What are the recommendations for preventing mother to child transmission of Human Immunodeficiency Virus (HIV) and caring for pediatric Acquired Immunodeficiency Syndrome (AIDS)?

Mother-to-Child HIV Transmission and Pediatric AIDS Care

Universal HIV testing of all pregnant women with opt-out consent and appropriate antiretroviral therapy (ART) administration during pregnancy, labor, and to the newborn are essential interventions to prevent mother-to-child transmission (MTCT) of HIV and optimize pediatric AIDS care. 1

Prevention of Mother-to-Child HIV Transmission

HIV Testing During Pregnancy

• Documented, routine HIV antibody testing should be performed for all pregnant women after notifying the patient that testing will be performed, unless the patient declines (opt-out consent) 1
• Repeat HIV testing is recommended in the third trimester (preferably before 36 weeks' gestation) for women in high HIV prevalence areas or those at increased risk of acquiring HIV 1
• For women with undocumented HIV status during labor, rapid HIV testing should be performed immediately with results available quickly enough to implement interventions 1

Antiretroviral Interventions for HIV-Infected Pregnant Women

• 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% 2
• For pregnant women who require treatment for their own health, ART should be initiated as soon as possible, including in the first trimester 1, 2
• For women who do not require treatment for their own health, prophylactic ART should still be administered, typically starting at 28 weeks gestation or as soon as feasible thereafter 1, 2
• The recommended regimen includes combination ART during pregnancy, intravenous zidovudine (AZT) during labor, and antiretroviral prophylaxis for the infant 1

Intrapartum Management

• For women in labor with undocumented HIV status, rapid HIV testing should be performed with results available within 12 hours of birth 1, 2
• For women with a positive rapid HIV test result, antiretroviral prophylaxis should be administered promptly to both mother and newborn without waiting for confirmatory test results 1
• Elective cesarean delivery at 38 weeks is recommended for HIV-infected women with viral loads >1000 copies/mL near delivery or unknown viral load 2

Infant Care and Prophylaxis

Antiretroviral Prophylaxis for HIV-Exposed Infants

• All infants born to HIV-infected mothers should receive antiretroviral prophylaxis, typically with zidovudine for 6 weeks after birth 1, 2
• For newborn infants whose mother's HIV status is unknown, rapid HIV testing should be performed on the mother or newborn, with results reported within 12 hours of birth 1
• If the mother or infant has a positive rapid HIV test result, antiretroviral prophylaxis should be initiated as soon as possible but certainly within 12 hours after birth 1
• The full 6-week course of infant antiretroviral prophylaxis should be provided to the family before discharge from the hospital 1

Infant Feeding Recommendations

• In resource-rich settings like the United States, HIV-infected mothers should not breastfeed regardless of ART status, as safe alternatives exist 1, 2
• If a mother tests positive on rapid HIV testing, she should be counseled not to breastfeed pending confirmatory testing 1
• Assistance with immediate initiation of hand and pump expression should be offered to maintain milk production in case confirmatory testing is negative 1
• In resource-limited settings, the WHO recommends HIV-infected mothers should breastfeed while being fully supported for ART adherence 2

Follow-up Care for HIV-Exposed and HIV-Infected Infants

Testing and Diagnosis

• For infants born to HIV-infected mothers, HIV testing should be performed to determine the infant's HIV status 1, 2
• For children younger than 18 months, direct detection of HIV DNA or RNA is required rather than antibody testing, as maternal antibodies can persist in the infant 1, 2

Prophylaxis Against Opportunistic Infections

• Prophylaxis with trimethoprim-sulfamethoxazole should be provided for HIV-exposed infants whose HIV status has not been determined or who are identified as HIV-infected to prevent Pneumocystis jiroveci pneumonia 1, 2

Nutritional Support for HIV-Infected Children

• Management of severe acute malnutrition in HIV-infected children follows a two-phase approach: stabilization and rehabilitation 2
• During the stabilization phase, a low-protein, milk-based therapeutic diet should be administered 2

Common Pitfalls and Challenges

Missed Opportunities for Prevention

• Lack of identification of maternal HIV status is the primary reason for new infant HIV infections 1, 2
• Failure to perform HIV testing during pregnancy or labor represents a significant missed opportunity for prevention 1
• Delayed initiation of antiretroviral therapy significantly reduces effectiveness of prevention 2, 3

Medication Considerations

• Pregnant women taking efavirenz should be informed that it must always be used in combination with other antiretroviral drugs 4
• Lopinavir/ritonavir use during pregnancy has not shown increased risk of birth defects compared to the general population 5
• There is concern about the development of antiretroviral-resistant HIV strains, particularly with nevirapine use, though this has not been associated with increased risk of transmission 6

Adverse Outcomes

• HIV-infected pregnant women are at 2-4 times higher risk of preterm birth compared to uninfected women 7
• Different antiretroviral regimens may be associated with varying rates of preterm birth 3, 7
• Pregnancy-associated changes in drug absorption, distribution, metabolism, and excretion require special consideration for antiretroviral dosing throughout pregnancy 8