NCCC Clinical Pearls: Case from the Perinatal HIV Hotline

The Case: The NCCC received a call from a hospital pediatrician about a baby who was born this morning to a woman with HIV. The baby was born via planned repeat Cesarean section at 39 weeks and 5 days. Records reflect that the mom is on HIV medications and has an undetectable viral load, but the caller doesn’t have access to all the details.  The mom does not plan to breastfeed. The caller is seeking information about antiretroviral prophylaxis for the baby.

We suggested that the caller try to gather more information about mom’s care, specifically the following:

  • When was she diagnosed with HIV (during this pregnancy or before)?
  • When was she started on antiretroviral medications and has she had any issues with adherence or accessing her medications during this pregnancy?
  • What are the dates and results of her viral load tests during pregnancy?

The caller was able to find the following information: Mom was diagnosed with HIV about 5 years ago and was started on a once daily fixed dose combination of elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide at that time. She was changed to a once daily fixed dose combination of rilpivirine/emtricitabine/tenofovir alafenamide in 2020 during her first pregnancy. As far as the caller is aware, she hasn’t had any lapses in adherence to her medication. Viral load monitoring has been conducted every three months during this pregnancy, and all results have been undetectable, according to notes. The caller verified that the viral load was “Not Detected” two weeks ago and also two months prior to that.

Our Response and Discussion: This baby is very low risk for HIV acquisition and can receive oral zidovudine (ZDV) syrup for 2 weeks as prophylaxis.

The current (as of October 2023) Perinatal and Pediatric HIV Clinical Guidelines in the United States (Recommendations for the Use of Antiretroviral Drugs During Pregnancy and Interventions to Reduce Perinatal HIV Transmission in the United States and Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection) recommend two weeks of oral ZDV syrup for the lowest-risk HIV-exposed infants. Weight-based dosing details are provided in the Guidelines (Management of Infants Born to People with HIV Infection), which indicate that the shortened 2-week course of ZDV prophylaxis is appropriate for infants ≥37 weeks' gestation born to a person with HIV who:

  • Is currently receiving and has received at least 10 consecutive weeks of ART during pregnancy, and
  • Has achieved and maintained or maintained viral suppression (defined as at least two consecutive tests with HIV RNA levels <50 copies/mL obtained at least 4 weeks apart) for the remainder of the pregnancy, and
  • Has HIV RNA <50 copies/mL at or after 36 weeks and within 4 weeks of delivery, and
  • Did not have acute HIV infection during pregnancy, and
  • Has reported good ART adherence, and adherence concerns have not been identified.

Infants considered to be at high risk of perinatal HIV transmission, who should be started on a three-drug regimen for prophylaxis, are infants at any gestational age born to a person with HIV who:

  • Did not receive antepartum ARV drugs, or
  • Received only intrapartum ARV drugs, or
  • Received antepartum ARV drugs but did not have viral suppression (as defined above) within 4 weeks prior to delivery, or
  • Had acute or primary HIV infection during pregnancy, or
  • Is newly diagnosed with HIV while breastfeeding (in which case, breastfeeding should be immediately discontinued)

All other infants born to a person with HIV should be given prophylaxis with 4-6 weeks of zidovudine.

All premature infants (<37 weeks gestation) should receive 4 to 6 weeks of ZDV unless they are at high risk of HIV acquisition.

This is an important change that brings United States guidelines in line with the guidance in the United Kingdom and other European countries and acknowledges the very low risk of HIV transmission in the setting of consistent ART use and viral suppression during pregnancy. It is important to note that this guidance is for formula-fed babies. As more parents with HIV are choosing to breastfeed/chestfeed their babies and are supported in this decision by the Perinatal and Pediatric HIV Clinical Guidelines and their clinicians, providers should refer to the Guidelines and call the Perinatal HIV Hotline with any questions about prophylaxis for breast/chestfed infants.

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