HIV in pregnancy

Alternative ART used in pregnant women, NRTIs (2)

(nucleotide reverse transcriptase inhibitors) Truvada (emtricitabine and tenofovir) Combivir (lamivudine and zidovudine) *combine with protease inhibitors (end in -navir)

CDC recommendations in all scenarios (3)

1. Resistance testing first (see if resistant to drugs) 2. Oral regimen during labor and delivery, add IV AZT if VL >400 near delivery. 3. Use preferred agents including an NRTI with good placental passage if feasible.

3 steps to stop MTCT (mother to child transmission) of HIV as part of the Global Plan

1. test all pregnant women for HIV 2. treat all HIV + pregnant women with ART and appropriate intra-partum management 3. continue lifelong ART after delivery (decreases transmission via breast-feeding in countries without infant formula and/or clean water)

When does perinatal HIV transmission occur most commonly?

3rd trimester, esp. week 36 through labor

AIDS defining CD4 count

< 200 (begin PCP [pneumocystis pneumonia] prophylaxis)

Infant born to HIV-infected mother who received no ARV before or during labor, tx?

AZT for 6 weeks combined with nevirapine at birth, 48 hours, and 96 hours after the second dose.

HIV infected pregnant woman who is ART naive, tx?

Consider delay of ART until after 1st trimester (avoid efavirenz). Use preferred agents including an NRTI with good placental passage (zidovudine/azidothymidine, lamivudine, emtricitabine, tenofovir, abacavir)

HIV infected woman receiving ART who becomes pregnant, tx?

Continue ART if suppressing viremia (<50 copies/cc). Adjust meds if viral load >1,000.

HIV infected pregnant woman who has received no ART prior to labor, tx?

Give IV AZT during labor and give AZT to the infant postpartum. Begin combination ART in infant as close to birth as possible.

Preconception counseling of HIV infected women, tx?

Start ART, include at least one agent with good placental passage (Truvada: emtricitabine and tenofovir, Combivir: lamivudine and zidovudine)

When should pregnant women have a second HIV test?

Third trimester (preferably < 36 weeks of gestation) *3rd trimester starts at week 27

When no IV AZT for mother?

VL <400 after 36 weeks

When C-section to avoid HIV transmission? VL and time?

VL >1,000 after 36 weeks

AIDS, best predictor of clinical outcome

Viral load

What is gold standard of care for HIV infected mother, intrapartum (during birth)? Drug of choice? Dose, how long? New dose, how long?

Zidovudine/Azidothymidine (AZT) 2 mg/kg IV over 1 hour 1 mg/kg/hr until delivery

Gold standard of care for neonate born to HIV infected mother, postpartum. Drug of choice? Dose, how often, for how long? When start?

Zidovudine/Azidothymidine (AZT) 2 mg/kg q6hrs po 6 weeks Start 8 to 12 hours after birth. No breast feeding!