Download perinatal HIV transmission

2/20/2017
PERINATAL
HIV
UPDATE
STEPHEN A THACKER, MD, FAAP
PEDIATRIC INFECTIOUS DISEASE
CHILDREN’S HOSPITAL OF SAVANNAH
PERINATAL UPDATE
OBJECTIVES
1. Update on HIV Epidemiology
2. Trends in vertical HIV transmission
3. Discussion of Georgia Laws on RPR and
HIV screening
4. Perinatal HIV Screening/Testing
5. Prophylaxis against vertical
transmission
MARCH 10 TH 2017
Vertical Transmission Rates of > 20%
BASELINE FACTS
• CDC estimates that nearly 50,000 individuals
become infected with HIV annually in the United
States.
• From 2009 through 2015, rate of diagnoses
remained relatively stable
• Antiretroviral medications given to women with HIV
during pregnancy and delivery and to their newborns in
the first weeks of life reduce the vertical transmission
rate from 25% to 2% or less.
• Even instituting maternal prophylaxis during labor and
delivery, neonatal prophylaxis within 24–48 hours of
delivery, or both, can substantially decrease rates of
infection in infants
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DIAGNOSES OF HIV INFECTION AMONG FEMALE ADULTS AND
ADOLESCENTS, BY RACE/ETHNICITY, 2010–2014—UNITED STATES AND 6
DEPENDENT AREAS
Only 81% of
people aware of
their HIV Dx in
GA
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis.
a Hispanics/Latinos can be of any race.
RATES OF NEW DIAGNOSES OF HIV INFECTION AMONG FEMALE ADULTS
AND ADOLESCENTS
2015—UNITED STATES AND 6 DEPENDENT AREAS
N = 7,498
TOTAL RATE = 5.4
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data for the year 2015 are
preliminary and based on 6 months reporting delay.
Georgia is #5 in the nation
RATES OF FEMALE ADULTS AND ADOLESCENTS LIVING WITH DIAGNOSED HIV INFECTION
YEAR-END 2014—UNITED STATES AND 6 DEPENDENT AREAS
N = 235,813
TOTAL RATE = 171.0
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data are based on address of
residence as of December 31, 2014 (i.e., most recent known address).
Georgia is #7 in the nation
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DIAGNOSES OF HIV INFECTION AND POPULATION AMONG FEMALE
ADULTS AND ADOLESCENTS, BY RACE/ETHNICITY, 2015—U.S.
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data for the year 2015 are preliminary
and based on 6 months reporting delay.
a Hispanics/Latinos can be of any race.
DIAGNOSES OF HIV INFECTION AMONG FEMALE ADULTS AND
ADOLESCENTS
BY REGION AND RACE/ETHNICITY, 2015—UNITED STATES
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data for the year 2015 are preliminary and based on 6
months reporting delay.
a Hispanics/Latinos can be of any race.
DIAGNOSES OF HIV INFECTION AMONG FEMALE ADULTS AND
ADOLESCENTS
BY RACE/ETHNICITY, 2015—UNITED STATES
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data for the year 2015 are preliminary and based on 6
months reporting delay. Rates are per 100,000 population.
a Hispanics/Latinos can be of any race.
DIAGNOSES OF HIV INFECTION AMONG FEMALE ADULTS AND
ADOLESCENTS, BY RACE/ETHNICITY AND TRANSMISSION CATEGORY,
2015—UNITED STATES AND 6 DEPENDENT AREAS
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. Data for the year 2015 are preliminary and based on 6
months reporting delay. Data have been statistically adjusted to account for missing transmission category.
a Hispanics/Latinos can be of any race.
b Heterosexual contact with a person known to have, or to be at high risk for, HIV infection.
c Includes blood transfusion, perinatal exposure, and risk factor not reported or not identified.
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Chatham Co. 707
out of every 100,000
living with HIV
Last Published:
In 2014 Chatham County
had 76 new diagnoses
(likely underrepresents
true value)
Ref: AIDSVu
https://aidsvu.org/map/?state=GA
VERTICAL (MTCT) TRANSMISSION
• 2012: there were 120 (reported) cases of perinatal acquired
HIV infections in the U.S.
VERTICAL
TRANSMISSION
• Any MTCT event should be considered a sentinel event for
the healthcare community
• Currently, unacceptable annual rate of newly diagnosed HIV-1
infections among infants in parts of the U.S.
• Marked racial disparity
• Most recent MTCT rate of 12.3/100 000 among African–
Americans versus 0.5/100 000 in Caucasians in Georgia
• GA MTCT rate is above the national average
• Enhanced Perinatal HIV Surveillance (EPS) program in
Georgia stated that the rate of perinatal HIV transmission in
the state between 2005 and 2010 was 2.5% compared with
2% nationally
AIDS 2015, Vol 29 No 12
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DIAGNOSES OF HIV INFECTION AND POPULATION IN
CHILDREN AGED <13 YEARS, BY RACE/ETHNICITY,
2014—UNITED STATES
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have
been statistically adjusted to account for reporting delays, but not for incomplete reporting.
bHispanics/Latinos
can be of any race
DIAGNOSES OF PERINATALLY ACQUIRED HIV
INFECTION AMONG CHILDREN BORN DURING 2012—
UNITED STATES AND 6 DEPENDENT AREAS
N = 120
RATES OF FEMALES AGED 15 44 YEARS LIVING
WITH HIV INFECTION, BY AREA OF RESIDENCE,
2013
UNITED STATES AND PUERTO RICO
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have
been statistically adjusted to account for reporting delays, but not for incomplete reporting.
DIAGNOSES OF PERINATALLY ACQUIRED HIV INFECTION
AMONG CHILDREN BORN IN THE UNITED STATES AND
PUERTO RICO DURING 2008-2012, BY AREA OF
RESIDENCE, UNITED STATES AND PUERTO RICO
N=672
Georgia was #1 in the nation
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed data have
been statistically adjusted to account for reporting delays, but not for incomplete reporting.
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TIME OF MATERNAL HIV TESTING AMONG CHILDREN WITH
DIAGNOSED PERINATALLY ACQUIRED HIV INFECTION AND
CHILDREN EXPOSED TO HIV, BIRTH YEARS 2008-2012—
UNITED STATES AND PUERTO RICO
TIME OF ANTIRETROVIRAL (ARV) ADMINISTRATION AMONG
PREGNANT WOMEN WITH HIV OR PERINATALLY EXPOSED
INFANTS
BIRTH YEARS 2008–2012—UNITED STATES AND PUERTO RICO
Note. Data include persons with a diagnosis of HIV infection regardless of stage of disease at diagnosis. All displayed
data have not been statistically adjusted. Exposure data from 47 areas.
HIV SCREENING OF
PREGNANT MOTHERS
ACOG RECS
AND
GA STATE LAW
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ACOG: COMMITTEE OPINION
RECOMMENDATIONS
REPEAT HIV TESTING IN THE
3RD TRIMESTER
• All pregnant women should be screened for HIV infection
as early as possible during each pregnancy
• Recommended for women in areas with high HIV
incidence or prevalence and women known to be
at high risk of acquiring HIV infection.
• Repeat HIV testing in the 3rd trimester for:
• women in areas with high HIV incidence or prevalence
• women known to be at risk of acquiring HIV infection.
• Women who were not tested earlier in pregnancy or whose
HIV status is otherwise undocumented should be offered rapid
screening on labor and delivery
•
If a rapid HIV test result in labor is reactive, antiretroviral
prophylaxis should be immediately initiated while waiting for
supplemental test results
ACOG: COMMITTEE OPINION Number 635 • June 2015
• health care facilities in which prenatal screening
identifies at least one pregnant woman infected
with HIV per 1,000 women screened
• Repeat testing in the third trimester, preferably
before 36 weeks of gestation
ACOG: COMMITTEE OPINION Number 635 • June 2015
REPEAT HIV TESTING IN THE
3RD TRIMESTER
Pregnant women at high risk of acquiring HIV:
1. diagnosed with another STD in the past year.
2. those who are injection drug users or whose sex
partners are injection drug users
3. those who exchange sex for money or drugs
4. those women with a new sex partner, more than
one sex partner during this pregnancy, or sex
partners known to be infected with HIV or at high
risk of HIV
http://www.legis.ga.gov/Legislation/en-US/display/20152016/HB/436
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GEORGIA HIV/SYPHILIS PREGNANCY
SCREENING ACT OF 2015: EFFECTIVE JULY
O.C.G.A. § 31-17-4.2 (2015)
§ 31-17-4.2. HIV and Syphilis Pregnancy Screening
(a) This Code section shall be known and may be cited as the "Georgia HIV/Syphilis Pregnancy Screening Act of 2015."
(b) Every physician and health care provider who assumes responsibility for the prenatal care of a pregnant woman during gestation and at
delivery shall be required to test such pregnant woman for HIV and syphilis except in cases where the woman refuses the testing.
Additionally, every physician and health care provider who provides prenatal care of a pregnant woman during the third trimester of gestation
shall offer to test such pregnant woman for HIV and syphilis at the time of first examination during that trimester or as soon as possible
thereafter, regardless of whether such testing was performed during the first two trimesters of her pregnancy.
Vote Calls: Our Representatives at Work
Apr/02/2015 - House Vote #428 Yea(156) Nay(10) NV(6) Exc(8)
(c) If at the time of delivery there is no written evidence that an HIV test or a syphilis test has been performed, the physician or other health
Apr/02/2015
Senate
Vote
care
provider in attendance at-the
delivery shall order
that a #330
test for HIV, Yea(47)
syphilis, or both beNay(0)
administered atNV(8)
the time of theExc(1)
delivery except in
cases where the woman refuses the testing; provided, however, that if available documentation indicates that a test for HIV and syphilis was
already performed during the third trimester of her pregnancy in accordance with subsection (b) of this Code section, and the woman does
Mar/13/2015
House
Vote
Yea(161)
Nay(7)
NV(5)
not
disclose when questioned-any
activities posing
a risk for#221
infection with
HIV or syphilis occurring
more recently
than wouldExc(7)
have been
detected by such test, the physician or health care provider in attendance at the delivery is not required to order such additional test.
(d) The woman shall be informed of the test to be conducted and her right to refuse. A pregnant woman shall submit to an HIV test and a
syphilis test pursuant to this Code section unless she specifically declines. If the woman tests positive for HIV or syphilis, counseling services
provided by the Department of Public Health shall be made available to her and she shall be referred to appropriate medical care providers
for herself and her child.
(e) If for any reason the pregnant woman is not tested for HIV and syphilis, that fact shall be recorded in the patient's records, which, if based
upon the refusal of the patient, shall relieve the physician or other health care provider of any other responsibility under this Code section.
(f) The Department of Public Health shall be authorized to promulgate rules and regulations for the purpose of administering the
requirements under this Code section.
HISTORY: Code 1981, § 31-17-4.2, enacted by Ga. L. 2007, p. 173, § 1/HB 429; Ga. L. 2009, p. 453, § 1-4/HB 228; Ga. L. 2011, p. 705, § 63/HB 214; Ga. L. 2015, p. 1346, § 1/HB 436.
http://www.legis.ga.gov/Legislation/en-US/display/20152016/HB/436
GEORGIA HIV/SYPHILIS PREGNANCY
SCREENING ACT OF 2015
“(c) If at the time of delivery there is no written evidence that
an HIV test or a syphilis test has been performed, the
physician or other health care provider in attendance at the
delivery shall order that a test for HIV, syphilis, or both be
administered at the time of the delivery except in cases
where the woman refuses the testing; provided, however, that
if available documentation indicates that a test for HIV and
syphilis was already performed during the third trimester of
her pregnancy in accordance with subsection (b) of this Code
section, and the woman does not disclose when questioned
any activities posing a risk for infection with HIV or syphilis
occurring more recently than would have been detected by
such test, the physician or health care provider in attendance at
the delivery is not required to order such additional test.”
GEORGIA HIV/SYPHILIS PREGNANCY
SCREENING ACT OF 2015
“(b) Every physician and health care provider who assumes responsibility
for the prenatal care of a pregnant woman during gestation and at
delivery shall be required to test such pregnant woman for HIV and
syphilis except in cases where the woman refuses the testing.
Additionally, every physician and health care
provider who provides prenatal care of a
pregnant woman during the third trimester of
gestation shall offer to test such pregnant
woman for HIV and syphilis at the time of first
examination during that trimester or as soon
as possible thereafter, regardless of whether
such testing was performed during the first
two trimesters of her pregnancy.”
Ref: http://www.lexisnexis.com/hottopics/gacode/Default.asp
A SUCCESS STORY:
PERINATAL HIV
PROPHYLAXIS
Ref: http://www.lexisnexis.com/hottopics/gacode/Default.asp
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STAGE 3 (AIDS) CLASSIFICATIONS AMONG PERSONS
WITH PERINATALLY ACQUIRED HIV INFECTION,1985–
2014—UNITED STATES AND 6 DEPENDENT AREAS
PERINATAL HIV
EXPOSURE TREATMENT
•
HIV (+) women should receive ART during pregnancy with a
goal of undetectable viral load.
• The following should generally be avoided because of a
potential increased risk of transmission, unless there are
clear obstetric indications:
• Artificial ROM in the setting of viremia
• Routine use of fetal scalp electrodes for fetal monitoring
• Operative delivery with forceps or a vacuum extractor
• Episiotomy
• Scheduled cesarean delivery is recommended for HIV –
infected pregnant women who have HIV RNA levels >1,000
copies/mL near the time of delivery at 38+ weeks.
Note. All displayed data have been statistically adjusted to account for reporting delays, but not for incomplete
reporting.
Ref: http://aidsinfo.nih.gov/guidelines Last updated October 26, 2016
PERINATAL HIV
EXPOSURE TREATMENT
PERINATAL HIV
EXPOSURE TREATMENT
• Intravenous zidovudine/AZT should be
administered to HIV-infected women with
HIV RNA >1,000 copies/mL (or unknown
viral load) near delivery
• All HIV-exposed infants should receive postpartum
antiretroviral drugs to reduce the risk of perinatal
transmission of HIV.
• Not required for HIV-infected women
receiving ART regimens who have HIV
RNA ≤1,000 copies/mL during late
pregnancy and near delivery and no
concerns regarding adherence ART
Ref: http://aidsinfo.nih.gov/guidelines Last updated October 26, 2016
• Goal is within 6-12 hrs of delivery
• A 4-week neonatal zidovudine prophylaxis regimen can
be used for full-term infants when the mother has received
standard ART during pregnancy with sustained viral
suppression and there are no concerns related to maternal
adherence.
• Otherwise, a 6-week course as part of a combination
infant prophylaxis regimen is recommended.
Ref: http://aidsinfo.nih.gov/guidelines Last updated October 26, 2016
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PERINATAL HIV
EXPOSURE TREATMENT
PERINATAL HIV
PROPHYLAXIS REGIMENS
•
Zidovudine given for 4-6 weeks
A combination infant prophylaxis regimen is recommended
in infants at higher risk of HIV acquisition, including those born
to HIV-infected women who:
• Have not received antepartum or intrapartum ARV drugs
• Have received only intrapartum ARV drugs
• Have received antepartum ARV drugs but do not have viral
suppression near delivery
• For infants born to mothers with unknown HIV status,
expedited HIV testing of mothers and/or infants is
recommended as soon as possible, either during labor or after
birth, with immediate initiation of infant ARV prophylaxis if the
initial expedited test is positive.
Oral:
• GA <30 weeks: 2 mg/kg/dose every 12 hours; at 4 weeks of age, increase dose
to 3 mg/kg/dose every 12 hours
• GA ≥30 weeks and <35 weeks: 2 mg/kg/dose every 12 hours; at PNA 15 days,
increase dose to 3 mg/kg/dose every 12 hours
• GA ≥35 weeks: 4 mg/kg/dose every 12 hours
If unable to tolerate enteral, use IV route:
• GA <30 weeks: 1.5 mg/kg/dose every 12 hours; at 4 weeks of age, increase
dose to 2.3 mg/kg/dose every 12 hours
• GA ≥30 weeks and <35 weeks: 1.5 mg/kg/dose every 12 hours; at PNA 15 days,
increase dose to 2.3 mg/kg/dose every 12 hours
• GA ≥35 weeks: 3 mg/kg/dose every 12 hours
Nevirapine at birth, 48 hours later, and 96 hours after the second dose
Ref: http://aidsinfo.nih.gov/guidelines Last updated October 26, 2016
PERINATAL HIV TESTING
• HIV testing under 15-18 months of age should generally be
done via HIV qualitative RNA or DNA PCR.
• Testing at time of birth has limited sensitivity (~50%)
• Testing Recommendations:
• HIV Qualitative PCR
• 2 weeks of life
• 6 weeks of life
• 4-6 months of life
• HIV Antibody Screen
• Some experts recommend proof of maternal antibody
clearance at 15-18 months as a final assessment
Dose: Fixed dose: if Birthweight 1.5 to 2 kg: 8 mg; if Birthweight >2 kg: 12 mg
TAKE HOMES
1. HIV disproportionately affects African American Women
in the South.
2. Early and 3rd trimester HIV screening is mandated by
GA State Law
3. ACOG recommends re-screening mothers with
continued risk for HIV acquisition.
4. Chatham Co and many counties in Georgia have some
of the highest incidence and prevalence of women with
HIV in the US per capita.
5. Vertical HIV transmission can nearly always be
prevented with identification and intervention.
6. Vertical Transmission of HIV is a sentinel event for a
healthcare community.
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THANK YOU!
Key References:
1. http://aidsinfo.gov
2. http://www.cdc.gov/hiv/statistics
3. http://aidsvu.org
Contact Information for any questions:
• [email protected]
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