Claire Gamble Friday 30th June 2017 Baby, Birth and Beyond. Claire Gamble Friday 30th June 2017

Heartlands Paediatric Department Regional Children's HIV service Dr Steve Welch, Kate Ghandi (Pharmacist) Yvonne and Claire (CNS’s) Care of +ve children Satellite clinics, Wolves, Cov, Leicester Follow up of babies born to +ve moms

Antenatal screening for HIV, and impact

Mums-to-be

Mother-to-child-transmission When an HIV positive woman passes the virus to her baby during pregnancy, labour and delivery during breastfeeding Without treatment, around 15-30% of babies born to HIV positive women will become infected with HIV during pregnancy and delivery. A further 5-20% will become infected through breastfeeding

Uptake of antiretroviral therapy and MTCT rate by year of birth for 3703 infants born to diagnosed women 1990-2004

New diagnosis Referral from screening midwife Reassure Obtain bloods STI screen Partner notification Start to treat Monitor carefully Vaginal delivery if VL <40

Known positive Patient normally calls dept Arrange to see to discuss concerns and worries Monitor carefully Vaginal delivery if <40

At Delivery VL <40 VL >40 NVD Start baby on single HIV medication asap Take bloods for HIV VL from mom and baby VL >40 Recommend C section AZT infusion Plan may include other meds from mom Start baby on triple HIV medication asap

Feeding All mothers known to be HIV positive, regardless of antiretroviral therapy, and infant PEP should be advised to exclusively formula feed from birth. It is well established that HIV can be transmitted from mother to child by breastfeeding. Evidence from Kenya puts the transmission rate at 16% over 2 years, accounting for almost half the total mother-to-child transmissions

Breast feeding Intensive support and monitoring of the mother and infant are recommended during any breastfeeding period, including monthly measurement of maternal HIV viral load, and monthly testing of the infant HIV viral load. Prolonged infant prophylaxis during the breastfeeding period, as opposed to maternal ART, is not recommended.

Inhibiting lactation Cabergoline should be administered during the first day post-partum. The recommended dose is 1 mg (two 0.5 mg tablets) given as a single dose.

Baby follow up VL at birth VL and development check at 6 weeks VL and development check at 3 months Antibody test at 2 yrs

Issues for positive children Family dynamics Confidentiality Disclosure Adherence/pill burden Transition Sexual health

Confidentiality & Disclosure Children often not aware of parents diagnosis Parents not always keen for the child to know their own diagnosis Who to tell School ‘BFF’s’, ‘Bae’s’ Partners

Adherence Big secret within family Reminder of diagnosis Poor in all chronic conditions in adolescence Can limit treatment options for future Mental health issues

Pill burden Adult: 2 tablets daily: Kivexa + efavirenz 600mg 9 year old, 25kg child: 7½ tablets daily abacavir 1½ tablets lamivudine 2 x 100mg tablets 4 efavirenz capsules 200mg + 50mg +50mg + 50mg