Serological testing:
-EIA (Enzyme immunoassay) is used as a screening test to
detect HIV antibodies.
-A repeated positive screening test is having 99.5%
sensitivity.
-For confirmation Western blot or immuno fluorescence assay
can be used.
-Usually antibody can be detected in 95% of patients within
one month of infection.
-So antibody serotesting does no exclude early infection.
-Early infection can be diagnosed using viral P24 core
antigen or viral RNA, DNA.
Mother to infant transmission:
-
Mother to infant transmission is the most common cause
of HIV infections among children.
-
Transplacental transmission is possible.
-
Bu usually transmission occurs in peripartum period.
-
Around 15 to 25% of infants born to untreated HIV-
infected mothers can get infected.
-
According to the severity of infection and CD4+ cell
proportion (<15%) pregnancy complications like preterm delivery, fetal
growth restriction, stillbirth etc can occur.
Risk factors for fetus – infant transmission:
-
Maternal plasma HIV -1 RNA viral burden
-
Preterm birth
-
Prolonged rupture of membranes
-
Concurrent genital ulcer disease
-
Breast – feeding
-
Invasive intrapartum monitoring
-
Chorioamnionitis
-
Plasma viral HIV-1 RNA levels have proven to be the
best predictor of risk for transmission to the infant.
-
A viral load of less than 1000 copies/ml is associated
with lowest risk of transmission. But actually transmission can occur at any
threshold level.
Management:
Antiretroviral therapy should be
offered to all HIV- infected pregnant women to treat the women and also to
reduce the risk of perinatal transmission.
It should be given regardless of
CD4+ T cell count or HIV RNA levels.
The approved antiretroviral drugs
are categorized into 4 groups.
o Nucleoside
reverse transcriptage inhibitors(NRTI): eg. Abacavir, Zidovudine, Lamivudine.
o Non
nucleoside reverse transcriptage inhibitors(NNRTI): eg. Efavirenz, Nevirapine.
o Protease
inhibitors(PI): eg. Lopinavir/ritonavir, Ritonavir.
o Fusion
inhibitors(FI): eg. Enfuvirtide.
Most of these
drugs belongs to category B,C drugs according to FDA.
Antiretroviral
regimens recommended for HIV-1 treatment in pregnancy are:
v
Protease inhibitor based HAART regimen (NNRTI
& FI sparing): eg. Lopinavir/ritonavir + Zidovudine etc.
v
NNRTI based HAART regimen (PI and FI sparing):
eg. Nevirapine + lamividine etc. Efavirenz should be avoided in the first
trimester.
v
Triple nucleoside reverse transcriptage
inhibitors regimen (NNRTI, PI and FI sparing): eg. Abacavir + lamivudine +
zidovudine
It should be used only when an
NNRTI or a PI based regimen cannot or should not be used as first-line therapy.
With treatment survival improves
and morbidity reduces.
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