Protocol for Infants Born to HIV-Seropositive Mothers

Special Immunology Service
Children's National Medical Center
October 6, 2000

Notes:

1) HIV DNA PCR is the test currently preferred at CNMC. HIV culture may be preferred at some institutions. HIV RNA quantitative (viral load), particularly the ultrasensitive assay detecting >50 copies of HIV RNA/ml, may prove to be a good alternative, but there is not enough data yet.

2) If HIV DNA PCR (or culture or HIV RNA assay) is positive at any time, the infant is presumed infected and the above protocol no longer applies. The child needs to be referred ASAP to a specialist for confirmatory tests and for early initiation of antiretroviral therapy, continued monitoring of T cells and HIV viral load. Such a child will also need Pneumocystis carinii pneumonia (PCP) prophylaxis until at least 1 year of age.

3) NEGATIVE HIV DNA PCR at birth has no value in ruling out HIV infection. Positive PCR is significant and provides an early clue that the child is infected and needs different management (see above).

4) Monitoring for Bactrim-induced neutropenia.

5) HIV serology should be positive at birth and early in life in all infants born to HIV-seropositive mothers. The uninfected infant should lose maternal antibodies to HIV and serorevert by 18 months of age. The loss of maternal antibodies is the final proof that the child is NOT infected since an occasional infected child can have one or more negative PCR tests in the first year of life (rare – about 1 percent).

6) More intensive monitoring of CBC and serum chemistries is indicated for infants exposed to multiple drugs in utero.

7) All infants born to HIV-seropositive women should be on zidovudine (AZT, ZDV) from birth until 6 weeks of age. This represents postexposure prophylaxis and is a part of the treatment aimed at prevention of vertical transmission of HIV. The dose of ZDV in neonates is 2 mg/kg/dose q6hr; for dosing in premature infants refer to the expert or the PHS recommendations. As more mothers are treated with more than one drug in pregnancy, it may become necessary to use more than one drug for postexposure prophylaxis of the newborn: consult experts.

8) All infants exposed to antiretroviral drugs in utero or neonatal period should be followed into adulthood because of the theoretical concerns about the potential for carcinogenicity of the nucleoside analogue antiretroviral drugs. The follow-up should include yearly physicals, and for older adolescent females, gynecologic evaluation with Pap smears.

9) PCP prophylaxis is started at 6 weeks of age (at 4 weeks of age for the infants who were not on ZDV postnatally) in all HIV-seropositive infants. The drug of choice is TMP-SMX (Bactrim), 75 mg of TMP compound/m2/dose given BID on Monday, Tuesday and Wednesday of each week. PCP prophylaxis may be discontinued if PCR tests at 1 and 4 months of age are negative and T cells are normal. See # 2 above for PCP prophylaxis in the infected infant.