Pregnant and breastfeeding women: A priority population for HIV viral load monitoring

Abstract

With more than 18 million HIV-infected individuals having initiated antiretroviral therapy (ART) in low- and middle-income countries (LMICs) by the end of 2016, ensuring effective HIV care and treatment services is a global public health priority [1]. Viral load (VL) quantification provides a direct measure of the effectiveness of ART, with a consistently elevated VL suggesting poor adherence or treatment failure and the need for intervention. In turn, HIV VL monitoring is now recognised as a key component of ART services in LMICs in World Health Organization (WHO) guidelines, with an emphasis on scaling up access to VL testing for ART programmes [2]. Pregnant and postpartum women are an important population within ART programmes. In many countries, the majority of identified HIV-infected adults are women, and many women of reproductive age are diagnosed with HIV infection during pregnancy through prevention of mother-to-child transmission of HIV (PMTCT) services in antenatal care (ANC) [3]. With universal eligibility for ART for all HIV-infected pregnant and postpartum women (based on the WHO’s 2013 ‘Option B+’ policy [4]), many women of reproductive age initiating ART do so during pregnancy. PMTCT services extend through early infant diagnosis around 6–10 weeks postpartum until the cessation of breastfeeding and documentation of the infant’s final HIV testing status, which may extend well beyond 1 year postpartum based on the recently updated infant feeding recommendations [5]. With ongoing risk of HIV transmission throughout breastfeeding, maintaining ART adherence and viral suppression is especially crucial during this period. Although the importance of routine VL monitoring for HIV-infected individuals on ART is widely recognised [6], there has been minimal attention to VL monitoring in pregnancy and the postpartum period. Here we discuss key considerations for VL monitoring in pregnant and breastfeeding women in the context of expanding access to VL monitoring (summarised in Box 1)