Clinical Scenario:
A 6-week-old infant was born to a mother living with HIV. The mother received antiretroviral therapy during pregnancy, but adherence was inconsistent. The infant received appropriate neonatal antiretroviral prophylaxis and remains clinically well. The mother is breastfeeding.
A virological test performed at 6 weeks is negative for HIV.
Which of the following is the most appropriate next step?
A. Stop HIV testing
B. Perform an HIV antibody test at 6 weeks
C. Repeat virological testing during breastfeeding
D. Start antiretroviral therapy in the infant
E. Perform CD4 testing at 6 weeks
Correct answer & Explanation:
Correct answer: C. Repeat virological testing during breastfeeding
Explanation
A negative HIV virological test at 6 weeks does not definitively exclude HIV infection in a breastfed infant, because HIV transmission can occur throughout the breastfeeding period.
Therefore, infants who remain at risk because of ongoing breastfeeding require repeat HIV virological testing according to the recommended testing schedule, including testing after the period of exposure has ended.
The important principle is:
A negative early virological test excludes infection acquired before that test, but does not exclude subsequent postnatal transmission through breastfeeding.
Why the other options are incorrect
A. Stop HIV testing — Incorrect:
The infant remains exposed to HIV through breastfeeding and therefore requires continued follow-up and testing.
B. HIV antibody test at 6 weeks — Incorrect:
Maternal HIV antibodies can persist in infants and therefore antibody testing is not appropriate for early diagnosis in young infants.
D. Start ART — Incorrect:
ART is not started solely because an HIV-exposed infant has a negative virological test.
E. CD4 testing — Incorrect:
CD4 count assesses immune status but does not establish whether the infant is infected.
Postgraduate Exam Pearl:
HIV-exposed infant + breastfeeding = ongoing risk of postnatal transmission.
Therefore, a single negative early virological test does not end follow-up. Testing should continue according to the national/WHO infant HIV testing algorithm, with a definitive assessment after breastfeeding has stopped.
References:
- World Health Organization. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach. Geneva: World Health Organization; 2021.
- World Health Organization. WHO recommendations for early infant diagnosis of HIV. Geneva: World Health Organization.
