HIV Flashcards
1
Q
The psychosocial care of women living with HIV during and after pregnancy
A
- Antenatal HIV care should be delivered by MDT, the precise composition of which will vary.
- Assessment of antenatal and postnatal depression should be undertaken at booking, and 4–6 weeks postpartum and 3–4 months postpartum in accordance with NICE guidelines.
2
Q
Screening and monitoring of pregnant women living with HIV
Sexual health screening
A
- Sexual health screening is recommended for pregnant women newly diagnosed with HIV.
- For women living with HIV and already engaged in HIV care who become pregnant, sexual health screening is suggested.
- Genital tract infections should be treated according to BASHH guidelines
3
Q
Screening and monitoring of pregnant women living with HIV
Laboratory monitoring of pregnant women living with HIV
A
- Pregnant women who are newly diagnosed with HIV do not require any additional baseline investigations compared with non-pregnant women living with HIV other than those routinely performed in the general antenatal clinic.
- HIV resistance testing should be completed and results available prior to initiation of treatment, except for late-presenting women. Women should be encouraged to continue cART post-delivery, but where they chose to stop cART, a further resistance test is recommended to ensure that mutations are not missed with reversion during the off-treatment period.
- In women conceiving on cART there should be a minimum of one CD4 cell count at baseline and one at delivery.
- In women who commence cART in pregnancy, a CD4 cell count should be performed as per routine initiation of cART.
- In women who commence cART in pregnancy, an HIV viral load should be performed 2–4 weeks after commencing cART, at least once every trimester, at 36 weeks and at delivery.
- In women commencing cART in pregnancy, liver function tests should be performed as per routine initiation of cART and then at each antenatal visit.
- In the event that a woman who has initiated cART during pregnancy has not suppressed plasma viral load <50 HIV RNA copies/mL at 36 weeks the following interventions are recommended:
• Review adherence and concomitant medication
• Perform resistance test if appropriate
• Consider therapeutic drug monitoring (TDM)
• Optimise to best regimen
• Consider intensification
4
Q
Current issues on the use of antiretroviral therapy in pregnancy and pregnancy outcomes
Conceiving on ART
A
- It is recommended that women conceiving on a cART regimen should continue this.
- Exceptions are: Non-standard regimens, for example protease inhibitor (PI) monotherapy, regimens which have been demonstrated to show lower pharmacokinetics in pregnancy and protease inhibitors demonstrated to increase risk of pre-term delivery.
- These should be modified to include (depending on tolerability, resistance and prior antiretroviral history) one or more agents that cross the placenta.
5
Q
Current issues on the use of antiretroviral therapy in pregnancy and pregnancy outcomes
Naïve to cART: mother needs ART for herself
A
- All pregnant women, including elite controllers, should start ART during pregnancy and continue lifelong.
- Women should commence ART as soon as they are able to do so in the second trimester, but within the first trimester if VL >100,000 HIV RNA copies/mL and/or CD4 cell count is less than 200 cells/mm3
- All women should have commenced ART by week 24 of pregnancy.
6
Q
Current issues on the use of antiretroviral therapy in pregnancy and pregnancy outcomes
Woman is not already on ART: what to start
A
- Women are recommended to start tenofovir disoproxil fumarate or abacavir with emtricitabine or lamivudine as a nucleoside backbone as recommended in the BHIVA adult antiretroviral treatment guidelines.
- In the absence of specific contraindications, it is recommended that the third agent in cART should be in accordance with the BHIVA adult antiretroviral treatment guidelines, where there are sufficient clinical and pharmacokinetic data for use of the third agent in pregnancy.
- It is recommended that an integrase inhibitor-based regimen is considered as the third agent of choice in patients with high baseline viral load (>100,000 HIV RNA copies/mL), where cART is being started late in pregnancy or where it is failing to suppress the virus.
- No routine dose alterations are recommended for ARVs during pregnancy if used at adult
licensed doses
1C - Consider third trimester TDM particularly if combining tenofovir and atazanavir
- If dosing off licence, consider switching to standard dosing throughout pregnancy or regular TDM
- Darunavir should be prescribed at the twice daily dose if known resistance and consideration should be given to using this higher dose if darunavir is initiated in pregnancy
- All women are recommended to commence lifelong cART. Where a woman declines cART despite on-going counselling and support to start therapy, zidovudine monotherapy is a nonpreferred option in women refusing cART who have a baseline VL of <10,000 HIV RNA copies/mL and a CD4 cell count of >350 cells/mm3
. and who consent to a Caesarean section
7
Q
Current issues on the use of antiretroviral therapy in pregnancy and pregnancy outcomes
- Late-presenting woman not on treatment
A
- A woman who presents after 28 weeks should commence cART without delay.
- If the viral load is unknown or >100,000 copies/mL a three- or four-drug regimen that includes raltegravir is suggested.
- For details on how to manage an untreated woman presenting in labour at term, please see section 8.1.6 (high-risk neonatal management). All women should be given a stat dose of nevirapine 200 mg;
and commence fixed-dose zidovudine with lamivudine;
and raltegravir and receive IV zidovudine for the duration of labour - In preterm labour, if the infant is unlikely to be able to absorb oral medications consider addition of double-dose tenofovir disoproxil fumarate to the treatment described in recommendation 6.5.3 to further load the baby.
- Women presenting in labour/ROM/requiring delivery without a documented HIV result must be recommended to have an urgent HIV test. A reactive/positive result must be acted upon immediately, with initiation of interventions to prevent vertical transmission of HIV without waiting for further/formal serological confirmation.
8
Q
Current issues on the use of antiretroviral therapy in pregnancy and pregnancy outcomes
A
- Stopping ART after delivery is not recommended; women who wish to stop ART should be counselled on the risks and managed as per the BHIVA guidelines for the antiretroviral treatment of adults living with HIV.
9
Q
HIV and hepatitis virus co-infections
Hepatitis B virus (HBV)
A
- On diagnosis of new HBV infection, confirmation of viraemia with quantitative HBV DNA, ‘e’ antigen status as well as HAV, HCV and HDV screening and tests to assess hepatic inflammation/fibrosis and liver function are recommended.
- Liver function tests should be repeated at 2 and 4 weeks after commencing ART to detect evidence of hepatotoxicity or immune reconstitution inflammatory syndrome (IRIS) and then monitored regularly throughout pregnancy and postpartum.
- Since there is no evidence of any adverse effect on maternal or neonatal health if women become pregnant while taking ART dually active against HBV, treatment should be continued.
- Tenofovir-DF and emtricitabine or lamivudine should form the backbone of an antiretroviral regimen in treatment-naïve patients with wild-type HIV/HBV infection and no contraindication to any drug.
- If tenofovir is not currently part of ART it should be added.
- Lamivudine/emtricitabine may be omitted from the antiretroviral regimen and tenofovir given as the sole anti-HBV agent if there is clinical or genotypic evidence of lamivudine/emtricitabine resistant HBV or HIV.
- Lamivudine or emtricitabine should not be used as the only active drug against HBV in cART because of the likelihood of emergent HBV resistance to these agents.
- Emtricitabine has potential antiviral benefits over lamivudine, is co-formulated with tenofovir (TDF and TAF), and appears to be equally safe during pregnancy and hence is the preferred option to be given with tenofovir in co-infection.
- In all HAV non-immune HBV co-infected women, HAV vaccine is recommended, after the first trimester, as per the normal schedule (0 and 6 months) unless the CD4 cell count is <300 cells/mm3 , when an additional dose (0, 1 and 6 months) may be indicated.
- cART active against both HBV and HIV should be continued in all HBV co-infected women postdelivery.
- Hepatitis flares that occur after delivery should be managed conservatively with careful monitoring.
- In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother has fully suppressed HIV viral load on cART, irrespective of HBV viral load.
- Neonatal immunisation with or without HBIG should commence within 24 hours of delivery. 1A
10
Q
HIV and hepatitis virus co-infections
Hepatitis C virus (HCV)
A
- On diagnosis of new HCV infection, confirmation of HCV viraemia with quantitative RNA and genotype, assessment of hepatic inflammation/fibrosis and liver function and concomitant liver disease should be performed.
- Liver function tests should be repeated at 2 and 4 weeks after commencing ART to detect evidence of hepatotoxicity or IRIS and then monitored regularly throughout pregnancy and BHIVA guidelines on the management of pregnancy for women living with HIV
postpartum. - Co-infected mothers with HCV should not be treated for HCV with ribavirin-based DAA therapies, and all women who discover they are pregnant while receiving treatment should discontinue both therapies immediately.
- Co-infected women of child-bearing age wishing to get pregnant should be prioritised for DAAbased HCV therapy.
- Vaccination against HBV is recommended for all HCV co-infected women after the first trimester, unless already immune.
- In all HAV non-immune HBV co-infected women, HAV vaccine is recommended, after the first trimester, as per the normal schedule (0 and 6 months) unless the CD4 cell count is <300 cells/mm3 , when an additional dose (0, 1 and 6 months) may be indicated.
- In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother is receiving effective cART for HIV, irrespective of HCV viral load.
- cART should be continued postpartum in all HCV/HIV co-infected women regardless of HCV viraemia, fibrosis stage or CD4 cell count.
11
Q
Obstetric management & HIV
Antenatal care
A
- Fetal ultrasound imaging should be performed as per national guidelines regardless of maternal HIV status.
- The combined screening test for trisomy 21 is recommended as this has the best sensitivity and specificity and will minimise the number of women who may need invasive testing.
- Invasive prenatal diagnostic testing should not be performed until after the HIV status of the mother is known, and should ideally be deferred until HIV viral load has been adequately suppressed to <50 HIV RNA copies/mL.
- If not on cART and the invasive diagnostic test procedure cannot be delayed until viral suppression is achieved, it is recommended that women should commence cART to include raltegravir and be given a single dose of nevirapine 2–4 hours prior to the
12
Q
Mode of delivery
A
Mode of delivery
- For women taking cART, a decision regarding recommended mode of delivery should be made after review of plasma HIV viral load results at 36 weeks.
- For women with a plasma viral load of <50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, planned vaginal delivery is recommended.
- For women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, PLCS should be
considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views. - Where the viral load is ≥ 400 HIV RNA copies/mL at 36 weeks, PLCS is recommended.
- In women for whom a vaginal delivery has been recommended and labour has commenced, obstetric management should follow the same guidelines as for the HIV-negative population.
- Vaginal birth after Caesarean section (VBAC) should be offered to women with a viral load <50 HIV RNA copies/mL.
- Where the indication for PLCS is the prevention of vertical transmission, PLCS should be undertaken at between 38 and 39 weeks’ gestation.
BHIVA guidelines on the management of pregnancy for women living with HIV
13
Q
Use of intrapartum intravenous infusion of zidovudine
A
- Intrapartum intravenous zidovudine infusion is recommended in the following circumstances:
- For women with a viral load of >1000 HIV RNA copies/mL plasma who present in labour, or with ruptured membranes or who are admitted for planned CS.
- For untreated women presenting in labour or with ruptured membranes in whom the current viral load is not known.
- There are no data to support the use of intrapartum intravenous zidovudine infusion in women on cART with a plasma HIV viral load <1000 HIV RNA copies/mL.
14
Q
Neonatal management
A
- Infant post-exposure prophylaxis (PEP).
VERY LOW RISK
Two weeks’ zidovudine monotherapy is recommended if all the following criteria are met:
• Mother has been on cART for longer than 10 weeks
AND
• Two documented maternal HIV viral loads <50 HIV RNA copies/mL during pregnancy at least 4 weeks apart
AND
• Maternal HIV viral load <50 HIV RNA copies/mL at or after 36 weeks
LOW RISK
Extend to 4 weeks’ zidovudine monotherapy:
• If the criteria in 9.1.1 are not all fulfilled but maternal HIV VL is <50 HIV RNA copies/mL at or after 36 weeks
• If baby born prematurely (<34 weeks) but most recent maternal HIV VL is <50 HIV RNA copies/mL
HIGH RISK 1C
Use combination PEP if maternal birth HIV VL known to be or likely to be >50 HIV RNA copies/mL on day of birth, if uncertainty about recent maternal adherence or if VL not known.
- Neonatal PEP should be commenced very soon after birth, certainly within 4 hours.
- In the context of known maternal resistance to zidovudine with VERY LOW or LOW risk, zidovudine monotherapy is still recommended for infant PEP.
- If HIGH RISK (combination PEP indicated) and there is a history of documented maternal zidovudine and/or nevirapine resistance, seek expert advice. If advice not immediately available, commence standard 3 drug PEP (zidovudine, lamivudine, nevirapine) until guidance
is provided.
15
Q
HIV-2
A
- If mother known to be HIV-2 infected follow the above advice but if HIGH RISK (combination PEP indicated) NVP will not be effective. Seek expert advice. If advice not immediately available commence AZT, 3TC and RAL until guidance available.
