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Chapter 117: Infant of HIV-Positive Mother

Avinash K. Shetty; Fatima Clouser; Yvonne A. Maldonado

INTRODUCTION

Perinatal transmission rates in the United States are at historic lows (<2%) because of the availability of effective interventions to prevent perinatal human immunodeficiency virus (HIV) transmission.1 However, transmission does occur in a small number of infants, primarily because of missed prevention opportunities.2, 3 The neonatologist plays a vital role in the prevention of perinatal HIV transmission in early identification of HIV-exposed newborns born to infected mothers who were not tested for HIV during pregnancy and in administering antiretroviral (ARV) prophylaxis to HIV-exposed infants as early as possible after birth.4,5 The primary care physician, in conjunction with a pediatric infectious disease specialist, must ensure appropriate follow-up to confirm or exclude the diagnosis of HIV infection in early infancy and provide ongoing counseling, support, and anticipatory guidance6 (Table 117-1). A comprehensive review of recommendations for evaluation and treatment of the HIV-exposed infant has been published by the American Academy of Pediatrics (AAP) and other experts.4,5,7,8 This chapter discusses the clinical evaluation, laboratory testing, and treatment of HIV-exposed infants, incorporating the recently updated Public Health Service guidelines with a focus on prevention of perinatal HIV transmission.5,6

Table 117-1Clinical Care of Infants Exposed to Human Immunodeficiency Virus (HIV)
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Table 117-1Clinical Care of Infants Exposed to Human Immunodeficiency Virus (HIV)

  • History and physical examination

  • Infant ARV prophylaxis

  • Avoidance of breast-feeding

    • Infant formula

  • Determination of HIV status

    • Virologic testing at 14–21 days, 1–2 months, and 4–6 months of age

    • HIV antibody testing at 12–18 months (for infants in whom serial virologic tests are negative in early infancy) to document HIV seroreversion and definitively exclude infectiona

  • PCP prophylaxis

    • TMP-SMX from 6 weeks and continued until HIV infection is presumptively or definitively excluded

  • Psychosocial support to mother and other caregivers

    Comprehensive well-baby care

    • Immunizations

    • Growth and development monitoring

    • Anticipatory guidance

Abbreviations: ARV, antiretroviral prophylaxis; PCP, Pneumocystis jiroveci pneumonia; TMP-SMX, trimethoprim-sulfamethoxazole.

aExpert recommendation. from references 5 and 14.

DIAGNOSIS/INDICATION

Universal prenatal HIV testing is the gateway to access effective antepartum, intrapartum, and postpartum interventions to prevent perinatal HIV transmission. All pregnant women must be routinely tested for HIV (“opt-out” approach) regardless of potential risk factors.9 Repeat testing during the third trimester of pregnancy is recommended for certain high-risk populations to identify new infections.9 HIV-negative women should receive counseling to maintain HIV-negative status during pregnancy and thereafter. In contrast, women with acute or recent HIV infection must be linked to care and receive a potent combination ARV drug regimen as soon as possible, with the goal of achieving viral load to undetectable levels and preventing perinatal HIV transmission.5 Scheduled cesarean delivery at 38 weeks’ gestation is recommended for HIV-positive women who have received ARV agents but have viral load greater than 1000 copies/mL ...

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