HIV in Children


Dr. Ira Shah
Last Updated: 15th July 2015

Antiretroviral prophylaxis and breast feeding

It has been clearly shown that when antiretrovirals are taken through the
pregnancy and breastfeeding stage, there is a greatly reduced HIV infection rate of 2 percent. But there must be 100 percent adherence to taking the drugs correctly, otherwise there is a risk that the baby will become infected with HIV or resistant to the medication. There needs to be good support for mothers to help them adhere to an extended drug regimen as well as keeping to 6 months of exclusive breastfeeding. This approach offers new hope for mothers with HIV infection who cannot safely feed their babies with replacement. It will improve the chances of infants remaining healthy and free of HIV infection as breast milk provides optimal nutrition and protects against other fatal childhood diseases such as pneumonia and diarrhea. This led to recommendations by WHO in 2013 as follows:

World Health Organization Rapid Advise for Use of antiretrovirals for treating pregnant women and preventing HIV infection in infants. 2013:

In pregnant women with confirmed HIV serostatus, initiation of antiretroviral therapy is recommended irrespective of gestational age and continued throughout pregnancy, delivery and thereafter. Infant born to these women should receive daily nevirapine (NVP) or zidovudine (AZT) from birth until 4 to 6 weeks of age. These women can then deliver their babies vaginally and also breast feed their babies. A once-daily fixed-dose combination of TDF + 3TC (or FTC) + EFV is recommended as first-line ART in pregnant and breastfeeding women, including pregnant women in the first trimester of pregnancy and women of childbearing age.

US guidelines for recommended first line ART in pregnant women (2015): In general, the same regimens as recommended for treatment of non-pregnant adults should be used in pregnant women unless there are known adverse effects for women, fetuses or infants that outweigh benefits. Preferred two-NRTI backbone are:

  • ABC/3TC
  • TDF/FTC or 3TC
  • ZDV/3TC
  • The 3rd drug that is to be given can be a PI or an NNRTI. The preferred PI is ATV/r (once a day) or LPV/r (twice a day). The preferred NNRTI is EFV.

    HIV-2 and PPTCT:
    If the mother has HIV-2 virus infection, a regimen with two nucleoside reverse transcriptase inhibitors (NRTIs) and a boosted protease inhibitor (PI) currently is recommended for HIV-2-infected pregnant women who require treatment for their own health because they have significant clinical disease or CD4 counts < 500 cells/mm3. For women who do not require treatment for their own health (clinically no significant disease and CD4 count > 500 cells/mm3), the following approaches are recommended:

    1. A boosted PI-based regimen (two NRTIs plus ritonavir-boosted lopinavir) for prophylaxis, with the drugs stopped postpartum
    2. Zidovudine prophylaxis alone during pregnancy and intrapartum
    3. All infants should receive the standard 6-week AZT prophylaxis
    4. No breast feeding
    Dr. Ira Shah
    Incharge Pediatric HIV and TB Clinic, B.J.Wadia Hospital for Children, Mumbai, India Consultant in Pediatric Infectious Diseases, Nanavati Hospital, Mumbai, India.
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