Writing Group

Dr A de Ruiter, Dr GP Taylor, Dr AJ Palfreeman, Ms P Clayden, Dr J Dhar, Dr K Gandhi, Dr Y Gilleece, Dr K Harding, Dr P Hay, Ms J Kennedy, Dr N Low-Beer, Dr H Lyall, Dr P Tookey, Dr S Welch and Dr E Wilkins on behalf of the BHIVA Guidelines Subcommittee

Introduction

The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of HIV-infected pregnant women. The scope includes guidance on the use of ART therapy both to prevent HIV mother-to-child transmission (MTCT) and for the welfare of the mother herself, guidance on mode of delivery and recommendations in specific patient populations where other factors need to be taken into consideration such as co infection with other agents. The guidelines are aimed at clinical professionals directly involved with and responsible for the care of pregnant women with HIV infection.

One of the major successes in the management of HIV-infected patients has been the prevention of MTCT of HIV-1. With the widespread implementation of routine antenatal screening for HIV-1, transmission of HIV-1 from mother-to-child is now a rare occurrence in the UK. Despite few recent randomised controlled trials regarding the use of antiretroviral therapy (ART) in pregnancy or obstetric intervention, practice continues to evolve. This is largely informed by observational data, theoretical considerations and expert opinion.

At the outset, the aim of the writing committee was to make these guidelines as clinically relevant and as practical as possible. The panel drew up a list of questions reflecting day to day practice and queries. It was acknowledged that the level of evidence for many of these topics was poor but recognised that there was a need to provide guidance. These guidelines have expanded on all areas relevant to the clinical care of HIV-positive pregnant women. The guidelines are intended to inform and aid healthcare workers in the management of pregnant women with HIV. They are not intended to be prescriptive or restrictive and it is recognised that situations will arise where the optimum management may deviate from these recommendations and new data will emerge to better inform practice.

A particular focus has been obstetric management. An increasing number of women are aiming for and achieving a vaginal delivery but the rate of emergency caesarean sections has increased. It is hoped that the recommendations contained within these guidelines will enable a further increase in vaginal deliveries.

Linked to this is the proposed starting gestation for women temporarily taking highly active antiretroviral therapy (HAART) in pregnancy, which has been brought forward depending on baseline viral load. It is anticipated that this will result in a larger proportion of women achieving a viral load of <50 HIV RNA cpm by 36 weeks gestation, thereby allowing them to plan for a vaginal delivery.

Additional guidance has been provided with regard to conception on HAART, the choice of specific drugs or drug classes and the management of women with hepatitis B virus or hepatitis C virus co-infection. For the first time these guidelines have addressed the issue of continuation of HAART post delivery in women with a baseline CD4 count of more than 350 cells/mL.

The paediatric section provides further guidance on infant post-exposure prophylaxis, drug dosing and safety. It is clear that there exists an urgent need for paediatric syrup preparations for a wider variety of antiretroviral drugs as the current options, particularly in the case of maternal viral resistance, are limited.

In key areas the National Study of HIV in Pregnancy and Childhood (NSHPC) informs the management of HIV in pregnancy through the comprehensive data collection, collation and analysis and the need to interrogate the data continues as practice changes.

Consultation feedback

The Writing Group is grateful for all comments, which will be reviewed before publication.

Please download the document and then submit any comments using the online form below.

The consultation period deadline to receive all feedback is Friday 24 February 2012.