6% with a false positive rate of 5.2% [208]. For women who present too late for the combined test, the most clinically and cost-effective serum screening test (triple or quadruple test)

should be offered between 15 + 0 and 20 + 0 weeks [207]. However, significantly increased levels of βHCG, α-fetoprotein and lower levels of UE3 (the elements of the ‘triple test’) have been observed in the HIV-positive population [209-211] while a reduction in βHCG in patients treated with PI-based [212] or with NNRTI-based HAART has been reported. As Down’s syndrome is associated with increased βHCG, theoretically, HIV infection per se may increase the false-positive rate in women and thus increase the number of invasive tests offered compared with the uninfected population. Pregnancy-associated plasma protein A and nuchal translucency are unaltered by HIV infection or ART [213] and are thus the preferred screening modality. Venetoclax manufacturer 7.1.3 Invasive prenatal PD0332991 concentration diagnostic testing should not be performed until after HIV status of the mother is known and should be ideally deferred until HIV VL has been adequately suppressed. Grading: 1C Limited data suggest amniocentesis is safe in women on HAART. There are minimal data on other forms of prenatal invasive testing. All clinicians performing a prenatal invasive test should know the woman’s HIV status, and if necessary delay the invasive

test until the HIV result is available. Where possible, amniocentesis should be deferred until VL is <50 HIV RNA copies/mL. The fetal medicine team should discuss management with an HIV physician if the woman is HIV positive and has a detectable VL. 7.1.4 If not on treatment and the invasive diagnostic test procedure cannot be delayed until viral suppression is complete, it is recommended that women should commence HAART to include raltegravir

and be given a single dose Baricitinib of nevirapine 2–4 h before the procedure. Grading: 1D The French Pediatric HIV Infection Study Group observed a relative risk of HIV transmission of 1.9 (95% CI 1.3–2.7; P = 0.003) with ‘antenatal procedures’ that included amniocentesis, cerclage, laser therapy and amnioscopy [214]. This study was conducted between 1985 and 1993 and, of the 1632 mother–infant pairs (overall transmission 19%), only 100 mothers had received zidovudine, mostly for advanced HIV infection. There are few studies on the safety of invasive testing in the HAART era. A study of 9302 pregnancies in France in 2009 (of which 166 had an amniocentesis) showed that the risk of MTCT in the untreated rose from 16% to 25% in those who had an amniocentesis, in those on zidovudine alone the risk rose from 3.3% to 6.1% and in those on HAART there were no transmissions in 81 mothers who underwent amniocentesis [215]. VL data were not reported, but in other settings suppression of VL reduces transmission.