Summary of "BHIVA guidelines - HIV in pregnancy with 2020 update"

This video provides a comprehensive review and update of the British HIV Association (BHIVA) guidelines for the management of HIV in pregnancy and postpartum, including key 2020 updates. The focus is on preventing vertical (mother-to-child) transmission, maternal and neonatal management, and addressing co-infections such as hepatitis B and C. It also covers psychological aspects, confidentiality issues, antiretroviral therapy (ART) regimens, and neonatal care.

Main Ideas, Concepts, and Lessons

1. HIV Transmission and Vertical Transmission Risk

HIV transmission modes: sexual, IV drug use, blood transfusion, and vertical transmission.
Vertical transmission risk without treatment: 25-40% in breastfeeding populations.
With ART and avoidance of breastfeeding, vertical transmission risk reduces to ~1%.
With combined ART (cART) and undetectable viral load (<50 copies/ml), risk is <0.57%.
Two key numbers to remember:
- On ART + no breastfeeding: ~1% transmission risk.
- On ART + undetectable viral load + no breastfeeding: <1% (0.57%).

2. Screening and Testing

Universal antenatal HIV screening in the UK (~95% uptake).
Types of HIV tests:
- p24 antigen test (detectable within 1 month of infection).
- HIV antibody test (window period up to 3 months).
Confirmatory testing after initial positive test.
Repeat testing in pregnancy if high-risk behavior identified.
Rapid HIV testing at labor if no prior testing (results in ~20 minutes).
Fourth-generation tests preferred.

3. Multidisciplinary Team (MDT) Care

Core MDT: HIV specialist/physician, obstetrician, specialist midwife, pediatrician, GP, health visitor.
Extended MDT: patient advocates, social workers, psychologists, counselors, health advisers, interpreters, pharmacists, clinical nurse specialists.
Importance of psychological support due to high rates of depression (30-55%) in HIV-positive pregnant women.
Mental health risk assessments at:
- Booking
- 4-6 weeks postpartum
- 3-4 months postpartum
Use of the "Whooley" questions for depression screening.

4. Confidentiality and Disclosure

Duty to maintain confidentiality balanced against duty to protect partners.
If woman refuses to disclose HIV status to partner, confidentiality may be broken to inform partner as last resort.
Counseling strategies include involving social workers and health advisers to facilitate disclosure.

5. STI Screening

All HIV-positive pregnant women (new or known) require screening for other STIs.
Incidence of STIs and bacterial vaginosis is higher in HIV-positive women.
STI co-infection increases risk and complicates management.

6. Investigations and Monitoring

Baseline and routine liver function tests (LFTs) due to ART hepatotoxicity and pregnancy-related liver conditions.
CD4 count measured twice: at baseline/initiation and before delivery.
Viral load monitoring schedule:
- For newly diagnosed: 2-4 weeks after ART initiation, every trimester, at 36 weeks, and at delivery.
- For known HIV-positive on ART: at 36 weeks and delivery.
HIV resistance testing before ART initiation unless late presentation (>28 weeks).

7. ART Regimens

cART consists of:
- Two NRTIs (nucleoside reverse transcriptase inhibitors) as backbone.
- One drug from NNRTI, protease inhibitor, or integrase inhibitor classes.
Important drug: Dolutegravir (DTG) associated with neural tube defects if taken at conception/early pregnancy.
- Women on DTG should take high-dose folic acid (5 mg) preconception and during first trimester.
- If starting DTG during pregnancy, start after 6 weeks gestation to avoid neural tube defects.
ART started lifelong during pregnancy and postpartum (no stopping after delivery).
Timing of ART initiation depends on viral load and CD4 count:
- Viral load >100,000 and CD4 <200: start in first trimester.
- Viral load 30,000-100,000: start early second trimester.
- Viral load <30,000: start anytime in second trimester.
- All women should be on ART by 24 weeks gestation.

8. Management of Late Presenters (Unknown or High Viral Load in Labor)

Use a 3-4 drug regimen including:
- Stat dose of nevirapine (200 mg)
- Lamivudine and Zidovudine
- Fourth drug: Raltegravir or Dolutegravir
IV Zidovudine during labor if viral load unknown or >1,000 copies/ml.