At least two reliable forms of effective contraception must be utilized. The outcome of an exposed pregnancy should be reported prospectively to the Ribavirin and Interferon Pregnancy Registries. 6.2.4 In all non-immune HCV coinfected women after the first trimester, vaccination against HBV is recommended. Grading: 2C 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 [35]. Nevertheless, several guidelines indicate that pregnancy is not a contraindication for HBV or HAV immunization, including in HCV coinfected pregnant women [[36],[37]]. In single-arm open studies in HIV uninfected persons, seroconversion rates for HBV are no different in the pregnant and non-pregnant AG-014699 in vivo 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 before delivery [38]. Patients with higher CD4 cell counts and on HAART generally show improved responses to Selumetinib nmr vaccination. Regardless of CD4 cell count, HBsAb level should be measured 6–8 weeks after completion of vaccination. 6.2.5 HAV vaccine is recommended as per the normal schedule (0 and 6–12 months) unless the CD4 cell count is <300 cells/μL when an additional dose may be indicated. Grading: 2C 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 Interleukin-2 receptor instead of the standard two [39]. 6.2.6 In the absence of obstetric complications, normal vaginal delivery can be recommended if the mother is receiving HAART. 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 mothers in the study who underwent CS compared with mothers who gave birth vaginally (OR 1.1 [40] to OR 1.19 [24]). In the first European Paediatric Hepatitis Network cohort, a subgroup analysis of women coinfected 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) [24]. However, in a later analysis from the European Paediatric Hepatitis Network (n = 208, 15.0%) no such association was found (OR 0.76; 95% CI 0.23–2.53) [29]. In the later analysis, MTCT of HCV was less (8.7% vs. 13.