HIV in Children

PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV

Dr. Ira Shah
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Last Updated: 15th July 2015

Elective caesarean section (ECS)


Elective caesarean section has been found to decrease transplacental hemorrhage during labor, reduce the length of exposure of baby to vagino-cervical secretions and reduces chances of ascending infection of HIV transmission. Studies have found that among HIV-1 infected women not taking ARV during pregnancy, ECS was efficacious for prevention of mother to child transmission (MTCT) of HIV-1, and decreased transmission by approximately 50 percent as compared to other modes of delivery.

However, elective caesarean section is associated with post-partum morbidity in form of fever, urinary tract infection, endometritis and thromboembolism. Also it is more expensive and not universally available especially in resource limited settings. When ARV prophylaxis to mother and child are available and replacement feeding can be issued, the added advantage of ECS is not seen and vaginal delivery may be a safe and inexpensive option in this setting.

In industrialized countries, elective caesarean section at 38 weeks of gestation is recommended when viral load is not totally suppressed at the end of pregnancy (i.e. HIV viral load is >1000 copies/ml).

Antiretroviral Prophylaxis


The first trial PACTG-076 in 1994 demonstrated efficacy of antiretrovirals to decrease mother to child transmission of HIV. Subsequently many trials have demonstrated gradual reduction of the in-utero and intra-partum transmission rates with an increasing length and potency of drug combinations used during pregnancy and at delivery.

The 3 most commonly used regimes

are :

  • Zidovudine (AZT) monotherapy starting at the end of first trimester of pregnancy in the mother and for 4 weeks in the infant, with one maternal and infant perinatal single dose Nevirapine (NVP) plus AZT + Lamivudine (3TC) during labor and for 7 days post-partum was administered. (AZT+ 3TC for one week helps to reduce risk of NVP resistance in the mother and infant). With replacement feeds, this regime decreased transmission rate to < 2%.
  • In industrialized countries, HAART (Triple drug therapy) is used in pregnant women as prophylaxis. For women with higher CD4 counts, protease inhibitor based regimens are recommended. Efavirenz (EFV) is now recommended for use in women even in first trimester (animal studies had initially found teratogenic effects of EFV and hence it was not recommended initially in the first trimester
  • Now with maternal HAART taken throughout the pregnancy and even later on while breastfeeding, there is a greatly reduced HIV transmission rate of 2 percent. But there must be 100 percent adherence to taking the drugs correctly, otherwise there is a risk that the baby will become infected with HIV or resistant to the medication. This approach offers new hope for mothers with HIV infection who cannot safely feed their babies with replacement.


PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV
Dr. Ira Shah
Incharge Pediatric HIV and TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India Consultant in Pediatric Infectious Diseases, Nanavati Hospital, Mumbai, India.
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