PMTCT Prevention of Mother-to-Child Transmission of HIV

1. PMTCTPrevention of Mother-to-Child Transmission of HIV Module 3: Specific Interventions to Prevent Mother to Child Transmission of HIV 1

2. Specific Objectives: By the end of the Module, the participants will be able to: • Describe the role of MNCH services in PMTCT • Describe the comprehensive antenatal care package for all pregnant women. • Discuss the antenatal management of women infected with HIV and women of unknown status. • Explain the management of labor and delivery in women infected with HIV and women whose status is unknown. 2

3. Specific Objectives contd.: • Explain postpartum care of women  infected with HIV and women whose HIV status is unknown. • Explain immediate and long term newborn care of infants born to mothers who are HIV infected ad mothers whose status is unknown. • Describe the nationally recommended antiretroviral regimens for pMTCT. 3

4. Role of MCH Services in the Prevention of HIV Infection • HIV infection is one of the most important health problems for pregnant mothers and newborns in many developing countries. PMTCT programmes need to be integrated as an essential part of MCH care. 4

5. Role of MCH Services in the Prevention of HIV Infection cont.. MCH programmes facilitate PMTCT by providing: • Support for couple testing and counslling,safe disclosure and care and support • Essential antenatal care • Family planning services • ARV treatment and prophylaxis • Safer delivery practices • Care of the newborn 5

6. Role of MCH Services in the Prevention of HIV Infection cont.. • Postnatal care for the mother and infant • Counselling and support for the woman's chosen infant-feeding method • Continuity of care and follow up of mother-baby pair • leadership in spearheading community PMTCT services • Integrating essential HIV care in MNCH services including TB screening, STI screening and ART. 6

7. Comprehensive MCH services • Recognise that the best approach to preventing HIV infection in infants and children begins with prevention of primary infection in parents-to-be. • Provide information to prevent unintended pregnancies in both women who are HIV-positive and high-risk women with unknown status. • Provide education in early recognition and treatment of STIs. • Provide education about reducing the risk of MTCT 7

8. Provision or refer to health care or community services • Primary services • HIV testing and counseling, including retesting for those who tested negative earlier. A woman who sero-converts is at higher risk of transmitting HIVto infant . Efforts need to be made to iniate the women as quickly as possible on combination ARVS. • CD4 testing • ARV prophylaxis or treatment • OI prophylaxis • TB/Syphilis screening • Adherence and nutrition counseling 8

9. Provision or refer to health care or community services • Secondary services • Palliative care • Psychosocial support • Spiritual support • Economic assistance or empowerment 9

10. Comprehensive MNCH services • Integration of PMTCT into preconception and ANC • Integration of PMTCT into postnatal MNCH services • Integration of PMTCT into Child Care Services 10

11. Comprehensive MCH services • Provide education about reducing the risk of MTCT. • Link and refer patients to health care and community services • Integrating essential HIV care in MNCH services including TB screening, STI screening and ART. 11

12. Integration of PMTCT into preconception and ANC • Primary prevention • Family planning • STI management • Reducing MTCT • Provision or to referral to other services such as TC, treatment, nutrition care, etc 12

13. Integration of PMTCT into postnatal MNCH services • Provision of medical and psychosocial care • Assessment of infant growth and development, nutritional support in terms of IYCF, immunisations, and early HIV testing and provision of extended ARV prophylaxis 13

14. Integration of PMTCT into postnatal MNCH services • Provides an opportunity for family planning services. • HIV testing, and counselling for family members, referrals to community-based support programmes • Retesting of HIV negative women. • Cervical cancer screening where available 14

15. Integration of PMTCT into Child Care Services • Every point of contact with the well child or sick child should be used as an opportunity to address HIV prevention, treatment and care • The revised Under-5-Card is the main tool that will aid health workers to give optimal service and track children 15

16. Integration of PMTCT into Child Care Services • Early Infant Diagnosis • ARV prophylaxis • Cotrimoxazole Prophylaxis • Immunization • growth monitoring and promotion • Infant feeding support • Tracing of siblings to the child who is HIV exposed and other routine services. • Consideration for male neonatal circumcision 16

17. Overview of the Comprehensive Antenatal Care Package g The Goals of Focused Antenatal Care • Health Promotion • Birth Preparedness/ Complication readiness • Disease Prevention • Early Detection and Treatment Group work 10 min: in 4 groups (discuss and present) 17

18. Essential Package of Integrated Antenatal Care Services • Health education: Provide information on safe motherhood with emphasis on • safer sex practices, • counselling and HIV testing, • treatment care and support for HIV. • Client history: Obtain detailed client history including social, medical and obstetric 18

19. Essential Package of Integrated Antenatal Care Services • Physical exam and vital signs: This should include assessment for Malaria, TB, and WHO staging of HIV disease • Abdominal exam • The following tests are required – RPR, Hb, urinalysis, blood grouping, HIV, CD4. 19

20. Essential Package of Integrated Antenatal Care Services • Tetanus toxoid immunizations: Administer as per national guidelines. • Nutritional assessment and counseling: Dispense iron and folate supplements and monitor for anemia • STI screening: Diagnose and treat according to National Protocol. Ensure that counseling is adequately done to avoid transmission or re-infection • Opportunistic Infection (OI) Prophylaxis: Cotrimoxazole prophylaxis for HIV positive women with CD4 less than 350/ml 20

21. Essential Package of Integrated Antenatal Care Services • Screening and care for other infections: Screen and treat infection that require out-patient management as per Integrate Technical guidelines, then refer Serious infection such as PCP. • Screening for Tuberculosis (TB): All HIV positive pregnant women should be screened for TB • Provision of Anti-malarials for ITP and treatment: Give 3 doses of IPT, identify acute cases and treat promptly recommend use of ITNs. • ARV prophylaxis during pregnancy: Give according to national protocol 21

22. Essential Package of Integrated Antenatal Care Services • Support and facilitate HAART during pregnancy when indicated • Give adequate Counseling on exclusive breastfeeding • Counselling on pregnancy danger signs: Provide women with information and instructions on seeking early care for pregnancy complications such as bleeding, fever and pre-eclampsia. • Partners and family: Ensure testing of partners and family and linking into treatment, care and support • Effective contraception plan: Include long-term family planning and counsel about consistent use of condoms during pregnancy, postnatal and breastfeeding periods 22

23. Discussion • Discuss the table on Summary of ANC and Labour Ward Services for HIV Positive and Negative Pregnant Women* 23

24. Management of an HIV positive woman in the Antenatal period • Antenatal care for women infected with HIV includes basic services recommended for every pregnant woman. • However, obstetric and medical care should be expanded to address the specific needs of women infected with HIV. 24

25. Management of an HIV positive woman in the Antenatal period • Provide routine ‘opt-out’ HIV Testing and Counselling for all pregnant women and their partners • Outline risks of acquiring HIV Infections during Pregnancy • Identify and manage Sexually Transmitted Infections (STIs) • Provide optimal Antiretroviral Therapy for pMTCT • Screen for Tuberculosis (TB) 25

26. Management of an HIV positive woman in the Antenatal period Provide optimal Antiretroviral Therapy for Pmtct • The gold standard is that all HIV positive women should have CD4 done in order to ascertain which is the best ARV option (prophylaxis or treatment). • In addition to ARV, an HIV positive woman needs to be on long term prophylaxis with cotrimoxazole. • Initial and ongoing adherence counseling is extremely important to ensure she adheres to the drugs prescribed. • Further support through safe disclosure to her partner is important. 26

27. Management of an HIV positive woman in the Antenatal period Screen for Tuberculosis (TB) • The following are the key questions that should be asked: • Are you currently coughing? • Do you have fever? • Have you recently lost weight? • Have you had night sweats recently? 27

28. Management of an HIV positive woman in the Antenatal period • Preventing or Treating Malaria in pregnancy: key essential interventions are IPT, prompt treatment of acute malaria and use of ITNs. For HIV positive women of Cotrimoxazole, IPT is not needed. • Avoid Invasive Procedures: Invasive procedures may increase risk of MTCT by exposing the fetus to maternal blood. • Provide Micronutrient Supplementation: Micronutrients, including vitamin A, are benefitial for HIV positive women • Prevent and Treat Anaemia: Ensure HB testing at least twice in pregnancy (at the beginning and end of pregnancy) 28

29. Management of an HIV positive woman in the Antenatal period • Infant Feeding: All women should exclusively breastfeed regardless of their HIV. • HIV positive women are encouraged to continue breastfeeding with complimentary feeds from six month to one year while giving extended NVP to the baby • Preventing opportunistic infections: Ensure all eligible are provided with Cotrimoxazole and monitor for signs and symptoms of progressive HIV disease and treat or refer. 29

30. Management of an HIV positive woman in the Antenatal period • Psychosocial and community support: In addition to the stress of pregnancy, HIV positive pregnant women face additional stress arising from concern for their babies’ and their own health. • They need to be given adequate psychosocial support and appropriately linked within the community and healthcare system for treatment, care and support. 30

31. Management of an HIV positive woman during Labour and Delivery • Test and Counsel if of unknown status at an opportune time. • Provide appropriate Antiretroviral Therapy • Use Universal Precautions and Good Infection Prevention Practices • Good Obstetric Practices: Avoid frequent cervical examinations, Avoid Artificial Rupture of Membranes, Avoid Prolonged Labour and Prolonged Membrane Rupture, Minimize the Risk of Postpartum Haemorrhage. 31

32. Management of an HIV positive woman during Labour and Delivery • Caesarean Section: Decisions about mode of delivery should be made with consideration of available resources, including antiretroviral agents, antimicrobial drugs, safe blood supply, etc., as well as information available about stage of maternal disease ( CD4 count, viral load). • Ensure Safe Transfusion Practices 32

33. Management of an HIV positive woman in the postnatal period MOTHER: • Antiretroviral therapy: Give appropriate therapy depending whether on prophylaxis or HAART. • CD4 count at 6 weeks and every 6 months there after . • Management of the mother immediately after delivery: Active management of third stage. • Initiate Breastfeeding • Observe for Signs or Symptoms of Postnatal Infections 33

34. Management of an HIV positive woman in the postnatal period MOTHER • Observe for Signs or Symptoms of Postnatal Infections: HIV-infected women may be at increased risk for postnatal infections and need to be given information before leaving the clinic or hospital about the early symptoms of infection and about where to return for treatment if necessary. • HIV positive women are encouraged to continue breastfeeding with complimentary feeds from six month to one year while giving extended NVP to the baby 34

35. Management of an HIV positive woman in the postnatal period MOTHER • Testing and Counselling After Delivery: Testing after delivery is still important because if she is positive the child will benefit from ARV prophylaxis and an appropriate infant feeding choice. • Prevention of New HIV Infections During Breastfeeding: Women who are newly infected while breastfeeding are at increased risk of transmitting infection to their babies and so safe sex practices need to be reinforced • Provide Postpartum Family Planning Counselling and Services 35

36. Management of HIV negative woman • Retesting for HIV every 3 months during pregnancy and throughout breastfeeding. • Risk reduction education and counseling • Aggressive management for those who seroconvert.(Initiate appropriate combination therapy.) • Encourage her to know the partner’s status 36

37. Management of an HIV exposed baby • Antiretroviral therapy: Provide Antiretroviral therapy as per national guidelines. • Immediate newborn care: should include cord clamping, wiping the infants mouth and nostrils, wiping of the infant dry, placing the infant skin-to-skin with the mother and assisting with the first feed. • Post delivery care: Give education for cord care, link to community support structures for infant feeding. 37

38. Management of an HIV exposed baby • Positioning and attachment: Ensure that mother is able to position and attach infant properly before discharge. • Ensure testing of Baby by PCR at 6 weeks and 6 months. • Antibody rapid testing at 12 and 18 months • Initiation of Cotrimoxazole prophylaxis at 6 weeks. • Ensure all infants attend under-five clinics and use this opportunity for follow up of HIV exposed infants 38

39. Continuing care after the postnatal period Encourage and make plans for continued health care in the following areas: • Routine gynecologic care, including pap smears, if available. • Ongoing treatment, care and support for HIV/AIDS and opportunistic infections along with nutritional support. • Treatment and monitoring of TB and malaria. • Referral for antiretroviral treatment • Referral for prophylaxis and treatment of OIs. 39

40. Postpartum care of women with unknown HIV status • They should be routinely tested at first contact and provided with care based on their HIV results. 40

41. Discussion • Discuss the table on postnatal care on pg… 41

42. ANTIRETROVIRAL THERAPY FOR PREGNANT WOMEN Prophylaxis: • For women whose CD4 count is >350 or WHO stage 1 or 2 combination prophylaxis is indicated. • Combination prophylaxis can reduced transmission rates to as low as 2%. • Single dose NVP is sub-standard and should not be used alone 42

43. ANTIRETROVIRAL THERAPY FOR PREGNANT WOMEN Treatment • For women with with CD4 counts < 350 and WHO stage 3 or 4 and • HAART suppresses viral load, improves health of the mother, and reduces MTCT in this group who are more likely to transmit in the absence of HAART • Lowest transmission rates of 1-2% can be achieved 43

44. ANTIRETROVIRAL THERAPY FOR PREGNANT WOMEN Side Effects Zidovudine AZT- Anemia • Nevirapine NVP- rash ( not associated with single dose administration) • Lamivudine 3TC- Minimal side effects Adherence to ARV drugs for PMTCT is of critical importance 44

45. What if a woman becomes pregnant while she is on HAART? • Review current medication • Counsel on the importance of adherence throughout pregnancy and breastfeeding • Consult HIV nearest ART clinic if there are any concerns, e. g (If on Effavirenz may need substitution) 45

46. What if an HIV woman is not on HAART? Do eligibility assessment • CD4 and /or WHO clinical assessment Highly Active Antiretroviral Therapy (HAART) should be started if the client is: • Stage 3 or 4 regardless of CD4 count. • Stage 1or 2 with a CD4 cell count less than 350/mm3 46

47. Table on Antiretroviral prophylaxis regimens for pMTCT • Refer to the table on antiretroviral prophylaxis regimens to prevent mother to child transmission of HIV in reference manual. 47

48. SUMMARY • Integrating PMTCT services into the essential package of MNCH services promotes improved care for all pregnant women and their children and provides the best opportunity for a successful PMTCT programme. • Specific interventions to reduce MTCT include ARV treatment and prophylaxis, safer delivery procedures, and counseling and support for safe infant feeding. 48

49. SUMMARY • Using antiretroviral drugs for treatment and prophylaxis reduces the risk of MTCT. • Prophylaxis with cotrimoxazole and the prevention and treatment of TB and malaria are part of comprehensive care for mothers infected with HIV and their infants. 49

50. SUMMARY • Safer delivery procedures include avoiding unnecessary invasive obstetrical procedures and offering the option of elective caesarean section when safe and feasible. • Infant-feeding counseling and support of the chosen option should continue throughout ANC, labor, delivery and postpartum to minimize the risk of MTCT . 50