Rationale for and Against Using a Risk-Based Postnatal Prophylaxis Algorithm

In FavorAgainst
Risk of HIV acquisition is not uniform among exposed infants; different approaches are needed to address different scenarios; patient-centered approach tailoring response to individual infant.Risk may become more uniform (and low) in near future, with rapid scale-up of more potent, efficacious, and tolerable maternal treatment with dolutegravir.
Low-risk infants avoid unnecessary antiretroviral drug exposure and the associated potential toxicities.A low rate of transmission persists even among low-risk infants, suggesting potential benefit from additional agents to all exposed infants.
High-risk infants benefit from more aggressive management with multiple drugs/agents.No evidence exists to support the efficacy of multiple drug perinatal prophylaxis when mothers are on effective treatment, with studies performed in the era of dolutegravir-based treatment.
Stratification aligns risk (toxicity): benefit (prophylaxis efficacy) of approaches with the transmission risk.Risk is difficult to assess and dynamic. Perinatal risk assessment depends on testing and medical records that are not always available. Over the duration of breastfeeding, individual maternal risk can change and can be difficult to assess without frequent visits and viral load testing.
Stratified approaches optimize health system resource use, aligning cost of more intensive regimens with target population that will derive the most benefit.Risk assessment adds complexity and is itself resource intensive, requiring testing and visits for mothers. It can be challenging for health systems and clinics to stock and implement multiple regimens for infants.