Perinatal transmission of bloodborne infections

• Main risk is for HIV and HBV

Investigations

Unknown maternal serostatus

• If possible, send STAT maternal HIV serology, HBV, HCV, and syphilis; can consider viral load
• For infant:
  • At birth send HIV, HBV (sAg, sAb, cAb), HCV-Ab, and syphilis serologies, as well as an HIV PCR (not viral load)
  • Repeat HIV PCR at 1, 2, and 4-6 months

HIV

Diagnosis

• 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

Management

Preventative management

• Immediate management depends on maternal viral load and treatment status
• In general, a mom with HIV should get IV zidovudine during labour

VL	Antenatal Rx	C-section	Neonatal Rx
>1000	Any	Yes	ART
40-999	None	Yes	ART
40-999	ART	Maybe	ART
<40	None	Maybe	ART
<40	ART	No	Zidovudine x4 weeks
Unknown	None	Maybe	ART
Unknown	ART	Maybe	Unclear

Selection of antiretrovirals

• Can either do a prophylactic regimen, or treat empirically
• Prophylaxis:
  • ZDV/NVP: zidovudine x6 weeks, plus nevirapine x3 in the first week of life
• Empiric treatment:
  • ZDV/3TC/NVP: zidovudine fir 6 weeks, plus lamivudine and nevirapine for 2 to 6 weeks
  • ZDV/3TC/RAL: zidovudine for 6 weeks, plus lamivudine and raltegravir for 2 to 6 weeks

Post-exposure follow-up

Age	Investigations	Management
Birth	CBC/diff, ALT, lactate, and HIV PCR	Start ART as described below
7 days	CBC/diff, nevirapine level	Dose-adjust nevirapine if needed
14 days	CBC/diff, nevirapine level, and HIV PCR	Dose-adjust nevirapine if needed
4 weeks	CBC/diff and ALT; ?HIV PCR?	Stop nevirapine if prior HIV PCR is negative, and continue other ART
6 weeks	?HIV PCR?	Stop zidovudine and lamivudine if HIV PCR has been negative
2 months		Review as needed
6 months	CBC/diff and ALT
18 months	HIV serology	Developmental assessment
3.5 years		Developmental assessment
5.5 years		Developmental assessment

Hepatitis B virus

• If mother has hepatitis B, or her status is unknown, then consider post-exposure prophylaxis with hepatitis B immune globulin and hepatitis B vaccine given within 12 hours of life
  • Vaccine prevents about 90% of infections, with HBIG adding a bit more
  • HBIG can be given up to 7 days of life but is most effective when given earlier

Hepatitis C virus

• Not urgent, as it is a chronic illness that may not manifest for decades
• Serology to be done at 18 months for diagnosis
• If significant anxiety, can send HCV-PCR

Further Reading

• AIDSinfo. Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States.