Transcript Women, Pregnancy and PMTCT - I-TECH

Women, HIV and PMTCT
Unit 11
HIV Care and ART:
A Course for Physicians
Learning Objectives
 Part 1: Women and HIV
 List women’s risk factors for HIV and identify
strategies to reduce risk
 Identify gynecological conditions associated with
HIV in women
 Describe gender differences in ARV treatment
2
Learning Objectives
 Part 2: HIV and PMTCT
 List the factors that affect HIV transmission
during pregnancy, labor, delivery and
breastfeeding
 Identify how to prescribe ART appropriately for
pregnant women and exposed newborns
 Describe labor, delivery and postpartum care for
HIV+ women and their infants
3
Part 1:
Women and HIV
Global Facts
 Of 40 million people living with HIV/AIDS
worldwide, 17.5 are women (2005)
 77% of all women living with HIV are in subSaharan Africa (2005)
 Among HIV positive adults, women account for
57% in sub-Saharan Africa, 26% in southeast
Asia, 27% in Europe, and 25% in the US (2005)
5
Source: UNAIDS/WHO 2004
6
Source: UNAIDS/WHO 2004
7
Vulnerability Factors
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Biological
Economic
Social
Cultural
“Women are most vulnerable to HIV infection,
given the social and economic disadvantages
they face in their day to day lives.”
• Dr. Nafis Sadik, Executive Director of the
United Nations Population Fund
8
Gender Differences
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Viral load
Disease progression
Drug pharmocokinetics
Lipodystrophy
Lactic acidosis
Contraceptives
Adherence
Gynecological issues
9
Viral Load and Disease
Progression
 Women may have lower viral loads than men in
early disease
 Low viral load may NOT truly reflect low risk for
progression
 Women and men progress at similar rates
 Gender is not significantly associated with time
to AIDS or survival time
10
Drug Pharmacokinetics
 Differences in weight and body mass
 Fat to muscle distribution
 Concentration of enzymes needed for drug
metabolism is different
 Hormonal effects
 Pregnancy
 Hormonal replacement therapy
 Oral contraceptives
11
Lipodystrophy
 Fat accumulation more common in women; fat
depletion more common in men
 Accumulation and depletion in different body
areas of same person occurs equally in men and
women
 Lipid abnormalities: triglyceride and cholesterol
level elevations more common in men
12
Lactic Acidosis
 The FDA has received 60 reports of lactic
acidosis associated with dual nucleosides, with
55% mortality
 83% in women; 50% >175lbs
 Presented with nonspecific symptoms
 Link between mitochondrial dysfunction and
lactic acidosis?
 Occurs in women with high CD4
13
Contraception and ART
 Because Efavirenz is contraindicated during
pregnancy, dual methods of contraception are
highly recommended for sexually active EFV
users: barriers plus
 Progestins (Depo-Provera)
 IUCD
 Nelfinavir, Nevirapine and Ritonavir
 Associated with decreased levels of ethinyl estradiol,
resulting in decreased contraceptive effectiveness
 Do not combine
14
Contraception and ART (2)
 NNRTIs and PIs interfere with blood levels of
combination oral contraceptives
 Additional barrier methods are recommended to
prevent pregnancy and transmission of HIV and
STIs
15
Women and Adherence
 Adherence issues are more complicated for
women who need special attention and support:
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Often don’t disclose HIV status due to stigma
May feel isolated
Caregivers
Challenges in accessing and maintaining care include
child care, transportation, inexperienced providers,
etc.
16
Optimal Adherence for Women
 Evaluate for mental health, substance abuse
and other “adherence interruptus” problems
 Assess HAART readiness
 Develop a mutually agreeable HAART regimen
specific to her lifestyle
 Prepare for side effects
 Encourage atmosphere of communication and
trust
 Be accessible and available
17
Gynecological Issues
 Conditions causing inflammation or infection increase
the likelihood a woman will acquire or transmit HIV
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Bacterial vaginosis
Cervicitis
Herpes ulcers
Genital warts
Condyloma
 Recurrent candidiasis
 Prevalent in 25-30% of women with HIV
 Risk increases 20-fold with CD4<100
 HPV genital warts associated with increased incidence
of cervical cancer
18
Care for HIV+ Women
 Regular gynecologic care
 Pap smear (yearly and as needed)
 Detects cervical dysplasia (human papillomavirus)
and sexually transmitted diseases
 Untreated HIV disease is associated with increased
risk of cervical abnormalities
 Reproductive counseling
19
Care for HIV+ Women
Desiring Pregnancy
 Give accurate information on MTCT
 Maintain good health and nutrition status
 Provide ARVs to eligible women, or consider
delaying until after the first trimester
20
Ongoing Care for Women with
HIV Infection
 Psychological support
 Social support
 Medical support
 Nutritional advice
 Prophylaxis of TB, PCP, malaria, other infections
 Physical examination that includes gynecologic exam
and cervical smears
21
Treatment Guidelines for
Women
 Guidelines are the same for women and men
 Women and men have similar responses to
initial ART
 Because many women weigh less than men, it is
important to monitor for toxicity
22
Part 2:
HIV, Pregnancy and
Preventing Maternal to Child
Transmission
Introduction
 HIV is a family infection
 Mothers and fathers have an impact on
transmission of HIV to the baby
 There is increased chance of transmission to the
baby when a woman becomes infected with HIV
when she is pregnant or breastfeeding
 Partners should have safer sex throughout
pregnancy and while breastfeeding
24
Pregnancy Outcome: Goals
 Uncomplicated pregnancy
 Healthy, uninfected infant
 Healthy mother who has not compromised her
future options for HIV therapy
25
HIV and Pregnancy
 Pregnancy does not
accelerate the
progression of HIV
disease to AIDS
 Patients with AIDS
are more likely to
suffer from
pregnancy-related
complications
26
Effect of Advanced HIV on
Pregnancy
 Decreased fertility
 Spontaneous abortion
 Infections (opportunistic, GU, postpartum, postsurgical)
 Preterm labor
 Premature rupture of membranes
 Low birth weight babies
 Stillbirths
27
Current Status of Mother-to-Child
Transmission
 Estimates of HIV transmission rates from women
to children are about 20-40%
 MTCT is by far the largest source of HIV
infection in children under 15
28
Estimated Risk of MTCT
(Adapted from De Cock KM et al, 2000)
Timing
Transmission Rate
Without Any
Interventions
During pregnancy
5-10%
During labor and delivery
10-15%
During breastfeeding
5-20%
Overall without breastfeeding
15-25%
Overall with breastfeeding to six months
20-35%
Overall with breastfeeding to 18-24 months
30-45%
Note: Rates vary because of differences in population characteristics such as maternal
CD4+ cell counts, RNA viral load and duration of breastfeeding.
“HIV transmission through breastfeeding: A review of available evidence.” Marie Louise
Newell; endorsed by UNICEF, UNFPA, WHO, UNAIDS. 2004 (adapted from De Cock
KM et al., 2000).
29
Of 100 Babies Born to HIV- Infected
Mothers Not on Treatment…
11 infected during breastfeeding
17 infected
during birth
67 not
infected*
5 infected
in utero
*without treatment for parents, most will be orphaned
30
Factors Influencing MTCT
 Viral Load
 The higher the viral load, the higher the risk of MTCT
 Lower risk through:
 Use of ART during pregnancy and postpartum to
mother and newborn
 Adequate nutrition, particularly vitamin A
31
Factors Influencing MTCT (2)
 Maternal factors increasing risk:
 Viral or parasitic placental infection (especially
malaria)
 Becoming infected with HIV during pregnancy
 Severe immune deficiency
 Advanced clinical and immunological state
 Maternal malnutrition
32
Factors Influencing MTCT (3)
 Labor and delivery factors increasing risk:
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Prolonged rupture of membranes (>4 hours)
Injury to birth canal during child birth
Antepartum procedures
Acute chorioamnionitis
Invasive fetal monitoring
Instrumental delivery
Mixing of maternal and fetal body fluids
Delayed infant cleaning and eye care
Routine infant airway suctioning
33
Factors Influencing MTCT (4)
 Fetal Conditions increasing risk:
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Premature delivery
Low birth weight
Immature immune status
First infant in a multiple birth
Oral diseases
34
National Strategies for PMTCT
 Primary prevention of HIV in childbearing
women
 Prevention of unintended pregnancy in HIVpositive women
 Prevention of transmission from HIV+ women to
their infants
 Treatment, care and support of women infected
with HIV, their infants and their families
35
Antenatal Care
 Primary prevention during pregnancy
 Education about safer sex with use of condoms for
mother and father
 Early treatment of STIs
 Safer sex during pregnancy and lactation
 Offer VCT to all pregnant women
 Antenatal visits are vital opportunities for
PMTCT for both HIV-positive and HIV-negative
women
36
Initial Examination
 All pregnant women
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Syphilis test
Hgb
HIV counseling and consent
HIV test (rapid, if available)
Rule out active TB
 If HIV positive:
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Baseline TLC
CD4 and CD8 counts
CD4/CD8 ratio and all other baseline tests (CBC, LFT, etc.)
Viral load screening
37
Initial Examination (2)
 Additionally, if HIV+:
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Duration of known HIV+ status
Past history of HIV-related illness and HAART
WHO Staging
Status of other children, partner, and partner
disclosure and referral
 Any medications taken for HIV-related illness since
beginning of pregnancy
38
Assess Maternal Psychosocial
Status
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Generalities and pains
Headaches
Anxiety
General malaise
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Depression
Palpitations
Insomnia
Irritability
39
Care of the HIV+ Pregnant Woman
 Treatment:
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OIs
STI
UTI
Vaginal candidiasis
ARV
Vitamin supplements
 Prophylaxis:
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Anemia
Tetanus (Toxic-TT)
Vitamin deficiency
Malaria
Pneumonia (PCP)
TB
40
PMTCT Clinical Scenarios
 Six possible clinical scenarios of a pregnant
woman:
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On ART and become pregnant
Pregnant and eligible for ART
Pregnant and not requiring ART
Pregnant and presenting after 34 weeks
Pregnant and presenting in labor
Woman and child presenting postpartum
41
Scenario 1: On ART and
Become Pregnant
 Woman on efavirenz
 Counsel about potential
teratogenicity
 Stop EFV and start NVP if in
first trimester
 Women on ZDV/DDI/LPV/r
 Continue treatment
 Full blood count monthly
 Monitor blood glucose levels
as appropriate
 Woman on
D4T/3TC/nevirapine
 Continue treatment or change
D4T to ZDV
 ALT monthly & when indicated
 Monthly full blood count if on
ZDV
42
Scenario 2: Pregnant and
Eligible for ART
 Begin first line therapy:
 ZDV 300 mg bid or D4T 40 mg every 12 hours (or 30
mg q 12 hours if <60 kg)
 and
 3TC 150 mg q12 hrs
 and
 NVP 200 mg qd for 2 weeks, then 200 mg q12 hrs
 If unable to use NVP, PI options include NFV,
LPV/r or SQV/r
 ALT q 2 weeks for 1 month, then q month and
then as indicated
43
Scenario 3: Pregnant and Not
Requiring ART
 Early stage HIV (WHO Stage I or II disease with
CD4 >200)
 Follow the national PMTCT guidelines
44
Scenario 4: Pregnant Woman
Presenting After 34 Weeks
 Defer ART
 Provide PMTCT
 Review need for ART after delivery
45
Scenario 5: Pregnant Woman
Presenting in Labor
 NVP single dose given at the onset of labor and
post delivery to the infant or
 AZT & 3TC to the mother during labor and infant
post delivery or
 IV AZT (alone or with NVP) to the mother and
AZT syrup to the infant post partum for six
weeks, in addition to a single dose of Nevirapine
46
Scenario 6: Woman and Child
Presenting Post Partum
 Initiate 6 week neonatal AZT protocol, preferably
within 6-12 hours of delivery or
 Single dose Nevirapine plus AZT for the infant
for four weeks
 Mother should be evaluated for HAART
47
Four Options for PMTCT
 (Scenarios 3-5)
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Nevirapine monotherapy to mother and infant
Zidovudine monotherapy to mother and infant
Nevirapine + zidovudine to mother and infant
Zidovudine + lamivudine to mother and infant
48
National PMTCT
Drug
Regimen to the Mother
Antepartum
1)
Nevirapine
2)
Zidovudine
300 mg po
BID from
36 weeks
onwards
Regimen to the Baby
Intrapartum
200 mg po at
onset of labor
^^2 mg/kg po single
dose within 72 hours
postpartum x1
300 mg po
every 3 hours
4 mg/kg BID po for 7
days beginning at 8-12
hours postpartum
600 mg at onset
of labor then
300 mg every 3
hours**
Same as above
49
3) Combination of zidovudine and nevirapine as above
National PMTCT (2)
Drug
4) Zidovudine
&
Lamivudine
Regimen to the Mother
Regimen to the
Baby
Antepartum
Intrapartum
300 mg po BID
from 36 weeks
onwards
&
600 mg po at
onset of labor,
then 300 po mg
every 3 hours
&
4 mg/kg po BID
for 7 days
150 mg po BID
from 36 weeks
onwards
150 mg at onset
of labor then 150
mg every 12
hours
2 mg/kg po BID
for 7 days, both
beginning within
72 hours
postpartum
&
50
Nevirapine Reduces Transmission
During Birth by 41%
No intervention
Single dose NVP to
mother and baby*
17 infected during birth
5 infected in utero
11 infected during BF
67 not infected
10 infected during birth*
5 infected in utero
11 infected during BF
74 not infected
Source: Adapted from Lancet 2003;362:859-68
51
Intrapartum Nevirapine
 Single dose (200 mg) to mother in labor
 Rapidly absorbed
 May rapidly reduce mother’s viral load in blood and
birth canal
 NVP crosses placenta and enters baby
 NVP provides prophylaxis to the baby during the birth
 No side effects with single dose (hepatotoxicity or
rash)
52
Postpartum Nevirapine
 Single dose (2 mg/kg, 0.2 ml/kg) to newborn 4872 hours after birth
 Maintains therapeutic levels in baby’s bloodstream for
the first week of life
 Acts as post-exposure prophylaxis
 No side effects with single dose
 If mother received her dose of NVP less than 2 hours
prior to delivery, give one dose of NVP to baby at birth
and a second dose at 48-72 hrs
53
Antiretroviral Resistance with
Nevirapine
 Following single-dose NVP, resistance mutations
present 6 weeks postpartum in
 20-30% of women
 46% of infants
 No longer detectable 12 months postpartum
(due to reappearance of wild type virus). Mutant
virus archived indefinitely
54
Antiretroviral Resistance with
Nevirapine (2)
 Following single-dose intrapartum NVP, some
mothers have a decreased response to NVPbased HAART
 Problem is the greatest if HAART is given within a few
months of single-dose NVP
 Risk of NVP resistance appears greatly
increased with second maternal dose
55
Postpartum NVP levels (HPLC)
(NVP IC50 =3-30 ng/ml)
Undetectable
5
10
15
20
Days post dose
Source: G. Jourdain et al. 11th CROI, San Francisco, CA, 2004. Abstract 41LB
56
3 and 6 Month Responders (50 copies/mL)
Copyright © 1998 Massachusetts Medical Society. All rights reserved. Source:
Jordain et al., NEJM 2004; 351: 229-240
57
Addition of Short-course ZDV/3TC to
Single-dose NVP for MTCT Prophylaxis
 Interim analysis of 61 mothers (target = 300)
with 6 weeks of resistance data
 No NNRTI resistance at baseline in any group
 NVP resistance at Week 6
 NVP alone
60%
 NVP plus combivir 10%
• NVP + ZDV/3TC x 4 d
• NVP + ZDV/3TC x 7 d
12.0%
10%
 No 184V or NRTI resistance detected
McIntyre J, et al. XV IAC, Bangkok 2004, #LBOrB09
58
ARV Therapy: HAART
 Results in the lowest risk of transmission to the
infant (<2%)
 Reduces the risk of the mother developing
resistance, thereby preserving her future
treatment options
 Improves maternal immune status, improving
survival
 Risks to infant appear to be minimal for most
regimens
59
Safety of NRTI Drugs in
Pregnancy
 Balance between PMTCT and therapy for
mother vs. potential teratogenicity, toxicity, and
drug resistance
 Human pregnancy data only for AZT, 3TC, ddI,
d4T
 No increase in birth defects have been observed
 NRTIs and mitochondrial toxicity: symptomatic
lactic acidosis and hepatic steatosis may have a
female preponderance
60
Safety of NRTI Drugs in
Pregnancy (2)
 Fatal lactic acidosis described in pregnant
women receiving ddI/d4T along with other ART
ddI/d4T SHOULD NOT BE USED
IN PREGNANT WOMEN
61
Safety of NNRTIs in
Pregnancy
 Single dose nevirapine has not been associated
with adverse side effects in women and children
 Nevirapine resistance risk as above
 Nevirapine elimination may be accelerated in infants
whose mother received chronic nevirapine as part of
ART. Significance?
 No human pregnancy data on long term use of
NNRTIs
62
Safety of NNRTIs in
Pregnancy (2)
 Efavirenz causes birth defects in exposed
newborns
 Significant birth defects in 15% of newborn monkeys
 Birth defects reported in newborn humans
 Efavirenz should never be used in the first
trimester
 Efavirenz is best avoided entirely during
pregnancy
63
Safety of PIs in Pregnancy
 Studies of blood levels and safety during
pregnancy in progress for:
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
Indinavir
Ritonavir
Saquinavir
Nelfinavir
 Studies in progress for
 Lopinavir/ritonavir (Kaletra)
 Amprenavir or fosamprenavir
 Atazanavir
64
Combination ART and
Pregnancy Outcome
 Development of typical adverse symptoms is
common
 May increase risk of pre-term deliveries
 Combination therapy started before pregnancy
may carry a higher risk of teratogenicity than
starting in the 2nd or 3rd trimester
 Until more information is known, HIV-infected
pregnant women who are receiving a successful
combination ART regimen should continue
(unless on efavirenz or ddI/d4T)
65
Labor and Delivery Care
Labor and Delivery Care
 To facilitate an opportunity for PMTCT:
 Offer HIV testing for women in labor
 If a woman accepts an HIV test, provide counseling
and rapid test
67
Labor and Delivery Care (2)
 Critical issues during labor
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Emotional support
Confidentiality
Secrecy, disclosure
Fear and concern about transmission
68
Labor and Delivery Care (3)
Do:
 Use partogram
 Perform vaginal cleansing
with 0.25% chlorhexidine
 Follow universal precautions
to avoid occupational
exposure
 Limit vaginal examinations
during labor
 Treat acute chorioamnionitis
 Perform early infant eye and
cord care
Don’t:
 Isolate
 Shave pubic area
 Perform routine episiotomy
 Rupture membranes
 Use vacuum extraction
and forceps if not indicated
69
Cesarean Section (CS)
 Reduces the risk of MTCT
 Not available and safe in many settings
 Not routinely performed for women with HIV
infection in developing countries
 Risks of morbidity associated with CS needs to
be carefully balanced with risk of MTCT
70
Postnatal Care of Mother
 Routine postnatal care
 Infant follow-up
 Close monitoring for secondary postpartum
hemorrhage
 Early recognition and treatment of infections
 Continue on HAART if patient is eligible (if on
HAART while pregnant)
 Commence on HAART if patient is eligible (if
HAART was not started while pregnant)
71
Postnatal Care of Mother (2)
 Extra nutrition and micronutrient support
 Counseling about safe disposal of infectious
soiled pads or other garments
 Family planning counseling
 Infant feeding counseling
 Social support
72
Family Planning
 Discuss family planning BEFORE discharge
 Assess risk behaviors and counsel on suitable
and effective methods
 Review birth control and infection control
 Dual protection to prevent and reduce further HIV
infection, STIs and pregnancy
 Data suggests hormonal contraception is less
effective with ARVs
 Access to emergency contraception
73
Infant Follow-up Schedule
 Follow-up at 6 hours, 6 days, 6 weeks, and
every 3 months
 Do full reassessment, and reclassification for
HIV at each visit
 Virological testing after 6 weeks
 Cotrimoxazole prophylaxis to all exposed infants
74
Case Studies: PMTCT
Case 1 – Introduction
 A pregnant 22-year-old woman with previously
diagnosed HIV infection comes for her first
antenatal clinic visit. She is in her first trimester
of her first pregnancy. No other complaints.
76
Case 1 Questions
1. What information do you need from her history
and physical, in addition to the usual
information collected in the antenatal clinic?
2. What laboratory tests will you request?
3. What education and counseling will you provide
while you wait for the results of the laboratory
tests?
77
Answers: Case 1, Q1
1. What information do you need from her history
and physical, in addition to the usual
information collected in the antenatal clinic?
 Why did she have an HIV test initially?
 Has she disclosed her HIV status to anyone?
 Has she had any HIV-related illness or
treatment?
78
Answers: Case 1, Q1 (2)
 Do a review of HIV-related symptoms and OIs
 Perform a full physical exam including
assessment for STIs
 Do gynecological and obstetric evaluation
 Stage the patient and decide on ART eligibility
79
Answers: Case 1, Q2
2.

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


What laboratory tests will you request?
Confirm or repeat HIV test
If available, measure CD4+ count and VL
RPR and other assessment for STI
Other usual antenatal testing
Other ARV-related testing if otherwise eligible
for combination ARV treatment (CBC, AST, ALT)
80
Answers: Case 1, Q3
3. What education and counseling will you provide
while you wait for the results of the laboratory
tests?
 Education and counseling on safe sex
practices during pregnancy
 You, or the counselor in clinic, may discuss with
her issues about disclosure of her status to her
husband/sexual partner. Ask what kind of
support she has
81
Answers: Case 1, Q3 (2)
 Counsel on risk of MTCT. Explain about use of
ARVs to reduce the risk for her newborn. Explain
you will do blood tests to see if she needs ART
for her own health
 Educate on adequate nutrition and prenatal care
 Counseling regarding infant feeding options
should begin during antenatal care
82
Case 2 – Introduction
 A 29-year-old woman in her third pregnancy,
delivered a healthy 3.5 kg baby girl an hour after
she arrived at the maternity.
 After the birth, she told the staff she had a
positive HIV test done in clinic, but did not take
the tablet given her before rushing to the
maternity because she did not want her family to
know about her HIV infection
83
Case 2 Questions
1. What treatment does she require now?
2. What treatment does her baby require?
84
Answers: Case 2, Q1
1. What treatment does she require now?
 Treating Sara so as to reduce the risk of
intrapartum HIV transmission is no longer an
option
 Sara will need a follow-up visit to assess her
immunologic status and to determine if she
needs HAART for her own health
 Needs counseling on disclosure issues
 Needs counseling on family planning
85
Answers: Case 2, Q2
2. What treatment does her baby require?
 The infant has not had any nevirapine exposure, as
Rosa did not take nevirapine at least 2 hours prior to
delivery
 The infant requires nevirapine 2 mg/kg:



First dose within 6 hours post-partum
Second dose 48-72 hours post-partum
OR NVP one dose plus AZT syrup for 6 weeks
86
Case 3 – Introduction
 A 21 year-old woman presents to the clinic with
pain in her mouth and chest upon swallowing.
She has had night sweats and diarrhea for one
month. Her usual weight was 58 kg
 On exam she weighed 51 kg, had no palpable
lymph nodes, and had oral candidiasis. She was
diagnosed with presumed esophageal
candidiasis and treated with oral fluconazole for
3 weeks. Her pain subsided and she began to
eat
87
Case 3 – Introduction (2)
 Based on the esophageal candidiasis, she had
WHO Stage IV disease, although no CD4 count
was available.
 She began daily cotrimoxazole for opportunistic
infection prophylaxis. She was started on first
line HAART with stavudine 30 mg bid,
lamivudine 150 mg bid, and nevirapine with the
usual dose escalation over 2 weeks.
 She has been adherent with her medications.
The night sweats and diarrhea have stopped,
her appetite has increased, and she gained 6 kg
88
Case 3 – Introduction (3)
 At her 6-month follow-up visit she reports that
her menstrual period is 2 months late. A
pregnancy test is positive
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Case 3 Questions
1.
2.
3.
4.
Should she continue her antiretroviral therapy?
How will you manage her intrapartum care?
How will you treat her after her delivery?
How will you treat her newborn?
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Answers: Case 3, Q1
1. Should she continue her ART?
 She is doing well on a standard ARV regimen,
which is safe in pregnancy
 Does not include efavirenz or ddI+d4T
 She is still in her first trimester of pregnancy, so
risks to her fetus are uncertain
 Options:
 Discontinue ARV until 10-12 weeks
 Continue current ART
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Answers: Case 3, Q2
2. How will you manage her intrapartum care?
 Practice safe obstetric procedures
 ART Option 1: (most practical)
 Continue stavudine, lamivudine, nevirapine as usual
 ART Option 2:
 Give zidovudine, lamivudine, nevirapine at standard
doses
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Answers: Case 3, Q2 (2)
 ART Option 3
 Zidovudine 600 mg loading dose by mouth followed
by 300 mg by mouth every 3 hours till delivery
 Lamivudine 150 mg by mouth every 12 hours
 Nevirapine 200 mg twelve hours daily as she used to
take it
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Answers: Case 3, Q3
3. How will you treat her after her delivery?
 She can resume her usual antiretroviral
combination after delivery
 She should be counseled on infant feeding
 There is no information so far on the effects of
maternal ART on risks of HIV transmission through
breast milk
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Answers: Case 3, Q4
4. How will you treat her newborn?
 Nevirapine syrup 2 mg/kg at 48-72 hours of life
as usual for HIV-exposed infants plus AZT syrup
for 4- 6 weeks
 Infant starts cotrimoxazole at 6 weeks
 Explain testing of infant at 18 months
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Key Points
 Women are more vulnerable to HIV due to
biological, economic, social, and cultural factors
 Women with HIV have special gynecological
needs and concerns
 Women and men with HIV progress at similar
rates; ART guidelines are not gender specific
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Key Points (2)
 All pregnant women should know their HIV
status in order to protect their children and
themselves
 Women with AIDS are more likely to suffer from
pregnancy-related complications
 Pregnant women who present with CD4
<200/mm3 irrespective of WHO stage should be
started on first line treatment: AZT, 3TC, NVP
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Key Points (3)
 Pregnant women should not receive efavirenz or
ddI/d4T
 Effective strategies are available for reducing the
risk of MTCT
 Nevirapine can reduce the risk of MTCT by 41%
 Use of HAART can reduce MTCT to less than
2%
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