• 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

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 

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 

• 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)

Table 2: Oral zidovudine dose at 4 mg/kg by weight

• 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
• 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)

• 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 

• 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
• 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 

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 
• 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