There are “missed
opportunities” for HIV-positive pregnant women with a suppressed viral load to
give birth vaginally, European research published in the Journal of Acquired Immune Deficiency Syndromes shows.
Europe recommend or permit a vaginal delivery when a woman has an undetectable
or very low viral load. However, investigators found that over a third of women with
viral suppression and no contraindications continue to have a caesarean
“Rates of vaginal
deliveries were lower than expected,” comment the authors. “Our results suggest that the policy for
vaginal delivery among women among women with undetectable or very low VL
[viral load] is only slowly becoming established within practice over time.”
caesarean section delivery – a caesarean
performed before the onset of labour or the rupture of membranes – was
recommended for HIV-positive women in 1999 when it was shown to reduce the risk
of mother-to-child transmission of HIV.
The widespread use
of combination antiretroviral therapy has reduced the risk of mother-to-child
transmission dramatically and rates of below 1% are seen across Europe. The additional
benefits of an elective caesarean section are open to question, especially as
the procedure can also involve risks.
Over the past
decade, guidelines across Europe for the management of HIV infection during
pregnancy have been changed and now recommend or permit a vaginal delivery for
women taking antiretroviral therapy with an undetectable or low (below 50
copies/ml and, in some circumstances, below 400 copies/ml) viral load.
wanted to see if these changes to guidelines had impacted on rates of women
with a suppressed viral load giving birth vaginally. To answer this question
they examined data collected between 2000 and 2010 in two studies (the European
Collaborative Study and the Swiss Mother and Child HIV Cohort Study). Data on 3013 deliveries to 2663 women were
available for analysis.
Overall, 48% of
the women were black, and the median maternal age at delivery was 32 years.
Three-quarters of the women were infected with HIV via heterosexual contact,
and 16% reported a history of injecting drug use. Most of the women (84%) had
no symptoms of HIV disease and the median CD4 cell count was 452 cells/mm3.
Only 8% of participants had severe immune suppression (a CD4 cell count below 200
women were aware they had HIV before conceiving and in a quarter of pregnancies
the participant conceived while taking antiretroviral drugs.
Only 8% of mothers
did not receive any HIV treatment during pregnancy or delivery. The proportion
receiving no antenatal therapy decreased after the introduction of new
guidelines from 9 to 4%.
Of the 1527 women
who initiated treatment during pregnancy, 78% did so during the first or second
The proportion of
women taking combination HIV treatment who achieved a viral load below 400
copies/ml at the time of delivery increased from 83 to 95% after the new
guidelines were in place.
were associated with a detectable viral load at the time of delivery. These
included late diagnosis during pregnancy (p < 0.001), younger age (p =
0.005), history of injecting drug use (p = 0.015), use of dual/monotherapy (p
< 0.001) and a CD4 cell count below 500 cells/mm3 (p < 0.001).
The proportion of
women giving birth vaginally increased from 17 to 52% after the change in
analysis to the 611 births after guidelines recommended or permitted vaginal
delivery showed that 45% of those to women with an undetectable viral load and
57% of those to women with a viral load between 50 and 399 copies/ml were
of deliveries after the guidelines change were via emergency caesarean section.
A fifth of emergency caesarean sections involved women with an undetectable
In the years
following the introduction of the guidelines, caesarean section was the mode of
delivery for 55% of women with an undetectable viral load. In a third of cases
there was a factor indicating the need for this mode of delivery. However, in
35% of cases the woman could have had a vaginal delivery.
pregnancy outcomes showed that 21% of deliveries were premature. Median birth
weight was 2.9 kg. The overall rate of mother-to-child-transmission was 1.6%.
The rate was 1.7% before the new guidelines but fell to 0.6% after their
“Rates of vaginal
delivery in HIV-positive pregnant women are increasing for women with
suppressed VL,” conclude the authors. “Despite this, there is evidence of
missed opportunities for viral suppression and for having a vaginal delivery in
women with a suppressed viral load.”