7.1.2 When to start ART in pregnant and breastfeeding women

Consolidated ARV guidelines, June 2013

Rationale and supporting evidence: Lifelong ART versus stopping ART after the risk of mother-to-child HIV transmission ends

The recommendation to provide lifelong ART to all pregnant and breastfeeding women with HIV or to continue ART only for those meeting treatment eligibility criteria for the woman’s health is conditional, based on the epidemic setting and country programme, and because of the lack of conclusive evidence on the impact and efficacy of fully implementing lifelong ART.

In generalized epidemic settings and in settings with limited access to CD4 testing, limited partner testing, long duration of breastfeeding or high rates of fertility, the benefits of lifelong ART for all pregnant and breastfeeding women with HIV are clear. It will assure maximum coverage for those needing treatment for their own health, avoid stopping and starting drugs with repeat pregnancies, provide early protection against mother-to-child transmission in future pregnancies, reduce the risk of HIV transmission to HIV-serodiscordant partners and improve maternal health.

With the new treatment eligibility threshold of CD4 ≤500 cells/mm3, approximately 60% of HIV-infected pregnant women will meet treatment eligibility criteria for their own health (97). Although not well quantified, it is likely that at least an additional 10–20% of women would become eligible for treatment over the subsequent two years after birth.

In countries with concentrated epidemics that have high access to CD4 testing, adequate capacity to provide ART to the pregnant and breastfeeding women eligible for treatment, low fertility rates and/or where breastfeeding for mothers with HIV is not recommended, consideration can be given to stopping the ARV drugs in women not eligible for ART after the period of mother-to-child transmission risk has ended.

Regardless of the approach, special effort and supportive initiatives are needed to optimize adherence, especially during breastfeeding, where many programmes currently have poor follow-up, and to assure effective linkages to long-term treatment. Chapter 10 provides additional guidance for national programmes on making the decision between lifelong ART and stopping ART (Box 10.4).

Enhanced ARV toxicity surveillance for exposure throughout pregnancy and the breastfeeding period is critical to evaluate the safety of this approach for women, the fetus and the child. This is especially true as an increasing number of women already receiving ART become pregnant, resulting in much higher levels of ARV drug exposure during early gestation (see Sections 7.2.2 on “What ART regimen to start with” and 7.4 on “Monitoring and substitutions for ARV drug toxicities”). In addition, implementation research is important to ensure that the many gaps in knowledge associated with lifelong ART are addressed.