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welcome to this week's Mountain West ADC
echo my name is Brian wood medical
director and I will turn it over to
today's speaker hi everybody
I'm gonna give a rapid-fire update just
more to let you know what has been
changed and then you can delve a little
bit deeper if you need most of the
changes and the perinatal guidelines
which we were just released last Friday
December 7th which is an update from the
November 2017 guidelines are pretty
minor and they are available here so I
just wanted to put in a slide to remind
us why we care about this so much and
this is the estimated incidence of
perinatal HIV infection for a hundred
thousand live births in the US since
1978 to 2013 and you can see you know
there was quite a peak at the beginning
of the epidemic and then they put in the
milestones of a lot of important things
that happened that helped decrease
perinatal transmission but thankfully it
has just continued to be a trend
downwards and at this point we think
about 5,000 women with HIV who give
birth in the United States every year in
2013 only 69 were born with HIV and the
incidence was 1.8 out of 100,000 births
the CDC has a goal of less than one out
of a hundred thousand live births and I
will just say that Brian and I sit here
and we give advice but we are not the
people who are taking care of these
women with HIV who are pregnant you are
and I really want to credit all of you
for helping with these numbers and so
many of you are taking care of these
pregnant women so I applaud you I'm
gonna go through just the changes and
again not the prettiest transitions but
we will just fly through so there was a
new section about women who desire to
breastfeed in the US and that was
actually added in March 27th March 27th
of 2018 but that was really only added
to formally to the guidelines now
breastfeeding is still not recommended
in the US when women with HIV do choose
to breastfeed
despite counseling they should be
counseled and they have a really nice
list of how to counsel these women to
minimize
the risk of transmission they recommend
saying to all pregnant women in the
United States we recommend
formula-feeding to avoid the risk of HIV
transmission to your baby through breast
milk do you have any questions or
concerns about that and we point out
that that's just a really nice
non-judgmental way to open this
conversation and we had a great eco talk
from Judy Levinson from Baylor on
November 2nd 2017 and I put a link to
that they also have made some changes in
the HIV testing section and one thing
they really stress for the first time is
making sure that partners of women with
or without HIV partners of any pregnant
women should be encouraged to be HIV
tested and that really hasn't been an
emphasis before and that's to make sure
that even if your patient doesn't have
HIV that they are not at ongoing risk
during their pregnancy of HIV if their
partner has HIV getting them linked to
care they also risk recommend a risk
assessment of all women considering
pregnancy and all pregnant women even if
they were previously tested negative and
I think that is because some people
think well they were pregnant a year ago
and they were HIV negative we don't need
to retest but it is really important to
retest and counsel every pregnancy
because things change and if women are
high-risk really talk about prevention
counseling and considering prep they
also stress retesting certain
individuals in the third trimester and
they stress before 36 weeks if possible
and they added this time women who are
incarcerated or who reside in states
that require third trimester testing I
searched long and hard to find which
states those were in the 2006 CDC
testing recommendations they have a list
I don't know if it's been updated since
then but that is what they actually
reference in these current perinatal
guidelines most of the states were in
the northeast and southeast and Texas
none included really the states that
most of us live in in women at high risk
even if they're not in a state that
mandates it we should think about their
trimester testing and certainly any
woman with signs or symptoms of acute
HIV in terms of changes in preconception
counseling they stress again it's very
important to discuss reproductive
desires with all women of child
aged on an ongoing basis throughout
their course of care and really
emphasize the primary treatment goal in
pregnancy is a sustained viral load
suppression for the health of the woman
baby and her partner and then of course
new counseling about diet a go Baron you
may all feel like we have hashed this
out and I sort of do too
so we're gonna go through quickly
through what they finally harmonized the
recommendations with the perinatal
guidelines and the ARV guidelines and
that is actually a kind of a theme in
these updates for the first time they
really try to make it so their
guidelines are harmonized or
synchronized with the antiretroviral
guidelines which is wonderful by their
own admission they change the guidelines
about diet egg Revere and that they are
very conservative and that was their
word and they said they will likely or
may change in 2019 while we have
additional data from this study that was
discontinued
so to summarize it as quickly as
possible
women who are starting to taper here
should have a pregnancy test women who
are pregnant and less than 14 weeks
since their last menstrual period or 12
weeks since conception or trying to
conceive or unable to consistently use
contraception should ideally not beyond
diet aggravator but after 14 weeks diet
egg Rivera is considered a preferred in
stay during pregnancy and if diet a
career is used at the time of delivery
or after delivery again discuss
contraception in these women how about
women who come to you are already on
dial you take Rivera but are in their
first trimester so to continue or not to
continue the counseling messages they
give us which I have to say are not real
convincing for changing is that neural
tube defects may have already occurred
depending on the current gestational age
the additional risk of these defects
developing during the remaining time in
the first trimester is probably small
everyone has a background risk of neural
tube defects regardless of whether they
have HIV or are on medications and that
changes in therapy even in the first
trimester are often associated with
viral rebound
increase the risk of perinatal HIV
transmission I think if you had that
conversation with your patient they
wouldn't be very likely to change but
it's important to have the conversation
so they're aware of risks and benefits
they also added some new information in
the reproductive options for Co
discordant couples which I found really
exciting and heartening because even in
the last guidelines they were still
quite tepid about you equals you
messaging but there really was more
emphasis on you equals you messaging
undetectable equals untranslated
suppressed and basically said if if the
HIV part of the partner living with HIV
has a suppressed viral load that they
can be engaging in condomless sexual
intercourse ideally around the time of
trying to conceive they also really
stress prep if the viral load is not
suppressed and the infected partner
there was significantly less emphasis on
assisted reproductive technologies which
previously were made to sound like the
most ideal options and they've really
de-emphasized them they mention them as
options but they don't emphasize them
they also added some clarity about
infertility workups for couples
attempting to conceive via condomless
sexual intercourse and they say if
conception doesn't occur within six
months these patients should have
infertility workup including semen
analysis and then finally if the male
partner does not have HIV they say it's
important to use condoms we're not
trying to conceive educate the male
partner about the importance of the
partners adherence to meds which is kind
of interesting I think trying to add
additional support I can see situations
if there's intimate partner violence
we're putting the partner in control of
nagging or encouraging adherence could
be a difficult situation but I think it
is important that everyone is aware of
the importance of the pregnant person
with HIV taking their AR T and then they
recommended HIV testing every three
months while attempting conception
without condoms in terms of general
principles regarding use of
antiretroviral
drugs during pregnancy I'm a little
surprised that this is something new and
I wonder if it's just the wording change
but they said it was new to screen for
depression and anxiety as part of their
assessment for supportive care provide
counseling about what to expect during
L&D and the postnatal period I feel like
we and the echo family have really
mastered this we've really realized how
important it is to talk to women before
they go into the delivery room as to
what to expect what to do about infant
feeding and how to handle those
situations if they're not going to
breastfeed they also talked about
coordinating services with a
multidisciplinary team which we are
doing I think great job in terms of
antiretroviral therapy and pregnancy
they have different categories and
they've actually added one preferred
alternative insufficient data to
recommend usually that's for initiation
in pregnancy and then they added not
recommended except in special
circumstances and that includes
situations in which treatment
experienced pregnant women may need to
initiate or continue drugs with limited
safety and efficacy data or specific
safety concerns and then there's a not
recommended section and then they added
a new table for situation specific
recommendations for a-artie and pregnant
women and those trying to conceive and
that is an amazing table I can highly
recommend it they basically go through
every single drug and have a
recommendation for every situation
whether they're initiating a RT whether
they've been on a RT before whether
they're failing their current regimen
all kinds of things so it's it's quite a
table and I borrowed this from Brian
when he gave his talk this summer about
what he thought was the optimal regimen
prior to this guideline update and the
big change is here are that these are
the preferred regimens for treatment
naive naive pregnant women the NRTI
backbones that they recommend are to
Nava beer with FTC or 3tc thing or a
back of their 3tc again with the same
restrictions that we always talk about
with
back here in terms of in STIs RAL tegra
beer or dial you take a beer after the
first trimester or considered preferred
and then pee is add as a nevere and
Ratana beer or boosted aruna beer with
her tone of air but that must be used be
ID I've highlighted the changes in red
here I think I might have forgotten to
highlight big tag review alternative
regimens are combivir AZT 3tc a Fabrice
or real pain with again the usual
restrictions and then in terms of P is
you can use LaPenta via Ratana beer
Brian and I were noting before this that
now the only single tablet regimen
that's even considered alternative are
fabrics in the form of a triplet or real
marina in the form of complainer so
that's a little bit disheartening and
now if a bronze has been given really
full rein to be used there's
insufficient data and basically all of
our newer medicines and not recommended
you can see that column and the key
change here is Cove assist at SoCo be
stat Kobus is step boost at regimens and
pregnancy there is significant concern
based on data about decreased plasma
levels in the second and third
trimesters and so if someone is on a
Cobie containing regimen they say
consider switching to another regimen
that is recommended for use in pregnancy
and if you must continue a Cobie
containing regimen absorption should be
optimized and viral load should be
monitored frequently so what if after
all your best efforts a patient has a
detectable viral load or via logic
failure well this section was updated to
include that you should really talk
about food requirements and possible
drug interactions and again this is
something we talk about here all the
time consider in ste resistance testing
if someone's previously been on on insti
they have a sex partner within ste
history or they're starting or changing
to an in steel eight in pregnancy and
then viral load testing is currently
recommended at 34 to 36 weeks gestation
for delivery planning providers may
consider repeat testing even after that
and select women who are at high
for viral rebound the cd4 cell count
monitoring recommendations were just
changed to say in most women if they
have consistently greater than 300 cd4
cells and they've been on a RT for
greater than two years that they do not
need to have a cd4 count checked after
the initial test at their first
antenatal visit and so again harmonizing
really with the ARV guidelines they
talked about women who have HIV and Hep
C and pregnancy and there's been data to
show that there's really low uptake of
Hep C testing and Hep C exposed infants
in general we think there's about a six
percent transmission risk of Hep C from
a mother to baby in women with HIV
that's probably double then we think
about 10 to 20 percent risk and so they
really want to stress that these babies
should be tested for hep c and they give
specific recommendations Hep C antibody
tests after 18 months Hep C RNA testing
is not recommended in the neonatal
period and definitely not before 2
months and they basically say also if
you have a negative Hep C RNA early on
it means nothing because my Aranea can
be intermittent in terms of acute HIV
and pregnancy it depends on when the
diagnosis is made in the first trimester
they recommend a boosted PIB used
because again concerns about diet at
Revere and they think raw egg Revere has
too low of a barrier to resistance in
the second trimester they want us to use
diet tagged Revere and they also point
out if you diagnosed someone with acute
HIV in the postpartum period make sure
they stop breastfeeding those infants of
women who develop acute HIV during their
pregnancy should be treated like a
high-risk infant for HIV exposure
because of the potential for high viral
very Mia they also point out that women
may be extremely susceptible to HIV
infection during pregnancy and
breastfeeding and so women who are at
high risk really need counseling and
discussion of prep delayed cord clamping
was addressed in
most recent guidelines and there was a
recent study of 64 hiv-positive mother
and infant pairs where the mother was
living with HIV and they compared these
are split down the middle delayed
clamping which was 120 seconds after
birth or early clamping cord clamping 30
seconds after birth and the mean
hemoglobin levels at 24 hours and one
month after birth were significantly
higher with delayed cord clamping and
there were no HIV transmissions
increased risk of jaundice or
polycythemia in 18 months with delayed
cord clamping again that's only 32
infants that had delayed cord clamping
they don't make a recommendation they
just put that data out there but they do
say in women without HIV ACOG recommends
delayed clamping in vigorous term and
preterm infants so I think we don't have
totally specific recommendations but we
have some nice early data to suggest
that delayed cord clamping may be safe
in this population I'm going to just
speed through this last few slides
postpartum follow-up of women with HIV
ACOG has changed their recommendations
to say that all women should have
contact with their obstetric care
provider within the first three weeks of
the postpartum period and that is
earlier than and I think it has always
been done women with HIV are recommended
to have a follow appointment with the
healthcare provider who manages their
HIV care whether that's their obstetric
provider or their HIV care provider
within two to four weeks after hospital
discharge and I think this is to really
stress retention and care and then make
sure that they're on the right a RT they
also really stress it's okay to change
AR T after delivery because in certain
point certain women you're gonna be able
to simplify their regimen because we
just talked about there's not a lot of
single tablet regimens AR T management
of newborns with perinatal HIV exposure
or perinatal HIV they just changed some
of the recommendations and I'm not going
to go through at length but there are
very minor changes they did stress that
in all cases where a newborn is
considered higher risk of HIV
acquisition AZT should be continued for
six weeks there's some debate about
whether other medications need to be
continued and then they also pointed out
that for women who have non bee
type HIV or group Oh HIV that there are
now tests available and those should be
used in those babies of those women and
finally we've been talking about
updating our echo birth plan I was
telling Brian I don't love the
expression birth plan because it gives
the idea that you can plan anything
about birth but we're going to update
this
now that the perinatal guidelines have
come out so that everyone can have
access to it thank you for watching this
edition of the Mountain West HIV project
echo didactic series if you're
interested in other talks we invite you
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echo until next week's edition the
spring load medical director signing off
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