PMTCT

PRESENTER:

KISIANGANI ISAAC

MORACHA KEVIN

MODERATOR:

PROF NYANDIKO

INTRODUCTION

• Mother-to-child transmission (MTCT) of HIV, also called perinatal or vertical transmission, occurs when HIV is spread from an HIV+ woman to her baby during pregnancy, labor and delivery or breastfeeding.

• Overall incidence without intervention is 15 to 45% distributed over:– Antenatal period – The labor and delivery period– Breastfeeding

• Around 15-30% of babies born to HIV positive women will become infected with HIV during pregnancy and delivery.

• A further 5-20% will become infected through breastfeeding.

• This rate can be reduced to levels below 5% with effective interventions.

INTRODUCTION

• The global community has committed itself to accelerate progress for the prevention of mother-to-child HIV transmission (PMTCT) through an initiative with the goal to eliminate new pediatric HIV infections by 2015 and improve maternal, newborn and child survival and health in the context of HIV.

INTRODUCTION

• In order to reduce MTCT, all pregnant women should have access to:– free or low-cost prenatal care – voluntary HIV testing and counseling. – If a pregnant woman is HIV+, access to ARV treatment

both to treat HIV and improve her own health, and to decrease the chances of HIV infection in her infant.

• Treatment options for preventing MTCT include giving antiretroviral drugs to the mother after the first trimester of pregnancy and during labor, and to her infant for the first 12 wks of life

EPIDEMIOLOGY

• The World Health Organization (WHO) estimated that >35.3 million persons worldwide were living with HIV infection at the end of 2012, including 3.3 million children <15 years of age.

• More than 95% of HIV+ women in the world live in developing countries and most HIV+ children are born in developing countries.

• In 2012, almost 2.3 million people acquired HIV 260,000 were <15 years and 1.6 million died, including 210,000 children.

• Kenya National AIDS/STI Control Programme (NASCOP) estimates that there were 1.55 million babies born in 2011 in Kenya and that as many as 6.3% of pregnant women in Kenya were living with HIV/ AIDS.

• In Kenya, an estimated 37,000 to 42,000 infants are infected with HIV annually due to mother-to-child transmission.

• Overall, 0.9% of children aged 18 months to 14 years were infected with HIV. This corresponds to an estimated 104,000 children infected with HIV nationwide.

• Note that this estimate does not include children younger than 18 months of age and children in North Eastern region. (KAIS 2012)

Risks of MTCT

Factors affecting risk of MTCT are:

• Maternal- Obstetric, Post partum B/Feeding

• Fetal and infant.

Maternal factors

• Advanced Disease• Low CD4• High plasma viral load• During acute HIV infection – early disease• During end stage disease • AIDS diagnosis/advanced HIV disease• High viral load genital secretions

• Vitamin A deficiency• Malaria• Behavioral factors; multiple sex partners• Anemia, sexually transmitted diseases,

chorioamnionitis

Obstetric factors

• PROM >4 hrs, risk increases by the hour (4%)• Episiotomy• Instrumental delivery; forces, vacuum• Invasive fetal monitoring• external cephalic version• Cord Milking/Delayed clumping• Prolonged labor• Transmission during labor and delivery occurs

when the infant sucks or aspirates cervical secretions that contain HIV, or when there are other mucous membrane exposure.

Fetal/infant factors

• Prematurity <37 weeks

• Lesions on skin and mucous membranes

• Trauma in birth canal

• Oral disease in the infant: oral ulcers or thrush

Postpartum Breastfeeding

Risk in postpartum breastfeeding influenced by:-

• Pattern; mixed increases risk

• Breast disease; cracked nipples, mastitis, breast engorgement, breast abscess

• Longer duration of exposure or prolonged breastfeeding

• Preventing HIV infection among prospective parents

• Avoiding unwanted pregnancies among HIV positive women

• Preventing the transmission of HIV from HIV positive mothers to their infants during pregnancy, labor, delivery and breastfeeding.

• Care and support of women, children and families infected and affected by HIV and AIDS

PILLARS OF PMTCT

Primary prevention

• Abstinence• Being faithful to one uninfected person• Right condom use• HIV testing and counselling;

– provider initiated– patient initiated

• Pre exposure prophylaxis• Post exposure prophylaxis• Careful use and disposal of sharp objects• Screening of blood before transfusion

Family planning

o Emergency contraception.o Barrier methods: Female and male condoms

provide protection against STIs and reduce the risk of HIV transmission

o Lactational Amenorrhoea Method (LAM)o Hormonal contraceptiono Intra-uterine contraceptive devices (IUCDs)o Surgical methodso Fertility Awareness Based methods : use of

Standard Days Method or Calendar method should have regular menstrual cycles.

MTCT interventions

ANTENATALo Group education: Include information on four ANC visits, breastfeeding,

personal hygiene, birth preparedness, danger signs, prevention of complications, skilled birth attendance, family planning, immunization schedule, post-natal care and HIV and AIDS management.

• Client history: Obtain routine data including medical, obstetric, and psychosocial history. Determine drug history, known allergies. Physical examination: Include vital signs, inspection, auscultation and palpation, breast Examination

• Abdominal and genital examination: Include inspection, palpation, fetal auscultation, speculum and bimanual examinations, where indicated, STI screening, cervical cancer screening(VIA)ANC Profile: Routine tests for syphilis, Hb, blood group and Rhesus factor, urinalysis

RECOMMENDATIONS

Testing and counseling for PG and B/F women:

• All to be tested and counseled during their 1st ANC visit. Repeat after 3mo for those who test –ve

• All B/Fng women who tested –ve during ANC or status unknown should also test.

• All PG and B/Fng women who opt-out or decline testing during 1st clinic visit should be offered counseling and testing in subsequent visit(s)

• Offer testing and counseling to all spouses/ sexual partners of HIV infected PG and B/Fng women.

RECOMMENDATIONS

HIV testing and counseling of infants and children <18mo:

• HIV exposure status of all infants should be established at the 6-week immunization visit or at 1st contact thereafter ,using maternal medical information.

• Conduct HIV Ab testing for mother or children <18mo age of unknown status to establish their HIV exposure status.

• All HIV –exposed infants should be offered routine DNA PCR testing at the 6-week immunization visit, or at the earliest opportunity for infants seen after 6 weeks age

•Infants with an initial positive HIV DNA PCR results should be presumed to be HIV infected and started on ART in line with national guidelines.

Testing and counseling of children >18mo:

• Conduct testing and counseling for all children presenting to the health facility irrespective of reason for their visit to the facility.

• Testing and counseling for all children of HIV infected adults ASAP, within 1mo of confirming the HIV + status of adult.

Disclosure of status to HIV = children and adolescents:

• Health Service Providers should support and advise caregivers to initiate disclosure of HIV status to the HIV infected child preferably from age of 6 Years

• Full Disclosure should occur when the child is developmentally ready ideally by 10 years (Before adolescence)

ARV in pregnancy

• All HIV-infected pregnant women should be counseled on comprehensive HIV care including use of ARVs for their own health and for PMTCT.

• All HIV-infected pregnant women should have their HIV disease staged

• All HIV-infected pregnant women should have baseline laboratory and other necessary diagnostic evaluations

• OI prophylaxis & micronutrient supplementation

• ARV are used for:

– Treatment: All HIV-infected pregnant women should start ART as soon as possible. HIV-infected pregnant women already on ART before becoming pregnant should continue ART.

– Prophylaxis:

• Option A

• Option B

• Option B+

• A once-daily fixed-dose combination of TDF + 3TC (or FTC) + EFV is recommended as first-line ART in pregnant and breastfeeding women, including pregnant women in the first trimester of pregnancy and women of childbearing age.

• The recommendation applies both to lifelong treatment and to ART initiated for PMTCT and then stopped

INTRAPARTUM:

• Minimize vaginal examinations.

• Use aseptic techniques in conducting delivery.

• Avoid routine artificial rupture of membranes (ARM).

• Avoid prolonged labor by use of a partograph.

• Avoid unnecessary trauma during delivery.

• Minimize the risk of postpartum hemorrhage.

• Use safe blood transfusion practices.

i) No ARVs taken in pregnancy?

Mother in early labor (up to 1 hour before delivery)

• Mother: Intrapartum period; Give mother NVP at onset of labor

• Postpartum: Start on TDF+3TC+EFV

Infant:

• Breastfeeding infant :Daily NVP 2mg/kg from birth until 1 week after all exposure to breast milk has ended

• Non-breastfeeding infant : NVP for 12 weeks

ii) Mother received HAART in Pregnancy

• Continue the HAART regimen through labor and delivery and post partum period

• Give infant Nevirapine syrup as above

• Link the mother baby pair to chronic HIV care in the post partum period

Mode of delivery:

• Elective caesarean section (CS) reduces the risk of HIV MTCT as compared to vaginal delivery if the viral load is >1000 copies per ml, but may not be available in many settings.

• IMMEDIATE POSTPARTUM

• Support infant feeding options. For all HIV negative women, women of unknown HIV status and HIV positive mothers opting for exclusive breastfeeding, initiate breastfeeding within half hour of birth.

• Identification of complications in mother and newborn - manage and/or refer appropriately

• Routine postpartum care: blood pressure measurement; breast examination; examination of the uterus, the perineum and lochia. Ensure regular passage of urine and proper hygiene to prevent infection; checking for signs of anemia, fever and tachycardia and Vitamin A supplementation

• All babies should receive their routine immunization (OPV and BCG) in their first hours of life

• Support exclusive breastfeeding (with cover of ARVs) until six months unless the mother has been counseled on replacement feeding and meets the AFASS criteria.

• Initiate/continue Cotrimoxazole for all HIV positive women

• For the newly diagnosed, perform WHO Staging, CD4 Count and treat/refer for ART appropriately.

• For mothers on ART/HAART; continue with treatment

MTCT interventions

LATE POSTPARTUM

• Breast care in breastfeeding mothers• Encourage daily cleaning of the breasts and avoiding the application of lotions.• Treat maternal vaginal candidiasis and infant oral candidiasis.• Educate mother on optimal breast feeding technique including exclusive breastfeeding.• Educate the mother on breast care to prevent complications (cracking and engorgement).• Express and heat treat the milk if breast has mastitis or abscess.

• Breast care in non breastfeeding mothers• Should wear a good supporting brassiere day and night.• Give analgesics for pain.• Initiate contraception within 4 weeks of delivery

• Lochia:• Put emphasis on good perineal hygiene and proper handling of body fluids.• Avoid contaminating the baby with body fluids or with bedding soiled with lochia.• Sharing of beds by mothers in the hospital should be discouraged.

• Caesarean Section• Broad spectrum antibiotics should be used routinely after CS.

• Essential maternal education and follow-up• Monitor for breast and pelvic infection at all post natal clinic visits.• Educate on prompt health seeking behavior.• Health education on hygiene, lochia and breast care.

• contraception• Care, support and treatment for HIV positive mother and child:

– Counselling. – OI prophylaxis and treatment.– Link to support groups and assessment of the need for ART.– Early infant diagnosis (EID) should be provided at six weeks and

thereafter

ARV prophylaxis for HIV exposed infants

1. Mother Dx with HIV during pregnancy at any gestation, labor , delivery and immediate post-partum irrespective of feeding option?

– Immediately initiate NVP prophylaxis for 12wks.

– Do HIV PCR test

– Initiate Rx if infant is infected

2. Infant identified as HIV exposed after birth (through infant or maternal HIV antibody testing) and is breastfeeding?

– Initiate NVP prophylaxis

– Do HIV PCR test

– If +ve initiate ART and stop NVP prophylaxis

– If –ve CT NVP up to 12 weeks

3. Infant identified as HIV exposed after birth (through infant or maternal HIV antibody testing) and is not breastfeeding/ on replacement feeding?

– Do HIV PCR test

– -ve? No drug for prophylaxis

– +ve? Initiate ART

4. Mother receiving ART but interrupts ART regimen while breastfeeding (such as toxicity stock-outs or refusal to continue)?

– Initiate NVP until 12wks after maternal ART is restarted or until 1wk after B/Fng has ended if mother does not restart ART

– Do HIV PCR test to infant

INFANT FEEDING IN HIV

a) Exclusive breast feeding for 6mths -is advisable, unless replacement feeding is AFASS for them and their infants before that time.

b) Exclusive replacement Feeding -should be AFASS

C) Complementary foods- If the conditions for replacement feeding are still not met for 6 mo then, ct b/f with additional complementary feeding 1st 12mo

Care and follow up of children of HIV-infected mothers

• All HIV exposed infants should be seen in the health care facility within two weeks of delivery.

• For all HIV exposed infants, monthly follow up visits are recommended beginning at six weeks through 2 years.

• Where possible, visits should be linked to the immunization and growth monitoring visits.

• All HIV exposed infants should be started on co-trimoxazole prophylaxis from 6 weeks of age.

REFERENCES

• Rapid advice guidelines June 2014

• Summary of new recommendations 2013.

• http://nascop.or.ke/prevention_of_mother_to_child.php