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Page 5 of 8 Guideline

the care required for the infant, breastfeeding mothers who approach to maternal management, infant prophylaxis, and
are not receiving integrated care as a mother-infant pair and recommendations for possible breastfeeding cessation and
who are receiving care at a separate ART clinic face a the prescription of infant formula.
significant challenge. General ART services have, to date, not
effectively identified breastfeeding mothers, nor monitored Infant post-exposure prophylaxis to be
their VLs at six-monthly intervals. If breastfeeding is to be provided at birth
protected by providing enhanced infant antiretroviral The delivery VL will determine the infant’s HIV transmission
prophylaxis in mothers who have detectable VLs, much will risk category. However, many mother-infant pairs will be
need to be done to improve the identification of breastfeeding discharged after birth but before the delivery VL results are
mothers and their infants, VL monitoring, and communication available. Then the most recently available VL result, that is,
with providers caring for their infants.
within the last 12 weeks, will determine the infant’s risk
category prior to discharge at birth. The laboratory barcode
Clinical interventions alone will not improve postpartum sticker or similar indicator of the delivery VL, clearly labelled
viral suppression. Health workers, supported by community ‘maternal’ to distinguish it from the infant’s HIV PCR
engagement and media campaigns, should empower barcode sticker, should be placed in the infant’s patient
mothers with knowledge regarding the importance of records, together with the Road-to-Health Booklet, to ensure
continued viral suppression for both maternal and child access to both maternal and infant birth-PCR results at the
health benefits. Women need to be equipped to anticipate 3–6-day postnatal visit. Adjustments can then also be made
adherence challenges in the postpartum period, including to the infant prophylaxis regimen, as appropriate.
disrupted routines, sleep deprivation, and postnatal
depression. Linkages to available resources should occur, for • Low-risk infants, namely infants born to mothers with a
example community health workers, mentor mothers, suppressed VL within the last 12 weeks of delivery, or at
MomConnect, or other support groups and clubs. delivery, should receive NVP daily for six weeks.
A concerted effort should be made by all in the care team to • High-risk infants identified at birth, namely no recent VL
ensure that the mother is retained in care, adherent to ART, available in the last 12 weeks of pregnancy or maternal
maintains VL suppression and has access to effective VL ≥ 1000 copies/mL, should receive high-risk
contraceptive services. prophylaxis: NVP daily for a minimum of 12 weeks and
AZT twice daily for six weeks.
Management of an elevated maternal human • A persistently elevated maternal VL in the breastfeeding period
immunodeficiency virus viral load is a further risk for HIV acquisition in the infant. 16,17 For
this reason, NVP should only be stopped after 12 weeks
Viral load suppression across the South African ART post-delivery if the maternal VL is < 1000 copies/mL.
programme is now defined as a VL of < 50 copies/mL. Any Otherwise NVP should be continued until a maternal VL
VL ≥ 50 copies/mL implies viral replication and risk to the of < 1000 copies/mL is achieved or until four weeks after
mother and infant. If the mother is on ART and her VL is breastfeeding cessation.
detectable, drug resistance must be considered. But such a
situation needs to trigger a thorough assessment, for Table 2 provides a summary of infant post-exposure
example evaluation of adherence, a check of medication prophylaxis to be given at birth, based on the infant’s risk
dosages, a review of potential drug-drug interactions and profile for HIV transmission and chosen feeding method.
the exclusion of intercurrent infection. A cause needs
to be identified and corrected. An elevated maternal VL
of ≥ 1000 copies/mL at delivery or during the breastfeeding Infant human immunodeficiency virus testing
period warrants initiating, extending, or re-starting high- Infant HIV PCR testing at birth is recommended in all HIV-
risk infant ART prophylaxis (see below). exposed infants, to identify intra-uterine transmission.
Wherever possible, birth HIV PCR tests should not be
The threshold for virological failure and switch to second- submitted with the mother’s name and details such as ‘Baby
line ART is influenced by the treatment regimen, namely of’. Mothers should be counselled during antenatal care to
an EFV or a DTG-containing regimen, and the prior provide the permanent name and surname of the child at
duration of ART. The definition of virological failure whilst on delivery. Correct identification information for the child will
an EFV-based regimen remains a VL of ≥ 1000 c/mL on two allow the birth PCR to be linked to later test records, and will
consecutive occasions ideally not longer than three months facilitate registration of the birth with home affairs before
apart, despite attention to adherence issues. The definition discharge.
of failure on a DTG-based regimen requires at least three
VLs ≥ 1000 copies/mL over a two-year period together HIV PCR testing at age 10 weeks is recommended to identify
with a focused effort to improve the patient’s adherence. perinatal HIV transmission. This remains part of the standard
Women failing to suppress on second- or third-line ART schedule of testing for HIV-exposed infants (Table 3).
warrant expert discussion or referral. These clients are However, the HIV PCR test at 18 weeks, previously performed
likely to be experiencing complex clinical and psychosocial in infants who received high-risk prophylaxis, has been
challenges and will likely benefit from an individualised discontinued due to inadequate uptake and non-alignment

http://www.sajhivmed.org.za 15 Open Access