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256 HIV - reducing mother-to-baby transmission of HIV v5a

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					                                                                                                                 Maternity Services


                          Reducing Mother to Baby Transmission of HIV

       Policy number                          MAT 256                                Version                        5a

       Author                                 Jane Oswin            Screening Coordinator
                                              Clinical Effectiveness
       Approved by                                                                   Date approved                  23 July 2009
                                              Forum
       Ratified by                            Wiltshire PCT Trust                    Date ratified                  22 October 2010
                                              Board

       Date issued                            27 July 2009                           Date expires                   21 October 2010
                                              This protocol provides overarching guidance for all staff on the
       Target audience
                                              development and management of policies, protocols, procedures,
                                              guidelines and care pathways.
                                              Wiltshire Community Health Services Maternity Policies and
       Related documents
                                              Procedures:

                                              150        Booking Policy
                                              367        Reporting & Management of Results of Screening Test

                                              This protocol has had an impact assessment against race, disability,
       Equality & diversity
                                              gender, age, sexual orientation and religion and belief equality and
                                              diversity criteria in line with current legislation and the requirements of
                                              the Single Equality Scheme.

                                              NHS Wiltshire is committed to promoting equality and respect for the
                                              people of Wiltshire and for our staff. Our aim is to ensure that the way
                                              we work with individuals and communities - and their representatives -
                                              and with our staff, challenges inequality and affirms difference. This
                                              means all our services are accessible, appropriate and sensitive to the
                                              needs of individuals.
                                              G-         Individual case review by multidisciplinary team at
       Monitoring Method
                                                         obstetric case review meeting

        Wiltshire Community Health Service is the arm’s-length provider body of NHS Wiltshire
                     and is wholly owned by and accountable to NHS Wiltshire




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       Consultation route

          Date of Issue                  Version               Distribution                             Amendments
        27.07.2009                      5i                 Clinical                         In section 7.0 Description of
                                                           Effectiveness                    antenatal service, sub- section 1:
                                                           Forum                            ‘Sample Collection – Midwives’
                                                                                            the following bullet points have
                                                                                            been included:
                                                                                            • Women who decline an HIV
                                                                                                test at booking should be re-
                                                                                                offered a test (at 28 weeks),
                                                                                                and should they decline
                                                                                                again, a third offer of a test
                                                                                                should be made at 36 weeks.
                                                                                            • Women with other risk factors
                                                                                                i.e. IV drug abusers who are
                                                                                                HIV negative at booking, may
                                                                                                be offered a routine second
                                                                                                test at 34-36 weeks, as
                                                                                                recommended in the British
                                                                                                HIV Association (BHIVA)
                                                                                                Pregnancy Guidelines.




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                                                                       Contents

       1.0SUMMARY................................................................................................................. 4
       2.0 AIMS ......................................................................................................................... 4
       3.0 BACKGROUND1 ....................................................................................................... 4
       4.0 HIV DISEASE IN BABIES AND CHILDREN ............................................................. 5
       5.0 INTERVENTION TO REDUCE VERTICAL TRANSMISSION ................................... 5
       6.0 COST EFFECTIVENESS OF THE UNIVERSAL HIV TEST OFFER ........................ 5
       7.0 DESCRIPTION OF ANTENATAL SERVICE ............................................................. 5
           SECTION 1: SAMPLE COLLECTION — MIDWIVES................................................... 6
           SECTION 2: SAMPLE ANALYSES — SCREENING LABORATORY .......................... 6
            Management of results............................................................................................. 7
           SECTION 3: ACTION ON RECEIPT OF NEGATIVE RESULTS .................................. 7
            Midwives .................................................................................................................. 7
           SECTION 4: ACTION ON RECEIPT OF WEAKLY POSITIVE RESULTS .................... 7
            Virologist .................................................................................................................. 7
            Screening Coordinator/ Senior Midwife in Antenatal Clinic – Princess Anne Wing .. 7
            Named Midwife & Sexual Health Advisor................................................................. 7
       8.0 USEFUL TELEPHONE NUMBERS........................................................................... 7
       9.0 NOTES & REFERENCES ......................................................................................... 8
       10.0 APPENDICES ......................................................................................................... 8
           EQUALITY & DIVERSITY IMPACT ASSESSMENT .................................................................. 9
           FLOW DIAGRAM FOR ANTENATAL SCREENING FOR HIV..................................................... 10




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       1.0 Summary

       The NHS Executive has accepted the recommendations from an expert group set up to
       develop targets aimed at reducing mother to baby transmission of human
       immunodeficiency virus (HIV). The recommendations for targets were intended to
       achieve the national objective of reducing the number of babies with HIV acquired from
       an infected mother during pregnancy, birth or through breast feeding by 80% by the
       year 2002. The targets were that all pregnant women should be offered and
       recommended an HIV test along with other antenatal screening tests, as an integral part
       of their antenatal care and that the offer be recorded with an uptake of a least 50% by
       31.12.2000 and 90% by 31.12.2002.

       The targets are aimed at increasing the uptake of antenatal HIV testing and the
       percentage of HIV infected pregnant women diagnosed at a sufficiently early stage so
       that women can be offered advice, treatment and interventions during antenatal care to
       reduce vertical transmission.


       2.0 Aims

       1. To ensure all pregnant women are given information regarding HIV testing to enable
          them to make an informed choice.
       2. To ensure that all women identified as HIV positive are offered effective
          interventions during the antenatal period to reduce vertical transmission.
       3. To ensure women identified as HIV positive be offered/given appropriate treatment
          for their babies in the neonatal period and specialist follow up and monitoring.
       4. To ensure that processes are in place to co-ordinate management and delivery of
          this programme.
       5. To ensure that clinical standards and audit methods to monitor the policy are in
          place to ensure high quality.


       3.0 Background1

       The Department of Health set up an expert group in April 1999 to develop targets aimed
       at reducing mother to baby transmission of HIV. From a study in 1997 more than 70% of
       HIV infection in pregnant women remained undiagnosed at the time of delivery. Many
       women do not find out about their infection until their child becomes symptomatic with
       HIV infection, or diagnosed with acquired immune deficiency syndrome (AIDS).

       There is considerable geographical variation in prevalence of HIV in pregnant women.
       Epidemiological data shows that in 1999 an estimated 380 births to HIV-infected women
       in the UK would have resulted in about 55 HIV infected infants. If all maternal infections
       had been diagnosed and interventions accepted by all HIV-infected mothers, fewer than
       10 infant HIV infections would have occurred.



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       4.0 HIV disease in babies and children

       Without any treatment, HIV infection in children results in chronic disease and about
       20% of HIV infected children develop AIDS and die within the first year of life. By the
       age of 6 years, about 25% of children will have died and most of the surviving children
       will have had some illness because of their infection. The long-term picture is unknown,
       but all children with HIV will benefit from early life-prolonging treatment.


       5.0 Intervention to reduce vertical transmission

       Once women are aware of their HIV infection, evidence suggests that most women
       accept interventions to reduce the risk of vertical transmission and protect their babies.
       For instance, if the following interventions are all accepted the risk of vertical
       transmission can be reduced from 25% to less than 5%:
           • use of anti-retroviral drugs
           • delivery by planned caesarean section
           • planned obstetric management
           • bottle feeding

       The prevalence of HIV infection amongst women giving birth in England and Wales has
       increased every year since 1990. Results from the unlinked Anonymous Surveys of HIV
       infection in pregnancy show that in 2003 the prevalence reached 1 in 180 (0.56%) in
       Inner London, 1 in 271 (0.37%) in Outer London and 1 in 1282 (0.081%) in the rest of
       England. The majority of these women are from Sub-Saharan Africa. The Department of
       Health policy of recommending an HIV test to every pregnant woman has resulted in an
       increase in the proportion of these women who are aware of their diagnosis prior to
       delivery and a decrease in the absolute number of infants infected in the UK.


       6.0 Cost effectiveness of the universal HIV test offer

       The National Screening Committee has sought reassurance that the universal antenatal
       HIV test offer has met the cost effectiveness criteria applied to other screening
       programmes. This has been shown for the country as a whole and for the majority of
       Health Authorities.


       7.0 Description of antenatal service

       This is shown schematically in the diagram (Appendix 1, page 8).




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       SECTION 1: SAMPLE COLLECTION — MIDWIVES

       •     All pregnant women should be offered screening for HIV as one of a number of
             blood tests routinely recommended in early pregnancy (including full blood count,
             blood group and rhesus status, VDRL, rubella and Hepatitis B screening).
       •     This is routinely performed by the midwife at booking at around 8 - 10 week’s
             gestation. Screening should also be offered to all women who book late, or women
             who arrive unbooked in labour.
       •     Screening should be offered during each pregnancy.
       •     The purpose and potential benefits of such screening tests should be explained to
             the woman using the information leaflet available.
       •     Women who require further information prior to making a decision should be referred
             to the local genito-urinary medicine or sexual health clinic. If the woman decides to
             have the test in either of these clinics, the results will not be available to the midwife.
       •     Women have a right to choose whether or not to have the test and their wishes
             should be respected.
       •     If a woman chooses not to take up screening for HIV, this should be recorded clearly
             in the maternity pack. The blood form for antenatal screening tests should clearly
             state that HIV testing is declined. If all blood tests are declined then the completed
             blood form should still be sent to the laboratory.
       •     Women who decline an HIV test at booking should be re-offered a test (at 28
             weeks), and should they decline again, a third offer of a test should be made at 36
             weeks.
       •     Women with other risk factors i.e. IV drug abusers who are HIV negative at booking,
             may be offered a routine second test at 34-36 weeks, as recommended in the British
             HIV Association (BHIVA) Pregnancy Guidelines.
       •     With the women’s consent, 10 cc of clotted blood is taken and sent to the Bristol
             Health Protection Agency (HPA), this is currently done for rubella/VDRL and
             Hepatitis B screening. The sample must be labelled in the presence of the woman.
       •     The form MUST be fully completed with full name, date of birth, NHS number or
             hospital number and midwife’s or maternity units name and code. Clinical details
             must include pregnant, gestation and expected date of delivery (EDD). Without this
             information, it will not be possible to monitor the quality of service.
       •     Midwives must specifically request HIV screening on the blood form. If the test is
             declined, this must be clearly recorded.
       •     Explain how results will be given. Inform women having shared care with the GP that
             the GP will also be informed of the results.
       •     Complete the screening page in the maternity notes.

       SECTION 2: SAMPLE ANALYSES — SCREENING LABORATORY

             •    Blood is tested for HIV using the blood sample already taken for other routine
                  investigations at the booking visit.
             •    Results categorised as follows: negative, positive or weakly positive (equivocal).
                  A weakly positive result is likely to be related to the screening test used and not
                  necessarily an indication of early HIV infection.
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             •    Bristol Public Health laboratory participates in the internal quality assurance
                  programme.


       Management of results

       Negative results        sent to midwife
       Positive results        head of virology will telephone the Screening Coordinator/
                               Senior Midwife in Antenatal Clinic – Princess Anne Wing.
       Weakly positive results Obstetrician Miss Dunlop with details. Hard copies of the
                               result will then be sent as agreed following discussion.


       SECTION 3: ACTION ON RECEIPT OF NEGATIVE RESULTS

       Midwives
          • Women are informed of results at next antenatal appointment.
          • If particularly anxious and women telephone for result, an earlier appointment
            should be arranged.
          • All results are filed in maternity notes or hospital notes depending on the
            woman’s preference.
          • The absence of a result in the notes does not imply anything about
          • HIV status, the woman or the laboratory should be asked for the result.
          • HIV results should not be given via the telephone even if negative.

       For positive results please refer to document 256a.

       SECTION 4: ACTION ON RECEIPT OF WEAKLY POSITIVE RESULTS

       Virologist
          • Contacts the Screening Coordinator/Senior Midwife in Antenatal Clinic – Princess
             Anne Wing.

       Screening Coordinator/ Senior Midwife in Antenatal Clinic – Princess Anne Wing
          • Contacts the named midwife with the result also discussed with Lead HIV
            Obstetrician.

       Named Midwife & Sexual Health Advisor
         • Will liaise with the local sexual health adviser. The midwife and health advisor will
           arrange an appointment with the woman as soon as practical for repeat testing
           and further counselling/support.


       8.0 USEFUL TELEPHONE NUMBERS

       Miss D Dunlop                                Consultant Obstetrician                                01225 824657

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       Dr Horn/Dr Fernandes                         Consultant GU Medicine                                 01225 824960

       Dr S Jones                                   Consultant Paediatrician                               01225 825405

       Dr P Rudd                                    Consultant Paediatrician                               01225 824393

       Lucy Whyatt                                  Sexual Health Advisors,                                01225 824558 – Direct
                                                    RUH
       Debbie Chadbon                                                                                      01225 824617 – Appts

       Jane Oswin                                   Screening Coordinator                                  01225 825414

       Jo Nelki                                     Sexual Health Advisor                                  01249 456502 – Office
                                                    Chippenham                                             01666 826186 – Appts

       Jane Downie/                                 Senior Midwives, ANC RUH                               01225 824650
       Helen Spurrel

       Lucy Whyatt and Debbie Chadbon are based at RUH and will assist Bath and Paulton
       based midwives

       Jo Nelki is based at Chippenham and will assist Wiltshire and Somerset based
       midwives.

       9.0 NOTES & REFERENCES

       1. Reducing mother to baby transmission of HIV, Health service circular, HSC
          1999/183 13 August 1999
       2. Health Protection Agency: Focus on prevention – HIV and other sexually transmitted
          infections in the UK 2003: An Update November 2003. 11-25-2004
       3. UK Health Departments. Reducing mother to baby transmission of HIV 1999
          London, NHS Executive Tookey P, National study of HIV in pregnancy. Newsletter
          59.2004
       4. UK National Guidelines for HIV 2008. British HIV Association www.bhiva.org


       10.0 APPENDICES

       Appendix 1 – Diversity and Equality Impact Assessment
       Appendix 2 - Flow diagram for antenatal screening for HIV




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                                                                                                                                          Appendix 1
                                                                                                                                          Page 1 of 1




                                Equality & Diversity Impact Assessment
        Title of Document                                                                      Reducing Mother to Baby
                                                                                               Transmission of HIV
        Is the policy new or existing?                                                         Existing


        Date policy was created
        Does this policy contain the Trust’s statement on                                      Yes √                   No
        Equality?

        Date policy is due to be reviewed                                                      18/03/2011

        Who was/will be consulted over this policy?                                            Lay input via Labour Ward Forum.

        What is the main purpose of this policy                                                •      National guidance.
                                                                                               •      Consistency of practice.
                                                                                               •      Compliance with CNST.
                                                                                               •      Evidenced-based practice.
        Is this policy contractual?                                                            No

        Who is this policy aimed at or who will be affected by                                 PCT staff
        it?
        What are the likely implications for the Trust of this                                 Compliance with national
        policy?                                                                                standards.

        What, if any, are the resource implications of this                                    Within financial budget
        policy?

        What is the legislation, ethic or other guiding principle                              Equality and diversity – Maternity
        behind this policy?                                                                    is accessible to all.

        Is this policy likely to have an adverse effect on any                                 No
        specific group taking into account: sex, gender,
        ethnicity, colour, national origin, and disability, physical
        or mental health?
        Could this policy discriminate directly or indirectly                                  No
        against any staff group with reference to Sex, Race
        Disability Discrimination acts or the Regulations on
        Religion or Belief and Sexual Orientation? If so how?
        If this policy could be discriminatory in any way, what                                N/A
        actions will be taken to remedy this?
        Where will this policy be stored and how will it be                                    Electronic storage – access
        accessed?                                                                              through the PCT’s internet and in
                                                                                               paper copy by request to the
                                                                                               communications team

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                                                                                                                                                                              Appendix 2
                                                                                                                                                                              Page 1 of 1

                                                      Flow diagram for antenatal screening for HIV
                                                       (For use in conjunction with written policy)


           Declined – record
           decision in maternity
           notes. Complete blood                                                                                      Offer Again at
                                                                                                                      next visit
           form – HIV test not to be
           done.




All pregnant                                Negative result – inform women at
women offered HIV                           next antenatal clinic
screening



                                                       Weakly positive results
           Accepted – recorded in
           maternity notes. Blood
           form and sample sent to                                                                              Refer consultant GU
           screening laboratory                                                                                 medicine – contact
                                                                                                                tracing, ongoing                                  Women
                                                                                                                management

                                         Positive result – Virologist contacts
                                         Screening Coordinator/Senior
                                         Midwife, Antenatal Clinic. Screening
                                         Coordinator/Senior Midwife contacts                                                                                                                Baby
                                         named midwife and sexual health
                                         advisor – early appointment, repeat
                                         test and counseling.                                                   Refer consultant                         Refer to consultant
                                                                                                                obstetrician – plan                      Paediatrician – plan
                                                                                                                for antenatal care                       for neonatal and
                                                                                                                and delivery                             ongoing management


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Description: 256 HIV - reducing mother-to-baby transmission of HIV v5a