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

HIV and Hepatitis Virus Co-infection

Assess hepatic inflammation/fibrosis and liver function for all patients with a new hepatitis B virus (HBV) or hepatitis C virus (HCV) diagnosis. Liver function tests should be repeated 2 and 4 weeks after the start of ART and then monitored regularly throughout the pregnancy and postpartum.

Use tenofovir DF and emtricitabine or lamivudine in the antiretroviral regimen in treatment-naıve patients with wild-type HIV/HBV co-infection and no contraindication to any of these drugs.

Add tenofovir DF to cART if it is not currently included.

Lamivudine/emtricitabine may be removed from the antiretroviral regimen and tenofovir DF given as the sole anti-HBV agent in cases of lamivudine/emtricitabine-resistant HBV.

Do not use lamivudine or emtricitabine as the sole active drug against HBV in cART since emergent HBV resistance to these agents is likely.

Hepatitis A virus (HAV) vaccination is recommended after the first trimester in all HAV non-immune women with HBV and HIV. An additional dose is recommended if the CD4 count is <300 cells/mm3.

Continue postpartum cART active against both HBV and HIV.

Normal vaginal delivery can be recommended if the patient is on cART and has fully suppressed HIV viral load regardless of the HBV viral load.

Start neonatal immunization with or without hepatitis B immunoglobulin (HBIG) within 24 hours of delivery.

Do not use ribavirin-based directly acting antiviral (DAA) therapies to treat HCV in women with both HCV and HIV. Stop HCV therapy for all women who find out that they are pregnant.

First trimester HBV vaccination is recommended for women with both HCV and HIV unless they are already immune.

Hepatitis A virus (HAV) vaccination is recommended after the first trimester in all HAV non-immune women with both HCV and HIV. An additional dose is recommended if the CD4 count is <300 cells/mm3.

Continue postpartum cART active against both HCV and HIV.

Obstetric Management

Use a combined screening test for fetal aneuploidies and noninvasive prenatal testing (NIPT) for those who screen at high risk.

Do not perform invasive prenatal diagnostic testing until HIV status is known. Invasive prenatal testing should be delayed until HIV viral load has been suppressed to <50 HIV RNA copies/mL. If invasive prenatal testing cannot be delayed until viral suppression is attained, women should start cART with raltegravir and include a single dose of nevirapine 2-4 hours before the procedure.

Have planned vaginal delivery for patients with a plasma viral load <50 HIV RNA copies/mL at 36 weeks without any contraindications.

Pre-labor cesarean section (PLCS) can be considered for those with a plasma viral load of 50-399 HIV RNA copies/mL at 36 weeks in consideration of future viral load, time on treatment, and obstetric and patient factors. PLCS is recommended with a viral load ≥400 HIV RNA copies/mL at 36 weeks.

Cesarean section should occur between 38 and 39 weeks' gestation when it is indicated for the prevention of vertical transmission.

Cesarean section can be performed after 39 weeks' gestation in cases where PLCS is needed for obstetric indications and plasma viral load is <50 HIV RNA copies/mL.

Delivery within 24 hours should occur in all cases of term pre-labor spontaneous rupture of membranes (SROM).

Immediate induction or augmentation of labor is recommended for patients with pre-labor SROM, a low threshold for treatment of intrapartum fever, and an HIV viral load <50 HIV RNA copies/mL.

Immediate cesarean section may be recommended for patients with SROM and a viral load of 50-399 HIV RNA copies/mL. However, this decision should include awareness of factors such as the future viral load and length of time on treatment. Immediate cesarean section should be performed for patients with SROM and an HIV viral load ≥400 HIV RNA copies/mL.

Intramuscular steroids, HIV viral load control, and discussion about the timing and mode of delivery is recommended when premature SROM happens at <34 weeks.

Intrapartum intravenous zidovudine infusion should be used for patients in labor, with SROM, with PLCS, and a viral load >1000 HIV RNA copies/mL plasma or if viral load is unknown. It can also be considered in patients on cART with a plasma HIV viral load of 50-1000 HIV RNA copies/mL.

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