Updated British HIV pregnancy guidelines published

Updated British guidelines for the care and treatment of HIV-positive pregnant women have been published.

There are few changes in the guidelines regarding the use of antiretroviral drugs during pregnancy, but there are now stronger data supporting the use of AZT monotherapy with an elective Caesarean delivery for selected women. The updated guidelines also reflect the results of recent studies showing that a planned vaginal delivery is an option for women treated with combination antiretroviral therapy with an undetectable viral load (below 50 copies/ml).

Other changes to the guidelines include a recommendation that repeat HIV tests should be offered to women who have an ongoing risk of HIV infection during pregnancy.

The full guidelines are published in HIV Medicine, the journal of the British HIV Association, and can be read online here.

Guidelines summary

Antenatal HIV testing

• An HIV test should be recommended for all women in the early stages of pregnancy, or as soon as possible if a woman presents late for antenatal care.
• There should be good record keeping detailing the offering and results of HIV tests. Test results should be available to appropriate staff on labour wards.
• Women with ongoing HIV risk should be offered repeat testing during pregnancy.
• Rapid HIV tests should be offered to women who present for labour unbooked.

Conception

• If a woman is HIV-positive and her partner is HIV-negative, self-insemination is recommended to reduce the risk of HIV transmission.
• A fertility assessment should be carried out if conception has not occurred six to twelve months after first attempting self-insemination.
• Sperm-washing is recommended if a man is HIV-positive and his female partner is HIV-negative. However, this is only offered at a few centres, is expensive and in many cases has to be funded by the patient.

Sexual health

• All pregnant women should be screened for sexually transmitted infections, and re-testing in the third trimester should be considered in some circumstances.

Support

• The team caring for an HIV-positive pregnant women should include, at the minimum, an HIV specialist, an obstetrician, a specialist midwife and a paediatrician.
• There should be a thorough assessment of the social circumstances of a woman who has been newly diagnosed with HIV during pregnancy.
• Disclosure to partners is encouraged and the HIV testing of other children is recommended.

Viral load and resistance testing

• Knowing viral load is key to preventing the transmission of HIV, therefore tests should be conducted at least every three months and at week 36.
• Viral load should also be checked two weeks after starting or changing treatment.
• Viral load should also be monitored at delivery.
• Resistance tests should be performed: at presentation; if a patients has a detectable viral load on treatment; at delivery if taking AZT monotherapy; within six weeks of stopping treatment that was suppressing viral load.

HIV treatment during pregnancy

• AZT monotherapy is a valid option for women with a viral load below 10,000 copies/ml, with no resistance to HIV drugs, who do not need to take combination HIV treatment for their own health, and who are prepared to have an elective Caesarean delivery.
• Combination antiretroviral therapy should consist of three drugs. If needed for the health of the mother, it should be started at the end of the first trimester. If the mother does not need to take treatment for her own health, it should be started between weeks 20-28 of pregnancy.
• Short-term antiretroviral therapy (START) for the prevention of mother-to-child transmission should be stopped after delivery, ideally when the mother’s viral load is below 50 copies/ml and with consideration of the half-life of each drug.

Toxicity of antiretroviral therapy during pregnancy

• Three drug antiretroviral therapy during pregnancy has been associated with an increased risk of premature delivery, particularly before week 34 of pregnancy.

Obstetric management – Caesarean delivery

• A Caesarean delivery is recommended if a woman is taking AZT monotherapy, or if viral load is above 50 copies/ml at the time of delivery.
• A Caesarean delivery should be considered for women with hepatitis C coinfection.
• Women taking triple drug antiretroviral therapy with an undetectable viral load have an option of a Caesarean delivery.
• Caesarean delivery should be timed for week 38 of pregnancy for women who have a detectable viral load or who are taking AZT monotherapy. For women with an undetectable viral load who are taking triple drug antiretroviral treatment, the Caesarean should be timed for week 39.

Obstetric management – vaginal delivery

• An elective vaginal delivery is an option for women taking triple drug antiretroviral therapy who have a viral load below 50 copies/ml at the time of delivery.
• There should be good communication between team members about planning and timing.
• Women should be given written care plans.

Obstetric management – intravenous AZT

• This should be given to women who took AZT monotherapy and to those with a detectable viral load at the time of delivery.

Hepatitis B and C

• All HIV-positive women should be tested for these viruses. Women infected with hepatitis B should receive antiretroviral therapy with drugs that are active against both HIV and hepatitis B. Women infected with hepatitis C should be offered triple drug antiretroviral therapy and are recommended to have an elective Caesarean delivery.

Management of infants

• Treatment with AZT monotherapy twice daily for four weeks should be provided.
• Triple antiretroviral therapy should be given as prophylaxis to babies whose mothers were untreated during pregnancy, or who had a detectable viral load at the time of delivery despite taking triple drug treatment.

Safety of antiretroviral therapy for infants

• There is no evidence to date of congenital malformations in humans resulting from exposure to any antiretroviral drugs (including efavirenz) in the first trimester.
• There is not enough evidence to exclude the possibility that most anti-HIV drugs might affect the growth and development of the foetus.
• There is laboratory evidence that exposure to antiretrovirals leads to mitochondrial depletion in infants, but the clinical significance of this is unknown.

Diagnosing HIV in infants

• To rule out infection, PCR tests should be performed at least twice.
• Tests to confirm the loss of maternal HIV antibodies should be performed after 18 months.

Breastfeeding

• Exclusive formula feeding is recommended.