Management of HIV in Pregnancy and Postpartum: British HIV Association 2019 Guidelines

British HIV Association (BHIVA) has released its latest 2019 Guidelines on the management of HIV in pregnancy and the postpartum period. This is an update of the 2011 British HIV Association Guidelines. The purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of women living with the human immunodeficiency virus (HIV) in the UK during pregnancy and postpartum and their infants.

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.

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.

Neonatal Management

• Two weeks of zidovudine monotherapy should be used if the mother has been on cART for more than 10 weeks, has two recorded maternal HIV viral loads during pregnancy <50 HIV RNA copies/mL at least 4 weeks apart, and a maternal HIV viral load <50 HIV RNA copies/mL at 36 weeks. Four weeks of zidovudine monotherapy is recommended if these factors are not met or if the infant is born prematurely.


• Combination infant postexposure prophylaxis should be used if maternal birth HIV viral load is >50 HIV RNA copies/mL or if it is not known.


• Infant postexposure prophylaxis should not be used for more than four weeks.


• Use co-trimoxazole prophylaxis from 1 month of age in cases with a positive HIV PCR screening or where there is a confirmed HIV diagnosis in the infant.


• Rotavirus vaccine is not contraindicated unless infant has confirmed HIV diagnosis and has severe immunosuppression.


• Offer cabergoline to suppress lactation for patients who are not breastfeeding by choice or due to a viral load >50 HIV RNA copies/mL.


• Perform molecular diagnostics for HIV infection in non-breastfed infants during the first 48 hours and before hospital discharge, at two weeks of age if they are high risk, at six and twelve weeks, and in instances when there is an additional risk.


• Perform molecular diagnostics for HIV infection in breastfed infants during the first 48 hours and prior to hospital discharge, at two weeks of age and monthly during breastfeeding, and at four and eight weeks after breastfeeding has been stopped.


• Check HIV antibody testing for seroreversion between 18-24 months of age.

Postpartum Management

• Recommend all patients continue cART postpartum.


• Assess the patient's mental health needs and refer for appropriate services.


• Schedule cytology three months after delivery.

Postpartum follow‐up may be an opportune time to revisit the testing of partners and/or older children. A woman newly diagnosed in pregnancy should be counselled and supported regarding testing of her other children and partner. When her viral load is undetectable for 6 months or more she will not transmit HIV sexually; however, she should be advised to use condoms with her untested or HIV‐negative partner until that time.