HIV IN PREGNANCY PANEL DISCUSSION

Transcription

1 HIV IN PREGNANCY PANEL DISCUSSION

2 Introduction Transmission from HIV infected mother to baby is the key mode of HIV transmission in children Annually about 14,000 New HIV Infections occur among children in India HIV infection causes about 10,000 deaths annually among children in India But It is possible to prevent HIV infection among children It is also possible to Minimize Mortality if children are infected Early detection and prompt treatment PPTCT Overview 3

3 HIV Prevalence Among Pregnant Women (ANC) National Average (ANC): 0.42% Estimated HIV positive Pregnant Women / year: 38,202 Higher prevalence in southern region of the country and pockets of high prevalence in rest of the country PPTCT Overview Source HSS , Department of AIDS Control, MOHFW/GoI

4 Brief about the virology of HIV

5 Brief about the virology of HIV It is a spherical, enveloped, single stranded RNA virus. The reverse transcriptase enzyme is a characteristic feature. P24 : core antigen, which can be detected in early stages of infection Envelop antigen gp 120, antiboties against this are present till terminal stages. IT IS A HIGHLY MUTABLE VIRUS

6 Inactivated by the following Temperature: 10 min at 60 and in seconds at 100 degree centigrade respectively In 10 min by: 50% ethanol, 35% isopropanol, 0.5% lysol, 0.5% paraformaldehyde, 0.3% hydrogen peroxide, 10% household bleach

7 What is the pathogenesis? Receptor for the virus is CD4 antigen Virus enters blood or tissues Comes in contact with cells having CD4 antigen(receptor). Ex: CD4 T lympphocyte and binds with the help of gp 120 Fusion with host cell by transmembrane gp41. Co receptors CCR5 and CCXR4 for viral entry HIV genome in internalized Reverse transcriptase produces DNA which is incorporated into host genome of infected cells Cell lysis, release of virons, infection of other cells

8 Modes of spread And Risk of transmission with each route

9 Mode of spread Risk of infection Blood and blood product transfusion 92% Receptive penile vaginal intercourse 0.1% Penetrative penile vaginal intercourse 0.04% Receptive anal intercourse 1.7% Penetrative anal intercourse 0.08% IV drug abuse(sharing of needles) 0.6% Mother to child transmission 15 to 45% Needle stick injuries 0.3%

10 Mrs A, patient living with HIV is 8 weeks pregnant. She comes to you with a query regarding the risk of transmission of HIV to her baby. What is MTCT/PTCT

11 PTCT : parent to child transmission of HIV MTCT : mother to child transmission of HIV PPTCT : Prevention of parent to child transmission of HIV

12 Estimated Risk of Mother to Child transmission in absence of any intervention Risk of HIV Transmission Transmission Rate During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% Overall without breastfeeding 15-25% Overall with breastfeeding up-to six months 20-35% Overall with breastfeeding for months 30-45% Source: WHO PPTCT Overview 9

13 What are the risk factors which increase the risk of MTCT

14 High viral load HIV subtype Resistant strains Advanced clinical stage Concurrent STI Maternal Risk Factors Influencing MTCT Recent infection Viral, bacterial and parasitic (esp. malaria) placental infection Malnourishment PPTCT Overview 8

15 Obstetrical Risk Factors Uterine manipulation (external cephalic version) Influencing MTCT Prolonged rupture of the membranes (>4 hours) Placental Disruption (abruption, chorioamnionitis) Intrapartum haemorrhage Invasive delivery techniques: episiotomies, forceps, use of metal cups for vacuum deliveries Vaginal delivery vs. caesarean section PPTCT Overview 9

16 Infant Risk Factors Influencing PTCT Immature Immune System Preterm baby Low birth weight (<2.5kg) First infant of multiple births Altered skin integrity Immature GI tract Genetic susceptibility HLA genotype CCR5 karyotype deletion PPTCT Overview 10

17 Infant Feeding Risk Factors Influencing Mother is infected with HIV while breastfeeding Breast pathologies (cracked nipples, mastitis or engorgement) Advanced HIV disease in the mother Poor maternal nutrition PTCT Mouth sores or an inflamed GI tract in baby Mixed feeding: Breast milk along with other feeds Prolonged breast feeding (6-18 months) PPTCT Overview 11

18 What is PPTCT And How can you achieve this

19 PPTCT: Overall Goals Four Pronged Strategy Prong 1: Primary prevention of HIV Prong 2: Prevent unintended pregnancies Prong 3: Prevention of MTCT Prong 4: Care, support and treatment HIV Negative general population, e.g. ARSH HIV +ve Not Pregnant Family Planning counselling in ICTC but more importantly at ART centres HIV +ve & Pregnant 11 HIV +ve Mother & Child

20 Mrs B is a primigravida with 6 weeks gestation. She underwent testing for HIV after counselling and was found to be positive.

21 What are the tests used for HIV testing What are the interventions during antenatal period to prevent MTCT What is the plan of antenatal follow up and management

22 Tests for HIV Screening test : ELISA (antibody) sensitivity of > 99.5% Confirmatory test : Western blot Additional tests : EIA (p24 antigen), RNA assay, DNA PCR Rapid tests : on blood or plasma. Results available within 1-60 min. Sensitivity 99%.

23 Interventions During Pregnancy Primary prevention of HIV in childbearing women Provide HIV information to ALL pregnant women Antenatal visits are opportunity for PPTCT Prevention of unwanted pregnancies in HIV-positive women Prevention of PTCT through ART (to mother and baby) Safe obstetric practices PPTCT Overview 13

24 What are the NACO guidelines for ART in Pregnancy

25 National PPTCT Algorithm HIV infected pregnant women Already on Life long ART Initiate ART Continue ART PPTCT Overview 23

26 ART in Pregnant women with HIV TDF (300mg) + 3TC (300mg) + EFV (600mg) FDC once daily pill, to be taken at bedtime PPTCT Overview 25

27 Recommendations for HIV positive pregnant women Pregnant Women who are detected to be HIV infected during antenatal care should be initiated on ART tenofovir, lamivudin and efavirenz (TDF+3TC+EFV) regardless of clinical stage or CD4 count. Obtain sample for CD4 count before initiating or soon after initiating ART. The initiation of ART should not be delayed for want of CD4 test results. PPTCT Overview 24

28 Antenatal management summary Start ART CD4 count at initiation of ART and every 3 months Serum hepatic transaminase levels, complete blood count at initiation of ART and after 4 weeks. Serological testing for Hepatitis B and C, syphilis. Screening for STI and appropriate treatment Evaluate the need for vaccination: Hepatitis B, pneumoccoccal, influenza, Tdap vaccines If CD4 count less that 250/cumm pneumocystis jiroveci prophylaxis is started.

29 Mrs. C is a primigravida on ART admitted in labor room in early labor with intact membranes. What are the interventions during labor and delivery period to prevent MTCT

30 Interventions During Labour and Delivery Minimise vaginal examinations Use partogram to monitor labour Avoid prolonged labour Consider oxytocin to shorten labour Avoid artificial rupture of membranes Do not use suction unless absolutely necessary Early cord clamping. PPTCT Overview 14

31 Interventions During Labour and Delivery Avoid unnecessary trauma during delivery Use non-invasive foetal monitoring Avoid invasive procedures Avoid routine episiotomy Minimise the use of forceps or vacuum extractors For all infants: Whe head is deli ered ipe i fa t s face ith gauze or cloth After infant is completely delivered, thoroughly wipe dry with a towel and transfer to the mother PPTCT Overview 15

32 Mrs D primigravida on ART is now 37 weeks of gestation. She was told by one of the Basic health workers that cesarean section reduces the risk of MTCT. What is the preferred mode of delivery in HIV positive pregnancy according to WHO/NACO What counseling will you do to this patient.

33 Considerations Regarding Mode of Delivery Caesarean section performed before the onset of labour and rupture of the membrane to reduce HIV transmission The risk of elective Caesarean for PMTCT should be assessed carefully in the context of factors such as: Risk of post-operative complications Safety of the blood supply Cost In India, normal vaginal delivery is recommended unless the woman has obstetric reasons (like foetal distress, obstructed labour, etc) for a C-section Lscs is beneficial only if the HIV RNA is more than 1000 copies per ml. Transmission rate is reduced only by 50%. Where as ART reduces the risk by 98 to 99%. PPTCT Overview 16

34 Primipara on the post natal day one is worried about the HIV status of her baby. She was on ART during antenatal period. what interventions can you do to prevent transmission of HIV to the infant What are other interventions and care issues for a baby born to an HIV

35 What tests will you do how do you follow up the infant and when can you tell the mother definitively about the HIV status of her child.

36 Interventions During Infancy Observe for signs and symptoms of HIV infection ARV Prophylaxis to infant All HIV exposed infants should receive cotrimoxazole at 4-6 weeks of age Follow standard immunisation schedule Routine well baby visits Early Infant Diagnosis: DNA PCR test at 6-12 weeks 18-month visit for HIV antibody testing PPTCT Overview 17

37 ARV Prophylaxis to infant Short-term use of Nevirapine syrup in infant upto the age of six weeks

38 Recommendations for HIV Exposed Infants Infants Weight Birth NVP daily dose (in mg) NVP daily dose (in ml) (10 mg Nevirapine in 1 ml suspension) Duration Birth weight less than 2000 gm Birth weight gm Birth weight more than 2500 gm 2 mg / kg once daily. In consultation with a pediatrician trained in HIV care 0.2 ml / kg once daily 10 mg once daily 1 ml once a day 15 mg once daily 1.5 ml once a day Up to 6 weeks irrespective of whether exclusively breast fed or exclusive replacement fed. PPTCT Overview 30

39 What advice will you give regarding infant feeding

40 Safer Infant Feeding Feeding options must be explained to all the mothers and they must be allowed to select their choice Exclusive Replacement feeding (ERF) if Affordable, Feasible, Acceptable, Sustainable and Safe (AFASS) PPTCT Overview 18

41 Safer Infant Feeding NACO Recommendations EID HIV positive: For these infants, exclusive breast feeding is to be done till 6 months. Breast feeding can be continued up to 12 months. EID HIV negative: Exclusive breast feeding is to be done till 6 months and start complimentary feeding at 6 months of age. Breastfeeding should continue up till 12 months only. Stopping of breast feeding should be done gradually over 1 month according to the comfort of the mother and child. Educate parents that HIV testing needs to be done again after cessation of breastfeeding according to the EID protocols. PPTCT Overview 19

42 What is the risk reduction with ART

43 Intervention ARV Interventions Risk of Mother-to-Child HIV Transmission No ARV, breastfeeding 30-45% No ARV, No breastfeeding 20-25% Short course with 1 ARV, breastfeeding 15-25% Short course with 1 ARV, No breastfeeding Short course with 2 ARVs, no breastfeeding 5-15% 5% 3 ARVs (ART), no breastfeeding 1% Source: WHO PPTCT Overview 21

44 A 23 year old G2P1L0 with 14 weeks of gestation has has to be started on ART. In her previous pregnancy she had taken single dose nevirapine at the onset of labor. What ART drugs should be given to her.

45 ART regimen for pregnant women having prior exposure to NNRTI for PPTCT Because of the risk of resistance (archived resistance) to NNRTI drugs in this population, Efavirenz in the TDF+3TC+EFV regimen may not be effective Thus, these TDF women + 3TC + will LPV/r require a protease inhibitor-based ART regimen FDC of TDF(300mg) + 3TC(300mg)-- 1 tab OD FDC of LPV(200mg)/r(50mg) tab BD PPTCT Overview 27

46 A primigravida with 12 weeks gestation is found to be HIV positive with a CD4 count of 250. How will you manage.

47 CPT for Pregnant Women The indications for Cotrimoxazole initiation in pregnant women follow that for other adults Cotrimoxazole prophylaxis prevents Opportunistic Infections (OIs) such as Pneumocystis jiroveci pneumonia (PCP), toxoplasmosis, diarrhoea as well as bacterial infections Cotrimoxazole should be started if CD4 count is <250 cells/mm 3 and continued through pregnancy, delivery and breast-feeding as per national guidelines PPTCT Overview 29

48 Mrs. x, 25 year old unbooked primigravida is admitted in labor. She is found to be HIV positive on rapid testing. Which ART regimen is appropriate for this patient.

49 ART regimen remains the same irrespective of the gestational age at which it is started Start ART (TDF+3TC+EFV) even if she is in labor Detailed evaluation is done after delivery.

50 Mrs. k, 31 year old HIV positive attends the antenatal clinic with 2 months amenorrhea. She has pulmonary tuberculosis and is on treatment. Which ART regimen in appropriate for her.

51 ART tenofovir, lamivudin and efavirenz (TDF+3TC+EFV) No drug interaction is seen with anti tubercular drugs

52 Mrs. A, 19 year old primi is admitted in second stage of labor. You have conducted her delivery. You did a rapid test and found it to be HIV positive. How will you manage this case and what precautions should you take in such situations.

53 Universal precautions to be followed for all cases. Refer the women to ART for evaluation Infant ARV prophylaxis and follow up should be done as per NACO recommendations

54 Advice on contraception Barriers have to be used even if the women is using other contraceptives If partner is also HIV positive? Is there a need to use barriers? Yes to prevent super infection and other STIs PPIUCD and Interval IUCDs can be used in women without AIDS. (WHO MEC cat 2) Hormonal contraceptives: Efavirenz, Nevirapine and Ritonavir boosted protease inhibitors reduce the efficacy of COC. DMPA injection and LNG IUS Can be used. Permanent sterilization

55 Key Points Best obstetric and appropriate infant feeding practices are the effective interventions to reduce PTCT ART initiation guidelines have been liberalised and simplified to have all the pregnant women with HIV under ART Triple drug (Tenofovir + Lamivudine + Efavirenz) ART is the best option made available to pregnant women with HIV in India Effecti e i ple e tatio of PPTCT co ti uu ith the planned linkages and referrals aimed to wipe out paediatric HIV in future PPTCT Overview 43

56 Thank you