Presentation on theme: "PMTCT of HIV-
Dr Abhimanyu Makane
MBBS CHIV FHM(CMC,Vellore) AAHIVS
Consultant HIV Physician Sterling Multispecialty Hospial,Nigdi,Pune."— Presentation transcript:
Dr Abhimanyu Makane Aditya Birla Memorial Hospital Sterling Multispeciality Hospital
HIV-1+ since 2001 Wife 33Y, Primary Teacher in Talegaon Husband 35Y, small vendor in PCMC Hail from traditional Punjabi family
Husband taking treatment from Govt ART On AZT/3TC/NVP Wife on TDF/3TC/EFV from Sterling Both virologically suppressed and doing immunologically good (CD4-500+) Haven’t disclosed HIV status to anybody apart from doctor
15-30% intrapartum 15% during breastfeeding. Pregnancy + Delivery + Breastfeeding = 20-40% without PMTCT Antenatal and post-natal PMTCT can decrease transmission to < 1%.
The HIV-infected partner must be virologically suppressed before conception Discordant Couples with HIV-Infected Female: ◦ Artificial insemination - Safest conception option ◦ Option of self-insemination with a partner’s sperm during the periovulatory period Discordant Couples with HIV-Infected Male: ◦ Donor sperm from an HIV-Neg male with artificial insemination is the safest option. ◦ If donor sperm is unacceptable, the use of sperm preparation techniques coupled with either IUI or IVF
May offer an additional tool to reduce the risk of sexual transmission. The utility of PrEP has not been studied.
Combined ◦ Antepartum cART ◦ Intrapartum cART, and ◦ Infant antiretroviral (ARV) prophylaxis recommended because ARV drugs reduce perinatal transmission ◦ By lowering maternal antepartum viral load and ◦ Providing infant pre- and post-exposure prophylaxis
Efavirenz- ? neural tube deffects Particularly during 1 st trimester exposure BHIVA and WHO don’t consider pregnancy a contraindication for EFV
Mrs B was doing fine on her EFV based cART At end of second trimester ◦ CD4 686 cell/mm3 ◦ Viral load undetectable
Depends on VL at 36-38 wks gestation and general obstetrical considerations. Schedule elective Csection if ◦ VL >1000, ◦ labor has not started and ◦ ROM has not occurred, ◦ May consider C-section with VL 50-1000; although not based on evidence of reduced risk of transmission. No HIV indication for Csection ◦ if maternal VL < 50.
Unless there are clear obstetric indications following should generally be avoided : ◦ Artificial rupture of membranes ◦ Operative delivery with forceps or a vacuum extractor and/or episiotomy
Mrs B was offered a C-section considering age and previous history of stillbirth by her obstetritian
PI increase methargine levels NNRTI decrease Methargine levels misoprostol, oxytocin, and prostaglandin F2 alpha are all safe
Mrs B gave birth to a female child- 3.4kg at 38 week gestation Advised strictly avoiding breastfeeding Baby offered ARV prophylaxis
Start AZT 6-12 hrs post-partum for 6 wks Standard AZT dose: 4 mg/kg BID Add NVP if mother did not have a suppressed VL at delivery ◦ Three doses 1. At Birth, Day-0 2. 48hrs after 1st dose, Day-3 3. 96hrs after 2nd dose, Day-7
Nucleic acid testing required upto18 mos ◦ because of placental antibody transfer. ◦ Age >2-4 wks, HIV DNA testing >90% sensitive ◦ Age >2-3 mos, HIV RNA >90% ◦ Test (1) 14-21 days, (2) 1-2 mos, (3) 4-6 mos. ◦ Repeat any positive nucleic acid test on a separate blood sample. ◦ Dx based on 2 positive NAAT HIV Ab reactive age >18 mos. HIV can be excluded with ◦ 2 negative NAAT age >14 days, ◦ 1 negative NAAT, age >2 months, ◦ negative HIV Ab test,age >18 mos.
Contraindicated where safe alternatives exist even if mother has HIV RNA < 50 and is receiving ART However, formula feeding increases mortality in resource-limited settings, thus breast feeding with continued maternal ART recommended in those setting.
Baby of Mrs B was tested with HIV proviral DNA at 4 weeks and 8weeks of gestation and declared negative Was not offered TMP-SMX prophylaxis
Conclusion-Effort of the government to integrate ART services with maternity care services is likely to have benefited the HIV positive mothers. HIV NegativeHIV Positive TFR2.780.84 ANC utilization78%92% Institutional delivery40%67%
Risks ◦ higher maternal VL ◦ lower CD4 count ◦ severe prematurity (< 33 wks) ◦ Multiple gestation (twin A at higher risk), ◦ smoking, active HSV, genital ulcer disease. Risk lower with ◦ Low VL ◦ effective ART ◦ Cesarean section delivery (when VL not suppressed) ◦ Intrapartum ART ◦ Formula feeding.
Antenatal and post-natal PMTCT can decrease transmission to < 1%. Pregnancy does not increase ◦ HIV progression, ◦ Risk of OIs, or ◦ HIV-related survival.