2.1) with the exception of elite controllers (see Section 5.5: Elite controllers). Grading: 1D Zidovudine monotherapy with a planned pre-labour pre-ROMs CS is a proven option for women not requiring treatment for themselves, with a pretreatment VL <10 000 HIV RNA copies/mL plasma. Observational studies conducted in the early 1990s, before the use of HAART, found a reduction in
MTCT with PLCS. In 1999, a large international meta-analysis (n = 8533)  and an RCT of mode of delivery in Europe (n = 436)  both demonstrated a protective effect of PLCS, with reductions in MTCT of 50% and 70% respectively. In the latter study, the risk of transmission in women who were taking zidovudine monotherapy and who were delivered by PLCS was <1%. Cohort data from the UK and Ireland between 2000 and 2006 have shown that the MTCT EPZ-6438 supplier selleckchem rate in women on zidovudine monotherapy combined
with PLCS was 0% (0 of 467 patients; 95% upper CI 0.8%) . This was not significantly different from the 0.7% transmission rate with HAART plus PLCS (17 of 2337 patients; 95% CI 0.4–1.2%) or the 0.7% rate with HAART plus planned vaginal delivery (four of 565 patients; 95% CI 0.2–1.8%). These findings support the option of zidovudine monotherapy in women not requiring treatment for themselves with low VLs who either have an obstetric indication for, or are prepared to be delivered by, PLCS. There is no evidence that women on HAART with a low VL have increased surgical morbidity compared with the HIV-negative population A Cochrane review evaluating the risk of postpartum morbidity according to mode of delivery included five studies: the European randomized mode of delivery trial and five observational studies from North America and Europe . This review found a higher incidence of minor much postpartum morbidity, including fever and anaemia requiring transfusion, among HIV-positive women delivered by CS compared with those who delivered vaginally. Low CD4 cell count and co-morbidities
such as diabetes were independent risk factors for postpartum morbidity. This review included women who were not on HAART. More recent cohort data from Europe , and from case-controlled studies in the USA  and UK  involving women on HAART with undetectable VLs have demonstrated very low rates of maternal morbidity, irrespective of mode of delivery. 7.2.5 Where the indication for PLCS is the prevention of MTCT, PLCS should be undertaken at between 38 and 39 weeks’ gestation. Grading: 1C Where PLCS is undertaken only for obstetric indications and plasma VL is <50 copies/mL, the usual obstetric considerations apply and timing will usually be at between 39 and 40 weeks.