Neonatal HIV

Background

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

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
  • Before this, there is the risk of detecting maternal antibodies

Prevention

• 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

Selection of Antiretrovirals

• 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

Follow-Up

All Exposed Infants

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

Infants on Prophylactic Zidovudine

• 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
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

Infants on Presumptive Antiretrovirals

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