PPTCT.pptx

Prevention of
Parent-to-Child
Transmission of HIV

CONTENTS
1. Understanding PPTCT
2. PPTCT Services in India
3. HIV Exposed Infant

NACO Data 2012-2013
Paediatric HIV can be prevented by effective PPTCT

Mother (Parent) to Child Transmission
• HIV transmission from Mother to child occurs
during:
– Pregnancy
– Labor and Delivery
– Breast-feeding
• Major factor that increases the risk of MTCT
– Amount of HIV (viral load) in the mother's blood

Why is PPTCT important?
• Key mode of HIV transmission in children
• 29 million pregnancies every year – 22000 in
HIV positive women
• Possible to prevent HIV infection among
infants and children
• Possible to minimise mortality, if detected
early and initiated on ART

Why is PPTCT important?
• Potentially eliminate Risk of HIV transmission
• Paediatric HIV is thus amenable to prevention
as well as effective management

Source: HSS 2010–-11, Dept of AIDS Control, MOHFW/GoI
National Average (ANC): 0.42%
Estimated HIV positive Pregnant
Women / year: 38,202
Higher prevalence in southern
region of the country and pockets
of high prevalence in rest of the
country
HIV Prevalence Among Pregnant Women (ANC)

0
1000
2000
3000
4000
5000
6000
Estimated HIV infected pregnantwomen Programme Detection in 2011-12
Aim: Detection of Positive
Pregnant Women in Low HIV
prevalence states which
contribute about 57% burden
Detection of HIV Positive Pregnant Women
State Wise 2011-12

Estimated Risk of Mother to Child transmission
Risk of HIV Transmission Transmission Rate
Transmission Rate
(with ARV)
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
1 ARV, Short course –
15-25%
2 ARVs, Short course
– 5%
3 ARVS (ART) – 2%
Overall without breastfeeding 15-25% 3 ARVS (ART) – 1%
Overall with breastfeeding up-to
six months
20-35%
Overall with breastfeeding for 18-
24 months
30-45%
Reference: De Cook KM, et al. JAMA.2000; 283(9):1175-82.

PPTCT Services
Vision:
Women and children, alive and free from HIV
Goal:
To work towards elimination of paediatric HIV and
improve maternal, newborn and child health and
survival in the context of HIV infection

PPTCT Services
Objectives:
1.To detect more than 80% HIV infected
pregnant women in India
2.To provide access to comprehensive PPTCT
services to more than 90% of the detected
pregnant women
3.To ensure more than 95% compliance with
ART in HIV infected pregnant and
breastfeeding women

PPTCT Services
Objectives:
4. To provide access to early infant diagnosis
to more than 90% HIV exposed infants
5. To ensure access to anti-retroviral drug
(ARV) prophylaxis or Anti-Retroviral Therapy
(ART) to 100% HIV exposed infants

HIV Negative
general
population,
e.g. ARSH
Prong 1:
Primary
prevention of
HIV
HIV +ve
Not Pregnant
Family Planning
Counselling at ART centres
& CSC
Prong 2:
Prevent
unintended
pregnancies
HIV +ve
& Pregnant
Prong 3:
Prevention of
MTCT
Four Pronged Strategy
ARSH: Adolescent
Reproductive and
Sexual Health
HIV +ve
Mother
& Child
Prong 4:
Care,
support and
treatment
Linkages
&referrals,
including EID

Interventions During Pregnancy
• Primary prevention of HIV in childbearing
women
• Provide HIV information to ALL pregnant women
• Prevention of unwanted pregnancies in HIV-
positive women
• Prevention of PTCT through ART
• Safe obstetric practices

Interventions During
Labour and Delivery
• Minimise vaginal examinations
• Avoid prolonged labour
– Consider oxytocin to shorten labour
• Avoid premature rupture of membranes
– Use partogram to measure labour
– Avoid artificial rupture of membranes
• Do not use suction unless absolutely necessary
• Early cord clamping after it stops pulsating and
after giving the mother oxytocin

Interventions During
Labour and Delivery
• Avoid unnecessary trauma during delivery
– Use non-invasive foetal monitoring
– Avoid invasive procedures
– Avoid routine episiotomy / support perineum
– Minimise the use of forceps or vacuum extractors
• 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

Considerations in Mode of Delivery
• In India, normal vaginal delivery is
recommended unless the woman has
obstetric reasons (like foetal distress,
obstructed labour) for a C-section
• Use of ART can reduce risk of PTCT better and
with less risk than a C-section

Safer Infant Feeding
• Feeding options must be explained to all the
mothers and they must be allowed to select
their informed choice
• Breastfeeding: NACO Recommendations
• Exclusive Replacement feeding (ERF)
– if Affordable, Feasible, Acceptable,
Sustainable and Safe (AFASS)

“In virologically
suppressed patients,
switching d4T to TDF as
part of a once-daily
regimen with 3TC and
EFV resulted in
maintenance of
virologic suppression
and continued CD4 cell
increases through 144
weeks.”
Reference: Cassetti et al. The safety and efficacy of switching stavudine to tenofovir df in
combination with lamivudine and efavirenz in hiv-1-infected patients; Three-year follow-
up after switching therapy. HIV Clin Trials. 2007; 8(6):381-90

ART in practice
ART Regimens in women pregnant and
breastfeeding with HIV
Who have not already received ART TDF + 3 TC + EFV
Who are already receiving ART Continue same regimen
Who have been exposed to NNRTI in past Replace NNRTI with PI (LPV/ r)
ART Regimens in women in active labour
Who have not already received ART TDF + 3 TC + EFV

Who is an HIV Exposed child/ infant?
Infants and children born to mothers infected
with HIV, until HIV infection can be reliably
excluded or confirmed in them.

Care of
HIV
Exposed
Child
Care at Birth
Infant feeding
ARV
Prophylaxis
Vaccines and
Vitamin A
Cotrimoxazole
Prophylaxis
Growth and
Development
Early Infant
Diagnosis
Follow up

Care at Birth
• Wipe mouth and nostrils as soon as head is
delivered
• Handle with gloves until all blood and
maternal secretions have been washed off.
• Clamp cord soon after birth, no milking, cover
with gauze during cutting to prevent splatter
• Initiate feeding within an hour as per
preferred choice

National Guidelines for feeding of HIV
exposed and infected children < 6 months
of age

The Six Criteria for Replacement Feeding

Safer Infant Feeding – WHO AFASS
Criteria
• Feeding options must be explained to all the
mothers and they must be allowed to select
their informed choice
• Breastfeeding: NACO Recommendations
• Exclusive Replacement feeding (ERF)
– if Affordable, Feasible, Acceptable,
Sustainable and Safe (AFASS)

Guidelines to introduce complementary feeding

ARV prophylaxis for infants born to women who did not
receive any ART (Home Delivery)
• Start at first encounter with health services
• Can be started even > 72 hours after birth
• Continue for minimum 6 weeks, by which time
the mother should be linked to appropriate
ART services
• Depends on how long the mother was on ART
(upto a minimum of 24 weeks)

Extended duration of Nevirapine prophylaxis in
infants
• Minimum of 6 weeks (whether exclusively breast fed or
exclusive replacement fed)
• Increased to 12 weeks, if ART to mother was started in late
pregnancy, during or after delivery and has not been on
adequate period of ART as to be effective to achieve optimal
viral suppression (which is at least 24 weeks- 6 months)
• The recommendation on extended Nevirapine duration (12
weeks) applies to infants of breast-feeding women only and
not those on exclusive replacement feeding
• Infants of women with prior exposure to NVP to get Syp AZT in
place of Syp NVP.
• Infants born to women infected with HIV-2 also get Syp AZT

Infants
Birth Weight
NVP daily dose
(in mg)
NVP daily dose (in ml)
(10mg/ml)
Duration
Infants with
birth weight
<2000 gm
2 mg/kg
once daily
0.2 ml/kg
once daily
Up to minimum of 6
weeks of age
regardless of
exclusively breast fed
or exclusively
replacement fed
Extended to 12
weeks, if the duration
of ART of the mother
is less than 24 weeks
and she is breast
feeding
Birth weight
2000 – 2500
gm
10 mg
once daily
1 ml once daily
Birth weight
>2500 gm
15 mg
once daily
1.5 ml
once daily
Recommended ARV Prophylaxis for
HIV Exposed Infants

Price – Rs. 121.45
for 100 ml

Vaccines and Vitamin A
• Can be immunized as per national schedule with
a few exceptions (live attenuated C/I in severe
immunocompromised state and CD4< 15%)
• BCG should be given at birth. However, if BCG
has not been given at birth, do not give in
symptomatic infants
• Rotavirus vaccine is recommended.
• JE Vaccine can be given
• Vitamin A as per schedule

Cotrimoxazole
• Protects against Pneumocystis jiroveci,
malaria, diarrhoea due to isospora and
cyclospora and toxoplasmosis.
• 5 mg/kg/day – starting at 6 weeks, continuing
till all diagnostic tests are negative at 18
months

Early Infant Diagnosis
Start Cotrimoxazole at 6 weeks
Feeding practice as per choice
Complementary feeding > 6
months
Continue Cotrimoxazole till 5 yrs
Initiate ART
Breastfeeding till 2 years
Control opportunistic inf
Repeat Antibody test at 12 months or 6
weeks after stopping BF
If symptomatic, repeat PCR
Breastfeeding till 1 year
Test for definitive at 18 months

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