EML

Z20.6

Description
Management of HIV-exposed infants

DESCRIPTION

An infant whose mother is HIV infected and in whom infant HIV infection has neither been confirmed nor excluded.

Transmission of HIV infection from mother to child may occur during pregnancy, during delivery, or via breast feeding. Prevention of mother to child transmission (PMTCT) can be effectively carried out with a very high success rate by fully suppressing the mother’s viral load with ART and giving prophylactic antiretroviral therapy to the infant. All attempts should be made to ensure that maternal viral loads are done, checked, recorded and acted upon during pregnancy, and that this information is available at time of delivery to ensure the correct PMTCT intervention is given to the infant.

With the effective use of antiretrovirals, the risk of HIV transmission through breast feeding is minimised. In situations where the viral load of the mother cannot be suppressed the risk of breast milk transmission remains significant.

The PMTCT plan starts with initiation of cART in the mother (either pre or post conception), thereafter, the HIV-exposed infant may be classified into one of the following categories which determines the appropriate infant prophylaxis regimen:

Low Risk
High Risk
Unknown Risk

MANAGEMENT OF HIV-EXPOSED INFANTS

**The infant prophylaxis stated in this table supersedes the National Consolidated guidelines for the Prevention of mother-to-child transmission of HIV (PMTCT) and management of HIV in children, adolescents and adults of 2015.

Unknown maternal status for any reason, including orphans and abandoned infants: Give NVP immediately. Test infant with rapid HIV test. If rapid HIV test can be done within 2 hours, then wait for HIV results before commencing NVP. If rapid HIV test positive continue NVP for 6 weeks. If negative discontinue NVP. If the rapid HIV test is positive do an HIV PCR. If negative, repeat HIV PCR at 10 weeks. If HIV PCR positive, initiate baby on triple ART immediately and send confirmatory HIV PCR.

Non-breastfeeding mother diagnosed HIV positive > 72 hours after delivery: Do not start NVP. Perform an HIV test on infant and if positive initiate ART.

Note: Remember to repeat the HIV PCR 6 weeks after breastfeeding cessation for all breastfed infants if < 18 months and repeat HIV rapid/ ELISA test if ≥ 18 months.

LoEI [1]

Note: All HIV PCR results need to be followed-up as a matter of urgency.

Nevirapine (NVP) and Zidovudine (AZT) doses for infant on PMTCT
See table above.

Give 1ˢᵗ dose as soon as possible after birth.
Ideally the birth PCR test should be done before administration of infant NVP and AZT, but any delay in testing should not delay the NVP and AZT administration.
Only one dose per 24-hour period; repeat dose once only if baby vomits.
If infant HIV PCR is positive at any time, stop NVP and AZT, confirm with 2ⁿᵈ HIV PCR test and initiate cART. Continue normal breastfeeding.

Nevirapine, oral, daily (syrup 10mg/mL) and Zidovudine, oral, twice daily (syrup 10mg/mL)
- Newborns ≥2 kg and term infants:

Infant Age/Wt	NVP Dose (Daily)	AZT Dose (Twice daily)
*Birth to 6 weeks*
2.0 - 2.49 kg	1 ml (10 mg) daily	1 ml (10 mg) twice daily
>2.5 kg	1.5 ml (15 mg) daily	1.5 ml (15 mg) twice daily
*6 weeks - 6 months*
	2 ml (20 mg) daily	6 ml (60mg) twice daily

Children > 6 months of age requiring prophylaxis should use treatment doses.

Premature newborn < 2 kg:
- Nevirapine, oral, daily

Weight	1 ^st 2 weeks after birth mg of NVP	After 1 ^st 2 weeks after birth mg of NVP
500 to < 625 g	1 mg	2 mg
625 to < 850 g	1.5 mg	3 mg
850 to < 1 200 g	2 mg	4 mg
1.2 to < 1.5 kg	3 mg	5 mg
1.5 to < 1.9 kg	3.5 mg	6 mg

If infant at time of discharge is severely underweight for age (3 SD or 3 z-scores below the mean) give NVP according to weight, (i.e. 4 mg/kg/dose daily) until in the normal weight for age range.

Zidovudine, oral, twice daily

Gestational Age at birth	1 ^st 2 weeks after birth	2-4 weeks after birth	4-6 weeks after birth	>6 weeks after birth
30-35 weeks	2 mg/kg	3 mg/kg	4 mg/kg	4 mg/kg
<30 weeks	2 mg/kg	2 mg/kg	3 mg/kg	4 mg/kg

LoEII [2]
LoEII [3]
LoEII [4]

ART Prophylaxis for infants who are unable to tolerate oral medication

Infants who are unable to tolerate oral medication/feeds should be initiated on intravenous zidovudine (AZT). On re-establishment of oral feeds/medications, intravenous zidovudine should be stopped and the infant commenced on the appropriate oral infant prophylaxis regimen. Ideally gestational age should be used to determine optimal dose.

Gestational Age (weeks)	Approximate birth weight	AZT IV dosing for first 14 days (If Unable to Tolerate Oral Agents)
≥ 35 weeks	≥ 2.5 kg	3 mg/kg body weight IV every 12 hours
< 35 weeks	< 2.5 kg	1.5 mg/kg body weight IV every12 hours

HIV Testing

Recommended Intervals for Infant and Child Testing

HIV PCR test	Rapid HIV Antibody test
At Birth All HIV exposed neonates. Repeat HIV PCR testing at 10 weeks and 18 weeks (if applicable) should be done on all HIV exposed infants with a prior negative or indeterminate HIV PCR. Any infant with a positive birth PCR should be urgently initiated on ART as per HIV infected neonate At 10 weeks All HIV-exposed infants. At 18 weeks All infants who received 12 weeks of infant prophylaxis.	At 18 months All HIV exposed infants. Patients already on ART should not have a repeat HIV antibody test. Breastfed infants: (6 weeks post cessation of breastfeeding) All HIV exposed infants - age appropriate: if <18 months old - do HIV PCR ≥ 18 months old - do rapid HIV Antibody test Family and social history (at all times) Parental request to test the child. Primary caregiver is able to give consent for HIV testing in the best interests of the child. Father or sibling with HIV infection. Death of mother, father or sibling. When the mother's HIV status is unknown, her whereabouts are unknown, or she is unavailable to be tested. All children (at all times) with Clinical features suggestive of HIV infection. Acute, severe illness. IMCI classification of Suspected symptomatic HIV infection. IMCI classification of Possible HIV infection. TB diagnosis or history of TB treatment. Risk of sexual assault. Wet-nurse or breastfed by a woman with unknown or HIV-positive status. Children considered for fostering of adoption.

HIV PCR test

Rapid HIV Antibody test

At Birth

All HIV exposed neonates.

HIV infected neonate

At 10 weeks

All HIV-exposed infants.

At 18 weeks

All infants who received 12 weeks of infant prophylaxis.

At 18 months

All HIV exposed infants.

Patients already on ART should not have a repeat HIV antibody test.

Breastfed infants: (6 weeks post cessation of breastfeeding)

All HIV exposed infants - age appropriate: if <18 months old - do HIV PCR
≥ 18 months old - do rapid HIV Antibody test

Family and social history (at all times)

Parental request to test the child.

Primary caregiver is able to give consent for HIV testing in the best interests of the child.

Father or sibling with HIV infection.

Death of mother, father or sibling.

When the mother's HIV status is unknown, her whereabouts are unknown, or she is unavailable to be tested.

All children (at all times) with

Clinical features suggestive of HIV infection.

Acute, severe illness.

IMCI classification of Suspected symptomatic HIV infection.

IMCI classification of Possible HIV infection.

TB diagnosis or history of TB treatment.

Risk of sexual assault.

Wet-nurse or breastfed by a woman with unknown or HIV-positive status.

Children considered for fostering of adoption.

If HIV PCR indeterminate or discordant refer to NHLS guideline. HIV infected neonate

Feeding advice

Exclusive breastfeeding is strongly recommended for the 1ˢᵗ 6 months, after which the nutritional requirements of the child will require the introduction of complementary foods, in addition to breastfeeding.
Except where a mother is shown to be failing cART, the advantages of breastfeeding exceed the risks of HIV transmission in a mother on cART and the mother should be encouraged to breast feed.
The use of flash pasteurisation or Pretoria pasteurisation to reduce HIV transmission is supported but may pose significant barriers to successful breast milk feeding due to the effort involved. It can be used as an interim measure, for instance during maternal mastitis.

Co-trimoxazole prophylaxis

Indications:

All HIV exposed infants starting from 4–6 weeks of age.

Discontinuation:

If the child is shown to be HIV uninfected and has not been breastfed for the last 6 weeks; or
If HIV infected, the immune system is fully reconstituted and >1 year of age (i.e. child 1 to 5 years of age: CD4>25%, or child >5 years of age: CD4>350 cells/mm³ on 2 tests at least 3–6 months apart).

Co-trimoxazole (sulfamethoxazole/trimethoprim), oral, once daily (everyday).