Human Immune Deficiency Virus Infection Dr Huda Taha Sep 2015

Epidemiology Virology Natural History Diagnosis Transmission HIV pregnancy

HIV pandemic continues to evolve Global Prevalence of HIV stabilise at 0.8% 25 million died of HIV 33 million living with HIV/ AIDS Every day: 4,900 die of HIV/AIDS 7,100 new HIV infection 3,200 on HAART : 2.6 million new infection 2 million died of HIV/ AIDS (1.7 million<15 Year old) 4 million receive HAART in Africa (50,000 in 2002) 1 million pregnant women on HAART

100,000 people are living with HIV, quarter are unaware of their infection (16,000 in 1990) ; 6660 new diagnoses of HIV 37 English PCT/ HIV prevalence >2:1000 1:5 HIV+ >50 Year old

“HIV in the UK” report Infection acquired within the UK almost doubled/ exceed those acquired abroad In the last 10 years, the biggest increases in people living with diagnosed HIV, East of England, the West Midlands and the North East over 3000 gay men were diagnosed with HIV: 1 in 20 gay men are now infected with HIV nationally 1 in 10 in London Universal testing

HIV is a Lentivirus a member of the Retrovirus family HIV infects vital cells in the human immune system such as helper T cells (specifically CD4 + T cells), macrophages and dendritic cells

Natural history HIV vs AIDS Acquisition of Infection Primary HIV infection Asymptomatic HIV infection Early symptomatic infection Late symptomatic infection Advance HIV disease

HIV infection in pregnant women

Case 1 ; Conceiving on HAART;

Use of antiretroviral therapy in pregnancy Should continue HAART

Case 2 Case 2 Naïve to HAART: mother needs ART for herself

Use of antiretroviral therapy in pregnancy Commence treatment as soon as possible NRTIs plus third agent ( NNRTI or PI) Consider third trimester TDM

Case 3 Case 3 Naïve to HAART: mother does not need HAART for herself

Use of antiretroviral therapy in pregnancy All women should have commenced ART by week 24 preg. NRTIs plus PI

Case 4 Late-presenting woman not on treatment

Use of antiretroviral therapy in pregnancy After 28 weeks should commence HAART without delay Unknown VL or > HAART plus Raltegravir Untreated woman presenting in labour ; HAART plus Raltegravir IV zidovudine for the duration of labour and delivery.

Women presenting ROM without a documented HIV result must be recommended to have an urgent HIV test A reactive/positive test must be acted upon immediately with initiation of the interventions for prevention of PMTCT without waiting for further/ formal serological confirmation.

Case 5 Untreated women; CD-4 count ≥ 350 cells/ml and VL <50 copies/mL (confirmed on a separate assay)

Elite controllers Can be treated with zidovudine monotherapy or with HAART Can aim for a vaginal delivery Should exclusively formula feed their infant

HIV in Pregnancy ANC Testing Sexual Health Preconception and fertility management MDT & documentation Psychosocial issues AZT monotherapy vs CART HIV testing in children Breast feeding

STI screening Recommended for pregnant women newly diagnosed with HIV. Suggested for HIV-positive women already engaged in care Genital tract infections should be treated according to BASHH guidelines.

Laboratory monitoring Routine Antenatal investigations HIV resistance testing Post short course treatment a further resistance test recommended CD-4 count Viral load 2–4 weeks after commencing HAART

LFT at initiation of HAART and then at each antenatal visit. If not achieved VL <50 copies/mL at 36 weeks the following interventions are recommended: - Review adherence and concomitant medication - Perform resistance test if appropriate - Consider therapeutic drug monitoring - Optimise to best regimen - Consider intensification

ART postpartum Continue HAART if CD4 count < 350 cells/ml co- infection with Hep C or Hep B > 500 if sero-discordant or co morbidity Can consider continuing between even if no co morbidities

Infant testing HIV DNA PCR (or HIV RNA testing) During the first 48 hours and prior to hospital discharge 6 weeks of age 12 weeks of age On other occasions if additional risk (breast-feeding) HIV antibody testing for seroreversion should be done at age 18 months

Psychosocial issues Antenatal HIV care should be delivered by a multidisciplinary team (MDT)

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