Guidelines to Antiretroviral Drug Therapy in Kenya: CHAPTER FIVE: MANAGEMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTED PREGNANT WOMEN AND PREVENTION OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV: 5.4 Antiretroviral Therapy to prevent MTCT

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	Guidelines to Antiretroviral Drug Therapy in Kenya (WHO; 2001; 78 pages)
		FOREWORD
		ACKNOWLEDGMENT
		CHAPTER ONE: INITIATING ANTIRETROVIRAL THERAPY
			1.1 Introduction
			1.2 Guidelines to making a diagnosis of HIV infection
			1.3 Laboratory Diagnosis of HIV infection
			1.4 Goals of therapy
			1.5 When to start therapy
			1.6 Risks and benefits of delayed initiation of therapy and of early therapy in the Asymptomatic HIV-Infected Patient
			1.7 Antiretroviral profile
			1.8 What drug combination to start with?
		CHAPTER TWO: MONITORING AND CHANGING THERAPY
			2.1 Surrogate markers
			2.2 Resistance testing
			2.3 How often should CD4 Cell Count and Viral Load be performed (Frequency)
			2.4 Treatment failure
			2.5 Reasons for non-adherence
			2.6 Considerations for changing a failing regimen
			2.7 Guidelines for changing an antiretroviral regimen for suspected drug failure
			2.8 Potential options for changing therapy*
		CHAPTER THREE: PHARMACOTHERAPEUTICS OF ARVS
			3.1 Characteristics of available antiretroviral drugs
			3.2 Pharmacokinetic properties of Antiretrovirals
		CHAPTER FOUR: GUIDELINES FOR THE USE OF ANTIRETROVIRAL DRUGS IN PAEDIATRIC HIV INFECTION
			4.1 Overview
			4.2 Diagnosis of HIV infection in children
			4.3 When to initiate treatment
			4.4 Initiation of treatment
			4.5 Agents to choose for initial treatment
			4.6 Dosages for paediatric formulations
			4.8 Monitoring
			4.9 When to change therapy
		CHAPTER FIVE: MANAGEMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTED PREGNANT WOMEN AND PREVENTION OF MOTHER TO CHILD TRANSMISSION (MTCT) OF HIV
			5.1 Overview
			5.2 Factors affecting mother to child transmission
			5.3 Outline antenatal, intrapartum postpartum and postnatal care
			5.4 Antiretroviral Therapy to prevent MTCT
		CHAPTER SIX: SPECIAL CONSIDERATIONS
			6.1 Acute retroviral syndrome (ARVS)
			6.2 ARV drugs and the treatment of Tuberculosis
			6.3 Immune recovery syndrome
		CHAPTER SEVEN: WHEN TO STOP TREATMENT (INTERRUPTIONS)
			7.1 Structured treatment interruptions (STI's)
			7.2 Non structured treatment interruption
		CHAPTER EIGHT: GUIDELINES FOR POST EXPOSURE PROPHYLAXIS
			8.1 Treatment of exposure sites
			8.2 Timing of post - HIV exposure prophylaxis initiation
			8.3 Assessment of exposure risk
			8.4 Post - HIV exposure prophylaxis
			8.5 Recommended HIV serology after exposure
			8.6 Management of health care workers with accidental exposure to HIV infection
			8.7 Management of hospital staff with sharp injury or exposure to blood and body fluids
			8.8 Management of non occupational exposure to HIV infection
			8.9 Management of non-sexual and non occupational Exposures to HIV
		CHAPTER NINE: ACCESS TO DRUGS IN KENYA
		APPENDICES
			I. Drug to drug interactions
			II. Drug to drug interactions (continued)
			III. Drug Interactions Between Antiretrovirals and Other Drugs
			IV. Nucleoside Reverse Transcriptase Inhibitors (NRTIS)
			V. Drug Interactions: Protease Inhibitors
			VI. Drug Interactions: Protease Inhibitors and Non-Nucleoside Reverse Transcriptase Inhibitors - Cont.
			VII. Drug That Should Not be Used With Antiretrovirals
			VIII. Drugs that should not be used with Protease Inhibitors Antiretrovirals
			IX. HIV-related drugs with overlapping toxicities
			X. Anti-retroviral therapy for preventing MTCT
		BACK COVER

5.4 Antiretroviral Therapy to prevent MTCT

The safety of most antiretroviral agents to the foetus and infant has not been established thus narrowing the choice of ARV drug therapy to prevent MTCT during pregnancy, labor, delivery and the postpartum/postnatal/ Infant periods. There are, however various regimes of ARV therapy currently favored and available for prevention of mother to child transmission of HIV infection as shown in table 5.3. According to the 'American FDA Pregnancy Categories", Zidovudine (ZDC) and Nevirapine (NVP), are in class "C" in which safety in human pregnancy has not been determined, animal studies are either positive for foetal risk, or have not been conducted, and the drug should not be used unless the potential benefit outweighs the potential risk to the foetus".

TABLE 5.3 ANTI-RETROVIRAL THERAPY FOR REDUCTION/PREVENTION OF MCT

Breast Feeding Status	Drug	ANC	Labour	Baby	% Reduction of MTCT
Non breast feeding	ZIDOVUDINE	100mg p.o. 5 times daily from 14-34 wk gest.	1.V 2.0mg/kg st, then 1 mg/kg/hr	2mg/kg p.o. 6hrly x 6 wks	68% (infection) status at 18 months)
Non breast feeding	ZIDOVUDINE	300mg p.o o.d, from 36-40 from gest.	300mg p.o, 3hrly	No	50% (infection status at 6 months age)
Breast feeding	NEVIRAPINE	No	200mg single dose at the onset of labour	2mg/kg single dose in the first 72 hours	47% (infection status at 6 weeks age)

In our Kenyan set up, if one is to use The Thai Regime, it is advisable to start treatment at 34 weeks gestation since most of our patients deliver before 40 weeks gestation and they would not have had optimum therapy, if the therapy is started at 36 weeks. Details of further regimes recommended in preventing MTCT are provided in Appendix XT 11.

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