It is also reassuring that in a randomized

trial of fundal pressure to expel the baby during Caesarean section, no evidence of materno-fetal transfusion was found [246]. buy MLN0128 For women taking cART, a decision regarding recommended mode of delivery should be made after review of plasma viral load results at 36 weeks 7.2.1 For women with a plasma viral load of < 50 HIV RNA copies/mL at 36 weeks, and in the absence of obstetric contraindications, a planned vaginal delivery is recommended. Grading: 1C 7.2.2 For women with a plasma viral load of 50–399 HIV RNA copies/mL at 36 weeks, PLCS should be considered, taking into account the actual INCB024360 price viral load, the trajectory of the viral load, length of time on treatment, adherence issues, obstetric factors and the woman’s views. Grading: 1C 7.2.3 Where the viral load is ≥ 400 HIV RNA copies/mL at 36 weeks, PLCS is recommended. Grading:

1C Published cohort data from the UK and other European countries have shown MTCT rates of < 0.5% in women with plasma viral load < 50 HIV RNA copies/mL taking cART, irrespective of mode of delivery [4,24,247,248 ]. These studies support the practice of recommending planned vaginal delivery for women on cART with plasma viral load < 50 HIV RNA copies/mL. Among HIV-positive women else taking cART in pregnancy and delivering between 2000 and 2006 in the UK and Ireland, there was no difference in MTCT rate whether they delivered by planned Caesarean section (0.7%; 17/2286) or planned vaginal delivery (0.7% ;4/559; AOR 1.24; 95% CI 0.34–4.52). Median viral load on cART was < 50 HIV RNA copies/mL (IQR 50–184). MTCT was 0.1% (three transmissions) in 2117 women on cART with a delivery viral load of < 50 HIV RNA copies/mL. Two of the three infants were born by elective (pre-labour) Caesarean section (0.2%, 2/1135) and one by planned vaginal delivery (0.2%, 1/417); two of the three had evidence of in utero transmission (being HIV DNA PCR positive at birth).

In this study there were no MTCT data for specific viral load thresholds or strata above 50 HIV RNA copies/mL plasma, but in the multivariate analysis, controlling for ART, mode of delivery, gestational age and sex, there was a 2.4-fold increased risk of transmission for every log10 increase in viral load, with lack of ART and mode of delivery strongly associated with transmission [4]. Data from the ANRS French Perinatal cohort reported on 5271 women delivering between 1997 and 2004 of whom 48% were on cART. In women on cART with a delivery viral load of < 400 copies/mL there was no significant difference in MTCT rates according to mode of delivery, with 3/747 (0.