dr yvonne gilleece - british hiv association
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Dr Yvonne GilleeceRoyal Sussex County Hospital, Brighton
BHIVA AUTUMN CONFERENCE 2014Including CHIVA Parallel Sessions
9-10 October 2014, Queen Elizabeth II Conference Centre, London
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Dr Yvonne GilleeceRoyal Sussex County Hospital, Brighton
BHIVA AUTUMN CONFERENCE 2014Including CHIVA Parallel Sessions
9-10 October 2014, Queen Elizabeth II Conference Centre, London
COMPETING INTEREST OF FINANCIAL VALUE > £1,000:
Speaker Name Statement
Dr Yvonne GilleeceHas received travel bursaries, educational grants and speaker fees from
Janssen-Cilag Pharmaceuticals and Bristol-Meyer Squibb
Date October 2014
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National survey of managementof
Pregnancy in women living with HIV
Yvonne GilleeceConsultant in HIV/GUM
Brighton & Sussex University Hospitals NHS Trust
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Pregnancy in women living with HIV
Presented today:
Results of survey of management arrangements
For Spring BHIVA 2015:
Results of audit using data routinely reported to National Study of HIV in Pregnancy and Childhood for women with EDD in 2013
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Survey method and responses
BHIVA invited audit lead clinicians at UK HIV services to participate
Requested to consult maternity and paediatric colleagues for relevant data
112* HIV services responded, listing 124 corresponding maternity services
*2 excluded from obstetric section and 1 from paediatric as data not obtained.
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Multidisciplinary working
111 services have MDT, 1 did not
110 stated composition:
All included HIV physician
1 had no obstetrician
2 had no paediatrician
8 had no midwife
Guidelines: MDTs, dedicated HIV specialist midwife and/or women’s HIV Clinical Nurse Specialist are recommended
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Multidisciplinary working
111 services have MDT, 1 did not
110 stated composition:
All included HIV physician
1 had no obstetrician
2 had no paediatrician
8 had no midwife
29 (26%) services had neither an HIV midwife nor women’s HIV CNS
31 (28%) had both HIV midwife/HIV CNS
29 (26%) HIV midwife
21 (19%) HIV CNS
2 (0.02%) not answered
Guidelines: MDTs, dedicated HIV specialist midwife and/or women’s HIV Clinical Nurse Specialist are recommended
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Time to be seen in HIV clinic after diagnosis via routine antenatal screen
Same or next working day 40 (35.7%)
2-3 days 23 (20.5%)
Within a week 29 (25.9%)
1-2 weeks 19 (17.0%)
Not answered 1 (0.9%)
Guidelines: Women needing HAART for own health to start within 2 weeks of diagnosis
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Sexual health screen
Start of pregnancy 3rd trimester (repeat)
Guidelines: Recommend near start of pregnancy if newly diagnosed, suggest for all. Consider repeat at 28 weeks
Screen all women with HIV
84 (75.0%)
Newly diagnosed during pregnancy
24 (21.4%)
Only if considered at risk
3 (2.7%)
Not answered 1 (0.9%)
Screen all women with HIV
55 (49.1%)
If vaginal delivery planned
5 (4.5%)
Only if considered at risk/STI earlierin pregnancy
50 (44.6%)
Other 2 (1.9%)
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ART in pregnancy
109 (97.4%) services have a policy, 2 did not, 1 no answer.
Regimen preferences were mainly in line with guidelines, but for pregnant woman with VL <10,000 copies/ml, CD4 >350 cells/mm3:
35 (31.3%) included DRV/r among preferred agents
7 (6.3%) included NVP
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Use of raltegravir
Widely used. For woman presenting after 28 weeks with VL >100,000 copies/ml:
Use routinely 56 50.0%
May use 43 38.4%
No policy, situation not arisen 11 9.8%
Would not use 1 0.9%
Not sure 1 0.9%
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Resistance testing after stopping short-term ART
Do routinely 55 (49.1%) Not routine 49 (43.8%) Not sure 8 (7.1%)
Of those testing routinely 77.4% do so within 6 weeks 7.5% defer until needing to re-start ART
Guidelines: Resistance test is recommended to ensure mutations are not missed with reversion while off-treatment
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Urgent HIV testing
Guidelines: Recommend urgent test for women presenting in labour/with ROM /needing delivery and no HIV result. If reactive, act immediately
Arrangement for urgent lab test 95 (84.8%)
POCT available in all delivery units 15 (13.4%)
Urgent lab test not available 1 (0.9%)
Not sure 1 (0.9%)
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Urgent HIV testing, cont.
Problem with urgent tests Timing for urgent tests
Guidelines: Recommend urgent test for women presenting in labour/with ROM /needing delivery and no HIV result. If reactive, act immediately.
> 2 hours during working hours
21 (18.8%)
> 2 hours outside working hours
56 (50.0%)
Problems experienced
10 (8.9%)
Provided without problems
40 (35.7%)
Need not arisen 55 (49.1%)
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Mode of delivery
Have a policy 107 (95.5%)
No policy 2 (1.8%)
Not sure/not answered 3 (2.7%)
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Mode of delivery, on highly active ART, VL <50 copies/ml at >36 weeks
• Planned vaginal delivery95 (84.8%)
• Maternal choice9 (8.0%)
• Pre-labour CS3 (2.7%)
• Other/not answered5 (4.5%)
Guidelines: Recommend planned vaginal delivery
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Timing of PLCS
If solely for MTCT prevention:
Guidelines: Recommend PLCS 38-39 weeks
0% 20% 40% 60% 80%
Before 37 weeks
37-38 weeks
38-39 weeks
39 weeks or later
Not answered
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Pre-labour rupture of membranes
Guidelines: At term, expedite delivery. If VL <50 copies/ml, induce labour.
At or after 36 weeks, VL <50 copies/ml
Induce labour 92 (83.6%)
Immediate caesarean 8 (7.3%)
Other 6 (5.5%)
Not sure/not answered 4 (3.6%)
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AmniocentesisGuidelines: Defer until HIV status known, and ideally until VL suppressed
Defer if possible until VL <50 copies/ml 70 63.6%
Offer as for women without HIV 9 8.2%
Always avoid 3 2.7%
Other 24 21.8%
Not sure/not answered 4 3.6%
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Obstetric proceduresGuidelines: No evidence for avoiding these, treat as if HIV negative
*at VL <50 copies/ml. 0% 10% 20% 30% 40% 50% 60% 70% 80%
External cephalic version
FBS/scalp monitor*
Amniotomy*
Episiotomy*
Avoid/do not offer
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Instrumental delivery*Guidelines: Avoid vacuum, forceps preferred
*at VL <50 copies/ml.
0% 10% 20% 30% 40%
Use forceps or vacuum
Avoid vacuum, use forceps
Avoid forceps, use vacuum
Avoid instrumental delivery if possible
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Cabergoline to suppress lactation
Offer routinely 62 (56.4%)
Do not use 21 (19.1%)
Offer in some circumstances 18 (16.4%)
Not sure/not answered 9 (8.2%)
Guidelines: No recommendation
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Infant ART prophylaxis
First dose within 4 hours for all
99 (89.2%)
1 case each of delay (2013-14)
4 (3.6%)
Not sure/not answered
8 (7.2%)
Guidelines: Commence very soon after birth, “certainly within 4 hours”
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Infant co-trimoxazole
Only if infected/HIV RNA/DNA positive 32 (28.8%)
Also if maternal VL >1000 copies/ml 41 (36.9%)
Also if infection not excluded 15 (13.5%)
Other 21 (18.9%)
Not answered 2 (1.8%)
Guidelines: If infected, HIV RNA/DNA+ or maternal VL >1000 copies/ml*
*and infection not excluded.
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Testing of infants/children
Infants born to HIV+ mother
110 (99.1%) have arrangements in place
1 not answered
Comments: arrangements mostly highly effective, all infants followed up.
Existing children of women diagnosed antenatally
103 (92.8%) have arrangements in place
8 (7.2%) not sure/not answered
Comments: effective at many sites, others report challenges.
Guidelines: All potentially exposed infants/children should be tested
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Conclusions
Management appears broadly in line with guidelines, but it is of concern that:
Urgent HIV testing takes >2 hours for 50% of services out of hours, and for 19% in hours
17% of HIV services take >1 week to see women diagnosed via antenatal screening
Only 49% of services routinely test for resistance after stopping short term ART, and some of these delay test until mutations may have reverted
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Conclusions, cont.
Areas of concern, continued:
PLCS is being offered unnecessarily
Some obstetric procedures may be being avoided unnecessarily
Cabergoline is not routinely offered in all services
Testing existing children of newly diagnosed women sometimes remains a challenge
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Recommendations
Maternity, HIV and laboratory services should review their management to ensure adherence to guidelines
In particular, effective procedures are needed for urgent HIV testing of women who present in labour/with ROM/needing delivery
PLCS and obstetric procedure policy requires review
Future guidelines should address the use of cabergoline
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Pregnancy audit using NSHPC data
Results spring 2015, outcomes including adherence to guidelines on:
Timing of ART initiation
Choice of ART regimen
Planned mode of delivery
Sexual health screening
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Acknowledgements
Thanks to all HIV, maternity and paediatric services which contributed information to the survey.
Audit & Standards Sub-Committee: A Freedman, D Asboe, A Brown, F Burns, D Churchill, K Clay, H Curtis, V Delpech, K Doerholt, Y Gilleece, P Gupta, J Musonda, C Okoli, O Olarinde, E Ong, S Raffe, M Rayment, A Rodger, C Sabin, A Sullivan, H Veerakathy.