Red Flags
- HIV-positive mother in late pregnancy or active labour without ART — emergency ART initiation; intrapartum/postpartum infant prophylaxis intensified[1]
- Acute seroconversion during pregnancy — high transmission risk; immediate ART, viral load monitoring, paediatric HIV consult[1]
- Infant exposed to HIV with detectable viral load at birth (high-risk) — extended dual or triple infant prophylaxis per protocol[1]
- Maternal viral load not suppressed at delivery — caesarean section consideration, intensified infant prophylaxis[1]
First-line treatment
Interventions
- Mode of delivery[1]Vaginal delivery acceptable when maternal viral load <1000 copies/mL near term. Elective caesarean at 38 weeks if VL ≥1000 or unknown
- Infant feeding[1]Exclusive breastfeeding for 6 months while mother on suppressive ART per WHO; or exclusive replacement feeding if AFASS criteria (acceptable, feasible, affordable, sustainable, safe). Avoid mixed feeding
- Family-centred screening[1]Test partner and previous children of HIV-positive pregnant women; integrate syphilis elimination
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Tenofovir + lamivudine + dolutegravir (maternal ART)[1] | NRTI + NRTI + INSTI | Tenofovir 300 mg + lamivudine 300 mg + dolutegravir 50 mg PO once daily, lifelong | — | Preferred maternal ART per WHO 2021+ updates and Tsepamo safety reassurance; lifelong regardless of CD4 |
| Nevirapine syrup (infant prophylaxis)[1] | NNRTI | Not applicable — paediatric prophylaxis only | 10 mg PO once daily for ≥4 weeks (low-risk) or 6 weeks (high-risk); replace with zidovudine + nevirapine combination in high-risk infants | Alternative or addition to zidovudine prophylaxis in HIV-exposed infants per risk |
| Zidovudine syrup (infant prophylaxis)[1] | NRTI | Not applicable — paediatric prophylaxis only | 4 mg/kg PO BD × 6 weeks (low-risk) or 12 weeks (high-risk) | Standard infant prophylaxis; combine with nevirapine in high-risk |
| Cotrimoxazole prophylaxis (HIV-exposed infants)[1] | Folate-pathway inhibitor | Not applicable — paediatric prophylaxis only | Per weight from 4–6 weeks until HIV negative status confirmed at 18 months | PCP prevention in HIV-exposed infants until exposure status resolved |
Tenofovir + lamivudine + dolutegravir (maternal ART)[1]
NRTI + NRTI + INSTI
- Adult
- Tenofovir 300 mg + lamivudine 300 mg + dolutegravir 50 mg PO once daily, lifelong
- Paediatric
- —
Preferred maternal ART per WHO 2021+ updates and Tsepamo safety reassurance; lifelong regardless of CD4
Nevirapine syrup (infant prophylaxis)[1]
NNRTI
- Adult
- Not applicable — paediatric prophylaxis only
- Paediatric
- 10 mg PO once daily for ≥4 weeks (low-risk) or 6 weeks (high-risk); replace with zidovudine + nevirapine combination in high-risk infants
Alternative or addition to zidovudine prophylaxis in HIV-exposed infants per risk
Zidovudine syrup (infant prophylaxis)[1]
NRTI
- Adult
- Not applicable — paediatric prophylaxis only
- Paediatric
- 4 mg/kg PO BD × 6 weeks (low-risk) or 12 weeks (high-risk)
Standard infant prophylaxis; combine with nevirapine in high-risk
Cotrimoxazole prophylaxis (HIV-exposed infants)[1]
Folate-pathway inhibitor
- Adult
- Not applicable — paediatric prophylaxis only
- Paediatric
- Per weight from 4–6 weeks until HIV negative status confirmed at 18 months
PCP prevention in HIV-exposed infants until exposure status resolved
Safety-net
- Take ART every day during and after pregnancy — interruptions raise viral load and transmission risk to your baby[1]
- Bring your baby for HIV PCR testing at the scheduled times even if they look well — early diagnosis allows life-saving treatment[1]
- Tell your obstetrician about ART early; some delivery plans (caesarean, intrapartum AZT) are based on your viral load near term[1]
Referral criteria
- Late pregnancy or labour HIV diagnosis without ARTEmergency PPTCT and obstetric care; immediate ART initiation[1]
- Maternal viral load not suppressed near termPPTCT and obstetric medicine for delivery planning and intensified infant prophylaxis[1]
- HIV-exposed infant with positive PCRPaediatric HIV / ART centre to initiate paediatric ART[1]
- Maternal acute seroconversion during pregnancy or breastfeedingPPTCT centre for immediate ART and serial viral load monitoring[1]
Clinical summary
Antenatal HIV screening, lifelong maternal ART, infant prophylaxis, and safe-feeding choices to eliminate vertical transmission of HIV.