The management of the HIV positive pregnant woman

The UK perspective

Dr Annemiek de Ruiter

Guy’s & St Thomas’ NHS Foundation Trust

London SE1 7EH

3500 HIV patients

Overview

• Epidemiology

• British HIV Association (BHIVA) guidelines

– Antiretroviral therapy

– Mode of delivery

– Breastfeeding

• Issues facing African women with HIV in the UK

• Experience of African women undergoing interventions to prevent infant HIV transmission in the UK

HIV care in the UK

• Testing for HIV and the treatment and

care of HIV is completely free of charge for

all patients

HIV and AIDS reporting section

National Infection Service

Public Health England

HIV in the United Kingdom: 2015

Presentation title - edit in Header and FooterPresentation title - edit in Header and Footer6

Estimated number of people living with HIV (both

diagnosed and undiagnosed): UK, 2014

HIV in the United Kingdom: 2014

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Treatment cascade of adults living with HIV: UK, 2014

HIV in the United Kingdom: 2014

Presentation title - edit in Header and Footer8 New HIV diagnoses and number of persons accessing HIV care in the United Kingdom: 2014

Proportion of HIV diagnosed persons with a viral load

<200 particles/mL who are receiving antiretroviral

therapy: United Kingdom, 2010-2014

94%92% 91%

88%92%

95% 93% 93%89%

94%96% 95% 94%90%

95%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Men who have sex withmen

Heterosexual men Hetrosexual women People who injectdrugs

All**

Pe

rce

nta

ge

se

en

fo

r H

IV c

are

Prevention group

2010 2012 2014

**Includes those with no exposure category reported

www.bhiva.org

BHIVA GuidelinesMaternal HAART

• If conceives on effective HAART – do not

change

• If starting HAART in pregnancy use abacavir or

tenofovir based HAART

• Antiviral Pregnancy Registry

• Newer single-tablet regimens used when

required

BHIVA GuidelinesMaternal HAART

• Commence as soon as possible

• All women should have started by 24 weeks

• Continue post delivery regardless of baseline

CD4

BHIVA GuidelinesMode of delivery

• Aim for vaginal delivery

• Viral load:

– <50 c/ml aim for vaginal delivery

– >400 c/ml aim for PLCS

– 50-400 c/ml decided on case by case basis

• Intrapartum zidovudine used less over recent

years

BHIVA Guidelines

Infant PEP

• Initiated within 4 hours of birth for 4 weeks

• Zidovudine monotherapy if all goes according to

plan

• Triple therapy (ZDV/3TC/NVP) if VL not

suppressed (since 2001)

www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Premature birth

Intl. AIDS Conference 2006, Abstract TUPE 0532

Prematurity and antiretroviral therapy: population-based HIV

surveillance in the UK and Ireland, 1990-2005

Figure 1: Percentage of deliveries at <37 weeks by type of ART and maternal

characteristics, with 95% confidence intervals

0

5

10

15

20

25

30

35

Mo

no

/du

al

HA

AR

T

Wh

ite

Bla

ck

Afr

ica

n

Oth

er

<2

5 y

ea

rs

25

-34

>=

35

Oth

er

IDU

No

Ye

s

>=

50

0

20

0-5

00

<2

00

Perc

en

t p

rem

atu

rity

CD4 cells/µl

HIV

symptoms

Source of

infectionMaternal ageEthnicityART

Data from the National Study of HIV in Pregnancy and Childhood (NSHPC)

2%

4%

9%

29,631

33,2

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

20

22

24

26

28

30

32

34

36

2000-2004 2005-2009 2010-2014

Pro

po

rtio

n ≥

40

ye

ars

at d

eliv

ery

Me

dia

n m

ate

rnal

age

(ye

ars)

Year of delivery

Maternal age by time period 2000-2014

Median age

Percent ≥40y at delivery

Results – trends in maternal age

0%

2%

4%

6%

8%

10%

12%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Year of delivery

Proportion ≥40 years old at delivery

All pregnancies

Pregnancies in primiparous women

Results – Pregnancy outcomes, all women

Younger mothersn=14646

Older mothers (>40y)n=856

p-value

Stillbirth 1.0% 1.6% 0.07

Twins 1.9% 3.0% 0.03

Congenital abnormalities

2.8% 4.2% 0.02

Preterm (<37wks) 13% 14% NS

Preterm (<31wks) 3% 4% NS

Birth weight <2.5kg 14% 14% NS

MTCT 0.8% 0.6% NS

African regions & migration to the UK

1961-1981

1991-2001

2001-2011

Office for National statistics: Immigration patterns of non-UK born populations in England and Wales in 2011 –

17/12/2013

Women, HIV & migration

• In high income countries women living with HIV

may frequently be from migrant populations

• Migration can impact wellbeing (fear of

immigration status, job insecurity, housing,

isolation, being far from family and friends)

• This can be compounded by HIV

Understanding of HIV

• Do not perceive themselves to be at risk of HIV

• Difficulty in accepting the diagnosis

• Denial

Impact of stigma

• Women fear disclosure to partner, friends,

family and community

• Fear rejection

• Fear disclosure to healthcare professionals and

employers and fear a lack of confidentiality

• Experience stigma in healthcare settings

• Acts as a barrier to accessing HIV treatment

• Stigma effectively silences the voices of women

Talking about HIV

• Talking to other people with and about HIV is a

beneficial process

• Women living with HIV are less likely to tell other

people about their HIV than men

• Peer support is invaluable…….if they access it

Dhairyawan R, Tariq S, Scourse R, Coyne K. Intimate partner violence in women living with

HIV attending an inner city clinic in the United Kingdom: prevalence and associated factors.

HIV Med, 2013 May; 14(5): 303-310.

Lifetime IPV = 52%

Dhairyawan R, Tariq S, Scourse R, Coyne K. Intimate partner violence in women living with

HIV attending an inner city clinic in the United Kingdom: prevalence and associated factors.

HIV Med, 2013 May; 14(5): 303-310.

IPV in past 1 year = 14%

Dhairyawan R, Tariq S, Scourse R, Coyne K. Intimate partner violence in women living with

HIV attending an inner city clinic in the United Kingdom: prevalence and associated factors.

HIV Med, 2013 May; 14(5): 303-310.

IPV during pregnancy = 14%

Dhairyawan R, Tariq S, Scourse R, Coyne K. Intimate partner violence in women living with

HIV attending an inner city clinic in the United Kingdom: prevalence and associated factors.

HIV Med, 2013 May; 14(5): 303-310.

Source: http://artnews.org/chrisofili/

HIV-positive African women’s engagement with HIV care in the UK during pregnancy

Dr Shema Tariq

Postdoctoral Clinical Research Fellow, UCL

Honorary Consultant GUM/HIV, Mortimer Market Centre

How do African women living with HIV in the UK

engage with HIV services and interventions during

and after pregnancy?

Overall question

1. Do ethnicity, region of birth and duration of residence in the UK affect African women’s access to HIV care during and after pregnancy?

2. If so, how?

3. What are women’s experiences?

Specifically

Number of women living with HIV reported as pregnant over time

Source: Tariq (unpublished, 2013)

Trends in maternal African region of birth, 1990-2010

51% of HIV+ women book late for antenatal care (≥ 13

weeks)

Group diagnosed before pregnancy: association between ethnicity and late booking

Late antenatal booking

AOR (95% CI) p

White (reference) 1.00 -

African 1.98 (1.27, 3.07) 0.002

Other black 1.21 (0.60, 2.43) 0.596

Other 0.86 (0.37, 1.96) 0.713

*Adjusted for maternal age, parity and reporting region; AOR, adjusted odds ratio; CI, confidence interval

97% of women receive ART in pregnancy with no difference

between African and white British women

Source: Tariq et al. IAS 2011: abstract TUPE283

80% of women had an undetectable viral load at

delivery with no differences according to ethnicity or other

measures of migration

Source: Tariq (unpublished work 2013)

Association between maternal African region of birth and not taking ART in pregnancy

AOR 1.77

p=0.005

Source: Tariq et al. IAS 2011: abstract TUPE283

Religious beliefs

Pentecostalism fosters resilience

• Source of great joy and personal empowerment• Belief in divine intervention fosters sense of hope for the future• The church can function as a surrogate family• Material assistance and advice at times of hardship

What constitutes a ‘miracle’?

Women cited the simplification of drug regimens, having an undetectable HIV viral load on treatment, continued good health

and the safe delivery of an HIV-negative child as evidence of divine intervention

Being pragmatic

I need God and medication. It’s like if you’re sitting an exam. God may lead you to read something before the exam and then you can answer the question. But if you

don’t even carry the text book...how do you do it?

Faith and spirituality

• Can be a barrier to accessing care for HIV

• Faith leaders may be unwilling to acknowledge HIV

• The role of prayer in healing and impact on use of ARVs

Stigma

The funny thing in Africa, especially my country, when they know you have this, even your baby can’t come close to you. It’s not like this in Uganda, in East Africa, because they know there they are in this situation – but in West

Africa, there not a lot of people with it. Even your mum, or your brother, or your sister, or your kid, no-one will come

close to you.

8/15 women described negative

experiences of maternity care

Source: Tariq et al. BHIVA 2014: abstract P136

“I could hear the midwife

outside telling the other one

to be careful as I was ‘high,

high risk”

When I think about the experiences I

had…I wanted four or five kids.

Now I said to my husband ‘no, this is

the end of it’.

www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Impact

I feel unhappy. I just accept it, but, in my heart, it pains me, because, as a woman you have to breastfeed your

baby.

It’s like I’m not having bond with the child.

Difficulties

The formula as well is very expensive. At some point we could not afford it was so expensive.

That’s what really make me feel sad because our culture in Africa you’re supposed to

breastfeed.

Fostering resilience

My first daughter she wasn’t breastfed and she’s okay so this one now, the current one, is not going to be

breastfed.

“It pains me because as a woman you have to breastfeed your baby” :

decision-making about infant feeding among African women living with

HIV in the UK

S Tariq, J Elford, P Tookey, J Anderson, A de Ruiter, R O’Connell, A Pillen

Sex Transm Infect doi:10.1136/sextrans-2015-052224

• cultural• lack of support

network• poverty• social pressure• disclosure

Difficulties Resilience

Impact

• financial help• examples of

healthy babies• creative excuses• support

• anxieties about child health• bonding• personal loss• Stigma• isolation

Formula feeding

Source: Tariq et al. IAC 2012: abstract 6632

Breastfeeding and HIV

• The majority of HIV-positive mothers abstain from breastfeeding

• Women are increasingly aware of different approaches in their country of origin

• BHIVA guidelines recommend formula feeding but will support breastfeeding in women on HAART with an undetectable viral load

• Overall 12% women (1055/8695) did not access care in the year after pregnancy

• Of those who did not access care eight were known to have died

• Almost 40% (414/1055) women who did not access care returned for care by the end of 2010

LTFU 1 year after pregnancy

n=6535 AOR (95% CI)a

White 1

Black African 1.96 (1.44, 2.67) *

Caribbean 1.47 (0.88, 2.44)

Other 1.00 (0.61,1.63)

a Adjusted for age, time since diagnosis, last CD4, last viral load, reporting area and year of pregnancy; * p<0.001

LTFU (1y) and maternal ethnicity

Experience of pregnancy amongst African

women living with HIV in the UK - summary

• Good outcomes

• Challenges

– Social circumstances

– Stigma

– Maternity care

– Infant feeding

• Maternal love and resilience

A person centred approach

Care must vary depending on the unique needs

and personal circumstances of each woman . . .

Culture

or religion

Immigration

Stigma and fear

of discrimination Co-morbid problems (e.g. alcoholism, drug use,

depression)

Family issues

Medical history

Violence

or sexual abuse

Sexual issues

Support

Stage of

HIV journey

Acceptance

of diagnosisInfant feeding

Disclosure

Socio-economic

factorsAge

A person centred approach

Care must vary depending on the unique needs

and personal circumstances of each woman . . .

Culture

or religion

Immigration

Stigma and fear

of discrimination Co-morbid problems (e.g. alcoholism, drug use,

depression)

Family issues

Medical history

Violence

or sexual abuse

Sexual issues

Support

Stage of

HIV journey

Acceptance

of diagnosisInfant feeding

Disclosure

Socio-economic

factorsAge

Source: http://artnews.org/chrisofili/

Thank you

Shema Tariq, Jane Anderson

Claire Townsend, Claire Thorne, Helen

Peters & Pat Tookey (NSHPC)

Cathy Nelson-Piercy & Kate Harding (GSTT)

Lynn Mofenson