New British HIV Association (BHIVA) guidelines on the management of HIV in pregnancy have been issued this month, emphasising the continuing scientific uncertainty over HIV transmission through breastfeeding despite undetectable viral load, and the importance of financial assistance for women on lower incomes who need to use formula feed.
The guidelines also contain new recommendations on the importance of assessing women living with HIV for depression during pregnancy and in the months after giving birth, and emphasise that all women living with HIV not already on antiretroviral therapy (ART) should begin ART during pregnancy, even if they are elite controllers with undetectable viral load.
Treatment should start as early as possible during pregnancy for women with viral loads above 100,000 copies/ml and no later than the beginning of the second trimester (month 4) of pregnancy for women with viral loads above 30,000 copies/ml, in order to give the best chance of suppressing viral load by the time of delivery.
The new guidelines recommend treatment with a backbone of tenofovir (TDF) or abacavir with emtricitabine or lamivudine. The guidelines recommend efavirenz or atazanavir/ritonavir as the preferred third agent due to there being more data on the safety of these drugs. Dolutegravir may be used after week 8 of pregnancy, owing to safety concerns over potential neural tube defects if the foetus is exposed to the drug in the early weeks of gestation.
Infant feeding advice
Advice on infant feeding has been updated in the 2018 guidelines to address the uncertainties surrounding HIV transmission through breast milk when viral load is undetectable on antiretroviral treatment.
“The undetectable=untransmissable (U=U) statement applies only to sexual transmission, and we currently lack data to apply this to breastfeeding,” the guidelines state. Nevertheless, the guidelines also recognise that some women on antiretroviral treatment will choose to breastfeed.
“Women who are virologically suppressed on cART with good adherence and who choose to breastfeed should be supported to do so, but should be informed about the low risk of transmission of HIV through breastfeeding in this situation and the requirement for extra maternal and infant clinical monitoring.
“When a woman decides to breastfeed, she and her infant should be reviewed monthly in clinic for HIV RNA viral load testing during and for 2 months after stopping breastfeeding.”
They should be supported in their decision, if they fulfil the following criteria:
- A fully suppressed HIV viral load (for as long a period as possible, but certainly during the last trimester of pregnancy)
- A good adherence history
- Strong engagement with the perinatal multidisciplinary team
- Prepared to attend for monthly clinic review and blood HIV viral load tests for themselves and their infant while breastfeeding and for 2 months after stopping.
Maternal ART (rather than infant pre-exposure prophylaxis (PrEP)) is advised to minimise HIV transmission through breastfeeding and safeguard the woman’s health.
BHIVA continues to recommend formula feeding as the safest way for a mother with HIV to feed her baby, recognising that it may come at an emotional cost to some mothers.
The guidelines also emphasise the importance of considering the financial costs of formula feeding for women, especially women with an irregular immigration status and no recourse to public funds, and women on low incomes.
“The provision of free formula milk, and the appropriate equipment to use it, alleviates any financial burden attached to this key prevention tool. This ensures that women can make decisions on how to feed their infant without being influenced by cost.”
“We advise discussing infant feeding intentions early in pregnancy so that appropriate information and support can be provided.”
Infant prophylaxis advice
The new guidelines recommend that for infants at very low risk of HIV transmission, the duration of zidovudine prophylaxis after birth can be reduced from 4 weeks to 2 weeks. Infants at very low risk are those born to mothers who meet all the following criteria:
- On antiretroviral treatment for at least 10 weeks prior to delivery
- Two maternal viral load tests below 50 copies/ml at least 4 weeks apart
- Undetectable viral load at week 36 of pregnancy
- Undetectable viral load after delivery.
Psychosocial care
The guidelines also included a prominent new section on psychosocial care, emphasising the importance of screening for depression in line with National Institute for Care and Health Excellence (NICE) guidance. The guidelines recommend that antenatal HIV care should be delivered by a multidisciplinary team, and that all pregnant women living with HIV are offered peer support where available.
Assessment of antenatal and postnatal depression should be undertaken at booking, and 4-6 weeks postpartum and 3-4 months postpartum in accordance with NICE guidelines.
Mental health assessments and postnatal review at 4-6 weeks postpartum are now auditable outcomes, so that clinics can judge how well they are performing in carrying out these checks.
Postpartum care
The guidelines also include a new section on postpartum care (i.e. after childbirth), which makes the following recommendations:
- Women who started ART during pregnancy are encouraged to continue treatment postpartum.
- Women should have their support needs assessed postpartum and be referred to appropriate services provided in the NHS Trust, community and/or voluntary groups without delay.
- All women should be reviewed in the postnatal period by a named member of the multidisciplinary team within 4-6 weeks, to aid retention in care and address any problems arising.
- Contraceptive needs should be discussed with all women, and ART may be changed to optimise a woman’s contraception choice as long as the ART prescribed is fully active against the viral genotype.
- Women should receive cervical screening 3 months after delivery.
- For the woman newly diagnosed with HIV in pregnancy, testing of her partner and/or other children should be completed.
British HIV Association. BHIVA guidelines for the management of HIV in pregnancy and postpartum. 2018.
The guidelines, as well as two patient information leaflets on infant feeding, can be downloaded here.