Prevention of vertical HIV transmission and management of the HIV-exposed infant in Canada in 2014

Question 1

What are the recommendations regarding HIV testing during pregnancy?

Answer 1

1. Advocate for universal HIV testing of pregnant women
2. If this fails test mother at delivery or the infant if maternal testing not possible
3. The maternal HIV status should be known before discharge of a neonate from hospital

Question 2

What are the recommendations regarding IV zidovudine during labour?

Answer 2

Recommend IV zidovudine for all HIV infected women in labour regardless of antepartum ART regimen, mode of delivery or viral load near delivery

Question 3

What are the recommendations for anti-retroviral therapy for infants?

Answer 3

1. Consultation with a pediatric HIV expert for all newborn infants of HIV infected mothers
2. All HIV exposed newborns should receive oral zidovudine for six weeks minimum
3. Urgent consultation with a pediatric HIV expert
   is essential when managing a newborn infant of an HIV-infected
   mother in the following circumstances:
   a) the mother did not consistently receive cART during pregnancy regardless of the reason
   b) the mother’s most recent viral load was either detectable (≥40 copies/mL) c) the mother’s viral load was not documented in the four weeks preceding delivery
   d) the mother did not receive intrapartum prophylaxis.
   Consultation before delivery, if possible, is ideal
4. PEP with triple cART or zidovudine plus nevirapine asap (no later than 72h of life) if:
   a) mother’s viral load elevated or suspected to be elevated on the basis of no antenatal therapy or poor adherence.
   Consult pediatric HIV expert re: specific antiretroviral and medication dosing
5. Lopinavir/ritonavir (Kaletra) should not be used in infants until a postmenstrual age of 42wks and a postnatal age of at least 14d

Question 4

What are the recommendations regarding infant feeding?

Answer 4

1. Exclusive formula feeding of infants born to HIV infected mothers
2. All provinces and territories provide free formula to all infants of HIV infected mothers for the first 12m of life
3. Consult a pediatric HIV expert if an HIV infected mother is found to be breastfeeding her infant. Personal and/or cultural beliefs surrounding breastfeeding should be explored, and any barriers to formula feeding identified to best support mothers in pursing formula feeds
4. Counsel against pre-mastication of food by caregivers with HIV infection

Question 5

What are the recommendations for follow-up of HIV exposed infants and children?

Answer 5

1. Qualitative or quantitative HIV DNA or RNA PCR for diagnosis in children <18mo
2. Consider involvement of a pediatric HIV expert to aid in the interpretation of test results
3. For most infants HIV infection can be reasonably excluded with two separately timed negative PCR tests (>1mo and 2nd >2mo). For children who receive cART at least one of the PCR tests should be >4mo
4. HIV status of exposed infants should be finalized using a serological assay between 18-24mo
5. Long-term follow-up of all children exposed in utero and perinatally to antiretroviral medications