If maternal HIV infection - infant follow-up and post natal prophylaxis

infant follow-up and post natal prophylaxis

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All babies of HIV infected women (regardless of the maternal viral load) should be bathed soon after birth to remove any potential infectious maternal secretions (1).

All infants should be offered antiretroviral prophylaxis regardless of maternal antenatal or intrapartum antiretroviral therapy, viral load, or mode of delivery.

• neonatal prophylaxis should be commenced very soon after birth, certainly within 4 hours and should be given for 4 weeks
• zidovudine monotherapy is recommended if maternal viral load is < 50 HIV RNA copies/mL at 36 weeks' gestation or thereafter prior to delivery (or mother delivered by planned caesarean section whilst on zidovudine monotherapy)
• three-drug infant therapy is recommended for all circumstances (other than above situation)
• infants < 72 hours old, born to untreated HIV positive mothers, should immediately initiate three-drug antiretroviral therapy for 4 weeks (1,2)

Baseline complete blood counts together with investigations to establish or rule out HIV infection should be carried out.

• molecular diagnostics for HIV infection should be performed on the following occasions
  • exclusively non breastfed women
    • during the first 48 hours and prior to hospital discharge
    • 2 weeks post cessation of infant prophylaxis (6 weeks of age)
    • 2 months post cessation of infant prophylaxis (12 weeks of age)
    • on other occasions if additional risk
    • HIV antibody testing for seroreversion should be checked at age 18 months
  • breastfed infants
    • babies known to be breastfed should be tested monthly by PCR, but not all breastfeeding will be disclosed, and all babies born to HIV-positive women should have a negative HIV antibody test documented at age 18 months (1)

Pneumocystis pneumonia (PCP) prophylaxis, with co-trimoxazole, should be initiated from age 4 weeks in:

• all HIV-infected infants
• infants with an initial positive HIV DNA/RNA test result (and continued until HIV infection has been excluded)
• infants whose mother's viral load at 36 weeks' gestational age or at delivery is > 1000 HIV RNA copies/mL despite combination antiretroviral therapy(cART) or unknown (and continued until HIV infection has been excluded) (2).

Infants born to HIV-positive mothers should follow the routine national primary immunization schedule (2)

All mothers known to be HIV positive, regardless of antiretroviral therapy, and infant prophylaxis, should be advised to exclusively formula feed from birth.

• if a mother who is on effective cART with a repeatedly undetectable viral load chooses to breastfeed, this should not constitute grounds for automatic referral to child protection teams. Maternal cART should be carefully monitored and continued until 1 week after all breastfeeding has ceased. Breastfeeding, except during the weaning period, should be exclusive and all breastfeeding, including the weaning period, should have been completed by the end of 6 months
• prolonged infant prophylaxis during the breastfeeding period, as opposed to maternal cART, is not recommended

Premastication of food for infants of HIV-infected mothers should be avoided, as this can potentiate the risk of HIV transmission (1).

Reference:

• (1) Rimawi BH et al. Management of HIV Infection during Pregnancy in the United States: Updated Evidence-Based Recommendations and Future Potential Practices. Infect Dis Obstet Gynecol. 2016;2016:7594306.
• (2) de Ruiter A et al. British HIV Association guidelines for the management of HIV infection in pregnant women 2012 (2014 interim review). HIV Med. 2014;15 Suppl 4:1-77