REDUCTION OF PERINATAL HIV TRANSMISSION by vla87225

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									                 REDUCTION OF PERINATAL HIV TRANSMISSION

POLICY STATEMENT:
Women account for a significant proportion of individuals with HIV infection; the majority of
these women are of childbearing age. Early diagnosis and management of HIV infection in these
women, and expert management of pregnant HIV-infected (and at-risk) women and their
newborns, can significantly reduce the risk of perinatal HIV transmission. The number of infants
born to HIV-infected mothers in Canada has increased progressively since 1996, but the
proportion of HIV-exposed infants who have become infected has decreased from 33% in 1996
to <0.5% in 2007.1

Maternal, perinatal and neonatal management may include the use of antiretroviral therapy for
both mother and infant. Antiretroviral therapy can be safely administered during pregnancy
and delivery, and to the newborn, with minimal risk of toxicity to the newborn.

Users are referred to the following documents for specific detailed recommendations:
    1. Ontario AIDS Bureau “Guidelines for the prevention of mother-to-child transmission of
       HIV and management of newborns born to HIV-infected mothers and to mothers with
       unknown HIV status” (pending);
    2. United States Public Health Service Task Force’s Recommendations for use of
       antiretroviral drugs in pregnant HIV infected women for maternal health and
       interventions to reduce perinatal HIV transmission in the United States, July 8, 2008.2
    3. Canadian consensus guidelines for the management of pregnancy, labour and delivery
       and for postpartum care in HIV-positive pregnant women and their offspring;3



POLICY:

General Recommendations:
1. HIV testing should be performed on all pregnant women, regardless of prior testing.
   Testing should occur early in pregnancy, be confidential, and accompanied by pre- and
   post-test counseling and consent. If there is suspected ongoing exposure to HIV infection,
   testing should be repeated later in pregnancy.
2. For high-risk women whose HIV status is unknown at the time of labour and delivery, rapid
   (point of care) HIV testing should be obtained if possible. Testing should be confidential and
   accompanied by pre- and post-test counseling and consent.
3. Physicians with expertise in caring for HIV- infected women during pregnancy and delivery,
   and their newborn infants, should be consulted as early as possible during pregnancy to a)
   facilitate coordination of care, and b) provide advice regarding the appropriate

This consensus-based policy was developed November 2008 by the Provincial Maternal-Newborn Advisory
Committee Infection Prevention and Control Work Group. It is recommended that by January 2011 this work will not
be used unless reviewed.
    management during pregnancy, labour and delivery, and the post-partum period (for both
    mother and newborn).
4. Prior to delivery, information regarding the mother’s HIV status should be communicated to
   both the delivery suite and to the health care providers who will provide care for the
   newborn immediately after birth.
5. Routine practices are to be used when caring for HIV positive women and their newborns;
   additional precautions are not required. No special cleaning, disinfection or sterilization of
   equipment is required.
6. During labour, scalp fetal heart monitoring, scalp pH sampling, intrauterine pressure
   measurements and artificial rupture of membranes should be avoided to reduce risk of
   transmission to the infant.
7. Follow-up with adult and pediatric HIV specialists should be arranged for both mother and
   newborn, preferably prior to discharge from hospital.
8. Breast feeding (or administration of expressed breast milk) is contraindicated if the mother
   is known to be HIV-infected, or is considered to be at high risk for HIV infection until results
   of HIV testing are known.


Antenatal Care of the Pregnant Woman

1. Pregnant women who are HIV-infected should be referred to an adult HIV specialist for
   management. Referral to a pediatric HIV specialist is also recommended prior to delivery, if
   possible, so that counselling can be provided to the mother regarding medical care of the
   infant.
2. Initiation / continuation of antiretroviral therapy should be determined by an HIV
   specialist. In general, the following principles apply:
        a. If the woman is already on antiretroviral therapy, therapy should be expected to
           continue during pregnancy.
        b. If the woman is not on antiretroviral therapy but maternal indications for treatment
           exist, combination therapy may be recommended to begin as soon as possible.
           Teratogenic drugs (such as efavirenz) should be avoided during the first trimester.
        c. If the woman is not on antiretroviral therapy and there are no maternal indications
           for therapy, i.e. therapy would be initiated solely to reduce risk of perinatal
           transmission, combination therapy may be offered after 14 weeks gestation and
           cessation of therapy may be considered post-partum.
3. Mode of delivery should be determined by an HIV specialist in conjunction with an
   obstetrician experienced in caring for HIV-infected women. In general, the following
   principles apply:
        a. Vaginal delivery can be considered if infection is well controlled (viral load VL < 50
           copies / mL within 2 months of delivery).
This consensus-based policy was developed November 2008 by the Provincial Maternal-Newborn Advisory
Committee Infection Prevention and Control Work Group. It is recommended that by January 2011 this work will not
be used unless reviewed.
        b. Caesarean section may be the optimal mode of delivery if: a) antiretroviral therapy
           is considered suboptimal (e.g. late diagnosis of HIV, lack of antenatal care, poor
           compliance with therapy, or failure of regimen), and / or b) recent HIV viral load is
           detectable (> 50 copies / ml)
Intrapartum Care

1. During labour, scalp fetal heart monitoring, scalp pH sampling, intrauterine pressure
   measurements and artificial rupture of membranes should be avoided to reduce risk of
   transmission to infant.
2. Antiretroviral therapy during labour and delivery should be directed by an HIV specialist. In
   general, intravenous zidovudine (ZDV) is recommended:
        a. Intravenous ZDV continuous infusion should be started at the onset of labour (regular
           contractions) or at rupture of membranes and continued until the cord is clamped
           (in addition to continuing any prior ART).
        b. For planned Caesarian section, intravenous ZDV is started at least 2 hours
           preoperatively and continued until delivery.
        c. Additional antiretroviral medications for the woman may be recommended
           depending on the clinical scenario.


Post-partum Care: Mother

1. Consult with an HIV specialist regarding continuation of antiretroviral therapy, and for
   follow-up.
2. Women must be counselled not to breastfeed or use expressed breast milk.


Post-partum Care: Infant

1. Wash the infant with soap and water as soon as possible. As per routine practices HCWs are
   to wear gloves for handling the infant until bathed.
2. Avoid intramuscular or other injections prior to bathing. If required for emergencies,
   thoroughly cleanse injection site with alcohol prior to injection.
3. Consult with a pediatric HIV specialist as soon as possible (if not already done) for specific
   recommendations regarding:
        a. Antiretroviral therapy for the infant. In general, zidovudine will be recommended
           but additional medications may be recommended depending on the clinical
           circumstances.
        b. Testing of the infant. In general, blood for HIV serology, CD4 count and HIV PCR, as
           well as a CBC and differential, should be obtained within 48 hours of birth.

This consensus-based policy was developed November 2008 by the Provincial Maternal-Newborn Advisory
Committee Infection Prevention and Control Work Group. It is recommended that by January 2011 this work will not
be used unless reviewed.
             Additional tests (e.g. for viral hepatitis, syphilis) may be indicated at this time
             depending on maternal status. Additional testing of the infant (until 18 months of
             age or beyond) will be required.
        c. Arrange for follow up within four weeks of birth with a paediatric HIV specialist.
4. Breastfeeding or administration of expressed breast milk is contraindicated.


REFERENCES:
1. Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada.
    HIV and AIDS in Canada. Surveillance report to December 31, 2007. http://www.phac-
    aspc.gc.ca/aids-sida/publication/survreport/pdf/survrep1207.pdf
2. Perinatal HIV Guidelines Working Group. Public Health Service Task Force recommendations
    for use of antiretroviral drugs in pregnant HIV-infected women for maternal health and
    interventions to reduce perinatal HIV transmission in the United States, July 8, 2008.
    http://www.hivatis.org/Guidelines/GuidelineDetail.aspx?MenuItem=Guidelines&Search=Off
    &GuidelineID=9&ClassID=2.
3. Canadian consensus guidelines for the management of pregnancy, labour and delivery and
    for postpartum care in HIV-positive pregnant women and their offspring (summary of 2002
    guidelines). Can Med Assoc J 2003;168:1671-4.




This consensus-based policy was developed November 2008 by the Provincial Maternal-Newborn Advisory
Committee Infection Prevention and Control Work Group. It is recommended that by January 2011 this work will not
be used unless reviewed.

								
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