Use of antiretrovirals in newborns

The recommendation from the US Centers for Disease Control and Prevention (CDC) for a health care worker with exposure of non-intact skin to a small volume of secretions from an HIV-infected person with an undetectable viral load is that he or she should receive 2 antiretroviral drugs for 4 weeks.¹ If the viral load of the HIV-infected person is more than 1500 RNA copies/mL and the volume of secretions is large, the health care worker should receive 3 antiretroviral drugs.¹

In contrast, the Canadian consensus guidelines for the management of pregnancy, labour and delivery and for postpartum care of HIV-positive women and their offspring² recommend that infants born to women who received suboptimal or no antiretroviral therapy during pregnancy should be given only the usual 6 weeks of oral zidovudine plus a single dose of nevirapine. There is an understandable reluctance to prescribe drugs to neonates when there is limited information on efficacy, correct dose and adverse effects in this age group. However, in the section on preconception counselling, the guidelines² advocate the use of a wide variety of antiretrovirals during the second and third trimester of pregnancy. They also state, “In women who would benefit from antiretroviral intervention before becoming pregnant, the objective is to achieve stable, maximal suppression of the viral load before conception.” Presumably, the antiretrovirals administered for this purpose would be continued throughout the first trimester. I am therefore surprised that the authors are reluctant to recommend at least a 2-week course of combination antiretrovirals for an infant with a significant risk of acquiring HIV. Surely it is worth exposing an infant to a combination of drugs that appears safe but for which we have only limited data if there is any reasonable possibility that the regimen will prevent HIV infection.

Joan L. Robinson Stollery Children's Hospital Edmonton, Alta.