Neonatal HIV

Background

Risk of infection during labour is 25 to 35%, and decreases to less than 1% with appropriate care

Up to 18 months of age, only use HIV PCR
- In general, all infants with perinatal exposure should be checked at 14 to 21 days, 1 to 2 months, and 4 to 6 months
- If high risk, can also check at birth and 2 to 4 weeks after stopping antiretrovirals
- Confirm a positive result with repeat testing
Serology can be tested starting at 18 to 24 months
- Before this, there is the risk of detecting maternal antibodies

Risk of acquisition during delivery is decreased substantially by appropriate management of the mother
It is further decreased by the use of either prophylactic zidovudine and nevirapine, or empiric treatment with zidovudine, lamivudine, and either nevirapine or raltegravir

Maternal Viral Load	Management of Neonate
<40	zidovudine for 4 to 6 weeks
40-999	zidovudine for 4 to 6 weeks, or combination ART
≥1000	combination ART
unknown	combination ART

Can either do a prophylactic regimen, or treat empirically
Prophylaxis is indicated for low risk of perinatal HIV transmission
- Zidovudine monotherapy for 4 to 6 weeks
- Duration of 4 weeks is indicated for situations where mother was on ART during pregnancy with sustained viral suppression and no concerns about adherence
Presumptive treatment is indicated in all other scenarios
- ZDV/3TC/NVP: zidovudine for 6 weeks, plus lamivudine and nevirapine for 2 to 6 weeks (preferred)
- ZDV/3TC/RAL: zidovudine for 6 weeks, plus lamivudine and raltegravir for 2 to 6 weeks
- Regarding duration, in the UK they typically treat for 2 weeks while in Canada it is typically 4 weeks
A previously-recommended option was prophylaxis with combination, but this is no longer routinely done
- ZDV/NVP: zidovudine x6 weeks, plus nevirapine x3 in the first week of life

Age	Investigations
14 to 21 days	HIV PCR
1 to 2 months	HIV PCR
4 to 6 months	HIV PCR
12 to 18 months	HIV serology
24 months	HIV serology, if positive at 12 to 18 months

If any of the PCR tests is positive, then full antiretroviral therapy should be started

Duration of 4 weeks is only recommended if they are at the lowest risk: mother on ART with suppressed viral load at delivery, no concerns about adherence, and received intrapartum zidovudine

Age	Diagnostic Tests	Management
≤48 hours	HIV PCR, ALT	start ART
1 week
2 weeks	HIV PCR
4 weeks	ALT	stop ART if PCR has been negative to date
6 weeks	HIV PCR	stop ART if PCR has been negative to date
2 to 6 weeks after stopping ART	HIV PCR	routine follow-up; start ART if PCR positive or serology at 24 months is positive
4 to 6 months	HIV PCR
12 to 18 months	HIV serology
24 months	HIV serology, if positive at 12 to 18 months

If any of the PCR tests is positive, then monotherapy should be stopped and full antiretroviral therapy should be started

Age	Diagnostic Tests	Management
≤48 hours	HIV PCR, ALT, CBC	start ART
1 week	CBC, nevirapine level	adjust nevirapine
2 weeks	HIV PCR, CBC, nevirapine level	adjust nevirapine
4 weeks	ALT, CBC
6 weeks	HIV PCR	stop ART if PCR has been negative to date
2 to 6 weeks after stopping ART	HIV PCR	routine follow-up; start ART if PCR positive or serology at 24 months is positive
4 to 6 months	HIV PCR
12 to 18 months	HIV serology
24 months	HIV serology, if positive at 12 to 18 months