Perinatal transmission of bloodborne infections: Difference between revisions

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==HIV==
==HIV==


⚫
*Risk of transmission from an untreated HIV-positive mother is approximately 25%, but less than 1% if treated
=== Background ===

⚫
* Risk of transmission from an untreated HIV-positive mother is approximately 25%

===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===
====Antepartum management====

*See [[HIV in pregnancy]] for management of an HIV-positive mother
*Note that integrase inhibitors are effective for achieving fast viral suppression

====Peripartum management====

*Immediate management depends on maternal viral load and treatment status
*In general, a mom with HIV should get IV [[zidovudine]] during labour
**If it is unavailable or resistant, could use any pregnancy-safe medication


{| class="wikitable"
{| class="wikitable"
! rowspan="2" |Viral Load
!VL!!Antenatal Rx!!C-section!!Neonatal Rx
! colspan="3" |Management of Mother
! rowspan="2" |Management of Infant
|-
|-
⚫
![[HIV treatment|ART]]
|>1000||Any||Yes||ART
![[Zidovudine]]
![[Cesarean section|C-section]]
|-
|-
|<40
|40-999||None||Yes||ART
|yes
|yes
|no
|[[zidovudine]] for 4 to 6 weeks
|-
|-
|40-999||ART||Maybe||ART
|40-999
|yes
|yes
|consider
|combination ART, or [[zidovudine]] monotherapy for 4-6 weeks
|-
|-
|≥1000
|<40||None||Maybe||ART
|yes
|yes
|yes
|combination ART
|-
|-
|unknown
|<40||ART||No||[[Zidovudine]] x4 weeks
|-
|yes
|yes
|Unknown||None||Maybe||ART
|-
|yes
|combination ART, adjusted based on results of maternal viral load
|Unknown||ART||Maybe||Unclear
|}
|}


====Selection of antiretrovirals====
=== Management of Mother ===


* See [[HIV in pregnancy]] for information about managing the mother ante-, intra-, and postpartum
*Can either do a prophylactic regimen, or treat empirically
* Mothers should be treated with antiretroviral therapy and monitored during pregnancy
*Prophylaxis:
* Intrapartum management is based on viral load, and includes continuing antiretrovirals, giving intravenous [[zidovudine]] during labour, and consideration of [[Cesarean section]]
**ZDV/NVP: [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] x6 weeks, plus [[nevirapine#Neonatal HIV prophylaxis|nevirapine]] x3 in the first week of life
* Following delivery, mothers should be counselled about the risks of breastfeeding
⚫
*Empiric treatment:
**ZDV/3TC/NVP: [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] for 6 weeks, plus [[lamivudine#Neonatal HIV prophylaxis|lamivudine]] and [[nevirapine#Neonatal HIV prophylaxis|nevirapine]] for 2 to 6 weeks (preferred)
**ZDV/3TC/RAL: [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] for 6 weeks, plus [[lamivudine#Neonatal HIV prophylaxis|lamivudine]] and [[raltegravir#Neonatal HIV prophylaxis|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

====Follow-up====
{| class="wikitable"
!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
|}


====Breastfeeding====
=== Management of Neonate ===


* See [[Neonatal HIV#Prevention|prevention of neonatal HIV]] for information about preventing disease in the newborn
*Generally recommend against breastfeeding for HIV-positive mothers in Canada, even if HIV is well-controlled
* An HIV PCR should be obtained within 48 hours of delivery, then regularly following delivery
**10-20% risk if breastfeeding and uncontrolled; less than 1% if fully and reliably suppressed
** If any single HIV PCR test is positive, then they are diagnosed with HIV and need ongoing treatment
*As well as risk of HIV transmission, it could theoretically expose child's HIV to low-level antivirals which could induce resistance
* A decision to treat the infant with either [[zidovudine]] monotherapy for 4 to 6 weeks, or presumptive antiretroviral therapy for at least 6 weeks, depends on the risk of infection


==Hepatitis B virus==
==Hepatitis B virus==

Latest revision as of 15:28, 18 September 2020

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

  • Risk of transmission from an untreated HIV-positive mother is approximately 25%, but less than 1% if treated
Viral Load Management of Mother Management of Infant
ART Zidovudine C-section
<40 yes yes no zidovudine for 4 to 6 weeks
40-999 yes yes consider combination ART, or zidovudine monotherapy for 4-6 weeks
≥1000 yes yes yes combination ART
unknown yes yes yes combination ART, adjusted based on results of maternal viral load

Management of Mother

  • See HIV in pregnancy for information about managing the mother ante-, intra-, and postpartum
  • Mothers should be treated with antiretroviral therapy and monitored during pregnancy
  • Intrapartum management is based on viral load, and includes continuing antiretrovirals, giving intravenous zidovudine during labour, and consideration of Cesarean section
  • Following delivery, mothers should be counselled about the risks of breastfeeding

Management of Neonate

  • See prevention of neonatal HIV for information about preventing disease in the newborn
  • An HIV PCR should be obtained within 48 hours of delivery, then regularly following delivery
    • If any single HIV PCR test is positive, then they are diagnosed with HIV and need ongoing treatment
  • A decision to treat the infant with either zidovudine monotherapy for 4 to 6 weeks, or presumptive antiretroviral therapy for at least 6 weeks, depends on the risk of infection

Hepatitis B virus

Hepatitis C virus

Further Reading

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