General Principles of 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 exposed to HIV during pregnancy and during breastfeeding is mainly from low and middle-income countries and 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 at MDT/PVC. If not available locally referrals are welcome to the Penta paediatric virtual clinic via the Guideline Team
• 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 may also be taken in to account e.g. mode of delivery, duration of rupture of membranes, prematurity 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
• Prophylactic doses of ART for PNP are available which differ from standard treatment doses. Some guidelines continue to use these prophylactic doses, but there is a move in several guidelines to use standard treatment doses for PNP to reduce the risk of confusion, and to simplify moving on to treatment in infants who do turn out to be 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 at 2 weeks of age. HIV serology can be done at around 2 years of age to confirm loss of placentally transferred maternal antibody
• Current evidence does not yet demonstrate that “undetectable = untransmissible” in the context of vertical transmission
• 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 and availability of regular MDT support and VL monitoring, then the option of supported breastfeeding should be provided
• In some countries, infant pre-exposure prophylaxis is offered for the duration of supported breastfeeding. In others, only the usual post birth regimen is recommended
• During supported breastfeeding, easy access to MDT support should be available throughout 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 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. Decision making around post-exposure prophylaxis should take in to account the time since most recent potential exposure
• If breastfeeding is stopped abruptly then cabergoline should be provided to help suppress lactation (note that the recommended cabergoline prescription is different for inhibition of lactation at birth compared to cessation of established breastfeeding)
• 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. 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 and so as short a duration of breastfeeding as possible should be encouraged with an aim to wean around 6 months of age
• Exclusive breastfeeding is considered lowest risk and 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