Prevention of maternal-child HIV transmission

http://web.a.ebscohost.com/dynamed/detail?sid=af9b2191-95eb-47d0-b987-
2d561ef26da3%40sessionmgr4001&vid=3&hid=4206&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNj
b3BlPXNpdGU%3d#db=dme&AN=116861


Prevention of maternal-child HIV transmission in resource-poor countries
HIV infection (list of topics)
Overview:
triple antiretroviral therapy (ART) regimens appear more effective than single or dual
agents (and short-course maternal regimens) for reducing mother-to-child HIV transmission
(level 2 [mid-level] evidence)
in United States
o combined antepartum, intrapartum, and infant antiretroviral prophylaxis is
recommended to reduce perinatal HIV transmission (DHHS Grade A, Level I)
o combination antepartum antiretroviral drug therapy with at least 3 drugs recommended
for all pregnant women with HIV infection (DHHS Grade A, Level I)
consider delaying antiretroviral prophylaxis until after first trimester (to reduce
possible fetal effects of exposure) in women with high CD4 count and low HIV RNA
levels or with nausea and vomiting, although earlier initiation may reduce perinatal
transmission (DHHS Grade A, Level III)
avoid starting efavirenz in first trimester (DHHS Grade A, Level III), however can be
continued if in established regimen with viral replication suppressed
avoid combinations of stavudine plus didanosine throughout pregnancy (DHHS
Grade A, Level II)
generally continue preexisting regimen if effectively suppressing viral replication
before pregnancy (DHHS Grade A, Level III)
if starting a new regimen, preferred regimen is combination of
zidovudine (ZDV) 300 mg twice daily or 200 mg 3 times daily
lamivudine (3TC) 150 mg twice daily or 300 mg once daily
nevirapine (NVP) 200 mg once daily for 14 days, then 200 mg twice daily
do not start NVP in women with CD4 count > 250 cells/mcL (DHHS Grade A,
Level II) but may continue NVP if already in use (DHHS Grade A, Level II)
alternatives to NVP are
efavirenz (EFV) 600 mg once daily, but do not use in first trimester
(DHHS Grade A, Level III)
lopinavir/ritonavir (LPV/r) 400 mg/100 mg twice daily, but some experts
recommend increasing dose in second and third trimesters to 600
mg/150 mg twice daily (DHHS Grade A, Level II)
ritonavir-boosted atazanavir (ATV/r) 300 mg/100 mg once daily, but
some experts recommend increasing dose in second and third trimesters
to 400 mg/100 mg
drug resistance testing recommended before starting treatment or prophylaxis if HIV
RNA levels > 500-1,000 copies/mL (DHHS Grade A, Level III), or suboptimal viral
suppression (DHHS Grade A, Level II)
if nonnucleoside reverse transcriptase inhibitor (NNRTI) (such as NVP or EFV) is
stopped, give nucleoside reverse transcriptase inhibitors (NRTIs) for at least 7 days
after NNRTI is stopped to reduce risk for drug resistance
o intrapartum care includes
intrapartum zidovudine (2 mg/kg IV over 1 hour at onset of labor [or 3 hours before
scheduled cesarean delivery] then 1 mg/kg/hour IV until delivery) recommended for
all pregnant women with HIV infection, regardless of their antepartum regimen
(DHHS Grade A, Level I)
continue antepartum combination antiretroviral therapy on schedule as much as
possible during labor or before cesarean delivery (DHHS Grade A, Level III) except
for switching zidovudine to IV for delivery (DHHS Grade A, Level III)
scheduled cesarean delivery at 38 weeks gestation recommended for women with
HIV RNA levels > 1,000 copies/mL near time of delivery (regardless of use of
antepartum antiretroviral drugs) (DHHS Grade A, Level II) and for women with
unknown HIV RNA levels near time of delivery (DHHS Grade A, Level II); elective
cesarean delivery associated with reduced risk of mother-to-child HIV-1 transmission
(level 2 [mid-level] evidence)
o infant antiretroviral prophylaxis
give zidovudine 4 mg/kg (reduced dosing if < 35 weeks gestation) orally twice daily
for 6 weeks from birth to all HIV-exposed neonates (DHHS Grade A, Level I)
for infants born to women with HIV infection who did not receive antepartum
antiretroviral drugs
give 3 doses of nevirapine in first week of life in addition to zidovudine for 6
weeks (DHHS Grade A, Level I)
addition of 3 doses of nevirapine in first week of life to 6-week zidovudine infant
prophylaxis may reduce HIV transmission rate in formula-fed infants (level 2
[mid-level] evidence)
o breastfeeding NOT recommended for women with HIV infection in United States (DHHS
Grade A, Level II), breastfeeding associated with increased rate of maternal-infant HIV
transmission compared to formula feeding (level 2 [mid-level] evidence)
in resource-poor countries
o triple ART recommended for pregnant women who need treatment for their own health
(WHO Strong recommendation, Moderate-quality evidence)
o for infant prophylaxis for mothers receiving ART, give nevirapine or zidovudine from
birth until age 4-6 weeks, whether infant is breastfeeding (WHO Strong
recommendation, Moderate-quality evidence) or receiving only replacement feeding
(WHO Conditional recommendation, Low-quality evidence)
o for prophylaxis for women who do not need treatment for their own health - 2 options
option A is maternal zidovudine prophylaxis during pregnancy, single-dose
nevirapine at onset of labor, zidovudine plus lamivudine during labor and delivery
and for 7 days postpartum, plus infant antiretroviral prophylaxis (nevirapine daily for
at least 4-6 weeks and until 1 week after last exposure to breast milk) (WHO Strong
recommendation, Low-quality evidence)
option B is maternal triple antiretroviral prophylaxis during pregnancy and
breastfeeding (WHO Strong recommendation, Moderate-quality evidence), plus
infant antiretroviral prophylaxis (nevirapine or zidovudine for 4-6 weeks) (WHO
Strong recommendation, Low-quality evidence)
option B may be more effective (level 2 [mid-level] evidence)
extended nevirapine prophylaxis for 6-14 weeks or for 6 months for infant may
reduce postnatal maternal-child transmission of HIV through breastfeeding (level 2
[mid-level] evidence)
o intrapartum single-dose nevirapine may increase treatment failure rates with NNRTI-
based ART starting within 6-12 months postpartum (level 2 [mid-level] evidence), can
be avoided by adding dual nucleoside reverse transcriptase inhibitor (NRTI) tail to
prophylaxis (level 3 [lacking direct] evidence) or starting non-NNRTI-based ART
o exclusive breastfeeding recommended for first 6 months of life (WHO Strong
recommendation, High-quality evidence), mothers with HIV infection should receive
lifelong ART or antiretroviral prophylaxis to reduce HIV transmission through
breastfeeding (WHO Strong recommendation, High-quality evidence)


Prevention of maternal-child HIV transmission in resource-poor
countries
http://web.a.ebscohost.com/dynamed/detail?sid=af9b2191-95eb-47d0-b987-
2d561ef26da3%40sessionmgr4001&vid=4&hid=4206&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXN
pdGU%3d#db=dme&AN=900603&anchor=WHOgrade

Updated 2014 Jul 01 04:30:00 PM: DHHS Panel on Treatment of HIV-Infected Pregnant
Women and Prevention of Perinatal Transmission guideline on use of antiretroviral drugs in
pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV
transmission in the United States (AIDSinfo 2014 Mar 28) view updateShow more updates

Related Summaries:
Prevention of maternal-child HIV transmission
HIV infection (list of topics)
Overview:
antiretroviral drugs for prevention of maternal-child HIV transmission
o for pregnant women who need treatment for their own health
start antiretroviral therapy (ART) for all pregnant women with confirmed HIV status
and either CD4 count 350 cells/mcL or WHO clinical stage 3 or 4 (WHO Strong
recommendation, Moderate-quality evidence)
start ART as soon as feasible regardless of gestational age - continue through
pregnancy, delivery, and thereafter (WHO Strong recommendation, Moderate-
quality evidence)
preferred first-line ART regimen is triple therapy including (WHO Strong
recommendation, Low-quality evidence)
zidovudine (AZT) 300 mg orally twice daily
lamivudine (3TC) 150 mg orally twice daily
a non-nucleoside reverse transcriptase inhibitor (NNRTI), either of
nevirapine (NVP) 200 mg orally twice daily
efavirenz (EFV) 600 mg once daily - avoid EFV in first trimester
triple antiretroviral therapy (ART) during pregnancy and postpartum for women who
are eligible for ART for their own health appears to reduce postnatal HIV
transmission to infants compared to short-course maternal treatment (level 2 [mid-
level] evidence)
o for infant prophylaxis for mothers receiving ART
give NVP or AZT from birth (within 6-12 hours or as soon as feasible after birth)
until aged 4-6 weeks, whether infant is breastfeeding (WHO Strong
recommendation, Moderate-quality evidence) or receiving only replacement feeding
(WHO Conditional recommendation, Low-quality evidence)
dose for infants with birth weight > 2,500 g is NVP 15 mg orally once daily or AZT
15 mg orally twice daily
o for women with HIV-2 infection alone
use AZT plus 3TC and either abacavir (ABC) or lopinavir and ritonavir (LPV/r)
(instead of NNRTI)
give infant AZT, not NVP
o for prophylaxis for women who do not need treatment for their own health
start antiretroviral prophylaxis as early as 14 weeks gestation, or as soon as possible
for women who present later in pregnancy, during labor, or after delivery (WHO
Strong recommendation, Low-quality evidence)
option A is maternal AZT prophylaxis plus infant antiretroviral prophylaxis
maternal antiretroviral prophylaxis using option A (WHO Strong
recommendation, Low-quality evidence)
antepartum AZT 300 mg orally twice daily
single-dose nevirapine (NVP) 200 mg orally at onset of labor
AZT 300 mg plus lamivudine (3TC) 150 mg twice daily during labor and
delivery and for 7 days postpartum
for infants (see below for Dosing)
if breastfeeding, give NVP daily from birth until 1 week after all exposure to
breast milk ends, minimum 4-6 weeks (WHO Strong recommendation,
Moderate-quality evidence)
if receiving only replacement feeding, give NVP daily, or single-dose NVP
plus twice-daily AZT, from birth until aged 4-6 weeks (WHO Conditional
recommendation, Low-quality evidence)
NVP not recommended for infants born to mothers infected solely with HIV-2
infection
related supporting evidence and considerations
in women with HIV infection presenting late in pregnancy, short course of
oral zidovudine (AZT) during late pregnancy and delivery reduces maternal-
child HIV transmission (level 1 [likely reliable] evidence)
addition of single-dose perinatal nevirapine (NVP) to maternal and neonatal
AZT further reduces perinatal HIV transmission (level 1 [likely reliable]
evidence)
option B is maternal triple antiretroviral prophylaxis plus infant
antiretroviral prophylaxis
maternal triple antiretroviral prophylaxis using option B (WHO Strong
recommendation, Moderate-quality evidence)
give mother triple antiretroviral prophylaxis daily during pregnancy
continue daily triple antiretroviral prophylaxis until delivery or, if
breastfeeding, until 1 week after all exposure to breast milk has ended
use any of following regimens
AZT 300 mg twice daily plus 3TC 150 mg twice daily with 1 of
lopinavir and ritonavir (LPV/r) 400 mg/100 mg twice daily
abacavir (ABC) 300 mg twice daily
efavirenz (EFV) 600 mg once daily - avoid EFV in first trimester
tenofovir (TDF) 300 mg once daily plus EFV 600 mg once daily (except in
first trimester) plus either of
3TC 150 mg twice daily
emtricitabine (FTC) 200 mg once daily
for infants (see below for Dosing)
if breastfeeding, give NVP once daily or AZT twice daily from birth until aged
4-6 weeks (WHO Strong recommendation, Low-quality evidence)
if receiving only replacement feeding, give NVP once daily or AZT twice daily
from birth until aged 4-6 weeks (WHO Conditional recommendation, Low-
quality evidence)
NVP not recommended for infants born to mothers infected solely with HIV-2
infection
option B may be more effective - triple antiretroviral prophylaxis (zidovudine,
lamivudine, lopinavir/ritonavir) during late pregnancy and breastfeeding associated
with reduced mortality and HIV transmission rates at 12 months compared to World
Health Organization (WHO) prophylaxis regimen option A (level 2 [mid-level]
evidence)
extended NVP prophylaxis for 6-14 weeks for infant may reduce postnatal maternal-
child transmission of HIV through breastfeeding (level 2 [mid-level] evidence)
for breastfeeding infants of mothers not receiving ART, extending NVP for 6
months instead of 6 weeks may further reduce risk of postnatal HIV transmission
(level 2 [mid-level] evidence)
o intrapartum single-dose NVP may increase treatment failure rates with NNRTI-based
ART starting within 6-12 months postpartum (level 2 [mid-level] evidence); can be
avoided by adding dual nucleoside reverse transcriptase inhibitor (NRTI) tail to
prophylaxis (level 3 [lacking direct] evidence) or starting non-NNRTI-based ART
for infant feeding in the context of HIV
o mothers known to have HIV infection should receive lifelong ART or antiretroviral
prophylaxis to reduce HIV transmission through breastfeeding (WHO Strong
recommendation, High-quality evidence)
o maternal triple ART appears to reduce postnatal HIV transmission in breastfeeding
infants (level 2 [mid-level] evidence)
o exclusive breastfeeding recommended for first 6 months of life (WHO Strong
recommendation, High-quality evidence)
breastfeeding associated with increased rate of maternal-infant HIV transmission
but lower infant mortality compared to formula feeding (level 2 [mid-level]
evidence)
among breastfed infants of mothers with HIV infection, exclusive breastfeeding
during first 6 months associated with reduced rates of mother-to-child HIV
transmission and mortality (level 2 [mid-level] evidence)
o introduce appropriate complementary foods after 6 months and continue to breastfeed
for first 12 months of life (WHO Strong recommendation, Low-quality evidence)
o when stopping breastfeeding
stop gradually within 1 month, and if receiving antiretroviral prophylaxis continue it
for 1 week after breastfeeding is fully stopped (WHO Strong recommendation, Low-
quality evidence)
early, abrupt weaning of breastfeeding does not appear to affect HIV-free survival
of infants with mothers with HIV infection in Zambia (level 2 [mid-level] evidence)