Upload
will-cheah
View
223
Download
0
Embed Size (px)
Citation preview
8/3/2019 Hiv in Pregnant Women
1/33
8/3/2019 Hiv in Pregnant Women
2/33
HIV is a complex chronic medicalcondition which, if untreated, is
associated with high morbidity andmortality.
8/3/2019 Hiv in Pregnant Women
3/33
Infectious particlesconsisting of an RNAgenome packaged in aprotein capsid,
surrounded by a lipidenvelope.
This lipid envelopecontains polypeptidechains including receptorbinding proteins (link tothe membrane receptorsof the host cell, initiatingthe process of infection)
http://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.phphttp://www.accessexcellence.org/RC/VL/GG/retrovirus.php8/3/2019 Hiv in Pregnant Women
4/33
RNA genome
cDNA
Host cell DNA
Reverse transcriptase:causes synthesis of acomplementary DNAmolecule using virus
RNA as a template.
8/3/2019 Hiv in Pregnant Women
5/33
RNA genome
cDNA
Host cell DNA
The cDNA producedfrom the RNA templatecontains the virally
derived geneticinstructions and allowsinfection of the host cellto proceed.
8/3/2019 Hiv in Pregnant Women
6/33
HIV preferentially targets lymphocytesexpressing CD4 molecules (CD4
lymphocytes), causing progressiveimmunosuppression.
When CD4 lymphocytes fall below acritical level (< 500 cells/mm3 ), infectedindividuals become more susceptible toopportunistic infections andmalignancies.
8/3/2019 Hiv in Pregnant Women
7/33
Sexualintercourse
Injecting druguse
Transfusion ofblood
From motherto child(pregnancy,
breastfeeding)
8/3/2019 Hiv in Pregnant Women
8/33
Normal >500 /mm3
CD4 < 200/mm3, diagnosed AIDSCD4 count
can detect to between 10 and 40 copies/ml.
50 copies/ml is the cut-off point used in studiesof mother-to-child transmission published inrecent years
Viral load
ESR
LFT
Tests for opportunistic infectionsBlood count
8/3/2019 Hiv in Pregnant Women
9/33
when theirCD4 counts go below 500
cells/mm3 or if they develop certainother infections.
8/3/2019 Hiv in Pregnant Women
10/33
For prevention of mother-to-childtransmission (therapy usually
discontinued at, or soon after, delivery)and
For treatment of the mother to preventmaternal disease progression (therapycontinued indefinitely after delivery).
8/3/2019 Hiv in Pregnant Women
11/33
All women who are HIV positive shouldbe advised to take anti-retroviral therapy
during pregnancy and at delivery
The decision to treat and the choice of
treatment must take into account bothmaternal and foetal considerations
8/3/2019 Hiv in Pregnant Women
12/33
H Highly
A
Active
A Anti
R Retroviral
T Therapy
8/3/2019 Hiv in Pregnant Women
13/33
Any combination of ARVs, when used incombination is able to suppress HIV
replication to a degree that can achieve a
plasma viral load below 50 copies/ml (below
level of detection).
8/3/2019 Hiv in Pregnant Women
14/33
8/3/2019 Hiv in Pregnant Women
15/33
2 Nucleoside RT inhibitor (NRTI)
+ 1 Protease inhibitor / NNRTI.
(AZT + ddI) or (ddI + d4T) or (AZT + 3TC) or(d4T + 3TC)
+ Indinavir(PI), or Nelfinavir (PI) or Efavirenz
(NNRTI).
8/3/2019 Hiv in Pregnant Women
16/33
MOA
Act as competitiveinhibitors of reverse
transcriptase. Compete with
nucleosidetriphosphates for
access to reversetranscriptase.
Abacavir
Didanosine
Emtricitabine
Lamivudine
Stavudine
Zidovudine (first)
Zalcitabine Tenofovir
8/3/2019 Hiv in Pregnant Women
17/33
MOA
NNRTIs interfere withreverse transcription
by directly binding tothe enzyme andretarding its function.
Efavirenz
Nevirapine
Delavirdine
8/3/2019 Hiv in Pregnant Women
18/33
MOA PIs are substrate analogues
for the HIV aspartylprotease enzyme, which isinvolved in the processing
of viral proteins. Once bound to the
enzyme active site theenzyme is blocked fromfurther activity. This inhibitsthe viral maturationprocess resulting in lack offunctional virionformation.
These drugs are synergisticwith reverse transcriptaseinhibitors and are typicallyused in second line HAART
treatment
Amprenavir Atazanavir Fosamprenavir (prodrug of
amprenavir) Indinavir Lopinavir Nelfinavir Ritonavir Saquinavir Tipranavir
8/3/2019 Hiv in Pregnant Women
19/33
NRTIs
Lactic acidosis
Myelotoxicity Peripheral
neuropathy
Stomatitis
NNRTIs
Rash 5%
Steven-JohnsonSyndrome
Hepatotoxicity
PIsHyperglycaemia
HyperlipidaemiaLipodystrophy
syndrome
8/3/2019 Hiv in Pregnant Women
20/33
Initiate HAARTAvoid teratogenic drugs
(efavirenz)in women ofchildbearing age.
Exclude pegnancybefore starting efavirenz
HIV-infectedwoman of
childbearingpotential butnot
pregnant,
hasindicationsfor initiating
ART
8/3/2019 Hiv in Pregnant Women
21/33
Continue HAART
Avoid efavirenz in first trimesterAvoid drugs with known
adverse potential for mother(didanosine + stavudinelipodystrophy, lactic acidosis)
ART should not be stopped in1st trimester if treatment isneeded.
HIV-infectedwomanwho is
receiving
HAART andbecomespregnant
8/3/2019 Hiv in Pregnant Women
22/33
Same as above
Use of zidovudine isrecommended
Nevirapine can be used as acomponent if benefit clearlyoutweighs the risk (due to risk
of hepatic toxicity)Exclude pegnancy before
starting efavirenz
HIV-infected
pregnantwoman
who is ARnave and
hasindications
for ART
8/3/2019 Hiv in Pregnant Women
23/33
HAART is
recommended forprophylaxis of perinataltransmission
Consider delayingHAART until after 1sttrimester
HIV-infectedpregnant
woman whois AR naveand does
not requiretreatment
for her ownhealth
8/3/2019 Hiv in Pregnant Women
24/33
Obtain full ART history and
evaluate the need for ARTPerform HIV drug resistance
testing prior to initiate ART
Initiate HAART based onresistance testing andhistory
HIV-infectedpregnant
woman whois AR
experiencedbut not
currentlyreceiving
ART
8/3/2019 Hiv in Pregnant Women
25/33
Zidovudinegiven ascontinuous
infusion duringlabour.
HIV-infectedwomanwho hasreceived
no ARTprior tolabour
8/3/2019 Hiv in Pregnant Women
26/33
Zidovudine for 6 weeks
started within 6 to 12hours after birth bycontinuous infusionover 1 hour.
Dose: 80 160 mg/m2
every 6 hours
Infant
8/3/2019 Hiv in Pregnant Women
27/33
AZT + LMV + NVP
TDF + LMV + EFV*TDF + LMV + NVP
AZT + LMV + EFV*
8/3/2019 Hiv in Pregnant Women
28/33
Nausea and vomiting
Any medication used for nausea and
vomiting must be assessed for drug-druginteraction with all HIV relatedmedications
8/3/2019 Hiv in Pregnant Women
29/33
Hyperglycaemia
Pregnancy is a risk factor
If treated with PIs, may have even higherrisk of glucose intolerance.
Educate women taking PIs about
symptoms of hyperglycaemia andclosely monitor glucose levels.
Check glucose tolerance at 20 24weeks and 30 34 weeks
8/3/2019 Hiv in Pregnant Women
30/33
Lactic acidosis
Reported when taking NRTI especiallydidanosine and stavudine.
These drugs should be avoided duringpregnancy
Clinical suspicion of lactic acidosis:
malaise, nausea or abdominaldiscomfort or pain.
Lactate levels, electrolytes and liverfunction should be monitored.
8/3/2019 Hiv in Pregnant Women
31/33
Prolong survival
Decrease morbidity
Improve quality of life
Reduce burden to family and community
Reduce transmission
8/3/2019 Hiv in Pregnant Women
32/33
8/3/2019 Hiv in Pregnant Women
33/33
Thank YouThank You
Do What you CanDo What you Can
with what you Havewith what you Have
Where you Are !Where you Are !
Theodore RooseveltTheodore Roosevelt