National Study Of HIV In Pregnancy And Childhood Research Articles

UK national clinical audit: management of pregnancies in women with HIV

BackgroundThe potential for HIV transmission between a pregnant woman and her unborn child was first recognized in 1982. Since then a complex package of measures to reduce risk has been developed. This project aims to review UK management of HIV in pregnancy as part of the British HIV Association (BHIVA) audit programme.MethodsThe National Study of HIV in Pregnancy and Childhood (NSHPC), a population-based surveillance study, provided data for pregnancies with an expected delivery date from 1/1/13 - 30/6/14. Services also completed a survey on local management policies. Data were audited against the 2012 BHIVA pregnancy guidelines.ResultsDuring the audit period 1483 pregnancies were reported and 112 services completed the survey. Use of dedicated multidisciplinary teams was reported by 99% although 26% included neither a specialist midwife nor nurse. 17% of services reported delays >1 week for HIV specialist review of women diagnosed antenatally. Problematic urgent HIV testing had been experienced by 9% of services although in a further 49% the need for urgent testing had not arisen. Delays of >2 h in obtaining urgent results were common.Antiretroviral therapy (ART) was started during pregnancy in 37% women with >94% regimens in accordance with guidelines. Late ART initiation was common, particularly in those with a low CD4 count or high viral load.Eleven percent of services reported local policy contrary to guidelines regarding delivery mode for women with a VL <50 copies/mL at ≥36 weeks. According to NSHPC reports 27% of women virologically eligible for vaginal delivery planned to deliver by CS.ConclusionsPregnant women in the UK are managed largely in accordance with BHIVA guidelines. Improvements are needed to ensure timely referral and ART initiation to ensure the best possible outcomes.

Operative vaginal delivery and invasive procedures in pregnancy among women living with HIV

ObjectivesTo describe the use and outcomes of operative delivery and invasive procedures in pregnancy amongst women living with HIV. Study designThe National Study of HIV in Pregnancy and Childhood (NSHPC) is a comprehensive population-based surveillance study in the UK and Ireland. The NSHPC has collected data on operative delivery since 2008, and invasive procedures in pregnancy (amniocentesis, cordocentesis, chorionic villus sampling) from 2012. Descriptive analyses were conducted on 278 pregnancies expected to deliver from 1 January 2008 with outcome reported to the NSHPC by 31 March 2016. ResultsAmong 9372 pregnancies in 2008–2016, there were 9072 livebirths with 251 operative deliveries and 27 invasive procedures in pregnancy reported. Information was available for 3023/3490 vaginal deliveries, and use of forceps or vacuum reported in 251deliveries (8.2%), increasing over calendar time to almost 10% by 2014–16. Forceps were used twice as often as vacuum delivery, and forceps use increased over time. One infant delivered operatively is known to have acquired HIV. From 2012 there were 4063 pregnancies resulting in 3952 livebirths, 83 terminations and 28 stillbirths. 2163/4063 had information on use (or not) of invasive procedures in pregnancy. Amniocentesis was reported in 25/2163 pregnancies, there was one report of chorionic villus sampling and one of cordocentesis. There were no reported transmissions following invasive procedures in pregnancy. ConclusionsThis is the largest study to date to report on operative delivery in women living with HIV on combined antiretroviral therapy (cART), and provides an up-to-date picture of invasive procedures during pregnancy in this group. Findings from this comprehensive national study are reassuring but numbers are currently low; on-going monitoring is crucial as obstetric care of women with HIV becomes normalised.

Maternal and foetal outcomes among 4118 women with HIV infection treated with lopinavir/ritonavir during pregnancy: analysis of population-based surveillance data from the national study of HIV in pregnancy and childhood in the United Kingdom and Ireland.

BackgroundThe National Study of HIV in Pregnancy and Childhood (NSHPC) conducts comprehensive population-based surveillance of pregnancies in women with HIV infection in the United Kingdom/Ireland. Use of antepartum antiretroviral therapy (ART) for prevention of mother-to-child transmission (MTCT) and to treat maternal infection, if required, is standard practise in this population; lopinavir/ritonavir (LPV/r) is commonly used. The study objective was to examine the use of LPV/r among pregnant women with HIV infection to describe maternal and foetal outcomes.MethodsThe NSHPC study collected maternal, perinatal and paediatric data through confidential and voluntary obstetric and paediatric reporting schemes. Pregnancies reported to the NSHPC by June 2013, due to deliver 2003–2012 and with LPV/r exposure were included in this analysis, using pregnancy as the unit of observation.ResultsFour thousand eight hundred sixty-four LPV/r-exposed pregnancies resulting in 4702 deliveries in 4118 women were identified. Maternal region of birth was primarily sub-Saharan Africa (77 %) or United Kingdom/Ireland (14 %). Median maternal age at conception was 30 years. LPV/r was initiated preconception in 980 (20 %) and postconception in 3884 (80 %) pregnancies; median duration of antepartum LPV/r exposure was 270 and 107 days, respectively. Viral load close to delivery was <50 copies/mL in 73 % and <1000 copies/mL in 94 % of women. 63 % of deliveries were by caesarean section (elective, 62 %; emergency, 38 %). Among singleton live births, 13 % were <37 weeks of gestation (2.5 % <32 weeks) and 15 % had birth weight <2500 g (2.3 % <1500 g). MTCT rates were 1.1 (2003–2007) and 0.5 % (2008–2012). 134 live born children (2.9 %) had ≥1 congenital abnormality.ConclusionsThe results of this analysis using real-world data from a large number of pregnant women with HIV infection in the United Kingdom and Ireland who received LPV/r-containing ART regimens demonstrate that these regimens have a good safety profile and are effective for viral suppression during pregnancy, with associated low rates of MTCT.

The risk of viral rebound in the year after delivery in women remaining on antiretroviral therapy.

Objective:The objective of this study is to assess the risk of viral rebound in postpartum women on suppressive combination antiretroviral therapy (cART).Methods:Using data from the UK Collaborative HIV Cohort (UK CHIC) study and the UK and Ireland National Study of HIV in Pregnancy and Childhood (NSHPC), women with HIV-RNA 50 copies/ml or less at delivery in 2006–2011, who started life-long cART during pregnancy (n = 321) or conceived on cART (n = 618), were matched by age, duration on cART and time period, with at least one control (non-postpartum). The cumulative probability of viral rebound (HIV-RNA >200 copies/ml) was assessed by Kaplan–Meier analysis; adjusted hazard ratios (aHRs) for the 0–3 and 3–12 months postdelivery (cases)/pseudo-delivery (controls) were calculated in Cox proportional hazards models.Results:In postpartum women who conceived on cART, 5.9% [95% confidence interval (95% CI) 4.0–7.7] experienced viral rebound by 3 months, and 2.2% (1.4–3.0%) of their controls. The risk of viral rebound was higher in postpartum women than in controls during the first 3 months [aHR 2.63 (1.58–4.39)] but not during the 3–12 months postdelivery/pseudo-delivery. In postpartum women who started cART during pregnancy, 27% (22–32%) experienced viral rebound by 3 months, and 3.0% (1.6–4.4%) of their controls. The risk of viral rebound was higher in postpartum women than in controls during both postdelivery/pseudo-delivery periods [<3 months: aHR 6.63 (3.58–12.29); 3–12 months: aHR 4.05 (2.03–8.09)].Conclusion:In women on suppressive cART, the risk of viral rebound is increased following delivery, especially in the first 3 months, which may be related to reduced adherence, indicating the need for additional adherence support for postpartum women.

Duration of ruptured membranes and mother-to-child HIV transmission: a prospective population-based surveillance study.

To investigate the association between duration of rupture of membranes (ROM) and mother-to-child HIV transmission (MTCT) rates in the era of combination antiretroviral therapy (cART). The National Study of HIV in Pregnancy and Childhood (NSHPC) undertakes comprehensive population-based surveillance of HIV in pregnant women and children. UK and Ireland. A cohort of 2398 singleton pregnancies delivered vaginally, or by emergency caesarean section, in women on cART in pregnancy during the period 2007-2012 with information on duration of ROM; HIV infection status was available for 1898 infants. Descriptive analysis of NSHPC data. Rates of MTCT. In 2116 pregnancies delivered at term, the median duration of ROM was 3 hours 30 minutes (interquartile range, IQR 1-8 hours). The overall MTCT rate for women delivering at term with duration of ROM ≥4 hours was 0.64% compared with 0.34% for ROM <4 hours, with no significant difference between the groups (OR 1.90, 95% CI 0.45-7.97). In women delivering at term with a viral load of <50 copies/ml, there was no evidence of a difference in MTCT rates with duration of ROM ≥4 hours, compared with <4 hours (0.14% for ≥4 hours versus 0.12% for <4 hour; OR 1.14, 95% CI 0.07-18.27). Among infants born preterm with infection status available, there were no transmissions in 163 deliveries where the maternal viral load was <50 copies/ml. No association was found between duration of ROM and MTCT in women taking cART. Rupture of membranes of more than 4 hours is not associated with MTCT of HIV in women on effective ART delivering at term.

Pregnancy is associated with elevation of liver enzymes in HIV-positive women on antiretroviral therapy.

Objective:The objective of this study is to assess whether pregnancy is associated with an increased risk of liver enzyme elevation (LEE) and severe LEE in HIV-positive women on antiretroviral therapy (ART).Design:Two observational studies: the UK Collaborative HIV Cohort (UK CHIC) study and the UK and Ireland National Study of HIV in Pregnancy and Childhood (NSHPC).Methods:Combined data from UK CHIC and NSHPC were used to identify factors associated with LEE (grade 1–4) and severe LEE (grade 3–4). Women starting ART in 2000–2012 were included irrespective of pregnancy status. Cox proportional hazards were used to assess fixed and time-dependent covariates including pregnancy status, CD4+ cell count, drug regimen and hepatitis B virus/hepatitis C virus (HBV/HCV) coinfection.Results:One-quarter (25.7%, 982/3815) of women were pregnant during follow-up, 14.2% (n = 541) when starting ART. The rate of LEE was 14.5/100 person-years in and 6.0/100 person-years outside of pregnancy. The rate of severe LEE was 3.9/100 person-years in and 0.6/100 person-years outside of pregnancy. The risk of LEE and severe LEE was increased during pregnancy [LEE: adjusted hazard ratio (aHR) 1.66 (1.31–2.09); severe LEE: aHR 3.57 (2.30–5.54)], including in secondary analyses excluding 541 women pregnant when starting ART. Other factors associated with LEE and severe LEE included lower CD4+ cell count (<250 cells/μl), HBV/HCV coinfection and calendar year.Conclusion:Although few women developed severe LEE, this study provides further evidence that pregnancy is associated with an increased risk of LEE and severe LEE, reinforcing the need for regular monitoring of liver biomarkers during pregnancy.

Outcomes related to 4864 pregnancies with exposure to lopinavir/ritonavir (LPV/r).

IntroductionDuring pregnancy, LPV/r is a common anchor drug employed to treat the mother's HIV-1 infection in addition to reducing the risk of mother-to-child transmission (MTCT). The National Study of HIV in Pregnancy and Childhood (NSHPC) conducts a comprehensive population-based surveillance of HIV infection in pregnant women exposed to antiretroviral therapy (ART) in the UK and Ireland; in 2003–2012 over a third of pregnancies reported to the NSHPC involved exposure to LPV/r.MethodsWe undertook a retrospective were descriptive analysis of individual NSHPC patient data, using pregnancy as the unit of observation. Clinical outcomes for pregnancies reported by June 2013, where women were exposed to LPV/r and due to deliver between January 2003 and December 2012, are described.ResultsA total of 4864 LPV/r exposed pregnancies in 4118 women were identified. These resulted in 4702 deliveries with 4759 live and 46 stillborn infants. Seventy five percent of women were born in sub-Saharan Africa, 13% in the UK or Ireland. Median maternal age at conception was 30 years. Nine hundred and eighty (20%) pregnancies were conceived while taking LPV/r, with a median duration of LPV/r exposure of 270 days. A total of 3884 (80%) pregnancies initiated LPV/r after conception, with a median duration of LPV/r exposure of 107 days. Viral load (VL) close to delivery was available for 4083/4702 (87%) deliveries, with VL <50 c/mL in 73% and <1000 c/mL in 94% of women. VL by timing of LPV/r initiation is shown in Table 1. Sixty three percent of deliveries were by C-section, of which 62% were classified as elective and 38% as emergency. Among singleton liveborn infants, 13% were born prior to 37 weeks gestation (2.5% <32 weeks) and 15% had birth weight <2500 g (2.3% <1500 g). HIV infection status was available for 4039 (89%) singleton infants. For the periods 2003–2007 and 2008–2012, MTCT rates were 1.1% (95% CI 0.6–1.6) and 0.5% (95% CI 0.2–0.8) respectively. Hundred and thirty four live born children (2.8%) had at least one congenital abnormality reported.ConclusionsIn the NSHPC database, in women exposed to LPV/r during pregnancy in the UK and Ireland, MTCT rates are low and continue to decline, and are similar to rates in the entire NSHPC cohort of women with diagnosed HIV [1]. The congenital abnormality rate is comparable with that reported for the uninfected population in this geographic region.

Does pregnancy increase the risk of ART-induced hepatotoxicity among HIV-positive women?

IntroductionHigh rates of hepatotoxicity have been observed among HIV-positive pregnant women using antiretroviral therapy (ART). However, the extent to which pregnancy affects the risk of ART-induced hepatotoxicity is unclear since studies in this area have generated conflicting results.Material and MethodsCombined data from the UK Collaborative HIV Cohort (UK CHIC) study and the UK and Ireland National Study of HIV in Pregnancy and Childhood (NSHPC) were used. Alanine aminotransferase (ALT) data were assessed according to the Division of AIDS toxicity guidelines to identify factors associated with liver enzyme elevation (LEE) (grade 1–4). Women starting ART in 2000–11 aged 16–49 years were included irrespective of pregnancy status at ART start. Cox proportional hazards were used to assess the associations between fixed (ethnicity, exposure group, HBV/HCV co-infection, prior ART use, and age, year, pregnancy status, viral load and CD4 count at ART start) and time-dependent covariates (pregnancy status, age, year, CD4 count, viral load, duration on ART) and the risk of LEE.ResultsOf the 3426 women included, one-quarter (25.0%, n=857) were pregnant during follow-up and 14.4% (n=492) started ART during pregnancy. The rate of LEE was 15/100 person-years (PY) during pregnancy and 6.1/100 PY outside pregnancy. The risk of LEE was increased during pregnancy (adjusted hazard ratio (aHR) 1.61 [1.26–2.06], p<0.001), including in secondary analysis excluding 493 women pregnant when starting ART. Other factors independently associated with LEE were lower CD4 count (<250 cells/mm3 vs. 251–350 cells/mm3 aHR 1.25 [1.02–1.54], p=0.03), HBV/HCV co-infection (aHR 1.94 [1.58–2.39], p<0.001), HIV acquired via injecting drug use (aHR 1.61 [1.15–2.24], p=0.01 vs. heterosexually) and calendar year (aHR 1.05 [1.02–1.08], p<0.001 per one year increase). Three ART drugs were associated with increased risk of LEE (efavirenz aHR 1.27 [1.06–1.50], p-value 0.008; maraviroc 4.19 [1.34–13.1], p=0.01; and nevirapine 1.59 [1.30–1.95], p-value <0.001). Use of zidovudine was associated with decreased risk of LEE (aHR 0.74 [0.63–0.87], p<0.001) as was increasing time on an NNRTI-based regimen (aHR 0.91 [0.86–0.96], p<0.001 per additional year).ConclusionsPregnant women were at increased risk of LEE, highlighting the importance of close monitoring of toxicity biomarkers during pregnancy.

Response to antiretroviral therapy (ART): comparing women with previous use of zidovudine monotherapy (ZDVm) in pregnancy with ART naïve women

BackgroundShort-term zidovudine monotherapy (ZDVm) remains an option for some pregnant HIV-positive women not requiring treatment for their own health but may affect treatment responses once antiretroviral therapy (ART) is subsequently started.MethodsData were obtained by linking two UK studies: the UK Collaborative HIV Cohort (UK CHIC) study and the National Study of HIV in Pregnancy and Childhood (NSHPC). Treatment responses were assessed for 2028 women initiating ART at least one year after HIV-diagnosis. Outcomes were compared using logistic regression, proportional hazards regression or linear regression.ResultsIn adjusted analyses, ART-naïve (n = 1937) and ZDVm-experienced (n = 91) women had similar increases in CD4 count and a similar proportion achieving virological suppression; both groups had a low risk of AIDS.ConclusionsIn this setting, antenatal ZDVm exposure did not adversely impact on outcomes once ART was initiated for the woman’s health.

Predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care.

To describe predictors of pregnancy and changes in pregnancy incidence among HIV-positive women accessing HIV clinical care. Data were obtained through the linkage of two separate studies: the UK Collaborative HIV Cohort study (UK CHIC), a cohort of adults attending 13 large HIV clinics; and the National Study of HIV in Pregnancy and Childhood (NSHPC), a national surveillance study of HIV-positive pregnant women. Pregnancy incidence was measured using the proportion of women in UK CHIC with a pregnancy reported to NSHPC. Generalized estimating equations were used to identify predictors of pregnancy and assess changes in pregnancy incidence in 2000-2009. The number of women accessing care at UK CHIC sites increased as did the number of pregnancies. Older women were less likely to have a pregnancy [adjusted relative rate (aRR) 0.44 per 10 year increment in age, [95% confidence interval (CI) (0.41-0.46)], P < 0.001] as were women with CD4 cell count less than 200 cells/μl compared with CD4 cell count 200-350 cells/μl [aRR 0.65 (0.55-0.77), P < 0.001] and women of white ethnicity compared with women of black African ethnicity [aRR 0.67 (0.57-0.80), P < 0.001]. The likelihood that women had a pregnancy increased over the study period [aRR 1.05 (1.03-1.07), P < 0.001). The rate of change did not significantly differ according to age group, antiretroviral therapy use, CD4 group or ethnicity. The pregnancy rate among women accessing HIV clinical care increased in 2000-2009. HIV-positive women with, or planning, a pregnancy require a high level of care and this is likely to continue and increase as more women of older age have pregnancies.

The impact of African ethnicity and migration on pregnancy in women living with HIV in the UK: design and methods

BackgroundThe number of reported pregnancies in women with diagnosed HIV in the UK increased from 80 in 1990 to over 1400 in 2010; the majority were among women born in sub-Saharan Africa. There is a paucity of research on how social adversity impacts upon pregnancy in HIV positive women in the UK; furthermore, little is known about important outcomes such as treatment uptake and return for follow-up after pregnancy. The aim of this study was to examine pregnancy in African women living with HIV in the UK.Methods and designThis was a two phase mixed methods study. The first phase involved analysis of data on approximately 12,000 pregnancies occurring between 2000 and 2010 reported to the UK’s National Study of HIV in Pregnancy and Childhood (NSHPC). The second phase was based in London and comprised: (i) semi-structured interviews with 23 pregnant African women living with HIV, 4 health care professionals and 2 voluntary sector workers; (ii) approximately 90 hours of ethnographic fieldwork in an HIV charity; and (iii) approximately 40 hours of ethnographic fieldwork in a Pentecostal church.DiscussionWe have developed an innovative methodology utilising epidemiological and anthropological methods to explore pregnancy in African women living with HIV in the UK. The data collected in this mixed methods study are currently being analysed and will facilitate the development of appropriate services for this group.

Using two on-going HIV studies to obtain clinical data from before, during and after pregnancy for HIV-positive women

BackgroundThe UK Collaborative HIV Cohort (UK CHIC) is an observational study that collates data on HIV-positive adults accessing HIV clinical care at (currently) 13 large clinics in the UK but does not collect pregnancy specific data. The National Study of HIV in Pregnancy and Childhood (NSHPC) collates data on HIV-positive women receiving antenatal care from every maternity unit in the UK and Ireland. Both studies collate pseudonymised data and neither dataset contains unique patient identifiers. A methodology was developed to find and match records for women reported to both studies thereby obtaining clinical and treatment data on pregnant HIV-positive women not available from either dataset alone.ResultsWomen in UK CHIC receiving HIV-clinical care in 1996–2009, were found in the NSHPC dataset by initially ‘linking’ records with identical date-of-birth, linked records were then accepted as a genuine ‘match’, if they had further matching fields including CD4 test date. In total, 2063 women were found in both datasets, representing 23.1% of HIV-positive women with a pregnancy in the UK (n = 8932). Clinical data was available in UK CHIC following most pregnancies (92.0%, 2471/2685 pregnancies starting before 2009). There was bias towards matching women with repeat pregnancies (35.9% (741/2063) of women found in both datasets had a repeat pregnancy compared to 21.9% (1502/6869) of women in NSHPC only) and matching women HIV diagnosed before their first reported pregnancy (54.8% (1131/2063) compared to 47.7% (3278/6869), respectively).ConclusionsThrough the use of demographic data and clinical dates, records from two independent studies were successfully matched, providing data not available from either study alone.

The association between ethnicity and late presentation to antenatal care among pregnant women living with HIV in the UK and Ireland

UK and Ireland guidelines state that all pregnant women should have their first antenatal care appointment by 13 weeks of pregnancy (antenatal booking). We present the results of an analysis looking at the association between maternal ethnicity and late antenatal booking in HIV-positive women in the UK and Ireland. We analysed data from the National Study of HIV in Pregnancy and Childhood (NSHPC). We included all pregnancies in women who were diagnosed with HIV before delivery and had an estimated delivery date between 1 January 2008 and 31 December 2009. Late booking was defined as antenatal booking at 13 weeks or later. The baseline reference group for all analyses comprised women of “white” ethnicity. Logistic regression models were fitted to estimate adjusted odds ratios (AOR). There were 2721 eligible reported pregnancies; 63% (1709) had data available on antenatal care booking date. In just over 50% of pregnancies (871/1709), the antenatal booking date was ≥13 weeks of pregnancy (i.e., late booking). Women diagnosed with HIV during the current pregnancy were more likely to present for antenatal care late than those previously diagnosed (59.1% vs. 47.5%, p<0.001). Where women knew their HIV status prior to becoming pregnant, the risk of late booking was raised for those of African ethnicity (AOR 1.80; 95% confidence interval (CI) 1.14, 2.82; p=0.011). In women diagnosed with HIV during pregnancy, the risk of late booking was also higher for women of African ethnicity (AOR 2.98: 95% CI 1.45, 6.11; p=0.003) and for women of other black ethnicity (AOR 3.74: 95% CI 1.28, 10.94; p=0.016). Overall, women of African or other black ethnicity were more likely to book late for antenatal care compared with white women, regardless of timing of diagnosis. This may have an adverse effect on maternal and infant outcomes, including mother-to-child transmission of HIV.

Audit of the Perinatal Recommendations from the 'Perinatal Transmission of HIV in England, 2002-2005' Report: Category: Scientific free paper

In 2007, a report was published documenting the findings of an audit regarding perinatal transmission of HIV undertaken by the Audit, Information and Analysis Unit (AIAU), the National Study of HIV in Pregnancy and Childhood (NSHPC), and the Children's HIV Association (CHIVA). This report set out perinatal recommendations aimed to improve diagnosis and management of HIV in pregnancy to further reduce mother-to-child transmission rates, and ultimately reduce childhood incidence of HIV infection.

Antiretroviral therapy and preterm delivery—a pooled analysis of data from the United States and Europe

To investigate reported differences in the association between highly active antiretroviral therapy (HAART) in pregnancy and the risk of preterm delivery among HIV-infected women. Combined analysis of data from three observational studies. USA and Europe. A total of 19, 585 singleton infants born to HIV-infected women, 1990-2006. Data from the Pediatric Spectrum of HIV Disease project (PSD), a US monitoring study, the European Collaborative Study (ECS), a consented cohort study, and the National Study of HIV in Pregnancy and Childhood (NSHPC), the United Kingdom and Ireland surveillance study. Preterm delivery rate (<37 weeks of gestation). Compared with monotherapy, HAART was associated with increased preterm delivery risk in the ECS (adjusted odds ratio [AOR] 2.40, 95% CI 1.49-3.86) and NSHPC (AOR 1.43, 95% CI 1.10-1.86), but not in the PSD (AOR 0.92, 95% CI 0.67-1.26), after adjusting for relevant covariates. Because of heterogeneity, data were not pooled for this comparison, but heterogeneity disappeared when HAART was compared with dual therapy (P = 0.26). In a pooled analysis, HAART was associated with 1.5-fold increased odds of preterm delivery compared with dual therapy (95% CI 1.19-1.87, P=0.001), after adjusting for covariates. Heterogeneity in the association between HAART and preterm delivery was not explained by study design, adjustment for confounders or a standard analytical approach, but may have been the result of substantial differences in populations and data collected. The pooled analysis comparing HAART with dual therapy showed an increased risk of preterm delivery associated with HAART.

In utero exposure to antiretroviral therapy: feasibility of long-term follow-up

Most uninfected children born to diagnosed HIV-infected women in the United Kingdom (UK) are exposed to antiretroviral therapy (ART) in utero and neonatally, and concerns exist about potential adverse effects of such exposure. We explored the feasibility of using national clinic-based follow-up to investigate the association between ART exposure and adverse health events occurring after the neonatal period. Active surveillance of obstetric and paediatric HIV infection is conducted through the National Study of HIV in Pregnancy and Childhood (NSHPC). Between 2002 and 2005, health professionals enrolled previously notified uninfected children in a consented follow-up study (the CHildren exposed to AntiRetroviral Therapy (CHART) study). Follow-up information was collected opportunistically using a standard questionnaire. Of 2104 eligible uninfected children born in the UK between 1996 and 2004, 704 (33.5%) were enrolled in CHART; parents of 4.8% (100/2104) declined, 2.8% (59/2104) had gone abroad, 21.6% (455/2104) were not contactable, and the remaining 37.3% (786/2104) were not enrolled mainly because of lack of clinic resources or unwillingness of health professionals to approach the families. Demographic characteristics and type of ART exposure for enrolled and non-enrolled children were similar. Latest information on enrolled children was available at a median age of 24 months. Minor childhood ailments were reported in the majority of children, febrile seizures in 1.6% (11/704), and major health problems in 3.8% (27/704). It was reassuring that prevalence of these outcomes was within UK norms, but numbers were small and duration of follow-up was limited. The difficulties encountered in enrolling and retaining children in this study indicate that comprehensive clinic-based follow-up of ART-exposed uninfected children is not practical. Alternative approaches are required; a robust, secure data linkage protocol would provide a more feasible and sustainable system for long-term monitoring of in utero ART exposure.

Young People in the United Kingdom and Ireland with Perinatally Acquired HIV: The Pediatric Legacy For Adult Services

Children with perinatally acquired HIV-1 infection are surviving into adolescence and increasingly transitioning toward adult services. Planning appropriate services in adult life requires an understanding of their progress through pediatric care. We describe the demographic features, disease progression, antiretroviral therapy (ART), and resistance in young people aged 10 years or more living in the United Kingdom and Ireland reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) with prospective annual follow-up in the Collaborative HIV Paediatric Study (CHIPS) between 1996 and September 2007. Six hundred fifty-four perinatally infected young people were identified; 76% black African, 57% born abroad. Median age at presentation and duration of follow-up was 1 and 11 years, respectively, if born in the United Kingdom/Ireland, and 8 and 5 years if born elsewhere. One hundred sixty-nine (26%) ever had an AIDS-defining illness. Ten died during adolescence. At last follow-up, 64% were on ART, 18% off treatment having previously received ART and 18% were ART naive. Of 518 who had received highly active antiretroviral therapy (HAART), 47% were triple class experienced. At last follow-up 77 (12%) had CD4 counts less than 200 per microliter; of those on HAART, 78% had HIV-1 RNA </=400 copies per milliliter, median CD4 count 554 (interquartile range [IQR] 324-802). Among 166 with resistance assays on HAART, 52% and 12% had dual- and triple-class HIV-1-associated resistance mutations, respectively. One hundred three (16%) young people had transferred to adult services. Young adults with perinatally acquired HIV-1 infection require coordinated multidisciplinary transitional care services and careful long-term follow-up in adult life.

British HIV Association and Children's HIV Association guidelines for the management of HIV infection in pregnant women 2008

Top of page Abstract Introduction 1.0 Summary of recommendations 2.0 Scenarios: interventions to reduce mother-to child transmission of HIV 3.0 Background: UK prevalence of HIV in pregnancy and risk of transmission 4.0 Antenatal HIV testing 5.0 Preconception and fertility management in men and women infected with HIV 6.0 Sexual health of HIV-positive pregnant women 7.0 Psychosocial issues 8.0 Viral load and resistance 9.0 Management of HIV-related complications in pregnancy 10.0 Antiretroviral therapy in pregnancy: efficacy 11.0 Antiretroviral therapy in pregnancy: toxicity 12.0 Antiretroviral therapy and pregnancy: pharmacokinetics 13.0 Obstetric management of pregnancy and delivery 14.0 Pregnancy in women with HIV-2 infection 15.0 HIV and hepatitis B and C coinfections 16.0 Management of infants born to HIV-infected mothers 17.0 Infant feeding and HIV transmission during breastfeeding References Appendix

Antiretroviral therapy and premature delivery in diagnosed HIV-infected women in the United Kingdom and Ireland

To explore the association between antiretroviral therapy in pregnancy and premature delivery, birthweight, stillbirth and neonatal mortality, in pregnancies in HIV-infected women delivering between 1990 and 2005. Pregnancies in women with diagnosed HIV infection in the UK and Ireland are notified to the National Study of HIV in Pregnancy and Childhood (NSHPC) through a well-established surveillance scheme. The prematurity rate (< 37 weeks gestation) was higher in women on highly active antiretroviral therapy (HAART) (14.1%, 476/3384) than in women on mono/dual therapy (10.1%, 107/1061), even after adjusting for ethnicity, maternal age, clinical status and injecting drug use as the source of HIV acquisition [adjusted odds ratio (AOR) = 1.51, 95% confidence interval (CI), 1.19-1.93; P = 0.001]. Delivery at < 35 weeks was even more strongly associated with HAART (AOR = 2.34; 95% CI, 1.64-3.37; P < 0.001). The effect was the same whether or not HAART included a protease inhibitor. In comparison with exposure to mono/dual therapy, exposure to HAART was associated with lower birthweight standardized for gestational age (P < 0.001), and an increased risk of stillbirth (AOR = 2.27; 95% CI, 0.96-5.41; P = 0.063). These findings, based on comprehensive population surveillance, demonstrate an increased risk of prematurity associated with HAART, and a possible association with other perinatal outcomes, including stillbirth and birthweight. Although the beneficial effects of antiretroviral therapy on mother-to-child transmission are indisputable, monitoring antiretroviral therapy in pregnancy remains a priority.

Uptake of antenatal HIV testing in the United Kingdom: 2000–2003

A policy for routine antenatal HIV testing was introduced in England in 1999, with uptake targets for 2000 and 2002; similar policies were subsequently introduced throughout the UK. Date of implementation of the policy and data for estimating annual uptake of testing 2000-2003 were collected through postal survey of unit-based obstetric respondents to the National Study of HIV in Pregnancy and Childhood (NSHPC). Implementation date was reported for every unit; uptake data were provided for about three-quarters of implementing units each year. The policy was implemented in 78% (152/195) of English units by end of 2000; 78% (89/114) of units providing data achieved at least 50% uptake that year. By 2002, almost one-third (46/151) of English units reported 90% uptake or more, and over half (84/151) 80%. All but three UK units introduced the policy by the end of 2003, and of those providing adequate uptake data, 38% (66/175) reported at least 90% uptake and 69% (121/175) at least 80%; however, 19% (41/216) of respondents still had difficulty providing adequate data for estimating uptake. High uptake of HIV testing was reported from most UK units for 2003, but simple, robust and uniform methods for monitoring uptake at local and regional levels are still required.