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HIV and Pregnancy

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Toñi Pocoví

on 3 January 2014

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Transcript of HIV and Pregnancy

HIV stands for the Human Immunodeficiency Virus. It first emerged 30 years ago. HIV attacks the body’s immune system leading to a progressive reduction in the number of T cells expressing CD4
Only affects human beings
There are over
35 million people
living with HIV worldwide (of which 25 million people live in Sub-Saharan Africa)
AIDS stands for Acquired Immune Deficiency Syndrome
HIV is considered a disability under the Equality Act 2010 and this means discrimination on the basis of someone’s HIV status is illegal
HIV is passed on from one person to another via body fluids
In the UK today, the main routes of transmission are:
Through vaginal or anal sex without a condom
By sharing injecting equipment or needles for injecting drugs or tattooing.
Les commonly, HIV is passed on through:
Oral sex
Mother-to-baby transmission
Breast feeding
In 2013, there are over 100,000 people living with HIV in the UK.
Approximately 1 in 4 people in the UK who are living with HIV do not know that they have the virus.
In the UK, an estimated 20,000 children live in a family affected by HIV.
The number of HIV tests performed in sexual health services increased to 902610 in 2012
In 2012, less than 1% of people with HIV died.
Because of effective treatments, most people living with HIV in the UK will not go on to develop AIDS.
HIV and Women: Over half of people living with HIV are women.
In sub-Saharan Africa, 60% of the 25 million HIV-infected adults are women.
The number of HIV-infected females continues to rise, with the greatest increases in Eastern Europe, Asia and Latin America.

- Objective:
Prevention of mother-to-child transmission (MTCT) and evaluation and treatment of HIV infected women
- Mother-to-child transmission may occur
in utero, during delivery or after birth
through
BF
- In the absence of BF, around
65%
of vertically infected infants acquire their infection
during birth
and approximately
35% are infected late in utero
. Fewer than 2% are infected in the early and middle stages of pregnancy
- Currently about
2%
of all HIV exposed infants are vertically infected
- Maternal, obstetrics and fetal factors are associated with MTCT. The two most important ones are maternal viral load and ART use during pregnancy
Effect of pregnancy on HIV progression
HIV and Pregnancy
Overview
UK Statistics
- Certain infections may be linked to spontaneous abortion, intrauterine growth retardation, preterm delivery and low birth weight

- Chorioamnionitis may lead to premature rupture of the membranes with the possibility of premature birth.

- Chorioamnionitis, prolonged ROMs and premature birth have all been associated with MTCT of HIV and may be interlinked

- Frequently associated with advanced untreated HIV disease
Effect of HIV infection on
pregnancy outcome
- Women not infected with HIV also show a reduction in CD4 T-cell subsets during pregnancy

- In women without advanced HIV disease, there is no increased risk of accelerated immunosuppression in pregnancy

- Percentages of CD4 and CD8 T cells remain stable throughout pregnancy and up to 6 months after birth
Gay and bisexual men – 42%
Black African women and men – 35%
Black Caribbean men and women – 3%
Prisoners – Prisoners are disproportionately affected by both HIV and hepatitis B and C.
Injecting drug users – Around 2%

* The primary mode of transmission among women is heterosexual transmission
Groups most affected by HIV in the UK
HAART and pregnancy - Management
- In women who either conceive on HAART or who do not require HAART for their own health there should be a minimum of
one CD4 cell count at baseline and one at delivery

- In women who commence HAART in pregnancy a VL should be performed
2–4 weeks after commencing HAART,
at least
once every trimester
, at
36 weeks and at delivery

- In women commencing HAART in pregnancy,
LFTs should be performed
as per routine initiation of HAART and then at
each antenatal visit

-
Hepatotoxicity
may occur because of the initiation of HAART and/or the development of obstetric complications

- Close liaison with the obstetric team is recommended
Pregnancy management
Antenatal

- HIV testing of all pregnant women is recommended

- Fetal ultrasound imaging should be performed as per national guidelines regardless of maternal HIV status

- Combined screening test for trisomy 21 is recommended

- Invasive prenatal diagnostic testing should not be performed until after HIV status of the mother is known and should be ideally deferred until HIV VL has been adequately suppressed

Intrapartum

- Vaginal delivery is recommended for women on HAART with HIV VL <50 HIV RNA copies/mL plasma at gestational week 36

- For women with a plasma VL of 50–399 HIV RNA copies/mL at 36 weeks, CS should be considered

- Where the VL is >400 HIV RNA copies/mL at 36 weeks, CS is recommended
Neonatal management

- Zidovudine monotherapy is recommended when there is a very low risk of HIV transmission.
- Infants <72 h old, born to untreated HIV-positive mothers, should immediately initiate three-drug ART for 4 weeks

Infant feeding
- All mothers known to be HIV positive, regardless of ART, and infant PEP (post-exposure prophylaxis), should be advised to exclusively formula feed from birth.
- Breastfeeding while not on HAART, or with detectable viraemia on HAART does constitute a potential child protection concern.

Postpartum management
Increased risk for postpartum complications

Some studies have suggested that complications due to infection, including fever, endometriosis, wound infection, UTI and sepsis, are increased
In addition, two reports have suggested an increase in blood loss requiring transfusion or resulting in anemia
PP depression and relapse in drug use are both common
Contraceptive services should be provided

MTCT
Salutogenic perspective
- Promote normality

- Preconception care

- Comprehensive care

- ART Counselling

- Support trhoughout all stages of pregnancy
Reference list
Powrie, R. O., Greene, M. F., Camann, W. & De Swiet, M. (2010). Medical disorders in obstetric practice. Chichester, West Sussex: Wiley-Blackwell.
Gazzard, B. (2002). AIDS Care, Handbook. Second edition. London : Mediscript Ltd.
Kennedy, J. (2004). HIV in pregnancy and childbirth. Second edition. London: Elsevier.
British HIV Association. (2012). British HIV Association guidelines for the management of HIV infection in pregnant women 2012.
HIV medicine. 12
(2). 87-157. doi; 10.1111/j.1468-1293.2012.01030.x
National AIDS Trust. (2013). NAT. Retrieved from: http://www.nat.org.uk/
Full transcript