Perinatal Exposure to HIV Requires Specialized, Coordinated Care

Pediatricians and pediatric HIV specialists need to coordinate their care plans for infants born with potential perinatal exposure to the virus, according to a new report from the American Academy of Pediatrics (AAP) published in the journal Pediatrics.

This requires determining HIV status in both mother and child through routine testing, after consent is given; continuing antiretroviral therapy (ART) throughout pregnancy; planning for a cesarean delivery at 38 weeks’ gestation, unless the HIV RNA level is below 1000 copies/mL; and postnatal ART for infants to reduce the risk of transmission of the virus.

The new report focuses on 4 major areas:

1. Identification of maternal HIV infection
2. Testing of the infant when the mother’s HIV infection status is unknown
3. Strategies for prevention of perinatal HIV transmission
4. Care of the infant exposed to HIV

Identification of Maternal HIV Infection

Patients are allowed to opt out of HIV testing, which is routine in most states, while receiving prenatal care; however, for those who are tested, the AAP now recommends a second test by 36 weeks’ gestation. A plasma HIV RNA test is recommended in addition to an antigen/antibody immunoassay test.

Testing of the Infant When the Mother’s HIV Infection Status Is Unknown

For this, the AAP recommends expedited testing of all infants “after consent procedures consistent with state and local law.” The prime time for treatment initiation in infants is 6 to 12 hours after birth. At this point, mothers should abstain from breastfeeding to prevent postnatal transmission of HIV. As more than 1 test is used to determine HIV status in infants, ART can be stopped and breastfeeding begun again following subsequent negative results.

Strategies for Prevention of Perinatal HIV Transmission

This more extensive area of the AAP report encompasses maternal treatment during pregnancy, interventions during labor and at delivery, and antiretroviral management for the infant exposed to HIV, which itself includes avoiding postnatal HIV infection and attempting to eliminate perinatal transmission of HIV.

Women whose HIV status is known, whether that be for years or a through a new diagnosis, need to continue their ART. Triplet therapy is the preferred treatment, “regardless of the plasma HIV RNA viral load or CD4 T-lymphocyte count.” They should also continue that medication on their usual dosing schedule.

If HIV status is unknown when labor begins, expedited testing is recommended. A positive result necessitates subsequent confirmatory testing and initiation of intravenous zidovudine (ZDV) and infant ART for all infants exposed. A negative result also calls for confirmatory testing, and should “negative” again be the determination, the ZDV and infant ART can both be stopped.

Presumptive HIV therapy is another course of action this part of the new report covers. This entails either a 4-week course of neonatal ZDV chemoprophylaxis for the infant if the mother received ART throughout her pregnancy and was virally suppressed or a 6-week course in higher-risk cases, such as if the mother had suboptimal management of HIV during the pregnancy.

“Early detection of HIV infection in the mother and evaluation and management of infants exposed to HIV remain the key to preventing perinatal transmission,” the study authors noted.

“To be most effective,” they continue, “these efforts should be sustained and involve integrated clinical management and social services.”

Care of the Infant Exposed to HIV

Testing for HIV in infants 18 months and younger differs from that for older children, adolescents, and adults, the report says. Routing serological testing is performed up to age 18 months, following initial negative HIV results, because passively transferred maternal HIV antibodies may be detected until that age.

Also among infants, HIV RNA assays may be preferred for testing if the mother is known to have, or is suspected of having, a non-B subtype of HIV. This is because DNA polymerase chain reaction assays are less sensitive at detection of this HIV type and have been known to produce false-negative results when being used to test for it.

Regardless, all infants exposed to HIV should undergo RNA, DNA, or total nucleic acid assay testing between 2 and 3 weeks post birth. Positive results should be immediately confirmed, while negative results call for additional testing at 1 to 2 and 4 to 6 months of age.

However, infants whose HIV infection status remains unknown at 6 weeks are recommended to receive prophylaxis until their HIV status is definitively determined. And if infants were exposed to ART in utero, they need to be monitored for both short- and long-term drug toxicity.

“In addition to standard clinical care for the newborn infant, it is important that appropriate steps are taken for early detection of HIV infection, appropriate vaccines are administered, and adequate counseling is provided to families living with HIV infection,” the authors noted. “The management of infants in whom HIV infection is diagnosed should be undertaken in consultation with a pediatric HIV specialist. This report updates previous AAP recommendations.”

Reference

Chadwick EG, MD, Ezeanolue EE. Evaluation and management of the infant exposed to HIV in the United States. Pediatrics. 2020;146(5):1-14. doi:10.1542/peds.2020-029058