Neonatal HIV: Difference between revisions

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== Background ==
−
#REDIRECT [[Perinatal transmission of HIV and HBV]]
  
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* Risk of infection during labour is 25 to 35%, and decreases to less than 1% with appropriate care
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==Diagnosis==
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*Up to 18 months of age, only use '''HIV PCR'''
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**In general, all infants with perinatal exposure should be checked at 14 to 21 days, 1 to 2 months, and 4 to 6 months
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**If high risk, can also check at birth and 2 to 4 weeks after stopping antiretrovirals
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**Confirm a positive result with repeat testing
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*'''Serology''' can be tested starting at 18 to 24 months
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**Before this, there is the risk of detecting maternal antibodies
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== Prevention ==
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* Risk of acquisition during delivery is decreased substantially by [[HIV in Pregnancy#Management|appropriate management of the mother]]
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* It is further decreased by the use of either prophylactic [[zidovudine]] and [[nevirapine]], or empiric treatment with [[zidovudine]], [[lamivudine]], and either [[nevirapine]] or [[raltegravir]]
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{| class="wikitable"
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!Maternal Viral Load
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!Management of Neonate
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|-
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|<40
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|[[zidovudine]] for 4 to 6 weeks
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|-
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|40-999
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|[[zidovudine]] for 4 to 6 weeks, or combination ART
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|-
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|≥1000
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|combination ART
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|-
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|unknown
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|combination ART
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|}
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====Selection of Antiretrovirals====
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*Can either do a prophylactic regimen, or treat empirically
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*'''Prophylaxis''' is indicated for low risk of perinatal HIV transmission
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**[[Zidovudine]] monotherapy for 4 to 6 weeks
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**Duration of 4 weeks is indicated for situations where mother was on ART during pregnancy with sustained viral suppression and no concerns about adherence
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*'''Presumptive treatment''' is indicated in all other scenarios
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**'''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)
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**'''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
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**Regarding duration, in the UK they typically treat for 2 weeks while in Canada it is typically 4 weeks
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*A previously-recommended option was prophylaxis with combination, but this is no longer routinely done
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**'''ZDV/NVP:''' [[Zidovudine#Neonatal HIV prophylaxis|zidovudine]] x6 weeks, plus [[nevirapine#Neonatal HIV prophylaxis|nevirapine]] x3 in the first week of life
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=== Follow-Up ===
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==== All Exposed Infants ====
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{| class="wikitable"
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!Age
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!Investigations
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|-
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|14 to 21 days
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|HIV PCR
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|-
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|1 to 2 months
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|HIV PCR
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|-
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|4 to 6 months
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|HIV PCR
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|-
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|12 to 18 months
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|HIV serology
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|-
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|24 months
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|HIV serology, if positive at 12 to 18 months
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|}
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* If any of the PCR tests is positive, then full antiretroviral therapy should be started
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==== Infants on Prophylactic Zidovudine ====
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* 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
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{| class="wikitable"
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!Age
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!Diagnostic Tests
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!Management
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|-
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|≤48 hours
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|HIV PCR, ALT
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|start ART
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|-
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|1 week
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|
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|
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|-
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|2 weeks
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|HIV PCR
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|
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|-
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|4 weeks
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|ALT
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| rowspan="2" |stop ART if PCR has been negative to date
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|-
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|6 weeks
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|HIV PCR
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|-
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|2 to 6 weeks after stopping ART
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|HIV PCR
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| rowspan="4" |routine follow-up; start ART if PCR positive or serology at 24 months is positive
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|-
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|4 to 6 months
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|HIV PCR
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|-
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|12 to 18 months
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|HIV serology
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|-
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|24 months
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|HIV serology, if positive at 12 to 18 months
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|}
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* If any of the PCR tests is positive, then monotherapy should be stopped and full antiretroviral therapy should be started
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==== Infants on Presumptive Antiretrovirals ====
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{| class="wikitable"
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!Age
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!Diagnostic Tests
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!Management
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|-
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|≤48 hours
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|HIV PCR, ALT, CBC
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|start ART
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|-
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|1 week
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|CBC, nevirapine level
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|adjust nevirapine
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|-
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|2 weeks
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|HIV PCR, CBC, nevirapine level
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|adjust nevirapine
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|-
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|4 weeks
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|ALT, CBC
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|
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|-
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|6 weeks
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|HIV PCR
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|stop ART if PCR has been negative to date
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|-
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|2 to 6 weeks after stopping ART
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|HIV PCR
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| rowspan="4" |routine follow-up; start ART if PCR positive or serology at 24 months is positive
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|-
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|4 to 6 months
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|HIV PCR
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|-
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|12 to 18 months
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|HIV serology
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|-
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|24 months
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|HIV serology, if positive at 12 to 18 months
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|}
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<br />
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[[Category:HIV]]
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[[Category:Pediatrics]]

Latest revision as of 11:33, 18 September 2020

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

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
  • A previously-recommended option was prophylaxis with combination, but this is no longer routinely done

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


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