by Deborah Bloch, M.D., FAAP, and
Larry K. Pickering, M.D., FIDSA, FPIDS, FAAP
• Diallo K, et al. “Early Diagnosis of HIV Infection
in Infants — One Caribbean and Six Sub-Saharan African Countries, 2011–2015.” MMWR.
The U.S. President’s Emergency Plan for AIDS
Relief (PEPFAR) was created in 2003 to establish an
AIDS-free generation, committing $5.2
billion in 2016 to programs that provide access to HIV/AIDS preventive,
diagnostic and treatment services and
research ( http://bit.ly/2j49Sef).
Despite global efforts, only four
countries have eliminated mother-to-child HIV transmission: Armenia,
Belarus, Cuba and Thailand, according to the World Health Organization
(WHO) ( http://bit.ly/2hNmBS6).
Furthermore, in 2015, 1. 4 million
children under 15 years of age were
living with HIV (including 170,000
infants born in 2015), mostly in
sub-Saharan Africa. In 2014, 150,000
children worldwide died from HIV-related illness.
Since 2011, the estimated annual number of
HIV-infected children has been reduced by 50%, yet
only half of children living with HIV have access to
antiretroviral therapy (ART). Early infant diagnosis
significantly reduces overall morbidity and mortality
of HIV when coupled with early treatment.
WHO recommends HIV DNA polymerase chain
reaction (PCR) testing at 4-6 weeks of life for HIV-exposed infants ( http://bit.ly/2iE4cHc).
The MMWR article reported on the progress of the
seven countries supported by PEPFAR for HIV testing
services, barriers to testing and HIV medical care for
infants from 2011-2015: Cote d’Ivoire, Democratic
Republic of the Congo, Haiti, Malawi, South Africa,
Uganda and Zambia. Data on the number of infant
HIV tests, percent HIV positive, age of infants at time
of testing, turnaround time from specimen collection
to return of results and mode of specimen transportation were collected.
During the study period, the total number of infant
HIV DNA PCR tests performed increased in all countries. In 2015, however, testing within the first 6 weeks
of life was greater than 50% of total infant tests only
in South Africa and Zambia.
In 2015, most of the countries demonstrated an overall decrease in the number of HIV-positive test results.
However, the number of positive results decreased by
more than 50% since 2011 in only Cote d’Ivoire, the
Democratic Republic of the Congo and Uganda.
Barriers to testing included difficulties in specimen
transport, long turnaround times between collection
and receipt of results, and limitations in supply chain
management. Modes of specimen transportation
included bicycle, motorcycle or car. Methods
of transmitting results included phone, text
message (unclear if sent to facility or directly
to patient), email, hard copies transported by
vehicle and web-based laboratory information
Barriers to early care included mother
and child lost to follow-up, weak linkage
between antenatal and postnatal care,
and inability to reach infants outside
the health care system.
Three countries reported that integration of HIV diagnostic services with
routine care, infant immunizations and
health outreach were crucial for success.
Public health and clinical applications
Progress has been made through 2015 in the field
of perinatal HIV medicine in several developing
countries. However, many obstacles, mostly logistic,
to timely infant testing remain. Additionally, the lack
of eradication of mother-to-child HIV transmission
persists in most of the world, including in the U.S.
As the world becomes increasingly globalized, U.S.
pediatricians should be aware of global HIV epidemiology and ensure adequate testing and treatment of
all immigrant patients. Clinicians also should remain
aware of local and global legislation regarding pediatric
HIV. If the goal of an AIDS-free generation is to be
reached, we all must advocate for continued support of
PEPFAR’s funding for mother and infant HIV testing
and treatment, in addition to better diagnostics and
timelier services in developing countries.
The first cases of AIDS were reported in the U.S.
in 1981. Now, fewer than 200 infants in the United
States are infected with HIV per year. Pediatricians
should be aware of their patients’ maternal HIV status
and knowledgeable about timing and methods of testing for HIV-exposed infants and treatment. Though
the WHO recommends testing at 4-6 weeks of life,
the U.S. Department of Health and Human Services
(HHS) recommends using either HIV DNA or HIV
RNA PCR tests at 14-21 days of life and repeating the
same test at 1-2 months of life (preferably two to four
weeks after cessation of infant ART prophylaxis) and
again at 4-6 months of life.
HHS also recommends starting low-risk HIV-exposed infants (infants whose mothers were on ART
during pregnancy and with undetectable viral loads
prenatally) on a four-week course of prophylactic zidovudine. Infants of high-risk mothers (mothers not
on ART during pregnancy or on ART only at delivery
or with detectable viral loads around time of delivery) should begin a six-week course of combination
therapy with zidovudine and nevirapine (http://bit.
Dr. Bloch is a pediatric infectious diseases fellow, PGY- 4, at
Emory University and
Children’s Hospital of
Atlanta (CHOA). Dr.
Pickering was editor of
the AAP Red Book from 2000-’ 12. He is adjunct
professor of pediatrics in the Department of Pediatrics
at Emory University School of Medicine and CHOA.
Andres Felipe Camacho-Gonzalez, M.D., FAAP, re-
viewed this article.
• For guidance on providing prophylactic therapy to infants at risk for HIV infection or for infants of mothers
whose HIV status is unknown, consult an HIV specialist
or call the National Perinatal HIV Hotline at 888-448-
8765 for a free consultation.
• More information on HIV infection can be found in the
AAP Red Book, http://bit.ly/2iv3884.
• The most up-to-date guidelines for testing and treatment of HIV-exposed infants in the U.S. can be found
1. The first cases of AIDS were reported in the U.S.
in what year?
2. In the U.S., what is the recommended age an
HIV-exposed infant should first be tested for HIV?
b) 14-21 days of life
c) 4-6 weeks
d) 18 months
3. Which of the following should be used to test for
HIV in an HIV-exposed infant?
a) HIV DNA PCR
b) HIV RNA PCR
c) HIV IgM and IgG
d) a or b, but the same test should be used each time
Q uestion #1- c; Q uestion #2 - b; Q uestion #3 - d
Dr. Bloch Dr. Pickering
• In 2015, 1. 4 million children worldwide under
15 years of age, including 170,000 infants born
in 2015, were estimated to be living with HIV
• In 2014, 150,000 children worldwide died
from HIV-related causes.
• HIV-related mortality in infants under 2 years
of age is 50% without appropriate treatment.
• In 2015, only 51% of the world’s HIV-infected
children had received antiretroviral therapy.
• Fewer than 200 U.S. infants are infected with
HIV per year.
Mother-to-child HIV transmission persists in most of the world