PTCT Transmission : Safe Delivery Practices,Immunotherapy,Vitamin A

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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.

Continued...

SAFE DELIVERY PRACTICES
- Elective LSCS : Many studies have shown that elective LSCS done at 38 weeks before rupture of membrane or onset of labor reduces the risk of HIV transmission by 20-50%. One recent study done by Swiss group compared the effect on vertical transmission of AZT alone as per 076 protocol, elective LSCS alone, combined elective LSCS and AZT and no interventions. They found that the chances of HIV transmission with combined AZT and elective LSCS were 0%, with elective LSCS alone 8%, with AZT alone 17% and with no intervention at all 20%
  
  Elective LSCS reduces the transplacental hemorrhage occurring during labor, reduces the length of exposure of baby to vagino-cervical secretions or maternal blood, reduces the quantum of infective material, reduces swallowing of infected material by baby and reduces chances of ascending infection to baby. All this reduces HIV transmission.
  
  However, elective LSCS in all HIV infected mother is a enormous task. It may increase maternal mortality as it may not be safe in some parts of our country. It will also increase the cost of therapy. Hence, decision has to be individualized depending upon the set-up and stage of HIV in mother.
- Vaginal delivery : Vaginal delivery leads to more chances of HIV infection. The Swiss study showed that the risk of transmission of HIV was 6% with LSCS and 20% with vaginal delivery. The chances increased to 29-31% if interventions are done during vaginal delivery like traumatic delivery or episiotomy. Hence episiotomy and other procedures should be avoided during vaginal delivery in HIV infected mothers.
- Cleaning of birth canal at delivery: Vaginal and cervical secretions are the most important sources of HIV infections to the baby during delivery. Cleaning of birth canal with virucidal/antiseptic agent at the time of delivery has been proposed as a means to decrease vertical transmission. Such an ideal agent that is effective, safe and inexpensive is still not available. Studies have been done in Africa using chlorhexidine for this purpose and were found to decrease vertical transmission. Other studies have failed to get the desired results. Hence search for the ideal agent still continues. Interestingly all these studies showed decrease in mortality in babies due to decreased incidence of neonatal sepsis. Hence cleaning of birth canal is beneficial both ways.
VITAMIN A AND NUTRITIONAL SUPPORT
Vitamin A deficiency is known to lead to high maternal HIV viral load as well as increased viral titers in breast milk, both of which lead to increased rate of vertical transmission. HIV itself leads to Vitamin A deficiency leading to a vicious cycle. Early studies have shown beneficial role of Vitamin A supplementation given to HIV positive mothers during pregnancy and lactation in decreasing vertical transmission. Besides this it also leads to decreased chances of infant mortality related to diarrhea and ARI in infants even in areas where Vitamin A deficiency is not common. Advantage of this strategy is that it is inexpensive, simple and yet effective mode of intervention. Only problem is that excessive Vitamin A given during pregnancy is known to lead to birth defects. Hence large scale studies are required to define exact role of Vitamin A. Recent study from Malwai in South Africa has shown no benefit of vitamin A supplementation in HIV infected mothers on vertical transmission. Improving nutrition also helps to decrease symptomatology of mothers and decrease the rate of vertical transmission. Simple advice of improving diet from available local home food can lead to better nutrition and better outcome of pregnancy.
IMMUNOTHERAPY
Maternal anti-HIV antibodies help to decrease vertical transmission. A study was conducted in Uganda where HIV infected pregnant mothers were given high dose of anti-HIV Ig obtained and purified from plasma of asymptomatic HIV infected persons. The results were not very encouraging besides the ethical issues of using any blood product obtained from HIV infected people. Similarly studies have been done in Haiti using anti-HIV Ig plus AZT in mothers or giving anti-HIV Ig to newborn. Again the results are not encouraging.

Some HIV exposed individuals do not get infected due to presence of HIV specific CD8 + cytotoxic T cells. Such manipulation of cell mediated immunity can be exploited to decrease vertical transmission.

There are more than 20 vaccines against HIV. Vaccination of pregnant women who are HIV positive using purified gp 120 and gp40 has been tried so as to boost up the antibody titers in mother, which will decrease vertical transmission. Such studies are in phase I of trial in USA.

Suggested further reading :

Kind C, Rudin C, Seigrist C et al. Prevention of vertical HIV transmission: additive protective effect of elective cesarean section and zidovudine prophylaxis. AIDS, 1998, 12: 205-210.

Wiktor SZ, Ekpini E, Katon JH et al. Short course oral zidovudine for prevention of mother to child transmission of HIV-I in Abedjan, Cote d'ivoire : a randomized trial. Lancet 1999, 353: 781-785.

Dabis F, Msellati P, Meda N et al. 6 month efficacy, tolerance and acceptability of a short regimen of oral zidovudine to reduce vertical transmission of HIV in breast fed children in Cote d' Ivoire and Burkina Faso: a double blind placebo-controlled multicentre trial. Lancet 1999, 353: 786-792.

Connor EM, Sperling RS, Gelber R et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994, 331: 1173-1180.

Schaffer N. Short course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand : a randomized controlled trial. Lancet 1999, 353: 773-780.

Culnane. Lack of long term effects of in utero exposure to zidovudine among uninfected children to HIV infected women. JAMA 1999, 281: 151-157.

HIV NET 012. Prophylaxis for maternal transmission of HIV-1. Lancet 1999, 354: 795-802.

Last created on 23-02-2001
Last updated on 26-05-2007

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