New recommendations aim to help pregnant women with HIV make informed choices

New recommendations on antiretroviral drugs for pregnant women living with HIV can help women make more informed choices about benefits and harms, say a panel of international experts in The BMJ today.

The recommendations, which take a patient's perspective rather than a public health perspective, differ from current guidelines, and are meant to support shared decision making between pregnant women and their healthcare provider, say the authors. The new guidelines suggest that most women are likely to prefer older HIV medications rather than the ones that are most often currently prescribed.

Their advice is part of The BMJ's Rapid Recommendations initiative - to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.

Every year about 1.4 million women living with HIV become pregnant. Most women take a combination of three antiretroviral drugs to reduce the risk of transmission to their child or for personal health reasons. Recent trial evidence suggested that the most commonly used drug combinations might increase the risk of premature birth and neonatal death compared with other drug combinations.

So an international panel - made up of women living with HIV, specialist doctors, and general practitioners - carried out a detailed analysis of the evidence to make recommendations.

Their suggestions are based on data from two systematic reviews (published in BMJ Open) that looked at the benefits and harms of different drug combinations for pregnant women with HIV and the values and preferences of women considering antiretroviral therapy.

Evidence from these reviews led the panel to recommend older alternatives instead of the most widely used drug combinations to help reduce the risk of premature birth and neonatal death - which almost all women said they were extremely keen to avoid.

The panel acknowledge that the number of antiretroviral therapy options that women can choose from and can be prescribed varies considerably throughout the world - and that, in many settings, alternative drugs may not be available.

They also point out that their recommendations, like all BMJ Rapid Recommendations, take a patient centred perspective. Whereas guidelines that take a public health perspective, such as the WHO guideline, need to consider resource use and might make different recommendations based on the same evidence.

And they recognise the operational challenges that alternative treatment options may introduce, particularly in low resource settings.

In conclusion, they say there is a lack of reliable trial data on the safety and efficacy of most commonly used combination antiretroviral therapy in pregnant women living with HIV.

They call for further research to inform treatment options, as well as efforts to overcome operational challenges "so that availability of the right choice of combination antiretroviral therapy is aligned with the best available evidence for almost all pregnant women living with HIV."

In a linked opinion piece, Alice Welbourn, a researcher, trainer, writer and activist on gender and sexual and reproductive health and rights, says women's fundamental rights to informed choices about what happens to their bodies are often curiously contested; especially if they are pregnant or have HIV. Yet, informed choices about risks and benefits form a critical part of long-term prognosis.

As Founding Director of the Salamander Trust, and a woman living with HIV, she welcomes the positive response by the new WHO director-general to support more people-centred policy developments.

She urges WHO to "ensure women's rights to informed, voluntary, and confidential choice about if, when, and how to start treatment safely, which treatment to consider, and how long to take it."