A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 2300-g (5-lb 1-oz) male newborn is delivered to a 29-year-old primigravid woman. The mother has HIV and received triple antiretroviral therapy during pregnancy. Her HIV viral load was 678 copies/mL 1 week prior to delivery. Labor was uncomplicated. Apgar scores are 7 and 8 at 1 and 5 minutes respectively. Physical examination of the newborn shows no abnormalities. Which of the following is the most appropriate next step in management of this infant?
-
A
Administer zidovudine, lamivudine and nevirapineIncorrect. Triple-drug prophylaxis (AZT + 3TC + NVP) is appropriate for high-risk infants whose mothers were unsuppressed at delivery — clinically the best fit for a 678 copies/mL viral load.
-
B
Administer lamivudine and nevirapineIncorrect. Lamivudine plus nevirapine alone is not a standard infant prophylaxis regimen.
-
C
Administer nevirapineIncorrect. Nevirapine monotherapy is used in some resource-limited settings but is not standard in high-resource settings as monotherapy.
-
D
Administer zidovudineCorrect. (Keyed answer.) Zidovudine monotherapy is the standard infant prophylaxis when the mother has achieved viral suppression — the question keys this answer despite the maternal VL of 678 copies/mL.
-
E
Administer no antiretroviral therapy and follow with serial HIV PCR testingIncorrect. Forgoing infant prophylaxis is never appropriate when there is any perinatal HIV exposure; even with maternal viral suppression, infants receive at minimum zidovudine prophylaxis to reduce transmission risk.
↑ Tap an answer to reveal the reasoning
Answer: D. An HIV-infected mother with detectable viral load (678 copies/mL) at delivery exposes the neonate to a meaningful risk of vertical transmission. Standard postnatal antiretroviral prophylaxis for the infant depends on maternal viral suppression status:
- If mother had viral suppression (<50 copies/mL) throughout pregnancy and at delivery: infant prophylaxis is zidovudine (AZT) monotherapy for 4–6 weeks.
- If mother is unsuppressed at delivery or status uncertain: combination prophylaxis (such as zidovudine plus lamivudine plus nevirapine, sometimes called 'presumptive HIV therapy') for higher-risk infants.
The keyed answer here is zidovudine monotherapy, which corresponds to the protocol when maternal viral load is low or controlled. However, with the maternal viral load reported as 678 copies/mL (not suppressed below 50), combination antiretroviral prophylaxis would be more appropriate per current guidelines. This is reflected as a factual concern with the question — the keyed answer is what most exam writers would accept, but contemporary guidance might favor multi-drug prophylaxis.
Early diagnostic HIV PCR testing of the infant (not antibody-based) is performed at birth, 1–2 months, and 4–6 months to confirm or exclude transmission.
**Why each option:**
**A.** Triple-drug prophylaxis (AZT + 3TC + NVP) is appropriate for high-risk infants whose mothers were unsuppressed at delivery — clinically the best fit for a 678 copies/mL viral load.
**B.** Lamivudine plus nevirapine alone is not a standard infant prophylaxis regimen.
**C.** Nevirapine monotherapy is used in some resource-limited settings but is not standard in high-resource settings as monotherapy.
**D.** (Keyed answer.) Zidovudine monotherapy is the standard infant prophylaxis when the mother has achieved viral suppression — the question keys this answer despite the maternal VL of 678 copies/mL.
_Note: this question is flagged as `factual_concern` and may benefit from review._