Pregnancy studies at 4th Joint BHIVA/BASHH Conference

Polly Clayden, HIV i-Base

Several presentations at the BHIVA/BASHH meeting showed real-world findings on HIV and pregnancy in the UK and revealed how clinical practice relates to the recommendations in the upcoming BHIVA pregnancy guidelines. [1]

One study looked at the influence of the guidelines on trends ART use in pregnancy in the UK/Ireland in 2005–2016. [2]

This analysis of 10,009 women, 13,757 singleton pregnancies and 54,119 individual drug exposures found that whenever BHIVA guidelines were updated, clinical practice followed. For example, in 2005 when tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) was not yet recommended as a backbone, only 0.2% of pregnancies were exposed to FTC and 2.7% to TDF, compared with 2016, when TDF/FTC was introduced as a “preferred option”, and 20.5% of women received FTC and 21.1% TDF. Similar findings were shown for other antiretrovirals. Overall the analysis demonstrated the responsiveness of antiretroviral prescription, both before and during pregnancy to changes in clinical guidance.

A presentation from the ongoing UK/Ireland audit of perinatal HIV infection showed an all-time low rate of vertical transmission in diagnosed women – less than 0.3% in 2012–2014. [3] A total of 108 cases were reported between April 2006 and April 2014; over two-thirds of these were born to undiagnosed women.

There were 25 children with perinatal HIV reported since 2014. Similarly, two-thirds (17/25) of the children were born to undiagnosed women, three mothers were diagnosed during, and five before pregnancy. Children’s age at diagnosis ranged from birth to eight years. Of the 17 women diagnosed after pregnancy, 12 infections were seroconversions, four women declined HIV tests (no recent cases) and one woman booked late.

At least 13 women had major complicating circumstances, including immigration, housing or mental health issues, intimate partner violence, and social services involvement.

A poster from Leeds Teaching Hospitals Trust described its policies for pregnant women who decline an HIV test. [4] The policies were developed after a pregnant woman at high risk for HIV repeatedly declined testing, and the lack of local or national policies became apparent.

The Trust states that a woman declining HIV testing at booking and 20 weeks will be seen by the obstetric consultant and offered cord blood testing at birth. If this is declined a full HIV risk assessment of her and her partner will be done and she will be informed that infant testing might be required. Women in the third trimester still declining HIV or cord blood testing will be discussed by the multidisciplinary team. The team applies a risk stratification for infant testing using a risk of 1:1000 (as in adult PEP) to start a court authority request.

Two posters reported on women who chose to breastfeed their infants. [5,6] Although formula feeding is still recommended, forty babies have been breastfed by women with HIV in the UK since 2012 with no transmissions.

A study conducted by Imperial Healthcare NHS Trust, and Chelsea and Westminster NHS Trust, London, UK looked at the experiences of eight women who breastfed 10 babies.  All women had partners of which five were documented as aware of the mother’s HIV. Three mothers identified extended family being unaware of their HIV as a reason for breastfeeding.

Three babies were breastfed for less than one week. Of remaining seven, average breast feeding duration was 33 weeks, three exclusively and four mixed fed. All mothers remained fully suppressed throughout duration of breastfeeding and all babies had negative viral load after completing breastfeeding.

Women who breastfed in this group faced many challenges. A higher proportion than expected had not informed their partners, family, or healthcare team about their HIV, raising concerns breastfeeding could be part of maintaining “the secret”.

A related poster from Leeds reported on five women who breastfed six babies over the past three years. Breastfeeding duration ranged from five days to 20 months. All women had good adherence to ART and blood tests during pregnancy and breastfeeding and there were no transmissions. All but one woman discussed breastfeeding plans with their doctor. This woman had not disclosed her HIV status to her partner and had financial pressures to breastfeed.

Both reports emphasised the importance supporting and understanding women’s decisions, and that it is considered safer for women to engage with services during breastfeeding than to do so without disclosing or engaging with care. Women with undetectable viral load who choose to breastfeed should be encouraged to inform those who need to know, so they can be appropriately supported.

Intimate partner violence often escalates in pregnancy. It is independently associated with adverse obstetric perinatal outcomes, and is documented to increase adverse health behaviour including smoking, alcohol and substance use.

BHIVA guidelines recommend screening HIV positive pregnant women for intimate partner violence and offering appropriate intervention as well as documenting other key social circumstances including sexual history, mental health status, housing issues, smoking, drug use and alcohol consumption.

A poster from St George’s University Hospital, London, described high levels of psychosocial vulnerability in pregnant women with HIV. [7]

In this cohort, there were 81 pregnancies were identified in 64 women. Of these, 21% of pregnancies were documented as having significant difficulty engaging with HIV care. Among those disclosing 51% (24/47) reported mental health issues, 18% (8/45) intimate partner violence and 50% (19/38) housing problems. Smoking, alcohol and substance use were frequently reported.

Significant levels of social vulnerability were seen in this small cohort of pregnant women but the authors noted that documentation was variable and they needed to find ways to improve this. Plans are underway to develop and evaluate a clinical proforma to aid documentation and adherence to BHIVA guidelines.

Overall vertical transmission is very low in the UK and the availability of safe and effective ART (combined with good multidisciplinary care) has been a major reason for this success.

But women with HIV can face many challenges against a background of draconian government cuts and policies that target the most vulnerable. The ongoing pregnancy audit continues to reveal that vertical transmission takes place against a background of complex social circumstances like housing, immigration, intimate partner violence and mental health issues.

So, as well as guidance on the clinical management of HIV in pregnancy, the emphasis on psychosocial issues (this section was both expanded and moved forward) in the BHIVA guidelines is welcome and hopefully will provide guidance to continue to deliver critical additional support to those women that need it.

References

All references are to the Programme and Abstracts of the Fourth Joint Conference of BHIVA/BASHH, Edinburgh, 17–20 April 2018. Published in HIV Medicine, 19 (Suppl. 2), s5–s20.
http://www.bhiva.org/AnnualConference2018Presentations.aspx

Gilleece Y. BHIVA HIV in pregnancy guidelines 2018. 4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Oral presentations in BHIVA/BASHH guidelines section. Thursday 19 April 2018.
Rasi V et al. Assessing the influence of BHIVA guidelines on trends in antiretroviral use in pregnancy in the UK and Ireland in 2005–2016. 4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Oral abstract O21.
Peters H et al. Audit of perinatally acquired HIV in UK-born infants reported 2014–2017. 4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Oral abstract O3.
“HIV test? No thank you.” New multidisciplinary policies for pregnant women who decline an HIV test. 4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Poster abstract P143.
Astill N et al. A case-note review of characteristics and outcomes of five HIV positive women who breastfed.  4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Poster abstract 144.
Seery P et al. Breasfeeding experiences of mothers with HIV from two UK centres. 4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Poster abstract P 145.
Bird E et al. High levels of psychosocial vulnerability in HIV-positive pregnant women attending an inner London HIV clinic. 4th Joint BHIVA/BASHH, 17-20 April 2018, Edinburgh. Poster abstract P146.