Preventing Mother-to-Child Transmission of HIV After

Birth
Last Reviewed: February 20, 2020

Key Points

 Babies born to women with HIV receive HIV medicine as soon as possible after birth, preferably within
6 to 12 hours of delivery. The HIV medicine protects the babies from infection with any HIV that passed from mother
to child during childbirth.
 HIV testing is recommended for all babies born to women with HIV at 14 to 21 days of life, at 1 to 2
months, and again at 4 to 6 months. Additional testing at birth and other time points is recommended for babies at
higher risk of mother-to-child transmission of HIV.
 If testing shows that a baby has HIV, the baby receives antiretroviral therapy (ART). ART is the daily
use of a combination of HIV medicines to treat HIV infection. ART helps people with HIV live longer, healthier lives.
 HIV can spread from a mother to her child through breast milk. In the United States, infant formula is a
safe and readily available alternative to breast milk. For these reasons, women with HIV who live in the United States
should not breastfeed their babies.

After birth, do babies born to women with HIV receive HIV medicines to
prevent mother-to-child transmission of HIV?
Babies born to women with HIV receive HIV medicine as soon as possible after birth, preferably within 6 to 12
hours of delivery. (HIV medicines are called antiretrovirals.) The HIV medicine protects the babies from
infection with any HIV that may have passed from mother to child during childbirth.

After birth, which HIV medicine do babies born to women with HIV receive?
The HIV medicine that a baby receives depends on the mother’s viral load and other factors.

Babies born to women who take HIV medicines as prescribed during pregnancy and who have sustained viral
suppression near delivery (defined as a viral load of less than 50 copies/mL) have a low risk of mother-to-child
transmission of HIV. These babies receive an HIV medicine called zidovudine (brand name: Retrovir) for 4
weeks after birth.

Babies at higher risk of mother-to-child transmission of HIV receive three HIV medicines for up to 6 weeks after
birth. This includes babies born to women who are not virally suppressed near delivery.

How soon after birth are babies born to women with HIV tested for HIV?
HIV testing is recommended for all babies born to women with HIV at 14 to 21 days of life, at 1 to 2 months,
and again at 4 to 6 months. Additional testing at birth and other time points is recommended for babies at
 higher risk of mother-to-child transmission of HIV. The HIV test (called a virologic test) looks for HIV in the
blood.

If testing shows that a baby has HIV, the baby receives antiretroviral therapy (ART). ART is the daily use of a
combination of HIV medicines to treat HIV infection. ART helps people with HIV live longer, healthier lives.

What other steps protect babies from HIV?

HIV can spread from a mother to her child through breast milk. In the United States, infant formula is a safe and
readily available alternative to breast milk. For these reasons, women with HIV who live in the United States
should not breastfeed their babies.

Additionally, babies should not eat food that was pre-chewed by a person with HIV.

This fact sheet is based on information from the following sources:

From the Centers for Disease Control and Prevention (CDC):

  HIV and Pregnant Women, Infants, and Children

From the Department of Health and Human Services:

 Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and
Interventions to Reduce Perinatal HIV Transmission in the United States:
o Management of Infants Born to Women with HIV Infection: Antiretroviral Management of
Newborns with Perinatal HIV Exposure or HIV Infection, Diagnosis of HIV Infection in Infants and Children,
and Initial Postnatal Management of the Neonate Exposed to HIV

Care of the infant born to an HIV-positive mother

Copyright and License information Disclaimer

Cet article est disponible en français. Voyez "Les soins au nourrisson né d’une mère séropositive".

This article has been cited by other articles in PMC.

The purpose of this statement is to provide information for physicians who provide care to newborns and may,
therefore, be involved in the care of a baby born to a human immunodeficiency virus (HIV)-positive mother. If
the infant is found to be HIV infected, a consultation with a paediatric HIV program is recommended.
Of the 16,236 AIDS cases reported in Canada up to December 1998, 7.5% of AIDS cases were among women
(1). The proportion of AIDS cases among adult women has steadily increased, from 6.2% of the AIDS cases
before 1990 to 13.6% in 1998. The estimated proportion of women among new HIV infections has also
increased from less than 5% in the early 1980s to 21.8% in 1998. Using information on HIV epidemiology
including recent seroprevalence studies and HIV testing surveys, it is estimated that across Canada over 5000
women are living with HIV (2). Almost all of the infected women are of childbearing age. HIV prevalence
studies among pregnant women indicate an average provincial rate for Canada of about three to four/10,000.
As of December 1998, across Canada, 924 babies have been identified as born to HIV-infected women, 325
have been confirmed as infected and 107 have died of AIDS (3).
To prevent vertical transmission of HIV, it is essential to identify the maternal infection. Even the most
thorough history and physical examination will identify fewer than half of the HIV-positive women. Therefore,
routinely offering HIV testing to all pregnant women is recommended (4). In a randomized, controlled trial,
therapy with the antiretroviral agent, zidovudine, in three phases (during pregnancy, during labour and delivery
and to the newborn) reduced the proportion of HIV-infected infants from 25% to 8% (5). In practice,
zidovudine therapy has been effective, with a reduction of vertical transmission rates to 5% or less (6,7).
Studies are continuing to determine the efficacy of using zidovudine in modified schedules (8). The only
antiretroviral agent that has been licensed for use in pregnancy is zidovudine. However, antiretroviral therapy
is such a rapidly evolving area that an expert should be consulted for appropriate HIV therapy for an HIV-
positive pregnant woman.
Antiretroviral therapy for an HIV-infected woman should be chosen to offer the best therapy for the woman’s
health while weighing the benefits and risks of the drugs for the fetus (9). The major benefit to the fetus is the
reduction of HIV transmission, and the major risk is potential drug toxicity. The literature on the toxicity of
antiretroviral agents in pregnancy is sparse. The most experience is with the use of zidovudine, and, so far, no
long term adverse effects have been observed (10). Because of the complexity and rapidity of change of
information on these issues, pregnant HIV-positive women need counselling to help them to make their
choices during pregnancy.
Obstetrical factors have been shown to affect mother-to-child transmission of HIV. In a prospective
observational study of 522 deliveries, it was found that the duration of rupture of membranes was a major
factor in the risk of perinatal transmission of HIV (11). If the membranes were ruptured for more than 4 h
compared with less than 4 h, the odds ratio was 1.82 (95% CI 1.1 to 3.0, P=0.02). In several prospective
studies and a meta-analysis, mode of delivery has been found to affect the transmission rate (12). The
European Mode of Delivery Study was a randomized controlled trial comparing the transmission rates for
elective caesarean section versus vaginal delivery. The transmission rates for delivery vaginally, by emergency
caesarean and elective caesarean section were 10.2%, 8.8% and 2.4%, respectively (P=0.009) (12). The lowest
rate, 2.1%, was in mothers on zidovudine delivering by caesarean section. In a meta-analysis of 15 prospective
cohort studies containing 8533 mother-child pairs, the likelihood of transmission was decreased by
approximately 50% with elective cesarean section compared with other modes of delivery (13). Among
mother-child pairs receiving antiretroviral therapy during the prenatal, intrapartum and neonatal periods, the
transmission rate was 2.0% among mothers who underwent elective cesarean section and 7.3% with other
modes of delivery.
Congenital HIV-infection has not been shown to cause dysmorphism. There are no clinical features that
distinguish infected from noninfected infants at birth. Therefore all HIV-exposed infants should receive
prophylaxis for HIV from birth. Treatment with zidovudine in the three periods – prenatal, intrapartum and
neonatal – is recommended, but there is potential benefit even if given in one or two periods. In situations
where maternal HIV therapy has been suboptimal, the HIV management of the infant must be individualized
so the opinion of an expert should be sought. Usually, the infant should receive zidovudine syrup as 2
mg/kg/dose qid for six weeks. If the infant is premature, the dose may need to be modified. One of the most
common side effects of zidovudine prophylaxis is anemia; therefore, hemoglobin should be checked at birth
and at one month of age. The mother’s medical record should be reviewed for other infectious agents that may
affect the infant, such as hepatitis B and C, herpes simplex, cytomegalovirus, toxoplasmosis, syphilis,
gonorrhea, chlamydia, and tuberculosis. Doctors should encourage giving hepatitis B vaccine to all infants of
HIV-infected women and, if the mother is a hepatitis B virus carrier, then in addition, giving the infant
hepatitis B immune globulin. It is recommended that an HIV-positive mother not breastfeed because of
potential HIV transmission through breast milk (14).
Because all babies will be HIV antibody positive due to a passive transfer of antibodies from their mother, the
diagnosis of HIV infection must be confirmed by testing for viral antigen (p24), HIV DNA sequences using
polymerase chain reaction (PCR) or HIV culture. Selected laboratories for a region perform these tests. Viral
load testing does use PCR testing; however, this is not the standard diagnostic test for HIV. A larger volume of
blood is required for viral load testing than for the diagnostic test using HIV DNA PCR testing. It is
hypothesized that infants who are infected peripartum do not have a measurable viremia until a few days after
birth and that most infections occur peripartum. Therefore, the sensitivity of available diagnostic tests for
perinatal HIV infection in the first 48 h of life is less than 50%. However, because there is increasing evidence
that supports early combination antiretroviral therapy, identification of infection as early as possible is
recommended (15). Cord blood should not be used to test the infant’s HIV status because of the risk of
contamination with the mother’s blood.
With current therapy that dramatically reduces the rate of mother-to-child transmission, almost all infants
followed should serorevert, that is, lose maternal HIV antibodies and become negative by all HIV tests. One
goal of care is to determine, as efficiently and safely as possible, which infants are not infected. In an infected
infant, the viral load increases rapidly over the first few weeks of life and, by 14 days of age, the sensitivity of
the DNA PCR reaches 93% (16). It has been shown that two sequential samples tested for HIV by either PCR
or culture have a negative predictive value of more than 90% (17). The sensitivity and specificity of virological
tests in detecting HIV-1 in exposed infants whose mothers where taking zidovudine is similar to that of tests in
untreated mother-infant pairs. The sensitivities of DNA PCR, RNA PCR and cell culture are 81.9%, 99.6% and
85.3%, respectively, and specificities are 97.1%, 100%, 99.6%, respectively (18). Therefore, if an infant has all
negative HIV tests by PCR or culture on two specimens, one at one month and another at two to four months
of age, that infant is very likely not infected. To confirm and document that an infant is not infected, he or she
should be followed to at least 18 months of age, at which time he or she should have no physical findings to
suggest HIV and an HIV antibody test that has become negative.
Pneumocystis carinii pneumonia (PCP) occurs most frequently in infants with HIV infection between two and
eight months of age, and there is a high mortality rate associated with PCP. Prophylaxis with
trimethoprim/sulphamethoxazole (TMP/SMX) is recommended for all infants until their HIV status is
determined (19). If the infant is known not to be infected, TMP/SMX should be stopped. For infants who have
been confirmed to be infected, TMP/SMX should be used as previously recommended (20).
Referral to a paediatric HIV program should be offered because the multidisciplinary teams in such programs
have the resources to deal with the complexity of medical and psychosocial issues that face many of these
families. Discussing new cases with an HIV specialist from the local region is helpful for the management of
the individual case and facilitates reporting to the Canadian Perinatal HIV Surveillance program so that the
epidemiology of perinatal HIV can be kept current.
Even after tests show that an infant is not infected, that child should still be followed annually because of the
psychosocial issues that may affect the health of a child living in a family with other members infected with
HIV. Some of the long term issues for an affected child are disclosure of the diagnosis of HIV of their mother
and/or other family members, chronic illness of a parent or sibling, and death of a parent or sibling.
In addition, follow-up for long term toxicity of drug exposure in utero is important. There is now a Canadian
registry for infants with antenatal exposure to antiretroviral agents. Health professionals are strongly
encouraged to call this registry so that the data in the registry truly reflects the population of infants exposed
(1-888-246-5840 or 416-813-6780). A summary of the guidleines for the management of the infant born to an
HIV-positive mother is given in Table 1.

TABLE 1
Timetable for the care of the infant vertically exposed to human immunodeficiency virus (HIV). This is
intended as a guideline only.

For the infant vertically exposed to HIV

  Ensure appropriate maternal care including antiretroviral therapy
Pregnancy  

 Offer counselling services

 Consider elective Cesarean section as a method to reduce perinatal transmission

During
 Give zidovudine intravenous 2 mg/kg/h for the first hour then 1 mg/kg/h
delivery  
 Reduce invasive monitoring, such as scalp electrodes

At birth  
 Breastfeeding is not recommended

 Start zidovudine syrup 2 mg/kg/dose qid for six weeks*

 Encourage the start of a hepatitis B vaccine series; if mother is hepatitis B surface

antigen-positive, give hepatitis B immune globulin and vaccine series

Before discharge
 Give blood test for HIV PCR (culture optional)†
from hospital  
 Take complete blood count (CBC)

 Consult with paediatric HIV program

At one month  
 Perform blood test for HIV PCR (culture optional)†

 Perform CBC and differential, and T cell counts

 Discontinue zidovudine at six weeks

 If a hepatitis B vaccine series is started, give a second dose

At two months  
 Provide routine immunizations‡

 Test blood for HIV PCR (culture optional)†

  Start Pneumocystis carinii pneumonia prophylaxis with trimethoprim-
sulphamethoxazole (TMP/SMX) as 2.5 mg/kg/dose TMP bid three days per week

At three to four
 Review all HIV tests†
months  
 -if all PCR and cultures are negative, it is likely that infant is not infected
and TMP/SMX can be discontinued

 -if more than one HIV PCR (or culture) is positive, the infant is confirmed
infected and should be referred to paediatric HIV program

At four
 Give routine immunizations
months  

For the infant with all negative antigen, PCR and culture tests, then

At six months  
 Perform a general and developmental assessment

 Give routine immunizations

 If a hepatitis B vaccine series is started, give a third dose

At 18 months  
 Perform general and developmental assessment

 Check HIV antibodies to ensure serorevertion

Annually  
 Perform general and developmental assessment

For the infant with a positive PCR or culture, follow in conjunction with a paediatric HIV program

Open in a separate window

*
Dose modification may be needed for a premature infant;

†
If one of polymerase chain reaction (PCR), p24 antigen (Ag) or culture tests is positive; it should be repeated immediately for
confirmation;

‡
Oral poliovirus vaccine should not be used (no longer available for routine use in Canada, all provinces having switched to
inactivated poliovirus vaccine); bacille Calmette-Guérin vaccine should not be given until the HIV status of the child is
established with certainty
 Go to:

Footnotes

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE

Members: Drs Upton Allen, The Hospital for Sick Children, Toronto, Ontario; François Boucher, Département de

pédiatrie, Centre Hospitalier Universitaire de Québec, Pavillon CHUL, Sainte-Foy, Québec; H Dele Davies, Division

of Infectious Diseases, Alberta Children’s Hospital, Calgary, Alberta; Gilles Delage, Laboratoire de santé publique du

Québec, Sainte-Anne-de-Bellevue, Québec (chair); Joanne Embree, The University of Manitoba, Winnipeg,

Manitoba; Mireille Lemay, Department of Infectious Diseases, Sainte-Justine Hospital, Montréal, Québec; Charles

Morin, Complexe hospitalier Sagamie, Chicoutimi, Québec (director responsible); David Speert, Division of Infectious

and Immunological Diseases, University of British Columbia, Vancouver, British Columbia; Ben Tan, Division of

Infectious Diseases, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan

Consultants: Drs Noni MacDonald, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia; Victor

Marchessault, Cumberland, Ontario

Liaisons: Drs Susan King, Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario

(Canadian Paediatric AIDS Research Group, principal author); Scott Halperin, Department of Pediatrics, IWK-Grace

Health Centre, Halifax, Nova Scotia (IMPACT); Monique Landry, Direction de la santé publique de Laval, Laval,

Québec (Public Health); Larry Pickering, Centre for Paediatric Research, Norfolk, Virginia (American Academy of

Pediatrics); John Waters, Alberta Health, Edmonton, Alberta (Epidemiology)

The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed.

Variations, taking into account individual circumstances, may be appropriate.