June, 2024

The June 2024 update to the clinical practice guideline No. 310 Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission. This revision provides contemporary recommendations based on an updated literature review up to May 2023.

[Atkinson A, Tulloch K, Boucoiran I, Money D. Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission. J Obstet Gynaecol Can. 2024;46(6):102551.]

Summary Statements:

1. With the consistent use of effective antiretroviral therapy and abstinence from breastfeeding, the risk of perinatal transmission of HIV is less than 1% (high).
2. Antiretroviral therapy is indicated for all pregnant women living with HIV, regardless of HIV viral load or CD4 cell count, for the woman’s own health, the prevention of HIV transmission to a partner, and the prevention of perinatal transmission (high).
3. Individualization of antiretroviral therapy will maximize adherence to the prescribed regimen in pregnancy (moderate).
4. Inclusion of data on pregnancies affected by HIV in surveillance programs allows for the collection of provincial and national data to guide future pregnancy policies (high).

Recommendations:

1. All pregnant women living with HIV should be treated with antiretroviral therapy regardless of baseline CD4 cell count and viral load (strong, moderate).
2. All women living with HIV who are planning a pregnancy or who become pregnant should have their individual circumstances discussed with experts in the area. Referral to both HIV treatment programs and obstetrical care providers should be made with the goal of a multidisciplinary plan for pregnancy care (strong, moderate).
3. Routine dosage adjustment of combination antiretroviral therapy is not currently recommended in pregnancy (strong, high).
4. Choice of pre-pregnancy antiretroviral therapy should consider whether sufficient data on safety and effectiveness is available for the regimen in pregnancy (strong, moderate).
5. Antiretroviral therapy should not be discontinued during the first trimester because of theoretical concerns regarding teratogenicity in women currently taking antiretroviral therapy (strong, moderate).
6. All women living with HIV (both those who still have a detectable viral load after exposure to antiretroviral therapy and those who are antiretroviral-naive) should have viral genotyping and testing for phenotypic resistance, where possible, to assist in optimizing antiretroviral therapy. Experienced clinicians in referral centres can aid in facilitating this testing and interpretation of the genotype testing to guide any necessary changes to the antiretroviral therapy. Testing for HLA B*5701, if not done previously, is recommended in the event abacavir is considered (strong, high).
7. Women living with HIV should generally continue established antiretroviral regimens (including those containing efavirenz, nevirapine, or dolutegravir) following the diagnosis of pregnancy. There are uncommon situations where antiretroviral switching is indicated following specialist review (conditional, moderate).
8. Whenever possible, antiretrovirals with no safety data should be avoided in pregnancy and particularly during the period of organogenesis (conditional, moderate).
9. If a pregnant woman has significant hyperemesis of pregnancy, antiretroviral therapy should not be initiated until nausea is adequately controlled. Most anti-nauseants used in pregnancy can be co-administered with antiretrovirals. If the woman is already on antiretroviral therapy and has severe hyperemesis of pregnancy, first maximize anti-nauseant regimens, and only discontinue antiretrovirals if unable to prevent emesis of the antiretroviral medication. If discontinued, stop all drugs at once, then reinstate all at once when nausea and vomiting are controlled (strong, moderate).
10. The woman’s clinical, virological, and immunological status should be assessed every 4 – 12 weeks, including at 36 weeks gestation, at delivery, and again 4 – 8 weeks postpartum. Specific testing should be individualized for the known toxicities of the antiretroviral regimen (conditional, moderate).
11. As for all pregnant women, those living with HIV, regardless of age, should be offered, through an informed consent process, first-trimester ultrasound (ideally at 11 – 14 weeks) and a prenatal screening test for the most common fetal aneuploidies (strong, moderate).
12. A detailed obstetrical ultrasound at 19 – 20 weeks gestation is routinely recommended for quality pregnancy care (strong, high). Additional ultrasounds, for fetal growth and amniotic fluid volume, should be considered with at least one additional ultrasound in the third trimester and further ultrasound assessments as guided by obstetrical/medical indications (conditional, moderate).
13. Mode of delivery should be discussed throughout pregnancy with plans made in the third trimester according to viral load and obstetric factors. Women on optimal antiretroviral therapy with undetectable viral loads (<50 copies/mL) measured in the 4 weeks prior to delivery are recommended to have a vaginal delivery in the absence of other obstetrical indications for cesarean delivery. If cesarean delivery is recommended for obstetrical indications, it can be conducted at the gestation required for those indications (strong, high).
14. Women not on optimal antiretroviral therapy (i.e., no antiretroviral therapy, unknown viral load, or viral load ≥400 copies/mL) should be offered scheduled pre-labour cesarean delivery at approximately 38 weeks gestation (strong, moderate).
15. Plans for delivery should include the recognition that there are higher rates of preterm delivery for women living with HIV (conditional, moderate).
16. For patients with detectable viral loads or suboptimal antiretroviral therapy adherence, intravenous zidovudine should be initiated as soon as possible after labour onset, rupture of membranes, or pre-cesarean (2 hours pre-op) until delivery, with continuation of the woman’s oral antiretroviral regimen, regardless of mode of delivery, current antiretroviral regimen, or viral load (conditional, low). This recommendation could be individualized, and intravenous zidovudine may not be necessary for extremely stable patients with undetectable viral loads (<50 copies/mL) under specialist advice (conditional, moderate).
17. For women without an existing HIV provider, a referral should be made as soon as possible. Plans for ongoing HIV care should be established antenatally, and maternal oral antiretroviral therapy should be continued through labour and postpartum. Later reassessment of the antiretroviral regimen can be made by the providers of adult HIV care (strong, high).
18. Infant feeding should be discussed with the woman and her care team. At present, in Canada, formula feeding remains the preferred method of infant feeding regardless of plasma HIV viral load and use of maternal antiretroviral therapy (strong, moderate). Should the woman choose to breastfeed, she should be supported during her pregnancy care, and consultation with pediatric HIV experts should be sought to plan for enhanced surveillance and/or prophylactic treatment for the infant (strong, moderate).