7. PREVENTION OF MOTHER TO CHILD TRANSIMISSION OF HIV.pptx

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1. PREVANTION OF MOTHER TO CHILD TRANSIMISSION OF HIV PRESENTER; NDALIJA Dotto E (MD3)

2. DEFINITIONS •PMTCT: prevention of mother-to-child transmission •HIV-Exposed Infant: baby born to a woman who is HIV-infected •Prophylaxis: giving a medication to prevent a disease/condition from occurring •Treatment/Therapy: giving a medication to control or treat a disease/condition that a patient has.

3. Newborns of mothers with HIV Maternal-Child-Transmission Newborns are at risk of contracting human immunodeficiency virus (HIV) vertically by mother-to-child transmission if they are exposed to HIV in; .utero , during birth(At labor and delivery) and breastfeeding. The major risk factor is a high maternal viral load.

4. Cont …. Without intervention, the risk of vertical HIV infection can be up to 30% and, compared to adults, vertically HIV-infected children progress much faster to AIDS. •5-10% become infected during pregnancy •10-20% become infected at labor and delivery •10-15% infected through breastfeeding

5. Pediatric HIV - Epidemiology •In 2012 2.3 million people were newly infected with HIV ‐550,000 newly infected children •More than 90% of pediatric HIV infections are acquired vertically •Without diagnosis and treatment 30% die before age 1 and 50% before 2 years

6. Risk Factors for MTCT Transmission risk is greatest when the mother’s viral load is high Viral loads increase with: Advanced HIV infection (AIDS) Recent HIV infection Concurrent viral, bacterial or parasitic infections High viral load is associated with low CD4 count

7. Cont … ‐Poor nutritional status ‐Inter-current STIs ‐Placental Infections (malaria, chorioamnionitis ) ‐Breast inflammation during breastfeeding

8. Cont …. ‐Prolonged rupture of membranes (more than 4 hours) ‐Obstetric procedures ‐Preterm delivery ‐Low birth weight ‐Duration of breastfeeding ‐Mixed feeding ‐Oral thrush or ulcerations in breastfeeding infants

9. Goal of PMTCT ‐ To “virtually eliminate” MTCT of HIV while improving care for infected parents and children. ‐ Essential for reaching 95/95/95 targets by 2030 • Virtual elimination = ‐ 95% reduction in new infections in infants ‐ MTCT rate of <5% ‐ at least 95% of all HIV‐exposed infants alive and uninfected at age of 2 years

10. 4 elements of a comprehensive approach to PMTCT •‐ 1 – Primary prevention of HIV among women of childbearing age and their partners ‐2 – Prevention of unintended pregnancies among women living with HIV ‐ 3 – Prevention of vertical transmission of HIV from mothers to their infants ‐4 – Provision of treatment, care and support to women living with HIV and their partners, infants, and families

11. Element 3: PMTCT Core Interventions ANTENATAL Determine maternal HIV status • Optimize virologic suppression INTRAPARTUM • Determine maternal HIV status • Use safer obstetric practices

12. Cont …. POSTPARTUM • Infant prophylaxis • Infant feeding options • Infant testing • Optimizing maternal viral suppression

13. ANTANATAL MANAGEMENT For HIV+ women: ‐ Monthly antenatal visits ‐ Conduct appropriate lab monitoring (next slide) ‐ Give Septrin prophylaxis if CD4<350 or unknown ‐ Standard antenatal care ‐ Screening for TB at every visit ‐ Testing and treatment for other STIs

14. POSTPARTUM MANAGEMENT If delivered at home, the infant should be brought to a health facility as soon as possible

15. TREATMENT Treatment is usually initiated in hospital. Monitor the treatment and adjust dosages according to increasing weight of the baby. If low transmission risk (effective maternal antiretroviral therapy (ART) and successfully suppressed viral load): uu Provide postnatal prophylaxis with nevirapine (NVP) or zidovudine (AZT) alone for 4–6 weeks .

16. CONT… If high transmission risk (mother was first identified as HIV-infected at delivery or in the postpartum, mother was infected during pregnancy or during breastfeeding, started ART late in pregnancy, or did not achieve viral suppression by the time of delivery): uu Provide dual drug prophylaxis ( zidovudin (AZT) plus nevirapine (NVP)) for the first 6 weeks. In breastfeeding infants, this should be followed by either an extra 6 weeks of zidovudin plus nevirapine or an extra 6 weeks of nevirapine alone

17. Diagnosis of HIV Infection in Children < 18 months •HIV DNA PCR is used to confirm HIV infection in infants and children ≤ 18 months of age. • DNA PCR at 6 weeks of age or at first visit for all exposed infants. •All children with negative initial DNA PCR should have an HIV test outside the window period, after complete cessation of breastfeeding

18. Cont … •If DNA PCR is positive or you make a presumptive diagnosis, start ART immediately while waiting for second HIV DNA-PCR results. • One positive DNA-PCR means the infant is likely infected -- initiate ART, and do second DNA PCR IMMEDIATELY to confirm the first test result. • Note: The second test should not delay ART initiation

19. Signs of infant HIV infection Failure to gain weight appropriately • Recurrent sepsis or severe infection • Recurrent severe pneumonia • Severe oral thrush • Hepatosplenomegaly

20. THE FINAL TEST Follow HIV-exposed infants clinically until they are definitively diagnosed as positive or negative • The final (definitive) HIV test should be either: Option 1: A rapid test • At least 3 months after breastfeeding stops AND • At least 18 months old Option 2: A DBS • At least 6 weeks after breastfeeding stops

21. Opportunistic Infections Many infections can be prevented by using cotrimoxazole prophylaxis, particularly:  PCP Pneumonia  Toxoplasmosis  Malaria

22. CONT….  All HIV-exposed infants should be on CTX prophylaxis until they test definitively negative  Start CTX at 6 weeks of age or the child’s first RCH visit, whichever is later  Stop ONLY after they:  Have no ongoing risk factors (usually breastfeeding) AND  Have tested negative outside the window period (usually a rapid test 3 months after breastfeeding stops AND after 18 months of age)

23. Infant feeding options in HIV+ mothers Exclusive Breastfeeding • Small chance of passing on the virus; • Costs nothing • Socially acceptable

24. CONT… Replacement Feeding • No chance of passing on the virus after breastfeeding cessation • VERY EXPENSIVE • Requires reliable clean water • Stigmatizing

25. At 12 months If child is healthy and likely negative: ‐ Breastfeeding should stop gradually (over one month) if a nutritious diet can be provided. ‐ Mother may need to be counseled on importance of stopping to breastfeed at 1 year . • If the child is HIV‐positive: ‐ Continue breastfeeding up to 24 months or beyond, as the mother and child desire.

26. REFERENCES POCKET BOOK OF Primary health care for children and adolescents •Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infections in Infants. WHO 2010.