1. Infecţia HIV şi concepţia, sarcina şi contracepţia
The slides overview the importance of planning for the possibility of pregnancy for all women of child bearing potential who are HIV positive or those who are HIV negative and in a relationship with an HIV-positive partner
This slide presentation has been produced as part of the Women for Positive Action initiative. Women for Positive Action aims to empower, educate and support women with HIV and the healthcare providers who treat them
The Women for Positive Action educational slide kits are intended for use by healthcare professionals, community representatives and patients who want to create or participate in learning opportunities relating to improving the care of women living with HIV.
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We do our best to ensure that all information and material on the slides is accurate as at 13 August 2009, and if you find anything that is inaccurate let us know and we will correct it as soon as practicable.
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Women for Positive Action is supported by a grant from Abbott.
Women for Positive Action is supported by a grant from Abbott

2. Contents Introducere Sarcina programată/neprogramată
Transmiterea materno-fetală (TMF)
Tratament şi îngrijiri
în timpul sarcinii şi după naştere
Testarea de rutină în timpul sarcinii
Nevoia cercetării aprofundate
Studii de caz
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3. Introducere
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4. Femeile infectate HIV reprezintă un grup important dar puţin recunoscut al pacienţilor serpozitivi
În anul 2007 au fost raportaţi 33 milioane de bolnavi
HIV.
16.5 din acestea erau femei.
Majoritatea sunt la o vârstă fertilă.
Peste 3.8 milioane dintre acestea nasc anual.
In 2007 an estimated 33 million people were living with HIV
The proportion of global HIV cases that are women is about 50% and women make up a higher proportion of new diagnoses, meaning the share of infections among women is increasing in several countries
Mode of infection for women is usually by heterosexual transmission in marriage – most of these women are monogamous
Most women with HIV are of childbearing potential
Over 3.28 million HIV+ women give birth each year, over 75% of these in sub-Saharan Africa
Sub-Saharan Africa is where the majority of the 410,000 new child infections of HIV occur1, mostly through mother-to-child transmission. Another term for this is vertical transmission, which may be the preferred term as it is less blame-laden
Reference
Report on the global AIDS epidemic 2008, UNAIDS, August 2008
În fiecare an, în jur de de copii sunt infectaţi
HIV, principala cale de transmitere find transmiterea
metrno-fetală.
Report on the global AIDS epidemic 2008, UNAIDS
Women for Positive Action is supported by a grant from Abbott

5. Rata prevalenţei HIV în rândul populaţiei feminine din Europa şi America de Nord
Ţara
Prevalenţă (%)
Estonia1
0.48
Ukraina1
0.34
Irlanda1
0.31
Belarus, Letonia, România, Federaţia Rusă, Spania, Marea Britanie1
0.1–0.2
Germania, Italia, Suedia, Polonia, Norvegia1
<0.1
Canada2,3
0.033–0.037
Bulgaria, Republica Cehă, Finlanda, Lituania, Serbia şi Muntenegru, Slovacia, Slovenia1
<0.03
Europe
Data for at least one year in from 23 European countries reported similar findings, with the following HIV prevalence rates among pregnant women:1
Estonia: 0.48% in 2002
Ukraine: 0.34% in 2004
Ireland: 0.31% in 2003
Belarus, Latvia, Romania, Russian Federation, Spain, UK: 0.1%–0.2%
Less than 0.1% elsewhere in Europe, including less than 0.03% in Bulgaria, Czech Republic, Finland, Lithuania, Serbia and Montenegro, Slovakia and Slovenia
Canada
The Alberta Universal Prenatal HIV Screening Program (in which all pregnant women are tested unless they opt out) reported an HIV infection rate of 0.033% pregnancies in An ongoing HIV seroprevalence study of pregnant women in Ontario reported a rate of %3
This rate is based on pregnant women who volunteered for testing (approximately 70%) whereas the rates in the other provinces (except Alberta) are based on complete samples from unlinked anonymous studies
References
Downs AM, Likatavicius G, Alix J, et al. HIV prevalence among pregnant women in Europe, 2000 to Program and abstracts of the XVI International AIDS Conference; August 13-18, 2006; Toronto, Canada. Abstract MOPE0521.
Jayaraman GC, Preiksaitis JK, Larke B. Mandatory reporting of HIV infection and opt-out prenatal screening for HIV infection: effect on testing rates. Can Med Assoc J 2003;168(6).
Remis SR, Swantee C, Major Cl et al. Increasing HIV testing of pregnant women in Ontario: results from the HIV seroprevalence study to September Can J Infect Dis 2003;14(Suppl A):79 (Abstract 322).
Rate mai mari ale prevalenţei HIV au fost depistate în rândul femeilor gravide din mai multe ţări, respectiv în anumite părţi din Ukraina şi în zone din jurul Londeri, Marea Britanie.
1. Downs AM, et al. IAS, 2006
2. Jayaraman et al. Can Med Assoc J, 2003
3. Remis SR, et al. Can J Infect Dis, 2003 5
Women for Positive Action este susţinută de un grant Abbott 5

6. Sarcina programată şi neprogramată
O componentă principală a sistemului de asistenţă a femeii HIV pozitive este planifarea unui set de îngrijiri a sarcinii programate sau neprogramate.
Cu ajutorul unui management optim, aproape orice femeie, aflată la vârstă fertilă poate da naştere unui copil seronegativ.
Women with HIV infection, like other women, may wish to plan pregnancy to start a family, control the size of their family, or avoid pregnancy
Health professionals should enable women to make reproductive choices by counselling, education and provision of contraception at the time of HIV diagnosis and during follow up
With access to optimal management, becoming pregnant and giving birth to a healthy, HIV negative baby is possible for the vast majority of women of childbearing age
Women for Positive Action is supported by a grant from Abbott

7. Planificarea sarcinii: Chestiuni de luat în calcul
Ce se întâmplă dacă bebeluşul meu este HIV pozitiv?
Când am să ştiu acest lucru??
Cum pot rămâne însărcinată fără a-mi infecta partenerul?
Se va schimba comportamentul personalului medical faţă de mine?
Cât de mare este riscul de a-mi infecta partenerul?
Care este riscul de îmbolnăvire pentru copilul meu? ?
Voi trăi suficient cât să îmi vad copii crescând?
Există riscul ca tratamentul să mă afecteze
pe mine sau pe copilul meu?
There are many common issues and concerns that the patient may consider when planning for a pregnancy
Care este metoda optimă de alimentaţie: prin alăptare sau
biberon?
Sarcina îmi poate afecta statusul HIV?
Este obligatorie intervenţia prin cezariană?
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8. Sarcina programată/neprogramată
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9. Sarcina neprogramată Aproximativ 83% din totalul sarcinilor
depistate la femeile HIV pozitive sunt
considerate ca fiind „neprogramate”
Factorii de risc asociaţi sarcinii sunt asemănători cu cei pentru HIV :
Consum de droguri (femeia sau partenerul ei);
Boli mentale;
Violenţa domestică;
Relaţii sexuale cu parteneri multiplii şi contact sexual neprotejat, în special în rândul adolescenţilor.
In an Italian cohort of 325 women receiving ART, less than half (42.9%) reported their current pregnancy as being ‘planned’1
Other studies have reported that only about 50% of pregnancies are planned2
Proportions of unplanned pregnancies as high as 83.3% have been reported among young women with HIV (13-21 years)3
Many of the risk factors for unplanned pregnancy also place women at increased risk for HIV. These include:
Substance abuse (the woman or her partner)
Mental illness
Domestic violence
Frequent unstable sexual relationships and unsafe sexual practices in adolescents
References
Floridia M, Ravizza M, Tamburrini E, et al. Diagnosis of HIV infection in pregnancy: data from a national cohort of pregnant women with HIV in Italy. Epidemiol Infect 2006 Oct;134(5):
Finer LB and Henshaw SK. Disparities in rates of unintended pregnancy in the United States, and Perspectives on Sexual and Reproductive Health 2006; 38(2):90-96
Koenig LJ, Espinoza L, Hodge K, Ruffo N. Young, seropositive, and pregnant: epidemiologic and psychosocial perspectives on pregnant adolescents with human immunodeficiency virus infection. Am J Obstet Gynecol 2007;197(3 Suppl):S
Women for Positive Action este susţinută de un grant Abbott
Koenig, LJ et al. Am J Obstet Gynecol, 2007

10. Planificarea etapelor de îngrijire a sarcinii neprogramate
Anticiparea unei sarcini la toate femeile HIV pozitive cu potenţial fertil.
Consultărea ghidurilor de specialitate şi stabilirea unei scheme de tratament ARV, care să suporte modificări minime în cazul apariţiei sarcinii.
Unwanted or unplanned pregnancy is a significant risk for women with HIV
While the optimal management of HIV during pregnancy usually leads to positive outcomes for both the mother and baby, unplanned pregnancies can disrupt an already complex situation for women with HIV and can be challenging in certain cases and situations
As so many pregnancies are unplanned, being of childbearing potential in itself should be a key factor when choosing an ART regimen
The possibility of pregnancy should be anticipated and suboptimal regimens avoided in preference for more suitable ones
It is important to chose a therapy regimen that is effective and needs minimal modification should the patient become pregnant
For example, avoiding EFZ and ddI+d4T regimens and unnecessary changes to regimens is recommended in most guidelines to avoid the risk of adverse events, poor adherence to therapy and the development of antiretroviral resistance
Always consult the most recently published local practice guidelines appropriate for your location, such as the European,1 British,2 French3 or US4 guidelines
References
European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008]
de Ruiter A, Mercey D, J Anderson J, et al. British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women HIV Medicine 2008;9:452–502
Ministère de la Santé et des Solidarités. Prise en charge médicale des personnes infectées par le VIH. Rapport 2006.
Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV- Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov).
Women for Positive Action este susţinută de un grant Abott

11. Consilierea reproducerii de rutină pentru femeile HIV pozitive este importantă:
Într-un studiu pe 700 de femei HIV pozitive, 22% au rămas însărcinate după diagnosticarea cu infecţie HIV, dar: ~ 57% dintre acestea nu discutaseră niciodată despre posibilitatea unei sarcini sau despre opţiunile de tratament, anterior sarcinii. ~ 42% aveau cunoştinţe limitate despre opţiunile de tratament ARV administrat în timpul primelor luni de sarcină.
A ‘Women Living Positive’ survey1 of 700 HIV positive women in the USA found that 22% of the survey participants became pregnant at some point after being diagnosed with HIV and of these:
57% never discussed pregnancy or treatment options during pregnancy with their HIV healthcare provider before becoming pregnant
42% reported having limited or no knowledge of appropriate antiretroviral options during early pregnancy
 Among the survey participants who had either previously considered pregnancy or who had been pregnant:
41% had not discussed the impact of pregnancy on their antiretroviral regimen
29% said that their HIV healthcare provider had not explained the adverse effects of certain antiretrovirals on maternal and foetal health
Reference
Bridge DA, Hodder S, Squires K et al. Clinicians Fail to Routinely Provide Reproductive Counselling to HIV-Infected Women in the United States. Program and abstracts of the 17th International AIDS Conference; August 3-8, 2008; Mexico City, Mexico. Abstract TUPE0911
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Bridge DA, et al. IAS Mexico City 2008

12. Din rândul femeilor care au luat în calcul o eventuală sarcină sau care erau gravide la momentul dignosticării HIV:
~ 41% nu discutaseră impactul sarcinii asupra TARV.
~ 29% nu discutaseră efectele adverse provocate de ARV.

13. Ce înseamnă consilierea reproducerii?
Sfaturi,educaţie şi discuţii despre:
Efectele contracepţiei
Chestiuni legate de reproducerea maternă
Concepţie sigură
Impactul HIV asupra sarcinii
Impactul sarcinii asupra HIV
Chestiuni psihologice,impactul postpartum asupra aderenţei şi sistemului ambulatoriu.
Sănătatea pe termen lung a mamei şi capacitatea ei de a-şi îngriji copilul.
Transmiterea matero-fetală.
Importanţa îngrijirii antenatale timpurii şi intense.
Adiminsitrarea ARV-urilor şi a altor medicamente pe durata sarcinii.
Reproductive counselling should be considered for all women of child bearing age as a part of primary care
For women who are HIV positive, education and counselling about pregnancy and HIV should be done early in the course of HIV care, not delayed until pregnant, so that informed and carefully considered decisions about contraception and pregnancy can be made
Local HIV support agencies should be contacted and encouraged to raise pre-pregnancy planning and information as part of their support programme. This way women will have the information and knowledge to make informed choices about having a family, and will be able to prepare for pregnancy if that is their choice. This would include information on the Swiss statement and the importance of reducing viral load in preventing MTCT
Discussions about pregnancy should be repeated at intervals throughout care, especially:
when personal circumstances change (e.g. new sexual partner, postpartum);
when there is non-compliance with effective contraception;
where therapies are considered which may have adverse effects in pregnancy; or
when the woman expresses a desire to become pregnant.
Counselling should be tailored according to whether the woman is part of a concordant couple, discordant couple, or whether she is living as a single woman
Reproductive counselling should include advice and education on reproductive choices, wishes and options, including:
Effective contraception
Safe conception if partner is HIV-negative
Impact of HIV on pregnancy course/outcome
Impact of pregnancy on HIV progression
Other reproductive issues based on maternal factors (e.g. coexisting drug / alcohol use; advanced maternal age; hypertension, diabetes)
General preconception issues such as nutritional counselling (e.g. folic acid) and the importance of early and intense antenatal care
Long term health of mother and care for children (guardianship issues)
Mother-to-child transmission and how to prevent it
Use of ARTs and other medications in pregnancy
Psychosocial issues, including possibility of judgment and stigmatization by family and community. Also postpartum issues and how these can impact on adherence and clinic visits
Lack of up-to-date knowledge on the risks of HIV transmission to partners under the various scenarios
Reproductive counselling involves a two-way interactive process that explores coping, decision-making and emotional reactions and plans / prepares for these
Dealing with depression, anxiety and worries, decision-making about disclosure, mode of delivery and feeding, adjustment to parenthood, anticipation of emotional turmoil and feelings
Also deals with issues of partnership/concerns of the couple, and financial issues. If possible, the partner should be included in the counselling process
Cultural issues should also be addressed during reproductive counselling. A French study showed factors influencing the desire for a child included reproductive potential, ethnicity and partner’s HIV-status.1 The desire for parenthood was 2-6 times higher in women born in sub-Saharan and north Africa than in women born in Europe, and 4 times higher in men from those areas. Relationship status was also an important issue. The study also indicated a strong need for education on pregnancy issues: 26% of women who perceived a “very high risk” of vertical transmission felt the desire for a child vs. 46% with a “very low risk” perception
Reference
1. Heard I, Sitta R, Lert F et al. Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12- VESPA Study). AIDS 2007, 21 (suppl 1): 77-82
Aceste discuţii implică o intercţiune între pacient şi medic prin care să se exploreze conceptele de cooperare, abilitate de decizie, reacţii emoţionale şi aptitudini de pregătire.
Tot odată ele trebuie să implice ambii partenerii şi să aibe o relevanţă culturală pentru aceştia.
Women for Positive Action este susţinută de un grant Abbott

14. Consilierea pre-concepţie reprezintă o strategie de reducere a riscului şi se axează pe:
Optimizarea management-ului HIV
Alegerea terapiei ARV
Testarea şi tratarea bolilor cu transmitere sexuală.
Opţiuni de reproducere- riscuri, costuri şi rate de succes.
Relaţii sexuale numai în perioadele fertile ale femeii.
Întreruprea relaţiilor sexuale neprotejate în momentul depistării sarcinii.
Evitarea iritaţiilor tractului genital.
Prezentarea la medic dacă aceste precauţii nu au dat rezultate după 6-12 luni (prezentare timpurie dacă vârsta >35 ani).
Posibilitatea eşecului terapeutic şi posibilitatea fizică de a îngriji un copil.
All couples wishing to become pregnant should receive pre-conception counselling that includes discussions about:
Optimising HIV management:
Attainment of a stable, maximally suppressed viral load prior to conception is recommended for women who are HIV positive on antiretroviral therapy, and wish to become pregnant. ART can result in undetectable viral loads and restoration of the immune system. Clinical studies suggest that treatment of HIV with ART reduces the risk of HIV transmission during unprotected sex.1 However, it should be made clear that the risk is reduced but not eliminated
Control of HIV infection also may increase the probability of pregnancy for an HIV positive woman
Tailored choice of ART:
It is important to chose a therapy regimen that is effective and would not need to be changed if the patient did become pregnant
Avoiding exposure to EFZ and ddI+d4T regimens and unnecessary changes to regimens is recommended to avoid the risk of adverse events, poor adherence to therapy and the development of antiretroviral resistance
Initiation of nevirapine is also contraindicated during pregnancy if baseline CD4 cell counts are above 250 cell/mm3, although it can be continued if it is part of a prior stable and tolerated regimen
Screening for and treating sexually transmitted infections
Information to enable them to make an informed choice about their reproductive options, the inherent risks and costs of each treatment and the likely chances of success
Counselling couples to have sex only when they are sure the woman is in the fertile period of her cycle. Using an ovulation indicator kit can help to pinpoint this time
Counselling couples to stop having unprotected sex as soon as pregnancy occurs
Counselling couples to avoid using products such as douches or herbs that will irritate the genital tract. Practices such as dry sex should also be avoided
The possibility of treatment failure and how they would cope if one or both parents fell seriously ill or died
Referral for fertility assessment is recommended if couples have been unsuccessful in getting pregnant after 6-12 months (or earlier if the woman is over 35 years)
References
McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. J Antimicrob Chemother 2006 Feb;57(2): Epub 2005 Dec 6
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15. Importanţa relaţiei pacient-medic
Ajuta femeia să
accepte schimbările provocate de
Infecţia HIV
Încurajează femeile să devină
parteneri activi
în îngrijirea
stării proprii de sănătate \
Suport
Relaţie pozitivă între pacient şi medic
Trust and effective, two-way communication are the building blocks of a positive therapeutic relationship between women and healthcare professionals (HCPs), which in turn is fundamental to support women on their HIV journey and achieve better outcomes
In addition to helping women overcome the challenges that HIV may bring, HCPs play a key role in empowering women to ask questions and enabling them to make informed decisions regarding their care
Încredere
Comunicare
deschisă
şi reciprocă
Respect
Compasiune
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16. Opţiuni de reproducere
Partener HIV+ şi parteneră HIV-
IUI- Înseminare intra-uterină, IVF feritlizare in vitro sau ICSI-injecţie cu spermă intracitoplasmică, după curătarea spermei
Concepţie pe cale naturală (dacă supresia virală dă rezultate)
Insemninare cu sperma donatorului la momentul ovulaţiei
Profilaxia pre- expunere (Pr.Exp)
Adopţie
Parteneră HIV+ & partener HIV-
Inseminarea spermei partenerului la momentul ovulaţiei (dacă nu s-a introdus încă schema ARV şi dacă încărcătura virală este nedecetabilă)
Concepţie pe cale naturală (dacă supresia virală dă rezultate)
Reproducere asistată în cazul insuficienţelei fertile
Adopţia
HIV discordant couples where one partner is HIV positive who desire to eliminate or significantly reduce HIV transmission risk to their HIV-negative partner are limited to the options listed below. However, all available options should be discussed with the couple and they should be supported in finding the best option for their personal situation.
HIV+ man & HIV- woman
Sperm washing: Several techniques of assisted reproduction are applied after processing of the male partner’s sperm. These options can be expensive and are not available in all countries. No case of transmission has been published since the first program was started in More information:
Natural conception: Men with effective viral suppression through long term use of ART should also be counselled on the current evidence regarding the low, but possible, risk of viral transmission to their uninfected partner if the couple attempts to conceive naturally. Should they elect to attempt natural conception, the couple should have regular screening for STIs and be advised to limit intercourse to the time of ovulation; the man should also be advised on the importance of adherence to medication and regular checking of plasma viral load
Insemination using donor sperm: this effectively removes the risk of viral transmission because sperm donors are screened for HIV and other blood-borne viruses. However, it also removes the option of genetic parenting from the HIV positive man
Pre-Exposure Prophylaxis: Currently no valid data exist on the use of pre-exposure prophylaxis (PrEP) with couples who desire to have children. Few research groups have included counseling on periovulatory sexual intercourse without a condom in their program. The assumption is that transmission risk can be reduced by having the HIV-negative female partner take an antiretroviral prophylaxis twice before periovulatory sexual intercourse. PrEP should only be considered in the HIV-negative female partner, if the male partner has a viral load below detection limit and a normozoospermia. In addition, no other sexually transmitted diseases should be present
Adoption: this is a more difficult option for couples because current adoption practice regards HIV in one or both partners as a significant undesirable factor when assessing the suitability of parents requesting to adopt. Nevertheless, this is an approach that has been successful for some serodiscordant couples
HIV+ woman & HIV- man
Self-insemination of partner’s sperm: Women not taking ART should be advised to avoid unprotected intercourse and be instructed on how to carry out self-insemination of her partner’s sperm at the time of ovulation in order to minimize viral transmission risk through unprotected intercourse
Natural conception: Women with effective viral suppression through long term use of ART should also be instructed on self-insemination but also be counselled on the current evidence regarding the low, but possible, risk of viral transmission to their uninfected partner if they attempt to conceive naturally. Should they elect to attempt natural conception, the couple should have regular screening for STIs and be advised to limit intercourse to the time of ovulation; the woman should also be advised on the importance of adherence to medication and regular checking of plasma viral load
Assisted reproduction: In case of fertility disorders in the female or male partner or both, several techniques of assisted reproduction (IVF, ICSI) can be applied, see above
Concordant couple
In cases where both partners are HIV-positive, semen processing or donor insemination may also be considered to avoid the risk of HIV superinfection, reinfection and resistance. However, in some countries the risk of superinfection or re-infection is so low that the need for assisted technique are not considered necessary, except in cases of fertility disorders
See references for further information on this topic:
Barreiro P, del Romero J, Leal M et al. Natural pregnancies in HIV-serodiscordant couples receiving successful antiretroviral therapy. J Akquir Immune Defic Syndr. 2006; 43:324-6.
Bujan L, Hollander L et al. for the CREAThE network. Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected:results from the European CREAThE network. AIDS 21:1909–1914, 2007
Thornton AC, Romanelli F, Collins JD. Reproduction decision making for couples affected by HIV: a review of the literature. Topics in HIV Medicine 2004; 12:
Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women's desires, intentions and decision-making in attaining motherhood. AIDS Care Jul;20(6):
Fiore S, Heard I, Thorne C, Savasi V, Coll O, Malyuta R, Niemiec T, Martinelli P, Tibaldi C, Newell ML. Reproductive experience of HIV-infected women living in Europe. Hum Reprod Sep;23(9):
Tandler-Schneider A, Sonnenberg-Schwan U, Gingelmaier A, Meurer A, Kremer H et al. Diagnostics and Treatment of HIV-affected Couples who Wish to have Children. Eur J Med Res 2008, 13(12):
Vernazza P, Hirschel B, Bernasconi E, Flepp M. HIV-infizierte Menschen ohne andere STD sind unter wirksamer antiretroviraler Therapie sexuell nicht infektiös. Schweizerische Ärztezeitung 2008; 89:5,
Parteneri HIV+
Inseminarea cu sperma donatorului sau spălarea spermei pentru prevenirea suprainfectărilor
Concepţia pe cale naturală
Reproducere asistată în cazul insuficienţelei fertile 16
Women for Positive Action este susţinută de un grant Abbott 16

17. HIV şi fertilitatea
Rata incidenţei insuficienţei fertile în rândul femeilor HIV pozitive este mai ridicată faţă de populaţia generală.
Asistenţa pe probleme fertile are implicaţii etice şi practice atât pentru pacienţi cât şi pentru medici.
Opţiuni de tratament al fertilităţii
Înseminare intra-uterină IUI (+/- spălarea spermei)
Fertilitare in vitro
Inseminare cu sperma donatorului
ICSI-injecţie intracitoplasmică cu spermă
Informaţii limitate despre succesul IVF/ICSI
Rata sarcinilor este este mai scăzută în cazul femeilor seropozitive HIV.
Conception, or becoming pregnant, is of particular concern for serodiscordant couples (those in which only one partner is HIV positive)
Preconception counselling and reproductive assistance have significant ethical and practical implications for the couple and the carers
HIV-positive couples can enjoy normal, healthy lives and should have access to the same care, services and opportunities as HIV-negative people
Safer sex is recommended. However, assisted reproductive technologies may aid serodiscordant couples in achieving pregnancy while at the same time minimizing the risk of HIV transmission to the uninfected partner
There is evidence that women with HIV show a higher incidence of fertility disorders, indicating increased demand for reproductive treatments
Women with HIV experience reduced pregnancy rates and higher rates of both planned abortion and miscarriage
HIV/AIDS may decrease male and/or female fertility1 by:
increased risk of female sterility (associated with coinfection with other STIs)2
decreasing production and motility of spermatozoa3 (male)
increasing fetal mortality (child)
and sometimes decrease frequency of sexual intercourse (male and female)
Data on the success rate of IVF/ICSI (intracytoplasmic sperm injection) in HIV positive women remain unclear, since current case numbers are too low to estimate exact rates. Only data on 205 cycles among 127 HIV positive women have been published.2 The pregnancy rate in HIV positive women (17% per embryo) was substantially below the rate in the general female population (26% per embryo)
References
Lewis JJC, Ronsmans C, Ezeh A, Gregson S. The population impact of HIV on fertility in sub-Saharan Africa. AIDS 2004;18(suppl 2):S35-S43.
van Leeuwen E, Prins JM, Jurriaans S, Boer K, Reiss P, Repping S, van der Veen F. Reproduction and fertility in human immunodeficiency virus type-1 infection. Hum Reprod Update 2007;13(2):
Bujan L, Sergerie M, Moinard N, Martinet S, Porte L, Massip P, Pasquier C, Daudin M. Decreased Semen Volume and Spermatozoa Motility in HIV-1 Infected Patients under Antiretroviral Treatment. Journal of Andrology 2007;28(3):
IUI, înseminare intra-uterină;
IVF, fertilizare in vitro;
ICSI, injecţie intracitoplasmică cu spermă
Women for Positive Action este susţinută de un grant Abbott

18. Contraceptivul ideal:
Sigur
Convenabil
Reversibil
Previne transmiterea infecţiei HIV
Să nu interacţioneze cu terapia HAART
ACCESIBIL din punct de vedere material.
The ideal contraceptive for an HIV positive woman would be:
Reliable
Safe (e.g. No increased risk of pelvic inflammatory disease)
Convenient – to fit in with the woman’s lifestyle and ensure compliance
Reversible – if future pregnancy is planned
Prevent the transmission of HIV to a negative partner
Not interfere with HAART
Affordable
Currently, the ideal contraception must involve condoms
Implică la momentul actual prezervativul 18
Women for Positive Action este susţinută de un grant Abbott 18

19. Metode contraceptive recomandabile femeilor infectate HIV:
Avantaje
Desavantaje
Folosirea prezervavului
(ambii parteneri )
Protecţie împotriva BTS-urilor
Se bazează pe cooperare
Tehnică de aplicare corectă
Incomod/ poate afecta contactul sexual
Pilula contraceptivă
Eficient
Pierdere mai puţină de sânge
Interacţiune medicamentoasă
Posibilitatea intensificării virale 
Nu reprezintă un factor de protecţie împotriva HIV/BTS
Plasture, inel, combo injectabil
Interacţiune medicamentoasă ?
Lipsă de date
 shedding?
There are a number of contraceptive options available for women who are HIV positive or who are in a relationship with an HIV positive partner. Contraceptive choices need to be made on an individual basis, with an awareness that condoms alone may provide insufficient protection from pregnancy. Of the alternatives:
Because of potential interactions between antiretroviral therapy (ART) and the combined oral contraceptive pill (COC), ORTHO EVRAs, the progestogen-only pill (POP) and implants, these methods may be best avoided for women on HAART or other liver enzyme-inducing drugs
There are no known adverse interactions between HAART and depot medroxyprogesterone acetate (DMPA), the levonorgestrel intrauterine system (LNG-IUS) and intrauterine devices (IUDs)
References
Mostad SB, Overbaugh J, DeVange DM, Welch MJ, Chohan B, Mandaliya K, Nyange P, Martin HL Jr, Ndinya-Achola J, Bwayo JJ, Kreiss JK. Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet 1997 Sep 27;350(9082):922-7.
Wang CC, McClelland RS, Overbaugh J, et al. The effect of hormonal contraception on genital tract shedding of HIV-1. AIDS 2004 ;18(2):205-9. 19
Mostad Lancet 1997; Wang AIDS 2004 19

20. Metode contraceptive recomandabile femeilor infectate HIV:
DMPA
Medroxyprogesteron
acetat de depozit
Avantaje reduse
Eficient
 shedding?
 viral set-point referinţă virală
Nu reprezintă un factor de protecţie împotriva HIV/BTS
IUD
Dispozitiv de
Contracepţie
intrauterin
Pierderea sângelui cu Copper T
Sângerare cu LNG-IUS (levonorgestrel-releasing intrauterine system)
 infecţie pelviană
Barieră cervicală
Protecţie împotriva unor BTS
 Risc de infecţie a tractului urinar
Tehnică de aplicare corectă
Sterilizare
Ireversibil
Cost
Metoda invazivă
Mostad Lancet 1997; Wang AIDS 2004

21. Transmiterea materno-fetală (TMF)
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22. Transmiterea materno-fetală (TMF)
Virusul HIV poate fi transmis de la mama la copil (transmitere verticală) în timpul sarcinii şi după:
Pe perioada sarcinii
În timpul travaliului şi naşterii.
Mother-to-child transmission can occur at various stages of pregnancy and motherhood:
During gestation within the womb (the period from conception to birth) – approximately 7%
During birth itself (labour/delivery) – about 18%
During breastfeeding – about 15%
References
Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994; 331:
Kind C, Rudin C, Siegrist CA, Wyler CA, Biedermann K, Lauper U, et al. Prevention of vertical HIV transmission: additive protective effect of elective cesarean section and zidovudine prophylaxis. Swiss Neonatal HIV Study Group. AIDS 1998; 12 (2):
The International Perinatal HIV Group. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1. N Engl J Med 1999; 340:
The European Mode of Delivery Collaboration. Elective cesarean section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomized clinical trial. Lancet 1999; 353:
Shapiro D, Tuomala R, Samelson R, Burchett S, Ciupak G, Mc Namara J et al. Mother-to-child HIV transmission according to antiretroviral therapy, mode of delivery and viral load (PACTG 367) [Abstract 114]. 9th Conference on Retroviruses and Oportunistic Infections. Seattle feb 2002
Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of Human Immunodeficiency Virus Type 1 Transmission Through Breastfeeding. Lancet 1992; 340:585-8.
Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, Ndinya-Achola J, Bwayo J, Onyango FE, Hughes J, Kreiss J Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA Mar 1; 283(9):
Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, Harris DR, Jackson JB, Leroy V, Meda N, Msellati P, Newell ML, Nsuati R, Read JS, Wiktor S; Breastfeeding and HIV International Transmission Study Group. J Infect Dis Jun 15; 189(12):
Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet Aug 7; 354(9177):471-6.
În timpul alăptarii
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23. Reducerea riscului de TMF
Fără aplicarea unei terapii şi a unor programe de prevenire optime riscul de transmitere a infecţiei HIV pe cale materno-fetală variază de la 12-45%, în funcţie de locaţie şi circumstanţele indivduale
If an HIV positive woman takes no preventative therapy and breastfeeds then the chance of her baby becoming infected is around 30% on average.1 It is greatly influenced by whether the child is breastfed
MTCT is almost entirely preventable, where services are available
Antiretroviral drugs can reduce mother-to-child transmission of HIV in one of more the following ways2:
by reducing viral replication and thus lowering plasma viral load in pregnant women;
through pre-exposure prophylaxis of babies by crossing the placenta;
through post-exposure prophylaxis of babies after delivery.
In developed countries, highly active antiretroviral therapy (HAART) has reduced the vertical transmission rates to around 1-2% but HAART is not yet widely available in low and middle income countries. In these countries, various simpler and less costly ART regimens have been offered to pregnant women and/or their newborn babies2
References
HIV and Infant Feeding. Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. Updated September Department of Health.
Volmink J, Siegfred NL, van der Merwe L, Brocklehurst P. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev Jan 24;(1):CD
The Working Group on Mother-To-Child Transmission of HIV. Rates of mother-to-child transmission of HIV-1 in Africa, America, and Europe: results from 13 perinatal studies. J Acquir Immune Defic Syndr Hum Retrovirol Apr 15;8(5):
Însă riscul TMF poate fi redus semnificativ, până la 2% dacă metodele de intervenţie sunt conforme realităţii.
Women for Positive Action este susţinută de un grant Abbott

24. Factori care influenţează transmiterea HIV de la mamă la copil
Factori materni
Factori de obstetrică
Necunoşterea statusului HIV
Nivelul HIV-1 RNA
Valoare scăzută a limfocitelor CD4
Alte infecţii e.g. hepatită C, CMV, bacterie vaginală
Consum de droguri injectabile
Lipsa profilaxiei ARV
Intervalul de timp de la ruperea mebranelor (ROM)
Chorio-amniotic
Naştere normală
Proceduri invazive
Many factors have been identified that influence the risk of mother-to-child transmission:
Maternal factors
The main risk factor, which is also a barrier to the prevention of perinatal HIV transmission, is lack of awareness of HIV status among pregnant women. Other maternal factors correlated with an increased risk of MTCT include:
Viral load, CD4 counts and clinical disease stage
Frequent, unprotected sex with multiple partners (possibly leading to increased risk of STIs, other inflammatory processes)
Smoking and substance use
Lack of ART prophylaxis during pregnancy
Obstetric factors
Length of ROM (rupture of fetal membranes): Early studies, before the widespread use of ZDV reported an increased transmission rate from 14% to 25% among mothers with ROM >4 hours before delivery
Chorioamnionitis: several studies reported that women with clinical chorioamnionitis had an increased transmission risk
Vaginal delivery: The benefit of caesarian section is not substantial when maternal viral load is undetectable
Invasive procedures, e.g. amniocentesis, fetal scalp electrodes should not be used in women with HIV infection
Other factors that can increase the chance of premature delivery, and therefore increase the risk of transmission, include premature contractions and pregnancies with multiple babies
Infant factors
Delivery before 34 weeks gestation
Some studies have shown differences in transmission rates depending on the sex of the child, but the evidence is not well established
See references for further information on this topic:
HIV and Infant Feeding. Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. Updated September Department of Health.
Cohan D, Feakins C, Wara D, Petru A, McNicholl I et al. Perinatal transmission of multidrug-resistant HIV-1 despite viral suppression on an enfuvirtide-based treatment regimen. AIDS 2005; 19 (9):
Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002; 360:
Wen SW, Smith G, Yang Q, Walker M. Epidemiology of preterm birth and neonatal outcome. Semin Fetal Neonatal Med 2004; 9 (6):
Steer P. The epidemiology of preterm labour. Br J Obstet Gynaecol 2005; 112 Suppl 1:1-3.
Ellis J, Williams H, Graves W, Lindsay MK. Human immunodeficiency virus infection is a risk factor for adverse perinatal outcome. Am J Obstet Gynecol 2002; 186:903-6.
Brocklehurst P, French R. The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta-analysis. Br J Obstet Gynaecol 1998; 105:
European Collaborative Study. Vertical transmission of HIV-1: maternal immune status and obstetric factors. AIDS 1996; 10:
Lorenzi P, Spicher VM, Laubereau B, Hirschel B, Kind C, Rudin C et al. Antiretroviral therapies in pregnancy: maternal, fetal and neonatal effects: Swiss HIV Cohort Study, the Swiss Collaborative HIV and Pregnancy Study and the Swiss Neonatal Study. AIDS 1998; 12 (18):F241-F247.
The European Collaborative Study and the Swiss Mother and Child HIV Cohort Study. Combination antiretroviral therapy and duration of pregnancy. AIDS 2000; 14:
Goldstein PJ, Smit R, Stevens M, Sever JL. Association between HIV in pregnancy and antiretroviral therapy, including protease inhibitors and low birth weight infants. Infect Dis Obstet Gynecol 2000; 8(2):94-8.
European Collaborative Study. Increased risk of adverse pregnancy outcomes in HIV-infected women treated with highly active antiretroviral therapy in Europe [Research letter]. AIDS 2004; 18:
Taha TE, Nour S, Kumwenda NI, Broadhead RL, Fiscus SA, Kafulafula G, Nkhoma C, Chen S, Hoover DR. Gender differences in perinatal HIV acquisition among African infants. Pediatrics Feb;115(2):e
Thorne C, Newell ML; European Collaborative Study. Are girls more at risk of intrauterine-acquired HIV infection than boys? AIDS Jan 23;18(2):344-7.
Factori care ţin de nou-născut
Naştere prematură
Sexul copilului? 24
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25. Infecţia HIV în rândul femeilor aflate la o vârstă fertilă.
Programele de reducerea a TMF trebuie să se axeze pe următoarele elemente:
Infecţia HIV în rândul femeilor aflate la o vârstă fertilă.
Sarcina neprogramată în rândul femeilor infectate HIV
Transmietrea HIV în timpul sarcinii, travaliului, naşterii şi alăptării.
The risk of mother-to-child transmission can be minimised in a number of ways:
Preventing HIV infection among women of childbearing potential in the first place
Reducing the chance of unplanned pregnancy among women with HIV
Minimising the risk of transmission during pregnancy, labour, delivery and breastfeeding through access to optimal counselling, treatment, antenatal and peer support services
Women for Positive Action este susţinută de un grant Abbott

26. Intervenţii de reducere a TMF
Cezariană
Hrană artificială
Evitarea procedurilor în timpul naşterii
Administrarea de ARV
Îngrijiri antenatale
TMF redusă
With access to optimal treatment and prevention the risk of MTCT is less than 2%
A comprehensive programme to reduce MTCT includes:
improved availability, quality, and use of antenatal and child health services
HIV testing and counselling for HIV in pregnancy
Antenatal care
Common antenatal protocols
Safe and effective antiretroviral agents
Obstetric interventions
Avoid amniotomy
Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood sampling
Restrict episiotomy
Elective cesarean section
Infection prevention practices
Post-natal care
Exclusive formula feeding
Contraceptive services
Peer support networks
Testare şi consiliere HIV antenatale
Practici de prevenire a infecţiilor
Women for Positive Action este susţinută de un grant Abbott

27. Tratament şi îngrijiri în timpul sarcinii şi naşterii
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28. Personalizarea îngrijrii
Mediul socio-economic
Vârsta
Probleme pe plan familial
Probleme pe plan sexual
Istoric medical
Sarcină
Îngrijirea acordată femeii infectate HIV trebuie
să depindă de nevoile şi circumstanţele
individuale ale fiecărei paciente
Suport
Stadiul evoluţiei
infecţiei HIV
Imigrare
Violenţă sau
abuz sexual
Potenţial fertil
Probleme de co-morbiditate (e.g. Consum de alcool,
consum de drouri, depresie)
The method and approach to HIV counselling and care will vary from woman to woman according to their unique needs and personal circumstances1
Religious and spiritual beliefs can influence a woman’s experience of HIV dramatically and may present specific challenges for treatment. For example, fasting periods may impact a woman’s ability to take her medication correctly. In addition, language and cultural barriers among migrant women can make communication and management difficult, leaving this group vulnerable2
References
Myers T et al. HIV testing and counselling: test providers’ experiences of best practices. AIDS Educ Prevention 2003; 15(4): 309–319
Kreps GL, Sparks L. Meeting the health literacy needs of immigrant populations. Patient Educ Couns 2008; 71(3): 328–332
Acceptarea diagnosticului
Cultură şau
religie
Limbă
şi nivel de înţelegere
Women for Positive Action este susţinută de un grant Abbott

29. Personalizarea îngrijrii
. . . Tineţi cont de femeie în contextul social e.g. ca mamă, parteneră, fiică, susţinător al familiei
Prescribing for women must take into consideration the social roles of women. For example, acknowledging:
Their future plans for, or likelihood of, becoming pregnant
The impact of treatment side effects on their ability to look after family members, including HIV-positive children
The convenience of regimens in relation to their daily activities
Women for Positive Action este susţinută de un grant Abbott

30. Îngrijire antenatală şi infecţia HIV
Îngrijirea anetanatală presupune:
Consilierea gravidelor cu privirea la riscul infecţiei HIV
Testarea HIV
Consiliere despre alte BTS şi despre sănătatea reproducerii şi sănătatea sexuală
Informare continuă despre practici sexuale sigure
Sfaturi despre nutriţie şi pericolul consumului de alcool, de droguri şi pericolul fumatului
Informaţii despre reţelele de susşinere de grup
The risk of MTCT is greatly reduced the sooner a woman can be diagnosed, through preventative measures such as therapy and avoiding breastfeeding
HIV positive women’s network such as ICW and PozFem UK have highlighted that being diagnosed during pregnancy is very traumatic. Those networks recommend testing women (when possible) before they get pregnant, when accessing contraception or other health services
Routine HIV testing for all pregnant women is now recommended in many parts of the world as part of routine antenatal care. After notifying the patient, counselling and testing is performed unless the patient declines HIV testing ("opt-out" consent or "right of refusal")
For women in labour with undocumented HIV-infection status during the current pregnancy, immediate maternal HIV testing with opt-out consent, using a rapid HIV antibody test is recommended in some countries
For women diagnosed through an antenatal testing programme, supportive post-test counselling must be provided, which may be via maternity or GUM services. The antenatal care available will depend on the resources available and the needs of the individual. A system of clear referral paths should be established in each unit or department so that pregnant women who are diagnosed with an HIV infection are managed and treated by the appropriate specialist teams. These multidisciplinary teams should ideally include an HIV specialist, an obstetrician, a specialist midwife and a paediatrician. Psychologists, social workers, counselling services, voluntary groups and community support groups can also play an important role
A thorough early assessment of the social circumstances of a newly diagnosed pregnant woman with HIV is essential, and specially tailored antenatal classes, where inappropriate emphasis on breast-feeding and vaginal delivery can be avoided, should be provided if possible
Peer support and mentoring can play an important role for pregnant woman with HIV, from helping them maintain adherence, supporting not breast feeding if that is required, and at all stages of pregnancy
Women for Positive Action este susţinută de un grant Abbott

31. Testarea în timpul sarcinii
Testare HIV
Încărcătură virală- Plasma HIV RNA
Biochimie şi evaluarea completă a numărului de celule CD4
Test de rezistenţă la medicamentele antivirale
Monitorizare a drogurilor terapeutice
Alte boli infecţioase
IDR la tuberculină
Testare hepatită B
Testare hepatită C
Frotiu Papanicolau şi testare HPV
Culturi urinare şi vaginale
Screening-ul diabetului în sarcină
Testare sindromul TORCH- toxoplasmoză, rubeolă, cytomegalovirus, herpes simplex, sifilis.
HIV-related tests in pregnancy can include:
Plasma HIV RNA viral load
Biochemistry and complete blood count (including platelet count and lymphocyte subsets (CD4 cell count)
Antiviral drug resistance testing
Therapeutic Drug Monitoring
Tests in pregnancy related to other risks can include:
Tuberculosis (can be endemic in countries from which women migrating to Europe and North America originate)
Liver function tests
Screening for sexually transmitted infections
Hepatitis B testing
Hepatitis C screening should be considered in cases of current or prior intravenous drug use
TORCH (diseases that cause congenital conditions if a foetus is exposed to them when in the uterus: Toxoplasmosis, Other (such as syphilis, varicella, mumps, parvovirus, and HIV), Rubella, Cytomegalovirus, Herpes simplex
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32. Obiectivele tratamentului pe timpul sarcinii
Sănătate optimă a mamei
Reducerea efectelor secundare la mamă
Reducerea transmiterii materno fetale
Reducerea riscului de îmbolnăvire al copilului
The goal of care in pregnancy is to have a mother with optimal health who is able to parent and enjoy being a mother to her uninfected baby
HIV treatment in pregnant women should aim for full suppression of HIV RNA by the time of delivery, and preferably by the third trimester in order to prevent mother-to-child transmission. This should be balanced with the risks of ART to the unborn child and side-effects of ART in the mother
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33. Care sunt recomandările ghidurilor de tratament?
Rezumatele ghidurilor de tratament europene (EACS), britanice (BHIVA) şi franţuzeşti pentru iniţierea terapiei la femeile care doresc să rămână gravide:
Sunt de preferat inhibitorii
de protează boostaţi
Nevirapina reprezintă o
alternativă de tratament
Boosted protease inhibitors are the preferred treatment choice for women with HIV wishing to become pregnant
Nevirapine is an alternative, but in women with CD4 counts greater than 250 cell/mm3 there is an increased risk of hepatotoxicity
Efavirenz should be avoided in pregnancy or in women planning pregnancy due to its teratogenic potential
References
European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008]
de Ruiter A, Mercey D, J Anderson J, et al. British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women HIV Medicine 2008;9:452–502.
Ministère de la Santé et des Solidarités. Prise en charge médicale des personnes infectées par le VIH. Rapport
Efavirenz are potenţial teratogenic (poate afecta dezvoltarea fătului) 33
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34. Ghidul european EACS
Administrarea aceluiaşi regim terapeutic tuturor pacientelor, inclusiv gravidelor, cu un număr de ajutări:
A se evita administrarea de Efavirenz
A nu se iniţia tratament cu Nevirapine, Abacavir şi TDF dacă acestea nu erau parte a schemei de tratament, anterioare sarcinii, caz în care se poate continua terapia cu aceste medicamente
A se adminsitra LPV/r sau SQV/r ca IP/r
ZDV ar trebui să facă parte din tratament
Regimen choices in pregnant women are the same as for non-pregnant women in general except:
Avoid efavirenz, which can cause birth defects
Avoid the ddI + d4T combination
Abacavir and nevirapine should not be started, but can be continued if a woman is already taking them and stable
Preferred protease inhibitors are lopinavir/ritonavir and ritonavir- boosted saquinavir
Zidovudine should be included in the regimen if possible, due to its ability to prevent mother-to-child HIV transmission
Reference
European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008]
European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe, 2008
Women for Positive Action este susţinută de un grant Abbott

35. Ipoteze legate de sarcină
Ghidurile generale: tratamentul pacientei HIV pozitive în timpul sarcinii
Toate cazurile de expunere la antiretrovirale în timpul sarcinii ar trebui înscrise în Registrul de Sarcină Antiretroviral Pregnancy Registry (detalii pe
Ipoteze legate de sarcină
Recomandări
Femei care rămân gravide după iniţierea
terpaiei ARV
Menţinerea terapiei ARV cu eliminarea
medicamentelor teratogene.
2. Femei care rămân gravide în perioada
anterioară introducerii tratamentului, care
îndeplinesc criteriile (CD4) pentru iniţierea terapiei
TARV.
2. Se demarează TARV – de preferinţă la
începutul celui de-al doilea trimestru de sarcină
3. Femei care rămân gravide în perioada
anterioară introducerii tratamentului, care nu
îndeplinesc criteriile (CD4) pentru iniţierea TARV
3. Se demarează TARV la începutul săptămânii
28 de sarcină (cel mai târziu cu 12 săptămâni
înainte de naştere); se poate iniţia TARV mai
devreme dacă se depistează o valoare mare a
încărcăturii virale în plasmă sau risc de naştere
prematură.
4. Femei ale căror monitorizzare începe
dupa săptămâna a 28-a de sarcină
4. Se iniţiază TARV imediat
Reference
European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008]
Women for Positive Action este susţinută de un grant Abbott
European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. 2008

36. Categoriile de recomandări ale ghidurilor americane:4 IP
INNRTI
INRTI
Inhibitori de intrare
Inhibitori de integrază
Medicamente
recomandate
Lopinavir/r
Nevirapină
Zidovudină*
Lamivudină*
Alternative
Indinavir
Ritonavir
Saquinavir HGC Nelfinavir
Abacavir#
Didanozină
Emtricitabină†
Stavudină
Date insuficiente
Amprenavir
Atazanavir
Fosamprenavir
Darunavir
Tipranavir
Tenofovir DF†
Enfuvirtide
Maraviroc
Raltegravir
Nerecomandate
Efavirenz†
Delavirdină
Zalcitabină
Reference
Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov).
*Zidovudina şi lamivudina sunt incluse ca doză fixă, combinată în componenţa Combivir; zidovudina, lamivudina şi abacavir sunt incluse ca doze fixă, combinată în Trizivir.
† Emtricitabina şi tenofovir sunt incluse ca doză fixă combinată în Truvada; emtricitabina, tenofovir, şi efavirenz asunt incluse ca doză fixă combinată în Atripla .
# Regimul triplu INRTI care include abacavir a fost mai puţin potent, dpdv virologic în comparaţie cu regimul HAART bazat pe IP. Regimul triplu INRTI ar trebui administrat numai în cazul în care un regim HAART INRTI bazat pe IP nu poate fi folosit. (e.g. din cauza interacţiunii medicamentoase). Un studiu care a evaluează administrarea de zidovudină/lamivudină/abacavir ca regim tereutic minimal/econom în rândul gravidelor cu HIV RNA <55,000 copii/mL este în desfăşurare.
Available at: Revision: July 8, 2008 36

37. Operaţia de cezariană vs naşterea normală
În rândul a 560 de femei cu nivel HIV RNA nedectabil, opţiunea pentru operaţia de cezariană a fost asociată cu un procentaj de 90% de reducere a riscului TMF, comparat cu opţiunea pentru naştere normală sau cu naşterea de urgenţă.
Operaţia de cezariană poate avea aceleaşi implicaţii ca şi naşterea normală, la sarcina dusă la termen a femeii cu încărcătură virală <400.
Among 560 women with undetectable HIV RNA levels, elective Caesarean section was associated with a 90% reduction in MTCT risk (odds ratio, 0.10; 95% CI, ), compared with vaginal delivery or emergency Caesarean section1
The authors suggest that offering an elective Caesarean section delivery to all HIV-positive women, even in areas where HAART is available, is appropriate clinical management, especially for persons with detectable viral loads
In another study, elective caesarean section tended to be inversely associated with MTCT in the overall population, but not in mothers who delivered at term with viral load <400 copies/ml [odds ratio (OR), 0.83; 95% CI, ; P = 0.37].2 Among them, only duration of antenatal therapy was associated with transmission (OR by week, 0.94; 95% CI, ; P = 0.03)
References
European Collaborative Study. Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy. Clin Infect Dis 2005;40(3):
Warszawski J, Tubiana R, Le Chenadec J, Blanche S, Teglas JP, Dollfus C, Faye A, Burgard M, Rouzioux C, Mandelbrot L; ANRS French Perinatal Cohort. Mother-to-child HIV transmission despite antiretroviral therapy in the ANRS French Perinatal Cohort. AIDS 2008;22(2):
ECS. Clin Infect Dis 2005; Warszawski J, et al. AIDS, 2008
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38. Profilaxia post-expunere a nou-născutului
Monoterapie
Triterapie
Pentru majoritatea nou
nascutilor:
ZDV monoterapie BID timp de 4 saptamani sau
Monoterapie ARV aletrnativă convenabilă, daca tratamentul mamei nu incdlude ZDV
Pentru nou-nascutii proveniţi
din:
Mame netratate
Mame cu RNA viral detectabil in ciuda terapiei combinate
SAU
Most infants should be given ZDV monotherapy twice daily (bid) for 4 weeks. Alternative suitable ART monotherapy may be given if maternal therapy does not include ZDV
Triple therapy should be given as post-exposure prophylaxis (PEP) for infants born to untreated mothers or mothers with detectable viraemia despite combination therapy
Reference
Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov).
Women for Positive Action este susţinută de un grant Abbott

39. Testul de rezistenţă HIV este recomandat:
Tuturor gravidelor naive, înainte de introducerea tratamentului sau prifilaxiei
Tuturor femeilor care primesc TARV antenatal, cu nivelul HIV RNA detectabil sau cu supresie virală subotpimă după iniţierea terapiei antiretrovirale.
Pentru o prevenire eficienta a transmiterii materno-fetale, iniţierea experimentală a terapiei antiretrovirale înainte de aflarea rezultatului testului de rezistenţă poate fi o supapă de siguranţă, ce va trebui ajustată nevoii pacientei ulterior.
Determining HIV genotype (or phenotype) may be warranted:
Pre-therapy (at presentation)
If viraemic on established therapy
If considering switching therapy
At delivery if on monotherapy
2 – 3 weeks after stopping suppressive therapy
Transmission of drug resistance to the infant can occur
ART resistance testing recommendations vary by locality. Ideally a baseline resistance assay should be performed on all pregnant women at diagnosis and a further test undertaken following short-term antiretroviral therapy (START). If this is not possible, resistance testing in ART naïve, HIV-positive pregnant patients is warranted, as is testing in patients with acute HIV infection and virologic failure or suboptimal viral suppression by ART
Switching to a more complex regimen during pregnancy may adversely affect adherence resulting in virologic failure at delivery. It may be beneficial to wait to initiate ART until the resistance testing results are available to avoid prescribing a suboptimal regimen
There is concern that the use of ZDV monotherapy in pregnancy may lead to the emergence of drug-resistant virus, possibly compromising the mother’s future care. Although early studies demonstrated resistance it now appears that the risk of developing ZDV resistance is likely to be low if monotherapy is restricted to drug-naïve asymptomatic women, with low viral loads and good CD4 cell counts
The long half-life of NVP and its low genetic barrier contribute to development of resistance, and this has implications for its use as a single-dose intervention or in a short-term HAART regimen
The high genetic barrier to resistance of boosted PIs and their short plasma half-life make them a more attractive option for START than NNRTIs
Transmission of drug-resistant virus to the infant can occur. Although some studies have indicated that drug resistance is not necessarily associated with an increased risk of perinatal transmission there is still insufficient information to define clearly the relationship between drug-resistant mutants and mother-to-child transmission
References
Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov).
de Ruiter A, Mercey D, J Anderson J, et al. British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women HIV Medicine 2008;9:452–502.
Available at: Revision: July 8, 2008 39
Women for Positive Action este susţinută de un grant Abbott 39

40. Co-infecţia cu hepatita B
Testarea pentru antigenul de suprafaţă în hepatita B
Terapiile bazate pe interferon şi ribavirină nu sunt recomandate în timpul sarcinii.
Tratmentul trebuie să includă tenofovir şi 3TC sau emtricitabină (FTC).
Monitorizarea atentă a toxicitatăţii hepatice.
Sugarii născuţi de femei infectate cu virusul hepatic B ar trebui să primească imunoglobulină pentru hepatita B (HBIG) şi să li se administreze o serie de trei doze de vaccin anti-hepatic B, în primele ore de la naştere.
Screening for hepatitis B surface antigen is recommended for all HIV-infected pregnant women who have not been screened during the current pregnancy
Interferon-alpha and pegylated interferon-alpha are not recommended during pregnancy
For pregnant women with chronic hepatitis B virus (HBV) (i.e. hepatitis B surface antigen positive for >6 months)/HIV coinfection who require antiretroviral treatment for HIV disease or who require anti- HBV therapy, a three-drug regimen including a dual NRTI backbone of tenofovir plus 3TC or emtricitabine (FTC) is usually recommended
For women who require treatment of HBV but not HIV, postpartum options include stopping antiretroviral drugs and initiating pegylated interferon-alpha for HBV treatment, or continuing the three-drug antiretroviral regimen
For pregnant women with HBV/HIV coinfection who do not require treatment for either HIV or HBV and therefore discontinue prophylaxis postpartum, consultation with an expert in HIV and HBV is recommended
Pregnant women with HBV/HIV coinfection receiving antiretroviral drugs should be counseled about signs and symptoms of liver toxicity and transaminases should be assessed 2 weeks following initiation of antiretroviral therapy or prophylaxis and then at least monthly.
Infants born to women with hepatitis B infection should receive hepatitis B immune globulin (HBIG) and initiate the three-dose hepatitis B vaccination series within 12 hours of birth
Reference
Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV- Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov) 40
Women for Positive Action este susţinută de un grant Abbott 40

41. Co-infecţia cu virusul hepatic C
Se recomandă testarea pentru depistarea infecţiei cu hepatită C (HCV) a tuturor gravidelor.
În cazul pacientelor cu această infecţie se recomandă ca terapia cu interferon să fie întreruptă pe durata sarcinii.
Toxicitatea hepatică trebuie monitorizată atent şi continuu.
Tipul de naştere ar trebui să se stabilească numai be baza infecţiei HIV.
Nou-născuţii ar trebui să fie testaţi pentru infecţia HCV prin testul HCV RNA la vârsta 2-6 luni şi pentru anticorpii HCV după vârsta de 15 luni.
Screening for hepatitis C virus (HCV) infection is recommended for all HIV-infected pregnant women who have not been screened during the current pregnancy
Pegylated interferon-alpha is not recommended and ribavirin is contraindicated during pregnancy.
Combination antiretroviral therapy with three drugs should be considered for all HCV/HIV coinfected pregnant women, regardless of CD4 count or HIV viral load; the antiretroviral drugs can be discontinued postpartum in women who do not require HIV therapy for their own health
Pregnant women with HCV/HIV coinfection receiving antiretroviral drugs should be counselled about signs and symptoms of liver toxicity, and transaminases should be assessed 2 weeks following initiation of antiretroviral therapy or prophylaxis in women not already receiving drugs, and then at least monthly
Decisions concerning mode of delivery in HCV/HIV coinfected pregnant women should be based on considerations related to HIV infection alone
Infants born to women with HCV/HIV coinfection should be evaluated for HCV infection by HCV RNA testing between 2 and 6 months of age and/or HCV antibody testing after 15 months of age
Reference
Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov) 41
Women for Positive Action este susţinută de un grant Abbott 41

42. Echilibru psihosocial, mental şi emoţional
Evaluarea statusului psihosocial înaintea concepţiei, în timpul sarcinii şi după
~ Chiar şi pacientele care nu suferă de boli mentale pot dezvolta patologii noi, precum depresia postpartum.
Persoanele cu antecedente de boli mentale sau care iau medicamente psihotrope trebuie să beneficieze de îngrijiri specializate şi de supraveghere continuă pentru:
Reevaluarea siguranţei şi eficienţei tratamentului psihotrop în timpul sarcinii
Monitorizarea aderenţei la tratamentul antiretroviral şi psihotrop 42
Women for Positive Action este susţinută de un grant Abbott 42

43. Testarea de rutină în timpul sarcinii
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44. Cel mai important element în procesul de reducere a riscului de transmitere materno fetală este cunoaşterea statusului HIV de către fiecare femeie în parte.
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45. Testare HIV de rutină pe perioada sarcinii, în lume
Austria 
Bulgaria
Bielorusia
Canada
Republica
Cehă
Danemarca
Estonia
Franţa
Germania
Grecia
Uungaria
Italia
Malta
Republica Moldova 
Olanda
Norvegia
Polonia
Portugalia
Federţia Rusă
Slovacia
Slovenia
Spania
Elveţia
Ukraina
Marea Britanie
România
Although many countries offer routine HIV testing in pregnancy, in some countries few women are routinely tested at any stage in their pregnancy. The slide shows those countries where routine ‘opt-out’ testing is performed. The countries without a tick have an alternative (or no) policy for testing1
HIV testing during pregnancy is an option available to women across Canada. However, physician guidelines and/or recommendations encouraging informed decisions regarding HIV testing during pregnancy vary by province and territory
References
Mounier-Jack S, Nielsen S, Coker RJ. HIV testing strategies across European countries. HIV Med 2008;9 Suppl 2:13-9.
Epi Update entitled "Perinatal Transmission of HIV," May 2004.
Adapted from Mounier-Jack et al., HIV Med, 2008

46. Recomandări pentru testarea HIV
Testul HIV trebuie oferit tuturor femeilor în timpul primelor trimestre de sarcină, sau cât de repede posibil, dacă pacienta se prezintă târziu la spital.
Acesta trebuie repetat periodic, în special persoanelor care se află la risc continuu de infecţie HIV.
Testare rapidă femeilor care se prezintă la spital în timpul travaliului.
Rezultatele testelor trebuie puse la dispoziţia personalului medical de pe secţiile specializate HIV.
Routine ‘opt-out’ HIV testing of pregnant women is key to prevention of mother-to-child transmission of HIV
Repeat testing in the third trimester and rapid HIV testing at labour and delivery are additional strategies to further reduce the rate of perinatal HIV transmission. Although the number of infected infants born to women who test negative in early pregnancy is low, any indication that a woman is at continuing risk of acquiring infection in pregnancy should be recorded, and repeat testing offered
New rapid testing methods allow identification of women who are HIV positive or HIV-exposed infants in 20 to 60 minutes
Midwives and doctors reviewing women during antenatal care should ensure that the HIV test result is clearly documented. Labour ward staff and any staff undertaking invasive genetic screening tests must be aware of a woman’s HIV status
Women for Positive Action is supported by a grant from Abbott

47. Necesitatea suţinerii şi continuării cercetării

48. Sarcina şi infecţia HIV: nevoia de mai multe date clinice şi studii
Datele despre sarcină/HIV şi copii expuşi TARV în utero sunt insuficiente, motiv pentru care este dificil de realizat un studiu în această zonă.
Rezultatele studiilor mici pe implicaţiile clinice sunt neclare.
Unele date relevă diferenţe între sexe în cazul TMF şi al rezistenţei la copii.
Însă, rezultatele pentru pre-adolescenţi sunt rareori desagregate pe sexe.
It is difficult to conduct studies in this arena and data on issues relating to pregnancy and HIV are relatively sparse
For example, some data show gender differences in MTCT, e.g.:
transmission in utero appears higher for female foetuses;
postpartum transmission is higher for males foetuses;
resistance is higher in male babies and there is a higher risk of transmission by breast feeding in boys.
However, data among pre-adolescents is rarely disaggregated according to gender, and studies in pregnant women and in pre-adolescents is relatively rare
Many findings are based on small studies and clinical implications are often unclear
While there are barriers to conducting adequately powered clinical studies in the setting of HIV and pregnancy, alternatives are needed to address the lack of data and to clarify the clinical significance of any findings
Este nevoie de alternative pentru
dresarea problemei lipsei datelor şi pentru clarificarea importanţei rezultatelor.
Women for Positive Action is supported by a grant from Abbott

49. Fişa de supravegehre a gravidei aflată în tratament ARV
Singurul proiect care evaluează expunerea prenatală la ARV în primul trimestru de sarcină (şi perioada de după).
Adună date anonime despre evoluţia fătului/mamei.
Oferă informaţii esenţiale care completează datele studiilor clinice.
Aceste date vor ajuta atât clinicienii cât şi pacienţii în aprecierea posbilelor beneficii şi riscuri şi ale tratamentului.
Gravidele în tratament ARV trebuie încurajate să se înregistreze în acest program de monitorizare.
The Antiretroviral Pregnancy Registry is intended to provide an early signal of any major teratogenic effect associated with a prenatal exposure to the ART 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 antiretroviral products
This Registry is the only project expressly established to evaluate first trimester, as well as later prenatal exposures to antiretroviral medications. Registry data supplement other sources of data and assist clinicians and patients in weighing potential risks and benefits of treatment
Women for Positive Action is supported by a grant from Abbott

50. Rata defectelor de naştere la nou-năcuţi
Posibile cazuri de expunere perinatală la LPV/r şi date complete de monitorizare:
0.72
23/955 (2.4%)
18/688 (2.6%)
5/267 (1.9%)
23 (2.4%)
955
Total (%)
Se exclud cazurile singulare de naşteri fără defecte, din cauza nespecificării trimestrului de expunere. Sunt incIuse în această categorie 920 cazuri singulare si 35 rezultate - nou-născuţi în viaţă.
** Defectele sunt recunoscute dupa criteriile CDC. Se exclud defectele raportate la piederile de sarcină <20 săptămâni. Se numeşte rezultat orice nou/născut în viaţă sau decedat, sau orice sarcină spontană ori indusă ≥20 săptămâni de gestaţie
(0.27, 1.91)
95% CI pentru riscul defectelor de naştere au apărut în timpul primului trimestru
Expunere în timpul trimestrelor 2/3
[1.5% - 3.6%]
Orice trimestru de sarcina
[1.6%-4.1%]
Trimestrele 2/3
[0.6%-4.3%]
Primul semestru
95% CI pentru rata de prevalenţa a naşterilor cu defecte pentru expunerea în:
Numărul naşterilor cu cel puţin un defect **
Numar de naşteri*
[95% CI]
This is the first adequately powered and published study on the overall risk of birth defects associated with LPV/r exposures during pregnancy. The APR reported an overall prevalence of birth defects of 2.7% among 9,948 ART exposed pregnancies and 2.8% among 2,673 pregnancies exposed during the first trimester.1 Other large observational studies have reported similar findings2-4
References
APR Steering Committee. Interim Report for 1 January 1989 through 31 July 2008, Available at
European Collaborative Study. Exposure to antiretroviral therapy in utero or early life: the health of uninfected children born to HIV-infected women. J Acquir Immune Defic Syndr 2003;32(4):380-7.
Townsend CL, Tookey PA, Cortina-Borja M, Peckham CS. Antiretroviral therapy and congenital abnormalities in infants born to HIV-1-infected women in the United Kingdom and Ireland, 1990 to J Acquir Immune Defic Syndr 2006;42(1):91- 4.
Watts DH, Li D, Handelsman E, Tilson H, et al. Assessment of birth defects according to maternal therapy among infants in the Women and Infants Transmission Study. J Acquir Immune Defic Syndr 2007;44(3):
Rata totală de 2.4% a prevalenţei defectelor de naştere, din cauza expunerii la LPV/r este mai scazută decât rata totală înregistrată de CDC- 2.67% 50
Women for Positive Action is supported by a grant from Abbott
Robert S. et al. XVII IAC, Mexico City, August 2008 #TUPE0120 50

51. Cercetări viitoare, întrebări specific clinice şi nevoi:
Evaluarea siguranţei medicamentelor şi farmacochineticelor
Optimizarea regimurilor de tratament neonatale pentru evaluarea perinatală a rezistenţei
Riscul alăptării dacă încărcătuta virală este nedectabilă
Înteruperea terapiei aniretrovirale
Optimizarea aderenţei
Rolul naşterii prin cezariană în rândul femeilor cu încărcătură virală nedectabilă sau cu perioadă scurtă de rupere a membranelor
Testare rapidă la momentul naşterii oferită femeilor care se prezintă târziu la medic
There is a paucity of data specifically on issues pertaining to women, pregnancy and HIV. Please see the references below for a selection of studies that have already been done in this area
See references for further information on this topic:
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, (5):
Ioannidis JP, Abrams EJ, Ammann A, et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads <1000 copies/mL. J Infect Dis, (4):
Cunningham CK, Chaix ML, Rekacewicz C, et al. Development of resistance mutations in women receiving standard antiretroviral therapy who received intrapartum nevirapine to prevent perinatal human immunodeficiency virus type 1 transmission: a substudy of pediatric AIDS clinical trials group protocol 316. J Infect Dis, (2):181-8.
Eshleman SH, Mracna M, Guay LA, et al. Selection and fading of resistance mutations in women and infants receiving nevirapine to prevent HIV-1 vertical transmission (HIVNET 012). AIDS, (15):
Lyons FE, Coughlan S, Byrne CM, et al. Emergence of antiretroviral resistance in HIV-positive women receiving combination antiretroviral therapy in pregnancy. AIDS, (1):63-7.
McIntyre J, Martinson N, Investigators for the Trial 1413, et al. Addition to short course combivir (CBV) to single dose viramune (sdNVP) for prevention of mother-to-child transmission (MTCT) of HIV-1 can significantly decrease the subsequent development of maternal NNRTI-resistant virus. XV International AIDS Conference; July 11-16, 2004; Bangkok, Thailand. Abstract LbOrB09.
Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial. The European Mode of Delivery Collaboration. Lancet, (9158):
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, (13):
Dominguez KL, Lindegren ML, D’Almada PJ, et al. Increasing trend of cesarean deliveries in HIV-infected women in the United States from 1994 to J Acquir Immune Defic Syndr, (2):232-8.
The International Perinatal HIV Group. Duration of ruptured membranes and vertical transmission of HIV-1: a meta- analysis from 15 prospective cohort studies. AIDS, (3):
Jamieson DJ, Clark J, Kourtis AP, et al. Recommendations for human immunodeficiency virus screening, prophylaxis, and treatment for pregnant women in the United States. Am J Obstet Gynecol, (3 Suppl):S
Bulterys M, Jamieson DJ, O’Sullivan MJ, et al. Rapid HIV-1 testing during labor: a multicenter study. JAMA, (2):
Women for Positive Action is supported by a grant from Abbott 51 51

52. Studii de caz
Women for Positive Action is supported by a grant from Abbott

53. Cazul 1: Fostă consumatoare de droguri injectabile
Femeie de 25 ani , HIV+
Sarcină de 8 săptămâni
Fostă consumatoare de roguri
Relativ stabilă în terapia de substituţie cu metadonă;
Pozitivă la Hepatita C (anticorpi şi PCR)
În afară de asistarea pacientei din punct de vedere al tratamentului şi naşterii, strict legate de infecţia HIV/SIDA, ce alte elemente ar putea fi luate în calcul?
Women for Positive Action is supported by a grant from Abbott

54. Probleme de luat în calcul
Stare emoţională şi mentală echilibrate:
Din proporţia totală a pacienţilor HIV, femeile sunt mai predispose diagnosticării cu probleme mentale decât bărbaţii.
Sarcina şi problemele legate de consumul de substanţe pot cauza probleme emoţionale şi de familie ale femeilor HIV pozitive.
Depistarea infecţiei HIV în timpul sarcinii este asociată unei rate de incidenţă mai mare de boli mentale (depresia postpartum) faţă de diagnosticarea în afara sarcinii.
Nu toate clinicile HIV oferă acces facil la serviciile psihiatrice perinatale.
Susţinerea grupului şi îndrumarea continue pot ajuta în astfel de cazuri.
In general, women are more likely to present and be diagnosed with mental health and emotional problems than men, especially depression and anxiety disorders. The incidence of mental and emotional problems is intensified in HIV positive women, during pregnancy, and among women with substance use problems
Women diagnosed during pregnancy have a higher incidence of mental health issues including postpartum depression than those diagnosed pre- pregnancy
Some (but not all) centres have good access to perinatal psychiatric services
Peer mentoring and support networks have an important role to play in achieving emotional well-being
Women for Positive Action is supported by a grant from Abbott

55. Probleme de luat în calcul
Se încurajează discutarea diagnosticului cu
partenerul.
Se recomandă testarea HIV şi a celorlaţi copii ai familei.
Sarcina reprezintă un motiv cheie de dezvăluirte a diagnosticului.
Cel mai probabil, o femeie îşi dezvăluie diagnosticul în timpul sarcinii, şi dacă nu, după naştere.
Ocazional, dezvăluirea diagnosticului poate avea consecinţe neprevăzute.
Disclosure
Disclosure to partners should be encouraged in all cases but may be viewed as a process that may take some time. Pregnancy is a key window for disclosure. Research shows that a woman is more likely to disclose during pregnancy, but if she doesn’t disclose then she is likely to do so postpartum
However, it is important to be aware of unwanted consequences of disclosure such as domestic violence and homelessness
Reassurance about confidentiality is extremely important, especially regarding family members and friends who may not know the diagnosis but are intimately involved with the pregnancy
Adherence
This is of vital importance for the success of therapy and pregnant women may need extra support and planning in this area, especially if there are practical or psychosocial issues that may impact adversely on adherence. Referral to peer support workers, psychology support and telephone contact may all be considered
Aderenţa
Înscrierea în programul de educare
Aderenţă şi monitorizare
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56. Probleme de luat în calcul
Contracepţia post-naştere:
Nu există încă o metodă contraceptivă ideală.
Dacă partenerul este HIV negativ se recomandă folosirea prezervativului.
În cazul suprimării virale complete, relaţiei stabile şi inexsitenţei altor BTS, riscul de transmitere HIV este mic. Cum ar trebui întrebările legate de această situaţie să fie adresate şi care ar fi acelea?
Multe ARV-uri interacţionează cu medicamentele contraceptive.
There is still no ideal contraceptive. With a negative partner the only effective form of contraception is condoms
The Swiss statement suggests that in cases of full viral suppression, stable partnerships and no other STDs, there is minimal risk of transmission. This is a statement of much debate. The clinicians managing this woman should consider how this question should be handled should it arise
Many ARVs interact with contraceptives although Depo-provera and IUDs can still be used. In this case, however, if the pregnancy is to proceed, these are not viable options
Women for Positive Action is supported by a grant from Abbott

57. Studiu de caz: rezultat test HIV discordant
Partenera, 33 ani, partenerul-33 ani se testează HIV înainte de a renunţa la prezervative, pentru a avea copii.
Rezultatul partenerei relevă un status
HIV pozitiv, în timp ce
partenerul este HIV negativ
Partenera refuză să îşi informeze
partenerul în legătură cu rezultatul testului
de teama unui eventual abandon.
Many national guidelines preserve patient confidentiality unless special circumstances call for disclosure, i.e. where non-disclosure represents a risk to the public or to another individual’s health. Indeed, there have been legal cases where doctors have been held accountable for non-disclosure
Counselling before HIV testing should introduce the topic of disclosure and, in the event of a positive result, post-test counselling can explore the specifics of who and how to tell
Some women may be at risk of violence, abandonment, financial loss, social discrimination and isolation when they disclose their status
Pe lângă gestionarea diagnosticului şi asistarea unei posbile sarcini ce alte chestiuni ar mai trebui luate în considerare?
Women for Positive Action is supported by a grant from Abbott

58. Probleme de luat în calcul
Dezvăluirea diagnosticului şi relaţia de
confidenţialitate medic-pacient
Multe ghiduri naţionale recomandă respectarea confidenţialităţii, cu excepţia situaţiilor speciale.
Consilierea pre şi post testare ar trebui să se axeze pe o discuţie liberă despre un posibil rezultat HIV+ şi despre metode de primire a “veştilor proaste”.
Au existat cazuri de incriminare a persoanelor HIV pozitive care au infectat alte persoane, precum şi cazuri de răspundere penală a medicilor care nu au dezvăluit diagnosticul.
Dezvăluirea diagnosticului fără permisiunea femeii poate deveni obligatorie însă trebuie luate în calcul consecinţele pentru relaţia medic-pacient.
Many national guidelines preserve confidentiality to patients unless there are special circumstances – such as an overriding public interest or risk to another individual’s health
Pre- and post-test counselling should openly discuss and anticipate such an outcome and propose how patients should prepare for ‘bad news’
There have been cases of criminalization of HIV positive patients who infected others, as well as doctors being criminally liable for non-disclosure
Disclosing to the HIV negative partner without the woman’s consent may be mandatory but will also have consequences for trust within the doctor-patient relationship that need to be anticipated
Women for Positive Action is supported by a grant from Abbott

59. Incriminarea transmiterii infecţiei HIV
În multe juridiscţii legea este neclară în această privinţă, variind de la ţară la ţară.
Este puţin probabil ca o persoană să fie urmărită penal şi acuzată, din punct de vedere etic pentru transmiterea neintenţionată a virusului HIV.
În două ţări europene au existat cazuri de incriminare a peroanelor conştiente de statusul lor HIV:
Scoţia
Cazul Stephen Kelly (Judecător Glenochil ) – Martie (Dreptul comun scoţian). Condamnat pentru infectarea “imprudentă” a fostei partenere.
Anglia
Mohammed Dica, Noiembrie 200
Sentinţa de vătămare corporală gravă pentru infectarea cu virsusul HIV, voluntară a două femei.
Menţinerea acuzaţiei la rejudecare în martie 2005
In certain countries, transmitting or exposing another person to HIV has been criminalised1. For example, in Scotland intravenous drug user Stephen Kelly was convicted after passing HIV to his female partner2. Similarly, in England, the first successful prosecution for HIV transmission was brought against Mohammed Dica2. Both convictions were based on the men acting recklessly or intentionally – as they were aware of their HIV status and the risk to their partners
In Sweden under the Contagious Disease Act an HIV positive person can be prosecuted for having unprotected sex
A court case in England some time ago of a mother living with HIV and breastfeeding, the outcome of which was not clear as the mother disappeared
It is unlikely that a person could be prosecuted for unintentional HIV transmission if they are ignorant of their own HIV status. The conviction in England of an undiagnosed HIV-positive man was a case where the patient had been treated for other sexually transmitted infections and warned of the high probability that he was HIV positive, but he failed to attend for a test.2 This is a complex area and as this may differ from country to country it is important to take country-specific advice on the current legal thinking
References
UNAIDS. Policy brief: Criminalization of HIV transmission. August
HIV transmission and the criminal law. Accessed November 59
Women for Positive Action is supported by a grant from Abbott 59

60. Studiu de caz: refuzul de a întrerupe alăptarea
Femeie de origine africană, emigrată în Europa
Stabilă pe ARV
Trăieşte într-o locuinţă oferită de stat, pe care o împarte cu o altă persoană
A născut un băiat HIV negativ, însă a decis să alăpteze, refuzând administrarea ARV
Se bazează pe credinţa că “Dumnezeu va avea grijă de el”
Breastfeeding is an important potential route of mother-to-child transmission. Where safe infant feeding alternatives are available, HIV infected women are usually advised to refrain from breastfeeding
In resource-poor settings where breast feeding is essential for infant survival, exclusive breast feeding for four to six months may be justified as the next best option after exclusive use of feeding alternatives
Pe lângă gestionarea tratamentului, ce alte chestiuni ar trebui luate în calcul?
Women for Positive Action is supported by a grant from Abbott

61. Probleme de luat în calcul
Suport social, îngrijire oferită mamei şi
copilului
Adresarea problemei legate de locuinţă autorităţilor competente, pentru ca aceasta să nu mai impartă camera cu altcineva. Astfel, femeia şi-ar putea schimba părerea vizavi de tratamentul copilului.
Este nevoie de suportul comunităţii şi a al leaderi-lor spirituali.
Încurajarea integrării în reţelele de suport comunitar.
Leaderii spirituali ai comunităţii o pot ajuta să adere la tratament şi pot discuta chestiuni legate de stigmatizare.
Ghidurile de îngrijire şi tratament sunt necesare pentru a informa pacienta despre riscul alăptării, în contextual declaraţiei din Elveţia.
Transmiterea virsului HIV prin alăptare trebuie să fie incriminată?
Options include addressing the patient’s housing situation so that she did not have to share a room with others. This may have changed her opinion about treating her baby
Peer support and mentoring can help with many aspects of pre- and post-natal care, including supporting and encouraging women not to breastfeed
Seeking community support, especially community faith leaders, can help in such cases. Faith leaders can also help to encourage adherence and issues related to stigma
Many patients with undetectable viral load are asking whether it is possible to breastfeed and guidelines are needed on how to advise on the risks in the light of the Swiss statement
A case came to court in England sometime ago of an HIV positive mother breast feeding, the outcome wasn’t clear as the mother disappeared. However, advice should be taken from in-country bodies
Women for Positive Action is supported by a grant from Abbott

62. Limitarea temporară a custodiei copilului şi îngrijirea acestuia de către specialişti
Copilul ar putea fi luat de sub grija mamei pe o perioadă limitată, revenind acasă după 4 luni, cu scopul de a adresa problema non-aderenţei la TARV a copilului, riscurile alăptării şi alte riscuri de transmitere a virusului HIV.
Cu toate acestea, soluţia mai sus menţionată ar reprezenta ultima opţiune, având în vedere consecinţele grave pentru mamă, respectiv impactul psihic asupra copilului şi mamei şi impactul asupra relaţiei medic-pacient-familie
The baby could be taken into care by a court of law and treated, then returned to the mother after 4 months. However, separating babies from their mothers should be a last resort as the consequences can be damaging in terms of the psychological impact on the mother and baby and the impact on the relationship between the healthcare providers and the family
Possible reasons for taking a child into care include:
Issues with acceptance of ART treatment
Threat of breastfeeding
Threat of transmission via other routes
Criminalisation of transmission has mainly occurred in cases of male to female transmission, however, laws criminalising HIV transmission – whether via sex, needle-sharing or from a mother to an unborn child or infant – are high on the agenda of many nations, despite little evidence that these laws modify behaviour in a beneficial way
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63. Credinţe Credinta este importantă pentru multe femei seropozitive HIV.
Pe cât posibil se recomandă considerarea “credinţei” şi nu respingerea ei.
Colaborarea cu ledear-ii spirituali ai comunităţii poate îmbunătaţi angajamentul pacientului faţă de el însuşi şi faţă de familie.
Human beings are often illogical in both their deep-held beliefs and their behaviours
Education is often not enough to modify damaging or risky behaviour
Beliefs are therefore a reality and an integral part of care as they are fundamental to the way most people think and act in everyday life
The same holds true for many women living with HIV – particularly those with strong religious and superstitious beliefs, as well as people with a strong faith in alternative and traditional forms of medicine
It is crucial to integrate science, medicine and these beliefs, rather than attempting to fight against a woman’s belief system with ‘science’ or ‘logic’
Stories can often be used to engage religious patients to accept their diagnosis or treatment
Sometimes encouraging religious patients to adhere to HIV medication as well as praying can be effective, e.g. “Do you pray for God to protect you when crossing a busy road? But, do you still look left and right as well? Taking medication is like looking left and right”
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64. Vă mulţumesc pentru atenţie!
Întrebări?
Women for Positive Action is supported by a grant from Abbott