Preventing Perinatal Transmission

1

Preventing Perinatal Transmission It Is a
Multi-factorial Issue
Gina M. Brown, MD
GM Brown, MD.Presented at IASUSA/RWCA Clinical
Conference, August 2004.
The International AIDS SocietyUSA
2
When does transmission occur?

• Antenatal 20
• Intrapartum 80
• Breastfeeding 14
• above baseline
• Lancet 340(8819)585

3
Antenatal transmission20

• Ob procedures?
• Amnio
• CVS
• PUBS
• Seroconversion during pregnancy
• High viral load
• Bleeding during pregnancy?
• AJOG 175(3pt1)661. 9/96

4
Labor and Delivery80

• Bleeding?
• Prolonged ROM
• Chorioamnionitis
• NSVD(?)
• High viral load

5
Breast feeding

• Overall OR 1.7 (1.0-2.9)
• Mastitis RR 3.9 (1.2-12.7)
• Breast Abscess RR 51.6 (4.7-571.0)
• Late transmissions (gt 2mos.)
• JID 183 (2)206 Jan 2001

6
Breast vs FormulaAnn NY Acad Sci 918136, Nov
2000
7
What contributes to transmission ?

• Illicit substance use
• All drugs 3 x risk
• Cocaine alone 2.98 x risk
• Hepatitis C
• 1.82 ? risk
• High viral load
• 4-5? risk at gt40-50K
• Landesman, NEJM 1996

8
Is it just PROM?J AIDS 22(4)379 Dec 1999

• Prospective f/u 172 women
• Overall transmission 23
• No placental inflammation 11.3
• Placental inflammation/ 25.5
• no immune suppression
• Immune suppression 37

9
ZDV effective when begun late Wade NEJM 11/98

• ZDV
• No treatment
• Antenatal
• Intrapartum
• Postpartum
• lt48 Hrs
• gt72 Hrs

• Transmission
• 26
• 6.1
• 5
• 10
• 18

10
Nevirapine issues

• Resistance after single dose prophylaxis
• Resistant strains in breast milk
• Side effects

11
How to treat

• Perinatal transmission
• ZDV or NVP monotherapy
• ZDV NVP
• ZDV 3TC (9)
• Treat for disease
• Three drugstwo different classes
• Include protease inhibitor
• Simple regimen

12
Medication during pregnancy

• Treat for HIV first
• No transmissions at viral load lt 1000 copies/ml
• 1 transmission for viral load lt1000 copies/ml
• HAART alone - without viral load effect
• Garcia, NEJM
• Ionnidis Retrovirus 2001

13
Ionnidis JID 183(4)539 2/2001

• 1201 women with VL lt 1000
• 1 perinatal transmission with treatment
• 9.8 perinatal transmission without treatment

14
What works?

• Cesarean section (VL gt 1000)
• Elective c/s-PNT decreased by 1/2
• Treatment for disease
• Keeping the viral load lt1000
• Avoid vacuum/forceps?
• Avoid fetal scalp sampling?
• Augmentation of labor with ROM?
• Nevirapine, 3TC