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appropriate HIV care post-delivery, (3) integrating services and all experts and health care workers who provided inputs
for mother-infant pairs to promote adherence and retention into the guideline.
in care, and (4) using VL monitoring strategically for the
timely detection of, and response to, elevated HIV VLs. Competing interests
Whilst maternal viral suppression remains the gold standard,
elevated HIV VLs will occur in selected women in the The authors have declared that no competing interests exist.
breastfeeding period. The second strategy is to provide
enhanced infant prophylaxis whilst every effort is made to Authors’ contributions
regain maternal viral suppression. U.D.F. conceptualised the paper and provided strategic
guidance to J.W. As lead author, J.W. synthesised all drafts,
Prophylaxis for infants of breastfeeding mothers managed input and prepared the paper in final form. U.D.F.
with an elevated human immunodeficiency reviewed all drafts and provided editorial support. A.G.,
virus viral load G.S., L.B. and J.N. provided strategic inputs and contributed

An elevated maternal HIV VL during breastfeeding can to all drafts. All authors read and commented on drafts and
occur either at the time of a new HIV diagnosis or because of approved the final version.
an unsuppressed VL on ART. Regardless of the cause, an
elevated HIV VL in a breastfeeding mother requires urgent Ethical consideration
clinical intervention and more frequent VL monitoring. With This article followed all ethical standards for carrying out
pre-treatment resistance to non-nucleoside reverse research without direct contact with human or animal subjects.
transcriptase inhibitors documented to be on the increase,
and the high likelihood (up to 40%) of viral resistance in the
mother with an elevated VL on ART, 29,30 these infants should Funding information
receive high-risk prophylaxis consisting of AZT twice daily This paper received no specific grant from any funding
for six weeks, and NVP daily for a minimum of 12 weeks, agency in the public, commercial, or not-for-profit sectors.
with infant NVP only stopped after confirmed maternal HIV
VL < 1000 c/mL, or breastfeeding cessation.
Data availability statement
Consolidated HIV PCR and VL Results for Action reports, Data sharing is not applicable to this article as no new data
generated daily or weekly from the NHLS data warehouse, were created or analysed in preparation of this manuscript.
can be used to fast track high-risk clients, including pregnant
women with high VLs and HIV-infected infants. Reports for Disclaimer
the public sector can be accessed by registering at http://
www.nicd.ac.za. The information presented in these guidelines conforms to
the current medical, nursing and pharmaceutical practice.
Conclusions
Contributors and editors cannot be held responsible for errors,
Whilst much progress has been made in preventing vertical individual responses to medicines, and other consequences.
transmission of HIV, much remains to be done. Overcoming
the ‘next frontier’ and preventing vertical HIV transmission References
during the breastfeeding period may well be the most
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http://www.sajhivmed.org.za 17 Open Access