title: Missed opportunities among HIV-positive women to control viral replication during pregnancy and to have a vaginal delivery.
abstract: BACKGROUND
  Most national guidelines for the prevention of mother-to-child transmission of HIV in Europe updated between 2001 and 2010 recommend vaginal deliveries for women with undetectable or very low viral load (VL). Our aim was to explore the impact of these new guidelines on the rates of vaginal deliveries among HIV-positive women in Europe.
  
  
  METHODS
  In a pooled analysis of data on HIV-positive pregnant women enrolled in the Swiss Mother & Child HIV Cohort Study and the European Collaborative Study 2000 to 2010, deliveries were classified as occurring pre- or postpublication of national guidelines recommending vaginal delivery.
  
  
  RESULTS
  Overall, 2663 women with 3013 deliveries were included from 10 countries; 28% women were diagnosed with HIV during pregnancy. Combination antiretroviral therapy was used in most pregnancies (2020, 73%), starting during the first or second trimester in 78% and during the third trimester in 22%; in 25% pregnancies, the woman conceived on combination antiretroviral therapy. Overall, in 86% pregnancies, a VL < 400 copies per milliliter was achieved before delivery. The proportion of vaginal deliveries increased from 17% (414/2377) before the change in guidelines to 52% (313/600) after; elective Caesarean section rates decreased from 65% to 27%. The proportion of women with undetectable VL having a Caesarean section was 55% after implementation of new guidelines. We observed a decrease of late preterm deliveries from 16% (377/2354) before to 7% (42/599) after the change in guidelines (P < 0.001).
  
  
  CONCLUSIONS
  There are still missed opportunities for women with HIV to fully suppress their VL and to deliver vaginally in Europe.
authors.affiliation: Department of Obstetrics and Gynecology, University Women's Hospital Basel, Basel CH-4031, Switzerland. mail@aebi-popp.com
authors.forename: Karoline
authors.initials: K
authors.lastname: Aebi-Popp
authors.forename: Fiona
authors.initials: F
authors.lastname: Mulcahy
authors.forename: Tracy R
authors.initials: TR
authors.lastname: Glass
authors.forename: Christoph
authors.initials: C
authors.lastname: Rudin
authors.forename: Begona
authors.initials: B
authors.lastname: Martinez de Tejada
authors.forename: Barbara
authors.initials: B
authors.lastname: Bertisch
authors.forename: Jan
authors.initials: J
authors.lastname: Fehr
authors.forename: Claudia
authors.initials: C
authors.lastname: Grawe
authors.forename: Kathrin
authors.initials: K
authors.lastname: Scheibner
authors.forename: Martin
authors.initials: M
authors.lastname: Rickenbach
authors.forename: Irene
authors.initials: I
authors.lastname: Hoesli
authors.forename: Claire
authors.initials: C
authors.lastname: Thorne
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D002585:Cesarean Section / Q000706:statistics & numerical data*; D015331:Cohort Studies; D036861:Delivery, Obstetric / Q000706:statistics & numerical data*; D004359:Drug Therapy, Combination; D017558:Elective Surgical Procedures / Q000706:statistics & numerical data; D005060:Europe / Q000453:epidemiology; D005260:Female; D017408:Guidelines as Topic; D015658:HIV Infections / Q000188:drug therapy / Q000517:prevention & control* / Q000635:transmission; D006291:Health Policy; D006801:Humans; D007231:Infant, Newborn; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control* / Q000706:statistics & numerical data; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control*; D019562:Viral Load / Q000187:drug effects*; D014779:Virus Replication
chemical_list: D019380:Anti-HIV Agents