UK national clinical audit: management of pregnancies in women with HIV

Pregnancy Management in HIV Viral Controllers: Twenty Years of Experience

(1) Background: The evidence base for the management of spontaneous viral controllers in pregnancy is lacking. We describe the management outcomes of pregnancies in a series of UK women with spontaneous HIV viral control (<100 copies/mL 2 occasions before or after pregnancy off ART). (2) Methods: A multi-centre, retrospective case series (1999-2021) comparing pre- and post-2012 when guidelines departed from zidovudine-monotherapy (ZDVm) as a first-line option. Demographic, virologic, obstetric and neonatal information were anonymised, collated and analysed in SPSS. (3) Results: A total of 49 live births were recorded in 29 women, 35 pre-2012 and 14 post. HIV infection was more commonly diagnosed in first reported pregnancy pre-2012 (15/35) compared to post (2/14), p = 0.10. Pre-2012 pregnancies were predominantly managed with ZDVm (28/35) with pre-labour caesarean section (PLCS) (24/35). Post-2012 4/14 received ZDVm and 10/14 triple ART, p = 0.002. Post-2012 mode of delivery was varied (5 vaginal, 6 PLCS and 3 emergency CS). No intrapartum ZDV infusions were given post-2012 compared to 11/35 deliveries pre-2012. During pregnancy, HIV was detected (> 50 copies/mL) in 14/49 pregnancies (29%) (median 92, range 51-6084). Neonatal ZDV post-exposure prophylaxis was recorded for 45/49 infants. No transmissions were reported. (4) Conclusion: UK practice has been influenced by the change in guidelines, but this has had little impact on CS rates.

Trends in management and outcomes of pregnant women living with HIV between 2008–2013 and 2014–2019: A retrospective cohort study

Background

Despite major advances in the care of pregnant women living with HIV (WLHIV), they remain at increased risk of adverse pregnancy outcomes. This study assesses recent developments in management and outcomes of pregnant WLHIV at a tertiary obstetric unit in the United Kingdom.

Methods

We conducted a retrospective cohort study of WLHIV delivering at the John Radcliffe Hospital, Oxford, during 2008–2019. Detailed data was collected for maternal, virological, obstetric, and perinatal characteristics. To determine changes over time, data from the periods 2008–13 and 2014–19 were compared.

Results

We identified 116 pregnancies in 94 WLHIV. Between 2008–2013 and 2014–2019, the rate of preconception HIV diagnosis increased from 73 to 90% (p = 0.021) and the proportion of WLHIV on combination ART (cART) at conception increased from 54 to 84% (p = 0.001). The median gestation at which cART was initiated antenatally decreased from 22+1 to 17+1 weeks (p = 0.003). In 2014-2019, 41% of WLHIV received non-nucleoside reverse transcriptase inhibitor-based cART, 37% protease inhibitor-based cART, and 22% of cART regimens contained an integrase inhibitor. The proportion of WLHIV with a viral load &lt;50 copies/mL at delivery rose from 87 to 94% (p = 0.235). Sixty-six percent of WLHIV delivered by Cesarean section, with a significant decrease over time in the rate of both planned (62–39%, p = 0.016) and actual (49–31%, p = 0.044) elective Cesarean. Perinatal outcomes included one case of perinatal HIV transmission (0.86%), 11% preterm birth, 15% small-for-gestational-age, and 2% stillbirth. There was an association between a viral load &gt;50 copies/mL at delivery and preterm delivery (p = 0.0004).

Conclusion

Virological, obstetric, and perinatal outcomes of WLHIV improved during the study period. Implementation of national guidance has led to an increase in preconception diagnosis and treatment, earlier initiation of antenatal treatment, a reduction in the number of women with a detectable viral load at delivery, and an increase in vaginal deliveries.

Infektionen mit dem humanen Immundefizienzvirus bei Kindern in Deutschland, 1999–2016

Hintergrund

Mutter-Kind-Übertragungen von humanem Immundefizienz Virus (HIV) sind durch antiretrovirale Therapie der Schwangeren und weitere medizinische Maßnahmen (Sectio-Entbindung, Postexpositionsprophylaxe beim Neugeborenen, Stillverzicht) verhinderbar. Weiterhin erfolgende Übertragungen sind überwiegend Folge mangelhafter Umsetzung der bekannten wirksamen Maßnahmen. Stand und Probleme bei der Erreichung einer Eliminierung von Mutter-Kind-Übertragungen von HIV in Deutschland werden beschrieben.

Methoden

Hauptquelle der Daten sind pseudonymisierte Meldedaten des HIV-Melderegisters am Robert Koch-Institut (RKI). Mittels einer intensivierten Surveillance für HIV-Meldungen zu Kindern werden Angaben zum Geburtsland, zum mütterlichen Herkunftsland und zur Kenntnis und zum Management der mütterlichen HIV-Infektion in der Schwangerschaft bei seit 1999 geborenen, mit HIV infizierten Kindern erhoben.

Ergebnisse

Bis Ende 2018 wurden bei zwischen dem 01.01.1999 und dem 31.12.2016 geborenen Kindern im Alter unter 15 Jahren in Deutschland 331 HIV-Diagnosen gemeldet. Bei 313 war eine Mutter-Kind-Übertragung der wahrscheinlichste Übertragungsweg. Von diesen 313 Kindern wurden 162 (52 %) in Deutschland geboren, aber nur 26 % der Mütter waren deutscher Herkunft. Die HIV-Übertragungshäufigkeit bei in Deutschland geborenen Kindern sank von 1,8/100.000 Lebendgeburten im Zeitraum 1999–2007 auf 0,8/100.000 im Zeitraum 2008–2016. Bei 59 % der in Deutschland geborenen Kinder war der HIV-Status der Mutter den betreuenden Ärzt*innen zum Zeitpunkt der Geburt nicht bekannt.

Schlussfolgerung

Ein fehlendes HIV-Testangebot für die Schwangere war Hauptursache für Übertragungen bei bis 2007 geborenen Kindern; bei später geborenen Kindern waren die Gründe vielfältiger und hingen oft mit mütterlicher Migration und Zugangsbarrieren in das Versorgungssystem zusammen.

Strategies for Prevention of Mother-to-Child Transmission Adopted in the "Real-World" Setting: Data From the Italian Register for HIV-1 Infection in Children

BACKGROUND

Strategies for prevention of HIV-1 mother-to-child transmission (PMTCT) have been continuously optimized. However, cases of vertical transmission continue to occur in high-income countries.

OBJECTIVES

To investigate changes in PMTCT strategies adopted by Italian clinicians over time and to evaluate risk factors for transmission.

METHODS

Data from mother-child pairs prospectively collected by the Italian Register, born in Italy in 1996-2016, were analyzed. Risk factors for MTCT were explored by logistic regression analyses.

RESULTS

Six thousand five hundred three children (348 infections) were included. In our cohort, the proportion of children born to foreign mothers increased from 18.3% (563/3078) in 1996%-2003% to 66.2% (559/857) in 2011-2016 (P < 0.0001). Combination neonatal prophylaxis use significantly (P < 0.0001) increased over time, reaching 6.3% (56/857) after 2010, and it was largely (4.2%) adopted in early preterm infants. The proportion of vaginal deliveries in women with undetectable viral load (VL) increased over time and was 9.9% (85/857) in 2011-2016; no infection occurred among them. In children followed up since birth MTCT, rate was 3.5% (96/2783) in 1996-2003; 1.4% (36/2480) in 2004-2010; and 1.1% (9/835) in 2011-2016. At a multivariate analysis, factors associated with MTCT were vaginal delivery with detectable or missing VL or nonelective caesarean delivery, prematurity, breastfeeding, lack of maternal or neonatal antiretroviral therapy, detectable maternal VL, and age at first observation. Previously described increased risk of offspring of immigrant women was not confirmed.

CONCLUSIONS

Risk of MTCT in Italy is ongoing, even in recent years, underling the need for implementation of the current screening program in pregnancy. Large combination neonatal prophylaxis use in preterm infants was observed, even if data on safety and efficacy in prematures are poor.

Vaginal delivery in women with HIV in Italy: results of 5 years of implementation of the national SIGO-HIV protocol

PURPOSE

To evaluate the maternal and neonatal safety of vaginal delivery in women with HIV following the implementation of a national protocol in Italy.

METHODS

Vaginal delivery was offered to all eligible women who presented antenatally at twelve participating clinical sites. Data collection and definition of outcomes followed the procedures of the National Program on Surveillance on Antiretroviral Treatment in Pregnancy. Pregnancy outcomes were compared according to the mode of delivery, classified as vaginal, elective cesarean (ECS) and non-elective cesarean section (NECS).

RESULTS

Among 580 women who delivered between January 2012 and September 2017, 142 (24.5%) had a vaginal delivery, 323 (55.7%) had an ECS and 115 (19.8%) had an NECS. The proportion of vaginal deliveries increased significantly over time, from 18.9% in 2012 to 35.3% in 2017 (p < 0.001). Women who delivered vaginally were younger, more commonly nulliparous, diagnosed with HIV during current pregnancy, and antiretroviral-naïve, but had a slightly longer duration of pregnancy, with significantly higher birthweight of newborns. NECS was associated with adverse pregnancy outcomes. The rate of HIV transmission was minimal (0.4%). There were no differences between vaginal and ECS about delivery complications, while NECS was more commonly associated with complications compared to ECS.

CONCLUSIONS

Vaginal delivery in HIV-infected women with suppressed viral load appears to be safe for mother and children. No cases of HIV transmission were observed. Despite an ongoing significant increase, the rate of vaginal delivery remains relatively low compared to other countries, and further progress is needed to promote this mode of delivery in clinical practice.

Paediatric HIV-1 infection: updated strategies of prevention mother-to-child transmission

INTRODUCTION

HIV-1 epidemiology is changing and prevention of mother-to-child transmission (PMTCT) strategies have been continuously optimized over time. However, the correct management of infected women during pregnancy is crucial for PMTCT and cases of vertical transmission continue to occur.

OBJECTIVE

To review the most recent evidence regarding the prevention of MTCT in resource-rich and resource-limited settings, focalizing on new possible approaches.

RESULTS

New issues regard the optimal antiretroviral therapy regimen for pregnant women with good immunological control, the use of intrapartum zidovudine (ZDV) in pregnant women with low viral load, the optimization of prophylaxis in the settings where breastfeeding is recommended and use of combined neonatal prophylaxis (CNP) in infants at high-risk for MTCT. Complete viral control, in recent years, has been achieved in most infected pregnant women, has led to change the recommended mode of delivery, since vaginal birth has become a safe option and is now largely recommended. Recent data reported a large use of CNP in preterm infants: this practice may be dangerous, due to the lack of safety data, and its efficacy and effectiveness is unproven.

CONCLUSION

Data are accumulating on efficacy, effectiveness and safety of different PMTCT strategies in various possible clinical scenarios, however further researches are needed in order to optimize the management of infants at extremely low risk for MTCT as well as in those presenting with high risk for infection.

Pregnancy outcomes of women with HIV in a district general hospital in the UK

The aim of this study was to describe the obstetrical and virological outcomes in HIV-infected pregnant women who delivered at a district general hospital in south London in the period from 2008 to 2014. Our review identified 137 pregnancies; most (60%, 63/105) of them were unplanned. The commonest mode of delivery was spontaneous vaginal delivery (SVD) (42%, 48/114) followed by emergency Caesarean section (32%, 36/114). Gestational age at delivery was ≥37 weeks in most (84%, 91/106) of the cases. Maternal HIV VL at or closest to delivery was undetectable (<40 copies/mL), <400 copies/mL and >1000 copies/mL in 73% (94/129), 90% (116/129) and 6% (8/129) of the pregnancies, respectively. None of the infants were infected with HIV making the rate of MTCT of HIV 0% (zero). Our study shows that favourable virological and obstetrical outcomes of HIV-infected pregnant women are achievable in non-tertiary HIV treatment centres. Impact Statement What is already known on this subject: Prevention of mother-to-child transmission (MTCT) of HIV has been one of the major public health successes in the last decades. This success was evident by the reduction of MTCT of HIV in the UK from 25.6% in the 1993 to only 0.46% in 2011. Furthermore, many reports from individual providers, mainly from tertiary centres, of HIV care in the UK also showed very low rates MTCT of HIV. What the results of this study add: Our study shows that favourable virological and obstetrical outcomes of HIV-infected pregnant women are achievable in non-tertiary HIV treatment centres. The MTCT of HIV rate in our hospital was zero in the period from 2008 to 2014. What the implications are of these findings for clinical practice and/or further research: Staff caring for pregnant HIV positive women in general hospitals and small-to-medium HIV clinics should liaise closely with each other and utilise the skill-mix within their hospital in order to provide a quality care that is similar to what is achieved in large teaching centres; however, a prompt referral to tertiary hospitals, when indicated, should be facilitated.

National audit of perinatal HIV infections in the UK, 2006-2013: what lessons can be learnt?

Objectives

The aim of the study was to investigate circumstances surrounding perinatal transmissions of HIV (PHIVs) in the UK.

Methods

The National Study of HIV in Pregnancy and Childhood conducts comprehensive surveillance of all pregnancies in women diagnosed with HIV infection and their infants in the UK; reports of all HIV‐diagnosed children are also sought, regardless of country of birth. Children with PHIV born in 2006–2013 and reported by 2014 were included in an audit, with additional data collection via telephone interviews with clinicians involved in each case. Contributing factors for each transmission were identified, and cases described according to main likely contributing factor, by maternal diagnosis timing.

Results

A total of 108 PHIVs were identified. Of the 41 (38%) infants whose mothers were diagnosed before delivery, it is probable that most were infected in utero, around 20% intrapartum and 20% through breastfeeding. Timing of transmission was unknown for most children of undiagnosed mothers. For infants born to diagnosed women, the most common contributing factors for transmission were difficulties with engagement and/or antiretroviral therapy (ART) adherence in pregnancy (14 of 41) and late antenatal booking (nine of 41); for the 67 children with undiagnosed mothers, these were decline of HIV testing (28 of 67) and seroconversion (23 of 67). Adverse social circumstances around the time of pregnancy were reported for 53% of women, including uncertain immigration status, housing problems and intimate partner violence. Eight children died, all born to undiagnosed mothers.

Conclusions

Priority areas requiring improvement include reducing incident infections, improving ART adherence and facilitating better engagement in care, with attention to addressing the health inequalities and adverse social situations faced by these women.