Management of HIV

Infection in pregnancy
SINTONG HALOMOAN SIANTURI 1061050120
MEDICAL STUDENT IN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY
FACULTY OF MEDICINE, CHRISTIAN UNIVERSITY OF INDONESIA, JAKARTA

PRELUDE

Human immunodeficiency virus (HIV) is a blood-borne

virus typically transmitted via sexual intercourse, shared
intravenous drug, and mother-to-child transmission
(MTCT), which can occur during the birth process or during
breastfeeding. HIV disease is caused by infection with HIV1 or HIV-2, which are retroviruses in the Retroviridae
family, Lentivirus genus.

PRELUDE

HIV infection has been a global epidemic around the world.

in the absence of intervention, the rates of HIV
transmission during pregnancy, labor or breastfeeding
vary from 15-45%.

Related to Hiv transmission from mother to child, 35%

during pregnancy, 65% during labor, and 7-20% during
breastfeeding.

Data from Indonesia Health ministry 2011 shows 21.103

pregnancy women who undergone HIV test 534 (2,5%) are
positive HIV infected.

PRELUDE

The use of ARV therapy in pregnancy and in labor approved

to be effective to reduce the HIV transmission by intrauterine
and intrapartum.

In high-income countries, MTCT rates as low as 12% have

been achieved with combination ART (cART) drug regimens
during pregnancy. In low-income and middle-income
countries where breastfeeding is common and access to
PMTCT services can be problematic, MTCT rates can be as
high as 2548%

PRELUDE

The purpose of this paper is to investigate the

pregnancy treatment and management of labour in
HIV infected women, to reduce the rate of HIV
transmission in pregnancy and to reduce the morbidity
and mortality rate of both mother and the fetus by
selecting the appropriate treatment and considering
the drugs safety and efficacy for the mother and the
fetus in all the treatment options available this day.

Treatment of HIV
Infection in
Pregnancy

Nonmedically

Management of
labour

Medically

Monotherapy
Triple NRTIs
NRTIs with a PI
NRTIs with a NNRTI

In pregnant women with mildly symptomatic HIV disease and no

prior treatment with antiretroviral drugs during the pregnancy, a
regimen consisting of zidovudine given ante partum and intra
partum to the mother and to the newborn for six weeks reduced
the risk of maternal-infant HIV transmission by approximately two
thirds.

 Patients

were randomly assigned to receive zidovudine

500 mg or placebo twice daily for 104 weeks, following a
250 mg four times daily dose regimen for the first 4
weeks.

Zidovudine

twice daily is effective in delaying progression

to symptomatic HIV disease in high-risk, asymptomatic
HIV-infected subjects.

Intrapartum transmission occurred in 24 infants in the

zidovudine-alone group, as compared with 11 infants in the
two-drug group (zidovudine+ nevirapine) and 12 in the
three-drug group (zidovudine +lamivudine+nelfinavir).
In Conclusions, neonates whose mothers did not receive
ART during pregnancy, prophylaxis with a two- or three-drug
ART regimen is superior to zidovudine alone for the
prevention of intrapartum HIV transmission.

 Birth

defects were observed in 16 of 623 live

births frm women exposed to EFV in first
trimester and in 6 of 184 live births from
women exposed to EFV in the second/third
trimester

The

prevalence of birth defects was not

significantly different between the first and
second/third trimester EFV exposure

Of 501 women, 405 delivered by VD, 74 delivered by NSCS and

22 by SCS.

Baseline antenatal CD4+ counts were lowest and HIV-1 RNA

levels highest in the NSCS group but HIV-1 RNA levels were
similar between groups at delivery.

Non-scheduled cesarean section was an independent risk factor

for postpartum mortality in HIV-1

The rate of decline in CD4+ cells and rate of increase in HIV-1

RNA did not differ between groups.

HIV-infected pregnant women took zidovudine, lamivudine, and either

nevirapine or nelfinavir from 3436 weeks gestation to 6 mo post
partum. Infants received single-dose nevirapine at birth.

HIV-transmission rates at birth, 6 weeks, and 6, 12, and 24 mo were

2.5%, 4.2%, 5.0%, 5.7%, and 7.0%

This trial shows that a maternal triple-antiretroviral regimen from late

pregnancy through 6 months of breastfeeding for PMTCT is safe and
feasible in a resource-limited setting

discussion

Trial study that has been conducted in Department of Obstetrics and

Gynecology and Womens Health, UMDNJ-New Jersey Medical School,
Newark, NJ by AIDS Clinical Trials Group got results that treatment
with zidovudine achieve decrease transmision rate 67,5% with better
drug adherence by lower drug administration 300 mg twice a aday or
200 mg three times a day.

Similar result has been shows by pediatrics AIDS clinical trial groups,
USA that zidovudine is a effective regimen in prevention mother to
child transmission.

discussion
Meanwhile,

randomized study that conducted by

Eunice Kennedy Shriver National Institute of Child
Health and Human Development at 17 sites at
brazil, south africa, and USA evaluated ARV regimen
on infant who mother just identified HIV positive at
intrapartum shows that using 2 or 3 ARV drug
regimen superior to prevent intrapartum
transmission than single dose ARV.

Discussion
A study that conducted in bostwana evaluated 560 hiv
infected pregnant women who receive Zidovudine,
lamivudine, and abacavir (NRTI group) or zidovudine,
lamivudine, and lopinavir/ritonavir (PI group) or zidovudine,
lamivudine, and nevirapine (observational group). The rate
of virologic suppression to less than 400 copies per
milliliter was high and did not differ significantly among the
three groups at delivery (96% in the NRTI group, 93% in the
pi group, and 94% in the observational group)

Discussion
Another

combination Arv that can be used are

tenofovir/emtricitabine 300 mg/200 mg and
nevirapine 200 mg or tenofovir/emticitabine
300/200 mg and atazanavir/ritonavir 300
mg/100 mg. Both as effective as ARV regimen
in HIV infected pregnant women although
adverse reaction higher in nevirapine regimen
(13,6% vs 3,6%)

DISCUSSION

Research that been conducted at university of california, san

fransisco (UCSF) and san fransisco general hospital bay area
perinatal AIDS center from august 1997 to april 2009 shows
that using NNRTI helps shortening the time that needed to
achieve viral load < 400 copy/ml.

Similar results has been shows by european collaborative study

that using additional NNRTI regimen helps faster viral load
supression rather than using PI regimen.

DISCUSSION

Meta-analysis that has been conducted by nathan ford et al

found that using efavirenz (NNRTI) during first trimester
pregnancy found 44 congenital abnormalities or 1,63% from
2023 newborn. Another NNRTI, such as Nevirapine shows that
using nevirapine at CD4 counts >250 cell/ul increase toxicity
risk. Similar result has been found by Kondo et al, Marazzi et al,
and Ouyang et al shows that 91 pregnant women from 1229
sample using nevirapine found severe hepatotoxic as 0,5%

DISCUSSION

A prospective cohort study was conducted in the Kenya Medical

Research Institute, Nairobi, Kenya, involving 501 women, 405
delivered by VD, 74 delivered by NSCS and 22 by SCS. After adjusting
for confounders, women who underwent NSCS had a 3.39 higher risk
of mortality in the first year postpartum compared to women with VD.

In this study of HIV-1 infected women in Kenya, we found that mode

of delivery was associated with mortality in the first year postpartum
with the greatest risk of death was among women who underwent a
non-scheduled cesarean section (NSCS).

DISCUSSION
Another

study reported by the French Perinatal Cohort

(Agence Nationale de Recherches sur le Sida/Enquete
Pe rinatale Francaise) also support this result.

Hiv

infected pregnant women

shows that vaginal
delivery increased from 25% to 53%. Since 2010, 4300
women with viral load before delivery < 400 copy/ ml,
49,% went vaginal delivery, 22% went NSCS, 28,7%
went SCS.

discussion

Study that has been conducted by Swiss Mother and Child HIV Cohort
study and The European Collaborative Study in 2000 to 2010 found
that 2663 with 3013 labor at 10 countries, 28% diagnosed with HIV
positive during pregnancy. Treatment with combination ARV start at
first trimester or second trimester (78%) and third trimester (22%)

Overall, in 86% pregnancy viral load supression <400 copy/ ml achieved

before delivery. Vagiinal delivery increased from 17% to 52% and SCS
decreased from 65% to 27%.Similar result has been shows by national
study at United Kigdom and Iireland that SCS decreased 66% at 1999
and 50% at 2006

discussion

Observational study that conducted by safe milk for african children at

malawi observe Hiv-positive pregnant women receiving aRV prophylaxis
from gestasional week 25 until 6 months after delivery and their
breastfed infants. Women with cd4 <350 cell/mm received combination
d4T 30 mg bid, 3tc 150 mg bid, and nvp 200 mg bid. Women with cd4
>350 cell/mm zdv 300 mg bid, nvp 200 mg bid. All infants receive single
dose NVP syrup (2mg/kgBW) during 72 hours post partum

All regimen has been shown effective and safe for mother or infants.
Similar result has been shown by study from The Kisumu Breastfeeding
Study

CONCLUSION

Combination ARV that can be used such as triiple NRTI/2

NRTI+NNRTI/2 NRTI+PI where viral load supressian <400 copy/ml
highly achieved during delivery (86%, 94% and 93%) where Using
NNRTI evafirenz during first trimester pregnancy shows congenital
abnormalities as 1,63% from 2023 newborn, although other NNRTI
such as nevirapine has serious adverse reaction like hepatotoxic as
0,5%

conclusion

Nowadays, with increase primary health care to MTCT and

effective prophylaxis using ARV combination, vaginal delivery
can be recommended. Vaginal delivery increase from 17% to
52% and selective caesar sectio decrease from 65% to 27%.
Furthermore, women who received >9 weeks of pre-partum
prophylaxis were significantly more likely to have an an
undetectable viral load both in plasma and in breast milk at
delivery.

Thank You
Sintong Halomoan Sianturi1061050120
MEDICAL STUDENT IN DEPARTMENT OF OBSTETRIC AND GYNAECOLOGY
FACULTY OF MEDICINE, CHRISTIAN UNIVERSITY OF INDONESIA, JAKARTA