Getting our priorities right: good practice guidance

Appendix 1: Children and Families at Risk of Blood-Borne Viruses

HIV and hepatitis B are blood-borne virus infections that are more prevalent in adults, children and families affected by problematic drug and alcohol use.

Children can be at risk of blood-borne viruses through:

• mother-to-child transmission (during pregnancy, childbirth and breastfeeding);
• 'household contact' with adults at risk or adults and children who are infected with blood-borne viruses; and
• accidental injury involving used injecting equipment e.g. a needle-stick injury.

Human immunodeficiency virus ( HIV): While a majority of early cases of HIV infection in Scotland were among injecting drug users this is no longer the case and new infections among injecting drug users are very uncommon. Nevertheless to maintain this success, all those with a history of injecting drug use should be provided with information about and the offer of testing for HIV infection together with measures to prevent infection (condoms, clean needles and syringes, substitute medication etc). There is a significant risk of mother-to-child transmission of HIV if the mother is not known to be HIV positive and/or does not receive appropriate treatment. However with appropriate specialist care the risk of transmission in the UK is less than 1%. Antenatal HIV testing is now routinely offered to all pregnant women in the UK. If offered together with appropriate information and support refusal is extremely uncommon and in Scotland the uptake is over 95%. Women who decline testing should receive a repeat offer later in pregnancy.

Hepatitis B ( HBV): Drug use in the UK increased dramatically in the mid-1980s and at that time there was also a dramatic increase in infections with HBV among injecting drug users. Introduction of harm reduction measures together with HBV vaccination programmes among drug users has reversed this trend and new HBV infections among drug users are now uncommon. There is a significant risk of mother-to-child transmission of HBV if the mother is not known to be HBV positive and/or mother and baby do not receive appropriate treatment. However, with immunisation of the baby at birth (and recently the offer of drug treatment for the pregnant woman) the rate of transmission in the UK is under 5%. Antenatal screening for HBV has been routinely offered in the UK for many years with current uptake of over 98%.

Hepatitis C ( HCV): HCV infection among injecting drug users in the UK is very common. However, in contrast with HIV and HBV infections the rate of vertical transmission is low (approximately 5%) and there are no interventions that can prevent this. There is therefore no need to modify maternity care if the woman is known to be HCV polymerase chain reaction positive and maternal HCV infection is not a contraindication to breast feeding. Consequently, there is no indication for routine antenatal screening.

In summary, adults with a history of injecting drug use attending primary care or addictions should be provided with information about and the offer of screening tests for these 3 blood borne viruses. Diagnostic testing may also be offered in other settings if indicated by clinical presentation. In pregnancy pregnant women with a history of injecting drug use should be offered information about all 3 blood-borne viruses and, according to UK guidelines, the offer of testing for HIV and HBV.

References

Whittaker, A. (2011) The essential guide to problem substance use during pregnancy: a resource book for professionals, London: DrugScope.

BHIVA, BASHH, BIS (2008) UK National Guidelines for HIV Testing 2008, British HIV Association, British Association of Sexual Health and HIV, British Infection Society, www.bhiva.org

BHIVA/ CHIVA (2008) Guidelines for the Management of HIV Infection in Pregnant Women, British HIV Association and Children's HIV Association, www.bhiva.org.

CHIVA (2011) http://www.chiva.org.uk/.

CHIVA ' Don't Forget the Children' - Guidance for the HIV testing of children with HIV-positive parents,

www.chiva.org.uk/files/guidelines/dont-forget.pdf.

CHIVA Standards of Care for Infants, Children, and Young People with HIV (Including Infants Born to Mothers with HIV)

www.chiva.org.uk/files/guidelines/chiva-standards2009.pdf

De Ruiter, A. et al (2008) British HIV Association and Children's HIV Association guidelines for the management of HIV infection in pregnant women 2008, HIV Medicine, 9, 452-502. www.bhiva.org.

RCM (2008) Hepatitis C Position Statement, London: Royal College of Midwives.

RCOG (2010) Green-top Guideline No.39 - Management of HIV in Pregnancy, www.rcog.org.uk.

Salisbury, D. Ramsay, M. and Noakes, K. Eds (2006) Immunisation against Infectious Disease: 'The Green Book', London, Department of Health, www.dh.gov.uk.

SIGN (2006) Management of Hepatitis C: A National Clinical Guideline No.92, Scottish Intercollegiate Guidelines Network, www.sign.ac.uk.

WHO (1996) Hepatitis B and Breastfeeding - Update No. 22, Geneva, World Health Organization.