Letters to the Editor

Indian Pediatrics 2002; 39:213-214  

Intrapartum Intervention for Prevention of HIV Transmission

I read with interest Dr. Jacob John’s valuable comments on prevention of perinatal HIV transmission(1). The issue of intrapartum intervention requires further clarifications. The letter says that elective Caesarean section before rupture of membranes or start of labor cannot be offered as a standard practice and intravenous zidovudine (ZDV) is of doubtful value.

Though the issue of perinatal HIV pre-vention is complex, these pregnant women should be provided with the most complete and current information about use of anti-retroviral therapy (ART), mode of delivery, and other issues. The couple should be allowed to make their own decisions regard-ing ART and mode of delivery. The couple’s autonomy in decision making should be respected.

Evidence suggests that substantial proportion of vertical transmission occurs during labor and delivery(2-5) and this may be circumvented by elective Caesarean delivery. Studies show that elective Caesarean section done before onset of labor and rupture of membrane was associated with a significant decrease (55%-80%) in HIV transmission compared to other types of delivery, and along with ZDV rate of transmission was as low as 0%-2%(6-9). Thus, elective Caesarean delivery has major additive effect in reducing vertical transmission. American College of Obstetricians and Gynecologists recommend elective Caesarean delivery at 38 weeks of gestation as an adjunct for preven-tion of transmission in pregnant women having viral load >1000 copies/ml(10).

Secondly, the effectiveness of intravenous ZDV has been shown in the ACTG 076 study(11) and it is still recommended in United States(12). However, due to unavail-ability and high cost, it can not be used in India.

Thirdly, if the couple opt for vaginal delivery then intrapartum oral ZDV prophy-laxis (300 mg every 3 hourly from onset of labor until delivery) should be given. The Thai study(13) has shown 51% efficacy by using short course antenatal ZDV (from 36 weeks) along with intrapartum ZDV and avoidance of breast-milk.

Thus the complete regimen (which should be offered) includes four lifelines: (i) Antepartum ZDV prophylaxis (4-6 weeks prior to delivery); (ii) Elective Caesarean delivery at 38 weeks or in case of vaginal delivery, intrapartum ZDV prophylaxis; (iii) Baby ZDV prophylaxis upto 6 weeks of life; and (iv) Avoidance of breast-milk.

When the HIV-infected women present in labor (which is the usual case in India), one can use either ZDV plus 3TC (lamivudine) regimen or nevirapine regime. Till the time nevirapine syrup is available, ZDV plus 3TC regimen should be offered - ZDV 600 mg orally at onset of labor, followed by 300 mg every 3 hourly until delivery plus 3TC 150 mg orally at onset, followed by 150 mg every 12 hourly until delivery. Mother and baby receive ZDV plus 3TC for 1 week postpartum. With the above regimen, 38% reduction was seen in breast-fed population(14). Avoidance of breast-milk is advisable for further reduction.

Jitendra S. Oswal,
Incharge, HIV Clinic,
Department of Pediatrics,
Bharati Hospital, Bharati Vidyapeeth,
Dhankawadi, Pune-Satara Road,
Pune 43, Maharashtra, India.
E-mail: [email protected]

 

1. John TJ. Mother to child transmission of HIV must be prevented. Indian Pediatr 2001; 38: 680-682.

2. Scarletti G. Pediatric HIV infection. Lancet 1999; 348: 863-868.

3. Ehenst A, Dietrich V, Dictor M. HIV in pregant women and their offspring: Evidence for late transmission. Lancet 1999; 338: 203-207.

4. Luzuriaga K, Mequilken P, Alimenti A, Somasundaran M, Hesselton R, Sullivan JL. Early viremia and immune response in vertical HIV virus type-1 infection. J Inf Dis 1993; 167: 1008-1013.

5. Rogers MF, Caldwell MB, Gwinn ML, Simonds RJ. Epidemiology of pediatric HIV virus infection in the United States. Acta Pediatr 1994; 400(Suppl): 5-7.

6. Mandelbrot L, Le Chenadec J, Berrebi A, Bongain A, Benifla JL, Delfraissy JF, et al. Interaction between Zidovudine prophylaxis and mode of delivery in the French Perinatal cohort. JAMA 1998; 280: 55-60.

7. The International Perinatal HIV Group. The mode of delivery and risk of vertical transmission of HIV-1. A meta-analysis of 15 prospective cohort studies. N Engl J Med 1999; 340: 977-987.

8. The European mode of delivery collaboration elctive Caesarean-section versus vaginal deli-very in prevention of vertical transmission: A randomized clinical trial. Lancet 1999; 353: 1035-1039.

9. Kind C, Rudin C, Siegrist CA, Wyler CA, Biedermann K, Lauper U, Prevention of vertical HIV transmission: Additive protective effect of Caesarean section and zidovudine prophylaxis. AIDS 1998; 12: 205-210.

10. American College of Obstetricians and Gynecologists Committee Opinion. Scheduled Caesarean delivery and the prevention of verti-cal transmission of HIV infection. American College of Obstetricians and Gynecologists, Number 234, May 2000.

11. Connor EM, Sperling RS, Gelber R. The ACTG 076 study group. Reduction of maternal infant transmission of HIV-1 with Zidovudine treatment. N Engl J Med 1994; 331: 1173-1180.

12. Perinatal HIV Guidelines Working Group Members: Public Health Service Task Force. Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. HIV Clincal Trials 2000; 1: 39-64.

13. Shaffer N, Chnachoowang R, Mock PA, Bhadrakom C, Siriwasin W, Young NL, et al. Short course zidovudine for perinatal HIV-1 transmission in Bangkok, Thailand: A randomized controlled perinatal HIV trans-mission study group. Lancet 1999; 353: 773-780.

14. Saba J. Interim analysis of early efficacy of three short ZDV/3TC combination regimens to prevent mother to child transmission of HIV-1. The PETRA Trial. Sixth Conference on Retro-virus and Opportunistic infections. Chicago, IL, January 1999, Abstract S-7.