HAART may provide more reassurance about prevention of MTCT but will also expose both mother and infant to more potential drug toxicities. The choice of HAART is as per Recommendation 5.3.3. Data

on the mode of delivery in elite controllers are sparse and limited to case reports Z-VAD-FMK in vivo [142]. The benefits of PLCS at various levels of viraemia are discussed in Section 7.2 (Mode of delivery). There are no data to support the use of PLCS for PMTCT when the VL is <50 HIV RNA copies/mL in women on ART. The Writing Group therefore recommends vaginal delivery for all elite controllers on ART. 5.6.1 The discontinuation of NNRTI-based HAART postpartum should be according to BHIVA guidelines for the treatment of HIV-1-positive adults with antiretroviral therapy 2012 (www.bhiva.org/PublishedandApproved). Grading: 1C The literature comparing strategies for stopping ART in pregnant women is limited and therefore no alternative recommendation, compared with non-pregnant women, is made. 5.6.2 ARV therapy should be continued in all pregnant women who commenced HAART with a history of an AIDS-defining illness or with a CD4 cell count <350 cells/μL as per adult treatment guidelines. Grading: 1B Available RCT data to address the question as to whether one should continue or stop HAART in women receiving it to prevent MTCT and not for their own health are sparse and have limited applicability

to current ART treatment practices. What information there is comes from early RCTs with zidovudine monotherapy [143] with or without HIV immunoglobulin [144] and from ATM/ATR inhibitor review observational studies with their inherent weaknesses [145-148]. Nevertheless, concerns have been raised regarding the discontinuation of ARVs postpartum in light of results from CD4-guided interruption studies (SMART [149] and TRIVICAN [150] in particular) although interruption of ART given for PMTCT after delivery is not completely

analogous. In both these studies, which were halted prematurely because of the significantly worse outcome in the CD4-guided interruption arm, lower CD4 cell count thresholds for resumption Rapamycin of therapy were used than would be currently based on clinical treatment guidelines. Moreover, these CD4-based treatment RCTs (SMART and TRIVICAN) and the major cohort studies (NA-ACCORD [151], ART-CC [152]) either excluded or did not collect data on pregnant women. Hence, these recommendations extrapolate data used to inform internationally accepted treatment guidelines for all adults as well as incorporating evidence available from the limited data for postpartum drug management. In addition, observations on the collated evidence of the deleterious effect of direct virus infection, and indirect inflammatory response and its correlation to CD4 cell count, allow tentative conclusions to be made on the potential for this to be prevented by cART.