LAURA BYRNE, HELEN PETERS & PAT A TOOKEY

UCL INSTITUTE OF CHILD HEALTH

Audit of perinatal HIV in the UK

since 2006: progress report

BACKGROUND

0

500

1000

1500

2000

2500

3000

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

2000-01 2002-03 2004-05 2006-07 2008-09 2010-11*

No

. o

f b

irth

s

1.4%

0.72%

1.1%

2.1%

0.46%

0.6%

~12,500 singleton births; significant decline in MTCT over time (p

BACKGROUND

Antenatal HIV screening in the UK

Mid-90s 1999 2000 2001

Diagnosed

before

delivery30% 60% 70% 80% 90% 95%

Routine

antenatal HIV

testing

Introduced

in EnglandIntroduced

throughout UK

Uptake of HIV

testing

80% in 2/3 units

90% in 1/3 unitsBut 20% of units no robust

method for estimate

>90%

overall

2002 2003 2004IDPS programme standards

published Sep 2010, fully

implemented by April 2012

2005 on

BACKGROUND

2007 Audit of perinatal HIV infection

Continuing problem of perinatal infection despite

low MTCT rate

Explored circumstances surrounding 87 cases

perinatal transmission 2002-2005

2/3 born to undiagnosed women

Most mothers had significant social issues

Findings informed standards & guidelines

AIM

Provide information about antenatal screening and

management of women whose infants acquire HIV perinatally

in order to contribute

To monitoring and improvement of antenatal HIV screening

protocols

To further reduction in the risk of perinatal HIV by

improving understanding of timing and circumstances of

maternal and infant acquisition of infection

METHODS

All pregnancies in diagnosed women living with HIV in the

UK and Ireland reported to NSHPC

Obstetric data actively reported from maternity units using

a scheme established under RCOG

Children diagnosed with HIV and children born to mothers

living with HIV reported via the BPSUs orange card system,

run by the RCPCH

Audit approved as substantial amendment to NSHPC

protocol by London MREC

METHODS

Enhanced data collection performed for each case born in

UK since 2006

Structured telephone interviews with reporting clinicians

METHODS

Expert review panel

Once data collection complete, anonymised case summary

drawn up

ERP made up of clinicians from relevant specialties + lay

representatives

Case summaries are discussed in themed batches

Discussions are minuted

Once all cases discussed, review meeting to decide

recommendations

RESULTS TO DATE

110 cases identified up to April 2014

>170 interviews with paediatric, obstetric and HIV

respondents

Participation agreed in 95%

One or more interviews carried out in 85%

35 cases where we hope to collect more data

25 cases discussed by ERP

RESULTS TO DATE

1

8

10

8

7

544

13

102

1

1110 cases of

perinatal HIV

transmission by

area of birth

V(4

Slide 11

V(4 Ireland looks cut off Visitor (sscm1228v), 08/05/2014

RESULTS TO DATE

Cases of perinatal HIV transmission 2006-2013

0

5

10

15

20

25

30

35

2006

(n=30)

2007

(n=27)

2008

(n=19)

2009

(n=12)

2010

(n=8)

2011

(n=7)

2012

(n=6)

2013

(n=1)

YEAR OF BIRTH

Mother diagnosed before

pregnancy

Mother diagnosed during

pregnancy

Mother diagnosed after

pregnancy or

undiagnosed

RESULTS TO DATE

Child age at diagnosis in undiagnosed women

0

2

4

6

8

10

12

Year of birth

4 yrs

RESULTS TO DATE

35%

8%26%

9%

22% Adherence

Late booker

Breastfeeding (postnatal

transmission)Miscellaneous

Information missing

Women diagnosed prior to pregnancy (23/110)

Main factor contributing to case of perinatal HIV

V(5

Slide 14

V(5 would put other/unknown last on each of theseVisitor (sscm1228v), 08/05/2014

RESULTS TO DATE

Main factor contributing to case of perinatal HIV

23%

9%

32%

9%

9%

4%

14%

Mother diagnosed during pregnancy (22/110)

Adherence

Declined test

Late booker

Seroconversion

Breastfeeding (postnatal)

Miscellaneous

Information missing

RESULTS TO DATE

37%

2%6%

8%

32%

15%Declined test

Late booker

Breastfeeding (postnatal

transmission)Problem with test

Seroconversion

Information missing

Mother diagnosed after or undiagnosed (65/110)

Main factor contributing to case of perinatal HIV

V(8

Slide 16

V(8 Worth commenting that some of these cases incomplete so the "other/unknowns" may fall into one of the other groups?Visitor (sscm1228v), 08/05/2014

RESULTS TO DATE

Social issues in pregnancy

& perinatal period

RESULTS TO DATE

70% at least one

social issue

RESULTS TO DATE

11% mental health problems

RESULTS TO DATE

7% intimate partner violence

RESULTS TO DATE

10% drug abuse

RESULTS TO DATE

26% housing problems

RESULTS TO DATE

28% immigration issues

RESULTS TO DATE

Timing of transmission to child by maternal diagnosis

0%

20%

40%

60%

80%

100%

Mother

diagnosed

before

pregnancy

(n=23)

Mother

diagnosed

during

pregnancy

(n=22)

Mother

diagnosed after

pregnancy or

undiagnosed

(n=65)

unknown

postnatal

intrapartum/postnatal

intrapartum

in utero/intrapartum

in utero

Evidence of a delay in

childs HIV diagnosis

in 24/65 cases born to

women undiagnosed

by delivery*

* 8/65 unclear or missing

DISCUSSION

Interim analysis data collection not complete

Significant delay in diagnosis for later years

60% of children born to undiagnosed mothers

High rates of social issues in pregnancy / perinatal period

Transmissions due to declined testing / problem with test

all pre-2010 (screening standards)

Methods now embedded into workings of NSHPC,

enhanced surveillance will continue

Full report on cases to date once ERP discussed all cases

and finalised recommendations

ACKNOWLEDGEMENTS

NSHPC staff including Icina Shakes, Kate Francis and Angela

Jackson

All the clinicians who have contributed to the audit

The members of our expert review panel

www.ucl.ac.uk/nshpc