Good management of HIV positive pregnant women in UK – with some room for improvement
Polly Clayden, HIV i-Base
Management of HIV positive pregnant women is broadly in line with the British HIV Association (BHIVA) guidelines, according to results of a national survey presented at the 2014 BHIVA Autumn Conference.
Yvonne Gilleece from the Royal Sussex County Hospital showed findings from this audit in which lead clinicians at UK HIV services were invited to participate. The respondents were asked to consult maternity and paediatric colleagues for relevant data. Responses were from 112 HIV services with 124 associated maternity services.
Dr Gilleece compared guideline recommendations to survey responses for the following categories:
Working in multidisciplinary teams
The guidelines recommend multidisciplinary working, in teams including a dedicated specialist midwife and/or a women’s HIV clinical nurse specialist.
The survey revealed that 111 of the 112 services have multidisciplinary teams, and only one does not. All of the 110 services with a description of the team included an HIV physician, one had no obstetrician, two no paediatrician and eight had no midwife.
Twenty-nine (26%) of the services had neither an HIV midwife nor a women’s clinical nurse specialist, but 31 (28%) had both, 29 (26%) and 21 (19%) had an HIV midwife and a women’s clinical nurse specialist respectively. Two services (0.02%) did not respond.
Time to be seen in HIV clinic
Following diagnosis via routine antenatal screening, the guidelines recommend women needing antiretroviral treatment (ART) for their own health start within two weeks.
Forty (35.7%) HIV services reported that women were seen in an HIV clinic on the same or the next working day as their diagnosis, 23 (20.5%) reported within two to three days, 29 (25.9%) within a week and 19 (17.0%) in one to two weeks. One service (0.9%) did not answer this question.
Sexual health screening
Screening for sexually transmitted infections (STIs) near the start of pregnancy is recommended for newly diagnosed pregnant women and suggested for all HIV positive pregnant women. The guidelines also state that a repeat screening at 28 weeks might be considered.
The survey found that 84 (75.0%) services screen all women with HIV for STIs at the start of pregnancy, 24 (21.4%) screen women who are diagnosed in pregnancy and three (2.7%) only screen women who are considered to be at risk. There was no answer from one service (0.9%).
Repeat screening for all women with HIV was undertaken in 55 (49.1%) services, five (4.5%) screened women who planned a vaginal delivery, 50 (44.6%) those that were considered to be at risk and/or had an STI earlier in pregnancy, and two (1.9) for other unspecified reasons.
ART in pregnancy
The majority of HIV services (109, 97.4%) have a policy for ART in pregnancy, two do not and one gave no answer.
Antiretroviral regimen preferences were largely as recommended in the guidelines, but 35 (31.3%) services included boosted darunavir among preferred drugs and seven (6.3%) included nevirapine for women with viral load <10,000 and CD4 >350 cells/mm3.
Raltegravir was quite widely used for women presenting late (>28 weeks) with viral load >100,000 copies/mL: 56 (50%) services did so routinely, 43 (38.4%) might use raltegravir, but 11 (9.8%) had no policy, as the situation had not arisen. Only one (0.9%) service would not use raltegravir and one (0.9%) was not sure.
Resistance testing after short-term ART
The guidelines recommend a resistance test after stopping a short course of ART in pregnancy to ensure mutations are not missed due to reversion to wild type virus while a woman is off treatment.
About half (55, 49.1%) of the services do routine resistance tests in this situation. The procedure is not routine for 49 (43.8%) and eight (7.1%) services were not sure.
Of those testing routinely, 77.4% do so within six weeks but 7.5% defer until re-starting ART.
Urgent HIV testing
For women presenting in labour, with ruptured membranes, and those needing to deliver with no HIV result the guidelines recommend and urgent HIV test.
The need for urgent testing had not arisen for 55 (49.1%) HIV services; testing was provided without problems by 40 (35.7%), but 10 (8.9%) services had experienced problems. The tests took over two hours to provide during working hours at 21(18.8%) services and outside working hours at 56 (50.0%).
Mode of delivery
The majority (107, 95.5%) of services have a delivery policy for HIV positive women, but two (1.8%) had no policy and three (2.7%) were not sure.
For women on ART with viral load <50 copies/mL at 36 weeks, the guidelines recommend planned vaginal delivery and this is the policy for 95 (84.8%) services. Maternal choice is policy at nine (8.0%) and a pre-labour Caesaren section at three (2.75%) services; five responded “other” or did not answer.
When pre-labour Caesaren section was performed for prevention of vertical transmission, about 70% of services did so at the recommended 38-39 weeks.
Pre-labour rupture of membranes
When pre-labour rupture of membranes occurs at term the guidelines recommend expedited delivery. If a woman’s viral load is <50 copies/mL, labour should be induced.
Most (92, 83.6%) services induce labour in this situation. Eight (7.3%) services would perform an immediate Caesarean, six (5.5%) responded “other” and four (3.6%) were not sure or did not answer.
Amniocentesis and obstetric procedures
The guidelines recommend deferring amniocentesis until a woman’s viral load is suppressed. Seventy (63.6%) services would delay amniocentesis if possible until <50 copies/mL, nine (8.2%) offer it as for HIV negative women, three (2.7%) always avoid it, 24 (21.8%) do an unspecified “other” and four 3.6%) were not sure or did not answer.
Although the guidelines state that there is no evidence for avoiding episiotomy, amniotomy and foetal blood sampling/scalp monitor in women with viral load <50 copies/mL, about 35%, 45% and 75% of services respectively avoid or would not offer these procedures. About 7% would avoid or not offer external cephalic version.
For instrumental delivery with viral load <50 copies/mL the guidelines recommend to avoid vacuum and use forceps. For this situation: 35% of services would avoid instrumental delivery if possible, 4% avoid forceps and use vacuum, 22% avoid vacuum and use forceps and 35% would use either.
Cabergoline to suppress lactation
There is no recommendation for cabergoline use in the guidelines, but 62 (56.4%) services offer this routinely, 21 (19.1%) do not use, 18 (16.4%) offer it in some circumstances, and nine (8.2%) were not sure or did not answer.
Infant ART prophylaxis and co-trimoxazole
The guidelines recommend commencing ART prophylaxis very soon after birth and “certainly within four hours”. Ninety-nine (89.2%) services give the first dose within four hours to all HIV exposed infants, four (3.6%) services reported one case each of delay 2013-2014 and eight (7.2%) were not sure or did not answer.
Co-trimoxazole is recommended for infected/HIV RNA/DNA positive infants or infants born to mothers with viral load >1000 copies/mL, where infection is not excluded. In these situations: 32 (28.8%) services would give co-trimoxazole to infants only if they were infected/HIV RNA/DNA positive, 41 (36.9%) also if maternal viral load was >1000 copies/mL, and 15 (13.5%) also if infection was not included. A further 21 (18.9%) answered “other” and two (1.8%) gave no answer.
Testing of infants/children
According to the guidelines, all potentially exposed infants/children should be tested. All but one service (that did not answer) – 110 (99.1%) – have arrangements to test exposed infants. These testing arrangements are mostly highly effective and all infants are followed up.
Fewer services have arrangements in place for existing children of women diagnosed in pregnancy, 103 (92.8%) with eight (7.2%) not sure or did not answer. These arrangements are effective at some sites but not all.
Dr Gilleece concluded that overall management of HIV positive women and their infants appears broadly in line with the BHIVA guidelines. But, she noted several areas of concern:
- Urgent HIV testing takes more than two hours at 50% of services outside working hours and 19% within in working hours.
- Seventeen percent of services take over a week to see women diagnosed during antenatal screening.
- Only 49% of services test for resistance routinely after stopping short-term ART. Some services delay tests until mutations could have reverted.
- Planned Caesarean sections are being offered unnecessarily.
- Some obstetric procedures might be being avoided unnecessarily.
- Cabergoline is not routinely offered at all services.
- Testing existing children of newly diagnosed women remains a challenge.
Dr Gilleece recommended that services review their management to ensure the guidelines are followed – particularly for urgent HIV testing – Caesarean and obstetric procedures also need to be reviewed, and use of cabergoline should be addressed in future guidelines.
Results of the audit using data routinely reported to the National Study of HIV in Pregnancy and Childhood will be presented in the next BHIVA conference spring 2015.
Outcomes including adherence to guidelines on timing of ART initiation, regimen choice, planned mode of delivery and sexual health screening will be reported.
Gilleece G. National survey of management of pregnancy in women living with HIV. BHIVA Autumn Conference. 9-10 October 2014. London.