What is the recommended management for an infant born by cesarean section (C-section) to a human immunodeficiency virus (HIV) positive mother?

From the Guidelines

The recommended management for an infant born by C-section to an HIV-positive mother includes immediate initiation of antiretroviral prophylaxis, preferably within 6-12 hours of birth, as outlined in the most recent guidelines 1. The standard regimen consists of zidovudine (ZDV) administered twice daily for 4-6 weeks, with dosing based on gestational age (2 mg/kg/dose for term infants). For higher-risk scenarios (such as mothers with detectable viral loads or inadequate prenatal antiretroviral therapy), a three-drug regimen adding nevirapine and lamivudine to zidovudine is recommended. Some key points to consider in the management of these infants include:

• The infant should undergo HIV testing with HIV DNA or RNA PCR at birth, 2-3 weeks, 1-2 months, and 4-6 months of age, as the sensitivity of virologic tests improves from 50% at birth to >90% at 2–4 weeks of age 1.
• Breastfeeding is contraindicated in developed countries where safe formula alternatives are available, as HIV can be transmitted through breast milk.
• Pneumocystis pneumonia prophylaxis with trimethoprim-sulfamethoxazole should be initiated at 4-6 weeks of age if HIV infection status remains indeterminate. This comprehensive approach significantly reduces the risk of mother-to-child transmission of HIV, which can occur during pregnancy, delivery, or breastfeeding, with antiretroviral prophylaxis blocking viral replication during the infant's period of exposure. It is also important to note that the mother's HIV status should be confirmed, and she should receive appropriate counseling and treatment to reduce the risk of transmission and promote her own health, as outlined in the guidelines 1.

From the Research

Management of Infant Born by C-Section to an HIV Positive Mother

• The management of an infant born by cesarean section (C-section) to a human immunodeficiency virus (HIV) positive mother involves the use of antiretroviral prophylaxis to prevent mother-to-child transmission of HIV 2, 3, 4, 5.
• A three-drug regimen, including nelfinavir, lamivudine, and zidovudine, has been shown to be effective in preventing perinatal transmission of HIV in infants born to HIV-positive mothers 2.
• The use of nevirapine, either alone or in combination with zidovudine, has also been studied as a prophylactic regimen to prevent mother-to-child transmission of HIV 3, 4.
• A study found that extended prophylaxis with nevirapine or with nevirapine and zidovudine significantly reduces postnatal HIV-1 infection, with longer duration of prophylaxis resulting in a greater reduction in the risk of infection 3.
• Another study developed an injectable, sustained-release nevirapine formulation that can provide preventative plasma drug levels for 6 weeks or longer from a single subcutaneous administration at birth 6.
• The World Health Organization (WHO) recommends the administration of a once-daily, oral, prophylactic regimen of nevirapine from birth until 4 to 6 weeks of age for infants born to HIV-infected mothers in regions without access to safe and nutritionally adequate alternatives to breast milk 6.
• A study found that nevirapine concentrations during the first month of life were adequate for prophylaxis in high-risk HIV-exposed infants receiving triple antiretroviral prophylaxis, with all infants maintaining nevirapine trough concentrations ≥0.1 mg/L 5.

Antiretroviral Prophylaxis Regimens

• Nelfinavir, lamivudine, and zidovudine: This three-drug regimen has been shown to be effective in preventing perinatal transmission of HIV in infants born to HIV-positive mothers 2.
• Nevirapine and zidovudine: This combination has been studied as a prophylactic regimen to prevent mother-to-child transmission of HIV, with extended prophylaxis resulting in a greater reduction in the risk of infection 3, 4.
• Nevirapine alone: This has been recommended by the WHO as a once-daily, oral, prophylactic regimen from birth until 4 to 6 weeks of age for infants born to HIV-infected mothers in regions without access to safe and nutritionally adequate alternatives to breast milk 6.
• Triple antiretroviral prophylaxis: This regimen, including zidovudine, lamivudine, and nevirapine, has been shown to provide adequate prophylactic concentrations during the first month of life in high-risk HIV-exposed infants 5.