Congenital HIV Infections

Introduction to Congenital HIV Infections

Congenital HIV infection, also known as perinatal or vertical HIV transmission, occurs when an HIV-positive mother transmits the virus to her child during pregnancy, labor, delivery, or breastfeeding. With proper interventions, the risk of transmission can be reduced to less than 1%.

  • HIV (Human Immunodeficiency Virus) is a retrovirus that attacks the immune system
  • Without intervention, transmission risk is 15-45%
  • Globally, an estimated 1.4 million HIV-positive women become pregnant each year

Understanding the mechanisms of transmission, clinical course, and management of congenital HIV is crucial for healthcare providers to prevent transmission and optimize outcomes for affected infants.

Transmission of Congenital HIV

The risk of vertical transmission of HIV can occur at different stages:

Timing of Transmission

  • In utero: Accounts for about 25-40% of infections
  • Intrapartum: Accounts for 60-75% of infections
  • Postpartum: Through breastfeeding, can add an additional 14% risk

Factors Influencing Transmission

  • Maternal viral load: Higher viral loads increase transmission risk
  • Maternal CD4 count: Lower CD4 counts increase risk
  • Duration of ruptured membranes
  • Mode of delivery: Elective C-section can reduce risk in certain situations
  • Antiretroviral therapy (ART) use during pregnancy and labor
  • Infant prophylaxis after birth
  • Breastfeeding practices

Prevention Strategies

  • Universal HIV screening during pregnancy
  • Antiretroviral therapy for all HIV-positive pregnant women
  • Intrapartum antiretroviral prophylaxis
  • Antiretroviral prophylaxis for newborns
  • Avoidance of breastfeeding in settings where safe alternatives are available

Clinical Manifestations of Congenital HIV

The clinical presentation of congenital HIV can vary widely, from asymptomatic infection to severe immunodeficiency:

Neonatal Period

  • Most infants are asymptomatic at birth
  • Non-specific findings may include:
    • Intrauterine growth restriction
    • Hepatosplenomegaly
    • Lymphadenopathy

Infancy and Early Childhood

  • Failure to thrive
  • Recurrent bacterial infections
  • Persistent oral candidiasis
  • Lymphoid interstitial pneumonitis
  • Developmental delay

AIDS-defining Illnesses

  • Pneumocystis jirovecii pneumonia
  • Cytomegalovirus disease
  • Mycobacterium avium complex infection
  • Cryptococcal meningitis
  • HIV encephalopathy

Long-term Complications

  • Chronic lung disease
  • Cardiovascular complications
  • Renal disease
  • Neurocognitive impairment
  • Malignancies (e.g., Kaposi sarcoma, lymphomas)

Diagnosis of Congenital HIV

Diagnosing congenital HIV requires a systematic approach due to the presence of maternal antibodies in infants:

Maternal Diagnosis

  • HIV antibody testing during pregnancy
  • Confirmation with Western blot or HIV RNA testing

Infant Testing

  • Virologic tests (preferred for infants <18 months):
    • HIV DNA PCR
    • HIV RNA PCR
  • Timing of virologic testing:
    • 14-21 days of life
    • 1-2 months of age
    • 4-6 months of age
  • Antibody testing:
    • Not reliable before 18 months due to maternal antibodies
    • Used for definitive diagnosis after 18 months

Additional Investigations

  • CD4 count and percentage
  • HIV viral load
  • Complete blood count
  • Liver and kidney function tests
  • Screening for co-infections (e.g., hepatitis B, hepatitis C, tuberculosis)

Management of Congenital HIV

Management of congenital HIV focuses on early initiation of antiretroviral therapy, prevention of opportunistic infections, and comprehensive care:

Antiretroviral Therapy (ART)

  • Initiate ART as soon as possible after diagnosis
  • Choice of regimen based on:
    • Age and weight of the infant
    • Potential drug interactions
    • Resistance patterns
  • Typical first-line regimens include:
    • Two nucleoside reverse transcriptase inhibitors (NRTIs) plus a protease inhibitor or integrase inhibitor
  • Regular monitoring of adherence, side effects, and treatment response

Prophylaxis for Opportunistic Infections

  • Pneumocystis jirovecii pneumonia prophylaxis for all HIV-exposed infants starting at 4-6 weeks of age
  • Other prophylaxis based on CD4 count and clinical status

Immunizations

  • Follow routine immunization schedule with some modifications
  • Avoid live vaccines in severely immunocompromised children

Nutritional Support

  • Regular growth monitoring
  • Nutritional counseling and supplementation as needed

Neurodevelopmental Assessment and Support

  • Regular developmental screening
  • Early intervention for developmental delays

Psychosocial Support

  • Counseling for families
  • Disclosure planning and support
  • Mental health services

Long-term Follow-up

  • Regular monitoring of CD4 count and viral load
  • Screening for long-term complications
  • Transition planning to adult care

Future Directions

  • Development of long-acting antiretroviral formulations
  • Research on HIV cure strategies
  • Improved point-of-care diagnostics for infants


Congenital HIV Infections
  1. Q: What is the primary mode of transmission for congenital HIV infections? A: Mother-to-child transmission during pregnancy, labor, delivery, or breastfeeding
  2. Q: Without intervention, what is the approximate risk of mother-to-child transmission of HIV? A: 15-45%
  3. Q: What is the most effective intervention to prevent mother-to-child transmission of HIV? A: Antiretroviral therapy (ART) for the mother during pregnancy and labor, and for the infant after birth
  4. Q: When should antiretroviral therapy be initiated in pregnant women with HIV? A: As soon as possible after HIV diagnosis, regardless of CD4 count or viral load
  5. Q: What is the recommended mode of delivery for HIV-positive mothers with high viral loads? A: Scheduled cesarean section at 38 weeks gestation
  6. Q: How long should infants born to HIV-positive mothers receive antiretroviral prophylaxis? A: For 4-6 weeks after birth
  7. Q: What test is used to diagnose HIV infection in infants younger than 18 months? A: HIV DNA or RNA PCR test
  8. Q: At what age can HIV infection be definitively diagnosed or ruled out in most infants? A: By 4-6 months of age with appropriate testing
  9. Q: What is the recommended feeding method for infants born to HIV-positive mothers in resource-rich settings? A: Exclusive formula feeding
  10. Q: In resource-limited settings, what is the WHO recommendation for infant feeding? A: Exclusive breastfeeding for 6 months with continued ART for mother and infant
  11. Q: What opportunistic infection is most common in infants with congenital HIV? A: Pneumocystis jirovecii pneumonia (PCP)
  12. Q: At what age should PCP prophylaxis be initiated in HIV-exposed infants? A: At 4-6 weeks of age, regardless of CD4 count
  13. Q: What is the most common presenting symptom of congenital HIV infection? A: Failure to thrive
  14. Q: How does congenital HIV infection affect an infant's growth and development? A: It can lead to growth failure, developmental delays, and cognitive impairment
  15. Q: What neurological complications are associated with congenital HIV infection? A: HIV encephalopathy, microcephaly, and seizures
  16. Q: How does congenital HIV infection affect the cardiovascular system? A: It can cause cardiomyopathy and pulmonary hypertension
  17. Q: What renal complications are associated with congenital HIV infection? A: HIV-associated nephropathy and medication-related nephrotoxicity
  18. Q: How does congenital HIV infection affect the immune system? A: It leads to progressive depletion of CD4+ T cells and immune dysfunction
  19. Q: What is the role of immunizations in infants with congenital HIV? A: They should receive all routine immunizations, with some modifications for live vaccines
  20. Q: How does congenital HIV infection affect an infant's hematological system? A: It can cause anemia, neutropenia, and thrombocytopenia
  21. Q: What gastrointestinal complications are common in infants with congenital HIV? A: Chronic diarrhea, malabsorption, and failure to thrive
  22. Q: How does congenital HIV infection affect the liver? A: It can cause hepatomegaly, elevated liver enzymes, and increased risk of hepatitis co-infection
  23. Q: What is the recommended first-line antiretroviral regimen for infants with HIV? A: A combination of two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor or integrase inhibitor
  24. Q: How often should CD4 count and viral load be monitored in infants with HIV? A: Every 3-4 months, or more frequently if clinically indicated
  25. Q: What is the role of resistance testing in managing congenital HIV infections? A: To guide the selection of appropriate antiretroviral regimens, especially in cases of treatment failure
  26. Q: How does congenital HIV infection affect bone metabolism? A: It can lead to decreased bone mineral density and increased risk of fractures
  27. Q: What is the long-term prognosis for children with congenital HIV infection who receive early ART? A: Significantly improved survival and quality of life, with many reaching adulthood
  28. Q: How does congenital HIV infection affect puberty and sexual development? A: It may lead to delayed puberty and growth failure
  29. Q: What is the importance of disclosure of HIV status to infected children? A: It promotes treatment adherence, mental health, and responsible sexual behavior as they grow older
  30. Q: How does congenital HIV infection impact the child's psychosocial development? A: It can lead to stigma, social isolation, and mental health issues


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