) Adults 15 and up living with HIV12,223 Adults 20 – 29 years old7,012 Children <14 years old202 New born7 (increasing maybe)

Let’s desire and design the same services for our patients…

What are the: Challenges? Barriers?

Use of ART in Pregnancy

Conceiving on ART? Continue mother’s ART even if it contains efavirenz or does not contain AZT Intensify to three drugs if on PI mono-therapy The combination of D4T and DDI should never be prescribed in pregnancy

ART Naive Low CD4: if mother requires ART for her own health start as soon as possible – Backbone of Kivexa/Truvada/Combivir plus PI or NNRTI depending on resistance or viral load – Darunavir od with TDM or bd – Elite controller: AZT monotherapy

ART Naive cont. High CD4: – Should be started on therapy by 24/40 weeks – Which REGIMEN? – Viral load result dependant <10,000 copies/ml (AZT plus C/S ) >100,000 copies/ml commence 3 drug regimen at the beginning of second trimester

Detectable Viral Load at 36/40 weeks! – Review adherence and concomitant medication ?antacid /PPI use – Perform Resistance Test (result may be too late) – Optimise to best regimen – Consider intensification

Late presenter? >28 weeks start ART without delay If the viral load unknown OR >100,000? – Use 3 or 4 drug regimen including raltegravir Untreated woman presenting in labour with or without ruptured membranes? – Urgent HIV test then if HIV+ve – Give loading dose with nevirapine, iv AZT, raltegravir; If Preterm Labour – Use 3 or 4 drug regimen including double dose tenofovir preceeding delivery (until the baby is able to absorb Rx)

Mode of Delivery? What are your guidelines? Depends on Viral load at term if you do a C/S or attempt a Normal Vaginal Delivery

ART for the baby WHO Guidelines Depends on mother's viral load at delivery- Suppressed Viral load + Bottle feeding = oral AZT 4 weeks Unknown or detectable viral load? = NVP 6-12 weeks BHIVA (UK): triple therapy 6 weeks usually Combivir + nevirapine

HIV and AIDS 2013 Romania Cumulative number people diagnosed with HIV since ,261 (of which 9,946 diagnosed as children) Adults aged 15 to 49 prevalence rate % (% - 0.2%) Adults 15 and up living with HIV12,223 Adults 20 – 29 years old7,012 Children <14 years old202 New born7

Any thoughts on the under 15 year old child infections?