British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018

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The overall 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. The scope includes guidance on the use of antiretroviral therapy (ART) both to prevent vertical transmission of HIV and for the welfare of the woman and her baby, 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 living with HIV. The 2018 guidelines have identified significant developments that have either led to a change in recommendation or a change in the strength of recommendation. More detail has been added in areas of controversy, particularly breastfeeding. New data that simply support the existing data have not routinely been included in this revision. A new section on the postpartum management of women has been added. Of note, the term "HIV" refers to HIV-1 throughout these guidelines, unless HIV-2 is specified. The British HIV Association (BHIVA) revised and updated the Association's guideline development manual in 2011 (www.bhiva.org/BHIVA-guideline-development). BHIVA has adopted the modified GRADE system for the assessment, evaluation and grading of evidence and the development of recommendations. Full details of the guideline development process including selection of the writing group and the conflict of interest policy are outlined in the manual. The guidelines were commissioned by the BHIVA Guidelines Subcommittee; the Subcommittee nominated the Chair and Vice-chair of the writing group, who then nominated a writing group of experts in the field based on their knowledge, expertise and freedom from conflicts of interest (the conflict of interest statements of members of the writing group are available and have been published along with these guidelines on the BHIVA website). In addition, BHIVA members were asked to volunteer as authors for the guidelines, again based on their knowledge, expertise and freedom from conflicts of interest. The scope, purpose and guideline topics were agreed by the writing group. Questions concerning each guideline topic were drafted and a systematic literature review undertaken by an information scientist. Details of the search questions (including the definition of populations, interventions, comparators and outcomes) are outlined in Appendix 1, and details of the search strategy can be found on the BHIVA website (www.bhiva.org/pregnancy-guidelines). The literature searches for the 2018 guidelines covered the period from July 2013 to July 2017 (with an additional search on ART in pregnancy from July 2017 to May 2018 in response to consultation comments), and included abstracts from selected conferences. For each topic and healthcare question, evidence was identified and evaluated by writing group members with expertise in the field. Using the modified GRADE system (see Appendix 2), members were responsible for assessing and grading the quality of evidence for predefined outcomes across studies and developing and grading the strength of recommendations. All writing group members received training in use of the modified GRADE criteria before assessing the evidence. Owing to the lack of data from randomised controlled trials in several important areas, the writing group was unable to assign high grades (in areas such as mode of delivery); however, recommendations have been given on best practice where decisions need to be made on the balance of available evidence. Recommendations are summarised and numbered sequentially within the text. The guidelines were published online for public consultation and external peer review was commissioned, comments from which resulted in minor revision prior to final approval by the writing group. BHIVA views the involvement of patient and community representatives in the guideline development process as both important and essential. The writing group included two patient representatives who were involved in all aspects of the guideline development. The following measures have been/will be undertaken to disseminate and aid implementation of the guidelines: There have been some changes in recommendations. We aim to revise these guidelines by 2021. In the meantime, the writing group will confer at least annually to consider new information from high-quality studies and will issue revisions or updates should clinically important and relevant data become available. Section 4. The psychosocial care of women living with HIV during and after pregnancy 4.1 Psychosocial issues around HIV and pregnancy 4.2 Perinatal mental health assessment Section 5. Screening and monitoring of pregnant women living with HIV 5.1 Sexual health screening 5.2 Laboratory monitoring of pregnant women living with HIV Section 6. Current issues on the use of ART in pregnancy and pregnancy outcomes 6.1 Conceiving on cART 6.2 Woman is not already on cART: when to start 6.3 Woman is not already on cART: what to start 2C 1C 6.4 Late-presenting woman not on treatment 1B 1B 2D 2D 6.7 Pharmacokinetics of antiretrovirals in pregnancy 6.8 Stopping ART postpartum 6.9 HIV-2 Section 7. HIV and hepatitis virus co-infections 7.1 Hepatitis B virus (HBV) 7.2 Hepatitis C virus (HCV) Section 8. Obstetric management 8.1 Antenatal management 8.2 Mode of delivery For women taking cART, a decision regarding recommended mode of delivery should be made after review of plasma HIV viral load results at 36 weeks. 8.3 Management of SROM 8.4 Use of intrapartum intravenous infusion of zidovudine 8.5 Place of birth 8.6 Water birth Section 9. Neonatal management 9.1 Infant PEP See Appendix 3 for dosing recommendations 9.1.8 Infant PEP and HIV-2 9.1.9 Infant PEP beyond 4 weeks 9.2 Pneumocystis pneumonia (PCP) prophylaxis 9.3 Immunisation 9.4 Infant feeding 9.4.3 Suppression of lactation 9.4.4 Choosing to breastfeed in the UK 9.5 Diagnosis of infant HIV status 9.6 Neonatal management in maternal hepatitis co-infection 9.7 HIV exposed but uninfected (HEU) Section 10. Postpartum management of women 10.1 Antiretroviral therapy 10.2 Support services 10.3 Postnatal follow-up of women 10.4 Mental health assessment and support 10.5 Contraception 10.6 Cervical cytology 10.7 Testing of partner and/or older children A key goal of managing HIV in pregnancy and postpartum is to optimise a woman's own health. Furthermore, one of the major successes in the management of individuals living with HIV has been the prevention of vertical transmission of HIV. With the widespread implementation of routine antenatal screening for HIV, vertical transmission is now a rare occurrence in the UK. Despite few recent randomised controlled trials of the use of 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 group was to make these guidelines as clinically relevant and as practical as possible. The writing group 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 management of HIV in pregnancy and the postpartum period. The guidelines are intended to inform and aid healthcare workers in the management of pregnancy in the context of 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. We recognise that a small number of trans and non-binary pe

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