Drug Therapy: Patient Education

Drug therapy
Women who require HIV treatment for their own health should take highly active antiretroviral therapy (HAART) and continue treatment postpartum. They may also require prophylaxis against pneumocystic pneumonia (PCP), depending on their CD4 lymphocyte count.
Women already taking HAART and/or PCP prophylaxis before pregnancy should not discontinue their medication. Antiretroviral therapy is given to prevent MTCT and to prevent maternal disease progression. The optimal regimen is determined on a case-by-case basis. Zidovudine (ZDV) is indicated for use in pregnancy for prevention of MTCT of HIV but single-agent ZDV therapy which does not suppress plasma viraemia to undetectable levels may allow the emergence of resistant virus. Potent combinations of three or more antiretroviral drugs (HAART) have now become the standard of care. Women with advanced HIV should be treated with a HAART regimen. The start of treatment should be deferred until after the first trimester, if possible, and should be continued after delivery. For women who do not require HIV treatment for their own health, HAART should be initiated between 20 and 28 weeks and discontinued at delivery. If they have a plasma viral load of less than 10,000 copies/ml and are prepared to be delivered by elective Caesarean section, an acceptable alternative is ZDV monotherapy initiated between 20 and 28 weeks, given orally, 250 mg twice daily, and intravenously started four hours before beginning the Caesarean section, continuing until the umbilical cord has been clamped. ZDV is usually administered orally to the neonate for four to six weeks. Combination antiretroviral therapy maximises the chance of preventing transmission and represents optimal therapy for the mother but may increase the risk of drug toxicity to the fetus. The use of antiretrovirals to reduce MTCT has resulted in resistant mutations and, in the Paediatric AIDS Clinical Trials Group Protocol, 15% of the women developed nevirapine-resistant mutations by 6 weeks' postpartum
Patient Education
Reinforce regularly and clearly the notion that, when the mother cares for herself, she is caring for her infant. Talk with the patient about stress, the importance of adequate mild-to-moderate exercise, and sufficient rest. Emphasize that regular prenatal care is extremely important to prevent complications of pregnancy. Use of a prenatal vitamin supplement is important, but cannot replace healthy food intake. Develop a plan with the patient for attaining the desired weight gain during pregnancy, while maintaining a healthy nutritional intake. Cigarette, alcohol, and drug use contribute to poor maternal nutrition and can harm the developing fetus. Illicit drug use increases the risk of transmitting HIV to the infant. Injection drug use can transmit HBV, HCV, and CMV to the mother and to the baby. Encourage cessation of cigarette, alcohol, and drug use, and offer referrals for treatment, as needed. Be sure the woman understands all planned procedures and treatments and understands their potential risks and benefits both to herself and to the fetus. Discuss the risks and benefits (to the woman and fetus) of each medication to be taken during pregnancy, including those for which there are limited data on teratogenicity. Discuss ART as part of the strategy to reduce the risk of perinatal HIV transmission to the fetus or newborn. For women at risk, diligent use of "safer sex" during pregnancy is important for preventing infection with STDs and CMV, which can cause more complications when HIV is present. STDs can harm fetal development and may increase the risk of HIV transmission to the baby. New genital herpes infections during pregnancy can cause severe complications and even death in neonates. For women with negative Toxoplasma titers, explain the need to avoid undercooked meat, soil, and cat feces. Teach the pregnant woman how to obtain medical attention quickly at the first signs of OI or other complication. Discuss what to watch for and how to get help when emergencies arise in the evenings or on weekends or holidays. Help the patient clarify her child care options and encourage her to begin putting in place long-term child care and guardianship plans in case she becomes too sick to care for her child or children.
LATEST UPDATE
The Numbers

In 2010, an estimated 217 children younger than the age of 13 years were diagnosed with HIV in the 46 states with long-term, confidential name-based HIV infection reporting since at least 2007; 162 (75%)1 of those children were perinatally infected. At the end of 2009, an estimated 10,834 persons who were diagnosed with HIV when they were younger than 13 years were living in the 46 states with long-term, confidential name-based HIV reporting. Of the total, 9,522 (88%) of these persons acquired HIV perinatally. Of these diagnoses of perinatal HIV infection, 63% were in blacks/African Americans, 22% were in Hispanics/Latinos,2 and 13% were in whites. These numbers include persons of all ages who were infected with HIV as children. The number of women with HIV giving birth in the United States increased approximately 30%, from 6,0007,000 in 2000 to 8,700 in 2006. Despite the increase in the number of women with HIV giving birth, the estimated number of perinatal HIV infections per year in all 50 states and 5 US dependent areas continues to decline. Among perinatally infected children born during 2007 through 2009, black/African American children had the highest HIV rate per 100,000 live births each year, although the rate decreased from 15.2 in 2007 to 9.9 in 2009. The rates for Hispanic/Latino and white children remained stable during this time. From the beginning of the epidemic through 2009, an estimated 5,626 people who were diagnosed with AIDS when they were younger than 13 years died in the 50 states and the District of Columbia. Of the total, 4,986 (89%) of them were infected perinatally.

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