PREVENTING

AND

HIV

INFECTION

IN

INFANTS,

CHILDREN,
YOUTH

The most important strategies to prevent MTCT in theUnited States have been administering
ARV drugs toHIV-infected mothers and their infants, elective caesareansection for HIV-infected
women who reach term withoutachieving plasma HIV virologic suppression, and providing
replacement feeding instead of breast milk to infants of HIV-infected mothers. In settings outside
the United States where infant replacement feeding confers an unacceptablyhigh risk of HIVunrelated morbidity and mortality (including in many sub-Saharan African countries), the
additionalstrategy of administering ARV drugs to mothers or infantsduring breastfeeding has
become an effective means to allow breastfeeding while reducing the risk of HIV transmission.
In the United States, however, all HIV-infectedwomen are still advised against breastfeeding,
regardless ofARV use and maternal plasma HIV suppression, becauseneither maternal nor infant
ARV prophylaxis completelyeliminates breast milk HIV transmission (residual transmission can
be as high as 5%) and safe and affordablereplacement feeding is available. (11)(12)The ability of
ARV drugs to prevent MTCTwas first foundin the landmark AIDS Clinical Trials Group 076
trial, whichfound that zidovudine administered during pregnancy,intrapartum, and (to the infant)
after birth could cut transmission from 26% to 8% in the absence of breastfeeding. (13)
Subsequent studies found even greater efficacy for combination ARV therapy (cART), which
was
generally
composed
of at least 3 ARV drugs from at least 2 different classes.Routine use of cART for pregnant
women in the United States has resulted in MTCT risk less than 1% to 2% andestimated annual
new infant infections numbering about 200 nationwide. (14) In fact, pregnant women who
achieveconsistent plasma HIV virologic suppression during pregnancy are at such low risk of
MTCT that neither electivecaesarean section nor intrapartum ARV therapy (intravenous
zidovudine) is recommended to further reduce transmission risk. (11) However, failure to
identify HIV infection in pregnant women, barriers that prevent HIV-infected women
fromreceiving
cARTduring
pregnancy,
and
incident
HIVinfection
in pregnant and breastfeeding women remain importantproblems that contribute to residual
infant
infections
inthe
United
States.
(14)(15)
The latest recommendations by the US Department ofHealth and Human Services for preventing
MTCT in the United States can be found at http://aidsinfo.nih.gov/guidelines/html/3/perinatalguidelines. The comprehensive prevention approach is multipronged: routine testing for HIVin
pregnant women, administering ARV drugs to HIVinfected pregnant women and their infants,
supportingwomens retention in care and adherence to cART, offering elective cesarean section
to women who have not achieved HIV plasma viral RNA concentration (viral load) less
than1000 copies/mL by the end of pregnancy, minimizinginvasive obstetric procedures (eg, fetal
scalp electrode),avoidance of breastfeeding, primary prevention of HIVinfection in women of
reproductive age, and ensuringaccess to family planning services for HIV-infected women.HIV
testing is recommended as early as possible in eachpregnancy, including for women who tested

HIV negativeduring a prior pregnancy. Retesting in late pregnancy shouldbe considered for all
HIV-seronegative women and is recommended for pregnant women who are at high risk of
HIVinfection, such as women with a known HIV-infected partner, history of injection drug use,
or sexually transmittedinfection (STI) diagnosis signs or symptoms of acute HIVinfection;
women who reside in jurisdictions with elevatedHIV incidence among women of childbearing
age (17 HIVcases per 100,000 person-years); and women receivinghealth care in facilities with
at least 1 diagnosed HIV caseper 1,000 pregnant women per year. (16)(17) Women presenting in
labor who have not received appropriate HIVtesting inpregnancy should undergo rapid HIV
antibodytesting. If the results are positive, a confirmatory HIV testshould be performed as soon
as possible, and maternal andinfant ARV therapy should be initiated, pending the confirmatory
test result. If the confirmatory HIV test result ispositive, infant ARV therapy should be
continued; if the testresult is negative, then infant ARV therapy should bestopped.Newborn
nurseries should have procedures in place toalert nursery staff when an HIV-exposed infant is
bornbecause neonatal ARV prophylaxis should be initiated assoon after birth as possible, ideally
within 6 to 12 hours (seethe Management of HIV-Exposed Infant section). On admission to the
newborn nursery and at the first newborn outpatient visit, documented maternal HIV testing
resultsshould be confirmed. For a newborn whose mother didnot receive appropriate HIV testing
in pregnancy, HIVexposure status should be confirmed by performing rapidHIV antibody testing
on the mother; if maternal testingcannot be performed, infant antibody testing should
beperformed to assess potential HIV exposure. If a rapidmaternal or infant antibody test result is
positive, the infantshould initiate ARV therapy immediately, pending confirmatory testing, as for
women with positive rapid antibodytest results during labor and delivery (see above).

IMUNISASI PADA ANAK DENGAN HIV

1. Vaksin Hepatitis B. Paling baik diberikan dalam waktu 12 jam setelah lahir dan didahului
pemberian injeksi vitamin K1. Bayi lahir dari ibu HBsAg positif, diberikan vaksin hepatitis B
dan imunoglobulin hepatitis B (HBIg) pada ekstremitas yang berbeda. Vaksinasi hepatitis B
selanjutnya dapat menggunakan vaksin hepatitis B monovalen atau vaksin kombinasi.
2. Vaksin Polio. Pada saat bayi dipulangkan harus diberikan vaksin polio oral (OPV-0).
Selanjutnya, untuk polio-1, polio-2, polio-3 dan polio booster dapat diberikan vaksin OPV atau
IPV, namun sebaiknya paling sedikit mendapat satu dosis vaksin IPV.
3. Vaksin BCG. Pemberian vaksin BCG dianjurkan sebelum 3 bulan, optimal umur 2 bulan.
Apabila diberikan sesudah umur 3 bulan, perlu dilakukan tes tuberkulin. Anak yang belum
terdiagnosis HIV atau sudah didiagnosis HIV tetapi sehat, maka BCG boleh diberikan.

4. Vaksin DTP. Vaksin DTP pertama diberikan paling cepat pada umur 6 minggu. Dapat
diberikan vaksin DTwP atau DTaP atau kombinasi dengan vaksin lain. Untuk anak umur lebih
dari 7 tahun DTP yang diberikan harus vaksin Td, dibooster setiap 10 tahun.
5. Vaksin Campak. Campak diberikan pada umur 9 bulan, 2 tahun dan pada SD kelas 1 (program
BIAS).
6. Vaksin Pneumokokus (PCV). Apabila diberikan pada umur 7-12 bulan, PCV diberikan 2 kali
dengan interval 2 bulan; pada umur lebih dari 1 tahun diberikan 1 kali. Keduanya perlu dosis
ulangan 1 kali pada umur lebih dari 12 bulan atau minimal 2 bulan setelah dosis terakhir. Pada
anak umur di atas 2 tahun PCV diberikan cukup satu kali.
7. Vaksin Rotavirus. Vaksin rotavirus monovalen diberikan 2 kali, vaksin rotavirus pentavalen
diberikan 3 kali. Vaksin rotavirus monovalen dosis I diberikan umur 6-14 minggu, dosis ke-2
diberikan dengan interval minimal 4 minggu. Sebaiknya vaksin rotavirus monovalen selesai
diberikan sebelum umur 16 minggu dan tidak melampaui umur 24 minggu. Vaksin rotavirus
pentavalen: dosis ke-1 diberikan umur 6-14 minggu, interval dosis ke-2, dan ke-3 4-10 minggu,
dosis ke-3 diberikan pada umur kurang dari 32 minggu (interval minimal 4 minggu).
8. Vaksin Varisela. Vaksin varisela dapat diberikan setelah umur 12 bulan, namun terbaik pada
umur sebelum masuk sekolah dasar. Bila diberikan pada umur lebih dari 12 tahun, perlu 2 dosis
dengan interval minimal 4 minggu.
9. Vaksin Influenza. Vaksin influenza diberikan pada umur minimal 6 bulan, diulang setiap
tahun. Untuk imunisasi pertama kali (primary immunization) pada anak umur kurang dari 9
tahun diberi dua kali dengan interval minimal 4 minggu. Untuk anak 6 <36 bulan, dosis 0,25
mL.
10. Vaksin Human papiloma virus (HPV). Vaksin HPV dapat diberikan mulai umur 10 tahun.
Vaksin HPV bivalen diberikan tiga kali dengan interval 0, 1, 6 bulan; vaksin HPV tetravalen
dengan interval 0, 2, 6 bulan.
11. Selama anak sehat (HIV positif maupun tidak), jadwal imunisasi dikerjakan menurut jadwal.
12. Bila anak sudah terinfeksi HIV dan mendapatkan pengobatan ARV, imunisasi dapat ditunda
hingga 6 bulan pengobatan. Bila mungkin lakukan pemeriksaanCD4, bila > 15% maka imunisasi
aman diberikan.