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Referral and warning signs
When to refer
Refer ALL HIV-exposed and HIV-infected infants to appropriate HIV care/ART clinic for ongoing management, monitoring, and support. Refer immediately if infant develops signs of severe illness.
Red flags
- Any Newborn/Young Infant Danger Sign.
- Signs suggestive of severe opportunistic infection (e.g., PCP pneumonia).
- Severe malnutrition.
- Failure to thrive despite adequate feeding support.
Signs and symptoms
- Infant may be asymptomatic.
- Potential signs of HIV infection if transmission occurred (usually appear later): Failure to thrive, recurrent infections, lymphadenopathy, hepatosplenomegaly, developmental delay, oral thrush.
Risk factors
- Mother living with HIV.
- Lack of maternal ART during pregnancy/delivery/breastfeeding.
- High maternal viral load.
- Premature birth.
- Prolonged rupture of membranes.
- Mixed feeding (breast milk + other fluids/foods <6 months).
Diagnosis
Clinical assessment
Identify exposure based on maternal HIV status. Assess infant feeding method. Check if mother/infant received ARV prophylaxis.
Investigations
- Confirm Maternal HIV Status (rapid test if unknown/undocumented).
- Infant HIV Testing (Virological - DNA PCR):
- - At Birth (if high risk or mother untreated).
- - At 6 weeks of age (standard).
- - 6 weeks after complete cessation of breastfeeding.
- Infant HIV Antibody Test: NOT useful for diagnosis <18 months (maternal antibodies). Can indicate exposure.
- Maternal Viral Load (if known).
Diagnostic criteria
Classification based on maternal HIV status and infant virological test results: Confirmed HIV Infection: Positive virological test. HIV Exposed: Mother HIV positive AND infant virological test negative/pending OR Infant <18m with positive antibody test. HIV Infection Unlikely: Negative HIV test in mother or infant >18m.
Management
Non-pharmacological management
- Counsel mother on infant feeding options (exclusive breastfeeding recommended with maternal ART adherence OR safe replacement feeding if AFASS criteria met).
- Support maternal ART adherence.
- Counsel on safer sex practices.
- Advise on home care for the infant.
- Linkage to HIV care for mother and infant.
Pharmacological treatment
- ARV Prophylaxis for HIV-Exposed Infant (HEI):
- - Follow current National PMTCT Guidelines.
- - Typically involves daily Nevirapine (NVP) +/- Zidovudine (AZT) depending on maternal ART status/viral load and infant risk.
- - Duration depends on feeding method (e.g., 6 weeks if replacement feeding, potentially longer if breastfeeding).
- Cotrimoxazole Prophylaxis:
- - Start at 6 weeks of age for ALL HIV-exposed infants.
- - Continue until HIV infection definitively excluded after cessation of breastfeeding.
- - Dose: 120mg tablet - 1 tab OD (<6m), 2 tabs OD (6m-5y).
- Confirmed HIV Infection:
- - Initiate lifelong ART immediately (See HIV Chapter).
- - Continue Cotrimoxazole prophylaxis.
- - Provide comprehensive HIV care.
Monitoring
Regular follow-up visits as per national guidelines (e.g., 6 weeks, 14 weeks, then linked to ART clinic if positive or routine child care if negative). Monitor growth, development, feeding. Ensure adherence to prophylaxis/ART. Repeat HIV testing at appropriate intervals.
Complications
- HIV transmission to infant.
- Opportunistic infections.
- Failure to thrive.
- Developmental delay.
- Side effects of ARVs/Cotrimoxazole.
- Stigma and discrimination.
Prevention
- PMTCT Interventions:
- - Universal maternal HIV testing.
- - Maternal ART initiation and adherence.
- - Infant ARV prophylaxis.
- - Safer infant feeding practices.
- - Safer delivery practices.
Patient education
- Importance of maternal ART adherence.
- Infant ARV prophylaxis administration and duration.
- Infant feeding choices and safety.
- Cotrimoxazole prophylaxis importance and schedule.
- HIV testing schedule for the infant.
- Recognizing signs of illness in the infant.
- Importance of follow-up appointments at HIV clinic.
- Disclosure and partner testing support.
Uganda-specific notes
PMTCT program is key. Exclusive breastfeeding is generally recommended for HIV-exposed infants when mother is on effective ART. Infant DNA PCR testing available at reference labs, results can take time. Cotrimoxazole prophylaxis is vital. Ensure linkage to care.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.2.4
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3, Sections 3.1.4, 3.1.9.3 (HIV Testing/PMTCT)
- Consolidated Guidelines for Prevention and Treatment of HIV in Uganda, MOH
(Current National PMTCT/ART protocols)