Infants born to HIV positive mothers - prophylaxis and follow up

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Last review: 28/06/2017  
Next review: 28/06/2020  
Clinical Guideline
CURRENT 
ID: 177 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Infants born to HIV positive mothers- prophylaxis and follow up

Summary of Guideline

  • This guideline is a local adaptation of the British HIV Association (BHIVA) guideline: “Guidelines for the management of HIV infection in Pregnant women 2014 (interim Review)” See http://www.bhiva.org/PublishedandApproved.aspx
  • The majority of HIV positive mothers will be identified prior to delivery. They will have interventions to reduce their viral load and intrapartum management to prevent mother to child transmission.
  • There must be effective communication between the HIV team, the obstetric team, the maternity pharmacist and the neonatal team to ensure these patients are identified. See guideline : Screening for and Management of HIV positive women in pregnancy
  • At risk babies will require blood samples on day 1, at 6 and 12 weeks and at 18 months to exclude vertical infection
  • At risk babies will require post exposure prophylaxis (PEP) anti-retroviral treatment.
  • Babies at very high risk will require pneumocystis carinii pneumonia prophylaxis.
  • Normally these infants must not receive maternal breast milk and should be formula fed- in highly selected cases which have been approved by the MDT mothers may be allowed to breast feed with additional monitoring.
  • Follow up of these infants will be in the neonatal infection clinic.
  • All routine vaccinations can be given except BCG

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Background

  • About 1 in 450 pregnant women in the UK are HIV positive, the majority in London where the rate is 1 in 250. T rate in Leeds is similar to the national rate and much higher than in many other cities and rural areas due to a high number of African asylum seekers being placed in Leeds in recent years.
  • The prevalence of HIV in sub-Saharan women is about 3%. Other risk groups include intravenous drug users and partners of HIV positive people.
  • The overall mother to child transmission (MTCT) rate has fallen from 25% in 1993 to 1.2% in 2006. The rate in those receiving 14 days antiretroviral treatment (ART) is <1% and in those with an undetectable viral load at 36 weeks is <0.1%.
  • Uptake of antenatal screening for HIV in Leeds now exceeds 98% and all diagnosed women are offered ART with a good uptake after counselling
  • Breastfeeding increase the risk of MTCT by an additional 16%, in women not taking ART.

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Diagnosis

  • The majority of women with HIV infection will have been identified prior to this pregnancy or diagnosed on antenatal screening.

Planning before delivery: (For details see maternity guideline: Screening for and Management of HIV positive women in pregnancy)

  • Parents should have seen the HIV screening midwife, their HIV physician and their obstetric consultant. An appointment with a paediatrician can be offered. Copy clinic letters should be sent to the link paediatrician (Dr Miall) and be available in the hand held notes.
  • The patients right to discretion and confidentiality should be respected
  • An individualized careplan will be used throughout the antenatal period and will include a birth plan detailing the time and mode of delivery. It will also include information on the  antenatal, intrapartum and post natal drug therapy required and a plan for infant feeding and breast milk suppression.  
  • Parents should be informed that their baby will need blood tests, that it will not be possible to establish the baby’s HIV status straight away and that post exposure prophylaxis will be required for 4 weeks. A parent information leaflet is available and mothers should receive this at their 36 week appointment. 
  • The mother will usually have received ART from the second trimester (various regimes), with the aim of reducing her viral load to <50 copies/mL. This drug regime is usually continued until after the baby has delivered. Intravenous zidovudine may be administered intrapartum if there is still detectable viral load. 

Child protection concerns:

(see also - Infants born to mother who refuses HIV testing in Pregnancy)

  • If, despite all efforts, the MDT is unable to persuade the mother to comply sufficiently with treatment antenatally, then a pre-birth planning meeting with social services should be held.
  • The mother should be informed that it is the paediatrician’s role to advocate on behalf of the child’s well being and therefore to prevent, where possible, HIV infection.
  • If the mother continues to refuse any intervention package, then legal permission should be sought at birth to treat the infant for 4 weeks with combination PEP and prevent breastfeeding.
  • Where a mother has declined antenatal testing AND is felt to be at high risk of HIV infection there should be an urgent MDT discussion as to whether the baby requires prophylaxis and testing. These mothers should have been discussed by the MDT antenatally. Contact screening midwife.
  • Refusal to avoid breastfeeding despite risk of transmission may not be legally preventable and in this situation the MDT must work with the mother to minimize the additional risk to the baby. This may involve consideration of ART postnatally and specialist advice should be sought for GUM. (see breastfeeding section)

Management at delivery

  • Maternal blood and body fluids, and the baby’s secretions, should be regarded as infective. Universal precautions should be taken.
  • Equipment may become contaminated with maternal blood. Wall suction should be used if needed. Laryngoscopes, T-piece masks etc will need sterilisation following use.
  • The baby should be considered infective until cleaned of all maternal blood and amniotic fluid.
  • The baby should be washed with liquid baby soap and water, dried and dressed, after appropriate skin to skin contact with the mother. Once washed gloves are no longer required when handling the baby.
  • Cord blood should not be used for HIV PCR tests (see below) because of the risk of contamination by maternal blood.
  • Vitamin K must not be administered IM until the skin has been thoroughly cleaned, to avoid inoculation with maternal blood.

Management in the postnatal period

  • As with any patient, wear gloves when attending to the cord, performing heel prick tests or handling blood or blood-stained fluids.
  • Ensure the relevant investigations are performed (see below)

Breastfeeding:

  • Breastfeeding increases the risk of transmission and in general the mother should be strongly advised against breastfeeding [Grade A evidence] and prescribed Cabergoline to suppress breast milk production. Formula milk should be provided. Vouchers for funding formula milk are available via “Skyline.
  • In a very small number of highly selected women with undetectable viral load and with prior agreement of the MDT, exclusive breast feeding may be supported for up to 6 months. These mothers will have additional screening tests. The baby will also need additional tests (see below) 
  • If breastfeeding is continued despite medical advice it may be appropriate for the mother to continue ART[ Grade A]. Seek expert advice
  • Discharge: The baby may be discharged at the normal time. A discharge advice (eDAN) note must be completed with complete details of the recommended PEP treatment (see below). Discretion may be required in the rare situation where the GP is unaware of the mother’s HIV diagnosis.
  • Follow up: This will be in the neonatal infection clinic. A notification letter (see attached) should be completed and sent to Dr Miall’s secretary Janice Keville (tel 65382, fax 65405). A copy of the referral form must only be filed in the notes once it has been sent/faxed.
  • Referral to the BPSU surveillance study will be undertaken by Dr Miall.
  • Immunisations: Infants born to HIV-positive mothers should follow the routine national primary immunisation schedule with the exception of BCG vaccinationGenerally, BCG vaccine should only be given when the exclusively formula-fed infant is confirmed HIV uninfected at 12–14 weeks. However BCG vaccination can be administered to patients with a high risk of tuberculosis exposure prior to discharge when maternal viral load less than 50 HIV RNA copies/mL at or after 36 weeks’ gestation. [Grade C evidence]
  • Disclosure: There may be situations where the mother has not disclosed her status to her partner. Confidentiality must be respected. If you have concerns these should be raised with the MDT team who are providing on-going care for the mother. 

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Investigation

  • All infants born to HIV positive mothers will be anti-HIV antibody positive for up to 18 months due to placental transfer of IgG. It is therefore necessary to establish HIV status using methods that detect HIV DNA or RNA.
  • PCR for HIV-1 RNA is the standard test used.
  • All samples must be labeled with biohazard stickers (on bottle and the form)
  • A minimum of 1mL blood is required in EDTA bottle, sent to the microbiology.
  • A maternal sample should already be available in the lab. Maternal HIV status, name and NHS number should be listed in the “clinical details” section at the bottom of the form. If the mother is not known to the lab then a maternal sample should be sent
  • HIV-2: If the mother has HIV-2 infection then the baby will need specific HIV-2 PCR tests instead of HIV-1 PCR tests. Please label request form clearly stating HIV-2 infection. The antibody test at 18 months covers HIV-1 and HIV-2 strains.
  • Day 1     1st HIV PCR
    This will only be positive if there has been trans-placental infection which is very rare. This sample must not be taken until the baby has been cleaned. Cord blood cannot be used.
    Hepatitis B /C serology if mother positive or not been tested 
    Baseline FBC, LFT is desirable.
  • 6 weeks  2nd HIV PCR (2 weeks post PEP  ending)
    Check at first outpatient follow up
    Repeat FBC, LFT if received triple PEP therapy.
    [Remember at this appointment to ask about siblings- see below]
  • 3-4 months   3rd HIV PCR (2 months after PEP)
    Can be performed at second review appointment.
    Repeat FBC, LFT if on PCP Prophylaxis
  • Additional tests:
  • If born extremely preterm (<30 weeks) or where very high risk of vertical transmission (e.g. poor compliance or breastfeeding against medical advice) it may be necessary to perform further monthly HIV PCR tests.
  • Where breastfeeding has been agreed the mother and baby should be tested at delivery, then monthly until cessation of breast feeding.  Following cessation of breast feeding baby will then need 2 weeks and 2 months post breast feeding bloods, followed by the usual HIV antibody test at 18 months of age.
  • 18 months  HIV Antibody test (serology) This is the final test to confirm that there has been no late vertical infection. It should not be undertaken earlier or it may be falsely positive due to residual maternal IgG antibody. If weekly positive this test should be repeated after a further 2 months.

If any of the HIV PCR tests are positive the baby must be discussed urgently with the children’s HIV specialist (Dr Chetcuti / Dr O’Riordan) and virology (Dr Hale) to guide further investigation and treatment.

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Treatment / Management

Prophylactic anti-retroviral treatment for the infant

Post exposure prophylaxis (PEP) should be given to the baby in all circumstances [Grade A evidence]. The drug regime will depend on the level of risk of MTCT (see below)

PEP should be administered very soon after birth, certainly within 4 hours. [Grade B evidence] Therefore it is essential for the midwife to consult the pharmacist in advance of delivery to ensure it is available.

Neonatal PEP should be continued for 4 weeks (Grade B) 

Missed dose: If a baby has a significant vomit within 15 minutes of a dose, this should be repeated. If the first dose after birth is not given within 4 hours, it should still be given as soon as possible. All delivery suites and maternity wards within LTHT stock both IV and oral anti viral medications to ensure that these first doses can be given promptly.

  • LOW RISK:
    Zidovudine monotherapy is recommended if maternal viral load is less than 50 HIV RNA copies/mL at 36 weeks or at delivery (or if mother delivered by planned LSCS whilst on zidovudine monotherapy) irrespective of the mother’s drug history or viral resistance pattern.[Grade B evidence]
    PCP prophylaxis with cotrimoxazole is not required in this situation.
    Breast fed infants, require the same duration of treatment as none breast fed infants.
  • HIGHER RISK:
    Three drug therapy is recommended in the following scenarios:
    1. Infants less than 72 hours old who are born to untreated HIV positive women.
    2. When maternal viral load at 36 weeks/delivery is greater than 50 HIV copies/mL.
    3. If  an HIV positive mother has not complied with treatment or viral load testing during pregnancy
    4. In extreme preterm infants give i.v. zidovudine and introduce oral triple therapy at the earliest opportunity if they are  able to tolerate oral medication. Discuss treatment with consultant neonatologist.

Three drug therapy is usually zidovudine (4 weeks), lamivudine (4 weeks) and nevirapine(2 weeks) [Grade B] Other drug combinations may be recommended in specific situations (e.g. known maternal drug resistance) see below. If alternative drug regimens are recommended ensure that pharmacy have been contacted and the required drugs have been ordered and supplied to the relevant wards prior to the predicted delivery date.

PCP Prophylaxis (Cotrimoxazole) should be initiated at 4 weeks  in:

  • All confirmed HIV infected infants [Grade B evidence]
  • All infants with an initial positive HIV PCR (continue until HIV excluded) 
  • Infants born to mother with viral load greater than 1000 HIV copies/mL or unknown viral load. [ Grade C]

PCP prophylaxis should be continued until HIV infection has been excluded.

Siblings: If the mother has older children these may not have been tested. Just because they are well does not mean they are not at risk. Please check with the mother whether any siblings in the UK have been tested and check these on the results server. If unsure discuss with Children’s HIV specialist nurse to arrange testing.

IF THE SCENARIO IS DIFFERENT FROM THOSE LISTED ABOVE SEEK URGENT EXPERT ADVICE: Check the antenatal care plan. If this does not provide sufficient information then advice on which triple therapy to use may be sought from the adult HIV team consultant or the GU medicine on call registrar (extension 26762 or via switchboard). Expert advice could also be sought from the Leeds Children’s HIV team (Dr Chetcuti / Dr O’Riordan) or from the paediatric infectious diseases department at St George’s hospital London-Tel no 0208 725 3262 and ask to speak to the on call consultant. Other drugs that may be recommended are abacavir (ABC), didanosine (ddI), tenofovir (TDF), entricitabine, nelfinavir, lopinavir/ritinovir (Kaletra®). Consult the Lead Neonatal or the Paediatric HIV pharmacist for appropriate doses, where possible these dose should be agreed prior to the expected delivery date and an individualised plan of drug doses and frequency written and placed in the maternal notes and on the appropriate neonatal units.  Please note although zidovudine, lamivudine and nevirapine are stocked on delivery suite other anti-retroviral drugs are not and will require pre-ordering to ensure that doses post-delivery are not delayed.

Neonatal post exposure prophylaxis formulary:
Neonatal post exposure prophylaxis formulary: Doses taken from 2012 Management of HIV infection in pregnant women (2012)

DRUG

GESTATION or WEIGHT

ROUTE

DOSE

FREQUENCY

Course length

SIDE EFFECTS

Zidovudine (AZT, ZDV, Retrovir®)

Preterm
less than or equal to 34weeks

IV

1.5mg/kg

12  Hourly

 

 

 

 

Start within 4 hours of birth.

Continue for 4 weeks

 

 

 

 

 

 

Anaemia
Neutropenia
Leucopenia

 

 

Preterm less than 30 weeks

PO

2mg/kg

12 hourly for 4 weeks

Preterm
30-34 weeks

PO

2 mg/kg

12 Hourly for first 2 weeks

then

8 hourly for 3rd and 4th week

Term or near term greater than 34 weeks. unable to take orally

IV

1.5mg/kg

6 Hourly

Term or near term (greater than 34 weeks)

PO

4 mg/kg

12 hourly

Nevirapine
(NVP, NEV, Virammune®)

Dose irrelevant of gestation but changes with age.

PO

If mother has received less than 3 days nevirapine

Start within 4 hours of birth.

2 week course only (long half-life)

Rash, hepatitis, Stevens–Johnson syndrome –. Monitor liver function
prior to initiating therapy

2mg/kg

Once daily for first week

then

4mg/kg

Once daily for the second week 

If mother has received more than 3 days nevirapine

4mg/kg

Once daily for 2 weeks

Lamivudine (3TC, Epivir®)

Dose irrelevant of gestation

PO

2mg/kg

12 hourly

For 4 weeks

Anaemia, neutropenia (but less common than with
zidovudine).

Pneumocystis jiroveci pneumonia (PJP), formerly known as Pneumocystis carinii pneumonia (PCP), prophylaxis is only recommended for high risk cases (i.e. those where the infant has required combination therapy). It should be commenced at 4 weeks and continued until PCR negative beyond 3 months of age.

 

Co-trimoxazole
(Septrin®)

Less than 2kg

PO

60mg

Once daily
on
Monday, Wednesday, Friday only

For high risk cases start at 4 weeks (after stopping PEP) Continue until confirmed HIV negative at 3-4 months.

Vomiting
Skin rash
Bone marrow suppression.

More than 2kg

PO

 

120mg

 

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The interventions aimed at advising a pregnant mother of the benefits and importance of antenatal screening for HIV are described in the maternity guideline: detail.aspx?ID=1367 

Infant born to a mother who has not had antenatal screening for HIV

Mother to child transmission (MTCT) of HIV can be reduced from about 30% to <0.1% with optimal interventions. All pregnant women are offered routine screening for HIV on an opt-out basis. In Leeds the uptake is 99.7%. This means there are a small number of women (30-50/year) who have declined testing. This may be due to a variety of reasons including needle-phobia, anxiety about the result or in a very few cases a desire to conceal their HIV status. Pregnant women persistently declining HIV screening will normally have been extensively counselled by the screening midwife and a consultant obstetrician. This may lead to the following scenarios:

A. Mother has declined antenatal HIV testing herself but accepts cord blood HIV testing of the baby

  1. This will have been discussed with the woman during pregnancy and she will have agreed to HIV testing of the baby’s cord blood at birth (thereby avoiding any distress to the baby by using needles to obtain venous blood). This will ensure the window of opportunity for interventions to prevent mother-to-child transmission of HIV is not missed. This is clearly in the child’s best interest as HIV is a serious life-long illness with potential significant complications despite recent advances in drug therapy. This discussion and outcome will have been documented in the maternity notes. A paediatric alert will be used to ensure the paediatric team are aware that the baby needs to have cord blood testing at birth.
  2. Breast feeding should be avoided until the HIV result is known. A point of care test should be performed on cord blood. If this is negative breast feeding may be permitted until the serology result is known. If the point of care test is positive breast feeding must be avoided and legal proceedings will need to start. 
  3. Cord blood should be sent for urgent HIV antibody* (serology sample) and HIV-RNA PCR (EDTA sample). If the HIV antibody test is negative, routine post natal care can continue. If the HIV antibody test is positive the baby should be started on Zidovudine, Nevirapine and Lamivudine. Counselling should be arranged for the mother from the GUM team.
    *The rationale for testing HIV antibody is that even if the mother is HIV positive most infants will be HIV-RNA negative at birth and so we could be falsely reassured by a negative PCR test.

B. Mother has declined antenatal HIV testing and also declines testing of the baby

  1. These cases should have been discussed at the Leeds HIV in pregnancy multi-disciplinary team (MDT) meeting. The information from the HIV risk assessment performed by the specialist screening midwife team will be used to calculate the risk of mother to child transmission of HIV using prevalence rates from the BASHH Post-exposure prophylaxis following sexual exposure guideline
    (see HIV in pregnancy guideline detail.aspx?ID=1367 ).
  2. If the risk to the baby above 1 in 1000 (0.1% which is the level of risk where post-exposure prophylaxis is recommended in adults), the woman will have been seen antenatally to explain that the risk of transmission is at a level where we believe it is in the baby’s best interest to have a HIV test at birth. The aim is to allow post-exposure prophylaxis to be urgently started (ideally within 6 hours of birth but within 72 hours) and avoidance of breast-feeding, to reduce the risk of mother to child transmission. This discussion will be documented in the hospital medical record.
  3. If the mother refuses to consent for cord blood testing and it is the view of the MDT that the child is at >1:1000 (0.1%) risk then steps should have been urgently taken to obtain court authority to allow the HIV testing, and treatment if needed. This must be discussed with the neonatal consultant, risk management and the children’s safeguarding team. The procedure for obtaining an emergency assessment order is outlined in appendix 2.
    Breastfeeding should be discouraged until result is known. Formula feeding or IV fluids can be offered as an alternative. If mother disregards this advice this will form part of the urgent court order to protect the baby from a perceived significant risk.
  4. Once court authority for investigation and treatment is obtained an urgent HIV antibody test and HIV-RNA PCR test should be performed. The baby should be started on Zidovudine, Nevirapine and Lamivudine until the result is known.  If the result is positive, counselling will be required for the mother. The baby will need to be admitted to transitional care / neonatal unit or foster care to ensure compliance with 4 weeks post exposure prophylaxis. Feeding will be as advised by the treatment order.

C. Mother presents in labour and has not had an antenatal HIV screening test

  1. Women presenting in labour or with pre-labour rupture of the membranes or requiring delivery without a documented HIV result should be recommended to have an HIV POCT (if available) and a blood sample sent to the laboratory marked as urgent so that the result will be available on next working day.
  2. If the POCT is positive, interventions to prevent mother-to-child transmission should be commenced immediately without waiting for serological confirmation from the laboratory.
  3. If the woman refuses HIV testing she should be offered testing of her baby at birth (using cord blood), following procedure outlined above (A).
  4. If the woman still declines antenatal testing and also declines testing of her baby then follow procedure outlined above (B).

Appendix 1

HIV prevalence in the UK is shown in Table 1.

The risks of HIV transmission per exposure are:

  • Unprotected receptive vaginal intercourse            1 in 1000
  • Sharing injecting equipment                                    1 in 149

Example of calculation of risk to baby (MTCT estimated at 30%, range 15-40%)

  1. Mother of black African origin =
    7.1% prevalence
    30% risk of MTCT
    7.1 x 0.3 = 2% ( more than 0.1% therefore regard as high risk)

  2. Mother has shared IV needle with known HIV positive person
    Risk of transmission = 1 in 149 = at least 0.67% risk that mother is HIV +ve
    30% risk of MTCT
    0.67x 0.3 = 0.2% (more than 0.1% therefore regard as high risk)

  3. Mother has had unprotected sex once with an IV drug user
    Prevalence in drug users= approx. 1%
    Risk of transmission by unprotected sex 1:1000=0.1%
    MTCT = 30%
    Risk to baby=1%  x 0.1% x 0.3 = 0.0003% (less than 0.1%, therefore does not meet criteria to pursue court authority).

Appendix 2 - How to apply for court authority to undertake an emergency assessment.

  • Consultant Neonatologist to immediately contact Children’s Safeguarding team and the Named Doctor for Child Protection to explain the level of perceived risk to baby. Contact details on the safeguarding website
  • Director of risk management to be immediately contacted by the Consultant neonatologist to explain proposed course of action, who will liaise with trust solicitor. Contact via switchboard / duty senior manager. 
  • Report to be urgently prepared by the Consultant neonatologist for submission to the family court (see outline case below) 

Outline case (will need to be modified depending on individual circumstances)

Name of Mother Date of Birth     NHS Number:
Current gestation:  Estimated date of delivery  
Name of baby (if born) Date of Birth NHS Number

We urgently require the court’s consideration of this case as we believe this baby to be at significant risk of ‘mother to child transmission’ (MTCT) of HIV. We believe this risk to be of such severity that without intervention the baby has a significant risk of acquiring lifelong HIV infection. Intervention with antiretroviral medication within 6 hours of birth (or at most within 72 hrs) and avoidance of breast feeding can significantly reduce this risk and prevent serious, life-threatening infection. We therefore seek the authority of the court to test the baby, to prevent breastfeeding pending the outcome of the testing and provide clinically appropriate treatment to reduce the risk of HIV infection.

Background:
In 2012, Leeds was designated as an area of high prevalence for HIV. Areas of high HIV prevalence are recommended to increase their HIV testing strategies in order to detect undiagnosed HIV and to ‘normalise’ HIV testing. Consequently, GP practices in areas of high HIV prevalence in Leeds routinely test all new patients registering with them on an opt-out basis and all acute medical hospital admissions in Leeds are routinely tested for HIV on an opt-out basis.

Routine opt-out antenatal HIV testing has been performed for many years in order to detect undiagnosed HIV in women so that they can benefit from HIV treatment if needed, but crucially to prevent mother to child transmission of HIV. All pregnant women are offered HIV testing on an opt-out basis as part of their antenatal booking blood tests. In Leeds 99.7% of women are tested antenatally for HIV.

Adults with mental capacity have the right to opt-out of HIV testing as they make the decisions about their own health and care. However with pregnancy there is an additional issue to consider, the health of the child. All health care workers have a duty of care to consider the health of the child born to pregnant women and if necessary to act in the interests of the child even if this is at odds with the mother’s wishes.

Mother to child transmission of HIV can be reduced from about 30% to about 0.1% with the interventions we have available (antenatal treatment with anti-retroviral agents, delivery by caesarean section, avoidance of breast feeding and post exposure prophylaxis (PEP) antiretroviral medication for the baby). In 2015 an analysis of national statistics showed that the majority of HIV positive babies in recent years were born to women who have not had a diagnostic HIV test before the birth.  Studies suggest HIV incidence is at least twice as high in mothers who have declined testing than in the general population.  The largest international study of babies born to mothers who had not received antenatal antiretroviral treatment suggests the vertical transmission rate can be reduced to 2.2-2.4% with triple antiretroviral PEP3.

Our aim is always to work in partnership with pregnant women to support them to have HIV testing prior to delivery. This enables us to introduce the interventions that reduce mother to child transmission of HIV.

However, there are a few women who decline antenatal HIV testing.

There is currently no national guidance on the management of these women; relevant authorities include the UK National Screening Committee for Infectious Diseases in Pregnancy, Public Health England, the British HIV Association (BHIVA) or the Children’s HIV Association (CHIVA).
 
Two of these national authorities do consider the management of the child in these cases. Both BHIVA and CHIVA guidelines suggest that an HIV test is strongly recommended in all infants born to mothers in whom the HIV status is unknown 1,2 .

Specific risk in this case
The maternity MDT considers the risk of MTCT of HIV in this case is at least 1 in _____. This risk is calculated as follows:

(A)Assessment of maternal HIV risk based on _______________ =    1 in X
(B) Risk of MTCT in untreated mother with high viral load = 30% (range 15-40%)
(C) Additional risk if mother breast feeds = 30%
Risk to child = A x (B+C)

This risk level >1:1000; (>0.1%) is significant, it is at a level where post-exposure prophylaxis treatment would be commenced for an adult exposed to the risk of contracting HIV.

National Guidance advises management that reduces the risk of a baby contracting HIV from 30% to <0.1%1,2.

Measures taken to explore this risk with the mother
Recognising this risk, the following professionals have explained this information; the risk of HIV & the management that we wish to deliver to the baby.

Outline the professionals that have discussed risk with mother, with dates and persons present (interpreter, advocate, family member)
Outline any reasons mother has given for declining testing
Are there any issues regarding the mother’s capacity to make this decision? 
Who has parental responsibility for the baby?
Has the proposed testing of the baby been discussed with the father?  What did he think should happen? If the father was not consulted, why was it not considered to be appropriate?
Are there any wider safeguarding concerns, is the Local Authority involved, is there any indication that the Local Authority might apply for Parental Responsibility or intervene in the care of the child?

Action
Given the assessed risk to the baby of HIV infection and the mother’s decision to withhold consent for testing the baby, Leeds Teaching Hospitals NHS Trust seeks the court’s authority to:-

  1. Undertake the HIV antibody and the HIV-RNA PCR blood test on the baby’s blood (venous or cord blood as appropriate);
  2. Take such steps as are necessary to prevent breastfeeding until the baby’s HIV results are known and, if the baby is HIV antibody positive, on a continuing basis (due to the risk of Mother to Child Transfer (MTCT) of HIV). This may include supervised contact only; and
  3. Where clinically indicated, ensure that the baby receives triple anti-retroviral medication for 4 weeks, with repeat testing of the baby’s blood at 4-6 weeks and 3-4 months. This may require prolonged hospital admission or foster care placement; and
  4. Where clinically indicated, ensure compliance with HIV testing of the baby at 4-6 weeks and at 3-4 months of age in the perinatal infection clinic. This would only be indicated if the initial HIV antibody test was positive.

Whilst the aim of testing the baby is to ensure the baby is able to receive the correct post exposure prophylaxis when required, a positive result in the baby would confirm that the mother is HIV positive. We would therefore offer suitable support, counselling and HIV treatment to the mother by our specialist HIV services.

References

  1. CHIVA guideline on perinatal care:
  2. BHIVA guidelines for the management of HIV infection in pregnant women  http://www.bhiva.org/pregnancy-guidelines.aspx
  3. Nielsen-Saines K1, Watts DH et al Three postpartum antiretroviral regimens to prevent intrapartum HIV infection. N Engl J Med. 2012 Jun 21;366(25):2368-79. doi: 10.1056/NEJMoa1108275.

Provenance

Record: 177
Objective:

Aims
To prevent the mother-to-child transmission (MTCT) of HIV

Objectives
To provide evidence-based recommendations for appropriate diagnosis, investigation and management of infants born to HIV positive mothers.

Clinical condition:

Prevention of mother to child transmission of HIV infection

Target patient group: Newborn infants born to HIV positive mothers in Leeds
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. British HIV Association (BHIVA) Guidelines for the management of HIV infection in pregnant women 2014 interim review. HIV medicine (2014), 15(Suppl 4), 1-77
     see : http://www.bhiva.org/ClinicalGuidelines.aspx
  2. Children’s HIV association (CHIVA). Perinatal transmission audit recommendations. Feb 2011.
  3. Children’s HIV association (CHIVA). Position statement on infant feeding in the UK.

References - How to apply for an emergency assessment court authority

  1. CHIVA guideline on perinatal care:
  2. BHIVA guidelines for the management of HIV infection in pregnant women  http://www.bhiva.org/pregnancy-guidelines.aspx
  3. Nielsen-Saines K1, Watts DH et al Three postpartum antiretroviral regimens to prevent intrapartum HIV infection. N Engl J Med. 2012 Jun 21;366(25):2368-79. doi: 10.1056/NEJMoa1108275.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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