Page 22 - HIVMED_v21_i1.indb

Page 4 of 8 Guideline

BOX 1: Use of dolutegravir in women of childbearing potential. If suppressed, the VL should be repeated at delivery. For
Care should be provided in ways that respect women’s autonomy in decision- WLWH and who are already on ART, the VL should be
making about their health, and services must provide information and options to
enable women to make informed choices. To this end, all women considering measured at the first antenatal care visit, as per previous
22
the use of dolutegravir (DTG) should be informed of the following:
guidelines. If suppressed, the VL is repeated at delivery,
• Dolutegravir is an effective and well tolerated antiretroviral drug that is safe to
use during pregnancy after closure of the foetal neural tube (from the seventh unless subsequent VL non-suppression is suspected. Accurate
week of pregnancy onwards). Current evidence indicates that DTG is safe to recording, of antenatal maternal VL testing data in the
use during lactation. 23,24
maternity case record, is crucial to ensure communication and
• Using DTG at the time of conception carries an approximately 0.3% risk of a
neural tube defect (NTD) in the infant, according to currently available continuity of care between antenatal and delivery services.
evidence. This compares to a 0.1% background risk of having a child with a
NTD if an alternative regimen is used. 20
• It is advised that any non-pregnant woman using DTG should use reliable and Women initiating ART at any time after 28 weeks gestation
effective contraception (hormonal methods or an intra-uterine contraceptive will have a VL measurement done at delivery and repeated
device). On subsequent changes in a woman’s fertility intentions, coupled with
concerns about the risk of NTDs, a switch from TLD to TEE may be offered, three months after delivery. If the mother-infant pair is
provided a suppressed HIV viral load in the last six months has been
documented. receiving integrated care, this VL should be aligned to the
• Women already on antiretroviral therapy wanting to switch to a DTG- 10-week well-child immunisation visit.
containing regimen should be aware of the following in addition to the points
listed above:
ß New side effects may be experienced when switching from an Viral load monitoring at delivery and six months
EFV-containing regimen to a DTG-containing regimen (insomnia, after delivery
headache or gastro-intestinal disturbances). These are uncommon,
usually mild and self-limiting, and should be reported to the health Previous implementation of VL monitoring in the PMTCT
care provider immediately without stopping treatment.
programme has been suboptimal. Thus, the VL monitoring
ß Efavirenz-based regimens should be taken at night, whilst the
DTG-based regimens can be taken either in the morning or at night. schedule, that had been linked to the ART history and timing
If insomnia is experienced, morning dosing might be preferable.
of ANC booking, has been changed to fixed time points
DTG, dolutegravir; NTD, neural tube defects; EFV, efavirenz; TLD, tenofovir,
lamivudine and dolutegravir; TEE, tenofovir, emtricitabine and efavirenz. linked to the pregnancy itself. A VL at delivery has, therefore,
been introduced for all WLWH. Much debate has ensued
Antiretroviral therapy is to be continued the following day with regard to the best timing of a VL around the time of
after understanding the woman’s fertility intentions and delivery. Whilst results of a VL done at 36 weeks’ gestation
appropriate counselling on the risk of DTG-associated NTDs would be available by the time of delivery, a significant
for her subsequent pregnancies. The recommended regimen proportion of women, including those with premature
in the period after birth is TLD. Concurrent use of effective labour, those with uncertain gestational age, and un-booked
contraception is recommended for all women at discharge deliveries, would not receive a VL at 36 weeks’ gestation.
from labour wards. Additionally, antenatal care usually occurs at a different
facility from delivery, and antenatal VL results may not be
Maternal human immunodeficiency virus viral available at the delivery site.
load monitoring
Potent ART regimens are most effective when coupled with A VL done at the actual time of delivery has the following
HIV VL monitoring to confirm good adherence and viral advantages:
suppression or to allow the timely detection of factors that • High in-facility birth rates, and previous rapid uptake
may negatively affect viral suppression (e.g. suboptimal and high coverage of infant birth PCR testing within
treatment adherence, drug interactions, intercurrent infections, labour wards, infer the possibility of near-universal
etc.). Importantly, VL monitoring can only be effective if coverage of the delivery VL.
coupled with a response to the test results, and women with • Uniformly performed VLs at time-point of delivery will
detectable VL results (VL > 50 c/mL) must be followed up for enable the health system to monitor and better enforce
urgent intervention, directed to ensure immediate viral the coverage of maternal VL testing.
suppression. Accurate national surveillance of maternal VL • Viral load testing at delivery allows for placing of the
suppression will require a means to distinguish between VLs reference to the maternal laboratory testing into the
done during antenatal care, at delivery, and after birth. Within infant’s Road-to-Health Booklet to provide a potential
the public sector this will be achieved through the use of link for PMTCT interventions, promoting integrated care
electronic gatekeeping codes submitted on National Health for the mother-infant pair and ensuring consideration of
Laboratory Service (NHLS) requisition forms (code maternal laboratory results during infant health care
C#DELIVERY applied to VLs at delivery, and C#PMTCT provision.
applied to VLs during the antenatal and postpartum periods). • It provides a means of epidemiological surveillance of
Of great importance, colleagues in the private sector may wish vertical transmission risk at delivery.
to discuss with their laboratory service the value or feasibility
of implementing such a coding system in their practice.
Given that more than half of vertical transmissions now
occur after delivery, 8,27 linked to postpartum challenges to
Viral load monitoring during the antenatal adherence and retention in care, 9,10,11,12 a maternal VL should
period be done at six months after delivery for all WLWH, aligned
Women initiating or re-initiating ART in pregnancy should to the six-month well-child immunisation visit, regardless of
have their first VL measured three months after starting ART. breastfeeding status. As the maternal VL impacts directly on

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