VIH, concepção, gravidez e contracepção

VIH, concepção, gravidez e contracepção
This presentation has been produced as part of the Women for Positive Action initiative, supported by Abbott. Women for Positive Action aims to empower, educate and support women with HIV and the healthcare providers who treat them The slides overview the importance of planning for the possibility of pregnancy for all women of child bearing potential who are HIV positive or those who are HIV negative and in a relationship with an HIV-positive partner

Índice Introdução Gravidez planeada/não planeada
Transmissão mãe-filho (MTCT) Tratamento e cuidados durante a gravidez e no pós-parto Testes de rotina durante a gravidez Necessidade de mais investigação Estudos de caso

Introdução

As mulheres seropositivas são um grupo importante mas subestimado
Estima-se que, em 2007, 33 milhões de pessoas eram portadoras de VIH 16,5 milhões delas eram mulheres A maior parte com potencial de concepção Mais de 3,28 milhões de mulheres portadoras de VIH dão à luz todos os anos In 2007 an estimated 33 million people were living with HIV The proportion of global HIV cases that are women is about 50% and women make up a higher proportion of new diagnoses, meaning the share of infections among women is increasing in several countries Mode of infection for women is usually by heterosexual transmission in marriage – most of these women are monogamous Most women with HIV are of childbearing potential Over 3.28 million HIV+ women give birth each year, over 75% of these in sub-Saharan Africa Sub-Saharan Africa is where the majority of the 410,000 new child infections of HIV occur1, mostly through mother-to-child transmission. Another term for this is vertical transmission, which may be the preferred term as it is less blame-laden References Report on the global AIDS epidemic 2008, UNAIDS, August 2008 Anualmente, até crianças são infectadas por VIH – a maior parte por transmissão mãe-filho Relatório sore a epidemia global de sida 2008, UNAIDS

Prevalência do VIH em mulheres grávidas na Europa e na América do Norte
País Prevalência (%) Estónia1 0.48 Ucrânia1 0.34 Irlanda1 0.31 Bielorrúsia, Letónia, Roménia, Federação Russa, Espanha, Reino Unido1 0.1–0.2 Alemanha, Itália, Suécia, Polónia, Noruega1 <0.1 Canadá2,3 0.033–0.037 Bulgária, República Checa, Finlândia, Lituânia, Sérvia e Montenegro, Eslováquia, Eslovénia1 <0.03 Europe Data for at least one year in from 23 European countries reported similar findings, with the following HIV prevalence rates among pregnant women: Estonia: 0.48% in 2002 Ukraine: 0.34% in 2004 Ireland: 0.31% in 2003 Belarus, Latvia, Romania, Russian Federation, Spain, UK: 0.1%–0.2% Less than 0.1% elsewhere in Europe, including less than 0.03% in Bulgaria, Czech Republic, Finland, Lithuania, Serbia and Montenegro, Slovakia and Slovenia Canada The Alberta Universal Prenatal HIV Screening Program (in which all pregnant women are tested unless they opt out) reported an HIV infection rate of 0.033% pregnancies in An ongoing HIV seroprevalence study of pregnant women in Ontario reported a rate of %2 This rate is based on pregnant women who volunteered for testing (approximately 70%) whereas the rates in the other provinces (except Alberta) are based on complete samples from unlinked anonymous studies References Downs AM, Likatavicius G, Alix J, et al. HIV prevalence among pregnant women in Europe, 2000 to Program and abstracts of the XVI International AIDS Conference; August 13-18, 2006; Toronto, Canada. Abstract MOPE0521. Jayaraman GC, Preiksaitis JK, Larke B. Mandatory reporting of HIV infection and opt-out prenatal screening for HIV infection: effect on testing rates. Can Med Assoc J 2003;168(6). Remis SR, Swantee C, Major Cl et al. Increasing HIV testing of pregnant women in Ontario: results from the HIV seroprevalence study to September Can J Infect Dis 2003;14(Suppl A):79 (Abstract 322). Detecção de bolsas mais elevadas de seroprevalência para o VIH entre mulheres grávidas em vários países, nomeadamente, em zonas da Ucrânia e nos arredores de Londres, no Reino Unido 1. Downs AM, et al. IAS, 2006 2. Jayaraman et al. Can Med Assoc J, 2003 3. Remis SR, et al. Can J Infect Dis, 2003 5 5

Gravidez – planeada e não planeada
A preparação para uma eventual gravidez, quer planeada ou não, é uma componente importante do tratamento Com acesso a uma gestão perfeita, dar à luz um bebé saudável e seronegativo é uma possibilidade para a esmagadora maioria das mulheres em idade de concepção Women with HIV infection, like other women, may wish to plan pregnancy to start a family, control the size of their family, or avoid pregnancy Health professionals should enable women to make reproductive choices by counselling, education and provision of contraception at the time of HIV diagnosis and during follow up With access to optimal management, becoming pregnant and giving birth to a healthy, HIV negative baby is possible for the vast majority of women of childbearing age

Planeamento da gravidez: Considerações
E se o meu bebé for seropositivo? Quando saberei? Como engravido sem infectar o meu parceiro? Serei tratada de forma diferente por quem me presta cuidados? Qual o risco de vir a infectar o meu parceiro? Qual o risco de o meu bebé ser infectado? ? Sobreviverei para ver os meus filhos crescerem? There are many common issues and concerns that the patient may consider when planning for a pregnancy O tratamento ser-me-á nocivo ou ao meu bebé? Deverei amamentar o bebé ou dar-lhe biberão? A gravidez irá agravar a minha seropositividade? Terei de me submeter a uma cesariana?

Gravidez planeada/ não planeada

Gravidez não planeada Até 83% das gravidezes de mulheres seropositivas constam como ‘não planeadas’ Os factores de risco da gravidez não planeada são os mesmos do VIH: toxicodependência (da mulher ou do parceiro) doença mental violência doméstica relações sexuais instáveis e frequentes e práticas sexuais inseguras entre adolescentes In an Italian cohort of 325 women receiving ART, less than half (42.9%) reported their current pregnancy as being ‘planned’1 Other studies have reported that only about 50% of pregnancies are planned2 Proportions of unplanned pregnancies as high as 83.3% have been reported among young women with HIV (13-21 years)3 Many of the risk factors for unplanned pregnancy also place women at increased risk for HIV. These include: Substance abuse (the woman or her partner) Mental illness Domestic violence Frequent unstable sexual relationships and unsafe sexual practices in adolescents References Floridia M, Ravizza M, Tamburrini E, et al. Diagnosis of HIV infection in pregnancy: data from a national cohort of pregnant women with HIV in Italy. Epidemiol Infect Oct;134(5): Finer LB and Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and Perspectives on Sexual and Reproductive Health 2006; 38(2):90-96 Koenig LJ, Espinoza L, Hodge K, Ruffo N. Young, seropositive, and pregnant: epidemiologic and psychosocial perspectives on pregnant adolescents with human immunodeficiency virus infection. Am J Obstet Gynecol 2007;197(3 Suppl):S Koenig, LJ et al. Am J Obstet Gynecol, 2007

Planeamento de gravidezes não planeadas
Previsão da possibilidade de gravidez em todas as mulheres seropositivas com potencial de concepção Consulta de directrizes e ponderação de regimes de TAR eficazes, requerendo alterações mínimas em caso de gravidez Unwanted or unplanned pregnancy is a significant risk for women with HIV While the optimal management of HIV during pregnancy usually leads to positive outcomes for both the mother and baby, unplanned pregnancies can disrupt an already complex situation for women with HIV and can be challenging in certain cases and situations As so many pregnancies are unplanned, being of childbearing potential in itself should be a key factor when choosing an ART regimen The possibility of pregnancy should be anticipated and suboptimal regimens avoided in preference for more suitable ones It is important to chose a therapy regimen that is effective and needs minimal modification should the patient become pregnant For example, avoiding EFZ and ddI+d4T regimens and unnecessary changes to regimens is recommended in most guidelines to avoid the risk of adverse events, poor adherence to therapy and the development of antiretroviral resistance Always consult the most recently published local practice guidelines appropriate for your location, such as the European,1 British,2 French3 or US4 guidelines References European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008] de Ruiter A, Mercey D, J Anderson J, et al. British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women HIV Medicine 2008;9:452–502 Ministère de la Santé et des Solidarités. Prise en charge médicale des personnes infectées par le VIH. Rapport Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov).

Importância do aconselhamento reprodutivo de rotina para mulheres seropositivas
Num estudo envolvendo 700 mulheres seropositivas, 22% engravidaram após o diagnóstico do VIH, mas 57% das mesmas nunca havia analisado opções de gravidez ou terapêuticas antes de engravidar 42% tinha conhecimento insuficiente ou nulo das opções de TARV na fase inicial da gravidez Entre as mulheres que ponderavam engravidar, ou grávidas à data do diagnóstico do VIH 41% não analisou o impacto da gravidez na TARV 29% não analisou os efeitos adversos da TARV A ‘Women Living Positive’ survey1 of 700 HIV positive women in the USA found that 22% of the survey participants became pregnant at some point after being diagnosed with HIV and of these: 57% never discussed pregnancy or treatment options during pregnancy with their HIV healthcare provider before becoming pregnant 42% reported having limited or no knowledge of appropriate antiretroviral options during early pregnancy Among the survey participants who had either previously considered pregnancy or who had been pregnant: 41% had not discussed the impact of pregnancy on their antiretroviral regimen 29% said that their HIV healthcare provider had not explained the adverse effects of certain antiretrovirals on maternal and foetal health References Bridge DA, Hodder S, Squires K et al. Clinicians Fail to Routinely Provide Reproductive Counselling to HIV-Infected Women in the United States. Program and abstracts of the 17th International AIDS Conference; August 3-8, 2008; Mexico City, Mexico. Abstract TUPE0911 Bridge DA, et al. IAS Mexico City 2008

O que é o aconselhamento reprodutivo?
Aconselhamento, educação e análise de: Saúde da mãe a longo prazo e capacidade de tratar das crianças Transmissão mãe-filho Importância de cuidados pré-natais precoces e intensivos Uso da TARV e de outros fármacos na gravidez Contracepção eficaz Questões de saúde reprodutiva materna Concepção segura Impacto do VIH na gravidez Impacto da gravidez no VIH Questões do foro psico-social, impacto do pós-parto na adesão e consultas de ambulatório Reproductive counselling should be considered for all women of child bearing age as a part of primary care For women who are HIV positive, education and counselling about pregnancy and HIV should be done early in the course of HIV care, not delayed until pregnant, so that informed and carefully considered decisions about contraception and pregnancy can be made Discussions about pregnancy should be repeated at intervals throughout care, especially: when personal circumstances change (e.g. new sexual partner, postpartum); when there is non-compliance with effective contraception; where therapies are considered which may have adverse effects in pregnancy; or when the woman expresses a desire to become pregnant. Counselling should be tailored according to whether the woman is part of a concordant couple, discordant couple, or whether she is living as a single woman Reproductive counselling should include advice and education on reproductive choices, wishes and options, including: Effective contraception Safe conception if partner is HIV-negative Impact of HIV on pregnancy course/outcome Impact of pregnancy on HIV progression Other reproductive issues based on maternal factors (e.g. coexisting drug / alcohol use; advanced maternal age; hypertension, diabetes) General preconception issues such as nutritional counselling (e.g. folic acid) and the importance of early and intense antenatal care Long term health of mother and care for children (guardianship issues) Mother-to-child transmission and how to prevent it Use of ARTs and other medications in pregnancy Psychosocial issues, including possibility of judgment and stigmatization by family and community. Also postpartum issues and how these can impact on adherence and clinic visits Lack of up-to-date knowledge on the risks of HIV transmission to partners under the various scenarios Reproductive counselling involves a two-way interactive process that explores coping, decision-making and emotional reactions and plans / prepares for these Dealing with depression, anxiety and worries, decision-making about disclosure, mode of delivery and feeding, adjustment to parenthood, anticipation of emotional turmoil and feelings Also deals with issues of partnership/concerns of the couple, and financial issues. If possible, the partner should be included in the counselling process Cultural issues should also be addressed during reproductive counselling. A French study showed factors influencing the desire for a child included reproductive potential, ethnicity and partner’s HIV-status.1 The desire for parenthood was 2-6 times higher in women born in sub-Saharan and north Africa than in women born in Europe, and 4 times higher in men from those areas. Relationship status was also an important issue. The study also indicated a strong need for education on pregnancy issues: 26% of women who perceived a “very high risk” of vertical transmission felt the desire for a child vs. 46% with a “very low risk” perception References 1. Heard I, Sitta R, Lert F et al. Reproductive choice in men and women living with HIV: evidence from a large representative sample of outpatients attending French hospitals (ANRS-EN12-VESPA Study). AIDS 2007, 21 (suppl 1): 77-82 Deverá implicar uma interacção bilateral, com vista a explorar estratégias de gestão, tomada de decisão, reacções do foro emocional e o planeamento/preparação Deverá envolver os parceiros e ser relevante do ponto de vista cultural

Aconselhamento pré-natal: uma estratégia de redução de risco
Optimização da gestão do VIH Escolha da TARV Despiste e tratamento de infecções sexualmente transmissíveis Opções reprodutivas – riscos, custos e índices de êxito Sexo apenas quando a mulher se encontra no período fértil do ciclo Parar de ter relações sexuais desprotegidas assim que engravida Evitar agentes irritantes do tracto genital Encaminhamento para avaliação se não for bem sucedida após 6 a 12 meses (mais cedo se tiver mais de 35 anos) Eventualidade de fracasso do tratamento e capacidade de cuidar da criança All couples wishing to become pregnant should receive pre-conception counselling that includes discussions about: Optimising HIV management: Attainment of a stable, maximally suppressed viral load prior to conception is recommended for women who are HIV positive on antiretroviral therapy, and wish to become pregnant. ART can result in undetectable viral loads and restoration of the immune system. Clinical studies suggest that treatment of HIV with ART reduces the risk of HIV transmission during unprotected sex.1 However, it should be made clear that the risk is reduced but not eliminated Control of HIV infection also may increase the probability of pregnancy for an HIV positive woman Tailored choice of ART: It is important to chose a therapy regimen that is effective and would not need to be changed if the patient did become pregnant Avoiding exposure to EFZ and ddI+d4T regimens and unnecessary changes to regimens is recommended to avoid the risk of adverse events, poor adherence to therapy and the development of antiretroviral resistance Initiation of nevirapine is also contraindicated during pregnancy if baseline CD4 cell counts are above 250 cell/mm3, although it can be continued if it is part of a prior stable and tolerated regimen Screening for and treating sexually transmitted infections Information to enable them to make an informed choice about their reproductive options, the inherent risks and costs of each treatment and the likely chances of success Counselling couples to have sex only when they are sure the woman is in the fertile period of her cycle. Using an ovulation indicator kit can help to pinpoint this time Counselling couples to stop having unprotected sex as soon as pregnancy occurs Counselling couples to avoid using products such as douches or herbs that will irritate the genital tract. Practices such as dry sex should also be avoided The possibility of treatment failure and how they would cope if one or both parents fell seriously ill or died Referral for fertility assessment is recommended if couples have been unsuccessful in getting pregnant after 6-12 months (or earlier if the woman is over 35 years) References McClelland RS, Baeten JM. Reducing HIV-1 transmission through prevention strategies targeting HIV-1-seropositive individuals. J Antimicrob Chemother 2006 Feb;57(2): Epub 2005 Dec 6

Opções reprodutivas Mulher seropositiva e homem seronegativo
Homem seropositivo e mulher seronegativa Inseminação intra-uterina (IUI), fertilização in vitro (IVF) ou microfertilização (ICSI) após lavagem de esperma Concepção natural (se a supressão virológica for eficaz) Inseminação com esperma de dador na ovulação Adopção Mulher seropositiva e homem seronegativo Inseminação com o esperma do parceiro na ovulação (se não seguir TAR / carga vírica detectável) Concepção natural (se a supressão virológica for eficaz) Reprodução assistida em caso de distúrbios de fertilidade Profilaxia pré-exposição (PPrE) HIV+ man & HIV- woman HIV discordant couples where the male is HIV positive who desire to eliminate or significantly reduce HIV transmission risk to their HIV-negative partner are limited to the options listed below. However, all available options should be discussed with the couple and they should be supported in finding the best option for their personal situation. Insemination using donor sperm: this effectively removes the risk of viral transmission because sperm donors are screened for HIV and other blood-borne viruses. However, it also removes the option of genetic parenting from the HIV positive man Sperm washing: the female partner is inseminated with the infected partner’s sperm, centrifuged first to separate spermatozoa from seminal fluid and associated non-sperm cells. This option is expensive, not 100% safe with regards to transmission, and not available in all countries Adoption: this is a more difficult option for couples because current adoption practice regards HIV in one or both partners as a significant undesirable factor when assessing the suitability of parents requesting to adopt. Nevertheless, this is an approach that has been successful for some serodiscordant couples HIV+ woman & HIV- man Self-insemination of partner’s sperm: Women not taking ART should be advised to avoid unprotected intercourse and be instructed on how to carry out self-insemination of her partner’s sperm at the time of ovulation in order to minimize viral transmission risk through unprotected intercourse Natural conception: Women with effective viral suppression through long term use of ART should also be instructed on self-insemination but also be counselled on the current evidence regarding the low, but possible, risk of viral transmission to their uninfected partner if they attempt to conceive naturally. Should they elect to attempt natural conception, the couple should have regular screening for STIs and be advised to limit intercourse to the time of ovulation; the woman should also be advised on the importance of adherence to medication and regular checking of plasma viral load Concordant couple In cases where both partners are HIV-positive, semen processing or donor insemination may also be considered to avoid the risk of HIV superinfection, reinfection and resistance. However, in some countries the risk of superinfection or re-infection is so low that the need for assisted technique are not considered necessary, except in cases of fertility disorders References Barreiro P, del Romero J, Leal M et al. Natural pregnancies in HIV-serodiscordant couples receiving successful antiretroviral therapy. J Akquir Immune Defic Syndr. 2006; 43:324-6. Thornton AC, Romanelli F, Collins JD. Reproduction decision making for couples affected by HIV: a review of the literature. Topics in HIV Medicine 2004; 12: 61-6. Kanniappan S, Jeyapaul MJ, Kalyanwala S. Desire for motherhood: exploring HIV-positive women's desires, intentions and decision-making in attaining motherhood. AIDS Care Jul;20(6): Fiore S, Heard I, Thorne C, Savasi V, Coll O, Malyuta R, Niemiec T, Martinelli P, Tibaldi C, Newell ML. Reproductive experience of HIV-infected women living in Europe. Hum Reprod Sep;23(9): Vernazza P, Hirschel B, Bernasconi E, Flepp M. HIV-infizierte Menschen ohne andere STD sind unter wirksamer antiretroviraler Therapie sexuell nicht infektiös. Schweizerische Ärztezeitung 2008; 89:5, Mulher e homem seropositivos Inseminação com esperma de dador ou lavagem de esperma para prevenir superinfecção Concepção natural Reprodução assistida em caso de distúrbios de fertilidade

VIH e fertilidade Está provado que as mulheres seropositivas apresentam uma maior incidência de distúrbios de fertilidade A fertilidade assistida tem implicações éticas e práticas relevantes para os doentes e profissionais Opções de tratamento de fertilidade IUI (+/- lavagem de esperma) ~ IVF Inseminação c/ esperma do dador ~ ICSI Dados limitados sobre o êxito de IVF/ICSI Índice de gravidez consideravelmente inferior em mulheres seropositivas Conception, or becoming pregnant, is of particular concern for serodiscordant couples (those in which only one partner is HIV positive) Preconception counselling and reproductive assistance have significant ethical and practical implications for the couple and the carers HIV-positive couples can enjoy normal, healthy lives and should have access to the same care, services and opportunities as HIV-negative people Safer sex is recommended. However, assisted reproductive technologies may aid serodiscordant couples in achieving pregnancy while at the same time minimizing the risk of HIV transmission to the uninfected partner There is evidence that women with HIV show a higher incidence of fertility disorders, indicating increased demand for reproductive treatments Women with HIV experience reduced pregnancy rates and higher rates of both planned abortion and miscarriage HIV/AIDS may decrease male and/or female fertility1 by: increased risk of female sterility (associated with coinfection with other STIs)2 decreasing production and motility of spermatozoa3 (male) increasing fetal mortality (child) and sometimes decrease frequency of sexual intercourse (male and female) Data on the success rate of IVF/ICSI (intracytoplasmic sperm injection) in HIV positive women remain unclear, since current case numbers are too low to estimate exact rates. Only data on 205 cycles among 127 HIV positive women have been published.2 The pregnancy rate in HIV positive women (17% per embryo) was substantially below the rate in the general female population (26% per embryo) References Lewis JJC, Ronsmans C, Ezeh A, Gregson S. The population impact of HIV on fertility in sub-Saharan Africa. AIDS 2004;18(suppl 2):S35-S43. van Leeuwen E, Prins JM, Jurriaans S, Boer K, Reiss P, Repping S, van der Veen F. Reproduction and fertility in human immunodeficiency virus type-1 infection. Hum Reprod Update 2007;13(2): Bujan L, Sergerie M, Moinard N, Martinet S, Porte L, Massip P, Pasquier C, Daudin M. Decreased Semen Volume and Spermatozoa Motility in HIV-1 Infected Patients under Antiretroviral Treatment. Journal of Andrology 2007;28(3): Coll O, Suy A, Figueras F, Vernaeve V, Martinez E, Mataro D, et al. Decreased pregnancy rate after in-vitro fertilization in HIV- infected women receiving HAART. AIDS 2006; 20:121-3. Peña JE, Thornton MH, Sauer MV. Assessing the clinical utility of in vitro fertilization with intracytoplasmic sperm injection in human immunodeficiency virus type 1 serodiscordant couples: report of 113 consecutive cycles. Fertil Steril 2003; 80: Stephenson JM, Griffioen A. The effect of HIV diagnosis on reproductive experience. Study Group for the Medical Research Council Collaborative Study of Women with HIV. AIDS 1996; 10: IUI, inseminação intra-uterina; IVF, fertilização in vitro; ICSI, injecção intracitoplasmática de espermatozóides

O contraceptivo ideal Fiável Seguro Conveniente Reversível
Previne a transmissão do VIH Não interfere com a HAART Acessível The ideal contraceptive for an HIV positive woman would be: Reliable Safe (e.g. No increased risk of pelvic inflammatory disease) Convenient – to fit in with the woman’s lifestyle and ensure compliance Reversible – if future pregnancy is planned Prevent the transmission of HIV to a negative partner Not interfere with HAART Affordable Currently, the ideal contraception must involve condoms actualmente significa que tem de incluir preservativos 16 16

Opções de contracepção no VIH
Método Vantagens Desvantagens Preservativos (masculino e feminino) Protecção de DST/VIH Necessidade de colaboração Técnica correcta Inconveniente / pode interferir com as relações sexuais Contraceptivos orais Eficaz Menor perda de sangue Interacções medicamentosas Possível  excreção vírica Não oferece protecção contra DST/VIH Penso, anel vaginal, injectável combinado Interacções medicamentosas? Falta de dados  excreção? DMPA Baixa manutenção  set point viral There are a number of contraceptive options available for women who are HIV positive or who are in a relationship with an HIV positive partner. Contraceptive choices need to be made on an individual basis, with an awareness that condoms alone may provide insufficient protection from pregnancy. Of the alternatives: Because of potential interactions between antiretroviral therapy (ART) and the combined oral contraceptive pill (COC), ORTHO EVRAs, the progestogen-only pill (POP) and implants, these methods may be best avoided for women on HAART or other liver enzyme-inducing drugs There are no known adverse interactions between HAART and depot medroxyprogesterone acetate (DMPA), the levonorgestrel intrauterine system (LNG-IUS) and intrauterine devices (IUDs) References Mostad SB, Overbaugh J, DeVange DM, Welch MJ, Chohan B, Mandaliya K, Nyange P, Martin HL Jr, Ndinya-Achola J, Bwayo JJ, Kreiss JK. Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet 1997 Sep 27;350(9082):922-7. Wang CC, McClelland RS, Overbaugh J, et al. The effect of hormonal contraception on genital tract shedding of HIV-1. AIDS 2004 ;18(2):205-9. 17 Mostad Lancet 1997; Wang AIDS 2004 17

Opções de contracepção no VIH
Método Vantagens Desvantagens DIU Baixa manutenção Eficaz Perda de sangue com T de cobre Excreção com SIU-LNG?  infecção pélvica Não oferece protecção contra DSTI/VIH Muco cervical Alguma protecção contra DST  Infecções do tracto urinário Exige técnica correcta Esterilização Irreversível Custo Invasivo There are a number of contraceptive options available for women who are HIV positive or who are in a relationship with an HIV positive partner. Contraceptive choices need to be made on an individual basis, with an awareness that condoms alone may provide insufficient protection from pregnancy. Of the alternatives: Because of potential interactions between antiretroviral therapy (ART) and the combined oral contraceptive pill (COC), ORTHO EVRAs, the progestogen-only pill (POP) and implants, these methods may be best avoided for women on HAART or other liver enzyme-inducing drugs There are no known adverse interactions between HAART and depot medroxyprogesterone acetate (DMPA), the levonorgestrel intrauterine system (LNG-IUS) and intrauterine devices (IUDs) References Mostad SB, Overbaugh J, DeVange DM, Welch MJ, Chohan B, Mandaliya K, Nyange P, Martin HL Jr, Ndinya-Achola J, Bwayo JJ, Kreiss JK. Hormonal contraception, vitamin A deficiency, and other risk factors for shedding of HIV-1 infected cells from the cervix and vagina. Lancet 1997 Sep 27;350(9082):922-7. Wang CC, McClelland RS, Overbaugh J, et al. The effect of hormonal contraception on genital tract shedding of HIV-1. AIDS 2004 ;18(2):205-9. 18 Mostad Lancet 1997; Wang AIDS 2004 18

Transmissão mãe-filho (MTCT)

Transmissão mãe-filho (MTCT)
O VIH pode ser transmitido de mãe para filho (transmissão vertical) em várias fases da gravidez e maternidade: Durante a gestação1 Durante o parto e a concepção2–5 Mother-to-child transmission can occur at various stages of pregnancy and motherhood: During gestation within the womb (the period from conception to birth) – approximately 7% During birth itself (labour/delivery) – about 18% During breastfeeding – about 15% References Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O’Sullivan MJ et al. Reduction of maternal- infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. N Engl J Med 1994; 331: Kind C, Rudin C, Siegrist CA, Wyler CA, Biedermann K, Lauper U, et al. Prevention of vertical HIV transmission: additive protective effect of elective cesarean section and zidovudine prophylaxis. Swiss Neonatal HIV Study Group. AIDS 1998; 12 (2): The International Perinatal HIV Group. The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1. N Engl J Med 1999; 340: The European Mode of Delivery Collaboration. Elective cesarean section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomized clinical trial. Lancet 1999; 353: Shapiro D, Tuomala R, Samelson R, Burchett S, Ciupak G, Mc Namara J et al. Mother-to-child HIV transmission according to antiretroviral therapy, mode of delivery and viral load (PACTG 367) [Abstract 114]. 9th Conference on Retroviruses and Oportunistic Infections. Seattle feb 2002 Dunn DT, Newell ML, Ades AE, Peckham CS. Risk of Human Immunodeficiency Virus Type 1 Transmission Through Breastfeeding. Lancet 1992; 340:585-8. Nduati R, John G, Mbori-Ngacha D, Richardson B, Overbaugh J, Mwatha A, Ndinya-Achola J, Bwayo J, Onyango FE, Hughes J, Kreiss J Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial. JAMA Mar 1; 283(9): Coutsoudis A, Dabis F, Fawzi W, Gaillard P, Haverkamp G, Harris DR, Jackson JB, Leroy V, Meda N, Msellati P, Newell ML, Nsuati R, Read JS, Wiktor S; Breastfeeding and HIV International Transmission Study Group. J Infect Dis Jun 15; 189(12): Coutsoudis A, Pillay K, Spooner E, Kuhn L, Coovadia HM. Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study. South African Vitamin A Study Group. Lancet Aug 7; 354(9177):471-6. Aleitamento materno6–9

Minimização do risco da MTCT
Sem uma terapêutica e prevenção perfeitas, o risco de transmissão do VIH de mãe para filho situa-se entre 12 e 45%, dependendo do contexto e circunstâncias pessoais If an HIV positive woman takes no preventative therapy and breastfeeds then the chance of her baby becoming infected is around 30% on average.1 It is greatly influenced by whether the child is breastfed MTCT is almost entirely preventable, where services are available Antiretroviral drugs can reduce mother-to-child transmission of HIV in one of more the following ways: by reducing viral replication and thus lowering plasma viral load in pregnant women; through pre-exposure prophylaxis of babies by crossing the placenta; through post-exposure prophylaxis of babies after delivery. In developed countries, highly active antiretroviral therapy (HAART) has reduced the vertical transmission rates to around 1-2% but HAART is not yet widely available in low and middle income countries. In these countries, various simpler and less costly ART regimens have been offered to pregnant women and/or their newborn babies2 References HIV and Infant Feeding. Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. Updated September Department of Health. Volmink J, Siegfred NL, van der Merwe L, Brocklehurst P. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev Jan 24;(1):CD The Working Group on Mother-To-Child Transmission of HIV. Rates of mother-to-child transmission of HIV-1 in Africa, America, and Europe: results from 13 perinatal studies. J Acquir Immune Defic Syndr Hum Retrovirol Apr 15;8(5): Uma intervenção perfeita reduz o risco de MTCT para menos de 2%

Factores que influenciam a transmissão perinatal de mãe para filho
Factores maternos Factores obstétricos Falta de consciência do estado serológico Níveis de RNA do HIV-1 Contagem baixa de linfócitos CD4 Outras infecções como, por exemplo, hepatite C, CMV, vaginose bacteriana Consumo de drogas injectáveis por parte da mãe Falta de profilaxia com TAR Extensão da ruptura das membranas fetais Corioamnionite Parto vaginal Procedimentos de tipo invasivo Many factors have been identified that influence the risk of mother-to-child transmission: Maternal factors The main risk factor, which is also a barrier to the prevention of perinatal HIV transmission, is lack of awareness of HIV status among pregnant women. Other maternal factors correlated with an increased risk of MTCT include: Viral load, CD4 counts and clinical disease stage Frequent, unprotected sex with multiple partners (possibly leading to increased risk of STIs, other inflammatory processes) Smoking and substance use Lack of ART prophylaxis during pregnancy Obstetric factors Length of ROM (rupture of fetal membranes): Early studies, before the widespread use of ZDV reported an increased transmission rate from 14% to 25% among mothers with ROM >4 hours before delivery Chorioamnionitis: several studies reported that women with clinical chorioamnionitis had an increased transmission risk Vaginal delivery: The benefit of caesarian section is not substantial when maternal viral load is undetectable Invasive procedures, e.g. amniocentesis, fetal scalp electrodes should not be used in women with HIV infection Other factors that can increase the chance of premature delivery, and therefore increase the risk of transmission, include premature contractions and pregnancies with multiple babies Infant factors Delivery before 34 weeks gestation Some studies have shown differences in transmission rates depending on the sex of the child, but the evidence is not well established References HIV and Infant Feeding. Guidance from the UK Chief Medical Officers’ Expert Advisory Group on AIDS. Updated September Department of Health. Cohan D, Feakins C, Wara D, Petru A, McNicholl I et al. Perinatal transmission of multidrug-resistant HIV-1 despite viral suppression on an enfuvirtide- based treatment regimen. AIDS 2005; 19 (9): Slattery MM, Morrison JJ. Preterm delivery. Lancet 2002; 360: Wen SW, Smith G, Yang Q, Walker M. Epidemiology of preterm birth and neonatal outcome. Semin Fetal Neonatal Med 2004; 9 (6): Steer P. The epidemiology of preterm labour. Br J Obstet Gynaecol 2005; 112 Suppl 1:1-3. Ellis J, Williams H, Graves W, Lindsay MK. Human immunodeficiency virus infection is a risk factor for adverse perinatal outcome. Am J Obstet Gynecol 2002; 186:903-6. Sociedad Española de Obstetricia y Ginecología (SEGO). Protocolos asistenciales en Obstetricia. Amenaza de parto pretérmino (2004). Disponible en: Brocklehurst P, French R. The association between maternal HIV infection and perinatal outcome: a systematic review of the literature and meta- analysis. Br J Obstet Gynaecol 1998; 105: European Collaborative Study. Vertical transmission of HIV-1: maternal immune status and obstetric factors. AIDS 1996; 10: Lorenzi P, Spicher VM, Laubereau B, Hirschel B, Kind C, Rudin C et al. Antiretroviral therapies in pregnancy: maternal, fetal and neonatal effects: Swiss HIV Cohort Study, the Swiss Collaborative HIV and Pregnancy Study and the Swiss Neonatal Study. AIDS 1998; 12 (18):F241-F247. The European Collaborative Study and the Swiss Mother and Child HIV Cohort Study. Combination antiretroviral therapy and duration of pregnancy. AIDS 2000; 14: Goldstein PJ, Smit R, Stevens M, Sever JL. Association between HIV in pregnancy and antiretroviral therapy, including protease inhibitors and low birth weight infants. Infect Dis Obstet Gynecol 2000; 8(2):94-8. European Collaborative Study. Increased risk of adverse pregnancy outcomes in HIV-infected women treated with highly active antiretroviral therapy in Europe [Research letter]. AIDS 2004; 18: Taha TE, Nour S, Kumwenda NI, Broadhead RL, Fiscus SA, Kafulafula G, Nkhoma C, Chen S, Hoover DR. Gender differences in perinatal HIV acquisition among African infants. Pediatrics Feb;115(2):e Thorne C, Newell ML; European Collaborative Study. Are girls more at risk of intrauterine-acquired HIV infection than boys? AIDS Jan 23;18(2):344-7. Factores ligados ao bebé Prematuridade Sexo do bebé? 22

Redução da MTCT: Questões a resolver
Infecção por VIH em mulheres com potencial de concepção Gravidez não planeada em mulheres seropositivas Transmissão durante a gravidez, parto e concepção, e aleitamento materno The risk of mother-to-child transmission can be minimised in a number of ways: Preventing HIV infection among women of childbearing potential in the first place Reducing the chance of unplanned pregnancy among women with HIV Minimising the risk of transmission during pregnancy, labour, delivery and breastfeeding through access to optimal counselling, treatment and antenatal services

Intervenções para travar a MTCT
Cesariana Suplementação com fórmula Evitar procedimentos durante o parto TAR Cuidados pré-natais Redução da MTCT With access to optimal treatment and prevention the risk of MTCT is less than 2% A comprehensive programme to reduce MTCT includes: improved availability, quality, and use of antenatal and child health services HIV testing and counselling for HIV in pregnancy Antenatal care Common antenatal protocols Safe and effective antiretroviral agents Obstetric interventions Avoid amniotomy Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood sampling Restrict episiotomy Elective cesarean section Infection prevention practices Post-natal care Exclusive formula feeding Contraceptive services Teste de VIH e aconselhamento pré-natal Práticas de prevenção da infecção

Tratamento e cuidados durante a gravidez e o parto

Cuidados pré-natais e VIH
Os cuidados pré-natais oferecem uma oportunidade para: Aconselhar as grávidas acerca do risco do VIH Disponibilizar o teste do VIH Aconselhar acerca de outras DST e saúde sexual e reprodutiva em geral Prestar aconselhamento regular sobre sexo seguro Prestar aconselhamento de saúde essencial acerca de nutrição e dos perigos da toxicodependência (álcool, consumo de tabaco e de drogas ilícitas) The risk of MTCT is greatly reduced the sooner a woman can be diagnosed, through preventative measures such as therapy and avoiding breastfeeding Routine HIV testing for all pregnant women is now recommended in many parts of the world as part of routine antenatal care. After notifying the patient, counselling and testing is performed unless the patient declines HIV testing ("opt-out" consent or "right of refusal") For women in labour with undocumented HIV-infection status during the current pregnancy, immediate maternal HIV testing with opt-out consent, using a rapid HIV antibody test is recommended in some countries For women diagnosed through an antenatal testing programme, supportive post-test counselling must be provided, which may be via maternity or GUM services. The antenatal care available will depend on the resources available and the needs of the individual. A system of clear referral paths should be established in each unit or department so that pregnant women who are diagnosed with an HIV infection are managed and treated by the appropriate specialist teams. These multidisciplinary teams should ideally include an HIV specialist, an obstetrician, a specialist midwife and a paediatrician. Psychologists, social workers, counselling services, voluntary groups and community support groups can also play an important role A thorough early assessment of the social circumstances of a newly diagnosed pregnant woman with HIV is essential, and specially tailored antenatal classes, where inappropriate emphasis on breast-feeding and vaginal delivery can be avoided, should be provided if possible

Testes na gravidez No âmbito do VIH Outras patologias infecciosas
carga vírica de RNA do VIH no plasma Bioquímica e contagem total de células no sangue (contagem de células CD4) Teste de resistência a fármacos anti-retrovíricos Monitorização Sérica da Terapêutica Outras patologias infecciosas Teste da tuberculina Teste da Hepatite B Teste da Hepatite C Citologia e teste do HPV Culturas urinária e vaginal Teste da diabetes na gravidez T.O.R.C.H. HIV-related tests in pregnancy can include: Plasma HIV RNA viral load Biochemistry and complete blood count (including platelet count and lymphocyte subsets (CD4 cell count) Antiviral drug resistance testing Therapeutic Drug Monitoring Tests in pregnancy related to other risks can include: Tuberculosis (can be endemic in countries from which women migrating to Europe and North America originate) Liver function tests Screening for sexually transmitted infections Hepatitis B testing Hepatitis C screening should be considered in cases of current or prior intravenous drug use TORCH (diseases that cause congenital conditions if a foetus is exposed to them when in the uterus: Toxoplasmosis, Other (such as syphilis, varicella, mumps, parvovirus, and HIV), Rubella, Cytomegalovirus, Herpes simplex

Objectivos do tratamento na gravidez
Saúde materna perfeita Minimização dos efeitos colaterais para a mãe Redução do risco de transmissão mãe-filho Minimização do risco para o bebé The goal of care in pregnancy is to have a mother with optimal health who is able to parent and enjoy being a mother to her uninfected baby HIV treatment in pregnant women should aim for full suppression of HIV RNA by the time of delivery, and preferably by the third trimester in order to prevent mother-to-child transmission. This should be balanced with the risks of ART to the unborn child and side-effects of ART in the mother

O que recomendam as directrizes de tratamento?
Resumo das directrizes europeias (da EACS), britânicas (da BHIVA) e francesas para o início da terapêutica em mulheres que pretendam engravidar: Preferência de inibidores da protease reforçados Nevirapina como alternativa Boosted protease inhibitors are the preferred treatment choice for women with HIV wishing to become pregnant Nevirapine is an alternative, but in women with CD4 counts greater than 250 cell/mm3 there is an increased risk of hepatotoxicity Efavirenz should be avoided in pregnancy or in women planning pregnancy due to its teratogenic potential References European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008] de Ruiter A, Mercey D, J Anderson J, et al. British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women HIV Medicine 2008;9:452–502. Ministère de la Santé et des Solidarités. Prise en charge médicale des personnes infectées par le VIH. Rapport Efavirenz potencialmente teratogénico 29

Directrizes europeias (da EACS)
Igual utilização do regime de TARV em mulheres grávidas e não grávidas, exceptuando: Evitar EFV Não deverá ser iniciada terapêutica com Abacavir, nevirapina e TDF (possibilidade de continuação se iniciados antes da gravidez) Utilização de LPV/r ou SQV/r como PI/r preferencial ZDV deverá fazer parte do regime Regimen choices in pregnant women are the same as for non-pregnant women in general except: Avoid efavirenz, which can cause birth defects Avoid the ddI + d4T combination Abacavir and nevirapine should not be started, but can be continued if a woman is already taking them and stable Preferred protease inhibitors are lopinavir/ritonavir and ritonavir- boosted saquinavir Zidovudine should be included in the regimen if possible, due to its ability to prevent mother-to-child HIV transmission References European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008] Directrizes da European AIDS Clinical Society (EACS) para a Gestão Clínica e Tratamento de Adultos Infectados com VIH na Europa, 2008

Directrizes gerais: tratamento do VIH na gravidez
Todos os casos de exposição a fármacos anti-retrovíricos durante a gravidez deverá ser comunicada ao Antiretroviral Pregnancy Registry (mais dados em Cenário de Gravidez Recomendação 1. Mulheres que engravidam quando já estão a fazer TAR 1. Manter a TARV mas alterar fármacos potencialmente tetarogénicos 2. Mulheres que engravidam sem experiência terapêutica, e que preenchem os requisitos (CD4) para iniciar a TARV 2. Iniciar TARV – o ideal é no início do 2º trimestre 3. Mulheres que engravidam sem experiência terapêutica, e que não preenchem os requisitos (CD4) para iniciar a TARV 3. Iniciar TARV no início da 28ª semana de gravidez (no mínimo, 12 semanas antes do parto); iniciar mais cedo se houver carga vírica elevada no plasma ou risco de prematuridade 4. Mulheres que começam a ser seguidas após a 28ª semana de gravidez 4. Início imediato da TARV References European AIDS Clinical Society (EACS) Guidelines for the Clinical Management and Treatment of HIV Infected Adults in Europe. October Available at: [Accessed November 2008] Directrizes da European AIDS Clinical Society (EACS) para a Gestão Clínica e Tratamento de Adultos Infectados com VIH na Europa. 2008

Inibidores da integrase
Categorias norte-americanas de directrizes de recomendação: Uso perinatal de ARV 4 PI’s NNRTI’s NRTI’s Inibidores de entrada Inibidores da integrase Recomendados Lopinavir/r Nevirapina Zidivudina* Lamivudina* Alternativos Indinavir Ritonavir Saquinavir HGC Nelfinavir Abacavir# Didanosina Emtricitabina† Estavudina Dados insuficientes Amprenavir Atazanavir Fosamprenavir Darunavir Tipranavir Tenofovir DF† Enfuvirtide Maraviroc Raltegravir Não recomendados Efavirenz† Delavirdina Zalcitabina References Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov). *A Zidivudina e a lamivudina estão incluídas como combinado de dose fixa no Combivir; a zidivudina, a lamivudina e o abacavir estão incluídos como combinado de dose fixa no Trizivir. † A emtricitabina e o tenofovir estão incluídos como combinado de dose fixa no Truvada; a emtricitabina, o tenofovir e o efavirenz estão incluídos como combinado de dose fixa no Atripla. # Os regimes triplos de NRTI, inlcuindo o abacavir, revelaram-se menos potentes em termos virológicos, comparativamente aos regimes de HAART baseados em PI. Os regimes triplos de NRTI deverão apenas ser utilizados caso não seja possível o uso de um regime HAART baseado em NNRTI ou PI (por exemplo, devido a interacções medicamentosas significativas). Está a ser desenvolvido um estudo que avalia a utilização de zidivudina/lamivudina/abacavir entre mulheres grávidas com RNA do VIH < cópias/mL enquanto regime que poupa classes de fármacos. Disponível em: Revisto a 8 de Julho de 2008 32

Cesariana versus parto vaginal
Em 560 mulheres com níveis de RNA do VIH não detectáveis, a cesariana electiva estava associada a uma redução de 90% do risco de MTCT, comparativamente ao parto vaginal ou à cesariana de urgência A cesariana poderá não ser uma opção melhor do que o parto vaginal em gravidezes de termo em mulheres com uma carga vírica <400 Among 560 women with undetectable HIV RNA levels, elective Caesarean section was associated with a 90% reduction in MTCT risk (odds ratio, 0.10; 95% CI, ), compared with vaginal delivery or emergency Caesarean section1 The authors suggest that offering an elective Caesarean section delivery to all HIV-positive women, even in areas where HAART is available, is appropriate clinical management, especially for persons with detectable viral loads In another study, elective caesarean section tended to be inversely associated with MTCT in the overall population, but not in mothers who delivered at term with viral load <400 copies/ml [odds ratio (OR), 0.83; 95% CI, ; P = 0.37].2 Among them, only duration of antenatal therapy was associated with transmission (OR by week, 0.94; 95% CI, ; P = 0.03) References European Collaborative Study. Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy. Clin Infect Dis 2005;40(3): Warszawski J, Tubiana R, Le Chenadec J, Blanche S, Teglas JP, Dollfus C, Faye A, Burgard M, Rouzioux C, Mandelbrot L; ANRS French Perinatal Cohort. Mother-to-child HIV transmission despite antiretroviral therapy in the ANRS French Perinatal Cohort. AIDS 2008;22(2):

Profilaxia pós-exposição (PPE) para bebés
Monoterapia Terapêutica tripla Para a maioria dos bebés: Monoterapia com ZDV b.i.d. durante 4 semanas ou Monoterapia alternativa adequada de TARV se a terapêutica seguida pela mãe não incluir ZDV Para bebés de: mães sem tratamento mães com RNA vírico detectável apesar de terapêutica combinada OU Most infants should be given ZDV monotherapy twice daily (bid) for 4 weeks. Alternative suitable ART monotherapy may be given if maternal therapy does not include ZDV Triple therapy should be given as post-exposure prophylaxis (PEP) for infants born to untreated mothers or mothers with detectable viraemia despite combination therapy References Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov).

Recomenda-se testes de resistência de fármacos ao VIH a
Todas as mulheres grávidas e sem experiência terapêutica, antes do início da terapêutica ou profilaxia com TAR Todas as mulheres em terapêutica pré-natal anti-retrovírica, com persistência de níveis de RNA do VIH detectáveis ou com supressão vírica insuficiente após o início da terapêutica anti-retrovírica Para a prevenção perfeita da transmissão perinatal, poderá justificar-se o início empírico da terapêutica anti-retrovírica antes do conhecimento dos resultados dos testes de resistência, com os necessários ajustes após a disponibilização dos resultados Determining HIV genotype (or phenotype) may be warranted: Pre-therapy (at presentation) If viraemic on established therapy If considering switching therapy At delivery if on monotherapy 2 – 3 weeks after stopping suppressive therapy Transmission of drug resistance to the infant can occur ART resistance testing recommendations vary by locality. Ideally a baseline resistance assay should be performed on all pregnant women at diagnosis and a further test undertaken following short-term antiretroviral therapy (START). If this is not possible, resistance testing in ART naïve, HIV-positive pregnant patients is warranted, as is testing in patients with acute HIV infection and virologic failure or suboptimal viral suppression by ART Switching to a more complex regimen during pregnancy may adversely affect adherence resulting in virologic failure at delivery. It may be beneficial to wait to initiate ART until the resistance testing results are available to avoid prescribing a suboptimal regimen There is concern that the use of ZDV monotherapy in pregnancy may lead to the emergence of drug-resistant virus, possibly compromising the mother’s future care. Although early studies demonstrated resistance it now appears that the risk of developing ZDV resistance is likely to be low if monotherapy is restricted to drug-naïve asymptomatic women, with low viral loads and good CD4 cell counts The long half-life of NVP and its low genetic barrier contribute to development of resistance, and this has implications for its use as a single-dose intervention or in a short-term HAART regimen The high genetic barrier to resistance of boosted PIs and their short plasma half-life make them a more attractive option for START than NNRTIs Transmission of drug-resistant virus to the infant can occur. Although some studies have indicated that drug resistance is not necessarily associated with an increased risk of perinatal transmission there is still insufficient information to define clearly the relationship between drug-resistant mutants and mother-to-child transmission References Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov). de Ruiter A, Mercey D, J Anderson J, et al. British HIV Association and Children’s HIV Association guidelines for the management of HIV infection in pregnant women HIV Medicine 2008;9:452–502. Disponível em: Revisto a 8 de Julho de 2008 35 35

Co-infecção por Vírus da Hepatite B
Detecção do antigénio de superfície da hepatite B Não são recomendadas terapêuticas com base em interferon e ribavirina durante a gravidez O tratamento deverá incluir tenofovir e 3TC ou emtricitabina (FTC) A toxicidade hepática deverá ser cuidadosamente vigiada Deverá ser administrada aos bebés de mulheres portadoras de hepatite B imunoglobulina anti-hepatite B (HBIG), e ser iniciada a série de vacinação de três doses da hepatite B nas 12 horas a seguir ao nascimento Screening for hepatitis B surface antigen is recommended for all HIV-infected pregnant women who have not been screened during the current pregnancy Interferon-alpha and pegylated interferon-alpha are not recommended during pregnancy For pregnant women with chronic hepatitis B virus (HBV) (i.e. hepatitis B surface antigen positive for >6 months)/HIV coinfection who require antiretroviral treatment for HIV disease or who require anti- HBV therapy, a three-drug regimen including a dual NRTI backbone of tenofovir plus 3TC or emtricitabine (FTC) is usually recommended For women who require treatment of HBV but not HIV, postpartum options include stopping antiretroviral drugs and initiating pegylated interferon-alpha for HBV treatment, or continuing the three-drug antiretroviral regimen For pregnant women with HBV/HIV coinfection who do not require treatment for either HIV or HBV and therefore discontinue prophylaxis postpartum, consultation with an expert in HIV and HBV is recommended Pregnant women with HBV/HIV coinfection receiving antiretroviral drugs should be counseled about signs and symptoms of liver toxicity and transaminases should be assessed 2 weeks following initiation of antiretroviral therapy or prophylaxis and then at least monthly. Infants born to women with hepatitis B infection should receive hepatitis B immune globulin (HBIG) and initiate the three-dose hepatitis B vaccination series within 12 hours of birth References Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV- Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov) 36 36

Co-infecção por Vírus da Hepatite C
Recomenda-se o despiste da infecção por vírus da hepatite C (HCV) Não são recomendadas terapêuticas com base em interferon e ribavirina durante a gravidez A toxicidade hepática deverá ser cuidadosamente vigiada A modalidade do parto deverá ser decidida exclusivamente com base na infecção por VIH Os bebés deverão ser submetidos a rastreio da infecção por HCV, através de testes do RNA do HCV, entre os 2 e os 6 meses de idade e/ou análise de anticorpos do HCV após os 15 meses de idade Screening for hepatitis C virus (HCV) infection is recommended for all HIV-infected pregnant women who have not been screened during the current pregnancy Pegylated interferon-alpha is not recommended and ribavirin is contraindicated during pregnancy. Combination antiretroviral therapy with three drugs should be considered for all HCV/HIV coinfected pregnant women, regardless of CD4 count or HIV viral load; the antiretroviral drugs can be discontinued postpartum in women who do not require HIV therapy for their own health Pregnant women with HCV/HIV coinfection receiving antiretroviral drugs should be counselled about signs and symptoms of liver toxicity, and transaminases should be assessed 2 weeks following initiation of antiretroviral therapy or prophylaxis in women not already receiving drugs, and then at least monthly Decisions concerning mode of delivery in HCV/HIV coinfected pregnant women should be based on considerations related to HIV infection alone Infants born to women with HCV/HIV coinfection should be evaluated for HCV infection by HCV RNA testing between 2 and 6 months of age and/or HCV antibody testing after 15 months of age References Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States - July 8, available on the AIDSinfo Web site (AIDSinfo.nih.gov) 37 37

Saúde psico-social, mental e bem-estar emocional
Avaliação do estado psicológico antes da concepção, durante a gravidez e a maternidade Mesmo em doentes sem doença mental, poderá ocorrer patologia nova, como a depressão pós-parto Os doentes com historial de perturbações mentais ou em terapêuticas com substâncias psicotrópicas deverão receber tratamento especializado e ser vigiados com vista à reavaliação da segurança e da eficácia do tratamento psicotrópico durante a gravidez com vista ao seguimento da adesão à terapêutica anti-retrovírica e psicotrópica 38 38

Testes de rotina durante a gravidez

Para reduzir a probabilidade de transmissão do VIH ao seu filho, a mulher tem de conhecer primeiro o seu estado serológico

Testes de VIH disponibilizados como testes de rotina na gravidez
Áustria  Bulgária Bielorússia Canadá República Checa Dinamarca Estónia França Alemanha Grécia Hungria Itália Malta Moldávia, República da  Países Baixos Noruega Polónia Portugal Federação Russa Eslováquia Eslovénia Espanha Suíça Ucrânia Reino Unido Although many countries offer routine HIV testing in pregnancy, in some countries few women are routinely tested at any stage in their pregnancy. The slide shows those countries where routine ‘opt-out’ testing is performed. The countries without a tick have an alternative (or no) policy for testing1 HIV testing during pregnancy is an option available to women across Canada. However, physician guidelines and/or recommendations encouraging informed decisions regarding HIV testing during pregnancy vary by province and territory References Mounier-Jack S, Nielsen S, Coker RJ. HIV testing strategies across European countries. HIV Med 2008;9 Suppl 2:13-9. Epi Update entitled "Perinatal Transmission of HIV," May 2004. Adaptado de Mounier-Jack et al., HIV Med, 2008

Recomendações relativas aos testes
Disponibilização do teste do VIH a todas as mulheres no início da gravidez, ou o mais rapidamente possível, caso se apresentem tardiamente à consulta de pré-natal Repetição do teste durante a gravidez em mulheres com risco continuado de contrair o VIH Teste rápido de VIH a mulheres admitidas para trabalho de parto Disponibilização dos resultados dos testes ao pessoal indicado dos blocos de partos Routine ‘opt-out’ HIV testing of pregnant women is key to prevention of mother-to-child transmission of HIV Repeat testing in the third trimester and rapid HIV testing at labour and delivery are additional strategies to further reduce the rate of perinatal HIV transmission. Although the number of infected infants born to women who test negative in early pregnancy is low, any indication that a woman is at continuing risk of acquiring infection in pregnancy should be recorded, and repeat testing offered New rapid testing methods allow identification of women who are HIV positive or HIV-exposed infants in 20 to 60 minutes Midwives and doctors reviewing women during antenatal care should ensure that the HIV test result is clearly documented. Labour ward staff and any staff undertaking invasive genetic screening tests must be aware of a woman’s HIV status

Necessidade de mais investigação

Gravidez e VIH: Necessidade de mais dados clínicos e de mais estudos
Os dados relativos à gravidez / VIH / exposição in utero de crianças ao ART são escassos – dificuldade de elaboração de estudos neste contexto Resultados baseados em estudos de pequena dimensão – implicações clínicas pouco claras Alguns dados revelam diferenças de género quanto à MTCT e à resistência do bebé Contudo, os dados relativos à pré-adolescência raramente são segmentados em função do género It is difficult to conduct studies in this arena and data on issues relating to pregnancy and HIV are relatively sparse For example, some data show gender differences in MTCT, e.g.: transmission in utero appears higher for female foetuses; postpartum transmission is higher for males foetuses; resistance is higher in male babies and there is a higher risk of transmission by breast feeding in boys. However, data among pre-adolescents is rarely disaggregated according to gender, and studies in pregnant women and in pre-adolescents is relatively rare Many findings are based on small studies and clinical implications are often unclear While there are barriers to conducting adequately powered clinical studies in the setting of HIV and pregnancy, alternatives are needed to address the lack of data and to clarify the clinical significance of any findings As alternativas terão de incidir sobre a falta de dados e esclarecer a relevância clínica dos resultados apurados

Registo de Gravidez Anti-retrovírica
Único projecto que avalia as exposições pré-natais à TARV no primeiro trimestre (e posteriores) Recolhe dados anónimos sobre resultados relativos ao feto / à mãe Disponibiliza informação importante para complementar dados de ensaio clínico Os dados irão ajudar os médicos / doentes a ponderar os potenciais riscos e benefícios da terapêutica As mulheres grávidas a seguir TAR deverão ser encorajadas a participar no registo The Antiretroviral Pregnancy Registry is intended to provide an early signal of any major teratogenic effect associated with a prenatal exposure to the ART products monitored through the Registry The Registry is a voluntary prospective, exposure-registration, observational study designed to collect and evaluate data on the outcomes of pregnancy exposures to antiretroviral products This Registry is the only project expressly established to evaluate first trimester, as well as later prenatal exposures to antiretroviral medications. Registry data supplement other sources of data and assist clinicians and patients in weighing potential risks and benefits of treatment

Índice de anomalias à nascença em nados vivos
Casos pesquisados com exposição trimestral conhecida ao LPV/r e dados de seguimento completos 0,72 23/955 (2,4%) 18/688 (2,6%) 5/267 (1,9%) 23 (2,4%) 955 Total (%) *Exclui 1 único nado vivo sem anomalias devido a trimestre de exposição inespecífico. Inclui 920 resultados de nados vivos únicos e 35 múltiplos. ** Apenas anomalias que preenchem os critérios do CDC. Exclui anomalias em perdas de gravidez <20 semanas. Um dos resultados é definido como nado vivo ou morto, ou uma perda de gravidez expontânea ou induzida ≥20 semanas de gestão. (0,27, 1,91) CI exacto de 95% para Risco de Anomalias à Nascença relativo ao 1o Trimestre Exposição Relativa a Exposições no 2º/3º Trimestre [1,5% - 3,6%] Qualquer trimestre [1,6%-4,1%] 2º/3º Trimestre [0,6%-4,3%] 1º Trimestre IC exacto de 95% para a prevalência de Anomalias à Nascença relativas a Exposições no: Número de Resultados com pelo menos Uma anomalia** Número de Nascimentos Vivos* [95% CI] This is the first adequately powered and published study on the overall risk of birth defects associated with LPV/r exposures during pregnancy. The APR reported an overall prevalence of birth defects of 2.7% among 9,948 ART exposed pregnancies and 2.8% among 2,673 pregnancies exposed during the first trimester.1 Other large observational studies have reported similar findings2-4 References APR Steering Committee. Interim Report for 1 January 1989 through 31 July 2008, Available at European Collaborative Study. Exposure to antiretroviral therapy in utero or early life: the health of uninfected children born to HIV-infected women. J Acquir Immune Defic Syndr 2003;32(4):380-7. Townsend CL, Tookey PA, Cortina-Borja M, Peckham CS. Antiretroviral therapy and congenital abnormalities in infants born to HIV-1-infected women in the United Kingdom and Ireland, 1990 to J Acquir Immune Defic Syndr 2006;42(1):91- 4. Watts DH, Li D, Handelsman E, Tilson H, et al. Assessment of birth defects according to maternal therapy among infants in the Women and Infants Transmission Study. J Acquir Immune Defic Syndr 2007;44(3): A prevalência geral de anomalias à nascença, de 2,4% em gravidezes com exposição ao LPV/r, é inferior à da prevalência geral de 2,67% do Registo do CDC 46 46

Investigação futura e questões e necessidades clínicas específicas
Avaliação da segurança dos fármacos e da farmacocinética Optimização dos regimes neonatais para avaliação perinatal de resistência aos fármacos Risco de aleitamento materno quando a carga vírica é indetectável Interrupção da terapêutica anti-retrovírica Optimização da adesão Papel do parto por cesariana em mulheres com carga vírica indetectável ou com ruptura de membranas de curta duração Disponibilização de teste rápido aquando do parto, para mulheres que se apresentem tardiamente Cooper ER, Charurat M, Mofenson LM, et al. Combination antiretroviral strategies for the treatment of pregnant HIV- 1 infected women and prevention of perinatal HIV-1 transmission. J Acquir Immune Defic Syndr Hum Retrovirol, (5): Ioannidis JP, Abrams EJ, Ammann A, et al. Perinatal transmission of human immunodeficiency virus type 1 by pregnant women with RNA virus loads <1000 copies/mL. J Infect Dis, (4): Cunningham CK, Chaix ML, Rekacewicz C, et al. Development of resistance mutations in women receiving standard antiretroviral therapy who received intrapartum nevirapine to prevent perinatal human immunodeficiency virus type 1 transmission: a substudy of pediatric AIDS clinical trials group protocol 316. J Infect Dis, (2):181-8. Eshleman SH, Mracna M, Guay LA, et al. Selection and fading of resistance mutations in women and infants receiving nevirapine to prevent HIV-1 vertical transmission (HIVNET 012). AIDS, (15): Lyons FE, Coughlan S, Byrne CM, et al. Emergence of antiretroviral resistance in HIV-positive women receiving combination antiretroviral therapy in pregnancy. AIDS, (1):63-7. McIntyre J, Martinson N, Investigators for the Trial 1413, et al. Addition to short course combivir (CBV) to single dose viramune (sdNVP) for prevention of mother-to-child transmission (MTCT) of HIV-1 can significantly decrease the subsequent development of maternal NNRTI-resistant virus. XV International AIDS Conference; July 11-16, 2004; Bangkok, Thailand. Abstract LbOrB09. Elective caesarean-section versus vaginal delivery in prevention of vertical HIV-1 transmission: a randomised clinical trial. The European Mode of Delivery Collaboration. Lancet, (9158): The International Perinatal HIV Group. The Mode of Delivery and the Risk of Vertical Transmission of Human Immunodeficiency Virus Type 1 - a Meta-Analysis of 15 Prospective Cohort Studies. N Engl J Med, (13): Dominguez KL, Lindegren ML, D’Almada PJ, et al. Increasing trend of cesarean deliveries in HIV-infected women in the United States from 1994 to J Acquir Immune Defic Syndr, (2):232-8. The International Perinatal HIV Group. Duration of ruptured membranes and vertical transmission of HIV-1: a meta- analysis from 15 prospective cohort studies. AIDS, (3): Jamieson DJ, Clark J, Kourtis AP, et al. Recommendations for human immunodeficiency virus screening, prophylaxis, and treatment for pregnant women in the United States. Am J Obstet Gynecol, (3 Suppl):S Bulterys M, Jamieson DJ, O’Sullivan MJ, et al. Rapid HIV-1 testing during labor: a multicenter study. JAMA, (2): 47 47

Estudos de caso

Estudo de caso: Ex-consumidora de drogas por via endovenosa
Mulher de 25 anos, seropositiva Grávida de 8 semanas Ex-consumidora de drogas injectáveis Manutenção relativamente estável com metadona Portadora de Hepatite C (anticorpo e PCR) Para além da gestão do tratamento e do parto em função das infecções por VIH / co-infecções, que outras questões há a ponderar?

Questões a ponderar Saúde mental e bem-estar emocional
As mulheres apresentam uma maior propensão para o diagnóstico de distúrbios emocionais e de saúde mental do que os homens A gravidez e os problemas de toxicodependência aumentam o risco de problemas do foro emocional ou familiar em mulheres com VIH Os diagnósticos de VIH durante a gravidez estão associados a uma incidência mais elevada de questões de saúde mental (por exemplo, depressão pós-parto), do que os diagnósticos fora da gravidez Nem todas as clínicas de VIH têm bom acesso a serviços de psiquiatria perinatal In general, women are more likely to present and be diagnosed with mental health and emotional problems than men, especially depression and anxiety disorders. The incidence of mental and emotional problems is intensified in HIV positive women, during pregnancy, and among women with substance use problems Women diagnosed during pregnancy have a higher incidence of mental health issues including postpartum depression than those diagnosed pre- pregnancy Some (but not all) centres have good access to perinatal psychiatric services

Questões a ponderar Revelação Encoraja-se a revelação aos parceiros
Recomenda-se que as outras crianças façam o teste do VIH A gravidez é uma janela chave para a revelação É mais provável que a mulher revele durante a gravidez. Se não o fizer, é provável que o faça no pós-parto Disclosure Disclosure to partners should be encouraged in all cases but may be viewed as a process that may take some time. Pregnancy is a key window for disclosure. Research shows that a woman is more likely to disclose during pregnancy, but if she doesn’t disclose then she is likely to do so postpartum Reassurance about confidentiality is extremely important, especially regarding family members and friends who may not know the diagnosis but are intimately involved with the pregnancy Adherence This is of vital importance for the success of therapy and pregnant women may need extra support and planning in this area, especially if there are practical or psychosocial issues that may impact adversely on adherence. Referral to peer support workers, psychology support and telephone contact may all be considered Adesão Inscrição em programa de educação Adesão e seguimento

Questões a ponderar Contracepção depois da gravidez
Continua a não haver contraceptivo ideal Se o parceiro for seronegativo recomenda-se o uso de preservativos Em casos de supressão vírica total, parceiros estáveis e ausência de outras DST, existe um risco mínimo de transmissão. Como deverão ser abordadas estas questões? Muitos ARV interagem com os contraceptivos There is still no ideal contraceptive. With a negative partner the only effective form of contraception is condoms The Swiss statement suggests that in cases of full viral suppression, stable partnerships and no other STDs, there is minimal risk of transmission. This is a statement of much debate. The clinicians managing this woman should consider how this question should be handled should it arise Many ARVs interact with contraceptives although Depo-provera and IUDs can still be used. In this case, however, if the pregnancy is to proceed, these are not viable options

Estudo de caso: Resultado díspar de teste de VIH
Mulher de 33 anos e parceiro do sexo masculino submetem-se a testes de VIH antes de interromper o uso do preservativo para planear uma família O resultado da mulher é seropositivo e o do homem é seronegativo A mulher recusa-se a informar o parceiro da sua seropositividade, por receio de ser abandonada Many national guidelines preserve patient confidentiality unless special circumstances call for disclosure, i.e. where non-disclosure represents a risk to the public or to another individual’s health. Indeed, there have been legal cases where doctors have been held accountable for non-disclosure Counselling before HIV testing should introduce the topic of disclosure and, in the event of a positive result, post-test counselling can explore the specifics of who and how to tell Some women may be at risk of violence, abandonment, financial loss, social discrimination and isolation when they disclose their status Para além da gestão do diagnóstico e da eventual gravidez, que outras questões há a ponderar?

Questões a ponderar Revelação e confidencialidade na relação entre doente e profissional de saúde Muitas directrizes nacionais salvaguardam a confidencialidade em relação aos doentes, exceptuando em circunstâncias especiais O aconselhamento pré-teste e pós-teste deverá analisar abertamente o resultado seropositivo e propor o modo como as pessoas se deverão preparar para receber “más notícias” Casos de criminalização de doentes seropositivos responsáveis pela infecção de terceiros, e de responsabilização criminal de médicos por não revelação A revelação sem o consentimento da mulher poderá ser obrigatória, podendo embora ter consequências negativas gravosas no que diz respeito à confiança na relação entre doente e médico Many national guidelines preserve confidentiality to patients unless there are special circumstances – such as an overriding public interest or risk to another individual’s health Pre- and post-test counselling should openly discuss and anticipate such an outcome and propose how patients should prepare for ‘bad news’ There have been cases of criminalization of HIV positive patients who infected others, as well as doctors being criminally liable for non-disclosure Disclosing to the HIV negative partner without the woman’s consent may be mandatory but will also have consequences for trust within the doctor- patient relationship that need to be anticipated

Criminalização da transmissão do VIH
Em muitas jurisdições, a Lei não é clara nesta matéria É improvável que alguém possa vir a ser processado de forma ética e bem sucedida pela transmissão não intencional do VIH Houve algumas condenações na Europa, no âmbito de casos raros em que os indivíduos não tinham consciência do seu estado, nomeadamente: Escócia Processo Stephen Kelly (julgamento Glenochil) – Março de 2001 (Jurisprudência escocesa) Condenado por “lesão negligente” da anterior parceira Inglaterra Mohammed Dica, Novembro de 2003 Ofensa gravosa à integridade física por infecção deliberada de duas mulheres com VIH Condenação confirmada em segundo julgamento de Março de 2005 In certain countries, transmitting or exposing another person to HIV has been criminalised1. For example, in Scotland intravenous drug user Stephen Kelly was convicted after passing HIV to his female partner2. Similarly, in England, the first successful prosecution for HIV transmission was brought against Mohammed Dica2. Both convictions were based on the men acting recklessly or intentionally – as they were aware of their HIV status and the risk to their partners In Sweden under the Contagious Disease Act an HIV positive person can be prosecuted for having unprotected sex However, it is unlikely that a person could be prosecuted for unintentional HIV transmission if they are ignorant of their own HIV status. The conviction in England of an undiagnosed HIV-positive man was a case where the patient had been treated for other sexually transmitted infections and warned of the high probability that he was HIV positive, but he failed to attend for a test2 References UNAIDS. Policy brief: Criminalization of HIV transmission. August HIV transmission and the criminal law. Accessed November 55 55

Estudo de caso: Recusa de renúncia ao aleitamento materno
Imigrante africana a viver na Europa A viver em alojamento estatal partilhado Deu à luz um rapaz seropositivo, mas tencionava amamentá-lo, recusando a administração de TARV Acreditava que “Deus olharia por ele” Breast feeding is an important potential route of mother-to-child transmission. Where safe infant feeding alternatives are available, HIV infected women are usually advised to refrain from breast feeding In resource poor settings where breast feeding is essential for infant survival, exclusive breast feeding for four to six months may be justified as the next best option after exclusive use of feeding alternatives Para além da gestão do tratamento, que alternativas deverão ser ponderadas?

Questões a ponderar Apoio social, dever de tratamento da mãe e do bebé
Resolução da situação de alojamento da doente, para que esta deixe de partilhar um quarto, o que poderá fazê-la mudar de opinião acerca do tratamento a dar ao bebé Procura de apoio comunitário, por exemplo, líderes religiosos da comunidade Os líderes religiosos poderão ajudar também a encorajar a adesão, e em questões relacionadas com a estigmatização Necessidade de directrizes sobre como prestar aconselhamento acerca dos riscos do aleitamento materno, à luz da Declaração Suíça Options include addressing the patient’s housing situation so that she did not have to share a room with others. This may have changed her opinion about treating her baby Seeking community support, especially community faith leaders, can help in such cases. Faith leaders can also help to encourage adherence and issues related to stigma Many patients with undetectable viral load are asking whether it is possible to breastfeed and guidelines are needed on how to advise on the risks in the light of the Swiss statement

Retirada da criança e entrega em instituição
O bebé poderia ser retirado à mãe e entregue a uma instituição, sendo-lhe devolvido passados os 4 meses em que seriam tratadas as questões da não-aceitação da TARV para a criança, do aleitamento e de outros riscos de transmissão No entanto, deveria ser um último recurso, uma vez que as consequências poderão ser altamente nefastas em termos do impacto psicológico na mãe e no bebé, e do impacto nas relações médico-doente-família The baby could be taken into care by a court of law and treated, then returned to the mother after 4 months. However, separating babies from their mothers should be a last resort as the consequences can be damaging in terms of the psychological impact on the mother and baby and the impact on the relationship between the healthcare providers and the family Possible reasons for taking a child into care include: Issues with acceptance of ART treatment Threat of breastfeeding Threat of transmission via other routes Criminalisation of transmission has mainly occurred in cases of male to female transmission, however, laws criminalising HIV transmission – whether via sex, needle-sharing or from a mother to an unborn child or infant – are high on the agenda of many nations, despite little evidence that these laws modify behaviour in a beneficial way 58 58

Crenças As crenças assumem importância para muitas mulheres seropositivas Sempre que possível, é mais eficaz colaborar “com” as crenças, não “combatê-las” Utilização de líderes religiosos e de “histórias” poderá melhorar o empenho Human beings are often illogical in both their deep-held beliefs and their behaviours Education is often not enough to modify damaging or risky behavior Beliefs are therefore a reality and an integral part of care as they are fundamental to the way most people think and act in everyday life The same holds true for many women living with HIV – particularly those with strong religious and superstitious beliefs, as well as people with a strong faith in alternative and traditional forms of medicine It is crucial to integrate science, medicine and these beliefs, rather than attempting to fight against a woman’s belief system with ‘science’ or ‘logic’ Stories can often be used to engage religious patients to accept their diagnosis or treatment Sometimes encouraging religious patients to adhere to HIV medication as well as praying can be effective, e.g. “Do you pray for God to protect you when crossing a busy road? But, do you still look left and right as well? Taking medication is like looking left and right” 59 59

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