Hiv in Pregnant Women

8/3/2019 Hiv in Pregnant Women

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HIV is a complex chronic medicalcondition which, if untreated, is

associated with high morbidity andmortality.


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Infectious particlesconsisting of an RNAgenome packaged in aprotein capsid,

surrounded by a lipidenvelope.

This lipid envelopecontains polypeptidechains including receptorbinding proteins (link tothe membrane receptorsof the host cell, initiatingthe process of infection)
http://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.php


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RNA genome

cDNA

Host cell DNA

Reverse transcriptase:causes synthesis of acomplementary DNAmolecule using virus

RNA as a template.


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RNA genome

cDNA

Host cell DNA

The cDNA producedfrom the RNA templatecontains the virally

derived geneticinstructions and allowsinfection of the host cellto proceed.


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HIV preferentially targets lymphocytesexpressing CD4 molecules (CD4

lymphocytes), causing progressiveimmunosuppression.

When CD4 lymphocytes fall below acritical level (< 500 cells/mm3 ), infectedindividuals become more susceptible toopportunistic infections andmalignancies.


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Sexualintercourse

Injecting druguse

Transfusion ofblood

From motherto child(pregnancy,

breastfeeding)


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Normal >500 /mm3

CD4 < 200/mm3, diagnosed AIDSCD4 count

can detect to between 10 and 40 copies/ml.

50 copies/ml is the cut-off point used in studiesof mother-to-child transmission published inrecent years

Viral load

ESR

LFT

Tests for opportunistic infectionsBlood count


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when theirCD4 counts go below 500

cells/mm3 or if they develop certainother infections.


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For prevention of mother-to-childtransmission (therapy usually

discontinued at, or soon after, delivery)and

For treatment of the mother to preventmaternal disease progression (therapycontinued indefinitely after delivery).


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All women who are HIV positive shouldbe advised to take anti-retroviral therapy

during pregnancy and at delivery

The decision to treat and the choice of

treatment must take into account bothmaternal and foetal considerations


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H Highly

A

Active

A Anti

R Retroviral

T Therapy


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Any combination of ARVs, when used incombination is able to suppress HIV

replication to a degree that can achieve a

plasma viral load below 50 copies/ml (below

level of detection).


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2 Nucleoside RT inhibitor (NRTI)

+ 1 Protease inhibitor / NNRTI.

(AZT + ddI) or (ddI + d4T) or (AZT + 3TC) or(d4T + 3TC)

+ Indinavir(PI), or Nelfinavir (PI) or Efavirenz

(NNRTI).


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MOA

Act as competitiveinhibitors of reverse

transcriptase. Compete with

nucleosidetriphosphates for

access to reversetranscriptase.

Abacavir

Didanosine

Emtricitabine

Lamivudine

Stavudine

Zidovudine (first)

Zalcitabine Tenofovir


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MOA

NNRTIs interfere withreverse transcription

by directly binding tothe enzyme andretarding its function.

Efavirenz

Nevirapine

Delavirdine


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MOA PIs are substrate analogues

for the HIV aspartylprotease enzyme, which isinvolved in the processing

of viral proteins. Once bound to the

enzyme active site theenzyme is blocked fromfurther activity. This inhibitsthe viral maturationprocess resulting in lack offunctional virionformation.

These drugs are synergisticwith reverse transcriptaseinhibitors and are typicallyused in second line HAART

treatment

Amprenavir Atazanavir Fosamprenavir (prodrug of

amprenavir) Indinavir Lopinavir Nelfinavir Ritonavir Saquinavir Tipranavir


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NRTIs

Lactic acidosis

Myelotoxicity Peripheral

neuropathy

Stomatitis

NNRTIs

Rash 5%

Steven-JohnsonSyndrome

Hepatotoxicity

PIsHyperglycaemia

HyperlipidaemiaLipodystrophy

syndrome


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Initiate HAARTAvoid teratogenic drugs

(efavirenz)in women ofchildbearing age.

Exclude pegnancybefore starting efavirenz

HIV-infectedwoman of

childbearingpotential butnot

pregnant,

hasindicationsfor initiating

ART


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Continue HAART

Avoid efavirenz in first trimesterAvoid drugs with known

adverse potential for mother(didanosine + stavudinelipodystrophy, lactic acidosis)

ART should not be stopped in1st trimester if treatment isneeded.

HIV-infectedwomanwho is

receiving

HAART andbecomespregnant


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Same as above

Use of zidovudine isrecommended

Nevirapine can be used as acomponent if benefit clearlyoutweighs the risk (due to risk

of hepatic toxicity)Exclude pegnancy before

starting efavirenz

HIV-infected

pregnantwoman

who is ARnave and

hasindications

for ART


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HAART is

recommended forprophylaxis of perinataltransmission

Consider delayingHAART until after 1sttrimester

HIV-infectedpregnant

woman whois AR naveand does

not requiretreatment

for her ownhealth


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Obtain full ART history and

evaluate the need for ARTPerform HIV drug resistance

testing prior to initiate ART

Initiate HAART based onresistance testing andhistory

HIV-infectedpregnant

woman whois AR

experiencedbut not

currentlyreceiving

ART


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Zidovudinegiven ascontinuous

infusion duringlabour.

HIV-infectedwomanwho hasreceived

no ARTprior tolabour


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Zidovudine for 6 weeks

started within 6 to 12hours after birth bycontinuous infusionover 1 hour.

Dose: 80 160 mg/m2

every 6 hours

Infant


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AZT + LMV + NVP

TDF + LMV + EFV*TDF + LMV + NVP

AZT + LMV + EFV*


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Nausea and vomiting

Any medication used for nausea and

vomiting must be assessed for drug-druginteraction with all HIV relatedmedications


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Hyperglycaemia

Pregnancy is a risk factor

If treated with PIs, may have even higherrisk of glucose intolerance.

Educate women taking PIs about

symptoms of hyperglycaemia andclosely monitor glucose levels.

Check glucose tolerance at 20 24weeks and 30 34 weeks


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Lactic acidosis

Reported when taking NRTI especiallydidanosine and stavudine.

These drugs should be avoided duringpregnancy

Clinical suspicion of lactic acidosis:

malaise, nausea or abdominaldiscomfort or pain.

Lactate levels, electrolytes and liverfunction should be monitored.


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Prolong survival

Decrease morbidity

Improve quality of life

Reduce burden to family and community

Reduce transmission


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Thank YouThank You

Do What you CanDo What you Can

with what you Havewith what you Have

Where you Are !Where you Are !

Theodore RooseveltTheodore Roosevelt

Hiv in Pregnant Women

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