Management of Infants born to HIV Positive Mothers

Joyce BangaNeonatal Nurse

What is the Extent of the problem in Romania?

WHO data regarding HIV/AID infection 2012 revealed

New cases detected =754

Children between 0-14 years =19

Vertical transmission =16

TRANSMISSION PREVENTABLE THROUGH EVIDENCE BASED PRE AND POSTNATAL CARE

Holistic approach to care of the infant

Care starts with multidisciplinary management of the mother in the antenatal period with good communication

Post delivery care of the infant focuses on – 1-Initial blood tests 2-Post exposure prophylaxis 3-Management of risk

factors for infection 4-Feeding

Emotional support of parents/carers

Discharge planning

Follow up appointments and Immunisations

Who are the members of the Antenatal Multidisciplinary Team?

•HIV GUM Consultant

•HIV Lead Consultant Obstetrician

•Specialist Screening Midwife

•Health Advisor

•Community Midwife

•Consultant Neonatologist

What is the Role of the Multidisciplinary Team

Discusses confidentiality and related care issues with the woman

Initial visit, verbal and written information on plan of care

Screening of infections offered

Follow up visits and antenatal scans arranged

Referral to Consultant Neonatologist for a management of plan for the baby post delivery. Concise information on what care to be given and rationale. Well documented.

Woman given chance to ask questions

Monthly Team discusses progress of all cases

Management of the Neonate – Post Exposure Prophylaxis

Wash baby immediately

Weigh baby to allow drug calculation. Zidovudine/HAART following

discussion with Neonatologist (individualised care) – HIGH RISK

Give antiretroviral medication within 4 hours of delivery orally

Educate mother drug administration

If preterm or sick neonate, give intravenous antiretroviral

Evidence of efficacy of PEP – Paediatric AIDS Clinical Trials Group Protocol 076 (ACTG 076) Connor et. al. (1994)

Who is the HIGH RISK BABY?

Mother has had <4 weeks antiretroviral therapy before delivery

Mother has persistently detectable viral load despite ART

The mother is found to be HIV infected after the infant has delivered, and the infant is less than 72 hours of age

The mother has had rupture of membranes >4 hours

Baby’s skin or mucosa have been breached, e.g. scalp electrode or accidental injury during C/S or forceps delivery

Initial blood tests (Day 1)

Obtain consent from parents

Collect blood sample from baby for HIV PCR (not cord blood) – can be contaminated with maternal blood

Maternal sample for HIV PCR – to ensure that the PCR primers used can detect the maternal virus. (different forms)

U&E + LFT to exclude in utero toxicity

FBC to exclude anaemia a side effect of Zidovudine

A viral load from mother

Hepatitis B Vaccination

If the mother is Hepatitis B+ve, give vaccine within the first 24 hours of age.

Ensure the Hep B notification form is completed so that the course is completed in the community.

Explain the importance of completing the course to the parents.

FEEDING

Give facts and advice against breastfeeding

Evidence – Simonon et. al. (1994) Kigali Rwanda.

If preterm give formula milk

If very preterm, consent for donor breast milk

Counsel re-stigma attached to not breastfeeding ( risk vs. stigma)

Postpartum Management of Women who are HIV Positive

An immediate dose of oral Cabergoline to suppress lactation

Encourage bonding with baby – open visiting for parents

Emotional support coming to reality with own infection while facing uncertainty about HIV status of their infant

Family support

Psychosocial meetings – avoid baby abandoning

Discharge Planning

? Need for interpreter service/Follow up clinics discussed

Ensure 4 weeks supply of antiretroviral treatment/formula milk supply

Ensure fixed aboard and confirm address before going home

Give advice on exposure to measles, shingles or chicken pox

Advice on early warning signs of opportunistic infection

NO BCG vaccination to be given prior to the infant’s negative status being confirmed

Include information in the discharge letter to avoid inadvertent BCG immunisation

Subsequent Outpatient Management

6-8 Weeks

Growth and development monitoring

FBC to monitor bone marrow depression

HIV PCR

Hep and Immunisation schedule followed

Week 12

Growth and development monitoring

HIV PCR

FBC

Hep B vaccine and immunisation schedule

If PCR negative – offer BCG immunisation

12 Months

General clinic review

18 Months

General clinic review

HIV antibody and HIV PCR. If negative and infant well, discharge from clinic

On Reflection

Mardarescu et al (2013) in their 12 year survey on 517 children aged 0-18 months confirmed = 15% infected with HIV

Some of the causes for transmission around Neonatal care. Breastfeeding and lack of prophylaxis in children

CONSEQUENCIES1. Psychological implications to the family2. Quality of life3. Costs from Paediatric to adulthood. Postma et al (2000)

estimated Paediatric care to £179 300

Any questions?

References

1. Connor EM, Rhoda MD, Sperling et al . (1994) Reduction of maternal-infant transmission of human immunodeficiency virus Type 1 with Zidovudine treatment. The New England Journal of Medicine 331 (18): 1173-1180.

2. Postma MJ, Beck EJ, Hankins CA et al. (2000) Cost effectiveness of expanded antenatal HIV testing in London. AIDS 14: 2383-2389.

3. Mardarescu M, Petre C, Streinu-Cercel A et al. (2013) Surveillance of mother to child transmission of HIV in Romania, a 12 year’s experience in the National Institute for Infectious Diseases ‘Prof. Dr. Matei Bals’ BMC Infect Dis 13(Suppl1)