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					Recognition and Management of
Perinatal HIV



 Elwyn M. Grimes, M.D.,F.A.C.O.G
      Cook County Hospital
         Chicago, Illinois
           Adults and children estimated
           to
           be living with HIV/AIDS,
North Africa

           12/2000 400 000Eastern Europe
  & Middle East

                            Western Europe & Central Asia
      North America
       920 000                540 000 700 000East Asia & Pacific
          Caribbean                     South     640 000
                                               & South-East Asia
            390 000
                                                 5.8 million
                                 Sub-Saharan
            Latin America           Africa                  Australia
               1.4                 25.3                     & New
              million             million                   Zealand
                                                              15 000


                      Total: 36.1
                       million
AIDS Cases, January 1986 - June 1999, U.S.


                                                                                   25
 Number of Cases




                   6,000




                                                                                        Percent of Cases
                                                                                   20


                   4,000                                                           15

                                                                                   10
                   2,000
                                                                                   5


                      0                                                            0
                           19861987198819891990 19911992199319941995199619971998 1999
          *Adjusted for reporting delay      Year of Diagnosis*
AIDS Rates per 100,000 Women
                                 Reported in 1999
      2.1
                     *                                                                        2.0
1.8
                                  *           1.7                                         *
             1.2                                          1.3                        30.0           NH    1.2
                                 1.6
                      2.5                                                                           MA   14.8
                                                                 3.4
                                                                                                    RI    7.2
                                               1.2                                 9.2              CT   13.0
       4.6                        1.9                                  1.8
               2.1                                         5.5 2.0                                  NJ   19.6
                           2.1                                               0.9                    DE   14.1
5.2                               2.5                                              7.4              MD
                                                3.6               2.7                                    21.0
                                                                                   6.7              DC   93.4
                                        1.5                     5.9
              4.7     0.9
                                                    3.0                       15.0       Rate per 100,000
                                                           9.1 6.3 13.4                       <5
                                 7.4
                                                    11.0                     5 _ 9.9
                                                                    23.2
                                                                             10+
       *                                            PR 21.3 VI 30.1         <5 cases
                     1.6                                                 US rate: 9.3
                                                                         N=10,780
                                                                                                         *
AIDS in Women, by Exposure Category
    Reported in 1999, United States
               Sex with                                                                                        Sex with men of
           injection drug user                                 Heterosexual                                      other or
                                                                                                                            †
                 11%                                           transmission                                    unspecified risk
                                                                       40                                          29%
                                                                       %



                                                                                                                    Other/
                                                                                                                 not identified*
           Injection drug use                                                                                        32%
                 27%
                                                          Transfusion recipient
                                                                 1%
*Includes patients whose medical record review is pending; patients who died, were lost to follow-up, or declined interview;
       and patients with other or undetermined modes of exposure
       †
       Includes sex with a bisexual male, a person with hemophilia, a transfusion recipient with HIV infection, or an HIV-infected
       person with an unspecified risk
US Pediatric AIDS Incidence


 1000
  900
  800
  700
  600
  500
                                                         Number
  400
  300
  200
  100
    0
        1992   1993   1994   1995   1996   1997   1998
HIV Prevalence among Childbearing
Women in Chicago: 1989-1997


    0.45%
    0.40%
    0.35%
    0.30%
    0.25%
    0.20%
                                                           %Positive
    0.15%
    0.10%
    0.05%
    0.00%
            1989 1990 1991 1992 1993 1994 1995 1996 1997
Perinatal HIV Transmission

   Perinatal AIDS cases peaked in 1992; then
    declined 67% from 1992-97.
   AIDS rates/100,000 births declined 69%
    (22.8 in 1992 to 6.2 in 1996)
   HIV-infected women giving birth declined
    17% (6990 in 1992 to 5579 in 1996)
   Perinatally exposed children receiving ZDV
    increased from 7% in 1993 to 91% in
    1997.

    Lindegren ML, et al. JAMA 1999;283(6):44531-8
    Maternal HIV Quantification and
    Perinatal Transmission

   Transmission Reported at All Levels
   Correlation of RNA Levels with T. Risk
   No threshold for zero or 100%
    Transmission
   Discordance between Plasma and
    Genital Tract HIV
    (Compartmentalization)
Mother-to-child transmission
               Take home messages

      ART reduces transmission regardless of setting
          Multiple factors found to influence rate
 Increase transmission          Decrease transmission
   Low birth weight                   ART
   Prematurity                        Elective C-section
   High maternal VL                   Lower maternal VL
   HIV-specific T helper cells
   Breast feeding
   PROM (hourly)
   Maternal AIDS
   Possibly ART resistance
      ACOG Guidelines For Pregnant
      Women with HIV


   HIV + pregnant women should be offered
    scheduled cesarean delivery at 38 weeks
    Women should be informed of the risks of
    cesarean delivery, and physicians should
    consider prophylactic antibiotics
   If viral load <1000, cesarean delivery many not
    offer additional benefit.
   Plasma viral load should be monitored every 3
    months during pregnancy

        ACOG Committee Opinion, August 19/99
    Ongoing Studies:Cook County
    Hospital

   WITS—WOMEN AND INFANTS
    TRANSMISSION STUDY
   WIHS—WOMEN’S INTERAGENCY HIV
    STUDY
   ACTG—AIDS CLINICAL TRIALS GROUP
   MIRIAD
         The MIRIAD Project

   Mother Infant Rapid Intervention At Delivery

   A 5 year, multi-site, CDC-sponsored project
       Atlanta, GA
       Chicago, IL
       Miami, FL
       New Orleans, LA
       New York City, NY
MIRIAD Study Aims

1) Assess innovative approaches to 24-hour
counseling and voluntary rapid HIV testing program
among women who present late to care or in labor
with unknown HIV status
2) Assess the feasibility of obtaining informed
consent during labor or soon after birth
3) Determine barriers to prenatal care and to HIV
testing
4) Assess ART given at labor and delivery or to the
neonate
5) Assess adherence to neonatal therapy
6) Determine subsequent receipt of ART and other
services, as indicated, for women and their children.
  Antiretroviral Treatment
  Options

Scenario #3 (HIV+ women in labor/ no
  prior therapy)
 1) Single dose nevirapine at the onset of labor
 followed by a single dose of nevirapine for the
 newborn at 48 hours
 2) Oral ZDV and 3TC during labor, followed by one
 week of oral ZDV/3TC for the newborn;
 3) Intrapartum intravenous ZDV followed by six
 weeks of ZDV for the newborn;
 4) Two-dose nevirapine regimen combined with
 intrapartum intravenous ZDV and six week ZDV for
 newborn.
 Antiretroviral Treatment
 Options
Scenario #4 (Infants born to mothers
  without
ART during pregnancy or intrapartum:
      The six-week neonatal ZDV component of the
 ZDV chemoprophylactic regimen should be discussed
 with the mother and offered for the newborn.
      ZDV should be initiated as soon as possible after
 delivery -preferably within 6-12 hours of birth.
      Some clinicians may choose to use ZDV in
 combination with other antiretroviral drugs,
 particularly if the mother is known or suspected to
 have ZDV-resistant virus.
           Background

   CORE Center sees one third of pregnant
    women with HIV in Chicago
   Most women enroll during their second or
    third trimester; a few are seen after they
    have delivered their infant.
   Through coordinated care and research
    efforts, we’ve learned important information
    about these women and children, even
    those seen after the infant is born.
Annual Enrollment of Pregnant
and Postpartum Women
                1996 1997 1998 1999 2000
        #        19   36   40   53   51


    % < 24 yr
                 5%   22% 20% 36% 24%

    AA           19   28   32   42   38
    Latina        -   4     7    8   10
    White/Oth     -   4     1    3   3
    % hx IDU    21% 18%    8%   11% 12%
                      Summary

   For the past 4 years there have been 1-3 infants born
    infected in the WCHP.
   In 2000, for the first time, there was no
    HIV transmission to newborns of women
    in WCHP.
   All mother/infant pairs, seen in WCHP, took ZDV and
    other anti-retrovirals during the perinatal period.
   One HIV+ infant was born at CCH in 12/00; mother
    (2 months in this country) not seen at CORE Center
    prior to delivery. (?MIRIAD candidate in the future)
     Perinatal Transmission
           1996-2000


   Amy Berrios, Marcia Katz, Linda Powell, Ken Boyer, Kathy Jennings,
Dorothy Regok, Helen Cejtin, Sandy Micci, Lucretia Rios, Mardge Cohen,
  Lashawna Moore, Julie Schmidt, Sheila Cooper, Nikki Mourikes, Janie
  Sewar Conigan, Jim McAuley, Audrey Stillerman, Renee Flores, Ella
Orange,Kim Stieglitz, Kimberly Harris, Renee Pearson, Calvine Thompson

				
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