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,
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 need
for blood transfusion

7
 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)
– Voluntary sterilization
1
Partial 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-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
– Proper disposal of placenta and other items

21
 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 Carcinogenici FDA

NRTI’s In animals ty in animals Pregnancy
(rodents) Category
Lamivudin Not C
e teratogenic
Stavudine Not Liver and C
teratogenic urinary tumours
Didanosine Not teratogenic Not carcinogenic B
Zalcitabine Hydrocephalus C

Abacavir Skeletal C
 IN UTERO EXPOSURE
Drug Teratogenicity Non Teratogenic FDA
PI’s in Animals Effects Pregnancy
Category
Ritonavi Slight incr. in B
r cryptorchidism

Saquina Not B
vir teratogenic
Indinavir Incr. Increased C
supranumery hyperbilirubinemia in
monkeys -neonatal
& cervical ribs
Nelfinavir Not teratogenic 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 @
• 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 100,000 26 of 64
 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