High-risk infants are defined as those:

• born to women with established HIV infection who have received less than four weeks of ART at the time of delivery; or
• born to women with established HIV infection with viral load >1000 copies/mL in the four weeks before delivery, if viral load is available; or
• born to women with incident HIV infection during pregnancy or breastfeeding; or
• born to women identified for the first time during the postpartum period, with or without a negative HIV test prenatally. Risk stratification remains essential to limiting unnecessary drug exposure. In settings where access to maternal viral load availability is unreliable, adopting a simpler means of assessing risk such as maternal time on ART may need to be further emphasized and reinforced in health worker training. Adherence support for breastfeeding mothers is also a critical intervention to support daily adherence to treatment and maintain retention in care, as well as to remind mothers of the infant-testing schedule. When an infant at high risk of infection is identified, a blood sample should be taken and sent for nucleic acid testing (NAT). It is important to ensure that mothers are adequately counselled so that they understand the rationale for a three-drug regimen which serves as both enhanced prophylaxis and presumptive treatment until HIV infection can be ruled out. Maternal ART should also be initiated or reinitiated at the time, as required. All efforts should be made to obtain an infant blood sample for NAT testing with return of test results within six weeks. If the test turns out to be negative, HIV prophylaxis may be stopped completely if maternal viral suppression can also be confirmed, or if there is reasonable assurance of maternal adherence to treatment. However, if the NAT test is negative but there is concern that maternal viral suppression has not been attained, prophylaxis should be maintained using a single ARV, with a preference for NVP. If the triple-drug regimen used for neonates is ABC+3TC+DTG, appropriate caution should be exercised depending on the formulation used. DTG must be dosed once every other day, or every 48 hours from birth until two weeks of life, after which dosing is once daily. At one month, dosing should then be adjusted based on the infant’s weight (see Table 4.1). The triple-drug fixed-dose combination of ABC, 3TC and DTG (known as “pALD”) is not appropriate for use in neonates but may be used in infants older than four weeks. Careful attention must be given to maternal counselling and supportive interventions to ensure that the right dosing schedule is followed and dosing can be adjusted as appropriate. Programmes should monitor infant prophylaxis regimens and formulations dispensed in order to support quantification efforts. At the global level this will provide clear messaging to suppliers on those products that are still required.