DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
Vertical transmission of HIV can be prevented only if maternal HIV status known
ANTENATAL
- Check latest version of care plan and last maternal HIV viral load
- If mother is to have zidovudine IV, ensure prescribed antenatally by obstetric team
- Confirm labour ward has antiretrovirals indicated for baby
- Recommend formula feeding; provide bottles/steriliser if necessary
- if mother wishes to breastfeed, refer to HIV team
POSTNATAL
Maternal blood tests
- Check HIV result of every mother
- if no result, recommend mother tested urgently (point of care, if available)
- if declined, offer baby testing (urgent HIV antibody)
- if declined, refer urgently to lead HIV consultant/consultant-on-call
NEONATAL
Very low risk
- 2 weeks’ zidovudine monotherapy recommended if all the following criteria met:
- mother has been on combined antiretroviral therapy (cART) >10 weeks and
- 2 documented maternal HIV viral loads <50 HIV RNA copies/mL during pregnancy ≥4 weeks apart and
- maternal HIV viral load <50 HIV RNA copies/mL at or after 36 weeks
Low risk group
- Extend to 4 weeks’ zidovudine monotherapy:
- if criteria for very low risk are not all fulfilled, but maternal HIV viral load <50 HIV RNA copies/mL at or after 36 weeks
- if baby born prematurely (<34 weeks) but most recent maternal HIV viral load <50 HIV RNA copies/mL
High risk group
- Use combination post-exposure prophylaxis (PEP) for 4 weeks:
- if maternal birth HIV viral load known to be or likely to be >50 HIV RNA copies/mL on day of birth
- if uncertainty about recent maternal adherence or
- if viral load not known
- If maternal resistance to zidovudine and/or nevirapine and viral load >50 copies/mL, follow individualised plan
- If no maternal resistance to zidovudine and/or nevirapine, or resistance result not immediately available, give baby zidovudine, lamivudine and nevirapine
- If mother diagnosed postpartum, start baby on triple therapy immediately if aged <72 hr
TREATMENT OF BABY
- Do not delay treatment for blood tests or any other reason
- Start as soon as possible after birth, definitely within 4 hr
Table 1: Zidovudine (10 mg/mL) (gestational age at birth) (duration – see above)
<30 weeks and on feeds | 2 mg/kg oral/NG 12-hrly |
30–34 weeks and on feeds |
2 mg/kg oral/NG 12-hrly for first 2 weeks Then if not very low risk: 2 mg/kg oral/NG 8-hrly for second 2 weeks |
<34 weeks and not tolerating feeds |
1.5 mg/kg IV over 30 min 12-hrly Change to 6-hrly at 34 weeks |
>34 weeks and feeding | 4 mg/kg oral 12-hrly (see Table 2) |
≥34 weeks and not tolerating feeds | 1.5 mg/kg IV over 30 min 6-hrly |
Table 2: Oral zidovudine dose at 4 mg/kg by weight
Weight range (kg) |
Oral dose (mg) 12-hrly (equivalent to 4 mg/kg) |
Volume (mL) to be given oral 12-hrly |
2.01–2.12 | 8.5 | 0.85 |
2.13–2.25 | 9 | 0.9 |
2.26–2.37 | 9.5 | 0.95 |
2.38–2.5 | 10 | 1 |
2.51–2.75 | 11 | 1.1 |
2.76–3.00 | 12 | 1.2 |
3.01–3.25 | 13 | 1.3 |
3.26–3.50 | 14 | 1.4 |
3.51–3.75 | 15 | 1.5 |
3.76–4.00 | 16 | 1.6 |
4.01–4.25 | 17 | 1.7 |
4.26–4.50 | 18 | 1.8 |
4.51–4.75 | 19 | 1.9 |
4.76–5.00 | 20 | 2 |
- Lamivudine 2 mg/kg oral 12-hrly for 4 weeks
- Nevirapine 2 mg/kg oral daily for 1 week, then 4 mg/kg daily for 1 week, then stop
- if mother on nevirapine >3 days, give baby 4 mg/kg daily for 2 weeks then stop
- Round doses up to the nearest 0.5 mg to assist administration
- If medication cannot be given orally, give zidovudine IV
- if high risk, change to zidovudine oral for 4 weeks as soon as medication can be given orally and add lamivudine oral for 4 weeks and nevirapine for 2 weeks
- If maternal viral load <50 copies/mL and previous resistance to zidovudine
- zidovudine monotherapy is recommended for infant PEP
- If maternal viral load >50 copies/mL and antiretroviral resistance
- follow individualised care plan
- if care plan not available discuss with lead consultant for HIV perinatal care
- follow individualised care plan
- Advice available (24 hr) from regional hub [e.g. Birmingham Heartlands Hospital (0121 424 2000), North Manchester (0161 624 0420)] or national lead centre in London: St Mary’s (0207 886 6666) or St George’s (0208 725 3262)
TESTING OF BABY
- HIV viral load (RNA PCR) minimum 2 mL EDTA venous (not cord/heel prick) to be sent to local virology laboratory within first 48 hr and before hospital discharge
- If recommended by HIV specialist also send HIV DNA PCR, (1.3 mL EDTA) to Public Health England at Colindale with paired sample from mother
DISCHARGE AND FOLLOW-UP
- Advise postnatal staff not to recommend breastfeeding
- Contact obstetric team to organise cabergoline for mother to suppress milk
- If mother does breastfeed, monthly HIV viral load testing for mother and baby
- stop breastfeeding immediately if:
- maternal HIV viral load detectable
- nipple infection (mastitis or Candida), cracked or bleeding
- mother or baby has diarrhoea or vomiting
- stop breastfeeding immediately if:
- If baby vomits within 30 min of taking medicines, or if medicine is seen in the vomit, give the dose again
- Prescribe first dose zidovudine as stat dose, then prescribe twice daily doses at convenient time of day e.g. 9 am and 9 pm (first 2 doses can be given close together without toxicity)
- Dose does not need to be changed with baby’s weight change
- Ensure mother confident to give antiretrovirals to baby
- Dispense antiretroviral supply on discharge
- Notify lead paediatric HIV/infectious diseases consultant who will notify British Paediatric Surveillance Unit
- Follow-up appointment with HIV/infectious diseases consultant at 2 weeks for high risk, or 6 weeks for low and very low risk
- Ensure all involved have record of perinatal care: mother, paediatrician, obstetrician, infectious diseases consultant
SUBSEQUENT MANAGEMENT
Investigations
- HIV viral load (RNA PCR) minimum 2 mL EDTA:
- exclusively non-breastfed babies:
- if high risk at aged 2 weeks
- all at 6 weeks (at least 2 weeks post cessation of infant prophylaxis) and
- at 12 weeks (at least 8 weeks post cessation of infant prophylaxis)
- on other occasions if additional risk
- HIV antibody testing at aged 2 yr if laboratory only using combined antibody/antigen test
- exclusively non-breastfed babies:
- Breastfed infants:
- HIV viral load at 2 weeks then every 4 weeks for as long as any breastfeeds, and 1 and 2 months after stopping breastfeeding
- then as above
PCP prophylaxis
- From aged 4 weeks if HIV positive
Immunisations
- Recommend all other vaccinations as per routine schedule (including rotavirus and MMR)
- Do not delay BCG if low or very low risk of HIV transmission and BCG indicated