Module 3 Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)
WHO recommendations on Prevention of Mother-to …...Prevention of HIV infection in pregnant women,...
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Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
WHO recommendations on Prevention of Mother-to-Child Transmission of HIV and the
Mother-Baby Pack
Dr Tin Tin SintMedical Officer - PMTCT
HIV Department
Joint WHO/UNAIDS Informal Consultation with Pharmaceutical Companies
Geneva, 16 December 2008
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Geographical distribution of HIV burden
Sub-Saharan Africa• 68% of PLHA, 76% of HIV mortality• Almost 61% of adults living with HIV in 2007 were women• 8 southern African countries contribute 1/3 all HIV incidence and mortality• 1-in-6 to 1-in-7 PLHA is South African
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
HIV mother-to-child transmission: countries with highest burden
• Nearly 90% of all HIV- positive children live in sub-Saharan Africa
• Well over 90% are infected through mother- to-child transmission
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Source: Black et al 2003
HIV/AIDS: an important cause of mortality in children aged less than five years in sub-
Saharan AfricaWorld distribution of under-five deaths
Each dot represents
5000 deaths
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Prevention-of-mother-to-child transmission of HIV: WHO guidelines
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Interventions to prevent mother-infant HIV transmission, by timing
HIV testing & counsellingARV to mother
ARV to newbornAvoid episiotomy and forcepsARVs to mother
Exclusive BF for 6 months No BF
Antenatal Labour & delivery Postpartum
Primary prevention of HIV infectionPrevention of unwanted pregnancies among HIV-infected women
Before pregnancy
ARV to mother
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Perinatal HIV transmission
• Background transmission risk: 15-45%– 15-30% risk during pregnancy and delivery– 10-20% additional risk postpartum via breastfeeding
• Transmission risk with interventions:– 20 - 25% No breastfeeding– 15 - 25% Short-course ARV breastfeeding – ~ 6% Short-course ARV, post partum ARV 6 mo, breastfeeding – 2 - 4 % Short-course ARV, no breastfeeding– 1% 2 or 3 ARV’s + elective C-section, no breastfeeding
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Recommendations for a Public Health Approach
2006
Antiretroviral Drugs for Treating Pregnant Women and
Preventing HIV Infection in Infants in Resource-Limited
Settings
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Recommended first-line ARV regimens for treating pregnant women and prophylactic regimen for infants
Mother
Antepartum AZT + 3TC + NVP twice daily
Intrapartum AZT + 3TC + NVP twice daily
Postpartum AZT + 3TC + NVP twice daily
Infant AZT x 7 days*
* If the mother receives < 4 wks of ART during pregnancy, give 4 wks of infant AZT
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
* If the woman receives at least 4 wks of AZT during pregnancy: omission of maternal NVP dose may be considered in which case infant should receive 4 wks of AZT; and women do not require 7-day tail of AZT and 3TC. ** If the mother receives < 4 wks of AZT during pregnancy, 4 weeks of infant AZT recommended The infant NVP dose must be given immediately at birth
ARV prophylactic regimens for HIV-infected pregnant women
Ranking Time of administrationPregnancy Labour Postpartum
Maternal Infant
Recommended AZT (>28 wks)
Sd-NVP *+
AZT/3TC
AZT/3TC x 7 days*
Sd NVP +
AZT x 7 days *
Alternative AZT (>28 wks)
Sd-NVP Sd NVP + AZT x 7 days **
Minimum--
Sd-NVP + AZT/3TC
AZT/3TC x 7 days
Sd NVP
Minimum -- Sd-NVP Sd NVP
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Prevention of Mother To Child Transmission of HIV
Zidovudine, Nevirapine and Lamivudine: first line HIV drugs used for PMTCT Cotrimoxazole: drug to prevent opportunistic infections
or
Counseling to Mum on infant
feeding
Continued infant feeding counseling &
support to Mum
CD4-testing: to determine stage of HIV-disease and needfor treatmentPCR-testing: to determine HIV status in childrenART: Antiretroviral Treatment (only when indicated by CD4- testing or clinical assessment)
If Mum HIV- positive, CD4- testing and/or
clinical assessment
(staging) takes place and
Cotrimoxazole provided for 12
months
If no need for ART,
Mum given Zidovudine
(from 28 weeks)
Mum at labor: single
dose Nevirapine
and Zidovudine
START: Recommend HIV testing at first ANC
visit
Mum: Zidovudine + Lamivudine (7
days) and referral for HIV
care
Baby: single dose
Nevirapine + Zidovudine for
7 days
At 6 weeks:
Baby: PCR testing to
determine HIV status. If HIV
infected, refer to ART
Provide Cotrimoxazole
for up to 2 years or until HIV risk
can be excluded
ART provided to Mum if needed on
basis of CD4 result or clinical
assessment
Mum: Zidovudine + Lamivudine (7 days) and referral for HIV care
Baby: single dose Nevirapine plus Zidovudine for 4 weeks
If Mum received no or less than 4 weeks of Zidovudine
If Mum received 4 or more weeks of Zidovudine
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Objectives of the Mother-Baby Pack
• Improve/increase PMTCT uptake• Reduce interruptions in access to ARVs and
Cotrimoxazole :– High incidence of first ANC visit, but sharp decrease in follow-up– Low rate (50%) of delivery in health facilities– Complexity of PMTCT regimen
• Facilitate adherence• Provide HIV Care and Treatment to both Mother and
Baby• Improve procurement, distribution and supply chain
management– Forecasting difficulties when managing products separately– Supply chain difficulties when managing products separately
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
The Ideal Pack
• Has all the medicines required• Is user friendly, manageable• One pack per mother/baby• Is usable outside of clinical setting• Holds incentives to encourage ANC/HIV clinic
attendance• Includes medicines that are stable, easy to use
and not bulky
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Pack contents - Medicines
During pregnancy• AZT 300mg: at least 200 tablets • CTX 960mg at least 100 tablets (or 200 tablets of 480mg)
During delivery• sd NVP 200mg one tablet• sd NVP 10mg/ml + dosing syringe • AZT 300mg two tablets• 3TC 150mg at least two tablets
After Delivery• AZT/3TC 300+150mg 20 tablets • AZT 10mg/ml + dosing syringe (100 ml bottle) (1 or 4
weeks )• CTX 960mg (mother) at least 70 tablets (up to first post natal 6 weeks)• CTX 100+20mg (baby) at least 70 tablets (to be started after 6
weeks of age)
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
AntepartumDuring pregnancy
PostpartumAfter delivery
IntrapartumDuring delivery
Zidovudine tablets
Cotrimoxazole tablets
Zidovudine + Lamivudine tablets & Cotrimoxazole tablets (mother)
Zidovudine syrup & Cotrimoxazole (baby)
Nevirapine (single dose),Zidovudine, Lamivudine tablets (mother)
Nevirapine Single Dose syrup (baby)
Pack Content
Will also include various (visual) guides/road maps, instructions and other relevant information
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Links
WHO pages: http://www.who.int/hiv/mtct/en/index.html
Guidelines on PMTCT and antiretroviral therapy: http://www.who.int/hiv/pub/guidelines/pmtctguidelines3.pdf
UNICEF:www.unicef.org/supply
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
Acknowledgement
• Bianca Kamps, Contracts Manager HIV/AIDS and Malaria, UNICEF, Copenhagen
• Atieno Ojoo, Technical Officer HIV/AIDS and Malaria, UNICEF, Copenhagen
Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access
THANK YOU