Drug regimes for PMTCT and their use during pregnancy, intrapartum and

postpartum

Session Objective and content

• Objective: At the end of the session the participant should be able Describe the various drug regimes for PMTCT used during pregnancy, intrapartum and postpartum including short course ART

• Content• Use of antiretroviral drugs and pregnancy• Selection of short course ART regimens for PMTCT--

efficacy, toxicity, timing of initiation and cessation• Use of HAART for PMTCT

Antiretrovirals in PMTCT

• ARV therapy– Long-term use of antiretroviral drugs to manage

maternal HIV/AIDS and prevent PMTCT.• ARV prophylaxis

– Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant.

• Prophylaxis with nevirapine• Prophylaxis with AZT and nevirapine• Post exposure prophylaxis• Prophylaxis with HAART

Antiretrovirals and pregnancy• Nucleoside analogue drugs are known to induce mitochondrial

dysfunction, – highest for zalcitabine (ddC), didanosine (ddI), stavudine (d4T).– Present as neuropathy, myopathy, cardiomyopathy, pancreatitis,

• Efavirenz: birth defects with first trimester exposure (polydactaly, hydronephrosis; bilateral hip dislocation, umbilical hernia, urinary obstruction and neural tube defects)

• Hyperglycemia, and diabetic ketoacidosis reported with protease inhibitor.

• increased risk of preterm delivery for infants exposed to combination therapy with or without protease particularly started before pregnancy

• CP450 inhibition by Protease inhibitors can lead to ergortism with administration of ergometrine

Interaction of Nevirapine for PMCT and for ART

• NNRTI based HAART, often with NVP, is the first line treatment regimen in resource limited settings based on WHO recommendations– Based on cost, efficacy, full awareness of toxicities

• NVP alone or in combination with other ARVs is the most commonly used drug for PMTCT in developing countries

• Concerns – safety concerns higher risk of liver and cutaneous adverse events among

women with>250 CD4 count with chronic (non single dose) NVP– Resistance even with single dose

Prophylaxis with Nevirapine (NVP)

• A single 200 mg tablet for the mother to take at the onset of labour

• A single dose of oral suspension (standard dosage = 2 mg/kg) to be given to the infant immediately after birth or within 72 hours of delivery.

Prophylaxis with AZT and NVP

• Antenatal– Mother: AZT 300 mg twice daily starting at 28 weeks or as soon thereafter as

possible. AZT may be started as late as 36 weeks.• Intrapartum

– Mother: AZT 300 mg at onset of labour and every 3 hours until delivery and single-dose NVP 200 mg at onset of labour.

OR – AZT 600 mg at onset of labour AND single-dose NVP 200 mg at onset of

labour.• Postpartum

– Infant: NVP 2 mg/kg oral suspension immediately after birth or within 72 hours of delivery and AZT 4 mg/kg twice a day for 7 days.

OR – NVP 2 mg/kg oral suspension immediately after birth or within

72 hours of delivery.

Post exposure prophylaxis

Regimen Infant TX and efficacy

Malawi Forgarty NVP statvs NVP stat + 7 day AZT

22%39% difference

14%

South Africa (secure future)

NVP statVsAZT 6 weeks

13.4%Vs 17% difference NS16.2%

HAART for PMTCT

• Avoid NVP• Avoid EFV unless in late pregnancy• Defer in 1st trimester• Monitor as with HAART treatment• Most experience with

– AZT/3TC/Kaletra– AZT/3TC/NFV

PMTCT plusThe implementation of strategies to provide

Treatment, care and support of women

infected with HIV, their infants and their

families.

PMTCT-Plus StrategiesChild

– Monitoring the growth and development of the HIV-exposed child including immunisations

– Prevention and treatment of opportunistic infections– Diagnosis of HIV

Mother and partner– Nutritional counseling– Psychosocial support– Support for implementation of safer infant-feeding practices– Counselling in family planning

Family– Assessment and initiation of ARV therapy– Linkage to related community service organisations and agencies

to promote continuity of care