NU636 Advanced Pharmacology : Essay Fountain

Question:

Case:

Linda is a 28-year-old female in a discordant relationship with her boyfriend of 1 year. Linda is 12 weeks pregnant based on her last menstrual period. She is engaged in HIV-care and is naïve to antiretroviral therapy (ART) because her CD4 cell count is 538 per mm3 and viral load is 8,300. No tobacco, alcohol, or illegal or illicit drug use.

Physical examination: Normal, healthy 28-year-old gravid female. She is overweight with a body mass index of 28.2. Laboratory and other tests: Genotype is pan-sensitive without HIV mutations. Ultrasound at her 2-day follow-up estimates she is 15 weeks pregnant.

Questions

What are the Public Health Service Panel on Antiretroviral Guidelines for Adults and Adolescents guidelines for HIV-positive pregnant females regarding starting ART?

What antiretroviral medications are recommended as first line?

Which drugs should be avoided? Provide a rationale for all answers. What education does Linda need regarding her medication?

Are there any risks to the baby during labor?

What should be done for the baby at birth if he/she tests positive for HIV?

What will the providers need to do in terms of monitoring the baby?

 

Answer:

Introduction

In pregnancy, women with HIV are recommended to be on antiretroviral therapy to maintain the viral loads at minimum to avoid transmission to the child in utero. Transmission from the mother to the child occurs in pregnancy, at birth, and during lactation. Due to the high risk of transmitting the virus to the child, guidelines have been set to manage pregnant mothers to ensure children born are not infected (Ambia, & Mandala, 2016). The assignment aims to explain the guidelines for HIV positive women who are pregnant, the drugs used, the necessary education required for the clients, the baby risks incurred during birth, and their management.

WHO panel has constructed guidelines for HIV-positive pregnant females recommending views on the use of antiretroviral therapy during pregnancy to promote safe pregnancy and delivery. During the first trimester, dolutegravir is not recommended for expectant women or females within the age of reproduction. This is due to its reported effects on the development and maturation of the neural tube. (Gumede-Moyo, Filteau, Munthali, Todd, & Musonda, 2017). However, there is a recommendation on CD4T lymphocyte cells count monitoring after the initial antenatal visit hence updated the guideline on the use of the antiretroviral drugs for adults and adolescents. The women using atazanavir require careful consideration when changing the treatment regime due to the side effects encountered with atazanavir.

Antiretroviral medication recommended as first-line

Drugs recommended as the first-line for the patient concerning that she has no viral mutations or reported drug resistance include a combination of lamivudine, Tenofovir, and efavirenz taken once a day (Goga et al., 2016). The combination enables the inhibition of the viral multiplication on the different stages of the replication cycle hence, minimizing the viral load.

 

What to be avoided

Some antiretroviral drugs should be avoided during the pregnancy because of effects of possible treatment failure during the second trimester and the third trimester, (Sinclair, Miller, Chambers, & Cooper, 2016).These drugs include atazanavir, darunavir, and elvitegravir, among others, while the likes of the bictegravir, doravirine, and the ibalizumab were all suggested by food and drug administration act to be used in individuals but are not recommended as first-line drugs in pregnancy. For the case of Linda, she must avoid contact with atazanavir, darunavir, and the elvitegravir for her safety measures since she is just in the 15 weeks of her pregnancy.

Health education

The patient has CD4 count of 538 with a viral load of 8300; she needs to be educated on the importance of compliance to her medication to raise the CD4 count to over 1000 and lower the viral load. High viral load increases the chances of vertical transmission to the baby (Okawa et al., 2015).  She needs education on the importance of a balanced diet and exercise to stay healthy during the pregnancy period to minimize the chances of mother to child transmission. She needs training on the importance of performing a drug susceptibility test to elicit the best drugs for her strain to minimize symptoms and lower chances of infecting the baby.

Baby risks

During labour, the chances of transmission are high since there is a mixing of maternal and baby fluids. Rupture of membranes during labour puts the baby at the risk of ingesting vaginal fluids and can lead to infection since they contain a high concentration of the virus. Most babies test positive for HIV at birth, which is normal since they bear maternal antibodies (Lang et al., 2019). In the event of a positive test, the test should be repeated at six weeks and three months, confirming with a PCR test to confirm the baby’s status. The clinicians should ensure the baby gets zidovudine syrup within six hours after birth to prevent infection from the virus. The zidovudine should be continued for six weeks, and in breastfeeding babies, they should be commenced on septrin after six weeks of zidovudine. PCR tests should be done after every six months till 18 months. In case the child tests positive in two tests, it is confirmed that the baby is infected, and a combination of antiretroviral therapy is commenced.

Vertical transmission of HIV can be minimized with adequate medication, education and diet during pregnancy. During birth, the aseptic technique should be applied in delivery following the guidelines to avoid infecting the baby. Prompt prophylactic medication should be given to babies after birth to prevent their infection.

 

References

Ambia, J., & Mandala, J. (2016). A systematic review of interventions to improve prevention of mother?to?child HIV transmission service delivery and promote retention. Journal of the International AIDS Society, 19(1), 20309.

Goga, A. E., Dinh, T. H., Jackson, D. J., Lombard, C. J., Puren, A., Sherman, G., … & Magasana, V. (2016). Population-level effectiveness of PMTCT Option A on early mother–to–child (MTCT) transmission of HIV in South Africa: implications for eliminating MTCT. Journal of global health, 6(2), 18-24.

Gumede-Moyo, S., Filteau, S., Munthali, T., Todd, J., & Musonda, P. (2017). Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: a systematic literature review. Medicine, 96(40), 58.

 Lang, R., Skinner, S., Ferguson, J., Jadavji, T., Stadnyk, M., & Gill, J. (2019). HIV infection after the prenatal screening: an open window leading to perinatal infection. AIDS care, 31(3), 306-309.

Okawa, S., Chirwa, M., Ishikawa, N., Kapyata, H., Msiska, C. Y., Syakantu, G., … & Yasuoka, J. (2015). Longitudinal adherence to antiretroviral drugs for preventing mother-to-child transmission of HIV in Zambia. BMC pregnancy and childbirth, 15(1), 258.

Sinclair, S. M., Miller, R. K., Chambers, C., & Cooper, E. M. (2016). Medication Safety During Pregnancy: Improving Evidence?Based Practice. Journal of midwifery & women’s health, 61(1), 52-67.

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