1) Prevention of Mother to Child Transmission (PMTCT) programs provide antiretroviral drugs, counseling, and support to pregnant women living with HIV to reduce the risk of transmitting the virus to their babies during pregnancy, childbirth, and breastfeeding. 2) Key interventions include antiretroviral prophylaxis for pregnant and breastfeeding women and their infants, safer delivery and infant feeding practices, and treatment, care and support for women and families. 3) In Tanzania, the national PMTCT program incorporates antiretroviral prophylaxis including various combination drug regimens during antenatal, intrapartum, postpartum, and infant periods, depending on when

1. Prevention Mother to Child
Transmission of HIV
(PMTCT)
.
1
FAHAD ZAKWAN

2. Facts on MTCT
• About 1,000 babies are infected with HIV every day
during pregnancy, birth or breastfeeding.
• Globally, there are approximately 1.4 million
pregnant women living with HIV in low- and middle-
income countries
• Over 90% of pediatric HIV is due to mother to child
transmission.
2

3. •An estimated 53% of pregnant women
living with HIV in the developing world
receive antiretroviral drugs to prevent
them from transmitting the virus to their
babies.
•PMTCT is now being incorporated in
Antenatal care.
3

4. What is the response?
•An intervention known as “prevention of mother-
to-child transmission of HIV,” or PMTCT,
 provides drugs,
 counseling and psychological support to help
mothers safeguard their infants against the virus.
Involve the family/partner.
4

5. HIV in general
5

6. Virology
•Human immunodeficiency virus (HIV) is a
lentivirus (a member of the retrovirus family)
that causes acquired immunodeficiency
syndrome (AIDS).
Progressive failure of the immune system allows
life-threatening opportunistic infections and
cancers to thrive.
6

7. The virion
7

8. ANTIBODY TESTING FOR HIV
8

9. Modes of transmission
High titers of HIV are found in the
following body fluids:
•Blood
•Semen
•Vaginal secretions
9

10. Route of transmission
• Unprotected sexual contact (vaginal, oral, anal)
• Parenteral exposure to contaminated blood
-sharing sharp penetrating objects
-Blood or blood product transfusion
-Occupational exposure like niddle pricks injuries
etc.
• Mother to child transmission
10

11. Most of the HIV infection in adults occurs
due to unprotected sexual
intercourse and the risk is increased in
cases of;
1. Presence of others STI or oral/genital
ulcers
2. Multiple sexual partners
3. High risk partners
11

12. Pathogenesis
12

14. Immune deficiency in HIV infection
• Persistent HIV infection with depletion of CD4 T-
helper cells is central to the pathogenesis of HIV
disease as manifested by immune deficiency,
susceptibility to opportunistic infections,
development of certain forms of cancer, and other
AIDS-defining illnesses.
• Other susceptible cells- monocytes, macrophages,
thymocytes, neurons, cells in the colon and the
cervix
14

15. Potential mechanisms for CD4T cell depletion
15

16. Other malfunctions of immune system in HIV
infected individuals
• B cell dysfunction
-B cells in patients with HIV infection also manifest many functional abnormalities, among them
polyclonal activation, hypergammaglobulinemia, autoantibody production as noted previously,
and impaired primary and secondary (memory) antibody responses to microorganisms, such as
encapsulated bacterial antigens.
-B cell abnormalities may be manifest at any, including an early, stage of HIV infection.
• HIV infection of lymphoid organs
lymphoid organs (lymph nodes, adenoids, tonsils) are the main anatomical sites of HIV infection
in the early and clinically latent stages of infection.
They may be latently infected, that is, contain HIV DNA without HIV RNA expression.
these latent infections can be activated by antigens (of other viruses and infectious agents),
mitogens, certain cytokines and growth factors to initiate or increase HIV production.
16

17. Lymph node involvement
Organs of the Immune System
Source: US Dept. of Health & Human Services, National Institutes of Health,
Understanding the Immune System: How it Works, NIH Sept. 2003, P. 4,
available at: http://www.thebody.com/niaid/pdfs/immune_system.pdf
17

18. Disease progress
Determined by:
1. Viral load
2. CD4+ T cell count
18

19. Disease progress
19

20. Clinical findings
Acute infection may be
•clinically asymptomatic
•Non-specific symptoms-fatigue, rash, night
sweats, headache, flu like symptoms, low grade
fevers.
AIDS characterized by profound
immunosuppression with OI/tumors
20

21. WHO staging
Why staging?
• Guides care
• Frame work for working up and management
• Treatment outcomes
• Diagnosis of HIV/AIDS in the absence of laboratory
Note that:
-Correlates closely with CD4 counts
-Specific infection tend to occur at a certain level of CD4
counts
21

22. STAGE I
•Asymptomatic
•Persistent generalized
lymphadenopathy
22

23. STAGE II
• Unexplained moderate weight loss<10%
• Recurrent RTI
• Herpes Zoster infection
• Recurrent oral ulceration
• Popular pruritic dermatitis
• Seborrhoic dermatitis
• Fungal nail infection
23

24. STAGE III
• Unexplained severe weight loss >10%
• Unexplained chronic diarrhea
• Unexplained persistent fever >37% (intermittent or constant)
• Persistent oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis
• Severe bacterial infections (pleural effusion, severe pneumonia,
empyema, bone or joint infection, meningitis or bacteremia)
• Acute necrotizing ulceration stomatitis or periodontitis
• Unexplained anemia or chronic thrombocytopenia
24

25. STAGE IV
• HIV wasting syndrome
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex
• Oropharyngeal candidiasis
• Extra pulmonary tuberculosis
• Kaposi's sarcoma
• Cytomegalovirus virus infection
• CNS toxoplasmosis
• HIV encephalopathy
25

26. • Extra pulmonary Cryptococcus infection
• Disseminated non-tuberculous mycobacterium infection
• Chronic isosporias
• Chronic cryptosporidiosis
• Recurrent septicemia
• Cerebral lymphomas
• Invasive cervical cancer
• HIV nephropathy or cardiomyopathy

27. MTCT
vertical transmission
•The overall MTCT rate is approximately 40%
without intervention
•MTCT can occur during:
Pregnancy
Labour and delivery
Breastfeeding
27

28. Vertical transmission (MTCT)
Antenatal
(before
delivery)
Intrapartum
(during delivery)
Through
placenta
5-10%
Increasing
with
gestational
age
Through
blood
10-20%
Highest risk
per time unit
Through
breast milk
10-20%
Postnatal
(during breastfeeding)
Total
risk
30-45%
Most of the infected infants will develop AIDS and die in early childhood.
28

29. Risk factors for transmission
1. Viral load:
Transmission is higher when the
mother’s viral load is high, as is the case
with advanced HIV infection (AIDS) or
with a new HIV infection.
29

30. Risk factors for transmission
2. Viral strain:
Transmission rates differ with
different strains of HIV.
Transmission is higher with HIV-1
than with HIV-2.
30

31. Risk factors for transmission
3. Viral resistance:
The presence of ARV-resistant strains of
HIV can increase the risk of MTCT. If the HIV
virus is resistant to certain ARV medications,
the medications will not work as effectively
to prevent MTCT.
31

32. Risk factors for transmission
4. HIV transmission during labour and delivery occurs
when the infant comes in contact with, ingests, or inhales
maternal blood or cervico-vaginal secretions that contain
HIV.
5. The presence of STIs increases the risk of MTCT of
HIV. Early identification and treatment of STIs in pregnant
women can reduce MTCT of HIV.
6. Other viral, maternal, obstetrical, foetal and infant factors,
alone or in combination, influence MTCT of HIV infection.
32

33. Pediatric HIV
•MTCT of HIV is by far the most common (90%)
cause of HIV infection among children under
the age of five year, and it accounts for about
5% of all new infections each year in Tanzania
•In Most case disease progression is faster and
they die in early childhood.
33

34. HIV and Pregnancy
34

35. EFFECT OF PREGNANCY ON HIV INFECTION
•In pregnancy, the immune function is
suppressed in both HIV-infected and non-
infected women.
•However Studies have shown that
pregnancy does not seem to have an effect
on the progression of HIV disease

36. EFFECT OF HIV ON PREGNANCY
• Increased risk of spontaneous abortions
• Double the rate of pre-term deliveries
• Increased risk of low birth weight (LBW)
• Increase in still births
• Increased risk of bacterial pneumonia, urinary tract
infections and other illnesses
• Increase in postpartum infections
36

37. Interventions
•Best obstetric practices
•ARV prophylaxis.
37

38. Care of Women in Labour and
Delivery
1.Administer ARV therapy and prophylaxis
during labour in accordance with national
guidelines.
Continue ARV therapy or administer ARV
prophylaxis during labour to reduce
maternal viral load and provide protection
to the infant.
38

39. 2. Use Standard Precautions (good
infection prevention practices) for
all patient care.
Use protective gear, safely use and
dispose of sharps, sterilize
equipment, and safely dispose of
contaminated materials.
39

40. 3. Minimize vaginal examinations.
Perform vaginal examinations only when
absolutely necessary, using sterile technique.
4. Avoid prolonged labour.
Consider use of oxytocic medications to shorten
labour when appropriate.
Use non-invasive foetal monitoring to assess need
for early intervention.
40

41. 5. Avoid artificial rupture of membranes.
Use a partogram to measure the progress of labour.
Avoid early rupture of membranes (before 7cm) unless
necessary.
6. Avoid unnecessary trauma during delivery.
Avoid invasive procedures, including scalp electrodes or scalp
sampling.
Avoid routine episiotomy.
Minimize the use of instrumental vaginal delivery.
41

42. 7. Minimize the risk of postpartum haemorrhage.
Carefully manage all stages of labour to prevent infection and
avoid prolonged labour.
Actively manage the third stage of labour, by using oxytocic
medications and controlled cord traction.
Perform uterine massage.
Repair genital track lacerations.
Carefully remove all products of conception.
42

43. 8. Use safe transfusion practices.
Minimize the use of blood transfusions.
Use only blood screened for HIV,
hepatitis B and C, and, when available,
syphilis and malaria.
43

44. The 4 Elements in a Comprehensive PMTCT
Programme
3. Prevention of HIV transmission from women infected with HIV to
their infants
2. Prevention of unintended pregnancies among women infected with
HIV
4. Provision of treatment, care and support to
women infected with HIV, their infants and families
1. Prevention of primary HIV infection
44

45. E1. Primary Prevention
Strategies:
•Promote access to VCT
•Promote “ABC” approach to safer sex including
providing access to condoms.
•Promote Standard Precautions to all healthcare
workers and in all service delivery points
45

46. E2. Preventing Unintended Pregnancies
 Family planning services include:
• Individual and couples counselling
• Information and skills needed to practise safer sex
• Access to contraceptives
To reduce the
number of
infants at risk for
MTCT…
Provide family planning services and safe,
consistent contraception to HIV-
infected women who do not want to
have more children.
Dual protection: Contraceptive options that
prevent both STIs/HIV and pregnancy
46

47. Routine HIV testing
(PITC)for all
pregnant women
Antiretroviral (ARV)
medications to
mother and infant
Safer delivery practices
Safer infant-feeding
practices
Identifies women infected with HIV
Reduces maternal viral load
Reduce infant’s exposure to HIV in
maternal blood/secretions
during labour and delivery
Reduce infant exposure to HIV
through breastfeeding
E3.PMTCT Core Interventions
47

48. E4a.Treatment, Care and Support
for Women and Families
•Prevention and treatment of OIs
•ARV treatment eligible women
•Nutritional support
•Psychosocial and community support
48

49. E4b. Treatment, Care and Support
for HIV-Exposed Infants
•Infants and children who are HIV-exposed require close
follow-up care, particularly in the first 2 years of life.
•Follow-up care includes:
–Nutritional support
–Immunisations
–Ctx prophylaxis
–HIV testing (EID-PCR 4-6 weeks)
–Ongoing monitoring of growth and development
49

50. RCH and PMTCT
•Integration of PMTCT programme in RCH
services helps all women by strengthening
maternal, infant and family care.
•ANC is the most common entry point into
PMTCT services.
•Referrals to HIV care and treatment clinics from
RCH services are critical for HIV-infected
women and children.
50

51. TanzaniaNational
PMTCT
Programme
51

52. ARV PROPHYLAXIS
1. Antenatal
2. Intrapartum
3. Postpartum
4. Infant
52

53. Women testing HIV-positive during ANC
• During ANC – start AZT 300 mg BD from 28 weeks or anytime
thereafter.
• During labour – Give single-dose NVP 200 mg at the onset of labour.
Give AZT 300 mg and 3TC 150mg at the onset of labour. Continue AZT
every 3 hours and 3TC every 12 hours until delivery.
• During the postpartum period - continue AZT 300 mg BD and 3TC 150
mg BD for 7 days
• All infants receive single-dose NVP 2 mg/kg as soon as possible after
delivery AND AZT syrup 4 mg/kg BD for 4 weeks or 1 week (7 days) if a
mother received at least 4 weeks of AZT during ANC.
53

54. Pregnant women presenting during labour
who test HIV-positive
• During labour – Give single-dose NVP 200 mg at the onset of labour.
Give AZT 300 mg and 3TC 150mg at the onset of labour. Continue AZT
every 3 hours and 3TC every 12 hours until delivery.
• During the postpartum period - continue AZT 300 mg BD and 3TC 150
mg BD for 7 days
• All infants receive single-dose NVP 2 mg/kg as soon as possible after
delivery AND AZT syrup 4 mg/kg BD for 4 weeks.
54

55. Mothers who test HIV-positive after delivery
•All infants receive single-dose NVP 2 mg/kg
immediately after birth AND AZT syrup 4 mg/kg
BD for 4 weeks.
•ARV prophylaxis should be started for the infant
as soon as he or she can tolerate oral feedings
and within 12 hours of delivery
55

56. Sites where Combination
ARV Medications are NOT
Available
56

57. Women testing HIV-positive during ANC
•During ANC – dispense single dose NVP at the 28
weeks visit or anytime thereafter.
Educate mother when to take the sdNVP during labor
(onset of labor)
•All infants receive sdNVP as soon as possible after
delivery but within 72 hours.
57

58. Mothers who test HIV-positive after delivery
•All infants receive single-dose NVP
2 mg/kg immediately after birth
but within 72 hours.
58

59. Key
•AZT=Zidovudine
•3TC= Lamivudine
•NVP=Nevirapine
59

60. Infant Feeding in the Context of HIV
Infection
If no actions are taken, 5 to 20%
of infants breastfed by HIV-
infected mothers may become
HIV-infected through
breastfeeding.
60

61. There are certain risk factors that increase the
likelihood of MTCT through breastfeeding. They
include:
• High viral load in the mother
• Recent HIV infection
• Advanced HIV infection (AIDS)
• Mastitis
• Cracked or bleeding nipples
• Breast abscesses
• Candida
• Ulcers or sores in the infant’s mouth
• Mixed feeding
61

62. Options
•Exclusive breastfeeding for
6months.
•Exclusive replacement feeding
NOTE: Mixed feeding increases
the risk
62

63. Infant feeding and HIV free Child survival
• In resource-limited countries breast-feeding is vital for infant survival
because a majority of women cannot implement other safe infant
feeding options.
• Refraining from breast-feeding altogether or stopping breast-feeding
at a very early age is a threat to child survival in these populations (Kuhn
et al. 1997, WHO collaborative study team on the role of breastfeeding on the prevention of infant mortality
2000, Kuhn et al. 2008).
• Studies from Zimbabwe, South Africa and Zambia have demonstrated
that infants who are exclusively breast-fed for up to 6 months have
lower HIV-1 infection rates than children who receive mixed feeding
(Coutsoudis 1999, Coutsoudis et al. 2001, Iliff et al. 2005, Coovadia et al. 2007, Kuhn et al. 2007).
• However, the risk of breast milk HIV transmission cannot be
eliminated by exclusive breast-feeding alone.
63

64. UN Feeding Recommendations: Mothers
with HIV Infection
• HIV-infected women should replacement feed when it is:
AFASS
–Acceptable
–Feasible
–Affordable
–Sustainable
–Safe
• Otherwise, they should breastfeed exclusively stopping as
soon as it can be done safely.
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65. Thank you!!
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