Dip Obs

1. HIV IN PREGNANCY
Themba Hospital DipObs Tutorials
By Dr N.E Manana

2. PMTCT IN ANTENATAL CARE
• Overview of the 2019 PMTCT Guidelines.
• Prevention of mother-to-child transmission (PMTCT) is part of an expanded package of care for the mother-infant pair and their family.
• For more in-depth information, consult the full guideline.
• Ensure that any guideline updates are available in your clinic and that any guideline changes are disseminated to all staff, and are rapidly
implemented.
There are four elements to PMTCT care:
• Primary prevention of HIV, especially among women of childbearing age
• Preventing unintended pregnancies and safe conception among women living with HIV
• Preventing HIV transmission from a woman living with HIV to her infant
• Providing appropriate treatment, care, and support to women living with HIV and their children and families
• The full guidelines are available from:
• https://www.knowledgehub.org.za/system/files/elibdownloads/201910/PMTCT%20Guideline%
2028%20October%20signed.pdf

3. PMTCT in antenatal care aims
• Identify all women who are HIV positive, including those who
seroconvert during pregnancy.
• Provide antiretroviral therapy (ART) on the same day that her HIV
positive status becomes known, to optimise maternal health and to
prevent mother to child transmission of HIV.
• Ensure HIV positive pregnant and breastfeeding women are virologically
suppressed on ART

4. HIV COUNSELLING AND TESTING
• All pregnant women should be encouraged to book for antenatal care early
• HIV testing services (HTS) should be offered to all pregnant and breastfeeding women with
unknown HIV status or those who tested negative three or more months previously.
• HTS should be offered at the first antenatal visit, and if HIV negative, at each routine BANC plus
visit
• All women should be given routine information about HIV testing and the PMTCT programme.
• A rapid test should be performed on a finger prick sample of blood. If the test is positive, a
second rapid HIV test using a test kit from a different supplier should be performed on a
second finger prick sample. If both tests are positive, the woman is confirmed HIV positive.
• If the first rapid test is positive, and the second rapid test is negative, then the testing
algorithm should be repeated. If the results are again discrepant, a laboratory ELISA test
should be performed.
• The healthcare provider should explain the reason for the laboratory test, and the woman
should be asked to return for the ELISA results. Results should be obtained within a week.
• Post-test counselling should be offered to both HIV positive and HIV negative women
• Women who opt-out of HIV testing should have individual ‘post refusal’ counselling where
risks of MTCT to the unborn baby should be highlighted.

6. Women who test negative
• All pregnant women are part of the PMTCT programme, whether they test positive or
negative
• Seroconversion in pregnancy or while breastfeeding has a high risk of vertical transmission,
due to a high maternal viral load and the absence of infant prophylaxis.
• In South Africa, 4% of women who were initially HIV-negative become positive later in
pregnancy.
• All pregnant women (HIV+ or not) should be encouraged to use condoms to prevent
seroconversion during pregnancy
• Partner involvement is important to promote condom use throughout pregnancy, the
breastfeeding period and thereafter.
• All pregnant women who test HIV-negative are to be offered repeat HIV testing at:
• Each routine BANC plus visit
• In early labour or immediately following delivery
• At the ten-week EPI visit
• Every three months throughout the breastfeeding period.

7. Women who test positive for HIV
All persons living with HIV, including HIV-positive pregnant and
breastfeeding women, are eligible for lifelong ART, irrespective of:
• CD4 count,
• Clinical stage
• Gestation
• Feeding choice.
• Timing of ART initiation in pregnancy is critical.
• ART should be initiated on the same day as her HIV status becomes
known unless contraindications exist.

8. ANTENATAL MANAGEMENT
• Initial assessment at first ANC visit
The following should be done for all HIV positive women:
• Routine booking investigations: haemoglobin (Hb), rhesus status, syphilis
• Symptom screening for tuberculosis (TB) and TB GeneXpert (GXP), and eligibility
assessment for TB preventative therapy (TPT)
• Clinical screening for sexually transmitted infections (STIs)
• Screening for active psychiatric illness or risk of mental health problems
• Women with HIV have higher rates of mental illness during pregnancy and poor
mental health is associated with negative pregnancy outcomes.
• Mental illness or psychological distress is a leading cause of difficulties with ART
adherence
• Women with HIV are more likely to experience domestic violence. Domestic violence
is linked to poor ART and maternity care adherence and poor obstetric outcomes

9. ANTENATAL MANAGEMENT
• Clinical and laboratory screening for renal disease, including serum creatinine
• Initiate/continue lifelong antiretroviral treatment as detailed below
• All newly diagnosed HIV-positive pregnant women are eligible for lifelong ART.
• Creatinine and CD4 count should still be done to determine renal function and the need for
prophylaxis (TB, PCP and CM).
• Tenofovir (TDF), lamivudine (3TC), and dolutegravir (DTG) is the preferred regimen for women
who are newly initiating ART from seven completed weeks of gestation onwards.
• However, each mother should understand the risks and benefits of DTG and EFV-based regimens.
• ART should be initiated on the same day as her HIV status becomes known, and after contra-
indications to ART have been excluded
• Pregnant women already on ART should continue their current ART regimen pending the result of
their 1st viral load (VL).
• Only if her VL is <50 c/ml, and she is no longer in the 1st six weeks, offer her the option of
switching to DTG.
• If her VL is ≥ 50 c/ml, manage her as per the VL Non-suppression algorithm .

10. ANTENATAL MANAGEMENT
• A switch to DTG needs to be preceded by appropriate counselling on the risk
for neural tube defects (NTDs) for subsequent pregnancies, postpartum
contraception, and the new side-effects that may be experienced when
switching to a different drug.
• Known HIV positive women, who are not currently on ART, but are ART-
exposed should initiate a DTG-containing regimen.
• If she has a documented VL that was suppressed while she was previously on
ART, start TLD.
• If no VL result is available, or her VL was not suppressed, start AZT, 3TC, and
DTG.
• Appropriate ART literacy education should be given to the woman before she
leaves the facility.
• All women living with HIV should be referred to a CHW to support adherence,
breastfeeding and retention in care pre- and post-delivery.

12. Initiation of ART for HIV positive pregnant or
breastfeeding women
• All HIV positive women at any time in pregnancy or breastfeeding, or known to be HIV
positive but not yet on treatment, should be initiated on ART
Determine if it is safe to start ART, as well as which ART regimen is suitable, by taking a
history and doing a clinical examination:
• Ask about TB symptoms, a history of renal disease, or current psychiatric symptoms.
• Determine the client’s WHO Clinical Stage.
Do the following tests on ALL HIV positive pregnant women, regardless of symptoms or
history:
• CD4 count
• s-Creatinine
• sputum for TB GXP, and
• urine dipstix

13. Contraindications to starting ART
• Contraindications to starting ART on the same day are TB symptoms with danger signs, or other signs
of severe disease, e.g. cryptococcal meningitis or pneumocystis pneumonia.
• If a woman is unwell with TB or other symptoms, refer for further assessment as a matter of urgency.
• If TB is suspected, do not start ART until TB is excluded/diagnosed, as these women may be at a
higher risk of developing IRIS.
• Do not start AZT monotherapy in situations where triple therapy ART is contra-indicated.
• AZT monotherapy has been associated with an increased risk of IRIS
• Remember that a negative TB GXP test in the presence of TB symptoms does not exclude TB!
• A thorough investigation for TB is essential for any women with TB symptoms, and extra-pulmonary
TB must be excluded. Investigate with a chest x-ray, a 2nd sputum for culture/line probe assay (LPA),
provide antibiotics as per National TB Guidelines, and any other investigations as indicated. If CD4
<100, do a urine LAM.
• If TB is diagnosed, first initiate TB treatment. Review in 2 weeks. If stable and tolerating TB
treatment, initiate ART.
• Remember that DTG requires boosting with TB treatment to 50 mg twice daily.

14. Reasons to initiate ART with an alternative
ART regimen
• Renal disease is not necessarily a contraindication to starting ART but may influence
which drugs are used in the ART regimen.
• TDF is contraindicated if the woman has a history of/suspected renal disease.
• Replace TDF with ABC until serum creatinine results can be reviewed.
• The woman must return within seven days for serum creatinine and CD4 results.
• Women who have creatinine levels > 85µmol/L and potential renal disease have high-
risk pregnancies; they need urgent referral to investigate the underlying cause and
will need ongoing antenatal care and delivery at a referral unit.
• These women will need alternative triple therapy (ABC, 3TC, DTG), with dose
adjustment of 3TC if necessary.
• Active psychiatric disease is only a contra-indication to starting EFV-containing ART.
• The majority of these women should be starting a DTG-containing regimen. If,
however, DTG is unsuitable, an alternative regimen containing atazanavir/ritonavir or
lopinavir/ritonavir should be considered

15. Routine ART initiation in the absence of
contraindications
• In the absence of any abnormalities on history taking or clinical examination, or in the
presence of mild TB symptoms in an otherwise well woman, ART can be initiated.
• For all women from the 7th week of pregnancy onwards, tenofovir, lamivudine and
dolutegravir (TLD) is the preferred regimen,
• The woman must return within seven days for her TB GXP, serum creatinine and CD4
results.
• If CD4 < 200 cells/mm3 start cotrimoxazole prophylaxis therapy (CPT). CPT is also
necessary for women with WHO stages two, three or four disease, or active TB.
• If CD4 < 100 cells/mm3, screen for cryptococcal disease. Send blood for serum
cryptococcal latex antigen test;
• If CD4 < 350 cells/mm3 and the client is tolerating ART, initiate TPT for 12 months.
Ensure that active TB has been excluded, and check for other contra-indications to TPT.
No tuberculin skin test is necessary

17. VL Monitoring schedule during pregnancy
and breastfeeding
• Newly diagnosed and initiated ART for the first time:
• Do 1st VL at 3 months on ART. If VL < 50 c/ml, repeat VL at delivery. Known HIV-positive
women already on ART: VL at first/booking visit in ANC, If VL < 50 c/ml, repeat VL at delivery.
• Known HIV-positive women, who are not currently on ART, but are ART exposed (e.g. previous
PMTCT, or ART LTFU) and who are initiating a DTG-containing regimen: Do 1st VL at 3 months
on ART. If VL < 50 c/ml, repeat VL at delivery.
• (If a women who is previously ART exposed chooses to re-initiate EFV rather than DTG, do a
VL before re-starting ART. Repeat the VL in one month. If more than one log drop in VL is
achieved, continue her current EFV-containing regimen and repeat VL in two months. If VL <
50 c/ml, repeat VL at delivery.
• If the repeat VL is ≥ 50 c/ml, manage according to the VL non-suppression algorithm
• Late presenter in ANC after 28 weeks, or at delivery Do 1st VL at delivery
• Do VL at 10-12 weeks post delivery (aligned with 10-week well child visit).
• If VL < 50 c/ml, repeat VL at 6 months after delivery (aligned with 6 month well child visit).
• VL monitoring should continue 6-monthly during breastfeeding If the VL is ≥ 50 c/ml

18. Important points on taking a VL and following
up
• Remember to insert the laboratory barcode sticker and record all VL, TB, and syphilis.
• VL done to ensure the electronic gatekeeping rules (EGK) do not lead to sample
rejection.
• Use the code C#PMTCT for all VLs done during ANC or the breastfeeding period.
• Use the code C#Delivery for all VLs done at the time of delivery.
• Ensure that the results of any VL test are checked within one week.
• If VL ≥ 50c/ml:
• Recall the mother-infant pair to the facility. Manage the mother according to the VL
non-suppression algorithm
• If the VL is ≥ 1000 c/ml, restart / extend infant prophylaxis if the mother is still
breastfeeding.
• If in doubt about when to take, or how to interpret, a VL result, call the HIV hotline
0800 212 506

20. Other laboratory monitoring for women on
ART
Women on TDF containing regimens (including the fixed-dose combination of TDF, 3TC
and DTG (TLD):
• Serum creatinine at three months, six months,12 months and every 12 months.
• If there is any evidence of renal impairment, refer the patient for investigation of the
cause, and to change from tenofovir to alternative ART, with dose adjustment if
necessary (most commonly this would be to ABC/3TC/DTG.
Women on zidovudine (AZT) containing regimens:
• Hb at three months and six months and every 12 months
Women on a protease inhibitor (PI) -based regimen (lopinavir/ritonavir [LPV/r],
atazanavir/ritonavir [ATV/r], darunavir/ritonavir [DRV/r]):
• Total cholesterol and triglycerides (TGs) at month 3
• If above acceptable range, do fasting cholesterol and TGs and if still above acceptable
range, obtain expert advice

21. Eligibility for switching to second-line
treatment
• Eligibility for second-line ART will be determined by the client’s VL, the current
regimen they are failing, and the time they have been on ART.
For women on an NNRTI-based regimen (EFV/NVP):
• Consider switching to second-line if virological failure confirmed, i.e. VL ≥ 1000
c/mL on two consecutive occasions and adherence issues addressed
For women on an InSTI (DTG) or PI-based regimen:
• • Consider switching to second-line if virological failure confirmed, i.e. VL ≥
1000 c/mL on at least three occasions over two years, or VL ≥ 1000 c/mL with
signs of immunological or clinical failure (i.e. declining CD4 and/or
opportunistic infections).
• Due to their high genetic barrier, resistance to DTG and PIs develops very slowly
• An elevated VL on DTG or LPV/r is, therefore, more likely to be related to
suboptimal adherence. .

22. Important points regarding switching to a
second-line ART regimen
• Any woman who requires a switch to second-line ART must have intensive
adherence counselling to ensure a high level of adherence and rapid viral
load suppression.
• Note that atazanavir/ritonavir cannot be given with rifampicin. If the
patient is on TB treatment, consult with a specialist.
• HBsAg must be checked before stopping tenofovir: if positive, stopping
tenofovir may lead to a fatal hepatitis B flare.
• Tenofovir should be continued as a 4th drug in the regimen.
• Women who fail to suppress despite switching to second-line, or who are
failing 2nd or 3rd line should be discussed with an expert/HIV hotline or
referred.

24. LABOUR AND DELIVERY
Primary Objective of PMTCT in labour and delivery:
• Conduct a safe delivery for the mother and infant
• Prevent MTCT during labour
• Provide respectful, compassionate care that takes into account that the
woman may be experiencing psychological distress.
• Maintain full confidentiality.
• Women previously testing HIV negative, women of unknown status :
• Offer an HIV test in labour if in the first stage (regardless when it was last
done), or after delivery if in the second stage.
• If a woman has indeterminate or discrepant HIV test results, treat the baby
as a high-risk HIV-exposed infant until the mother’s HIV status can be
confirmed.

25. LABOUR AND DELIVERY
HIV positive women on ART:
• Ensure that the regimen and duration of treatment is documented
• Pregnant women already on ART should continue their current ART regimen at usual
dosing times during labour. No additional treatment is necessary.
Check if the mother has had a VL result in the last 12 weeks and categorise the risk for
the infant:
• VL < 1000c/ml = Low risk
• VL ≥ 1000 c/ml = High risk
• No VL result in the last 12 weeks = High risk
• All women must have a VL test done at the time of delivery.
• Although this VL result will mostly still be unknown when infant prophylaxis is
initiated.
• The results of the delivery VL must be checked at the 3-6-day postnatal visit, and the
management of the mother-infant pair adjusted accordingly.

26. LABOUR AND DELIVERY
HIV positive women not on ART and newly diagnosed HIV positive women:
• These women may be at greater risk of having psychological and social difficulties,
(including experiencing violence and trauma) and need compassionate care.
• Give a stat single fixed-dose combination tablet of TDF, 3TC and DTG (TLD) and a single
stat dose of NVP 200mg.
• Lifelong ART should be initiated the following day after contra-indications to ART have
been excluded
• TLD is the preferred regimen, provided the mother has been provided with all necessary
information on DTG and EFV-based regimens.
• A contraceptive method is recommended. Provide her with a choice of contraceptive
options as desired.
• Request a CD4 count and serum creatinine. Ensure the CD4 and creatinine results are
available at the three to six-day postnatal visit.
• Appropriate ART literacy education should be given to the women before she leaves the
facility.

27. MANAGEMENT OF LABOUR
Safer delivery techniques for vaginal delivery:
• Mother to child transmission is increased in the following situations, which should, therefore, be avoided.
• Artificial rupture of membranes (AROM) as a means of augmenting labour unless there is a specific obstetric
indication.
• Prolonged rupture of membranes. The duration of ruptured membranes prior to delivery should be as short as
possible (ideally 4 hours or less).
• Instrumental delivery.
• Invasive monitoring procedures, e.g. foetal blood sampling and episiotomy.
• Following delivery, suctioning of the airway (trachea) of the neonate should only be performed if there is
meconium stained liquor and the baby needs resuscitation. If so, a laryngoscope must be used to allow
suctioning under direct vision, before mask ventilation is commenced.
• If there is no skilled attendant who can perform laryngoscopy, proceed directly to mask ventilation. For neonates
born with meconium-stained liquor but who are vigorous at birth, secretions can be wiped away, with gentle
suctioning of the nose and mouth only if needed.
• Prophylactic antibiotics are not required for HIV positive women who have normal deliveries.
• Augment labour if not in spontaneous labour after four hours
• Prophylactic antibiotics as for all women with pre-labour rupture of membranes

28. MANAGEMENT OF LABOUR
Caesarean delivery
• Caesarean delivery in HIV positive women is performed for the same obstetric indications as in HIV negative women.
• If she is not yet on ART, ensure that she has received her stat single fixed-dose combination tablet of TDF, 3TC and DTG (TLD) and a single stat dose of NVP
200mg prior to the procedure
Surgical Prophylaxis for Caesarean Delivery (CD):
• Provide antibiotic prophylaxis to all pregnant women, including HIV-infected pregnant women before surgery.
• Since HIV positive patients are immunocompromised and at increased risk of post-surgical wound infections, prophylactic antibiotics are given for both elective
and emergency caesarean delivery.
• In most instances, a single antibiotic dose before the procedure is sufficient for prophylaxis.
• Cefazolin and azithromycin should be administered together as a stat dose, as recommended by the essential medicines list (2019) for prophylaxis before
caesarean delivery. Recommended dosages are as follows:
• Cefazolin, IV stat. <60 kg: 1 g, 60–100 kg: 2 g, >100 kg: 3 g
• PLUS Azithromycin 500 mg IV stat
Postoperative prophylactic antimicrobial administration is not recommended for most surgeries as this selects for antimicrobial resistance.
However, women living with HIV who have the following risk factors may be at higher risk of infection post caesarean delivery:
• Advanced immunosuppression.
• Prolonged rupture of membranes (>18 hours).
• Multiple vaginal examinations during labour (>5 PVs).
• Second stage CD.
• These women should be monitored carefully and have any infection treated appropriately.

29. POSTPARTUM CARE
Primary objectives of PMTCT in labour and delivery
• Prevent MTCT breastmilk transmission
• Retain mother in care and maintain viral suppression
• Care applicable to all women before discharge from labour ward
• All Infants born should receive skin-to-skin contact with their mothers, regardless of the mother’s HIV
status within 1 hour after delivery.
• All infants should start feeding within one hour after delivery.
• Remember psychological distress and experiences of trauma can interfere with initiation and
maintenance of breastfeeding
• At discharge, ensure contraception has been administered after appropriate counselling.
• Re-emphasise the need for the consistent and correct use of condoms as part of dual contraception,
• Women who previously tested HIV negative, and women of unknown status, Retest the HIV-negative
mother if she was not retested in labour
• Retest every HIV-negative mother at the 10-week visit (~ three months postpartum), the six-month
visit, and every three months while breastfeeding.

30. Women living with HIV
• At discharge from the labour ward, provide the mother with a two-months supply of ART and six-weeks supply of
infant prophylaxis.
• Re-emphasise the need for infant prophylaxis and consistent maternal ART adherence to maintain viral suppression
and prevent vertical HIV transmission during the breastfeeding period.
• Communicate follow-up appointment dates for the six-day postnatal visit and again at six weeks at a named facility.
• Provide necessary referral letters. Provide an ART transfer-out letter if she will receive her ART at a different facility.
• However, it is recommended that the mother-baby pair continue to receive integrated care within the maternal
and child health stream until the baby is two years old or no longer breastfeeding.
• If the woman has presented “unbooked” in labour and has not yet initiated CPT, initiate CPT before discharge if
CD4 count ≤ 200 cells/mm3, or WHO clinical stage 2, 3, or 4.
• Exclusive breastfeeding, South Africa actively promotes, protects and supports exclusive breastfeeding.
• All HIV positive women should be encouraged to exclusively breastfeed for six months, with appropriate
complementary food being introduced from six months and to continue breastfeeding for up to 12 months.
• The risks of mixed feeding within the first six months must be discussed).
• A breastfeeding infant of a mother with a new HIV diagnosis or an elevated VL should be considered as “high-risk”.
Given that breastfeeding should be promoted and protected to continue as long as possible, high-risk prophylaxis
during breastfeeding allows the infant to be protected.
• At the same time, every effort should be made to re-suppress the breastfeeding mother’s VL.
• Infants of mothers failing second or third-line ART (VL > 1000 copies/ml) should not be breastfed, and formula
feeds provided.
• If she is newly diagnosed during the breastfeeding period, initiate ART

31. Management of the HIV-exposed infant at
birth
• All HIV-exposed Infants should receive a birth HIV-PCR to identify HIV transmission that occurred in-utero.
• All HIV-exposed Infants should receive a minimum of six weeks post-exposure prophylaxis with NVP.
• Identify the high-risk infants for whom additional prophylaxis must be provided:
• Mother with a VL of ≥ 1000 c/ml at delivery (or most recent VL taken during the last 12 weeks of antenatal
care), or Mother with no VL results in the last 12 weeks.
• These infants should be provided with high-risk prophylaxis until the result of the delivery-VL can be checked
at the 3-6-day postnatal visit.
• When the delivery-VL result is known, the infant can be re-classified as high/ low-risk and prophylaxis
adjusted accordingly.
• All high-risk infants who are breastfed should receive additional AZT for the first six weeks of life and should
receive NVP for a minimum of 12 weeks.
• NVP should only be stopped when the breastfeeding mother has a VL of less than 1000 c/ml, or until four
weeks after she has stopped breastfeeding.
• All high-risk infants who are exclusively formula-fed should receive AZT for six weeks and NVP for six weeks.

33. General follow-up care in the period after
birth
• It is critical to know the VL of a breastfeeding mother living with HIV,
• It is recommended that the mother-baby pair continue to receive integrated care
within the maternal and child health stream until the baby is two years old or no
longer breastfeeding.
At all visits up to 24 months after birth, and longer if indicated:
• Screen for TB at every follow-up visit, provide TPT if eligible, and CTMX according
to guidelines
• Screen for postpartum depression and anxiety
• Provide contraception and STI screening
• Provide infant feeding counselling and support according to the Infant and Young
Child Feeding Policy
• Counsel on the safe use of water, sanitation and hygiene (WASH)
• A pap smear can be done from six weeks onwards

34. HIV related care at the 3-6 day postpartum
visit
• Check the mother’s ART adherence.
Check the result of the delivery-VL. (If not yet available, follow-up again in 1 week. If VL
not done at delivery, do VL at this visit).
If necessary, re-classify infant as high/ low-risk and adjust prophylaxis accordingly.
• If VL ≥ 50 c/ml: manage mother as per VL Non-suppression Algorithm
• If VL ≥ 1000 c/ml: manage infant as a high-risk infant, i.e. add AZT for six weeks, and
extend NVP until mother’s VL is <1000 c/ml.
• Check adherence/tolerance to NVP (and AZT, if applicable).
• Ask the mother to explain how she administers the infant’s medication.
• Follow-up results of birth PCR and manage accordingly.
• Any HIV positive neonate should be discussed/referred to a clinician experienced in
managing an HIV-positive neonate.
• ART should be initiated even if the infant weighs less than 2,5 kg

35. HIV related care at the 6-week postpartum
visit
• Check the mother’s ART adherence.
• Ensure that birth PCR and mother’s VL results were checked
• Repeat VL if delivery-VL was ≥ 1000 c/ml.
• Check mother’s ART supply and confirm where she will be receiving her
ongoing ART care
• For low-risk infants: stop NVP if mother’s VL at delivery was <1000 c/ml.
• For high-risk infants: stop AZT, continue NVP for a minimum of 12 weeks, or
until four weeks after all breastfeeding has stopped.
• Remember to adjust NVP dosages according to weight and age.
• All HEI’s: start cotrimoxazole prophylaxis therapy (CPT), even if birth PCR was
negative.

36. Stopping infant prophylaxis
• Stop NVP after 12 weeks only if the mother’s VL is < 1000 c/ml.
• If the maternal VL is not suppressed by 12 weeks, continued NVP until
mother’s VL is <1000 c/ml, or until four weeks after all breastfeeding has
stopped.
• Continue cotrimoxazole prophylaxis until the infant is confirmed HIV
negative six weeks post-cessation of breastfeeding.
• For formula-fed infants, CPT may be stopped if the infant is confirmed to
be HIV negative at the 10-weeks PCR test.
• If a child tests HIV positive at any stage, stop NVP prophylaxis, initiate
ART, do a confirmatory HIV PCR, and continue CPT according to
guidelines

37. Timing and type of HIV test
HIV-exposed
infants
HIV-unexposed
infants
HIV PCR test at birth X
HIV PCR test at age 10 weeks X
HIV PCR test at age 6 months (offer HIV testing for documented HIV
negative mothers or mothers with unknown HIV status)
X
Age-appropriate HIV test at 6 weeks post-cessation of breastfeeding X
HIV antibody test at age 18 months (rapid test) (universal testing) X X
Age-appropriate HIV test anytime the child is unwell X X
If any HIV test is positive, the diagnosis is confirmed with a repeat HIV test
(see guidelines below in Table 6), and ART is initiated immediately
X X

39. The child who tests positive for HIV
• Any child under two years with a positive HIV-PCR or a positive HIV rapid test should have
their HIV status confirmed with an HIV-PCR test on a new sample.
At the clinician’s discretion, the HIV-PCR may be replaced by a viral load test which has the
advantage of both confirming the HIV diagnosis and providing a baseline VL for monitoring the
child’s response to ART.
Any child who tests HIV positive should initiate ART according to the Paediatric ART guideline as
a matter of urgency.
Do not wait for the confirmatory result before initiating ART but ensure that this result is
checked.
For any child that tests HIV-positive ensure that:
• Confirmatory testing has been done
• The child is tracked and linked to care
• The mother and other significant caregivers are counselled appropriately
• CHWs are involved
• The child is registered on Tier.net & retained in care

40. Infants of mothers of unknown status
Including orphans and abandoned infants:
• Abandoned infants with unknown HIV exposure should be treated as a high-
risk, HIV-exposed infant.
• Perform an HIV-PCR and HIV rapid test.
• Provide high-risk infant prophylaxis: start NVP once daily for 6 weeks and AZT
twice daily for 6 weeks.
• If the PCR is negative, complete the 6 weeks of prophylaxis.
• Repeat the HIV-PCR at 10 weeks of age or 4 weeks after stopping NVP.
• If the second PCR is negative, provide further routine management as for an
HIV-exposed and uninfected child.
• If either PCR is positive, discontinue prophylaxis, initiate ART and confirm the
results with a second HIV PCR or VL.

41. Thank You