Antenatal Guidelines. No.25 HIV screening and Management of HIV positive women

Transcription

1 Antenatal Guidelines No.25 HIV screening and Management of HIV positive women 1. Introduction All pregnant women should be recommended an HIV screening test at an early stage in pregnancy or as soon as possible if they present for antenatal care at a later stage. See section Staff Training All staff offering the test should have received training on current HIV clinical management and issues around testing. 3. Women who decline HIV blood test All pregnant women who decline the test at the first offer should be recommended it on at least one more occasion, preferably during the second trimester and have pre test counselling undertaken by one of the GUM Health Advisers. If women have been exposed to risk during the pregnancy, the HIV test should be repeated as appropriate. Midwifery services will send copies of booking form of all women who opt out of HIV testing to the Health advisers in GUM. The Health Advisers will contact the patient to discuss and to encourage testing at 28 weeks. The outcome, either the result of the test or whether not tested should be communicated to midwife and GP and written in the hand held notes. Women who choose not to be tested will be requested to sign that they have been counselled regarding the risks of not testing. (Appendix 1) Close communication between all members of the team is essential. Regular communication from the GUM/HIV team to the antenatal and neonatal teams will normally be undertaken by the CNS in HIV. 4. Retesting in Pregnancy In cases where there are identified risk factors less than 3 months before the 'booking test', or after the test, repeat testing should be carried out as appropriate: discuss with GUM clinic Health Adviser or consultant microbiologist. Advice about avoidance of infection should be provided to women, along with information on the availability of testing on request. Close communication between all members of the team is essential. 5. Tests after 20 weeks and unbooked women presenting in labour (see appendix 2) Women booking or being tested after 20 weeks (including those who are referred to the GUM Health Advisers) should have blood samples marked as urgent for rapid testing. Rapid or near patient testing should be considered for women who arrive in labour unbooked and a reactive test acted upon. CLI.MAT.GUI HIV screening and Management of HIV positive women 1

2 6. HIV test results 6.1 Negative HIV test Negative HIV test results will be sent to the GP in the normal way with the hepatitis B, syphilis and rubella results. Negative screening test results should be reported back to women at the 12 week ultrasound scan appointment or at the next antenatal visit. Any woman with results missing at 16 weeks appointment will need to have samples repeated. Results should be recorded in the maternity notes/electronic patient record, on receipt of the information 6.2 Positive HIV test Positive results should normally be given in person within 2 weeks of testing. Any positive results are notified to the GP by a telephone call from a consultant microbiologist (this normally occurs within 5 working days). The GP normally gives the results to the patient and arranges for her to be seen within GUM as soon as possible. The GUM Health Advisers are also notified by telephone by the consultant microbiologist at the same time. The Health Advisers will diary the positive test result for action within one working week if they have not already by that time received the referral from the GP. It is the Health Advisers responsibility to ensure that the appropriate action is taken. When an HIV positive diagnosis is made and the pregnant woman has been seen in GUM, Miss Montague must be notified in writing immediately by the attending GUM / HIV physician. All women diagnosed with HIV should have an STI screen as early as possible during the pregnancy. Consideration should be given to repeating the STI screen at 28 weeks and undertaking repeat treponemal serology. All HIV positive pregnant women should be screened for hepatitis C. HIV positive women should be encouraged to disclose their status to their partner. Partner testing should becarried out. Testing any other children for HIV is recommended. Every effort should be undertaken by the GUM department to ensure this is done by making the appropriate arrangements with paediatrics. 8.3 Confirmed Positive Result A further appointment will be made in GU Medicine for the results of the repeat test and full support and clinical management will commence if confirmation of a positive result is received. It is clearly important that the doctors and midwives directly involved in the woman's care, and a Consultant Paediatrician who will care for the child, are aware of the result. An appointment will then be made with the Consultant Obstetrician for an ongoing plan of care, which will include a referral to a Consultant Paediatrician to plan neonatal care and to the consultant GUM physician (or designated consultant HIV physician, if different). The necessary subsequent obstetric, adult medical and paediatric management is not covered by this policy. 9. Women who refuse HIV testing in Labour Information for the duty obstetrician, if patient presents in labour without HIV status being known In the circumstances of a patient presenting in labour, if her HIV status has not been assessed already, or no result documented, this needs to be performed within 4 hours of admission. CLI.MAT.GUI HIV screening and Management of HIV positive women 2

3 The microbiology technician will need to be contacted to perform this, as an emergency, irrespective of the hour of day. If the patient refuses to have this test, she needs counselling by the duty obstetric registrar or in exceptional circumstances by the duty consultant. This counselling must be performed at a level she can understand and trained interpreters must be used if her understanding of English is poor. (NB no family members to be used for translation purposes). Issues to explain to the patient include: Knowledge of anyone who is HIV positive can help us significantly reduce the chances of transmitting the virus to the fetus/neonate. If she unknowingly carries the virus, but has no treatment in the antenatal period, labours, delivers vaginally, and breastfeeds, the child has approximately 25% chance of contracting the virus. If we know a woman has the virus we can reduce this risk to less than 1% chance of the child contracting the virus by treating the mother before delivery. We would also deliver by caesarean section with an intravenous infusion of antiretroviral medication. Breastfeeding must be avoided. The neonatal team may consider treating the baby as if it is HIV positive who is delivered, with a high risk mother who has refused to be tested. This would involve medication and repeated blood tests for the baby. The results would remain confidential, with only clinical staff involved in her and her baby s care being aware of the results. 10. Antenatal treatment CD4 and viral load results should normally be available within 2 weeks of the woman being informed of her diagnosis. However, if delivery is imminent, treatment decisions should not delayed pending these results. Resistance testing should be undertaken on all HIV infected women and repeated according to current guidelines. Antiretroviral therapy (ART) will normally be started before 24 weeks. Women s individual circumstances will be considered so that ART is started at the appropriate time for each woman depending on gestation at diagnosis, previous obstetric history, HIV viral load and other relevant conditions e.g. a woman who has previously delivered at 28 weeks ideally needs to be on ART by 14 weeks gestation. For women presenting at 20 weeks or later, resistance testing should be fast-tracked and ideally should be available within 2 weeks. Empiric treatment should not be delayed pending resistance results for women who have indications for starting ART immediately. The viral load should be quantified At least every 3 months and at week 36 on established therapy 2 weeks after starting or changing therapy Just prior to delivery Resistance therapy should be undertaken: Pre-therapy If viraemic on established therapy At delivery if on monotherapy 2-3 weeks after stopping suppressive therapy CLI.MAT.GUI HIV screening and Management of HIV positive women 3

4 For detailed guidance on ART in pregnancy refer to the BHIVA guidelines for the management of HIV infection in pregnant women In summary - balance the risk of HIV transmission with toxicities of therapy Zidovudine monotherapy remains a valid option for women With repeatedly <6-10,000 HIV RNA copies/ml plasma Wild type virus Not requiring HAART for maternal health Not wishing to take HAART in pregnancy Willing to deliver by PLCS Commence before 30 weeks Antenatal drug therapy The choice of antenatal drug therapy should be prescribed by a HIV specialist according to BHIVA guidelines (found on the website - Do not prescribe dual NRTI therapy Prescribe effective (3 or more drug) combination therapy If indicated for maternal health as per adult guidelines Some combinations may not be appropriate during pregnancy If baseline maternal viraemia >10,000 cpm or CDA <350 If there is no maternal indication for HAART, commencing before 24 weeks As an alternative to ZDV monotherapy plus pre labour CS Drug resistance detected on resistance testing Short term ART (START) for prevention of mother to child transmission should Be discontinued after delivery ideally when vial load <50 cpm Be discontinued after careful consideration of the half life of each component to avoid unplanned monotherapy after stopping, especially drugs with a low genetic barrier to resistance Under the guidance of a HIV physician Avoid stavudine plus didanosine as NRTI backbone whenever possible (and monitor lactate is unavoidable) Use current adult doses for all ART in pregnancy Consider the use of therapeutic drug monitoring of protease inhibitors HAART commenced prior to conception should usually be continued throughout the pregnancy 11. Treatment in labour Inform consultants in Obstetrics, GU medicine, Medical Microbiology and neonatology. Those with CD4 < 200/mm 3, or those with AIDS and a previous episode of pneumocystis pneumonia should be given prophylaxis to reduce the risk of pneumocystis pneumonia. Use septrin with or without nebulised pentamidine (septrin NOT contraindicated in pregnancy in this situation). Zidovudine (Azidothymidine, AZT) monotherapy reduces transmission from 26 to 8% in those without an undetectable HIV viral load and not on HAART. Zidovudine during delivery is not required if the mother is established on HAART and has an undetectable HIV viral load. CLI.MAT.GUI HIV screening and Management of HIV positive women 4

5 Delivery Zidovudine must commence at least 4 hours prior to delivery and continue until the cord is clamped. Zidovudine 2 mg / kg IV over 1 hour then 1 mg / kg / hr The drug is to be drawn up in 50ml syringes, each of which to contain a single 20ml vial (200mg) zidovudine diluted with 30mls 5% dextrose to a volume of 50mls. This gives a drug concentration of 200mg zidovudine in 50mls = 4mg per ml. The syringe driver will be set at a rate of 40ml per hour for the first hour then a maintenance dose of 20mls per hour until the baby is delivered. Between 3-4 syringes are usually required in this time frame Consider delivery by caesarean section. This may reduce the vertical transmission rate by 50% if the woman is not established on highly active antiretroviral therapy (HAART) with an undetectable viral load. Gloves, aprons and face protection should be used during delivery. ARM, FSE and FBS should be avoided unless the mother has an undetectable HIV viral load Early cord clamping and early bathing of baby may reduce transmission Strongly advise NOT to breast feed. If a women insists on breast feeding and is known to be HIV positive, it should be discussed with the HIV consultant. Cord blood to be sent for viral load and FBC as well as paired cord blood gases. Paediatric team to be present and co-ordinate the post-delivery neonatal management Do not offer a CS on the grounds of HIV status to prevent mother-to-child transmission of HIV to: women on any anti-retroviral therapy with a viral load of less than 50 copies per ml. Inform women that in these circumstances the risk of HIV transmission is the same for a CS and a vaginal birth. For women with a plasma viral load of 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. 12. Location of Results and Documentation in Medical Notes The printed positive HIV results from the laboratory will be retained in the confidential G.U. Medicine notes. It is recommended that the consultant obstetrician records the following within the patient's hand held obstetric notes: "Viral illness - should not breast feed for elective caesarean section at weeks It is also recommended that the woman be asked to keep a sealed envelope labelled "birth plan" in the back of her hand held obstetric notes. This should include her antiretroviral drug regime and the names of her consultant obstetrician, HIV consultant, and paediatrician, named midwife and health adviser and contact numbers. This is particularly important if she requires treatment outside the area. 13. Record Keeping and documentation CLI.MAT.GUI HIV screening and Management of HIV positive women 5

6 It should be clearly documented in the woman s hand held notes that the HIV test has been offered. If any of the routine antenatal blood tests are declined this must be clearly indicated. Appendix 1 I have seen the Health Advisers in GUM today. I have been counselled regarding HIV testing and HIV in pregnancy. I have been advised of the benefits of HIV testing for my own health and my baby s health. I understand the risks to my baby of not having an HIV test. I choose not to have an HIV test today. Name of patient Date Signature I have explained HIV in pregnancy to the patient and I have answered all the questions raised. Name of person taking consent Date Signature (Health Adviser in GUM) Appendix 2 Information for the duty obstetrician, if patient presents in labour without HIV status being known In the circumstances of a patient presenting in labour, if her HIV status has not been assessed already, this needs to be performed within 4 hours of admission. The microbiology technician will need to be contacted to perform this, as an emergency, irrespective of the hour of day. If the patient refuses to have this test, she needs counselling by the duty obstetric registrar or in exceptional circumstances by the duty consultant. This counselling must be performed at a level she can understand and trained interpreters must be used if her understanding of English is poor. (NB no family members to be used for translation purposes). Issues to explain to the patient include: Knowledge of anyone who is HIV positive can help us significantly reduce the chances of transmitting the virus to the fetus/neonate. If she unknowingly carries the virus, but has no treatment in the antenatal period, labours, delivers vaginally, and breastfeeds, the child has approximately 25% chance of contracting the virus. If we know a woman has the virus we can reduce this risk to less than 1% chance of the child contracting the virus by treating the mother before delivery. We would also deliver by caesarean section with an intravenous infusion of antiretroviral medication. Breastfeeding must be avoided. CLI.MAT.GUI HIV screening and Management of HIV positive women 6

7 The neonatal team may consider treating the baby as if it is HIV positive who is delivered, with a high risk mother who has refused to be tested. This would involve medication and repeated blood tests for the baby. The results would remain confidential, with only clinical staff involved in her and her baby s care being aware of the results. Monitoring and Audit Auditable standards: Please refer to audit tool, location: Maternity on cl2-file11, Guidelines Reports to: Clinical Effectiveness Committee responsible for action plan and implementation of recommendations from audit Frequency of audit: Annual Responsible person: Screening midwife Cross references Neonatal Guideline: Management of Infants born to Low Risk HIV +ve Mothers Antenatal Guideline 31 - Maternity Hand Held Notes, Hospital Records and Record Keeping Antenatal Guideline 44 - Guideline development within the maternity services References RCOG Guideline 39: Management of HIV in Pregnancy. RCOG 2004 Hawkins D, Blott M, Clayden P et al; BHIVA Guidelines Writing Committee. Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission of HIV. HIV Med, 2005, 6 (Suppl 2), Guideline Committee Author Zoe Warwick (Associate Spec Obs, Gynae & GUM) Imogen Montague (Consultant Obstetrician) Work Address Maternity Unit, Derriford Hospital, Plymouth, Devon, PL6 8DH Version 4 Changes Timely review Date Ratified Sep 14 Valid Until Date Sep 17 CLI.MAT.GUI HIV screening and Management of HIV positive women 7

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