A de Ruiter

Earlier initiation of ART and further decline in mother-to-child HIV transmission rates, 2000-2011

Objectives:To analyze mother-to-child HIV transmission (MTCT) rates over time in light of changes in management, demographic, and pregnancy characteristics. Design:Population-based surveillance data on diagnosed HIV-positive women and their infants are routinely collected in the UK and Ireland. Methods:A total of 12 486 singleton pregnancies delivered in 2000–2011 were analyzed. HIV infection status was available for 11 515 infants (92.2%). Results:The rate of MTCT declined from 2.1% (17/816) in 2000–2001 to 0.46% (nine of 1975, 95% confidence interval: 0.21–0.86%) in 2010–2011 (trend, P = 0.01), because of a combination of factors including earlier initiation of antenatal combination antiretroviral therapy (cART). Excluding 63 infants who were breastfed or acquired HIV postnatally, MTCT risk was significantly higher for all modes of delivery in women with viral load of 50–399 copies/ml (1.0%, 14/1349), compared with viral load of less than 50 copies/ml (0.09%, six of 6347, P <0.001). Among the former (viral load 50–399 copies/ml), the risk of MTCT was 0.26% (two of 777) following elective cesarean section and 1.1% (two of 188) following planned vaginal delivery (P = 0.17), excluding in-utero transmissions. MTCT probability declined rapidly with each additional week of treatment initially, followed by a slower decline up to about 15 weeks of cART, with substantial differences by baseline viral load. Conclusion:MTCT rates in the UK and Ireland have continued to decline since 2006, reaching an all-time low of 5 per 1000 in 2010–2011. This was primarily because of a reduction in transmissions associated with late initiation or nonreceipt of antenatal cART, and an increase in the proportion of women on cART at conception.

British HIV Association guidelines for the management of HIV infection in pregnant women 2012

The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of human immunodeficiency virus (HIV)-positive pregnant women in the UK. The scope includes guidance on the use of antiretroviral therapy (ART) both to prevent HIV mother-to-child transmission (MTCT) and for the welfare of the mother herself, guidance on mode of delivery and recommendations in specific patient populations where other factors need to be taken into consideration,such as coinfection with other agents. The guidelines are aimed at clinical professionals directly involved with, and responsible for, the care of pregnant women with HIV infection.

A COMPARISON BETWEEN CYTOLOGY AND HISTOLOGY TO DETECT ANAL INTRAEPITHELIAL NEOPLASIA

INTRODUCTION--Anal intraepithelial neoplasia (AIN), which may be a precursor of anal carcinoma, has been identified on histology following minor anal surgical procedures, in particular the removal of perianal condylomata, in increasing numbers of homosexual and bisexual men. Anal cytology has recently been proposed as a useful method of identifying AIN lesions. OBJECTIVE--To compare anal cytology with histology as a method of detecting AIN. METHODS--215 homosexual and bisexual men attending a central London sexually transmitted diseases clinic had an anal cytological smear performed under standard conditions. The perianal area and anal canal were then examined using a colposcope, and areas macroscopically suggestive of intraepithelial neoplasia were biopsied. RESULTS--176 of the 215 patients were biopsied of whom 76 had AIN on histology. 154 of the 215 patients had an adequate anal smear of whom 46 and 85 had cytological features of both HPV and AIN, or HPV alone respectively. Including features of HPV alone as an abnormal smear, anal cytology, when compared with anoscopy and histology as the gold standard for diagnosing AIN, resulted in a sensitivity of 87.5%, a specificity of 16.3%, a positive predictive value of 37.4% and a negative predictive value of 69.6%. Restricting abnormal smears to those with features of both HPV and AIN resulted in a sensitivity of 33.9%, a specificity of 72.5%, a positive predictive value of 41.3% and a negative predictive value of 65.7%. CONCLUSION--Anal cytology is a sensitive but nonspecific method of identifying patients with biopsy proven AIN if cytological features of HPV alone are included as abnormal smears. Specificity is improved by restricting abnormal smears to those with features of both HPV and AIN but this markedly lowers the sensitivity of the test. At present, anoscopy and histology are required in addition to anal cytology to differentiate between patients who simply have anal condylomata and those who also have AIN.

Ethnic differences in stage of presentation of adults newly diagnosed with HIV‐1 infection in south London

To establish whether there were ethnic differences in demographic characteristics, the stage at HIV diagnosis and reasons for and location of HIV testing between 1998 and 2000 in a large ethnically diverse HIV‐1‐infected clinic population in south London in the era of highly active antiretroviral therapy.

Guidelines for the management of HIV infection in pregnant women and the prevention of mother-to-child transmission. British HIV Association

Aims of the guidelines These guidelines, drawn up by a multidisciplinary group of clinicians and lay workers active in the management of pregnant women infected with HIV, aim to give up‐to‐date information on interventions to reduce the risk of mother to child transmission of the virus. The evidence on the use of interventions to prevent mother to child transmission of HIV has been graded according to the strength of the data as per the definitions of the US Agency for Health Care Policy and Research [ 1 ]. Weighted evidence on the use of combination antiretroviral therapy (ART) for the treatment of HIV infection per se is presented in the BHIVA guidelines for adults [ 2,3 ]. The highest level evidence (i.e. randomised controlled trials (RCTs) or large, well conducted meta‐analyses) is only available for formula feeding, prelabour caesarean section and zidovudine monotherapy. The need to treat mothers for HIV infection has led to the widespread use of ART in pregnancy which in turn results in new questions such as how to deliver when the mother, on therapy, has no detectable plasma viraemia with the most sensitive assays. In addressing many common and/or difficult clinical scenarios in the absence of ‘best evidence’ the guidelines rely heavily on ‘expert opinion’.

Safety of nevirapine in pregnancy

Nevirapine has been widely used in pregnancy for its efficacy, low pill burden, bioavailability and rapid transplacental transfer. Concern about nevirapine toxicity during pregnancy has emerged over recent years.

New mutations associated with resistance not detected following zidovudine monotherapy in pregnancy when used in accordance with British HIV Association guidelines

To determine whether mutations conferring drug resistance are detectable after zidovudine monotherapy (ZDVm) in pregnancy, using both standard genotyping and more sensitive cloning assays.

Pregnancy in HIV-infected teenagers in London.

The aim of the study was to describe pregnancies in HIV‐infected teenagers.

Immunosuppression among HIV‐1‐positive patients attending for care: experience from two large HIV centres in the United Kingdom

The aim of the study was to describe the prevalence of and examine the factors associated with immunosuppression (CD4<200 cells/μL) among HIV‐infected patients attending two large inner London treatment centres.