3.30 MB - Academy of Medicine of Malaysia

MANAGEMENT OF HIV INFECTION IN CHILDREN
Despite these limitations, several conclusions can be drawn from the
findings of these studies:
PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT)
Three components of treatment or prophylaxis (i.e. antenatal, intrapartum
and neonatal) are important as each component contributes towards
reduction in the risk of mother- to-child transmission (MTCT).
Longer courses of antenatal antiretroviral (ARV) prophylaxis or therapy
beginning earlier in pregnancy are more efficacious in reducing MTCT.
Longer ARV prophylaxis for the infant is not a substitute for longer duration
of the maternal antenatal component. However, regimens that provide
longer infant prophylaxis appear to be beneficial if the mother has
received less than 4 weeks of HAART or ARV prophylaxis before delivery.
Combination regimens are generally more efficacious than a single-drug
regimen.
Exposure to antiretroviral therapy or prophylaxis may induce development
of viral resistance towards the drugs used (especially nevirapine, but
also lamivudine) in mothers and potentially also in their infants; this
may limit the choice or efficacy of antiretroviral therapies during the 6
to 12 months following delivery.
Adequate counselling, support and monitoring to ensure adherence to
the prescribed ARV regimen and chosen method of infant feeding are
essential to PMTCT program success.
Four commonly encountered perinatal scenarios and the recommended
approaches to ARV prophylaxis for PMTCT are discussed below:
According to the Malaysian CPG on Management of HIV Infection in
Pregnant Women (2008) 23, Level 9 , women with World Health Organisation
(WHO) stage 3 or 4 disease or with CD4 lymphocyte counts less than 250
per mm3 at diagnosis should be commenced on HAART, while those who are
asymptomatic and with CD4 cell counts more than 250 per mm 3 at diagnosis
are given short term antiretroviral therapy (START).
Scenario 1: HIV infected pregnant mother who is already on HAART
The risk of MTCT in this group is low but not negligible and depends on the
degree of viral suppression in the mother. The duration of ZDV for the infant
is based on the data extrapolated from PACTG 076 study.
As the evidence for the optimal duration of infant component of ZDV is still
inconclusive, the current recommendations differ from country to country,
22, Level
ranging from one week in some countries to four to six weeks in others.
9; 24, Level 9;25, Level 9
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