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Section 8 — Infectious Disease & Sepsis Verify against local policy v1.0 · July 2026 Baylor Ed. 33 cross-checked Sept 2026

Chapter 8.6 — Perinatal HIV & Hepatitis B

Preventing mother-to-child transmission: risk-stratified infant antiretroviral prophylaxis and testing for HIV, and the hepatitis B birth-dose vaccine ± immunoglobulin — built on West Midlands Neonatal Guidelines 2025–28, BHIVA/CHIVA and WHO/AAP guidance

Educational guideline — verify locally. Infant antiretroviral regimens, testing schedules, feeding advice, and hepatitis B vaccine/HBIG timing are country- and risk-specific and change over time; verify against current national HIV/hepatitis guidelines and specialist advice. Does not replace attending or specialist judgment.
BEDSIDE ACTION BOX

1. Overview

Overview

Perinatal (vertical) transmission of HIV and hepatitis B is highly preventable. For HIV, maternal antiretroviral therapy, appropriate delivery planning, risk-stratified infant antiretroviral prophylaxis, virological testing, and feeding advice together reduce transmission to very low levels. For hepatitis B, the timely birth-dose vaccine (with immunoglobulin for high-risk infants) and completion of the series prevent most perinatal infection. Both require early identification, national-protocol-guided management, and specialist involvement.

Why This Topic Matters

Missed or delayed prophylaxis leads to preventable lifelong infection. The interventions are simple and effective but time-sensitive (start ART prophylaxis and give the hepatitis B birth dose promptly), and correct testing (HIV PCR, not antibody) avoids misdiagnosis.

2. Who This Guideline Applies To

Scope
  • Infants born to mothers with HIV and/or hepatitis B (HBsAg-positive or unknown status).
  • Teams delivering prophylaxis, testing, immunization, and feeding advice.
  • Cross-references: congenital infections (8.3), immunizations (5.5), and discharge/follow-up (2.5).

3. Key Definitions

TermDefinition
MTCT / vertical transmissionMother-to-child transmission of infection.
Infant ART prophylaxisPost-exposure antiretroviral(s) to prevent HIV acquisition; regimen by maternal risk.
HIV virological (PCR) testDetects the virus (not antibody) — required in infants because maternal antibody crosses the placenta.
HBIGHepatitis B immunoglobulin — passive immunity for high-risk exposed infants.
Birth doseHepatitis B vaccine given soon after birth to prevent perinatal HBV.

4. HIV — Prevention of Transmission

Risk-Stratified Infant Prophylaxis
  • Maternal ART with a suppressed viral load is the foundation; delivery mode and intrapartum management follow obstetric/HIV policy.
  • Start infant antiretroviral prophylaxis as soon as possible after birth (ideally within hours).
  • The regimen depends on maternal transmission risk: low risk (suppressed maternal viral load) generally receives single-drug prophylaxis for a defined period; higher risk (detectable/unknown viral load, late/poor treatment) receives combination (multi-drug) prophylaxis per national protocol.
  • Follow the current national guideline for exact drugs, doses, and duration; involve specialist HIV services.
How risk is classified (Baylor Ed. 33, from the US perinatal HIV guidelines)

The birthing parent's viral load is the single most important factor — the higher it is and the longer viraemia lasts, the greater the risk. In-utero transmission rises with gestational age and peaks in the third trimester, but the intrapartum period carries the highest risk overall. Viraemia may be documented or presumed — a new or acute diagnosis in pregnancy, no ART, or a known lapse in adherence all count as presumed viraemia.

  • Low risk (both periods): under 50 copies/mL from 20 weeks through delivery — ideally two consecutive tests at least 4 weeks apart. Levels before 20 weeks do not change this.
  • Low-to-moderate risk for the in-utero period: ≥50 copies/mL between 20 weeks and 4 weeks before delivery, but under 50 in the final 4 weeks — intrapartum risk stays low.
  • High risk (both periods): ≥50 copies/mL within the 4 weeks before delivery. Earlier levels do not alter this.

Start antiretrovirals as close to birth as possible, preferably within 6 hours. A scheduled caesarean may be advised when the viral load is above 1000 copies/mL or unknown. With current strategies, transmission in the US and Europe is under 1% — and stays under 1%, though not zero, with breastfeeding if the parent maintains an undetectable load on strict ART.

Risk groupInfant regimenVirological testing schedule
Low riskZidovudine monotherapy for 2 weeksBirth (recommended for all, required if breastfeeding), 14–21 days, 1–2 months (timed at least 2 weeks after zidovudine stops), 4–6 months
High riskPresumptive three-drug therapy for 2–6 weeks — zidovudine, lamivudine, and either nevirapine or raltegravir. Raltegravir if the parent has HIV-2, which is not susceptible to nevirapine. Only zidovudine, lamivudine and nevirapine are approved below 37 weeks. If the three-drug course runs under 6 weeks, continue zidovudine alone to complete 6 weeks.Birth, 14–21 days, 1–2 months, 2–3 months (2–6 weeks after the drugs stop), 4–6 months
Neither low nor highThree-drug presumptive therapy for 2–6 weeks or zidovudine prophylaxis for 2–6 weeks, decided case by case. If the birth NAT is negative, de-escalate to zidovudine alone. Every infant in this group gets at least 2 weeks of zidovudine.As for high risk, with the post-treatment test timed to the actual duration
Unconfirmed parental status, or infant with a positive HIV antibody testThree-drug presumptive therapy as for high risk. If supplemental testing confirms the birthing parent does not have HIV, stop all infant antiretrovirals.Birth HIV NAT
Drug and gestational age at birthInitial doseDose change
Zidovudine, ≥35 weeks4 mg/kg/dose twice dailyNone
Zidovudine, ≥30 to <35 weeks2 mg/kg/dose twice dailyIncrease to 3 mg/kg/dose twice daily at 2 weeks
Zidovudine, <30 weeks2 mg/kg/dose twice dailyIncrease to 3 mg/kg/dose twice daily at 4 weeks
Lamivudine, ≥32 weeks2 mg/kg/dose twice dailyIncrease to 4 mg/kg/dose twice daily at 4 weeks
Nevirapine, ≥37 weeks6 mg/kg/dose twice dailyNone
Nevirapine, ≥34 to <37 weeks4 mg/kg/dose twice dailyIncrease to 6 mg/kg/dose twice daily at 1 week
Nevirapine, ≥32 to <34 weeks2 mg/kg/dose twice dailyIncrease to 4 mg/kg at 2 weeks, then 6 mg/kg at 4 weeks
Nevirapine extended prophylaxis during breastfeeding (≥32 weeks), 10 mg/mL suspension once daily: birth to 6 weeks — 10 mg (1 mL) at 2 to <3.0 kg, 15 mg (1.5 mL) at ≥3.0 kg; 6 weeks to 6 months — 20 mg (2 mL); 6 to 9 months — 30 mg (3 mL); 9 to 18 months — 40 mg (4 mL). Continue until 6 weeks after weaning.

Baylor Ed. 33, Table 9-8. The intravenous zidovudine dose is 75% of the oral dose at the same interval, and zidovudine is not recommended for prophylaxis beyond 6 weeks. The FDA has not approved a nevirapine dose below 1 month — the figures come from modelling and expert opinion. Verify against clinicalinfo.hiv.gov and a paediatric HIV expert; the National Perinatal HIV Hotline is 888-448-8765.

Feeding, monitoring and co-infection
  • Stop breastfeeding temporarily if the parent's viral load becomes detectable, while it is rechecked and the cause explored; stop permanently at ≥200 copies/mL, or with cracked, bleeding nipples or mastitis. Replacement feeding is strongly recommended when the parent is not on ART or not suppressed. New viraemia during breastfeeding: start three-drug therapy (zidovudine, lamivudine, dolutegravir) for 2–6 weeks — dolutegravir cannot be used below 4 weeks or 3 kg, so use nevirapine or raltegravir instead.
  • Testing while breastfeeding: birth, 14–21 days, 1–2 months, 2–4 months if the gap would exceed 3 months, 4–6 months; at least every 3 months beyond 6 months of breastfeeding; and after weaning at 4–6 weeks and 4–6 months.
  • Two negative virological tests exclude HIV in a non-breastfed infant — the first at ≥1 month and at least 2–6 weeks after antiretrovirals stop, the second at ≥4 months, with no other evidence of infection. Antibody and antigen/antibody tests must not be used under 18 months because of transplacental maternal antibody. Do the birth NAT before starting antiretrovirals or immediately after; if it is positive, start three-drug therapy at once without waiting for the confirmatory result.
  • Haematology: baseline haemoglobin and neutrophil count before presumptive multi-drug therapy, repeated if it continues past 4 weeks.
  • PJP prophylaxis with trimethoprim-sulfamethoxazole from 4–6 weeks in all high-risk exposed infants whose testing has not excluded infection.
  • Screen for congenital CMV — commoner in HIV-exposed infants — with CMV PCR on urine or saliva within the first 21 days, and evaluate for HSV, hepatitis B and C, syphilis, toxoplasmosis, tuberculosis and Zika if the parent has or may have them.

5. HIV — Infant Testing

Use Virological (PCR) Testing
  • Test with HIV virological (PCR/nucleic-acid) assays at the nationally scheduled time points (e.g., early after birth, and further tests over the first weeks/months), because maternal antibody makes infant antibody tests unreliable until later infancy.
  • A final antibody test later (per protocol) confirms clearance of maternal antibody and definitive non-infection.
  • Continue prophylaxis and follow-up per national policy; involve specialist services for interpretation.

6. Infant Feeding

Follow National Policy
  • Replacement feeding — properly prepared formula or pasteurized donor milk — eliminates postnatal transmission, and is recommended when the parent is not consistently virally suppressed.
  • Where WHO guidance applies (many settings), exclusive breastfeeding with maternal ART may be recommended because the benefits outweigh a small residual risk.
  • Support the mother's informed, policy-consistent decision; provide feeding support and confidentiality.
Current US approach: shared decision-making (Baylor Ed. 33)
  • Offer evidence-based counselling on every feeding option and agree the plan together. Many parents with HIV have cultural or medical reasons to want to breastfeed — explore and respect them, and support the plan once chosen.
  • With consistent viral suppression through pregnancy and postpartum, breastfeeding transmission risk falls below 1% — but not to zero.
  • If breastfeeding is chosen, exclusive breastfeeding for up to 6 months is preferred over mixed feeding, though intermittent formula may be medically needed.
  • Involve paediatric retrovirology in any decision to breastfeed (ideally prenatally) and tell them about any formula supplementation. Baylor's retrovirology team usually recommends zidovudine, nevirapine and lamivudine for 4–6 weeks plus HIV RNA testing at birth (see the prophylaxis table above).
  • NICU: pumped and stored milk may need infection-control processes many units do not yet have; decide the use of mother's own milk for preterm infants case by case with retrovirology.

Updated: this page previously said formula is "generally recommended" in high-income settings. That reflects older US guidance. Baylor Ed. 33 — in line with the current US perinatal HIV guidelines and AAP — now frames the choice as shared decision-making, recommending replacement feeding specifically when viral suppression is not consistent.

7. Hepatitis B

Birth-Dose Vaccine ± HBIG
  • Give the hepatitis B vaccine birth dose promptly to infants of HBsAg-positive or unknown-status mothers (and per universal birth-dose programs).
  • Add HBIG for infants of HBsAg-positive mothers within the recommended window per policy.
  • For very-low-birth-weight infants of HBsAg-positive mothers, the birth dose may not count toward the primary series (give it plus HBIG, then complete the standard series) — verify locally.
  • Complete the hepatitis B series on schedule and arrange post-vaccination serology testing per policy; breastfeeding is not contraindicated once vaccinated/HBIG given.
Maternal statusBirth weightHepatitis B vaccine (5 mcg of the 10 mcg/mL product)HBIG 0.5 mL IM
HBsAg positiveAll birth weightsWithin 12 hours of birth, concurrently with HBIG but at a separate siteWithin 12 hours of birth, separate syringe and site
HBsAg negative<2000 gAt 1 month of age or hospital discharge, whichever comes first—
≥2000 gWithin 24 hours of birth—
HBsAg unknown<2000 gWithin 12 hours of birthWithin 12 hours of birth, unless the maternal status is confirmed negative by then
≥2000 gWithin 12 hours of birthWithin 7 days if maternal status is confirmed positive; otherwise by 7 days of life or at discharge, whichever is first, if the status is still unknown

Baylor Ed. 33, Table 9-7. Below 2000 g the birth dose does not count toward the three-dose series — those infants need four doses in total. Arrange primary-care follow-up at 1 month (preferable) to 2 months chronological age regardless of birth weight or gestation, and again at 6 months, for doses 2 and 3. Test infants of HBsAg-positive mothers for HBsAg and anti-HBs at 9–12 months, after at least three vaccine doses. Without prophylaxis, vertical transmission runs at 70–90% when the mother is HBsAg and HBeAg positive, and 5–20% when HBeAg negative; up to 90% of infants infected perinatally develop chronic infection, typically appearing as chronic antigenaemia with mild enzyme rises from 2–6 months rather than as neonatal illness (under 1% show signs at birth).

7+. No Maternal History: the Abandoned Newborn and the Non-Sterile Delivery (Baylor Ed. 33)

Well-appearing abandoned newborn — assume every exposure is unknown
  • Where: estimate gestation with a Ballard score — 35 weeks or more and clinically stable: consider the mother–baby unit; below 35 weeks: NICU.
  • Consults: social work and paediatric retrovirology.
  • Laboratory: point-of-care glucose, chemistries, liver function tests, CBC, RPR, HSV blood PCR and HSV surface PCR, urine drug screen and meconium drug panel, blood culture, and rapid HIV antibody/antigen testing — starting antiretroviral therapy while results are pending, as retrovirology advises (see the HIV section above).
  • Medications: IM vitamin K, erythromycin eye prophylaxis, hepatitis B vaccine plus HBIG, tetanus immunoglobulin, and empiric ampicillin plus amikacin for a 48-hour rule-out (aminoglycoside choice per local antibiogram).
  • If clinical or laboratory findings raise concern for sepsis: lumbar puncture for CSF culture, cell count and HSV PCR; start IV acyclovir; transfer to the NICU if the infant is on the mother–baby unit.
Non-sterile delivery — think about tetanus
  • Judge infection risk case by case. When the cord was not cut with a sterile instrument, neonatal tetanus becomes a consideration — the risk is low, because most immunized mothers pass on protective antibody.
  • If maternal tetanus immunization is unknown or inadequate and the cord was cut non-sterilely: give tetanus immunoglobulin 250 IU IM as soon as possible, regardless of age or weight. If it is unavailable, give IVIG.

8. Management Algorithm

1
Identify exposure at/before birth
Review maternal HIV status/viral load and hepatitis B status; plan prophylaxis in advance.
2
HIV: start prophylaxis promptly
Risk-stratified infant ART as soon as possible; single vs combination per maternal risk and national policy.
3
HIV: schedule virological testing & feeding
PCR at scheduled time points; feeding advice per national policy; specialist follow-up.
4
Hepatitis B: vaccine ± HBIG
Birth-dose vaccine promptly; HBIG for HBsAg-positive exposure; complete the series; VLBW rules.
5
Follow-up & support
Serology (HBV) and definitive HIV status per protocol; specialist and family/psychosocial support; confidentiality.
6
⚠ Do-not-miss
Delayed prophylaxis/birth dose; using HIV antibody (not PCR) in infants; missed HBIG; and incomplete series/follow-up.

9. Monitoring & Follow-up

ItemDetail
HIV virological testsAt scheduled time points; final antibody test to confirm non-infection.
Infant ART prophylaxisAdherence, tolerance, and (per regimen) hematological monitoring.
Hepatitis B series & serologyComplete series; post-vaccination serology per policy.
Feeding & growthSupport policy-consistent feeding; monitor growth.
Specialist follow-upPediatric infectious diseases; psychosocial and confidentiality support.

10. Precautions

Safety Cautions
  • Start infant HIV prophylaxis and the hepatitis B birth dose promptly — these are time-sensitive.
  • Use HIV virological (PCR) testing in infants — not antibody tests.
  • Give HBIG to infants of HBsAg-positive mothers within the recommended window; verify VLBW hepatitis B rules.
  • Follow current national policy for regimens, testing, and feeding (these change over time).
  • Maintain confidentiality and provide non-judgmental family/psychosocial support; involve specialists.

11. Escalation & Family Support

Family-Centered Communication
  • "There are very effective ways to protect your baby from catching HIV or hepatitis B. We give your baby medicine or a vaccine soon after birth and do specific tests to make sure they stay well."
  • "We'll support you with feeding advice and follow-up, and everything is kept confidential."

12. Key Pearls

High-Value Clinical Pearls
  • Start infant HIV antiretroviral prophylaxis ASAP; regimen (single vs combination) depends on maternal transmission risk.
  • Test infants for HIV with virological PCR, not antibody (maternal antibody crosses the placenta).
  • Feeding advice follows national policy (formula in high-income settings; breastfeeding with ART where WHO guidance applies).
  • Hepatitis B: prompt birth-dose vaccine, plus HBIG for HBsAg-positive exposure; complete the series and check serology.
  • VLBW HBsAg-exposed infants have schedule-specific hepatitis B rules.
  • Involve specialists; maintain confidentiality and family support.

13. Common Mistakes to Avoid

MistakeWhy it harmsBetter practice
Delaying prophylaxis/birth dose.Preventable infection.Start promptly.
HIV antibody testing in infants.False positives (maternal antibody).Use virological PCR.
Fixed single-drug for all HIV exposure.Under-prophylaxis in high risk.Risk-stratify (single vs combination).
Missing HBIG.HBV transmission.HBIG for HBsAg-positive exposure.
Ignoring VLBW HepB rules.Inadequate protection.Follow schedule-specific rules.

14. Board-Style High-Yield Summary

Key Takeaways
  • HIV: maternal ART + risk-stratified infant prophylaxis (single vs combination) started ASAP + virological PCR testing + policy-based feeding.
  • Use HIV PCR (not antibody) in infants; a later antibody test confirms non-infection.
  • Feeding: formula in high-income settings; breastfeeding with ART where WHO guidance applies.
  • Hepatitis B: prompt birth-dose vaccine + HBIG for HBsAg-positive exposure; complete series; serology.
  • VLBW HBsAg-exposed infants have schedule-specific hepatitis B rules.
  • Follow current national policy, involve specialists, and maintain confidentiality/family support.

15. References

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