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Yes. Newborn infants may become infected with HIV:
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.
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.
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.
Unless there is meconium-stained amniotic fluid or 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.
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.
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 six 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.
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 six weeks should have a rapid HIV screen at 18 months.
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 six weeks of age. The test will become positive more than six weeks after delivery in infants infected with HIV via breast milk.
Therefore the PCR test should be repeated six weeks after the last feed of breast milk has been given.
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.
Without treatment with ARV drugs, infants who present with AIDS soon after delivery usually die within the first three months of life. Most infants who present with AIDS in the first three months after birth are dead by six months of age without treatment while infants who present with AIDS after three months may survive beyond five 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.
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.
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 given ARV prophylaxis or treatment during pregnancy, labour and the first weeks of breastfeeding. However it will still reduce the risk of HIV transmission during labour and delivery even if the mother did not receive ARV drugs, if a rapid test is used to detect HIV-positive women during or immediately after labour or if she only started ARVs during the last 8 weeks of their pregnancy.
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 six 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 one hour.
Daily nevirapine can be stopped when the infant is six weeks old even in breastfed infants if the mother is on ARV treatment. In breastfed infants of HIV positive mothers who are not on ARV treatment, prophylactic NVP should be continued until one week after the last feed of breast milk.
All HIV-exposed infants should be given a daily dose of NVP for six weeks after delivery.
Most term infants will need 1.5 ml NVP from birth to six 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 10mg/ml||Less than 2.0 kg||First 2 weeks: 2mg/kg||0.2ml/kg|
|Next 4 weeks: 4mg/kg||0.4ml/kg|
|2.0 – 2.5 kg||Birth to 6 weeks: 10mg||1.0ml|
|More than 2.5 kg||Birth to 6 weeks: 15mg||1.5 ml|
Most studies show that non-exclusive (mixed) breastfeeding for up to two 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 prophylaxis or treatment for at least 8 weeks before the onset of labour should have a very low or not undetectable viral load. The risk of transmission will be about 0.5% to 1% for the first 6 months of breastfeeding. This small risk continues if the mother breastfeeding beyond 6 months. Extended breastfeeding should be advised, as the health benefits of breastfeeding is more important than the small risk of transmission especially in poor communities.
Mothers on Option B who are taking ARV drugs for prophylaxis must continue taking the ARV drugs until one week after the last feed of breast milk.
The HIV transmission rate is lower with exclusive breastfeeding than with mixed breastfeeding.
HIV is present in breast milk. Even with an undetectable 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.
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.
Good breast care and breastfeeding management are important to reduce the risk of HIV transmission.
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 one week of completely stopping breastfeeding.
All pregnant women must receive thorough infant feeding counselling during pregnancy. This requires four 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:
Mothers who formula feed their infants should comply with the WHO criteria for safe formula feeding.
If women are receiving ARV treatment or prophylaxis and the infant’s PCR was negative at 6 weeks, they should continue breastfeeding for one year. A mother of an infant confirmed to be HIV infected should be encouraged to breastfeed until 24 months.
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:
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.
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.
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 screened again for HIV at the 6 weeks postnatal visit and at 3 months followed by 3 monthly screening while breastfeeding.
HIV-negative women should breastfeed their infants.
The many advantages of breastfeeding, especially exclusive breastfeeding, include:
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.
If a woman chooses not to breastfeed, it is important that she is taught to formula feed safely.
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 six 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 mix feeding in town 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.
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.
Yes, as these infants must be correctly managed. It is very important that they are not lost to the health services after delivery.
They should be followed routinely at the local mother-and-baby clinic for the first six 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 six weeks after delivery on all HIV-exposed infants:
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, then the infant is infected.
All infants under five 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 five years of age with HIV infection must be started on antiretroviral treatment.
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 if they have no clinical signs of HIV infection.
Prophylaxis against Pneumocystis infection and other bacterial infections should be given to all HIV-infected infants. Usually treatment is started at six weeks of age with co-trimoxazole syrup. Prophylaxis should be stopped if the PCR test is negative. Prophylaxis can usually be stopped at one 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.
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 six weeks.
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 ABC (abacavir), 3TC and lopinavir/ritonavir.
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 and yet 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. There are thousands of orphaned infants in South Africa.
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 at discharged the next morning and the infant referred to the nearest ARV clinic to be started on ARV treatment.
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 risks of transmitting HIV to her fetus.
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.
Yes as a positive PCR test would indicate that the infant was infected with HIV during pregnancy.
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.
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. 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.
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.
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.
The mother must be advised to exclusively breastfeed her infants for 6 months followed by extended breastfeeding once she introduces solid feeds.
The risk is low as the mother is healthy with stage 1 disease and she has been on FDC for last half of her pregnancy. The risk of transmission through breastfeeding is also low and would be about 0.5% to 1% for each 6 months of breastfeeding.
Give an oral dose of NVP after birth followed by a daily dose of NVP to the age of six weeks. The first dose must be given as soon as possible after birth, but within 72 hours of birth.
Mothers on ARV drugs for at least 8 weeks prior to onset of labour have a very low if not undetectable 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 8 weeks of their pregnancy.
A healthy male infant is born to an HIV-positive woman who has not taken her ARV drugs regularly. She breastfeeds as she cannot afford to bottle feed. At two 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.
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.
Yes. Generalised lymphadenopathy, hepatomegaly and splenomegaly all suggest that the diagnosis of AIDS is correct.
A positive PCR test would confirm the diagnosis of HIV infection.
The infant would probably have a bacterial pneumonia, Pneumocystis pneumonia or tuberculosis.
By starting co-trimoxazole prophylaxis at six weeks.
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 one 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 two weeks. Now the infant takes the breast well and at 4 weeks of age is ready to go home.
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.
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.
Both mother and infant need to be assessed for ARV treatment. The mother needs to be started on FDC and the infant on daily NVP. 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.
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.
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 young infant from becoming an AIDS orphan.