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"Eliminating HIV Mother to Baby Transmission: A Status Report on Perinatal HIV in Florida ". Ana M. Puga, MD- Medical Director Comprehensive Family AIDS Program Ryan White Part D Program- Broward County Children’s Diagnostic & Treatment Center. Objectives.

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Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

"Eliminating HIV Mother to Baby Transmission: A Status Report on Perinatal HIV in Florida"

Ana M. Puga, MD- Medical Director

Comprehensive Family AIDS Program

Ryan White Part D Program- Broward County

Children’s Diagnostic & Treatment Center


Objectives
Objectives Report on Perinatal HIV in Florida

  • Participants will know the impact of Perinatal HIV in Florida

  • Participants will learn ways to reduce HIV transmissions from mothers to babies in their communities

  • Participants will understand the risks of HIV acquisition for women and infants.

  • Participants will know necessary management of HIV pregnant women in order to prevent perinatal transmission. 


Hi i m marta
Hi, I’m Marta Report on Perinatal HIV in Florida

  • Married to first and only boyfriend for the past 2 years

  • Excited about starting a family now

  • As soon as she missed a period, she went to the doctor for prenatal care

  • Along with the ultrasound, she was told that her HIV test came back positive!


Aids in the u s
AIDS in the U.S. Report on Perinatal HIV in Florida

In the U.S. HIV/AIDS is the

#2 cause of death in

African Americans aged 25-44.

In Florida, it is #1

~An average 56,300 new HIV infections in the US per year.

530,757 AIDS DEATHS

~1.039 – 1.185 million

people living with

HIV in the US**

Florida is #2 in the US for new cases in

women and children.

~25% new HIV infections in people under 25.

In 13 to 19-year-olds,

male-to-female ratio = 1:1.

~125,000 people living with HIV in Florida.***


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Scope of the Epidemic in the United States among Women and Children

  • AIDS in women has risen from 7% early in the epidemic to 24% - 26% of adult cases today

  • 73 new HIV/AIDS cases reported in children in 2007

  • 181,802 AIDS cases in women reported through 2005

  • 10,000–20,000 estimated children/youth living with HIV infection (8797 under the age of 13)

  • 100- 270 babies continue to be born each year with HIV infection


Florida hiv rates
Florida HIV Rates Children

1 in 208 Floridians are known to be currently living with HIV infection.

  • 1 in 415 Whites are known to be infected

  • 1 in 67 Blacks are known to be infected

  • 1 in 230 Hispanics are known to be infected


Impact of perinatal hiv in florida
Impact of Perinatal HIV in Florida Children

  • Florida has 114,057 people with AIDS and 43,814 people living with HIV

  • Statewide rate is 31.1 per 100,000

  • All counties but 1 had at least 1 HIV case in 2009

  • 10 counties had >100 cases of HIV in 2009

    • Broward, Duval, Hillsborough, Lee, Miami-Dade, Orange, Palm Beach, Pinellas, Polk, and Volusia

    • 77% of all cases in first 9 counties above

    • 50% of cases in SE Florida


Impact of perinatal hiv in florida1
Impact of Perinatal HIV in Florida Children

  • Cases have shifted from 23% white to 34% white from 2002 to 2009 and from 62% black to 46% black

  • Black women 15 X higher than white women

  • Hispanic women 2.5 X higher than white women

  • 47% of cases occurred in 20 – 40 year old

  • Transmission risk for women: 90% heterosexual contact


Impact of perinatal hiv in florida2
Impact of Perinatal HIV in Florida Children

  • Florida ranks 2nd in Pediatric cases

  • Infected cases declined 96% from 201 in 1992 to 8 in 2008

  • 601 babies were born to HIV positive women in Florida in 2008 (8- 1.3% were infected)

    • 7 of 8 new status before pregnancy

    • 5-63% had PNC only 3 of these had adequate PNC

    • 4-50% received ART during pregnancy

    • 4-50% received AZT at delivery

    • 7-87% received AZT for baby


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Impact of Perinatal HIV in Florida Children

  • Of the 136 Infected babies born in Florida from 2000-2005:

  • 27% of all mothers that delivered an infected infant did not know they were positive prior to delivery.

  • 20% of all mothers that delivered an infected infants contracted HIV during the pregnancy.

  • The trend continues

    • Of the four infected infants born in 2010, one was born to a mother who had two negative HIV tests (1st and 3rd trimester) and 17 prenatal care visits during her pregnancy.

  • FL DOH Perinatal Prevent Project Surveillance Data, 2011


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Case Rate per 100,000 Children

0

0.1 to 15.0

15.1 to 30.0

> 30.0

HIV Cases Reported by County of Residence*

Florida, 2008

N= 7,111

Based on 2008 statewide population estimates, the 2008 state rate is 47.1 per 100,000 population.

*County totals exclude Department of Corrections cases (N=477). This map does not reflect HIV incidence.

Numbers on counties are cases reported.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

HIV/AIDS Pediatric Cases Children

By Expanded Modes of Exposure

Born in and Reported in 2000-2008

South Florida Counties (N=85), Florida

Miami-Dade (N=41)

Broward (N=29)

Palm Beach (N=15)

Mom IDU

Mom-Sex Risk

Mom’s Risk-Other/Unkn.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

<1 year Children

1 year

2+ years

HIV/AIDS Pediatric Cases

By Age at First Diagnosis

Born in and Reported in 2000-2008

South Florida Counties (N=85), Florida

Miami-Dade (N=41)

Broward (N=29)

Palm Beach (N=15)


Pediatric aids cases by age group and year of diagnosis florida 1990 2008
Pediatric AIDS Cases by Age Group Childrenand Year of Diagnosis, Florida, 1990-2008*

N=1,430

These data represent a 81% decline in pediatric AIDS cases diagnosed from 1992 (N=178) to 2008 (N=34).

*Due to reporting lags, 2008 data are provisional. Data as of 08/25/09


Hi i m tom
Hi, I’m Tom Children

  • I am 17 and have my first serious girlfriend

  • We just graduated high school and decided it was ok to have sex now.

  • Since it was the first time for both of us, we didn’t use protection- she was on the pill.

  • Later that month, I find out I was born with the AIDS virus


Perinatally acquired hiv not aids cases by age at diagnosis n 618 florida born through 2008
Perinatally Acquired HIV (not AIDS) Cases Childrenby Age at Diagnosis (N=618)Florida, Born through 2008

Number of Cases

< 2 yrs of age

Age in Months

Age in Years

*34% (N=210) were <6 mos. and 50% (N=308) were <2 yrs..

Furthermore, 24 (4%) were diagnosed after the age of 12, data as of 09/30/09.


Perinatally acquired aids cases by age at diagnosis n 1 684 florida born through 2008
Perinatally Acquired AIDS Cases Childrenby Age at Diagnosis (N=1,684)Florida, Born through 2008

Number of Cases

< 2 yrs of age

Age in Years

Age in Months

*21% (N=359) were <6 mos. and 52% (N=868) were <2 yrs..

Furthermore, 220 (13%) were diagnosed after the age of 12, data as of 09/30/09.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Living HIV/AIDS Cases Children

0

1 - 10

11 - 25

26 - 50

over 50

Living Perinatal AIDS or HIV (not AIDS)Born through 2008, by County of DiagnosisFlorida, (N=1,446)

N=1,446

Florida reported 1,446 pediatric (<13 years) AIDS or HIV cases through 2008, with the majority (62%) of these cases reported from Miami-Dade (N=401), Broward (N=243) Palm Beach (N=151) and Hillsborough (N=99) counties. Data as of 09/30/09


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Participants will learn ways to reduce HIV transmissions from mothers to babies in their communities


Maternal to child transmission
Maternal to Child Transmission from mothers to babies in their communities


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Perinatal HIV/AIDS Cases by Year of Birth from mothers to babies in their communities

Reported in Florida*, 1977-2008** (N=2,306)

Note:These data represent a 96% decline in HIV-perinatally infected births from 1992 (N=204) to 2008 (N=9)

*Includes all perinatal HIV/AIDS cases diagnosed in Florida, regardless of place of birth.

**HIV Infection Reporting began July, 2007. 2008 data are provisional. Data as of 09/30/09.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Prenatal HIV Testing Among Women from mothers to babies in their communities

Delivering a Live Birth, Florida, 1996-2007

= 95% C.I.

Comment: Florida’s percentage of childbearing women tested perinatally for HIV is the highest in the U.S., which has probably contributed to the continued decline in pediatric HIV/AIDS cases. Source: Florida Pregnancy Risk Assessment Monitoring System (PRAMS),(2006 or 2008 not available, 2007 had half of normal sample size).http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/PRAMS/Data_Books.htm


Hiv testing
HIV Testing from mothers to babies in their communities

  • Who should get tested?

    • CDC recommends routine testing of EVERYONE 13-64 years of age regardless of risk factor one time then annually based on risk.


Hiv testing laws in florida
HIV Testing Laws in Florida from mothers to babies in their communities

  • Mandatory Offering of HIV test at initiation of Prenatal Care and at 28-32 weeks if initial test is negative

  • Mandatory Offering at Delivery or of newborn if no test available

  • Reporting of all HIV positive tests and exposed newborn testing < 18 months whether positive or negative

  • Super-confidential

  • HIV considered STD in Florida Statutes- youth > 12 years of age can seek testing and care on own


Types of hiv tests
Types of HIV Tests from mothers to babies in their communities

  • Antibody Tests- HIV ELISA/EIA and Western Blot

    • Blood or Oral

    • Standard or Rapid

    • Anonymous or Confidential

  • Viral Tests- HIV RNA-PCR, DNA-PCR, bDNA, Culture, p24 antigen

    • Blood

    • Quantitative and qualitative


New perinatal cases
New Perinatal Cases from mothers to babies in their communities

  • Failed MTCT intervention opportunities

  • Late presenters/No Prenatal care

  • Non-adherent women

    • Substance using

    • Mental illness

  • Missed early childhood cases

  • Unexplained failures


Fimr is a community cycle of improvement
FIMR is a Community Cycle of Improvement from mothers to babies in their communities


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Case Review Process from mothers to babies in their communities

Case Definition

• HIV exposed infant/fetus > 24 weeks gestation and < 24 months of age at the time of review

• Prioritized for each community, not randomly selected

• Cases are selected based on key indicators of missed HIV prevention or treatment opportunities. (late maternal HIV diagnosis during prenatal period, lack of maternal hiv treatment or poor viral suppression during pregnancy)


Fimr hiv by ethnicity
FIMR/HIV by Ethnicity from mothers to babies in their communities

When examining the cases reviewed by mother’s ethnicity, the largest number of cases reviewed were African American, followed by Haitian.


Fimr hiv by zip code
FIMR/HIV by Zip Code from mothers to babies in their communities


Fimr hiv cases and time of diagnosis
FIMR/HIV Cases and Time of Diagnosis from mothers to babies in their communities

More than half of the sample of mothers, were diagnosed HIV positive at this pregnancy.


Fimr hiv by entry to prenatal care
FIMR/HIV by Entry to Prenatal Care from mothers to babies in their communities

Only 22% of the mothers entered prenatal care in the first trimester.


Fimr hiv by mother s age
FIMR/HIV by Mother’s Age from mothers to babies in their communities


Fimr hiv contributing factors
FIMR/HIV Contributing Factors from mothers to babies in their communities


Healthy start data details
Healthy Start data details from mothers to babies in their communities

  • 12 of the 18 mothers received a Healthy Start screen

  • 2 out of the 12 declined Healthy Start services.

  • 3 mothers were not referred for service.

  • 7 mothers were referred but were unable to be found.


Fimr hiv identified gaps
FIMR/HIV Identified Gaps from mothers to babies in their communities

  • ♦ Lack of preconception care

  • ♦ No prenatal care

  • ♦ Inappropriate HIV Care during pregnancy

  • ♦ Services not linking:

    between incarceration, parole, and medical services

    among community providers in maternal/child health and HIV services

  • No resources for mental health care for HIV + women especially if they are pregnant

  • Poor knowledge of and ability to access care

  • Inconsistent Healthy Start referrals

  • Patients of private OB and pediatric providers not receiving appropriate follow up and management of HIV Care


Fimr hiv identified gaps1
FIMR/HIV Identified Gaps from mothers to babies in their communities

♦ Labor and Delivery –

  • Timeliness of HIV medication delivery

  • Incomplete bilateral tubal ligation requests

  • Lack of screening for substance or alcohol abuse upon admission

  • Lack of substance abuse referrals on those with history of positive screen

  • Lack of psychiatry/psychology consults ordered for patients with mental health issues

  • No follow up on mental health referrals made

  • Lack of documentation of HIV medical follow up

  • Overall gaps between labor and delivery and post partum


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida
Time of Maternal HIV Testing from mothers to babies in their communitiesAmong Perinatal HIV/AIDS CasesBorn in and Reported in Florida, 2000-2008 (N=170)

Note: 124 (73%) of the 170 mom’s knew they were infected prior to birth.

*2008 data are provisional.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Percent of Pregnant Women Giving Birth from mothers to babies in their communities

To a Child Diagnosed with HIV in Florida and

Were Known to be HIV Positive Prior to Delivery

By Year of Birth 2000-2008* (124 of 170 births (73%))

*2008 data are not complete due to reporting lag.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Mothers of Perinatally HIV-Infected Cases from mothers to babies in their communities

According to Receipt of

Prenatal Care and/or Prenatal ART*

Born in and Reported in Florida, 2000-2008**

And Mom’s HIV status was known prior to delivery (N=170)

Yes

No

Adequate Prenatal Care

Began by 4th month with 5+ visits

Any Prenatal ART

AZT and/or antiretrovirals

*ART – Antiretroviral Therapy

**2008 data are provisional.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Mothers of Perinatally HIV-Infected Cases from mothers to babies in their communities

According to Receipt of

Caesarean Deliveryand/or ART at Delivery

Born in and Reported in Florida, 2000-2008**

And Mom’s HIV status was known prior to delivery (N=170)

Yes

No

ART during Labor

AZT and/or antiretrovirals

Caesarean

Delivery

*ART – Antiretroviral Therapy

**2008 data are provisional.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Percent of Mothers of Perinatally HIV-Infected Cases from mothers to babies in their communities

Who Abused Drugs or Had an STD During Pregnancy

Born in and Reported in Florida, 2000-2008 (N=170)

Abused Drugs

Had an STD

A total of 21 (12%) of the moms had both abused drugs and had an STD during pregnancy.

*2008 data are not complete due to reporting lag.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Perinatally HIV-Infected Cases from mothers to babies in their communities

Status of Receiving Neonatal Drugs and Breastfeeding

Born in and Reported in Florida, 2000-2008 (N=170)

Received any Neonatal Drugs

Breastfed

*2008 data are provisional.


What gaps exist in your community
What Gaps Exist in Your Community? from mothers to babies in their communities


Gaps identified by comprehensive family aids program
Gaps identified by Comprehensive Family AIDS Program from mothers to babies in their communities

  • Lack of HIV providers willing to serve HIV + pregnant women

  • OB providers unable to keep up with frequent changes in HIV management of pregnant women

  • Women avoiding care due to denial or stigma

  • Lack of education among women regarding HIV care during pregnancy

  • Co-morbidities affecting woman’s ability to adhere to prenatal care or HIV treatment


Cfap perinatal enhanced service program
CFAP Perinatal Enhanced Service Program from mothers to babies in their communities

  • Initiated in 2002 to further reduce perinatal transmission

  • Average transmission rate from 1996-2001 was 6.4%

  • After enhanced services initiated- transmission dropped significantly from 4.5% to 1.5% in first year

  • Average transmission rate from 2002-2009 was 1.8% (Transmission Rate for those linked to CFAP during these years = 0.2%)

  • Transmission in 2010 was ZERO!


Cfap perinatal program
CFAP Perinatal Program from mothers to babies in their communities

* Mother referred 21 days prior to delivery


Cfap perinatal program1
CFAP Perinatal Program from mothers to babies in their communities

*Mother did not adhere to medications


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Prenatal care from mothers to babies in their communities

Client receives results.

Provider tests

Unlesswoman refuses.

Provider and client’s

adherence to regimen:

antenatal, intrapartum,

and neonatal.

If HIV positive,

prophylactic treatment is offered and accepted.

Follow-up care, &

avoidance of

breastfeeding

Steps to Prevention Success


Steps to prevention success
Steps to Prevention Success from mothers to babies in their communities

  • Care Coordination

  • Co-morbidity Management

  • Close monitored follow up


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Participants will understand the risks of HIV acquisition for women and infants.


Hi i am veronica
Hi, I am Veronica acquisition for women and infants.

  • I have been married for 3 years

  • We’re both very excited about our expected baby boy

  • My HIV tests was negative and the ultrasound shows a healthy baby

  • I haven’t missed a single visit to prenatal care

  • The doctor says I need another HIV test

  • This time it’s positive

  • How can that be- I haven’t had sex with anyone else?


Women and hiv
Women and HIV acquisition for women and infants.

  • Who is at risk?

    • Pregnant women

    • Women with frequent yeast infections

    • Women with other vaginal infections

    • Women who have sex without a condom

    • Women who share needles

    • Women who had blood transfusion before 1986

    • Women from other countries where universal precautions are not practiced

    • Women whose partners have unprotected sex with them and others


Pediatric and adolescent hiv
Pediatric and Adolescent HIV acquisition for women and infants.

  • Who is at risk?

    • Infants, children and youth born to a positive mother

    • Infants exposed to pre-mastication

    • Breastfeeding from positive mom

    • Children and youth who have been sexually abused

    • Youth who have unprotected sex or share needles


Preconception counseling care recommendations for women of childbearing age
Preconception Counseling & Care Recommendations for Women of Childbearing Age

  • Contraception counseling to avoid unintended pregnancy is an essential part of care

  • Counsel on safe sexual practices, eliminating alcohol, illicit drug use, and smoking

  • Evaluation of HIV-infected woman includes assessment of HIV disease status and need for ARV therapy

  • For women on ART, review regimen in terms of potential pregnancy; avoid EFV

  • Attain a stable maximally suppressed VL prior to conception

www.aidsetc.org


Removing perinatal transmission risks in hiv positive pregnant women

Removing Perinatal Transmission Risks in HIV Childbearing Age Positive Pregnant Women

You can help!


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Possible Missed Opportunities to Prevent Perinatal Transmission of HIV Among HIV/AIDS CasesBorn in and Reported in Florida, 2000-2008**** (N=170)


Ways you can help
Ways you can help! Transmission of HIV Among HIV/AIDS Cases

  • Incorporate HIV education into all your cases

  • Learn what women should expect during pregnancy care if positive and educate them to make sure gaps are avoided

  • Emphasize protection for women who test negative at the beginning of pregnancy

  • Remove stigma and discrimination by normalizing HIV as a disease that can affect any woman in pregnancy.


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Participants will know the necessary management of HIV pregnant women in order to prevent perinatal transmission. 


Basic hiv education
Basic HIV education HIV pregnant women in order to prevent perinatal transmission. 

  • HIV is the virus that causes Acquired Immuno-Deficiency Syndrome(AIDS)

  • If you get medical care & take treatment, you can expect essentially a normal life expectancy

  • Transmission is through exchange of body fluids/blood- anyone who has unprotected sex is at risk. This means ALL PREGNANT WOMEN

  • Rates are very high in Florida and you cannot tell by looking at someone that they have HIV


Basic hiv education1
Basic HIV education HIV pregnant women in order to prevent perinatal transmission. 

  • With medications and prenatal care you can have an HIV negative healthy baby

  • You can receive care and treatment even if you have no insurance or even if you are not here legally

  • You cannot pass HIV to others by everyday casual contact

  • Your test results are super confidential- no one but the doctor and health department need to know


Antepartum care

Antepartum Care HIV pregnant women in order to prevent perinatal transmission. 


Pregnancy counseling and care recommendations
Pregnancy Counseling and Care Recommendations HIV pregnant women in order to prevent perinatal transmission. 

  • Assessment of HIV disease status

  • Resistance testing

  • Recommendations regarding initiating ART or altering the current ARV regimen- Use ZDV in 3 drug regimen when feasible

  • ARV prophylaxis for ALL pregnant HIV-infected women, regardless of VL or CD4 count (AI)

  • Discuss known benefits and potential risks of ARVs during pregnancy (AIII)

www.aidsetc.org


Current arv medications
Current ARV Medications HIV pregnant women in order to prevent perinatal transmission. 

www.aidsetc.org


Types of arv regimens for pregnant women
Types of ARV Regimens for HIV pregnant women in order to prevent perinatal transmission. Pregnant Women

NNRTI based

(1 NNRTI + 2 NRTI backbone)

PI based

(1 or 2 PIs + 2 NRTI backbone)

68

June 2010

www.aidsetc.org


Lab monitoring
Lab Monitoring HIV pregnant women in order to prevent perinatal transmission. 

Check CD4cell count at initial visit (AI)

Monitor CD4 at least every 3 months thereafter (BIII)

Monitor plasma HIV RNA levels

Offer C- section at 38 weeks, if viral load not below 1000 c/ml at 36 weeks/near delivery

69

June 2010

www.aidsetc.org


Intrapartum care

Intrapartum Care HIV pregnant women in order to prevent perinatal transmission. 


Intrapartum management
Intrapartum Management HIV pregnant women in order to prevent perinatal transmission. 

  • IV ZDV recommended for all HIV-infected women during labor

  • Scheduled Cesarean delivery recommended for women on ART who have suboptimal Viral Load suppression >1000c/ml

  • Avoid Artificial ROM, Invasive monitoring and/or Forceps or vacuum assistance


Intrapartum arv prophylaxis
Intrapartum ARV Prophylaxis HIV pregnant women in order to prevent perinatal transmission. 

  • For women with unknown HIV status who present in labor, perform rapid HIV antibody testing (AII)

    • If first test result is positive

      • Start IV ZDV immediately (without waiting for confirmatory test result)

      • Perform confirmatory test (AII)

      • If confirmatory test is positive, give infant 6 weeks of ZDV (AI)

      • If confirmatory test is negative, infant ZDV is stopped

www.aidsetc.org


Intrapartum arv prophylaxis1
Intrapartum ARV Prophylaxis HIV pregnant women in order to prevent perinatal transmission. 

  • If mother received no antepartum ARVs, start IV ZDV during labor and give 6 weeks of infant ZDV (AII)

  • Few data on benefit of adding other ARVs to intrapartum/ newborn ZDV regimen

  • Some experts combine IV intrapartum/6-week newborn ZDV with single-dose NVP (CIII)

    • If single-dose NVP is given, cover with ARV ‘tail’ to reduce NVP resistance (AII)

www.aidsetc.org


Postpartum care

Postpartum Care HIV pregnant women in order to prevent perinatal transmission. 


Postpartum follow up
Postpartum Follow-Up HIV pregnant women in order to prevent perinatal transmission. 

  • Immediate postpartum period poses unique challenges for adherence (AII)

    • New or continued supportive services arranged before discharge

  • Breastfeeding not recommended in US due to the risk of transmission of HIV via breast milk (AI)

www.aidsetc.org


Postpartum follow up1
Postpartum Follow-Up HIV pregnant women in order to prevent perinatal transmission. 

  • Contraceptive counseling/information includes:

    • Condom use to prevent HIV and STD transmission

      • Unintended pregnancy rate is high with condom use alone

    • Safety and efficacy of intrauterine devices (IUDs) and hormonal methods for HIV-infected women

    • Drug interactions between oral contraceptives and many PIs and NNRTIs

      • Interactions do not rule out use of hormonal contraceptive

www.aidsetc.org


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

Comprehensive Care of Women Postpartum HIV pregnant women in order to prevent perinatal transmission. 

  • Primary and HIV specialty care

  • Ob/GYN and family planning services

  • Mental health and substance abuse treatment as needed

  • Coordination of care through case management for the woman and her family

  • Support services for the family


Neonatal postnatal care

Neonatal Postnatal Care HIV pregnant women in order to prevent perinatal transmission. 


Diagnosis of hiv in the hiv exposed neonate
Diagnosis of HIV in the HIV-Exposed Neonate HIV pregnant women in order to prevent perinatal transmission. 

  • Use DNA-PCR to diagnose HIV infection in infants <18 months of age

    • Maternal HIV antibody crosses the placenta and is detectable in the exposed infant up to age 18 months

  • Perform at a minimum at: Age 14-21 days (some perform at birth), 1-2 months, 4-6 months

  • If positive, confirm with a second virologic test on a different specimen

  • 2 positive tests constitute a diagnosis of HIV

www.aidsetc.org


Diagnosis of hiv in the hiv exposed neonate1
Diagnosis of HIV in the HIV-Exposed Neonate HIV pregnant women in order to prevent perinatal transmission. 

Presumptive exclusion of HIV: ≥2 negative tests (one at ≥ 14 days, another at ≥1 month of age)

Definitive exclusion of HIV in nonbreastfed infants: 2 negative virologic tests at ≥1 month and ≥4 months of age

Many experts confirm negative status with HIV antibody at age 12-18 months

80

June 2010

www.aidsetc.org


Infants born to mothers with unknown hiv infection status
Infants Born to Mothers with Unknown HIV Infection Status HIV pregnant women in order to prevent perinatal transmission. 

  • Rapid HIV antibody testing of mother and/or infant recommended as soon as possible after birth

    • If either mother’s or infant’s HIV antibody test is positive:

      • Start infant ARV prophylaxis immediately (AII)

      • Perform confirmatory test (e.g., Western blot) (AIII)

      • If confirmatory test is positive, obtain HIV DNA PCR for infant (AIII)

        • If positive: discontinue ARV prophylaxis for newborn and refer to pediatric HIV specialist for confirmation of diagnosis and for treatment (AI)

    • If negative:

      • Discontinue ARV prophylaxis

www.aidsetc.org


Infant arv prophylaxis
Infant ARV Prophylaxis HIV pregnant women in order to prevent perinatal transmission. 

  • 6-week ZDV chemoprophylaxis advised for all HIV-exposed neonates (AI)

    • Start as close to the time of birth as possible (within 6-12 hours of delivery) (AII)

    • Adjust dose for premature infants

  • Start regardless of maternal ZDV resistance history (BIII)

  • ARV drugs other than ZDV not recommended in premature infants (BIII)

www.aidsetc.org


Infant pcp prophylaxis
Infant PCP Prophylaxis HIV pregnant women in order to prevent perinatal transmission. 

Start oral TMP-SMX at 4-6 wks for all HIV-infected infants and exposed infants if does not have 2 negative tests (one at greater than 4 weeks of age)

83

June 2010

www.aidsetc.org


Breastfeeding
Breastfeeding HIV pregnant women in order to prevent perinatal transmission. 

HIV may be transmitted via breast milk

Breastfeeding is not recommended for HIV-infected women (including those on ART) (AII)

This recommendation applies to the United States, where safe infant feeding alternatives are available

84

June 2010

www.aidsetc.org


Premastication
Premastication HIV pregnant women in order to prevent perinatal transmission. 

  • A newly identified mode of transmission for infants

  • 4 cases reported in the US

  • EpiAIDS study by CDC confirmed practice

  • Common practice in low income families and in certain racial/ethnic cultures


Monitoring of the hiv exposed neonate
Monitoring of the HIV-Exposed Neonate HIV pregnant women in order to prevent perinatal transmission. 

  • Laboratory monitoring

    • CBC and differential as baseline (BIII)

      • Schedule of hematologic monitoring depends on baseline results and clinical factors (CIII)

    • Consult pediatric HIV specialist if hematologic abnormalities identified (CIII)

    • For infants exposed to ART, some experts recommend more intensive monitoring of CBC, serum chemistry, and LFTs (CIII)

    • Routine serum lactate not recommended

      • Consider if infant has severe clinical symptoms (CIII)

www.aidsetc.org


Long term follow up of hiv exposed infants
Long Term Follow-up of HIV Exposed Infants HIV pregnant women in order to prevent perinatal transmission. 

  • Long term effects of HIV exposure

  • Adverse effects of medications

  • Potential premastication exposure

  • Increased risk of acquisition during adolescence


Challenges in hiv care of women
Challenges in HIV care of Women HIV pregnant women in order to prevent perinatal transmission. 

  • Stigma/ discrimination

  • Poverty

  • History of childhood sexual abuse

  • Mental illness

  • Substance use

  • Single heads of households

  • Child care

  • Lack of insurance

  • Lack of transportation

  • Denial


Hiv prevention education
HIV Prevention Education HIV pregnant women in order to prevent perinatal transmission. 

  • Don’t make assumptions

  • Offer test to anyone who has had unprotected sex

  • Use negative results to reinforce safer sex practices

  • Know that being aware of status reduces transmission and improves survival

  • There are effective treatments and they are tolerated better if started early


Challenges that remain in 2011
Challenges that remain in 2011 HIV pregnant women in order to prevent perinatal transmission. 

  • Prevention is KEY!

  • HIV testing of all pregnant women

  • Prenatal care for all women

  • More intervention with substance using women

  • Eliminating any missed opportunities for perinatal prevention

  • Education on breastfeeding and premastication

  • Better tracking of infants through 18 months of age

  • Testing of all children of positive woman


Eliminating hiv mother to baby transmission a status report on perinatal hiv in florida

  • USPHS Task Force Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and to Reduce Perinatal HIV-1 Transmission in the United States: Updated recommendations available online at AIDSInfo website (www.aidsinfo.nih.gov)

  • Florida Caribbean AIDS Education & Training Center (www.faetc.org)

  • Call CDTC for consultation: 954-728-1036 (Nadia Graham)

    • Ana M. Puga, MD- cell:954-548-0859 office 954-728-8080 ext 1017

Further Information


Questions
Questions? Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and to Reduce Perinatal HIV-1 Transmission in the United States: Updated recommendations available online at AIDSInfo website (

  • Thank you!