Misleading headlines muddy the water

The headline ‘Giving birth in water’ referring to the randomised controlled trial by Cluett et al(1) of water immersion versus augmentation for dystocia in labour, fuels the confusion about labour and delivery in water. This and other studies provide good evidence for the benefits of immersion in water during labour(2). But contrary to the BMJ headline, this study is not about the risks or benefits of delivery in water. Cluett et al reported a mean delay of 6 hours (range 2-10) between women leaving the pool and birth. We conducted a national surveillance study of deliveries in water and the results were compatible with there being a small overall increase or decrease in perinatal mortality among babies delivered in water(3). We concluded that perinatal mortality was not substantially higher among these infants than among those delivered conventionally. However, we, like others (4) did raise the possibility of specific harms, particularly for water aspiration and blood loss due to snapped umbilical cord. How should clinicians advise women wishing to deliver in water? The trial that needs to be done is to randomise women who labour in water, to pulling the plug (or getting out of the bath), versus remaining immersed for the second stage of labour. This may be difficult since women are likely to have strong preferences one way or the other

Pregnancies in older women living with HIV in the UK and Ireland.

OBJECTIVES: The aim of the study was to compare maternal characteristics and pregnancy outcomes in women aged < 40 years and ≥ 40 years in a large unselected population of HIV-positive women delivering in the UK and Ireland between 2000 and 2014. METHODS: Comprehensive population-based surveillance data on all HIV-positive pregnant women and their children seen for care in the UK and Ireland are collected through the National Study of HIV in Pregnancy and Childhood. All singleton and multiple pregnancies reported by the end of June 2015 resulting in live birth or stillbirth to women diagnosed with HIV infection before delivery and delivering in 2000-2014 were included. Logistic regression models were fitted in analyses examining the association between older maternal age and specific outcomes (preterm delivery and stillbirth). RESULTS: Among 15 501 pregnancies in HIV-positive women, the proportion in older women (≥ 40 years) increased from 2.1% (73 of 3419) in 2000-2004 to 8.9% (510 of 5748) in 2010-2014 (P < 0.001). Compared with pregnancies in younger women, those in older women were more likely to result in multiple birth (3.0 vs. 1.9% in younger women; P = 0.03), stillbirth (adjusted odds ratio 2.39; P = 0.004) or an infant with a chromosomal abnormality (1.6 vs. 0.2%, respectively; P < 0.001). However, there was no increased risk of preterm delivery, low birth weight or mother-to-child HIV transmission among older mothers. CONCLUSIONS: There has been a significant increase over time in the proportion of deliveries to women living with HIV aged ≥ 40 years, which has implications for pregnancy management, given their increased risk of multiple births, stillbirth and chromosomal anomalies, as also apparent in the general population

"It pains me because as a woman you have to breastfeed your baby": decision-making about infant feeding among African women living with HIV in the UK

OBJECTIVES: UK guidance advises HIV-positive women to abstain from breast feeding. Although this eliminates the risk of postnatal vertical transmission of HIV, the impact of replacement feeding on mothers is often overlooked. This qualitative study examines, for the first time in the UK, decision-making about infant feeding among African women living with HIV. METHODS: Between 2010 and 2011, we conducted semistructured interviews with 23 HIV-positive African women who were pregnant or had recently given birth. We recruited participants from three HIV antenatal clinics in London. RESULTS: Women highlighted the cultural importance of breast feeding in African communities and the social pressure to breast feed, also describing fears that replacement feeding would signify their HIV status. Participants had significant concerns about physical and psychological effects of replacement feeding on their child and felt their identity as good mothers was compromised by not breast feeding. However, almost all chose to refrain from breast feeding, driven by the desire to minimise vertical transmission risk. Participants' resilience was strengthened by financial assistance with replacement feeding, examples of healthy formula-fed children and support from partners, family, peers and professionals. CONCLUSIONS: The decision to avoid breast feeding came at considerable emotional cost to participants. Professionals should be aware of the difficulties encountered by HIV-positive women in refraining from breast feeding, especially those from migrant African communities where breast feeding is culturally normative. Appropriate financial and emotional support increases women's capacity to adhere to their infant-feeding decisions and may reduce the emotional impact

Rubella infection in pregnancy and congenital rubella in United Kingdom, 2003 to 2016

Although rubella is usually a mild, sometimes asymptomatic illness in childhood, the consequences of rubella infection in pregnancy can be devastating. In 2010, the Pan American Health Organisation announced that the Region of the Americas had eliminated rubella and congenital rubella syndrome (CRS) [1,2]. In the same year all 53 Member States of the World Health Organization (WHO) European Region committed to the goal of eliminating endemic transmission of measles and rubella, initially by 2015 and later revised to 2020. For the elimination of rubella and congenital rubella, high coverage of a two-dose childhood vaccination programme of a rubella-containing vaccine must be sustained [3]. Rubella can be easily mistaken for a number of other viral infections, and in order to monitor progress towards elimination it is essential that countries across Europe have robust surveillance systems in place to identify all suspected cases and reliably confirm or exclude rubella and congenital rubella infection (CRI) using appropriate laboratory methods [4]. Surveillance systems and laboratory confirmation of rubella and congenital rubella cases vary across Europe. Despite the elimination goals set for the WHO European Region, three of 28 European Union (EU) countries do not have national surveillance systems for all rubella cases [5,6]. In 2016, only 5% of all cases reported to the European Centre for Disease Prevention and Control (ECDC) were laboratory-confirmed. The United Kingdom (UK) vaccination strategy and programme surveillance is very similar to other western European countries and is based on laboratory-confirmed cases. It is, however, the only country to perform routine IgM confirmatory testing of oral fluid of notified cases (since 1994), which has strengthened surveillance and improved ascertainment [7-9]. The consequences of rubella infection in the first 20 weeks of pregnancy, and the relationship between gestational week of exposure and likelihood of fetal loss or features of congenital rubella syndrome, have been well documented [10,11]. With the introduction of effective vaccination strategies in the UK, the incidence of rubella has decreased dramatically and the last large outbreak of rubella occurred in 1995–96. Most clinicians who have qualified in this country in the past 20 years will never have seen a case of rubella, rubella infection in pregnancy or congenital rubella. Before routine vaccination was introduced, rubella was a common childhood disease in the UK with 80% of adults having evidence of prior infection [12]. Rubella vaccination was introduced for susceptible women and girls aged 11–14 years in 1970 with the aim of allowing most girls to acquire natural immunity in earlier childhood [13,14]. Non-immune women of child-bearing age were also targeted following the introduction of antenatal screening for rubella susceptibility based on rubella IgG testing throughout the UK in the early 1970s. The main programme aim was to ensure women of childbearing age were immune to rubella and thus prevent primary infection in pregnancy. This strategy successfully increased the proportion of women with antibodies to rubella from 85–90% in 1970 to 97–98% in 1987 [15]. Surveillance of CRS and CRI infections was established in the UK in 1971 to monitor the effectiveness of the vaccination programme [16]. While programmes to directly protect women of childbearing age against rubella successfully reduced cases of congenital rubella and terminations following rubella infection in pregnancy [16,17], the disease continued to circulate among young children, who were a potential source of infection to any women who remained susceptible. In 1988, a combined measles-mumps-rubella (MMR) vaccination was introduced into the routine childhood schedule at 12–15 months of age. The rubella component of MMR vaccine is highly effective and a single dose of a rubella-containing vaccine confers around 95–100% protection; the measles and mumps components require two doses to reach high levels of effectiveness [10,18]. A successful mass school-based measles-rubella immunisation campaign targeting all children aged 5–16 years was conducted in 1994 to prevent a predicted measles epidemic and to address continuing high levels of rubella susceptibility in school-aged children, particularly among boys [15]. To ensure continued high population protection, a routine second dose of MMR for 3–4-year-olds was introduced from 1996, when selective immunisation of schoolgirls ended. Uptake of the two-dose schedule by fifth birthday in the UK reached 75% by June 2005 [19] and was 88.5% in October to December 2016 [20]. MMR first-dose coverage by fifth birthday reached the 95% WHO elimination target for the first time in 2016. Determination of rubella susceptibility is not straightforward. The widespread use of an ELISA cut-off value of 10IU/ml, generally accepted as evidence of immunity, is based on levels following vaccination [21]. Vaccine-induced rubella antibody levels, while protective, appear to be lower at a population level than those resulting from naturally acquired infection. With an increasing proportion of UK-born women acquiring immunity through vaccination rather than natural infection and the absence of circulating rubella in the UK, reported antenatal susceptibility rates have increased in recent years based on this cut-off value [9]. In 2013, 27% of all births in England were to women born outside the UK, with geographical variation peaking in London at 58% [22]. Many of these women are likely to have come from rubella-endemic countries, with no or disrupted routine immunisation against rubella. A higher proportion of non-UK-born mothers, particularly those from sub-Saharan Africa and south-east Asia were more likely to be seronegative than UK-born women or white British women [23], [24] and analysis of antenatal rubella susceptibility data from London suggested that between 16% and 65% of non-UK-born women were susceptible in 2007 [25]. This paper summarises cases of laboratory-confirmed rubella infection in pregnancy (IIP), CRI and CRS reported to Public Health England (PHE) and other national surveillance programmes in the UK between 2003 and 2016

Clinical Status of Adolescents with Perinatal HIV at Transfer to Adult Care in the UK/Ireland

BACKGROUND: Increasing numbers of children infected perinatally with human immunodeficiency virus (HIV) are surviving to adolescence and transitioning to adult care, yet there are scarce data on their clinical status at transfer. METHODS: We analyzed prospective cohort data from the UK/Ireland national Collaborative HIV Pediatric Study (CHIPS). Clinical status at last pediatric clinic visit prior to transfer was described. Factors associated with higher CD4 cell count and viral load (VL) suppression<400 c/mL among patients on antiretroviral therapy (ART) at transfer were assessed using linear and logistic regression, respectively. Data were matched with the UK HIV Drug Resistance Database (UKHIVDRB) to assess cumulative resistance profiles at transfer. RESULTS: Of 1,907 children followed in CHIPS from 1996 to November 2014, 644 (34%) transferred to adult care: 53% were female, 62% born outside the UK/Ireland, 75% black African. At last pediatric follow-up, median age was 17.4 years [interquartile range 16.5,18.1], 27% had previous AIDS diagnosis, CD4 was 444 cells/mm3 [280, 643], 76% were on ART, 13% off-ART, and 11% ART-naive. Among patients on ART, 74% had VL<400 c/mL. In multivariable analysis, higher CD4 at transfer was associated with younger age, higher CD4 at ART initiation and lower VL at transfer (P ≤ .001). Predictors of viral suppression include no AIDS diagnosis and later year of transfer (P ≤ .05). Of 291 patients with resistance data, 82% had resistance to ≥1 drug class, 56% to ≥2 classes and 12% had triple-class resistance. CONCLUSION: Three-quarters of adolescents were on stable ART at transfer, of whom 74% were virologically suppressed. The prevalence of triple-class resistance was relatively low at 12%

CD4 cell count and the risk of AIDS or death in HIV-Infected adults on combination antiretroviral therapy with a suppressed viral load: a longitudinal cohort study from COHERE.

BACKGROUND: Most adults infected with HIV achieve viral suppression within a year of starting combination antiretroviral therapy (cART). It is important to understand the risk of AIDS events or death for patients with a suppressed viral load. METHODS AND FINDINGS: Using data from the Collaboration of Observational HIV Epidemiological Research Europe (2010 merger), we assessed the risk of a new AIDS-defining event or death in successfully treated patients. We accumulated episodes of viral suppression for each patient while on cART, each episode beginning with the second of two consecutive plasma viral load measurements 500 copies/µl, the first of two consecutive measurements between 50-500 copies/µl, cART interruption or administrative censoring. We used stratified multivariate Cox models to estimate the association between time updated CD4 cell count and a new AIDS event or death or death alone. 75,336 patients contributed 104,265 suppression episodes and were suppressed while on cART for a median 2.7 years. The mortality rate was 4.8 per 1,000 years of viral suppression. A higher CD4 cell count was always associated with a reduced risk of a new AIDS event or death; with a hazard ratio per 100 cells/µl (95% CI) of: 0.35 (0.30-0.40) for counts <200 cells/µl, 0.81 (0.71-0.92) for counts 200 to <350 cells/µl, 0.74 (0.66-0.83) for counts 350 to <500 cells/µl, and 0.96 (0.92-0.99) for counts ≥500 cells/µl. A higher CD4 cell count became even more beneficial over time for patients with CD4 cell counts <200 cells/µl. CONCLUSIONS: Despite the low mortality rate, the risk of a new AIDS event or death follows a CD4 cell count gradient in patients with viral suppression. A higher CD4 cell count was associated with the greatest benefit for patients with a CD4 cell count <200 cells/µl but still some slight benefit for those with a CD4 cell count ≥500 cells/µl

Young people in the United Kingdom and Ireland with perinatally acquired HIV: The pediatric legacy for adult services

Children with perinatally acquired HIV-1 infection are surviving into adolescence and increasingly transitioning toward adult services. Planning appropriate services in adult life requires an understanding of their progress through pediatric care. We describe the demographic features, disease progression, antiretroviral therapy (ART), and resistance in young people aged 10 years or more living in the United Kingdom and Ireland reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) with prospective annual follow-up in the Collaborative HIV Paediatric Study (CHIPS) between 1996 and September 2007. Six hundred fifty-four perinatally infected young people were identified; 76% black African, 57% born abroad. Median age at presentation and duration of follow-up was 1 and 11 years, respectively, if born in the United Kingdom/Ireland, and 8 and 5 years if born elsewhere. One hundred sixty-nine (26%) ever had an AIDS-defining illness. Ten died during adolescence. At last follow-up, 64% were on ART, 18% off treatment having previously received ART and 18% were ART naive. Of 518 who had received highly active antiretroviral therapy (HAART), 47% were triple class experienced. At last follow-up 77 (12%) had CD4 counts less than 200 per microliter; of those on HAART, 78% had HIV-1 RNA <= 400 copies per milliliter, median CD4 count 554 (interquartile range [IQR] 324-802). Among 166 with resistance assays on HAART, 52% and 12% had dual- and triple-class HIV-1-associated resistance mutations, respectively. One hundred three (16%) young people had transferred to adult services. Young adults with perinatally acquired HIV-1 infection require coordinated multidisciplinary transitional care services and careful long-term follow-up in adult life