Yes Alabama, We Still Have Perinatal HIV Transmission

3 Cases In The Past Year2011

Goals and objectives

• How to test all pregnant women for HIV .• How to preventing HIV transmission from

mother to child• How to treat HIV exposed infants

DIAGNOSING HIV•Adults and children older than 2 years old•HIV ELISA -repeatedly reactive•HIV WESTERN BLOT-Positive•Positive tests tells that one has antibodies to HIV Virus

ELISA•ELISA-Tests for antibodies•If the specimen does not react to the EIA [ENZYME IMMUNOASSAY] it is reported as negative•If it is reactive- a second EIA is done on the same sample-if it is also reactive –it is reported as repeatedly reactive

CONFIRMATORY TEST WESTERN BLOT•WESTERN BLOT TEST is the confirmatory test•Western blot looks for the HIV Virus Antigen Bands•The test must have 2 of the HIV Virus Bands to be reactive

REACTIVE TESTREPEATEDLY REACTIVE ELISA

POSITIVE WESTERN BLOT

2 OR MORE BANDS ARE PRESENT

INDETERMINATE• REPEATERLY REACTIVE ELISA•ONLY A SINGLE BAND BY WESTERN BLOT

CAUSES OF INDETERMINATE WESTERN BLOT•NO SEROCONVERSION•Advanced HIV with <Titers of p24•HIV2—Common in WEST AFRICA•HIV subtype O , NON-CLADE B•Autoibodies due to collagen-vascular or auto-immune disease•Cross-reactive alloantibodies from pregnancy,blood transfusions or organ transplants•Receipt of HIV Vaccine•Child losing it mother HIV antibodies

HIV TESTING•HIV Virus causes lymphocyte count to go down

•CD4 [T lymphocyte] is the main target of the HIV virus•HIV testing looks for immunsuppression•HIV causes antibodies to be created by attaching antigens to CD4 cells•HVI RNA PCR and HIV DNA PCR measure the amount of virus that is present in the blood

CHILDREN LESS THAN 2 YEARS OLD•Children born to HIV Positive mothers will test positive to their mother’s antibodies[at time of birth]•They are HIV exposed but not always infected with the HIV Virus Usually the antibodies are gone by age 18 months

HIV Polymerase Chain Reaction

• HIV DNA PCR• HIV RNA PCR• Measures the amount of Viral Replication• HIV DNA PCR the amount of viral replication

present or not• HIV RNA PCR measure to amount of viral

replication

Natural History of HIV Infection

• Viral Transmission• Primary HIV Infection: Acute retroviral

Syndrome [2-4 weeks]• Seroconversion [95.5% within 6 months]• Early asymptomatic HIV infection [5-8 years]• Early symptomatic HIV Infection

How Infants Become Infected

• IN Utero before Delivery• At birth during Delivery• Infected after birth by Breast Feeding• Studies Demonstrate that Children diagnosed

less than 1 year and an AIDS diagnosis do not survive as long as those who are diagnosis later

HIV Positive Mothers

• Opt-out HIV Testing, they will not know that they are HIV + if they are not tested

• Risk Assessment : Don’t use it to decide who test

• Offer HIV specialty Perinatal Care including Antiretrovirals

• Rapid Testing in Labor and Delivery if HIV status is not known or recent STD

How to Prevent Perinatal Transmission?

• 1. Prevent Women from Becoming HIV Infected!!

• 2. Offer All Pregnant Women at the Perinatal Medical Visits HIV Testing

• 3. Opt Out testing• 4. Educated Women to be Aware of HIV

Infection Risk• 5. Rapid HIV Testing if unknown at L&D

Goals of ARV Therapy

To prolong life and improve quality of life

To suppress HIV to below the limits of detection or as low as possible, for as long as possible

To preserve or restore immune function

RAPID TESTING

Oral quick=Rapid ELISA testing in 10 to 30 minutes

Oral Quick can be done on children as young as 13 years of age

Can be done by finger stick or oral swab Positive test needs to be confirmed

Case One

• Mother thought she was going thru Menopause.

• She had not had any menstrual periods in about 6 months.

• She goes to the GYN and found that not only was she pregnant she was also HIV positive.

• Start on HIV Antiretroviral at 32 weeks.

Case Two

• Mom got into OB early around 8 weeks. HIV OPT-OUT testing was negative.

• Around week 26 mom had STD and was treated

• At L&D, Mom had rapid HIV test which was positive.

• Mom delivered vaginally no AZT• Baby tested HIV Positive in the hospital

Case Three

• Mom lived in rural Alabama• No transportation to Obstetrical care• Mom goes into labor called ambulance and

delivered in the ambulance.• Mom tested positive for HIV at the Hospital

What do these Sentinel Cases have in common ?

• Lack of repeat HIV testing• Lack of education in the Medical

community• Lack of transportation• Lack of knowledge in the general

population

How to prevent further Cases

• Communication:• ADPH website on HIV and pregancy• Availability of HIV Information:

aidsifo.nih.gov/guild lines• Public awareness• Test all patients

Postpartum ManagementInfant Antiretroviral Prophylaxis

(Last updated:9/14/2011)

• Panel’s Recommendations:The 6-week neonatal component of the zidovudine chemoprophylaxis regimen is recommended for all HIV-exposed neonates to reduce perinatal transmission of HIV (AI).

• Zidovudine should be initiated as close to the time of birth as possible, preferably within 6–12 hours of delivery (AII).

• The 6-week zidovudine prophylaxis regimen is recommended at gestational age-appropriate doses; zidovudine should be dosed differently for premature infants less than 35 weeks than for infants at least 35 weeks of age (see Zidovudine Dosing and Table 8) (AII).

• In the United States, the use of antiretroviral (ARV) drugs other than zidovudine cannot be recommended in premature infants because of lack of dosing and safety data (BIII).

• The use of intrapartum/neonatal zidovudine is recommended regardless of maternal history of zidovudine resistance (BIII).

• Infants born to HIV-infected women who have not received antepartum ARV drugs

• should receive prophylaxis with a combination ARV drug regimen, begun as soon after birth as possible (AI).

• A randomized, controlled trial has shown that a 2 drug regimen of zidovudine given for 6 weeks combined with three doses of nevirapine in the first week of life (at birth, 48 hours later, and 96 hours after the second dose) is as effective as but less toxic than a 3 drug regimen of zidovudine, nelfinavir and lamivudine.

• The 2-drug regimen is preferred due to lower toxicity and because nelfinavir powder is no longer available in the United States. (see General Considerations for Choice of Infant Prophylaxis and Table 9) (AI).

• Table 8. Recommended Intrapartum Maternal and Neonatal Zidovudine Dosing for Prevention of Mother to Child Transmission of HIV

• Maternal Intrapartum Zidovudine (ZDV) Dosing Duration ZDV 2 mg per kg body weight intravenously over 1 hour, followed by continuous infusion of 1 mg per kg body weight per hour Onset of labor until delivery of infant

• Neonatal Zidovudine (ZDV) Dosing Duration • ZDV ≥35 weeks gestation:4 mg per kg body

weight per dose given orally twice daily, started as soon after birth as possible and preferably within 6-12 hours of delivery (or, if unable to tolerate oral agents, 1.5 mg per kg body weight per dose intravenously, beginning within 6–12 hours of delivery, then every 6 hours) Birth through 6 weeks

• ZDV <35 to ≥30 weeks gestation: • 2 mg per kg body weight per dose given orally

(or 1.5 mg per kg body weight per dose intravenously), started as soon after birth as possible and preferably within 6-12 hours of delivery, then every 12 hours, advanced to every 8 hours at age 2 weeks Birth through 6 weeks

• ZDV <30 weeks gestation: • 2 mg per kg body weight per dose given orally

(or 1.5 mg/kg/dose intravenously) started as soon after birth as possible and preferably within 6-12 hours of delivery, then every 12 hours, advanced to every 8 hours at 4 weeks of age Birth through 6 weeks

• General Considerations for Choice of Infant Prophylaxis

• Infants born to mothers who have received standard antepartum and intrapartum ARV prophylaxis and have undetectable viral loads are at very low risk of HIV transmission.

• However, the risk of transmission is increased when maternal viral load at delivery is high or maternal antepartum and/or intrapartum prophylaxis was not received. Most experts feel that the potential benefit of combining zidovudine infant prophylaxis with additional

• ARV drugs may exceed the risk of multiple drug exposure to infants born to: a. mothers who received antepartum and intrapartum ARV drugs but who had suboptimal viral suppression at delivery, particularly if delivery was vaginal; b. mothers who received only intrapartum ARV drugs; c. mothers who received no antepartum or intrapartum ARV drugs; and d. mothers with known ARV drug-resistant virus.

• All pregnant women who are HIV positive or who test HIV positive should be referred to

• an HIV specialist• An infant that is born to mother who has a

positive HIV test should be referred to an HIV specialist for children for evaluation

The Family Clinic• The Family Clinic/ UAB• @ Children’s Hospital of Alabama• Barbara Corley, CRNP• 205-939-9400• DR. Marsha Sturdevant• 205-939-9400 Department of OB/GYN• UAB School of Medicine• Maternal Fetal Medicine

Physician on call 205-934-mist• Gail Williams, OBCC, RN 205-934-

2170 MAO: Dr. Dill 1-334-280-3388( Montgomery) MAO Dothan: 334-836-0830

• St. George’s Clinic• Cooper Green Hospital• Jane Mobley, MD• 205-930-3287 1917 Clinic• UAB• Truus H Delfos-Broner CNM• 205-934-6684 Davis Clinic• 256-536-4700• Mary E Marr

• Family Clinic /UAB Montgomery• Lucia Robinson • 1 888 467 0765

• The National Perinatal HIV Hotline (1-888-448-8765)

• The National Perinatal HIV Hotline is a federally funded service providing free clinical consultation to providers caring for HIV-infected pregnant women and their infants.