UK BHIVA pregnancy guidelines updated (2018)
There have been some changes in recommendations in the 2018 BHIVA pregnancy guidelines. The particular focus areas are psychosocial, infant feeding, neonatal and postnatal management as well a few updates on use of specific antiretrovirals in pregnant women living with HIV.
The new guidelines include updated prevalence data showing that very low vertical HIV transmission rates continue in the UK and Ireland: an estimated 0.27% in 2012–2014.
During this period, 85% of deliveries were to women who became pregnant when they already knew their HIV status. About half of the women were having a second or subsequent child since they were diagnosed.
Almost all women received ART during pregnancy, and the proportion conceiving on ART increased from 40% in 2007–2011 to 60% in 2012–2014.
The proportion of vaginal deliveries also increased: from 37% to 46%. But emergency caesarean section rates are still high: around 20–25% of deliveries.
The proportion of pregnancies in women over 40 rose from 2% in 2000–2004 to 9% in 2010–2014. And a growing number of pregnant women have vertically acquired HIV.
The main changes in recommendations for the management of HIV in pregnancy and postpartum are as follows:
The section on psychosocial care of women living with HIV during and after pregnancy has been expanded and moved to the beginning of the guidelines to reflect its importance.
The need for antenatal HIV care to be delivered by a multi-disciplinary team is emphasised. The guidelines also recommend that women are assessed for antenatal and postnatal depression at booking, 4–6 weeks postpartum and 3–4 months postpartum, following NICE guidance.
The guidelines continue to stress that in the UK and other high-income settings, the safest way to feed infants born to women with HIV is with formula milk, as there is a small on-going risk of exposure to HIV with breastfeeding.
ART significantly reduces, but does not completely eliminate, the risk of vertical transmission through breastfeeding. U=U applies only to sexual transmission, and there are currently insufficient data to apply this to breastfeeding.
Women should receive appropriate support from their multi-disciplinary team, including peer support, psychological and practical support, as well as financial support for formula feeding.
Women who formula feed their infants should be offered cabergoline to suppress lactation.
But the updated advice also includes new data on breastfeeding and the emotional impact of not breastfeeding on women.
Women who are fully suppressed on ART and choose to breastfeed should be advised of the small on-going risk of HIV transmission and supported in their decision. The woman and her infant should be reviewed monthly in clinic for viral load testing during breastfeeding and two months after stopping.
All women (including elite controllers) are recommended to start (or continue) and remain on lifelong ART.
New data are included on tenofovir DF, raltegravir, rilpivirine, dolutegravir, elvitegravir and cobicistat.
Abacavir/lamivudine or tenofovir DF/emtricitabine with efavirenz or atazanavir/r are recommended for women starting ART in pregnancy. Dolutegravir is recommended after eight weeks’ gestation.
It is recommended that women conceiving on effective ART should continue with this. Exceptions that require modification are: non-standard regimens, for example protease inhibitor monotherapy; regimens like darunavir/cobicistat and elvitegravir/cobicistat that have shown lower pharmacokinetics in pregnancy, or where there is no pharmacokinetic data such as raltegravir 1200 mg once daily.
A woman who conceives on dolutegravir should see her doctor as soon as possible to discuss current evidence on neural tube defects.
Infant post-exposure prophylaxis (PEP)
The length of infant PEP has been stratified according to risk of transmission being very low, low or high risk by maternal viral load and ART. Two weeks of zidovudine monotherapy is recommended if the following criteria are met: a woman has been on ART for longer than 10 weeks; and has two documented viral loads <50 copies/mL during pregnancy at least four weeks apart; and viral load <50 copies/mL at or after 36 weeks.
Information has been added on tenofovir alafenamide for hepatitis B and on direct-acting agents for hepatitis C.
A new section has been added on the postpartum management of women living with HIV. This includes recommendations on contraception, continuing and/or modifying ART after delivery as well as assessment of their mental health needs postpartum.
The writing group aim to next revise these guidelines by 2021.
The writing group will meet at least once a year to consider new information and will issue revisions or updates in reaction to clinically important and relevant data should it become available.
BHIVA. BHIVA guidelines on the management of HIV in pregnancy and postpartum 2018.