Postpartum Follow-Up of People with HIV

Actualizado Reviewed
Panel's Recommendations
  • Continuous antiretroviral therapy (ART) currently is recommended for all individuals with HIV to reduce the risk of disease progression and prevent the sexual transmission of HIV (AI).
  • ART should be continued after delivery (AI). Any plans for modifying ART after delivery should be made in consultation with the individual and their HIV care provider, ideally before delivery, taking into consideration the recommended regimens for nonpregnant adults (AIII) and plans for future pregnancies.
  • Because the immediate postpartum period poses unique challenges to ART adherence and retention in HIV care, arrangements for new or continued supportive services should be made throughout pregnancy and before postpartum hospital discharge (AII).
  • People with a positive HIV test during labor should receive confirmatory testing; see Pregnancy and Postpartum HIV Testing and Identification of Perinatal and Postnatal HIV Exposure. If testing confirms HIV infection, ART should be offered, and the person should be given a supply of ART before postpartum hospital discharge to prevent treatment interruption (AII). Immediate linkage to HIV care and comprehensive follow-up also is needed (AII).
  • Infants of people who have HIV newly diagnosed in the intrapartum period should begin presumptive HIV therapy, and a supply of ART for their infants should be provided before postpartum hospital discharge (AII) (see Antiretroviral Management of Infants with Perinatal HIV Exposure or HIV Infection).
  • People with HIV should receive evidence-based counseling to support shared decision-making about infant feeding options prior to and during pregnancy; counseling and plans for infant feeding should be reviewed again after delivery (AIII) (see Infant Feeding for Individuals with HIV in the United States).
  • Clinicians should discuss future reproductive plans and timing, as well as the risks and benefits of conceiving while on specific antiretroviral (ARV) medications (AII). The use of appropriate contraceptive options to prevent unintended pregnancy and optimal interpregnancy intervals should also be discussed (AII) (see Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV).
  • Contraceptive counseling should involve shared decision-making and should start during the prenatal period; a contraceptive plan should be developed before postpartum hospital discharge, as desired by the patient (AII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

The postpartum period provides an opportunity to review and optimize a patient’s health care. Comprehensive medical care and supportive services are particularly important for people with HIV and their families, who often face multiple medical and social challenges. Components of comprehensive care include the following services, as needed:

  • Primary care, gynecologic/obstetric care, and HIV specialty care;
  • Pediatric and pediatric HIV specialty care for the infant;
  • Sexual and reproductive health services, including contraception;
  • Mental health services;
  • Substance use prevention and treatment;
  • Supportive services;
  • Coordination of care through case management for the patient, their child (or children), and other family members; and
  • Prevention of secondary transmission for partners with differing HIV status, including counseling on the use of condoms, antiretroviral therapy (ART) to maintain virologic suppression in the partner with HIV (i.e., treatment as prevention), and the potential use of pre-exposure prophylaxis (PrEP) by the partner without HIV (see Pre-exposure Prophylaxis [PrEP] to Prevent HIV During Periconception, Antepartum, and Postpartum Periods).

Supportive services should be tailored to the individual’s needs and can include screening for intimate partner violence; case management; childcare; respite care; assistance with basic needs, such as housing, food, and transportation; peer counseling; and legal and advocacy services. Ideally, these services should begin before pregnancy and continue throughout pregnancy and the postpartum period.

During the postpartum period, immediate linkage to care, comprehensive medical assessment, counseling, and follow-up are required for all people with HIV and particularly for those who have a new positive HIV test during labor or at delivery. This is important because intrapartum diagnosis of HIV has been negatively associated with HIV care outcomes in the postpartum period.1,2 The American College of Obstetricians and Gynecologists recommends that all people have contact with their obstetrician-gynecologists within 3 weeks postpartum and that postpartum care be provided as an ongoing process based on an individual’s needs rather than as a single postpartum visit.3 People with HIV, particularly those who struggle with ART adherence, should have a follow-up appointment with the health care provider who manages their HIV care—whether that is an obstetrician or an HIV health care provider—within 2 to 4 weeks of postpartum hospital discharge. People who have difficulty attending in-person appointments should consider telemedicine visits.4

When care is not co-located or not within the same health care system, a case manager’s role for care coordination becomes even more crucial. People who are receiving case management are more likely to have viral suppression and be retained in care.5 Alternative models of HIV care delivery—such as HIV-adapted group prenatal care—have been associated with higher retention in HIV care for women in the postpartum period.6 Ensuring continuity of ART between the antepartum and postpartum periods is especially critical. People with HIV newly diagnosed in the intrapartum period should receive ART, and presumptive HIV therapy should be initiated immediately for the newborn before hospital discharge. Special hospital programs may need to be established to support dispensing ART to birthing parents before discharge.

Transgender and gender-diverse people who were assigned female sex at birth may require additional support and linkage to care during the postpartum period (see Perinatal HIV Prevention for Transgender and Gender-Diverse People Assigned Female at Birth).7-9

Postpartum Antiretroviral Therapy

ART should be continued postpartum. Decisions about changes to an ART regimen after delivery should be made after discussion between the individual and their HIV care provider, ideally before delivery. When providing counseling about postpartum ART, health care providers should consider the person’s desire for future planned pregnancies or the potential for unplanned pregnancies in the context of the person’s anticipated ART regimen, choice of contraceptive, and the potential for any drug–drug interactions during the postpartum period that were not an issue during pregnancy (see Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV and Appendix C: Antiretroviral Counseling Guide for Health Care Providers). Some ART regimens that are recommended for nonpregnant adults may not be recommended for use during pregnancy or for people who are trying to conceive (see the Adult and Adolescent Antiretroviral Guidelines). See Recommendations for Use of Antiretroviral Drugs During Pregnancy, Table 4. Antepartum Screenings and Assessments for Pregnant People with HIV, Table 5. HIV-Related Laboratory Monitoring Schedule for Pregnant People with HIV, Teratogenicity, and Antiretroviral Drug Regimens and Pregnancy Outcomes for additional information and specific recommendations regarding regimens for use during pregnancy and when trying to conceive.

ART is currently recommended for all individuals with HIV to reduce the risk of disease progression and to prevent secondary transmission of HIV.10 The Strategic Timing of AntiRetroviral Treatment (START)11 and TEMPRANO trials12 were randomized clinical trials that demonstrated that early ART can reduce the risk of disease progression, even in individuals with CD4 T lymphocyte cell counts >500 cells/mm3, and the HIV Prevention Trials Network (HPTN) 052 randomized clinical trial demonstrated that effective ART can reduce the risk of sexual transmission of HIV to a partner without HIV by 100%.13 People with HIV who take ART as prescribed and achieve and maintain an undetectable viral load have effectively no risk of transmitting HIV through sex (i.e., Undetectable = Untransmittable).14

Helping people with HIV understand the need for lifelong ART is a priority during postpartum care. Several studies have demonstrated significant decreases in ART adherence postpartum.15-19 During the postpartum period, people may have difficulty with medical appointment follow-up—including appointment adherence—which can affect ART adherence. Systematic monitoring of retention in HIV care is recommended for all individuals with HIV, but special attention is warranted during the postpartum period.

Adherence to ART and Postpartum Depression

Symptoms of depression have been associated with lower ART adherence and viral suppression during pregnancy and the postpartum period.20 Furthermore, postpartum depression is common among people with HIV.2,21-24 The U.S. Preventive Services Task Force recommends screening all postpartum people for postpartum depression25 using a validated tool (e.g., the Edinburgh Postnatal Depression Scale); such screening is especially important for people with HIV who appear to be at increased risk for postpartum depression and poor ART adherence during the postpartum period. Enquiring about intimate partner violence, food or housing insecurity, and substance use is also important, as these factors have been associated with worsening depressive symptoms.26 People should be counseled that postpartum physical and psychological changes (and the stresses and demands of caring for a new baby) may make adherence more difficult and that additional support may be needed during this period.5,27-30

Poor adherence has been shown to be associated with virologic failure, development of antiretroviral (ARV) drug resistance, and decreased long-term effectiveness of ART.31-33 In people who achieve viral suppression by the time of delivery, postpartum ART simplification to once-daily, coformulated regimens—which are often the preferred initial regimens for nonpregnant adults—could promote adherence during this challenging time. Efforts to maintain adequate adherence during the postpartum period may ensure effectiveness of therapy (see Adherence to the Continuum of Care in the Adult and Adolescent Antiretroviral Guidelines). For people who are continuing ART and who received increased protease inhibitor doses during pregnancy, available data suggest that doses can be reduced to standard doses immediately after delivery. In addition, such behavioral interventions as peer support and text messaging may help improve retention in HIV care postpartum.34

Secondary Sexual Transmission and Contraception

The postpartum period is a critical time for addressing safer sex practices to reduce secondary transmission of HIV to partners,35 and clinicians should begin discussing these practices with the patient during the prenatal period. Topics for discussion during counseling on prevention of secondary transmission to the partner without HIV should include condom use, ART for the partner with HIV to maintain viral suppression below the limit of detection, and the potential use of PrEP by the partner without HIV. With full, sustained viral suppression (undetectable viral load) in the person with HIV—with or without reliable PrEP use by the partner—there is no risk of sexual transmission (see Reproductive Options for Couples When One or Both Partners Have HIV and National Institutes of Health’s Treatment as Prevention guidance for more information).

Comprehensive prepregnancy counseling and contraception should be integrated into all health care visits, with special attention given to these topics during routine prenatal and postpartum visits. Lack of breastfeeding is associated with earlier return of fertility. Ovulation returns as early as 6 weeks postpartum, and it can occur earlier in some people—even before resumption of menses—putting them at risk of pregnancy soon after delivery.36 HIV does not preclude the use of any contraceptive method (see Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives). The contraceptive plans for people with HIV should not differ from those for people without HIV; however, because of the significantly higher prevalence of unplanned pregnancy in people with HIV,37 establishing contraceptive plans early, using shared decision-making, is important. If a long-acting reversible contraceptive (LARC)—such as an injectable, implant, or intrauterine device (IUD)—is desired by the patient, it should be inserted before postpartum hospital discharge or during the routine postpartum visit. If LARC insertion is planned for the postpartum visit and the patient desires a contraceptive method in the interim, intramuscular depot medroxyprogesterone acetate is an option that can be given before postpartum hospital discharge. People should be advised to avoid interpregnancy intervals shorter than 6 months.3,38,39

The potential for drug–drug interactions between several ARV drugs and hormonal contraceptives is discussed in Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV and Table 3. Drug Interactions Between Antiretroviral Agents and Hormonal Contraceptives. A systematic review conducted for the World Health Organization summarized the research on hormonal contraception, IUD use, and risk of HIV infection and concluded that women with HIV can use all forms of contraception.40,41 This is consistent with Centers for Disease Control and Prevention recommendations advocating access to a broad range of effective contraceptive methods, including combined hormonal contraceptives, progestin-only pills, depot medroxyprogesterone acetate, and implants.42

Infant Feeding

People with HIV should receive evidence-based counseling to support shared decision-making about infant feeding options prior to and during pregnancy (see Infant Feeding Counseling for Individuals with HIV in the United States. Counseling and plans for infant feeding should be reviewed again after delivery.

Lactation Inhibition

For people who do not breastfeed, symptoms related to breast engorgement can be very unpleasant in the days following labor and delivery. Supportive measures—such as using acetaminophen or ibuprofen for pain control, alternating hot and cold compresses on the breasts, or wearing a tight-fitting bra—can help relieve symptoms related to breast engorgement.3 Although pharmacologic options for lactation inhibition generally are not used in the United States, recent data suggest cabergoline may be appropriate for some people.43,44 Cabergoline is a dopamine agonist/ergot derivative that reduces the production of prolactin; however, it is not approved by the U.S. Food and Drug Administration for lactation inhibition.45,46 Cabergoline is contraindicated for women with hypertension—including pregnancy-induced hypertension, preeclampsia, or eclampsia—or liver disease and for women being treated with antipsychotics or those who have a history of puerperal psychosis.47 Bromocriptine, another dopamine agonist, is no longer used for lactation inhibition because of serious cardiovascular and neurologic complications associated with its use.48

References

  1. Momplaisir FM, Brady KA, Fekete T, et al. Time of HIV diagnosis and engagement in prenatal care impact virologic outcomes of pregnant women with HIV. PLoS One. 2015;10(7):e0132262. Available at: https://pubmed.ncbi.nlm.nih.gov/26132142.
  2. Paioni P, Aebi-Popp K, Martinez de Tejada B, et al. Viral suppression and retention in HIV care during the postpartum period among women living with HIV: a longitudinal multicenter cohort study. Lancet Reg Health Eur. 2023;31:100656. Available at: https://pubmed.ncbi.nlm.nih.gov/37303945.
  3. American College of Obstetricians and Gynecologists. ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018;131(5):e140-e150. Available at: https://pubmed.ncbi.nlm.nih.gov/29683911.
  4. Whittington JR, Magann EF. Telemedicine in high-risk obstetrics. Obstet Gynecol Clin North Am. 2020;47(2):249-257. Available at: https://pubmed.ncbi.nlm.nih.gov/32451016.
  5. Anderson EA, Momplaisir FM, Corson C, Brady KA. Assessing the impact of perinatal HIV case management on outcomes along the HIV care continuum for pregnant and postpartum women living with HIV, Philadelphia 2005–2013. AIDS Behav. 2017;21(9):2670-2681. Available at: https://pubmed.ncbi.nlm.nih.gov/28176167.
  6. McKinney J, Jackson J, Sangi-Haghpeykar H, et al. HIV-adapted group prenatal care: assessing viral suppression and postpartum retention in care. AIDS Patient Care STDS. 2021;35(2):39-46. Available at: https://pubmed.ncbi.nlm.nih.gov/33571047.
  7. American College of Obstetricians Gynecologists' Committee on Gynecologic Practice, American College of Obstetricians Gynecologists' Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG committee opinion, number 823. Obstet Gynecol. 2021;137(3):e75-e88. Available at: https://pubmed.ncbi.nlm.nih.gov/33595253.
  8. MacDonald T, Noel-Weiss J, West D, et al. Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth. 2016;16:106. Available at: https://pubmed.ncbi.nlm.nih.gov/27183978.
  9. MacLean LR. Preconception, pregnancy, birthing, and lactation needs of transgender men. Nurs Womens Health. 2021;25(2):129-138. Available at: https://pubmed.ncbi.nlm.nih.gov/33651985.
  10. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. 2022. Available at: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/whats-new-guidelines.
  11. INSIGHT START Study Group, Lundgren JD, Babiker AG, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373(9):795-807. Available at: https://pubmed.ncbi.nlm.nih.gov/26192873.
  12. TEMPRANO ANRS study group. A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N Engl J Med. 2015;373(9):808-822. Available at: https://pubmed.ncbi.nlm.nih.gov/26193126.
  13. Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830-839. Available at: https://pubmed.ncbi.nlm.nih.gov/27424812.
  14. Centers for Disease Control and Prevention. HIV transmission. 2019. Available at: https://www.cdc.gov/hiv/basics/transmission.html.
  15. Kreitchmann R, Coelho DF, Kakehasi FM, et al. Long-term postpartum adherence to antiretroviral drugs among women in Latin America. Int J STD AIDS. 2016;27(5):377-386. Available at: https://pubmed.ncbi.nlm.nih.gov/25931238.
  16. Kaida A, Kanters S, Chaworth-Musters T. Antiretroviral adherence during pregnancy and postpartum among HIV-positive women receiving highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada (1997-2008). Presented at: International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention; 2011. Rome, Italy. 
  17. Mellins CA, Chu C, Malee K, et al. Adherence to antiretroviral treatment among pregnant and postpartum HIV-infected women. AIDS Care. 2008;20(8):958-968. Available at: https://pubmed.ncbi.nlm.nih.gov/18608073.
  18. Adams JW, Brady KA, Michael YL, et al. Postpartum engagement in HIV care: an important predictor of long-term retention in care and viral suppression. Clin Infect Dis. 2015;61(12):1880-1887. Available at: https://pubmed.ncbi.nlm.nih.gov/26265499.
  19. Nachega JB, Uthman OA, Anderson J, et al. Adherence to antiretroviral therapy during and after pregnancy in low-income, middle-income, and high-income countries: a systematic review and meta-analysis. AIDS. 2012;26(16):2039-2052. Available at: https://pubmed.ncbi.nlm.nih.gov/22951634.
  20. Momplaisir F, Hussein M, Kacanek D, et al. Perinatal depressive symptoms, HIV suppression, and the underlying role of ART adherence: A longitudinal mediation analysis in the IMPAACT P1025 cohort. Clin Infect Dis. 2021. Available at: https://pubmed.ncbi.nlm.nih.gov/33982083.
  21. Aaron E, Bonacquisti A, Geller PA, Polansky M. Perinatal depression and anxiety in women with and without human immunodeficiency virus infection. Womens Health Issues. 2015;25(5):579-585. Available at: https://pubmed.ncbi.nlm.nih.gov/26093677.
  22. Ion A, Wagner AC, Greene S, et al. HIV-related stigma in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada. AIDS Care. 2017;29(2):137-144. Available at: https://pubmed.ncbi.nlm.nih.gov/27449254.
  23. Wielding S, Scott A. What women want: social characteristics, gender-based violence and social support preferences in a cohort of women living with HIV. Int J STD AIDS. 2017;28(5):486-490. Available at: https://pubmed.ncbi.nlm.nih.gov/27270691.
  24. Gauthreaux C, Negron J, Castellanos D, et al. The association between pregnancy intendedness and experiencing symptoms of postpartum depression among new mothers in the United States, 2009 to 2011:a secondary analysis of PRAMS data. Medicine (Baltimore). 2017;96(6):e5851. Available at: https://pubmed.ncbi.nlm.nih.gov/28178128.
  25. O'Connor E, Rossom RC, Henninger M, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;315(4):388-406. Available at: https://pubmed.ncbi.nlm.nih.gov/26813212.
  26. Larsen AM, Osborn L, Ronen K, et al. Trajectories of depression symptoms from pregnancy through 24 months postpartum among Kenyan women living with HIV. J Acquir Immune Defic Syndr. 2022;90(5):473-481. Available at: https://pubmed.ncbi.nlm.nih.gov/35394987.
  27. Cohn SE, Umbleja T, Mrus J, et al. Prior illicit drug use and missed prenatal vitamins predict nonadherence to antiretroviral therapy in pregnancy: adherence analysis A5084. AIDS Patient Care STDS. 2008;22(1):29-40. Available at: https://pubmed.ncbi.nlm.nih.gov/18442305.
  28. Ickovics JR, Wilson TE, Royce RA, et al. Prenatal and postpartum zidovudine adherence among pregnant women with HIV: results of a MEMS substudy from the perinatal guidelines evaluation project. J Acquir Immune Defic Syndr. 2002;30(3):311-315. Available at: https://pubmed.ncbi.nlm.nih.gov/12131568.
  29. Bardeguez AD, Lindsey JC, Shannon M, et al. Adherence to antiretrovirals among US women during and after pregnancy. J Acquir Immune Defic Syndr. 2008;48(4):408-417. Available at: https://pubmed.ncbi.nlm.nih.gov/18614923.
  30. Buchberg MK, Fletcher FE, Vidrine DJ, et al. A mixed-methods approach to understanding barriers to postpartum retention in care among low-income, HIV-infected women. AIDS Patient Care STDS. 2015;29(3):126-132. Available at: https://pubmed.ncbi.nlm.nih.gov/25612217.
  31. Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133(1):21-30. Available at: https://pubmed.ncbi.nlm.nih.gov/10877736.
  32. Le Moing V, Chene G, Carrieri MP, et al. Clinical, biologic, and behavioral predictors of early immunologic and virologic response in HIV-infected patients initiating protease inhibitors. J Acquir Immune Defic Syndr. 2001;27(4):372-376. Available at: https://pubmed.ncbi.nlm.nih.gov/11468425.
  33. Murri R, Ammassari A, Gallicano K, et al. Patient-reported nonadherence to HAART is related to protease inhibitor levels. J Acquir Immune Defic Syndr. 2000;24(2):123-128. Available at: https://pubmed.ncbi.nlm.nih.gov/10935687.
  34. Abuogi LL, Onono M, Odeny TA, et al. Effects of behavioural interventions on postpartum retention and adherence among women with HIV on lifelong ART: the results of a cluster randomized trial in Kenya (the MOTIVATE trial). J Int AIDS Soc. 2022;25(1):e25852. Available at: https://pubmed.ncbi.nlm.nih.gov/35041776.
  35. Cates W, Jr., Steiner MJ. Dual protection against unintended pregnancy and sexually transmitted infections: what is the best contraceptive approach? Sex Transm Dis. 2002;29(3):168-174. Available at: https://pubmed.ncbi.nlm.nih.gov/11875378.
  36. Jackson E, Glasier A. Return of ovulation and menses in postpartum nonlactating women: a systematic review. Obstet Gynecol. 2011;117(3):657-662. Available at: https://pubmed.ncbi.nlm.nih.gov/21343770.
  37. Sutton MY, Patel R, Frazier EL. Unplanned pregnancies among HIV-infected women in care-United States. J Acquir Immune Defic Syndr. 2014;65(3):350-358. Available at: https://pubmed.ncbi.nlm.nih.gov/24189153.
  38. Sholapurkar SL. Is there an ideal interpregnancy interval after a live birth, miscarriage or other adverse pregnancy outcomes? J Obstet Gynaecol. 2010;30(2):107-110. Available at: https://pubmed.ncbi.nlm.nih.gov/20143964.
  39. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006;295(15):1809-1823. Available at: https://pubmed.ncbi.nlm.nih.gov/16622143.
  40. World Health Organization. Review of priorities in research: hormnonal contraception and IUDs and HIV infection. Presented at; 2010. Geneva, Switzerland. Available at: http://www.who.int/reproductivehealth/publications/rtis/rhr_10_21/en.
  41. Polis CB, Curtis KM. Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence. Lancet Infect Dis. 2013;13(9):797-808. Available at: https://pubmed.ncbi.nlm.nih.gov/23871397.
  42. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep. 2016;65(3):1-103. Available at: https://pubmed.ncbi.nlm.nih.gov/27467196.
  43. Tulloch KJ, Dodin P, Tremblay-Racine F, et al. Cabergoline: a review of its use in the inhibition of lactation for women living with HIV. J Int AIDS Soc. 2019;22(6):e25322. Available at: https://pubmed.ncbi.nlm.nih.gov/31183987.
  44. Harris K, Murphy KE, Horn D, et al. Safety of cabergoline for postpartum lactation inhibition or suppression: a systematic review. J Obstet Gynaecol Can. 2020;42(3):308-315 e320. Available at: https://pubmed.ncbi.nlm.nih.gov/31285168.
  45. Henkel A, Johnson SA, Reeves MF, et al. Cabergoline for lactation inhibition after second-trimester abortion or pregnancy loss: a randomized controlled trial. Obstet Gynecol. 2023;141(6):1115-1123. Available at: https://pubmed.ncbi.nlm.nih.gov/37486652.
  46. National Institute of Child Health and Human Development. Cabergoline. Drugs and Lactation Database (LactMed(R)). 2023. Available at: https://pubmed.ncbi.nlm.nih.gov/30000386.
  47. Dostinex (cabergoline) [package insert]. Food and Drug Administration. 2019. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020664s011lbl.pdf.
  48. Bromocriptine mesylate (Parlodel) for the prevention of physiological lactation; opportunity for a hearing on a proposal to withdraw approval of the indication [package insert]. Food and Drug Administration. 1994. Available at: https://www.govinfo.gov/content/pkg/FR-1994-08-23/html/94-20562.htm.

 

Panel's Recommendations
  • Continuous antiretroviral therapy (ART) currently is recommended for all individuals with HIV to reduce the risk of disease progression and prevent the sexual transmission of HIV (AI).
  • ART should be continued after delivery (AI). Any plans for modifying ART after delivery should be made in consultation with the individual and their HIV care provider, ideally before delivery, taking into consideration the recommended regimens for nonpregnant adults (AIII) and plans for future pregnancies.
  • Because the immediate postpartum period poses unique challenges to ART adherence and retention in HIV care, arrangements for new or continued supportive services should be made throughout pregnancy and before postpartum hospital discharge (AII).
  • People with a positive HIV test during labor should receive confirmatory testing; see Pregnancy and Postpartum HIV Testing and Identification of Perinatal and Postnatal HIV Exposure. If testing confirms HIV infection, ART should be offered, and the person should be given a supply of ART before postpartum hospital discharge to prevent treatment interruption (AII). Immediate linkage to HIV care and comprehensive follow-up also is needed (AII).
  • Infants of people who have HIV newly diagnosed in the intrapartum period should begin presumptive HIV therapy, and a supply of ART for their infants should be provided before postpartum hospital discharge (AII) (see Antiretroviral Management of Infants with Perinatal HIV Exposure or HIV Infection).
  • People with HIV should receive evidence-based counseling to support shared decision-making about infant feeding options prior to and during pregnancy; counseling and plans for infant feeding should be reviewed again after delivery (AIII) (see Infant Feeding for Individuals with HIV in the United States).
  • Clinicians should discuss future reproductive plans and timing, as well as the risks and benefits of conceiving while on specific antiretroviral (ARV) medications (AII). The use of appropriate contraceptive options to prevent unintended pregnancy and optimal interpregnancy intervals should also be discussed (AII) (see Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV).
  • Contraceptive counseling should involve shared decision-making and should start during the prenatal period; a contraceptive plan should be developed before postpartum hospital discharge, as desired by the patient (AII).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional

Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

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