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Management of HIV Infection in pregnancy Sintong halomoan sianturi 1061050120Medical student in Department of obstetric and gynaecologyFaculty of medicine, Christian university of Indonesia, jakarta

PRELUDEHuman immunodeficiency virus (HIV) is a blood-borne virus typically transmitted via sexual intercourse, shared intravenous drug, and mother-to-child transmission (MTCT), which can occur during the birth process or during breastfeeding. HIV disease is caused by infection with HIV-1 or HIV-2, which are retroviruses in the Retroviridae family, Lentivirus genus.PRELUDEHIV infection has been a global epidemic around the world. in the absence of intervention, the rates of HIV transmission during pregnancy, labor or breastfeeding vary from 15-45%. Related to Hiv transmission from mother to child, 35% during pregnancy, 65% during labor, and 7-20% during breastfeeding. Data from Indonesia Health ministry 2011 shows 21.103 pregnancy women who undergone HIV test 534 (2,5%) are positive HIV infected.PRELUDEThe use of ARV therapy in pregnancy and in labor approved to be effective to reduce the HIV transmission by intrauterine and intrapartum. In high-income countries, MTCT rates as low as 12% have been achieved with combination ART (cART) drug regimens during pregnancy. In low-income and middle-income countries where breastfeeding is common and access to PMTCT services can be problematic, MTCT rates can be as high as 2548%PRELUDEThe purpose of this paper is to investigate the pregnancy treatment and management of labour in HIV infected women, to reduce the rate of HIV transmission in pregnancy and to reduce the morbidity and mortality rate of both mother and the fetus by selecting the appropriate treatment and considering the drugs safety and efficacy for the mother and the fetus in all the treatment options available this day.

In pregnant women with mildly symptomatic HIV disease and no prior treatment with antiretroviral drugs during the pregnancy, a regimen consisting of zidovudine given ante partum and intra partum to the mother and to the newborn for six weeks reduced the risk of maternal-infant HIV transmission by approximately two thirds.

Patients were randomly assigned to receive zidovudine 500 mg or placebo twice daily for 104 weeks, following a 250 mg four times daily dose regimen for the first 4 weeks.Zidovudine twice daily is effective in delaying progression to symptomatic HIV disease in high-risk, asymptomatic HIV-infected subjects.

Intrapartum transmission occurred in 24 infants in the zidovudine-alone group, as compared with 11 infants in the two-drug group (zidovudine+ nevirapine) and 12 in the three-drug group (zidovudine +lamivudine+nelfinavir).

In Conclusions, neonates whose mothers did not receive ART during pregnancy, prophylaxis with a two- or three-drug ART regimen is superior to zidovudine alone for the prevention of intrapartum HIV transmission.

Birth defects were observed in 16 of 623 live births frm women exposed to EFV in first trimester and in 6 of 184 live births from women exposed to EFV in the second/third trimesterThe prevalence of birth defects was not significantly different between the first and second/third trimester EFV exposure

Of 501 women, 405 delivered by VD, 74 delivered by NSCS and 22 by SCS. Baseline antenatal CD4+ counts were lowest and HIV-1 RNA levels highest in the NSCS group but HIV-1 RNA levels were similar between groups at delivery. Non-scheduled cesarean section was an independent risk factor for postpartum mortality in HIV-1The rate of decline in CD4+ cells and rate of increase in HIV-1 RNA did not differ between groups.

HIV-infected pregnant women took zidovudine, lamivudine, and either nevirapine or nelfinavir from 3436 weeks gestation to 6 mo post partum. Infants received single-dose nevirapine at birth. HIV-transmission rates at birth, 6 weeks, and 6, 12, and 24 mo were 2.5%, 4.2%, 5.0%, 5.7%, and 7.0%This trial shows that a maternal triple-antiretroviral regimen from late pregnancy through 6 months of breastfeeding for PMTCT is safe and feasible in a resource-limited setting

discussionTrial study that has been conducted in Department of Obstetrics and Gynecology and Womens Health, UMDNJ-New Jersey Medical School, Newark, NJ by AIDS Clinical Trials Group got results that treatment with zidovudine achieve decrease transmision rate 67,5% with better drug adherence by lower drug administration 300 mg twice a aday or 200 mg three times a day. Similar result has been shows by pediatrics AIDS clinical trial groups, USA that zidovudine is a effective regimen in prevention mother to child transmission.

discussionMeanwhile, randomized study that conducted by Eunice Kennedy Shriver National Institute of Child Health and Human Development at 17 sites at brazil, south africa, and USA evaluated ARV regimen on infant who mother just identified HIV positive at intrapartum shows that using 2 or 3 ARV drug regimen superior to prevent intrapartum transmission than single dose ARV.Discussion A study that conducted in bostwana evaluated 560 hiv infected pregnant women who receive Zidovudine, lamivudine, and abacavir (NRTI group) or zidovudine, lamivudine, and lopinavir/ritonavir (PI group) or zidovudine, lamivudine, and nevirapine (observational group). The rate of virologic suppression to less than 400 copies per milliliter was high and did not differ significantly among the three groups at delivery (96% in the NRTI group, 93% in the pi group, and 94% in the observational group)Discussion Another combination Arv that can be used are tenofovir/emtricitabine 300 mg/200 mg and nevirapine 200 mg or tenofovir/emticitabine 300/200 mg and atazanavir/ritonavir 300 mg/100 mg. Both as effective as ARV regimen in HIV infected pregnant women although adverse reaction higher in nevirapine regimen (13,6% vs 3,6%)

Research that been conducted at university of california, san fransisco (UCSF) and san fransisco general hospital bay area perinatal AIDS center from august 1997 to april 2009 shows that using NNRTI helps shortening the time that needed to achieve viral load < 400 copy/ml. Similar results has been shows by european collaborative study that using additional NNRTI regimen helps faster viral load supression rather than using PI regimen.DISCUSSIONMeta-analysis that has been conducted by nathan ford et al found that using efavirenz (NNRTI) during first trimester pregnancy found 44 congenital abnormalities or 1,63% from 2023 newborn. Another NNRTI, such as Nevirapine shows that using nevirapine at CD4 counts >250 cell/ul increase toxicity risk. Similar result has been found by Kondo et al, Marazzi et al, and Ouyang et al shows that 91 pregnant women from 1229 sample using nevirapine found severe hepatotoxic as 0,5%DISCUSSIONDISCUSSIONA prospective cohort study was conducted in the Kenya Medical Research Institute, Nairobi, Kenya, involving 501 women, 405 delivered by VD, 74 delivered by NSCS and 22 by SCS. After adjusting for confounders, women who underwent NSCS had a 3.39 higher risk of mortality in the first year postpartum compared to women with VD. In this study of HIV-1 infected women in Kenya, we found that mode of delivery was associated with mortality in the first year postpartum with the greatest risk of death was among women who underwent a non-scheduled cesarean section (NSCS).DISCUSSIONAnother study reported by the French Perinatal Cohort (Agence Nationale de Recherches sur le Sida/Enquete Pe rinatale Francaise) also support this result.Hiv infected pregnant women shows that vaginal delivery increased from 25% to 53%. Since 2010, 4300 women with viral load before delivery < 400 copy/ ml, 49,% went vaginal delivery, 22% went NSCS, 28,7% went SCS.

discussionStudy that has been conducted by Swiss Mother and Child HIV Cohort study and The European Collaborative Study in 2000 to 2010 found that 2663 with 3013 labor at 10 countries, 28% diagnosed with HIV positive during pregnancy. Treatment with combination ARV start at first trimester or second trimester (78%) and third trimester (22%)Overall, in 86% pregnancy viral load supression