HIV in Pregnancy: ID of intrapartum and perinatal HIV exposures

Question 1

Vertical rate of transmission f HIV in Canada?

Answer 1

<2%

Question 2

When no interventions are undertaken during pregnancy, delivery or the neonatal period, perinatal HIV transmission rates can be as high as ____%.

Answer 2

25

Question 3

Risk factors for higher transmission rates of HIV?

Answer 3

Pregnant women with:

• Late or no prenatal care
• Injection drug use
• Recent illness suggestive of HIV seroconversion
• Regular unprotected sex with a partner known to be living with HIV (or with significant risk for HIV infection)
• Diagnosis of sexually transmitted infections during pregnancy
• Emigration from an HIV-endemic area
• Recent incarceration

Question 4

When does transmission typically occur?

Answer 4

Some in utero, but majority at time of delivery

Question 5

Additional risk for infection?

Answer 5

If breastfed

Question 6

When is risk of transmission especially high?

Answer 6

When mother has acute or early untreated infection

Question 7

While the number of HIV-infected newborns has declined in NA since implementation of HIV testing in pregnancy, there is a related rise in _______.

Answer 7

The number of infants exposed to antiretroviral agents in utero

Question 8

Long-term outcomes of concern after intrauterine exposure to antiretroviral agents?

Answer 8

-Neurodevelopmental and learning problems

Question 9

Standard approach to diagnosing HIV infection during pregnancy in Canada?

Answer 9

Multistep serology testing

• First step: a screening test for HIV antibodies using an enzyme immunoassay
• If immunoassay reactive, the sample is re-tested using a more specific confirmatory test for HIV antibodies (e.g. Western blot)

Question 10

What are the ways that transmission of HIV from mother to child can be reduced and virtually eliminated?

Answer 10

• HIV testing during pregnancy
• Appropriate perinatal antiretroviral therapy
• Reducing HIV exposure during delivery
• Avoiding breastfeeding

Question 11

Recommendation re: HIV testing in pregnancy?

Answer 11

HIV testing in early pregnancy is recommended as the standard of care in Canada for all pregnant women

Question 12

When is repeat testing throughout pregnancy recommended?

Answer 12

• For all women who are HIV-seronegative on initial testing, but who are known t be at high risk for HIV acquisition
• Repeat testing in the third trimester (ideally before 36 weeks) should also be considered for other HIV-seronegative women when their ongoing risk of acquiring HIV is unclear

Question 13

Health care providers caring for pregnant women who are identified as being HIV-positive should__________________.

Answer 13

Consult with specialists with expertise in managing HIV in pregnancy for advice on counselling about prevention of transmission to the infant and to sexual partners, appropriate antiretroviral therapy, optimal follow-up durinig pregnancy, and intrapartum and postnattal prophylaxis.

Question 14

Failing to ensure that the HIV status of a pregnant women is conveyed to the team who will be caring for her at delivery increases risk of ______ and may result in_____.

Answer 14

Neonatal HIV transmission, unnecessary exposure of the newborn to antiretrovirals.

Question 15

Women who present in labour with undocumented HIV status should undergo _______.

Answer 15

Rapid HIV testing at the time of labour or delivery.

Question 16

What to do if results of rapid HIV testing at time of labour or delivery are positive?

Answer 16

• Intrapartum and infant postnatal antiretroviral prophylaxis should be initiated immediately, pending results of the confirmatory HIV antibody test
• Consult urgently with a Peds ID specialist because preferred antiretroviral regimens are evolving

Question 17

Women who have not been tested for HIV before or during labour should undergo ________. What if they are not available or refuse testing? What if they refuse permission to have infant tested?

Answer 17

• Rapid HIV antibody testing in the immediate postpartum period
• If unavailable or refuse, newborns must undergo rapid HIV antibody testing
• If refuse permission to have infant tested, child protection authorities may need to be notified

Question 18

What to do if test results are positive for mother OR infant?

Answer 18

• Infant antiretroviral prophylaxis should be initiated immediately and no later than 72h post delivery
• Breastfeeding should be deferred until confirmatory HIV antibody test result is available and proves negative

Question 19

What to do if rapid HIV antibody testing unavailable and there is concern that the mother is high risk for HIV infection?

Answer 19

Consider starting newborn antiretroviral prophylaxis pending test results

Question 20

What to do when a mother or newborn tests positive for HIV antibody (i.e. exposure)?

Answer 20

• The infant should be tested immediately for infection by HIV DNA or RNA PCR within 48h of birth if possible
• If positive, prophylaxis should be stopped and antiretroviral treatment initiated in consult with Peds ID

Question 21

What to do for HIV seronegative women in whom acute HIV infection is suspected during pregnancy, intrapartum or while breastfeeding?

Answer 21

A virologic test (e.g. HIV RNA PCR, or antigen test) should be perrformed as soon as possible because antibody tests may be negative early in HIV infection

Question 22

Results of maternal and infant HIV testing should be __________.

Answer 22

Documented in the newborn’s medical record and communicated to the newborn’s primary care provider

Question 23

What to do if HIV infection was initially diagnosed int he mother during or after delivery?

Answer 23

Arrangement should be made for her appropriate follow-up and ongoing care

Question 24

What should HCPs monitor for in infants who have been exposed to HIV infection or antiretroviral agents?

Answer 24

• Short-term effects e.g. anemia, neutropenia

- Long-term outcomes e.g. general health, growth and neurodevelopment

Question 25

______ is recommended for infants in foster care and for adoptees whose birth mother’s HIV infection status is not known.

Answer 25

HIV antibody testing