Preventing the spread of the HIV infection and controlling mother-to-child transmission in a co-operation project between Bologna and the district of Tharaka (Kenya)

 

 

 

At this time, the community of Materi (Tharaka) has the availability of services of a dispensary and a maternity hospital managed by nursing personnel, which is capable of performing approximately 700 births per year.

The epidemiological statistics relating to the spread of the HIV infection among pregnant women correspond to those identified in the current maternity hospital, such as 23%. It is expected that, with the foreseen opening of the local Hospital, the number of births will increase significantly to a likely figure of approximately 1.000 per year.

The entire population of 110.000 people living in the Tharaka district, who will be reached by the healthcare information/mobilisation programmes trough the involvement of the mobile clinic healthcare team, can be considered as beneficiaries of the specific co-operation project.

The direct beneficiaries of the PMTC program will be considered the expectant mothers, the mothers and their respective children, who will join the programme of prevention, diagnosis and treatment of HIV infection.

 

Strategy to prevent mother-to-child transmission of HIV (as recommended by WHO)

 

Primary prevention of HIV infection among parents

 

Prevention of unwanted pregnancies in women known to be infected with HIV

 

Prevention of HIV transmission from HIV-infected women to their infants

 

 

Main project objectives

 

To improve the healthcare conditions of the population of the Tharaka district, by preventing the spread of HIV infection

 

To reduce mother-to-child transmission of HIV infection

 

To ensure the survival of the mother and baby pair for as long as possible, to safeguard the family unit

 

 

Expected results

Reduction of the risk of infection among pregnant mothers

Reduction in the rate of mother-to-child transmission of HIV infection

Increased survival and quality of life of infected mothers, as far as possible

Improved professional autonomy of local medical and health care personnel involved in prevention, diagnostic and treatment of HIV infection and related diseases

Knowledge and awareness of the population of the real problems associated with HIV disease, and concurrent reduction of precoceived ideas in relation to it.

 

 

Materials and methods

 

Prevention phase: throughout the region, to raise the level of awareness about HIV infection among young people in schools, military barracks, the countryside and the villages (Healthcare Mobilisation Programme, carried out with a specifically addressed mobile unit), to promote a change in the behaviour of the people in order to avoid HIV infection. To do this, it will be necessary to undertake a mapping of the territory to:

- Identify relevant villages

- Identify existing infrastructures and their features

- Identify the population profile of the village

- Acquire knowledge of the local behavioral uses

       - Take a census of the population to identify the extent of the diffusion iof the disease

        - Take a census of pregnant women, and pregnancies expected in the short- and mid-term future

 

Diagnostic phase: identification and recognition of the disease (VCT)

 

Treatment phase: PMTC program

 

The care of HIV-infected women during antenatal period, labor and delivery and the post-partum will include:

- Intensive counseling and voluntary testing (VCT)

- Screening/obstetric interventions

- Laboratory investigations

- Specific (antiretroviral) treatment

- Prophylactic measures

 

The local personnel (medical doctors, nurses, obstetrics, laboratory technicians, and so on), will be trained by the resident hospital medical team.

 

 

Antenatal care

 

VCT recommended to all pregnant women

 

Every HIV-infected pregnant woman will receive a specific information and couseling proggram focusing on:

            - the rate of mother-to-child transmission of HIV, and the strategy to reduce the risk

            - the potential effects of antiretroviral treatment during the course of the pregnancy

            - the necessity of periodic monitoring up to the moment of childbirth

            - the need to resort to a scheduled Caesarean section to further reduce risk of vertical transmission

            - the necessity to avoid breastfeeding

 

Monitoring every two or three months of at least the following parameters:

 

            - Clinical assessment (total body weight, blood pressure, nutritional state, current stage of advancement and course of the pregnancy, physical symptoms, eventual opportunistic infections)

            - Laboratory assessment (complete blood cells count, evalutation of CD4+ lymphocyte count whenever possible, glycemia,  hepatic and renal function, urinalysis)

            - Antiretroviral treatment during pregnancy

      (performed as recommended by the up-to-date international guidelines on anti-retroviral therapy):

 

 

Symptomatic HIV infection (stage IV, CDC):

                        Zidovudine + lamivudine + nevirapine

            to be initiated as soon as possible, regardless of the total lymphocyte count, to be continued up to birth, and to be maintained after completion of the pregnancy (together with eventual specific treatment of opportunistic infections and/or STIs)

 

Asymptomatic HIV infection (stage I, II, III, CDC):

 

                                        - T CD4+ lymphocyte count <200/ml: see case 1

                                        - Total lymphocyte <1200/ml: see case 1

                                        - Total lymphocyte >1200/ml (or CD4+ >200/mmc)

                                        Zidovudine + lamivudine, or zidovudine alone

                                 Administered from the 14^th week of pregnancy, and to be continued up to the birth.

                                 Treatment interruption has to be taken into account when the pregnancy reaches term.

 

 

 

 

Stage of HIV infection	Total lymphocyte count/ml	T CD4+ lymphocyte count/ml	Treatment	Duration
Stage IV, CDC	All	All	ZDV + 3TC + NVP	To start as soon as possible, to maintain after delivery
Stage I, II, III, CDC	< 1200	-	ZDV + 3TC + NVP	To start as soon as possible, to maintain after delivery
	All	< 200
	> 1200	-	ZDV + 3TC or ZDV	From 14th week of pregnancy, up to delivery
	All	> 200

 

 

 

Antiretroviral drug dosage and mode of administration

 

Zidovudine:                  250 mg BID, for women with a body weight <60 Kg

                                               300 mg BID, for  women with a body weight >60 Kg

 

Lamivudine:                  150 mg BID (or 300 mg QD), regardless of body weight

 

Zidovudine                     300 mg + 150 mg BID (COMBIVIR^®)

plus lamivudine             (only for women with a body weight >60 Kg)

 

Nevirapine:                   200 mg QD for the first 14 days, then 200 mg BID, regardless of body weight

 

 

Intrapartum care

 

- Whenever possible, perform a scheduled Caesarean section at 38^th or 39 ^th week of pregnancy

 

- Administer i.v. zidovudine at 2 mg/kg, staring three hours before delivery, and continuing infusion over one hour, followed by continuous i.v. infusion of 1 mg/Kg/hour up to the birth

 

 

Postpartum care

 

- For all new-born babies: prophylactic treatment with zidovudine oral solution, beginning 8-12 hours following birth, at the dosage of 2 mg/Kg every 6 hours during the first 6 weeks of life, or 1.5 mg/kg i.v. zidovudine every 6 hours for the new-born babies unable to tolerate oral administration. At the end of the prophylactic treatment, an evaluation of serum hemoglobin levels should be obtained. 

 

- In accordance with internationally recognized guidelines, babies born to HIV-infected mothers will be weaned with artificial milk up to the age of one-and-a-half years.

 

 

 

 

Should the woman is already in an advanced state of pregnancy when first coming under our observation, or should she refused antiretroviral treatment during pregnancy, prophylactic therapy based on zidovudine alone is recommended, regardless of the clinical and immune conditions of the mother. The following schedule should be therefore followed:

 

Mother: zidovudine: 250 or 300 mg BID to start as soon as possible after the 14^th week of pregnancy, plus i.v. zidovudine at 2 mg/kg to start three hours before delivery, and subsequent infusion over 1 hour followed by continuous infusion of 1 mg/Kg/h up to the birth

 

Newborn baby: zidovudine at 2 mg/kg as oral solution every 6 hours for 6 weeks, beginning 8-12 hours after birth or 1.5 mg/kg i.v. zidovudine every 6 hours for the new-born babies unable to tolerate oral administration.

 

In the event that the HIV-infected woman is already in labour when first coming under our observation, or she refused anti-retroviral therapy and prophylactic treatment with zidovudine during pregnancy, prophylactic treatment with the non-nucleoside analogue nevirapine is recommended, according to the subsequent schedule:

 

Mother: nevirapine at 200 mg (single dose) to the mother, soon before delivery 

 

New-born baby: nevirapine at 2 mg/kg within the first 72 hours of birth

 

 

Careful clinical and haematologic monitoring should be performed to the mother and and her baby, at least every three months, to assess their general conditions, the rate of mother-to-child transmission of HIV infection (with serial serological controls interesting the child after 6, 12 and 18 months of life), and the efficacy, tolerability and eventual need of change of antiretroviral regimen for the mother, due to resistance, toxicity, poor adherence, or reduced tolerability rate.

 

 

Francesco Chiodo, Marina Tadolini, Roberto Manfredi

Department of Clinical and Experimental Medicine, Division of Infectious Diseases, University of Bologna “Alma Mater Studiorum”, Policlinico S. Orsola-Malpighi, Bologna