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Interventions to Reduce Mother-to-Child Transmission
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Interventions to Reduce Mother-to-Child Transmission
• HIV testing in pregnancy
• Antenatal care
• Antiretroviral agents
• Obstetric interventions
• Avoid amniotomy
• Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood sampling
• Restrict episiotomy
• Elective cesarean section
• Remember infection prevention practices
• Newborn feeding: Breastmilk vs. formula
Prevention strategies for vertical transmission include decreasing maternal viral load, decreasing maternal-fetal transfusion and fetal exposure to maternal secretions, and avoidance of breast feeding when possible.
These are:
• Termination of pregnancy
• Behavioural interventions
- Reduction in the frequency of unprotected sexual intercourse during pregnancy
- Reduction in the number of sexual partners during pregnancy
- Lifestyle changes, including avoidance of drug use and smoking in pregnancy
• Therapeutic interventions
- Antiretroviral therapy: zidovudine alone or combination, long- or short-course
- Vitamin A and other micronutrients
- Immunotherapy
- Treatment of STD
• Obstetric interventions
- Avoidance of invasive tests
- Birth canal cleansing
- Caesarean section delivery
• Modification of infant feeding practice
- Avoidance of breastfeeding
- Early cessation of breastfeeding
In untreated patients, the average time between initial infection and the development of AIDS is 10 years.
Management of pregnancy with HIV
HIV testing should be offered to all pregnant women as part of routine prenatal care. All women living with HIV who are planning a pregnancy or who become pregnant should have their individual situations discussed with experts in the area, with referral to both HIV treatment programs and obstetrical care providers, and an overall plan should be made for their pregnancy care. The care of the HIV-infected obstetric patient parallels that of the nonpregnant HIV-infected patient and includes monitoring of immune status, prophylaxis as indicated for opportunistic infections, and testing for other sexually transmitted diseases. All women living with HIV who are contemplating pregnancy should be receiving antiretroviral therapy (ART), and have a plasma viral load below the limit of detection prior to conception.
Health care providers should watch for symptoms of AIDS and pregnancy complications of HIV infection. HIV medicines, given to women with HIV during pregnancy and childbirth and to their babies after birth, reduce the risk of mother-to-child transmission of HIV. It is proved, that with the consistent use of combination antiretroviral therapy and abstinence from breastfeeding, the risk of perinatal transmission is < 1%.
Antenatal Care
• Most HIV-infected women will be asymptomatic
• Watch for signs/symptoms of AIDS and pregnancy-related complications
• Unless complication develops, no need to increase number of visits
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• Treat STDs and other coinfections
• Counsel against unprotected intercourse
• Avoid invasive procedures and external cephalic version
• Give antiretroviral agents, if available
• Counsel about nutrition
Antiretroviral therapy
In addition to the standard antenatal assessments for all pregnant women, the initial evaluation of women, living with HIV, should include assessment of HIV disease status, and recommendations for HIV-related medical care (plans to initiate, continue, or modify antiretroviral therapy ). This initial assessment should include the following:
• Review of prior HIV-related illnesses and past CD4 T lymphocyte (CD4) cell counts and plasma HIV RNA levels;
• Current CD4 cell count;
• Current plasma HIV RNA level;
• Assessment of the need for prophylaxis against opportunistic infections such as Pneumocystis jirovecii pneumonia and Mycobacterium avium complex);
• Screening for hepatitis A virus (HAV), hepatitis C virus, and tuberculosis in addition to standard screening for hepatitis B virus (HBV) infection;
• Screening for and treatment of sexually transmitted infections such as syphilis, Chlamydia trachomatis and Neisseria gonorrhea and trichomonas,
• Complete blood cell count and renal and liver function testing;
• History of prior and current antiretroviral (ARV) drug use, including prior ARV use for prevention of perinatal transmission or treatment of HIV and history of adherence problems;
• Results of prior and current ARV drug-resistance studies;
• History of adverse effects or toxicities from prior ARV regimens;
• Assessment of supportive care needs (e. g., mental health services, substance abuse treatment, smoking cessation), as well as support to help ensure lifelong antiretroviral therapy (ART);
• Intimate partner violence-related screening and supportive care needs;
• Referral of sexual partner(s) for HIV testing and ARV treatment or prophylaxis; and
• Referral of children for HIV testing
Antiretroviral therapy (ART) during pregnancy is necessary for all patients living with HIV, should focus on the reduction of perinatal transmission and the treatment of maternal human immunodeficiency virus (HIV) disease. For prevention of perinatal transmission of HIV, ART should be administered at all time points, including antepartum and intrapartum to the woman as well as postnatally to the neonate. ART should be initiated as early in pregnancy as possible, to prevent perinatal transmission regardless of plasma HIV RNA copy number or CD4 T lymphocyte count. Maintenance of a viral load below the limit of detection throughout pregnancy and lifetime of the individual living with HIV is recommended.
l Zidovudine (ZDV) long course:
Zidovudine given orally after 14 weeks of pregnancy, intravenously during labour and for six weeks to the neonate in a nonbreastfed population has been shown to reduce mother-to-child transmission of HIV-1 significantly.
Pediatric AIDS Clinical Trials Group (PACTG) 076 Zidovudine (ZDV) Regimen has become the standard of care during pregnancy in many developed countries, with a concomitant decrease in reported transmission rates. (Table 29. )
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