Elimination of parent to child transmission of HIV, Syphilis and HBV

 

Prepared by Dr Tammy Meyers, Dr Nicholas Medland (RAG Chair) and members of the RAG’s Clinical Care – HIV, Viral Hepatitis and SRH Sub-Groups 

UPDATED ON: 29 June 2020

 

 

Disclaimer: The recommendations provided are the opinions of the authors and are not intended to provide a standard of care, or practice. This document does not reflect a systematic review of the evidence but will be revised to include relevant future systematic review findings. The recommendations are not intended to replace national guidance. 

 

This document does not cover management of COVID in pregnancy or neonates. Links to relevant guidance are provided at the end.

 

Efforts must be made to ensure that pregnant women and their newborn infants receive uninterrupted services, with the aim of improving maternal and infant outcomes. Antenatal and perinatal care includes diagnosis and treatment of maternal transmissible diseases such as HIV, syphilis and hepatitis B infections. The Regional framework for the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis in Asia and the Pacific, 2018–2030, sets out steps for countries to reach targets for improved maternal health and elimination of these diseases in children.[1]

 

The following important services should continue to be offered
(modification of service delivery models to reduce COVID-19 exposure and relieve health system burden may include telehealth, digital platforms, mobile phones or social media)
 

 

  • Delivery of age appropriate comprehensive sexuality education (CSE) or family life education (FLE), including about HIV/STIs and their prevention, sexuality and sexual health, sexual and gender-based violence, reproduction and reproductive health, and pregnancy prevention, management and care.
  • Provide linkages to adolescent sexual and reproductive health services including peer support groups
  • Ensure ongoing access to menstrual products for girls and women
  • Ensure ongoing access to Post-exposure prophylaxis (PEP) in combination with counselling and other post violence care services in case of sexual violence/rape.

 

  • Ensure women of reproductive age have access to a variety of modern contraceptive methods, including long-acting, reversible contraceptive (LARC) methods and also condoms and lubricant.
  • Ensure women are versed in correct and consistent use.
  • Women and girls should also have ongoing access to emergency contraception as needed
  • Ensure women diagnosed as living with HIV and sexually transmitted infections (STIs) have adequate contraceptive guidance and access to prevent unintended pregnancies.
     
  • Mental health issues must be considered for girls and women who are susceptible, especially during pregnancy and in relation to HIV/Syphilis/Hepatitis B or other STI’s. This may be more pronounced or difficult to detect during the COVID-19 pandemic. All members of the clinical team, community services, patients and carers should be alert to mental health issues and know how to respond to them.

Antenatal visits must continue but the nature of contact may change significantly to reduce COVID-19 risk and manage service demand. 
 

HIV, syphilis and HBsAg testing should occur at first antenatal contact - All pregnant women should be tested for HIV, syphilis and HBsAg at least once and as early as possible.[2]

  • Consider HIV self-screening or use of HIV/syphilis dual test if available
  • Arrange confirmatory HIV testing for pregnant women with a reactive HIV test
  • Repeat HIV and syphilis testing in the 3rd trimester in previously negative high-risk women   
  • HBsAg testing in pregnancy is now recommended for all pregnant women.[2]
  • Testing for other STIs if available
  • Prioritise discussion about partner testing
     

HIV: 

  • Link to care and treatment and rapid initiation of ART.[3] 
  • Ensure continuous ART supply for pregnant women living with HIV to maintain maternal health and for PMTCT
  • Dispense multiple (3-6) months supply of medication and condoms, including postnatal supply
  • Consider dispensing infant supply if mother unable to travel
  • Ensure hospital pharmacies review and maintain adequate buffer stock
  • Avoid patient travel to receive ART (deliver ART or prescription or dispense locally)  
  • Liaise with pharmacies when patients are attending

Syphilis: 

  • Treat pregnant syphilis positive women without delay with benzathine penicillin (see syphilis guidelines for options if penicillin allergic or stock-out).[4]  
  • Treat infants born to mothers who were inadequately treated/not treated.
  • Conduct further testing of pregnant woman following national guidelines and manage accordingly

Hepatitis B: 

  • HBV vaccination – all infants should receive first dose during the first 24 hours after birth followed by 2-3 doses, no less than 4 weeks apart following national immunization protocols.
  • Mother HBsAg positive – infant to receive HBIG if available as per local guidelines
  • Mother HBsAg positive - refer to clinical services if available for further evaluation including HBV DNA or HBeAg testing. If HBV DNA ≥ 5.3 log10 IU/ml or HBeAg positive, provide tenofovir prophylaxis from the 28 weeks of pregnancy until at least birth. Women who need treatment for their own disease should be managed as per WHO hepatitis B treatment guidelines.[5]    

Syndromic management of STIs as indicated
 

 

Mothers:

  • Provide treatment, follow-up care and appropriate and confidential partner notification services for women diagnosed with HIV, syphilis or another STI

 

Infants

  • Early infant diagnosis at 4-6 weeks and ART initiation, if positive, should not be delayed
  • ART prophylaxis for 6-12 weeks (12 weeks for high risk breast fed infants)
  • Final HIV antibody test (18 month or post-breastfeeding test) can be deferred if necessary
  • HBV exposed infants – post vaccination HBV serology 3-12 months after vaccination completed. 
  • Provide treatment for any laboratory diagnosed STIs or STI signs, e.g. including neonatal conjunctivitis or pneumonia.
  • Women with HIV or STI’s are expected to have similar COVID-19 outcomes and should get the same high level of care for COVID-19, including hospital admission, oxygen, intensive care, ventilator support 

Be aware of other signs and symptoms of STIs during pregnancy and newborn infant and manage accordingly, including miscarriage, ectopic pregnancy, preterm labour (under 37 weeks), low birthweight, birth defects and disabilities, stillbirth or neonatal death. If possible the cause should be investigated and documented with reporting to health authorities.
 

The World Health Organization
https://www.healthynewbornnetwork.org/hnn-content/uploads/Breastfeeding_COVID_WHO_FAQ_28Apr2020.pdf

UNFPA - COVID-19 Technical Brief for Antenatal Care Services 
https://www.aidsdatahub.org/sites/default/files/publication/UNFPA-Antenatal-Care-during-COVID19_2020.pdf

University of Birmingham, COVID-19 in Pregnancy (PregCOV-19LSR)
https://www.birmingham.ac.uk/research/who-collaborating-centre/pregcov/index.aspx

RANZCOG - Coronavirus Disease (COVID-19) in Pregnancy A guide for resource-limited environments http://www.ranzcog.edu.au/COVID-19-limited-resources

Elizabeth Glazer Paediatric AIDS Foundation - COVID-19 and its Impact on Pregnancy and Potential Mother-to-Child SARS-CoV-2 Viral Transmission. Evidence to Action Webinar April 15 2020 https://www.youtube.com/watch?time_continue=1181&v=NM1sMsmW0uQ&feature=emb_title

  1. Regional framework for the triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis in Asia and the Pacific, 2018–2030. Manila, Philippines, World Health Organization Regional Office for the Western Pacific. 2018. Licence: CC BY-NC-SA 3.0 IGO.
  2. Consolidated guidelines on HIV testing services for a changing epidemic 2019 https://www.who.int/publications-detail/consolidated-guidelines-on-hiv-testing-services-for-a-changing-epidemic
  3. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection - Recommendations for a public health approach - Second  ed
  4. WHO guidelines for the treatment of Treponema pallidum (syphilis). World Health Organization 2016 (https://www.who.int/reproductivehealth/publications/rtis/syphilis-treatment-guidelines/en/
  5. World Health Organization Global Hepatitis Programme Prevention of mother-to-child transmission of hepatitis B virus (HBV): Guidelines on antiviral prophylaxis in pregnancy  January 2020


 

SARS-CoV-2 has been detected in saliva (8), faeces (9, 10), and in semen in some (11), but not all (12, 13),  studies. A small study detected no SARS-CoV-2 in vaginal fluids (14), however angiotensin-converting enzyme2 (ACE 2), which is the receptor used by SARS-CoV-2 to enter host cells, is expressed in the vagina, uterus and ovaries (15). Currently there is no evidence that transmission of SARS-CoV-2 occurs via the faecal-oral route or via exposure to semen, or vaginal secretions. 

There are no data currently available on whether different types of sexual practices have different levels of risk for transmission of SARS-CoV-2.