By Carolyn Chu, MD, MSc, Clinical Director of the Clinician Consultation Center

[Editor’s Note: In recognition of National Women and Girls HIV/AIDS Awareness Day, we present this case study of a pregnant woman with HIV, written up by Carolyn Chu, MD, MSc, Clinical Director of the Clinician Consultation Center (CCC). Funded by the Health Resources and Services Administration (HRSA) and based out of University of California, San Francisco’s Department of Family and Community Medicine, the CCC has been providing consultation and education resources to health care providers across the US for over 25 years. This post centers on CCC’s cost-free and confidential Perinatal HIV Hotline. Read a previous post about CCC’s PEPline, a warmline for clinicians to call for advice on occupational bloodborne pathogen exposure. Learn more and access CCC’s services at the bottom of this post.]

An obstetrician working with a local health department called the national Perinatal HIV Hotline about a 29-year-old female at 34 weeks gestation who was transferred to the hospital from a prenatal visit after reporting regular contractions over the last two days.  This was the woman’s third pregnancy, and she had undergone two prior C-sections.  She tested positive for HIV at 20 weeks and was rapidly started on co-formulated TDF/FTC (brand name Truvada®) and raltegravir (Isentress®) on the day of diagnosis per current recommendation.  Her past medical history also included mild asthma, opioid use disorder, and methamphetamine use disorder.  She had been taking buprenorphine for the past three months and her dose at the time was 8 mg, three times per day.  Her most recent HIV viral load was 1,200 copies/mL last month, up from 840 copies/mL the month prior.  The patient reported recent difficulties with ART adherence and had forgotten to take the evening raltegravir dose “a few times”.

The labor and delivery team was planning to admit the patient for at least an observation period including fetal non-stress testing and evaluation to exclude complications associated with preterm labor.  The patient had previously agreed to a scheduled repeat C-section since she’d had two prior ones.

The obstetrician had several questions and wanted to ensure all recommended interventions were implemented:

1. What is the ideal timing of delivery?
2. Does the patient need to receive intravenous (IV) zidovudine (ZDV, also AZT)?
3. What other interventions and monitoring would be indicated?

To find answers, the obstetrician called the national Perinatal HIV Hotline, which is available for clinicians 24 hours a day, seven days a week, and free of charge. The Perinatal HIV consultant clarified that the initial priority should be confirming whether the patient is in preterm labor and also recommended expedited testing for maternal HIV viral load and ART resistance testing (genotype) now.  If she is in labor, she should be evaluated and managed according to standard obstetric practices, regardless of her HIV status.  ART medications and related monitoring should be continued throughout her admission with special attention to potential drug interactions.

If she is not in preterm labor, although some hospital units might discharge women after excluding obstetric complications, the consultant advised that admission might be strongly considered here given increasing maternal viremia and ART adherence challenges.  Benefits of admission beyond short-term observation include ensuring medication administration through direct observation, ART modification as needed, frequent (i.e. weekly) viral load monitoring, and greater ability to facilitate additional laboratory testing, as indicated.  If the patient is not in labor and elects to go home, she should have close follow-up, with someone frequently checking in on medication adherence and viral load monitoring.  If the patient desired changing to a once-daily ART combination, the consultant advised that the team call back as soon as this was further explored with the patient, and that genotype results might affect decision-making around her next combination.

The latest DHHS Perinatal HIV Guidelines (updated Dec 7, 2018) recommend planned Cesarean section at 38 weeks to minimize perinatal HIV transmission for women whose HIV viral load is > 1000 copies/mL near time of delivery, irrespective of whether the woman has been on ART.  For this patient, as long as she does not experience additional complications, if her viral load goes back to ≤ 1000 copies/mL with continued effective ART, she could be delivered at 39 weeks as originally planned.  Intravenous AZT is recommended at delivery if VL is ˃ 1000 copies/mL, and may be considered between 50 and 999 copies/mL; it is not required for women on ART who have viral load ≤ 50 copies/mL during late pregnancy and near delivery and no concerns regarding adherence.

The Perinatal HIV consultant also reached out to the CCC’s Substance Use Warmline team to provide guidance on managing buprenorphine dosing and perioperative pain around delivery.  The substance use consultant advised continuing the current buprenorphine dosing through surgery, and that pain management could occur with an epidural, regional anesthesia, and/or opioids as needed.  Opioids can help address pain in patients who are already on buprenorphine, although the higher affinity opioids may be most effective.  The patient should be continued on buprenorphine postpartum, although her dose would likely need to be decreased at some point.  She should be monitored closely for signs of sedation in the weeks following delivery and doses should be decreased as indicated.

The CCC also reminded the caller to pass on the importance of screening for syphilis and viral hepatitis, given increased rates of congenital syphilis and hepatitis C during pregnancy.  Although current guidelines do not recommend treatment during pregnancy/breastfeeding (data from a phase 1 study on ledipasvir/sofosbuvir will be shared at CROI 2019), timely screening and diagnosis of these conditions are important, and linkage to an experienced provider can help facilitate appropriate pre-treatment evaluation and counseling after delivery.  Infants born to mothers with hepatitis C during pregnancy should also be tested per current guidelines.  Finally, the Perinatal HIV consultant encouraged the caller to pass on the Hotline’s number to the hospital pediatric team to begin early planning for infant ART management and testing after delivery.

To reach a CCC Perinatal HIV Hotline consultant, call 888-448-8765 (the Hotline is available 24 hrs/day, 7 days/week).  To reach a CCC Substance Use consultant, call the Substance Use Warmline at 855-300-3595 Mondays-Fridays, 9am-8pm ET (voicemail is available after hours and on weekends; case inquiries can also be submitted online at http://nccc.ucsf.edu/clinician-consultation/substance-use-management/).  For additional information on the CCC, please visit nccc.ucsf.edu.  All consultations are cost-free and confidential, and no patient identifiers are collected.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1OHA30039-03-01 (AIDS Education and Training Centers National Clinician Consultation Center) awarded to the University of California, San Francisco.