**4.6. What are the best moment and the recommended route for delivery?**

A cesarean section should be indicated at 38 weeks of gestation in women with HIV infection without ART during pregnancy, in women without a VL result at gestation week 34, or in cases of VL >1,000 copies/ml (Grade B recommendation).

A vaginal delivery may be allowed in mothers under ART from 24 weeks of gestation or earlier, with VL <1,000 copies/ml at week 34, CD4 T-cell counts above 250, and that additionally meet the following conditions:


Invasive maneuvers (amniocentesis, chorionic villus biopsy, internal monitoring, artificial rupture of membranes) and instrumental delivery (forceps, spatulas) should be avoided (Grade D recommendation) though oxytocin may be used for labor guidance. The use of methylergonovine for the management of uterine inertia should be avoided if the patient is using protease inhibitors.

Elective cesarean section at 38 weeks of gestation, before an eventual rupture of membranes or initiation of spontaneous labor, substantially reduces the risk of HIV transmission. On its own, elective cesarean section reduces the risk of HIV transmission in 50%. Cesarean section together with antiretroviral therapy during the antenatal period, during delivery and admin‐ istered to the newborn with the addition of termination of breastfeeding, achieves decreases close to 90% with final vertical transmission rates under 2% (Level 2++ evidence) [52-57].

Studies with large patient numbers have failed to show benefits in favor of cesarean section in women undergoing ART with VL <1,000 copies/ml. Shapiro showed transmission rates for vaginal delivery of 0.8 v/s 0.5 for cesarean section (OR 1.4 (0.2-6.4)) in patients with viral load lower than 1,000 copies/ml. (Level 2+ evidence) [53]. Moreover, cesarean section has been seen to cause 7-10-fold increases in morbidity, mainly infectious, as compared to vaginal delivery (Level 2+ evidence) [57]. Obstetric procedures that increase the risk of fetal exposure to maternal blood such as amniocentesis, villus biopsy, and invasive monitoring have been implicated by some researchers as transmission risk factors (Level 2+ evidence) [30]. The use of oxytocin is not contraindicated; however, ergot derivatives accumulate in patients receiving protease inhibitors because of the inhibitory action of the latter on cytochrome 3A4, and exaggerated vasoconstriction and ischemia have been described in relation with their use in association (Level 4 evidence) [15-20].

#### **4.7. Antiretroviral drugs used during delivery or cesarean section**

Intrapartum intravenous AZT shall be used in the indicated dose, regardless of the chosen route for delivery (Grade B recommendation), as follows:


Nevirapine 200 mg single dose before cesarean section shall be added in any of the following settings (Grade B recommendation):

**•** The late initiation of the protocol (later than 34 weeks and patients that failed to complete 4 weeks of ART upon delivery)

**•** VL week 34 >1,000 copies/ml

**•** Care provided by specialist physician

62 Trends in Basic and Therapeutic Options in HIV Infection - Towards a Functional Cure

Invasive maneuvers (amniocentesis, chorionic villus biopsy, internal monitoring, artificial rupture of membranes) and instrumental delivery (forceps, spatulas) should be avoided (Grade D recommendation) though oxytocin may be used for labor guidance. The use of methylergonovine for the management of uterine inertia should be avoided if the patient is

Elective cesarean section at 38 weeks of gestation, before an eventual rupture of membranes or initiation of spontaneous labor, substantially reduces the risk of HIV transmission. On its own, elective cesarean section reduces the risk of HIV transmission in 50%. Cesarean section together with antiretroviral therapy during the antenatal period, during delivery and admin‐ istered to the newborn with the addition of termination of breastfeeding, achieves decreases close to 90% with final vertical transmission rates under 2% (Level 2++ evidence) [52-57].

Studies with large patient numbers have failed to show benefits in favor of cesarean section in women undergoing ART with VL <1,000 copies/ml. Shapiro showed transmission rates for vaginal delivery of 0.8 v/s 0.5 for cesarean section (OR 1.4 (0.2-6.4)) in patients with viral load lower than 1,000 copies/ml. (Level 2+ evidence) [53]. Moreover, cesarean section has been seen to cause 7-10-fold increases in morbidity, mainly infectious, as compared to vaginal delivery (Level 2+ evidence) [57]. Obstetric procedures that increase the risk of fetal exposure to maternal blood such as amniocentesis, villus biopsy, and invasive monitoring have been implicated by some researchers as transmission risk factors (Level 2+ evidence) [30]. The use of oxytocin is not contraindicated; however, ergot derivatives accumulate in patients receiving protease inhibitors because of the inhibitory action of the latter on cytochrome 3A4, and exaggerated vasoconstriction and ischemia have been described in relation with their use in

Intrapartum intravenous AZT shall be used in the indicated dose, regardless of the chosen

**•** Maintenance dose: 1 mg/kg/h during cesarean section (to run 3 h after the loading dose) or

**•** In case AZT 200 mg is unavailable, the oral administration of AZT/3TC upon the initiation

Nevirapine 200 mg single dose before cesarean section shall be added in any of the following

**•** The late initiation of the protocol (later than 34 weeks and patients that failed to complete

**•** Loading dose: 2 mg/kg, infused over 1 h (in case of cesarean, 4 h prior to surgery)

**•** Informed consent from the patient

association (Level 4 evidence) [15-20].

during labor, until the cord is clamped

settings (Grade B recommendation):

4 weeks of ART upon delivery)

**4.7. Antiretroviral drugs used during delivery or cesarean section**

of labor or 4 h prior to scheduled cesarean section is recommended

route for delivery (Grade B recommendation), as follows:

using protease inhibitors.

**•** Intrapartum HIV (+) diagnosis that did not receive ART

When NVP is used intrapartum, AZT/3TC should be added for 7 days postpartum to decrease the risk of developing resistance to NVP (Grade B recommendation).

The use of IV AZT during delivery enables reaching effective fetal plasma levels thus generating a preexposure prophylaxis. The latter, together with the oral administration of AZT suspension to the newborn for 6 weeks, enables a postexposure prophylaxis that as a whole has an impact on VT regardless of the patient having received AZT within her ART regimen during pregnancy or even, in the case of an eventual resistance to AZT (Level 2+ + evidence) [53-55].
