Management of infants born to HIV positive mothers

For women with detectable viral load at the time of delivery (ie > 50 copies/ml), elective pre-labour caesarean section reduces the risk of transmission. Where the maternal viral load is not detectable at delivery caesarean section confers little additional benefit, and vaginal delivery is recommended wherever possible. This is particularly true where a mother may be returning to a developing country with reduced access to caesarean section for subsequent pregnancies. The decision as to mode of delivery will generally have been made prior to labour by a consultant obstetrician.

Most neonates born to mothers known to be HIV infected in pregnancy will have been exposed to anti-retroviral therapy in utero and during labour. Regimes vary according to maternal health and viral load, and it is important that each case is considered individually, particularly if there is any drug resistance. A plan of management for the infant should be documented in the mother’s electronic patient record prior to delivery.

It is important that the paediatrician on call is notified as soon as the mother is admitted either for elective caesarean section or in active labour so that arrangements can be made for treatment of the baby within 4 hours of birth. It is not necessary either for the paediatrician to attend the delivery or for the baby to be admitted routinely to the nursery.

In the event of threatened or actual preterm labour, an assessment must be made by a consultant obstetrician as to the most appropriate mode of delivery. This decision will be influenced by the presence of ruptured membranes. At <32 weeks’ gestation, delivery should be postponed if possible, pending administration of antenatal steroids.

The infant's face and eyes should be cleaned at delivery and the infant bathed as soon as is practicable after birth, taking care to avoid hypothermia.

In most cases a plan of management for the infant will have been documented in the mother’s casenotes. It is important, however, to check that the circumstances leading to this decision have not changed (e.g. maternal viral load); if there is any doubt as to the most appropriate treatment for the infant, the case should be discussed with the on-call consultant.

Baseline bloods (venous sample) should be taken on day 1, unless the baby is born at the weekend. Outwith normal working hours, blood samples can be taken soon after delivery and stored in the refrigerator until the next morning. For babies born at the weekend (after 4.00pm on Friday) blood samples should be deferred until first thing on the Monday morning.

DO NOT DELAY ADMINISTRATION OF POST-EXPOSURE PROPHYLAXIS PENDING THESE BLOODS

• HIV RNA. (NB Choose HIV viral load on Trakcare) This will be analysed at the Regional Virus Laboratory in the New Lister Building at Glasgow Royal Infirmary. See sample requirements below. Note that cord blood is not suitable for PCR because of the likelihood of contamination by maternal blood. 
• If the mother’s HIV antibody status is not known, please also request HIV antibody screen (this can be done on the same EDTA sample)
• If the baby is unwell for any reason, investigations should include amylase, lactate and capillary blood gases as certain antiretroviral drugs (particularly protease inhibitors) can cause metabolic disturbance.

Sample requirements for the HIV RNA test

• 2ml blood (minimum 1.5ml)
• EDTA (purple top) – use small adult vacutainer
• Phone lab so that they can look out for the sample
  • 0141 201 8722 (select option 1)
  • NB - 38722 short code within Glasgow

• Send sample to the Regional Virus Laboratory, Glasgow Royal Infirmary
• At the weekends, please ensure sample arrives in the laboratory before 12.30pm (call first)

All infants born to HIV infected mothers should be immunised according to the standard schedules, including oral rotavirus vaccine. Low and very low risk babies at increased risk of tuberculosis should be offered BCG shortly after birth or at the first available clinic appointment. For the convenience of parents, BCG may be offered in the neonatal clinic at six weeks of age. coincident with the first repeat viral load.

Higher risk babies (i.e. detectable maternal viral load or breast fed) should not be given BCG vaccination until tested negative at three months (or 2 months after the cessation of breast feeding – see section on Breast-feeding and HIV infection below)

As per current BHIVA (British HIV Association) guidelines (2018):

1. VERY LOW RISK: (all 3 criteria to be fulfilled)

• Mother has received combination anti-retroviral therapy for at least 10 weeks leading up to delivery
• Maternal viral load has been < 50 copies/mL on the two most recent occasions during pregnancy, at least 4 weeks apart.
• Gestation > 34 weeks

Two weeks’ zidovudine monotherapy (even if maternal resistance)

Dosage: oral zidovudine 4 mg/kg twice daily from birth to 2 weeks of age

2. LOW RISK:

• If the criteria for very low risk babies (above) are not all fulfilled but maternal HIV viral load is <50 HIV RNA copies/mL at or after 36 weeks;
• If the infant is born prematurely (<34 weeks) but most recent maternal HIV viral load is <50 HIV RNA copies/mL.

Four weeks’ zidovudine monotherapy (even if maternal resistance)

Dosage:        

1. Well infant > 34 weeks’ gestation
Oral zidovudine 4mg/kg twice daily from birth to 4 weeks of age

2. Well infant, 30 – 33⁺⁶ weeks’ gestation
Oral zidovudine 2mg/kg twice daily for the first 2 weeks then 2mg/kg three times daily for a further 2 weeks

3. Well preterm infant, < 30 weeks’ gestation
Oral zidovudine 2mg/kg twice daily for 4 weeks

4. Any infant who is sick or intolerant of oral medication
> 34 weeks’ gestation – IV zidovudine 1.5mg/kg every 6 hours
< 34 weeks’ gestation - IV zidovudine 1.5mg/kg every 12 hours - change to every 6 hours once baby is 34⁺⁰ weeks corrected gestational age.
If there is any doubt that oral medication will not be tolerated the baby should be admitted to special care. Have a low threshold for starting parenteral treatment.

3. HIGHER RISK:

• < 72 hours old born to untreated HIV positive mother or infants born to mothers who have a known or likely detectable viral load (> 50 copies/ml) or if maternal compliance is in doubt

Triple therapy – see below

In addition, some higher risk infants will require PCP prophylaxis

• Initial positive infant HIV RNA test, or any viral load > 50 copies/mL thereafter, until HIV infection excluded

Treatment – Triple therapy – see below – then, from 4 weeks of age, co-trimoxazole as PCP prophylaxis given orally until the child is confirmed likely free of infection at three months. The dose is given as a single daily dose three times weekly on Mondays, Wednesdays and Fridays. The dose is 120 mg up to 6 months of age and 240 mg between 6 and 12 months, of the paediatric suspension (240mg/5ml) given three times weekly. It is the responsibility of the doctor discharging the child to ensure that arrangements for prescription and supply of co-trimoxazole (when required) are in place before the baby goes home. The GP should be contacted by telephone, and if this is not possible, the baby should be given an early outpatient appointment for clinic at 2 weeks of age.

Note that treatment regimen may need to be adjusted if the mother has a history of multiple antiretroviral therapy exposure and resistance. Such cases will require consultant discussion (preferably before delivery). 

Breast feeding is an important route of transmission of HIV. In the UK, where safe infant feeding alternatives are available, HIV infected women are advised to formula feed, and there are arrangements for free provision of infant formula to HIV positive women. BHIVA guidelines recommend that mothers who agree to formula feed should be offered lactation suppression; please ensure that this has been considered by the obstetric/midwifery team.

NB. When mothers are at high risk of acquiring HIV infection, but have tested negative throughout pregnancy, the risk of transmission through breastfeeding is about 30% when a mother acquires HIV infection after delivery.

There is now evidence from developing countries that breast feeding while mum’s viral load is fully suppressed is safe, and BHIVA/CHIVA no longer regard a decision to breast feed as grounds for referral to child protection services. For HIV positive women who choose to breast feed, maternal HAART should be carefully monitored and continued until one week after all breastfeeding has ceased. The mother’s viral load should be tested monthly to ensure that HIV virus remains undetectable; this testing will be undertaken by the obstetric/ID team. It is recommended that breastfeeding be exclusive, and completed by the end of 6 months.

Prolonged infant prophylaxis during the breastfeeding period is not recommended - the baby should receive 2 or 4 weeks of oral zidovudine as per standard guidelines.

The breast fed baby’s follow-up and testing should be as follows:

viral load at 2 weeks and at 6 weeks

viral load monthly thereafter until 2 months after cessation of breastfeeding

HIV antibody at 22 - 24 months

BCG vaccine (if indicated) should not be given until the final viral load is shown to be negative (ie 2 months after cessation of breast feeding). There is no need for mantoux testing in babies less than one year of age.

Breast feeding advice and support

If the mother develops a cracked nipple or mastitis, breast feeding from that side should be temporarily suspended, and urgent lactation support sought. Lactation may be maintained by expressed/pumping of milk, but milk from the affected breast should be discarded.

Breast feeding should cease by six months.

There is little evidence to support the transition to formula feeding, which should ideally occur before the introduction of weaning foods. If mother’s viral load is undetectable, it is however unlikely that a few days of mixed breast and bottle feeding poses a significant risk.

Abrupt cessation of breast feeding is likely to result in breast engorgement; this may be alleviated by a gradual reduction in expressing/pumping of milk after the baby has been transitioned to formula feeding (the expressed milk should be discarded). The support of a health visitor and/or lactation expert should be sought. 

Useful parental information has been prepared by BHIVA:

HIV and breastfeeding your baby

General information on infant feeding for women living with HIV

Unless there are other medical or social problems, the infant can be discharged home once medical and nursing staff are happy that the oral antiretroviral medication is being tolerated. It is very important that the mother understands the importance of good compliance with the treatment, and that she is advised to seek help early if the baby does not tolerate the medication or becomes unwell in any way.

Arrangements should be made for review at 6 (or 2, if breast fed) weeks of age, and the parents informed that blood tests will be repeated at this visit. N.B. A double appointment slot  should be requested.

Remember to check if the HIV status of any siblings has been checked; if not, then refer to Drs. Conor Doherty or Rosie Hague at RHC.

Follow up testing

N.B. In order to avoid confusion follow up bloods must be labelled with the following

• Baby’s birth surname as well as (if appropriate) his/her registered surname
• Hospital number
• CHI number
• Date of birth.

(High risk or breast fed babies only) 2 weeks: HIV RNA PCR. (HIV Viral load on TrakCare)

6 weeks:  HIV RNA PCR. (HIV Viral load on TrakCare)

3 months:  HIV RNA PCR. (HIV Viral load on TrakCare)

NB – interpreting viral load results – A viral load of < 40 copies/mL is a negative test.  If the sample was of too little volume a 1:10 dilution will be performed and the result will show as < 80 (or 400) copies/mL.  This also indicates a negative result. Since BHIVA recommend a cut off of 50 copies/mL, a result of 45 copies/mL would not change the infant’s risk category.

If baby is HIV RNA positive, then he/she should be referred immediately to Drs. Conor Doherty or Rosie Hague at RHC Glasgow. 

9-10 months:  Clinic appointment to monitor developmental progress. Advise parents that infant will be seen again at 22-24 months to check for disappearance of maternal antibody.

22-24 months:  Clinical review, HIV antibody (HIV Screen on TrakCare) to check for disappearance of maternal antibody. This requires 1-2ml EDTA sample