Clinical Manual for Management of the HIV-Infected ... - myCME.com

3–34 | Clinical Manual for Management of the HIV-Infected Adult/2006
Postpartum Follow-Up of the Woman with HIV Infection
Women with HIV infection who have delivered
recently need access to a comprehensive array of services
for themselves and their infants. The clinician should
refer the postpartum woman not only to her primary
obstetric and HIV providers for family planning and
HIV management, but also to a pediatric HIV specialist
for care for her infant. She should also be referred as
needed for mental health, substance abuse, and social
support services. The clinician should be alert for
indications of postpartum depression and should offer
treatment promptly. Adherence to ARV regimens may
be particularly difficult in the immediate postpartum
period because of the physical changes postpartum and
the demands of a new baby.
Women should be evaluated for their ongoing need
for ART postpartum. If combination ART was
given only or primarily to reduce the risk of perinatal
transmission, the woman and her clinician may wish to
consider discontinuing therapy after pregnancy, with
the option to resume ART when she meets the criteria
for treatment. Generally, all drugs should be stopped at
once, but if the drugs have very different half-lives, their
discontinuation should be staggered to decrease the risk
of resistance, (eg, in regimens containing nevirapine,
which has a long half-life). Drugs with a short half-life
should be continued for several days to 1 week after the
nevirapine is discontinued.
Follow-Up of the HIV-Exposed Infant
The HIV-exposed infant should be referred to a
pediatric HIV specialist for diagnostic testing and
monitoring of health status. Newborns should be
discharged home with a supply of ZDV oral syrup. The
newborn should receive ZDV syrup at a dose of 2 mg/
kg body weight per dose every 6 hours beginning 8-12
hours after birth and continuing for 6 weeks.
Traditional HIV antibody testing cannot be used in
infants because maternal antibodies may persist for up
to 18 months. Diagnosis of HIV infection in infants
requires virologic testing with HIV DNA polymerase
chain reaction (PCR) or HIV RNA PCR. The DHHS
Pediatric ARV Guidelines recommend testing at birth to
14 days, at 1-2 months, and at 3-6 months. HIV DNA
PCR is a sensitive test that detects viral DNA in the
patient’s peripheral monocytes. Although the sensitivity
of DNA PCR is 1 month
of age, with 1 being done at >4 months of age. Antibody
testing is recommended at age 12-18 months to
document seroreversion.
Infants should have a baseline complete blood count
and should be monitored for anemia while they are
taking ZDV. The DHHS Perinatal ARV Guidelines recommend
Pneumocystis jiroveci pneumonia (PCP) prophylaxis
for HIV-exposed infants beginning at 6 weeks
(when the ZDV is completed) and continuing until age
6 months or until HIV infection can be ruled out.
Parents and family care givers need to be educated that
the infant must be monitored closely until an HIV
diagnosis is made or is ruled out. They also need to
know that the infant’s exposure to ARV agents in utero
is an important part of the infant’s medical history
and should be shared with future health care providers.
Although no long-term consequences of ARV exposure
have been confirmed, the child may be at risk for longterm
problems.
Antiretroviral Pregnancy Registry
To improve tracking of pregnancy-related adverse effects
and fetal effects, an Antiretroviral Pregnancy
Registry has been established as a collaborative project
among the pharmaceutical industry, pediatric and obstetric
providers, the CDC, and the National Institutes
of Health. The registry collects observational data on
HIV-infected pregnant women taking ARV medications
to determine whether patterns of fetal or neonatal
abnormalities occur. Pregnant women taking ARVs can
be placed in this confidential follow-up study by calling
800-258-4263, 8:30 am to 5:30 pm eastern time; the fax
number is 800-800-1052. Information is confidential
and patients’ names are not used. Providers are encouraged
to add to the available information on fetal risk by
using this registry at first contact with a pregnant woman
taking ARVs. More information can be obtained at
http://www.APRegistry.com.