title: The last and first frontier--emerging challenges for HIV treatment and prevention in the first week of life with emphasis on premature and low birth weight infants.
abstract: BACKGROUND
  There is new emphasis on identifying and treating HIV in the first days of life and also an appreciation that low birth weight (LBW) and preterm delivery (PTD) frequently accompany HIV-related pregnancy. Even in the absence of HIV, PTD and LBW contribute substantially to neonatal and infant mortality. HIV-exposed and -infected infants with these characteristics have received little attention thus far. As HIV programs expand to meet the 90-90-90 target for ending the HIV pandemic, attention should focus on newborn infants, including those delivered preterm or of LBW.
  
  
  CONCLUSIONS
  In high prevalence settings, infant diagnosis of HIV is usually undertaken after the neonatal period. However, as in utero infection may be diagnosed at birth, earlier initiation of therapy may limit viral replication and prevent early damage. Globally, there is growing awareness that preterm and LBW infants constitute a substantial proportion of births each year. Preterm infants are at high risk for vertical transmission. Feeding difficulties, apnoea of prematurity and vulnerability to sepsis occur commonly. Feeding intolerance, a frequent occurrence, may compromise oral administration of medications. Although there is growing experience with post-exposure prophylaxis for HIV-exposed term newborn infants, there is less experience with preterm and LBW infants. For treatment, there are even fewer options for preterm infants. Only zidovudine has adequate dosing recommendations for treating term and preterm infants and has an intravenous formulation, essential if feeding intolerance occurs. Nevirapine dosing for prevention, but not treatment, is well established for both term and preterm infants.HIV diagnosis at birth is likely to be extremely stressful for new parents, more so if caring for preterm or LBW infants. Programs need to adapt to support the medical and emotional needs of young infants and their parents, where interventions may be lifesaving.
  
  
  CONCLUSIONS
  New focus is required for the newborn baby, including those born preterm, with LBW or small for gestational age to consolidate gains already made in early diagnosis and treatment of young children.
authors.affiliation: Division of Paediatric Infectious Diseases, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Children's Hospital, Stellenbosch University, Stellenbosch, South Africa; mcot@sun.ac.za.
authors.forename: Mark F
authors.initials: MF
authors.lastname: Cotton
authors.affiliation: Division of Neonatology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Children's Hospital, Stellenbosch University, Stellenbosch, South Africa.
authors.forename: Sandi
authors.initials: S
authors.lastname: Holgate
authors.affiliation: Médecins Sans Frontières, Khayelitsha, South Africa.
authors.forename: Aurelie
authors.initials: A
authors.lastname: Nelson
authors.affiliation: Division of Paediatric Infectious Diseases, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Tygerberg Children's Hospital, Stellenbosch University, Stellenbosch, South Africa.
authors.forename: Helena
authors.initials: H
authors.lastname: Rabie
authors.affiliation: Médecins Sans Frontières, Khayelitsha, South Africa.
authors.forename: Catherine
authors.initials: C
authors.lastname: Wedderburn
authors.affiliation: Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA.
authors.forename: Mark
authors.initials: M
authors.lastname: Mirochnick
mesh_terms: D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000517:prevention & control*; D006801:Humans; D007223:Infant; D007230:Infant, Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D018445:Infectious Disease Transmission, Vertical / Q000517:prevention & control; D019829:Nevirapine / Q000627:therapeutic use; D011247:Pregnancy; D015215:Zidovudine / Q000627:therapeutic use
chemical_list: D015215:Zidovudine; D019829:Nevirapine
keywords: antiretrovirals; low birth weight; management; premature; small for gestation