Prenatal Period

• A paediatric consultant (usually Dr Rowley) should aim to see the parent and discuss the
  postnatal management of the infant with her. A High Risk obstetrician and Obstetric Physician
  will usually monitor the pregnancy.
• A copy of this guideline should be placed in the mother's notes for reference during the
  pregnancy and labour/delivery.
• Maternal blood specimen should be taken for HIV PCR prior to zidovudine being commenced. If not an established patient here, send to be processed by Auckland City Hospital Department of Virology and Immunology, LabPlus, Building 31, Auckland Hospital (3x EDTA tubes). This will confirm that the mother's virus is detectable by PCR in the Auckland system.
• Confirm that zidovudine syrup is available at the Auckland City Hospital Pharmacy. This will ensure availability if there is premature delivery. Liaise with paediatric pharmacist 93- 4136.
• Obtain details of maternal antiretroviral treatment during pregnancy and current HIV viral load prior to delivery.

Post Delivery

• Vitamin K should be given intramuscularly once the baby has been bathed. The baby is to be admitted to the postnatal ward, and the number of paediatric staff involved in the care of the baby should be kept to a minimum.
• Breastfeeding is contraindicated (as there is an increased risk of HIV transmission to babies, and an alternative - that is, infant formula - is available).
• Anti-retroviral treatment should be commenced within 4 hours of birth. Zidovudine oral liquid is stocked on NICU, ward 98 and labour & Birthing suite.

Testing

• Any positive PCR test must be confirmed by repeat test to confirm infection.
• Repeat HIV PCR and antibody testing after 18months is necessary until the serology is negative.
• If there is concern regarding confidentiality, it is optional to use a code for all lab forms: 4 letter, 6 number code - first 2 letters of the last name, first letter of the Christian
   

Treatment

Antiretrovirals

The firstline choice for all babies is:

• Zidovudine (AZT):  see zidovudine protocol.

Possible additions to therapy following discussion between the neonatologist and paediatric ID team are -

• Nevirapine if indicated 2mg/kg, single dose to be given ASAP within 3 days of birth. As this is non formulary - contact the pharmacist in advance to arrange a supply.
• Lamivudine (3TC, 10mg/ml) 2mg/kg/dose twice-daily to start within 8 hours of delivery. As this is non formulary - contact the pharmacist in advance to arrange a supply.

Prophylaxis:

• If the initial PCR is positive or if the mother has an unsuppressed viral load at delivery, start Co-Trimoxazole 0.5mls/kg, daily at 6 weeks. Stop when testing at 4 months confirms absence of HIV infection.

Immunisations

• No BCG vaccination or other live vaccines should be given until it is clear that the infant is HIV negative at the final test performed at 12-18 months. If there is extremely high TB risk (eg. mother on active treatment) discuss with ID team regarding earlier BCG immunisation.
  • Inform the parents that their baby should not receive BCG vaccination so that they can inform community health workers who may offer immunisation prior to the infant's negative status being confirmed.
  • Include this information in the discharge letter to avoid inadvertent BCG immunisation.

People to be Contacted

1. Neonatologists – Dr Simon Rowley (or in his absence, the on-call Level 2 specialist) should be contacted during normal working hours.
   • If the baby is born overnight, the on-duty registrar or NS-ANP should be contacted immediately after delivery and should notify Dr Rowley (or the on-call specialist) at the first available opportunity.
   • Paediatric Infectious Disease Team (Dr L Voss, through ADHB operator). Phone as well as written consultation form should be sent.
   • Virologist - Dr K Croxson, Department of Virology and Immunology, LabPlus Building 31, Auckland Hospital, ext 6130, loc 93-4197, should be informed that the bloods are being sent.
2. Virologist - Dr K Croxson, Department of Virology and Immunology, LabPlus Building 31, Auckland Hospital, ext 6130, loc 93-4197, should be informed that the bloods are being sent.

Follow Up

Dr Rowley will follow these babies at the Neonatal Outpatient Clinic until 18 months, unless they are infected when care will be transferred to Dr L Voss, Starship Children’s Hospital.

•  ALL babies require a discharge letter to the GP, copied to Dr Rowley, Dr L Voss and parents.

Arranging Discharge Medication

• As a rule anti-retroviral therapy for discharge is not supplied by the ward. Discharge planning for antiretroviral oral liquids will require application for Special Authority with endorsement from an approved antiretroviral prescriber eg. S.Rowley, L.Voss, E.Best, E.Wilson or D.Lennon.
  On the assumption that the Special Authority will be approved the outpatient supplies should be obtained by the clinician from a community pharmacy eg. Level 5 Pharmacy Auckland City Hospital or Grafton Pharmacy, and handed to the mother, along with some oral syringes prior to discharge.
   
• Notify the ward pharmacist of any pending discharge patient and ensure the mother/caregiver has been instructed in administration and is competent.