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 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. GKT137831 Grading: 1C   Exceptions are:     (1) Protease inhibitor (PI) monotherapy should be intensified to include (depending on tolerability, resistance and prior antiretroviral selleck chemical 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 5.2.1 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: PLEKHM2 1C 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.