Genital Tract Infections in HIV- Infected Pregnant Women in South West London

Transcription

1 Genital Tract Infections in HIV- Infected Pregnant Women in South West London A Hegazi, N Ramskill, M Norbrook, E Dwyer, S Milne, B Nathan, S Esterich, A ElGalib, T Morgan, A Barbour, P Hay St George s University Hospital Kingston Hospital Croydon University Hospital St Helier Hospital South West London HIV & GUM Clinical Services Network

2 Genital Tract Infections in Pregnancy Associated with adverse perinatal outcomes such as PTD and LBW. May increase risk of HIV MTCT BHIVA guidelines since 2001 suggest STI screening in pregnancy the Writing Group suggests screening for genital tract infections including evidence of BV. This should be done as early as possible in pregnancy and consideration should be given to repeating this at around 28 weeks. Syphilis serology should be performed on both occasions.* BHIVA Pregnancy Guidelines (Updated 2014) * Introduced in 2008 version

3 Previous Studies in the UK and Europe Slough Cohort 1 (n=97) % European Collaborative Study 2 (n=530) Vaginal Candidiasis 22% -- Bacterial Vaginosis 11% -- Genital Warts 7% 15% Genital Herpes 3% 2% Chlamydia 3% 1% Trichomoniasis 1% 2% Syphilis 0% 2% Gonorrhoea 0% 0.3% Includes abnormal cervical cytology 1 Duncan S et al. Managing HIV in pregnancy in a community-based sexual health clinic: a decade in review. International journal of STD & AIDS. 2012;23(11): Landes M et al. Prevalence of sexually transmitted infections in HIV-1 infected pregnant women in Europe. European journal of epidemiology. 2007;22(12):

4 Sub-Saharan Africa Point Prevalence (%) 95% CI n East and Southern Africa Syphilis Gonorrhoea Chlamydia Trichomoniasis Bacterial Vaginosis West and Central Africa Syphilis Gonorrhoea Chlamydia Trichomoniasis Bacterial Vaginosis Chico RM et. Al Prevalence of malaria and sexually transmitted and reproductive tract infections in pregnancy in sub-saharan Africa: a systematic review. JAMA. 2012;307(19):

5 Methods Retrospective case notes review of HIV infected pregnant women at 4 South London HIV Centres 1/1/04-1/1/14 St George's University Hospital Croydon University Hospital Kingston Hospital St Helier Hospital Cases identified through via KC60/GUMCAD codes Patients receiving their main HIV care elsewhere excluded Data analysed in MS Excel South West London HIV & GUM Clinical Services Network

6 Results St George s Hospital Croydon University Hospital Kingston Hospital St Helier Hospital 371 Pregnancies 233 Patients 93 Pregnancies 68 Patients 89 Pregnancies 55 Patients 44 Pregnancies 32 Patients 597 Pregnancies in 383 Patients South West London HIV & GUM Clinical Services Network

7 Region of Birth Europe 6% UK 14% Americas 4% West Africa 18% Asia 1% Central Africa 2% East Africa 26% Southern Africa 29% n= 383

8 Demographics Ethnicity (n=383) Black African White Other Region of Origin (n=383) Sub-Saharan Africa UK/Ireland Elsewhere Likely Route of Transmission (n=383) Heterosexual Sex Vertical Infection IVDU/Other This Cohort NSHPC Cohort * 77% 13% 14% 75% 15% 10% 96% 3% 1% Antenatal Diagnosis (n= 584) 22% Median diagnosis time (non-antenatal) 4.9 yrs prior to pregnancy 75% 11% 14% 77% 14% 9% 97% 0.3% 2.5% Median Age (n=597) 32 (IQR 29-37) 32 (IQR 28-36) 40% * pregnancies Townsend CL, Byrne L, Cortina-Borja M, Thorne C, de Ruiter A, Lyall H, et al. Earlier initiation of ART and further decline in mother-to-child HIV transmission rates, AIDS. 2014;28(7):

9 Obstetric Parameters Planned Pregnancy (n=497) 46 % Place of Delivery (n=561) Same centre receiving HIV care Other UK Centre Overseas Viral Load (copies/ml) at Delivery (n=365*) < >1000 *Excludes patients undergoing TOP or who miscarried Planned Mode of Delivery (n=476) Vaginal Delivery Elective Caesarean Section TOP Actual Mode of Delivery (n=526) Elective Caesarean Section Vaginal Delivery Emergency Caesarean Section TOP Miscarriage

10 Sexual History RMP in 95% of pregnancies (n=496) Median relationship duration (n=331) 4 yrs [IQR 1.3-7] Presumed father in all but 3 cases. 11 women (3.8%) reported additional sexual partners during pregnancy. Partners HIV status (n=423) 47% HIV Negative 37% HIV Positive 16% Untested

11 STI Screening 1 st Trimester STI Screen at Presentation 265 Repeat STI Screen -- 2 nd Trimester rd Trimester n=349 n=120

12 STI Prevalence 1 st Trimester Screen 3 rd Trimester Screen Positive Diagnoses (n) Prevalence (%) Positive Diagnoses (n) Prevalence (%) Candidiasis 63/ / Bacterial Vaginosis 59/ / Group B Strep 14/ /89 13 Trichomoniasis 9/ /154 4 Chlamydia 6/ /165 2 Syphilis 1/ / Gonorrhoea 1/ / st Trimester 3 rd Trimester Warts (Recurrence) 6 (3) 10 (3) HSV (Recurrence) 12 (8) 14 (2) For the purposes of analysis 2 nd trimester STI screens included with 1 st trimester if used as presentation screen, otherwise included with 3 rd trimester

13 Infant Outcomes Median birthweight 3.1Kg (n=255) 13% low birthweight (<2.5Kg) [7% Nationally] Median gestation at delivery 39/40 90% born at term [89%NSHPC] Vertical transmissions HIV x 2 Hepatitis C x 1 No documented direct STI related complications ONS 2015

14 Patients diagnosed with STIs* STI diagnosis was significantly associated with Antenatal HIV diagnosis (incident pregnancy) [58 vs 21%, p<0.0001] Disclosing additional sexual partners during pregnancy [16 vs. 3%, p=0.002] Nulliparity [57 vs 14%, P<0.0001] Shorter relationship duration [Median 3.5 vs. 4 yrs P=0.0003] Partner of unknown HIV status [40 vs 14%, P<0.001] Non-significant association with Lower median birthweight [2795 vs. 3140g, p=0.1] Preterm birth [36 vs. 14%, p=0.1] Younger median age [29 vs. 32yrs p=0.2] No association seen with UK vs. non-uk born Black vs. Non-Black Ethnicity Relationship status Past history of STI Planned vs. Unplanned Pregnancy Patients perceived to have significant difficulty engaging with HIV care *Non-Viral STIs Chlamydia, Gonorrhoea, Syphilis and Trichomoniasis.

15 STI Diagnoses and Timing of Screens Presentation STI Screen Repeat STI Screen Chlamydia 8 Gonorrhoea 1 Same Patient Trichomoniasis 11 Syphilis 2 Chlamydia 2 Gonorrhoea 1 Trichomoniasis 4 Syphilis 0 2 new CT infections (1 GC & TV +ve).both with significant difficulties engaging with HIV care. 2 Known TV from 1 st Trimester 2 new infections (PN issues)

16 Discussion Low STI prevalence Similar to other published studies in UK/Europe Limited data for comparison with HIV uninfected cohorts No new cases of syphilis were diagnosed on repeat screening. Benefits of detecting and treating STIs in pregnancy clear for most STIs. Benefits in terms of preventing HIV MTCT in UK context not established.

17 Possible Reasons for Low STI Prevalence STI screening in past 78% diagnosed with HIV prior to pregnancy - likely to have been screened for STIs prior to pregnancy as per UK standard of care. Older mothers less likely to be at risk of STIs Median age at pregnancy =32 [30 nationally 1 ] 16% aged <25 [21% nationally 1 ] Relationship Factors 95% in a regular relationship <4% disclosed additional sexual partners Low proportion of IVDU Anecdotally smoking, drug and alcohol use uncommon in cohort Male partners Many engaged with sexual health services for HIV care/testing 1 ONS 2015

18 Limitations Retrospective study design and dependence on written documentation Reliance on self reported STI histories?impact of social acceptability bias and partner notification concerns. Natural history of HPV and HSV means many infections diagnosed acquired prior to prior to pregnancy. Likely role for immune status. Small number of STIs diagnosed -? analysis underpowered to detect any significant differences in the characteristics of those with and without STIs.

19 Conclusions STI prevalence was low STI screening at first presentation in pregnancy would pick up most, but not all relevant STIs Further information about STIs in this population may impact future screening guidelines. Acknowledgements Alison Barbour, Michael Bird, Ellen Dwyer, Carol Dyer, Ali ElGalib, Steven Esterich, Phillip Hay, Christian Kemble, Kate Korley, Roisin Marrinan, Stephanie Milne, Thea Morgan, Stella Murphy, Bavithra Nathan, Marion Norbrook, Nikki Ramskill, Penny Smith, Helen Webb, Alison Watts, Ben Watts