| Pregnancy, Pediatrics
and HIV Infection: Guidelines for Your Practice Page 4 |
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| 4. Maternal
Follow-up During pregnancy, the patient should be referred to social services to address any need for financial support related to medication coverage. Patients with past or current substance use should be encouraged to enroll in a treatment program. Women should also be referred to an obstetrician, primary care, and/or a provider with experience in HIV management for long term care, which will include a decision regarding the need for therapy during and after the delivery for maternal health. Reproductive options should also be discussed with the patient during pregnancy and the immediate postpartum period. Finally when feasible, the patient should receive information regarding participation in clinical trials to improve maternal health and/or decrease HIV-1 transmission. |
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| 5. Infant
Follow-Up The women should be aware of the need for neonatal treatment in the immediate period after birth with AZT until week 6. At six weeks of age, all infants born to a mother with HIV infection should receive TMP-SMX (Bactrim, Septra) for prophylaxis against Pneumocystis carinii pneumonia. Prophylaxis should continue until 12 months of age or until HIV infection is ruled out. Follow-up testing and clinical care for the child should also be discussed. The mother should be made aware that her child must undergo testing in the neonatal period for at least the first 4 months after birth to determine if he or she has become infected. Treatment options in case of infection should be discussed. |
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| She should be referred to social services and experienced pediatric personnel. The patient should be re-assured that the transmission rate is relatively low among those that comply with treatment during pregnancy, but in the event that the infant is found to be positive, antiretroviral therapy offers the posibility for keeping the child healthy for many years. | |
| 6. Management
of the HIV Positive Pregnant Women If a woman is found positive, she should undergo clinical evaluation to stage her HIV disease. A CD4 count and a viral load should be done at baseline and every trimester. Antiretroviral therapy should be offered either for maternal health or to decrease perinatal HIV-1 transmission according to current PHS guidelines. The goal is to suppress the patient's viral load below the limits of detection for as long as possible to restore or preserve immune function. Reduction of viral load to <1,000 copies/ml has been shown to reduce the risk of perinatal transmission to 0-2%. |
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| 7. Antiretroviral
Agents Antiretroviral agents should be offered to prevent the risk of perinatal HIV transmission. Women should be counseled about using antiretroviral agents to maintain optimal health. The risk of perinatal transmission should be given in developing the regimen. Options for antiretroviral experienced patients should be discussed with an expert in perinatal HIV. In developing a regimen, it is important to discuss AZT, a medication that can reduce the risk of perinatal HIV transmission. In addition to disclosing the benefits of therapy to help support a woman's decision, it is equally important to discuss the risks of therapy. |
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| As a result of maternal deaths from lactic acidosis some combinations are not recommended during pregnancy unless there are no available ARV options (specifically DDI + d4T). Patients should be monitored for antiretroviral related toxicities every 4-6 weeks. Acceptance or refusal to use antiretroviral therapy should not result in a denial of care or punitive actions. Efavirenz should also be avoided since clinical trains in cynomolgus monkeys found evidence of birth defects. | |
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