HIV In Mothers and

Children
 What Is HIV/AIDS?
• Acquired immunodeficiency syndrome
(AIDS) is caused by the human
immunodeficiency virus (HIV).

• HIV attacks and destroys white blood

cells, causing a defect in the body’s
immune system.

2
 What Is HIV/AIDS?
• The immune system of an HIV-infected
person becomes so weakened that it
cannot protect itself from serious
infections. When this happens, the
person clinically has AIDS.

• AIDS may manifest as early as 2 years

or as late as 10 years after infection
with HIV.
3
 Number of People with
HIV/AIDS by Region
Western Europe Eastern Europe &
North America 500,000 Central Asia
890,000 270,000 East Asia
North Africa & & Pacific
Caribbean Middle East 560,000
330,000 210,000
South and
Sub-Saharan South East Asia
Africa 6.7 million
Latin 22.5 million
America
1.4 million
Australia and New Zealand
12,000

Source: UNAIDS/WHO 1998. 4

 HIV Transmission Through
Sexual Contact
• Of every 100 HIV infected adults, 75-85
have been infected through
unprotected intercourse
– 70% of these infections are from
heterosexual intercourse

• STDs, especially ulcerative lesions in

genitalia, increase risk of transmission
Source: UNAIDS/WHO 1996. 5
Modes of HIV Transmission

• Sexual intercourse
• Accidental exposure to blood/blood
products (e.g., blood transfusions,
shared needles, contaminated
instruments)
• Mother to child during:
– pregnancy
– birth
– breastfeeding 6
 Women and HIV
Social Risk Factors
– Illiteracy
– Lack of awareness of preventive measures
Biological risk factors
– Twice as easy for women to contract HIV from
men
– Physiology of women (e.g., menstruation,
intercourse)
– Pregnancy-associated conditions (e.g., anemia,
menorrhagia and hemorrhage) increase the
7
need for blood transfusion
 HIV and Contraception
• Contraception with protection
– Male condom (latex and vinyl)
– Female condom
– Nonoxynol-9 (antiviral spermicidal cream)1
– Diaphragm1
• Methods appropriate for use by women with
HIV. They should use a condom for their
partner’s protection.
– Hormonals (COCs, Implants, PICs)
–Partial
1 Voluntary sterilization
protection if used without condom 8
Effect of AIDS on Pregnancy
• Infertility
• Repeated abortions
• Prematurity
• Intrauterine growth retardation
• Stillbirths
• Congenital abnormalities
• Embryopathies
9
HIV Transmission from Mother to
Infant
• Antenatal
– In utero by transplacental passage

• Intranatal
– Exposure to maternal blood and vaginal
secretions during labor and delivery

• Postnatal
– Postpartum through breastfeeding
Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998. 10
HIV Transmission from Mother to
Infant

• 25-35% of all infants born to HIV-infected

women in developing countries become
infected

• 90% of HIV-infected infants and children

were infected by mother

Source: UNAIDS/WHO 1996; UNAIDS/WHO 1998. 11

• approximately 600,000 HIV-infected infants
are born every year–at least 1,600 every
day–in resource-constrained countries.

• Transmission occurs during pregnancy, labor

and delivery, and breastfeeding.

• The rate of mother to child transmission has

been reduced to less than 5 percent
among the limited number of HIV-infected
women in developed countries.
• high rates are largely due to
the lack of access to:
– HIV voluntary counseling and
testing
– replacement feeding
– selective caesarean section
– antiretroviral drug therapy
 HIV Transmission
HIV cannot be transmitted by:
– Casual person to person contact at home
or work or in social or public places
– Food, air, water
– Insect/mosquito bites
– Coughing, sneezing, spitting
– Shaking hands, touching, dry kissing or
hugging
– Swimming pools, toilets, etc. 14
 AIDS and Infants
• Symptoms generally develop by 6
months of age
– Diarrhea
– Failure to thrive
• Most of these children die before their
second birthday
• Children born to HIV-infected parents
are likely to become orphans
15
Reducing pediatric HIV infection
and disease involves three stages:
• preventing HIV infection among women
of childbearing age
• preventing unwanted pregnancy among
HIV-positive women
• preventing mother to child transmission
during pregnancy, labor and delivery, and
breastfeeding
 BENEFITS TO HIV TESTING
• EARLY COUNSELING AND TREATMENT
OF HIV INFECTION
• ABILITY TO MAKE DECISIONS
REGARDING PREGNANCY
• IMPLEMENTATION OF STRATEGIES TO
ATTEMPT TO PREVENT TRANSMISSION
TO FETUS
 WHO SHOULD WE SCREEN?
• ALL PREGNANT WOMEN

• TARGETED TESTING FAILS TO IDENTIFY

A SUBSTANTIAL PROPORTION OF HIV
POSITIVE WOMEN
Anti-Retroviral Based Prevention Strategies

• zidovudine (AZT) administered to the

mother from 14 weeks of gestation and
to the child during the first seven days
after birth, reduced the risk of mother
to child transmission among non-
breastfeeding mothers by two-thirds.
• Two similar studies conducted in Côte
d’Ivoire and Burkina Faso among
breastfeeding mothers demonstrated a
37 percent reduction in mother to
child transmission.
Anti-Retroviral Based Prevention Strategies

• A study in Uganda demonstrated a 47

percent reduction in mother to child
transmission following the
administration of a single dose of
nevirapine to the mother at onset of
labor and to the baby within 72 hours
after birth.
• The combination of AZT and lamivudine
in a short-course regimen also has been
shown to reduce mother to child
transmission.
Protecting Health Care Workers
During Labor and Delivery
• Precautions during labor:
– Protection from blood and amniotic fluids
– Protection from sharp instruments
• Resuscitation of baby:
– No mouth to mouth suction
– No mouth to mouth breathing
• Precautions following labor:
– Proper disinfection of instruments
21
– Proper disposal of placenta and other items
 PRETEST COUNSELING
• TAKE RISK HISTORY AND COUNCIL
REGARDING RISK REDUCTION
• DISCUSS REASONS FOR TEST
• PROVIDE INFORMATION TO WOMEN
REGARDING TESTING & ILLNESS
• RISKS & BENEFITS OF TESTING
• CONFIDENTIALITY OF RESULTS
• ASSESS WINDOW PERIOD
• PERSON HAS RIGHT TO REFUSE TESTING
 POST-TEST COUNSELING
• HIV RESULTS SHOULD BE GIVEN IN
PERSON
• ASSESS PATIENT’S UNDERSTANDING
• ENCOURAGE PATIENT TO EXPRESS
FEELINGS AND ASK QUESTIONS
• NEGATIVE AND INDETERMINATE RESULTS:
DISCUSS NEED FOR REPEAT TESTING
 POSITIVE RESULT
• IDENTIFY IMMEDIATE CONCERNS
• IDENTIFY SUPPORTS
• EFFECT OF HIV ON PREGNANCY
• RISK OF TRANSMISSION TO FETUS
DURING PREGNANCY, L&D, BF
• MEASURES TO DECREASE HIV
TRANSMISSION
 CONCLUSIONS
• ALL PREGNANT WOMEN SHOULD BE
OFFERRED HIV TESTING
• PRE- & POST- TEST COUNSELING FOR
ALL PREGNANT WOMEN
• TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED
ANTENATAL CARE
 INTRODUCTION
• MULTIDISCIPLINARY TEAM APPROACH

• MEDICAL NEEDS

• SOCIAL AND PSYCHOLOGICAL NEEDS

 ANTENATAL CARE
• SIMILAR TO CARE FOR HIV NEGATIVE WOMEN

• PREGNANCY NOT HIGH RISK

• SAME NUMBER OF ANTENATAL VISITS

• AVOID INVASIVE ANTENATAL TESTS OR

PROCEDURES
 FIRST VISIT
• PATIENT HISTORY
• DATES OF 1ST POSITIVE HIV TEST
• HIV RISK FACTORS
• HIV CARE AT TIME OF CONCEPTION
• SEROLOGIC STATUS OF PARTNER
• OTHER STD’S
• OPPORTUNISTIC INFECTIONS
• DRUG HISTORY
 FIRST VISIT
• INVESTIGATIONS
• CBC & DIFFERENTIAL
• LYTES, GLUCOSE, RFT’S, LFT’S, LIVER
ENZYMES
• CD4+ COUNT, CD8 COUNT, CD4/CD8
• VIRAL LOAD
• SEROLOGY FOR HEP A, B, C, SYPHILIS,
RUBELLA, TOXO, CMV
• TB SKIN TEST
 FOLLOW UP VISITS
• STANDARD OBSTETRICAL ROUTINE
• INCREASE SURVEILLANCE ONLY IF
WARRANTED
• LABS EVERY 3 MONTHS
• CD4+ COUNT
• VIRAL LOAD
• SEROLOGY FOR TOXOPLASMOSIS AND
SYPHILIS
OPPORTUNISTIC INFECTIONS
• PROPHYLAXIS SHOULD BE OFFERED IN
PREGNANCY FOR THE FOLLOWING
• PNEUMOCYSTIS CARINII PNEUMONIA
• TOXOPLASMOSIS
• TUBERCULOSIS
• MYCOBACTERIUM AVIUM COMPLEX
• VARICELLA ZOSTER
• HEPATITIS A, B
 CONCLUSION
• HIV IN PREGNANCY SHOULD BE
MANAGED BY MULTIDISCIPLINARY
TEAM
• ANTENATAL CARE IS SIMILAR TO THAT
OF HIV POSITIVE WOMEN
• PREGNANCY NOT CONSIDERED HIGH
RISK SIMPLY BY VIRTUE OF HIV
INFECTION
ANTIRETROVIRAL USE
 ANTEPARTUM
ANTIRETROVIRAL USE
• GOALS:
– CONTROL DISEASE IN MOTHER
– REDUCE PERINATAL TRANSMISSION
• VERY LITTLE DATA AVAILABLE ON
EFFECTS IN PREGNANCY
• MOST DATA ASSESSES ZIDOVUDINE
• LITTLE DATA ON OTHER DRUGS
 CONCLUSIONS
• ZIDOVUDINE REDUCES PERINATAL
TRANSMISSION IN WOMEN AT
DIFFERENT STAGES OF DISEASE
• LONG AS WELL AS SHORTER REGIMENS
EFFECTIVE
• STILL EFFECTIVE IN BREASTFEEDING
POPULATIONS
• USE OF OTHER ANTIRETROVIRALS IN
COMBINATION WITH ZDV PROMISING,
STILL INVESTIGATIONAL
IN UTERO EXPOSURE
 IN UTERO EXPOSURE

Drug Teratogenicity Carcinogenicity FDA

NRTI’s In animals in animals Pregnancy
(rodents) Category
Lamivudine Not C
teratogenic
Stavudine Not Liver and C
teratogenic urinary tumours
Didanosine Not Not B
teratogenic carcinogenic
Zalcitabine Hydrocephalu C
s
Abacavir Skeletal C
 IN UTERO EXPOSURE
Drug Teratogenicity in Non Teratogenic FDA
PI’s Animals Effects Pregnancy
Category
Ritonavir Slight incr. in B
cryptorchidism

Saquinavi Not teratogenic B

r
Indinavir Incr. Increased C
supranumery & hyperbilirubinemia
cervical ribs in monkeys -
Nelfinavir Not teratogenic neonatal B
ANTIRETROVIRAL THERAPY
DURING LABOR & DELIVERY
 IV ZIDOVUDINE
• ZDV LOADING DOSE AT ONSET OF
LABOR 2MG/KG OVER 1 HR
• CONTINUOUS INFUSION WHILE IN
LABOR 1MG/KG/HR
• INCREASING EVIDENCE THAT MOST
PERINATAL TRANSMISSION OCCURS
NEAR TIME OF OR DURING DELIVERY
• REDUCTION OF PERINATAL
TRANSMISSION DUE TO SYSTEMIC
ANTIRETROVIRAL DRUG LEVELS IN
NEONATE AT TIME OF DELIVERY
 IV ZIDOVUDINE
• ZDV READILY CROSSES PLACENTA
• INITIAL IV DOSE RESULTS IN VIRUCIDAL
LEVELS IN MOM & INFANT
• CONTINUOUS INFUSION ENSURES
STABLE DRUG LEVELS IN INFANT
DURING BIRTH
 ORAL ZIDOVUDINE
• IF IV ZDV NOT AVAILABLE, ORAL ZDV
MAY BE USED INTRAPARTUM
• ZDV 600MG PO @ ONSET OF LABOR
• 300MG PO Q3H IN LABOR
 BANGKOK, LANCET 1999
• RANDOMIZED PLACEBO CONTROLLED
• ZDV 300MG PO BID FROM 36WKS GA
UNTIL ONSET OF LABOR
• 300MG PO Q3H WHILE IN LABOR
• ALL WOMEN ADVISED NOT TO
BREASTFEED
• TRANSMISSION RATES: 9.4% IN RX
GROUP; 18.9% IN CONTROL GROUP
 ABIDJAN, LANCET 1999
• SIMILAR TRIAL TO BANGKOK, BUT IN
BREASTFEEDING WOMEN

6 MONTHS 4.5 YEARS

ZDV 16.5% 21%
PLACEBO 26.1% 31%
EFFICACY 37% 30%
 COTE D’IVOIRE & BURKINA
FASO, LANCET 1999
• PLACEBO VS ZDV STARTED @ 36-38
WKS GA
• 300MG PO DAILY
• 600MG PO AT ONSET OF LABOR
• 300MG PO BID UNTIL 7 DAYS PP
• >85% OF INFANTS BREASTFED >3MOS
• 18% VS 27.5 % TRANSMISSION @
6MOS (38% EFFICACY)
• RESULTS SHOW SHORT-COURSE PO
ZDV SAFE & EFFECTIVE IN ING RISK
OF MOTHER-TO-CHILD TRANSMISSION
• PREVENTION RATES NOT AS HIGH AS
WITH IV ZDV
 ORAL NEVIRAPINE
• NON-NUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITOR
• VERY LONG HALF-LIFE
• RAPID DEV’T OF DRUG RESISTANCE
 HIVNET 012 STUDY
GUAY ET AL - 1999
• 13626  RANDOMIZED - NVP VS ZDV
• NVP REGIMEN
• 200MG PO AT ONSET OF LABOR
• 2MG/KG PO DOSE TO BABY 72HR DEL’Y
• ZDV REGIMEN
• 600MG PO AT ONSET OF LABOR
• 300MG PO Q3H DURING LABOR
• 4MG/KG BID x7 DAYS TO INFANTS
 HIVNET 012 - RESULTS

ZDV NVP
3 DAYS 10.4% 8.2%
6-8 WKS 21.3% 11.9%
14-16 WKS 25.1% 13.1%
 SO WHAT?
• EFFICACY OF SHORT-COURSE NVP 47%
GREATER THAN SHORT COURSE ZDV

• CURRENTLY SHORT-COURSE PO NVP

NOT COMPARED TO IV ZDV FOR
TRANSMISSION PREVENTION
 CONCLUSIONS
• DURING LABOR - ZDV 2MG/KG IV
LOADING DOSE, THEN 1MG/KG/HR
• IF IV ZDV NOT AVAILABLE CONSIDER
PO REGIMEN
• MAY CONSIDER ADDITION OF
NVP 200MG PO TO IV ZDV @ ONSET
OF LABOR
OBSTETRICAL
PRACTICE
 OBSTETRICAL PRACTICE

• 70 % OF HIV TRANSMISSION OCCURS

INTRAPARTUM.
• THE GOAL OF OBSTETRICAL
MANAGEMENT OF THE HIV PATIENT IS
TO AVOID THOSE PRACTICES THAT
INCREASE RISK OF TRANSMISSION.
 OBSTETRICAL PRACTICE
RUPTURE OF MEMBRANES
LANDESMAN ET AL., 1996

• RUPTURED MEMBRANES ONE OF

MANY VARIABLES EXAMINED
• 281 MOTHER-CHILD PAIRS WITH
MEMBRANES RUPTURED LESS THAN 4
HOURS
• 206 MOTHER-CHILD PAIRS WITH
MEMBRANES RUPTURED MORE THAN 4
HOURS
 RUPTURE OF MEMBRANES
LANDESMAN ET AL., 1996

25

20

15
less than 4 h
10 greater than 4 h

0
% Infants Infected
 OBSTETRICAL PRACTICE
MODE OF DELIVERY - VAGINAL
• ARTIFICIAL RUPTURE OF MEMBRANES
SHOULD BE AVOIDED
• RUPTURE OF MEMBRANES PAST 4 HOURS
SHOULD BE AVOIDED
• FETAL SCALP SAMPLING AND THE USE OF
SCALP ELECTRODES SHOULD BE AVOIDED
 MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999

• RANDOMIZED CLINICAL TRIAL

• 370 MOTHER-CHILD PAIRS ANALYZED
• 203 DELIVERED BY C-S
• 167 DELIVERED VAGINALLY
 MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999

12

10

8
C-S
6
Vag.
4

0
% INFANTS INFECTED
 MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999

• 203 C-S PERFORMED

• 165 WERE PERFORMED ELECTIVELY
• 31 WERE PERFORMED EMERGENTLY
 MODE OF DELIVERY:
EUROPEAN MODE OF DELIVERY
COLLABORATION – MARCH, 1999
9
8
7
6
5 Elective
4 Emergency
3
2
1
0
% Infected Infants
 MODE OF DELIVERY: META-ANALYSIS
THE INTERNATIONAL PERINATAL HIV
GROUP, APRIL 1999
• 15 PROSPECTIVE COHORT STUDIES
• 8533 MOTHER-CHILD PAIRS
• REDUCTION OF TRANSMISSION 50% (OR
0.43, 95% CI, 0.33 – 0.56) WITH ELECTIVE C-S
VS. OTHER MODES OF DELIVERY
• REDUCTION OF TRANSMISSION 87% (OR
0.13, 95% CI, 0.09 – 0.19) WITH ELECTIVE C-S
& PACTG 076
 MODE OF DELIVERY – CAESAREAN
SECTION
• HIV INFECTED WOMEN SHOULD BE COUNSELLED
ABOUT ELECTIVE C-S
• VERTICAL TRANSMISSION IS REDUCED TO 2% WITH
PACTG 076 THERAPY AND ELECTIVE C-S
• WOMEN WITH HIGH VIRAL LOADS MAY BENEFIT
MOST FROM C-S
• TO AVOID SROM & ONSET OF LABOUR, ELECTIVE C-S
IS PERFORMED AT 38 WEEKS
• AFTER SROM OR ONSET OF LABOUR C-S IS LESS
PROTECTIVE
• TO AVOID C-S MORBIDITY, ANTIBIOTIC PROPHYLAXIS
SHOULD BE CONSIDERED
VIRAL LOAD
 HIV IN PREGNANCY – VIRAL LOAD
WOMEN AND INFANTS TRANSMISSION STUDY (WITS): GARCIA ET AL.,
1999

HIV Viral Load Number of HIV

(Copies per mL) Transmissions
Less than 1,000 0 of 57

1,000 – 10,000 32 of 193

10,001 – 50,000 39 of 183

50,001 – 100,000 17 of 54
Greater than 26 of 64
100,000
 HIV IN PREGNANCY – VIRAL LOAD
WOMEN AND INFANTS TRANSMISSION STUDY (WITS): GARCIA ET AL.,
1999

45
40
35
30 less than 1,000
25 1,001-10,000
20 10,001-50,000
15 50,001-100,000
10 more than 100,000
5
0
% INFANTS INFECTED
BREASTFEEDING IN HIV
POSITIVE WOMEN
 INTRODUCTION
• HIV DNA PRESENT IN BREAST MILK
• HIV TRANSMISSION CAN OCCUR
THROUGH BREASTFEEDING
• BREASTFEEDING IS AN INDEPENDENT
RISK FACTOR FOR HIV TRANSMISSION
 EVIDENCE TO SUPPORT
TRANSMISSION
• ISOLATION OF HIV-1 FROM CELLULAR
& NON-CELLULAR FRACTIONS OF
BREAST MILK
• CASE REPORTS OF INFECTED CHILDREN
BREASTFED BY MOTHERS WHO
ACQUIRED HIV POSTPARTUM
 EVIDENCE TO SUPPORT
TRANSMISSION
• DOCUMENTATION OF OTHER
RETROVIRUSES TRANSMITTED THROUGH
BREAST MILK

• CASE REPORTS OF BREAST FED CHILDREN

WHO WERE INITIALLY HIV NEGATIVE
BUT SEROCONVERTED DURING
BREASTFEEDING
 POLICIES

• AVOIDANCE OF BREASTFEEDING IS
CONTROVERSIAL AND DEPENDS ON
INTERNAL MILIEU

• DEVELOPING COUNTRIES VS
INDUSTRIALIZED COUNTRIES
 POLICIES
• UNAIDS REVISED STATEMENT 1998:
WOMEN SHOULD BE OFFERED HIV
COUNSELING AND TESTING, BE
INFORMED OF RISKS AND BENEFITS OF
BREASTFEEDING IF THE MOTHER IS HIV
POSITIVE, AND SHOULD MAKE A
DECISION THAT TAKES INTO ACCOUNT
THE INDIVIDUAL &FAMILY SITUATIONS
 MECHANISM OF
TRANSMISSION
• EXACT MECHANISM OF TRANSMISSION
THROUGH BREAST MILK STILL NOT
WELL UNDERSTOOD
• INFECTION VIA CELL-FREE HIV IN BREAST
MILK OR VIA HIV-INFECTED CELLS
• SUSCEPTIBILITY OF IMMATURE NEONATAL
GI TRACT TO VIRUS
• GI TRACT MUCOSAL DAMAGE
 DURATION OF
BREASTFEEDING

• STUDIES -  IN TRANSMISSION WITH

INCREASING DURATION OF
BREASTFEEDING
 MALAWI, JAMA 1999
• CUMULATIVE INFECTION RISK WHILE
BREASTFEEDING
• 3.5% AT END OF 5 MONTHS
• 7.0% AT END OF 11 MONTHS
• 8.9% AT END OF 17 MONTHS
• 10.3% AT END OF 23 MONTHS
• NO FURTHER TRANSMISSION AFTER
BREASTFEEDING STOPPED
 MULTICENTER STUDY,
LANCET 1998
• CUMULATIVE INFECTION RISK WHILE
BREASTFEEDING
• 0.7% AT END OF 6 MONTHS
• 0.95% AT END OF 9 MONTHS
• 2.5% AT END OF 12 MONTHS
• 6.3% AT END OF 18 MONTHS
• 7.4% AT END OF 24 MONTHS
• 9.2% AT END OF 36 MONTHS
 DURATION OF
BREASTFEEDING
• ? EARLY WEANING POLICY
• PROBLEMS WITH EARLY WEANING
• ADVERSE NEONATAL EFFECTS
• COLOSTRUM HIGHLY INFECTIOUS
 EXCLUSIVITY OF
BRESTFEEDING

• STUDIES - INFANTS EXCLUSIVELY

BREAST FED AT LOWER RISK OF
ACQUIRING HIV THAN THOSE FED
WITH OTHER TYPES OF MILK, TEA, OR
JUICE WHILE BEING BREAST FED
 BRAZIL STUDY, 1998
• CHILDREN FED WITH OTHER TYPES OF
MILK WHILE BEING BREASTFED WERE
AT 2.2-FOLD GREATER RISK OF HIV
INFECTION THAN THOSE EXCLUSIVELY
BREASTFED
• CHILDREN FED WITH TEA OR FRUIT
JUICE WHLE BEING BREASTFED WERE
AT 2.6-FOLD GREATER RISK OF
INFECTION
 DURBAN (SOUTH AFRICA),
LANCET 1999
• 3 GROUPS OF CHILDREN - NEVER
BREASTFED, EXCLUSIVELY BREASTFED,
MIXED FEEDING
• NO SIGNIFICANT DIFFERENCE IN
TRANSMISSION BETWEEN NEVER AND
EXCLUSIVELY BREASTFED GROUPS
• SIGNIFICANTLY INCREASED RISK OF
TRANSMISSION FOR MIXED FEEDING
 INTERPRETATION

• IMMUNE FACTORS IN BREAST MILK

• GROWTH FACTORS IN BREAST MILK
• MUCOSAL DAMAGE WITH MIXED
FEEDING
 MATERNAL FACTORS
• CRACKED NIPPLES
• BLEEDING NIPPLES
• PARITY
 CONCLUSION
• PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION STILL
NOT WELL UNDERSTOOD
• WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
• WOMEN WHO BREASTFEED SHOULD
BE INFORMED THAT TRANSMISSION
CAN OCCUR
SUMMARY
 HIV SCREENING
• ALL PREGNANT WOMEN SHOULD BE
OFFERRED HIV TESTING
• PRE- & POST- TEST COUNSELING FOR
ALL PREGNANT WOMEN
• TARGETED TESTING OF PREGNANT
WOMEN WHO REPORT HIGH RISK
BEHAVIOR NOT RECOMMENDED
 ANTENATAL CARE
• HIV IN PREGNANCY REQUIRES
MULTIDISCIPLINARY APPROACH
• ANTENATAL CARE IS SIMILAR TO THAT OF
HIV -VE WOMEN
• PREGNANCY NOT HIGH RISK
• AVOID INVASIVE PROCEDURES
• MONITOR CD4+ AND VIRAL LOAD AT LEAST
EVERY 3 MONTHS IF ABLE TO PROVIDE
ANTIRETROVIRAL THERAPY
 ANTIRETROVIRAL USE
• Zidovudine reduces perinatal
transmission in women at different
stages of disease
• long (ante, peri, and postnatal) as well
as shorter regimens effective
• still effective in breastfeeding
populations
• Use of other antiretrovirals in
combination with ZDV promising, still
investigational
 INTRAPARTUM
ANTIRETROVIRAL THERAPY
• DURING LABOR - ZDV 2MG/KG IV
LOADING DOSE, THEN 1MG/KG/HR
• IF IV ZDV NOT AVAILABLE CONSIDER
PO REGIMEN
• MAY CONSIDER ADDITION OF
NVP 200MG PO TO IV ZDV @ ONSET
OF LABOR
 BREASTFEEDING
• PRECISE RISK FACTORS AND
MECHANISM OF TRANSMISSION STILL
NOT WELL UNDERSTOOD
• WOMEN WHO ARE HIV POSITIVE
SHOULD BE ADVISED TO AVOID
BREASTFEEDING
• WOMEN WHO BREASTFEED SHOULD
BE INFORMED THAT TRANSMISSION
CAN OCCUR