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P29 Infant postnatal prophylaxis (PNP) following maternal viraemia during breastfeeding with human immunodeficiency virus (HIV)
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  1. Neil Tickner1,
  2. Emily Lees2,
  3. Hermione Lyall1,
  4. Paddy McMaster3,
  5. Birgitte Smith4,
  6. Lucy Cliffe5,
  7. Graham Taylor6,
  8. Caroline Foster1
  1. 1Imperial College Hospitals NHS Trust, London
  2. 2University of Oxford, Oxford Children’s Hospital
  3. 3Manchester University NHS Foundation Trust
  4. 4Hvidovre Hospital, Copenhagen University Hospital
  5. 5Nottingham University NHS Foundation Trust, Nottingham Children’s Hospital
  6. 6Department of Retrovirology, Imperial College London

Abstract

Background Increasingly, women living with HIV in resource-rich settings are choosing to breastfeed, but experience in managing maternal viraemia during breastfeeding and transmission risks to the infant are limited. In low- to middle-income settings, the overall postnatal risk of HIV transmission via breast milk when women are treated with combination ART has been reported as 0.30 (95% CI 0.1–0.6) to 1.08% (95% CI 0.32–1.85) at 6 months.1 2

Method Case series from the Paediatric Virtual Clinic (PVC) including national and international referrals.

Results Case 1:

Term infant, mother suppressed on tenofovir disoproxil/emtricitabine, darunavir/ritonavir. Received 4 weeks of zidovudine (AZT) after birth; maternal and infant viral load (VL) at 0 and 6 weeks undetectable. At 3 months, maternal VL 760 copies/mL. Breastfeeding discontinued, infant started neonatal dose PNP (AZT 4 mg/kg/BD, Lamivudine(3TC) 2 mg/kg/BD, Nevirapine 4 mg/kg/OD). Following PVC discussion, changed to treatment doses: dolutegravir (DTG dispersible 5 mg/OD), 3TC (5 mg/kg/BD), AZT (12 mg/kg/BD) for one month.

Case 2:

Term infant, mother suppressed on DTG, abacavir, 3TC. Received 2 weeks of AZT after birth; maternal and infant VL at 0 and 4 weeks undetectable. At 1 month, maternal VL 451 copies/mL. Breastfeeding discontinued and infant started PNP (dosing as above). Dispersible DTG unavailable; DTG half 10 mg film-coated tablet administered. Following PVC discussion, increased to 10 mg whilst dispersible DTG obtained.

Case 3:

Three-year old exclusively breastfed for 6 months, ongoing nocturnal breastfeeds. New maternal HIV diagnosis after prolonged febrile illness; VL 126,381 copies/mL. Antenatal serology negative, child VL undetectable and antibody negative. Breastfeeding discontinued with difficulty, despite behavioural support and cabergoline provision (with dosing for established lactation). PNP commenced with DTG, 3TC, AZT for one month.

All children were confirmed HIV uninfected 12 weeks post-PNP.

Conclusions These cases highlight the MDT challenges and paediatric clinical pharmacist expertise required to support interventional PNP in infancy and early childhood following maternal viraemia during breastfeeding. National guidelines are needed. Case 1 shows the importance of establishing the correct drug regime using treatment doses. Neonatal PNP dosing is not appropriate after 4 weeks of age and dolutegravir is a more appropriate third agent added to an NRTI backbone. Case 2 highlights the difference in bioavailability between dispersible and film-coated tablet DTG formulations; with dosing ratio of ~1:1.6 respectively. Although the barrier to resistance of DTG is high, treatment failure is reported with suboptimal drug levels. Maternal seroconversion during breast feeding causes up to 50% of mother-to-infant transmissions worldwide; Case 3 highlights the difficulty of prompt cessation of established breastfeeding despite pharmacological and family support, and consideration of the risk of transmission in an older child.

References

  1. Flynn P, Taha T, Cababasay MP, et al. Prevention of HIV-1 transmission through breastfeeding: Efficacy and safety of maternal antiretroviral therapy versus infant nevirapine prophylaxis for duration of breastfeeding in HIV-1-infected women with high CD4 cell count (IMPAACT PROMISE): a randomized, open label, clinical trial. J Acquir Immune Defic Syndr 2018;77:383–392.

  2. Bispo S, Chikhungu L, Rollins N, et al. Postnatal HIV transmission in breastfed infants of HIV-infected women on ART: a systematic review and meta-analysis. J Int AIDS Soc 2017;20:1–8.

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