Prevention of Mother-to-child Transmission(PMTCT)
2011
Ashraf CoovadiaDepartment Of Paediatrics & Child HealthRahima Moosa Mother and Child Hospital
University of The Witwatersrand
Overview
Statistics Timing of Transmission Risk Factors for MTCT History of pMTCT Interventions Revised SA pMTCT policy 2010
Antenatal Prevalence - SA
Antenatal Prevalence - SA
Just under a third of pregnant women (29.3%) in South Africa are HIV Positive
One out of four babies (25%) born to all HIV positive mothers will acquire HIV from their mother ( if no intervention is offered )
That means at least 75% of babies are uninfected at birth!
Mother to Child Transmission
Background
55% of all HIV-1 positive adults are women of child bearing age.
Seroprevalence rates among pregnant women exceeds 30% in many urban populations in sub-Saharan Africa
MTCT Rates
~10 - 30% in non-breastfeeding population of HIV-1 positive women in more developed countries
25 -45% in breast-feeding populations in Africa
intrapartum67%
in utero33%
Timing of transmission in Non breast-feeding
Transmission in Children
breastfeeding30%
intrapartum60%
in utero10%
Timing of transmission Breastfeeding
Pregnancy Labour and Delivery Breastfeeding
High maternal VL
Placental infection
STIs
Maternal malnutrition
High maternal VL
ROM >4 hours before
labour begins
Invasive delivery
procedures
First infant in
multiple birth
Chorioamnionitis
High maternal VL
Duration of
breastfeeding
Early mixed feeding
Breast abscesses,
nipple fissures,
mastitis
Poor maternal
nutritional status
Oral disease in the
baby
Risk Factors for MTCT
History of PMTCT and ARV interventions
ACTG 076 1994, AZT to mother from 2nd trimester,
IV during labour and delivery, 6 weeks to infant; transmission reduced from 25%-8%
Shorter course therapies sought Thai regimen PETRA
HIVNET 012 Nevirapine one dose to mother and one
dose to baby (transmission reduced to 13%)
What did we know and when did we know it? Perinatal HIV Clinical Trial Results
1994 U.S. AZT Trial ACTG 076• 67% reduction in transmission
1998 Thai Bangkok short AP/IP AZT trial
• 50% reduction in transmission
1998 Cote d‘Ivoire short AP/IP AZT trials
• 37% reduction in transmission (breastfeeding)
1999 PETRA AZT/3TC trial (6 wk results)• 50% reduction with longest arm. • 38% reduction with the IP/PP arm
1999 Uganda 2-dose IP/PP NVP trial (HIVNET 012)• 47% reduction in transmission (breastfeeding)
1994 2004
2000 ThailandLong vs short AZT regimens
• 4% TR in LL (non BF)
2002 Cote d’Ivoire DITRAME +
• 6.2% TR with AZT & IP/PP NVP
2004 Thailand PHPT• 1.9% AZT + NVP
2003 DITRAME + 1201.1• 4.7% TR with AZT/3TC &
IP/PP NVP
MTCT: The four-pronged strategy
• Primary prevention of HIV in parents-to-be
• Prevention of unwanted pregnancies
• Prevention of transmission from HIV-infected mother to infant
• Appropriate treatment and care
Interventions
Before conceptionPrimary prevention of HIV in parents-to-bePrevention of unwanted pregnancies AntenatalIdentification of women requiring HAART or PMTCT ARV
courseAvoidance of unprotected sex with HIV+ partner PeripartumGood obstetric practiceElective Caesarian sectionARV – Nevirapine given in labour PostnatalAvoidance of breastfeeding – where safe, feasible,
acceptable
Standard ANC procedure Group pre-test counselling – PMTCT information
Individual counselling
Obtain verbal consent and proceed to test
Test results Post-test counselling and further PMTCT
information
Screening HIV test
Screening positiveScreening Negative
NegativeConfirmatory HIV test
Confirmatory positive
Confirmatory negative
NB! Retest at 32 weeks or ( 6 weeks after initial test )
Final result positive
Indeterminate
Send for HIV ELISA
Indeterminate Elisa send for PCR DNA test (diagnostic PCR)
Positive /Negative final result
Screening HIV test
Staging – highly simplified
Stage 1 - healthy
Stage 2 – skin conditions
Stage 3 – oral conditions and pulmonary TB
Stage 4 – other opportunistic infections
Zidovudine (AZT)
Dual therapy – antenatal AZT and intrapartum sd-NVP – introduced in February 2008
Addition of antenatal AZT further decreases transmission to 5%
Timing of initiation of AZT changed now to be in line with new WHO guidelines – from 14 weeks gestation
AZT cont...
According to president Zuma’s mandate on 1 December 2009, AZT for PMTCT should be
started from 14 weeks of pregnancy instead of 28 weeks
All HIV-infected pregnant women seen at antenatal clinics at 14 weeks of pregnancy and above must be started on AZT while awaiting CD4 cell count result
AZT cont... If the CD4 cell count is above 350
cells/mm3, AZT is continued until labour begins.
During labour, sd-NVP is issued in labour ward together with AZT 300mg 3 hourly until delivery. The women is then given TDF + FTC (acts as the tail cover)
If the CD4 cell count is less than 350 cells/mm3, the pregnant woman qualifies for ART).
AZT is stopped once ART is started, no additional AZT during labour nor tail required.
AZT AND ANAEMIA IN PREGNANCY
Anaemia is common in pregnancy Various causes: nutritional (iron deficiency),
HIV-related are common
AZT may exacerbate an existing anaemia, or cause the haemoglobin to drop
Prescribe adequate doses of haematinics – for all women and advise on how to take iron
Haemoglobin monitoring
Hb ≥ 11g/dl Ferrous Sulphate 200mg daily/Folic acid 5mg daily
Iron Supplementation
Hb >8g/dl <10g/dl Ferrous Sulphate 200mg tds/Folic acid 5mg daily
Hb <8g/dl Ferrous sulphate 200mg tds/Folic acid 5mg daily Urgent referral for investigation
For women on AZT 4 weekly Hb monitoring Consider initiating ART
Haematinics and monitoring (BANC)
Repeat Hb weekly
<14 weeks
>14weeks
Stage 3, 4 (any gestation)
Stage 3, 4 (any gestation)
Return1 week,ART/AZT from 14weeks
Start AZT results 1
week
Refer for anaemia start AZT when Hb >8
AZT immediately refer for ART
Hb, TB screen,CD4, Stage, Start FeSO4 and Folic Acid
1st Visit – HIV Infected
Hb > 8
Hb < 8
Management in labour
Single dose Nevirapine + AZT 300mg 3 hourly
To reduce intrapartum transmission (esp. unbooked mothers presenting in labour)
Reduces transmission to around 10% by 6 weeks testing
TDF + FTC stat after delivery
Combination therapy reduces resistance due to sdNVP
AZT started at 1st visit
Subsequent ANC visits
Check CD4 cell count resultALT if abnormal – HebBSagU&E + Weight (creatinine clearance)
CD4 ≤ 350 or stage 3 & 4
CD4 > 350Stage 1 & 2
Same day referral to ARV clinic for ART, AZT stopped once ARTinitiated
AZT 300 mg 12 hourlyGive 4 weeks supply
ANCBooking
Case finding do a CD4 cell count
Less than 14 weeks
(NVP,TDF,3TC)
Continue AZT
CD4 <350
HIV stagingCD4 result within 1weekStart AZT from 14 weeks
From 14 weeks,
•initiate ART
(EFV,TDF,3TC)
CD4 < 350
CD4>350
PMTCT and ART initiations NEW
PMTCT and ART initiation outline:
1. ANC booking visit2. Rapid HIV test positive3. HIV staging and CD4 cell count 4. Gestational age from 14 wks to 42 wks -
initiate AZT same same day5. CD4 count result within 1 week6. A. CD4 >350 – continue AZT B. CD4: <350 or stage 3 or 4 – initiate ART:
TDF, 3TC and NVP/EFVTDF, 3TC and NVP/EFV
Labour and delivery
Minimize number of PV exams to decrease risk of infection
Avoid prolonged labour
Avoid artificial rupture of membranes
Avoid traumatic vaginal delivery
Labour and delivery
Avoid routine episiotomy
Suction baby only when indicated, i.e. no routine suctioning
Wipe baby clean immediately after delivery to remove blood & liquor
HIV infectedmother on PMTCT regimen or no treatment
NVP statAZT 300mg 3 hourly during labour
Infant NVP 6 weeks*Delivery
Tail cover FTC/TDF stat dose post delivery
At onset of labour
HIV infectedmother on ART
Continue ART regimen 12
hourly throughout
labour
Mother continueART lifelong
At onset of labour NEW
Caesarian section
Routine C/S for HIV neither indicated nor feasible in government hospitals.
Elective C/S (Obstetric indication): give sd NVP at least 4 hours before
surgery If patient on ART, continue medication
at usual times Emergency C/S, antiretroviral treatment /
prophylaxis should be given stat Tail cover post C/S
Feeding practices
SAFE FEEDING PRACTICES For all HIV positive women Either exclusive replacement feeding
or exclusive breast feeding AFASS must be assessed on an individual
basis
Feeding choices for HIV infected women
Mixed feeding strongly discouraged BREAST FEEDING: exclusive breastfeeding
recommended for 1st 6 months of life . If she wants to stop at 6 months AFASS must
be reassessed Cessation of breastfeeding before 6 months
not recommended. Introduce complementary foods from 6 months in addition to continuing with breastfeeding
Feeding choices for HIV infected women
REPLACEMENT FEEDING: If women chose not to breast feed, exclusive formula feeding (i.e. no breast milk) should be practiced
Provision of free formula for at least 6 months Complementary foods should be introduced from 6 months
If the mother is known to be HIV positive – the infant is referred to as HIV EXPOSED
If the mother is known to be HIV positive – the infant is referred to as HIV EXPOSED
AVOID MISLABELINGAVOID MISLABELING
Post natal care
All women of unknown HIV status should be offered HIV testing and
counseling prior to discharge All HIV exposed infants to receive NVP daily for
6 weeks *All abandoned infants considered to be in their
first 72 hours of life, provide NVP daily for six weeks or until HIV ELISA confirms no HIV exposure
IdentifyHIV -exposed infant
6 weeks:Start CTXDo PCR Stop NVP
Prompt referral for
ART. Continue CTX
Switch to EBF if possible
PCR
PCR positive
PCR negative
*HIV negativeStop CTX
Exclusive formula fed
.
Stop infant NVP at 6 weeks
Continue infant NVP until breastfeeding cessation or max 1year
Infants of Breastfeeding mothers
VENOUSCAPILLARY
Blood collection
V
1ml
500 ul(0.5 ml)
PCR Positive
Do Viral load on separate
blood sample
Repeat DNA PCR
Initiate ART while waiting for VL
results
VL ≥ 10000 copies/ml(4log)
Continue ART
Confirm HIV infection in infants
.
VL ≤10000 copies/ml
Testing breastfed infants
6 week PCR (as for all HIV-exposed infants) BEFORE breastfeeding is stopped, do HIV
test: if positive, continue breastfeeding, refer for initiation if negative, stop breastfeeding
AFTER breastfeeding is stopped, do HIV test: if positive, try to re-initiate breastfeeding
refer for initiation if negative, currently HIV-uninfected
" All HIV-exposed infants should have a rapid test at 18 months to confirm their status unless they are already on ART"
Rapid test at 18 months
The provision of a “tail” to prevent Nevirapine resistance for women receiving sdNVP in labour
Dispensing daily NVP to the baby for 6 weeks (instead of AZT).
For breastfed infants NVP continues daily for 1 week after breastfeeding stops preferably no more than 12 months if mother not on ART.
pMTCT and feeding choices
HIV is present and transmitted via breast milk
Formula feeding is difficult in many areas especially rural
Women should be fully informed about choices and supported in their decision by health care workers (WHO)
Exclusive Breastfeeding (for 4 months)
BENEFITS Optimal nutrition Saves time, money
and effort Reduced exposure
to germs Better immunity Less allergy Socially acceptable Bonding
RISKS Transmits HIV
Exclusive Formula feeding
BENEFITS No transmission
of HIV through breast milk
RISKS Cost- may have
higher risk of poor growth
Infectious diseases, such as diarrhoea and pneumonia if hygiene, sanitation and access to clean water is poor
PMTCT RATES
Of all HIV Infected Women
75 % HIV Negative Babies
25 % HIV Infected BabiesWhere no intervention
> 95% HIV Negative Babies !
< 5% Infected
Take Home Messages All women have a right to receive PMTCT All babies have a right to be protected through
PMTCT Testing of all women is key to the realization of
these rights Provision of appropriate and timely
interventions is critical to diminishing MTCT risk Feeding choice needs to be an informed one Paediatric Diagnosis is a key component of
PMTCT Paediatric HIV is ERADICABLE
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