What is the recommended approach for preventing mother to child transmission of Human Immunodeficiency Virus (HIV) and caring for pediatric Acquired Immunodeficiency Syndrome (AIDS) patients?

Prevention of Mother-to-Child HIV Transmission and Pediatric AIDS Care

The most effective approach for preventing mother-to-child transmission (MTCT) of HIV includes universal HIV testing of pregnant women, early initiation of antiretroviral therapy (ART) during pregnancy, appropriate delivery methods, and proper infant feeding practices based on resource availability. 1

Maternal HIV Testing and Prevention

• Universal HIV testing should be performed for all pregnant women using an "opt-out" consent approach, with repeat testing in the third trimester for high-risk women 1
• For women in labor with undocumented HIV status, rapid HIV testing should be performed immediately with results available within 12 hours of birth 1
• If rapid HIV test is positive, antiretroviral prophylaxis should be started promptly for both mother and infant without waiting for confirmatory testing 1

Antiretroviral Interventions During Pregnancy

• HIV-infected pregnant women should receive combination antiretroviral therapy (ART) as early as possible in pregnancy, ideally before conception 1
• Without ART intervention, HIV-infected pregnant women have a 15-45% risk of transmitting the virus to their child; with effective ART, this risk can be reduced to less than 5% 1
• The recommended regimen depends on maternal health status:
  • For women requiring treatment for their own health: Full combination ART (typically including zidovudine 300mg twice daily) should be continued throughout pregnancy 1, 2
  • For women not requiring treatment for their own health: Prophylactic regimens should still include combination therapy rather than single-drug approaches 1

Intrapartum Management

• Elective cesarean delivery at 38 weeks is recommended for HIV-infected women with viral loads >1000 copies/mL near delivery time or unknown viral load, reducing transmission risk by approximately 50% 1
• Intravenous zidovudine should be administered during labor for women with HIV RNA levels >1000 copies/mL 1
• For women identified as HIV-positive during labor, immediate intrapartum antiretroviral prophylaxis should be started 1

Infant Prophylaxis and Care

• All infants born to HIV-infected mothers should receive antiretroviral prophylaxis, typically with zidovudine for 6 weeks 1
• For high-risk scenarios (mothers with no prenatal ART or poor viral suppression), experts may recommend additional antiretroviral drugs beyond zidovudine alone 1
• Infant dosing of zidovudine should be calculated based on body weight: 4mg/kg twice daily for 4-6 weeks 1, 2
• For infants whose mothers received no antiretroviral therapy, prophylaxis should be started as soon as possible after birth, ideally within 12 hours 1

Infant Feeding Recommendations

• In resource-rich settings like the United States, HIV-infected women should not breastfeed regardless of maternal ART use, as safe feeding alternatives exist 1
• In resource-limited settings where formula feeding may increase mortality risk from malnutrition and infectious diseases, the WHO recommends:
  • HIV-infected mothers should breastfeed for at least 12 months while being fully supported for ART adherence 1
  • Earlier ART initiation in pregnancy is significantly associated with plasma viral suppression, reducing transmission risk during breastfeeding 1

Nutritional Support for HIV-Infected Children

• Management of severe acute malnutrition (SAM) in HIV-infected children follows a two-phase approach: stabilization and rehabilitation 1
• During stabilization, F-75 (a low-protein, milk-based therapeutic diet) should be administered 1
• During rehabilitation, ready-to-use therapeutic foods (RUTFs) are recommended 1
• Home-based treatment with RUTF has shown better outcomes than clinic-based approaches, especially in rural areas 1

Follow-up Care for HIV-Exposed Infants

• All HIV-exposed infants should receive appropriate testing to determine infection status 1
• Prophylaxis against Pneumocystis jiroveci pneumonia should be provided for infants with undetermined or positive HIV status 1
• The full 6-week course of infant antiretroviral prophylaxis should be provided to families before hospital discharge 1
• Comprehensive follow-up care should include monitoring for medication side effects, growth assessment, and developmental screening 1

Common Pitfalls and Caveats

• Failure to test pregnant women for HIV is the most significant missed opportunity for prevention 1
• Delayed initiation of antiretroviral therapy significantly reduces effectiveness of prevention 1
• Inconsistent adherence to maternal ART during pregnancy and breastfeeding increases transmission risk 1
• Lack of coordination between obstetric and pediatric care can lead to gaps in prophylaxis administration 1
• In resource-limited settings, balancing the risks of HIV transmission through breastfeeding against the risks of not breastfeeding requires careful consideration 1