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

2. Malawi PMTCT Training Package
Module Objectives
Discuss the epidemiology of MTCT in Malawi
Discuss biological, social, and cultural factors explaining women’s vulnerability to HIV infection.
Define mother-to-child transmission of HV infection (MTCT).
Explain the factors that influence the transmission of HIV from mother to child.
Malawi PMTCT Training Package

3. Module Objectives (continued)
Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children.
Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children.
Malawi PMTCT Training Package

4. Malawi PMTCT Training Package
Unit 1
HIV in Malawi
Malawi PMTCT Training Package

5. Malawi PMTCT Training Package
Unit 1 Objectives
Discuss the epidemiology of MTCT in Malawi.
Discuss biological, social and cultural factors explaining women’s vulnerability to HIV infection.
Malawi PMTCT Training Package

6. Malawi PMTCT Training Package
HIV Infection Rates
HIV can spread rapidly
Some African countries with previously low HIV infection rates among pregnant women now have high infection rates.
For example, in Swaziland HIV prevalence among pregnant women increased greatly:
4% in 1992
34% in 2000
43% in 2004
HIV epidemic in Malawi has not exhausted its potential for growth.
Malawi PMTCT Training Package

7. Malawi PMTCT Training Package
HIV Infection Rates
400,000 AIDS orphans in Malawi.
The number or orphans is increasing by 60,000/year.
The death rate for adults aged has tripled since 1990.
The number of tuberculosis cases is triple what it would have been.
Malawi PMTCT Training Package

8. Interactive Discussion
Exercise 2.1
Epidemiology of HIV:
Interactive Discussion
Malawi PMTCT Training Package

9. Malawi PMTCT Training Package
Gender & HIV
In Malawi, women (aged 15-24) are more than two times as likely to be HIV-infected than men.
Biological, social, cultural factors contribute to increased vulnerability of women to HIV infection.
Awareness of these factors is first step in addressing gender and HIV issues.
Malawi PMTCT Training Package

10. Factors Increasing Vulnerability of Women to HIV Infection
Socio-cultural factors
Educational level
Inability to negotiate safer sex
Trauma & bleeding during sex
Sex with older men
Exchanging sex for necessities of survival
Lack of access to information on HIV and STIs
Malawi PMTCT Training Package

11. Factors Increasing Vulnerability of Women to HIV Infection (continued)
Biological factors :
Cervical cells (Langerhans cells) may provide portal of entry for HIV.
Vulva/vaginal inflammation or ulceration
Silent/undiagnosed STIs & PID
Sexual intercourse during menstruation
Malawi PMTCT Training Package

12. Factors that Influence Sexual Behaviour of Men
Socio-cultural factors:
Failure to seek care for HIV/STIs
Culturally accepted practice of having multiple sex partners
Ego-driven behaviours to display manhood
Peer pressure to conform to unsafe sex practices
Malawi PMTCT Training Package

13. Factors Affecting Both Sexes
Lack of information on sexuality and physical development
Lack of skills to negotiate safer sex
Limited access to health services:
Testing and counselling
Risk reduction
Testing/treatment of STIs
Malawi PMTCT Training Package

14. Exercise 2.2 Local HIV-Related Terminology: Interactive Discussion
Malawi PMTCT Training Package

15. Mother-to-Child Transmission of HIV Infection
Unit 2
Mother-to-Child Transmission of HIV Infection
Malawi PMTCT Training Package

16. Malawi PMTCT Training Package
Unit 2 Objectives
Define mother-to-child transmission of HV infection (MTCT).
Explain the factors that influence the transmission of HIV from mother to child.
Malawi PMTCT Training Package

17. Mother-to-Child Transmission (MTCT)
Definition:
Transmission of HIV from a mother to her baby during pregnancy, labour, delivery, and breastfeeding.
Also called vertical transmission or perinatal transmission
“MTCT” does not attach blame to mother
Malawi PMTCT Training Package

18. Malawi PMTCT Training Package
When can MTCT occur?
Timing of MTCT:
During pregnancy
During labour and delivery
During breastfeeding
Malawi PMTCT Training Package

19. Rates and Timing of MTCT
Without intervention, 25%-50% of babies born to HIV-infected women will be HIV-infected.
Most transmission occurs during labour and delivery
Substantial risk of transmission also exists during breastfeeding
Malawi PMTCT Training Package

20. HIV Outcomes of Infants Born to Women Infected with HIV
100 infants born to HIV-infected women who breastfeed, without any interventions
50 to 75 infants will not be HIV-infected
25 to 50 infants will be HIV-infected
5–10 infants infected during pregnancy
10-20 infants infected during labour and delivery
10-20 infants infected during breast-feeding
Malawi PMTCT Training Package

21. Maternal Factors Associated with Increased Risk of HIV Transmission
Malawi PMTCT Training Package

22. Summary of PMTCT Interventions
Malawi PMTCT Training Package

23. Effect of Pregnancy on HIV
Effect of pregnancy on HIV infection:
Immune function is suppressed during pregnancy.
Studies show little effect of pregnancy on HIV progression in asymptomatic HIV-infected women
African women in late stage disease found to have more complications during pregnancy, labour and delivery, and postpartum period.
Malawi PMTCT Training Package

24. Effect of HIV on Pregnancy
Pregnancy-related complications for women with HIV include:
Increased risk of spontaneous abortions
Double the rate of pre-term deliveries
Increased risk of having LBW infant
Increased risk of stillbirths
Increased risk of bacterial pneumonia, urinary tract and other postnatal infections
Malawi PMTCT Training Package

25. Malawi PMTCT Training Package
Unit 3
Comprehensive Approach to Prevention of HIV Infection in Infants and Young Children
Malawi PMTCT Training Package

26. Malawi PMTCT Training Package
Unit 3 Objectives
Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children
Malawi PMTCT Training Package

27. Comprehensive Approach to PMTCT
HIV prevention efforts reach fewer than one in five people at risk
Four elements of comprehensive approach to PMTCT target different populations
Malawi PMTCT Training Package

28. Comprehensive Approach to PMTCT: Four Elements
Element 1: Primary Prevention of HIV infection
Element 2: Prevention of unintended pregnancies among women with HIV
Element 3: Prevention of HIV transmission from women infected with HIV to their infants
Element 4: Provision of treatment, care, and support to women infected with HIV, their infants, and their families
Malawi PMTCT Training Package

29. Comprehensive Approach to PMTCT: Four Elements (continued)
Using Element 3 alone only reduces HIV transmission to infants by 2%-12%
Prevention of primary HIV infection in women (Element 1) and unintended pregnancies among HIV-infected women (Element 2) decreases proportion of infants infected by 35%-45%.
Malawi PMTCT Training Package

30. Element 1: Primary Prevention of HIV Infection
Primary prevention is the most effective way to control spread of HIV.
Behaviour change interventions (BCI)
Prevention and treatment of STIs
Testing and counselling
Promotion and provision of condoms
Prevention of HIV in young people
Malawi PMTCT Training Package

31. Behaviour Change Intervention (BCI)
Backbone of primary prevention of MTCT of HIV
Three main strategies used in BCI:
Communication for behaviour change
Social mobilization
Advocacy
Malawi PMTCT Training Package

32. Malawi PMTCT Training Package
Primary Prevention
Prevention and early treatment of STIs
Presence of STIs generally increases risk of HIV infection
HIV infection tends to increase severity of STIs
Importance of testing and counselling
Entry point or “gateway” into HIV-related prevention and care services, including PMTCT services and family planning
Malawi PMTCT Training Package

33. Malawi PMTCT Training Package
Primary Prevention
Promotion and provision of condoms
Consistent and correct condom use can prevent STIs, HIV and unintended pregnancies
Prevention of HIV in young people
Provide information about HIV and AIDS
Teach “life skills”
Malawi PMTCT Training Package

34. Exercise 2.3 Supporting Condom Use: Discussion and Demonstration
Malawi PMTCT Training Package

35. Malawi PMTCT Training Package
Exercise 2.4
The Handshake Game:
Interactive Game
Malawi PMTCT Training Package

36. Malawi PMTCT Training Package
Element 2: Prevention of Unintended Pregnancies among Women who are HIV-infected
Family planning integral part of Malawi Safe Motherhood Initiative
Access to contraceptives
Early diagnosis and treatment of STIs, including HIV
Continued health promotion, risk reduction and family planning advice; including sex education, complete with information about how condoms provide dual protection against both pregnancy and STIs, including HIV.
Malawi PMTCT Training Package

37. Element 2: Common Contraceptive Options
Malawi PMTCT Training Package

38. Element 3: Prevention of HIV Transmission from Women to their Infants
Core PMTCT Interventions
HIV testing and counselling
ARV prophylaxis or therapy
Safer obstetric practices
Infant feeding counselling and support
Malawi PMTCT Training Package

39. Malawi PMTCT Training Package
Element 3 (continued)
Partner involvement in PMTCT
Both partners responsible for safer sex during and after pregnancy.
Both partners should be tested and counselled for HIV.
Both partners responsible for child feeding.
Malawi PMTCT Training Package

40. Malawi PMTCT Training Package
Element 3 (continued)
ARV prophylaxis and therapy for mother
ARV prophylaxis refers to ARV drugs given to mother and infant for PMTCT
No long-term benefits to mother from ARV prophylaxis
Pregnant women, with advanced HIV infection may receive ARV therapy
CD4 count or clinical staging according to WHO guidelines to determine eligibility for ARV therapy
Malawi PMTCT Training Package

41. Malawi PMTCT Training Package
Element 4: Provision of Treatment, Care, and Support to Women Infected with HIV, their Infants, Children and Families
Treatment, care, and support services for women
Prevention and treatment of opportunistic infections e.g. cotrimoxazole preventative therapy
ARV therapy (at ARV clinics)
Treatment of symptoms
Nutritional support
Reproductive health care (including family planning services)
Psychosocial and community support
Palliative care
Malawi PMTCT Training Package

42. Malawi PMTCT Training Package
Element 4 (continued)
Treatment, care and support of infants and children who are HIV-exposed
Infants and children who are HIV-exposed require regular follow-up care, especially during the first 2 years of life
Care should include:
Cotrimoxazole preventive therapy
Screening, diagnosis and treatment of tuberculosis
Immunizations
HIV testing
Ongoing monitoring of feeding, nutritional status, growth, and development
Malawi PMTCT Training Package

43. Malawi PMTCT Training Package
Unit 4
Role of Maternal and Child Health Services and Reproductive Health Services for the Prevention of HIV Infection in Infants and Young Children
Malawi PMTCT Training Package

44. Malawi PMTCT Training Package
Unit 4 Objective
Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children
Malawi PMTCT Training Package

45. Maternal and Child Health (MCH) Services
PMTCT services most effective when integrated into RH and MCH services
Antenatal care most common entry point into PMTCT services
MCH services facilitate PMTCT
RHU facilitates PMTCT
HIV/AIDS Unit facilitates PMTCT
Malawi PMTCT Training Package

46. Comprehensive PMTCT Services
Group pre-test HIV-related education & routine testing
Individual counselling
Partner involvement
Community mobilization
Family planning services
Post-test counselling, including infant feeding counselling
Nutrition counselling and supplements
ARV prophylaxis or clinical staging & referral to ART clinics
Follow-up care
Malawi PMTCT Training Package

47. Malawi PMTCT Training Package
Module 2: Key Points
Approximately 80,000 women/year in Malawi need PMTCT services to prevent passing HIV to their infants
Young women in Malawi are 2.2 times more likely to be HIV-infected than young men. This is due to biological, social, and cultural factors.
The overall MTCT of HIV rate is approximately 40% without intervention.
Malawi PMTCT Training Package

48. Module 2: Key Points (continued)
Effective PMTCT services provide access to interventions that can significantly reduce the rate of MTCT.
Because ARV prophylaxis alone does not treat the mother’s infection, ongoing care and ARV therapy (if eligible) is needed.
Malawi PMTCT Training Package

49. Module 2: Key Points (continued)
The four elements of a comprehensive PMTCT programme effectively reduce MTCT of HIV:
Primary prevention of HIV infection
Prevention of unintended pregnancies in 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
Malawi PMTCT Training Package

50. Module 2: Key Points (continued)
MCH, especially ANC services are an entry point to the range of services that provide treatment, care, and support to the woman who is HIV-infected and her family.
Linkages to community services can enhance treatment, care, and support.
Malawi PMTCT Training Package