Chair: Susan Cole, UKC
Speaker: Dr Rita Browne, Chelsea and Westminster hospital
Facilitator: Beatrice Nabulya
Rapporteur: Harriet Nyambalirwa, UKC
This workshop was attended by 18 people and gave participants the opportunity to find out about the latest research on mother-to-baby transmission, labour and breastfeeding. Dr Rita Browne, a specialist registrar started the session with a presentation and overview of the current situation.
The World Health Organisation estimates that there are 38 million people living with HIV (end of 2003) and 50% are female. 57% of those living in sub-Saharan Africa are female and 1/3 in the UK are female. Data to June 2004 shows that 2446 HIV un-infected and 1151 infected babies have been born to HIV positive women in the UK. There has been a decrease in HIV infected babies born since 1997 and an increase in HIV negative babies born to HIV positive mothers. This correlates with the introduction of offering routine HIV tests to pregnant women thus allowing implementation of procedures to decrease transmission during pregnancy and delivery in women diagnosed during antenatal care.
Rita explained the options for serodiscordant couples:
Sperm washing (if the man is HIV positive)
Self insemination (if the woman is HIV positive)
Timed intercourse (the risk depends on viral load). This option is not recommended by Rita.
For concordant couples, sperm washing is recommended. This is because couples may be carrying different subtypes of the virus with different mutations. It may take a while for a woman to get pregnant and unprotected sex during that time may lead to transmission of viruses from one partner to the other. The risk of this is lower if both partners have an undetectable viral load.
It is best that these couples discuss planned conception beforehand with either their clinic doctor, health advisor or ideally a unit involved with a sperm washing programme so that they know what is best for them, as no one recommendation will fit all in this case.
Rita highlighted the other things to consider when planning a pregnancy:
Starting folic acid (continuing until late in the second trimester)
Eating a balanced diet
Having a healthy lifestyle (exercising, stopping smoking, alcohol reduction)
Discussing with your HIV doctor (about the best time for pregnancy, the best HIV medication or whether to change existing medication)
Consider discussing with other medical professionals (e.g. women’s health adviser)
Interventions to reduce mother to child transmission are the most effective methods of reducing transmission. With no intervention MTCT is 25-30%, whereas with intervention it is less than 1%. The options and timing of interventions:
During pregnancy
Antiretroviral therapy (ART)
Treating vaginal infections
During delivery
Antiretroviral therapy
Planned/unplanned Caesarean (C)-section
After delivery
Avoiding breastfeeding
Anti-retroviral therapy for the baby
If a woman is already on combination ART prior to pregnancy she will be advised to continue, the aim being to have a viral load of less than 50. If a woman is diagnosed during pregnancy with CD4 over 200 she can start combination therapy at 24 weeks or if her viral load is less than 10,000 she may only need to take AZT alone from 28 weeks.
Rita said that in her personal opinion, women with CD4 >200 should have combination therapy in all cases during pregnancy to suppress their viral load to undetectable. This gives them the option of having either a vaginal delivery or C-section. Patients only on AZT will be advised to have a C-section. Also it is easier to manage subsequent pregnancies as the Chelsea and Westminster are seeing women having 2 or 3 successful pregnancies.
If a woman is diagnosed in pregnancy and her CD4 is less than 200 she will be advised to start combination ART immediately and will continue after delivery. Septrin will also be recommended, alongside a higher dose of folic acid.
The current preferred combination is two nucleoside analogues and a boosted protease inhibitor. Nevirapine should also be avoided if CD4 is less than 250 due to the risk of hyper-sensitive reactions and liver problems. A resistance test may be needed to guide treatment, and blood levels of PIs or NNRTSs may need to be monitored. There is a slightly increased risk of new onset diabetes during pregnancy in women on combination therapy which includes a protease inhibitor, compared to women not on protease inhibitors (3.5% versus 1.35%). This is low overall. There have also been reports of lactic acidosis occurring in women on D4T and DDI together, thus this combination should be avoided in pregnancy.
If a woman’s viral load is more than 50 at 36 weeks, she will be advised to have a C-section at 38 weeks. However, if the viral load is less than 50, she can discuss whether to have a vaginal delivery or C-section with the obstetrician.
Rita advised women not to panic if they don’t get the planned mode of delivery. An AZT drip will be used if the viral load is more than 50. A combination involving an NNRTI is preferred if a women is diagnosed late in pregnancy (late third trimester) or in labour because NNRTIS will allow for quicker penetration of the medication through the placenta to the baby. If your viral load is undetectable you will not need a drip of AZT.
After the birth (mum)
Bottle feeding is recommended to avoid transmitting the virus to the baby (there are tablets to suppress the mother’s breast milk)
Option to stop ART if CD4 count was more than 250 when started on ART
If stopping Nevirapine or Efavirenz change to a PI for three weeks before stopping all the drugs. NNRTIs have a much longer half-life than the other drugs so this allows for all the NNRTI to have been excreted before the rest of the combination is stopped to prevent the development of NNRTI resistance
After the birth (baby)
The baby gets four weeks of medication, which is usually one drug. In cases where the mother is newly diagnosed, if the viral load is high, triple therapy is recommended
A PCR test for HIV DNA is done at birth, 6 and 12 weeks. If it is negative at 3 months, then there is a 95% chance of the baby being HIV negative. An HIV antibody test needs to be done at 18 months. If it is done earlier it may be positive because of antibodies passed to the baby from mum, but by 18 months all the maternal antibodies would have been lost
There is no evidence that pregnancy accelerates HIV progression. There are an increasing number of women having more than one pregnancy.
Discuss contraception and annual smears with health professionals.
Using combination ART to prevent MTCT is advantageous rather than AZT alone
Pregnancy is a physiological process
Nausea, back pain and heartburn are part of the joys of being pregnant!
Having a baby is a fulfilling experience no one should be denied if they wish it
How effective is bottle feeding?
Rita explained that formula milk has improved and is very good for babies. Bottle feeding prevents virus transmission to the baby.
If the baby is negative with a C-section, does the baby take medication?
Currently all babies are treated for 4 weeks. This applies even if their PCR test at birth is negative. The drug is often AZT but may vary depending on the resistant mutations in the mother. If mum had a high viral load at delivery, the baby gets triple combination therapy.
Can you go through the process of IVF if you are not an established couple?
Not so sure, think you need to be a couple.
How about conceiving naturally? Is there any evidence that HIV reduces fertility?
Your chances of getting pregnant depends on several factors including your age, stage of infection, previous gynaecology history etc. If you are unwell with a low CD4 count your fertility may be less as you may not be ovulating and men may have low testosterone and sperm counts. However if you are well and have a good CD4 count your chances are better. If you have been recently diagnosed and have a low CD count (<100 especially) it may be best for you to wait till you are stable on therapy before trying.
What sort of safe vaccines should be considered for the baby?
No TB vaccination when the baby is positive
TB vaccination at 18 months for a negative baby
The infants can have the usual childhood vaccinations like diphtheria, pertussis and tetanus. MMR can be given if they are negative or not severely immuno-suppressed if positive. If babies are positive they should not have the live polio vaccine
If planning a pregnancy, think about what lifestyle, medication or other changes are necessary to ensure the best outcome for the baby
When on medication full adherence is essential to get an undetectable viral load as soon as possible and prevent the development of resistant viruses
Discuss the preferred mode of delivery with an obstetrician in advance
Effective intervention in pregnancy reduces transmission to <1%
For women on combination therapy it may be possible to have a vaginal delivery but this should be discussed with the obstetrician
Sperm-washing is now recommended when both partners are living with HIV
There is a need for more information for people living with HIV (men and women) about planning for pregnancy
Care of women in pregnancy should involve an HIV physician, obstetrician, paediatrician, specialist nurses and health advisors
There should be more information and funding for sperm-washing
This workshop was evaluated by 15 people between the ages of 27 and 47 (average age 38).
Gender
8 female, 7 male
Ethnicity
9 black African, 2 white, 3 not stated, 1 other non-white
Sexuality
13 heterosexual, 2 gay
Usefulness
Very useful |
Useful |
Not useful |
74%(11) |
13% (2) |
13% (2) |
7 people set themselves action points
Informing others:
Will advise on this to those ready to have a baby
Educate those who still want to conceive
Deliver the info I have to the community
Write about it (drama)
Planning a pregnancy:
Planning for a baby
Need a child now, very educative
Get a check up before pregnancy
Move on to Managing The Media