HIV transmission to extremely low birth weight infants

Placental weights of neonates born with symptomatic congenital syphilis

Background

Syphilis during pregnancy remains an important global health concern causing miscarriage, stillbirth, preterm birth and neonatal death. As part of the fetal infection, placental changes occur which may include a heavier placenta than expected.

Methods

A cohort of 50 neonates with symptomatic congenital syphilis has previously been described. This cohort was admitted to Groote Schuur neonatal unit in Cape Town South Africa from 2011 to 2013. For this study, the placental weights of the neonates were analyzed and compared to population based placental centiles.

Results

There was data for 37 placentae. Heavy placentae (>90th centile) occurred in 76% of placentae in the study. All 6 infants with birth weights ≥2,500 g had heavy placentae. There was no correlation between placental centile and death.

Conclusion

Heavy placenta are an important and frequent finding with symptomatic congenital syphilis, especially in the larger neonates.

Highly Active Antiretroviral Therapy in an Extremely Low Birth Weight Newborn With in Utero Transmission of HIV

The management of perinatal HIV infection in preterm infants is hampered by the lack of evidence informing optimal antiretroviral treatment for these vulnerable newborns. We present a case of an extremely preterm infant with HIV infection treated immediately with a 3-drug antiretroviral regimen and achieving stable suppression of HIV plasma viral load.

Peripartum HIV infection in very low birth weight infants fed 'raw' mother's own milk

Background

HIV-exposed very low birth weight (VLBW) infants (≤ 1500 g) are considered at high risk of peripartum mother-to-child HIV transmission (MTCT). In the past, they received formula to prevent breast milk related HIV transmission. This denied them the benefits of breast milk, thus exposing the infant to the risk of necrotising enterocolitis (NEC). From 2010, ‘raw’ mother’s own milk (rMOM) has been recommended for term infants whose mothers’ received antenatal antiretroviral therapy (ART). At the same time, the infant received antiretroviral (ARV) prophylaxis as per the National Prevention of MTCT programme.

Objectives

To determine the cumulative incidence of peripartum HIV infection by 4–6 weeks of age in HIV-exposed VLBW infants, who received rMOM and infant ARV prophylaxis.

Method

A retrospective, observational audit over 3 years at a single institution was undertaken. The study population comprised HIV-exposed VLBW infants who received both nevirapine prophylaxis and rMOM from birth until discharge. A positive HIV-PCR by 4–6 weeks of life was used to confirm maternal to infant HIV transmission.

Results

Of the 80 eligible infants admitted between 2010 and 2013, 63 (79%) were exposed to antenatal ART. Seventy-eight (97.5%) tested HIV-PCR negative at 4–6 weeks. Of the two infants who tested positive, both presented with features of an acute HIV infection. The absence of MTCT in the remaining 78 infants given ARV prophylaxis and rMOM suggests that rMOM is an unlikely source of infection in the two infected infants.

Conclusion

rMOM, in the presence of infant prophylaxis, was a safe feeding option for HIV-exposed VLBW infants. It should be strongly considered for these infants, as rMOM likely provides additional maternal and child benefits.

HIV Transmission to Premature Very Low Birth Weight Infants

There is sparse literature about HIV transmission in preterm infants. Eighty-two HIV-exposed preterm infants received birth polymerase chain reactions (PCRs). Five (6.1%) were HIV positive with all 5 mothers receiving inadequate antiretrovirals. Of the PCR-negative infants, 9 died and 87% of the survivors received further PCR testing which remained negative. With correct care, intrapartum transmission of HIV can virtually be eliminated.

Antiretrovirals causing severe pre-eclampsia

BACKGROUND

Extremely low birth weight infants (ELBW) (⩽1000g) at our tertiary hospital have a much higher HIV exposure rate than bigger babies and are mainly delivered due to complications of pre-eclampsia. Studies investigating the effect of HIV or antiretroviral therapy on pre-eclampsia, a partially immune-mediated disease have produced contradictory results.

OBJECTIVE

To determine if there was an association between pre-eclampsia and HIV and/or antiretrovirals in the mothers of ELBW infants.

STUDY DESIGN

A prospective database was maintained for all ELBW infants born from August 2011 till January 2013. Data included maternal information such as HIV status, antiretroviral medication (duration and type) and mode and indication for delivery.

RESULTS

Of the 195 mothers who delivered ELBW infants, 46 (24%) were HIV positive. This is significantly different to the 17% HIV prevalence in mothers with bigger children (p=0.02). The main indication (59%) for delivery of the infant was hypertension related with the majority of these (94%) being classified as pre-eclampsia. Although HIV on its own showed no association (p=0.13), mothers who received greater than 4weeks of antiretrovirals were more likely to develop severe pre-eclampsia (p=0.007).

CONCLUSION

The debate about ARVs and PET is not yet over. We postulate that in a small group of susceptible women, ARVs may trigger early severe PET. It is unclear from our study if this would be due on a toxic or immune basis.

The last and first frontier--emerging challenges for HIV treatment and prevention in the first week of life with emphasis on premature and low birth weight infants

Introduction

There is new emphasis on identifying and treating HIV in the first days of life and also an appreciation that low birth weight (LBW) and preterm delivery (PTD) frequently accompany HIV-related pregnancy. Even in the absence of HIV, PTD and LBW contribute substantially to neonatal and infant mortality. HIV-exposed and -infected infants with these characteristics have received little attention thus far. As HIV programs expand to meet the 90-90-90 target for ending the HIV pandemic, attention should focus on newborn infants, including those delivered preterm or of LBW.

Discussion

In high prevalence settings, infant diagnosis of HIV is usually undertaken after the neonatal period. However, as in utero infection may be diagnosed at birth, earlier initiation of therapy may limit viral replication and prevent early damage. Globally, there is growing awareness that preterm and LBW infants constitute a substantial proportion of births each year. Preterm infants are at high risk for vertical transmission. Feeding difficulties, apnoea of prematurity and vulnerability to sepsis occur commonly. Feeding intolerance, a frequent occurrence, may compromise oral administration of medications. Although there is growing experience with post-exposure prophylaxis for HIV-exposed term newborn infants, there is less experience with preterm and LBW infants. For treatment, there are even fewer options for preterm infants. Only zidovudine has adequate dosing recommendations for treating term and preterm infants and has an intravenous formulation, essential if feeding intolerance occurs. Nevirapine dosing for prevention, but not treatment, is well established for both term and preterm infants.

HIV diagnosis at birth is likely to be extremely stressful for new parents, more so if caring for preterm or LBW infants. Programs need to adapt to support the medical and emotional needs of young infants and their parents, where interventions may be lifesaving.

Conclusions

New focus is required for the newborn baby, including those born preterm, with LBW or small for gestational age to consolidate gains already made in early diagnosis and treatment of young children.