Preventing mother to child HIV transmission · LONDON, UK [email protected] CHIVA...
Transcript of Preventing mother to child HIV transmission · LONDON, UK [email protected] CHIVA...
Babies born to mothers living with HIV who
maintained an undetectable viral load
throughout pregnancy do not require ARVs
Gareth Tudor-Williams Imperial College Healthcare NHS Trust
St. Mary’s Hospital
&
Imperial College
LONDON, UK
CHIVA debate, 27 May 2016
Happy mother
Happy baby
It’s on the cards she has a sexual partner
It’s on the cards she has a sexual partner
It’s on the cards she has a sexual partner
Current BHIVA guidelines:
Sexual exposure to someone with a consistently
undetectable viral load:
no PEP recommended
ACTG 076 trial
• Monotherapy with ZDV
for mother and infant
reduced transmission of
HIV from 25% to 8%
• Connor et al. NEJM
1994; 331: 1173-1180
Duke University / Burroughs Wellcome,
N.Carolina, USA 1989-1991
ACTG 076 – ‘Belt & Braces’ approach
• Majority of scientific
community did not think
zidovudine monotherapy
would prevent vertical
transmission
• Therefore pre-, peri- and
post-partum dosing chosen
• Length of Rx for baby was
arbitrary
How long to treat the baby?
Evidence from the Thai HPTN trial:
ZDV for mother ZDV for infant Transmission rate
From 28 weeks gestation 6 weeks 6.5%
From 28 weeks gestation 3 days 4.7%
NEJM 2000 Oct 5;343(14):982-91
Transplacental PEP – neonatal drug half-lives
ARV transplacental transfer and T1/2 in neonate:
SD Nevirapine 7 days
DD Tenofovir 24-48 hours
Raltegravir 24-48 hours (longer in prems)
Other NRTI’s < 24 hours
PI’s very poor transplacental Tx
ART which crosses the placenta “preloads”
the infant for delivery & the first few days of life
BHIVA guidelines - Infant PEP ‘tailored to HIV risk’
Low Risk (maternal VL <50 c/ml at 36 weeks)
• PEP – monotherapy (Zidovudine 4mg/kg every 12 hrs)
• Start < 4 hours after birth
• Continue for 4 weeks
BHIVA guidelines - Infant PEP ‘tailored to HIV risk’
Low Risk (maternal VL <50 c/ml at 36 weeks)
• PEP – monotherapy (Zidovudine 4mg/kg every 12 hrs)
• Start < 4 hours after birth
• Continue for 4 weeks
BHIVA guidelines - Infant PEP ‘tailored to HIV risk’
Low Risk (maternal VL <50 c/ml at 36 weeks)
• PEP – monotherapy (Zidovudine 4mg/kg every 12 hrs)
• Start < 4 hours after birth
• Continue for 4 weeks
I have to give doses
at 3am
Stigma
• ‘The Liquid’
• Can’t tell the child’s
father
• Can’t tell anyone at home
• Can’t tell GP
Another anaemic baby
Happy mother
Happy baby
The place for ZDV as PEP for infants
is in the history books!
Babies born to mothers living with HIV who
maintained an undetectable viral load
throughout pregnancy do not require ARVs
CHIVA debate, 27 May 2016
Acknowledgments
• My colleagues in our multi-disciplinary ‘Family Clinic’
HIV team at St. Mary’s, especially Graham Taylor, Alice
Walley, Paula Seery, Sophie Raghunanan, Neil Tickner
and……
Hermione Lyall