How can we keep reducing vertical transmissions of HIV in the UK?
At our annual conference, we were lucky enough to have Dr Hermione Lyall from the Imperial College Healthcare NHS Trust talk through where we are on the vertical transmission of HIV in the UK.
The data on the vertical transmission of HIV tells an extremely positive story over the last 25 years. One that “brings tears to my eyes,” says Hermione Lyall, as she looked over a graph showing ever falling numbers of these transmissions whilst speaking at Chiva’s annual conference.
So where are we now?
- The rate of vertical transmission was at 0.25% in 2018-19, and has been below 0.4% since 2012. That’s compared to 2.86% in 2000-2001.
- 89.6% of women were on ART at the conception of their child in 2018-19 compared with 77.8% in 2014-15.
- 99.8% of pregnant women take up their antenatal screening for HIV and other infections.
- And now, 90% of those who do have HIV already knew they did before their pregnancy, a very different picture to what we saw in the early 2000s.
This drop in transmissions and other improvements are the result of over two decades of amazing effort by practitioners and partners trying to make pregnancy more normal for women living with HIV. But how can we keep improving, and bring transmission down even further?
Who are the 0.25%?
Adverse social circumstances are a significant issue in most (but not all) cases of the vertical transmissions that do still occur. These circumstances could include: mental health issues, housing concerns, the involvement of social services, immigration problems or intimate partner violence, for example. These adverse factors make life more complicated and it can be harder for people to take their treatment and attend appointments.
There are two contributing factors:
- The mother has booked late, so they haven’t been able to get treatment
- There have been difficulties in engagement with healthcare
As healthcare providers we have to do everything we can to help engage those women.
It’s important we review every case of vertical HIV transmission which occurs in the UK. These are investigated as “serious incidents” by the Clinical Expert Review Panel and entered into the national ongoing audit, so we can learn what we can look at and change.
Getting to undetectable = untransmittable
Vertical transmissions do also still happen among women and birthing parents who are completely undetectable, and this is why we can’t definitively say U=U is totally true for breastfeeding and pregnancy in the UK. Two of the recent cases of vertical transmission had no contributing factors.
But a study in France of 5,500 women has shown that where they were virally suppressed at delivery, not breastfeeding and undetectable throughout, there were no transmissions. These are very exciting results but unfortunately, we have not reached this point yet in the UK.
How can we improve care for women?
Hermione highlighted some themes for how to improve our care for women, and therefore bring vertical transmissions down further, include:
- Better sexual health education on STIs, pregnancy and HIV seroconversion. Women and their partners need to know how to access sexual healthcare during pregnancy. It’s worth remembering that pregnant women still have sex, and therefore their situation may change.
- Fast turnaround on screenings. If an unscreened woman turns up in labour, we should be able to do a test and get an HIV result within an hour or two, giving treatment to the newborn baby and avoiding breastfeeding until we can get the result.
- A well-functioning multi-disciplinary team, with regular team meetings and regional meetings which help support clinical teams with complex patients, ensuring continuity of care for women. This should include ongoing education and shared learning for all members of the team.
“It’s amazing how many strides have been made over the last 25 years. But we can still do better,” she said. “And that’s all about working together. It’s that partnership between women and all of the multidisciplinary team. It’s about being fully aware of the adverse circumstances women are living through.”