module 3 specific interventions for the prevention of mother-to-child transmission of hiv (pmtct)
TRANSCRIPT
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
PMTCT Generic Training Package Module 3, Slide 3
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 4
Session 1
Antiretroviral Therapy and Antiretroviral Prophylaxis for PMTCT
PMTCT Generic Training Package Module 3, Slide 5
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 6
ARV Therapy and ARV Prophylaxis
What is the difference between ARV therapy and ARV prophylaxis?
PMTCT Generic Training Package Module 3, Slide 7
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 8
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 9
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
PMTCT Generic Training Package Module 3, Slide 10
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 11
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
PMTCT Generic Training Package Module 3, Slide 12
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 13
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
PMTCT Generic Training Package Module 3, Slide 14
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
PMTCT Generic Training Package Module 3, Slide 15
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 16
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 17
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 18
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 19
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 20
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 21
Session 2
Antenatal Management of Women Infected with HIV and Women of
Unknown HIV Status
PMTCT Generic Training Package Module 3, Slide 22
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 23
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 24
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 Generic Training Package Module 3, Slide 25
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 26
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 27
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 28
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 29
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
PMTCT Generic Training Package Module 3, Slide 30
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 31
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
PMTCT Generic Training Package Module 3, Slide 32
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
PMTCT Generic Training Package Module 3, Slide 33
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
PMTCT Generic Training Package Module 3, Slide 34
Exercise 3.1
Antenatal care: case studies
PMTCT Generic Training Package Module 3, Slide 35
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 36
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 37
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 Generic Training Package Module 3, Slide 38
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 39
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 40
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 41
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 42
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 43
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 44
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 45
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
PMTCT Generic Training Package Module 3, Slide 46
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 47
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 48
Exercise 3.2
Labour & delivery ARV prophylaxis: case studies
PMTCT Generic Training Package Module 3, Slide 49
Session 4
Postpartum Care of Women Infected with HIV and Women of Unknown
HIV Status
PMTCT Generic Training Package Module 3, Slide 50
Session 4 Objectives
Describe postpartum care of women infected with HIV and women of unknown HIV status
PMTCT Generic Training Package Module 3, Slide 51
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 52
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
PMTCT Generic Training Package Module 3, Slide 53
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
PMTCT Generic Training Package Module 3, Slide 54
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 55
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
PMTCT Generic Training Package Module 3, Slide 56
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
PMTCT Generic Training Package Module 3, Slide 57
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 58
Exercise 3.3
Postpartum care of women infected with HIV: case studies
PMTCT Generic Training Package Module 3, Slide 59
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 60
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 61
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 62
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 63
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 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
PMTCT Generic Training Package Module 3, Slide 64
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 65
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 66
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 67
Exercise 3.4
Care of infants who are HIV-exposed: case studies
PMTCT Generic Training Package Module 3, Slide 68
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
PMTCT Generic Training Package Module 3, Slide 69
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
PMTCT Generic Training Package Module 3, Slide 70
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 71
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 72
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 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