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COMMENTARY |
National Perinatal HIV Consultation and Referral Service (Perinatal Hotline), National Clinicians' Consultation Center, University of California, San Francisco General Hospital, San Francisco, California
You are called by an obstetrical colleague to help with a difficult situation: a 28-year-old woman is in active labor with frequent strong contractions and 7-cm cervical dilatation. A rapid HIV test, performed 30 minutes ago, has just been reported as positive. The labor and delivery clinicians and the pharmacy are working frantically to obtain antiretroviral medicines for the woman, and they need your help with care of the soon-to-arrive infant.
Pediatricians will be encountering this type of challenging scenario more frequently during the next few years. Although mother-to-child transmission of HIV has declined dramatically in the last decade, perinatal HIV exposure remains a critically important problem. HIV continues to increase among women of childbearing age; however, many women remain unaware of their HIV status. Position statements from the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists1 as well as the Centers for Disease Control and Prevention2, 3 have strongly recommended universal HIV testing during pregnancy, both as a routine part of prenatal care and during labor and delivery. As HIV testing becomes standard, more pregnant women with positive HIV tests will be identified, which will require urgent interventions to prevent HIV transmission to the infant. These important changes are carrying many pediatricians into a somewhat unfamiliar realm: caring for newborns exposed to HIV.
The recent improvement in rapid HIV tests and their increased use in labor and delivery are giving clinicians a last-minute opportunity to prevent transmission to the infant.
The current generation of rapid HIV tests performs better than the standard enzyme-linked immunosorbent assay screening test, with sensitivities and specificities of >99%.4 Because of the low prevalence of HIV among pregnant women in the United States, a considerable number of false-positive tests will occur.5 These unavoidable false-positive tests can result in unnecessary anxiety and drug exposure. Nevertheless, all positive tests need to be considered true positives until confirmatory HIV testing can be performed, usually with standard enzyme-linked immunosorbent assay and Western blot tests.
A positive HIV test in a pregnant woman has immediate management implications. Aggressive treatment of the mother and infant has resulted in a decrease in transmission to 
1%.6 Even if the mother has not received previous HIV treatment, initiating antiretroviral therapy during labor has been shown to have a protective effect for the infant. The optimal mode of delivery can include vaginal delivery or cesarean section depending on multiple obstetrical and HIV factors.7 All hospitals should have intravenous zidovudine for the mother and zidovudine suspension for the newborn. The newborn will need to be treated with antiretroviral drugs within 8 to 12 hours after birth. Most infants require the basic regimen of zidovudine (Retrovir) suspension, 2 mg/kg per dose every 6 hours orally. However, certain situations present an increased risk of transmission and can require more complex drug regimens. These situations include prolonged rupture of membranes, a mother who has not received antiretroviral treatment during pregnancy, and mothers with known or suspected antiretroviral drug resistance. Such cases need expert consultation.
Breastfeeding, which doubles the risk of HIV transmission, is contraindicated for infants of HIV-infected mothers in all areas of the world in which women have access to clean water and formula.8
The infant will need a preliminary HIV test within 48 hours.9 Direct viral testing with a proviral DNA polymerase chain reaction test or RNA viral-load test is required (depending on laboratory availability). HIV-exposed infants can have detectable maternal antibodies until 18 months of age. Therefore, HIV antibody tests should not be ordered. A common clinical error is to send the newborn's blood for HIV antibody testing; the resulting positive test raises enormous unnecessary concerns. HIV can be ruled out confidently if repeat direct viral testing is negative at 1 and 4 months.
After discharge, exposed infants (most of whom will be uninfected) can be followed by a primary care provider in much the same way as any other infant. All standard immunizations should be given at normal intervals during the first year. Zidovudine should be continued for 6 weeks, when trimethoprim/sulfamethoxazole should be initiated for Pneumocystis carinii pneumonia prophylaxis until HIV is ruled out at 4 months. Because the pediatrician or family physician will have the most contact with the family, postpartum counseling and referral to social services are key components of primary care. Referral to HIV experts, especially those who are associated with a Pediatric AIDS Clinical Trials Group, can link both infected and uninfected infants to important clinical trials and to special social and other services.
The most important source of up-to-date information and guidance on perinatal HIV is the Public Health Service guidelines, available at: www.aidsinfo.nih.gov.guidelines. The time-sensitive nature of many of these clinical problems, however, can require immediate consultation. Our national perinatal HIV consultation and referral service (Perinatal Hotline: 1-888-448-8765), staffed by physicians and clinical pharmacists at the University of California, San Francisco General Hospital, is available 24 hours per day. This hotline provides free consultation to physicians, nurses, nurse practitioners, and other clinicians involved in perinatal care.
Prompt management of pregnant women and their HIV-exposed infants is critical for avoiding the devastating effects of unrecognized and untreated HIV in children. As HIV testing in pregnancy becomes routine, pediatricians will be called on more and more to exercise their essential role in helping to eliminate perinatal HIV in the United States.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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Address correspondence to Ronald H. Goldschmidt, MD, San Francisco General Hospital, San Francisco, CA 94110. E-mail: rgoldschmidt{at}nccc.ucsf.edu
Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
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REFERENCES |
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 TOP REFERENCES |
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This article has been cited by other articles:
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  R. Yogev and J. P. Harisiades Opportunities to Prevent HIV Transmission in Newborns Pediatrics, July 1, 2006; 118(1): 436 - 437. [Full Text] [PDF]
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