Caring for the HIVInfected Pregnant Woman

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Caring for the HIV-Infected Pregnant Woman

• 2nd AETC Consultants Skills-Building Workshop
• August 9, 2002

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Panel Members

• Deb Cohan, M.D.
• Margaret Jeter, M.S.W.
• Kirsten Balano, PharmD
• Amy Kindrick, MD, MPH

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Objectives

• Describe a multidisciplinary collaborative
  consultation model
• Share experiences in consultation across
  disciplines
• Discuss strategies for optimizing the
  consultative care of patients with complex
  problems

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The AETC Consultation
Patient
Pt 2
Primary Provider
Consultant
Pt 4
Pt 3
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Consulting for Multidisciplinary Teams Special
Challenges

• HIV experience among team members may vary
• Priorities of individual team members may vary
• Team may be lacking key skills
• Communication between team members may not be
  optimal

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Goals of Treatment

• Optimize maternal health
• Optimize fetal/neonatal health
• Minimize perinatal transmission risk
• Minimize treatment toxicity

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The Multidisciplinary Care Team

• Primary care provider
• Primary OB
• Social worker
• Clinical pharmacist
• HIV specialist
• Perinatologist
• Labor and Delivery staff
• Neonatologist/pediatrician

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Cases

• Woman with 18 week IUP and newly-diagnosed HIV
  infection
• HIV woman with 32 week IUP, malignant HTN, and
  recent cocaine use

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Case 1

• 21 y/o woman presents to PCP with amenorrhea
  HCG
• 14 weeks by dates
• Prenatal labs drawn
• HIV counseling provided and testing offered
• HIV EIA reactive

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What Resources Does the PCP Need?

• Confirmation of diagnosis
• Help delivering the news
• Basic HIV information, including perinatal risks
  and treatment options
• OB consultant (if not FP)
• HIV consultant
• Social services support
• Psychiatric consultant

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The Consultation Web
PCP
Pharmacist Subspecialists
Local OB
HIVSpecialist
Perinatologist
Social Worker
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PCP Consults HIV Specialist

• Western blot interpretation confirms infection
• Basic HIV information reviewed
• Approaches to delivering the news discussed
• Psychosocial referral recommended

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PCP Consults Local OB

• PCP refers woman to local OB
• Sono confirms twin IUP
• Prenatal care initiated

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What Resources Does the Local OB Need?

• Basic HIV information
• HIV consultant
• High-risk perinatologist
• Neonatologist/pediatrician
• Psychosocial support services

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Local OB Consults HIV Specialist

• Basic HIV information reviewed
• HIV-specific ante-natal care needs discussed

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Local OB Consults Perinatologist

• OB refers woman to high-risk perinatologist
• Metabolic status assessed
• Amniocentesis considered
• Risks and benefits of vaginal vs. cesarean
  delivery for twin IUP discussed

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What Resources Does Perinatologist Need?

• HIV consultant
• HAART regimen selection
• Resistance testing
• OI prophylaxis assessment
• HIV-experienced perinatologist
• Obstetrical management
• HIV-experienced neonatologist
• Infant care

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OB/Perinatologist Consults HIV Specialist

• HIV assessment suggests advanced maternal
  immunosuppression
• Risks and benefits of specific HAART regimens
  discussed and options offered
• Adherence challenges described
• Resistance testing considered
• DDx of common OI signs/sxs reviewed
• Vaginal vs. cesarean delivery for transmission
  prevention discussed

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What Resources Does the HIV Specialist Need?

• Resistance testing panel
• HIV-experienced pharmacist with pharmaco-kinetic
  and dynamic expertise
• HIV-experienced perinatologist and neonatologist
• HIV-experienced medical and surgical
  subspecialists

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Case 1 Initial Assessment

• Medical assessment
• CD4 20 cells/mm3
• VL gt500,000 copies/ml
• ROS occasional nausea and breathlessness
• Psychosocial assessment
• Lives with mother and extended family
• Anxious and depressed
• Fearful of disclosure
• Wants to carry pregnancy

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Case 1 Medical Interventions

• HAART recommended
• Provide medication adherence counseling/support
• Begin CBV/NLF
• Develop contingency plan for symptom management
• Nausea and breathlessness evaluated
• PCP and MAC prophylaxis initiated
• Prenatal care continued

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Case 1 Psychosocial Interventions

• Suicide and domestic violence risk assessed
• Counseling and case management referrals made
• Family and peer support network identified
• Housing and insurance needs assessed

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Case 1 Medical Course

• VL after 4 weeks on HAART 80,000 copies/ml
• Adherence reviewed
• Genotype resistance test obtained
• HAART regimen adjusted
• VL after 8 weeks lt50 copies/ml

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Case 1 Obstetrical Course

• Breach presentation at 36 weeks
• Elective c-section at 38 weeks planned
• ROM and spontaneous labor onset at 37 weeks
• Emergency c-section performed

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Case 1 Peripartum Issues

• Advance planning is critical
• ARV management
• Medication availability
• Route of administration
• PK, PD and interaction considerations
• Intrapartum and neonatal orders in advance
• Delivery
• Infection control
• Neonatal management plan

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Expanded Role For AETC Consultant

• Provide clinical information to individual team
  members
• Identify gaps in care team
• Facilitate communication between team members

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Case 2

• HIV woman with IUP, followed at BAPAC
• CBV/NLF during previous pregnancy
• CBV/NLF restarted at 12 weeks of current
  pregnancy
• Intermittant cocaine use
• Erratic adherence
• History of hypertension

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Case 2 Acute Presentation

• Brought by social worker to clinic after several
  missed visits
• 32 weeks gestation
• Blood pressure 230/110
• No HAART for several days
• Admitted from clinic

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Case 2 Hospital Course

• BP medically controlled
• No other pregnancy-related complications
  identified
• ARVs resumed
• Elopement risk recognized

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Who Is On The Team?
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Case 2 Team Members

• Perinatologist
• HIV-experienced CNM
• L D staff
• Social worker
• Neonatologist

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Case 2 Management Issues

• HAART regimen
• Continue vs change
• Antihypertensive regimen
• Drug-drug interactions
• Obstetrical strategy
• Induce vs wait
• Vaginal vs cesarean
• Psychosocial strategy
• Elopement risk
• Drug dependency

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Strategies For Multidisciplinary Team
Consultation

• Identify team members and assess individual
  consultation needs
• Provide clinical consultation for individual team
  members
• Consider gaps in team capacity and propose
  solutions to fill gaps
• Facilitate communication between team members

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Collaborative Consultation Model
HIV Consultant
Primary OB
PCP
HIV Perinatologist
Sub-spec Consultants
Pediatrician
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National HIV/AIDS Clinicians Consultation Center

• University of California San Francisco
• San Francisco General Hospital
• Supported by
• Health Resources and Services Administration
  (HRSA)
• AIDS Education and Training Centers (AETCs)
• and
• Centers for Disease Control and Prevention (CDC)
• http//www.ucsf.edu/hivcntr

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National Clinicians Post-Exposure Prophylaxis
Hotline (PEPline)

• For questions about occupational exposures to HIV
  and other blood-borne pathogens

• (888) HIV - 4911
• (888) 448 - 4911
• 24 hours/day
• 7 days/week

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National HIV Telephone Consultation Service
(Warmline)

• For questions about HIV/AIDS clinical care

(800) 933 - 3413 Monday through Friday 9 am to 8
pm EST