Pediatric HIV Infection

Posted by Graham McMahon • June 18th, 2010

Approximately 200,000 infants worldwide become infected with human immunodeficiency virus type 1 (HIV-1) annually through breast-feeding. In a  randomized trial by Chasela et al. involving 2369 mother–infant pairs in Malawi,  the use of either maternal antiretroviral therapy or infant nevirapine through the age of 6 months was found to significantly decrease the rate of maternal transmission of HIV-1 during breast-feeding.

The use of antiretroviral drugs during pregnancy, labor, and delivery effectively reduce intrauterine and intrapartum HIV transmission. However, without prophylaxis, an additional 9% of HIV-1-negative infants who are born to HIV-infected mothers will become infected after 18 months of breast-feeding.

Clinical Pearls

What feeding strategy is recommended by the World Health Organization (WHO)?

Although formula feeding decreases the risk of postnatal HIV transmission, it is associated with an increased rate of early death. Thus, exclusive breast-feeding is recommended by the WHO for HIV-infected women in resource-limited settings for the first 6 months of life.

What treatment is associated with the lowest frequency of HIV infection among infants of HIV-infected mothers who breast-feed?

Among infants who were HIV-free at 2 weeks, the estimated risk of HIV infection by 28 weeks was 5.7% in the control group (referent group), 2.9% in the maternal-antiretroviral group, and 1.7% in the infant-nevirapine group. Although not designed to compare intervention arms, there was a borderline (log rank P=0.07) indication that infant HIV-free survival may be greater when the infant received prophylaxis compared with the maternal-antiretroviral arm.

Morning Report Questions

Q: What are the advantages of treatment of an infant as compared to maternal treatment for the prevention of HIV infection during breast-feeding?

A: Infant nevirapine requires only a low-cost daily dose and is associated with manageable toxicity. Additionally, the potential for resistance is minimized, since a small proportion of infants receiving prophylaxis would become infected, and they are unlikely to transmit the virus. On the other hand, the maternal prophylaxis regimen may have advantages beyond simply protecting the infant, including maintaining maternal health. However, treatment interruption or poor adherence may increase the risk of developing resistant HIV strains and restrict the mother’s future treatment options. Additionally, maternal triple-drug prophylaxis is costly and requires laboratory monitoring. Resistance may also occur in infants who become infected while their mothers are on triple-drug prophylaxis.

Q: What are the characteristics of the nevirapine hypersensitivity syndrome in infants?

A: The nevirapine hypersensitivity syndrome in the infant consisted of rash usually with eosinophilia with or without fever.

Table 2. Estimates of the Cumulative Risk of HIV-1 Infection and a Composite of HIV-1 Infection or Death among Infants Who Were HIV-1-Negative at 2 Weeks.

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