Guidance on evaluation and management of infants exposed to HIV has been updated in a new AAP clinical report that highlights strategies for prevention of perinatal HIV transmission, the importance of early detection and treatment, and the pediatrician’s role.
The report Evaluation and Management of the Infant Exposed to HIV in the United States, from the Committee on Pediatric AIDS, is available at https://doi.org/10.1542/peds.2020-029058 and will be published in the November issue of Pediatrics.
About 8,500 women with HIV give birth every year in the U.S., but the rate of perinatal transmission is down drastically due to preventive strategies. These include opt-out HIV testing of all pregnant women, combination antiretroviral therapy (ART) during pregnancy and labor, planned cesarean delivery for some, avoidance of breastfeeding and provision of antiretroviral (ARV) prophylaxis to the exposed infant.
The clinical report, updated from 2009, includes new information on the importance of third-trimester testing, a change in how long prophylaxis is given to low-risk infants (four weeks instead of six), the need for infant prophylaxis as early as possible after birth for very high-risk infants, and a link to a national guideline for the latest recommendations on drug management of infants.
A second HIV test in the third trimester, preferably before 36 weeks of gestation, should be considered for all pregnant women. This is important to confirm that infection has not taken place during pregnancy, and it has been deemed cost-effective even in low-prevalence areas.
Until recently, this protocol has not been part of standard of care, said Ellen Gould Chadwick, M.D., FAAP, a lead author of the clinical report and immediate past chair of the Committee on Pediatric AIDS. However, states vary in their testing legislation; in some states it is used only in certain risk categories.
“If a mother acquires HIV infection during pregnancy, it is perhaps the highest risk of transmission to the infant. And so it’s important not to miss it because you still have a chance to intervene to prevent transmission to the infant,” she said.
For drug management of infants born to women living with HIV, the report links to national guidelines (https://bit.ly/2GBda5x), which are updated at least yearly.
Another change recommends the length of zidovudine (ZDV) prophylaxis for infants at low risk should be four weeks instead of six. This applies to full-term infants born to women who received ART during pregnancy with documented viral suppression.
Infant prophylaxis for very high-risk infants involves presumptive treatment with the full (three-drug) regimen administered as early as possible and continued at least until it is determined that the infant does not have intrauterine HIV infection. A national panel of experts now considers this the preferred approach, Dr. Chadwick said.
Pediatricians with a patient who tests positive for HIV should connect with an HIV specialist who cares regularly for pediatric patients.
“Very often what we do is manage children with HIV with the pediatrician — we do the specialty care and they do the primary care,” said Dr. Chadwick, director of the Section of Pediatric, Adolescent and Maternal HIV Infection at Ann & Robert H. Lurie Children’s Hospital of Chicago. “There are good data that show patients with HIV cared for by an HIV expert by and large do much better.”
Pediatricians without a local resource can get 24/7 consultation on HIV issues from the National Clinician Consultation Center,https://nccc.ucsf.edu/clinician-consultation/perinatal-hiv-aids/.
Overall, Dr. Chadwick is pleased with improvements in reducing perinatal transmission of HIV infection, now down to 1% or less for women who receive prenatal care.
“The strides that have been made since the beginning of the epidemic are enormous,” she said. “But it’s still possible for HIV to be unrecognized, and if it’s not tested for, it’s easily missed. That’s why opt-out testing during pregnancy is so important.”
The report also recommends the following:
- Whenever possible, maternal HIV infection should be identified before or during pregnancy.
- If the mother’s HIV serostatus is unknown at the time of labor or birth, the newborn’s health care provider should perform expedited HIV antibody testing on the mother or the newborn or antigen/antibody testing on the mother, with consent consistent with state and local laws. The results should be reported to health care providers quickly enough to allow effective ARV prophylaxis to be given to the infant at least within six to 12 hours after birth.
- Intravenous ZDV for the mother and presumptive HIV therapy for the newborn should be given promptly after a new positive rapid antibody or antigen/antibody test result — without waiting for results of supplemental HIV testing, and breastfeeding should not be initiated. If supplemental tests are negative — indicating the infant was not exposed to HIV — then ARV drugs should be stopped, and breastfeeding can be initiated.
- For more information on diagnostic testing, regimens and immunizations, consult the clinical report.