Management of Infants born to HIV Positive Mothers

1. Management of Infants born to HIV Positive Mothers Joyce Banga Neonatal Nurse

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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.

10. 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)

11. 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

12. 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

13. Subsequent Outpatient Management • 6-8 Weeks • Growth and development monitoring • FBC to monitor bone marrow depression • HIV PCR • Hep and Immunisation schedule followed

14. Week 12 • Growth and development monitoring • HIV PCR • FBC • Hep B vaccine and immunisation schedule • If PCR negative – offer BCG immunisation

15. 12 Months • General clinic review

16. 18 Months • General clinic review • HIV antibody and HIV PCR. If negative and infant well, discharge from clinic

17. 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 CONSEQUENCIES • Psychological implications to the family • Quality of life • Costs from Paediatric to adulthood. Postma et al (2000) estimated Paediatric care to £179 300

18. Any questions?

19. References • 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. • Postma MJ, Beck EJ, Hankins CA et al. (2000) Cost effectiveness of expanded antenatal HIV testing in London. AIDS 14: 2383-2389. • 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 Dis13(Suppl1)