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A Multi-District Audit of the Management of HIV Infection in Pregnant Women and the Prevention of Mother-to-Child Transmission: Yorkshire HIV Pregnancy Audit

Posted on: Saturday, 29 October 2005, 03:02 CDT

By Brady, Sophie K; Monteiro, Eric F

Summary: A regional audit was performed to compare clinical practice against the British HIV Association guidelines1 for the management of HIV infection in pregnancy. Data were collected from 2000 to 2002 from eight clinics across Yorkshire using a questionnaire. There were 22 live births to 22 HIV+ pregnant women. There were no cases of transmission of HIV from mother to child. The majority (20/ 22) of mothers received therapy as recommended in the guidelines, with only two initially receiving inappropriate dual therapy. In all, 16/22 (73%) had elective caesarean sections, 5/22 (23%) emergency sections after the onset of labour and one had a vaginal delivery. Also, 12/22 (55%) definitely received intravenous zidovudine during delivery. Added to these, 19/22 infants received appropriate antiretroviral medication for four to six weeks after birth. No mothers were known to have breast-fed.

Keywords: HIV, pregnancy, audit, British HIV Association (BHIVA) guidelines

Introduction

Since the recommendation in 19992 that pregnant women must be offered an HIV test as an integral part of their antenatal care, the numbers of HIV diagnoses in pregnancy have risen.3 Despite the rise in the numbers of women who have been diagnosed as a result of the increase in antenatal testing, most physicians in the region have experience of managing only a few, if any, HIV+ (positive) pregnancies. Nationally, the prevalence of HIV infection in pregnant women is 0.14%3 but there are wide variations, and in particular in Yorkshire in 2002, the prevalence of HIV in pregnant women who accepted testing in individual clinics was in the range 0-0.14%.

It is well known that with antiretroviral medication for the mother during pregnancy and labour, planned caesarean section, avoidance of breastfeeding and antiretroviral medication for the neonate, the rate of transmission of HIV from mother to child is markedly reduced. Therefore, the correct management of the few HIV+ pregnancies seen by most clinicians in the region is of utmost importance in minimizing mother-to-child transmission. This audit aimed to compare the management of HIV in pregnancy in Yorkshire with the standards set out in the national guidelines and make recommendations for improved practice based on the results.

Methods

Questionnaires were sent out to members of the Yorkshire Audit Group for HIV-Related Diseases, requesting details of HIV+ pregnancies that had resulted in live births encountered since May 2000 to 30 April 2002. Individual clinicians from both genitourinary (GU) medicine and infectious dis eases were responsible for documenting demographics, date of HIV diagnosis relative to presentation of pregnancy, details of antiretroviral drugs received during pregnancy and delivery, whether screening for genital infections had taken place, whether resistance testing had been performed and why, mode and timing of delivery and viral loads (VLs) nearest delivery. Information regarding the care of the neonate was also requested: details of antiretroviral drug therapy prescribed and for how long, whether bottle-or breast-fed, HIV tests performed and results, and presence of congenital abnormalities. Clinical practice was compared with standards set in the British HIV Association (BHIVA) 2001 guidelines.1

Results

Eight clinics across Yorkshire had been involved in the care of pregnant women with HIV infection from May 2000 to May 2002. Individual clinics had experienced from 0-10 pregnant HIV + women in a two-year period. There were 22 live births. The women were aged 23- 39. The majority (16/22) were black African, five were white and one black Caribbean.

Screening for STIs

During 11(50%) pregnancies, full screening for STIs was documented.

Resistance testing

This was performed in five pregnancies, one because of inadequate virological control at 18 weeks and the remaining four because they were 'new patients' or 'pretreatment'.

Antiretroviral therapy (ART) during pregnancy

The BHIVA guidelines recommend therapy according to certain clinical scenarios. Table 1 shows in detail the specific regimens prescribed during pregnancy relative to each clinical scenario, changes (if any) made to the antiretroviral combination and VLs nearest delivery.

Two patients received dual therapy -for one this was started in South Africa and for the other in a centre that managed a total of two HIV+ pregnancies in two years. For scenarios 1-3, all mothers commenced therapy in the second or early third trimester, apart from one mother who refused treatment until 36 weeks gestation.

The delivery

There were 16 (73%) elective caesarean sections mainly performed at 38 weeks. Five (23%) caesarean sections were performed as emergencies after onset of labour from 35 weeks onwards. A vaginal delivery occurred for one patient on zidovudine monotherapy; her VL nearest the time of delivery was 135copies/mL. Specific information on the use of intravenous zidovudine was received in 12 out of 22 (55%). We are not aware that intravenous zidovudine was not used.

Maternal treatment post delivery

In 18 out of 22 deliveries the maternal CD4 count had been >200 cells/mm3 at baseline. Therapy was discontinued after 12 of these deliveries immediately and up to four weeks later. VLs nearest the time of delivery were undetectable for six and in the range 50-250 copies/mL for the remainder (six). For three patients this information was not available. Three continued therapy: the baseline CD4s had been 210, 220 and 273. VLs at delivery were 210, not detected and 54 copies/mL, respectively.

Infant treatment

Zidovudine syrup was given to 18 infants for four to six weeks. Lamivudine was given to one infant whose maternal combination was lamivudine + abacavir + nevirapine. All infants were bottle-fed. For three infants this information was not available, as the mothers had relocated to a different region.

There were no reported cases of congenital abnormalities. All infants were HIV-negative to date.

Discussion

This audit demonstrated that HIV + women during pregnancy generally receive appropriate management in a variety of different clinics across Yorkshire as compared with national guidelines.1 The success of maternal treatment is reflected in the absence of any HIV + infants to prenatally diagnosed mothers.

BHIVA gives guidance on management of HIV + pregnancy with examples of different scenarios. In this cohort, this advice was generally followed. However, it is of concern that two mothers initially received dual therapy and subsequently had nevirapine added during viral rebound. Dual therapy is not recommended because of the increased possibility of resistance5'6 and the addition of a single new agent to a failing regimen is not recommended for similar reasons.

Intravenous zidovudine is recommended for all deliveries where the mother is taking AZT as part of her combination. Many clinicians in Yorkshire could not confirm whether their patients had received this or not. It is likely that the actual percentage of women who received intravenous zidovudine is higher, but as it was administered by a different team of doctors this was often not documented in the patients' genitourinary or infectious disease notes.

It is possible that the number of women with VLs nearing undetectable levels at delivery is higher as many clinicians stated VL data from 33 weeks gestation to two weeks post-partum. Mother-to- child transmission is known to be more likely when the VL is detectable at the time of delivery and therefore this is a further measure of the success of treatment given to pregnant mothers with HIV in Yorkshire.

Screening for genital infections should be performed as early as possible during pregnancy and repeated at around 28 weeks gestation.1 Only 50% patients had one full screen for genital infections. In no cases was it repeated. Women may be at risk of genital infections through risky sexual behaviour. Full screening is recommended on the basis that increased genital tract VL secondary to infection may increase the risk of mother-to-child transmission and therefore diagnosing and treating these infections may lower this risk. Infections such as Chlnim/din trnchomntis and bacterial vaginosis are also associated with preterm delivery.7'8 It was evident from the audit that some clinicians thought that genital screening tests were being done by the obstetricians but exact details were vague.

Table 1 Details of HIV+ pregnant patients with regard to clinical scenarios described in British HIV Association (BHIVA) guidelines

This audit highlighted areas for improvement in communication between differing teams of doctors. For example, only 55% deliveries were known to have definitely involved administration of intravenous zidovudine to the mother and few HIV physicians knew exact details of testing for the neonate. Hand-held records have been suggested and prototypes developed.4 In Yorkshire, this was suggested as a way to improve the care of future HIV + pregnant mothers.

References

1 Lyall EG, Blott M, de Ruiter A, et al. British HIV Association. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. HlV Mcd 2001;2:314- 34

2 Department of Health, UK. Reducing Mother to Baby \Transmission of HIV. HSC 1999/183

3 Department of Health, UK. Unlinked Anonymous Surveys Steering Group. Prevalence of HIV and hepatitis infections in the UK 2001. Annual Report of the Unlinked Anonymous Prevalence Monitoring Programme. December 2002

4 Dhar J. Maternal Sexual Health Group. Perinatal Care Plan. [www.aidsmap.com/chiva]

5 Blanche S, Rouzioux C, Mandelbrot L, Delfrassy J-F, Mayaux MJ. Zidovudine-Lamivudine for prevention of mother to child HIV-I transmission. Sixth Conference on Retroviruses and Opportunistic Infections. Chicago, USA, 31 January-4 February 1999

6 Clarke JR, Braganza R, Mirza A, et al. Rapid development of genotypic resistance to lamivudine when combined with zidovudine in pregnancy. J Med Virol 1999;59:364-8

7 Andrews WW, Goldenburg RL, Mercer B, et al. The Preterm Prediction Study: association of second-trimester genitourinary chlamydia infection with subsequent spontaneous preterm birth. Am J Obstet Gynecol 2000;183:662

8 Leitich H, Bodner-Adler B, Brunbauer M, Kaider A, Egarter C, Hussein P. Bacterial vaginosis as a risk factor for preterm delivery: a meta-analysis. Am J Obstet Gynecol 2003; 189:139-47

(Accepted 14 September 2004)

Sophie K Brady MRCP and Eric F Monteiro FRCP, on behalf of the Yorkshire Audit Group for HIV-Related Diseases

Department of Genitourinary Medicine, Leeds General Infirmary, Great George Street, Leeds LSI 3EX, UK

Correspondence to: Sophie K Brady

Email: sophie.brady@leedsth.nh5.uk

Copyright Royal Society of Medicine Press Ltd. Oct 2005

Source: International Journal of STD & AIDS

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