Treatment of Infants with HIV-1 Infection

The Committee on Pediatric AIDS (acquired immunodeficiency syndrome) of the American Academy of Pediatrics (AAP) and the Infectious Diseases and Immunization Committee of the Canadian Paediatric Society have released a revised clinical report on human immunodeficiency virus (HIV) infection in infants. “Evaluation and Treatment of the Human Immunodeficiency Virus-1–Exposed Infant” appears in the August 2004 issue of Pediatrics and is available online at http://pediatrics.aappublications.org/cgi/content/full/114/2/497.

In developed countries, care and treatment are available for pregnant women and infants that can decrease the rate of HIV infections around or at the time of birth to 2 percent or less. Whenever possible, maternal HIV-1 infection should be identified before or during pregnancy, because this allows for earlier initiation of care for the mother and for more effective interventions to prevent perinatal transmission. If the maternal HIV-1 infection status is unknown at the time of the infant’s birth, then HIV-1 testing of the mother or the infant is recommended with maternal consent and with results available within 24 hours of birth. The expedited HIV-1 enzyme immunoassay and rapid HIV-1 test are screening tests that may be used in this setting. If the test result for HIV-1 is positive, prophylactic antiretroviral therapy should be started promptly in the infant and confirmatory HIV-1 testing should be performed. Among the recommendations are the following:

• HIV-1–infected mothers should not breastfeed their infants and should be educated about safe alternatives.

• Maternal health information should be reviewed to determine if the HIV-1–exposed infant may have been exposed to maternal coinfections including tuberculosis, syphilis, toxoplasmosis, hepatitis B or C, cytomegalovirus, or herpes simplex virus. Diagnostic testing and treatment of the infant are based on maternal findings.

• Physicians should provide counseling to parents and caregivers of HIV-1–exposed infants about HIV-1 infection, including anticipatory guidance on the course of illness, infection-control measures, care of the infant, diagnostic tests, and potential drug toxicity.

• All HIV-1–exposed infants should undergo virologic testing for HIV-1 at birth, at four to seven weeks of age, and again at eight to 16 weeks of age to reasonably exclude HIV-1 infection as early as possible. If any test result is positive, the test should be repeated immediately for confirmation. If all test results are negative, the infant should have serologic testing repeated at 12 months of age or older to document disappearance of the HIV-1 antibody, which definitively excludes HIV-1 infection.

• All infants exposed to antiretroviral agents in utero or as infants should be monitored for short- and long-term drug toxicity.

• Prophylaxis for Pneumocystis pneumonia (PCP) should be started at four to six weeks of age in HIV-1–exposed infants in whom infection has not been excluded. PCP prophylaxis may be discontinued when HIV-1 infection has been reasonably excluded.

• Immunizations and tuberculosis screening should be provided for HIV-1–exposed infants in accordance with national guidelines. In the United States, immunization guidelines are established by the AAP, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians.

• HIV-1 testing should be offered and recommended to family members.

• The physician providing care for the HIV-1–exposed or HIV-1–infected infant should consult with a pediatric HIV-1 specialist and, if the HIV-1–infected mother is an adolescent, also should consult with a physician familiar with the care of adolescents.