Primary Care Approach To The Primary Care Approach To The HIV PatientHIV Patient

Tahseen J. Siddiqui, Tahseen J. Siddiqui, M.D., M.R.C.PM.D., M.R.C.PMedical Director, Medical Director,

Infectious Disease/HIV/STD Prevention & Care ProgramInfectious Disease/HIV/STD Prevention & Care ProgramJackson Park Hospital & Medical Center ChicagoJackson Park Hospital & Medical Center Chicago

HISTORY& EPIDEMIOLOGY OF HIV HISTORY& EPIDEMIOLOGY OF HIV

HIV-? a descendant of a Simian Immunodeficiency HIV-? a descendant of a Simian Immunodeficiency Virus (SIV), transferred iatrogenically (polio/small Virus (SIV), transferred iatrogenically (polio/small pox vacc)pox vacc)

1981- First case in the USA (KS > PCP)1981- First case in the USA (KS > PCP) Globally, ~40 million adults and 2.2 million children Globally, ~40 million adults and 2.2 million children

living with HIV living with HIV During 2004, some 4.9 million people became During 2004, some 4.9 million people became

infected with the HIV and 3.1 million died from AIDSinfected with the HIV and 3.1 million died from AIDS In the US ~ 421,873 persons living with HIV;~ In the US ~ 421,873 persons living with HIV;~

40,000 become infected each year, and 16,316 died of 40,000 become infected each year, and 16,316 died of AIDS (2005); ~25% unaware of their HIVAIDS (2005); ~25% unaware of their HIV

Reemergence of TB (MDR-late 1980s New York Reemergence of TB (MDR-late 1980s New York city), Syphilis ((2003) city), Syphilis ((2003)

Dr. Conant and Dr. Volberg discussing Kaposi's Sarcoma1981

EPIDEMIOLOGYEPIDEMIOLOGYGlobal Distribution of HIVGlobal Distribution of HIV

Officially, there are 1,710 people living with HIV in Pakistan today, a nation of over 140 million. However, given the taboo nature of the subject, few infected people disclose their status. Some experts estimate the true number of HIV-positive people to be closer to 80,000. Around 2.5 million people in India are living with HIV.

Increase In HIV CasesIncrease In HIV Cases

USA STATESUSA STATESGeographical Distribution of HIV/AIDS (2003)Geographical Distribution of HIV/AIDS (2003)

72% of all AIDS cases to date have been reported from just ten states

New YorkNew York - /66,311 - /66,311 CaliforniaCalifornia - /55,612 - /55,612FloridaFlorida 32,196 / 42,861 32,196 / 42,861TexasTexas 20,820 /29,958 20,820 /29,958New JerseyNew Jersey 15,192/ 16,969 15,192/ 16,969IllinoisIllinois - /14,241 - /14,241GeorgiaGeorgia - /13,963 - /13,963MarylandMaryland - /12,830 - /12,830North CarolinaNorth Carolina 11,118 /6,519 11,118 /6,519 Total 172,714 /393,375Total 172,714 /393,375

Racial & Gender DifferencesRacial & Gender Differences

HIV/AIDS Diagnoses among Adults and Adolescents, HIV/AIDS Diagnoses among Adults and Adolescents, by Transmission Category — 33 States, 2001–2004by Transmission Category — 33 States, 2001–2004

MSM61%IDU

16%

Heterosexual17%

MSM/IDU 5% Other 1%

Males(n ≈ 112,000)

Females(n ≈ 45,000)

Heterosexual76%

IDU21%

Other 3%

MMWR, Nov 18, 2005

Changing Faces of HIV/AIDSChanging Faces of HIV/AIDSNo Longer A Disease of Gay Men And Drug AbusersNo Longer A Disease of Gay Men And Drug Abusers

Modes Of TransmissionModes Of Transmission

A GUIDE TO THE CLINICAL CARE OF WOMEN WITH HIV

Epidemiology and Natural History of HIV Infection in Women

HIV TRANSMISSION HIV TRANSMISSION (Average, per episode, involving HIV-infected source (Average, per episode, involving HIV-infected source patientpatient))

Percutaneous (blood)Percutaneous (blood)11 0.3%0.3%

Mucocutaneous (blood)Mucocutaneous (blood)22 0.09%0.09%

Receptive anal intercourseReceptive anal intercourse33 1%1%

Insertive anal intercourseInsertive anal intercourse44 0.06%0.06%

Receptive vaginal intercourseReceptive vaginal intercourse55 0.1 – 0.2%0.1 – 0.2%

Insertive vaginal intercourseInsertive vaginal intercourse66 0.03 – 0.14%0.03 – 0.14%

Receptive oral (male)Receptive oral (male)77 0.06%0.06%

Female-female orogenitalFemale-female orogenital88 4 case reports4 case reports

IDU needle sharingIDU needle sharing99 0.67%0.67%

Vertical (no prophylaxis)Vertical (no prophylaxis)1010 24%24%

HCV 3% and HBV 30% risk by needle stick injury

You CANNOT get HIV from:You CANNOT get HIV from:

a toilet seat a toilet seat being coughed or sneezed on being coughed or sneezed on sharing eating utensils sharing eating utensils living with someone who is HIV living with someone who is HIV

positive positive sharing a bathroomsharing a bathroom tears, saliva, or sweattears, saliva, or sweat casual contactcasual contact Being exposed to vomitus, urine or Being exposed to vomitus, urine or

stoolstoolIn High Risk exposure, prophylaxis (2-3 drugs) is recommended. Must start <72 h and continue for 4 weeks

FACTORS FACILITATING FACTORS FACILITATING

TRANSMISSION & PROGRESSION OF HIVTRANSMISSION & PROGRESSION OF HIV

INFECTIOUSNESS OF THE HOSTINFECTIOUSNESS OF THE HOST VL>1000,000VL>1000,000

SUSCEPTIBILITY OF THE RECIPIENTSUSCEPTIBILITY OF THE RECIPIENT

11) Physical/Physiological Factors) Physical/Physiological FactorsInflammation or disruption of the genital or rectal mucosa Inflammation or disruption of the genital or rectal mucosa (sex during (sex during menstruationmenstruation, traumatic , traumatic sexual intercoursesexual intercourse, ulcerative and non-, ulcerative and non-ulcerative ulcerative STDs STDs and changes in the vaginal flora, as characterized by bacterial and changes in the vaginal flora, as characterized by bacterial vaginosis) and vaginosis) and lack of circumcisionlack of circumcision in heterosexual men,, may facilitate in heterosexual men,, may facilitate acquisition of HIV.acquisition of HIV.

2) 2) GeneticGenetic or Immunologic Factors or Immunologic Factors CCR5 (coreceptor with cd4) homozygotes are resistant to HIV infection and to CCR5 (coreceptor with cd4) homozygotes are resistant to HIV infection and to HLA Class 1 heterozygotes have slow progression .HLA Class 1 heterozygotes have slow progression .

Hivcycle.swf

HIV CycleHIV Cycle

HIV TimelineHIV TimelineUNTREATED NATURAL HISTORY UNTREATED NATURAL HISTORY

HIV HIV NATURAL HISTORY NATURAL HISTORY Based On CD4 Cell Count & Viral LoadBased On CD4 Cell Count & Viral Load

Primary HIV Primary HIV InfectionInfection (4-12 weeks post infx) (4-12 weeks post infx)Seroconversion Illness, Acute Retroviral Syndrome Seroconversion Illness, Acute Retroviral Syndrome

(‘Bad Flu’)(‘Bad Flu’)

44

52

55

57

59

74

86

0 10 20 30 40 50 60 70 80 90 100

adenopathy

pharyngitis

headache

rash

myalgias

lethargy

fever

21

40

45

10

15

24

0 20 40 60 80 100

transaminitis

leukopenia

thrombocytopenia

genital ulcers

oral ulcers

aseptic meningitis

Opportunistic InfectionsOpportunistic Infections

PRIMARY PRIMARY AIDS Defining IllnessesAIDS Defining Illnesses

•Candidiasis (Thush, esophageal, trachea, or lungs)•Cervical cancer (invasive)•Coccidioidomycosis, Cryptococcosis, Histoplasmosis (disseminated or extrapulmonary)•Cryptosporidiosis, Isosporiasis (> 1 month )•Cytomegalovirus disease (CMV) (other than liver, spleen or lymph nodes) •Encephalopathy (HIV-related)•Herpes simplex (>1 month or in an area other than the skin such as esophagus or lungs)•Kaposi's sarcoma (KS)•Lymphoma (Burkitt's, immunoblastic or primary brain )•Mycobacterium avium complex (MAC)•Pneumocystis jiroveci pneumonia (PCP)•Pneumonia (recurrent)•Progressive multifocal leukoencephalopathy (PML)•Salmonella septicemia (recurrent)•Toxoplasmosis of the brain•Tuberculosis•Wasting syndrome

Sources: Information prov

HIV Presents To DermatologistHIV Presents To Dermatologist

Kaposi's sarcoma

SEROCONVERSION ILLNESS

Herpes Simplex

Herpes Zoster (Shingles) Molluscum Contagiosum

Kaposi's sarcoma

Warts Oral 'Hairy' Leukoplakia

Oral Candidiasis 'Thrush'

onchomycosis

Bacillary angiomatosis

HIV Presents To DermatologistHIV Presents To Dermatologist

psoriasis

Seborrheic dermatitis

HSV

Crypto disseminated

HIV Presents To PulmonologistHIV Presents To Pulmonologist

PCP Military TB

Kaposi's sarcoma

HIV Presents To GastroenterologistHIV Presents To Gastroenterologist

Candida esophagitis (HSV) esophagitis

CMV Proctitis Primary gastric lymphoma Kaposi's sarcoma – GI lesions

HIV Presents To NephrologistHIV Presents To Nephrologist

HIV-Associated Nephropathy HIV-Associated Nephropathy HIVANHIVAN

Nephrotic syndrome Nephrotic syndrome (1) proteinuria, (2) azotemia, (3) normal-to-large kidneys (1) proteinuria, (2) azotemia, (3) normal-to-large kidneys

on ultrasonography images, (4) normal pressure, and (5) on ultrasonography images, (4) normal pressure, and (5) focal segmental glomerulosclerosis (FSGS) on renal biopsy focal segmental glomerulosclerosis (FSGS) on renal biopsy findings. findings.

Rapid progression to renal failure and end-stage renal Rapid progression to renal failure and end-stage renal disease (ESRD) disease (ESRD)

Male-to-female ratio of 10:1. Male-to-female ratio of 10:1. Mean age of persons is 33 years. Mean age of persons is 33 years. Third leading cause of ESRD among black persons aged Third leading cause of ESRD among black persons aged

20-64 years. 20-64 years. 50% are intravenous addicts 50% are intravenous addicts CD4 count in these patients is usually depressed below 200 CD4 count in these patients is usually depressed below 200

cells/cells/L, but HIVAN has been reported in patients with L, but HIVAN has been reported in patients with higher CD4 counts higher CD4 counts

Tx: HAART, ACE Inh, Steroids, cyclosporine, Dialysis, Tx: HAART, ACE Inh, Steroids, cyclosporine, Dialysis, TransplantTransplant

Collapsing form of focal segmental glomerulosclerosis

HIV Presents To NeurologistHIV Presents To Neurologist Peripheral neuropathyPeripheral neuropathy

the most frequent neurologic the most frequent neurologic disorder associated with disorder associated with HIV(occurs in over 30% of HIV(occurs in over 30% of individuals with AIDS. individuals with AIDS.

predominantly sensory predominantly sensory neuropathy (PSN) or distal neuropathy (PSN) or distal symmetric polyneuropathy symmetric polyneuropathy (DSPN), and medication-induced (DSPN), and medication-induced toxic neuropathy.(antiretroviral toxic neuropathy.(antiretroviral agents ddI and d4T ) agents ddI and d4T )

HIV Presents To NeurologistHIV Presents To Neurologist HIV-Associated HIV-Associated MyopathyMyopathy/ AZT / AZT

MyopathyMyopathy

Pain and weakness thighs and Pain and weakness thighs and shoulders shoulders

(CPK/EMG/NCVs) (CPK/EMG/NCVs)

PolyradiculitisPolyradiculitis : Rapidly evolving : Rapidly evolving weakness and numbness in legs weakness and numbness in legs (both proximally and distally), with (both proximally and distally), with bowel/bladder incontinence. bowel/bladder incontinence. EMG/NCV shows multilevel nerve EMG/NCV shows multilevel nerve root involvement. Spinal fluid root involvement. Spinal fluid helpful in determining etiology helpful in determining etiology (cytomegalovirus or herpes (cytomegalovirus or herpes simplex virus infections, simplex virus infections, lymphomatous infiltration). lymphomatous infiltration).

PML

AIDS DementiaPrimary CNS Lymphoma

CNS Toxo

Metabolic AbnormalitiesMetabolic Abnormalities

Changes in glucose and lipids occur early after the initiation of therapy and before the development of body shape changes.

HIV- HAART HIV- HAART VsVs HEART HEART

Metabolic AbnormalitiesMetabolic Abnormalities

HIV Infection Itself Increase the Risk of DiabetesHIV Infection Itself Increase the Risk of Diabetes

relative risk of 3.32

ManagementManagement

StandardStandard guidelines (diet,exercise, weight loss) but be realistic! guidelines (diet,exercise, weight loss) but be realistic! Treatment modifications (Avoid Treatment modifications (Avoid PIPI-based regimens in -based regimens in

DM/Dyslipidemia)DM/Dyslipidemia) Insulin-sensitizing agents (Insulin-sensitizing agents (metforminmetformin (lactic acid?) & (lactic acid?) &

glitazonesglitazones (liver dis?) (liver dis?) SStatins: tatins: pravastatinpravastatin preferred, preferred, atorvastatin atorvastatin with caution andwith caution and

Simvastatin/lovastatin Simvastatin/lovastatin are contraindicated because of drug are contraindicated because of drug interactions with interactions with PIsPIs..

Fibric acid analoguesFibric acid analogues (gemfibrozil/fenofibrate)(gemfibrozil/fenofibrate) preferred initial preferred initial therapy for TG >therapy for TG >500 mg/dl500 mg/dl..

HIV LipodystrophyHIV Lipodystrophy‘Fat Redistribution Syndrome’‘Fat Redistribution Syndrome’

Similar to a Similar to a CushingoidCushingoid patint patint

Overall incidence of lipodystrophy Overall incidence of lipodystrophy 17%17%

Median time on HAART ~18 months, Median time on HAART ~18 months, ((NRTI NRTI +/- +/- PI)PI)

Management of Lipodystrophy

No proven therapyNo proven therapy Modifications of the treatmentModifications of the treatment regimen may halt progress regimen may halt progress MetforminMetformin,, preferred in HIV patients with hyperglycemia/insulin preferred in HIV patients with hyperglycemia/insulin

resistance and dyslipidemia/lipodystrophy.resistance and dyslipidemia/lipodystrophy. Glitazones/growth hormoneGlitazones/growth hormone is currently under investigation is currently under investigation TestosteroneTestosterone replacement in hypogonadal HIV-1 infected men replacement in hypogonadal HIV-1 infected men

with central obesity decreases visceral fat and improves insulin with central obesity decreases visceral fat and improves insulin sensitivity.sensitivity.

Cosmetic Surgery: Cosmetic Surgery: Facial reconstruction, Liposuction / Facial reconstruction, Liposuction / lipectom lipectom

‘‘Sculptra’ Polylactic acid injectionsSculptra’ Polylactic acid injections

Metabolic Bone Metabolic Bone DiseaseDisease

Osteonecrosis:Osteonecrosis:Involving femoral/humeral Involving femoral/humeral heads, femoral condyles, heads, femoral condyles, proximal tibia and small bones proximal tibia and small bones in hand/wrist, can be caused by in hand/wrist, can be caused by HIV/HAARTHIV/HAART

Osteopenia & Osteoporosis:Osteopenia & Osteoporosis: Occurs Occurs in HIV seropositive in HIV seropositive patients with low CD4+ cells. Rates patients with low CD4+ cells. Rates of osteopenia (22%-50%) and of osteopenia (22%-50%) and osteoporosis (3%-21%) in osteoporosis (3%-21%) in PI-based PI-based HAARTHAART

Advancing HIV Prevention: Advancing HIV Prevention: New StrategiesNew Strategies

CDC HIV Testing Services for Inpatients and Outpatients in Acute-Care Hospital Settings, recommended routine HIV screening of all adults,

adolescents, and pregnant women in health care settings in the United States.

• Persons at high risk for HIV infection should be screened for HIV at least annually.

• Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.

• Prevention counseling should not be required with HIV diagnostic testing

• HIV Vaccines…. In clinical trials• Circumcision… reduces HIV transmission by ~60%• Save sex (condoms)• STDs… prompt treatment and prevention• HCW…avoid potential exposures/PEP• HIV is reportable to the Health Department

September 22, 2006

Rapid DiagnosisRapid DiagnosisFour FDA-approved Rapid HIV TestsFour FDA-approved Rapid HIV Tests

SensitivitySensitivity

(95% C.I.)(95% C.I.)

SpecificitySpecificity

(95% C.I.)(95% C.I.)

OraQuick AdvanceOraQuick Advance

- whole blood- whole blood

- oral fluid- oral fluid

- plasma- plasma

99.6 99.6 (98.5 - 99.9)(98.5 - 99.9)

99.3 99.3 (98.4 - 99.7)(98.4 - 99.7)

99.6 99.6 (98.5 - 99.9)(98.5 - 99.9)

100 100 (99.7-100)(99.7-100)

99.8 99.8 (99.6 – 99.9)(99.6 – 99.9)

99.9 99.9 (99.6 – 99.9)(99.6 – 99.9)

Uni-Gold RecombigenUni-Gold Recombigen - whole blood- whole blood

- serum/plasma- serum/plasma

100 100 (99.5 – 100) (99.5 – 100)

100 100 (99.5 – 100)(99.5 – 100)

99.7 99.7 (99.0 – 100)(99.0 – 100)

99.8 99.8 (99.3 – 100)(99.3 – 100)

SensitivitySensitivity

(95% C.I.)(95% C.I.)

SpecificitySpecificity

(95% C.I.)(95% C.I.)

Reveal Reveal G2G2 - serum- serum

- plasma- plasma

99.8 99.8 (99.2 – 100)(99.2 – 100)

99.8 99.8 (99.0 – 100)(99.0 – 100)

99.1 99.1 (98.8 – 99.4)(98.8 – 99.4)

98.6 98.6 (98.4 – 98.8)(98.4 – 98.8)

MultispotMultispot -- serum/plasma serum/plasma

- HIV-2- HIV-2

100 (99.9 – 100)100 (99.9 – 100)

100 (99.7 – 100)100 (99.7 – 100)

99.9 (99.8 – 100)99.9 (99.8 – 100)

Results are available in 10-20 min

HIV- Diagnostic TestsHIV- Diagnostic Tests

Confirmatory test essential (Confirmatory test essential (ELISAELISA)) For For Western blotWestern blot::

Venipuncture for whole bloodVenipuncture for whole blood Oral fluid specimenOral fluid specimen

Follow-up testing of persons with Follow-up testing of persons with negative or indeterminate Western blot negative or indeterminate Western blot results after 4 weeksresults after 4 weeks

Microplate ELISA: coloured wells indicate reactivity

Interpretation of Western blot results for HIV antibody

Treatment With HAART Treatment With HAART (Highly Active Antiretroviral Therapy)(Highly Active Antiretroviral Therapy)

*The pre-HAART era *The pre-HAART era (1994-1995)(1994-1995)

*Early-HAART *Early-HAART (1996-1997)(1996-1997)

*Late-HAART *Late-HAART (1998 onwards)(1998 onwards)

Incidence of AIDS was about 50% Incidence of AIDS was about 50% lower in late-HAART when lower in late-HAART when compared with early-HAART. The compared with early-HAART. The incidence of death also decreased incidence of death also decreased significantlysignificantly

Median survival on HAART is now Median survival on HAART is now ~ 25 years~ 25 years

‘‘COSTS’ Of HAARTCOSTS’ Of HAART

*Price Tag

*Side Effects

*Resistance

Globally, more than 90 percent of HIV-positive patients do not have access to HAARTGlobally, more than 90 percent of HIV-positive patients do not have access to HAART

When to Start HAARTWhen to Start HAARTChronic InfectionChronic Infection

Clinical Clinical CategoryCategory

CD4CD4++ T Cell T Cell CountCount

Plasma HIV Plasma HIV RNARNA

RecommendationRecommendation

Symptomatic Symptomatic (AIDS, severe (AIDS, severe symptoms)symptoms)

Any valueAny value Any valueAny value TreatTreat

Asymptomatic, Asymptomatic, AIDSAIDS

<200 cells/µL<200 cells/µL Any valueAny value TreatTreat

AsymptomaticAsymptomatic >200 cells/µL >200 cells/µL but <350 but <350 cells/µLcells/µL

Any valueAny value Treatment should be Treatment should be offered, with consideration offered, with consideration of pros and consof pros and cons

When to Start HAARTWhen to Start HAARTChronic InfectionChronic Infection

Clinical Clinical CategoryCategory

CD4CD4++ T Cell T Cell CountCount

Plasma HIV Plasma HIV RNARNA

RecommendationRecommendation

AsymptomaticAsymptomatic >350 cells/µL>350 cells/µL >100,000 >100,000 copies/mL copies/mL

Most clinicians recommend Most clinicians recommend deferring therapy; some will deferring therapy; some will treattreat

AsymptomaticAsymptomatic CD4CD4++ T cells T cells >350 cells/µL>350 cells/µL

<100,000 <100,000 copies/mL copies/mL

Defer therapyDefer therapy

Pre-Treatment EvaluationPre-Treatment Evaluation

Establish Establish readinessreadiness to start therapy (physical/psych/drug rehab) to start therapy (physical/psych/drug rehab) Ensure Ensure Adherence & complianceAdherence & compliance Provide Provide educationeducation on medication dosing/transmission on medication dosing/transmission Anticipate and treat side effects Anticipate and treat side effects Social Social supportsupport/ Focus groups/ Focus groups SimplifySimplify regimens, dosing, and food requirements regimens, dosing, and food requirements Comprehensive careComprehensive care.Utilize team approach with nurses, .Utilize team approach with nurses,

pharmacists, and peer counselors pharmacists, and peer counselors Provide Provide confidentialityconfidentiality and and respectrespect

BASELINE EVALUATION

Confirm HIV (ELISA and Western blot)

CD4 count/Viral load (2-8 w after initiating therapy then after every 3-4 months)2-8 w after initiating therapy then after every 3-4 months)

CMP: including liver and renal function

CBC/Diff

Lipid profile: total cholesterol, HDL, LDL, triglycerides

Serologies: RPR, toxoplasma IgG, hepatitis A, hepatitis B, hepatitis C CMV, varicella-zoster virus (if no history of chickenpox or shingles),

PPD (annually)

G6PD (in selected patients)

Pap smear/Anal Pap/STD screening

Vaccination; (annual Influenza/ Pneumovax 3-5 y/ HBV series/ HPV (revaccinate once CD4>200)

In addition: • Resistance testing (Genotype/Phenotype) in chronically infected patients prior to initiating

antiretroviral therapy • Chest x-ray if clinically indicated.

Initial Treatment: Initial Treatment: Preferred RegimensPreferred Regimens

**Avoid inAvoid in pregnant women and women with high pregnancy potential. pregnant women and women with high pregnancy potential.

Efavirenz* Efavirenz* (Sustiva) (Sustiva) plusplus

+ (lamivudine or emtricitabine) + (lamivudine or emtricitabine)

+ (zidovudine or tenofovir)+ (zidovudine or tenofovir)

(Combivir/Truvada)(Combivir/Truvada)

2-52-5

Lopinavir/ritonavir Lopinavir/ritonavir (Kaletra)(Kaletra) plusplus

+ (lamivudine or emtricitabine) + (lamivudine or emtricitabine)

+ zidovudine+ zidovudine

8-108-10

NNRTI-Based

PI-Based

pills/day

HIV And PregnancyHIV And Pregnancy Without HAART during pregnancy, mother-to-child

transmission ~25% (Highest during the intrapartum period)

Rapid TestingRapid Testing at labor/delivery to late-presenting at labor/delivery to late-presenting womenwomen

ProphylaxisProphylaxis should be initiated as soon as possible should be initiated as soon as possible after a positive rapid HIV testafter a positive rapid HIV test

Cesarean SectionCesarean Section ( (VL>1000 copies/mL) Women with HIV should not breastfeed

3-part ZDV Regimen3-part ZDV Regimen Antepartum

100 mg ZDV po 5x day, started at 14-34 weeks gestation Intrapartum

During labor, 1-hour initial dose 2 mg/kg IV followed by continuous infusion of 1 mg/kg/hr until delivery

Postpartum/infant regimen2 mg/kg po q 6 hr for 6 weeks, start 8-12 hours after birth

Risk reduction from 22.6% to 7.6%)

Today, risk of perinatal transmission can be <2% with effective antiretroviral therapy (HAART) elective cesarean section (C/S) as appropriate formula feeding

ThanksThanks