Canadian consensus guidelines for the management of pregnant HIV-positive women and their offspring

Background: The optimal care of HIV-positive pregnant women and the prevention of mother-to-child transmission of HIV have become important health care issues, in Canada and throughout the world. Patterns of care for HIV-positive pregnant women and their infants have changed dramatically over the past 5 years, with advances in our understanding of HIVrelated disease and its treatment and of the pathogenesis of perinatal HIV transmission, as well as advances in our ability to successfully intervene. Combination antiretroviral therapy is now recognized as standard care in pregnancy, despite limited data on safety, tolerability and efficacy, and this therapy is associated with marked reductions in rates of perinatal HIV transmission. Optimal management of labour and delivery is also vital for improving maternal and infant outcomes. Previous guidelines for the care of HIV-positive individuals have focused on nonpregnant adults or were published before the introduction of combination antiretroviral regimens and before changes in management of labour and delivery. For these reasons, new Canadian guidelines were needed. Objective of guidelines: To assist HIV-positive women and their care teams in making decisions regarding optimal management during pregnancy, delivery and the postpartum period. Benefits of implementing guidelines: Optimal prenatal, intrapartum and postpartum care of the woman and her infant will result in significant reduction in perinatal HIV transmission (from about 25% to less than 1% with optimal care), improve pregnancy outcomes, minimize the risk of toxic effects to the fetus/neonate, and improve short-term and long-term health outcomes for the mother. Methods: In October 1998, a representative group of Canadian HIV and infectious disease specialists, obstetricians, family physicians, pediatric HIV specialists, and community members convened to review recently published guidelines and their supporting scientific literature. Common clinical scenarios were discussed, and group consensus was achieved for recommended approaches to management. Information that became available later (either in published form or through presentations at major HIV and infectious disease conferences) was systematically reviewed before the guidelines were finalized. Multiple drafts of the guidelines were reviewed by all workshop participants. In addition, the guidelines were reviewed and endorsed by the Canadian Pediatric AIDS Research Group and the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada. The supporting evidence for all recommendations was evaluated, and levels of evidence are indicated. Recommendations: Recommendations for preconception counselling and HIV testing, antenatal care, intrapartum care and postpartum care of both the mother and the infant were developed. [please set link to “Recommendations for the management …” section later in this document] Clinical scenarios: Specific recommendations were developed for the management of 7 common clinical scenarios: an HIV-infected pregnant woman who is not receiving antiretroviral therapy when pregnancy is confirmed; an HIV-infected pregnant woman receiving combination antiretroviral therapy when pregnancy is confirmed; a woman diagnosed with HIV infection, who presents or is referred for care within 1 month of term; a woman who probably has detectable plasma viral load at term (because of suboptimal antiretroviral therapy during the pregnancy, problems with adherence or other drug-related issues, or lack of pregnancy care); an infant born to a known HIV-positive mother who received no antiretroviral therapy during pregnancy or intrapartum; a woman who experiences primary HIV infection (seroconversion) during pregnancy; and a pregnant woman presenting at delivery with significant risk factors but unknown HIV status. These scenarios are discussed in a separate CMAJ Practice article. Conclusions: The care of HIV-positive pregnant women and their infants is complex. Ideally, such care should involve the woman herself, her HIV specialist, an HIV-experienced obstetrician and a pediatric HIV specialist. The assistance of a pharmacist and a dietitian with HIV expertise is also invaluable. This area of medicine and science is evolving, and it is anticipated that these guidelines will also evolve.