HIV in Pregnancy. In Practice. Cheryl Roth Pauline F. Hrenchir Christine J. Pacheco

Transcription

1 In Practice Photo istock Collection / thinkstockphotos.com IImagine this scenario: You are working on a Saturday afternoon when a woman comes into the obstetrics triage unit. She is pregnant for the fourth time and has had three term births, zero preterm births, zero abortions/miscarriages, and three living children. She presents at approximately 28 to 32 weeks gestation, and in early labor. She states that she has had no prenatal care HIV in Pregnancy Cheryl Roth Pauline F. Hrenchir Christine J. Pacheco and that her water broke about an hour ago. A urine drug screening result is positive for cocaine and group B streptococci, and test results for chlamydia and gonorrhea are negative. The Abstract In the United States, women with HIV have the ability to make informed choices relating to their reproductive lives more now than ever before. The increasing availability of antiretroviral therapy has spurred renewed interest among many HIV-positive women in their decisions about whether to have children. It is important for perinatal nurses to understand the maternal and fetal implications of HIV in pregnancy, including parameters for treatment and the drug regimens typically used during the antepartum, intrapartum, and postpartum periods. Keywords antiretroviral therapy HIV human immunodeficiency virus pregnancy nwhjournal.org 2016, AWHONN 87

2 In Practice laboratory has just called to notify you that her human immunodeficiency virus (HIV) screening result is positive. What Is HIV? HIV is a virus spread through bodily fluids that affects specific cells of the immune system called Undiagnosed maternal HIV infection before conception, unplanned pregnancies, delays in accessing antenatal care, and lack of education are the most significant risk factors associated with womanto-fetus transmission of the virus CD4+ cells, which are a type of T cell. Over time, the HIV virus can destroy so many T cells that the body cannot fight off infections and disease. When this happens, the HIV infection leads to acquired immunodeficiency syndrome (AIDS). Although there is no cure for HIV, disease progression to AIDS is no longer inevitable (Centers for Disease Control and Prevention [CDC], 2014). Undiagnosed maternal HIV infection before conception, unplanned pregnancies, delays in accessing antenatal care, and lack of education are the most significant risk factors associated with woman-to-fetus transmission of the virus (CDC, 2014). Early intervention with initialization and compliance with antiretroviral therapy improves life expectancy and quality of life. Antiretroviral therapy has decreased the risk of woman-to-fetus (vertical) transmission of HIV (CDC, 2014). Most vertical transmission occurs close to or during labor and birth, at the onset of placental separation and/or rupture of membranes (Mnyani, Simango, Murphy, Chersich, & McIntyre, 2014). In the United States, women with HIV have the ability to make informed choices relating to their reproductive lives more now than ever before. The increasing availability of antiretroviral therapy makes for a renewed interest in some women s decisions to have children and to engage in preconception counseling (François- Xavier Bagnoud Center, 2012). The number of newborns infected with HIV born each year in the United States has fallen from approximately 1,750 in the mid-1990s to approximately 143 in 2010 (CDC, 2010). The CDC states that perinatal HIV transmission rates are less than 1% ( in 100,000 births) when antiretroviral therapy is initiated and adhered to during pregnancy (CDC, 2014). When antiretroviral therapy is begun intrapartum, the rate of transmission is approximately 10%, compared with a transmission rate of 25% among infants born to women receiving no preventive treatment (Beigi, 2013). Cheryl Roth, PhD, WHNP- BC, RNC-OB, RNFA, is a nurse practitioner in Labor & Delivery; Pauline F. Hrenchir, MSL, MSN, RN, RNFA, is the director of the Women s Service Line; Christine J. Pacheco, MSN, RN, is a staff nurse; all authors are at HonorHealth Scottsdale Shea in Scottsdale, AZ. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: Cheryl.Roth@honorhealth.com. Photo Antonio Diaz / thinkstockphotos.com 88 Nursing for Women s Health Volume 20 Issue 1

3 The CDC (2014) recommend HIV testing for all pregnant women in routine prenatal tests and routine third-trimester screening for women with high-risk behaviors or who are displaying signs or symptoms of HIV. Although a woman can decline testing for HIV, receiving education from clinicians about HIV and about the importance of knowing their HIV status can help women make more informed decisions. Antiretroviral Therapy During Pregnancy Triple therapy combination regimens of antiretroviral drugs (also known as combination antiretroviral therapy, or cart) are generally used during pregnancy to keep the viral load suppressed. The most common triple therapy regimen is zidovudine plus lamivudine plus lopinavir/ritonavir or atazanavir/ritonavir (Hughes & Cu-Uvin, 2015). These medications are given orally. Additional administration of intrapartum intravenous zidovudine depends on a woman s HIV viral load at the time of birth. Zidovudine crosses the placenta rapidly and can provide pre-exposure prophylaxis to the fetus (Hughes & Cu-Uvin, 2015). Other drugs or combinations of drugs may also be used, depending on an individual s disease course and the recommendations of the infectious disease clinician. Tenofovir is preferred instead of zidovudine for pregnant women with a co-infection of HIV and hepatitis B. Efavirenz, which is generally not used in pregnancy, is a first-line nonnucleoside reverse transcriptase inhibitor with potential teratogenic risks, including neural tube defects, facial clefts, and anophthalmia, when used in the first 8 weeks of pregnancy. Raltegravir has been used in late pregnancy among women with high viral loads because of its ability to rapidly decrease viral load within 2 weeks, although the efficacy and safety of this have not been evaluated (Hughes & Cu-Uvin, 2015). In Practice Box 1. Antepartum Considerations All pregnant HIV-infected women should receive cart to prevent perinatal transmission regardless of plasma HIV RNA copy number or CD4 T lymphocyte count. The goal of cart is to maintain a viral load below the limit of detection throughout pregnancy (AIDSinfo, 2015, p. 3). This is usually triple therapy and based on what a patient has taken before. Laboratory test results (HIV RNA, CD4 T lymphocytes, initial genotyping of HIV virus) should be monitored per CDC protocol, the goal being a viral load of <1,000 copies/ml (Pennsylvania/ MidAtlantic AIDS Education and Training Center, 2014). Potential teratogenic effects of antiretroviral prophylaxis may be avoided when delayed until after completion of the first trimester (Pennsylvania/MidAtlantic AIDS Education and Training Center, 2014). Note. cart = combination antiretroviral therapy. Photo istock Collection / thinkstockphotos.com February March 2016 Nursing for Women s Health 89

4 Box 2. Intrapartum Considerations Scheduled cesarean birth at 38 weeks gestation to minimize perinatal transmission of HIV is recommended for women with HIV RNA levels >1,000 copies/ml or unknown HIV levels near the time of birth, irrespective of administration of antepartum antiretroviral drugs (Aberg et al., 2013). It is not clear whether cesarean birth after spontaneous rupture of membranes or onset of labor provides benefit in preventing perinatal transmission (Pennsylvania/MidAtlantic AIDS Education and Training Center, 2014). Because there is insufficient evidence to determine whether cesarean delivery after rupture of membranes or onset of labor reduces the risk of perinatal HIV transmission, management of women originally scheduled for cesarean delivery who present with ruptured membranes or in labor must be individualized at the time of presentation. In these circumstances, consultation with an expert in perinatal HIV (e.g., telephone consultation with the National Perinatal HIV/AIDS Clinical Consultation Center at (888) ) may be helpful in rapidly developing an individualized plan (AIDSinfo, 2015, p. 14). Intravenous (IV) zidovudine should be administered to HIV-infected women with HIV RNA >1,000 copies/ml (or unknown HIV RNA) near delivery, but is not required for HIV-infected women receiving cart regimens who have HIV RNA 1,000 copies/ml during late pregnancy and near delivery and no concerns regarding adherence to the cart regimen (AIDSinfo, 2015, p. 13). Women whose HIV status is unknown who present in labor should undergo expedited HIV antibody testing. If the results are positive, a confirmatory HIV test should be done as soon as possible and maternal IV zidovudine and infant (combination antiretroviral prophylaxis) drugs should be initiated pending results of the confirmatory test (AIDSinfo, 2015, p. 13). Repeat HIV testing in the third trimester is recommended for pregnant women with initial negative HIV antibody tests who are known to be at risk of acquiring HIV, are receiving care in facilities that have an HIV incidence in pregnant women of at least 1 per 1,000 per year, are incarcerated, or who reside in jurisdictions with elevated HIV incidence (AIDSinfo, 2015, p. 14). Note. cart = combination antiretroviral therapy; IV = intravenous. Practice Considerations Practice considerations for antepartum, intrapartum, postpartum women, and postpartum neonates are shown in Boxes 1, 2, 3, and 4, respectively. The Rest of the Story... Returning to our scenario, the woman denied knowledge that she was HIV positive. Confirmatory tests were ordered, and zidovudine was given intravenously pending test results. Because the woman s viral load was unknown, the obstetric provider recommended birth via cesarean. After birth, it was confirmed that the woman had HIV, with a viral load >1,000. Combination antiretroviral therapy was initiated with zidovudine, lamivudine, and lopinavir/ritonavir, and the woman was referred to an infectious disease specialist for follow-up. Her neonate was treated with prophylactic combination antiretroviral therapy. The case manager and child life specialist were very involved in the care of the woman and newborn before discharge, and referrals were made to the appropriate social services. Final HIV status of the newborn was unfortunately unknown because of loss to follow-up; the woman did not bring the child in for pediatric or pediatric infectious disease appointments. NWH References Aberg, J. A., Gallant, J. E., Ghanem, K. G., Emmanuel, P., Zingman, B. S., & Horberg, M. A. (2013). Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clinical Infectious Diseases, 58(1), doi: /cid/cit757 AIDSinfo. (2015). Recommendations for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Bethesda, MD: National Institutes of Health. Retrieved from: aidsinfo.nih.gov/contentfiles/ lvguidelines/peri_recommendations.pdf Beigi, R. (2013). Test everyone and test early. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from campaigns/ottl/clinicians/beigi.html Centers for Disease Control and Prevention. (2010). HIV Surveillance Report, 2010 (Vol. 22). Atlanta, GA: Author. Retrieved from surveillance/resources/reports/ Centers for Disease Control and Prevention. (2013). Eliminating perinatal HIV transmission: A curriculum for OB/ GYN Resident and Midwifery Programs [slides]. Atlanta: GA: Author. Retrieved from materials/hivtransmission/docs/ hivtransmission.pdf 90 Nursing for Women s Health Volume 20 Issue 1

5 Centers for Disease Control and Prevention. (2014). HIV among pregnant women, infants, and children. Atlanta, GA: Author. Retrieved from facts/index.html François-Xavier Bagnoud Center. (2012). Are you HIV-positive and thinking about having a baby? A guide to preconception health for women living with HIV. Newark, NJ: Author. Retrieved from files/pdf/client%20informational%20 brochure.pdf Hughes, B., & Cu-Uvin, S. (2015). Use of antiretroviral medications in pregnant HIV-infected patients and their infants in resource-rich settings. Retrieved from antiretroviral-treatment-of-pregnant -hiv-infected-women-and-antiretroviral -prophylaxis-of-their-infants-in -resource-rich-settings Mnyani, C., Simango, A., Murphy, J., Chersich, M., & McIntyre, J. (2014). Patient factors to target for elimination of mother-to-child transmission of HIV. Globalization and Health, 10, 36. doi: / Pennsylvania/MidAtlantic AIDS Education and Training Center. (2014). Guidelines for use of HIV combination antiretroviral therapy in the perinatal period. Pittsburgh, PA: Author. Retrieved from default/files/resources_files/art%20 in%20preg%20clinical%20card% %20final%20%283%29.pdf Box 3. Postpartum Considerations (Women) Decisions regarding continuing combination antiretroviral therapy after birth should be made in consultation with a woman and her HIV health care provider, ideally before birth. Combination antiretroviral therapy is currently recommended for all HIVinfected individuals to reduce the risk of disease progression and to prevent HIV sexual transmission, although the strength and evidence for this recommendation varies by pretreatment CD4+ T lymphocyte count (Pennsylvania/MidAtlantic AIDS Education and Training Center, 2014). Decisions should take into account current recommendations for initiation of combination antiretroviral therapy in adults, pretreatment CD4+ cell counts and trajectory, HIV RNA levels, adherence issues, whether a woman has an HIV-uninfected partner, and patient preference (CDC, 2014). For women continuing combination antiretroviral therapy postpartum, arrangements for new or continued supportive services should be made before hospital discharge, because the immediate postpartum period poses unique challenges to adherence. Contraceptive counseling should be a critical aspect of postpartum care. Women with a positive rapid HIV antibody test during labor require immediate linkage to HIV care and comprehensive follow-up, including confirmation of HIV infection. If infection is confirmed, a full health assessment is warranted, including evaluation for associated medical conditions, counseling related to newly diagnosed HIV infection, and assessment of need for cart and opportunistic infection prophylaxis (AIDSinfo, 2015, p. 16). It is recommended that women with HIV infection in the United States should not breastfeed and that women considering breastfeeding should know their HIV status (CDC, 2014). Note. cart = combination antiretroviral therapy. Box 4. Postpartum Considerations (Neonates) Newborns exposed to HIV in utero should receive antiretroviral postexposure prophylaxis and undergo HIV virologic diagnostic testing at days of life, at 1 2 months of age, and at 4 6 months of age (Aberg et al., 2013, p. 25). Infant ZDV dosing: 4 mg/kg/dose every 12 hours or 2 mg/kg/dose every 6 hours for 6 weeks. ZDV for 4 weeks may be considered if maternal viral load was suppressed with consistent cart use during pregnancy (Pennsylvania/ MidAtlantic AIDS Education and Training Center, 2014, p. 2). Zidovudine, at gestational-age-appropriate doses, should be initiated as close to the time of birth as possible, preferably within 6 to 12 hours of delivery (AIDSinfo, 2015, p. 17). An additional 15% to 29% of infants will be infected if there is breastfeeding (CDC, 2013, slide 95). It is important to provide additional support to a woman who is counseled against breastfeeding because of her HIV status, especially in situations when breastfeeding would be expected by those in her immediate support group (Hughes & Cu-Uvin, 2015). Note. cart = combination antiretroviral therapy; ZDV = zidovudine. February March 2016 Nursing for Women s Health 91