HIV in pregnancy BHIVA

Question 1

What is the UK prevalence of HIV?

Answer 1

2/1000 women giving birth
3.5/1000 in London

Question 2

Rate of diagnosed HIV mother to child transmission?

Answer 2

1.2%
<1% if at least 14 days ART

Question 3

How much does breastfeeding increase risk of vertical transmission to baby?

Answer 3

50%, should not breastfeed

Question 4

For women on effective cART before pregnancy are advised to continue except:

Answer 4

1 Protease inhibitor monotherpy
2. Regime’s low pharmacokinetics in pregnancy - darunavir/cobicistat and elvitegravir/cobicistat, raltegravir

Question 5

If dolutegravir given, what potential SE and how to avoid?

Answer 5

Increased risk neural tube defect, start after 6 weeks, high dose folic acid

Question 6

Recommend NRTI backbone in pregnancy?

Answer 6

Abacavir/lamivudine
or
Tenofovir/emtricitabine

Question 7

Reccomened 3rd agent in pregnancy?

Answer 7

Efavirenz or Atazanavir

Question 8

If not on cART when to commence based on HIV RNA copies?

Answer 8

<30,000: 2nd trimester
30-100,000: Start of 2nd trimester
>100,000 or CD count <200: 1st trimester

All women should be started by 24 weeks. Continue lifelong.

Question 9

If women Dx late >28 weeks what should be offered?

Answer 9

3-4 drug regime including raltegravir or dolutegravir

Question 10

Antenatal testing for women with HIV should include?

Answer 10

VL every 1-2 months and at 36 weeks
CD4 count
LFT
lactate
GTT

Question 11

If invasive procedure required and HIV status not known?

Answer 11

Delay procedure until status know or VL has been suppressed

Question 12

Management of untreated women presenting in labour

Answer 12

Stat diose nevirapine 200mg
Commence PO zidovudine 300mg, Lamivudine 150mgBD, raltegravir 400mg BD

IV zidovudine in Jaipur

Question 13

What adjustment if preterm baby?

Answer 13

Double dose tenofovir

Question 14

SROM and unknown HIV status?

Answer 14

Urgent HIV test, if reactive +ve - act upon immediately

Question 15

How to decide on MOD with 36 week viral load

Answer 15

<50 consider VD
50-399 - consider ELCS (based on viral load, trend, length tome on Tx, adherence, obs factors, mat views)
>400 ELCS

Question 16

If zidovudine monotherapy what MOD

Answer 16

ELCS, unless elite controller

Question 17

Which women require zidovudine infusion in labour?

Answer 17

Viral load >1000 - labour, SROM, ELCS
Women where viral load unknown
Zidovudine mono therapy

Question 18

Which women can have ECV?

Answer 18

Viral load <50

Question 19

If CS being performed for reducing risk of vertical transmission, when should it be performed?

Answer 19

38-39 weeks
If obs reasons and viral load <50 can by after 39 weeks

Question 20

If PROM and HIV +ve

Answer 20

Delivery within 24 hrs
Viral load <50 - augment
50-399, consider
+400 CS

Deliver if >34 weeks
<34 weeks PPROM - steroid, optimise HIV viral load, MDT discussion

Question 21

When should infant PEP be commenced?

Answer 21

Within 4 hours of delivery

Question 22

Which babies are considered very low risk, how much treatment do they need?

Answer 22

cART >10 weeks +
Viral load <50, 4 weeks apart
<50 at 36 weeks

2 weeks zidovudine

Question 23

Which babies are considered low risk, how much treatment do they need?

Answer 23

If criteria above not met but viral load <50 at or after 36 weeks
Preterm most recent <50

4 weeks zidovudine

Question 24

Which babies are considered high risk, how much treatment do they need?

Answer 24

Combination PEP if viral load unknown >50

Question 25

If mother breast feeding

Answer 25

Give PEP as above

Question 26

What pneumocystis pneumonia prophylaxis should be considered for neonate?

Answer 26

From 1 month if HIV PCR +ve or confirmed HIV, give co-trimoxazole

Question 27

How often should infant molecular dx for HIV be carried out if formula feeding?

Answer 27

1st 48hrs
Before discharge
2 weeks - if high risk
6 weeks (or at least 2 weeks after prophylaxis)
12 weeks (8 weeks after stopping PEP)

Question 28

If breast feeding how often should have infant HIV testing

Answer 28

1st 48 hours
Prior to discharge
2 weeks
Monthly during breastfeeding
4 and 8 weeks after stopping breast feeding

Question 29

When should antibody testing occur?

Answer 29

If mother antibody status nor known - at first sample
22-24 months (or 8 week after stopping BF if this is later)

Question 30

Postpartum care for mother with HIV

Answer 30

Review MDT 4-6 weeks
Assess mental health
Contraception
Cervical cytology at 3 month post delivery
Test partner/other children if new Dx