Naco guidelines

1. NACO GUIDELINES IN TREATING
HIV IN PREGNANCY

2. PPTCT and ART in Pregnant Women
Parent to child transmission (PTCT) is a major route for transmission of new
HIV infections in children. PTCT contributes to about 4% of HIV infections in
India. The Prevention of Parent to Child Transmission (PPTCT) programme is
being implemented under NACP to achieve the goal of Elimination of Mother
to Child Transmission (EMTCT). Children born to women living with HIV
acquire HIV infection from their mother, either during pregnancy,
labour/delivery or through breastfeeding which is largely preventable with
appropriate intervention, by providing ART to mothers and ARV prophylaxis
to infants

3. Risk of HIV transmission from mother to child with or without interventions
ARV Intervention Risk of HIV Transmission from Mother to Child
No ARV; breastfeeding 30–45%
No ARV; no breastfeeding 20–25%
Short course with one ARV; breastfeeding 15–25%
Short course with one ARV; no breastfeeding 5–15%
Short course with two ARVs; breastfeeding 5%
3 ARVs (ART) with breastfeeding 2%
3 ARVs (ART) with No breastfeeding 1%

4. PPTCT Services in India
• The PPTCT services provide access to all pregnant women for HIV diagnostic,
prevention, care and treatment services and have the reach to a wide area,
including sub-district level. As such, the key objective is to ensure integrated
PPTCT services delivery with existing Reproductive and Child Health (RCH)
programme.

5. • 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
• The programme will strive to detect HIV-infected pregnant women and
provide ART to all of them. Further, it will ensure access to early infant
diagnosis (EID) to HIV-exposed infants, ARV prophylaxis or ART.

6. India’s Commitment to EMTCT
India is committed to achieving the EMTCT goal of HIV so that no child is born
with HIV and the mothers are kept alive.
Targets for process indicators for validation of EMTCT (to be maintained for at least
2 years) are as follows:
• >95% of all estimated pregnant women are registered for antenatal care and
receive at least 1 antenatal care check-up;
• >95% of all estimated pregnant women are tested for HIV;
• >95% of all HIV positive pregnant women are on ART.

7. The Essential Package of PPTCT Services includes the following:
• Offer Routine HIV counselling and testing to all pregnant women enrolled in
antenatal care with ‘opt out’ option.
• Ensure involvement of spouse and other family members and move from an
‘antenatal carecentric’ to a ‘family-centric’ approach.
• Provide lifelong ART, as per national guidelines to all pregnant and breastfeeding
HIVinfected women regardless of CD4 count and clinical stage.
• Provide care for associated conditions (like, STI/RTI, TB and other OIs,
hypertension, diabetes).

8. • Promote institutional deliveries of all HIV-infected pregnant women
(ANMs/ ASHAs, community workers to accompany to institutions;
reduction of stigma and discrimination among healthcare providers
through sensitization and capacity building).
• Perform plasma viral load testing at 32–36 weeks of gestation to
determine the risk of HIV transmission to the baby.
• Provide ARV prophylaxis to infants as per national guidelines.

9. • Provide nutrition counselling and psychosocial support to HIV-infected pregnant women
(linkages with ANMs, ASHAs, Community outreach workers, District level networks to advise
them on the right foods to take and go to Anganwadi centres for nutritional support and to
the district level network of Positive People for peer counselling and psychosocial support).
• Provide counselling and support for initiation of exclusive breastfeeds within an hour of
delivery as the preferred option and continue for 6 months. After 6 months, complementary
feeding should be given along with breast feeds. Mothers living with HIV should breastfeed
for at least 12 months and may continue breastfeeding for up to 24 months or beyond, like
the general population, while being fully supported for ART adherence.

10. • Integrate follow-up of HIV-exposed infants into routine healthcare services
including immunization.
• Ensure initiation of CPT and EID using HIV-TNA PCR at 6 weeks of age
onwards as per NACO EID guidelines.
• Strengthen community follow-up and outreach through local community
networks to support HIV-positive pregnant women and their families

11. Four-Pronged strategy for PPTCT

12. The National PPTCT programme recognizes the four elements integral to preventing HIV
transmission among women and children. These include the following:
Prong 1: Primary prevention of HIV, especially among women of childbearing age
• The first prong is primary prevention of HIV among women of childbearing age. This
can be achieved by implementation of the general population-based HIV prevention
strategy and the Adolescent Reproductive and Sexual Health (ARSH) programme. Some
components of primary prevention include promoting condoms through social
marketing and community-based distribution system, behaviour change
communication and social mobilization campaigns and prevention, diagnosis and
treatment of STIs.
Prong 2: Prevention of unintended pregnancies among women living with HIV
• The second prong focuses on preventing unintended pregnancies in HIV-positive
women. This strategy aims at educating all HIV-positive women on available options of
contraception and family planning methods. HIV-positive women should be assisted in
making decisions regarding planning a pregnancy and childbirth by the staff of ICTC,
ART centre and CSC.

13. Prong 3: Prevention of HIV transmission from pregnant women infected with HIV to their
children
• The third prong is to implement interventions to prevent PTCT of HIV from positive pregnant
mothers to their babies. This includes linking of HIV-positive pregnant mothers to ART centre for
ART initiation, counselling for adherence to ART and safe sex practices, referral for plasma viral
load between 32 and 36 weeks of pregnancy to determine the risk of HIV transmission to the
baby and decision on type of infant ARV prophylaxis.
• Institutional deliveries and ARV prophylaxis to their babies with infant feeding counselling
Prong 4: Provide care, support and treatment to women living with HIV and to their children
and families
• The fourth prong focuses on care, support and treatment given to HIV-positive women and their
children and family. This includes treatment support, feeding counselling, immunization, linking
their children to the PPTCT centre for care of HIV-exposed infant including the EID programme.

14. Risk Factors Associated with Increase in Parent to
Child Transmission of HIV
Maternal and obstetrical factors that increase the risk of HIV transmission:
• Recent HIV infection in the mother
• High viral load, advanced HIV disease in mother
• STIs
• Obstetric procedures:
 Forceps/vacuum delivery
 Prolonged labour
 Invasive foetal monitoring
• Maternal malnutrition
• Conditions of breasts (sore nipple, breast abscess, mastitis etc.)
Infant-related factors that increase the risk of HIV transmission
• Preterm/low birth weight baby
• Condition of baby’s mouth (oral ulcers, thrush)
• Mixed feeding

15. PPTCT interventions
Interventions during pregnancy:
• Provide HIV information to ALL pregnant women.
• Antenatal visits are opportunity for PPTCT.
• Prevention of PTCT through ART
• Referral for viral load between 32 and 36 weeks of pregnancy to determine the ARV
prophylaxis of the child depending on the risk „
• Counselling for institutional delivery so that interventions for PPTCT can be undertaken
• Counselling on infant feeding practices and ARV prophylaxis for the child
• Safe obstetric practices

16. Interventions during labour and delivery:
Under the cover of Maternal ART, the care given to HIV-infected mothers and
their babies is like the care given to uninfected mothers and their babies. When
delivering HIV-infected women, follow safe delivery techniques as follows:
• Standard work precautions
• Minimize vaginal examinations and use aseptic techniques.
• Avoid prolonged labour; consider oxytocin to shorten labour.

17. • Avoid artificial rupture of membranes.
• Use non-invasive foetal monitoring and avoid invasive procedures.
• Support perineum and avoid routine episiotomy.
• Avoid instrumental delivery as much as possible unless indicated. If
indicated, low cavity outlet forceps delivery is preferable to a ventouse
delivery because it is generally associated with lower rates of foetal trauma
than a ventouse delivery.

18. • Considerations in mode of delivery: In India, normal vaginal delivery is
considered unless the woman has obstetric indications (like foetal distress,
obstructed labour) for a Caesarean section.
• Suctioning the newborn with a nasogastric tube should be avoided unless
there is meconium staining of the liquor. If suctioning the baby is a must, then
we need to keep the suction pressure below 100 mm Hg pressure or use a
bulb suction.
• Avoid milking the cord and delayed cord clamping. Cord clamping after it
stops pulsating and after giving the oxytocin injection immediately after
delivery as part of active management of third stage of labour

19. • Infants should be handled with gloves until all blood and maternal
secretions have been washed off. Always cover the cord with gloved hands
and gauze before cutting the cord to avoid blood splattering.
• Wipe and clean the baby’s mouth and nostrils as soon as the head is
delivered.
• Initiate feeding within the first hour of birth according to the preferred
and informed choice of the couple.

20. Infant Feeding
• The two infant feeding options available for the HIV-positive mother are exclusive
breastfeeding (EBF) or exclusive replacement feeding (ERF).
• Counselling for infant feeding should begin in the antenatal period itself. All HIV-positive
pregnant women should be informed about infant feeding options, namely EBF or ERF.
Pros and cons of both options must be discussed with the parents so that they can make
an informed choice.
• EBF means giving a baby only breast milk and no other liquids or solids, not even water.
Drops or syrups consisting of vitamins, mineral supplements, medicines or vaccines are
permitted.

21. • EBF provides the infant with all required nutrients and immunological
factors that help to protect them against common infections. Breastfeeding
is to be started within one hour, both in a normal vaginal delivery and in a
Caesarean-section delivery.
• EBF maximizes the chances of survival of these infants and is
recommended as the preferred choice of infant feeding for HIV-exposed
infants in India.

22. • ERF is the process of feeding a baby, who is not breastfeeding, with a diet
that provides the baby its nutrient requirements. „
Replacement feeding includes feeding the baby animal milk, dairy milk, and
infant formulas. It is important to counsel parents that the feed must be
prepared in a hygienic manner and should be given with a spoon and bowl.
Avoid bottle feeding.
• Mixed feeding increases the risk of transmission of HIV and should be
avoided.

23. • When EBF is not possible for any reason (maternal sickness, twins),
mothers and HCWs can be reassured that maternal ART reduces the risk of
postnatal HIV transmission in the context of mixed feeding as well.
• Healthcare providers and counsellors should be trained to help pregnant
women/couple in reaching the right decision and to support them in
implementing their preferred choice.

24. Current National Guidelines for Infant Feeding in HIV
exposed and Infected Infants Less Than 6 Months of Age
• EBF for the first 6 months of life is recommended.
• Beyond 6 months of age, breastfeeding should continue while complementary feeds
are introduced.
• Breastfeeding should only stop once a nutritionally adequate and safe diet without
breast milk can be provided to the child.
• Mothers living with HIV should breastfeed for at least 12 months and may continue
breastfeeding for up to 24 months or beyond, like the general population, while
being fully supported for ART adherence.

25. • If the HIV-positive mother plans to return to work, she can be reassured by HCWs that
shorter duration of breastfeeding of less than 12 months is better than never initiating
breastfeeding at all.
• Breastfeeding is made SAFE by giving ART to the mother and ARV prophylaxis to the
baby.
• With optimal adherence to ART and a suppressed maternal viral load, there remains no
difference in infant feeding guidelines for HIV-exposed versus unexposed infants.
• Mothers should follow protected sex practices and ART adherence to reduce risk of HIV
transmission to their babies

26. What ART to Start?
ART in Pregnant and Breastfeeding Women
ART works for PPTCT by
• Reducing the maternal viral load
• Loading the foetus with ARVs that prevent the transmitted virions from
replicating
• Improving overall health of mother
Reducing the risk of transmission to the HIV-exposed infant Mothers need to be
repeatedly counselled on adherence to ART throughout the period of pregnancy
and breastfeeding to reduce the risk of HIV transmission to the baby.
Counselling should be done for care of breast and nipples if mother is opting for
breastfeeding.

28. Care and Assessment of Women Presenting
Directly in Labour
• Labour room nurse will offer bedside counselling and HIV screening test.
• If the woman consents, screen for HIV using the ‘Whole Blood Finger Prick
Test’ in delivery room or labour ward.
• If reactive for HIV, the medical officer in charge will initiate ART as per the
guideline (TDF + 3TC + DTG) and ensure HIV confirmation at ICTC.
• Labour room nurse informs the ICTC counsellor and laboratory technician
for further confirmation of HIV status as per guidelines.
• If tested negative at ICTC, the ART is stopped. If HIV-positive status is
confirmed at ICTC, ensure linkage to ART centre, collect blood for CD4
count and continue the ART as per guidelines.