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Gina M. Brown, MD

Preventing Perinatal Transmission: It Is a Multi-factorial Issue. Gina M. Brown, MD. GM Brown, MD. Presented at IAS –USA/ RWCA Clinical Conference, August 2004. The International AIDS Society–USA. When does transmission occur?. Antenatal ~20% Intrapartum ~80% Breastfeeding ~14%*

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Gina M. Brown, MD

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  1. Preventing Perinatal Transmission: It Is a Multi-factorial Issue Gina M. Brown, MD GM Brown, MD.Presented at IAS–USA/RWCA Clinical Conference, August 2004. The International AIDS Society–USA

  2. When does transmission occur? • Antenatal ~20% • Intrapartum ~80% • Breastfeeding ~14%* *above baseline Lancet 340(8819):585

  3. Antenatal transmission~20% • Ob procedures? • Amnio • CVS • PUBS • Seroconversion during pregnancy • High viral load • Bleeding during pregnancy?* AJOG 175(3pt1):661. 9/96

  4. Labor and Delivery~80% • Bleeding? • Prolonged ROM • Chorioamnionitis • NSVD(?) • High viral load

  5. Breast feeding • Overall OR 1.7 (1.0-2.9) • Mastitis* RR 3.9 (1.2-12.7) • Breast Abscess* RR 51.6 (4.7-571.0) * Late transmissions (> 2mos.) JID 183 (2):206 Jan 2001

  6. Breast vs FormulaAnn NY Acad Sci 918:136, Nov 2000

  7. What contributes to transmission ? • Illicit substance use • All drugs 3 x risk • Cocaine alone 2.98 x risk • Hepatitis C • 1.82  risk • High viral load • 4-5 risk at >40-50K Landesman, NEJM 1996

  8. Is it just PROM?J AIDS 22(4):379 Dec 1999 • Prospective f/u 172 women • Overall transmission 23% No placental inflammation 11.3% Placental inflammation/ 25.5% no immune suppression Immune suppression 37%

  9. ZDV No treatment Antenatal Intrapartum Postpartum <48 Hrs >72 Hrs Transmission 26 % 6.1% ~5% 10% 18% ZDV effective when begun lateWade NEJM 11/98

  10. Nevirapine issues • Resistance after single dose prophylaxis • Resistant strains in breast milk • Side effects

  11. How to “treat” • Perinatal transmission • ZDV or NVP monotherapy • ZDV + NVP • ZDV + 3TC (9%) • Treat for disease • Three drugs—two different classes • Include protease inhibitor ** Simple regimen

  12. Medication during pregnancy • Treat for HIV first • No transmissions at viral load < 1000 copies/ml * • 1% transmission for viral load <1000 copies/ml** • HAART alone** - without viral load effect * Garcia, NEJM ** Ionnidis Retrovirus 2001

  13. Ionnidis JID 183(4):539 2/2001 • 1201 women with VL < 1000 • 1% perinatal transmission with treatment • 9.8% perinatal transmission without treatment

  14. What works? • Cesarean section (VL > 1000) • Elective c/s-PNT decreased by 1/2 • Treatment for disease • Keeping the viral load <1000 • Avoid vacuum/forceps? • Avoid fetal scalp sampling? • Augmentation of labor with ROM? • Nevirapine, 3TC

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