Module 3 Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)

Module 3

Specific Interventions for the Prevention of Mother-to-Child

Transmission of HIV (PMTCT)

PMTCT Generic Training Package Module 3, Slide 2

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


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


Session 1

Antiretroviral Therapy and Antiretroviral Prophylaxis for PMTCT


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


ARV Therapy and ARV Prophylaxis

What is the difference between ARV therapy and ARV prophylaxis?


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


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


Starting ARV Therapy:WHO Recommendations

If CD4 count is not available:

Treat all symptomatic patients at WHO Stages 3 and 4

When to start ARVs is based on symptoms of HIV infection and, where available, laboratory test results.

See Table 3.1


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


Becoming Pregnant while on ARV Therapy

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

WHO recommendations:WHO recommendations:

See Appendix 3-A for more information on managing ARV therapy during pregnancy


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


WHO Recommendation:Zidovudine (AZT) + lamivudine (3TC) +

nevirapine (NVP)

First-line ARV Therapy for Pregnant Women

Pregnant women should be closely monitored for toxicity, including hepatitis, from NVP during the first 12 weeks of therapy


Commonly Used ARV drugs for PMTCT

AZTZidovudine

• Absorbed quickly • Well tolerated• Can cause mild anaemia• Taken with our without food

NVPNevirapine

• 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

3TCLamivudine

• Absorbed quickly• Taken with our without food


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


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


ARV Prophylaxis

All HIV-infected pregnant women who are not eligible for ARV therapy should be offered ARV prophylaxis for PMTCT


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


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


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


Session 2

Antenatal Management of Women Infected with HIV and Women of

Unknown HIV Status



Understand the antenatal management of women infected with HIV and women of unknown HIV status


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


Integrating PMTCT Servicesinto 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 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 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)


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


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


Common Infections inHIV-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


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


Common Infections inHIV-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


Psychosocial & CommunitySupport

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 HIV-infected woman is receiving from family and friends

Where available, HCWs should refer HIV-infected pregnant women to organizations that provide support


ANC Services for HIV-Infected Women (Table 3.2)

Patient history

Physical exam, vital signs

Lab tests

Nutritional assessment & counselling

STI screening

TB and malaria assessment and treatment

OI and malaria prophylaxis

Tetanus immunization

ARV therapy/ prophylaxis

Infant feeding

Counselling on safer pregnancy, HIV danger signs

Partners/family (testing, support)

Effective contraception planning


Exercise 3.1

Antenatal care: case studies


Session 3

Management of Women Infected with HIV and Women of Unknown HIV

Status during Labour and Delivery



Explain the management of labour and delivery in women infected with HIV and women of unknown HIV status


PMTCT During Labour & Delivery

Labour and delivery (L&D) practices for HIV-infected women should follow standard obstetric practices, set forth by national and international standards


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


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


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 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 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



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



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


Considerations RegardingMode 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


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


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


Exercise 3.2

Labour & delivery ARV prophylaxis: case studies


Session 4

Postpartum Care of Women Infected with HIV and Women of Unknown

HIV Status



Describe postpartum care of women infected with HIV and women of unknown HIV status


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


Postpartum Care forHIV-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


Postpartum Care for HIV-infectedWomen: 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


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


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 HIV-positive 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


Postpartum Care: Womenof 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


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


Exercise 3.3

Postpartum care of women infected with HIV: case studies


Session 5

Care of Infants who are HIV-exposed and Infants Born to 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


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


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



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 mouth-operated 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



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


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


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


Exercise 3.4

Care of infants who are HIV-exposed: case studies


Key Points

Specific PMTCT interventions for women who test HIV-positive 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


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 cost-effective manner



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



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



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 follow-up care and treatment and family planning

Care of infants exposed to HIV requires special measures in the delivery setting in addition to Standard Precautions

Module 3 Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)

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Transcript of Module 3 Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)