Around one in seven adolescent females with HIV have been pregnant, according to an audit of UK clinics reported at the joint conference of the British HIV Association (BHIVA) and the British Association of Sexual Health and HIV (BASHH) last month.
Most of the pregnancies were unplanned and a quarter were terminated. Although there were problems with adherence to antiretroviral medication in many cases, fortunately none of the pregnancies resulted in transmission of HIV to the infant.
These cases highlight the need for sexual health education for those young people who acquired HIV from mother-to-child transmission in the 1980s and 1990s. To help health professionals with this work, the HIV in Young People Network (HYPNET) and the Children’s HIV Association (CHIVA) last week published draft guidance on the management of sexual and reproductive health for adolescents living with HIV.
The pregnancy audit was conducted by sending a questionnaire to 19 participating clinics, who were asked to review the medical notes of all vertically-infected females who were aged twelve or over attending the clinic. Information was collected on a total of 172 individuals, of whom 27 had had a total of 36 pregnancies.
Of the 36 reported pregnancies:
- 75% were unplanned.
- 86% involved regular partners.
- 39% of partners were not aware of the woman’s HIV status.
- 25% of the pregnancies were terminated.
- 14% ended in miscarriage.
- 50% resulted in a live birth and 11% in an ongoing pregnancy at the time of reporting.
Of the 18 live births, 89% of the mothers were on combination therapy at the time of delivery. Women on therapy had a median CD4 count of 252 cells/mm3 (range 54-437) and a median viral load of 79 copies/ml (range < 50 to 588,844).
In only 8 of the 18 live births (44%) did the mother have an HIV viral load of <50 copies/ml before delivery. 80% of mothers had poor adherence to treatment during pregnancy, with two being given Directly Observed Therapy (DOT).
One third of the babies were delivered prematurely, and five of them required neonatal intensive care. Three had a low birth weight. No congenital anomalies were reported.
No cases of HIV transmission were recorded.
Two-thirds of the young mothers were reported as having complex social needs, with one quarter of their babies requiring foster care.
This is the first time that specific guidance on managing the sexual and reproductive health of HIV-positive adolescents has been published. The document makes it clear that, even if the issue is not raised by the young person, then paediatricians should take responsibility for covering sexual health education and needs during consultations, with the process starting well before sexual maturity is reached. The guidance states that HIV-positive adolescents require the same sexual health information as their HIV-negative peers, as well as further help on applying it while living with HIV.
Topics which need to be discussed include preventing the transmission of HIV and other sexually transmitted infections; contraception; symptoms and treatment of sexually transmitted infections; vaccinations; HIV disclosure; post-exposure prophylaxis; conception options and fertility issues; pregnancy and avoiding mother-to-child transmission; options if there is an unplanned pregnancy; sexual exploitation and sexual violence; sexual difficulties; psychological support for negotiating safe sex, self-assertion, bullying or other issues.
The guidance explores some of the issue involved in delivering sexual health work with this age group. Sexual health services for young people should be confidential (without disclosure to a parent or guardian), provided that the young person is assessed as being ‘Gillick competent’ (has the maturity to make their own decisions and to understand the implications of them). For under 16s, Gillick competence needs to be assessed at each clinical visit as it can change over time.
The guidance notes that adolescents value consultations that are non-judgemental, give them correct information and which maintain confidentiality. Professionals are encouraged to use simple language, check understanding and not overload adolescents with too much information. They should not make assumptions about whether the young person is sexually active or what their sexuality is.
The draft guidance is open for comments and feedback until May 28.
Williams B. Pregnancy outcomes in women growing up with HIV acquired perinatally or in early childhood. HIV Medicine 11 (supplement 1), P144, 2010.