Essentials of Management of Pregnancy in HIV-Infected Women: A Handbook for Obstetricians and Gynecologists Narendra Malhotra
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1Introduction
2

Prevention of Perinatal Transmission—An OverviewChapter 1

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In India, women account for around one million out of 2.5 million estimated number of people living with HIV/AIDS.
The prevalence rate for adult females is 0.29%, while for males it is 0.43%. This means that for every 100 people living with HIV and AIDS (PLHAs), 61 are men and 39 women.
With 27 million pregnancies a year and an overall estimated 0.3% prevalence rate of HIV infection among pregnant women, it is estimated that about 100,000 HIV infected women deliver every year in India.
It is recognized that mother-to-child transmission remains a significant driver of the global HIV/AIDS epidemic, because of disparities in health care provision.
Before the use of antiretroviral prophylaxis, reported vertical transmission rates of HIV ranged from an infected mother is 14–32%, if not breastfed and is 25–48%, if breastfed.
In February 1994, PACTG Protocol 076 demonstrated that zidovudine (ZDV) could reduce the risk of mother-to-child transmission by nearly 70%. The intervening period has seen significant advancement in the use of antiretroviral therapy that has extended life expectancy among HIV-infected patients and reduced the risk of mother-to-child HIV transmission very effectively.
Today, risk of perinatal transmission can be less than 2% with effective antiretroviral therapy (ART), elective cesarean section and appropriate infant feeding practices.
As a result, HIV-infected women may not differ substantially from uninfected women regarding reproductive patterns or their intention to have children.
Studies have proven that optimal antiretroviral therapy lowers the transmission rate both by decreasing maternal plasma viral loads and decreasing genital HIV levels.
More than two-thirds of this transmission occurs during labor when the baby is exposed to maternal genital fluids.
A significant proportion of transmission of HIV occurs through breastfeeding.5
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Fig. 1.1: Clinical trials and observational studies have demonstrated that a variety of antiretroviral regimens reduce the risk of maternal-child HIV transmission, with the greatest risk reductions seen with longer duration and more complex regimens
The ideal approach will be to have undetectable maternal viral loads by administering optimal antiretroviral therapy.
Antiretroviral therapy and appropriate infant feeding practices are the primary interventions that reduce the risk of mother-to-child HIV transmission.
In last few years better understanding of the viral life cycle, biology, and immunologic mechanisms, and the pathophysiology of toxicities and side effects has lead to development of new targets and drugs.
Thus, current therapeutic interventions focus on administration of aggressive antiretroviral therapy to maximally and durably suppress viral multiplication, preserve immunological architecture and functions and reduce the development of resistance.
Newer agents and fixed dose combinations (FDC) has come designed specifically for greater convenience and tolerability, better adherence and thus decrease resistance, and to treat resistant isolates, should they pop up.6
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Fig. 1.2: Cartoon about HIV epidemic(Photograph courtesy: Dr. Pradeep Shrivastava, CDRI, Lucknow)
Treatment regimen and strategies for PMTCT have become complex.
This book describes strategies to manage conception, pregnancy, and reproductive health in HIV-infected women.
Following chapters summarizes the consensus recommendations of various guidelines for HIV therapy in pregnancy and perinatal chemoprophylaxis.
Reference is made to latest guidelines of WHO, National AIDS Control Organisation of India (NACO), International AIDS Society (IAS), the US Public Health Service, CDC, the British HIV Association (BHIVA), and German (ADIG).
In addition, when managing HIV positive pregnant women, providers are urged to refer detailed and continuously updated recommendations of guidelines on websites of above named organizations.