Interventions to Decrease PTCT Transmission : Vertical Transmission

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

Infectious Diseases in Children

HIV Prevention From Parent to Child

Infectious Diseases in Children

HIV Infection

Malaria In Children

Tropical Splenomegaly Syndrome

Pneumonias In Children

Chickenpox

Varicella Zoster Virus

Clinical Manifestations Of Congenital Syphilis

H.influenzae - B Prevention Enteric Fever

Hand, Foot and Mouth Disease

Dengue and Dengue Hemorrhagic

H1N1 Influenza Epidemic

Varicella Infection in Pregnancy

Chikungunya - Indian Prespective

Enteric Fever

Otitis Media In Children

Utility of PCR Tests for Diagnosis of HIV in Infants Exposed to HIV Virus

Nonsurgical Treatment of Cystic Echinococcosis

Drug Resistant Tuberculosis in Children in India

Role of Quantiferon Gold Test (Interferon gamma release assay) for Diagnosis of Tuberculosis in Children

Clinical Tools

Clinical Vignettes

Diseases & Conditions

Drugs Interaction Calculator

Podcasts

Patient Management Online

Diagnostic Dilemma

Question of the Day

Diagnostic Aid

VACCINE REMINDER

"Get the Vaccine Schedule for your child."

Ask Queries

SPECIALIST ANSWERS

FIND DIAGNOSIS

Today's Poll

Should teicoplannin, colistin be used in case of neonatal sepsis where culture does not reveal any organism_?

No, it should be used only after drug sensitivity report

Yes, under guidance of an infectious disease expert

Vote

Results

PREVENTION OF PARENT TO CHILD TRANSMISSION OF HIV INFECTION

HIV Infection Prevention From Parent to Child Transmission

Interventions To Decrease PTCT Transmission

Related topics

Magnitude of Problem and Factors Affecting Vertical Transmission Efficacy

Timing of Vertical Transmission and Phases of PTCT Prevention

Dr. Nitin Shah
Hon. Pediatrician- UHC, LTMG Hospital, Mumbai.
Treasurer, Indian Academy of Pediatrics, 1998-2001

Dr. M.R.Lokeshwar
Hon. Pediatrician, U.H.C., LTMG Hospital, Mumbai
and P.D. Hinduja National Hospital, Mumbai
Consultant Pediatric Hematologist-Oncologist, Lilavati Hospital, Mumbai.

Interventions to decrease PTCT transmission

Different interventions undertaken to prevent vertical transmission include: -

Antiretroviral
Infant
Elective
Cleaning
Vitamin
Immunotherapy

ANTI-RETROVIRAL DRUGS
The most successful intervention decreasing vertical transmission is the use of anti-retroviral drugs during pregnancy, labor and postpartally to mother and baby. Most extensively and successfully used drug is AZT used as monotherapy since 1994. Even nevirapine has been used successfully as monotherapy since 1999. Of late combination of two drugs or more has been used successfully bringing down the vertical transmission to < 2%.
There are many trials done in this regard like PACTG 076 protocol, Thai-CDC protocol, Uganda protocol using nevirapine, French perinatal cohort study, Cote d' ivoire study, PETRA Study, SAINT Study etc. We will discuss some of the important studies. Most studies target the last months of gestation, labor and post-partum period for 1 week for mother and for 6 weeks to baby postnatally.
- PACTG 076 Protocol
  This multicentric study by the Pediatric AIDS Clinical Trial Group was done in 1994 in USA and France. HIV +ve mothers who were AZT naive and had CD4+ counts > 200 were enrolled between 14-35 weeks of gestations. They were not enrolled before 14 weeks due to fear of teratogenicity by AZT and not after 35 weeks as it was considered too late to start AZT. All enrolled mothers were given AZT in the dose of 100 mg 5 times a day from day of enrollment till onset of labor. On day of delivery they were given IV AZT in the dose of 1 mg/kg/hr in drip form till delivery. After delivery the baby was put on oral AZT in the dose of 8 mg/kg/day in 4 divided doses, starting the first dose within 12 hrs of birth and it was continued for 6 weeks. All babies were born by elective LSCS at 38 weeks of gestation and all the babies were given formula feeds and breast-feeding was not allowed at all. The results of vertical transmission were compared with matched control group of mother and child pairs who were given placebo instead of AZT in the same schedule.
  
  The results at 18 months showed the transmission rate to be 26% in placebo group and 8% in AZT group, this means 68% efficacy of AZT in preventing PTCT. This has been the best efficacy reported by any study so far. In fact with the interim reports, the trial was stopped prematurely as it was unethical to continue placebo group. All the subsequent trials are compared with 076 trial.
- Problems with 076 protocol
  Though 076 protocol is ideal, it has many practical problems for developing countries. Firstly it is a lengthy protocol both for mother and baby. It will lead to increased cost, decreased compliance and hence failure in majority. It starts very early in gestation which means mothers have to register early and all mothers need to be tested for HIV, both are difficult in developing countries. Thirdly, it needs IV AZT during labor, which is not available in India. It needs elective LSCS, which is not available and safe all over country. Lastly, it needs only top feeding in babies, which may not be desirable, safe, affordable and acceptable to mothers. Hence there is need for shorter, less complicated protocols for developing countries.
Thai-CDC Protocol (short course AZT protocol)
This protocol was tried in Bangkok, Thailand in 1998, in collaboration with CDC keeping in mind the need for simple, short term AZT protocol for developing countries. In this protocol HIV positive mothers were enrolled at 34 weeks of gestation and were given AZT orally in the dose of 300 mg BD till onset of labor. During labor they were given oral AZT in the dose of 300 mg 3 hourly till delivery to a maximum of 4 doses. LSCS was not mandatory. However, all babies were given formula feeds and breast feeding was not allowed. Baby was not given AZT at all. At 3 months the transmission rate was 18.9% in placebo group and 9.4% in AZT group. It means AZT in such a short course still had 50% efficacy in preventing vertical transmission. This may appear 15% less than 076 protocol but it has many advantages. Firstly, it is a short protocol and that too only for mother for just one month. This is affordable, acceptable by many leading to better compliance. Mother could be enrolled even if they register as late as 35 weeks of gestation. It was not mandatory to do LSCS. Only oral AZT was continued during labor and not IV AZT. The only drawback was avoidance of breast feeding. Yet this protocol is ideally suited for developing countries.

In India during phase I feasibility trial of AZT this protocol is being used with only modification being - allowing breast feeding. It is a multicentric study done in 11 medical colleges in 5 states of high prevalence involving 1,47,262 deliveries, of which 1,08,799 (74%) were offered pretest counseling, 6,424 accepted screening (59%), 1203 were found HIV positive (1.9%) of which 462 were put on AZT. The results of this trial are awaited.