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Page 6 of 8 Guideline

TABLE 2: Infant HIV post-exposure prophylaxis given at birth.
Risk category Indications Infant prophylaxis
• Low-risk infant at birth, whether breastfed • Maternal VL at delivery < 1000 copies/mL • Infant NVP at birth and then daily for six weeks
or exclusively formula fed
• High-risk infant at birth in the breastfed • Mother not on ART at delivery, or • Infant NVP for a minimum of 12 weeks. Infant NVP only discontinued
infant after confirmation of maternal VL being < 1000 copies/mL, and or
• Mother on ART with HIV VL ≥ 1000 copies/mL at delivery, until four weeks after cessation of all breastfeeding.
or prior to 12 weeks
• No HIV VL result available at delivery or prior to 12 weeks • Infant AZT twice daily for six weeks
• High-risk infant at birth in the infant • Mother not on ART at delivery, or • Infant NVP at birth and then daily for six weeks (provided that
exclusively formula fed from birth avoiding breastfeeding is documented and sustained), and
• Mother on ART with HIV VL ≥ 1000 copies/mL at delivery,
or prior to 12 weeks • Infant AZT twice daily for six weeks
• No HIV VL result available at delivery or prior to 12 weeks
ART, antiretroviral therapy; AZT, zidovudine; NVP, nevirapine; VL, viral load; HIV, human immunodeficiency virus.
TABLE 3: Time points for routine HIV testing in HIV-exposed and HIV-unexposed TABLE 4: HIV tests for initial and confirmatory testing in children according to
children. age: 2019 prevention of mother-to-child transmission guidelines.
Timing and type of HIV test HIV- HIV-
exposed unexposed Age of child Initial HIV test Confirmatory HIV test
infants infants Below 18 months of age HIV PCR test HIV PCR test (or VL test)
HIV PCR test at birth x - 18–24 months HIV Rapid/ELISA test HIV PCR test
HIV PCR test at age 10 weeks x - Two years and older HIV Rapid/ELISA test HIV Rapid/ELISA test
HIV PCR test at age six months (offer HIV testing for x - ELISA, enzyme-linked immunosorbent assay; HIV, human immunodeficiency virus; PCR,
documented HIV negative mothers or mothers with unknown polymerase chain reaction; VL, viral load.
HIV status)
Age-appropriate HIV test at six weeks post-cessation of x -
breastfeeding An HIV antibody test (HIV rapid or ELISA [enzyme-linked
HIV antibody test at age 18 months (rapid test or HIV ELISA) x x immunosorbent assay] test) is used as a screening test above
(universal testing)
Age-appropriate HIV test at anytime the child is unwell x x 18 months of age. However, in a small percentage of children
If any HIV test is positive, the diagnosis is confirmed with a x x the maternal antibodies persist beyond 18 months of age,
repeat HIV test (see guidelines below in Table 4) , and ART is potentially resulting in false-positive HIV diagnoses and
initiated immediately.
inappropriate initiation of lifelong ART. Therefore, HIV
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ART, antiretroviral therapy; ELISA, enzyme-linked immunosorbent assay; HIV, human
immunodeficiency virus; PCR, polymerase chain reaction; VL, viral load. PCR testing is now recommended as confirmatory testing in
all HIV-positive HIV rapid or ELISA tests in children under
with any child immunisation visit. Instead, all HIV-exposed two years of age. A summary of initial and confirmatory HIV
infants, both low and high risk, are to receive an HIV PCR test testing is outlined in Table 4.
at the six-month integrated well-child visit. Over 80% of
infants who acquire HIV do so by six months of age, At the clinician’s discretion, the HIV PCR may be replaced by
highlighting the importance of this six-month HIV PCR test. a VL test, which has the advantage of both confirming the
8
However, the risk of infant HIV acquisition may shift to more HIV diagnosis and providing a baseline VL for monitoring
than 20% after six months of age if longer periods of the child’s response to ART. Diagnostic difficulties, for
breastfeeding are achieved. Breastfed infants who test HIV example indeterminate HIV PCR test results, require urgent
negative, particularly those on antiretroviral prophylaxis, expert advice.
should not be assumed to be uninfected until after the age-
appropriate post-weaning HIV test has been performed.
Breastfeeding
At six months of age, the HIV status of all infants not already Due to the expanded access to ART in South Africa, the
known to be HIV-exposed should be established by offering country-level recommendations for breastfeeding are now
an HIV test to the mother. This maternal HIV test should fall the same whether or not the mother is living with HIV. 15,28
into the routine three-monthly HIV testing schedule for all These recommendations include exclusive breastfeeding for
breastfeeding mothers who are not yet known to be living the first six months, the introduction of appropriate
with HIV. If a maternal HIV test is not feasible, consent should complementary foods thereafter, and continued breastfeeding
be obtained to perform a rapid test on the child. Care that is for two years or longer. Given the numerous benefits of
provided in an integrated manner to the mother-infant pair breastfeeding for the health and well-being of all children, it
greatly facilitates this process of (1) identifying a women as is imperative that mothers are supported to breastfeed their
breastfeeding, (2) identifying those women who require HIV infants for the longest possible duration whilst maintaining
testing, and (3) determining the care required by the infant as viral suppression and reducing the risk of HIV-transmission
informed by the mother’s results. Breastfeeding mothers who through breastmilk exposure.
are not receiving integrated care face a significant challenge
with regard to repeat HIV testing. Much will need to be done To reduce HIV transmission during breastfeeding, the guideline
to ensure that breastfeeding mothers are able to access HIV outlines two major strategies. The first is to improve viral
testing services within family planning clinics and other suppression rates in the period after birth by (1) providing
general health services, and that her infant receives the potent and well-tolerated ART regimens – including DTG,
appropriate care according to her test results. (2) outlining mechanisms for linking mothers back into

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