MTCT rates in the UK and Ireland have continued to decline since 2006, reaching an all-time low of 5 per 1000 in 2010-2011. This was primarily because of a reduction in transmissions associated with late initiation or nonreceipt of antenatal cART, and an increase in the proportion of women on cART at conception.

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Objectives:To estimate the incidence of first pregnancy in women living with perinatally acquired HIV (PHIV) in the United Kingdom and to compare pregnancy management and outcomes with age-matched women with behaviourally acquired HIV (BHIV).Design:The National Study of HIV in Pregnancy and Childhood is a comprehensive, population-based surveillance study that collects demographic and clinical data on all pregnant women living with HIV, their children, and all HIV-infected children in the United Kingdom and Ireland.Methods:The incident rate ratio of first pregnancy was calculated for all women of reproductive age who had been reported to the National Study of HIV in Pregnancy and Childhood as vertically infected children. These women and their pregnancies were compared to age-matched pregnant women with BHIV.Results:Of the 630 women with PHIV reported in the United Kingdom as children, 7% (45) went on to have at least one pregnancy, with 70 pregnancies reported. The incident rate ratio of first pregnancy was 13/1000 woman-years. The BHIV comparison group comprised 118 women (184 pregnancies). Women with PHIV were more likely to be on combined antiretroviral therapy at conception and have a lower baseline CD4+ cell count (P < 0.01 for both). In adjusted analysis, PHIV and a low baseline CD4+ cell count were risk factors for detectable viral load near delivery; older age at conception and being on combined antiretroviral therapy at conception reduced this risk.Conclusion:Women with PHIV in the United Kingdom have a low pregnancy incidence, but those who become pregnant are at risk of detectable viral load near delivery, reflecting their often complex clinical history, adherence, and drug resistance issues.

Invasive disease due to Acinetobacter baumannii is an increasing problem in health care settings worldwide. Whether certain clones of A. baumannii are more likely to cause invasive disease in hospitalized patients is unknown. We studied all patients at a public teaching hospital in Houston, Texas, from whom the Acinetobacter calcoaceticus-Acinetobacter baumannii complex was isolated over a 14-month period in 2005 to 2006. One hundred seven unique patient isolates were identified, with 87 of the strains classified as being A. baumannii, the majority of which were multidrug resistant. The A. baumannii isolates were comprised of 18 unique pulsed-field types, with strains of clone A and clone B accounting for 66 of the 87 isolates. Epidemiologic analysis showed the predominance of the two A. baumannii clones at distinct time periods, with the remainder of the A. baumannii and non-A. baumannii strains being evenly distributed. Patients from whom clone A strains were isolated were more likely to be bacteremic than were patients with other A. baumannii isolates. Conversely, clone B strains were more likely to be isolated from patients with tertiary peritonitis. Patients from whom clone A was isolated had a significantly higher rate of mortality. Multilocus sequence typing demonstrated that clones A and B are related to each other and to A. baumannii strains previously isolated in Western Europe, sharing five of seven alleles. Taken together, we conclude that the outbreak of the A. calcoaceticus-A. baumannii complex in our institution was due to two distinct A. baumannii clones that were associated with significantly different patient outcomes.

The SARS-CoV-2 (COVID-19) pandemic has had a global influence on health care. The authors examined the early effect of hospital- and state-mandated restrictions on an orthopedic surgery department and hypothesized that the volume of ambulatory clinic encounters, office and surgical procedures, and cases would dramatically decrease. A retrospective review was performed of all encounters in an orthopedic surgery department at a level I academic trauma center during a 4-week period, from March 16, 2020, to April 12, 2020. The results were compared with two control 4-week periods, February 17, 2020, to March 15, 2020, and March 16, 2019, to April 12, 2019. Weekly volume and work relative value units (RVUs) of clinic encounters, office and surgical procedures, and cases were assessed. The type of ambulatory visit also was recorded. Comparisons of mean weekly volume and RVUs between the study and control periods were performed with Student's t test. Surgical cases were categorized into fracture or dislocation, acute soft tissue or nerve injury, infection, oncology, and elective or nonurgent. After implementation of hospital- and state-mandated restrictions on elective health care, the volume of ambulatory orthopedic surgery clinic encounters decreased by 74% to 77%, the volume of clinic procedures decreased by 95%, and the volume of surgical cases decreased by 88%. The percentage of clinic visits performed via telemedicine increased from 0.3% to 81.2%. Elective surgical cases ceased, and the volume of nonelective surgical cases decreased by 51%. During the first 4 weeks after COVID-19–related restrictions were imposed, an immediate and dramatic effect was observed. Compared with the control periods, significant reductions were seen in the volume of ambulatory encounters, office-based procedures, and surgical cases. In addition, the volume of nonelective surgical cases decreased by 51%. [ Orthopedics . 2020;43(4):228–232.]

ObjectivesDespite very low rates of vertical transmission of HIV in the UK overall, rates are higher among women starting antenatal antiretroviral therapy (ART) late. We investigated the timing of key elements of the care of HIV‐positive pregnant women [antenatal care booking, HIV laboratory assessment (CD4 count and HIV viral load) and antenatal ART initiation], to assess whether clinical practice is changing in line with recommendations, and to investigate factors associated with delayed care.MethodsWe used the UK's National Study of HIV in Pregnancy and Childhood for 2009−2014. Data were analysed by fitting logistic regression and Cox proportional hazards models.ResultsA total of 5693 births were reported; 79.5% were in women diagnosed with HIV prior to that pregnancy. Median gestation at antenatal booking was 12.1 weeks [interquartile range (IQR) 10.0–15.6 weeks] and booking was significantly earlier during 2012–2014 vs. 2009–2011 (P < 0.001), although only in previously diagnosed women. Overall, 42.2% of pregnancies were booked late (≥ 13 gestational weeks). Among women not already on treatment, antenatal ART commenced at a median of 21.4 (IQR18.1–24.5) weeks and started significantly earlier in the most recent time period (P < 0.001). Compared with previously diagnosed women, those newly diagnosed during the current pregnancy booked later for antenatal care and started antenatal ART later (both P < 0.001). Multivariable analyses revealed demographic variations in access to or uptake of care, with groups including migrants and parous women initiating care later.ConclusionsAlthough women are accessing antenatal and HIV care earlier in pregnancy, some continue to face barriers to timely initiation of antenatal care and ART.

ObjectivesThe aim of the study was to investigate circumstances surrounding perinatal transmissions of HIV (PHIVs) in the UK.MethodsThe National Study of HIV in Pregnancy and Childhood conducts comprehensive surveillance of all pregnancies in women diagnosed with HIV infection and their infants in the UK; reports of all HIV‐diagnosed children are also sought, regardless of country of birth. Children with PHIV born in 2006–2013 and reported by 2014 were included in an audit, with additional data collection via telephone interviews with clinicians involved in each case. Contributing factors for each transmission were identified, and cases described according to main likely contributing factor, by maternal diagnosis timing.ResultsA total of 108 PHIVs were identified. Of the 41 (38%) infants whose mothers were diagnosed before delivery, it is probable that most were infected in utero, around 20% intrapartum and 20% through breastfeeding. Timing of transmission was unknown for most children of undiagnosed mothers. For infants born to diagnosed women, the most common contributing factors for transmission were difficulties with engagement and/or antiretroviral therapy (ART) adherence in pregnancy (14 of 41) and late antenatal booking (nine of 41); for the 67 children with undiagnosed mothers, these were decline of HIV testing (28 of 67) and seroconversion (23 of 67). Adverse social circumstances around the time of pregnancy were reported for 53% of women, including uncertain immigration status, housing problems and intimate partner violence. Eight children died, all born to undiagnosed mothers.ConclusionsPriority areas requiring improvement include reducing incident infections, improving ART adherence and facilitating better engagement in care, with attention to addressing the health inequalities and adverse social situations faced by these women.