6.0 HIV and hepatitis virus coinfections

Abstract

HIV MedicineVolume 13, Issue S2 p. 113-118 British HIV Association Guidelines for the Management of HIV Infection in Pregnant Women 2012Free Access 6.0 HIV and hepatitis virus coinfections First published: 26 July 2012 https://doi.org/10.1111/j.1468-1293.2012.1030_7.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat 6.1 Hepatitis B virus The combination of HIV, chronic HBV infection and pregnancy presents unique management questions. Referral to the local designated specialist should be undertaken to ensure that all aspects of care are addressed, including: the effects of HBV/HIV on pregnancy; effects of pregnancy on the course of coinfection; drug management for both HBV and HIV; and PMTCT for both viruses. The prevalence of HBV coinfection in pregnant women tends to reflect that of the adult population (Europe/Africa 4–10%) [3[4[#5]6]165] and is 40% higher than that found in the general population (HIV positive vs. HIV uninfected: RR 1.40; 95% CI 1.16–1.69) 6. Up to one-third of hepatitis B surface antigen (HBsAg) are wild type [hepatitis B e antigen (HBeAg)-positive] and, depending on region, up to 6% are coinfected with HDV. Rates of HBV/HIV coinfection vary with race and ethnicity so that changing immigration patterns in Western countries with traditionally low prevalence may significantly influence rates at a regional level (e.g. 6% among Asian women in the USA vs. 0.6% in white women) 7. The same is true for injection drug use (prevalence <0.1% in north-west Europe compared to 1–4% in southern Europe) and sexual transmission (prevalence higher in men who have sex with men). Although plausible because of higher levels of HBV DNA in coinfected women, there is no evidence of increased MTCT in coinfection over mono-infection. The impact of pregnancy on women with HBV mono-infection is small. There appears to be no worsening of liver disease in the majority of women, although case reports of hepatic exacerbations/fulminant hepatic failure have been reported; alanine transferase (ALT) levels tend to fall, HBeAg seroconversion occurs in a small minority and may be associated with liver dysfunction, and HBV DNA levels may rise by as much as one log10. The impact of HBV infection on pregnancy appears negligible. By contrast, the effect of HIV on HBV disease progression includes: higher levels of HBV replication (HBV DNA levels and proportion HBeAg-positive); higher mortality when compared to HIV or HBV mono-infection; higher rate of chronicity (20–80% compared with 3–5% in HIV-negative with risk increasing with lower CD4 cell counts at the time of HBV acquisition); lower ALT levels; higher rate of hepatoma; lower rate of spontaneous loss of HBeAg or HBsAg and seroconversion to anti-hepatitis B e antibody and anti-hepatitis B surface antibody (HBsAb); faster progression to cirrhosis; and higher incidence of lamivudine resistance 8. 6.1.1 On diagnosis of new HBV infection, confirmation of viraemia with quantitative HBV DNA, as well as HAV, HCV and HDV screening and tests to assess hepatic inflammation and function are recommended. Grading: 1C 6.1.2 LFTs should be repeated at 2 weeks after commencing HAART to detect evidence of hepatotoxicity or IRIS and then monitored throughout pregnancy and postpartum. Grading: 1C 6.1.3 In the immediate period after discontinuing drugs with anti-HBV activity, LFTs and HBV DNA should be monitored frequently. Grading: 1C In a pregnant HIV-positive woman, newly diagnosed with HBV (HBsAg-positive on antenatal screening or diagnosed preconception), baseline hepatitis B markers (hepatitis B core antibody/HBeAg status) and level of the virus (HBV DNA), degree of inflammation and synthetic function (ALT, aspartate transaminase, albumin, INR), assessment of fibrosis, and exclusion of additional causes of liver disease (e.g. haemochromatosis, autoimmune hepatitis) are indicated. Additionally, patients should be assessed for the need for HAV (HAV IgG antibody) immunization as well as for HDV coinfection (HDV serology). Fibroscan is contraindicated during pregnancy, so where there is suspicion of advanced liver disease, ultrasound scanning should be performed. It is important where cirrhosis is found to be present that there is close liaison with the hepatologist because of a significantly increased rate of complications: additionally, acute liver failure can occur on reactivation of HBV disease if anti-HBV treatment is discontinued 9. However, in the absence of decompensated disease and with HAART incorporating anti-HBV drugs and close monitoring, most women with cirrhosis do not have obstetric complications from their HBV infection. Because of the risk of ARV-related hepatotoxicity and a hepatitis flare from immune reconstitution, it is important to repeat LFTs at 2 weeks post-initiation of cART. Through pregnancy, it is routine to monitor LFT tests at each antenatal clinic appointment as a marker for potential obstetric complications (HELLP, pre-eclampsia, acute fatty liver, etc.), particularly in the final trimester. Finally, in those diagnosed late and not receiving HBV treatment incorporated into HAART, LFT flares may be seen shortly after delivery, which in some relates to HBeAg seroconversion and reappearance or a marked increase in HBV DNA levels. Where acute HBV has been diagnosed, there are no data to support management and each case needs to be managed with specialist advice. Data suggest that lamivudine, as part of HAART, does not completely protect against the development of acute HBV infection, although it is unknown whether this is also the case with tenofovir with or without lamivudine/emtricitabine. Although there is a theoretical risk of high HBV DNA levels and the linked association with increased risk of transmission combined with the potential for acute hepatitis and threat to maternal and fetal health, the presumption would be that this would be abrogated by the patient already being on HAART incorporating tenofovir and either emtricitabine or lamivudine. 6.1.4 Where pegylated interferon or adefovir is being used to treat HBV in a woman who does not yet require HIV treatment and who discovers she is pregnant, treatment should be switched to a tenofovir-based HAART regimen. Grading: 1C If a woman on pegylated interferon becomes pregnant, it should be discontinued and changed to a tenofovir-based HAART regimen because of the antiproliferative effect of the drug. Few data are available on the risk of congenital malformation with first trimester exposure to the newer therapies telbivudine (FDA category B) and entecavir (FDA Category C). The outcome of the pregnancy should be reported to the Interferon Pregnancy and Antiretroviral Pregnancy Registries. 6.1.5 As there is no evidence of any adverse effect on maternal or neonatal health if women become pregnant while taking ART active against HBV, treatment should be continued. Grading: 1C For tenofovir, emtricitabine and lamivudine, APR 1 and the Development of Antiretroviral Therapy Study (DART) have not identified any increased risk in prevalence or any specific pattern of anomaly, even when administered in the first trimester. Hence, when a patient becomes pregnant on an anti-HBV viral agent as part of their HAART (tenofovir, lamivudine or emtricitabine), as for HIV management, HAART should be continued. This is because the potential risk to the fetus from drug exposure is outweighed by that of a hepatitis flare or liver disease progression if the drug(s) were to be discontinued in addition to HIV virological rebound and risk of MTCT. Because entecavir has activity against HIV, it is not recommended unless given with active HAART in a coinfected patient. Moreover, it has been found to have significant carcinogenic potential in animal studies and therefore its use as an antiviral drug for HBV during pregnancy should be avoided. Lamivudine has been extensively used, as has tenofovir and to a lesser extent emtricitabine, for the treatment of HIV mono-infection during pregnancy, and lamivudine and telbivudine have been used in HBV mono-infected pregnant women and all have been found to be safe. There are limited data on adefovir use in pregnancy and it is not recommended. Where it is being used in a woman for management of HBV but who does not require HIV treatment, this should be switched to tenofovir incorporated into her HAART regimen. In the context of coinfection during pregnancy where HAART is indicated, there is unlikely to be a situation where it would be used instead of tenofovir. There is no evidence of any adverse effect on maternal health if women become pregnant while taking tenofovir, lamivudine or emtricitabine: these drugs are recommended as NRTI choices in national 10 and international guidelines 2. 6.1.6 In all HAV non-immune HBV coinfected women, HAV vaccine is recommended after the first trimester as per the normal schedule (0 and 6–12 months) unless the CD4 cell count is <300 cells/μL, when an additional dose may be indicated. Grading: 1D Immunization for HAV uses inactivated vaccines. Data for HAV vaccine in pregnancy are limited. Nevertheless, several guidelines indicate that pregnancy is not a contraindication for HAV immunization, including in HBV coinfected pregnant women [11,12]. For HAV vaccines, patients with higher CD4 cell counts and on HAART generally show improved responses to vaccination. HIV-positive persons with CD4 cell counts <300 cells/μL should receive three doses of HAV vaccine over 6–12 months instead of the standard two. 6.1.7 Tenofovir and emtricitabine should form the backbone of an ART regimen in naïve patients with wild-type HIV/HBV infection and no contraindication to either drug (Grading: 1B). 6.1.8 If tenofovir is not currently part of HAART it should be added. Grading: 1B 6.1.9 Lamivudine/emtricitabine may be omitted from the ARV regimen and tenofovir given as the sole anti-HBV agent if there is clinical or genotypic evidence of lamivudine/emtricitabine resistant HBV. Grading: 1C 6.1.10 Lamivudine or emtricitabine should not be used as the only active drug against HBV in HAART because of the likelihood of emergent HBV resistance to these agents. Grading: 1B 6.1.11 Emtricitabine has potential antiviral benefits over lamivudine, is coformulated with tenofovir, and appears to be equally safe during pregnancy and hence is the preferred option to be given with tenofovir in coinfection. Grading: 2D All HBV/HIV coinfected women should receive HAART containing tenofovir with emtricitabine or lamivudine treatment during pregnancy, unless contraindicated. Although lamivudine and emtricitabine are potent anti-HBV agents, monotherapy is associated with a high likelihood of HBV resistance in coinfected persons and hence therapy with either of these drugs, without a second anti-HBV active drug, is not recommended. Tenofovir is effective at suppressing HBV DNA in mono- and coinfected patients and may induce HBeAg seroconversion although, as for other antivirals, this may be less likely in coinfection. HBV resistance is extremely rare and combination with lamivudine or emtricitabine has been demonstrated to be effective at suppressing HBV DNA and may induce HBeAg seroconversion. Combining lamivudine/emtricitabine with tenofovir may also reduce the risk of breakthrough HBV viraemia 10. Emtricitabine is structurally similar to lamivudine but has a longer half-life and selects for resistance for both HBV and HIV less rapidly and less often. Although not currently approved for HBV treatment, it induces a sharp reduction of HBV DNA in both mono- and coinfected patients. In one RCT of coinfected patients naïve to antivirals, combining emtricitabine with tenofovir has been shown to be more effective than emtricitabine alone (median time-weighted average concentration decrease was −5.32 log10 IU/mL in the tenofovir/emtricitabine group vs. −3.25 IU/mL in the emtricitabine group: P = 0.036) 13. Further studies comparing emtricitabine/lamivudine with lamivudine alone produced similar results 14. In addition, the PROMISE study includes a substudy examining pregnant women with CD4 cell counts >350 cells/μL randomly allocated to either tenofovir/emtricitabine or zidovudine/lamivudine and lopinavir/ritonavir with outcome measures of pregnancy HBV VLs, HBV transmission, pregnancy outcomes, and postpartum ALT and HBV VL. Lamivudine/emtricitabine-resistant strains will respond to tenofovir. LFT results should be monitored frequently after starting HAART because of the possibility of an inflammatory flare from immune reconstitution (see Section 6.1.3). Postpartum management of hepatitis B virus coinfection 6.1.12 Where the CD4 cell count is <500 cells/μL, HAART should be continued postpartum if HBV coinfection exists because of the increased risk of HBV progressive disease. Grading: 1B 6.1.13 Where the CD4 cell count is >500 cells/μL and there is no other indication to treat HBV, consideration should be given to continuing anti-HBV treatment postpartum with HAART incorporating tenofovir and emtricitabine. Grading: 2C 6.1.14 If a decision is taken to discontinue therapy, careful monitoring of liver function is imperative. Grading: 2D 6.1.15 Where the CD4 cell count is >500 cells/μL and there is HBV viraemia and evidence of liver inflammation or fibrosis, HAART containing tenofovir and emtricitabine should be continued. Grading: 2C 6.1.16 Hepatitis flares that occur after HAART cessation should be treated by resumption of active anti-HBV treatment before significant liver dysfunction occurs. Grading: 2D The decision to continue ART or not postpartum depends on whether HAART was indicated for maternal health and the level of HBV-related hepatic activity/fibrosis. There is consensus that all persons with active (HBsAg-positive and/or HBV DNA-positive) coinfection should receive ARVs if their CD4 cell count is <500 cells/μL [2,11]. Hence, HAART incorporating agents active against HBV (tenofovir and emtricitabine) should be continued in this group. In those women with CD4 cell counts of >500 cells/μL with a baseline HBV DNA >2000 IU/mL and/or evidence of fibrosis on biopsy or Fibroscan, HBV treatment should be continued because of the risk of progressive liver disease if discontinued. In these patients, HAART incorporating tenofovir and emtricitabine should be continued. Adefovir is an option and has been evaluated against HBV in coinfected patients. It does not select resistance against tenofovir but is less active than tenofovir. Neither entecavir (has antiviral activity to HIV and selects resistance) nor telbivudine (high resistance rates) are suitable in coinfection. In those with CD4 cell counts over 500 cells/μL who received HAART to prevent MTCT and who are not HBV viraemic (>2000 IU/mL) or have evidence of established liver disease, strong consideration should be given to continuing anti-HBV therapy, in the form of tenofovir-based HAART because of the risk of progression of liver disease in coinfection. Inflammatory flares, which may be severe, particularly in persons with cirrhosis can occur because of viral escape and HBV viraemia, if anti-HBV drugs are stopped. In an RCT comparing lamivudine with placebo for reducing HBV MTCT in patients with HBV mono-infection, an immediate increase in HBV DNA levels was observed on discontinuation of lamivudine postpartum 15. Similarly, hepatitis flares among HIV/HBV coinfected patients have been reported upon the discontinuation of lamivudine, emtricitabine and tenofovir. In the Swiss HIV observational cohort, liver enzyme elevation occurred in 29% of patients who discontinued lamivudine and in 5% this was severe, with three patients presenting with fulminant hepatitis 16 at a median time of 6 weeks after discontinuation. Hepatitis flares that occurred after ART cessation should be treated by resumption of active anti-HBV treatment before significant liver failure occurs. 6.1.17 In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother has fully suppressed HIV VL on HAART. Grading: 2C No data exist to support any benefit from PLCS in mothers with HBV/HIV coinfection and no robust RCT exists in HBV mono-infected women. In a meta-analysis of mono-infected HBV women (four randomized trials all from China involving 789 people were included) where routine HBV neonatal vaccine and HBIG were used, there was strong evidence that PLCS vs. vaginal delivery could effectively reduce the rate of MTCT of HBV (RR 0.41; 95% CI 0.28–0.60) 17. However, methodological concerns, including lack of information on randomization procedure, lack of allocation concealment and lack of blinding make the role of PLCS for PMTCT of HBV uncertain. In addition, a meta-analysis of six RCTs where lamivudine was used from the third trimester has demonstrated that lamivudine is effective in reducing transmission (HR: 0.31; 95% CI 0.15–0.63) 18. Similarly, a single RCT in women positive for HBsAg and with an HBV DNA > 106 IU/mL demonstrated that telbivudine was also effective in reducing MTCT for HBV (2.11% vs. 13.4%; P < 0.04) and lowering risk of postpartum ALT flare. Hence, the lack of a scientifically robust RCT evaluating the role of CS in preventing MTCT for mothers with HBV mono-infection and lack of any cohort or RCT data to support the use of CS in coinfection argue against advocating this in coinfected mothers. Although HBV DNA levels are increased as a result of HIV, the efficacy of lamivudine as well as telbivudine in reducing the rate of intrapartum transmission in mono-infection, efficacy of lamivudine, tenofovir and emtricitabine as part of HAART in reducing HBV DNA in non-pregnant coinfected patients, and use of tenofovir with either lamivudine or emtricitabine as standard practice in coinfected patients, collectively provide further reason against recommending CS in those coinfected. 6.1.18 Neonatal immunization with or without HBIG should commence within 24 h of delivery. Grading: 1A Immunoprophylaxis with HBV vaccine with or without HBIG given to the neonate has been shown in separate meta-analyses of RCTs to significantly reduce MTCT from HBV mono-infected women. In the absence of neonatal immunization with HBV vaccine with or without HBIG, the rate of MTCT from a mono-infected mother who is HBsAg-positive and HBeAg-positive is 70–90% and for women who are HBsAg-positive but HBeAg-negative, 10–40%. By coadministering vaccination (effectiveness of vaccine vs. placebo RR: 0.28; 95% CI 0.2–0.4) and HBIG (effectiveness of HBIG/vaccine vs. vaccine alone RR: 0.54; 95% CI 0.41–0.73), transmission rates can be reduced to between 0% and 14%. However, 10% of the offspring of HBV carriers become chronic hepatitis B sufferers in early life despite this mainly being because of infection in utero. The most important determinant of prophylaxis failure has been shown to be maternal serum HBV DNA levels. Transmission rates as high as 32%, despite active/passive immunization with vaccine and HBIG have been reported in infants born to mothers with HBV DNA concentrations >1.1 × 107 IU/mL. ART with HBV activity (lamivudine/emtricitabine, tenofovir) can reduce this risk to a negligible level 19. 6.2 Hepatitis C virus Antenatal prevalence of HCV mono-infection ranges from <1 to about 2.5% increasing to 3–50% in coinfection with the wide range reflecting the proportion of women who are injecting drug users or come from high HCV prevalence areas in the cohorts studied [20,21]. Several meta-analyses and systematic reviews have shown the overall rate of MTCT for HCV approximates 5% (range 2–10%) if the mother is anti-HCV-positive only. Coinfection is associated with a significant increase in HCV transmission (OR up to 2.82) compared to HCV mono-infection [22[23[#24]Ent]183]. In addition, a higher rate of MTCT is seen in mothers who are coinfected and HCV viraemic compared to those who are coinfected and non-viraemic (OR 2.82) as well as to HCV viraemic but HIV-negative (OR 1.97) [22,23]. Acquisition of infection of HCV is more likely in infants also becoming infected with HIV and vertical transmission of HIV occurs more often from women coinfected with HIV and HCV than from those infected with HIV only (OR 1.82) where a modest association was found with HCV VL 25. Numerous studies have shown that the height of the HCV VL correlates with the risk of HCV MTCT and it is likely there is a linear relationship between VL and transmission as for HIV [26,27]. Invasive obstetric procedures, internal fetal monitoring, prolonged ROMs and female infant sex have also been associated with transmission but breastfeeding and CS do not pose an additional risk in mono-infected mothers [28,29]. Effective HAART significantly reduces the rate of HCV transmission, possibly by reducing HCV viraemia [29,30]. No correlation with HCV genotype or interleukin-28 polymorphisms and transmission has been identified [26,31,32]. Both intrauterine and intrapartum infection probably occur, but the relative contribution of each is uncertain. However, approximately one-third of neonates are HCV-viraemic at birth suggesting acquisition in utero 33. 6.2.1 On diagnosis of new HCV infection, confirmation of HCV viraemia with quantitative VL and genotype, assessment of hepatic inflammation and function and concomitant liver disease should be performed. Grading: 1C 6.2.2 LFTs should be repeated at 2 weeks after commencing HAART to detect evidence of hepatotoxicity or IRIS and then monitored throughout pregnancy and postpartum. Grading: 1C In a pregnant HIV-positive woman newly diagnosed with HCV, in addition to referral to the local designated specialist, baseline investigations including the presence (HCV RNA) and level of the virus (HCV VL), genotype and subtype, degree of inflammation and synthetic function (ALT, aspartate transaminase, albumin, INR), assessment of fibrosis, and exclusion of additional causes of liver disease (e.g. haemochromatosis, autoimmune hepatitis) are indicated. Additionally, patients should be assessed for the need for HAV (HAV IgG antibody) and HBV (HBsAb) immunization, as well as for HBV coinfection (HBsAg). Fibroscan is contraindicated during pregnancy so that where there is suspicion of advanced liver disease, liver ultrasound scanning should be performed. It is important where cirrhosis is found to be present that there is close liaison with the hepatologist because of a significantly increased rate of complications 9. However, in the absence of decompensated disease, most women with cirrhosis do not have obstetric complications from their HCV infection. Because of the risk of ART-related hepatotoxicity and a hepatitis flare from immune reconstitution, it is important to repeat LFTs at 2 weeks post-initiation of HAART. Through pregnancy, it is routine to monitor LFT results at each antenatal clinic appointment as a marker for potential obstetric complications (HELLP, pre-eclampsia, acute fatty liver, etc.), particularly in the final trimester. Where there is a suspicion that acute hepatitis C may be presenting during pregnancy, it is important to monitor the HCV VL through pregnancy at 4-weekly intervals. In chronically infected patients there is unlikely to have been significant change in the HCV VL. However, the prenatal VL will give some idea as to the risk of MTCT and may be worth repeating near delivery. If pregnancy has occurred during treatment for HCV with pegylated interferon and ribavirin, in addition to immediate discontinuation of treatment, thyroid function test should be included in the routine bloods as thyroid dysfunction occurs in approximately 7% of patients. Finally, it is recognized that a small number of coinfected patients are HCV antibody negative but HCV viraemic. Where there is evidence of liver inflammation or fibrosis, profound immune deficiency, or risk factors, an HCV VL assay should be performed. 6.2.3 Coinfected mothers with HCV should not be treated for HCV with pegylated interferon with or without ribavirin and all women who discover they are pregnant while receiving treatment should discontinue both pegylated interferon and ribavirin immediately. Grading: 1B There is no evidence that HCV can be transmitted vertically in the absence of HCV viraemia so only viraemic patients would be considered for therapy. The current standard of care in HCV therapy is the combination of pegylated interferon and ribavirin with the addition of either telaprevir or boceprevir for genotype 1. There are no definitive studies on the safety of HCV antiviral therapy during pregnancy. However, pegylated interferons are abortifacient at high doses in monkeys and when given in the first trimester have been associated with an increased risk of fetal loss and low birthweight in humans. Ribavirin has been assigned to category X by the FDA and is not recommended for use in pregnancy. Significant teratogenic and/or embryocidal effects have been demonstrated in all animal species exposed to ribavirin. It is contraindicated in pregnancy and in male partners of women who are pregnant. Hence, active treatment during pregnancy can only be considered once directly acting antiviral agents have been shown to be safe and effective in combinations without pegylated interferon and ribavirin. In the Ribavirin Registry, 6.1% of women who received ribavirin at some point during their pregnancy had offspring with birth defects 34. Given the evidence from animal data, women with coinfection should discontinue HCV therapy as soon as pregnancy is confirmed. Extreme care must be taken to avoid pregnancy during therapy and for the 6 months after completion of therapy in both female patients and in female partners of male patients who are taking ribavirin therapy. At least two reliable forms of effective contraception must be utilized. The outcome of an exposed pregnancy should be reported prospectively to the Ribavirin and Interferon Pregnancy Registries. 6.2.4 In all non-immune HCV coinfected women after the first trimester, vaccination against HBV is recommended. Grading: 2C Immunization for HBV uses an inactivated vaccine. Limited data are available on the use of hepatitis B vaccination in pregnancy and none in HIV-positive pregnant women. Moreover, no randomized trial has been performed on the optimum dosing schedule for use in pregnancy 35. Nevertheless, several guidelines indicate that pregnancy is not a contraindication for HBV or HAV immunization, including in HCV coinfected pregnant women [36,37]. In single-arm open studies in HIV uninfected persons, seroconversion rates for HBV are no different in the pregnant and non-pregnant woman and no fetal risks have been reported. In a prospective clinical trial in pregnant women, an accelerated schedule at 0, 1 and 4 months was found to be effective, well tolerated and had the advantage of potential completion before delivery 38. Patients with higher CD4 cell counts and on HAART generally show improved responses to vaccination. Regardless of CD4 cell count, HBsAb level should be measured 6–8 weeks after completion of vaccination. 6.2.5 HAV vaccine is recommended as per the normal schedule (0 and 6–12 months) unless the CD4 cell count is <300 cells/μL when an additional dose may be indicated. Grading: 2C Immunization for HAV also uses an inactivated vaccine and data for HAV vaccination in this setting are similarly limited. HIV-positive persons with CD4 cell counts <300 cells/μL should receive three doses of HAV vaccine over 6–12 months instead of the standard two 39. 6.2.6 In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother is receiving HAART. Grading: 2C As HCV antiviral therapy is contraindicated in pregnant women due to possible teratogenicity, mode of delivery remains the only possible risk factor amenable to intervention. No randomized studies of CS compared to normal vaginal delivery to prevent HCV MTCT have been performed. In mono-infection, two meta-analyses failed to show a significant decrease in HCV vertical transmission among mothers in the study who underwent CS compared with mothers who gave birth vaginally (OR 1.1 40 to OR 1.19 24). In the first European Paediatric Hepatitis Network cohort, a subgroup analysis of women coinfected with HIV (n = 503, 35.4%) demonstrated a reduced risk of vertical transmission of HCV with CS (OR 0.43; 95% CI 0.23–0.80) 24. However, in a later analysis from the European Paediatric Hepatitis Network (n = 208, 15.0%) no such association was found (OR 0.76; 95% CI 0.23–2.53) 29. In the later analysis, MTCT of HCV was less (8.7% vs. 13.9%) and more women probably received HAART (41%), which was associated with a significant HCV VL reduction compared to those who received monotherapy or no therapy (OR 0.26; 95% CI 0.07–1.01). There was also a trend to lower HCV VL in this group, which may go some way to explaining this. Also, in a small French cohort of coinfected women (29% on HAART), rate of transmission did not differ significantly between children born by vaginal delivery or CS 41. HAART should be given to all HCV/HIV coinfected pregnant women, regardless of CD4 cell count or HIV VL because of the evidence of increased HIV transmission in coinfected mothers. Postpartum management of hepatitis C virus coinfection 6.2.7 Where the CD4 cell count is <500 cells/μL, HAART should be continued if active HCV coinfection exists because of the increased risk of progressive HCV-related liver disease. Gra