The document addresses the WHO consolidated guidelines on sexual and reproductive health and rights for women living with HIV, emphasizing the rising prevalence of HIV in the Philippines and the need for integrated health services. It highlights the importance of early HIV prevention and management, especially among adolescents and pregnant women, while recommending adherence to antiretroviral therapy. Additionally, it discusses various aspects of maternal health, such as delivery methods and infant feeding recommendations for HIV-positive mothers.

1. FILIPINO WLHIV
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Caraga Regional Hospital
Philippine Gateway Hotel, Surigao City
1 September 2017

2. OBJECTIVES
• To discuss the WHO consolidated
guideline on sexual and
reproductive health and rights of
women living with HIV and to
relate this to local guidelines
• To identify the available
resources in the management of
WLHIV
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3. UNAIDS 2016 Estimates
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Philippines is one of nine countries with
increasing prevalence >25%.
Others are Bangladesh, Guinea-Bissaue, Georgia, Indonesia, Kazakhstan, Kyrgyzstan, Republic of Moldova, and Sri Lanka.

4. PHILIPPINES NOW
•  MSM
•  IV drug use
•  gender-based violence
•  teenage pregnancy
•  single mothers
•  new cases of HIV
•  AIDS-related deaths
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5. HIV 101
HIV is a virus that attacks the
immune system.
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6. HIV 101
2. As the viral load increases, the
CD4 lymphocyte count decreases.
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7. HVMADAMBA2017
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

8. HVMADAMBA2017
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

9. HVMADAMBA2017
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

10. HVMADAMBA2017
HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

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

12. The age group with the biggest proportion
of cases has become younger!
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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

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

14. HIV+ Pregnant Patients
• In June 2017, 11
cases of pregnant
women with HIV
were reported. 3
cases from Region
7.
• Median age was 23
years old
• Age Range: 15-31
yo
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HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

15. VSMMC HIV TREATMENT HUB
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PLHIV alive on ART 1,395
male 1,116
female 279
PMTCT cases 74
Pedia cases 10

16. • 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
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17. HIV Modes of Transmission
25-40%
the risk of perinatal acquisition without intervention
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18. HIV/AIDS EPIDEMIC TRENDS IN THE PHILIPPINES
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HIV/AIDS and ART Registry of the Philippines, Department of Health Epidemiology Bureau

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

22. CREATING AN
ENABLING
ENVIRONMENT
Healthy Sexuality across the life course
Integration of SRHR and HIV services
Community Empowerment

24. 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.

25. 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.

26. Recommendation Strength of
Recommendation,
quality of evidence
Sexually transmitted infections (STI)
and family planning services can be
integrated with HIV care settings.
Conditional
recommendation, very
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.

27. 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.

28. Protection from violence
Recommendation Strength of
Recommendation,
quality of evidence
Care for women experiencing intimate
partner violence and sexual assault should,
as much as possible, be integrated into
existing health services rather than as
stand-alone service.
Strong
recommendation,
very low-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

29. 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.

30. 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

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. ANTENTAL CARE
AND MATERNAL
HEALTH SERVICES

40. pregnant women living with HIV
*since 2010 to June 2017
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41. 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
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42. Philippine Obstetrical and Gynecological Society (Foundation) Inc
Clinical Practice Recommendation on
Prevention of Mother to Child Transmission of HIV Infection
November 2015
• HIV Screening
• Antiretroviral Drugs
• Management of Delivery
• Infant Feeding
• Contraception
POGS Clinical Practice Recommendations on PMTCT
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43. 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
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44. 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
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45. 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
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46. 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
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47. MODE OF
DELIVERY

48. Management of Delivery
Role of Cesarean Section
Cesarean delivery should be scheduled at
completed 38 weeks age of gestation:
 Have no prenatal consults
 Have not received anti-HIV medications during pregnancy
 Have a viral load greater than 1,000 copies/mL at 36 weeks
AOG
 Have unknown viral load near the time of delivery
POGS Clinical Practice Recommendations on PMTCT of HIV Infection, 2015.
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49. Management of Delivery
Rupture of Membranes
If there is spontaneous rupture of amniotic bag
of less then 4 hours, perform an emergency
cesarean section, unless delivery is imminent.
*the risk of vertical transmission increased by 2% for every
increase of 1 hour in the duration of ruptured membranes
POGS Clinical Practice Recommendations on PMTCT of HIV Infection, 2015.
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50. Management of Delivery
Role of Vaginal Delivery
Vaginal delivery may be performed when the risk
of mother-to-child transmission of HIV is low
 Take anti-HIV medications during pregnancy
 Have a viral load less than 1,000 copies/mL near the
time of delivery
 If ever membranes rupture, the time elapsed should
not be more than 4 hours to delivery.
POGS Clinical Practice Recommendations on PMTCT of HIV Infection, 2015.
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51. 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. Minimize infant’s and
health provider’s exposure to blood.
 Latching on is done ONLY IF breastfeeding
has been chosen.
POGS Clinical Practice Recommendations on PMTCT of HIV Infection, 2015.
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52. Antenatal Care and
Maternal Health Services
Recommendation Strength of
Recommendation,
quality of evidence
WHO recommends that elective cesarean
section should not be routinely
recommended to women with HIV.
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. Antenatal Care and
Maternal Health Services
Recommendation Strength of
Recommendation,
quality of evidence
Late cord clamping (performed
approximately 1-3 minutes after birth) is
recommended for all births while
initiating simultaneous essential newborn
care.
Strong
recommendation,
moderate-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

54. 1. In planning for child delivery, the benefits and risks
of different modes of delivery should be discussed
by the health care providers (e.g. obstetrician) to
women living with HIV, including vaginal delivery,
elective and non-elective C-section while being
adherent to ART.

55. 2. For risks of mother to child transmission of HIV to
be significantly reduced, especially during child
delivery, the pregnant WLHIV should be initiated
and fully adherent with ART as early as possible in
pregnancy.

56. 3. Pregnant WLHIV need not be isolated during labor
and delivery because of their HIV status. Health
facility staff must perform standard precautions
and infection control in all patients regardless of
their patients’ HIV status.

57. 4. Elective cesarean section (C-section) should not be
routinely recommended to women living with HIV.
C-sections should only be performed for standard
obstetric indications.
5. When elective cesarean section is medically
indicated, it shall be offered and should be
scheduled at 38 weeks.

58. Antenatal Care and Maternal Health Services
Recommendation Strength of
Recommendation,
quality of evidence
Anti-retroviral therapy (ART) should be
initiated in all pregnant and breastfeeding
women living with HIV, regardless of WHO
clinical stage and at any CD4 cell count,
and continued lifelong.
Strong
recommendation,
moderate-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

59. INFANT FEEDING

60. Infant Feeding
Avoid all breastfeeding in women who
are HIV positive.
 HIV infection is in the shortlist of medical
conditions where replacement feeding may
be permanently justified.
POGS Clinical Practice Recommendations on PMTCT of HIV, 2015.
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61. Infant Feeding
 Option A: where ARVs are available,
mothers known to be HIV-infected are
recommended to breastfeed until 12
months of age
 Option B: total avoidance of all
breastfeeding
Guidelines on HIV and Infant Feeding. 2010. Principles and Recommendations for Infant Feeding in the
context of HIV and a Summary of Evidanee. World Health Organization, Geneva, Switzerland, 2010.
POGS Clinical Practice Recommendations on PMTCT of HIV, 2015.
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62. Infant Feeding
OPTION B (avoidance of breastfeeding) is
the strategy that may give Filipino infants of
HIV (+) mothers the greatest chance of HIV-
free survival.
 Breastfeeding is staunchly supported and
practiced
 Formula feeding is similarly widely accepted,
available and practiced in situations where
breastfeeding cannot be sustained
POGS Clinical Practice Recommendations on PMTCT of HIV, 2015.
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63. Infant Feeding
• continuing ARV medications
• replacement feeding:
Acceptable
Feasible
Affordable
Sustainable
Safe (AFASS)
• risks, follow up and other options for replacement feeding
• relieve breast engorgement
POGS Clinical Practice Recommendations on PMTCT
HVMADAMBA2017

64. Antenatal Care and
Maternal Health Services
Recommendation Strength of
Recommendation,
quality of evidence
Mothers living with HIV should breastfeed
for at least 12 months and may continue
breastfeeding for up to 24 months or
longer while being fully supported for ART
adherence.
Strong
recommendation,
low-quality
evidence for 12
months, very low-
quality evidence
for 24 months
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

65. Mothers living with HIV are strongly recommended to
exclusively breastfeed their infant in the first 6
months of life. Thereafter, complementary foods must
be introduced and may continue breastfeeding for up
to 24 months or longer while being fully supported for
ART adherence.

66. Infant Feeding
PATIENT’S CHOICE
INFORMED CONSENT
NO MIXED FEEDING
EXCLUSIVE breastfeeding
or
AFASS replacement feeding
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67. Sexually transmitted infection and cervical
cancer services
Recommendation Strength of
Recommendation,
quality of evidence
Sexually transmitted infection (STI) and
family planning services can be integrated
within HIV care settings.
Conditional
recommendation,
very low-quality
evidence
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

68. Sexually transmitted infection and cervical
cancer services
Recommendation Strength of
Recommendation,
quality of evidence
WHO recommends the human papilloma
virus (HPV) vaccine for girls in the age
group 9-13 years.
No details on
strength or
quality found, but
recommendation
is based on the
GRADE approach
Consolidated guideline on sexual and reproductive health and rights of women living with HIV. Geneva:
World Health Organization; 2017.

69. 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
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70. These slides are available at
http://www.slideshare.net/HelenMadamba
#HealthXPH
tweetchat
Healthcare Conversations on Twitter
Saturdays 9:00 p.m. to 10:00 p.m.
@helenvmadamba
https://www.facebook.com/Helen-V-Madamba
Sleepless in Cebu
http://helenvmadamba.blogspot.com/

72. #HealthXPH tweetchat
Healthcare Conversations on Twitter
Saturdays 9:00 p.m. to 10:00 p.m.
“Use of Technology to
improve Maternal Health”

74. “HIV will end with me!”
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75. FILIPINO WLHIV
Helen V. Madamba, MD MPH-TM FPOGS FPIDSOG
Caraga Regional Hospital
Philippine Gateway Hotel, Surigao City
1 September 2017

77. Registration Rates:
Pre-registrationConsultants: P1200 Residents/Paramedical: P800
On-site: Consultants: P1500 Residents/Paramedical P1000
*DEADLINE OF PRE-REGISTRATION: September 8, 2017.
Payment Details:
1.Pay directly to Dr. Alcantara’s secretary, Ms. Catalina Daclison at Room 314, Chong Hua Medical Arts
Bldg.3 (M-F: 3-6 pm, Sat: 12nn-4pm), landline: (032) 4120965.
2.Deposit your payment through BDO (Clarita B. Alcantara, Account No. 2310468009) and email validated
deposit slip to vsmmcpostgrad@yahoo.com.
3.Hospital Chief Residents until September 4, 2017
Contact Us:
Dr. Clarita B. Alcantara +63 9173216924
Dr. Catherine M. Timbal +63 9328772400
REGISTRATION