student

1. Care of HIV positive pregnant and breastfeeding
Women
Feb 1, 2023

2. Learning objectives
• Overview of PMTCT
• Describe the 4 prongs of comprehensive PMTCT
• Describe the PMTCT continuum of services through
Antenatal, Labor and delivery, and Post-natal care.

3. The goal of eMTCT
• Is to “eliminate new HIV infections among children and keep
their mothers alive by 2025.”Without intervention, the overall
mother-to-child transmission rates for HIV range from 15%–
35%.
• The new terminology is eVT of HIV, Syphilis
and Hepatitis.
• Transmission can occur during pregnancy, labour
& delivery and breastfeeding.
The PMTCT program aims for elimination of HIV transmission from mother to
child….as well as reduction of mortality & morbidity among HIV-positive women
and HIV-exposed/infected infants

4. End of breastfeeding
6 week EID with rapid TAT. POCT preferable
where available
Final confirmatory EID at 18mths or 3 months
after complete cessation of breastfeeding
Overview of PMTCT

5. Prepartum
•ART
•Clinical Evaluation and Provision of Routine Care –MM flip chart
•CTX Preventive therapy & Malaria Prevention
•TB Screening & Prevention
•VL Monitoring
•Nutritional Counselling & Support
Partum
•Encourage all pregnant women to delivery in the facility
•It she intends to deliver from home ,find out who will be attending to her delivery and how hygiene &
measures to prevent transmission risk during delivery
•MM flip chart
Postpartum
•ARV prophylaxis ,Establishing breastfeeding, Linkage to PMTCT/EID
•EID cascade 6 weeks, 9 months, 18 Months and 3 Months after cession of breast feeding
•MM flip chart
HIV Positive Pregnant/Breastfeeding Milestone

6. PMTCT_EID Coverage 0 – 2 Months

7. Health facility
# of Exposed infants
registered between oct 2018-
Sept 2019
# HV infected HIV un-infected
Final status
unknown
Died without status
known
% unknown
outcome
EZO Hospital 98 0 78 17 3 17%
Yangiri Primary Health Care Centre 6 0 5 1 0 17%
Naandi Primary Health Care Centre 25 1 19 4 1 16%
Maridi County Hospital 71 5 40 25 1 35%
Nzara PHCC 132 1 126 4 1 3%
Basukangbi PHCC #DIV/0!
Sakure Primary Health Care Centre 11 3 7 0 1 0%
Bangasu Primary Health Care Centre 4 0 4 0 0 0%
Gangura Primary Health Care Centre 24 0 18 6 0 25%
Yambio Primary Health Care Centre 154 1 96 52 5 34%
Bazungua Primary Health care centre 14 0 11 3 0 21%
Yambio Hospital 234 3 172 54 5 23%

8. All 4 “prongs” of PMTCT must be addressed in order
to achieve global and national targets.
• Aims to prevent women and men from HIV. Interventions include: Behavioural change
communication of safer sex, HIV testing & counselling oral PrEP.
Prong 1: Primary prevention of HIV infection
• This element addresses the long term family planning and contraceptive needs of women
living with HIV.
Prong 2: Prevent unintended pregnancies among women living with HIV
• Focuses on access and utilization of the recommended package of PMTCT for HIV-infected
women and their infants – HTS, ART, Safe delivery, IYCF counseling, etc
Prong 3: Prevent HIV transmission from women living with HIV to their
infants
• Addresses the treatment, care & support needs of HIV-infected women, their children &
families–ART, CTX, nutrition, EID, immunization, growth monitoring, psychosocial support
Prong 4: Provision of treatment, care, and support to women living with
HIV and their children and families

9. PMTCT model of care & Clinic Systems
ART Clinic
PMTCT/MCH
Initial point of care
Scenario 1: Mother identified in ANC
During ANC: Mother should be enrolled
on ART in MCH. ART card opened & UAN
obtained from ART clinic
ANC, PMTCT, HEI Registers
 HIV/ART Card
 Appointment calendar
1
2
Maternity
3
4
Mother
linked
back
to
PMTCT
clinic
after
delivery
Maternity Register
Maternity PMTCT register
 ART Register
 ART care card
 Appointment calendar

10. PMTCT model of care & Clinic Systems
PMTCT/MCH
ART Clinic
(initial point of care)
Scenario 2: Mothers already on ART (at ART Clinic)
 ART Register
 ART care card
 Appt Book
 ANC, PMTCT, HEI Registers
 Appointment calendar
 ART care card
1
4
3
Maternity
2
Mother
linked
back
to
PMTCT
clinic
after
delivery

11. Before Pregnancy
Primary Prevention of
HIV infection
HTS for women,
couple/partner HTS,
linkage to ART for
sero-discordant
couples
Prevention of
unintended pregnancy
among women living
with HIV
Antenatal
PITC, Retest in 3rd
trimester if negative
ART for mother &
Basic HIV care (CPT,
ITNs , TPT)
Counseling on Infant
feeding and support
Community outreach
to support partner
involvement and HTS
Labour and Delivery
PITC (offer PITC if
never tested or tested
negative in 1st
trimester).
Safer delivery practices
to decrease risk of
infant exposure to
HIV.
Lifelong ART.
ARVs prophylaxis to
the newborn .
Post Partum
PITC (offer PITC if never
tested);
Life long ART.
Routine Immunization,
Growth monitoring, IYCF
support
Early Infant Diagnosis
(EID) & ART for infected
infants
SRH services including FP
for mother
PMTCT interventions should be provided as a continuum of
services during pregnancy, Labor & delivery and Breastfeeding

12. Interventions for HIV positive pregnant women (ANC)

13. 1. ART
• The goal of ART for HIV positive pregnant women
is to:
• To restore and maintain the mother’s immune
function and therefore general health(OI,TB)
• To prevent transmission of HIV in utero, at L&D
and during breastfeeding.
• Lifelong ART in the mother protects the current
pregnancy
• Maternal ART with optimal viral suppression
reduces the risk of HIV transmission to HIV
negative in serodiscordant couples.

14. ART
• All women living with HIV who are identified during pregnancy,
labour, or while breastfeeding should be started on lifelong ART
(option B+) irrespective of CD4 counts or WHO clinical stage.
• What to start with (first line ART):
• Once daily FDC of TDF/3TC/DTG 600/300/50mg
• For who become pregnant while on ART, continue the same ART
regimen, unless there is evidence of (virological) treatment failure.

15. 2. Clinical evaluation and provision of routine care
• Review monthly until after delivery.
• At every clinic visit, perform a comprehensive clinical evaluation,
including
oObstetric examinations.
oScreen and manage any underlying infections/health conditions
o Screening and management of opportunistic infections (OIs)
oClinical staging
oPreventive therapy for OIs including CPT,TPT
o Nutrition assessment, counselling, and support
oVL Monitoring every 6 months post-initation and every 6 month thereafter
until cession of breastfeeding.

16. 3. Cotrimoxazole (CTX) preventive therapy &
Malaria prevention
• All HIV positive pregnant & breastfeeding women should be
receive CTX, which also provides prophylaxis against malaria
• Pregnant women living with HIV can start taking CTX
preventive therapy at any gestational age.
o NB: If the woman is already receiving cotrimoxazole prophylaxis, should not be
giving sulphadoxinepyrimethamine (Fansidar) for intermittent preventive treatment
of Malaria.
• All pregnant & breastfeeding women should be encouraged to
sleep under an insecticide-treated mosquito net to prevent
malaria.

17. • Pregnant women with un-treated TB disease are more likely to give birth to
babies that are premature or of low birth weight.
• TB also increases the risk of vertical transmission of HIV to the unborn
child.
• At every visit, an HIV positive pregnant and breastfeeding woman should be
screened for TB, using the TB symptom screen:
o Cough for any duration,
o Fever for any duration,
o Night sweats,
o Weight loss or in the case of pregnant women, failure to gain weight.
• Screen for TB and take appropriate action, including INH for eligible women
4. TB Screening and Prevention

18. 5. Viral load (VL) monitoring
• All pregnant and breastfeeding women living with HIV followed up
in the MCH/PMTCT should have routine VL monitoring.
• For HIV positive women already on ART, obtain VL as soon as
pregnancy is confirmed at first ANC visit, to identify women at risk
of in utero transmission.
• For all pregnant women, regardless of ART initiation timing,
conduct VL testing at 34–36 weeks of gestation (or at least at
delivery) to identify women who may be at risk of treatment failure
and/or may deliver infants at high risk or perinatal transmission.

19. Viral load (VL) monitoring
• For pregnant women receiving ART before conception, conduct a
VL test at first ANC to identify women at risk of in utero
transmission.
If VL ≥1,000 copies/ml, follow the treatment monitoring algorithm
, and consider NAT at birth.
• For women starting ART during pregnancy, conduct a VL test
3months after ART initiation to ensure that there has been rapid VL
suppression.
 If VL ≥1,000 copies/ml, follow the treatment monitoring algorithm
and consider NAT at birth.

20. • For all breastfeeding women, regardless of when ART was initiated,
conduct a VL test 3months after delivery and 6 months thereafter to
detect viraemic episodes during the postnatal period.
If VL is ≥1,000 copies/ml, follow the treatment monitoring algorithm
and consider NAT at birth.
Viral load (VL) monitoring

21. 6. Nutritional counselling and support
• Pregnant and breastfeeding women living with HIV should receive
nutritional education, assessment & counselling at every ANC visit
and all postpartum follow-up visits.
• Pregnant mothers identified with nutritional problems should be
referred for appropriate management
• Counsel mothers to exclusively breastfeed for 6months and continue
breastfeeding with the addition of complementary foods till the child
is at least 12 months.
• Give Iron, folic acid and multivitamins to pregnant and breastfeeding
women living with HIV according to national guidelines

22. 7. Delivery plan
• Discuss with the mother the choice of where she intends to deliver
from and who will be attending to her delivery.
• The healthcare provider should;
oEncourage all pregnant women to delivery in the facility under the care of
skilled healthcare provider.
oGive the mother a bottle of ARV prophylaxis (depending on Risk
classification) to be given to the baby in case of home delivery and document
in the ANC card.
oGive advice on dosing and safe storage of ARV prophylaxis – to be kept
at room temperature and avoid hot storage environments.
• If she intends to deliver from home, find out who will be attending
to her delivery, and how hygiene and measures to prevent
transmission risk during delivery will be ensured.

23. Interventions for PMTCT in Labour & delivery

24. 1. ART
• HIV positive pregnant women identified during Labour &
Delivery should immediately be started on lifelong ART
(TDF/3TC+DTG), preferably before delivery
• For women already on ART, continue the same ART
regimen at regular prescribed intervals.
• All HIV positive women presenting in labour should be
entered and documented in the Maternity PMTCT register.

25. 2. Safe obstetric practices
• Safe obstetric practices help to reduce the risk of HIV
transmission during labour & delivery, and reduce maternal
and infant death
The safe obstetric practices should include:
• Use of a partogram to allow for early detection and
management of prolonged labour
• Avoid routine (artificial) rupture of membranes (ARM);
oIf prolonged labour is due to poor uterine contraction, perform ARM at
≥6cm cervical dilation and augment with oxytocin (Pitocin) or misoprostol
• Do not perform routine episiotomy except for specific
obstetric indications(e.g. vacuum extraction)

26. Safe obstetric practices
• Do not ‘milk’ the umbilical cord before cutting
• Actively manage the third stage of labour
oActive management reduces the risk of postpartum hemorrhage
which increases exposure of the newborn to maternal blood.
oIt involves three important components:
• Giving oxytocin within 1 minute following the birth of the baby
• Delivery of the placenta using controlled cord traction, and
• Massaging the uterus after delivery of the placenta
• Immediately after birth, wipe the baby dry with a towel to
remove maternal body fluids.

27. i) ARV prophylaxis for the
HIV-exposed infant
• Administer infant ARV
prophylaxis for all HIV exposed
infants immediately after birth –
within 6 hours, up to 72 hours
ii) Establishing breastfeeding
• Offer infant feeding counseling
according to the guidance
• Support the mother to initiate
breastfeeding within 1 hour of
delivery
• Teach and observe feeding
technique
Infant Age Daily NVP dosing Daily AZT dosing
Birth to 6 weeks
· Birth Weight 2000-
2499 grams
· Birth Weight ≥
2500 grams
10mg once daily
(1ml)
15mg once daily
(1.5ml)
10mg twice daily
(1ml)
15mg twice daily
(1.5ml)
> 6 weeks to 12
weeks
20mg once daily
(2mls of syrup once
daily or half a 50mg
tablet once daily)
60mg twice daily (6
ml of syrup twice
daily or a 60 mg
tablet twice daily)
3. Immediate postpartum period interventions

28. Immediate postpartum period interventions
iii) Linkage to PMTCT clinic/HEI care point
• Before discharge (a day after delivery), physically link the mother
and her newborn baby to the PMTCT clinic where;
oThe baby will be enrolled for HEI care, and
oThe mother (if newly diagnosed during labour and delivery) is enrolled
in PMTCT for onward follow up.

29. Immediate postpartum period interventions
PBF mother
• Regimen Optimization
• Adherence assessment
• Psychosocial support
• Infant follow up planning
• Infant prophylaxis counseling
• Infant feeding support
• Parenting support
Infant
• Infant enhanced prophylaxis
schedule and dosing
• EID with rapid turnaround time
• Weight check
• Newborn exam
• Immunization
• Linkage to OVC program

30. Expectations :
1. Improved collaboration with community team :Linkage of PBFW to
(MM/COVs) and use EDD calendar.
2. Management HVL in HIV positive PBFW.
3. Preparing mothers for delivery (gloves ,ARVs prophylaxis., soaps, next
appointment).
4. Care of HEI including EID (especially EID in below 2 month ), use
the new simplified EID diagnosis Algorithm .
5. Improved Documentation(ANC-PMTCT,HEIs registers).
6. Monthly monitoring tool ( VL in PBFW &PMTCT-FO).
7. Continues on-site mentorship .

31. KEY MESSAGES

32. PMTCT INTERVENTIONS
HTS
(Mother)
ART Intervention
(Mother)
ART Intervention
(Infant)
ANC
L&D
PNC/ BF
*Known HIV+
mother NOT ON
ART
*Known HIV+
mother ON ART >4
weeks @delivery
*Known HIV+
mother ON ART <4
weeks @delivery
*HEI
- -
HTS at 1st ANC visit;
For HIV neg women,
repeat HTS in 3rd
Trimester
Unknown HIV status,
tested neg, repeat HTS
at 6 weeks, and 6
monthly till end of BF
Unknown HIV status,
tested neg but missed
retesting in 3rd
trimester, offer HTS
Do not offer HTS
Do not offer HTS
Provide lifelong
TDF + 3TC + DTG
Provide lifelong
TDF + 3TC + DTG
Provide lifelong
TDF + 3TC + DTG
Provide lifelong
TDF + 3TC + DTG
Continue current
Regimen
Low Risk: NVP for 6 weeks
High Risk: NVP + AZT for 12
weeks
At first contact: Low Risk:
NVP for 6 weeks; High
Risk: NVP + AZT for 12
weeks
CTX & EID (PCR) at 6
weeks of age
NIL
At first contact:
High Risk: NVP + AZT for
12 weeks
At first contact:
Low Risk: NVP for 6 weeks
At first contact:
High Risk: NVP + AZT for
12 weeks
Do not offer HTS Continue current
Regimen

33. Infant Follow up
oInfant needs to be followed up till the final HIV status is
determined at 18 months.
oThe follow up schedule remains the same as in the HEI visit schedule and care
package recommended by the national guidelines – including continuation on CTX
Birth 6 wks 10 wks 14 wks 5mo 6 mo 9 mo 12 mo 15 mo 18 mo 24 mo
Immunizations x X X X - X X X - x -
Clinical assessment x X X X X X X X X X x
Growth
monitoring
x X X X X X X X X X x
Developmental
assessment
N/A x X X X X X X X X x
Prophylaxis ARV prophylaxis started at birth: i) NVP for 6 weeks for low risk infants; or ii) NVP+AZT for 12 weeks for high risk infants
None
Cotrimoxazole started at 6 weeks of age or at first contact soon thereafter and continued until infant is determined
to be HIV negative
Infant diagnosis
testing
Do 1st PCR at 6 weeks of age or as soon as infant is
identified thereafter
Rapid test at 9 months Antibody test
Counseling and
Feeding advice
x X X X X X X X X X X
Treatment (ART) Immediately initiate on ART if i) PCR is positive (<18 months) & take confirmatory (2nd ) PCR at the time of starting on
ART or ii) Antibody test is positive (>18 months)
Mothers care and
treatment
X X X X X X X X X X X

34. Thank you