Professional Documents
Culture Documents
Management of HIV in first trimester surgical terminations. She has a regular male
partner of two years, who is also HIV positive on treatment, and
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:7 203 Ó 2018 Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING
support from the health visiting team and social services (given
Recommendations for mode of delivery based on viral her history of IDU). She opts to exclusively formula feed as per
load guidance and all follow up HIV testing in the infant is negative.
Viral load Recommended mode of delivery She continues to remain virally suppressed on her ART regimen.
(copies/ml)
at 36 weeks Case 2
A 34 year old caucasian British commercial sex worker (CSW),
<50 Planned vaginal (in absence of obstetric
G4 P1 þ 2, is diagnosed with HIV at booking (14/40) having
contraindications)
previously had her last negative HIV test one year ago. She is
50e399 Planned caesarean section (between 38 and
otherwise well and has no evidence of HIV related illness.
39 weeks) should be considered taking into
She has had two previous terminations and carried one
account the actual viral load and its trajectory,
pregnancy to term and now has a five-year old daughter who is
length of time on treatment, adherence issues,
in foster care. That pregnancy was uncomplicated and she had a
the woman’s views and obstetric factors.
normal birth.
400 Planned caesarean section (between 38 and
39 week) is recommended Initial and pharmacological management
Women diagnosed with HIV in pregnancy should have immedi-
Table 1
ate emotional support and counseling, initially from a sexual
health advisor who may then involve peer support, clinical
Neonatal management psychology or psychiatry as necessary. Health advisors can be
All infants born to HIV positive mothers are given post exposure accessed via your local genitourinary medicine (GUM) service.
prophylaxis (PEP). In all cases where the mother is virally sup- Social services should be informed as necessary. Health advisors
pressed prior to delivery, which is defined as <50 copies/ml at 36 will also arrange contact tracing and possible testing of any
weeks, zidovudine (AZT) monotherapy for four weeks is given. children from previous pregnancies according to testing history.
Dosing varies according to gestation at delivery and reference to Women who are diagnosed with HIV in pregnancy should be
the British HIV Association (BHIVA) guidelines should be made referred to GUM services for full sexual health screening and any
for dosing schedules (see further reading). genital tract infections should be treated in accordance with
In all other cases three-drug therapy should be considered i.e.: national guidelines (British Association for HIV and Sexual
If the mother is untreated or not virally suppressed Health e BASHH). Referral for sexual health screening
If the viral load is not known should also be considered in women with known HIV infection
If HIV is diagnosed immediately postnatally (see below) according to risk factors.
Infants born to HIV positive mothers should follow the routine Women diagnosed with HIV in pregnancy should be referred
national immunization schedule. for urgent assessment by an HIV specialist clinic where routine
bloods for newly diagnosed patients, including screening for viral
Infant feeding hepatitis, syphilis and opportunistic infection, as well as HIV
Whilst ART can significantly reduce the risk of post-natal trans- specific bloods (CD4, VL and resistance testing) should be sent in
mission of HIV it does not abolish it completely. The current conjunction with a thorough assessment by an HIV physician.
guidance is that all HIV positive women should be advised to All patients newly diagnosed with HIV are now offered im-
exclusively formula feed their child. However, if the mother does mediate ART regardless of immune status at diagnosis and
opt to breastfeed, as long as she is virally suppressed, this should women diagnosed with HIV in pregnancy would also be offered
not be considered a child protection issue and she should be an immediate start. If the woman objects to an immediate start
offered intensive support (see below for further discussion). she should at least start by week 24 of pregnancy or by week 14 if
her VL >30,000. If her VL >100,000 at diagnosis, she should be
Neonatal HIV testing
strongly advised to start immediately.
In exclusively non-breastfed infants, HIV testing with an HIV
The exact ART regimen may vary according to local guide-
DNA or RNA PCR should be performed at the following times:
lines, individual physician preference and the viral load and
48 hours post delivery
resistance profile, but generally will be standard triple therapy
2 weeks post cessation of PEP (so at 6 weeks of age)
with a dual nucleoside backbone and either a boosted protease
12 weeks of age
inhibitor or integrase inhibitor. If the viral load is unknown or
HIV antibody testing should also be performed at 18e24
very high (>100,000) then a four-drug regimen, which includes
months of age to rule out rare cases of HIV seroconversion in the
an integrase inhibitor, may be considered.
infant without detectable virus on PCR.
Once the woman has been started on ART she should have the
If the mother is breastfeeding additional testing should be
viral load checked 2e4 weeks post commencement and then at
performed (see below).
least once per trimester and at 36 weeks. More intensive moni-
toring may be necessary if she has failure to suppress for any
Case 1 continued
reason. If the viral load is not suppressed as expected, resistance
She has an uncomplicated vaginal delivery at 41 þ 2 and is fully testing should be sent and this would be organized and evaluated
compliant with the infant PEP regimen. She has intensive by her HIV physician.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:7 204 Ó 2018 Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING
Prior to the introduction of immediate ART being offered to all guidance (with IM steroids) but, in addition, virological control
newly diagnosed patients (as above), HIV in pregnancy guide- should be optimized and there should a multidisciplinary dis-
lines allowed for stopping ART post delivery for those with a high cussion about the timing of delivery.
CD4 count at baseline. Updated guidelines, taking into account
this new research and practice, are still awaited but are likely to Infant feeding
state that women should be advised to continue on antiretroviral As discussed above, all HIV positive women, regardless of ART
therapy after pregnancy regardless of immune status. In- should be advised to formula feed from birth. However, if
terruptions in therapy can be harmful for a number for reasons, women who have a repeatedly suppressed viral load on ART
not least because uncontrolled virus is a risk factor for HIV choose to breastfeed after sufficient counseling as to the risk,
related complications, even if the CD4 count is normal. then this no longer constitutes grounds for immediate child
protection referral (as it has done in the past). The woman
Case 2 continued should be counseled that if she wishes to breastfeed she should
do so exclusively (except during the weaning period) and that all
The patient is counseled initially by a health advisor who ar- breastfeeding should cease after six months.
ranges contact tracing. She has one regular male partner who is The woman should be supported intensively during the period
an IDU although she does not currently use herself. The health of breastfeeding with regards to ART adherence and monitoring,
advisor team refer her to peer support and social services as well until one week after all breastfeeding has ceased. Additional
as arrange her initial appointment with an HIV physician. monthly testing of both mother and infant is recommended
Her initial investigations reveal: during this time. There is no change to the recommendation for
CD4 count 457 (23%) and an HIV viral load 87,000 copies per neonatal PEP, however, with the duration of therapy remaining
ml at four weeks.
Resistance profile: NAD
Hepatitis A e natural immunity Case 3
Hepatitis B e vaccinated with sAb >1000
Hepatitis C PCR negative A 37 year old British/Nigerian woman (G5 P3) presents to A&E at
Sexual health screening: 37/40 with a possible deep vein thrombosis (DVT) following a
Syphilis TPPA pos, RPR 64 (indicates current infection) flight from Nigeria to the UK. She has not had any antenatal care
Throat, rectal and vaginal swabs are all positive for chlamydia in the UK. DVT is ruled out by the accident and emergency
(rectal swab negative for LGV), negative for gonorrhoea. department but she is noted to have some evidence of immu-
She is given a stat dose of benzathine penicillin for syphilis, nosuppression with oral thrush and some skin lesions suspicious
azithromycin for chlamydia and commenced on Kivexa (abacavir of Kaposi’s Sarcoma (KS). A rapid HIV test is performed which is
and lamivudine), one tablet daily, and raltegravir 400 mg twice reactive.
daily for HIV. She is referred to the obstetric and HIV teams for urgent
A viral load three weeks later (18/40) is undetectable (<50 assessment.
copies/ml) and remains so at repeat checks at 24/40 and 36/40. She reports having had an uncomplicated pregnancy. She has
Her pregnancy is uncomplicated until 34/40 when the baby is three children and has previously had three uncomplicated
found to be in breech presentation. A second scan at 36 weeks vaginal deliveries in Nigeria with minimal intervention and
confirms the baby is still in breech. She opts for ECV at 36 weeks wishes to deliver vaginally again. Her children are 2, 5 and 8
which is successful but complicated by premature rupture of years old. She is married and lives with her husband in Nigeria.
membranes. She is immediately induced and delivers a healthy She has no other sexual partners.
baby boy six hours later with no further complications. She ex- She reports being fit and well prior to her pregnancy. She can
presses a wish to breastfeed. not remember how long she has had the skin lesions. She has
never had an HIV test before. Aside from the oral thrush and skin
Obstetric management lesions, multisystem examination does not reveal any evidence
ECV can be offered to women with HIV at 36þ weeks as long as of opportunistic infection.
the viral load is <50 copies/ml and in the absence of obstetric A few days later, initial bloods reveal:
complications. CD4 57 (4%) cells/mL and a viral load of 57,000 copies/ml.
In all cases of pre-labour rupture of membranes (ROM) at Resistance profile: NAD.
term, delivery should be expedited. If the viral load is <50 Viral hepatitis screen is negative
copies/ml induction of labour is recommended and there should Syphilis screen: TPPA neg, RPR negative
be a low threshold for treatment of intrapartum pyrexia. Sexual health screening NAD
If the viral load is 50e999 immediate caesarean section should
be considered taking into account the actual viral load and it’s Initial and pharmacological management
trajectory, any adherence issues, the length of time on treatment All patients presenting with HIV later than 28/40 should be
and the woman’s wishes. If the viral load is 1000 then imme- started on ART without delay. If the viral load is unknown or
diate caesarean section is recommended. >100,000 then a four-drug regimen including an integrase in-
All cases of prolonged premature rupture of membranes hibitor (eg raltegravir or dolutegravir) is suggested.
(PPROM) at 34 weeks should be managed as above. When Women presenting in labour or requiring delivery without a
PPROM occurs at <34 weeks it should be managed as per RCOG documented HIV result should have an immediate rapid HIV test
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:7 205 Ó 2018 Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING
and a reactive result should be acted on immediately without viral load at 36 weeks is >1000 copies/ml then co-trimoxazole
delay for serological confirmation. should also be given to the infant until HIV infection has been
Women presenting with HIV at term should be given an im- ruled out (even in the case of a negative initial HIV DNA/RNA
mediate stat dose of nevirapine as well as commenced on daily test).
ART. The initial nevirapine dose crosses the placenta within two The mother may need intensive support during this time, as
hours and maintains an effective concentration in the neonate for she may not wish to disclose her HIV status to all members of the
up to ten days. It is also recommended that intravenous zidovu- household or her wider family. This may be more commonly
dine be infused for the duration of labour and delivery (see below). seen in women from cultures where HIV infection remains highly
If late presenters go into pre term labour, such that the infant stigmatised. Support may be via the health visiting team, social
may not be able to absorb medications, double dose tenofovir for services, or an HIV specialist community nurse if available in
the mother should be considered in order to pre load the baby that area. In extreme circumstances, directly observed therapy
with PEP. may be necessary.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:7 206 Ó 2018 Elsevier Ltd. All rights reserved.
CASE-BASED LEARNING
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 28:7 207 Ó 2018 Elsevier Ltd. All rights reserved.