New British HIV Association (BHIVA) guidelines on the management of HIV in pregnancy have been issued this month, emphasising the continuing scientific uncertainty over HIV transmission through breastfeeding despite undetectable viral load, and the importance of financial assistance for women on lower incomes who need to use formula feed.
The guidelines also contain new recommendations on the importance of assessing women living with HIV for depression during pregnancy and in the months after giving birth, and emphasise that all women living with HIV not already on antiretroviral therapy (ART) should begin ART during pregnancy, even if they are elite controllers with undetectable viral load.
Treatment should start as early as possible during pregnancy for women with viral loads above 100,000 copies/ml and no later than the beginning of the second trimester (month 4) of pregnancy for women with viral loads above 30,000 copies/ml, in order to give the best chance of suppressing viral load by the time of delivery.
The new guidelines recommend treatment with a backbone of tenofovir (TDF) or abacavir with emtricitabine or lamivudine. The guidelines recommend efavirenz or atazanavir/ritonavir as the preferred third agent due to there being more data on the safety of these drugs. Dolutegravir may be used after week 8 of pregnancy, owing to safety concerns over potential neural tube defects if the foetus is exposed to the drug in the early weeks of gestation.