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Definition of Fever - Temperature Thresholds by Body Site

What is Fever?

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Definition of Fever - By Source/Context

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Fever Thresholds by Measurement Site

Note: Axillary temperature is not listed in this table because it is considered unreliable. Widely accepted clinical guidance (Mayo Clinic, Children's Mercy) uses axillary ≥37.2°C (99°F) as the fever threshold, though it runs ~0.5-1°C lower than rectal.

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Site-by-Site Breakdown (Summary)

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Special Populations

• Neonates/Infants (Roberts & Hedges): Rectal fever defined as ≥38.0°C in infants <30 days; ≥38.1°C in 1-2 months; ≥38.2°C in 2-3 months
• Neutropenic fever (Harrison's): Single oral ≥38.3°C OR ≥38.0°C sustained ≥1 hour
• FUO (Harrison's, Goldman-Cecil, Frameworks for Internal Medicine): >38.3°C on several occasions, illness >3 weeks, no diagnosis after 1 week of evaluation
• Elderly: May have blunted febrile response; Rosen's notes a lower functional threshold should be considered in frail older adults

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Temperature Conversion Reference

• °C to °F: (°C × 9/5) + 32
• °F to °C: (°F - 32) × 5/9

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Key Takeaway

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Quick Reference - Most Important Points

1. Meningococcemia - fever + spreading petechiae + sepsis signs = give IV Ceftriaxone BEFORE all results. Do NOT wait. This kills in hours.
2. Acute Leukemia (ALL/AML) - gum bleeding + bone pain + pallor + blasts on blood film → urgent oncology referral. AML (M4/M5) specifically causes gum infiltration/bleeding.
3. ITP - isolated thrombocytopenia, usually post-viral, usually afebrile. Treat with IVIG or steroids if platelets <30,000 or mucosal bleeding present.
4. Dengue - in endemic areas, classic fever + petechiae + thrombocytopenia + hemoconcentration. NS1 antigen test early, IgM later.

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Fever of Unknown Origin (FUO)

Historical Background

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Definition - Evolution Over Time

Original Definition (Petersdorf & Beeson, 1961)

Fever ≥38.3°C (≥101°F) on at least 3 occasions, illness lasting ≥3 weeks, and no diagnosis after 1 week of inpatient evaluation

Revised Definition (Durack & Street, 1991)

3 outpatient visits OR 3 days of inpatient investigation (replacing the mandatory 1-week hospitalization)

Current Definition (Harrison's Principles of Internal Medicine 22e, 2025)

Important: A minimum qualifying diagnostic workup must be completed before labeling a fever as FUO, to exclude common and self-limiting illnesses.

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The Four Categories of FUO (Durack & Street, 1991 - still widely used)

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Causes of Classic FUO - The "Big Four" Categories

1. Infectious (most common in developing countries)

• Intra-abdominal abscess (liver, spleen, perinephric) - #1 infectious cause in industrialized world
• Tuberculosis (especially extrapulmonary, miliary, hepatic)
• Infective endocarditis (especially culture-negative)
• Osteomyelitis
• Viral: EBV, CMV, HIV (acute seroconversion)
• Zoonoses: brucellosis, cat-scratch disease, Q fever, leptospirosis
• Malaria (travel history)

2. Non-Infectious Inflammatory Diseases (NIIDs) - most common in Western countries

• Adult-onset Still's disease (AOSD) - quotidian fever ≥39°C + salmon-colored rash + arthritis + serum ferritin often >2000 ng/mL; presents as FUO in up to 10% of cases
• Giant Cell Arteritis (GCA) / Polymyalgia Rheumatica - common in >50 yrs
• Systemic Lupus Erythematosus (SLE)
• Rheumatoid arthritis
• Vasculitides: Wegener's (GPA), Polyarteritis nodosa
• Sarcoidosis
• Familial Mediterranean Fever (FMF) - periodic fever, responds to colchicine
• Adult Crohn's disease / IBD
• IgG4-related disease

3. Malignancy

• Lymphomas (Hodgkin and Non-Hodgkin) - most common malignant cause
• Leukemia
• Renal cell carcinoma (classic "internist's tumor" - causes FUO)
• Hepatocellular carcinoma
• Atrial myxoma (tumor-related IL-6 release)

4. Miscellaneous / Other

• Drug fever (any drug can cause it; common: antibiotics, antiepileptics, allopurinol)
• Factitious fever (self-induced)
• Thromboembolic disease (DVT/PE)
• Hyperthyroidism / thyroiditis
• Adrenal insufficiency
• Periodic fever syndromes (autoinflammatory)
• Undiagnosed (in Western cohorts, up to >50% may remain without diagnosis - "the FUO paradox")

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Geographic Distribution of FUO Causes (Harrison's 22e Table 22-1)

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The "FUO Paradox"

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Approach to FUO - Key Investigations

Tier 1 - Always Do First

• CBC with differential + ESR + CRP
• LFTs, RFTs, LDH, uric acid
• Serum ferritin (>2000 = AOSD; >10,000 = hemophagocytic lymphohistiocytosis)
• Blood cultures x3 (before antibiotics)
• Urine culture
• Chest X-ray
• ANA, RF, ANCA
• HIV serology
• TST (tuberculin) or IGRA (for TB)
• Urine protein, microscopy

Tier 2 - Based on Clues

• CT abdomen/pelvis (occult abscess, lymphoma, RCC)
• Echocardiography (endocarditis)
• 18F-FDG PET-CT - localizes active lesions; correct diagnosis in >50% of FUO cases; particularly useful for vasculitis, sarcoidosis, lymphoma, occult infection
• Bone marrow biopsy (malignancy, TB, leishmaniasis)
• Serology: EBV, CMV, Brucella, Q fever, Bartonella, toxoplasma
• Colonoscopy/capsule endoscopy (Crohn's, lymphoma)
• Temporal artery biopsy (if GCA suspected)
• Skin biopsy (vasculitis)

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Treatment

• Hemodynamic instability → empirical antibiotics
• Positive IGRA/TST + extrapulmonary TB pattern → empirical antituberculous therapy (after cultures/PCR sent)
• FMF suspected → colchicine trial
• AOSD or GCA likely (infection/malignancy excluded) → glucocorticoids

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Prognosis

• In FUO patients without a final diagnosis after full evaluation, the majority spontaneously become symptom-free
• Mortality risk is highest during the index admission
• Patients with no diagnosis after extensive workup generally have a favorable prognosis

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Dengue - Complications, Lab Investigations, and Management

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WHO 2009 Classification of Dengue Severity

DENGUE
    ├── 1. Dengue WITHOUT warning signs
    ├── 2. Dengue WITH warning signs  ← Watch carefully
    └── 3. SEVERE DENGUE              ← Emergency

Warning Signs (appear near defervescence, days 3-7):

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation (ascites, pleural effusion)
• Mucosal bleeding (gums, nose, vaginal)
• Lethargy / restlessness
• Liver enlargement >2 cm
• Rising hematocrit with rapid fall in platelet count (lab warning sign)

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Phases of Dengue and When Complications Occur

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Complications of Dengue

1. Dengue Hemorrhagic Fever (DHF)

• Fever lasting 2-7 days
• Hemorrhagic tendency (positive tourniquet test OR spontaneous bleeding)
• Thrombocytopenia (platelets ≤100,000/µL)
• Evidence of plasma leakage: hematocrit rise ≥20% from baseline, pleural effusion, ascites

2. Dengue Shock Syndrome (DSS)

3. Severe Dengue (WHO 2009)

• Severe plasma leakage → shock or respiratory distress
• Severe bleeding (clinician-assessed)
• Severe organ involvement:
  • Liver: AST or ALT ≥1000 IU/L
  • CNS: Impaired consciousness
  • Heart and other organs

4. Expanded Dengue Syndrome (EDS)

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Laboratory Investigations

Diagnostic Tests for Dengue (Confirm the Infection)

• Days 1-5: NS1 antigen (+ PCR if available)
• Days 5-7: NS1 may be negative; IgM may not yet be positive → use IgG
• After day 5: IgM antibody
• Convalescence: IgG paired sera (fourfold rise confirms)

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Monitoring Labs (for Complications and Disease Severity)

Mandatory in ALL admitted patients:

Tourniquet Test (Rumple-Leede):

• Inflate BP cuff to midpoint between systolic and diastolic for 15 minutes
• >20 petechiae in a 2.5 cm circle = positive (capillary fragility)
• Key clinical bedside test for dengue hemorrhagic tendency

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Additional Labs Based on Complication

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Imaging

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Management

WHO Group A - Home Management (Dengue without warning signs, clinically stable)

• Oral fluids (ORS, coconut water, juice) - maintain adequate hydration
• Paracetamol 15 mg/kg/dose (max 4 doses/day) for fever and pain
• AVOID: Aspirin, ibuprofen, NSAIDs (increase bleeding risk; aspirin = Reye syndrome in children)
• Instructions: return immediately if warning signs develop

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WHO Group B - Hospital Admission

Without Warning Signs:

• Oral fluids if tolerated
• IV fluids if not tolerating orally: 0.9% NaCl or Ringer's Lactate at maintenance rate for 24-48 hrs
• Serial CBC, HCT monitoring

WITH Warning Signs (Dengue + Warning Signs):

1. Baseline HCT before fluids
2. IV isotonic fluids (0.9% NaCl or Ringer's Lactate):
   • 5-7 mL/kg/hr x 1-2 hrs → then 3-5 mL/kg/hr x 2-4 hrs → then 2-3 mL/kg/hr until oral intake adequate
3. Monitor HCT every 2-4 hrs; adjust fluid rate based on HCT trends
4. Monitor urine output (target 0.5 mL/kg/hr, check every 6-8 hrs)
5. Daily platelet count

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WHO Group C - Emergency (Severe Dengue / DSS)

Dengue Shock Syndrome - Compensated Shock:

1. Immediate IV isotonic crystalloid bolus: 10-20 mL/kg over 15-30 mins
2. Reassess clinically after each bolus (HR, BP, capillary refill, HCT)
3. If improved: reduce to 10 mL/kg/hr, then step down as above
4. If HCT rises despite fluids → use colloids (dextran-40 or gelatin solutions 10-20 mL/kg)

Uncompensated Shock (hypotension):

1. Rapid bolus 20 mL/kg crystalloid over 15-30 mins
2. If poor response → colloid bolus
3. If refractory → Norepinephrine (vasopressor of choice per ISCCM 2024); avoid excessive fluids in capillary leak
4. ICU monitoring: HCT, urine output hourly, blood gas, lactate

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Transfusion Thresholds in Dengue

Note: Platelet transfusions are often rapidly destroyed; transfuse only for active bleeding or pre-procedure - not for platelet count alone.

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Management of Specific Complications

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What NOT to Do in Dengue

• No aspirin / NSAIDs (bleeding risk + Reye syndrome in children)
• No prophylactic platelet transfusion for count alone without bleeding
• No steroids routinely (no proven benefit; may increase GI bleeding)
• No antibiotics unless secondary bacterial infection confirmed
• Avoid fluid overload - both hypovolemia AND over-hydration are dangerous; use HCT to guide

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Summary Monitoring Schedule

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Typhoid Fever - Management Regimen

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Understanding Resistance Patterns First (CRITICAL for drug choice)

Key point from Red Book 2021: Most typhoid diagnosed in the US and UK is now fluoroquinolone non-susceptible. Do NOT use fluoroquinolones empirically for travelers from South Asia (India, Pakistan, Bangladesh, Nepal).

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Empirical Treatment - Based on Travel History (Before Sensitivity Results)

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Treatment Regimens by Susceptibility Profile

1. UNCOMPLICATED ENTERIC FEVER

Susceptible to Fluoroquinolones

NOT Susceptible to Fluoroquinolones (MDR / DSC)

Note: Relapse rates are lower with azithromycin than with fluoroquinolones or ceftriaxone (Red Book 2021).

XDR Typhoid (Pakistan-origin, resistant to ceftriaxone + fluoroquinolones)

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2. SEVERE / COMPLICATED ENTERIC FEVER (requires hospitalization, IV therapy)

Susceptible to Fluoroquinolones

NOT Susceptible to Fluoroquinolones (MDR/FQ-R)

XDR Severe Disease

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3. OLD "FIRST-LINE" DRUGS (only if proven susceptibility on culture)

These three form the classic MDR triad - resistance to all three defines MDR typhoid.

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Treatment Duration Summary

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Adjunctive Treatment

Corticosteroids (for severe toxemia ONLY)

• Indication: Delirium, obtundation, stupor, coma, or shock
• Regimen (Goldman-Cecil, Red Book 2021):
  • Dexamethasone 3 mg/kg IV initial dose
  • Then 1 mg/kg IV every 6 hours for 48 hours total
• Caution: Can mask signs of intestinal perforation - do NOT continue beyond 48 hours

Supportive Care

• IV fluids: 0.9% NaCl for dehydration, correct electrolytes and acid-base disturbances
• Antipyretics: Paracetamol only (avoid aspirin/NSAIDs - salicylates should be avoided)
• Nutritional support: soft, easily digestible diet (avoid high-residue food - risk of perforation)
• Blood transfusion if intestinal hemorrhage causes significant anemia

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Management of Complications

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Chronic Carrier State

• Defined as: stool/urine positive for S. Typhi >12 months after acute infection
• At-risk: gallbladder disease (bile provides reservoir), ~1-4% of untreated patients
• Treatment:
  • Ciprofloxacin 750 mg PO twice daily x 28 days (if susceptible) - concentrated in bile
  • Or Norfloxacin 400 mg twice daily x 28 days
  • If fluoroquinolone resistant: azithromycin (limited data)
  • Cholecystectomy + antibiotics if medical therapy fails (gallstones act as biofilm scaffold)

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Prevention

TCV (conjugate) is now the WHO-preferred vaccine and is recommended for countries with high incidence, especially for children <2 years (unconjugated Vi CPS not effective in this age group).

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Quick Reference Decision Algorithm

Typhoid suspected
        ↓
Send: Blood cultures x3, stool/urine culture, Widal (low sensitivity), CBC, LFTs
        ↓
Travel history?
    ↓                              ↓
Pakistan / Iraq /             Other endemic area
No travel                          ↓
    ↓                     Ceftriaxone IV (severe)
Uncomplicated:              OR Azithromycin (mild)
  Azithromycin 7 days
Severe:
  Meropenem IV 10-14 days
        ↓
Culture & Sensitivity results available?
        ↓
Tailor therapy to susceptibility
        ↓
Temperature normal ≥2-3 days → step down to oral, complete course
        ↓
Monitor for relapse (especially within 4 weeks)

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Key Exam Points

1. MDR = resistant to ampicillin + chloramphenicol + TMP-SMX → treat with ceftriaxone or azithromycin
2. XDR = MDR + resistant to fluoroquinolones + ceftriaxone → treat with meropenem ± azithromycin
3. Do NOT use fluoroquinolones empirically for travelers from South Asia
4. Dexamethasone only for delirium/coma/shock - 3 mg/kg then 1 mg/kg q6h x 48 hrs
5. Perforation = laparotomy + broad-spectrum cover
6. Chronic carrier treatment = ciprofloxacin x 28 days (or cholecystectomy if failed)
7. Azithromycin has the lowest relapse rate of all regimens

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Confirmation of HIV in a Newborn

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Why Standard Antibody Tests CANNOT Be Used in Infants < 18 Months

• A positive HIV antibody test in a newborn or infant < 18 months only confirms maternal HIV infection - it does NOT confirm infant infection
• A negative antibody test also does not confirm the infant is uninfected during this window
• Therefore, antibody tests (including 4th-generation Ag/Ab assays) must NOT be used to diagnose or exclude HIV in infants < 18 months

Guideline (US HHS 2024, AII recommendation): Virologic assays (HIV RNA or HIV DNA nucleic acid tests [NATs]) that directly detect HIV must be used to diagnose HIV in infants and children aged <18 months with perinatal HIV exposure.

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Tests Used for Diagnosis in Newborns/Infants < 18 Months

1. HIV DNA PCR (Most widely used)

• Detects intracellular HIV viral DNA in peripheral blood mononuclear cells (PBMCs)
• Does NOT depend on active viral replication
• Specificity: 99.8% at birth; 100% at 1, 3, and 6 months
• Sensitivity by age:

• Can be performed on dried blood spots (DBS) - useful in resource-limited settings

2. HIV RNA PCR (Quantitative / Qualitative)

• Detects extracellular viral RNA in plasma
• Equally recommended alongside HIV DNA PCR (AII)
• Specificity: 100% at birth, 1, 3, and 6 months
• Same sensitivity profile as DNA PCR
• Also gives baseline viral load (useful for treatment decisions)
• Preferred for detecting non-subtype B HIV (Group O, HIV from Africa/SE Asia) - important for immigrants

3. HIV RNA Qualitative Assay (APTIMA HIV-1 RNA Qualitative Assay)

• FDA-approved alternative diagnostic test for infants
• Can be used when initial DNA PCR is positive (for confirmation)

4. HIV p24 Antigen Test

• Detects viral capsid protein
• NOT recommended for newborn diagnosis in the US - sensitivity and specificity inferior to NATs in the first months of life
• Used in resource-limited settings where PCR unavailable

5. HIV Antibody Test (ELISA / 4th gen Ag/Ab)

• NOT used for diagnosis in < 18 months (maternal antibody interference)
• Used only after 18 months to confirm loss of maternal antibodies (seroreversion = infant is uninfected)

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Testing Schedule: Virologic (NAT) Testing

Official Schedule from Red Book 2021 (AAP) / HHS 2024 Guidelines

• Had no prenatal care
• Received no antepartum/intrapartum ARVs
• Only received intrapartum ARVs
• Started ART late (late 2nd or 3rd trimester)
• Had acute HIV infection during pregnancy
• Had detectable viral load near delivery

Higher-risk infants: additional test at birth AND at 8-10 weeks (2-4 weeks after stopping ARV prophylaxis)

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Interpreting Results: Positive vs. Negative

Confirming HIV INFECTION (Positive Diagnosis)

• Two separate positive virologic tests (HIV DNA PCR or RNA PCR) from two different blood samples at different time points

A single positive result is presumptive - always repeat immediately on a new sample before labelling infant as infected (false positives can occur with both RNA and DNA assays)

• Perform HIV RNA quantitative load (baseline viral load)
• Perform HIV genotype (resistance testing to guide ART choice)
• Initiate ART as soon as possible

Excluding HIV INFECTION (Negative Diagnosis - Non-Breastfeeding)

• DNA PCR negative at ≥1 month AND at ≥4 months = HIV infection excluded (non-breastfed)

For Breastfed Infants

• Breastfeeding continues to pose transmission risk throughout the breastfeeding period
• Testing must be repeated 6 weeks after complete cessation of breastfeeding
• Cannot exclude HIV infection until 6 weeks post-weaning testing is negative

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Final Confirmation at 18 Months (Antibody Seroreversion)

• All HIV-exposed infants (even those with negative PCRs) should have HIV antibody test at 18 months
• If antibody negative at 18 months: confirms HIV-uninfected (maternal antibodies have cleared)
• If antibody positive at 18 months: perform NAT to confirm true infection (rare - residual maternal antibodies can occasionally persist slightly longer)

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Summary Algorithm

Newborn of HIV-positive mother
            ↓
DO NOT use HIV antibody test (maternal IgG interference)
            ↓
Use HIV DNA PCR or HIV RNA PCR (NAT)
            ↓
Higher risk → test at birth, 2-3 weeks, 4-6 weeks, 8 weeks, 4-6 months
Low risk   → test at 2-3 weeks, 4-6 weeks, 4-6 months
            ↓
ANY POSITIVE RESULT?
   YES ↓                          NO ↓
Repeat immediately on           Continue scheduled testing
new blood sample                (2 negatives ≥1 month apart
   ↓                             after age 1 month = excluded)
SECOND POSITIVE?                        ↓
   YES → HIV CONFIRMED           HIV antibody test at 18 months
   ↓                             (confirms seroreversion)
HIV RNA viral load
HIV genotype (resistance)
Start ART urgently

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Key Points Summary Table

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Breastfeeding Counselling in HIV-Positive Mothers

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The Core Dilemma

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How HIV Transmits via Breast Milk

• HIV (both cell-free RNA and cell-associated virus) is present in breast milk
• Transmission can occur with each feed throughout the entire breastfeeding period
• Risk is highest in early months, and is continuous throughout breastfeeding
• Exclusive breastfeeding carries a lower risk than mixed feeding (adding water, formula, or solids alongside breast milk increases gut permeability and transmission risk)

Risk Factors for Higher HIV Transmission via Breast Milk

Quantifying the Risk

• Untreated mother: 15-35% overall mother-to-child transmission risk; breastfeeding accounts for an additional 15-20% of infant HIV infections
• Mother on ART with undetectable viral load (<50 copies/mL): breastfeeding transmission risk <1% (but not zero)
• Plasma viral load <1000 copies/mL: transmission very unlikely
• Plasma viral load <50 copies/mL: transmission extremely unlikely

Important caveat: Low-level detectable HIV virus (<100 copies/mL) has been found in breast milk even when plasma viral load is undetectable - clinical significance for transmission is unknown but cannot be dismissed.

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Part 1: RESOURCE-RICH SETTINGS (USA, UK, Canada, Europe, Australia)

Official Position (US HHS Panel 2024, CDC 2024, AAP 2024)

If Mother is NOT on ART or NOT Virally Suppressed

• Formula feeding or pasteurized donor human milk from a milk bank should be used
• Provide formula feeding support (preparation, barriers, financial assistance)

If Mother IS on ART with Sustained Undetectable Viral Load

What to tell the mother in a resource-rich setting:

1. Formula feeding or pasteurized donor human milk completely eliminates the risk of HIV transmission through feeding
2. If you are on ART with an undetectable viral load, the risk of transmitting HIV through breastfeeding is <1%, but not zero
3. If you choose to breastfeed, you will need:
   • Strict ART adherence throughout breastfeeding
   • Regular viral load monitoring (every 1-3 months during breastfeeding)
   • Infant HIV testing with NAT during and after breastfeeding period
   • Infant ARV prophylaxis (specific regimen depends on risk level)
   • To stop breastfeeding immediately if viral load becomes detectable
   • Testing 6 weeks after cessation of breastfeeding
4. If you choose not to breastfeed, you will be supported fully with formula preparation and feeding support
5. Mixed feeding (breast + formula) is not recommended as it may increase transmission risk compared to exclusive breastfeeding

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Part 2: RESOURCE-LIMITED SETTINGS (Sub-Saharan Africa, South/Southeast Asia, Latin America)

The WHO Position (WHO 2023)

• Formula feeding requires safe water, clean utensils, regular supply - often unavailable
• Formula-fed HIV-exposed infants in resource-limited settings have significantly higher mortality from diarrhoea and pneumonia
• Not breastfeeding signals HIV status and leads to stigma, discrimination, and social harm

WHO Recommendation:

"Mothers living with HIV should breastfeed for at least 12 months and may continue for up to 24 months or beyond (similar to the general population) while being fully supported for ART adherence."

AFASS Criteria - Before Recommending Replacement Feeding in Resource-Limited Settings

WHO Breastfeeding Guidance in Resource-Limited Settings:

1. Exclusively breastfeed for first 6 months (no water, formula, or solids)
2. Continue breastfeeding with complementary foods from 6 months onwards
3. Breastfeed for at least 12 months - can continue to 24 months (while on ART)
4. Continue maternal ART throughout breastfeeding period (not just during pregnancy)
5. Weaning should be gradual (over several weeks) - abrupt weaning risks mastitis and increased transmission; sudden weaning also puts infant at risk of malnutrition
6. After weaning: test infant 6 weeks post-cessation

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Counselling Framework - Practical Points for ALL Settings

When to Begin Counselling

• Before conception (if patient known HIV-positive and planning pregnancy)
• As early as possible in pregnancy (first antenatal visit)
• Reviewed throughout pregnancy
• Again after delivery (update plan, re-discuss, confirm readiness)

Key Counselling Messages

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Stopping Breastfeeding - Guidance

When to Stop Immediately (Resource-Rich Settings):

• Maternal viral load becomes detectable during breastfeeding
• Mastitis not responding to treatment
• Bleeding/cracked nipples not resolving
• Mother decides to stop ART

How to Wean (Gradual Weaning Recommended):

• Reduce frequency gradually (e.g., once every 4-6 hours, then once daily, then stop) over several days to weeks
• During transition: use cup feeding with formula or expressed heat-treated milk
• Do not abruptly stop (risk of mastitis → increases transmission risk during transition)
• After cessation: test infant with HIV NAT at 6 weeks post-weaning

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Summary Comparison Table

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Non-Judgmental, Patient-Centered Approach (2024 Emphasis)

• Shared decision-making - the mother's informed choice is respected
• Non-judgmental counselling - no stigma for choosing either option
• Cultural sensitivity - especially around stigma in communities where not breastfeeding "reveals" HIV status
• Health equity lens - barriers to breastfeeding and formula feeding must both be addressed
• Support regardless of choice - if she breastfeeds, support safe breastfeeding; if she formula feeds, support preparation and access

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