4 HIV in the newborn infant
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- Introduction to HIV-exposed newborn infants
- Diagnosing HIV infection in infants
- Preventing HIV infection in newborn infants
- HIV transmission in breast milk
- Breastfeeding HIV-exposed infants
- Formula feeding HIV-exposed infants
- Care of HIV-exposed infants
- HIV infection in infants
- Case studies
When you have completed this unit you should be able to:
- List the routes whereby infants can be infected with HIV.
- Correctly interpret diagnostic tests for HIV in infants.
- Use antiretroviral drugs prophylactically in newborn infants.
- Explain the risks and benefits of breastfeeding in HIV-positive mothers.
- Advise HIV-positive mothers on the choice of feeding methods.
- Manage infants born to HIV-positive women.
Introduction to HIV-exposed newborn infants
4-1 Can newborn infants become infected with HIV?
Yes. Newborn infants may become infected with HIV:
- During pregnancy when HIV may cross the placenta from a mother to infect her fetus.
- During labour and delivery when the infant may become infected with HIV present in cervical secretions and maternal blood.
- After delivery when the infant may become infected with HIV present in breast milk.
- Rarely, the infant may become infected with HIV from transfused blood or by HIV-contaminated needles.
Both the fetus and newborn infant can become infected with HIV.
Infants cannot become infected by touching, hugging or kissing them. Neither can they become infected if vitamin K is given by intramuscular injection after they have been well dried.
The spread of HIV from a mother to her fetus or infant is called mother-to-child transmission (MTCT) or vertical transmission. Nearly all infants and young children with HIV infection have been infected by vertical transmission.
4-2 Do HIV-infected infants usually appear normal at birth?
Most infants that have been infected with HIV during pregnancy, labour or delivery appear normal at birth. Therefore it is not possible to decide by physical examination alone whether or not a newborn infant is infected with HIV.
Most infants with HIV infection appear normal and healthy at birth.
4-3 Does HIV infection cause congenital abnormalities?
HIV infection of the fetus does not cause congenital malformations. However, HIV-infected infants have an increased risk of having a low birth weight, especially if their mother is ill and underweight.
4-4 Should all infants born to HIV-positive mothers be suctioned at delivery?
Unless the infant needs resuscitation, these infants must not have their mouth and nose routinely suctioned after birth as this may damage the mucous membranes and, thereby, increase the risk of HIV infection. Routine suctioning should be avoided in all infants.
Diagnosing HIV infection in infants
4-5 Can the HIV screening tests commonly used on adults diagnose HIV infection in a newborn infant?
The diagnosis of HIV infection in a newborn infant is difficult as most HIV-infected infants appear to be normal and healthy at delivery. The HIV antibodies tested for in the ELISA and rapid HIV screening tests cross the placenta from mother to fetus. Therefore, if the mother’s HIV screening test is positive then the infant’s test will also be positive, whether or not the infant is infected with HIV. All infants born to HIV-positive women will have a positive HIV screening test at delivery. As a result, the HIV screening tests for adults is not useful in infants during the first months of life.
A positive HIV antibody screening test in the newborn infant does not necessarily mean that the infant is infected with HIV.
4-6 What blood tests are used to diagnose HIV infection in a young infant?
A DNA PCR test is routinely done at 6 weeks in all infants born to HIV positive women. If the PCR test is positive then the infant is infected with HIV. If the test is negative and infant is still being breastfed, the test should only be done again 6 weeks after the last feed of breast milk. A negative test, if the mother has formula feed her infant from birth, indicates an uninfected infant.
The results of the HIV tests in the infant, plus other details of management, must be added to the Road-to-Health booklet.
4-7 When can the HIV antibody screening tests be used to diagnose HIV infection in HIV exposed infants?
By 18 months after delivery all maternal HIV antibodies will have disappeared from the infant. A positive screening test at 18 months (a rapid test) indicates that the HIV antibodies are being produced by the infant and have not crossed from the mother during pregnancy. Therefore, two positive screening tests for HIV in an infant of 18 months or older indicate that the infant is infected with HIV. A negative screening test confirms that the infant has not been infected by HIV if the infant is no longer breastfeeding. This is a convenient time to screen these infants as they are attending a clinic for their booster immunisations.
All HIV-exposed infants with a negative polymerase chain reaction (PCR) test at 6 weeks should have a rapid HIV screen at 18 months.
4-8 Can the PCR test be used to identify when an infant became infected with HIV?
Yes, sometimes it may be helpful in identifying the time of infection. If the fetus is infected in early pregnancy then the PCR on the infant’s blood will be positive at birth. However, if the infant only becomes infected in the last weeks of pregnancy or during labour and delivery the PCR will be negative at birth and only become positive by 6 weeks of age. The test will become positive more than 6 weeks after delivery in infants infected with HIV via breast milk.
Therefore the PCR test should be repeated 6 weeks after the last feed of breast milk has been given.
4-9 When do infants with HIV infection present with clinical signs of illness if they do not receive antiretroviral treatment?
- Infants who are infected during pregnancy usually become ill in the first 3 months after delivery. They also rapidly progress to AIDS. Infants who are infected in the first half of pregnancy may present with signs of HIV infection as early as the first few weeks after delivery.
- Infants that are infected during labour and delivery, or via breast milk, usually present much later and have a more slowly progressing illness. Signs of HIV infection in these infants usually present between 6 months and 5 years.
The earlier the infection with HIV the sooner the clinical signs of symptomatic HIV infection appear. The onset of symptomatic HIV infection can be prevented or delayed by ARV treatment.
If infants diagnosed to be HIV infected are started on ARV treatment while they are still healthy this will prevent them becoming symptomatic and developing the clinical signs of HIV infection.
4-10 At what age do HIV-infected infants die of AIDS?
Without treatment with ARV drugs, infants who present with AIDS soon after delivery usually die within the first 3 months of life. Most infants who present with AIDS in the first 3 months after birth are dead by 6 months of age without treatment while infants who present with AIDS after 3 months may survive beyond 5 years. The earlier the infection with HIV, the sooner AIDS develops and the worse the prognosis.
If infants diagnosed to be HIV infected are started on ARV treatment while they are healthy this would prevent most deaths of HIV infected infants and children.
4-11 When are infants at high risk for HIV infection during the antenatal period and during labour?
- Unbooked mothers diagnosed to be HIV positive during labour or postpartum
- Mothers that defaulted ARV treatment during pregnancy
- Mothers that became infected during pregnancy
- Mothers with advanced HIV disease (stage 4)
- Mothers known to have a viral load above 1000 copies/ml
- Mothers that have been on ARV treatment for less than 12 weeks before delivery
- Mothers that give birth to preterm infants (less than 37 weeks) or low birth weight infants (less than 2500 g)
- Mothers diagnosed with TB or syphilis during pregnancy
- Mothers with drug resistant HIV infection
- Mothers with chorioamnionitis at the time of delivery
4-12 When should a PCR test be done on infants who are at high risk of HIV infection before birth?
Ideally they should be screened with a PCR test before discharge from hospital after delivery. If diagnosed to be HIV infected and started on ARV treatment, these infants at high risk for early disease and death will remain healthy.
Preventing HIV infection in newborn infants
4-13 Can antiretroviral drugs be given to the infant after delivery to reduce the risk of HIV transmission?
Yes. If the mother is HIV positive, the infant should be given ARV prophylaxis after delivery (post exposure prophylaxis). This is most effective in reducing the risk of HIV transmission if the mother has been started on ARV treatment before or during pregnancy. However it will still reduce the risk of HIV transmission during labour and delivery even if the mother did not receive ARV drugs.
4-14 How should ARV drugs be given to the infant to reduce the risk of vertical transmission?
All HIV-exposed infants, whether the mother has received ARV treatment, ARV prophylaxis or no ARV drugs at all, should be given an oral dose of NVP after birth followed by a daily dose of NVP to the age of 6 weeks. The first dose must be given as soon as possible after birth, but within 72 hours of birth. However, if the mother has not been given any ARV drugs, the first dose of NVP to the infant must be within 1 hour.
Daily nevirapine can be stopped when the infant is 6 weeks old even in breastfed infants if the mother was on ARV treatment for at least 6 weeks prior to delivery. In breastfed infants of HIV positive mothers who are not on ARV treatment prophylactic NVP should be continued until 1 week after the last feed of breast milk.
All HIV-exposed infants should be given a daily dose of NVP for 6 weeks after delivery.
- If a mother was on ARV treatment for less than 6 weeks before delivery the infant’s NVP prophylaxis should be extended to 12 weeks and the PCR repeated at 18 weeks.
If the mother has a high viral load above 1000 copies/ml, or other high risk factors for HIV transmission, AZT syrup twice daily should be given to the infant in addition to NVP for 6 weeks (dual prophylaxis).
Infants at high risk for HIV transmission during the antenatal period and labour should receive AZT syrup twice daily for 6 weeks in addition to daily NVP (dual prophylaxis).
4-15 What is the daily dose of NVP for infants?
Most term infants will need 1.5 ml NVP from birth to 6 weeks. Thereafter the amount of NVP will increase as the infant gains weight. Dosages are shown in table 4-1.
|Birth weight||Daily dosage||Quantity|
|NVP syrup 10 mg/ml||Less than 2.0 kg||First 2 weeks: 2 mg/kg||0.2 ml/kg|
|Next 4 weeks: 4 mg/kg||0.4 ml/kg|
|2.0 – 2.5 kg||Birth to 6 weeks: 10 mg||1.0 ml|
|More than 2.5 kg||Birth to 6 weeks: 15 mg||1.5 ml|
The twice daily dose of AZT for infants between 2 and 2.5 kg is 10 mg (1 ml) while the twice daily dose for infants above 2.5 kg is 15 mg (1.5 ml).
HIV transmission in breast milk
4-16 What is the risk of HIV transmission from breastfeeding?
Most studies show that non-exclusive (mixed) breastfeeding for up to 2 years increases the risk of HIV transmission by an additional 15% if ARV prophylaxis is not given to the infant. The longer the mother breastfeeds, the greater is the risk of HIV transmission.
Mothers on ARV treatment for at least 6 weeks before the onset of labour should have a non-detectable viral load. The risk of transmission will be very small with correct ARV management. Therefore exclusive breastfeeding for 6 months should be advised, as the health benefits of breastfeeding is more important than the small risk of transmission especially in poor communities.
Mothers who are HIV positive should continue ARV treatment for life and their infants continue NVP prophylaxis until 6 weeks. If the mother is not on ARV treatment continue the nevirapine until 1 week after the last feed of breast milk.
The HIV transmission rate is lower with exclusive breastfeeding than with mixed breastfeeding.
- The reason why mixed feeding, with both breast milk and formula or solids, increases the risk of HIV infection might be because formula and solids can cause mild bowel inflammation. This may allow HIV in breast milk to pass into the bloodstream.
4-17 When can HIV be transmitted in breast milk?
HIV is present in breast milk. Even with a non-detectable viral load HIV could be present in the white cells (leucocytes) in the breast milk. Therefore, infants can be infected with HIV at any time while they are still breastfed or receive expressed breast milk. Some infants may be infected by breast milk many months after delivery. Transmission is very low with correct ARV management of mother and infant.
- The risk of HIV transmission during 6 months of exclusive breast feeding is very low if the mothers is on ARVs with a non-detectable viral load is 0.3%.
4-18 Can an infant be infected with HIV from another woman’s breast milk?
Yes. An infant born to an HIV-negative mother may become infected with HIV if the infant receives breast milk from an HIV-positive woman. Breastfeeding another woman’s infant, or using breast milk from anyone other than the infant’s mother, is dangerous. Pasteurised breast milk donated from HIV-negative women can be safely used under strict control in newborn-care nurseries.
4-19 What factors may increase the risk of HIV transmission by breast milk?
- If the mother becomes infected with HIV while she is still breastfeeding, the risk of HIV transmission to the infant is as high as 50%. Therefore, breastfeeding women who are HIV negative should not have unprotected sexual intercourse.
- The risk is also increased in women who have a low CD4 count or clinical signs of AIDS.
- Cracked or bleeding nipples and mastitis or breast abscess increase the risk of transmission. Good breast care is important for HIV-positive women who breastfeed.
- Milk from engorged breasts contains an increased number of white cells due to duct damage resulting in an increased the risk of HIV transmission.
- Sores in the infant’s mouth, such as oral thrush, may increase the risk of HIV infection. HIV mothers should take their infants to a clinic for treatment if they notice oral thrush.
- Mixed feeding, with breast milk plus formula feeds or solids, increases the risk of HIV transmission.
Good breast care and breastfeeding management are important to reduce the risk of HIV transmission.
- Engorgement, inflammation or infection of the breast increases the number of leucocytes and the viral load of HIV in the milk.
Breastfeeding HIV-exposed infants
4-20 Should all HIV-positive mothers breastfeed?
There are both dangers and advantages to HIV-positive women breastfeeding. However, the advantages of breastfeeding are the lower risk of gastroenteritis, pneumonia and undernutrition, especially in poor communities. Therefore, many HIV-positive mothers from poor communities should be advised to exclusively breastfeed their infants for 6 months followed by extended breastfeeding after introducing solid foods. The final choice must be the mother’s. She should be helped to make an informed decision.
Women should be advised to breastfeed unless the risk of HIV transmission in breast milk is greater than the dangers of formula feeding.
Several studies have showed that the overall HIV free survival in HIV-exposed infants from poor communities is significantly better when women breastfed compared to women who formula fed.
Women in poor communities should be advised to exclusively breastfeed for 6 months followed by extended breastfeeding when solids are introduced. The mothers on ARV prophylaxis must continue taking their ARV drugs until 1 week of completely stopping breastfeeding.
4-21 What breastfeeding information should be given to HIV-positive women?
All pregnant women must receive thorough infant feeding counselling during pregnancy. This requires 4 counselling sessions. During these session the importance of breastfeeding, the dangers of not breastfeeding and the addition of complementary breastfeeding following 6 months of age must be discussed.
The WHO suggests that women who choose to formula feed their infants should only formula feed if all the following are present:
- Formula is available and affordable.
- There is access to clean water and sanitation.
- The mother is able to clean bottles and teats, or cups, safely.
- The mother can mix formula correctly.
- There is good primary care at local clinics.
Mothers who formula feed their infants should comply with the WHO criteria for safe formula feeding.
4-22 For how long should HIV-positive mothers breastfeed?
If women are receiving ARV treatment and the infant’s PCR was negative at 6 weeks, they should continue breastfeeding for 1 year. A mother of an infant confirmed to be HIV infected should be encouraged to breastfeed until 24 months.
4-23 How can feeding breast milk be made safer for an HIV-exposed infant?
Heat treatment of breast milk by pasteurisation kills HIV but also reduces the level of anti-infective properties, especially white cells. Home pasteurisation can be done as follows:
- Boil 450 ml water in a pot.
- Remove the pot from the heat when the water starts to boil.
- Place a glass jar, containing 50 to 150 ml expressed milk, into the hot water and allow to stand for 15 minutes.
Pouring boiling water from a kettle around the jar of milk standing in an empty pot can also be used. This method is particularly useful when caring for HIV-exposed preterm infants in hospital. Commercial pasteurisers are available but are very expensive.
4-24 How can feeding formula milk be made safer for any infant?
Cup feeding with formula milk is safer than bottle feeding as a cup is easier to clean with soap and water. After washing well, allow the empty cup to stand and dry. A feeding cup, which can be used to measure water, mix formula and give a feed, is now commercially available. Cup feeding can also be used to give expressed breast milk to preterm infants who are not able to breastfeed yet.
It is easier and safer to clean a cup than a bottle.
All hospitals should use cups rather than bottles to formula feed infants.
- Specially designed feeding cups can be obtained from Sinapi Biomedical (email@example.com or 021 887 5260).
4-25 Should HIV-negative women breastfeed?
Yes. It is very important that all HIV-negative women be encouraged to exclusively breastfeed their infants for 6 months followed by extended breastfeeding for as long as possible. Formula feeding in these mothers has many disadvantages, especially in poor communities where infection and undernutrition are common. All breastfeeding women should practise safe sex. These mothers need to be screened again for HIV at the 6 weeks postnatal visit and then 3 monthly while breastfeeding.
HIV-negative women should breastfeed their infants.
The many advantages of breastfeeding, especially exclusive breastfeeding, include:
- Breast milk provides infants with a balanced diet that meets all their nutritional needs.
- Breastfeeding reduces the risk of infections, especially gastroenteritis.
- It is cheap.
- Exclusive breastfeeding reduces the risk of becoming pregnant again soon after the delivery of the infant.
- It promotes bonding between mother and infant.
- It is usually socially and culturally acceptable.
4-26 When should women decide on the method of feeding their infants?
Whenever possible this decision should be made before or during pregnancy and not after delivery. This allows the woman time to consider all the advantages and disadvantages of breastfeeding. There is also time for counselling HIV-positive women.
The final decision must be made by the mother herself once she has been advised and she has discussed the options with family or friends. The medical and nursing staff must support the mother in whatever feeding methods she decides is best for her and her infant.
Formula feeding HIV-exposed infants
4-27 What advice should be given to a mother who decides to use milk formula?
- She must be sure that she can afford to buy adequate amounts of milk formula, and that she will have regular access to milk formula.
- She must have access to a source of safe, clean water. Fuel (such as wood or paraffin) or electricity is needed to boil water to sterilise bottles.
- She must be taught to mix the milk powder correctly and not to make the milk too weak or too strong.
- She should use a cup, rather than a bottle and teat, to feed her infant as a cup is easier to clean, especially if facilities to sterilise bottles and teats are not available.
- If bottles and teats are used, they should be cleaned and sterilised before each feed.
- She should wash her hands with soap and water before preparing a feed.
- She should exclusively formula feed and not give a few breastfeeds as well.
If a woman chooses not to breastfeed, it is important that she is taught to formula feed safely.
4-28 Why may an HIV-positive mother decide to breastfeed even if she can afford milk formula?
Usually she has not been counselled about the advantages of breastfeeding and still believes that breastfeeding is dangerous for the infant if the mother is HIV positive.
4-29 What can be done to help poor HIV-positive women obtain milk formula?
Sometimes poor women in urban areas meet the criteria for safe formula feeding but cannot afford to buy formula. For these women free milk formula could be provided on prescription. This requires prior arrangement within health facilities.
The state cannot provide free milk formula to all infants born to HIV-positive mothers in rural areas. Formula feeding for the first 6 months requires at least 40 x 500 g tins of milk, which is very expensive.
Providing free formula for HIV-exposed infants born in towns and cities may be a disadvantage if mothers are planning to take their infants back to rural areas soon after delivery. This could be disastrous for these infants if their mothers lose their breast milk and do not have access to free or affordable formula once they leave town. Equally dangerous is the practice of mixed feeding in towns. Mothers do this so that they will be able to breastfeed when they return to the rural areas where free milk is often not available.
For these reasons the state has decided not to routinely provide free milk formula for infants of HIV positive mothers.
4-30 How could the state control the distribution of free or cheap milk formula to infants of HIV-positive women?
This problem does not have a simple answer. Formula milk could be dispensed by primary-care clinics and hospitals. If possible, milk should not be dispensed by those clinics where breastfeeding is promoted as this gives a confusing message to mothers. Every effort must be made to discourage the prescription of milk formula to HIV-negative women or women who do not know their HIV status. Breastfeeding must be promoted in these women.
Breastfeeding must be protected and promoted in HIV-negative women.
Care of HIV-exposed infants
4-31 Should all HIV-exposed infants be followed up after delivery?
Yes, as these infants must be correctly managed. It is very important that they are not lost to the health services after delivery.
4-32 How should infants born to HIV-positive mothers be followed up?
They should be followed routinely at the local mother-and-baby clinic for the first 6 weeks after delivery. During this time mothers must be encouraged to give their infants daily prophylactic NVP.
A PCR test should then be done at 10 weeks after delivery on all HIV-exposed infants:
- If the PCR test is positive the infant has been infected with HIV.
- If the test is negative and the mother has never breastfed or given breast milk, the infant is not infected.
- If the test is negative but the mother has breastfed or given breast milk, the infant should be follow up and the test repeated 6 weeks after the last feed of breast milk. This is to assess whether the infant might have been infected late with HIV via breast milk.
It is cost-effective to use PCR testing as infants who are not HIV infected can receive routine infant care only. Infants with a positive PCR test are infected with HIV and need to be started on an appropriate ARV regimen.
A rapid screening test for HIV should be done at 18 months on all infants born to HIV-positive women, except those with positive PCR results. If the test is negative at 18 months, then the mother can be reassured that her infant is not infected, provided that she is no longer breastfeeding. If the test is positive and confirmed with another rapid HIV test, then the infant is infected.
HIV infection in infants
4-33 What is the management of infants infected with HIV?
- The mother must be counselled and informed about the diagnosis and management.
- Start antiretroviral treatment for life.
- Start co-trimoxazole prophylaxis.
- Provide multivitamin or vitamin A supplements.
- Give routine immunisations.
- Look for early signs of HIV infection.
- Ensure that the infant is well nourished.
- Monitor growth in the Road-to-Health booklet.
All infants under 5 years of age with HIV infection must be started on ARV treatment as the risk of symptomatic HIV and death is high in infants infected before, during or soon after delivery.
All infants under 5 years of age with HIV infection must be started on antiretroviral treatment.
4-34 What immunisation can be given safely to HIV-positive infants?
Infants born to HIV-positive women should receive all the routine immunisations.
It is important to immunise HIV-infected infants against these important infections, while they are still well. However infants with clinical signs of symptomatic HIV infection must not be given live vaccines (BCG, polio, measles, mumps and rubella). They can safely be given killed vaccines (DPT, Haemophilus and Hepatitis B).
Routine immunisations should be given to HIV-positive infants.
4-35 Why should co-trimoxazole prophylaxis be given to HIV-infected infants?
Prophylaxis against Pneumocystis infection and other bacterial infections should be given to all HIV-infected infants. Usually treatment is started at 6 weeks of age with co-trimoxazole syrup. Prophylaxis should be stopped if the PCR test is negative. Prophylaxis can usually be stopped at 1 year of age in infants on antiretroviral treatment. Co-trimoxazole (Septran, Bactrim, Purbac) syrup is started as a 2.5 ml dose every day. Adverse effects to co-trimoxazole are uncommon in young children. However, the drug should be stopped immediately if the child develops a generalised rash.
Prophylaxis against tuberculosis is usually not given routinely.
4-36 What is the importance of vitamin A supplements in infants with HIV infection?
In undernourished communities mothers may be deficient in vitamin A during pregnancy. As a result young infants may also be vitamin A deficient. A lack of vitamin A reduces the function of the immune system. Therefore, giving supplements of vitamin A to HIV-infected infants may reduce the risk of opportunistic infections and may slow the progress to AIDS. It is recommended that all HIV-infected infants receive 50 000 units of oral vitamin A at 6 weeks.
4-37 What are the presenting signs of HIV infection in a young infant?
- Failure to thrive with poor weight gain or with weight loss
- Severe or persistent oral thrush
- Generalised lymphadenopathy
- Hepatomegaly and splenomegaly
- Chronic, watery diarrhoea
- Recurrent infections
- Severe eczema or itchy papules
4-38 What infections are commonly seen in children with HIV infection?
- Severe bacterial infections such as pneumonia, meningitis, septicaemia, arthritis, osteitis or abscesses
- Recurrent, mild bacterial infections such as otitis media
- Severe herpes simplex infection
- Severe chickenpox or measles
- Unusual infections often associated with AIDS, such as those caused by Pneumocystis. These are known as opportunistic infections. Pneumocystis usually presents as a severe pneumonia.
4-39 How is the clinical diagnosis of HIV infection confirmed?
- A positive PCR test in infants less than 18 months.
- A positive rapid HIV screening test in infants at or over the age of 18 months, the test need to be confirmed with another rapid HIV test.
4-40 Who should care for an infant who is infected with HIV?
If possible they should be followed up regularly by a local primary-care clinic. However seriously ill infants may need to be referred to a special HIV clinic or to a hospital. All children with clinical signs of HIV infection who are not on antiretroviral treatment should be urgently referred as they need to start treatment. The aim is to identify those untreated HIV-infected infants before they have a damaged immune system and become seriously ill. It is important that there is good communication between the primary-care clinics and the HIV clinics in each health district.
First-line antiretroviral treatment in young infants is given with AZT, 3T and NVP and switched to ABC (abacavir), 3TC and lopinavir/ritonavir after 4 weeks. The treatment should be given according tp the paediatric dosing chart.
4-41 What is an AIDS orphan?
One of the major tragedies of the HIV epidemic is that thousands of children are abandoned as orphans when their mothers die of AIDS. Many of these infants are not infected with HIV but are at risk of dying from malnutrition and neglect. Many HIV-infected mothers will die before their children are teenagers. It is the responsibility of families, the community and the state to care for these children. Often the child is cared for by a grandmother. Every effort must be made to keep AIDS orphans in their original community. This will require state subsidies and pensions.
If mothers are provided with antiretroviral treatment, many AIDS orphans can be prevented. Many of the infants who have lost their mother but are not orphaned, are not well cared for by the extended family who may already be caring for other infants whose mothers have died of AIDS.
Case study 1
An unbooked 18 year old G1 P0 woman is admitted at term in labour at a MOU. Her cervix is fully dilated and she deliveries within minutes. The mother and infant appear to be healthy. Both the initial and repeat rapid HIV tests done on the mother following the delivery are positive. The mother is regarded as at high risk for transmission and a rapid HIV test is done on a heel prick blood sample of the infant. The positive test on the infant is confirmed by a positive repeat test. No ARV prophylaxis is given to the infant who is thought to be already infected with HIV. The mother is started on FDC and discharged the next morning and the infant referred to the nearest ARV clinic to be started on ARV treatment.
1. Is this mother at high risk of transmitting HIV to her fetus during pregnancy and delivery?
The mother is unbooked and only diagnosed to be HIV positive following delivery. As she was not taking any ARV drugs during the antenatal period and labour she is at high risk of transmitting HIV to her fetus.
2. Can rapid HIV tests (antibody screening) be used to diagnose HIV infection in HIV exposed infants following delivery?
The HIV antibodies tested for in the rapid HIV screening tests cross the placenta from mother to fetus. Therefore, if the mother’s HIV screening test is positive then the infant’s test will also be positive, whether or not the infant is infected with HIV. All infants born to HIV-positive women will have a positive HIV screening test at delivery. As a result, the rapid HIV screening tests is not useful in infants during the first 18 months of life.
3. Could a PCR test be used to decide whether the infant was already infected with HIV at delivery?
Yes, a positive PCR test would indicate that the infant was infected with HIV during pregnancy.
4. Should post exposure prophylaxis be withheld if infants are thought to be at high risk for transmission?
No, all HIV-exposed infants, whether the mother has received ARV treatment, ARV prophylaxis or no ARV drugs at all, should be given an oral dose of NVP syrup after birth followed by a daily dose of NVP. The risk of transmission during labour is high if mothers are not on ARV drugs. This risk could be reduced considerably by giving NVP to the infant as soon as possible after delivery. The infant is at high risk for transmission and should receive AZT syrup twice daily for 6 weeks in addition to daily NVP (dual prophylaxis).
Case study 2
A 27 year old G1 P0 woman has delivered a healthy infant at term following an uneventful pregnancy. She is HIV positive with stage 1 disease and a CD4 count of 475 cells/ml. She was started on FDC at 20 weeks gestation and was compliant during pregnancy and labour. At 32 weeks her viral load was non-detectable. The mother is unemployed and lives in an informal settlement without electricity in her house and no clean water supply and proper sanitation. The mother says she chose to formula feed her infant as she does not want to take any risks with transmitting HIV to her infant with breastfeeding. She also states that she only wants to give the best to her infant.
1. Do you agree that formula feeding is the correct feeding option for this infant?
No, this mother does not comply with the criteria to safely formula feed her infant. Formula milk is expensive and she will not be able to afford formula milk. Access to clean water and sanitation is not present and it would be difficult for the mother to clean bottles and teats, or cups, safely.
2. What important information should be provided to the mother?
The advantages of breastfeeding should be explained to the mother. The overall HIV free survival in HIV-exposed infants from poor communities is significantly better when women breastfeed compared to women who formula feed. The risk of death due to gastroenteritis, pneumonia and undernutrition is significantly increased especially in poor communities.
3. What additional information regarding breastfeeding must be provided to the mother?
The mother must be advised to exclusively breastfeed her infants for 6 months followed by extended breastfeeding once she introduces solid feeds.
4. What is the mother’s risk of transmitting HIV to the infant during pregnancy, labour and breast deeding?
The risk is low as the mother is healthy with stage 1 disease and she has been on FDC for at least 12 weeks before delivery. The risk of transmission through breastfeeding is also low and would be about 0.3% if complaint with the ARVs and with a non-detectable viral load for each 6 months of breastfeeding.
5. What ARV prophylaxis must be prescribed for the infant?
Give an oral dose of NVP after birth followed by a daily dose of NVP to the age of 6 weeks if the mother was on ARVs the last 6 weeks before she delivered. The first dose must be given as soon as possible after birth, but within 72 hours of birth.
6. Would it be safe for the mother to stop the infant’s daily NVP at 6 weeks?
Mothers on ARV drugs for at least 6 weeks prior to onset of labour have a very low if not non-detectable viral load and NVP should be stopped at 6 weeks. Continuing with daily NVP beyond 6 weeks is only recommended for infants of breastfeeding mothers who only started on ARV prophylaxis or treatment during the last 6 weeks of their pregnancy.
Case study 3
A healthy male infant is born to an HIV-positive woman who has not taken her ARV drugs regularly. During pregnancy her viral load was 20 000 copies/ml. She breastfeeds as she cannot afford to bottle feed. At 2 months she brings her son to the clinic for the first time since delivery. The infant has not gained weight and has severe oral thrush and loose stools. On examination, generalised lymphadenopathy is noted as well as an enlarged liver and spleen.
1. What diagnosis would you suspect with the history of failure to thrive and oral thrush?
Severe thrush in an HIV-negative infant may result in poor weight gain as the infant finds sucking very painful. However, the combination of thrush, poor weight gain and loose stools in an infant born to an HIV-positive woman suggests very strongly that this infant has developed symptomatic HIV infection.
2. Would the clinical signs on examination support this diagnosis?
Yes. Generalised lymphadenopathy, hepatomegaly and splenomegaly all suggest that the diagnosis of AIDS is correct.
3. What blood tests could be used to confirm this diagnosis?
A positive PCR test would confirm the diagnosis of HIV infection.
4. If this infant developed signs of pneumonia, what additional diagnosis would you suspect?
The infant would probably have a bacterial pneumonia, Pneumocystis pneumonia or tuberculosis.
5. How can Pneumocystis pneumonia be prevented?
ARV treatment should be started and co-trimoxazole prophylaxis added as the infant is older than at 6 weeks.
Case study 4
A preterm infant is born to an undernourished woman who was found to be HIV positive when screened at booking. She was not started on FDC and was only seen again when she was admitted in preterm labour and delivered a 1.5 kg infant 1 hour later. She did not receive NVP and AZT prior to delivery. NVP syrup was not given to the infant as the infant was preterm. The infant was given expressed breast milk by nasogastric tube for 2 weeks. Now the infant takes the breast well and at 4 weeks of age is ready to go home.
1. Why is this infant at an increased risk of HIV infection before delivery?
Because the infant was born preterm and the mother did not receive FDC prophylaxis. Neither the mother nor her infant have been given NVP. Her undernourished state could also be a sign of AIDS. This would suggest that she has a high viral load.
2. Do you agree with the choice of feeding method?
Yes, breastfeeding is the correct option. The milk must be pasteurised while in hospital followed by home pasteurization as the mother has not been on FDC for 8 weeks.
3. How should this mother and infant be managed?
The mother must be started on ARV treatment. The infant must be started on both daily NVP and twice daily AZT as there is a high risk of HIV transmission. The dosage of NVP syrup needs to be adjusted according the birth weight. A 1.5 kg infant should receive 0.2 ml/kg of NVP daily for the first 2 weeks followed by 0.4 ml/kg daily. The dose of AZT syrup should be 10 mg twice a day. The AZT need to be stopped after 6 weeks and the NVP should be continued for 12 weeks. A PCR test need to be done and the result obtained before discharge hospital to rule out the possibility that the infant was infected during the antenatal period.
4. What is the danger of prescribing milk formula?
Women may be tempted to stop breastfeeding and use milk formula. It is very important that all women be advised and assisted to breastfeed. Prescribed milk may result in women not breastfeeding, even if they plan to move soon to a rural area where prescribed milk is not available.
5. What management should the mother receive?
She should be started on FDC. This will prolong her life, reduce the risk of HIV transmission in her breast milk and may prevent her infant from becoming an AIDS orphan.