AAP releases updated guideline on management of infants exposed to HIV
USA: The American Academy of Pediatrics (AAP) has released an updated guideline on the evaluation and management of infants born to women with HIV infection. The guideline is published in the AAP journal Pediatrics.
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 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.
Key recommendations include:
- Whenever possible, maternal HIV infection should be identified before or during pregnancy, which allows earlier initiation of care for the woman and for more effective interventions to prevent perinatal transmission. The AAP recommends documented, routine HIV testing for all pregnant women in the United States after notifying the patient that testing will be performed, unless the patient declines HIV testing (opt-out consent or right of refusal). All HIV testing, including during the third trimester, should be performed in a manner consistent with state and local laws.
- Avoidance of breastfeeding has been and continues to be a standard, strong recommendation for women living with HIV in the United States because maternal ART dramatically reduces but does not eliminate breast milk transmission, and safe infant feeding alternatives are readily available in the United States.
- Intravenous ZDV for the mother and presumptive HIV therapy for the newborn infant should be administered promptly on the basis of a positive rapid antibody or antigen/antibody test result without waiting for the results of supplemental HIV testing, and breastfeeding should not be initiated. If the rapid test result is positive, supplemental testing should be performed, and if supplemental test results are negative (indicating that the infant was not truly exposed to HIV), then antiretroviral drugs should be stopped and breastfeeding can be initiated.
- If the mother's HIV serostatus is unknown at the time of labor or birth, the newborn infant's health care provider should perform expedited HIV antibody testing on the mother or the newborn infant or antigen/antibody testing on the mother, with appropriate consent consistent with state and local laws. The results should be reported to health care providers quickly enough to allow effective antiretroviral prophylaxis to be administered to the infant as soon as possible after birth and certainly within 6 to 12 hours after birth.
- Pediatricians should provide counseling to parents and caregivers of infants exposed to HIV about HIV infection, including routine care of the infant, diagnostic tests, and potential drug toxicities.
- Initial testing in the first few days of life allows identification of in utero infection and should be considered if maternal antiretroviral drugs were not administered during pregnancy or in other high-risk situations (see text). If an HIV NAAT for the newborn infant was not performed shortly after birth, or if such test results were negative, diagnostic testing with an HIV NAAT is performed at 14 to 21 days of age because the diagnostic sensitivity of virological assays increases rapidly by 2 weeks of age.
- All infants exposed to HIV should undergo virological testing with HIV DNA, RNA, or total nucleic acid assays at 14 to 21 days of age. If results are negative, these tests should be repeated at 1 to 2 and 4 to 6 months of age to identify or exclude HIV infection as early as possible. If any test result is positive, the test should be repeated immediately for confirmation.
- For nonbreastfeeding infants and children younger than 18 months with no positive HIV virological test results, presumptive exclusion of HIV infection is based on 2 negative HIV RNA or DNA NAAT results from separate specimens, both of which were obtained at ≥2 weeks of age and 1 of which was obtained at ≥4 weeks of age, 1 negative HIV RNA or DNA NAAT result obtained at ≥8 weeks of age, or 1 negative HIV antibody test result obtained at ≥6 months of age.
- Definitive exclusion of HIV infection in a nonbreastfed infant is based on 2 or more negative HIV RNA or DNA test results, with 1 negative result at age ≥1 month and 1 negative result at age ≥4 months, or 2 negative HIV antibody test results from separate specimens obtained at age ≥6 months.
- Many experts confirm the absence of HIV infection with a negative HIV antibody assay result at 12 to 24 months of age. These laboratory tests can only be used to exclude HIV infection if there is no other laboratory or clinical evidence of HIV infection (ie, no subsequent positive results from NAATs if tests were performed and no AIDS-defining condition for which there is no other underlying condition of immunosuppression) and the child is not receiving antiretroviral drugs.
- The practitioner providing care for an infant with HIV infection should consult with a pediatric HIV specialist. An alternative service for advice on prevention of perinatal HIV transmission or HIV management is the National Clinician Consultation Center (https://nccc.ucsf.edu/clinician-consultation/perinatal-hiv-aids/). If the infant's mother is an adolescent, consultation with a practitioner familiar with the care of adolescents is advised.
- HIV testing should be offered and recommended to immediate family members of infants exposed to HIV.
- Immunizations and TB screening should be provided for infants exposed to HIV in accordance with published guidelines. A BCG vaccine should not be administered to infants in whom HIV infection is diagnosed.
- All infants exposed to antiretroviral agents in utero or as newborn infants should be monitored for short- and long-term drug toxicity.
- PCP prophylaxis is not recommended for infants who are presumptively or definitively not infected with HIV (see recommendations 9 and 10). Infants with indeterminate HIV infection status after 6 weeks of age should receive prophylaxis until they are determined presumptively or definitively not to be infected with HIV.
The guideline, "Evaluation and Management of the Infant Exposed to HIV in the United States," is published in the AAP journal Pediatrics.