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Prevention of Parent To Child Transmission PPTCT

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Prevention of Parent To Child Transmission PPTCT

  1. 1. Prevention of Parent-to-Child Transmission (PPTCT)PPTCT Overview
  2. 2. Session Objectives By the end of the session, the participants will be able to discuss: • Describe NACO’s four-pronged strategy for PPTCT • Understand the factors that influence PTCT • Understand interventions to reduce PTCT • Discuss measures to overcome PPTCT issues in a resource-restricted settingPPTCT Overview 2
  3. 3. Routes of Transmission of HIV NACO Annual Report 2009-2010PPTCT Overview 3
  4. 4. HIV and Women in India Indicator Number Number of women who are HIV infected 0.9 million (38%) in India and % of total Number of annual pregnancies in India 27 million Estimated number of HIV positive 43,000 pregnancies (2009)PPTCT Overview 4
  5. 5. NACO’s 4-Pronged PPTCT Strategy • Primary prevention of HIV among women of childbearing age • Preventing unintended pregnancies among women living with HIV • Preventing HIV transmission from a woman living with HIV to her infant • Providing appropriate treatment, care and support to women living with HIV and their children and familiesPPTCT Overview 5
  6. 6. Estimated Risk and Timing of PTCT in the Absence of Interventions Transmission Risk of HIV Transmission Rate During pregnancy 5-10% During labour and delivery 10-15% During breastfeeding 5-20% Overall without breastfeeding 15-25% Overall with breastfeeding to six months 20-35% Overall with breastfeeding to 18-24 months 30-45% Source: WHOPPTCT Overview 6
  7. 7. Risk of HIV Transmission • What are the factors that influence mother- to-child transmission risk ?PPTCT Overview 7
  8. 8. Maternal Risk Factors Influencing PTCT • High viral load • HIV subtype • Resistant strains • Advanced clinical stage • Concurrent STI • Recent infection • Viral, bacterial and parasitic (esp. malaria) placental infection • MalnourishmentPPTCT Overview 8
  9. 9. Obstetrical Risk Factors Influencing PTCT • Uterine manipulation (amnio, external cephalic version) • Prolonged rupture of the membranes (>4 hours) • Placental Disruption (abruption, chorioamnionitis) • Intrapartum haemorrhage • Invasive foetal monitoring (scalp electrode/scalp blood sampling) • Invasive delivery techniques: episiotomies, forceps, use of metal cups for vacuum deliveries • Vaginal delivery vs. caesarean sectionPPTCT Overview 9
  10. 10. Infant Risk Factors Influencing PTCT • Immature Immune System – Preterm baby • Low birth weight (<2.5kg) • First infant of multiple birth • Altered skin integrity • Immature GI tract • Genetic susceptibility – HLA genotype – CCR5 karyotype deletionPPTCT Overview 10
  11. 11. Infant Feeding Risk Factors Influencing PTCT • Mother is infected with HIV while breastfeeding • Breast pathologies (cracked nipples, mastitis, or engorgement) • Advanced HIV disease in the mother • Poor maternal nutrition • Mouth sores or an inflamed GI tract in baby • Mixed feeding: Breast milk along with other foods • Prolonged breast feeding (6-18 months)PPTCT Overview 11
  12. 12. Interventions During Pregnancy • Primary prevention of HIV in childbearing women • Provide HIV information to ALL pregnant women • Antenatal visits are opportunity for PPTCT • Prevention of unwanted pregnancy in HIV-positive women • Prevention of PTCT through ART (to mother and baby) • Safe obstetric practicesPPTCT Overview 12
  13. 13. Interventions During Labour and Delivery 1. Minimise vaginal examinations 2. Avoid prolonged labour – Consider using oxytocin to shorten labour when appropriate 3. Avoid premature rupture of membranes – Use partogram to measure labour – Avoid artificial rupture of membranes (unless necessary) 4. Avoid unnecessary trauma during delivery – Use non-invasive foetal monitoring – Avoid invasive procedures, such as using scalp electrodes or scalp sampling – Avoid routine episiotomy – Minimise the use of forceps or vacuum extractors – Uterine manipulation - amnio, external cephalic version (ECV)PPTCT Overview 12
  14. 14. Interventions During Labour and Delivery • Do not use suction unless absolutely necessary – If suction is a must, use either mechanical suction at <100 mm Hg pressure or bulb suction, rather than mouth-operated suction • Clamp cord after it stops pulsating and after giving the mother oxytocin • 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 motherPPTCT Overview 14
  15. 15. Considerations Regarding Mode of Delivery • Caesarean section performed before the onset of labour or membrane rupture has been associated with reduced HIV Transmission from Mother to Child • The risk of elective Caesarean for PMTCT should be assessed carefully in the context of factors such as: – Risk of post-operative complications – Safety of the blood supply – Cost • In India, normal vaginal delivery is recommended unless the woman has obstetric reasons (like foetal distress, obstructed labour, etc) for a C-section • Use of ART can reduce risk of PTCT better and with less risk than a C-sectionPPTCT Overview 15
  16. 16. Interventions During Infancy • Observe for signs and symptoms of HIV infection • All HIV exposed infants should receive cotrimoxazole at 4-6 weeks of age • Follow standard immunisation schedule • Routine well baby visits • DNA PCR • 18-month visit for HIV testingPPTCT Overview 16
  17. 17. Interventions for Safer Infant Feeding • Exclusive breastfeeding • Support good breast health and hygiene • Replacement feeding – if Affordable, Feasible, Acceptable, Sustainable and Safe (AFASS) • Avoiding addition of supplements or mixed feeding which enhance HIV transmission Discussions with mothers about the above must consider personal, familial and cultural concernsPPTCT Overview 17
  18. 18. Outcome of various Feeding options BMJ, 2001, 322:3; bmj.comPPTCT Overview 18
  19. 19. Anti Retroviral prophylaxis and therapy • ARV prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother-to- infant • ARV therapy: Long-term use of antiretroviral drugs to treat maternal HIV and for PPTCT • ARVs during pregnancy decrease the HIV viral load in the mother’s blood, thus lowering the chance of her infant to get exposed to the virusPPTCT Overview 19
  20. 20. ARV Interventions Intervention Risk of Mother-to-Child HIV Transmission No ARV, breastfeeding 30-45% No ARV, No breastfeeding 20-25% Short course with 1 ARV, 15-25% breastfeeding Short course with 1 ARV, 5-15% No breastfeeding Short course with 2 ARVs, 5% no breastfeeding 3 ARVs (ART), no breastfeeding 1% 2 ARVs, breastfeeding unknown 3 ARVs (ART), breastfeeding unknownPPTCT Overview Source: WHO 20
  21. 21. Antiretroviral Prophylaxis: Monotherapy • Nevirapine (NACO Guidelines) – Mother - Single dose NVP 200mg onset of labour – Baby - Syrup NVP 2mg/kg within 72 hours of delivery • Revised NACO Guidelines will be in place shortlyPPTCT Overview 21
  22. 22. ARV prophylaxis during Labour & Delivery for HIV-infected Women • Administer ARV therapy or ARV prophylaxis during labour according to national guidelines to reduce maternal viral load and provide protection to the infant • Avoid repeat dosing of single-dose NEVIRAPINE (e.g., in the case of false labour), as this can cause viral resistance – Ensure that a woman is in true labour before administering a single-dose of NVP – Document NVP administration clearly on a patient’s partogramme or medical record to avoid accidental repeat dosingPPTCT Overview 22
  23. 23. Discussion Question What are the challenges of using single dose Nevirapine for prophylaxis ?PPTCT Overview 23
  24. 24. ART in Pregnancy Guidelines for initiation of ART (2010) WHO CD4 (cells/cu.mm) Clinical Staging I and II Start ART at CD4 Count <350 III and IV Start ART irrespective of CD4 Count Strict Monitoring of Adverse effects of Nevirapine is needed if CD4 count is >250PPTCT Overview 24
  25. 25. First line Regimens for Pregnant Women Eligible for ART • AZT/3TC/NVP is the preferred regimen • Stavudine to be given in the place of Zidovudine in those having low haemoglobin (<9G%) • Women with contraindications to NVP (hepatotoxicity and rash) can be given EFV • Avoid Efavirenz during First Trimester of Pregnancy (teratogenic in first trimester) • Efavirenz to be used with caution and with “thorough” counselling of the risks to foetusPPTCT Overview 25
  26. 26. Discussion question Can we give NVP based ART to a woman who has had single dose-NVP for PPTCT? NACO ART guidelines 2007; CID 2008; 46: 622-4.PPTCT Overview 26
  27. 27. NACO’s Key Principles (1) • ART is only one component of PPTCT • Selection of ART is based on: • Effective regimen available for treatment of maternal disease • Teratogenic potential of the drugs should pregnancy occur • Provide ART to pregnant women based on national guidelinesPPTCT Overview 27
  28. 28. NACO’s Key Principles (2) • Offer pregnant women the most efficacious PPTCT regimens • Simple and effective regimens should be used in order to expand coverage and benefit more people • Simple ARV with NVP should be considered as short term alternative until changes in national health system takes placePPTCT Overview 28
  29. 29. Case Study 1 25 year-old patient, primigravida at 20 weeks gestation: – Diagnosed as HIV-positive at the antenatal outpatient department – ART facilities available 1. What ARV regimen is appropriate for this patient? 2. What other services will this patient need?PPTCT Overview 29
  30. 30. Case Study 2 An unregistered primagravida patient: – Admitted with labour pains for 2 hours – Rapid test for HIV is positive 1. What ARV regimen is appropriate for this patient? 2. What other services will this patient need?PPTCT Overview 30
  31. 31. Case Study 3 A pregnant woman, in the first trimester, comes with CD4 cell count of 176 1. Does this woman need ART? 2. How will you manage this pregnant woman? 3. If the woman is also suffering from pulmonary TB, how will you manage?PPTCT Overview 31
  32. 32. Challenges to Implementing Interventions to Prevent PTCT • A significant proportion of deliveries continue to be unsupervised Home deliveries in many states • Many of the hospital deliveries still remain uncovered by PPTCT for different reasons • Most of the private institutional deliveries are not covered by PPTCT • Gaps in initiating early ART for the eligible HIV positive pregnant mothers • Infant feeding practices / options for HIV exposed infants: varied perceptions, opinions and advicesPPTCT Overview 32
  33. 33. Key Points • PTCT risk is affected by four factors: – Maternal – Obstetrical – Infant – Infant feeding • Appropriate interventions and ART can reduce PTCT risk • ARV prophylaxis, safer obstetric and infant feeding practices are effective interventions to reduce PTCTPPTCT Overview 33

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