HIV MedicineVolume 15, Issue S4 p. 1-77 British HIV Association Guidelines for the Management of HIV Infection in Pregnant Women 2012 (2014 interim review). This supplement was published by the British HIV Association and Wiley with no external financial supportFree Access British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review) First published: 25 September 2014 https://doi.org/10.1111/hiv.12185Citations: 12 (Updated May 2014. All changed text is cast in yellow highlight.) AboutSectionsPDF 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 onFacebookTwitterLinkedInRedditWechat Writing Group Members Dr Annemiek de Ruiter, Consultant Physician in Genitourinary Medicine, Guy's and St Thomas’ NHS Foundation Trust, London (Chair) Dr Graham P Taylor, Professor of Human Retrovirology, Section of Infectious Diseases, Imperial College London (Vice Chair) Ms Polly Clayden, UK Community Advisory Board representative/HIV treatment advocates network Dr Jyoti Dhar, Consultant in Genitourinary Medicine, University Hospitals of Leicester NHS Trust Mrs Kate Gandhi, Specialist HIV Pharmacist, Heart of England NHS Foundation Trust, Birmingham Dr Yvonne Gilleece, Consultant Physician in HIV and Genitourinary Medicine, Brighton and Sussex University Hospitals NHS Trust Dr Kate Harding, Consultant Obstetrician, Guy's and St Thomas’ Hospital NHS Foundation Trust, London Dr Phillip Hay, Reader and Honorary Consultant, St George's Healthcare NHS Trust, London Ms Jane Kennedy, Consultant Midwife, Homerton University Hospital NHS Foundation Trust, London Dr Naomi Low-Beer, Consultant Obstetrician and Gynaecologist, Chelsea and Westminster Hospital NHS Foundation Trust, London Dr Hermione Lyall, Chief of Service for Paediatrics and Consultant Paediatrician in Infectious Diseases, Imperial College Healthcare NHS Trust, London Dr Adrian Palfreeman, Consultant in Genitourinary Medicine, University Hospitals of Leicester NHS Trust Dr Siobhan O'Shea, Principal Virologist, Infection Services, GSTS Pathology, Guy's and St Thomas’ Hospital NHS Foundation Trust, London Dr Pat Tookey, Senior Lecturer and Principal Investigator National Study of HIV in Pregnancy and Childhood, UCL Institute of Child Health, London Ms Jennifer Tosswill, Clinical Scientist, Viral Reference Department, Public Health England, Colindale, London. Dr Steven Welch, Consultant in Paediatric Infectious Diseases, Heart of England NHS Foundation Trust, Birmingham Dr Ed Wilkins, Consultant Physician in Infectious Diseases and Director of the HIV Research Unit, North Manchester General Hospital Contents Scope and purpose 5 1.1 Guideline development process 5 1.2 Patient involvement 5 1.3 Dissemination and implementation 5 1.4 Summary of Guideline update and date of next review 5 Recommendations and auditable outcomes 7 2.1 Recommendations 7 2.2 Auditable outcomes 12 Introduction 14 3.1 UK prevalence of HIV in pregnancy and risk of transmission 14 3.2 HIV infection in children 15 3.3 Antenatal HIV screening 15 3.4 Reporting and long-term follow up 16 3.5 National Study of HIV in Pregnancy and Childhood (NSHPC) 16 Screening and monitoring of HIV-positive pregnant women 17 4.1 Screening 17 4.2 Laboratory monitoring of HIV-positive pregnant women 18 Use of antiretroviral therapy in pregnancy 20 5.1 Conceiving on cART 20 5.2 Naïve to cART: mother needs ART for herself 21 5.3 Naïve to cART: mother does not need cART for herself 25 5.4 Late-presenting woman not on treatment 27 5.5 Elite controllers 28 5.6 Stopping ART postpartum 28 HIV and hepatitis virus co-infections 31 6.1 Hepatitis B virus (HBV) 31 6.2 Hepatitis C virus (HCV) 34 Obstetric management 38 7.1 Antenatal management 38 7.2 Mode of delivery 39 7.3 Management of spontaneous rupture of membranes 42 7.4 Use of intrapartum intravenous infusion of zidovudine 44 Neonatal management 45 8.1 Infant post-exposure prophylaxis 45 8.2 Pneumocystis pneumonia (PCP) prophylaxis 49 8.3 Immunization 50 8.4 Infant feeding 50 8.5 Diagnosis of infant HIV status 51 8.6 Child protection 52 Psychosocial issues 53 Acknowledgements and conflicts of interest 55 References 56 Appendix 1: summary of the modified GRADE system 71 A1.1 References 71 Appendix 2: systematic literature search 72 A2.1 Questions and PICO criteria 72 A2.2 Search 1: safety and efficacy of antiretrovirals in pregnancy 72 A2.3 Search 2: hepatitis viruses co-infection 72 A2.4 Search 3: delivery, fetal monitoring and obstetric issues 73 A2.5 Search 4: paediatric issues 73 A2.6 Search 5: investigations and monitoring in pregnancy 73 Appendix 3: search protocols (main databases search) 74 A3.1 Search 1: when to initiate ART 74 A3.2 Search 2: hepatitis co infection 74 A3.3 Search 3: fetal monitoring and obstetric issues 75 A3.4 Search 4: paediatric issues 75 A3.5 Search 5: investigations and monitoring in pregnancy 76 Appendix 4 77 A4.1 Antiretroviral therapies for which sufficient numbers of pregnancies with first trimester exposure have been monitored to detect a two-fold increase in overall birth defects 77 A4.2 Advisory Committee Consensus 77 1. Scope and purpose The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of human immunodeficiency virus (HIV)-positive pregnant women in the UK. The scope includes guidance on the use of antiretroviral therapy (ART) both to prevent HIV mother-to-child transmission (MTCT) and for the welfare of the mother herself, 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 with HIV infection. The purpose of the 2014 interim review is to identify significant developments that would either lead to a change in recommendation or a change in the strength of recommendation. These changes and the supporting evidence are highlighted. More detail has been added in areas of controversy. New data that simply support the existing data have not routinely been included in this revision. Guideline development process The British HIV Association (BHIVA) revised and updated the Association's guideline development manual in 2011 (www.bhiva.org/GuidelineDevelopmentManual.aspx; see also Appendix 1). 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 who nominated the Chair of the Writing Group and deputy. They then nominated a Writing Group of experts in the field 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 and strategy (including the definition of populations, interventions and outcomes) are outlined in Appendices 2 and 3. The literature searches for the 2012 guidelines covered the period up until September 2011 and included abstracts from selected conferences. For the interim review, conference abstracts and publications since September 2011 until end July 2013 were considered. 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 1), 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 randomized controlled trials in several important areas the Writing Group were unable to assign high grades (in areas such as mode of delivery); however, they have made recommendations on best practice where decisions need to be made on the balance of available evidence. Recommendations are summarized 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. Patient involvement BHIVA views the involvement of patient and community representatives in the guideline development process as both important and essential. The Writing Group included a patient representative who was involved in all aspects of the guideline development. Dissemination and implementation The following measures have been/will be undertaken to disseminate and aid implementation of the guidelines: E-publication on the BHIVA website and the journal HIV Medicine Publication in HIV Medicine Shortened version detailing concise summary of recommendations E-learning module accredited for CME Educational slide set to support local and regional educational meetings National BHIVA audit programme Summary of Guideline update and date of next review There have been no major changes in recommendation. The prevalence data from the UK have been updated. Safety: new data on efavirenz and raltegravir Prescribing: darunavir updated Resistance: data on mutations associated with the use of zidovudine monotherapy added; 21 days' antiretroviral cover advocated to prevent mutations following single-dose nevirapine. IV zidovudine: guidance refined to include all viral loads > 1000 rather than 10 000 HIV RNA copies/mL plasma. Hepatitis: information added on telaprevir and boceprevir. Mode of delivery: new data on transmission rates by mode of delivery at low viral load (50–399 copies/mL) added, strengthening the evidence for the existing recommendation to consider PLCS at these viral loads. Infant diagnostic section has been updated. No other change to paediatric section including infant feeding advice. The guidelines will be next fully updated and revised in 2017. The Writing Group will, however, continue to confer regularly to consider new information from high-quality studies and publish amendments and addendums to the current recommendations prior to the full revision date where this is thought to be clinically important to ensure continued best clinical practice. 2. Recommendations and auditable outcomes Recommendations Section 4: Screening and monitoring of HIV-positive pregnant women 4.1 Screening 4.1.1 Sexual health screening is recommended for pregnant women newly diagnosed with HIV. Grading: 1B 4.1.2 For HIV-positive women already engaged in HIV care who become pregnant sexual health screening is suggested. Grading: 2C 4.1.3 Genital tract infections should be treated according to BASHH guidelines. Grading: 1B 4.2 Laboratory monitoring of HIV-positive pregnant women 4.2.1 Newly diagnosed HIV-positive pregnant women do not require any additional baseline investigations compared with non-pregnant HIV-positive women other than those routinely performed in the general antenatal clinic. Grading: 1D 4.2.2 HIV resistance testing should be performed prior to initiation of treatment (as per the BHIVA guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy 2012), except for late-presenting women. Post short-course treatment a further resistance test is recommended to ensure that mutations are not missed with reversion during the off-treatment period. Grading: 1D 4.2.3 In women who either conceive on cART or who do not require cART for their own health there should be a minimum of one CD4 cell count at baseline and one at delivery. Grading: 2D 4.2.4 In women who commence cART in pregnancy HIV viral load should be performed 2–4 weeks after commencing cART, at least once every trimester, at 36 weeks and at delivery. Grading: 1C 4.2.5 In women commencing cART in pregnancy liver function tests should be performed as per routine initiation of cART and then at each antenatal visit. Grading: 1C 4.2.6 In the event that a woman who has initiated cART during pregnancy has not achieved a plasma viral load of < 50 HIV RNA copies/mL at 36 weeks the following interventions are recommended: Review adherence and concomitant medication Perform resistance test if appropriate Consider therapeutic drug monitoring (TDM) Optimize to best regimen Consider intensification Grading: 1C Section 5: Use of antiretroviral therapy in pregnancy 5.1 Conceiving on cART 5.1.1 It is recommended that women conceiving on an effective cART regimen should continue this even if it contains efavirenz or does not contain zidovudine. Grading: 1C Exceptions are: (1) Protease inhibitor (PI) monotherapy should be intensified to include (depending on tolerability, resistance and prior antiretroviral history) one or more agents that cross the placenta. Grading: 2D (2) The combination of stavudine and didanosine should not be prescribed in pregnancy. Grading: 1D 5.2 Naïve to cART: mother needs ART for herself 5.2.1 Women requiring ART for their own health should commence treatment as soon as possible as per the BHIVA guidelines for the treatment of HIV-1 positive adults with antiretroviral therapy 2012. Grading: 1A 5.2.2 Although there is most evidence and experience in pregnancy with zidovudine plus lamivudine, tenofovir plus emtricitabine or abacavir plus lamivudine are acceptable nucleoside backbones. Grading: 2C 5.2.3 In the absence of specific contraindications it is recommended that the third agent in cART should be efavirenz or nevirapine (if the CD4 cell count is less than 250 cells/μL) or a boosted PI. Grading: 1C 5.2.4 No routine dose alterations are recommended for ARVs during pregnancy if used at adult licensed doses. Grading: 1C Consider third trimester TDM particularly if combining tenofovir and atazanavir. Grading: 2C If dosing off licence consider switching to standard dosing throughout pregnancy or regular TDM. Consider twice daily darunavir if initiating darunavir-based ART or if known resistance. Grading: 2C Grading: 1C 5.3 Naïve to cART: mother does not need cART for herself 5.3.1 All women should have commenced ART by week 24 of pregnancy. Grading: 1C 5.3.2 Although there is most evidence and experience in pregnancy with zidovudine plus lamivudine, tenofovir plus emtricitabine or abacavir plus lamivudine are acceptable nucleoside backbones. Grading: 2C 5.3.3 In the absence of specific contraindications it is recommended that cART should be boosted-PI-based. The combination of zidovudine, lamivudine and abacavir can be used if the baseline viral load is < 100 000 HIV RNA copies/mL plasma. Grading: 1C 5.3.4 Zidovudine monotherapy can be used in women planning a caesarean section who have a baseline VL of < 10 000 HIV RNA copies/mL and a CD4 of > 350 cells/μL. Grading: 1A 5.3.5 Women who do not require treatment for themselves should commence temporary cART at the beginning of the second trimester if the baseline VL is > 30 000 HIV RNA copies/mL (Consider starting earlier if VL > 100 000 HIV RNA copies/mL). Grading: 1C 5.4 Late-presenting woman not on treatment 5.4.1 A woman who presents after 28 weeks should commence cART without delay. Grading: 1B 5.4.2 If the viral load is unknown or > 100 000 HIV RNA copies/mL a three or four drug regimen that includes raltegravir is suggested. Grading: 2D 5.4.3 An untreated woman presenting in labour at term should be given a stat dose of nevirapine and commence fixed-dose zidovudine with lamivudine and raltegravir. Grading: 1B Grading: 1B Grading: 2D 5.4.4 It is suggested that intravenous zidovudine be infused for the duration of labour and delivery. Grading: 2C 5.4.5 In preterm labour, if the infant is unlikely to be able to absorb oral medications consider the addition of double-dose tenofovir (to the treatment described in 5.4.2) to further load the baby. Grading: 2C 5.4.6 Women presenting in labour/with rupture of membranes (ROM)/requiring delivery without a documented HIV result must be recommended to have an urgent HIV test. A reactive/positive result must be acted upon immediately with initiation of the interventions for prevention of mother to child transmission (PMTCT) without waiting for further/formal serological confirmation. Grading: 1D 5.5 Elite controllers 5.5.1 Untreated women with a CD4 cell count ≥ 350 cells/μL and a viral load of < 50 HIV RNA copies/mL (confirmed on a separate assay): Can be treated with zidovudine monotherapy or with cART (including abacavir/lamivudine/zidovudine). Grading: 1D Can aim for a vaginal delivery. Grading: 1C Should exclusively formula feed their infant. Grading: 1D 5.6 Stopping ART postpartum 5.6.1 The discontinuation of non-nucleoside reverse transcriptase inhibitor (NNRTI)-based cART postpartum should be according to BHIVA guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012. Grading: 1C 5.6.2 Antiretroviral therapy should be continued postpartum in women who commenced cART with a history of an AIDS-defining illness or with a CD4 cell count < 350 cells/μL as per adult treatment guidelines. Grading: 1B 5.6.3 ART should be continued in all women who commenced cART for MTCT with a CD4 cell count of between 350 and 500 cells/μL during pregnancy who are co-infected with hepatitis B virus (HBV) or hepatitis C virus (HCV) in accordance with adult treatment guidelines. Grading: 1B 5.6.4 ART can be continued in all women who commenced cART for MTCT with a CD4 cell count of between 350 and 500 cells/μL during pregnancy. Grading: 2C 5.6.5 ART should be discontinued in all women who commenced cART for MTCT with a CD4 cell count of > 500 cells/μL unless there is discordance with her partner or co-morbidity as outlined in Section 6. Grading: 2B Section 6: HIV and hepatitis virus co-infections 6.1 Hepatitis B virus (HBV) 6.1.1 On diagnosis of new HBV infection, confirmation of viraemia with quantitative HBV DNA, as well as hepatitis A virus (HAV), HCV and hepatitis delta virus (HDV) screening and tests to assess hepatic inflammation and function are recommended. Grading: 1C 6.1.2 Liver function tests should be repeated at 2 weeks after commencing cART to detect evidence of hepatotoxicity or immune reconstitution inflammatory syndrome (IRIS) and then monitored throughout pregnancy and postpartum. Grading: 1C 6.1.3 Where pegylated interferon or adefovir is being used to treat HBV in a woman who does not yet require HIV treatment who discovers she is pregnant, treatment should be switched to a tenofovir-based cART regimen. Grading: 1C 6.1.4 Since there is no evidence of any adverse effect on maternal or neonatal health if women become pregnant while taking antiretroviral therapy active against HBV these should be continued. Grading: 1C 6.1.5 Tenofovir and emtricitabine or lamivudine should form the backbone of an antiretroviral regimen in treatment-naïve patients with wild-type HIV/HBV infection and no contraindication to any drug. Grading: 1B 6.1.6 If tenofovir is not currently part of cART it should be added. Grading: 1B 6.1.7 Lamivudine/emtricitabine may be omitted from the antiretroviral regimen and tenofovir given as the sole anti-HBV agent if there is clinical or genotypic evidence of lamivudine/ emtricitabine resistant HBV. Grading: 1C 6.1.8 Lamivudine or emtricitabine should not be used as the only active drug against HBV in cART because of the likelihood of emergent HBV resistance to these agents. Grading: 1B 6.1.9 Emtricitabine has potential antiviral benefits over lamivudine, is co-formulated with tenofovir, and appears to be equally safe during pregnancy and hence is the preferred option to be given with tenofovir in co-infection. Grading: 2D 6.1.10 In all HAV non-immune HBV co-infected 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: 1A Grading: 1D 6.1.11 Where the pre-cART CD4 cell count is < 500 cells/μL cART should be continued postpartum if HBV co-infection exists because of the increased risk of HBV progressive disease. Grading: 1B 6.1.12 Where the pre-cART CD4 cell count is > 500 cells/μL, transaminases are normal, HBV DNA < 2000 IU/mL and there is minimal or no fibrosis, patients should be given the option to continue tenofovir-based ART or to stop all ART. Grading: 1C 6.1.13 If a decision is taken to discontinue therapy postpartum careful monitoring of liver function is imperative. Grading: 2D 6.1.14 Where the CD4 cell count is > 500 cells/μL but HBV DNA > 2000 IU/mL and/or there is evidence of liver inflammation or fibrosis, tenofovir-based cART should be continued. Grading: 2C 6.1.15 Hepatitis flares that occur after cART cessation should be treated by resumption of active anti-HBV treatment before significant liver dysfunction occurs. Grading: 2D 6.1.16 In the absence of obstetric complications, normal vaginal delivery can be recommended, if the mother has fully suppressed HIV viral load on cART. Grading: 1C 6.1.17 Neonatal immunization with or without HBIG should commence within 24 hours of delivery. Grading: 1A 6.2 Hepatitis C virus (HCV) 6.2.1 On diagnosis of new HCV infection, confirmation of HCV viraemia with quantitative viral load (VL) and genotype, assessment of hepatic inflammation and function and concomitant liver disease should be performed. Grading: 1C 6.2.2 Liver function tests should be repeated at 2 weeks after commencing cART to detect evidence of ARV hepatotoxicity or IRIS and then monitored throughout pregnancy and postpartum. Grading: 1C 6.2.3 Co-infected 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. This includes patients receiving triple therapy with boceprevir or telaprevir. Grading: 1B 6.2.4 Vaccination against HBV is recommended for all HCV co-infected women after the first trimester, unless already immune. Grading: 1C 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: 1A Grading: 1D 6.2.6 In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother is receiving effective cART. Grading: 2C 6.2.7 Where the CD4 cell count is < 500 cells/μL, cART should be continued if HCV viraemia exists because of the increased risk of progressive HCV-related liver disease. Grading: 1B 6.2.8 Where the pre-cART CD4 cell count was > 500 cells/μL and there is no HCV viraemia or fibrosis, cART should be discontinued. Grading: 2C 6.2.9 Where the CD4 cell count is > 500 cells/μL and there is HCV viraemia and evidence of liver inflammation or fibrosis, continuing cART is preferable because of a benefit on fibrosis progression. Grading: 2B 6.2.10 Where the CD4 cell count is between 350 and 500 cells/μL and there is no evidence of viraemia, inflammation, or fibrosis, continuing cART is recommended. Grading: 1C Section 7: Obstetric management 7.1 Antenatal care 7.1.1 Fetal ultrasound imaging should be performed as per national guidelines regardless of maternal HIV status. Grading: 1D 7.1.2 The combined screening test for trisomy 21 is recommended as this has the best sensitivity and specificity and will minimize the number of women who may need invasive testing. Grading: 1A 7.1.3 Invasive prenatal diagnostic testing should not be performed until after the HIV status of the mother is known and should ideally be deferred until HIV viral load has been adequately suppressed. Grading: 1C 7.1.4 If not on treatment and the invasive diagnostic test procedure cannot be delayed until viral suppression is achieved, it is recommended that women should commence cART to include raltegravir and be given a single dose of nevirapine 2–4 hours prior to the procedure. Grading: 1D 7.1.5 External cephalic version (ECV) can be performed in women with HIV. Grading: 2D 7.2 Mode of delivery For women taking cART, a decision regarding recommended mode of delivery should be made after review of plasma viral load results at 36 weeks. 7.2.1 For women with a plasma viral load of < 50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, a planned vaginal delivery is recommended. Grading: 1C 7.2.2 For women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, PLCS should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman's views. Grading: 1C 7.2.3 Where the viral load is ≥ 400 HIV RNA copies/mL at 36 weeks, PLCS is recommended. Grading: 1C 7.2.4 In women for whom a vaginal delivery has been recommended and labour has commenced obstetric management should follow the same guidelines as for the uninfected population. Grading: 1C 7.2.5 Vaginal birth after Caesarean section (VBAC) should be offered to women with a viral load < 50 HIV RNA copies/mL. Grading: 1D 7.2.6 Delivery by PLCS is recommended for women, except elite controllers, taking zidovudine monotherapy irrespective of plasma viral load at the time of delivery Grading: 1A 7.2.7 Delivery by PLCS is recommended for women with viral load > 400 HIV RNA copies/mL regardless of ART (see Recommendation 7.2.3). Grading: 2C 7.2.8 Where the indication for PLCS is the prevention of MTCT, PLCS should be undertaken at between 38 and 39 weeks' gestation. Grading: 1C 7.3 Management of spontaneous rupture of membranes 7.3.1 In all cases of term pre-labour spontaneous rupture of the membranes (ROM) delivery should be expedited. Grading: 1C 7.3.2 If maternal HIV viral load is < 50 HIV RNA copies/mL immediate induction of labour is recommended, with a low threshold for treatment of intrapartum pyrexia. Grading: 1C 7.3.3 For women with a last measured plasma viral load of 50–999 HIV RNA copies/mL, immediate Caesarean section should be considered, taking into account the actual viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman's views. Grading: 1C 7.3.4 If maternal HIV viral load is ≥ 1000 RNA copies/mL plasma immediate Caesarean section is recommended. Grading: 1C 7.3.5 The management of prolonged premature rupture of membranes (PPROM) at ≥ 34 weeks is the same as term ROM except women who are 34–37 weeks' gestation will require group B streptococcus prophylaxis in line with national guidelines. Grading: 1C 7.3.6 When PPROM occurs at < 34 weeks. Grading: 1C Intramuscular steroids should be administered in accordance with national guidelines Virological control should be optimized There should be multidisciplinary discussion about the timing and mode of delivery 7.4 Use of intrapartum intravenous infusion of zidovudine 7.4.1 Intrapartum intravenous zidovudine infusion is recommended in the following circumstances. For women with a viral load of > 1000 HIV RNA copies/mL plasma who present in labour, or with ruptured membranes or who are admitted for planned CS Grading: 1C For untreated women presenting in labour or with ruptured membranes in whom the current viral load is not known. Grading: 1C In women on zidovudine monotherapy undergoing a PLCS intravenous zidovudine can be considered. Continued oral dosing is a reasonable alternative. Grading: 1B Section 8 Neonatal management 8.1 Infant post-exposure prophylaxis (PEP) 8.1.1 Zidovudine monotherapy is recommended if maternal viral load is < 50 HIV RNA copies/mL at 36 weeks' gestation or thereafter prior to delivery (or mother delivered by PLCS whilst on zidovudine monotherapy). Grading: 1C 8.1.2 Infants < 72 hours old, born to untreated HIV-positive mothers, should immediately initiate three-drug therapy for 4 weeks. Grading: 1C 8.1.3 Three-drug infant therapy is recommended for all circumstances other than Recommendation 8.1.1 where maternal viral load at 36 weeks' gestation/delivery is not < 50 HIV RNA copies/mL. Grading: 2C 8.1.4 Neonatal PEP should be commenced very soon after birth, certainly within 4 hours. Grading: 1C 8.1.5 Neonatal PEP should be given for 4 weeks. Grading: 1C 8.2 Pneumocystis pneumonia (PCP) prophylaxis 8.2.1 PCP prophylaxis, with co-trimoxazole, should be initiated from age 4 weeks in: All HIV-infected infants. Grading: 1C Infants with an initial positive HIV DNA/RNA test result (and continued until HIV infection has been ex