Complex needs but good pregnancy outcomes for HIV-positive teenagers in London

The rate of mother-to-child HIV transmission among HIV-positive teenagers in London is low, investigators report in HIV Medicine. However, they found that the young women faced “difficult medical and social circumstances,” that condom use was low, and that a quarter of women had a second pregnancy within a year of delivery.

“This study identifies a need for more effective strategies in the management of HIV-infected teenagers with particular emphasis on sexual and reproductive health,” comment the authors.

Because of the effectiveness of antiretroviral therapy, many children infected with HIV at birth are now surviving into adulthood. In addition, young people aged 16 to 24 account for 11% of new HIV diagnoses in the UK.

Studies conducted in HIV-positive adolescents have found that many have complex psychosocial problems, and that there are high levels of sexual risk behaviour and recreational drug use.

However, there is very little information on pregnancy in teenagers living with HIV in the UK.

Therefore investigators from London and Oxford retrospectively examined the medical case notes of HIV-positive teenagers (13 to 19 years) who became pregnant between 2000 and 2007 and received their care at twelve specialist HIV clinics in London.

A total of 58 women who had 67 pregnancies were identified. The median age at which the women became pregnant was 18.

Over three-quarters were black (African, 59%; Caribbean, 17%). One woman was known to have been HIV-positive since birth, and vertical transmission could not be ruled out for 43% of women.  They were already sexually active when they were diagnosed with HIV in their early teens.

Almost two-thirds (63%) of individuals had their HIV infection diagnosed through routine antenatal screening.

“Significant and complex psychosocial problems” were highly prevalent. A history of sexual abuse was reported by 45% of patients, housing problems by 58% and financial concerns by 62%.

Most of the patients (92%) had had a sexual health screen in the year before they became pregnant, and 45% had a history of sexually transmitted infections. Condom use was low and was reported by only 35% of individuals and 65% said they used no method of contraception.

An analysis of case notes showed that just 45% of patients were counselled about contraception after delivery and 25% had a second pregnancy within a year.

Most of the pregnancies (82%) were unplanned, and only four patients were taking HIV therapy at the time of conception.

Nevertheless, 94% of individuals took some form of antiretroviral therapy during pregnancy, and for 81% of women the primary purpose was to prevent mother-to-child transmission of the virus. At the time of delivery 62% of women had an undetectable viral load.

Complications were recorded for 13% of pregnancies. The most common mode of delivery was elective Caesarean section (56%). Emergency Caesareans were performed in 15% of cases and 29% of infants were delivered vaginally.

All but one of the infants were born alive. In addition one was HIV-infected. This baby was delivered by elective Caesarean section but nevertheless had detectable viral load within 48 hours of birth. The mother was diagnosed late in pregnancy (week 29), at which time she had a viral load of 11 500 copies/ml, and investigators therefore believe that her infant was infected in the womb. The baby started HIV therapy within a month of delivery and was well when last seen in the clinic

The investigators emphasise that despite their vulnerability and difficult social and medical circumstances, these HIV-positive teenagers had “favourable” obstetric and virologic outcomes.

They attribute this to the “multidisciplinary care the patients received.” At all the hospitals participating in the study, the patients were looked after by a team that included a specialist HIV physician, an obstetrician, a paediatrician and specialist midwife.

Nevertheless, they believe their study identified “a need for more effective strategies in the management of HIV-infected teenagers with particular emphasis on sexual and reproductive health.” To meet these needs, the authors call for the establishment of “a one-stop shop including HIV care, sexual and reproductive health input and psychosocial support in an appropriate environment provided by skilled staff in a sensitive and nonjudgmental manner.”

Elgalib A et al. Pregnancy in HIV-infected teenagers in London. HIV Med 12: 118-23, 2011 (click here for the study’s free abstract).