HIV Flashcards
When to test for HIV in pregnancy
At booking, 20 weeks, 32 weeks, in labour, 6 months post party, and every 3 months whilst breastfeeding.
Baseline work up before commencing on ART
Counselling, CD4, creatinine, WHO staging and TB screening, Hb, and RPR/TPHA.
First-line ART in pregnancy
ART should be commenced immediately. If it cannot be, they should get zidovudine prophylaxis until it can be.
Start on FDC if no contraindications. FDC is tenofovir (300mg), emtricitabine (200mg) and efavirenz (600mg).
Advise on side effects: renal dysfunction, neuropsychiatric effects, rash, GI upset and headaches/dizziness.
Management of HIV diagnosed in labour
Give 200mg Nevirapine stat, Truvada (tenofovir 300mg + emtricitabine 200mg) stat and Zidovudine 300mg stat and then every three hours during the course of labour.
Start on FDC the next day if no contraindications.
Follow up in 1 week for counselling and adherence support.
Viral load monitoring in newly diagnosed patient (or newly commenced on ART) on ART
Start ART immediately and do 1st VL in 3 months.
If <400copies/ml then repeat again in 3 months.
If 400-1000 copies/ml: adherence counselling and repeat in 3 months.
If >1000 copies/ml: adherence counselling. If<28/40 then repeat in 3 months. If >28/40 then repeat in 1 month.
If <1000 at repeat, then repeat again in 3 months to assess for downward trend.
At repeat test:
a) if <28 weeks and still >1000: switch to 2nd line.
b) If >28 weeks and log drop <1: switch to 2nd line
c) If >28 week with VL>1000 but log drop>1: continue 1st line and retest VL in 3 months. Infant to be managed as high risk exposure post-delivery.
If patient was already known with HIV on ART, then do a VL at that visit and see in 2 weeks to review result. Rest of algorithm follows as above depending on if VL if <400, 400-1000 or >1000.
Viral load monitoring during breastfeeding
a) If already on ART: do VL at commencement of breastfeeding and follow up for result in 2/52.
b) If newly diagnosed or newly commenced on ART during breastfeeding, do VL in 3 months time.
From that result:
If <400: continue ART and repeat VL every 6 months.
If 400-1000: counsel on adherence and repeat in 3 months
If >1000: counsel on adherence and repeat in 3 months, if <1000 then can repeat 6 monthly. If still >1000, then change to 2nd line regimen.
Breastfeeding recommendation for HIV positive mothers
Mothers should be on ART and breastfeed exclusively for first 6/12. For the following 6/12 they can do complementary solids.
Should not do mixed feeding.
If infant tests positive, then PMTCT aims change and mom should breastfeed for 2 years as this is better for HIV positive babies.
HIV testing in infants
All HIV exposed babies are tested at birth (with HIV PCR).
If they are not receiving ART, they should be retested at 10 weeks, 9 months and 18 months.
Babies being breastfed and thus receiving NVP for 12 weeks should be tested 6 weeks after NVP is stopped, and then 6 weeks after breastfeeding is stopped.
What additional medications do we give to women with particularly low CD4s?
CD4<200: Bactrim for PCP prophylaxis
CD4<100: Do a CLAT. If positive: need to discuss with specialist before giving fluconazole prophylaxis.
Isoniazid preventative therapy in pregnancy
IPT is safe in pregnancy and breastfeeding.
HIV positive women who are on ART should have a TST done. If this is positive, they get IPT for 36 months, if negative for 12 months.
Women not yet on ART should have a TST. If this is positive, they get IPT for 36 months. If negative they don’t need IPT.
If a TST is not available, women not on ART yet get IPT for 6 months, and women on ART get it for 12 months.
Second line ART regimen in pregnancy
Always do HBSAg first.
If negative then standard 2nd line: Zidovudine, lamivudine and Alluvia (LPV/RTV).
If positive, keep on a TDF inclusive regimen.
If on TB Rx, need to double dose of Alluvia.
Other precautions to prevent HIV transmission antenatally
Avoid amniocentesis unless mom virally suppressed.
Avoid ECV.
Manage promptly in ROM as high transmission risk after 4 hours.
Avoid scalp clips in labour.
ARVs in exposed infant
Low risk (VL<1000): get 6 weeks of NVP
High risk:
a) If breastfeeding: NVP for 12 weeks an AZT for 6 weeks (or until VL<1000)
b) if formula feeding: NVP and AZT for 6 weeks
What increases risk of HIV transmission to baby?
Transmission can be antepartum (in utero transmission usually in 3rd trimester), intrapartum or postpartum. High VL Premature baby/SGA baby Chorioamnionitis Prolonged labour PROM Vaginal delivery Mixed feeding Invasive procedures (amnio, scalp clip, ECV)
10 Steps for PMTCT
- Test 2. Retest 3. Keep mom negative 4. Start HAARt if positive 5. Check VL 6. Manage high VL 7. Know how to Mx if Dx in labour 8. Know what to avoid 9. Postnatally treat mom and baby, 10. Breastfeeding
