Neonatal HIV

What is Neonatal HIV?

Over 95% of children with HIV got the virus from their mothers while in the womb or at birth. HIV acts the same way in children as it does in adults. But it’s a bit more challenging for kids because their immune system, responsible for defending the body against illnesses, isn’t as strong as an adult’s. For this reason, if a baby or young child gets HIV, they are more likely to get opportunistic infections, which are illnesses that take advantage of weak immune systems. That’s why giving them treatment promptly is critical; otherwise, their disease might get worse quickly.

One of the biggest achievements in the medical world is the prevention of HIV transmission from mother to baby. Now, if appropriate strategies are implemented, the chance of a baby getting HIV from their mother is less than 1%. Increasing the routine screenings for HIV and treating pregnant women who have the virus has resulted in a significant reduction in HIV transmission to babies. There are proven methods to prevent AIDS that can be applied at various stages during and after the pregnancy, which can improve the baby’s health. Antiretroviral therapies, or ART, medicines that stop HIV from growing, can be given to the mother during the pregnancy, during the natural or cesarean delivery, and to the baby after birth or during breastfeeding.

What Causes Neonatal HIV?

HIV, or Human Immunodeficiency Virus, is a virus that carries its genetic information in a molecule called ribonucleic acid (RNA). Two versions of this virus exist: HIV-1 and HIV-2. HIV-1 is the most common type globally, and it spreads more easily and progresses faster than HIV-2. It’s believed that this virus originated from wild chimpanzees in Central Africa.

HIV can be transmitted, or passed from person to person, in several ways. These include unprotected sex, sharing needles for drug use, blood transfusions (particularly in developing countries), from mother to child during childbirth, or through breastfeeding.”

If a mother with HIV breastfeeds, there’s a 12-14% chance she could pass the virus to her baby, especially if she has a lot of the virus in her body. This risk increases even further if there is no use of medication that fights HIV (known as Antiretroviral Therapy or ART) during pregnancy. Without this therapy, about 25% of babies born to HIV-positive mothers could get infected.

Several factors have been observed to increase this risk of mother-to-child transmission. For instance, high levels of the virus in the mother’s blood or breast milk, recent infection of the mother, advanced disease in the mother, and a low count of a specific type of immune cell (CD4+ T-cell) can all increase the risk of transmission.

Risk Factors and Frequency for Neonatal HIV

Transmission of HIV from mother to child during pregnancy or childbirth is a global issue, with around 160,000 babies getting infected every year as of 2018. Most of these cases are found in sub-Saharan Africa. However, over the last 20 years, such transmission has decreased significantly, falling to less than 1% in the United States and Europe.

• About 5,000 pregnant women in the United States are HIV positive.
• In 2013, only 69 babies were born with HIV in the U.S., that’s about 1.8 out of every 100,000 live births.
• Goals set by the U.S. Centers for Disease Control and Prevention to eliminate this type of HIV spread have led to a significant drop in transmission rates.
• They aim to lower the rate of babies born with HIV to less than 1 in 100,000 births.
• At the height of HIV transmission in 1991, about 42.8 out of every 100,000 babies were born with HIV. But by 2015, this rate had dropped to about 1.3 per 100,000.
• Due to discrepancies in healthcare access, Black infants are about 5 times more likely to be born with HIV than White infants.

Signs and Symptoms of Neonatal HIV

Babies with HIV may not show any signs for the first few months, or even years of their lives. This can make it hard to diagnose them. Some kids with HIV might not show any signs until they are 3 to 5 years old. Without any treatment, kids with HIV may have:

• Repeated blood infections
• Increased chances of opportunistic infections
• Frequent diarrhea
• Heart muscle disease (cardiomyopathy)
• Liver inflammation (hepatitis)
• Widely enlarged lymph nodes (generalized lymphadenopathy)
• Enlargement of the spleen or liver (splenomegaly, hepatomegaly)
• Mouth yeast infection (oral candidiasis)
• Cancers
• Problems with the brain and nerves – like slow growth, delayed mental development, low IQ, and overall delays in development

The Centers for Disease Control and Prevention (CDC) strongly encourages all pregnant women to get tested for HIV as a standard part of their prenatal care. If a pregnant woman knows she has HIV, she can start treatment that helps protect her baby from the virus. However, in some places around the world, women may not have easy access to healthcare services. This means some women might not know they have HIV until they deliver their baby. If a woman hasn’t been tested for HIV during her pregnancy, she should get a quick HIV test when she delivers her baby. By using special virus tests, doctors can usually tell if a baby has HIV when they turn 4 to 6 months old.

Testing for Neonatal HIV

Testing for HIV in newborn babies is different to adults and older children. It’s not suitable to look for HIV antibodies, as a positive result might just indicate that the baby has received antibodies from their mother, not that they have the virus themselves. Instead, doctors use other tests which check for the virus itself. These include viral load tests or nucleic acid tests (NATS), which can probe for the presence of the virus’s genetic material.

The only test of this type which has been approved by the FDA is the APTIMA HIV-1 RNA Qualitative Assay. These kits can detect HIV in 30% to 50% of babies at their birth, and give almost 100% definite results by the time the baby is 4 to 6 months old. The RNA quantitative test has been found to be just as accurate as the DNA PCR test, providing 100% specificity at birth, 1 month, 3 months, and 6 months. Two negative tests done at 1 month and before 6 months are needed to completely rule out HIV. In addition, the baby must have no symptoms and other markers of HIV, such as a normal or high count of CD4 T-lymphocytes, which are immune cells that HIV targets.

Doctors classify babies as high or low risk of having HIV. Babies born to mothers who’ve had good antenatal care and who took their antiretroviral therapy (drugs to stop the virus reproducing) properly, with the result that they have undetectable viral loads, are considered low risk. But, if the baby was born to a mother who didn’t have antenatal care, had high levels of HIV virus, and was only diagnosed with HIV during pregnancy, their baby is considered high risk.

The recommended testing schedule for HIV varies depending on the perceived infection risk. Low risk babies are tested at 14-21 days, 1-2 months, and again at 4-6 months, while high risk babies are tested at multiple points – birth, 14-21 days, 1-2 months, 2-3 months, and 4-6 months.

If a baby is diagnosed with HIV, various additional tests are required. These include counts of different types of white blood cells, a measure of the viral load, checks on growth and development, and for other conditions connected with HIV. Before starting treatment with antiretroviral drugs, further assessments including genetic testing, baseline CD4 count, viral load measure, full blood count, liver and kidney function tests, a comprehensive metabolic panel, urinalysis, serum lipids, and blood glucose checks are needed.

Treatment Options for Neonatal HIV

The Panel on Antiretroviral Therapy and Medical Management of Children Living with HIV strongly recommends starting antiretroviral therapy (ART) in all children with HIV. ART is a type of treatment that works to slow the progression of the HIV virus in the body. Since the introduction of ART in newborns, there has been a large 80% to 90% decrease in sickness and death. Studies have confirmed that starting ART early can help to decrease the levels of the virus and slow the progression of the disease. It is suggested that newborns exposed to HIV should begin receiving ART within 6 hours of birth to help reduce sickness, suppress the virus, and prevent progression of the disease.

Choosing the right combination of medicines in ART for children and newborns can be difficult, as there are not many studies comparing different drug combinations in these age groups. Most of the information comes from non-randomized studies and early stages of drug trials. The typical approach to starting antiretroviral therapy in children includes two types of medicines (nucleoside reverse transcriptase inhibitors) along with a third drug from another group. This could be an integrase strand transfer inhibitor, a protease inhibitor with a booster, or a non-nucleoside reverse transcriptase inhibitor. These are all types of medications used to prevent HIV from replicating in the body. Factors such as the child’s age, weight, family preference, drug resistance, and genetic testing should be considered before starting the treatment.

There have been a few studies comparing adding a protease inhibitor versus a non-nucleoside reverse transcriptase inhibitor to the standard drug treatment for children. While one study showed that a protease inhibitor could be more effective, another study did not find a significant difference. The protease inhibitor should be avoided in newborns younger than 14 days.

For beginning an ART regimen based on integrase strand transfer inhibitors (another type of HIV medication), the information mostly comes from safety trials and studies in adults. Four integrase strand transfer inhibitors are approved to treat children starting ART, which have been chosen due to their low toxicity and high effectiveness in controlling the virus.

In terms of the standard dual-drug regimen for newborns and infants under 3 months, Zidovudine and lamivudine or emtricitabine are the preferred choices. For infants 3 months and older, abacavir combined with lamivudine or emtricitabine is preferred. Various combinations of these medicines are recommended for different age groups. The primary goal of all these treatment regimens is to effectively control the progression of HIV and maintain the health of the child.

What else can Neonatal HIV be?

When doctors are trying to determine if a patient has HIV, they also need to rule out other illnesses that might cause similar symptoms. These might include:

• Malnutrition
• Swollen lymph nodes (lymphadenopathy)
• Long-term anaemia in children (pediatric chronic anemia)
• Disorder in digestion and absorption of food nutrients (malabsorption syndrome)
• Delays in physical growth (constitutional growth delay)
• Autoimmune disorders and prolonged, non-cancerous low white blood cell count (chronic benign neutropenia)
• Other conditions causing weakened immune system (other immunodeficiencies)

In addition, doctors should also check for other infections that can be present from birth including:

• Syphilis
• TORCH infections (Toxoplasmosis, Rubella, Cytomegalovirus, Herpes Simplex virus)
• Hepatitis B
• Hepatitis C
• Tuberculosis

What to expect with Neonatal HIV

Left untreated, HIV can increase the chances of serious illness and death. However, thanks to advancements in antiretroviral therapy (medicine to stop the virus from replicating), increased monitoring, and clinical trial data, children and adults with HIV now have better prospects for their health and wellbeing. On average, those with HIV can expect to live up to at least 10 years of age, though around 15% of children may experience a more rapid progression of the disease.

For the best outcome, it’s important that doctors work closely with patients to tailor their treatment. This might include optimizing their diet for better health, controlling the replication of the virus with medication, beginning intensive treatment for any additional infections that take advantage of their weakened immune system, and managing any social stresses that could affect their health.

Patients with HIV run a higher risk of complications if they also have other infections or blood disorders. These might include anemia (a lack of iron in the blood), thrombocytopenia (a low platelet count), and neutropenia (a low count of a specific type of white blood cell).

Possible Complications When Diagnosed with Neonatal HIV

Babies and children with HIV have weakened immune systems, which increases their risk of getting infections, and develops health issues like yeast infection in the throat (candida esophagitis), a type of pneumonia caused by Pneumocystis jirovecii, and various cancers. They also face more complications if the HIV virus in their body resists antiretroviral drugs, used to manage the disease. Nonetheless, by closely watching the child’s condition and performing tests to ensure the drugs are working effectively, it’s possible to use the most suitable and efficacious treatment plan.

Risks for Babies and Children with HIV:

• Greater chance of getting infections
• Candida esophagitis (yeast infection in the throat)
• Pneumocystis jirovecii pneumonia (a type of pneumonia)
• Different types of cancers
• Increased complications due to resistance to antiretroviral drugs

Preventative Measures:

• Close monitoring of the child’s condition
• Regular drug-resistance testing
• Selection of the most effective treatment regimen

Preventing Neonatal HIV

Before starting or changing antiretroviral therapy (ART), which is a treatment for HIV, the doctor should identify any possible hurdles and any issues with following the treatment plan. The development of new medicines and improvements in how they are made have led to treatments that are easier to take, have fewer side effects and are easier to stick with.

HIV-positive mothers are advised against breastfeeding their babies unless the baby is HIV-positive too. If a mother decides to continue breastfeeding, the baby should be regularly checked and tested every 3 months while breastfeeding and for 4 to 6 weeks, 3 months, and 6 months after she stops breastfeeding. It is also important for mothers to know about the risks of feeding their babies food that has been chewed by the mother or someone else.