HIV

Question 1

How to support mental health in woman with HIV

Answer 1

Antenatal HIV care should be delivered by a multidisciplinary team (MDT).

We recommend that pregnant women living with HIV are offered peer support where available.

Assessment of antenatal and postnatal depression should be undertaken at booking, and 4–6
weeks postpartum and 3–4 months postpartum in accordance with National Institute for Care
and Health Excellence (NICE) guidelines.

Question 2

When is sexual health screening indicated in woman with HIV

With new HIV dx what other tests need to be done

Answer 2

New Dx HIV or when she becomes pregnant

Hep A/B/C/ screen
STI screen
syph 
Latent Tb 
Toxo

Question 3

What do you before starting treatment?

Answer 3

HIV resistance testing should be completed and results available prior to initiation of treatment, except for late-presenting women (after 28 weeks).

Women should be encouraged to continue combination (c)ART 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 offtreatment period

Question 4

When starting treatment what other tests are needed? How do you monitor treatment effect?

Answer 4

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 with the addition of a CD4 count at delivery even if starting at CD4
>350 cells/mm3

In women who commence cART in pregnancy,
an HIV viral load +
LFTs should be performed 2–4 weeks after commencing cART, at least once every trimester, at 36 weeks and at delivery.

Question 5

If a woman on cART viral load is not suppress what do you need to consider

Answer 5

In the event that a woman who has initiated cART during pregnancy has not suppressed plasma
viral load to <50 HIV RNA copies/mL, the following interventions are recommended:

• Review adherence (including a full exploration of potential impacting factors) and concomitant medication;
• Perform resistance test if appropriate;
• Consider therapeutic drug monitoring (TDM);
• Optimise to best regimen;
• Consider intensification.

Question 6

If already on ART - is it safe to conceive on?

Any exceptions?

Answer 6

It is recommended that women conceiving on an effective cART regimen should continue this
treatment

Exceptions are:
• Non-standard regimens, for example protease inhibitor (PI) monotherapy;
• Regimens that have been demonstrated to show lower pharmacokinetics in pregnancy such
as darunavir/cobicistat and elvitegravir/cobicistat, or where there is an absence of
pharmacokinetic data such as for raltegravir 1200 mg once daily (od) (should be administered 400 mg twice daily [bd]). These should be modified to include (depending on tolerability, resistance and prior antiretroviral history) one or more agents that cross the
placenta. A woman conceiving on dolutegravir should see her physician as soon as possible to discuss current evidence on neural tube defects.

Question 7

When to start ART?

What factors effect when it is started?

Answer 7

All women not on cART should commence cART:
• As soon as they are able to do so in the second trimester where the baseline viral load
≤30,000 HIV RNA copies/mL;
• At the start of the second trimester, or as soon as possible thereafter, in women with a
baseline viral load of 30,000–100,000 HIV RNA copies/mL;
• Within the first trimester if viral load >100,000 HIV RNA copies/mL and/or CD4 cell count is less than 200 cells/mm3
.
All women should have commenced cART by week 24 of pregnancy.

Question 8

What cART to start

Answer 8

Women are recommended to start tenofovir DF or abacavir with emtricitabine or lamivudine as
a nucleoside backbone.

It is recommended that the third agent in cART should be efavirenz or atazanavir/r, as these are
agents with the most safety data in pregnancy.

Question 9

Is zidovudine monotherapy ever indicated?

Answer 9

Zidovudine monotherapy is not recommended and should only be used in women declining
cART with a viral load of <10,000 HIV RNA copies/mL and willing to have a caesarean section (CS).

PI monotherapy, tenofovir alafenamide, darunavir/cobicistat and elvitegravir/cobicistat are not
recommended in pregnancy.

Question 10

When to start ART

Answer 10

A woman who presents after 28 weeks should commence cART without delay.

If the viral load is unknown or >100,000 HIV RNA copies/mL, a three- or four-drug regimen that
includes raltegravir 400 mg bd or dolutegravir 50 mg od is suggested.

Management of an untreated woman presenting in labour at term.
• All women should be given a stat dose of nevirapine 200 mg; and commence oral zidovudine 300 mg and lamivudine 150 mg bd; and raltegravir 400 mg bd;and receive intravenous zidovudine for the duration of labour.

Question 11

What tests once + HIV infection

Answer 11

viral load - HBV DNA
e antigen status
hep A / hep C / Hep D testing 
LFT
PT
USS

Question 12

Why do we want repeated LFTs?

Answer 12

LFTs 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.

Question 13

cART can be used to treat hep B and HIV in pregnancy

If treating hep B too which drug must you add

Answer 13

tenofivir

take care with one drug treatment with Lamivudine or emtricitabine (this one is better) as hep B resistance can form

Question 14

Vaccinations for HIV + HepB + woman

Answer 14

In all HAV non-immune women with HBV and HIV, HAV vaccination 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.

Question 15

How to monitor hep B flares post natally?

Answer 15

Hepatitis flares that occur after delivery should be managed conservatively with careful monitoring.

Question 16

MOD? For HIV and Hep B ?

Answer 16

In the absence of obstetric complications, normal vaginal delivery can be recommended if the woman has fully suppressed HIV viral load on cART, irrespective of HBV viral load.

Question 17

If new hep C what to test for

Answer 17

Hep C viral load
Genotype 
Coags 
LFTs 
liver USS

Question 18

Can you treat for HIV and hep C in pregnancy

Answer 18

Ribovirin hep C based treatments should be stopped in pregnancy

Question 19

What vaccines are indicated in pregnancy if Hep C and HIV +

Answer 19

Vaccination against HBV is recommended for all women with both HCV and HIV after the first trimester, unless already immune.
In all HAV non-immune women with both HCV and HIV, HAV vaccination 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

Question 20

What anomaly screening test should be offered for HIV + woman

Answer 20

The combined screening test for fetal aneuploidies and non-invasive prenatal testing (NIPT) for
those who screen as high risk is recommended as this has the best sensitivity and specificity and
will minimise the number of women who may need invasive testing.

Question 21

When is prenatal diagnostic testing considered safe?

Answer 21

Invasive prenatal diagnostic testing should not be performed until after the HIV status of the
woman 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 procedure..

Question 22

When is ECV safe ?

Answer 22

External cephalic version (ECV) can be offered to women with plasma viral load <50 HIV RNA
copies/mL.

Question 23

When to decide re MOD?

Answer 23

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.

Question 24

When is a NVD safe?

Answer 24

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 should be supported.
If levels <50 then VBAC safe

Question 25

What about borderline viral loads? what is the recommendation re MOD?

Answer 25

For women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, pre-labour CS (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. For women with SROM and a last measured plasma viral load of 50–399 HIV RNA copies/mL, immediate CS is recommended, but should take 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.

Question 26

When is a ELSCS recommended?

Answer 26

Where the viral load is ≥400 HIV RNA copies/mL at 36 weeks, PLCS is recommended. Where the indication for CS is the prevention of vertical transmission, CS should be undertaken at between 38 and 39 weeks’ gestation. Where PLCS is undertaken only for obstetric indications and plasma viral load is <50 HIV RNA copies/mL, the usual obstetric considerations apply and the CS will usually be performed after 39 weeks’ gestation.

Question 27

HIV + PROM

Answer 27

In all cases of term pre-labour SROM, delivery within 24 hours should be the aim. If maternal HIV viral load is <50 HIV RNA copies/mL, immediate induction or augmentation of labour is recommended in women who have pre-labour SROM, with a low threshold for treatment of intrapartum pyrexia.

Question 28

PROM + high viral load?

Answer 28

For women with SROM and maternal HIV viral load ≥400 HIV RNA copies/mL, immediate CS is recommended

Question 29

How to manage PPROM over 34 weeks?

Answer 29

The management of preterm SROM at ≥34 weeks is the same as that of term SROM, except that women at 34–37 weeks’ gestation will require group B streptococcus prophylaxis in line with national guidelines.

Question 30

How to manage PPROM

Answer 30

When premature SROM occurs at <34 weeks: • Intramuscular steroids should be administered in accordance with national guidelines; • Where HIV viral load is not controlled, this should be optimised; • There should be multidisciplinary discussion about the timing and mode of delivery

Question 31

When is Intrapartum intravenous zidovudine infusion is recommended in the following circumstances:

Answer 31

For women with a viral load >1000 HIV RNA copies/mL plasma who present in labour or with SROM or who are admitted for PLCS. For untreated women presenting in labour or with SROM in whom the current viral load is not known; The use of intrapartum intravenous zidovudine infusion can be considered in women on cART with a plasma HIV viral load between 50 and 1000 HIV RNA copies/mL.

Question 32

Where to deliver?

Answer 32

All women living with HIV are recommended to give birth in a facility that has direct access to paediatric care (i.e. a co-located birth centre or obstetric unit).

Question 33

Can HIV + Woman have a waterbirth?

Answer 33

There is scant safety evidence to support water births in women living with HIV; however, women who choose a water birth should be supported to achieve this where the viral load is <50 HIV RNA copies/mL.

Question 34

Does does very low risk to neonates mean? What is the treatment?

Answer 34

Two weeks of zidovudine monotherapy is recommended if all the following criteria are met: • The woman 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.

Question 35

What is a low risk neonate? how to treat?

Answer 35

Extend to 4 weeks of zidovudine monotherapy: • If the criteria in 9.1.1 are not all fulfilled but maternal HIV viral load is <50 HIV RNA copies/mL at or after 36 weeks; • If the infant is born prematurely (<34 weeks) but most recent maternal HIV viral load is <50 HIV RNA copies/mL.

Question 36

HIGH RISK neonates - how to treat | who to treat

Answer 36

Use combination PEP if maternal birth HIV viral load is known to be or likely to be >50 HIV RNA copies/mL on day of birth, if uncertainty about recent maternal adherence or if viral load is not known.

Question 37

When to start neonatal treatment | What is there is maternal resistance to Tx

Answer 37

Neonatal PEP should be commenced as soon as possible after birth, and at least 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 is not immediately available, commence standard three-drug PEP (zidovudine, lamivudine and nevirapine) until guidance is provided.

Question 38

Max length of time to give neonatal PEP

Answer 38

Infant PEP should not be given beyond 4 weeks PEP should not be restarted unless significant subsequent exposure (e.g. maternal viral load detectable during breastfeeding). Seek expert advice regarding need for PEP following breast milk exposure during an episode of maternal viraemia.

Question 39

Do you give infants PCP | pneumocystis pneumonai prophylaxis

Answer 39

Co-trimoxazole prophylaxis is recommended from 1 month of age if HIV PCR screening is positive at any stage or if the infant is confirmed to be diagnosed with HIV. This should only be stopped if HIV infection is subsequently exclude

Question 40

Breastfeeding and HIV

Answer 40

In the UK and other high-income settings, the safest way to feed infants born to women with HIV is with formula milk, as there is no on-going risk of HIV exposure after birth. We therefore continue to recommend that women living with HIV feed their babies with formula milk. Women advised not to breastfeed for their baby’s health should be provided with free formula feed to minimise vertical transmission of HIV. Women not breastfeeding their infant by choice, or because of viral load >50 HIV RNA copies/mL, should be offered cabergoline to suppress lactation.

Question 41

If a mum decides to breast feed

Answer 41

When a woman decides to breastfeed, she and her infant should be reviewed monthly in clinic for HIV RNA viral load testing during and for 2 months after stopping breastfeeding

Question 42

How to test neonates | fir HIV status that are not breast fed?

Answer 42

* During the first 48 hours and prior to hospital discharge; * If HIGH RISK, at 2 weeks of age; * At 6 weeks (or at least 2 weeks after cessation of infant prophylaxis*); * At 12 weeks (or at least 8 weeks after cessation of infant prophylaxis*); * On other occasions if additional risk; * HIV antibody testing for seroreversion should be checked at age 18–24 months

Question 43

How to test neonates | fir HIV status that are not breast fed?

Answer 43

* During the first 48 hours and prior to hospital discharge; * At 2 weeks of age; * Monthly for the duration of breastfeeding; * At 4 and 8 weeks after cessation of breastfeeding; * HIV antibody testing for seroreversion should be checked at age 18–24 months.

Question 44

How to manage HIV exposed children (not affected)

Answer 44

In light of evidence for possible increased infectious morbidity in HIV exposed but uninfected (HEU) children, timely routine vaccination should be ensured and general practitioners (GPs), health visitors and secondary care physicians should be made aware of possible increased risk in order to inform decisions when assessing risk in primary care.

Question 45

Postpartum what do to with their tx + other management steps

Answer 45

Continue it Women should have their support needs assessed postpartum and be referred to appropriate services in the Trust, community and/or voluntary groups without delay. All women should be reviewed in the postnatal period by a named member of the MDT within 4–6 weeks. Women should have their mental health needs assessed postpartum and those assessed as having mental health issues should be referred to appropriate services in the Trust, community and/or voluntary groups without delay. Contraception Smear 3/12 pp

Question 46

Who else should be testing if a woman is HIV +

Answer 46

For the woman newly diagnosed with HIV in pregnancy, testing of her partner and/or other children should be completed

Question 47

Who gets PCP prophylaxis

Answer 47

Indication CD4 count under 200 Co trimoxazole is the agent recommended in pregnancy for PCP prophylaxis There are concerns about teratogenicity but there is no good evidence and it is believed the benefits outweight the potential risk Baseline risk 3.5%, TMPSMX is 4.8% in T1 and 1.4% T2

Question 48

HIV + Vaccinations Pre preg (or post preg) In Preg

Answer 48

Pre preg Varicella MMR In preg Influenxa dTAP

Question 49

HIV + Vaccinations Pre preg (or post preg) In Preg

Answer 49

Pre preg Varicella MMR Pneumococcal In preg Influenza dTAP Hep B hep A

Question 50

Antenatal ultrasound suggestions

Answer 50

First trimester USS to be sure of dates Detailed second trimester scan if no ART incase there is a low incidence complication Fundal height monitoring and USS if concerns

Question 51

What icnreases the risk of vertical transmission

Answer 51

``` Virus / disease factors High viral load VT is <1% if <1000 copies/ml Seroconversion during pregnancy Low CD4 count No treatment ``` ``` Maternal factors AMA Vit A deficiency Smoking Intercurrent STIs particularly with ulceration Unprotected sex with multiple partners Use of illicit drugs esp cocaine Hep c co infection ``` ``` Obstetric factors Prolonged ROM (over 4 hours) doubles transmission risk Chorioamnionitis PTL Prematurity <35 weeks LBW Vaginal delivery Antepartum invasive procedures Amniocentesis / CVS FBS Breastfeeding or mixed breast and bottle feeding ```

Question 52

What are vertical transmission rates | with and without tx

Answer 52

Vary around the world no treatment 15-45% with Tx 0.1%