ICL 8.3: Mother to Child Transmission of HIV Flashcards
27 year old woman presents at 10 weeks gestation for a new patient evaluation. she has been diagnosed with HIV. CD4 count is 740. her viral load is 2400 copies/mL. she has no significant past medical history, no known drug allergies and takes a multivitamin pill daily. her PE and vital signs are within normal limits. what is the most appropriate step in the management of this patient?
recommend ART therapy now with 3 weeks and consideration of vaginal delivery without IV AZT if the HIV viral load at 26 weeks is undetectable
no breastfeeding
is there a vaccine for HIV?
yes!
we want to end the epidemic by 2030
goal: 95% know their diagnosis, of which 95% are in care and of those, 95% have an undetectable viral load with ZERO neonatal transmission
how many neonatal cases of HIV were there in the US?
44 cases
what is the leading cause of death among women of reproductive age?
HIV
without treatment, kids of these women 1/3 will die by their first birthday and 1/2 by their second
if you have HIV, what is your life expectancy
basically normal life expectancy if you are cared for early enough!
what is the global plan for stopping mother-child HIV transmission?
- test all pregnancy women for HIV
- treat all HIV+ women with appropriate antiretroviral therapy and appropriate intra-partum and post-partum management
- continue lifelong ART after delivery to decrease transmission via breast feeding in countries where there is limited access to clean water
when do we test pregnant women for HIV?
should test ALL women for HIV as early as possible during each pregnancy; encourage testing at subsequent visits if declined
when do we test pregnant women for HIV a second time?
during the third trimester is cost effective even in areas of low HIV prevalence especially for women who:
- receive health care in jurisdictions with elevated incidence of HIV or AIDSa among women aged 15-45
- women who receive health care in facilities in which prenatal screening identifies at least one HIV infected pregnant women per 1000 women screened
- women who are known to be at high risk for acquiring HIV
- women who have signs of symptoms consistent with acute HIV
how common is maternal transmission of HIV to the fetus?
MCT HIV transmission occurs relatively frequently without treatment
there are no parameters/thresholds for transmission or protection….
there are multiple risk factors that contribute to a graded response to transmission to the child like viral load or maternal health
when does perinatal HIV transmission occur during the course of pregnancy?
it’s important to understand the timing and pathophysiology of MTCT in order to evaluate treatment strategies
what time period is HIV most transmitted to the fetus?
around 30% intrapartum transmission
around 70% in utero transmission
in the first 6 weeks is very unlikely for the baby to get HIV so during the first trimester it’s rare to infect the baby
36 weeks through labor is when the vast majority of infections to the fetus occur! this is good because it means there are many opportunities to intervene and block transmission to the fetus since transmission doesn’t occur till late in the 3rd trimester or even through labor
when is the most common period of maternal transmission of HIV in the US?
when women become infected with HIV in the postpartum period while they’re breastfeeding and they have a huge viral load that goes to the breastmilk and goes to the baby
what was the PACTG 076 study?
landmark study that demonstrated effective therapy to decrease MCT of HIV!
it revolutionized care of HIV infected women and set the gold standard for subsequent care
zidovudine (AZT) was the drug used and given to HIV+ pregnant women before they have birth and then also during labor and then postpartum the neonate got some too and made sure not to breastfeed –> infants were evaluated for HIV at 12, 24 and 78 weeks and the study showed there was a 70% reduction in maternal transmission! in the placebo group 25% were infected which is the normal statistic for MCT
what are the MTCT guidelines for HIV?
get an immediate HIV test during pregnancy and start ART asap if the test is positive
keeping giving it and try to get the viral load to be undetectable and test at least every 3 months
if the VL is still 1000+ at week 36 then give IV AZT during labor and do an elective c-section during week 38
what antepartum care do you give antepartum to HIV+ mothers?
- 2 NRTIs + INSTI
ex. tenofovir/emtricitabine + raltegravir
or
- 2NRTIs + boosted PI
ex. tenofovir/emtricitabine + boosted darunavir
