Case Report Follows Postpartum Mother-to-Child HIV Transmission

A case report published in Pediatrics discusses potential ways to prevent mother-to-child transmission (MTCT) of HIV through the case of a mother who failed to receive her HIV-1 diagnosis until months after giving birth and only then following the diagnosis of both HIV-1 and Pneumocystis jirovecii pneumonia in her child.

Although MTCT of HIV is infrequent in the United States, the authors emphasize the importance of understanding each transmission to identify missed opportunities among common cases.

This case at the center of their report focuses on a married, multiparous woman in her early 30s from New York state who did not receive her diagnosis until 4 days after her child, which occurred at age 28 weeks and after 11 medical care encounters, “with persistent and deteriorating symptoms,” the authors noted.

The mother’s first prenatal visit occurred at 10 weeks gestation, and she received regular prenatal care throughout her pregnancy, which was deemed uncomplicated. Although maternal prenatal testing did result in a group B Streptococcus diagnosis, there were no documented sexually transmitted infections (STIs). In addition, HIV tests came back negative during her first trimester (fourth-generation antigen and antibody [Ab]) and at labor and delivery (third-generation rapid HIV-1 and HIV-2 Ab).

However, the authors noted the third-generation test may not have caught acute infection.

“Hospital policy, driven largely by its location in a high HIV prevalence area, requires expedited testing at labor and delivery, if no maternal third trimester HIV test is documented in the medical record,” the authors explained.

The infant was born at 39 weeks’ gestation, weighing approximately 6.5 lb, and received a diagnosis for an inherited genetic disorder, with referrals for genetic counseling and evaluation. A dried blood sample tested negative for maternal HIV-1 immunoglobulin G antibodies; this test was performed in the 48 hours following the birth.

“Nonspecific symptoms, unrelated to the inherited genetic disorder, were first documented at the age of 15 weeks when the infant presented with a 10-day history of fever, dry cough, posttussive vomiting, diarrhea, and sneezing,” the authors wrote. “Sneezing subsided but the remaining symptoms persisted and progressed to include decreased appetite, refusal to breastfeed, and vomiting with oral intake.”

The infant was relocated from an ambulatory clinic to the emergency department (ED) for supportive therapy at age 17 weeks old, was evaluated by various subspeciality providers from ages 23 to 27 weeks, and received a diagnosis of gastroesophageal reflux disorder around age 27 weeks. After struggling to gain weight and experiencing respiratory decompensation, the child was hospitalized and received an HIV-1 diagnosis at age 28 weeks, or 6.5 months.

“HIV-1 viral load at diagnosis was > 10 000 000 copies/mL (7 log copies/mL); cluster of differentiation 4 T lymphocyte count was 278 cells/mm³,” the authors explained. “Bronchial lavage identified Pneumocystis jirovecii pneumonia.”

At the same time the infant’s symptoms were first documented, the mother—after attending 3- and 6-week postpartum visits—presented with symptoms including tactile fever, chills, and vomiting. A week later, she admitted herself to the ED for whole-body aches, fever, nausea, and debilitating headache. The mother seroconverted postnatally and also received an HIV diagnosis around 28 weeks postpartum. The mother’s partner was not screened during the antenatal or postpartum period.

According to the authors, transmission likely occurred through breastfeeding, but MTCT during pregnancy or birth cannot be fully ruled out, and the timing of infection and seroconversion is vital to understand and prevent MTCT in breastfeeding infants. In the context of antiretroviral therapy, data are currently inconclusive on whether exclusive breastfeeding or mixed feeding affect MTCT. While the CDC, American Academy of Pediatrics, and other groups have established recommendations for mothers with HIV, they are insufficient to protect infants whose mothers seroconvert in the postpartum period, the authors wrote.

“The assessment of risks to mother and infant, including maternal risk behaviors and partner testing, must extend beyond pregnancy and be a routine component of prenatal, discharge, postpartum, and early pediatric care, with messaging tailored to mothers and their partners about prevention of HIV and STIs,” the authors concluded. “Even with extensive screening, [acute HIV infection] may be missed, but HIV should always be considered when individuals are symptomatic, partners have not been (recently) screened (as part of routine and ‘sick visit’ care), and even when maternal testing was recent and negative.”

Reference

Swain C-A, Kaufman S, Miranda W, et al. Postpartum mother-to-child transmission of HIV in a breastfeeding infant. Pediatrics. Published online January 19, 2022. doi:10.1542/peds.2021-051360