Postnatal Prophylaxis and Infant Feeding

Also see Treatment of Pregnant Women with HIV or Women Considering Pregnancy

Evidence to guide practice in relation to postnatal prophylaxis (PNP) and feeding for infants at risk of HIV acquisition during pregnancy and during breastfeeding comes mainly from low and middle-income countries and is limited in settings with universal access to maternal ART, and regular viral load monitoring as well as alternative feeding options. Consequently, guidance and practices vary across Europe, and in other high-income settings. Some general principles are consistent across all settings

Complex antenatal and PNP cases should be discussed within an MDT or PVC. If not available locally referrals are welcome to an international PVC via the Guideline Team
In the context of vertical transmission, current evidence does not demonstrate that “undetectable = untransmissible”
Recommendations for PNP should be based on risk stratification. The most important factor is maternal HIV VL at the time of delivery. Other important factors determining the risk are duration of ART before or during pregnancy, and VL in the weeks leading up to delivery. Other risk factors for transmission include: mode of delivery, duration of rupture of membranes, prematurity, concomitant STIs, etc.
If an infant is considered very low risk for transmission, in most settings, single agent PNP (most commonly ZDV or NVP) for 2-6 weeks is recommended. In some countries, it is recommended that neonates fulfilling criteria for very low risk do not require PNP
For infants at higher risk of acquiring HIV, combination PNP is recommended (2 or 3 agents e.g. NVP/ZDV/3TC) for 4 weeks. Maternal treatment history and resistance test results, and the risk of transmitted resistance should be taken into account when deciding on optimal combination PNP components according to local / national guidelines
Prophylactic doses of ART for PNP are available which differ from standard treatment doses, some guidelines continue to use these prophylactic doses. However, standard treatment doses for PNP are now preferred, to reduce the risk of confusion and to simplify transition to treatment in infants diagnosed with HIV
For non-breastfed infants, PCR based infant testing should take place at birth, 2 weeks after stopping PNP and at 3 months of age. If high risk of transmission an additional PCR can be done within 2 weeks of life. HIV serology can be done at around 2 years of age to confirm loss of placentally transferred maternal antibodies
Principles of shared decision making should be followed when considering choices around infant feeding. Accessible, clear information relating to low but non-zero risk of transmission during breastfeeding should be provided to all pregnant women, ideally well before delivery
If specific criteria are met, including: optimal maternal ART adherence, suppressed VL, availability of regular MDT support, and VL monitoring, then the option of supported breastfeeding should be provided
In the majority of countries the usual PNP duration is recommended for breast fed infants. In some countries duration of PNP is extended for the duration of breastfeeding. Easy access to MDT support should be available throughout the period of supported breastfeeding, and especially during times of complications such as detectable maternal VL, mastitis or other intercurrent illness (mother or infant)
Regular (1-2 monthly) monitoring of maternal VL is recommended to rapidly identify maternal viral rebound. If maternal VL is detectable during breastfeeding, alternative feeding options should be used, breastfeeding should be interrupted or stopped, and post-exposure prophylaxis should be considered for the infant
If breastfeeding is stopped abruptly then cabergoline should be provided to suppress lactation (note that the recommended cabergoline prescription is different for inhibition of lactation at birth compared to cessation of established breastfeeding (for further details see here)
Infant PCR based HIV testing should take place regularly during breastfeeding and 2-4 weeks after cessation of breastfeeding with follow up PCR testing as per usual practice (e.g. 2-3 months after stopping breastfeeding)
The risk of HIV transmission during breastfeeding with an undetectable VL in maternal blood is very low, but not zero, and continues with longer duration of breastfeeding, so as short a duration of breastfeeding as possible should be encouraged
Exclusive breastfeeding is considered lowest risk, but in the context of suppressed maternal VL, occasional formula milk can be used (e.g. during periods of mastitis). Mixed feeding (i.e. breastfeeding and solids) especially in very young infants before 6 months of age potentially increases the risk of HIV transmission and should be avoided