Babies of pregnant women living with HIV can be born free of HIV infection. HIV counselling and testing is the gateway to diagnosis, treatment, care and support. Healthcare services need to provide enabling environments to support and empower women living with HIV and their children, to increase HIV knowledge and reduce stigma and discrimination.

1. PREVENTION OF MOTHER TO
CHILD TRANSMISSION OF HIV
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
HIV/AIDS Core Team (HACT) Orientation for Private and Public Hospitals
Northwinds Hotel, Salinas Drive, Cebu City
13-14 March 2018

2. OBJECTIVES
• To discuss the principles of HIV
transmission and management
• To emphasize HIV screening,
counselling and testing during
pregnancy
• To identify the available
resources in the management of
HIV/AIDS in pregnancy

3. PHILIPPINES NOW
•  IV drug use
•  gender-based violence
•  teenage pregnancy
•  single mothers
•  new cases of HIV
•  AIDS-related deaths

4. HIV 101
1. HIV is a virus that attacks the
immune system
2. As the viral load increases, the CD4
lymphocyte count decreases.
3. When CD4 count <200 cells,
presence of opportunistic infections
and diseases signal AIDS

5. HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

6. HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

7. HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

8. HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

9. HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

10. HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau
HVMADAMBA2018

11. The age group with the biggest proportion
of cases has become younger!
HVMADAMBA2018
15-24 year
age group
*25% in
2006-2010
*29% in
2011-2017
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

12. HIV among Females
HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

13. Geographical Distribution
HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

14. Modes of Transmission
HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

15. Modes of Transmission
HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

16. Modes of Transmission
HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

17. HIV+ Pregnant Patients
HVMADAMBA2018
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

18. • Primary prevention of HIV infection
for key populations has to start in
adolescence mainly because
infections now occur at a younger
age.
• On average, the initiation to sex and
drug use is between 14 and 19 years
old.
http://www.unicef.org/philippines/hivaids.html

19. HIV in 6 PH cities may reach
'uncontrollable' rates – DOH
Prevalence rate among males who have sex with males
http://www.rappler.com/nation/89412-hiv-6-philippine-cities-uncontrollable-rates

20. PREVENTION OF MOTHER TO CHILD
TRANSMISSION (PMTCT) OF HIV

21. PREVENTION OF MOTHER TO CHILD
TRANSMISSION OF HIV
• Prong 1. Primary prevention of HIV among women
of child-bearing age.
• Prong 2. Preventing unintended pregnancies
among women living with HIV.
• Prong 3. Preventing HIV transmission among
women living with HIV to her infant.
• Prong 4. Providing treatment, care and support to
women living with HIV, their children and their
families.
https://www.hsph.harvard.edu/population/aids/philippines.aids.09.pdf
HVMADAMBA 2016

22. Prong 1. Primary prevention of HIV
among women of child-bearing age.
• A – abstinence
• B – be faithful
• C – check your status
• D – don’t do drugs
• E – educate yourself and
others
HVMADAMBA 2016

23. Prong 1. Primary prevention of HIV among women of child-bearing age.

24. Contraception
• Best protection obtained by:
– Choosing sexual activities that do not allow
semen, fluid from the vagina, or blood to
enter the mouth, vagina or anus of the
partner
– Correct and consistent use of condoms
during every sexual act
– Reducing the number of partners
POGS Clinical Practice Recommendations on PMTCT
Prong 2. Preventing unintended pregnancies among women living with HIV.

25. Philippine Obstetrical and Gynecological Society
(Foundation) Inc
Clinical Practice Recommendation on Prevention of Mother to
Child Transmission of HIV Infection
• HIV Screening
• Antiretroviral Drugs
• Management of Delivery
• Infant Feeding
• Contraception
POGS Clinical Practice Recommendations on PMTCT
Prong 3. Preventing HIV transmission among women living with HIV to her infant.

26. CEBU NOW
pregnant women living with HIV
+6 pregnant women on 2nd
pregnancy since HIV diagnosis
*since 2010 to present

27. HIV Screening
Preliminary Counselling Dialogue
Providers of obstetric care should
inform the patient that an HIV
screening test will be performed as
part of the recommended routine
antenatal package of tests of
infections (HBsAg, RPR/VDRL,
rubella IgG, papsmear, urine
culture)
POGS Clinical Practice Recommendations on PMTCT

28. 5%
• Only five per cent of HIV-positive
pregnant women have received
antiretroviral medicines to prevent
mother-to-child transmission.
• Very few of those at-risk have taken an
HIV test, with the number at zero for
those under 18 years.
http://www.unicef.org/philippines/hivaids.html#.V2yW-_l95rQ
HVMADAMBA 2016

29. HIV Screening
Preliminary Counselling Dialogue
Key Message:
The fact that you are pregnant is an
evidence of unprotected penetrative
sexual contact which is a mode of
transmission for HIV.
POGS Clinical Practice Recommendations on PMTCT

30. HIV Screening
Preliminary Counselling Dialogue
• Part of thorough assessment of her status
in relation to her pregnancy
• Routine interview + standard counselling
about HIV
• Strictly confidential
• Opt out - and still receive
the same standard care
POGS Clinical Practice Recommendations on PMTCT

31. Anti-retroviral (ARV) Drugs
Different Clinical Scenarios
1. Woman already receiving ARV
treatment for her own health –
continue.
2. ARV-naïve HIV-infected pregnant
woman with indication for own
health, start ARV regardless of AOG
3. ARV-naïve HIV-infected pregnant
woman, ARV prophylaxis started at
14 weeks AOG
POGS Clinical Practice Recommendations on PMTCT

32. Anti-retroviral (ARV) Drugs
Eligibility for ARV Prophylaxis
• Option A: maternal AZT + infant ARV
prophylaxis
• Option B: maternal triple ARV prophylaxis
until delivery or if breastfeeding, until 1
week after all exposure to breast milk
ended
• Option B+: start triple ARVs as soon as
diagnosed and continued for life
POGS Clinical Practice Recommendations on PMTCT

33. Anti-retroviral (ARV) Drugs
Advantages of Option B+
• PMTCT program : simplify
requirements
• Child : extended protection against
mother-to-child transmission
• Partners : prevention benefit against
sexual transmission in sero-
discordant couples
POGS Clinical Practice Recommendations on PMTCT

34. Anti-retroviral (ARV) Drugs
Advantages of Option B+
• Earlier treatment for woman’s health and
avoiding risks of stopping and starting
triple ARVs especially in settings of high
fertility
• Simple message to communities
“once ARV started, it is
taken for life.”
POGS Clinical Practice Recommendations on PMTCT

35. Vicente Sotto Memorial Medical Center
09561273994
or refer to Dr. Helen Madamba
(09228936749) at VSMMC

36. Management of Delivery
POGS Clinical Guidelines on HIV 2015
 An elective cesarean delivery is
scheduled at 38 weeks AOG
 Emergency CS is done for those in
labor and with ruptured membranes <4
hours unless delivery is imminent
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.

37. Management of Delivery
POGS Clinical Guidelines on HIV 2015
Vaginal delivery maybe done when the
risk of maternal to child transmission is
low:
- those who had ARV treatment
- HIV viral load <1000 copies/ml
- if with ruptured membranes, the time
elapsed should be <4 hours to delivery
POGS Clinical Practice Recommendation on PMTCT of HIV Infection. November 2015.

38. Management of Delivery
Essential Intrapartum Newborn Care (EINC)
 Thoroughly dry newborn infant
× vigorous suctioning
 Skin to skin bonding should be encouraged
× Delayed clamping of umbilical cord is NOT
recommended.
 Latching on is done ONLY IF breastfeeding
has been chosen.
POGS Clinical Practice Recommendations on PMTCT

39. Infant Feeding
INFORMED CONSENT
NO MIXED FEEDING
EXCLUSIVE breastfeeding
or
AFASS replacement feeding

40. Infant Feeding
• continuing ARV medications
• replacement feeding: acceptable,
feasible, affordable, sustainable
and safe (AFASS)
• risks, follow up and other options for
replacement feeding
• relieve breast engorgement
POGS Clinical Practice Recommendations on PMTCT

41. Prevention of HIV Infection of
Health Care Workers
• Standard
precautions
• Post-exposure
prophylaxis
• Hospital infection
control
POGS Clinical Practice Recommendations on PMTCT

42. Prong 4. Providing treatment, care and support to women living
with HIV, their children and their families.
• Immunization
• Healthy Lifestyle
• STI & Cancer Screening
• Opportunistic Infections
• Support Groups
• Livelihood Skills Training
• Advocacy to reduce Stigma and
Discrimination
• HIV Awareness Campaigns

43. Framework of
WHO
recommendations
and good practice
statements to
advance the sexual
and reproductive
health and rights of
women living with
HIV

44. CREATING AN ENABLING ENVIRONMENT
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017.

45. Healthy sexuality across the life course
Recommendation Strength of
Recommendation,
quality of evidence
Adolescent-friendly health
services should be implemented
in HIV services to ensure
engagement and improved
outcomes.
Strong
recommendation,
low-quality evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017.

46. Recommendation Strength of
Recommendation,
quality of evidence
In generalized epidemic settings, anti-
retroviral therapy should be initiated and
maintained in eligible pregnant and
postpartum women and in infants at
maternal and child health care settings,
with linkage and referral to ongoing HIV
care and ART, where appropriate.
Strong
recommendation,
low-quality
evidence
Integration of SRHR and HIV service
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017.

47. Protection from violence
Recommendation Strength of
Recommendation,
quality of evidence
Women who disclose any form of violence
by an intimate partner or sexual assault by
any perpetuator should be offered
immediate support. Healthcare providers
should, as a minimum, offer first-line
support when women disclose violence.
Strong
recommendation,
indirect evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017.

48. Community empowerment
Recommendation Strength of
Recommendation,
quality of evidence
Introduce new, or reinforce existing, policies
that prevent discrimination against health
workers with HIV or TB, and adopt
interventions aimed at stigma reduction
among colleagues and supervisors.
Strong
recommendation,
moderate quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva: World Health Organization; 2017.

49. HEALTH
INTERVENTIONS
Sexual Health Counselling and Support
Violence against Women Services
Family Planning and Infertility Services
Antenatal care and maternal health services
Safe abortion services
Sexually transmitted infection and cervical
cancer services

50. Sexual health counselling and support
Recommendation Strength of
Recommendation,
quality of evidence
WHO recommends that for WLHIV,
interventions on self-efficacy and
empowerment around sexual and
reproductive health and rights should be
provided to maximize their health and fulfill
their rights.
Strong
recommendation,
low quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

51. Violence against Women Services
Recommendation Strength of
Recommendation,
quality of evidence
WHO recommends that policy-makers and
service providers who support WLHIV who
are considering voluntary HIV disclosure
should recognize that many fear, or are
experiencing, or are at risk of intimate
partner violence.
Strong
recommendation,
low- quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

52. Violence against Women Services
Recommendation Strength of
Recommendation,
quality of evidence
Children of school age should be told their
HIV positive status and the status of their
parents or caregivers; younger children
should be told their status incrementally to
accommodate their cognitive skills and
emotional maturity, in preparation for full
disclosure.
Strong
recommendation,
low-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

53. Family planning & infertility services
Recommendation Strength of
Recommendation,
quality of evidence
Anti-retroviral therapy (ART) should be
initiated in all adults living with HIV
regardless of WHO clinical signs and at any
CD4 cell count.
Strong
recommendation,
modoerate-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

54. Family planning & infertility services
Recommendation Strength of
Recommendation,
quality of evidence
The correct and consistent use of condoms
with condom-compatible lubricants is
recommended for all key populations to
prevent sexual transmission of HIV and
sexually transmitted infections (STIs).
Strong
recommendation,
moderate-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

55. Family planning & infertility services
Recommendation Strength of
Recommendation,
quality of evidence
Women living with asymptomatic or mild
HIV clinical disease can use the following
hormonal contraceptives without
restriction:
• Combined oral contraceptive pills
• Combined injectable contraceptives
• Contraceptive patches and rings
• Progestogen-only pills, progestogen-only injectibles
• Norethisterone enenthate and levonorgestrel and
etonorgestrel implants
Strength of
recommendation
is indicated by
MEC category
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

56. Family planning & infertility services
Recommendation Strength of
Recommendation,
quality of evidence
Women living with severe or advanced HIV
clinical disease should generally not initiate
use of the LNG-IUD (MEC Category 3 for
initiation) until their illness has improved to
asymptomatic or mild HIV clinical disease.
Moderate- to very
low-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

57. Family planning & infertility services
Recommendation Strength of
Recommendation,
quality of evidence
Women who already have an LNG-IUD
inserted and who develop severe or
advanced HIV clinical disease need not have
their IUD removed (MEC Category 2 for
continuation).
LNG-IUD users with severe or advanced HIV
clinical disease should be closely monitored
for pelvic infection.
Moderate- to low-
quality evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

58. “HIV will end with me!”

59. #HealthXPH
tweetchat
Healthcare Conversations on Twitter
Saturdays 9:00 p.m. to 10:00 p.m.
@helenvmadamba
https://www.facebook.com/Helen-V-Madamba
http://www.slideshare.net/HelenMadamba
http://helenvmadamba.blogspot.com/

60. PREVENTION OF MOTHER TO
CHILD TRANSMISSION OF HIV
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
HIV/AIDS Core Team (HACT) Orientation for Private and Public Hospitals
Northwinds Hotel, Salinas Drive, Cebu City
13-14 March 2018