BHIVA pregnancy audit 2013 to 2014

Polly Clayden, HIV i-Base

The BHIVA pregnancy audit, presented at the spring 2014 BHIVA Conference, revealed:

Most initial ART regimens were compliant with BHIVA guidelines.
ART was started in nearly 80% of cases.
Only 29% of newly diagnosed women with CD4 <350 cells/mm3 started ART within 2 weeks.
Many women started ART late and this was mostly not explained by late booking.
More than half of deliveries were by caesarean section.
27% of women with viral load <50 copies/mL at >36 weeks planned for caesarean section.

The audit uses confidential data collected for the National Survey on HIV in Pregnancy and Childhood (NSHPC). Reporting to the NSHPC is voluntary and currently receives data from approximately 225 centres.

Pregnancies with an estimated delivery date between 1 January 2013 and 30 June 2014 were included. BHIVA audited data against outcomes described in its 2012 guidelines. Sonia Raffe from Royal Sussex County Hospital, Brighton presented these findings.

During the 18 month period there were 1483 pregnancies in 1469 HIV positive women. The majority (73.7%) were black African; 17% white; 3.1% black Caribbean; and 6.1% other or undocumented. Almost two thirds (64.8%) of women were aged 30 to 39 years at their estimated delivery date; 23% were 20 to 29; 11% were 40 or more; and only 0.8% were 16 to 19. Most women (85.2%) acquired HIV through heterosexual sex.

Of the total pregnancies, 1263/1483 (85.2%) women were diagnosed with HIV before they became pregnant: 920 conceived on ART; 332 off ART; and ART status for the remaining 11 were unclear. The 217 (14.6%) women who were diagnosed in pregnancy included 6 known seroconverters. The time of diagnosis was unclear for 3 women.

Of the diagnoses in pregnancy, 140/217 (65%) were made between 0 and 15 weeks; 53 (24%) were between 16 and 23 weeks; 17 (8%) between 24 and 35 weeks; and 7 (3%) were diagnosed at 36 weeks or later.

ART in pregnancy

The audit found management of women who had conceived off ART but were indicated for treatment for HIV to be 94% compliant with BHIVA guidelines; 3% of women received different antiretrovirals to the recommended ones (including one who was given AZT monotherapy); and management of 3% was unknown or not reported.

For women who conceive off ART and are not indicated for treatment for their own health, the BHIVA recommendations are stratified by viral load. The audit found excellent compliance among this group (n=338): 98%, 99% and 100% for viral loads <10,000, 10,000 to 100,000 and >100,000 copies/mL respectively. Only 8 women (5%) in the <10,000 copies/mL group received AZT monotherapy.

Management of 2 late presenters with very high viral loads (booked after 28 weeks, viral load unknown or >100,000 copies/mL) was 100% compliant with the guidelines, which recommend intensive regimens containing raltegravir.

Dr Raffe included a few extra observations:

9 women had started NVP with a reported CD4 count of >250 cells/mm3.
Raltegravir was included in first line regimens in 5.1% of all pregnancies and in 15.3% with viral load >30,000 copies/mL
73 women started darunavir in pregnancy (despite it not being a preferred antiretroviral).

In 12 pregnancies no ART was reported; 8 were ongoing at the time of the audit. The remaining 4 resulted in live births: 2 women declined ART but had elective Caesarean sections; 1 was diagnosed in labour and delivered vaginally; and 1 was known to be HIV positive but not booked for antenatal care and delivered vaginally.

Timing of ART

The results for starting ART were disappointing.

The guidelines recommend that women who need treatment (CD4 <350 cells/mm3 or otherwise indicated) start ART as soon as possible. The audit looked at a start date within 2 weeks of diagnosis.

Of the 105 women diagnosed during pregnancy with CD4 <350 cells/mm3, only 29% started ART within the target time of 2 weeks. Almost half (n=43) started 29 days or more after diagnosis.

Of 108 women who were diagnosed before conception with <350 cells/mm3, 33 started within 2 weeks of booking and 44 started ART more than 29 days after diagnosis.

The recommendation for women with viral load <30,000 copies/mL is to start ART by the beginning of week 24 of gestation and >30,000 copies/mL by the beginning of week 16.

Starting ART for women with <30,000 copies/mL was 76% compliant with guidelines but only 38% compliant for those in the >30,000 copies/mL group.

Sexual health screening

BHIVA recommend that all women diagnosed with HIV have a sexual health screening. There was a marked increase in sexual health screening over the audit period. For women diagnosed with HIV during pregnancy the rate rose from <10% in the first quarter of 2013 to nearly 80% in the second quarter of 2014. The overall rate was lower, about 50% by the second quarter of 2014 across all pregnancies.

Viral load reporting

Of a total of 1354 pregnancies resulting in live births, 613 (45%) had viral load results from between 36 weeks gestation and delivery as recommended; 21% and 29% had viral load data from 34 to 35 weeks gestation or earlier in pregnancy respectively; and 4% had none.

Mode of delivery

The guidelines recommend a planned vaginal delivery for women with viral load <50 copies/mL at >36 weeks gestation. It is recommended that women with an intermediate viral load between 50 and 399 copies/mL consider caesarean section taking into account individual factors. Women with viral load >400 copies/mL are recommended a planned caesarean section.

A total of 1134 women had <50 copies/mL at some point during their pregnancy. Of this group, 786/1134 (69%) planned a vaginal delivery. Out of the women that met the audit target with viral load results from >36 weeks, 391/540 (72%) planned a vaginal delivery ie were compliant with the guidelines. Dr Raffe noted that 27% of women in the latter group planned for a caesarean section.

There were 50 women with a viral load in the intermediate range at >36 weeks: 24 planned for a vaginal delivery and 26 for caesarean section. A further 21 women with last reported viral load 50 to 399 copies/mL at 0 to 35 weeks planned for vaginal delivery. Dr Raffe suggested that this might reflect under-reporting of viral load measurements.

Fewer women (n=24) had a viral load of >400 at >36 weeks: 19 planned for a caesarean section of which 18 did so and 1 had an unplanned delivery; 3 planned for a vaginal delivery but all went on to have a caesarean section; 1 woman was diagnosed in labour; and 1 woman did not book antenatally.

As viral load data were incomplete it was unclear how many women delivered with a viral load >400 copies/mL but Dr Raffe said this could have been as many as 29. At least 3 women did so at >37 weeks: 1 planning a caesarean section on ART had an unplanned birth at 37 weeks with 16,402 copies/mL; 1 diagnosed during labour with 18,924 copies/mL; and 1 known HIV positive but unbooked for antenatal care with viral load after delivery of 57,000 copies/mL. Two of the infants were confirmed uninfected and 1 had a negative test at birth but no later test results.

Overall 719 (53%) women delivered by caesarean and 630 (47%) delivered vaginally. Types of caesarean were: 50% emergency; 35% elective; and 15% for MTCT.

The audit compared planned and actual mode of delivery. Of the 889 women who planned a vaginal delivery, 69% achieved this; 28% had an emergency caesarean; 20% and elective one; and 0.8% had a caesarean for MTCT.

Only 2% of women who planned an elective caesarean section delivered vaginally; 21% had an emergency caesarean; 23% had one for MTCT; but over half (54%) had an elective one as planned.

A large group (61%) of women with no reported plan had an emergency caesarean; 26% had an elective one; 7% for MTCT; and mode of delivery was unknown for 7%. Dr Raffe said that 18 women in this group delivered before 36 weeks – including 16 by emergency caesarean section – and it is likely that some women delivered before making a plan.

Comment

The presentation concluded with some recommendations. The first that maternity and HIV services should review and agree pathways to ensure rapid assessment and prompt start of ART. In the discussion after the presentation it was noted that this group of women can be very difficult to reach and vital support is being cut by draconian government policies.

Secondly, clinicians should encourage women to plan vaginal delivery unless obstetric factors or insufficient virological control means a woman is indicated for caesarean section. The rate of caesarean section in England is about 25% but only 11% are elective – so the rate in HIV positive women who are virologically suppressed seems high.

Of note the National Survey of Management of Pregnancy in Women Living with HIV presented at the autumn 2014 BHIVA conference found that some centres have a policy of maternal choice rather than recommending vaginal delivery for eligible women – which should be reviewed. If a woman has an undetectable viral load and is not otherwise indicated for a caesarean, having one is not necessarily safer.

Finally, that use of ART should be consistently reported to the Antiretroviral Registry (APR) – although this was not directly discussed in the audit, it is a recommendation that we have also made for years.

Reference:

Raffe S et al. Audit of management of pregnancy in HIV. 21st Annual Conference of the British HIV Association (BHIVA), 21–24 April 2015, Brighton.
http://www.bhiva.org/150423SoniaRaffe.aspx