Evaluation and Management of the Infant Exposed to HIV in the United States
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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Evaluation and Management of the
Infant Exposed to HIV in the
United States
Ellen Gould Chadwick, MD, FAAP,a Echezona Edozie Ezeanolue, MD, MPH, FAAP,b,c COMMITTEE ON PEDIATRIC AIDS
Pediatricians play a crucial role in optimizing the prevention of perinatal abstract
transmission of HIV infection. Pediatricians provide antiretroviral prophylaxis
to infants born to women with HIV type 1 (HIV) infection during pregnancy and
to those whose mother’s status was first identified during labor or delivery.
Infants whose mothers have an undetermined HIV status should be tested for a
Department of Pediatrics, Feinberg School of Medicine, Northwestern
HIV infection within the boundaries of state laws and receive presumptive University and Ann & Robert H. Lurie Children’s Hospital of Chicago,
Chicago, Illinois; bHealthySunrise Foundation, Las Vegas, Nevada; and
HIV therapy if the results are positive. Pediatricians promote avoidance of c
Department of Pediatrics, College of Medicine, University of Nigeria,
postnatal HIV transmission by advising mothers with HIV not to breastfeed. Nsukka, Nigeria
Pediatricians test the infant exposed to HIV for determination of HIV infection
Clinical reports from the American Academy of Pediatrics benefit from
and monitor possible short- and long-term toxicity from antiretroviral expertise and resources of liaisons and internal (AAP) and external
reviewers. However, clinical reports from the American Academy of
exposure. Finally, pediatricians support families living with HIV by providing Pediatrics may not reflect the views of the liaisons or the
counseling to parents or caregivers as an important component of care. organizations or government agencies that they represent.
The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
All clinical reports from the American Academy of Pediatrics
INTRODUCTION automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
Each year approximately 8500 women with HIV infection give birth in the
United States.1 Through the implementation of effective, cost-saving2 This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have filed
preventive strategies during pregnancy, the rate of perinatal transmission conflict of interest statements with the American Academy of
of HIV has remained low at ,1% to 2%.1 These preventive strategies Pediatrics. Any conflicts have been resolved through a process
approved by the Board of Directors. The American Academy of
include (1) the provision of universal opt-out HIV testing for all pregnant Pediatrics has neither solicited nor accepted any commercial
women and for those who have HIV infection, administration of involvement in the development of the content of this publication.
combination antiretroviral therapy (ART) during pregnancy and labor; DOI: https://doi.org/10.1542/peds.2020-029058
(2) planned cesarean delivery before the onset of labor and rupture of Address correspondence to Ellen Gould Chadwick, MD.
membranes for pregnant women with an HIV viral load of .1000 copies E-mail: EGChadwick@luriechildrens.org
per mL before delivery; (3) provision of antiretroviral prophylaxis to the PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
infant exposed to HIV for 4 to 6 weeks; and (4) complete avoidance of
Copyright © 2020 by the American Academy of Pediatrics
breastfeeding. Perinatal transmission occurs mostly when there is failure
of implementation of these strategies, outlined in a separate 2008
American Academy of Pediatrics (AAP) policy statement titled “HIV To cite: Chadwick EG, AAP COMMITTEE ON PEDIATRIC AIDS.
Evaluation and Management of the Infant Exposed to HIV
Testing and Prophylaxis to Prevent Mother-to-Child Transmission in the
in the United States. Pediatrics. 2020;146(5):e2020029058
United States.”3,4 This clinical report offers guidance on the evaluation and
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PEDIATRICS Volume 146, number 5, November 2020:e2020029058 FROM THE AMERICAN ACADEMY OF PEDIATRICSmanagement of infants born to during the current pregnancy) should to breastfeed is also made during the
women with HIV infection. have HIV testing repeated in the third prenatal period. The current US
In addition to standard clinical care trimester.8 A plasma HIV RNA test is Department of Health and Human
for the newborn infant, it is important recommended in addition to routine Services (HHS) Panel on Treatment of
that appropriate steps are taken for antigen/antibody immunoassay Pregnant Women With HIV Infection
early detection of HIV infection, testing when the possibility of acute and Prevention of Perinatal
appropriate vaccines are retroviral syndrome is suspected in Transmission (Perinatal Guidelines
administered, and adequate a pregnant woman.9 Panel) recommends the use of
counseling is provided to families a combination of at least 3
living with HIV infection. The antiretroviral drugs during pregnancy
TESTING OF THE INFANT WHEN THE
management of infants in whom and labor for all pregnant women
MOTHER’S HIV INFECTION STATUS IS
HIV infection is diagnosed should UNKNOWN with HIV infection regardless of the
be undertaken in consultation plasma HIV RNA viral load or CD41
When the HIV status of the mother is T-lymphocyte count.11
with a pediatric HIV specialist. unknown, expedited HIV testing
This report updates previous AAP should be performed on the infant
recommendations.5 Interventions During Labor and at
after consent procedures consistent Delivery
with state and local law. Expedited
IDENTIFICATION OF MATERNAL HIV HIV antigen/antibody testing allows Pregnant women with HIV infection
INFECTION timely identification of HIV infection generally continue the routine dosing
in women whose HIV status is schedule of their ART regimen during
Although there has been a dramatic labor if possible. Intravenous
decrease in the number of new HIV unknown late in pregnancy, during
labor, or in the immediate postpartum zidovudine (ZDV), also known as
infections in infants in the United azidothymidine (AZT), is added for
States since 1994, when antiretroviral period and is generally available on
a 24-hour basis at all facilities with pregnant women with HIV RNA
prophylaxis was first documented to .1000 copies per mL close to
prevent perinatal transmission, maternity services and/or a neonatal
care unit. Positive HIV antigen/ delivery and may be considered for
transmission continues to occur, RNA levels between 50 and 999
albeit rarely.1 Documented cases of antibody test results should be
urgently reported to health care copies per mL, but it is no longer
perinatal transmission declined recommended for pregnant women
rapidly after the adoption of the providers so that presumptive HIV
therapy can be initiated in the infant with documented HIV RNA levels
recommendation by the Centers for ,50 copies per mL near delivery.12
Disease Control and Prevention as soon after birth as possible and
ideally within 6 to 12 hours of life. In Planned cesarean delivery before
(CDC), the AAP, and the American labor and the rupture of membranes
College of Obstetricians and addition, breastfeeding should be
postponed, and the infant should be at 38 weeks’ gestation is
Gynecologists for routine HIV testing recommended for all pregnant
for all pregnant women in the United given formula feedings. If
supplemental test results are women with HIV RNA levels of
States. HIV testing is now part of $1000 copies per mL near the time
routine prenatal care in most states negative, antiretroviral drugs should
be stopped, and breastfeeding may be of delivery regardless of maternal HIV
unless the patient declines, which is treatment.13 Cesarean delivery solely
also known as “opt-out” consent or reinstated.8
for the prevention of transmission is
“right of refusal.”6,7 A second HIV test not recommended for pregnant
during the third trimester, preferably STRATEGIES FOR PREVENTION OF women with HIV RNA levels ,1000
before 36 weeks’ gestation, has been PERINATAL HIV TRANSMISSION copies per mL because of the low risk
found to be cost-effective even in low- of perinatal transmission of HIV in
prevalence areas and should be Maternal Treatment During
Pregnancy this group and the increased risk of
considered for all pregnant women.2 complications with a major surgical
In particular, pregnant women at high Most women with HIV infection in the procedure.13
risk for incident HIV infection (eg, United States have access to free
those who are incarcerated, reside in prenatal care, which allows for the Women who present in labor with
communities with an HIV incidence initiation of effective ART in women unknown HIV status should receive
greater than 1 per 1000 per year, in whom HIV is newly diagnosed or expedited HIV testing with
inject drugs, exchange sex for money continuation of treatment in those a combined HIV antigen/antibody
or drugs, are sex partners of who are currently receiving ART.10 test. If the screening result is positive,
individuals living with HIV, or have The determination of the appropriate supplemental testing with an HIV-1/
had a new or more than 1 sex partner mode of delivery and the decision not HIV-2 antibody differentiation
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2 FROM THE AMERICAN ACADEMY OF PEDIATRICSimmunoassay and HIV RNA testing or raltegravir (RAL) to construct antiretroviral prophylaxis regimens
should be performed urgently, a presumptive HIV therapy regimen for different clinical scenarios and
and intravenous ZDV should be (see tables in ref 15).15 This 3-drug provide specific neonatal
initiated pending the result of the combination antiretroviral drug antiretroviral dosing
supplemental test.12 Prompt regimen is recommended for infants recommendations.
initiation of intravenous ZDV, born to mothers who (1) received
The administration of ZDV (possibly
followed by infant antiretroviral prenatal antiretroviral drugs but had
with other antiretroviral agents) to
prophylaxis, may decrease the risk of suboptimal viral suppression at
the infant should be initiated as soon
perinatal transmission of HIV in these delivery, (2) received only
as possible after birth and certainly
settings.14 Cesarean delivery before intrapartum antiretroviral drugs,
within 6 to 12 hours after delivery.27
rupture of membranes, if feasible, (3) received no antepartum or
If the infant’s HIV exposure is first
may also be considered, but there is intrapartum antiretroviral drugs, or
recognized between 12 and 48 hours
insufficient evidence to determine if (4) have known drug-resistant virus.
after delivery, presumptive HIV
cesarean delivery during labor Decisions about using a combination
therapy should be initiated in that
reduces perinatal transmission.13 If antiretroviral regimen over ZDV
time period.15 Data from animal
the supplemental results are negative, monotherapy can be made after
studies indicate that the longer the
maternal and infant antiretroviral balancing the benefits of enhanced
delay in institution of prophylaxis, the
prophylaxis should be stopped. prevention of perinatal transmission
less likely that infection will be
of HIV infection over possible toxicity
Antiretroviral Management for the prevented. In most animal studies,
from multiple drugs. The most
Infant Exposed to HIV antiretroviral prophylaxis initiated 24
information about the use of
to 36 hours after exposure is not as
Postnatal antiretroviral drugs should antiretroviral combinations in
effective for preventing infection.28–30
be provided to all infants exposed to neonates is available for older
HIV to reduce the risk of perinatal regimens such as ZDV in combination The full course of drug supply needed
HIV transmission. Antiretroviral with either single-dose for the entire 4 to 6 weeks should be
prophylaxis is defined as the nevirapine16–19 or 3 doses of supplied to the infant before
administration of 1 or more nevirapine in the first week of life20 discharge from the hospital
antiretroviral drug(s) to a newborn or the dual combination of ZDV and irrespective of availability of out-of-
infant without confirmed HIV lamivudine.21–24 pocket payment or insurance
infection to reduce the risk of HIV coverage because pediatric
acquisition, whereas presumptive HIV When making decisions to use antiretroviral formulations are not
therapy consists of the administration combination antiretroviral drugs, widely available in commercial
of a 3-drug combination antiretroviral consultation with a pediatrician pharmacies.15
regimen to newborn infants at experienced in the care of children
highest risk of HIV acquisition. with HIV infection or the National Avoidance of Postnatal HIV Infection
Presumptive HIV therapy is intended Clinician Consultation Center Postnatal transmission of HIV
to be preliminary treatment of (https://nccc.ucsf.edu/clinician- through ingestion of human milk
a newborn infant who is later consultation/perinatal-hiv-aids/) is from a mother with HIV infection is
confirmed to have HIV infection but beneficial. Monitoring for hematologic well documented, and prolonged
also serves as prophylaxis against toxicity is necessary for any breastfeeding from untreated
perinatal transmission. Prophylaxis combination of ZDV and lamivudine mothers has resulted in rates as high
has historically been achieved by compared to ZDV alone. Long-lasting as 9% to 15%.31 However, studies in
giving a 6-week neonatal ZDV resistance is possible if the infant is low-resource countries have revealed
chemoprophylaxis regimen. However, already infected when prophylaxis is that maternal and/or infant
term infants born to women who given; this was most evident when antiretroviral drug administration
received ART during pregnancy with nevirapine was used as a single agent during lactation reduces the risk of
documented viral suppression can be for prophylaxis.25 The HHS Panel on HIV transmission to the infant via
given a 4-week course.15 In higher- Treatment of Pregnant Women with human milk.32,33 Because the risk of
risk cases, experts on the Perinatal HIV Infection and Prevention of infant mortality from infectious
Guidelines Panel recommend Perinatal Transmission15 and Panel diseases and malnutrition is low in
combining a 6-week infant ZDV on Antiretroviral Therapy and the United States and effective
prophylaxis regimen with 2 Medical Management of Children alternative sources of feeding are
additional antiretroviral drugs Living with HIV26 each publish an readily available, women with HIV
including lamivudine (also known as extensive discussion of infection, including those receiving
“3TC”) and either nevirapine (NVP) considerations for infant ART, should be counseled not to
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PEDIATRICS Volume 146, number 5, November 2020 3breastfeed their infants or donate Supplemental Nutrition Program for Passively transferred maternal HIV
their milk.34 Although maternal ART Women, Infants, and Children, are antibodies may be detectable in an
has been shown to reduce the helpful in many cases. Evaluation of exposed but uninfected infant’s
concentration of cell-free HIV in infant feeding practices with bloodstream until approximately
human milk, it does not affect the suggestions for safer feeding options 18 months of age. Therefore, routine
amount of cell-associated virus in and advice against premastication serological testing of infants exposed
human milk.35 In addition, (the practice of prechewing solid food to HIV and children before the age of
discordance between the viral load in before feeding it to another), which is 18 months is generally only
plasma and human milk has been a potential risk factor for HIV informative if the test result is
observed. There is also differential transmission, are indicated.38 negative.
penetration of antiretroviral drugs
into human milk, with some Polymerase chain reaction (PCR)
Framework for the Total Elimination of
antiretroviral drugs having assays that directly detect HIV DNA
Perinatal Transmission of HIV
concentrations in human milk that or RNA (generically referred to as HIV
Several strategies have been nucleic acid amplification tests
are higher than in maternal plasma, documented that could potentially
and others have lower or [NAATs]) represent the gold standard
lead to the elimination of perinatal for diagnostic testing of infants and
undetectable human milk transmission of HIV. Early detection
concentrations.36 These factors raise young children younger than 18
of HIV infection in the mother and months. With such testing, the
concerns about infant drug toxicity evaluation and management of
and the potential for selection of diagnosis or the presumptive
infants exposed to HIV remain the key exclusion of HIV infection can be
drug-resistant virus within human to preventing perinatal transmission.
milk. Therefore, in the United States, established within the first several
This involves coordination of clinical weeks of life among nonbreastfed
where safe alternatives to care and social services, long-term
breastfeeding are available, all infants. Although neonatal
follow-up of infants exposed to HIV, antiretroviral drugs may decrease the
women with HIV infection should and ongoing HIV surveillance.39 In
avoid breastfeeding.37 concentration of HIV RNA in infant
many cases, early detection is not plasma in the first 6 weeks of life,42
achieved because of social issues such HIV DNA PCR results generally
Cultural differences require that
as lack of access to mental, remain positive in most individuals
counseling the mother about the
preventive, and general health care or taking ART who have undetectable
avoidance of breastfeeding should be
substance use.40,41 Interventions plasma HIV RNA. The sensitivity of
conducted in a sensitive manner. For
targeted to at-risk populations can both DNA and RNA PCR testing is
some women, not being able to
minimize missed opportunities for high,43,44 so either can be used for the
breastfeed may be the hardest
the prevention of perinatal diagnosis of HIV infection in
component of their effort to protect
transmission of HIV. To be most infancy.45 False-positive results with
their newborn infant from acquiring
effective, these efforts should be low-level viral copy numbers have
HIV infection.37 Other mothers,
sustained and involve integrated been described when using HIV RNA
particularly those who have
clinical management and social assays,42,46,47 reinforcing the
emigrated from parts of the world
services.39 importance of repeating any positive
where breastfeeding is nearly
universal, may feel that formula assay result to confirm the diagnosis
feeding their infant discloses their of HIV infection in infancy. False-
CARE OF THE INFANT EXPOSED TO HIV
own HIV infection to family or negative results occur rarely, and
friends. As a result, recommendations Testing to Determine the Infant’s HIV retesting could be considered
to prevent perinatal transmission Infection Status (perhaps by using a different test) if
may not always be followed. Open, Identification of the infant born to clinical findings suggest the presence
nonjudgmental communication about a mother with HIV infection and early of HIV infection.
feeding practices facilitates determination of the presence or
appropriate follow-up and testing of absence of HIV infection in the infant Detection of Non–Subtype B HIV and
all infants, including those whose are critical to allow early initiation of HIV-2
mothers choose to breastfeed after prophylaxis or presumptive HIV For infants born to women known or
appropriate counseling.34 Education therapy and provision of needed care. suspected to have infection with non-
covering appropriate formula feeding Appropriate HIV diagnostic testing B subtypes of HIV, use of HIV RNA
and the cost of formula can be for infants and children younger than assays may be preferable to the use of
provided to women. Referrals, 18 months differs from that for older HIV DNA assays for diagnostic testing.
including enrollment in the Special children, adolescents, and adults. Women who acquire HIV infection in
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4 FROM THE AMERICAN ACADEMY OF PEDIATRICSNorth America are most commonly additional virological diagnostic first week of life and a subsequent
infected with HIV subtype B.48 testing at birth as well as 2 to 4 weeks positive test result are considered
Women who acquire HIV outside of after cessation of antiretroviral to have intrapartum infection.55
North America are often infected with prophylaxis should be considered.12 Cord blood specimens are not
other HIV subtypes. Subtypes C and D used for HIV RNA or DNA testing
predominate in southern and eastern An HIV NAAT should be performed at because they are associated with
Africa, subtype C predominates on birth or in the first few days of life for an unacceptably high rate of false-
the Indian subcontinent, and subtype infants at highest risk of infection, positive test results.
E predominates in much of Southeast including those whose mothers
Asia.48 HIV DNA PCR assays may be received no antiretroviral drugs When a mother’s HIV status is
less sensitive in the detection of non- during pregnancy, when maternal unknown at delivery or after birth,
B subtype HIV, and false-negative HIV prophylaxis was started late in expedited HIV testing (preferably
DNA PCR assay results have been pregnancy or during labor, or if the a combined test for HIV antigen and
reported in infants infected with non- mother had primary HIV infection antibody) for mother and/or infant
B subtype HIV.49,50 Some of the during pregnancy. In the absence of should be performed. In the event of
currently available HIV RNA assays maternal ART, as many as 30% to a positive initial test result,
have improved sensitivity for 40% of infants with HIV infection can presumptive HIV therapy is initiated
detection of non-B subtype HIV be identified by 48 hours of age.53,54 in the infant as soon as possible
infection, although even these assays Infants with a positive NAAT result at pending the result of a supplemental
may not detect all non-B subtypes, or before 48 hours of age are test.15 Treatment should be stopped if
such as the uncommon group O HIV considered to have in utero infection results of supplemental testing with
strain. When testing infants with HIV, whereas infants who have HIV antibody and a NAAT are
suspected of infection with non-B a negative NAAT result during the negative.
subtype HIV, consultation with
a pediatrician experienced in the care
TABLE 1 Evaluation and Treatment of the Infant Exposed to HIV-1 (Birth to 18 Months of Age), in
of infants and children with HIV
Addition to Routine Pediatric Care and Immunizations
infection is recommended. a
Action Infant Age
HIV-2 is a retrovirus similar to HIV Birth 14 d 4 wk 6 wk 8 wk 4 mo 12–18
and is found most commonly in mo
western Africa. It is less virulent, with Antiretroviral prophylaxis or presumptive HIV X X X X — — —
a slower rate of progression of clinical therapyb
disease and lower rates of perinatal Recommend against breastfeeding and X X X X X X X
premastication
transmission.51 However, NAATs for
Hemoglobin or complete blood cell count X — Xc — Xc — —
HIV will not identify HIV-2, so if HIV-1 DNA or RNA PCR assayd e
Xf X — g
X —
infection with HIV-2 is suspected, Initiate PCP prophylaxish — — — X — — —
consultation with the CDC via the Antibody to HIV-1i — — — — — — X
state department of health may be X, indication to conduct the specified action; —, not applicable.
sought to help arrange specific HIV-2 a See the text for detailed discussion of each action. If during this period, HIV infection is diagnosed in the infant,
laboratory monitoring and immunizations should follow guidelines for treatment of pediatric HIV infection.52
testing. b Antiretroviral prophylaxis or presumptive HIV therapy, depending on the infant’s risk of acquiring HIV (see text) is
initiated as soon as possible after birth but certainly within 6–12 hours. ZDV prophylaxis is continued for 4–6 weeks, at
which time it is stopped.
Timing of Diagnostic Testing in c Checked at 4 weeks by some experts and rechecked at 8 weeks if the week 4 hemoglobin level was significantly low.
Infants With Known Perinatal d All infants exposed to HIV-1 should undergo virological testing for HIV-1 with HIV-1 DNA or RNA PCR assays at 14 to
Exposure to HIV 21 days of age and, if results are negative, they should be repeated at 1 to 2 and 4 to 6 months of age to identify or
exclude HIV-1 infection as early as possible. Any positive test result at any age is promptly repeated to confirm the
For infants with known perinatal diagnosis of HIV-1 infection.
exposure, it is recommended that e HIV-1 DNA or RNA PCR assay testing in the first few days of life allows identification of in utero infection and should be
diagnostic testing with HIV DNA or considered if maternal antiretroviral agents were not administered during pregnancy or in other high-risk situations. A
negative test result at this age requires repeat testing to exclude HIV-1 infection.
RNA assays be performed at 14 to f A negative test result at this age requires repeat testing to exclude HIV-1 infection. Presumptive uninfected indicates
21 days of age, and if results are a negative NAAT result at $14 days and $4 weeks (1 month) of age; definitive uninfected indicates a negative NAAT result
negative, they should be repeated at 1 at $1 and $4 months of age (see text for complete details).
g For higher-risk infants, additional virological diagnostic testing should be considered 2 to 4 weeks after cessation of
to 2 months of age and again at 4 to antiretroviral prophylaxis (ie, at 8–10 weeks of life).
6 months of age (Table 1).52 For h Infants with indeterminate HIV-1 infection status should receive prophylaxis starting at 4–6 weeks of age until they are
infants at a higher risk of perinatal deemed to be presumptively or definitively uninfected with HIV-1. Prophylaxis is not recommended for infants who meet
criteria for presumptive or definitive lack of HIV-1 infection; therefore, a NAAT at 2 and 4–6 weeks of age allows for
HIV transmission who receive avoidance of PCP prophylaxis if both results are negative.
multiple antiretroviral drugs, i Many experts confirm the absence of HIV-1 infection with a negative HIV-1 antibody assay result at 12–18 months of age.
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PEDIATRICS Volume 146, number 5, November 2020 5If an HIV NAAT for the newborn use in infants who do not meet the weeks, 3 months, and 6 months after
infant was not performed shortly criteria for HIV infection noted breastfeeding cessation.52
after birth, or if such test results were above.52
negative, diagnostic testing with an Role of HIV Antibody Testing in
In nonbreastfeeding infants younger Infants Exposed to HIV
HIV NAAT is performed at 14 to
than 18 months with no positive HIV
21 days of age because the diagnostic In infants exposed to HIV who are not
NAAT results, presumptive exclusion
sensitivity of virological assays infected with HIV, maternal HIV
of HIV infection is based on the
increases rapidly by 2 weeks of age.53 antibodies transferred in utero may
following:
This change in assay sensitivity persist through 18 months of age.
reflects the biology of perinatal • two negative HIV RNA or DNA Loss of HIV antibody in an infant with
transmission, such that when HIV is NAAT results, from separate previously negative HIV NAAT results
acquired at the time of delivery, it specimens, both of which were (seroreversion) definitively confirms
may take up to 2 weeks for a NAAT to obtained at $2 weeks of age and 1 that the infant is not infected with
be able to detect the virus.55 of which was obtained at $4 weeks HIV. Many infants exposed to HIV
Therefore, negative results of HIV of age; or serorevert to HIV antibody negativity
DNA PCR or RNA tests performed • one negative HIV RNA or DNA by 12 months of age.57 Many experts
before 14 days of age are less helpful NAAT result from a specimen confirm the absence of HIV infection
in excluding HIV infection acquired at obtained at $8 weeks of age; or with a negative HIV antibody assay
the time of birth than are results of • one negative HIV antibody test result at 12 to 18 months of age. If an
tests performed at or after 14 days result obtained at $6 months infant exposed to HIV who is not
of age. of age. known to be infected is tested at
12 months of age and is still antibody-
Management if an HIV Virological Definitive exclusion of HIV infection positive, then testing should be
Test Result Is Positive in a nonbreastfed infant is based on repeated at 18 to 24 months of age.
If any of the HIV NAAT results are the following: Performing the first antibody test at
positive, an immediate repeat HIV • two or more negative HIV RNA or 18 months of age to confirm
NAAT is recommended to confirm the DNA NAAT results, with 1 negative seroreversion may avoid the cost and
diagnosis of HIV infection. A diagnosis result at age $1 month and 1 pain of performing 2 tests. Positive
of HIV infection can be made on the negative result at age $4 months; HIV antibodies at 24 months of age or
basis of 2 separate blood samples, or older may indicate HIV infection and
each of which is positive for HIV DNA • two negative HIV antibody test should be confirmed with an HIV
or RNA. If infection is confirmed, results from separate specimens virological test.26 A confirmed NAAT
a pediatric HIV specialist should be obtained at age $6 months. result at or beyond 24 months of age
consulted for advice regarding ART in an infant with infection previously
In the unusual case of an infant with
and care. HIV disease can progress excluded as outlined above suggests
a positive HIV NAAT result followed
rapidly in infants with HIV infection, that the infant was infected after
by a negative NAAT result, an expert
and neither CD41 T-lymphocyte infancy, such as through
in the care of children with HIV
count nor HIV RNA copy number is breastfeeding, premastication of solid
infection can be consulted for further
a reliable predictor of the risk of food by a caregiver with HIV
testing recommendations.
disease progression in infants.53 infection,34 or sexual abuse.
Many experts confirm the absence of
Interpretation of Negative HIV Test HIV infection with a negative HIV Prevention of Pneumocystis jirovecii
Results antibody assay result at 12 to Pneumonia
On the basis of analysis of HIV DNA or 18 months of age (see next section). The most common severe
RNA assay results from multiple For both presumptive and definitive opportunistic infection in infants and
studies, the CDC has revised the case exclusion of infection, the child children with HIV infection is
definition for exclusion of HIV should have no other laboratory (eg, Pneumocystis jirovecii pneumonia
infection in infants for surveillance no positive NAAT results) or clinical (PCP). PCP incidence in untreated
purposes.56 The definitions supplied (eg, no AIDS-defining conditions) infants with HIV is highest during the
here are based on the CDC evidence of HIV infection. For infants first year of life, with cases peaking at
surveillance definitions and are who have been breastfed, a similar 3 to 6 months of age.58,59
appropriate for the management of testing algorithm can be followed, Chemoprophylaxis is highly effective
children born to women with HIV with additional testing every in the prevention of PCP and should
infection. These definitions of 3 months during breastfeeding be administered to infants in whom
exclusion of HIV infection are only for followed by monitoring at 4 to 6 HIV infection is diagnosed from 4 to
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6 FROM THE AMERICAN ACADEMY OF PEDIATRICS6 weeks of age until their first any other person in the family The 6-week ZDV regimen in infants
birthday. Thereafter, the need for receives a diagnosis of acid-fast can cause anemia, which largely
prophylaxis is based on age-specific bacillus smear-positive TB, the infant remains clinically insignificant and
CD41 T-lymphocyte counts and/or should be separated from that person generally resolves after termination
percentages.60 Trimethoprim- until the TB infection has been of ZDV prophylaxis. If anemia persists
sulfamethoxazole is the most treated with anti-TB medications and even after stopping the ZDV regimen,
common drug used for prophylaxis a physician has determined that the alternative etiologies are likely
because of its high efficacy, relative person is no longer contagious. In the responsible. Anemia can be severe in
safety, low cost, and broad event that a pregnant woman has infants taking ZDV who were born
antimicrobial spectrum60 (for documented TB that can be spread by prematurely or with other medical
further discussion, see ref 60). the hematogenous route, the infant problems. Also, administration of ZDV
should be evaluated for congenital TB in combination with other
PCP prophylaxis is not recommended
by a pediatric infectious disease antiretroviral drugs can cause
for infants with presumptive lack of
expert. hematologic toxicity.68 The timing of
HIV infection (see previous section)
monitoring of hematologic toxicity
but should be initiated for infants Immunizations from ZDV prophylaxis depends on
with indeterminate HIV infection
Each year, the CDC publishes many factors such as baseline
status starting at 4 to 6 weeks of
immunization schedules for children hematologic values, gestational age at
age.60 Thus, for infants with negative
and adolescents 0 to 18 years of age62 birth, clinical condition of the child,
HIV NAAT results at 2 and 4 to
as well as for children with HIV receipt of concomitant medications,
6 weeks of age (presumptively not
infection.63 All routine infant and maternal antepartum therapy.
infected with HIV), PCP prophylaxis
immunizations should be given to Hemoglobin and neutrophil counts
can be avoided completely. For an
infants exposed to HIV. If HIV should be measured in infants who
infant exposed to HIV with
infection is confirmed in an infant have taken ZDV- and/or lamivudine-
indeterminate HIV infection status
exposed to HIV, then guidelines for containing antiretroviral regimens for
who initiated prophylaxis at 4 to
the child with HIV infection should be 4 or more weeks.
6 weeks of age and subsequently
followed.62,63
meets criteria for presumptive or The decision of whether to
definitive lack of HIV infection, PCP Monitoring for Toxicity From In Utero discontinue antiretroviral prophylaxis
prophylaxis can be stopped. and Neonatal Antiretroviral Drug early because of identification of
Exposure hematologic abnormalities is made on
Prevention of Tuberculosis the basis of factors such as severity of
Monitoring for and Management of
Increased risk of tuberculosis (TB) Short-term Toxicity During Infant the laboratory abnormality,
among adults living with HIV Antiretroviral Prophylaxis associated clinical symptoms,
infection is well documented. Because duration of infant prophylaxis already
Because exposure to maternal
infants and children with TB infection received, the magnitude of the risk of
antiretroviral drugs taken during
and disease are usually infected by an HIV infection in the infant (as
pregnancy can cause small but
adult with whom they live and have assessed by maternal receipt of ART,
apparent variations of hemoglobin
daily contact, TB infection status maternal viral load near delivery, and
and neutrophil counts, a baseline
information should be obtained about mode of delivery), and availability of
complete blood cell and differential
the mother and all other household alternative interventions (eg, red
count has been recommended for the
contacts of infants born to mothers blood cell transfusion) in consultation
newborn infant.64 The risk of anemia
with HIV. Bacille Calmette-Guerin with a pediatric HIV specialist.
and neutropenia is greater in infants
immunization is not recommended
whose mothers received ART during Routine measurement of serum
for infants born to women with HIV
pregnancy, but mild anemia was also lactate concentration in
infection in the United States and
observed commonly in infants whose asymptomatic neonates to screen for
should not be administered to infants
mothers received ZDV monotherapy possible mitochondrial toxicity
and children with known HIV
compared with infants whose related to ZDV prophylaxis is not
infection because of its potential to
mothers received no antiretroviral recommended because the clinical
cause disseminated disease.61
drugs during pregnancy.65 relevance of increased lactate
If an infant is exposed to anyone with Nonetheless, the advantages of concentrations in the absence of
active TB, the infant should be maternal ART for prevention of symptoms is unknown, transient
evaluated for TB disease and perinatal transmission are far greater elevations return to normal, and
managed according to published than hematologic toxicity in the there is poor predictive value for later
guidelines.61 If the infant’s mother or newborn infant.66,67 appearance of symptomatic
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PEDIATRICS Volume 146, number 5, November 2020 7toxicity.69,70 However, if severe the siblings, should be tested because include adherence to medications to
clinical symptoms, particularly it is possible, albeit unusual, for prevent perinatal transmission of HIV
neurologic symptoms, develop in the perinatally infected children to and prompt assessment of illness in
infant, a serum lactate concentration remain asymptomatic into the infant exposed to HIV as well as
should be obtained. If the serum adolescence.80,81 the schedule of follow-up visits for
lactate concentration is significantly assessment and laboratory assays
elevated in an infant with compatible Counseling and Support (both for diagnosis of HIV infection
clinical symptoms, a pediatric HIV An HIV diagnosis can have and to check for any adverse effects
expert can help determine if a significant impact on an individual of antiretroviral exposure).
antiretroviral prophylaxis should be and his or her family. When Breastfeeding is not recommended
terminated. In general, prophylaxis counseling the mother of an infant even if mothers are receiving ART for
should continue unless there is exposed to HIV, exploring whether their own HIV disease.37
a compelling reason to stop. HIV infection was recently diagnosed Counseling should include education
in the mother during or after about the risks of HIV transmission,
Long-term Toxicity
pregnancy and whether she needs including the lack of transmission risk
Research has not revealed significant a referral for her own care may in family activities such as eating,
risk of neoplasia or organ-system contribute to care of the whole family. bathing, or sleeping together.
toxicities from in utero exposure to Additionally, some families may Planning regarding future
ZDV or other antiretroviral drugs.71 require support related to an HIV- reproductive plans for the family,
The issue of mitochondrial associated illness or death in other likely in collaboration with the
dysfunction from the use of ART has family members. family’s adult HIV and gynecologic
been unsubstantiated69 but remains
Increased need for social and and obstetric providers, can minimize
under investigation. However, in
psychological support services may the risk of HIV acquisition for sexual
children exposed to HIV with severe
result from factors including partners and perinatal transmission
clinical symptoms, neurologic or
economic hardship, substance use, in future pregnancies.
cardiac in particular, mitochondrial
dysfunction is part of the differential depression, social isolation, lack of
Confidentiality should be maintained
diagnosis in HIV infection.70,72–77 health care, unemployment, difficulty
at all times. In some cases, one or
in finding housing, or domestic
Information regarding in utero and/ more family members may not be
violence. In addition, fear of loss of
or neonatal antiretroviral exposure is aware of the HIV infection status of
existing supports and services, such
an important part of a permanent the mother, which warrants extra
as loss of support from a partner or
record, particularly in uninfected caution in the labor and delivery unit
loss of employment, insurance, or
children. Uninfected children and when discussing the postpartum
health care coverage are important
management of the infant or in the
perinatally exposed to HIV have been considerations.82–84 Particularly
found to have a higher rate of pediatric office when discussing care
vulnerable are pregnant adolescents
childhood infections in the first year of the child.
with HIV infection.85
of life than unexposed children and
benefit from regular medical care.78,79 Additional factors may be present for HIV Exposure and Infection Status
Yearly follow-up into adulthood to women who have emigrated from Reporting
monitor for long-term toxicity such other countries, in particular factors
Name-based HIV reporting to state
as cancer or neurodevelopmental related to culture and concerns about
health departments is required in all
or metabolic disorders is immigration status. This population
states and territories for surveillance
appropriate.71 may have been subject to or know of
purposes.86 In addition, many states
stigmatization and discrimination
require reporting pregnancy in
Testing Family Members against people with HIV infection. In
women living with HIV and the
addition, distrust or
HIV screening should be infection status of their infants. To
misunderstanding of the US medical
recommended and offered to all facilitate the required reporting, even
system may complicate care and
immediate family members with when reporting is delegated to
follow-up of the infant.
unknown HIV infection status; this another party, the pediatrician should
should be performed with the An outline of plans for medical care collect the maternal antiretroviral
mother’s consent to include the for the infant will help new parents, treatment history, maternal
infant’s father and/or mother’s sexual foster parents, or other caregivers demographics, labor and delivery
partners. All siblings of the infant optimally care for their infant record, and newborn records at the
exposed to HIV, regardless of age of exposed to HIV. Important topics time of birth.
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8 FROM THE AMERICAN ACADEMY OF PEDIATRICSSUMMARY (SEE TABLE 1) should be stopped and with no positive HIV virological
1. Whenever possible, maternal HIV breastfeeding can be initiated. test results, presumptive
infection should be identified 4. Avoidance of breastfeeding has exclusion of HIV infection is
before or during pregnancy, been and continues to be based on 2 negative HIV RNA or
which allows earlier initiation of a standard, strong DNA NAAT results from separate
care for the woman and for more recommendation for women specimens, both of which were
effective interventions to prevent living with HIV in the United obtained at $2 weeks of age
perinatal transmission. The AAP States because maternal ART and 1 of which was obtained
recommends documented, dramatically reduces but at $4 weeks of age, 1 negative
routine HIV testing for all does not eliminate breast HIV RNA or DNA NAAT result
pregnant women in the United milk transmission, and safe obtained at $8 weeks of age,
States after notifying the patient infant feeding alternatives are or 1 negative HIV antibody test
that testing will be performed, result obtained at $6 months
readily available in the United
unless the patient declines HIV of age.
States.
testing (opt-out consent or right 9. Definitive exclusion of HIV
5. Pediatricians should provide
of refusal). All HIV testing, infection in a nonbreastfed infant
counseling to parents and
including during the third is based on 2 or more negative
caregivers of infants exposed to
trimester, should be performed in HIV RNA or DNA test results,
HIV about HIV infection,
a manner consistent with state with 1 negative result at age
including routine care of the
and local laws. $1 month and 1 negative result
infant, diagnostic tests, and
at age $4 months, or 2 negative
2. If the mother’s HIV serostatus is potential drug toxicities.
HIV antibody test results from
unknown at the time of labor or 6. All infants exposed to HIV should separate specimens obtained at
birth, the newborn infant’s health undergo virological testing with age $6 months.
care provider should perform HIV DNA, RNA, or total nucleic
expedited HIV antibody testing 10. Many experts confirm the
acid assays at 14 to 21 days of
on the mother or the newborn absence of HIV infection with
age. If results are negative, these
infant or antigen/antibody a negative HIV antibody assay
tests should be repeated at 1 to 2
testing on the mother, with result at 12 to 24 months of
and 4 to 6 months of age to age. These laboratory tests can
appropriate consent consistent
identify or exclude HIV infection only be used to exclude HIV
with state and local laws. The
as early as possible. If any test infection if there is no other
results should be reported to
result is positive, the test should laboratory or clinical evidence of
health care providers quickly
be repeated immediately for HIV infection (ie, no subsequent
enough to allow effective
confirmation. positive results from NAATs
antiretroviral prophylaxis to be
administered to the infant as 7. Initial testing in the first few days if tests were performed and
soon as possible after birth and of life allows identification of in no AIDS-defining condition
certainly within 6 to 12 hours utero infection and should be for which there is no other
after birth. considered if maternal underlying condition of
antiretroviral drugs were not immunosuppression) and the
3. Intravenous ZDV for the mother
administered during pregnancy child is not receiving
and presumptive HIV therapy for
or in other high-risk situations antiretroviral drugs.
the newborn infant should be
(see text). If an HIV NAAT for 11. PCP prophylaxis is not
administered promptly on the
basis of a positive rapid antibody the newborn infant was not recommended for infants who
or antigen/antibody test result performed shortly after birth, are presumptively or definitively
without waiting for the results of or if such test results were not infected with HIV (see
supplemental HIV testing, and negative, diagnostic testing recommendations 9 and 10).
breastfeeding should not be with an HIV NAAT is performed Infants with indeterminate
initiated. If the rapid test result is at 14 to 21 days of age HIV infection status after 6 weeks
positive, supplemental testing because the diagnostic of age should receive prophylaxis
should be performed, and if sensitivity of virological assays until they are determined
supplemental test results are increases rapidly by 2 weeks presumptively or definitively
negative (indicating that the of age. not to be infected with HIV.
infant was not truly exposed to 8. For nonbreastfeeding infants and 12. All infants exposed to
HIV), then antiretroviral drugs children younger than 18 months antiretroviral agents in utero or
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PEDIATRICS Volume 146, number 5, November 2020 9as newborn infants should be LEAD AUTHORS George Siberry, MD, MPH, FAAP – United
monitored for short- and long- States Agency for International Development
Ellen Gould Chadwick, MD, FAAP
(USAID)
term drug toxicity. Echezona Edozie Ezeanolue, MD, MPH, FAAP
Bill G. Kapogiannis, MD – Eunice Kennedy
13. Immunizations and TB screening Shriver National Institute for Child Health and
should be provided for infants Human Development
COMMITTEE ON PEDIATRIC AIDS,
exposed to HIV in accordance 2018–2019
with published guidelines. A Ellen Gould Chadwick, MD, FAAP, STAFF
BCG vaccine should not be Chairperson
administered to infants in whom Anjie Emanuel, MPH
Echezona Edozie Ezeanolue, MD, MPH, FAAP
HIV infection is diagnosed. Katherine Kai-Chi Hsu, MD, MPH, FAAP
Athena P. Kourtis, MD, PhD, MPH, FAAP
14. HIV testing should be offered and Ayesha Mirza, MD, FAAP
recommended to immediate Rosemary M. Olivero, MD, FAAP
family members of infants Natella Yurievna Rakhmanina, MD, ABBREVIATIONS
exposed to HIV. PhD, FAAP
Carina Rodriguez, MD, FAAP AAP: American Academy of
15. The practitioner providing care Pediatrics
for an infant with HIV infection ART: antiretroviral therapy
should consult with a pediatric PREVIOUS COMMITTEE ON PEDIATRIC AIDS CDC: Centers for Disease Control
HIV specialist. An alternative MEMBER and Prevention
service for advice on prevention Elizabeth Montgomery Collins, MD, HHS: US Department of Health and
of perinatal HIV transmission or MPH, FAAP Human Services
HIV management is the National NAAT: nucleic acid
Clinician Consultation Center CONSULTANT amplification test
(https://nccc.ucsf.edu/clinician- PCP: Pneumocystis jirovecii
Athena P. Kourtis, MD, PhD, MPH, FAAP
consultation/perinatal-hiv-aids/). pneumonia
If the infant’s mother is an PCR: polymerase chain reaction
adolescent, consultation with LIAISONS TB: tuberculosis
a practitioner familiar with the Steve Nesheim, MD – Centers for Disease ZDV: zidovudine
care of adolescents is advised. Control and Prevention
FINANCIAL DISCLOSURE: Dr Chadwick disclosed a financial relationship in which her spouse owns stock in pharmaceutical companies that manufacture drugs
used to treat HIV/AIDS; and Dr Ezeanolue has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: Dr Chadwick disclosed a financial relationship in which her spouse owns stock in pharmaceutical companies that manufacture
drugs used to treat HIV/AIDS; and Dr Ezeanolue has indicated he has no potential conflicts of interest to disclose.
REFERENCES
1. Nesheim SR, Wiener J, Fitz Harris LF, transmission in the United States. AIDS. 6. Mofensen LM; Centers for Disease
Lampe MA, Weidle PJ. Brief report: 2015;29(12):1511–1515 Control and Prevention, U.S. Public
estimated incidence of perinatally Health Service Task Force. U.S. Public
4. American Academy of Pediatrics
acquired HIV infection in the Health Service Task Force
Committee on Pediatric AIDS. HIV
United States, 1978-2013. J Acquir recommendations for use of
testing and prophylaxis to prevent
Immune Defic Syndr. 2017;76(5): antiretroviral drugs in pregnant HIV-1-
mother-to-child transmission in the
461–464 infected women for maternal health
United States. Pediatrics. 2008;122(5):
2. Bert F, Gualano MR, Biancone P, et al. 1127–1134 and interventions to reduce perinatal
HIV screening in pregnant women: HIV-1 transmission in the United States.
5. Havens PL, Mofenson LM; American MMWR Recomm Rep. 2002;51(RR):
a systematic review of cost-
Academy of Pediatrics Committee on 1–38–4
effectiveness studies. Int J Health Plann
Pediatric AIDS. Evaluation and
Manage. 2018;33(1):31–50 7. Committee on Obstetric Practice; HIV
management of the infant exposed to
3. Camacho-Gonzalez AF, Kingbo M-H, HIV-1 in the United States. [published Expert Work Group. ACOG Committee
Boylan A, Eckard AR, Chahroudi A, correction appears in Pediatrics. 2012; Opinion No. 752: prenatal and perinatal
Chakraborty R. Missed opportunities 130(6):1183–1184]. Pediatrics. 2009; human immunodeficiency virus testing.
for prevention of mother-to-child 123(1):175–187 Obstet Gynecol. 2018;132(3):e138–e142
Downloaded from www.aappublications.org/news by guest on December 30, 2020
10 FROM THE AMERICAN ACADEMY OF PEDIATRICS8. Panel on Treatment of Pregnant Women Available at: https://clinicalinfo.hiv.gov/ Study Group. Lamivudine-zidovudine
with HIV Infection and Prevention of en/guidelines/perinatal/transmission- combination for prevention of
Perinatal Transmission. and-mode-delivery?view=full Accessed maternal-infant transmission of HIV-1.
Recommendations for the Use of September 23, 2020 JAMA. 2001;285(16):2083–2093
Antiretroviral Drugs in Pregnant 14. Wade NA, Zielinski MA, Butsashvili M, 22. Moodley D, Moodley J, Coovadia H, et al.;
Women with HIV Infection and et al. Decline in perinatal HIV South African Intrapartum Nevirapine
Interventions to Reduce Perinatal HIV transmission in New York State (1997- Trial (SAINT) Investigators. A
Transmission in the United States. 2000). J Acquir Immune Defic Syndr. multicenter randomized controlled trial
Available at: https://clinicalinfo.hiv.gov/ 2004;36(5):1075–1082 of nevirapine versus a combination of
en/guidelines/perinatal/maternal-hiv-
15. Panel on Treatment of Pregnant Women zidovudine and lamivudine to reduce
testing-and-identification-perinatal-hiv-
with HIV Infection and Prevention of intrapartum and early postpartum
exposure. Accessed September 23, 2020
Perinatal Transmission. mother-to-child transmission of human
9. Centers for Disease Control and Recommendations for the Use of immunodeficiency virus type 1. J Infect
Prevention; Association of Public Health Antiretroviral Drugs in Pregnant Dis. 2003;187(5):725–735
Laboratories. Laboratory Testing for the Women with HIV Infection and
Diagnosis of HIV Infection: Updated 23. Moodley D, Pillay K, Naidoo K, et al.
Interventions to Reduce Perinatal HIV Pharmacokinetics of zidovudine and
Recommendations. Atlanta, GA: Centers Transmission in the United States.
for Disease Control and Prevention; lamivudine in neonates following
Available at: https://clinicalinfo.hiv.gov/ coadministration of oral doses every
2014. Available at: http://stacks.cdc.gov/ en/guidelines/perinatal/antiretroviral-
view/cdc/23447. Accessed January 8, 12 hours. J Clin Pharmacol. 2001;41(7):
management-newborns-perinatal-hiv- 732–741
2020 exposure-or-hiv-infection?view=full
10. American Pregnancy Association. Accessed September 23, 2020 24. Moodley J, Moodley D, Pillay K, et al.
Medicaid for pregnant women. Pharmacokinetics and antiretroviral
16. Dabis F, Bequet L, Ekouevi DK, et al.;
Available at: https:// activity of lamivudine alone or when
ANRS 1201/1202 DITRAME PLUS Study
americanpregnancy.org/first-year-of- coadministered with zidovudine in
Group. Field efficacy of zidovudine,
life/medicaid-for-pregnant-women/. human immunodeficiency virus type 1-
lamivudine and single-dose nevirapine
Accessed January 8, 2020 to prevent peripartum HIV infected pregnant women and their
transmission. AIDS. 2005;19(3):309–318 offspring. J Infect Dis. 1998;178(5):
11. Panel on Treatment of Pregnant Women
1327–1333
with HIV Infection and Prevention of 17. Lallemant M, Jourdain G, Le Coeur S,
Perinatal Transmission. et al.; Perinatal HIV Prevention Trial 25. McIntyre JA, Hopley M, Moodley D, et al.
Recommendations for the Use of (Thailand) Investigators. Single-dose Efficacy of short-course AZT plus 3TC to
Antiretroviral Drugs in Pregnant perinatal nevirapine plus standard reduce nevirapine resistance in the
Women with HIV Infection and zidovudine to prevent mother-to-child prevention of mother-to-child HIV
Interventions to Reduce Perinatal HIV transmission of HIV-1 in Thailand. transmission: a randomized clinical
Transmission in the United States. N Engl J Med. 2004;351(3):217–228 trial. PLoS Med. 2009;6(10):e1000172
Available at https://clinicalinfo.hiv.gov/
en/guidelines/perinatal/overview-2? 18. Taha TE, Kumwenda NI, Hoover DR, et al. 26. Panel on Antiretroviral Therapy and
view=full. Accessed September 23, 2020 Nevirapine and zidovudine at birth to Medical Management of Children Living
reduce perinatal transmission of HIV in with HIV. Guidelines for the Use of
12. Panel on Treatment of Pregnant Women an African setting: a randomized Antiretroviral Agents in Pediatric HIV
with HIV Infection and Prevention of controlled trial. JAMA. 2004;292(2): Infection. Available at: https://
Perinatal Transmission. 202–209 clinicalinfo.hiv.gov/en/guidelines/
Recommendations for the Use of pediatric-arv/antiretroviral-
Antiretroviral Drugs in Pregnant 19. Mirochnick M, Fenton T, Gagnier P, et al.;
Pediatric AIDS Clinical Trials Group management-newborns-perinatal-hiv-
Women with HIV Infection and exposure-or-hiv-infection?view=full.
Interventions to Reduce Perinatal HIV Protocol 250 Team. Pharmacokinetics of
nevirapine in human immunodeficiency Accessed September 23, 2020
Transmission in the United States.
Available at: https://clinicalinfo.hiv.gov/e virus type 1-infected pregnant women 27. Wade NA, Birkhead GS, Warren BL, et al.
n/guidelines/perinatal/intrapartum-anti and their neonates. J Infect Dis. 1998; Abbreviated regimens of zidovudine
retroviral-therapyprophylaxis?view=full 178(2):368–374 prophylaxis and perinatal transmission
Accessed September 23, 2020 20. Nielsen-Saines K, Watts DH, Veloso VG, of the human immunodeficiency virus.
et al.; NICHD HPTN 040/PACTG 1043 N Engl J Med. 1998;339(20):1409–1414
13. Panel on Treatment of Pregnant Women
with HIV Infection and Prevention of Protocol Team. Three postpartum 28. Van Rompay KKA, Otsyula MG, Marthas
Perinatal Transmission. antiretroviral regimens to prevent ML, Miller CJ, McChesney MB, Pedersen
Recommendations for the Use of intrapartum HIV infection. N Engl J Med. NC. Immediate zidovudine treatment
Antiretroviral Drugs in Pregnant 2012;366(25):2368–2379 protects simian immunodeficiency
Women with HIV Infection and 21. Mandelbrot L, Landreau-Mascaro A, virus-infected newborn macaques
Interventions to Reduce Perinatal HIV Rekacewicz C, et al.; Agence Nationale against rapid onset of AIDS. Antimicrob
Transmission in the United States. de Recherches sur le SIDA (ANRS) 075 Agents Chemother. 1995;39(1):125–131
Downloaded from www.aappublications.org/news by guest on December 30, 2020
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