Prevention of mother-to-child HIV transmission

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]

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

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

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

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]

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]

Antenatal HIV screening, lifelong maternal ART, infant prophylaxis, and safe-feeding choices to eliminate vertical transmission of HIV.

1.NACO National Guidelines for Prevention of Parent-to-Child Transmission of HIV (PPTCT); WHO Consolidated Guidelines on HIV Testing, Treatment, and PMTCT (2024)