1. Module 3 Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)

2. PMTCT Generic Training PackageModule 3, Slide 2 Module Objectives  Describe the difference between ARV therapy and ARV prophylaxis  List the criteria for starting pregnant women on ARV therapy  List the recommended ARV drugs for PMTCT  Understand the antenatal management of women infected with HIV and women of unknown HIV status

3. PMTCT Generic Training PackageModule 3, Slide 3 Module Objectives (Continued)  Explain the management of labour and delivery for women infected with HIV and women of unknown HIV status  Describe postpartum care of women infected with HIV and women of unknown HIV status  Describe the care of infants born to mothers who are HIV-infected and infants born to women of unknown HIV status

4. PMTCT Generic Training PackageModule 3, Slide 4 Session 1 Antiretroviral Therapy and Antiretroviral Prophylaxis for PMTCT

5. PMTCT Generic Training PackageModule 3, Slide 5 Session 1 Objectives  Describe the difference between ARV therapy and ARV prophylaxis  List the criteria for starting pregnant women on ARV therapy  List the recommended ARV drugs for PMTCT

6. PMTCT Generic Training PackageModule 3, Slide 6 ARV Therapy and ARV Prophylaxis What is the difference between ARV therapy and ARV prophylaxis?

7. PMTCT Generic Training PackageModule 3, Slide 7 ARV Therapy and ARV Prophylaxis  ARV therapy: Long-term use of antiretroviral drugs to treat maternal HIV and for PMTCT  ARV prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother-to-infant ARVs during pregnancy decrease the amount of virus in the mother’s blood, lowering the chance her infant will be exposed to the virus

8. PMTCT Generic Training PackageModule 3, Slide 8 Antiretroviral (ARV) Therapy  Improves the health of women  Decreases the risk of transmitting HIV to infant  Pregnant women who are HIV-infected and who are eligible for antiretroviral (ARV) therapy should receive treatment according to national or WHO guidelines. ARV  Is provided by PMTCT programmes or by referral to HIV care and treatment clinic

9. PMTCT Generic Training PackageModule 3, Slide 9 Starting ARV Therapy: WHO Recommendations  If CD4 count is not available:  Treat all symptomatic patients at WHO Stages 3 and 4  When to start ARVs is based on symptoms of HIV infection and, where available, laboratory test results. See Table 3.1

10. PMTCT Generic Training PackageModule 3, Slide 10 Starting ARV Therapy: WHO Recommendations (Continued)  If CD4 count is available:  Treat all patients with CD4 counts <200 cells/mm 3  Treat all HIV-infected pregnant women in Stage 3 whose CD4 count is <350 cells/mm 3  Consider treatment for the non-pregnant in Stage 3 if CD4 count is < 350 cells/mm 3

11. PMTCT Generic Training PackageModule 3, Slide 11 Becoming Pregnant while on ARV Therapy  Continue to take ARV therapy throughout pregnancy, labour, delivery and postpartum  Infants born to mothers on ARV therapy should receive one week of ARV prophylaxis with AZT  If a woman is on efavirenz (EFV) as a part of her ARV therapy and becomes pregnant:  Substitute NVP for EFV if pregnancy if recognized during 1 st trimester  Continue EFV if recognized during 2 nd or 3 rd trimester WHO recommendations:  See Appendix 3-A for more information on managing ARV therapy during pregnancy

12. PMTCT Generic Training PackageModule 3, Slide 12 Starting ARV Therapy during Pregnancy  A pregnant woman eligible for ARV therapy based on national or international guidelines should start treatment as soon as possible, even during the 1 st trimester  All ARV drugs are associated with some toxicity  The risk for a pregnant woman and her child from ARV therapy varies and is dependent on the:  Stage of pregnancy  Duration of therapy  Number of drugs used

13. PMTCT Generic Training PackageModule 3, Slide 13 WHO Recommendation: Zidovudine (AZT) + lamivudine (3TC) + nevirapine (NVP) First-line ARV Therapy for Pregnant Women  Pregnant women should be closely monitored for toxicity, including hepatitis, from NVP during the first 12 weeks of therapy

14. PMTCT Generic Training PackageModule 3, Slide 14 Commonly Used ARV drugs for PMTCT AZT Zidovudine Absorbed quickly Well tolerated Can cause mild anaemia Taken with our without food NVP Nevirapine Absorbed quickly Long half life protects the infant Can cause hepatotoxicty in women with higher CD4 Hepatotoxicity does not apply to single-dose regimen Can cause viral resistance even after one dose Taken with our without food 3TC Lamivudine Absorbed quickly Taken with our without food

15. PMTCT Generic Training PackageModule 3, Slide 15 Delaying Start of ARV Therapy  Delaying the start of ARV therapy can be considered if a pregnant woman:  Suffers frequently from nausea, a common side effect of some ARVs  Is in her first trimester and concerned about the effects of ARVs on the developing fetus  HOWEVER, if a woman’s clinical or immune status suggests she is severely ill, the benefits of early ARV therapy outweigh any potential risk to the fetus

16. PMTCT Generic Training PackageModule 3, Slide 16 HIV-Infected Pregnant Woman with TB  First priority is to treat the TB  With careful clinical management, a pregnant woman can be treated for both HIV and TB  Drugs need to be monitored very closely to avoid interactions and side effects  See Appendix 3-A for more information on managing an HIV-infected pregnant woman with TB

17. PMTCT Generic Training PackageModule 3, Slide 17 ARV Prophylaxis  All HIV-infected pregnant women who are not eligible for ARV therapy should be offered ARV prophylaxis for PMTCT

18. PMTCT Generic Training PackageModule 3, Slide 18 ARV Prophylaxis for PMTCT: WHO Recommendations  Use combination regimens of AZT, 3TC and a single dose of NVP because they:  Are more effective in preventing MTCT  Can reduce viral resistance  See Appendix 3-B for the WHO recommended PMTCT ARV regimens

19. PMTCT Generic Training PackageModule 3, Slide 19 Viral Resistance and ARVs  HIV can mutate or change so it becomes resistant to specific ARV drugs — whether used for therapy or prophylaxis  When viral resistance occurs, these ARV drugs are no longer as effective  Additional information on viral resistance can be found in Module 7

20. PMTCT Generic Training PackageModule 3, Slide 20 WHO Recommendations on Single-dose NVP  Resistance can develop when a single dose of NVP is given during labour  Single dose NVP is the minimum recommended regimen where capacity is limited; should only be used where other options not available  Single-dose NVP is given to a mother at the onset of labour and to her infant as soon as possible after delivery  Specific obstacles to delivering more effective combination regimens should be identified and actions taken to address them

21. PMTCT Generic Training PackageModule 3, Slide 21 Session 2 Antenatal Management of Women Infected with HIV and Women of Unknown HIV Status

22. PMTCT Generic Training PackageModule 3, Slide 22 Session 2 Objectives  Understand the antenatal management of women infected with HIV and women of unknown HIV status

23. PMTCT Generic Training PackageModule 3, Slide 23 Antenatal Care  ANC improves the general health and well-being of mothers and their families  Good maternal healthcare not only improves pregnancy outcomes, but also helps women with HIV stay healthy longer

24. PMTCT Generic Training PackageModule 3, Slide 24 Integrating PMTCT Services into MCH Programmes Integrating PMTCT and MCH programmes ensures that:  PMTCT programmes have access to MCH patients  PMTCT services benefit from the expertise and experience of HCWs working in MCH services  PMTCT services are normalized as a part of care

25. PMTCT Generic Training PackageModule 3, Slide 25 PMTCT Services in MCH Care  Health information and education  Education about HIV and HIV prevention including safer sex  HIV testing and counselling  Partner HIV testing and counselling, including couple counselling, either on-site or by referral  ARV therapy or ARV prophylaxis (ARV therapy may be provided either on-site or by referral)

26. PMTCT Generic Training PackageModule 3, Slide 26 PMTCT Services in MCH Care (Continued)  Treatment, care & support for HIV infection  Information on infant feeding options, counselling and support  Screening, prevention and treatment of opportunistic infections and other HIV-related conditions  Co-trimoxazole prophylaxis against PCP, malaria and other infections  Diagnosis and treatment of sexually transmitted infections (STIs)

27. PMTCT Generic Training PackageModule 3, Slide 27 Role of HIV Testing in PMTCT  HIV testing and counselling is the critical initial step to provide healthcare workers (HCWs) with the opportunity to offer PMTCT services Determining the HIV status of a pregnant woman is the gateway to PMTCT interventions

28. PMTCT Generic Training PackageModule 3, Slide 28 ANC Services for HIV-infected Women  Include all of the basic services (e.g., services for all pregnant women regardless of HIV infection status)  In addition, an HIV-infected pregnant woman has other care and support needs (outlined in Table 3.2). The PMTCT interventions in this module are primarily in reference to women infected with HIV-1  See Appendix 3-C for more information about PMTCT and HIV-2

29. PMTCT Generic Training PackageModule 3, Slide 29 Common Infections in HIV-Infected Women  Women with HIV are susceptible to opportunistic infections, HIV-related infections and other common infections because their immune systems are not working well  All infections can increase the risk of MTCT  HCWs should follow national guidelines for prophylaxis and treatment of all infections that can affect HIV patients  Effective prevention reduces rates of illness and death among HIV-infected pregnant women

30. PMTCT Generic Training PackageModule 3, Slide 30 Common Infections in HIV-infected Women (Continued)  Opportunistic infections:  Tuberculosis  Pneumocystis pneumonia (PCP)  HIV-related infections:  Recurrent vaginal candidiasis  Other common infections:  Sexually transmitted infections (STIs)  Urinary tract infections  Respiratory infections  Malaria, where prevalent

31. PMTCT Generic Training PackageModule 3, Slide 31 Common Infections in HIV-Infected Women (Continued)  Co-trimoxazole prophylaxis prevents common infections:  PCP pneumonia  Other bacterial pneumonias  Malaria  Toxoplasmosis  Certain causes of diarrhoea  Co-trimoxazole prophylaxis is likely to improve overall pregnancy outcomes  See Module 7 for more information on PCP prophylaxis

32. PMTCT Generic Training PackageModule 3, Slide 32 Psychosocial & Community Support  Pregnant women with HIV may have concerns about the health of the baby, their own health and disclosure of their status  HCWs should assess how much support an HIV- infected woman is receiving from family and friends  Where available, HCWs should refer HIV-infected pregnant women to organizations that provide support

33. PMTCT Generic Training PackageModule 3, Slide 33 ANC Services for HIV-Infected Women (Table 3.2)  Patient history  Physical exam, vital signs  Lab tests  Nutritional assessment & counselling  STI screening  TB and malaria assessment and treatment  OI and malaria prophylaxis  Tetanus immunization  ARV therapy/ prophylaxis  Infant feeding  Counselling on safer pregnancy, HIV danger signs  Partners/family (testing, support)  Effective contraception planning

34. PMTCT Generic Training PackageModule 3, Slide 34 Exercise 3.1 Antenatal care: case studies

35. PMTCT Generic Training PackageModule 3, Slide 35 Session 3 Management of Women Infected with HIV and Women of Unknown HIV Status during Labour and Delivery

36. PMTCT Generic Training PackageModule 3, Slide 36 Session 3 Objectives  Explain the management of labour and delivery in women infected with HIV and women of unknown HIV status

37. PMTCT Generic Training PackageModule 3, Slide 37 PMTCT During Labour & Delivery  Labour and delivery (L&D) practices for HIV- infected women should follow standard obstetric practices, set forth by national and international standards

38. PMTCT Generic Training PackageModule 3, Slide 38 PMTCT During Labour & Delivery (Continued)  Standard obstetric practices include Standard Precautions:  Wearing protective gear  Using and disposing of sharps safely  Sterilizing equipment and safely disposing of contaminated materials

39. PMTCT Generic Training PackageModule 3, Slide 39 Standard Precautions in L&D  Reduce the risk of transmission of blood-borne pathogens from the patient to the HCW  Used when caring for all patients, regardless of diagnosis or presumed HIV infection status  Because of risk of contact with blood, use of Standard Precautions is particularly important during delivery  Discussed in greater detail in Module 8

40. PMTCT Generic Training PackageModule 3, Slide 40 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 NVP (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 partogram or medical record to avoid accidental repeat dosing

41. PMTCT Generic Training PackageModule 3, Slide 41 PMTCT during L&D 1.Minimize 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)

42. PMTCT Generic Training PackageModule 3, Slide 42 PMTCT during L&D (Continued) 4.Avoid unnecessary trauma during delivery.  Use non-invasive fetal monitoring  Avoid invasive procedures, such as using scalp electrodes or scalp sampling  Avoid routine episiotomy  Minimize the use of forceps or vacuum extractors

43. PMTCT Generic Training PackageModule 3, Slide 43 PMTCT during L&D (Continued) 5.Minimize risk of postpartum haemorrhage  Actively manage the third stage of labour  Give oxytocin immediately after delivery  Use controlled cord traction  Perform uterine massage  Carefully repair genital tract lacerations  Carefully remove all products of conception

44. PMTCT Generic Training PackageModule 3, Slide 44 PMTCT during L&D (Continued) 6.Use safe blood transfusion practices  Minimize use of blood transfusions  Use only blood screened for HIV and, when available, screened for syphilis, malaria and hepatitis B and C

45. PMTCT Generic Training PackageModule 3, Slide 45 Considerations Regarding Mode of Delivery  Caesarean section performed before the onset of labour or membrane rupture has been associated with reduced MTCT Elective Caesarean, along with safer infant feeding practices and ARV therapy or ARV prophylaxis, has greatly reduced the rate of MTCT in countries where this procedure is safe and available

46. PMTCT Generic Training PackageModule 3, Slide 46 Considerations Regarding Mode of Delivery (continued)  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

47. PMTCT Generic Training PackageModule 3, Slide 47 HIV Testing during Labour  Testing during labour is the last opportunity before childbirth to identify women infected with HIV  A woman of unknown HIV status at labour should be offered HIV testing and counselling  ARV prophylaxis, when initiated during labour for the woman and just after birth for the infant, can reduce MTCT by as much as 50%  See Module 5 for additional information on HIV testing during labour

48. PMTCT Generic Training PackageModule 3, Slide 48 Exercise 3.2 Labour & delivery ARV prophylaxis: case studies

49. PMTCT Generic Training PackageModule 3, Slide 49 Session 4 Postpartum Care of Women Infected with HIV and Women of Unknown HIV Status

50. PMTCT Generic Training PackageModule 3, Slide 50 Session 4 Objectives  Describe postpartum care of women infected with HIV and women of unknown HIV status

51. PMTCT Generic Training PackageModule 3, Slide 51 Postpartum Care for HIV-infected Women  Immediate post-delivery care:  Assess amount of vaginal bleeding  Dispose of blood-stained/ soaked linens or pads safely  Infant feeding:  Provide information about infant feeding options and support mother’s infant feeding choice  Ensure mother is provided with infant feeding counselling and support. Observe feeding technique and provide assistance

52. PMTCT Generic Training PackageModule 3, Slide 52 Postpartum Care for HIV-infected Women (Continued) Teach about signs and symptoms of postpartum infection:  Burning with urination  Fever  Foul smelling lochia  Cough, sputum and shortness of breath  Redness, pain, pus or drainage from incision or episiotomy  Severe lower abdominal pain  Breast pain, redness or warmth

53. PMTCT Generic Training PackageModule 3, Slide 53 Postpartum Care for HIV-infected Women: Education Provide education about postpartum period and follow-up care:  Teach mother about perineal and breast care  Ensure mother knows how and where to dispose of infectious materials such as lochia- and blood-stained sanitary pads  Emphasize importance of postpartum follow-up care for HIV-infected mother and her HIV-exposed infant

54. PMTCT Generic Training PackageModule 3, Slide 54 Postpartum Care for HIV-infected Women: Family Planning  Discussion of contraception and family planning goals begins in ANC and continues in postpartum period  Main family planning goals for HIV-infected women:  Prevent unintended pregnancy using effective method of birth control  Space children (can help reduce maternal and infant morbidity and mortality)  Educate women and families about contraceptive choices

55. PMTCT Generic Training PackageModule 3, Slide 55 Postpartum Care for HIV-infected Women: Continuing Care  Encourage and make plans for continuing healthcare in the following areas:  Routine gynaecologic care, including Pap smears, if available  Ongoing treatment, care and support for new HIV- positive mother, including referral for ARV therapy if eligible  Nutritional counselling and support  Referral for prophylaxis and treatment of HIV-related conditions, including TB and malaria

56. PMTCT Generic Training PackageModule 3, Slide 56 Postpartum Care: Women of Unknown HIV Status  Women whose HIV status is unknown should receive same postpartum care as women with HIV, except should be counselled and supported to breastfeed exclusively  Encourage women whose HIV status is unknown to test for HIV

57. PMTCT Generic Training PackageModule 3, Slide 57 Women Testing HIV-positive After Delivery  If mother tests HIV-positive post-delivery:  Provide safer infant feeding information, counselling and support  Provide (as soon as possible) infant prophylaxis as per national guidelines  Provide referrals for infant HIV testing  Provide referrals for ARV treatment, care and support  Provide referrals for co-trimoxazole prophylaxis for the mother, if eligible, and to her infant starting at 4-6 weeks

58. PMTCT Generic Training PackageModule 3, Slide 58 Exercise 3.3 Postpartum care of women infected with HIV: case studies

59. PMTCT Generic Training PackageModule 3, Slide 59 Session 5 Care of Infants who are HIV-exposed and Infants Born to Women of Unknown HIV Status

60. PMTCT Generic Training PackageModule 3, Slide 60 Session 5 Objectives  Describe the care of infants born to mothers who are HIV-infected and infants born to women of unknown HIV status

61. PMTCT Generic Training PackageModule 3, Slide 61 Immediate Infant Care: Following Delivery  Reduce MTCT by minimizing infant exposure to maternal blood and body fluids  Offer ARV prophylaxis for the infant as soon as possible, including low birth weight infants and those with low Apgar scores  Emphasize the importance of infant ARV prophylaxis, which is safe for infants  For more information on ARV prophylaxis for infants, see Appendix 3-B

62. PMTCT Generic Training PackageModule 3, Slide 62 Immediate Infant Care: Following Delivery (Continued)  Care for the HIV-exposed infant should follow standard best practice and Standard Precautions  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 mother  Ask mother about feeding choice; if breastfeeding, help to initiate

63. PMTCT Generic Training PackageModule 3, Slide 63 Immediate Infant Care: Following Delivery (Continued)  Do not suction unless infant does not breathe within 30 seconds of birth  If must suction, 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;  Do not milk the cord, and cover with gloved hand or gauze before cutting

64. PMTCT Generic Training PackageModule 3, Slide 64 Immediate Infant Care: Following Delivery (Continued)  Administer dose of vitamin K and silver nitrate eye ointment according to national guidelines  Immunize according to national guidelines  Use Standard Precautions when handling infant  Specialized care for sick and preterm infants should follow national and international standards

65. PMTCT Generic Training PackageModule 3, Slide 65 Follow-up Infant Care  Care for infants exposed to HIV:  Should follow best practices for well-child care  Should also include package of services designed specifically for HIV-exposed infants

66. PMTCT Generic Training PackageModule 3, Slide 66 Follow-up Infant Care (Continued)  Care for infants born to women of unknown HIV status:  Provide immediate care as if exposed to HIV  Offer testing and counselling as soon as possible. If the mother tests HIV-positive within 72 hours of delivery, give ARV prophylaxis and provide information on infant feeding options and infant feeding counselling and support.  (If she is not tested for HIV) Encourage exclusive breastfeeding

67. PMTCT Generic Training PackageModule 3, Slide 67 Exercise 3.4 Care of infants who are HIV-exposed: case studies

68. PMTCT Generic Training PackageModule 3, Slide 68 Key Points  Specific PMTCT interventions for women who test HIV- positive include:  ARV therapy or ARV prophylaxis  Information, counselling and support for safer infant feeding  Safer delivery practices that include precautions to reduce infant’s exposure to maternal blood and secretions

69. PMTCT Generic Training PackageModule 3, Slide 69 Key Points (Continued)  ARV therapy and prophylaxis reduce the risk of MTCT. ARV combination prophylaxis regimens are more effective than the single-dose NVP regimen  Integrating PMTCT services into existing MCH programmes normalizes HIV testing and other PMTCT interventions and allows for wide coverage in a cost- effective manner

70. PMTCT Generic Training PackageModule 3, Slide 70 Key Points (Continued)  Comprehensive ANC should address the special needs of HIV-infected women, e.g., assessing and treating TB, starting co-trimoxazole prophylaxis and referring for ARV therapy when indicated. Good ANC ensures a mother’s health as well as reduces the risk of MTCT  Mothers require information on infant feeding options, infant feeding counselling and support during ANC, labour and delivery and the postpartum period

71. PMTCT Generic Training PackageModule 3, Slide 71 Key Points (Continued)  Standard obstetric practices apply to all women in labour and delivery, regardless of HIV-status. For women with HIV and those of unknown HIV status, there are additional steps or precautions to minimize the contact between the infant and the mother’s blood and secretions

72. PMTCT Generic Training PackageModule 3, Slide 72 Key Points (Continued)  When providing postpartum care to women infected with HIV, HCWs should follow national guidelines. In addition, they should review with the mother, the signs and symptoms of postpartum infection, provide education on disposal of infectious materials and emphasize the importance of follow- up care and treatment and family planning  Care of infants exposed to HIV requires special measures in the delivery setting in addition to Standard Precautions