What if …
Q.69 What if a mother's CD4 count falls below 350 while she is breastfeeding her infant?
All mothers should have a CD4 count each 6 months as part of routine care. It is important to monitor CD4 counts over time. The reasons for any decline in CD4 count should be assessed and appropriate action taken.
- if the mother is not on lifelong ARV treatment, the decline in CD4 count might be a function of natural disease progression or an opportunistic infection. While mothers are being assessed and initiated on ART, infants should be started on daily NVP to reduce the risk of transmission. NVP can be stopped about 6-8 weeks after ART has been started in mothers.
- if the mother is already on lifelong ARV treatment, possible reasons for the fall in CD4 count might include an opportunistic infection, such as tuberculosis, or non-adherence to ARVs, or resistance to ARVs. The mother should continue breastfeeding while the situation is assessed, but should receive appropriate counselling (see Q.71). If the mother’s health deteriorates to the point that she can no longer breastfeed, then efforts should be made to obtain breast milk from another mother who is not HIV-infected (a wet-nurse) or from a breast-milk bank in preference to infant formula, where possible.
- if the mother has been taking triple ARVs as in Option B, then infants might be started on daily NVP until the cause of the decline in CD4 count is determined and lifelong ARV treatment is initiated.
- if the child is already receiving daily NVP as part of Option A, then mothers should be encouraged to adhere to giving the NVP. At the same time, she should be rapidly assessed and initiated on lifelong ARV treatment.