Grading: 1C Immunization for HBV uses an inactivated vaccine. Limited data are available on the use of hepatitis B vaccination in pregnancy and none in HIV-positive pregnant women. Moreover, no randomized trial has been performed on the optimum dosing schedule

for use in pregnancy [222]. Nevertheless, several guidelines indicate that pregnancy is not a contraindication for HBV or HAV immunization, including p38 MAPK assay in HCV co-infected pregnant women [199, 200]. In single-arm open studies in HIV uninfected persons, seroconversion rates for HBV are no different in the pregnant and non-pregnant woman and no fetal risks have been reported. In a prospective clinical trial in pregnant women, an accelerated schedule at 0, 1, and 4 months was found to be effective, well tolerated, and had the advantage of potential completion prior to delivery [223]. Patients with higher CD4 cell counts and on cART generally show improved responses to vaccination. Regardless of CD4 cell count, anti-HBs level should be measured 6–8 weeks after completion of vaccination. In a systematic review IWR-1 and meta-analysis of five studies, an increased-dose HBV vaccination schedule

improved anti-HBs response rates compared to standard-dose HBV vaccination (OR 1.96; 95% CI: 1.47–2.61) with separate randomized trial data demonstrating improved serological response with four-dose regimens [224]. 6.2.5 HAV vaccine is recommended as per the normal schedule (0 and 6–12 months) Grading: 1A unless the CD4 cell count is less than 300 cells/μL when an

additional dose may be indicated. Grading: 1D Immunization for HAV also uses an inactivated vaccine and data for HAV vaccination in this setting are similarly limited. HIV-positive persons with CD4 cell counts < 300 cells/μL should receive three doses of HAV vaccine over 6–12 months instead of the standard two [225]. 6.2.6 In the absence of obstetric complications, normal vaginal delivery can be recommended Rucaparib manufacturer if the mother is receiving effective cART. Grading: 2C As HCV antiviral therapy is contraindicated in pregnant women due to possible teratogenicity, mode of delivery remains the only possible risk factor amenable to intervention. No randomized studies of CS compared to normal vaginal delivery to prevent HCV MTCT have been performed. In mono-infection, two meta-analyses failed to show a significant decrease in HCV vertical transmission among study mothers who underwent CS compared with mothers who gave birth vaginally (OR 1.1 [226] to OR 1.19 [211]). In the first European Paediatric Hepatitis Network cohort, a subgroup analysis of women co-infected with HIV (n = 503, 35.4%) demonstrated a reduced risk of vertical transmission of HCV with CS (OR 0.43; 95% CI 0.23–0.80) [211]. However, in a later analysis from the EPHN (n = 208, 15.0%) no such association was found (OR 0.76; 95% CI 0.23–2.53) [216]. In the later analysis, MTCT of HCV was less (8.7% vs. 13.