How should a newborn of an HIV‑positive (or unknown status) mother be managed regarding antiretroviral prophylaxis, HIV testing schedule, treatment if infected, and breastfeeding recommendations?

Management of Neonatal HIV Exposure

All newborns born to HIV-positive mothers or mothers with unknown HIV status must receive antiretroviral prophylaxis initiated within 6-12 hours of birth, with a full 6-week course of zidovudine as the standard regimen, and breastfeeding must be completely avoided in resource-rich settings. 1, 2

Immediate Actions for Unknown Maternal HIV Status

Rapid HIV testing must be performed immediately when maternal HIV status is unknown at delivery:

• Perform rapid HIV antibody testing on the mother or newborn with results available within 12 hours of birth 3
• Start antiretroviral prophylaxis immediately based on a positive rapid test result without waiting for confirmatory testing 3
• If confirmatory testing is negative, discontinue prophylaxis and breastfeeding may be initiated 3
• Rapid testing should be available 24 hours per day at all facilities with obstetric units or newborn nurseries 3

Antiretroviral Prophylaxis Protocol

Timing of Initiation

Prophylaxis must begin as soon as possible after birth, ideally within 6 hours but absolutely by 12 hours after delivery to maximize effectiveness 1, 2:

• After 48 hours, efficacy is substantially reduced 1
• By 14 days of age, HIV infection is already established in most infected infants, making later prophylaxis ineffective 1

Standard Regimen

The cornerstone of neonatal prophylaxis is a 6-week course of zidovudine (ZDV) 1, 2:

• This applies to all HIV-exposed infants regardless of maternal treatment history 1
• The full 6-week course with careful administration instructions must be provided to the family before hospital discharge 3, 1
• Complete the full course even if the infant appears healthy and early testing is negative 1

High-Risk Infants

For infants born to mothers who received no or inadequate antiretroviral therapy during pregnancy:

• These infants require more aggressive prophylaxis at minimum with the standard 6-week ZDV regimen 1
• Some experts recommend combination antiretroviral prophylaxis, though definitive efficacy data are limited 1

HIV Testing Schedule for Exposed Infants

Virologic testing (HIV DNA or RNA assays) is the gold standard for diagnosis in infants under 18 months because maternal antibodies can persist until 18 months of age 4:

Recommended Testing Timeline

• First test: Within the first 14 days of life 4
• Second test: At 1-2 months of age 4
• Third test: At 3-6 months of age 4
• Confirmatory antibody test: At 12-18 months of age to document loss of maternal antibodies 4

Diagnostic Criteria

• HIV infection is confirmed with 2 positive HIV DNA or RNA assay results 4
• Presumptive exclusion of infection requires 2 negative virologic tests (one at ≥2 weeks and one at ≥4 weeks of age), or 1 negative test at ≥8 weeks of age 4
• Definitive exclusion requires 2 negative virologic tests (one at ≥1 month and one at ≥4 months), or 2 negative antibody tests at ≥6 months of age 4

Management of Infected Infants

If an infant tests positive for HIV, immediate specialist consultation and treatment initiation is mandatory 3:

• HIV-infected infants should undergo HIV resistance testing 3
• Initiate antiretroviral therapy in the first year of life regardless of CD4 count, RNA level, or clinical status due to rapid disease progression 3
• All HIV-infected infants must be managed by a specialist with expertise in pediatric HIV 3, 5

Breastfeeding Recommendations

HIV-infected mothers must not breastfeed under any circumstances in the United States and other resource-rich settings 3, 2:

• This prohibition applies regardless of maternal antiretroviral therapy use 2
• Formula feeding completely eliminates postnatal transmission risk 2
• If a mother tests positive on rapid testing, breastfeeding should be avoided immediately while awaiting confirmatory results 3
• Assistance with hand and pump expression should be offered to maintain milk production in case confirmatory testing is negative 3

Critical Pitfalls to Avoid

Never delay prophylaxis while awaiting confirmatory HIV testing results - the window for effective prophylaxis is extremely narrow 1:

• The most significant missed prevention opportunity is failure to test pregnant women for HIV 2
• Do not discontinue prophylaxis prematurely even if early infant HIV testing is negative - the full 6-week course is essential 1
• Do not assume that a negative antibody test in an infant under 18 months rules out infection - only virologic testing is diagnostic 4

Specialist Consultation

All care of HIV-exposed and HIV-infected newborns must be performed in consultation with specialists experienced in pediatric HIV infection 3, 5:

• This includes decisions about prophylaxis regimens, diagnostic testing interpretation, and treatment initiation 3
• Early specialist involvement optimizes outcomes and prevents management errors 3