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Preventing Parent To Child Transmission Of HIV. Rationale For PPTCT in India. 27 Million pregnancies per year 108,000 infected pregnancies Annual cohort of 32,000 infected newborns 25,000 – 50,000 deaths within 2-5 years. 0.4% prevalence. 30% transmission. Transmission Rates.

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slide2

Rationale For PPTCT in India

  • 27 Million pregnancies per year
  • 108,000 infected pregnancies
  • Annual cohort of 32,000 infected newborns
  • 25,000 – 50,000 deaths within 2-5 years

0.4%prevalence

30% transmission

slide3

Transmission Rates

Developed : 14% - 33%

Developing : 21% - 43%

Variations in risk factors amongst different ethnic population

MTC transmission of HIV-2 is low : 1 - 3 %

( lower viral load throughout natural history )

slide4

Issues Concerning Obstetricians

  • Testing ( timing )
  • Pre-pregnancy management
  • Management in pregnancy / labor
  • Preventing transmission / contraception
  • HIV and the health care worker
slide5

TODAY, IT’S

A NATIONAL

PROGRAM

diagnosis of perinatal transmission and it s timing
Diagnosis of Perinatal Transmissionand it’s Timing
  • HIV antibodies passively transmitted
  • Negative, if loss of antibodies by 18 months

Virologic Tests (HIV DNA, RNA PCR)

  • Antepartum infection, if tests +ve within 48 hrs. of delivery
  • Intrapartum, if test -ve within 48 hrs. but +ve after 1 wk.
  • Breast feeding, if test -ve between 2-6 mts, but infant later has HIV infection / disease
slide7

Timing Of Transmission

  • Antepartum - 30% - 50%
  • Intrapartum - 50% - 70%
  • Breast feeding- 14% - 29%
slide8

Without ARV drugs during pregnancy MTCT varies from 13-39%

  • Cases documented intrauterine, intrapartum, and postpartum by breastfeeding
    • In utero 25%–40% of cases
    • Intrapartum 60%–75% of cases
    • Additional risk with breastfeeding
      • 14%  risk with established infection
      • 29%  risk with primary infection

Timing of Perinatal HIV Transmission

Current evidence suggests most

transmission occurs during the intrapartum period

slide9

Risk Factors for Transmission

  • Viral, maternal, obstetrical, foetal, and infant-related factors all influence the risk of MTCT.
  • The most important risk factor for MTCT is the amount of HIV virus in the mother\'s blood, known as the viral load.
  • The risk of transmission to the infant is greatest when the viral load is high — which is often the case with recent HIV infection or advanced HIV/AIDS.
slide10

Factors Affecting Transmission

  • Maternal Viral Load
  • Maternal Immune Status
  • Background Genital Tract Infections
  • Lifestyle & Behavioral Factors
  • Obstetric Factors
slide11

Strategies to Prevent MTC Transmission

  • Medical Termination of Pregnancy (MTP)
  • Antiretrovirals
  • Identification & Prevention of Risk Factors
  • Optimizing Obstetric Practices
slide12

Medical Termination of Pregnancy

  • Few opt for MTP
          • Late registrations & identification
          • Wish to continue pregnancy (social pressures)
guidelines
Guidelines
  • U.S. - Perinatal HIV Working Group Guidelines
  • RCOG Guidelines
  • WHO Guidelines
  • NACO Recommendations
the four prong model for prevention of mother to child hiv transmission naco
The Four Prong Model for Prevention of Mother to Child HIV Transmission: NACO

Prong 1

  • Primary Prevention of HIV Infection Among Women of Child Bearing Age and Young People.

Prong II

  • Prevention of Unintended Pregnancy Among HIV Infected Women

Prong III

  • Prevention of HIV Transmission from infected mother to her infant.

Prong IV

  • PPTCT Plus Provide Care and Support for HIV-infected Women and their Families
prevention of primary hiv infection
Prevention of Primary HIV Infection

Primary prevention strategies include the following components:

  • Safer and responsible sexual behaviour and practices.
  • Abstinence, Be faithful, Condom use
  • Early diagnosis and treatment of STIs can reduce the incidence of HIV in the general population by about 40%.
  • Make HIV testing and counselling widely available.
  • Provide suitable counselling for women who are HIV-negative.
prevention of unintended pregnancies among women infected with hiv
Prevention of Unintended Pregnancies among Women Infected with HIV

Provide

  • Reproductive health education to encourage them to make informed decisions
  • Provide safe accessible and effective contraception
  • Safe, legal and early termination of pregnancy
hiv related treatment care and support services for women
HIV-Related Treatment, Care And Support Services For Women

Services for women include the following:

  • Prevention and treatment of opportunistic infections
  • ARV treatment
  • Treatment of symptoms
  • Palliative care
  • Nutritional support
  • Reproductive health care, including family planning and counselling
  • Psychosocial and community support
slide18

Antiretrovirals

Mode of action

  • Reduce maternal viral load
  • Treatment effect is independent of viral load or CD4 counts
  • Pre-exposure prophylaxis of the fetus
  • ZDV is metabolized into the active triphosphate within the placenta
slide19

Antiretrovirals

  • Long term monotherapy with ZDV (ACTG 076)

Antepartum : ZDV 100mg 5 times / day

Intrapartum : IV ZDV not available

ZDV 300mg 3 hrly till delivery

Infant : Syr. ZDV 2mg /kg

4 times/day x 6 wks

  • Efficacy in preventing transmission – 67%
slide20

Antiretrovirals

  • Short term monotherapy with ZDV (Thai)

Antepartum (>36wks) ZDV 300mg bd

Intrapartum ZDV 300mg 3 hrly

till delivery

  • Efficacy in preventing transmission:

without BF – 51%

with BF – 37%

combination antiretroviral therapy haart guidelines to prevent mtc transmission
Advantages

Prevention of MTC – 1%

Avoids EL CS if viral load < 1000 copies or undetectable

Disadvantages

Cost

Toxicity and drug interactions (DDI & D4T, PI, anti-TB)

Adherence / compliance

Drug resistance

Teratogenesis

Specialist care

Combination Antiretroviral TherapyHAART-Guidelines to prevent MTC transmission
slide22

Identification & Prevention

of Risk Factors

  • Improving Nutritional Status
  • Search & Treat Infection (STDs & Opportunistic)
  • P/Sexam between 24 to 34 wks.
  • Tobacco Intervention (dentifrice, smoking)
factors affecting hiv transmission during labor and delivery
Factors Affecting HIV Transmission During Labor And Delivery
  • Greater risk of MTCT of HIV during labor and delivery
  • The HIV is acquired due to swallowing or aspiration of maternal blood or cervical secretions
  • Microtransfusion due to placental bed massage with uterine contractions
  • High maternal viral load (new or advanced HIV/AIDS)
  • Long duration following rupture of membranes often in the form of ARM
factors affecting hiv transmission during labor and delivery1
Factors Affecting HIV Transmission During Labor And Delivery
  • Acute chorio-amnionitis (resulting from untreated STDs or other infections)
  • Invasive delivery techniques that increase the baby’s contact with maternal blood e.g., episiotomy, foetal scalp monitoring etc.
  • First infant in a multiple birth
optimizing labor practices
Optimizing Labor Practices

AVOID

  • Early rupture of membrane
  • Fetal scalp electrode / sampling
  • Difficult Labor / Instrumental delivery
optimizing obstetric practices
Optimizing Obstetric Practices

Elective Cesarean Section

  • Randomized European Mode of Delivery Trial

Lancet 1999, 353: 1035

  • Large Meta-analysis of 15 Prospective Cohort studies

N Eng J Med 1999; 340: 977

  • French Cohort Experience

JAMA 1998; 280:55.

Elective C.S. (done at 38 wks) confers a 50%

reduction in transmission rates as compared to vaginal birth in a non breast fed population

should cs be routine
Should CS Be Routine

NO

  • Operative Morbidity & Availability
  • Role of HAART
  • Maternal HIV 1 RNA levels
intrapartum intervention
Intrapartum Intervention

Antiretrovirals

  • Nevirapine ( HIVNET ) Single Dose At onset of labour – 200mg single dose
  • Infant – Syr. Nevirapine 2mg/kg single dose within 72 hours
  • Efficacy in preventing transmission with breastfeeding – 47%
nvp prophylaxis
NVP Prophylaxis
  • Is absorbed rapidly
  • Crosses placenta efficiently after single oral dose of 200 mgs.
  • A long elimination half-life of 40 hours
  • In infants median half life is 45- 72 hours of elimination of maternal NVP
  • NVP administered to mother at least two hours before child birth
  • 2mg per kg single dose NVP suspension for the baby within 72 hours of birth ( Median half life 37- 46 hour )
nvp prophylaxis1
NVP Prophylaxis

Benefits of NVP

  • taken by mouth therefore easier to maintain confidentiality
  • inexpensive
  • does not require refrigeration
  • no significant side effect or drug resistance after single dose
single dose nvp plus standard zdv to prevent mtct in thailand
Single-dose NVP Plus Standard ZDV to Prevent MTCT in Thailand

Women: ZDV prophylaxis in 3rd trimester

Infants: 1 wk ZDV + formula feeding

Mother-infant pairs n = 1844

Delivery before

interim analysis

Final as-treated

Group B: Single-dose NVP (200 mg to mother) + Placebo (to infant) + ZDVn = 721

Group A: Single-dose NVP to both mother (200 mg) and infant (6 mg) + ZDV n = 724

Group C: Placebo (to mother) + Placebo (to infant) + ZDV

n = 399

P = .00026

6.3%

1.1%

2.8%

NS

1.9%

Lallemant M et al. N Engl J Med 2004; 351: 217-228

naco protocol for unregistered women
NACO Protocol for Unregistered Women
  • Pre-test counselling
  • Informed written consent
  • Single HIV rapid test (bed side performed by any HCW)
  • If positive NVP as prescribed to mother and baby
  • Fresh sample of mother to be collected and sent for testing to VCTC.
  • Report to mother with proper post-test counselling
  • Encourage mother to follow-up with DIC / VCTC
  • Follow-up of baby upto 18 months.
hiv transmission through breastfeeding
HIV Transmission through Breastfeeding

Approx 14% risk of transmission

Risk Factors

  • HIV is present in milk, although viral concentrations are significantly lower than in blood.
  • The pattern of breastfeeding:
      • babies who are exclusively breastfed have a lower risk of being infected than those who are mixed fed
  • Breast pathologies
      • mastitis
      • cracked nipples
      • bloody nipples
      • other breast infections
hiv transmission through breastfeeding1
HIV Transmission through Breastfeeding
    • Breastfeeding duration
      • the longer it is continued, the higher the risk of transmission
    • Maternal viral load:
      • the risk is believed to double, 30% if a woman becomes infected with HIV for the first time while breastfeeding
      • Maternal immune status, advanced AIDS
  • Poor maternal nutritional status
      • Oral disease in the baby (eg, thrush or sores)
slide35

Breast Feeding

  • Recent WHO guidelines
  • Wherever alternative feeds can be provided the option to breast feed or not should be explained
  • Individualize depending on education, resources & understanding of safe milk substitute practices
  • Encourage early weaning, breast milk expression with pasteurization.
national hiv infant feeding protocol
National HIV Infant - Feeding Protocol
  • Avoidance of all breastfeeding
  • Replacement feeding (formula milk, animal milk ) recommended if acceptable, feasible, affordable, sustainable & safe
  • Mixed feeding is not recommended
  • Otherwise –exclusive breastfeeding is recommended during first six months of life
postnatal follow up visit
Postnatal Follow-up Visit
  • Contraception
  • Condom use
care and support of the infant and child who are hiv exposed
Care And Support Of The Infant And Child Who Are HIV-exposed
  • Nutritional support
  • Support the mother’s infant-feeding choice
  • Provide education on hydration and early reporting of diarrhoea
  • Monitor for growth and development
  • Monitor for signs of infection that can alter feeding patterns
  • Regular follow-up care, especially during the first 2 years of life including immunisations and HIV testing
immunization
Immunization

Children-with known or suspected asymptomatic HIV infection should receive all EPI vaccines according to national schedules.

  • Adult HIV positive individuals should not receive live bacteria or live virus vaccines (eg- oral polio virus, measles, varicella, mumps, and yellow fever vaccines)
  • Pneumococcal, hepatitis B, influenza vaccines may be given to HIV positive persons.
pre pregnancy management
Pre-pregnancy Management

For Discordant Couples and Those Practicing Safe Sex

  • Transmission is 1 in 500 per sexual act

when limiting unprotected intercourse to around ovulation

  • Sperm washing & IUI
  • ICSI
partner involvement in pptct
Partner Involvement in PPTCT
  • PPTCT efforts should be as comprehensive as possible and acknowledge that both mothers and fathers have an impact on transmission of HIV to the infant
  • Both partners need to be aware of the importance of safer sex throughout pregnancy and breastfeeding.
  • Both partners should be tested and counselled for HIV.
  • Both partners should be made aware of and provided with PMTCT interventions.
slide42

Take Home Message

ANC Visit (Enrollment)

Pre-test group Counseling

including partner counseling

Informed Consent for HIV testing ( Opt-out strategy)

ANC Check up and Blood collection

HIV testing by 3 different antigenic principles

Post-test Counseling (infant feeding)

 Positive mothers

slide43

PPTCT FLOW CHART

Positive mothers

Counseled for MTP / mode of delivery / Infant feeding / STI / TB / Risk reduction Strategies

Nevirapine prophylaxis to mother during labour

Neonate Monitoring

Nevirapine to the new born (within 72 hrs)

Follow up (PNC OPD, well baby clinic)

HIV testing Baby 18 months

Continuum, Care and Support (ART / OIs, Diet / nutrition, referrals NGO / CBOs)

take home message
Take Home Message
  • HIV testing and counselling Identifies women infected with HIV
  • ARV prophylaxis decreases risk of MTCT by
    • reducing viral load in mother
    • preventing the virus from fixing itself in the infant
  • Optimizing the obstetric practices to decrease viral exposure at birth
    • avoid prolonged ROM, episiotomy, forceps application, fetal blood sample, fetal electrodes may use various methods of vaginal lavage before and after delivery.
    • Consider Elective CS at 38 weeks of pregnancy before onset of labor or ROM
take home message1
Take Home Message
  • Changing life style and dietary habits
    • Improve nutritional status of mother
    • Provide vitamin and mineral supplementation
    • Use of tobacco and other hard drugs to be stopped
  • Reducing exposure to the virus through breast feeding
    • WHO recommendation in developed world is not to breast feed but in developing countries, choice of BF can be offered after proper counseling
concept dr duru shah
Concept – Dr. Duru Shah
  • Editors

Dr. Sangeeta Agrawal

Dr. Reena Wani

  • Contributors

Dr. Kaizad R Damania

NACO, MDACS Guidelines

we acknowledge the efforts of our
We acknowledge the efforts of our :

Coordinators :

  • Dr. Sangeeta Agrawal - Central
  • Dr. Narendra Malhotra - North
  • Dr. Hema Divakar - South
  • Dr. P. C. Mahapatra - East
  • Dr. Uday Thanawala - West

In bringing the FOGSI YOUTH EXPRESS to your city.

this youth express has been possible through an educational grant from
This Youth Express has been possible through an educational grant from :
  • Charak Pharma Pvt. Ltd
  • CIPLA Ltd.
  • Emcure Pharmaceuticals Ltd
  • GlaxoSmithKline Pharmaceuticals Limited
  • Glenmark Pharmaceuticals Ltd.
  • Metropolis Health Services (India) Pvt.Ltd.
  • Organon India Ltd
  • Roche Pharmaceuticals Ltd.
  • Sandoz Private Limited
  • USV Limited
  • Wyeth Limited
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