The randomized PROMISE study should provide a definitive answer to this question. Recent data indicate a 96% reduction in transmission between heterosexual discordant couples if the infected partner is treated with cART [178]. Therefore a women with a baseline CD4 cell count > 350 cells/μL and an HIV viral load > 50 HIV RNA copies/mL can be offered continued therapy with cART in this setting. 5.6.5. ART should be discontinued in all women who commenced
cART for PMTCT with a CD4 cell count of > 500 cells/μL unless there is discordance with her partner or co-morbidity as outlined in Section 6: HIV learn more and hepatitis virus co-infections. Grading: 2B Only one cohort study has demonstrated benefit in starting therapy in adults who have a CD4 cell count > 500 cells/μL (NA-ACCORD) [173]: specifically, this was not observed in the ART-CC analysis [174]. In addition, several small CD4-guided interruption studies using a higher threshold than SMART of commencing below 350 cells/μL (TRIESTAN [179], STACCATO [180]) and seroconversion treatment studies have not shown significant clinical benefit with fixed courses of early treatment [181]. Lastly, durable CD4 cell count benefits have been demonstrated in women receiving short-term find more ARV therapy to prevent MTCT when initiating above 500 cells/μL indicating no short-term harm in this strategy
and possible benefits [182]. The combination of HIV, chronic hepatitis B virus (HBV) infection and pregnancy presents unique management questions. Referral to the local designated specialist should be undertaken to ensure that all aspects of care, including the effects of HBV/HIV on pregnancy, effects of pregnancy on the course of co-infection, drug management for both HBV and HIV, and prevention of mother-to-infant transmission
for both viruses are addressed. Pregnant women with advanced cirrhosis should be managed in a tertiary centre with a hepatologist. The prevalence of HBV co-infection in pregnant women tends to RAS p21 protein activator 1 reflect that of the adult population (Europe/Africa 4–10%) [183-186] and is 40% higher than that found in the general population (HIV positive vs. HIV uninfected: RR 1.40; 95% CI 1.16–1.69) [186]. Up to one-third of HBsAg are wild type (HBeAg-positive) and, depending on region, up to 6% co-infected with hepatitis delta virus. Rates of HBV/HIV co-infection vary with race and ethnicity so that changing immigration patterns in Western countries with traditionally low prevalence may significantly influence rates at a regional level (e.g. 6% amongst Asian women in the USA vs. 0.6% in white women) [187]. The same is true for injection drug use (prevalence < 0.1% in North-West Europe compared to 1–4% in Southern Europe) and sexual transmission (prevalence higher in MSM).