Management of HIV in Pregnancy and Postpartum Clinical Practice Guidelines (2019)

British HIV Association (BHIVA)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

April 03, 2019

The guidelines on management of HIV in pregnancy and postpartum were released on March 14, 2019, by the British HIV Association (BHIVA).[1]

Screening

Pregnant women living with HIV should be offered peer support if it is available.

Evaluation of antenatal and postnatal depression should be made at booking, 4-6 weeks postpartum and 3-4 months postpartum.

Pregnant women diagnosed with HIV should be screened for sexual health.

Complete HIV drug resistance testing before treatment is initiated except in women presenting after 28 weeks.

Perform a CD4 cell count at the initiation of combination antiretroviral therapy (cART) and an additional CD4 count at delivery.

For women who begin cART during pregnancy, perform an HIV viral load 2-4 weeks after starting, at least once every trimester, at 36 weeks, and at the time of delivery.

Perform liver function tests in women who begin cART during pregnancy and again with each routine blood test.

If a patient has started cART during pregnancy and has not suppressed plasma viral load to <50 HIV RNA copies/mL, recommend an adherence review, resistance testing, therapeutic drug monitoring, regimen optimization, and treatment intensification.

Antiretroviral Therapy (ART) During Pregnancy

Continue cART treatment for patients who are conceiving and on an effective cART regimen.

Start ART during pregnancy and advise to continue lifelong treatment for all pregnant women including elite controllers.

Start cART in the second trimester when the baseline viral load is ≤30,000 HIV RNA copies/mL, at the start of the second trimester when the baseline viral load is 30,000-100,000 HIV RNA copies/mL, and within the first trimester if the viral load is >100,000 HIV RNA copies/mL and/or CD4 cell count is less than 200 cells/mm3.

All women should have started cART by the 24th week of pregnancy.

Efavirenz or atazanavir/r should be the third cART agent. Alternatives include rilpivirine (25 mg od), raltegravir (400 mg bd) or darunavir/r (600/100 mg bd).

Dolutegravir (50 mg od) may be considered after confirmed 8 weeks' gestation.

Zidovudine monotherapy should only be used in women declining cART with a viral load of <10,000 HIV RNA copies/mL and having a cesarean section.

Do not use PI monotherapy, tenofovir alafenamide, darunavir/cobicistat and elvitegravir/cobicistat.

All women who have been untreated and present in labor at term should be given a stat dose of nevirapine 200 mg and start oral zidovudine 300 mg and lamivudine 150 mg bd.

An urgent HIV test is needed for women without HIV documentation presenting in labor with spontaneous rupture of the membranes. Immediately start interventions to prevent vertical transmission of HIV.

Except for raltegravir, which should be given as 400 mg bd, do not alter routine antiretroviral doses if adult standard doses are used.

Do not stop ART after delivery and counsel women who request to stop ART on the risks.

In women with HIV-2, a boosted PI-based regimen such as twice daily darunavir/r should be used.

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