The clinical difficulties faced by Katumba-Lunyenya et al when presented with a sick preterm infant at risk of perinatal transmission of HIV, who later had proven congenital tuberculosis and possible aspergillosis, are enormously challenging, even before considering the infection control, public health, public relations, and media issues that this case highlights.

PREVENTING TRANSMISSION OF HIV

The high maternal viral load, vaginal delivery, and premature birth are all likely to have increased the risk of perinatal transmission of HIV in this case. We do not know the mother’s CD4 count or the circumstances of her delayed antenatal HIV test result. However, it seems possible that her CD4 count was low, and antiretroviral therapy may have been indicated earlier than 24 weeks on maternal health grounds if this information had been available to her doctors. The most important factor in relation to HIV transmission is probably maternal viral load, and this may be reduced by log numbers even if the antiretroviral therapy is only on board for a matter of days. Initiation of maternal antiretroviral therapy earlier in the second trimester might have driven …