Transcript Module 3 - National Centre for AIDS and STD Control (NCASC)

Module 3
Specific Interventions for the
Prevention of Mother-to-Child
Transmission of HIV
(PMTCT)
Module Objectives
 Describe the difference between ARV therapy and ARV
prophylaxis
 List the criteria for starting pregnant women on ARV
therapy
 List the recommended ARV drugs for PMTCT
 Understand the antenatal management of women
infected with HIV and women of unknown HIV status
PMTCT Generic Training Package
Module 3, Slide 2
Module Objectives
(Continued)
 Explain the management of labour and delivery for
women infected with HIV and women of unknown HIV
status
 Describe postpartum care of women infected with HIV
and women of unknown HIV status
 Describe the care of infants born to mothers who are
HIV-infected and infants born to women of unknown HIV
status
PMTCT Generic Training Package
Module 3, Slide 3
Session 1
Antiretroviral Therapy and
Antiretroviral Prophylaxis for PMTCT
PMTCT Generic Training Package
Module 3, Slide 4
Session 1 Objectives
 Describe the difference between ARV therapy and ARV
prophylaxis
 List the criteria for starting pregnant women on ARV
therapy
 List the recommended ARV drugs for PMTCT
PMTCT Generic Training Package
Module 3, Slide 5
ARV Therapy and ARV
Prophylaxis
What is the difference between ARV
therapy and ARV prophylaxis?
PMTCT Generic Training Package
Module 3, Slide 6
ARV Therapy and ARV
Prophylaxis
 ARV therapy: Long-term use of antiretroviral drugs to
treat maternal HIV and for PMTCT
 ARV prophylaxis: Short-term use of antiretroviral drugs
to reduce HIV transmission from mother-to-infant
ARVs during pregnancy decrease the amount of virus
in the mother’s blood, lowering the chance her infant
will be exposed to the virus
PMTCT Generic Training Package
Module 3, Slide 7
Antiretroviral (ARV) Therapy
 Improves the health of women
 Decreases the risk of transmitting HIV to
infant
 Pregnant women who are HIV-infected and
who are eligible for antiretroviral (ARV)
therapy should receive treatment
according to national or WHO guidelines.
ARV
 Is provided by PMTCT programmes or by
referral to HIV care and treatment clinic
PMTCT Generic Training Package
Module 3, Slide 8
Starting ARV Therapy:
WHO Recommendations
 When to start ARVs is based on symptoms of HIV
infection and, where available, laboratory test results.
See Table 3.1
 If CD4 count is not available:
 Treat all symptomatic patients at WHO Stages 3
and 4
PMTCT Generic Training Package
Module 3, Slide 9
Starting ARV Therapy:
WHO Recommendations
(Continued)
 If CD4 count is available:
 Treat all patients with CD4 counts <200 cells/mm3
 Treat all HIV-infected pregnant women in
Stage 3 whose CD4 count is <350 cells/mm3
 Consider treatment for the non-pregnant in Stage 3
if CD4 count is < 350 cells/mm3
PMTCT Generic Training Package
Module 3, Slide 10
Becoming Pregnant while on
ARV Therapy
WHO recommendations:
 Continue to take ARV therapy throughout pregnancy, labour,
delivery and postpartum
 Infants born to mothers on ARV therapy should receive one
week of ARV prophylaxis with AZT
 If a woman is on efavirenz (EFV) as a part of her ARV therapy
and becomes pregnant:
 Substitute NVP for EFV if pregnancy if recognized
during 1st trimester
 Continue EFV if recognized during 2nd or 3rd trimester
 See Appendix 3-A for more information on managing ARV therapy during
pregnancy
PMTCT Generic Training Package
Module 3, Slide 11
Starting ARV Therapy during
Pregnancy
 A pregnant woman eligible for ARV therapy based on
national or international guidelines should start
treatment as soon as possible, even during the 1st
trimester
 All ARV drugs are associated with some toxicity
 The risk for a pregnant woman and her child from ARV
therapy varies and is dependent on the:
 Stage of pregnancy
 Duration of therapy
 Number of drugs used
PMTCT Generic Training Package
Module 3, Slide 12
First-line ARV Therapy for
Pregnant Women
WHO Recommendation:
Zidovudine (AZT) + lamivudine (3TC) +
nevirapine (NVP)
 Pregnant women should be closely monitored for
toxicity, including hepatitis, from NVP during the first 12
weeks of therapy
PMTCT Generic Training Package
Module 3, Slide 13
Commonly Used ARV drugs for
PMTCT
AZT
Zidovudine
NVP
Nevirapine
3TC
Lamivudine
•
•
•
•
Absorbed quickly
Well tolerated
Can cause mild anaemia
Taken with our without food
•
•
•
•
•
•
Absorbed quickly
Long half life protects the infant
Can cause hepatotoxicty in women with higher CD4
Hepatotoxicity does not apply to single-dose regimen
Can cause viral resistance even after one dose
Taken with our without food
• Absorbed quickly
• Taken with our without food
PMTCT Generic Training Package
Module 3, Slide 14
Delaying Start of ARV Therapy
 Delaying the start of ARV therapy can be considered if a
pregnant woman:
 Suffers frequently from nausea, a common side effect of
some ARVs
 Is in her first trimester and concerned about the effects of
ARVs on the developing fetus
 HOWEVER, if a woman’s clinical or immune status
suggests she is severely ill, the benefits of early ARV
therapy outweigh any potential risk to the fetus
PMTCT Generic Training Package
Module 3, Slide 15
HIV-Infected Pregnant Woman
with TB
 First priority is to treat the TB
 With careful clinical management, a pregnant woman
can be treated for both HIV and TB
 Drugs need to be monitored very closely to avoid
interactions and side effects
 See Appendix 3-A for more information on managing an
HIV-infected pregnant woman with TB
PMTCT Generic Training Package
Module 3, Slide 16
ARV Prophylaxis
 All HIV-infected pregnant
women who are not eligible
for ARV therapy should be
offered ARV prophylaxis for
PMTCT
PMTCT Generic Training Package
Module 3, Slide 17
ARV Prophylaxis for PMTCT:
WHO Recommendations
 Use combination regimens of AZT, 3TC and a single
dose of NVP because they:
 Are more effective in preventing MTCT
 Can reduce viral resistance
 See Appendix 3-B for the WHO recommended PMTCT ARV
regimens
PMTCT Generic Training Package
Module 3, Slide 18
Viral Resistance and ARVs
 HIV can mutate or change so it
becomes resistant to specific ARV
drugs — whether used for therapy
or prophylaxis
 When viral resistance occurs,
these ARV drugs are no longer as
effective
 Additional information on viral resistance
can be found in Module 7
PMTCT Generic Training Package
Module 3, Slide 19
WHO Recommendations on
Single-dose NVP
 Resistance can develop when a single
dose of NVP is given during labour
 Single dose NVP is the minimum recommended
regimen where capacity is limited; should only be used
where other options not available
 Single-dose NVP is given to a mother at the onset of labour
and to her infant as soon as possible after delivery
 Specific obstacles to delivering more effective
combination regimens should be identified and actions
taken to address them
PMTCT Generic Training Package
Module 3, Slide 20
Session 2
Antenatal Management of Women
Infected with HIV and Women of
Unknown HIV Status
PMTCT Generic Training Package
Module 3, Slide 21
Session 2 Objectives
 Understand the antenatal management of women
infected with HIV and women of unknown HIV status
PMTCT Generic Training Package
Module 3, Slide 22
Antenatal Care
 ANC improves the general
health and well-being of
mothers and their families
 Good maternal healthcare not
only improves pregnancy
outcomes, but also helps
women with HIV stay healthy
longer
PMTCT Generic Training Package
Module 3, Slide 23
Integrating PMTCT Services
into MCH Programmes
Integrating PMTCT and MCH programmes ensures that:
 PMTCT programmes have access to MCH patients
 PMTCT services benefit from the expertise and
experience of HCWs working in MCH services
 PMTCT services are normalized as a part of care
PMTCT Generic Training Package
Module 3, Slide 24
PMTCT Services in MCH Care
 Health information and education
 Education about HIV and HIV prevention including
safer sex
 HIV testing and counselling
 Partner HIV testing and counselling, including couple
counselling, either on-site or by referral
 ARV therapy or ARV prophylaxis (ARV therapy may be
provided either on-site or by referral)
PMTCT Generic Training Package
Module 3, Slide 25
PMTCT Services in MCH Care
(Continued)
 Treatment, care & support for HIV infection
 Information on infant feeding options, counselling and
support
 Screening, prevention and treatment of opportunistic
infections and other HIV-related conditions
 Co-trimoxazole prophylaxis against PCP, malaria and
other infections
 Diagnosis and treatment of sexually transmitted
infections (STIs)
PMTCT Generic Training Package
Module 3, Slide 26
Role of HIV Testing in PMTCT
 HIV testing and counselling is the critical initial step to
provide healthcare workers (HCWs) with the opportunity
to offer PMTCT services
Determining the HIV status of a pregnant
woman is the gateway to PMTCT
interventions
PMTCT Generic Training Package
Module 3, Slide 27
ANC Services for HIV-infected
Women
 Include all of the basic services (e.g., services for all
pregnant women regardless of HIV infection status)
 In addition, an HIV-infected pregnant woman has other
care and support needs (outlined in Table 3.2). The
PMTCT interventions in this module are primarily in
reference to women infected with HIV-1
 See Appendix 3-C for more information about PMTCT and HIV-2
PMTCT Generic Training Package
Module 3, Slide 28
Common Infections in
HIV-Infected Women
 Women with HIV are susceptible to opportunistic
infections, HIV-related infections and other common
infections because their immune systems are not
working well
 All infections can increase the risk of MTCT
 HCWs should follow national guidelines for prophylaxis
and treatment of all infections that can affect HIV
patients
 Effective prevention reduces rates of illness and death
among HIV-infected pregnant women
PMTCT Generic Training Package
Module 3, Slide 29
Common Infections in
HIV-infected Women
(Continued)
 Opportunistic infections:
 Tuberculosis
 Pneumocystis pneumonia (PCP)
 HIV-related infections:
 Recurrent vaginal candidiasis
 Other common infections:
 Sexually transmitted infections (STIs)
 Urinary tract infections
 Respiratory infections
 Malaria, where prevalent
PMTCT Generic Training Package
Module 3, Slide 30
Common Infections in
HIV-Infected Women
(Continued)
Co-trimoxazole prophylaxis prevents common infections:
 PCP pneumonia
 Other bacterial pneumonias
 Malaria
 Toxoplasmosis
 Certain causes of diarrhoea
 Co-trimoxazole prophylaxis is likely to improve overall
pregnancy outcomes
 See Module 7 for more information on PCP prophylaxis
PMTCT Generic Training Package
Module 3, Slide 31
Psychosocial & Community
Support
 Pregnant women with HIV may have concerns about
the health of the baby, their own health and disclosure
of their status
 HCWs should assess how much support an HIVinfected woman is receiving from family and friends
 Where available, HCWs should refer HIV-infected
pregnant women to organizations that provide support
PMTCT Generic Training Package
Module 3, Slide 32
ANC Services for HIV-Infected
Women (Table 3.2)
 Patient history
 Tetanus immunization
 Physical exam, vital signs
 ARV therapy/ prophylaxis
 Lab tests
 Infant feeding
 Nutritional assessment &
counselling
 Counselling on safer
pregnancy, HIV danger
signs
 STI screening
 TB and malaria assessment
and treatment
 OI and malaria prophylaxis
PMTCT Generic Training Package
 Partners/family (testing,
support)
 Effective contraception
planning
Module 3, Slide 33
Exercise 3.1
Antenatal care: case studies
PMTCT Generic Training Package
Module 3, Slide 34
Session 3
Management of Women Infected with
HIV and Women of Unknown HIV
Status during Labour and Delivery
PMTCT Generic Training Package
Module 3, Slide 35
Session 3 Objectives
 Explain the management
of labour and delivery in
women infected with HIV
and women of unknown
HIV status
PMTCT Generic Training Package
Module 3, Slide 36
PMTCT During Labour & Delivery
 Labour and
delivery (L&D)
practices for HIVinfected women
should follow
standard obstetric
practices, set forth
by national and
international
standards
PMTCT Generic Training Package
Module 3, Slide 37
PMTCT During Labour &
Delivery
(Continued)
 Standard obstetric practices include Standard Precautions:
Wearing protective
gear
Using and disposing
of sharps safely
Sterilizing equipment
and safely disposing
of contaminated
materials
PMTCT Generic Training Package
Module 3, Slide 38
Standard Precautions in L&D
 Reduce the risk of transmission of blood-borne
pathogens from the patient to the HCW
 Used when caring for all patients, regardless of
diagnosis or presumed HIV infection status
 Because of risk of contact with blood, use of Standard
Precautions is particularly important during delivery
 Discussed in greater detail in Module 8
PMTCT Generic Training Package
Module 3, Slide 39
Labour & Delivery for
HIV-infected Women
 Administer ARV therapy or ARV prophylaxis during
labour according to national guidelines to reduce
maternal viral load and provide protection to the infant
 Avoid repeat dosing of single-dose NVP (e.g., in the
case of false labour) as this can cause viral resistance
 Ensure that a woman is in true labour before administering a
single-dose of NVP
 Document NVP administration clearly on a patient’s
partogram or medical record to avoid accidental repeat
dosing
PMTCT Generic Training Package
Module 3, Slide 40
PMTCT during L&D
1. Minimize vaginal examinations
2. Avoid prolonged labour

Consider using oxytocin to shorten labour when
appropriate
3. Avoid premature rupture of membranes

Use partogram to measure labour

Avoid artificial rupture of membranes (unless necessary)
PMTCT Generic Training Package
Module 3, Slide 41
PMTCT during L&D
(Continued)
4. Avoid unnecessary trauma during delivery.

Use non-invasive fetal monitoring

Avoid invasive procedures, such as using scalp
electrodes or scalp sampling

Avoid routine episiotomy

Minimize the use of forceps or vacuum extractors
PMTCT Generic Training Package
Module 3, Slide 42
PMTCT during L&D
(Continued)
5. Minimize risk of postpartum haemorrhage

Actively manage the third stage of labour

Give oxytocin immediately after delivery

Use controlled cord traction

Perform uterine massage

Carefully repair genital tract lacerations

Carefully remove all products of conception
PMTCT Generic Training Package
Module 3, Slide 43
PMTCT during L&D
(Continued)
6. Use safe blood transfusion practices

Minimize use of blood transfusions

Use only blood screened for HIV and, when available,
screened for syphilis, malaria and hepatitis B and C
PMTCT Generic Training Package
Module 3, Slide 44
Considerations Regarding
Mode of Delivery
 Caesarean section performed before the onset of
labour or membrane rupture has been associated with
reduced MTCT
Elective Caesarean, along with safer infant feeding
practices and ARV therapy or ARV prophylaxis, has
greatly reduced the rate of MTCT in countries where this
procedure is safe and available
PMTCT Generic Training Package
Module 3, Slide 45
Considerations Regarding
Mode of Delivery
(continued)
 The risk of elective Caesarean for PMTCT should be
assessed carefully in the context of factors such as:
 Risk of post-operative complications
 Safety of the blood supply
 Cost
PMTCT Generic Training Package
Module 3, Slide 46
HIV Testing during Labour
 Testing during labour is the last opportunity before
childbirth to identify women infected with HIV
 A woman of unknown HIV status at labour should be
offered HIV testing and counselling
 ARV prophylaxis, when initiated during labour for
the woman and just after birth for the infant, can
reduce MTCT by as much as 50%
 See Module 5 for additional information on HIV testing during
labour
PMTCT Generic Training Package
Module 3, Slide 47
Exercise 3.2
Labour & delivery ARV prophylaxis:
case studies
PMTCT Generic Training Package
Module 3, Slide 48
Session 4
Postpartum Care of Women Infected
with HIV and Women of Unknown
HIV Status
PMTCT Generic Training Package
Module 3, Slide 49
Session 4 Objectives
 Describe postpartum care of women infected with HIV
and women of unknown HIV status
PMTCT Generic Training Package
Module 3, Slide 50
Postpartum Care for
HIV-infected Women
 Immediate post-delivery care:
 Assess amount of vaginal bleeding
 Dispose of blood-stained/ soaked linens or pads safely
 Infant feeding:
 Provide information about infant feeding options and
support mother’s infant feeding choice
 Ensure mother is provided with infant feeding
counselling and support. Observe feeding technique and
provide assistance
PMTCT Generic Training Package
Module 3, Slide 51
Postpartum Care for
HIV-infected Women
(Continued)
Teach about signs and symptoms of postpartum infection:
 Burning with urination
 Fever
 Foul smelling lochia
 Cough, sputum and shortness of breath
 Redness, pain, pus or drainage from incision or episiotomy
 Severe lower abdominal pain
 Breast pain, redness or warmth
PMTCT Generic Training Package
Module 3, Slide 52
Postpartum Care for HIV-infected
Women: Education
Provide education about postpartum period and
follow-up care:
 Teach mother about perineal and breast care
 Ensure mother knows how and where to dispose of
infectious materials such as lochia- and blood-stained
sanitary pads
 Emphasize importance of postpartum follow-up care for
HIV-infected mother and her HIV-exposed infant
PMTCT Generic Training Package
Module 3, Slide 53
Postpartum Care for HIV-infected
Women: Family Planning
 Discussion of contraception and family planning goals
begins in ANC and continues in postpartum period
 Main family planning goals for HIV-infected women:
 Prevent unintended pregnancy
using effective method of birth control
 Space children (can help reduce
maternal and infant morbidity and mortality)
 Educate women and families about
contraceptive choices
PMTCT Generic Training Package
Module 3, Slide 54
Postpartum Care for HIV-infected
Women: Continuing Care
 Encourage and make plans for continuing healthcare in
the following areas:
 Routine gynaecologic care, including Pap smears, if
available
 Ongoing treatment, care and support for new HIVpositive mother, including referral for ARV therapy if
eligible
 Nutritional counselling and support
 Referral for prophylaxis and treatment of HIV-related
conditions, including TB and malaria
PMTCT Generic Training Package
Module 3, Slide 55
Postpartum Care: Women
of Unknown HIV Status
 Women whose HIV status is unknown should receive
same postpartum care as women with HIV, except
should be counselled and supported to breastfeed
exclusively
 Encourage women whose HIV status is unknown to test
for HIV
PMTCT Generic Training Package
Module 3, Slide 56
Women Testing HIV-positive
After Delivery
 If mother tests HIV-positive post-delivery:
 Provide safer infant feeding information, counselling
and support
 Provide (as soon as possible) infant prophylaxis as
per national guidelines
 Provide referrals for infant HIV testing
 Provide referrals for ARV treatment, care and support
 Provide referrals for co-trimoxazole prophylaxis for
the mother, if eligible, and to her infant starting at 4-6
weeks
PMTCT Generic Training Package
Module 3, Slide 57
Exercise 3.3
Postpartum care of women infected
with HIV: case studies
PMTCT Generic Training Package
Module 3, Slide 58
Session 5
Care of Infants who are HIV-exposed
and Infants Born to Women of
Unknown HIV Status
PMTCT Generic Training Package
Module 3, Slide 59
Session 5 Objectives
 Describe the care of infants born to mothers who are
HIV-infected and infants born to women of unknown HIV
status
PMTCT Generic Training Package
Module 3, Slide 60
Immediate Infant Care:
Following Delivery
 Reduce MTCT by minimizing infant
exposure to maternal blood and
body fluids
 Offer ARV prophylaxis for the infant as
soon as possible, including low birth
weight infants and those with low
Apgar scores
 Emphasize the importance of infant
ARV prophylaxis, which is safe for
infants
 For more information on ARV prophylaxis for infants, see Appendix 3-B
PMTCT Generic Training Package
Module 3, Slide 61
Immediate Infant Care:
Following Delivery
(Continued)
 Care for the HIV-exposed infant should follow
standard best practice and Standard Precautions
 For all infants:
 When head is delivered wipe
infant’s face with gauze or cloth
 After infant is completely delivered, thoroughly
wipe dry with a towel and transfer to the mother
 Ask mother about feeding choice; if breastfeeding,
help to initiate
PMTCT Generic Training Package
Module 3, Slide 62
Immediate Infant Care:
Following Delivery
(Continued)
 Do not suction unless infant does not breathe within
30 seconds of birth
 If must suction, use either mechanical suction at < 100
mm Hg pressure or bulb suction, rather than mouthoperated suction
 Clamp cord after it stops pulsating and after giving the
mother oxytocin;
 Do not milk the cord, and cover with gloved hand or
gauze before cutting
PMTCT Generic Training Package
Module 3, Slide 63
Immediate Infant Care:
Following Delivery
(Continued)
 Administer dose of vitamin K and silver
nitrate eye ointment according to national
guidelines
 Immunize according to national guidelines
 Use Standard Precautions when handling
infant
 Specialized care for sick and preterm
infants should follow national and
international standards
PMTCT Generic Training Package
Module 3, Slide 64
Follow-up Infant Care
 Care for infants exposed to
HIV:
 Should follow best practices
for well-child care
 Should also include package of
services designed specifically
for HIV-exposed infants
PMTCT Generic Training Package
Module 3, Slide 65
Follow-up Infant Care
(Continued)
 Care for infants born to women of unknown HIV
status:
 Provide immediate care as if exposed to HIV
 Offer testing and counselling as soon as possible.
If the mother tests HIV-positive within 72 hours of
delivery, give ARV prophylaxis and provide
information on infant feeding options and infant
feeding counselling and support.
 (If she is not tested for HIV) Encourage exclusive
breastfeeding
PMTCT Generic Training Package
Module 3, Slide 66
Exercise 3.4
Care of infants who are HIV-exposed:
case studies
PMTCT Generic Training Package
Module 3, Slide 67
Key Points
 Specific PMTCT interventions for women who test HIVpositive include:
 ARV therapy or ARV prophylaxis
 Information, counselling and support for safer infant
feeding
 Safer delivery practices that include precautions to
reduce infant’s exposure to maternal blood and
secretions
PMTCT Generic Training Package
Module 3, Slide 68
Key Points
(Continued)
 ARV therapy and prophylaxis reduce the risk of MTCT.
ARV combination prophylaxis regimens are more
effective than the single-dose NVP regimen
 Integrating PMTCT services into existing MCH
programmes normalizes HIV testing and other PMTCT
interventions and allows for wide coverage in a costeffective manner
PMTCT Generic Training Package
Module 3, Slide 69
Key Points
(Continued)
 Comprehensive ANC should address the special needs
of HIV-infected women, e.g., assessing and treating TB,
starting co-trimoxazole prophylaxis and referring for
ARV therapy when indicated. Good ANC ensures a
mother’s health as well as reduces the risk of MTCT
 Mothers require information on infant feeding options,
infant feeding counselling and support during ANC,
labour and delivery and the postpartum period
PMTCT Generic Training Package
Module 3, Slide 70
Key Points
(Continued)
 Standard obstetric practices apply to all women in
labour and delivery, regardless of HIV-status. For
women with HIV and those of unknown HIV status,
there are additional steps or precautions to
minimize the contact between the infant and the
mother’s blood and secretions
PMTCT Generic Training Package
Module 3, Slide 71
Key Points
(Continued)
 When providing postpartum care to women infected
with HIV, HCWs should follow national guidelines.
In addition, they should review with the mother, the
signs and symptoms of postpartum infection,
provide education on disposal of infectious
materials and emphasize the importance of followup care and treatment and family planning
 Care of infants exposed to HIV requires special
measures in the delivery setting in addition to Standard
Precautions
PMTCT Generic Training Package
Module 3, Slide 72