British HIV Association guidelines for the management of HIV infection in pregnant women 2018
The overall purpose of these guidelines is to provide guidance on best clinical practice in the treatment and management of pregnant women living with HIV (human immunodeficiency virus) in the UK and their infants. The scope includes guidance on the use of antiretroviral therapy (ART) both to prevent vertical transmission of HIV 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 living with HIV. The 2018 guidelines have identified significant developments that have either led to a change in recommendation or a change in the strength of recommendation. More detail has been added in areas of controversy, particularly breastfeeding. New data that simply support the existing data have not routinely been included in this revision. A new section on the postnatal management of women has been added. 1.1
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 and Vice Chair of the Writing Group, who then nominated a Writing Group of experts in the field based on their knowledge, expertise and freedom from conflicts of interest. In addition, BHIVA members were asked to come forward as authors for the guidelines, again 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 2018 guidelines covered the period from July 2013 up until July 2017 and included abstracts from selected conferences. 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 randomised controlled trials in several important areas the Writing Group was unable to assign high grades (in areas such as mode of delivery); however, recommendations have been given on best practice where decisions need to be made on the balance of available evidence. Recommendations are summarised 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.
1.2 Patient involvement BHIVA views the involvement of patient and community representatives in the guideline development BHIVA guidelines on the management of pregnancy for women living with HIV 7 process as both important and essential. The Writing Group included a patient representative who was involved in all aspects of the guideline development.
1.3 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
1.4 Summary of guideline update and date of next review There have been some changes in recommendations. The prevalence data from the UK have been updated.
• We have updated infant feeding advice to include new data on breastfeeding and the emotional impact not breastfeeding may have on women. We discuss the use of cabergoline in nonbreastfeeding women. Length of infant PEP has been shortened where risk of vertical transmission is VERY LOW.
• We have expanded the section on 'The psychosocial care of women living with HIV during and after pregnancy' and moved its position within the guidelines.
• Safety: new data on raltegravir, rilpivirine, dolutegravir, elvitegravir.
• Prescribing: all women are recommended to start on treatment and remain on it lifelong.
As this includes elite controllers this section has been removed.
• Hepatitis: information added on tenofovir alafenamide for hepatitis B and direct acting agents for hepatitis C.
• We have added a section on the postnatal management of women living with HIV. The guidelines will be next fully updated and revised in 2023. 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.
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