5%) transmissions in the vaginal delivery group (P = 0.35). The effect of mode of delivery was also analysed for women delivering with a viral load of > 10 000 HIV RNA copies/mL and no significant protective effect of elective Caesarean section was seen (OR 1.46; 0.37–5.80).

MTCT was low at 0.4% in women delivering with a viral load of < 50 HIV RNA copies/mL but mode of delivery data for this subset were not provided [24]. In contrast, data from the ECS Epacadostat manufacturer of 5238 women delivering between 1985 and December 2007 showed that in 960 women delivering with a viral load of < 400 HIV RNA copies/mL, elective Caesarean section was associated with an 80% decreased risk of MTCT (AOR 0.2; 95% CI 0.05–0.65) adjusting for cART and prematurity. There were only two transmissions amongst 599 women delivering with viral loads of < 50 HIV RNA copies/mL (MTCT 0.4%) with one delivering vaginally at < 34 weeks and one by ECS at 37 weeks, but further analysis was not possible [248]. A potential explanation for the differing conclusions of the effect of mode of delivery on MTCT in women with delivery plasma viral loads of < 400 HIV RNA copies/mL in these two studies is that the true value of the plasma viral load in studies that use assays with a lower limit

of detection of 400 copies/mL, is not known. It is conceivable that there may exist a significant difference in the viral load distribution < 400 copies/mL between different cohorts which could account for the contrasting findings. This highlights the fact that it is not possible to infer that MTCT rates from studies using a viral

load assay Cell Cycle inhibitor with a cut-off of < 400 HIV RNA copies/mL can necessarily be applied to patients with plasma viral loads of 50–399 HIV RNA copies/mL using current assays with lower limits of detection of 50 HIV RNA copies/mL or less. The only published data on the impact of mode of delivery on MTCT rates for women with plasma viral loads ZD1839 cost between 50 and 399 HIV RNA copies/mL are from the NSHPC UK and Ireland cohort 2000–2011 [5]. They report that ‘For all modes of delivery, the risk of MTCT was significantly higher in women with viral loads of 50–399 copies/mL (1.04%, 14/1349), compared with viral load < 50 copies/mL (0.09%, 6/6347, P < 0.001). Among the former (viral load 50–399 copies/mL), the risk of MTCT was 0.26% (2/777) following elective caesarean section and 1.06% (2/188) following planned vaginal delivery (P = 0.17), excluding in utero transmissions. A similar pattern is seen with unpublished data from the ECS cohort: of 405 women the transmission rates were 0.37% (95% CI 0.099–2.06) for PLCS and 1.46% (95% CI 0.18–5.17) for all other modes of delivery. Although in neither data set a statistically significant difference in MTCT is observed due to the small number of events, both suggest that for women with plasma viral loads between 50 and 399 HIV RNA copies/mL, the risk of MTCT for women intending vaginal delivery is about twice that of PLCS.