Prophylaxis and treatment of HIV-1 infection in pregnancy – Swedish Recommendations 2017

Figures & data

Table 1. Dosing of antiretrovirals to the woman at delivery and to the infant as post-exposure prophylaxis.

To the woman
HIV RNA >150 copies/mL at delivery aiming at sufficient drug exposure to the infant as soon as possible.
Intravenous infusion of zidovudine: 2 mg/kg should be given over 1 h. After this, the infusion rate should be 1 mg/kg until the child is born. When a caesarean section is planned, the infusion should be initiated 4 h prior to surgery. When delivery is expected within an hour or when emergency section within approximately the same interval, the infusion is initiated as soon as possible and the loading dose 2 mg/kg may be administered in 30 min instead of 1 h
Tablet nevirapine: 200 mg (alternatively 20 mL oral solution 10 mg/mL) single dose 4–12 h before estimated delivery. If the women did not receive nevirapine >2 h before delivery (sufficient amount did not pass the placental barrier) an additional dose of 2 mg/kg is given to the infant as soon as possible after delivery
To the infant
Routinely to all infants if there is no indication for individualized treatment  • Zidovudine (oral solution 10 mg/mL)    • Infants born >week 35:      • Zidovudine 4 mg/kg q12h for 4 weeks (oral solution)      • If oral treatment not is possible: intravenous zidovudine 3 mg/kg q12h      • Start treatment within 4 h after delivery      • Treatment for a total of 4 weeks    • Infants born gestational week 30–34:      • Zidovudine 2 mg/kg q12h (oral solution) or 1.5 mg/kg q12h intravenously      • After 2 weeks dose adjustment to 3 mg/kg q12h or 2.3 mg/kg q12h intravenously    • Infants born < gestational week 30:      • Zidovudine 2 mg/kg q12h (oral solution) or 1.5 mg/kg q12h intravenously for 4 weeks
Other treatment options when extended prophylaxis in indicated:  • Abacavir (oral solution 20 mg/mL)    • Abacavir 2 mg/kg q12h for 4 weeks  • Lamivudine (oral solution 10 mg/mL)    • Lamivudine 2 mg/kg q12h for 4 weeks    • First line therapy in combination prophylaxis together with zidovudine  • Tenofovir (oral powder 33 mg/g)    • Single dose tenofovir 13 mg/kg  • Nevirapine (oral solution 10 mg/mL)
• If maternal HIV RNA at delivery >150 copies/mL and the mother received nevirapine before delivery according to above, single dose nevirapine 2 mg/kg orally to the child at 48–72 h of age. If the mother did not receive nevirapine >2 h before delivery (sufficient amount did not have time to pass the placenta) an additional dose of 2 mg/kg is given to the infant immediately after birth
• Lopinavir/r (oral solution 80 mg lopinavir/20 mg ritonavir/mL)    • Infants <14 days old:      • Caution because of case reports of suspected toxicity in prematurely born infants (transient adrenal insufficiency, life-threatening brady arrhythmia, cardiac insuffiency, lactic acidosis, acute renal failure, central nervous system and respiratory depression. Toxicity may be due to the drug itself and/or propylene glycol 15.3%, and ethanol 42.4% contained in the oral solution). If there is lack of options and lopinavir/r is given to infants <14 days of age and/or younger than gestational age 42 weeks, administration should be done in hospital under close observation (Grade of recommendation D). • Lopinavir/r 300 mg lopinavir/75 mg ritonavir/m^2 q12h.

Table 2. Follow-up of infants born to HIV-infected mothers.

Clinical evaluation and blood sampling
• 0–3 days	HIV RNA. Umbilical cord blood should not be used, due to the risk of contamination with maternal blood. Sampling may be performed at the same time as the PKU test at >48 h of age to minimize the number of sampling occasions
• 6 weeks	HIV RNA
• 4 months	HIV RNA
• 20–24 months	HIV antibodies

This scheme applies to children with an indeterminate or negative HIV status. The number of sampling occasions is decreased compared to previous recommendations and it is important that all samplings are performed on recommended time and that results is received on all tests. Otherwise the diagnosis of an HIV-infected infant may be seriously delayed. If an HIV infection is suspected or established, antiretroviral treatment should be considered, and the follow-up and sampling schedule should be intensified.