CIPLADOC - AIDS Update - PREVENTING VERTICAL TRANSMISSION OF HIV



AIDS Updates

PREVENTING VERTICAL TRANSMISSION OF HIV IN VARIOUS CLINICAL SCENARIOS Adapted from: DHHS Guidelines, February 4, 2002


SCENARIO 1:
HIV-INFECTED PREGNANT WOMEN WHO HAVENOT RECEIVED PRIOR ANTIRETROVIRAL THERAPY

The Protocol 076 regimen, initiated after the first trimester, should be recommended for all pregnant women with HIV infection. Protocol 076 regimen Antepartum: Oral administration of 100 mg zidovudine (ZDV) five times daily, initiated at 14-34 weeks' gestation and continued throughout the pregnancy. Intrapartum: During labour, intravenous (I.V.) administration of ZDV* in a 1-hour initial dose of 2 mg/kg body weight, followed by a continuous infusion of 1 mg/kg body weight/hour until delivery. Also administration of 300 mg ZDV 3 hourly during labour may be an alternative when I.V. zidovudine is not available. Postpartum:* Oral administration of ZDV to the newborn (ZDV syrup at 2 mg/kg body weight/dose every 6 hours) for the first 6 weeks of life, beginning at 8-12 hours after birth. The combination of ZDV chemoprophylaxis with additional antiretroviral drugs for treatment of HIV infection is recommended for infected women whose clinical, immunologic or virologic status require treatment or who have HIV RNA over 1,000 copies/mL regardless of clinical or immunologic status.

SCENARIO 2:
HIV-INFECTED WOMEN RECEIVING

HIV-1 infected women receiving antiretroviral therapy in whom pregnancy is identified after the first trimester should continue therapy. ZDV should be a component of the antenatal antiretroviral treatment regimen after the first trimester whenever possible. For women receiving antiretroviral therapy in whom pregnancy is recognized during the first trimester, the woman should be counselled regarding the benefits and potential risks of antiretroviral administration during this period. Regardless of the antepartum antiretroviral regimen, ZDV administration is recommended during the intrapartum period and for the newborn.

SCENARIO 3:
HIV-INFECTED WOMEN IN LABOUR WHO HAVE HAD NO PRIOR THERAPY

Options include: Single dose nevirapine at the onset of labour followed by a single dose of nevirapine for the newborn at age 48 hours Oral ZDV and Lamivudine (3TC) during labour followed by one week of oral ZDV/3TC for the newborn

Options	Maternal Intrapartum dose	Infant Postpartum dose	Data on Transmission	Advantages

1. Nevirapine	Single 200 mg oral dose at onset of labour	Single 2 mg/kg oral dose at age 48-72 hours* *If the mother received nevirapine less than one hour prior to delivery, the infant should be given 2 mg/kg oral nevirapine as soon as possible after birth and again at 48-72 hours.	Transmission at six weeks 12% with nevirapine compared to 21% with ZDV, a 47% reduction	Inexpensive Oral regimen Simple, easy to administer Can give directly observed treatment
2. ZDV/3TC	ZDV 600 mg orally at onset of labour, followed by 300 mg orally every 3 hours until delivery and 3TC 150 mg orally at onset of labour, followed by 150 mg orally every 12 hours until delivery	ZDV 4 mg/kg orally every 12 hours and 3TC 2 mg/kg orally every 12 hours for seven days	Transmission at six weeks 10% with ZDV/3TC compared to 17% with placebo, a 38% reduction	Oral regimen Compliance easier than six weeks of ZDV alone as infant regimen is only one week

In the immediate postpartum period, the woman should have appropriate assessments (e.g. CD4+ count and HIV-1 RNA copy number) to determine whether antiretroviral therapy is recommended for her own health.

SCENARIO 4:
INFANTS BORN TO MOTHERS WHO HAVE RECEIVED NO ANTIRETROVIRAL THERAPY DURING PREGNANCY OR INTRAPARTUM

The six week neonatal ZDV component of the Protocol 076 regimen should be discussed with the mother and offered for the newborn. ZDV should be initiated as soon as possible after delivery - preferably within 6-12 hours of birth. The infant should undergo early diagnosis testing so that if HIV-infected, treatment can be initiated as soon as possible.