Dr. Ira Shah
M.D, DNB, DCH(Gold Medalist), FCPS

Vertical transmission of HIV is the predominant mode of transmission of HIV in children and thus prevention of vertical transmission will significantly decrease the incidence of HIV in children. Several trials have recommended several protocols but the goal of therapy should be 100% prevention. However due to resource constraints, the ideal treatment may not be the best for all situations. Hence, these guidelines have been developed to determine and establish what is best in each situation.

- Avoiding pregnancy
- Medical termination of pregnancy
- Antiretroviral drugs in mother to prevent intrauterine & during labour transmission
- Avoiding vaginal delivery
- No breast feeding to prevent breast milk transmission
- ARV in the baby as post-exposure prophylaxis

Resource restricted setting
- Single dose Nevirapine (200 mg) to mother at time of labour
- Single dose NVP (2 mg/kg) to baby within 72 hours of birth
- Normal vaginal delivery
- Continue breast feeding

Transmission risk decreases to 14%.

Diagnosis: - Presumptive diagnosis in form of clinical symptoms and a positive HIV ELISA test
Confirmatory diagnosis – HIV ELISA at 18 months of age.

Prophylaxis – Cotrimoxazole (5 mg/kg/day) OD from 1 month of life.


Resource limited settings
- Zidovudine (AZT) to mother (300 mg BD) from 32 weeks of gestation
                        +
  Single dose Nevirapine (NVP) (200 mg) to mother at time of labour followed by AZT (300 mg BD)   and Lamivudine (3TC – 150 mg BD) for one week after delivery (to prevent NVP resistance as NVP   has a long half life)
- AZT (2 mg/kg/dose qds) to baby for 4 weeks from birth
  Single dose Nevirapine (2 mg/kg) to baby within 72 hours of birth
- No breast feeding.

Transmission risk decreases to < 5%.

Diagnosis: - Provisional diagnosis can be established by doing HIV DNA PCR only if clinical suspicion in a symptomatic child.
Confirmatory diagnosis – HIV ELISA at 18 months of age.

Prophylaxis – Cotrimoxazole (5 mg/kg/day) OD from 1 month of life till proven to be negative. If child is positive, should be continued if child is symptomatic.

Resourceful setting
-  Monitor mother’s HIV viral load and CD4 cell count.
-  If mother’s CD4 count is less than 350 cells/cumm and viral load is more than 1000 copies/ml then    triple drug ART (avoid efavirenz) should be given. Preferably the schedule should be 2 NRT1 + 1 PI.
-  If mother’s CD4 cell count is more than 350 cells/cumm and she is asymptomatic,
       AZT (300 mg bd) from 32 weeks gestation
                        +
   Single dose NVP (200 mg) at time of labour should be given followed by AZT (300 mg BD) and    Lamivudine (3TC – 150 mg BD) for one week after delivery (to prevent NVP resistance as NVP has    a long half life)
- Delivery – Elective LSCS if mother has is symptomatic for HIV, or has CD4 count < 350    cells/cumm or viral load more than 1000 copies/ml. Vaginal delivery if viral load is less than 1000    copies/ml and CD4 count is above 350 cells/cumm.
-  Baby – AZT (2 mg/kg/dose qds) for 4 weeks from birth.
-  No breast feeding.

Transmission risk decreases to < 2%.

Diagnosis –HIV DNA PCR at 6 weeks of life.
Confirmatory diagnosis: - Repeat HIV DNA PCR as early as possible. If both PCR negative, it is suggestive of no infection. If PCR is positive, one should do HIV viral load to determine course regarding ART and confirm the HIV disease by ELISA at 18 months.

Prophylaxis: - If first HIV DNA PCR is positive, Cotrimoxazole (5 mg/kg/day) OD till proven to be negative. If HIV DNA PCR is negative, no prophylaxis is required.

Should receive all vaccines including BCG, OPV. In an HIV infected child, Measles vaccine should be based on CD4 count. Measles and MMR vaccine should be given if CD4 percent is more than 25%. If the serostatus of the child is not known, measles and MMR may be given if child is clinically asymptomatic and has good immunity.