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Prevention of Mother to Child Transmission

(PMTCT) of HIV

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:Describe modes of mother to child transmission (MTCT) of HIV Explain the risk factors for MTCTDescribe ways to prevent MTCTExplain use of ARVs in pregnancy and for PMTCT

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Overview: HIV in Women (1)

Globally, 15.9 million adult women living with HIV • 65% of PLHIV in sub-Saharan Africa are

women• 43% of PLHIV in Caribbean are women

Proportion of women living with HIV in Latin America, Asia and Eastern Europe is increasing

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Overview: HIV in Women (2)Percent of adults living with HIV who are female (1990-2007)

WHO and CDC. Prevention of mother-to-child transmission of HIV Generic Training Package, Draft. January 2008.

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Percentage of pregnant women who received an HIV test in low- and middle-income

countries by region, 2005 and 2009–2012

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Percentage of HIV + Pregnant Women Receiving ARVs for PMTCT 2005, 2008, 2009

Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector by WHO, UNICEF, UNAIDS, 2010

32%

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Mother to Child Transmission (MTCT) in Vietnam

National Sentinel Surveillance Data:• HIV prevalence in Vietnam 0.5%• HIV-1 prevalence in antenatal women

0.4% (0-1.9%)• 1.5-2 million births per year• 6000-7000 babies exposed to HIV at

birth

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Pathogenesis and Risk Factors for HIV MTCT

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Question: What are the three main times that a mother can transmit HIV

to her infant?

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MTCT Overview (1)

MTCT can occur during: Pregnancy (5-10%) Labor and delivery (10-20%) Breastfeeding (10-15%)

Without intervention, the overall MTCT rate is 25-40%

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MTCT Overview (2)

10-20%

5-10% 10-15%

Pregnancy Breast feedingD

elivery

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Pathogenesis: HIV Transmission in uterus During Pregnancy

Placenta's membrane separates mother ‘s uterus from fetus:• Can prevent at least 60% from HIV

transmission When structure of placenta’s

membrane is destroyed , HIV crosses over the placenta

Transmission can occur from the first trimester until the end of gestation

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Pathogenesis: HIV TransmissionDuring Labor/Delivery

Bleeding increases quantity of HIV in vagina, increases risk of transmission:• Uterine contractions damages small vessel• Episiotomy, forceps or vacuum damage large blood vessels

Lesions caused by examination and operation on:• Vaginal and cervical excoriations of mothers• Skin, mucous membrane of baby

Baby contacts directly with wall of vagina (bleeding)

Baby swallows vaginal fluids containing HIV

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Pathogenesis: HIV TransmissionDuring Breastfeeding

HIV from lymphocyte of mother penetrates into milk

Damaged nipple (inflamed, ulcerated, scratched,...) increases HIV transmission risk when baby breastfed

Mechanism of HIV transmission is unknown but maybe HIV penetrates to damaged intestine of baby

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Group Brainstorm: What are Some Risk Factors for MTCT?

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MTCT Risk Factors increasing risk(1)

Factor relates High viral load, the HIV level in

vagina is higher the risk of transmission is higher

Genotype of HIV may be responsible for high risk of transmission in different stages

Low CD4 cell or rate of CD4/CD8 decreases

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MTCT Risk Factors increasing rate (2)

Obstetric factor/mother’s clinical situation

Acute infection or advanced stage STI, Illicit drug use Vitamin A deficiency , nutritional status Chorioamnionitis , Prolonged rupture of

membrane Invasive procedures

• Episiotomy, forceps, scalp electrodes, etc

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MTCT Risk Factors increasing rate (3)

Fetus/ infant• Pre-term• Breastfed Infant with oral lesions

Nourishment with:• Breastfeeding• Mixed feeding in first 6 months

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MTCT Risk Factors reducing rate (4)

Scheduled Caesarean section delivery help to reduce approximately by 50% of risk

Some ARVs have effectiveness to reduce risk • Example AZT, 3TC, NVP, Aluvia,…

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PMTCT Interventions

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Comprehensive intervention strategy in PMTCT

The comprehensive intervention strategy promoted by WHO:

Prevention of HIV transmission among women

Prevent unwanted pregnancy Intervention for HIV women Appropriate care and treatment for

mothers and their children

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Universal prevention: HIV, HBV,… HIV Counseling and testing The use of ARV: reduce HIV viral load Safe obstetric practice:

• Avoid invasive procedures for mother and child• Considering C-section

Continuum services of post partum care

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Small Group Activity: What are Some Ways to Prevent Mother to Child

Transmission?

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PMTCT Strategies

Timely PMTCT interventions save babies

Category General Approach

First Steps Test for HIV during pregnancy

Antepartum interventions

HIV counseling and testingARVs for PMTCT

Intrapartum interventions

Rapid HIV testingAvoid invasive procedures

Postpartum interventions

Provide ARVs to newbornAvoid breastfeeding

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Antiretroviral Therapy in Pregnancy and

PMTCT

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Viral Load and the Risk of MTCT

High maternal viral load is a major risk factor for MTCT of HIV

This supports the idea that the risk of transmission is most related to the baby’s overall exposure to virus

Therefore, reducing maternal viral load by ARVs is an effective way to prevent MTCT

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ARV in Pregnancy

Status of Mother Action

If mother needs treatment for her own health (meets criteria for ARV)

Give 3-drug ARV regimen

If mother does not yet need treatment for her own health (does not meet criteria for ARV)

PMTCT with A or B regimen

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What Are The Criteria For Starting Triple ART In A

Pregnant Woman in Vietnam?

The criteria to start a woman on ARV treatment are the same for

pregnant and non-pregnant women

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Criteria for ART Initiation in Pregnant Women

CD4 ≤ 350 cells/mm³ irrespective of clinical stage

Clinical stage 3 or 4 irrespective of CD4 cell count

Modification and Supplement to the Guidelines for Diagnosis and Treatment of HIV/AIDS, MOH November 2011

* ART for pregnant woman is also doingPMTCT

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ARV Drugs Used in Pregnancy

Drug Comment

AZT • safe and efficacious• longest track record for PMTCT

3TC• safe• easy to tolerate• low toxicity

NVP or a PI • (LPV/r in VN)

3 NRTIs • in special circumstances

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ART Regimens Recommended in Pregnancy

AZT + 3TC + NVP

Guidelines for the Diagnosis and Treatment of HIV/AIDS. Ministry of Health, 2009.

Condition Substitution

When AZT cannot be used

Replace AZT with d4T or ABC

When NVP cannot be used

AZT + 3TC + EFV (if gestation age > 12 weeks) or AZT + 3TC + LPV/r or AZT + 3TC + ABC

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Reminder: NVP Hypersensitivity

Most common side effects are rash and hepatic adverse events

Risk of symptomatic rash with hepatic toxicity is 9.8 times more common in women with CD4 > 250• Unknown whether risk is increased in

pregnant women, though cases have been reported

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ARVs that Should be Avoided in Pregnancy

Efavirenz May be teratogenic during 1st trimester (but not an indication for abortion)

Tenofovir Bone demineralization seen in animals, but benefits may outweigh risks

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PMTCT Regimens in Vietnam

Pregnant woman does not meet criteria to treat ARV for

her own

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PMTCT Regimen A: Mother

During pregnancy

• AZT 300mg bid from week 14 (or whenever diagnosed with HIV after week 14) until labor

During labor

• NVP 200mg + AZT 600mg + 3TC 150mg

• Then AZT 300mg + 3TC 150mg every 12 hours

Post-partum • AZT 300mg + 3TC 150mg every 12

hours for 7 days

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PMTCT Regimen A: Infant

A single dose of NVP 6 mg, immediately after birth

PLUS AZT 4mg/kg twice daily for 4 weeks

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PMTCT Regimen B: Mother

During pregnancy

• AZT 300mg + 3TC 150mg + LPV/r 400/100 twice daily

• From week 14 (or whenever diagnosed with HIV after week 14)

During labor • Continue triple ARV prophylaxis

Post-partum • Continue triple ARV prophylaxis until

one week after all exposure to breast milk has ended

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PMTCT Regimen B: Infant

AZT 4mg/kg twice daily for 4 weeks

Triple ART in PMTCT

Benefits: Lowers VL most

effectively in mother Reduces

transmission to < 2%

Decreases risk of viral resistance

Downsides: More expensive Higher pill burden More monitoring

required

Triple ARV treatment, if available, may be safely started any time after the first trimester

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Single-Dose Nevirapine at Delivery

Benefits Inexpensive Easy to implement Effective for

women who present late to care

Transmission rate reduced from 30% to 12%

Downsides Less effective than

other regimens Risk of NNRTI

resistance

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ARV Treatment in Pregnancy:

Some Scenarios

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Scenario 1

Nga has been taking ARVs for the past 6 months, and recently found out that she is pregnant.

What is the appropriate course of action in this scenario?

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Scenario 1: Action

First, review her ARV regimen, then use chart below to determine course:

If…. Then….

Patient is on EFV

• switch from Efavirenz to either Nevirapine or Lopinavir/ritonavir depending on CD4 count

• or continue EFV if in 2nd or 3rd trimester

Patient is on D4T/DDI

• switch to AZT/3TC

Hgb <7.5gm/dl

• TDF can be used in place of AZT

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Scenario 2

Trang is pregnant and HIV positive. She is eligible for ARVs, but has not yet started to take them.

What is the appropriate course of action in this scenario?

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Scenario 2: Action: Start ART

*Contraindications to NVP: CD4 > 250 cells/mm3, allergy to NVP, or history of NVP hepatotoxicity

Regimen CommentsPreferred first line

AZT + 3TC + NVP

Alternate regimen (1)

AZT + 3TC + EFV

If pregnant > 12 weeks and have contraindication to using NVP*

Alternate regimen (2)

AZT + 3TC + LPV/r

If pregnant < 12 weeks and have contraindication to using NVP* or > 12 weeks and have contraindication to using both NVP and EFV

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Scenario 3

Lan Anh is pregnant and HIV positive, but is not yet eligible for ARVs.

What is the appropriate course of action in this scenario?

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Scenario 3: Answer

Follow PMTCT protocol Prescribe ARVs for PMTCT

When Whattwice a day from week 14 until labor • AZT 300mg

at start of labor• NVP 200mg• AZT 600mg• 3TC 150mg

every 12 hours during labor • AZT 300mg• 3TC 150mg

every 12 hours for 7 days after delivery

• AZT 300mg• 3TC 150mg

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ARVs in Pregnancy: SummaryAntenatal Care

Assess HIV status

Mother needs ART

Mother does not need ART

AZT-3TC-NVP

AntepartumAZT from 14 weeks

IntrapartumAZT + 3TC

+ single dose NVP

Post partum AZT + 3TC for 7 days

For newborn

Single dose NVP

immediately

Followed by AZT 4 weeks

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Post partum continuum care (1)

Counseling for mother on: Family planning, safe sex: condom use Prevention of transmission for partner Options and practices to nourish her

child: breastfeeding, formula feeding Refer to continuum care and treatment

service

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Post partum continuum care (2)

To her child : Continue ARV regimen of MOH

guideline for PMTCT Refer the child to a suitable Ped OPC

to be followed up and treated continuously

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PCR results at Pasteur of HCMC

Source : Pasteur/ the South 2012

PCRNeg

Non PMTCT

Incomplete PMTCT

Complete PMTCT

PCR pos Total

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Key Points

Increasing number of women in Vietnam with HIV; more babies potentially exposed

MTCT can occur during: • Pregnancy• Labor and delivery • Breastfeeding

PMTCT strategies include:• HIV counseling and testing• Safe obstetrics • ART• Avoid breastfeeding• Post partum continuum care for pair of mother and

child

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Thank you

Questions?