Appropriate care of infants born to women with HIV infection



Appropriate care of infants born to women with HIV infection.

The pediatrician plays a key role in the prevention of mother-to-child transmission of HIV-1 infection. For infants born to women with HIV-1 infection identified during pregnancy, the pediatrician ensures antiretroviral prophylaxis is provided to the infant to decrease the risk of acquiring HIV-1 infection and promotes avoidance of postnatal HIV-1 transmission by advising HIV-1-infected women not to breastfeed. The pediatrician should perform HIV-1 antibody testing for infants born to women whose HIV-1 infection status was not determined during pregnancy or labor. For HIV-1-exposed infants the pediatrician monitors the infant for early determination of HIV-1 infection status and for possible short and long-term toxicity of antiretroviral exposures. Provision of chemoprophylaxis for Pneumocystis jirovecii pneumonia, and support of families living with HIV-1 by providing counseling to parents or caregivers are also important components of care.

Pediatricians need to learn of the recent changes proposed by CDC, HRSA, and AAP concerning testing and treatment of children born at risk of HIV infection.

Reference:

1. Working Group on Antiretroviral Therapy and Medical Management of HIV-Infected C. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV-Infected Children, February, 28, 2008. In; 2008.

Appropriate approach to HIV testing of pregnant women

Universal HIV testing of pregnant women in the United States is the key to prevention of mother-to-child transmission (MTCT) of HIV. Repeat testing in the third trimester and rapid HIV testing at labor and delivery are additional strategies to further reduce the rate of perinatal HIV transmission. Prevention of MTCT of HIV is most effective when antiretroviral (ARV) drugs are received by the mother during her pregnancy and continued through delivery and then administered to the infant after birth. ARV drugs are effective in reducing the risk of MTCT of HIV even when prophylaxis is started for the infant soon after birth. New rapid testing methods allow identification of HIV-infected women or HIV-exposed infants in 20 to 60 minutes. The American Academy of Pediatrics recommends documented, routine HIV testing for all pregnant women in the United States after notifying the patient that testing will be performed, unless the patient declines HIV testing (“opt-out” consent, or “right of refusal”). For women in labor with undocumented HIV infection status during the current pregnancy, immediate maternal HIV testing with opt-out consent, using a rapid HIV antibody test, is recommended. Positive HIV antibody screening test results should be confirmed with immunofluorescent antibody or Western blot assay. For women with a positive rapid HIV antibody test result, ARV prophylaxis should be administered promptly to the mother and newborn infant on the basis of the positive result of the rapid antibody test, without waiting for results of confirmatory HIV testing. If the confirmatory test result is negative, then prophylaxis should be discontinued. For a newborn infant whose mother’s HIV serostatus is unknown, the health care professional should perform rapid HIV antibody testing on the mother or on the newborn infant, with results reported to the health care professional not later than 12 hours after the infant’s birth. If the rapid HIV antibody test result is positive, ARV prophylaxis should be instituted as soon as possible after birth but certainly by 12 hours after delivery, pending completion of confirmatory HIV testing. The mother should be counseled not to breastfeed the infant. Assistance with immediate initiation of hand and pump expression to stimulate milk production should be offered to the mother, given the possibility that the confirmatory test result may be negative. If the confirmatory test result is negative, then prophylaxis should be stopped and breastfeeding may be initiated. If the confirmatory test result is positive, infants should receive ARV prophylaxis for 6 weeks after birth, and the mother should not breastfeed the infant.

Reference:

1. Perinatal HIV Guidelines Working G. Public Health Service Task Force Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States. Available at . Accessed 11/05/2007. 2007;2007:1-96.

Appropriate HIV testing of Adolescents and incorporation of HIV testing/sexual health into adolescent care.

In September 2006, the CDC published “Revised Recommendations for HIV testing in Adults, Adolescents and Pregnant Women in Health Care Settings” which recommends that HIV screening be routinely performed for all patients aged 13 to 64 years who are seen in health care settings. Written informed consent specific for HIV testing is no longer recommended, and prevention counseling for patients being tested for HIV is de-emphasized. The CDC is expanding public health campaigns to emphasize routine HIV testing, and encourage state legislators to reevaluate their HIV-related legislation in light of the new recommendations. Pediatricians who provide care to adolescents and young adults will have questions and concerns regarding the rationale for and the implementation of these new recommendations. Practitioners will need to be well-informed about the scientific basis for the new recommendations, and about new technologies and resources that are available to assist them in implementing the recommendations. Operational issues including informed consent, confidentiality, reimbursement, prevention education and linkage to care will also need to be addressed. This CME program is needed to review the rationale for policies that relate to HIV testing, risk assessment and prevention education so that pediatricians caring for adolescents in their practice will be aware of CDC guidelines.

Reference:

1. Centers for Disease C. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Morbidity & Mortality Weekly Report 2006;55:1-24.

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