British HIV Association guidelines for the management of HIV in pregnancy and postpartum 2018 (2019 second interim update) BHIVA guidelines on the management of HIV in pregnancy and postpartum Guideline writing group Dr Yvonne Gilleece (Chair) Honorary Clinical Senior Lecturer and Consultant Physician in HIV and Genitourinary Medicine, Brighton and Sussex University Hospitals NHS Trust Dr Shema Tariq Postdoctoral Clinical Research Fellow, University College London, and Honorary Consultant Physician in HIV, Central and North (Vice-chair) West London NHS Foundation Trust Ms Funmi Awosusi Barts Health NHS Trust, London/HIV Pharmacy Association Dr Alasdair Bamford Consultant in Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London Dr Sanjay Bhagani Consultant Physician in Infectious Diseases, Royal Free Hospital NHS Trust, London Dr Laura Byrne Locum Consultant in HIV Medicine, St George’s University Hospitals NHS Foundation Trust, London Dr Emily Clarke Consultant in Genitourinary Medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust Ms Polly Clayden UK Community Advisory Board representative/HIV treatment advocates network Dr Hermione Lyall Clinical Director for Children’s Services and Consultant Paediatrician in Infectious Diseases, Imperial College Healthcare NHS Trust, London Dr Rebecca Metcalfe Consultant in Sexual Health and HIV Medicine, NHS Greater Glasgow and Clyde Dr Adrian Palfreeman Consultant in Genitourinary Medicine, University Hospitals of Leicester NHS Trust Dr Luciana Rubinstein Consultant in Genitourinary Medicine, London North West Healthcare University NHS Trust, London Ms Sonali Sonecha Lead Directorate Pharmacist HIV/GUM, Chelsea and Westminster Healthcare NHS Foundation Trust, London Dr Lisa Thorley UK Community Advisory Board representative Dr Pat Tookey Honorary Senior Lecturer and Co-Investigator National Study of HIV in Pregnancy and Childhood, UCL Great Ormond Street Institute of Child Health, London Ms Jennifer Tosswill Clinical Scientist, Viral Reference Department, Public Health England, London Mr David Utting Consultant Obstetrician and Gynaecologist, Brighton and Sussex University Hospitals NHS Trust Dr Steven Welch Consultant in Paediatric Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham Ms Alison Wright Consultant Obstetrician and Gynaecologist, Royal Free Hospitals NHS Foundation Trust, London 2 BHIVA guidelines on the management of HIV in pregnancy and postpartum 3 BHIVA guidelines on the management of HIV in pregnancy and postpartum Contents Guideline writing group ............................................................................................................... 2 1. Scope and purpose ................................................................................................................... 8 1.1 Guideline development process ............................................................................................................. 8 1.2 Patient involvement .............................................................................................................................. 8 1.3 Dissemination and implementation ....................................................................................................... 9 1.4 Summary of guideline update and date of next review ........................................................................... 9 2. Recommendations and auditable outcomes ........................................................................... 10 2.1 Recommendations ............................................................................................................................... 10 Section 4. The psychosocial care of women living with HIV during and after pregnancy ................................. 10 Section 5. Screening and monitoring of pregnant women living with HIV ........................................................ 10 Section 6. Current issues on the use of ART in pregnancy and pregnancy outcomes ....................................... 11 Section 7. HIV and hepatitis virus co-infections ................................................................................................ 13 Section 8. Obstetric management ..................................................................................................................... 15 Section 9. Neonatal management ..................................................................................................................... 17 Section 10. Postpartum management of women .............................................................................................. 19 2.2 Auditable outcomes ............................................................................................................................. 21 3. Introduction ........................................................................................................................... 22 3.1 UK prevalence and epidemiology of HIV in pregnancy, antenatal screening and risk of transmission ....... 22 3.2 HIV infection in children ....................................................................................................................... 23 3.3 Reporting and long-term follow-up ....................................................................................................... 24 3.4 National Study of HIV in Pregnancy and Childhood (NSHPC)................................................................... 24 3.5 References ........................................................................................................................................... 24 4. The psychosocial care of women living with HIV during and after pregnancy ........................... 26 4.1 Psychosocial issues around HIV and pregnancy...................................................................................... 26 4.1.1 Social issues .............................................................................................................................................. 26 4.1.2 Psychosocial care ...................................................................................................................................... 27 4.1.3 The antenatal HIV MDT ............................................................................................................................ 27 4.1.4 The psychosocial care of women newly diagnosed with HIV during pregnancy ...................................... 28 4.2 Perinatal mental health assessment ...................................................................................................... 28 4.3 References ........................................................................................................................................... 29 5. Screening and monitoring of pregnant women living with HIV ................................................ 31 5.1 Sexual health screening ........................................................................................................................ 31 5.1.1 Herpes simplex virus ................................................................................................................................. 31 5.1.2 Chorioamnionitis and BV .......................................................................................................................... 32 5.1.3 STI screening ............................................................................................................................................. 32 4 BHIVA guidelines on the management of HIV in pregnancy and postpartum 5.1.4 Cervical cytology ....................................................................................................................................... 33 5.1.5 Contraception ........................................................................................................................................... 33 5.2 Laboratory monitoring of pregnant women living with HIV .................................................................... 33 5.2.1 Failure to suppress .................................................................................................................................... 34 5.3 References ........................................................................................................................................... 34 6. Current issues in the use of ART in pregnancy and pregnancy outcomes ................................. 37 6.1 Conceiving on cART .............................................................................................................................. 37 6.2 Woman is not already on cART: when to start ....................................................................................... 38 6.2.1 Elite controllers ......................................................................................................................................... 38 6.2.2 All women not on cART should commence cART ..................................................................................... 38 6.3 Woman is not already on cART: what to start ........................................................................................ 39 6.4 Late-presenting woman not on treatment ............................................................................................. 40 6.5 Evidence on teratogenicity, neonatal outcomes and ART ....................................................................... 42 6.6 Preterm delivery (PTD) ........................................................................................................................