Perinatal transmission of HIV in England 2002-2005
Polly Clayden, HIV i-Base
A report published by the NHS Audit, Information and Analysis Unit (AIAU) in collaboration with the National Study of HIV in Pregnancy and Childhood (NSHPC), and the Childrens HIV Association of the UK and Ireland (CHIVA), describes the circumstances in which infants are born HIV-positive, despite well documented interventions that can reduce mother to child transmission to almost zero in this country.
The authors write, Across the UK more than 30 infants are still being infected annually, and each carries a substantial human and economic cost.
The audit looked at children who were born in England during the four year period between January 2002 and December 2005 and who were reported to the NSHPC as HIV-positive by April 2006.
The audit identified 87 children; 33/87 infants were born to women who were diagnosed before or within 48 hours of delivery. The audit identified failure of communication, between health care professionals and the mother, and between themselves, and failure to ascertain or act upon suboptimal virological responses as issues.
The audit also found the problem of preterm delivery reducing the time for antiretroviral therapy to be given during pregnancy. The authors suggest, in some cases, the obstetric history would have identified the risk of premature delivery, highlighting the need for individualised management.
Among the 54 infants born to undiagnosed women, at least 20% were born following maternal seroconversion during pregnancy.
In some cases, care was not accessed because health workers or the women themselves were not sure if HIV in pregnancy is an emergency condition and therefore eligible for free NHS treatment.
No transmissions occurred in mothers and infants receiving optimal care (according to the BHIVA guidelines) and with an undetectable maternal viral load at delivery.
The audit makes a number of recommendations including:
- All pregnant women should be recommended an HIV test at time of booking. Any woman who declines a test, should be recommended one on at least one more occasion by a health worker with specialist training.
- Any woman receiving a test after 20 weeks should have her blood samples marked for rapid testing.
- Women tested at 28 weeks or later should have point of care testing (or rapid testing within 24 hours).
- Rapid/same day tests should be recommended to women who present in labour with unknown HIV status.
- Potentially mitigating adverse social circumstances should be well documented. Women with complex social needs should receive appropriate referrals and support from a multidisciplinary team.
- A womans circumstances should be considered so ART can be started at the appropriate time. For example if a woman has previously delivered at 28 weeks ART ideally needs to be initiated at 20 weeks.
- BHIVA guidelines for active management for all modes of delivery should be followed.
- There should be no delay in provision of neonatal ART. In cases where there is an increased risk of transmission triple therapy should be considered.
- HIV care and treatment for a woman in pregnancy, and for the infant should be considered emergency care. Care should be free regardless of immigration, asylum or residence status.
This audit is quite revealing. There needs to be some clarification about point of care testing, especially in relation to women in labour. In this setting POCT is the test of choice and the result must be acted upon.
A rapid or same day test with a result several hours later simply isnt good enough especially as the majority of presentations will be out of hours, simply because there are only 40 in hours a week compared to 124 out of hours hours. Therefore, all units need to have this facility in place.
Its good that they give really clear recommendations for women who may have been dissuaded from attending because of fears that they are not eligible for treatment.
The other significant question is of course what to do about seroconversions in pregnancy and as yet there is no simply answer.
Perinatal transmission of HIV in England 2002-2005. October 2007. Download from CHIVA website: http://www.chiva.org.uk/publications/PDF/2007/perinatal.pdf