Pediatric ID Previous presentation by Susan Schuval, MD Perinatal HIV Pediatric ID Previous presentation by Susan Schuval, MD

An infant is born to a 30 year old HIV-infected Case 1 An infant is born to a 30 year old HIV-infected woman and you are called to evaluate the infant in the Well Baby Nursery The infant is 4 hours old and doing well after a normal spontaneous vaginal delivery Birth weight: 3 kg Gestational age: 39 weeks

QUESTION 1 Which information is most valuable in determining this infant’s risk for perinatal HIV acquisition? Maternal antiretroviral medications administered during pregnancy Date of maternal HIV diagnosis Maternal viral load Maternal CD4 lymphocyte count

QUESTION 1 Which information is most valuable in determining this infant’s risk for perinatal HIV acquisition? Maternal antiretroviral medications administered during pregnancy Date of maternal HIV diagnosis Maternal viral load Maternal CD4 lymphocyte count

QUESTION 1-DISCUSSION Maternal viral load is the most important factor in determining whether HIV will be transmitted from mother to infant. Caesarean section is performed routinely for HIV-infected women with viral loads > 1000 copies/mL. The timing of perinatal HIV transmission is not known but probably occurs intrapartum

ADDITIONAL HISTORY The mother had an undetectable viral load one month prior to delivery and was treated with Reyataz, Norvir, and Sustiva during the 2nd and 3rd trimesters. Her last CD4 count was 1200.

QUESTION 2 What is the best way to test the infant for HIV infection? A. HIV serology: EIA/Western Blot B. DNA PCR C. RNA PCR D. p24 antigen test

QUESTION 2-DISCUSSION HIV DNA PCR is the most sensitive assay available to test for HIV infection. HIV-exposed infants followed by the Pediatric ID Clinic are seen at birth, 2 weeks of age, 6 weeks of age, 4 months and 18 months for PCR and serologic testing.

HIV Testing of Infants Infants born to HIV-infected women will routinely test positive for anti-HIV antibodies because these are transmitted from mother to infant. In the Pediatric ID Clinic, HIV-exposed infants are followed until they “serorevert”and lose the HIV antibodies, usually between 12-18 months of age.

QUESTION 3 Which regimen is most effective in reducing perinatal HIV transmission? A. Maternal treatment with AZT during labor and delivery only B. Maternal treatment with AZT during pregnancy only Neonatal AZT for a 6 week course All of the above

QUESTION 3-DISCUSSION The 3-part regimen of: Maternal treatment with AZT during 2nd and 3rd trimesters of pregnancy, Maternal AZT during labor and delivery, and Neonatal AZT for a 6 week course Has been shown to reduce perinatal HIV transmission from 24% to 8% (70% reduction). Mechanism of action of perinatal AZT: unknown -Lowers viral load (accounts for 17% of observed efficicay) -pre-exposure prophylaxis of infant (thru transplacental AZT passage) -post-exposure prophylaxis of infant (thru continued AZT administration to the infant after birth)i

EPIDEMIOLOGY Over 90% of pediatric HIV infection results from perinatal transmission U.S: 6000-7000 HIV+ women give birth annually 2004: 84 HIV+ infants born Peaked in mid 1990’s: 1750- HIV+ infants born 2000: 284-367 2202: 236 2004: 84

                                                                                                                            Home > Topics > Perinatal Interventions > Overview of Clinical PMTCT Trials Overview of Clinical Trials on Prevention of Mother-to-Child HIV Transmission                                                                                                                                                                                                      November 2003 Lynne M. Mofenson, MD, National Institutes of Health Back to Slide Index       Slide 23: Mother to Child HIV Transmission in the U.S. Over Time                                                                                                                                                  Download this individual powerpoint slide                                                                                                 Contact           |           Subscribe           |           Disclaimer           |           Site Map Copyright 2005. All rights reserved. E-mail Editor@WomenChildrenHIV.org with questions or comments.

QUESTION 4 How are infants who test HIV-positive treated? AZT monotherapy Bactrim alone Zithromax Highly active antiretroviral therapy

QUESTION 4-DISUSSION Infants testing HIV DNA PCR-positive are treated with combination antiretroviral therapy (HAART=highly active retroviral therapy) and PCP prophylaxis.