1. Module 2 Overview of HIV Prevention in Mothers, Infants and Young Children

2. PMTCT Generic Training PackageModule 2, Slide 2 Module Objectives  Provide an overview of mother-to-child transmission of HIV (MTCT)  Identify factors that increase the risk of MTCT  Describe the four elements of a comprehensive approach to prevention of HIV infection in infants and young children

3. PMTCT Generic Training PackageModule 2, Slide 3 Module Objectives (Continued)  Provide examples of each of the four elements  Describe the role of maternal and child health (MCH) services in the prevention of HIV infection in infants and young children

4. PMTCT Generic Training PackageModule 2, Slide 4 Session 1 Introduction to Mother-to-Child Transmission of HIV

5. PMTCT Generic Training PackageModule 2, Slide 5 Session 1 Objectives  Provide an overview of mother-to-child transmission of HIV (MTCT)  Identify factors that increase the risk of MTCT

6. PMTCT Generic Training PackageModule 2, Slide 6 MTCT  Mother-to-child transmission of HIV (MTCT) is the transmission of HIV from an infected mother to her baby during pregnancy, labour and delivery and breastfeeding  Also known as “vertical transmission” or “perinatal transmission”  Most children with HIV acquired the virus through MTCT

7. PMTCT Generic Training PackageModule 2, Slide 7 PMTCT  PMTCT: common term for programmes, services and interventions whose goal is to reduce the risk of MTCT

8. PMTCT Generic Training PackageModule 2, Slide 8 PMTCT (Continued)  PMTCT services include:  HIV testing and counselling during ANC, labour and delivery and postpartum  Provision of ARV drugs to mother and infant  Safer delivery practices  Infant feeding information, counselling and support  Referrals to comprehensive treatment, care and social support for mothers and families with HIV infection

9. PMTCT Generic Training PackageModule 2, Slide 9 Universal Access  The idea that everyone has a right to the prevention, care, support and treatment related to HIV and AIDS

10. PMTCT Generic Training PackageModule 2, Slide 10 Access to PMTCT UNICEF PMTCT Report Card 2005 Findings: In 2005, only 11% of women in 58 countries surveyed received PMTCT counselling and less than 10% were tested for HIV In 2006, less than 10% of pregnant women who tested HIV-positive worldwide received ARV drugs for PMTCT

11. PMTCT Generic Training PackageModule 2, Slide 11 Barriers to Universal Access to PMTCT  Weak healthcare systems, inadequate ANC  Limited access to pre-test counselling  Lack of effective coordination to oversee implementation  Inadequate community engagement  Stigma and discrimination  Lack of awareness that HIV can be passed from mother- to-child  Inadequate access to ARV therapy or prophylaxis

12. PMTCT Generic Training PackageModule 2, Slide 12 Scale-up of PMTCT  Scale-up of PMTCT services is essential  To avoid new infections among children  As part of the strategy to realize the vision of an HIV-free and AIDS-free generation

13. PMTCT Generic Training PackageModule 2, Slide 13 Exercise 2.1 Local HIV Terminology: Discussion

14. PMTCT Generic Training PackageModule 2, Slide 14 MTCT: Overview  The term “MTCT” attaches no blame or stigma to a woman who gives birth to a child who is HIV-infected  Does not suggest deliberate transmission by mother, who is often unaware of her own infection status and unfamiliar with how HIV is passed from mother-to-child

15. PMTCT Generic Training PackageModule 2, Slide 15 MTCT: Overview (Continued) both  The term should not hide this fact: either the woman or her sexual partner may introduce HIV into a family—and both of them share responsibility for preventing transmission to the infant

16. PMTCT Generic Training PackageModule 2, Slide 16 MTCT Overview (Continued)  MTCT can occur during  Pregnancy  Labour and delivery  Breastfeeding Without intervention, the overall MTCT rate is 20-45%

17. PMTCT Generic Training PackageModule 2, Slide 17 MTCT Overview (Continued)  Risk of transmission during breastfeeding depends on:  Use of safer breastfeeding practices (e.g., avoidance of mixed feeding)  Duration of breastfeeding

18. PMTCT Generic Training PackageModule 2, Slide 18 MTCT Overview (Continued)  With breastfeeding to six months overall transmission rate is 20-35%  With breastfeeding to 18-24 months overall transmission rate increases to 30-45%

19. PMTCT Generic Training PackageModule 2, Slide 19 100 infants born to HIV-infected women who breastfeed, without any interventions 55–80 infants will not be HIV- infected 5-10 infants infected during pregnancy 10-15 infants infected during labour and delivery 5-20 infants infected during breast- feeding 20-45 infants will be HIV-infected HIV-Exposed Infant Outcomes

20. PMTCT Generic Training PackageModule 2, Slide 20 Reducing MTCT  In industrialized countries the rate of MTCT has been reduced to 2% MTCT can be reduced by 40-70% through core PMTCT interventions

21. PMTCT Generic Training PackageModule 2, Slide 21 Transmission Risk Factors What are the risk factors for MTCT?

22. PMTCT Generic Training PackageModule 2, Slide 22 Transmission Risk Factors  Risk of transmission to infant is highest when mother’s viral load is high, e.g. in:  Recent HIV infection  Advanced AIDS The most important risk factor for MTCT is the amount of HIV in the mother's blood. This is known as the viral load

23. PMTCT Generic Training PackageModule 2, Slide 23 Transmission Risk Factors (Continued) During Pregnancy: 1.High maternal viral load (new infection or advanced AIDS) 2.Viral, bacterial, or parasitic placental infections, such as malaria 3.Sexually transmitted infections (STIs)

24. PMTCT Generic Training PackageModule 2, Slide 24 Transmission Risk Factors (Continued) During Labour and Delivery: 1.High maternal viral load (new infection or advanced AIDS) 2.Rupture of membranes for more than 4 hours 3.Invasive delivery procedures that increase contact with mother's infected blood or body fluid 4.Chorioamnionitis 5.Preterm delivery 6.Low birthweight

25. PMTCT Generic Training PackageModule 2, Slide 25 Transmission Risk Factors (Continued) During Breastfeeding: 1.High maternal viral load (new infection or advanced AIDS) 2.Duration of breastfeeding 3.Mixed feeding (giving water, other liquids, or solid foods in addition to breastfeeding) 4.Breast abscesses, nipple fissures, mastitis 5.Oral disease in the baby (e.g. thrush or sores)

26. PMTCT Generic Training PackageModule 2, Slide 26 HIV and Pregnancy Effect of pregnancy on HIV infection:  Pregnancy suppresses immune function in both HIV-infected and non-infected women  Studies have shown that pregnancy does not seem to have an effect on progression of HIV disease

27. PMTCT Generic Training PackageModule 2, Slide 27 Effect of HIV on Pregnancy  More complications, including increased risk of:  Spontaneous abortions and still birth  Stillbirth  Pre-term deliveries  Low birth weight infants  Bacterial pneumonia, UTI and other illnesses  Postnatal infections  It is critical that pregnant women with HIV get the best possible ANC and postpartum care

28. PMTCT Generic Training PackageModule 2, Slide 28 Session 2 Comprehensive Approach to Prevention of HIV Infection in Infants and Young Children

29. PMTCT Generic Training PackageModule 2, Slide 29 Session 2 Objectives  Describe the four elements of a comprehensive approach to prevention of HIV infection in infants and young children  Provide examples of each of the four elements

30. PMTCT Generic Training PackageModule 2, Slide 30 Comprehensive Approach to Preventing HIV Infection in Infants and Young Children  To significantly reduce MTCT and achieve targets, PMTCT must be viewed as a comprehensive public health approach  Focus is on:  Women with HIV and their partners, children and families  Parents-to-be whose HIV status is unknown or who have tested HIV-negative

31. PMTCT Generic Training PackageModule 2, Slide 31 Four Elements of a Comprehensive Approach ElementTarget Population  Primary preventionWomen and men who are sexually active  Prevention of unintended pregnancies among women infected with HIV HIV-infected women  Prevention of HIV transmission from women with HIV to their infants HIV-infected women  Provision of treatment, care and support to women with HIV, their infants and families HIV-infected women, their children and families

32. PMTCT Generic Training PackageModule 2, Slide 32 Elements 1 and 2  Elements 1 and 2 are the most effective ways to prevent MTCT  Element 1: Prevention of HIV infection in all women and men.  Also called “primary prevention”  Element 2: Prevention of unintended pregnancy among women infected with HIV

33. PMTCT Generic Training PackageModule 2, Slide 33 Elements 1 and 2 (Continued) Elements 1 and 2 are beneficial to women and can decrease the percentage of infants who become infected with HIV by 35% to 45% in many countries See Appendix 2-A

34. PMTCT Generic Training PackageModule 2, Slide 34 Element 1: Primary Prevention of HIV  Primary prevention: most effective way of controlling the spread of HIV  Must continue to be a major part of every comprehensive country response to HIV

35. PMTCT Generic Training PackageModule 2, Slide 35 Element 1: Primary Prevention of HIV (Continued)  “ABC”: an HIV primary prevention strategy  A = Abstain  B = Be faithful to one partner  also called “mutual faithfulness” or “mutual monogamy”  C = Use condoms correctly and consistently (every time)

36. PMTCT Generic Training PackageModule 2, Slide 36 Primary Prevention: Issues for Women  Especially for young women, successful implementation of the “ABCs” may require support  Factors contributing to women’s vulnerability to HIV include poverty, culturally defined roles, lack of information, abuse, violence, coercion by men and the inability to negotiate safer sex  HCWs can help women address these challenges through education, support and community linkages

37. PMTCT Generic Training PackageModule 2, Slide 37 Mutual Faithfulness  Mutual faithfulness is effective when:  Both partners are HIV-negative and have no other risk of HIV infection  Both partners are HIV-positive  If one is HIV-positive and the other HIV-negative then mutual faithfulness must be combined with condom use to be effective

38. PMTCT Generic Training PackageModule 2, Slide 38 Condom Access  Male and female condoms, when used correctly and consistently, can help prevent:  HIV transmission  STIs  Unintended pregnancy  PMTCT programmes should make male and female condoms available

39. PMTCT Generic Training PackageModule 2, Slide 39 Condom Access: HCW’s Role  HCWs should:  Provide clients with information on how to use condoms  Support client who is negotiating with partner for safer sex  Promote joint responsibility for preventing the transmission of HIV

40. PMTCT Generic Training PackageModule 2, Slide 40 STIs: Prevention & Early Treatment  STIs affect HIV and vice versa  Having other STIs increases the risk of HIV infection  HIV infection tends to make an STI more severe and less responsive to conventional treatment

41. PMTCT Generic Training PackageModule 2, Slide 41 STIs: Prevention & Early Treatment (Continued)  Early diagnosis and treatment of STIs: Can reduce incidence of HIV in general population by about 40% STI treatment services present an opportunity to provide information on HIV infection & MTCT and to refer for testing and counselling

42. PMTCT Generic Training PackageModule 2, Slide 42 HIV Testing and Counselling  HIV screening or diagnostic HIV testing and counselling should be: Routinely offered to clients attending in-patient and community-based services, e.g.: Hospital, ANC, family planning, STI and post-delivery settings Widely available and, where necessary, re-oriented to meet young people’s needs

43. PMTCT Generic Training PackageModule 2, Slide 43 Counselling for HIV-Negatives  Can be a powerful tool to:  Encourage adoption of safer sex practices  Encourage partner HIV testing  Discuss family planning  Provides patients the opportunity to learn how to protect themselves and their infants from HIV infection

44. PMTCT Generic Training PackageModule 2, Slide 44 Male Circumcision  WHO and UNAIDS recommend male circumcision be available in countries highly affected by HIV  Recent studies show that male circumcision reduces risk of heterosexually acquired HIV infection in men by ~60%  Should be performed by trained providers only in sanitary settings with adequate equipment and counselling

45. PMTCT Generic Training PackageModule 2, Slide 45 Male Circumcision (Continued)  Counselling of men and partners necessary to prevent:  developing false sense of safety  engaging in high-risk behaviours (could undermine partial protection provided by male circumcision)  Male circumcision does not provide complete protection against HIV: circumcised men must continue to use other forms of protection from HIV, such as condoms

46. PMTCT Generic Training PackageModule 2, Slide 46 Blood-to-Blood Transfusion  Screen all blood and blood products for HIV according to national guidelines  Follow Standard Precautions (including Universal Precautions) in the clinic setting

47. PMTCT Generic Training PackageModule 2, Slide 47 Exercise 2.2 HIV and STI handshake: group game

48. PMTCT Generic Training PackageModule 2, Slide 48 Element 2: Preventing Unintended Pregnancies  Family planning saves lives and enhances the health status of women and their families  The cost of infection and child deaths averted through family planning is substantially less than the cost of child death averted through the 3rd and 4th elements  Family planning provides intrinsic benefits by helping women avoid unintended pregnancy and, in effect, saving lives and enhancing the health status of women and their families

49. PMTCT Generic Training PackageModule 2, Slide 49 Element 2: Preventing Unintended Pregnancies (Continued)  Unintended pregnancies are avoidable  Family planning counselling helps women and/or couples to:  Prevent unintended pregnancies  Discuss condoms and condom use: dual protection against unintended pregnancy and STIs  Get emergency contraceptive services  Get referrals to providers of care, treatment and support

50. PMTCT Generic Training PackageModule 2, Slide 50 Effective Family Planning  Prevents unintended pregnancies  Spaces births  Helps women who are HIV-infected protect their own health while taking care of their families

51. PMTCT Generic Training PackageModule 2, Slide 51 Effective Family Planning (Continued)  It is important that pregnant women practise safer sex:  Pregnant women are at a higher risk of acquiring HIV than non-pregnant women, and  Pregnant women who are newly infected are more likely to pass HIV to their infants

52. PMTCT Generic Training PackageModule 2, Slide 52 Family Planning Counselling  Should be conducted with particular sensitivity, in private  Must demonstrate respect for clients’ rights

53. PMTCT Generic Training PackageModule 2, Slide 53 Family Planning Counselling (Continued)  Every woman, regardless of her HIV status, has the right to make a free and informed decision about  Whether and when she becomes pregnant  Whether to use contraception  Which method to use  Where possible, encourage women to include their partners in family planning counselling sessions

54. PMTCT Generic Training PackageModule 2, Slide 54 Family Planning Counselling (Continued)  3 steps to family planning counselling with an HIV- infected women:  Step 1: Discuss HIV and pregnancy  Step 2: Support the client to select a contraceptive method  Step 3: Discuss HIV and fertility

55. PMTCT Generic Training PackageModule 2, Slide 55 Family Planning Counselling (Continued) Step 1: Discuss HIV and pregnancy, including the following points:  Pregnancy does not accelerate HIV progression  Pregnant HIV-infected women should attend ANC, take advantage of available PMTCT interventions and get care and treatment  Consider the realities of caring for and raising a child, particularly if the child is unwell or even HIV-infected

56. PMTCT Generic Training PackageModule 2, Slide 56 Step 2: Support the client to select a contraceptive method  Most methods of contraception are safe for use by women with HIV  Condoms are important as dual protection Family Planning Counselling (Continued)  Condoms  Hormonal contraceptives  IUDs  LAM  Sterilization

57. PMTCT Generic Training PackageModule 2, Slide 57 Contraceptive Methods Step 2 (continued): Hormonal contraceptives, are highly effective but:  HCWs should counsel women about possible interactions between hormonal contraceptives and ARV drugs. The use of a back-up method like a condom is recommended.  Women taking rifampicin for tuberculosis usually need to use a back-up method of contraception like condoms.

58. PMTCT Generic Training PackageModule 2, Slide 58 Contraceptive Methods (Continued) Step 2 (continued):  IUDs can be used by asymptomatic or mildly symptomatic women; they are not recommended for women with advanced HIV who are not on ARV therapy  Spermicides, or diaphragm with spermicides should not be used  Fertility awareness-based methods are unreliable and should not be used

59. PMTCT Generic Training PackageModule 2, Slide 59 Contraceptive Methods (Continued) Step 2 (continued):  Lactational amenorrhea method (LAM) should only be used by women who  (i) are less than 6 months postpartum  (ii) are exclusively breastfeeding, and  (iii) have not resumed menstruating  Sterilization is effective for women with HIV

60. PMTCT Generic Training PackageModule 2, Slide 60 Family Planning Counselling (Continued) Step 3: Discuss HIV and fertility  HIV may reduce fertility by as much as 40% but ARV therapy increases fertility  Ensure that couples are aware of possibility of fertility returning  Emphasize family planning

61. PMTCT Generic Training PackageModule 2, Slide 61 Element 3: PMTCT  PMTCT programmes:  Identify pregnant women with HIV  Provide HIV-infected pregnant women with interventions for PMTCT

62. PMTCT Generic Training PackageModule 2, Slide 62 Element 3: PMTCT Interventions InterventionThese interventions work by… HIV testing and counselling during ANC, labour and delivery and postpartum (individual, couple, group)  Providing information about HIV, PMTCT, safer sex  Identifying women infected with HIV Provision of antiretroviral (ARV) drugs to mother and infant Reducing maternal viral load Safer delivery practicesReducing infant exposure to maternal blood Infant feeding information, counselling and support Reducing infant exposure to the virus in breast milk Referrals to comprehensive treatment, care and social support for mothers and families with HIV infection Ensuring the woman and her family have access to life-saving care, treatment and support services

63. PMTCT Generic Training PackageModule 2, Slide 63 Partner Involvement in PMTCT  PMTCT interventions should be based on the principle that both mothers and fathers have an effect on HIV transmission to the infant Involving both men and women in all 4 elements is vital to the success of PMTCT

64. PMTCT Generic Training PackageModule 2, Slide 64 Partner Involvement in PMTCT (Continued)  Both partners should be:  Participating in decisions about preventing HIV transmission  Playing an important role in using family planning methods  Getting tested and counselled for HIV

65. PMTCT Generic Training PackageModule 2, Slide 65 Partner Involvement in PMTCT (Continued)  Both partners should be:  Responsible for safer sex during pregnancy, breastfeeding  Getting information about PMTCT services from HCWs  Responsible for choosing a safer infant feeding method  A partner’s support is valuable for seeking and participating in HIV-related care, treatment and support

66. PMTCT Generic Training PackageModule 2, Slide 66 Element 4: Treatment, Care and Support  Medical care and social support are important for women living with HIV, enabling them to address concerns about their own health and the health and future of their children and families

67. PMTCT Generic Training PackageModule 2, Slide 67 Linkages to Care  Linkages to long-term treatment, care, support services are critical. Such services include:  ARV therapy  Symptom management  Prevention and treatment of HIV-related conditions  Reproductive health care: family planning and contraception counselling  Nutritional support  Psychosocial and community support  Palliative care, if indicated

68. PMTCT Generic Training PackageModule 2, Slide 68 Linkages for HIV-Exposed Infants and Children  Infants and children born to HIV-infected mothers require regular follow-up care, especially during the first two years of life  Immunizations  Prophylaxis for Pneumocystis pneumonia, other common infections  HIV testing  Monitoring of feeding, nutrition, growth and development

69. PMTCT Generic Training PackageModule 2, Slide 69 Linkages for HIV-Exposed Infants and Children (Continued)  Linkage essential for HIV-exposed children as they are at higher risk for illness and malnutrition:  May be infected with HIV and become ill—even with adequate healthcare and nutrition  If receiving replacement feeding, may be at risk of infections and malnutrition  If mother is ill, she may have difficulty caring for her children

70. PMTCT Generic Training PackageModule 2, Slide 70 Session 3 Role of Maternal and Child Health Services in the Prevention of HIV Infection in Infants and Young Children

71. PMTCT Generic Training PackageModule 2, Slide 71 Session 3 Objectives  Describe the role of maternal and child health (MCH) services in the prevention of HIV infection in infants and young children

72. PMTCT Generic Training PackageModule 2, Slide 72 Integrating PMTCT into MCH Services  Access to comprehensive MCH services is central to efforts to reduce HIV in infants and young children  PMTCT programmes need to be integrated into existing MCH care ANC is the most common entry point for a pregnant woman into the healthcare system; enrolment should ensure access to necessary PMTCT interventions

73. PMTCT Generic Training PackageModule 2, Slide 73 Comprehensive MCH Services  Structure usually includes services such as:  ANC  Immunization programmes for infants and children  Postpartum care  Comprehensive approach likely to strengthen maternal, infant and family care

74. PMTCT Generic Training PackageModule 2, Slide 74 Role of Comprehensive MCH Services  Provide comprehensive ANC care  Prevent primary infection in parents-to-be  Provide family planning services to HIV-infected couples and women of childbearing age of unknown HIV status  Educate women and their partners about reducing the risk of MTCT  Provide core PMTCT interventions  Provide education about prevention, early recognition of STIs  Provide or refer to STI care and treatment  Offer or refer for primary care of adults and children

75. PMTCT Generic Training PackageModule 2, Slide 75 Role of Comprehensive MCH Services (Continued)  Refer women and families to health and community services for palliative care, psychosocial and spiritual support, economic assistance  Educate patients about how to recognize symptoms of opportunistic infections and measures they can take to prevent such infections  Educate patients about how to recognize early signs and symptoms of HIV infection in the infant or child

76. PMTCT Generic Training PackageModule 2, Slide 76 Key Points  Risk of MTCT without intervention is 20–45%  Effective PMTCT programmes provide access to interventions that can significantly reduce the rate of MTCT  Risk of transmission to the infant is highest when the mother’s viral load is high. Two of the main reasons that a mother may have a high viral load are: recent HIV infection and advanced AIDS

77. PMTCT Generic Training PackageModule 2, Slide 77 Key Points (Continued)  A comprehensive approach is needed to prevent HIV infection in infants, young children. The four elements of the comprehensive approach to PMTCT are:  Primary prevention of HIV infection  Prevention of unintended pregnancies among women infected with HIV  Prevention of HIV transmission from women infected with HIV to their infants  Provision of treatment, care and support to women infected with HIV, their infants and their families

78. PMTCT Generic Training PackageModule 2, Slide 78 Key Points (Continued)  MCH services, especially ANC care, are an entry point into the range of services required to meet the needs of HIV-infected women and their families