BEHAVIRAL CHANGE AND PMTCT (HIV CARE AND MANAGEMENT).pdf

BEHAVIRAL CHANGE AND PMTCT (HIV CARE AND MANAGEMENT).pdf

1. HIV/AIDS MANAGEMENT IN
PUBLIC HEALTH
INTROCUCTION TO HIV CARE AND
MANAGEMENT
BY
MUTEGEKI ADOLF

2. HIV/AIDS RELATED BEHAVIORAL
CHANGE
•HIV/AIDS related behavioral change" refers to
deliberate modifications in personal behaviors, like
sexual practices or needle sharing, aimed at reducing
the risk of contracting or transmitting HIV, often
achieved through education campaigns and
interventions that focus on increasing awareness,
promoting condom use, limiting sexual partners, and
encouraging HIV testing.

3. HIV PREVENTIONSERVICES
3. Biomedical, Behavioural and Structuralinterventions
6.Safe MaleCircumscion
7.Post Exposure Prophylaxis
8.Pre ExposureProphylaxis
13.Prevention and Management Of Gender Based
Violence
2
3

4. BehavioralChange&
Risk Reduction
Interventions
BiomedicalPrevention
Interventions
Structural
Interventions
1.Servicedelivery
2.Risk assessment forclient
3.Provide socio-behavioral
change communication
(SBCC) and link toservices
asappropriate
4.Condom promotionand
provision
1.Comprehensivecondom
programming,
2.STI screeningand
treatment,
3.eMTCT,
4.Safe MaleCircumcision
(SMC)
5.ART forprevention
6.PEP
7.PrEP
8.Blood TransfusionSafety.
Focused onaddressing:
1.Social (stigma,Gender
inequality)
2.Cultural & Religiousbeliefs
3.Economic (lackof
livelihoodopportunities)
4.Legal-political(lawsand
regulation)driversofthe
HIVepidemic
Overview of HIV PreventionInterventions 3
4

5. HIV/AIDS RELATED BEHAVIORAL
CHANGE
•HIV/AIDS related behavioral change" refers to
deliberate modifications in personal behaviors, like
sexual practices or needle sharing, aimed at reducing
the risk of contracting or transmitting HIV, often
achieved through education campaigns and
interventions that focus on increasing awareness,
promoting condom use, limiting sexual partners, and
encouraging HIV testing.

6. HIV/AIDS PREVENTIONBEHAVIORAL
CHANGES:
•Increased condom use:Consistently using condoms
during sexual intercourse is a keybehavior change to
prevent HIV transmission.
•Practicing safer injection practices:For individuals
who inject drugs, using clean needles and syringes is
essential to prevent HIV transmission.

7. •HIV Testing and Counseling (HTC):Promoting routine
HIV testing to increase awareness of one's status and
enable early intervention.
•Voluntary Medical Male Circumcision (VMMC):
Advocating for male circumcision as a strategy to reduce
HIV acquisition risk.
•Reduction in Risky Sexual Behaviors:
•Reducing multiple sexual partners.
•Delaying sexual debut among adolescents.
•Avoiding transactional or intergenerational sex.

8. 2. ADHERENCE TO HIV TREATMENT (ART)
•Medication Adherence:Ensuring people living with HIV (PLHIV) take
antiretroviral therapy (ART) consistently to achieve viral suppression.
•Retention in Care:Encouraging continuous follow-up with healthcare
providers to monitor treatment progress.
•Disclosure and Support Systems:Promoting safe disclosure of HIV status to
partners or family members to strengthen adherence support.
3. STIGMA AND DISCRIMINATION REDUCTION
•Community Education:Raising awareness about HIV/AIDS to challenge myths
and misconceptions.
•Empowerment of PLHIV:Encouraging self-acceptance and participation in
peer support groups.
•Advocacy for Rights:Promoting policies and programs that protect PLHIV
from discrimination.

9. 4. BEHAVIORAL CHANGE STRATEGIES
•Peer Education:Using trained peer educators to share
accurate HIV/AIDS information within communities.
•Mass Media Campaigns:Leveraging radio, TV, and social
media to disseminate HIV prevention and treatment
messages.
•School-Based Interventions:Integrating HIV education into
school curricula to promote safer sexual behaviors among
adolescents.
•Community Mobilization:Engaging community leaders and
religious groups in HIV prevention efforts.

10. CHALLENGES TO BEHAVIORAL CHANGE
•Cultural and Social Norms:Some traditions
discourage open discussions on sexual health.
•Low Perceived Risk:Many people underestimate
their vulnerability to HIV.
•Access to Services:Limited availability of HIV testing
and ART services can hinder behavior change.
•Stigma and Fear:Fear of discrimination discourages
people from seeking HIV-related services.

11. Services for Behavioral Change and Risk Reduction
Purpose: Todelayfirstsexual encounter, reduce unsafe sex (particularlyconcurrent
sexual partnerships); and discourage cross-generational and transactionalsex.
4
Area Guidance
Service
delivery
HIV prevention focal person at eachfacility
All staff offering HIV prevention services should betrained-including in
Genderand Sexuality Diversity(GSD)
Peer-led models for priority populations, including youngpeople
Outreaches & Drop-in Centres for KPs andPPs
Job aids to support standardization for qualityassurance
Promote youth and KP friendly services (use peer-ledmodels)
Ensure linkage and follow-up between facility andcommunity
Risk
assessment
forclient
Assesssexualbehavioroftheclient,includingcondomuseand
transactionalsex
Discuss knowledge of partner HIV status and sexualbehavior
Assess for STIs and link totreatment
Asses for gender-basedviolence
Discuss sexual and reproductive health services and link toservices
Offer HTS based on risk (use HTS eligibilitytool)
Conductpsychosocialassessment
11

12. BIOMEDICAL INTERVENTIONS
•These involve medical approaches that directly reduce
HIV transmission.
a) Safe Male Circumcision (SMC)
•Reduces the risk of heterosexual men acquiring HIV by
approximately 60%.
•Recommended as part of a comprehensive HIV
prevention strategy.
•Must be combined with other methods like condom use
and behavior change.

13. b) Post-Exposure Prophylaxis (PEP)
•A 28-day course of antiretroviral (ARV) drugs taken after potential HIV
exposure.
•Should be started within 72 hoursof exposure for effectiveness.
•Used in cases of occupational exposure (health workers), sexual assault, or
unprotected sex.
c) Pre-Exposure Prophylaxis (PrEP)
•Daily ARV medication (e.g., Tenofovir+ Emtricitabine) taken by HIV-negative
individuals at high risk.
•Recommended for key populations like:
•Serodiscordantcouples(one partner is HIV-positive, the other negative).
•Sex workers.
•Men who have sex with men (MSM).
•Injecting drug users.

14. d) HIV Testing and Counseling (HTC)
•Knowing one’s status is crucial for prevention and early treatment.
•Includes provider-initiated testing, community-based testing, and
self-testing.
e) Prevention of Mother-to-Child Transmission
(PMTCT)
•HIV-positive pregnant women receive ART to prevent
transmission to the baby.
•Includes early infant diagnosis and exclusive breastfeeding
recommendations.

15. f) Treatment as Prevention
•Ensuring HIV-positive individuals adhere to
ARTto achieve undetectable viral load (U=U),
which prevents transmission.

16. HIV TESTING SERVICES AND LINKAGE TOCARE
1. HIV Testing Services(HTS)
2.Eligibility for HIV RecencyTesting
3.Index ClientTesting
4.SNS and SNSImplementation
5.HIVSELF-TESTING
6.Linkage to HIV Care and TreatmentServices
14
16

17. 1. HIV TESTING SERVICES (HTS)
•HTS includes a range of approaches designed to identify HIV-positive
individuals and link them to care. Key testing models include:
•Provider-Initiated Testing and Counseling (PITC):Routine testing offered
at health facilities.
•Community-Based Testing:Testing conducted in homes, workplaces, or
outreach sites.
•HIV Self-Testing (HIVST):Individuals test themselves using an HIV test kit.
•Index Client Testing:Identifying and testing sexual or biological contacts
of an HIV-positive person.
•Social Network Strategy (SNS):Engaging peers or networks to encourage
testing.

18. 3. INDEX CLIENT TESTING
•Index testing is a strategy to identify and test contacts of an HIV-positive
individual (index client)to find additional cases of HIV.
How It Works:
•Elicitation:The index client is counseled and asked to list sexual partners or
biological children.
•Contact Tracing:Identified contacts are notified and offered HIV testing.
•Testing and Linkage:Contacts who test positive are linked to HIV care and
treatment.
Types of Index Testing:
•Passive Index Testing:The index client notifiestheir contacts to get tested.
•Active Index Testing:A healthcare provider contacts the partners for
voluntary testing.

19. HIV testing algorithm (>18 months ofage)
ScreeningTest
DETERMINE
Report HIVNegative
Reactive
Non-Reactive
Non-Reactive Reactive
Tie-BreakerTest
SD BIO-LINE
Report HIVPositive
ConfirmatoryTest
STAT-PAK
Non-Reactive
Reactive
Report HIVNegative
Report asINCONCLUSIVE:
Re-test after 14days
21
ForclientswhoseresultsareInconclusiveaftertherecommended14daysfollowingafirstinconclusivetestresult,asampleshouldbe
collected,labelled“2ndINC”andsenttotheNationalReferencelaboratory(CPHL)fortesting.Aresultwillbesentbackaseither
POSITIVEorNEGATIVE.Sampleandresulttransportationwillutilizetheexistinghubsystem.
2219

20. HIV testing algorithm using the HIV-Syphilis Duo Kit in MCHsettings 22
1.Within MCH settings, use HIV/Syphilis Duo test for women who previously tested negative for
HIV and Syphilis or those whose status isunknown
2.For those already known HIV positive (TRRK), test for Syphilis using the single rapid Syphilis
tests.
3.For women with evidence of Syphilis treatment within a year, test for HIV using the National
Testing Algorithm
4.Retesting for verification in MCH setting: use the same algorithm as initialtest
2320

21. Outcome of an HIV Test SerialAlgorithm 23
TEST1
Determine HIV1/2
TEST2
Stat-Pak HIV1/2
TEST3
SD Bioline HIV1/2
HIV Status
Non-reactive Negative
Reactive Reactive Positive
Reactive Non-reactive Non-reactive Negative
Reactive Non-reactive Reactive Inconclusive
Keymessages
1.AntibodytestdetectforthepresenceofHIVantibodywhilevirologicaltestsdetectfortheHIVviral
genetic
material.
2.Always follow the sequence of the test in thealgorithm
3.Collect adequate volume of blood required for thetest
4.Always follow test procedures as per the kitSOP
5.Correctly interpret individual test result as Non-Reactive, Reactive or invalid, and final result as
Negative, Positive orinconclusive
2421

22. When to Re-test forHIV
24
Population category When tore-test
Individuals exposed to HIV within four weeks
before HIVtesting
Four weeks after the 1
sttest
Keypopulations Depending on risk of exposure in the past 3months
HIV-negative partners in discordantcouples Depending on risk of exposure in the past 3months
Pregnantwomen 1
st trimester/1
st ANC visit, then in the 3
rd trimester/during
labor or delivery
Breastfeedingwomen Everythreemonthsuntilthreemonthsafter
cessation of
breastfeeding
Confirmed and presumptive TBPatients Four weeks after the 1
sttest
TB, Hepatitis and STIpatients Four weeks aftertesting
PEPclients At one month, three months and six months after completing
the PEP course
PrEP Every 3months
HIV-exposed infants (HEIs) Nine months of age, six weeks after cessation of
breastfeeding and at 18 months ofage
Children who are still breastfeedingbeyond
18 months ofage
3 months after cessation ofbreastfeeding
INCONCLUSIVEresults 14 days after the lasttest
VMMCclients- All clients beforeSMC
Children and adolescents(2-14years) Risk based with exceptions explained earlier in these
guidelines
Family planningclients Risk based
Sexual offenders and survivors ofSGBV Four weeks after the 1sttest
Index testing-Sexual partners and biological
children
Four weeks after the 1sttest 22

23. INDEX TESTING APPROACHES
(APN)
27
2823
2.ClientReferral=Youtellyourpartner(s)aboutyourHIV
status
and encourage him or her to come to the health facility
for an HIVtest.
3.ContractReferral=Youandthecounsellorwillwork
togethertonotifyyourpartner(s).Youwillhave14days
totellyourpartner(s).Afterwhich,thecounsellorwill
contactyourpartner
(s)andofferthemHIVtestingservices.
4.DualReferral=Thecounsellor/providerwillsitwithyou
andyourpartner(s)andsupportyouasyoutellyour
partneraboutyourHIVstatus.

24. HIVSELF-TESTING
Blood-Based AgeCategory Oral AgeCategory
Surecheck ≥15years Oraquick
(Orasure)
≥ 2years
INSTI ≥ 15years
(CheckNow) ≥ 15years
Mylan ≥ 15years
Wondfo ≥ 15years
HIV Self -Testing (HIVST) is a process in which a person collects his or her own specimen (oral fluid or blood)
and performs a test and interprets the result, often in a private setting, either alone or with someone he or she
trusts.
HIV self-testing is a triaging test and is not sufficient to make an HIV-positivediagnosis.
A reactive (positive) self-test result should be confirmed using the validated national testing algorithm by
trained HTSprovider.
A person testing negative is advised to re-test after 3 months if tested within 3 months of possible HIV
exposure or are at ongoing HIVrisk.
In case of an invalid HIVST result, repeat the HIVST using a new kit, health care worker tosupport
HIVST forPrEP
•Blood based HIVST is an alternative for PrEP refill in case of absence of the national HTS standard
recommendation in patients onPrEP.
35
24

25. Benefits and Target groups for HIVSelf-Testing
37
Benefits ofHIVST
•Promotes access to and createsdemand
for HTS among those unreached by
existingservices
•Convenient anddiscreet
•Increases patientautonomy
•Assuresconfidentiality
•Empowersindividuals
•Contributes to early diagnosisand
treatment
•Reduces the workload of serviceproviders
•Promotes selfcare
HIV Self-Testingapproaches
•1. Directly Assisted HIVself-testing
•2. Unassisted HIVself-testing
Prioritized Groups for HIVST in publichealth
facilitiesinclude:
•Children 2 -14yrs (Care-giver oralassisted
screening)
•Adolescent Girls & Young Women & Boys(AGYWB)
•Men including partners of Pregnant womenand
lactatingmothers
•Individuals 50 years andabove
•Key and PriorityPopulations
Other populations that may benefit from HIVSTon
general marketinclude:
–Generalpopulation
3825

26. The HIV Self-TestingSstrategy
38
3926

27. Linkage to HIV Care and TreatmentServices
ENTRYPOINT
Registration
GroupEducation
Pre-testCounseling
HTS Register/ HTS ClientCard
TestingPoint/Laboratory
Daily Activity Register for HIVkits
Refer to PreventionServices
Post-test Counseling
Client ResultsSlip
Is client enrolling at thisfacility?
Refer to anotherfacility
FillComprehensiveReferral&LinkageForms(HMIS081A)
Followuptoconfirmenrollmentintocare
Use the Follow up/Trackingschedule
Enroll in care and give client an enrollment
number
ARTRegister
39
YES NO
HIV-positive
HIV-negative
Fill in Linkage &Pre-ART
register
4027

28. Elimination of Mother-to-Child Transmission
(EMTCT) and Maternal, Newborn, Child, and
Adolescent Health (MNCAH)
•EMTCT (Elimination of Mother-to-Child Transmission)is a key
strategy in ending pediatric HIV by ensuring that HIV-positive
mothers do not pass the virus to their babies. It focuses on HIV
prevention, early diagnosis, and effective treatmentfor mothers
and infants.
•MNCAH (Maternal, Newborn, Child, and Adolescent Health)
addresses the health and well-being of women, infants, children,
and adolescents, ensuring integrated services for HIV and
reproductive health.

29. Mother-to-Child Transmission (MTCT) of HIV
(vertical transmission)
•Mother-to-child transmission (MTCT)occurs when
an HIV-positive mother passes the virus to her baby
during pregnancy, labor and delivery, or
breastfeeding.
•Without intervention, the risk of transmission can be
15–45%, but with effective Prevention of Mother-to-
Child Transmission (PMTCT) strategies, this risk can
be reduced to less than 2%.

30. Routes of MTCT
•HIV can be transmitted from mother to child through the following ways:
•During Pregnancy (In Utero):
•HIV crosses the placenta and infects the fetus.
•Factors increasing risk:
•High maternal viral load.
•Poor maternal nutrition.
•Placental inflammation or infections (e.g., syphilis).
•During Labor and Delivery (Intrapartum):
•The highest risk period (accounts for 50–70% of MTCT cases).
•Exposure to HIV-infected blood and genital secretions during birth.
•Risk factors:
•Prolonged labor and rupture of membranes.
•Vaginal delivery without ART.
•Invasive delivery procedures (e.g., forceps, episiotomy).
•During Breastfeeding (Postnatal):
•Breast milk can contain HIV, leading to infection.
•Risk factors:
•Mixed feeding (breastfeeding + other foods/liquids before 6 months).
•Breast health issues (cracked nipples, mastitis).
•High maternal viral load.

31. 2. Risk Factors for MTCT
A. Maternal Factors:
•High viral load(low adherence to ART or late diagnosis).
•Low CD4 count(weaker immune system).
•Advanced HIV stage (AIDS).
•Co-infections(STIs, TB, syphilis).
•Malnutrition and anemia.
B. Obstetric Factors:
•Prolonged labor or rupture of membranes > 4 hours.
•Invasive procedures(forceps, vacuum extraction).
•Bleeding complications.
C. Infant Factors:
•Prematurity (low birth weight infants are at higher risk).
•Mixed feeding (breastfeeding + other foods/liquids before 6 months).
•Delayed or missed infant prophylaxis (e.g., Nevirapine).

32. Service Tasks
HTS and syphilis testing
in the MNCAH setting and
during community
outreachactivities
Provide HIV/AIDS Education and offer HTS to all adolescent girls and women of
reproductive age and theirpartners.
Provide HTS to all adolescent girls and women of reproductive age and theirpartners.
Offer syphilis testing and refer to care/treatment services asnecessary.
Link all who test positive to HIV care and treatment services and offer risk reductioncounseling
to all who test HIVnegative.
IEC/BCC
IEC (InformationEducation
and Communication)
BCC (Behavioral change
communication)
•Provide IEC/BCC on safer sex practices, including dual protection(condom promotion) and
delay
of onset of sexualactivity.
•Discuss childbearing needs (current and future) to reduce stigma and encourage engagement
in testing, future care and PrEPuptake.
•Educate and provide FP/ contraception counseling and/or safer conception options(e.g., PrEP,
timed unprotectedintercourse)consistentwithPLHIV’schildbearingdesires(currentand
future).
Other preventionservices•SMC: Offer and refer for SMC services to male partners of the adolescentgirls and women.
•GBV: Screen all adolescent girls and women of reproductive age for GBV and offer
services within MCH including post exposureprophylaxis
•PrEP: Offer PrEP to eligible adolescent girls and women of reproductive age in line withthe
guidelines forPrEP
•Special consideration should be given to women in discordant relations who desire to
get pregnant
STI and HBVscreening
andtreatment
CounselandscreenadolescentgirlsandwomenforSTIsincludingsyphilisandHBVandmanage
theSTIs.
**Remember to document all services provided in theregisters
Preventing HIV infection in adolescent girls and
women of reproductiveage
43
32

33. Family Planning and HIV integratedservices
44
Service Tasks
Counsel
adolescent
girls and
women
routinelyfor
FP
•Provide routine FP/contraceptive information and counseling at ANC, PNC, YCC and ART
services
•Assess for HIV status and refer adolescent girls and women with unknown status for HTS
services.
•Screen for pregnancy before startingFP/contraception.
•Encourage HIV-infected women to discuss their reproductive healthchoices
•Provide information and counseling:
oALL Contraceptive methods, advantages and sideeffects
oCommon myths & misconceptions aboutFP/contraception
oAdvantages of dual protection and negotiating condomuse
oWhat to do when pregnancyoccurs
oAddress misconceptionse.g
Misconception Correctresponse
“Usinghor
acquisition”
monal contraception increases the riskof HIV Thereisnoincreasedriskof HIVacquisitioninwomenusingoral
hormonalcontraception.
“Hormonal
co increased
V
ntraceptioncauses a decrease in CD4
count, L and progression toAIDS event or
death.”
Thereisnoevidencethathormonalcontraceptioncausesadecrease
in CD4 count, an increase in VL, or progression toAIDS event or
death
Counselon
safe
conceptio
n
For HIV-positive women/couples who desirepregnancy
Discuss strategiesto:
Reduce the likelihood of HIV transmission toinfants.
Reduce HIV transmission risk to HIV negative partner by initiating and adhering to ART
and providing PrEP for the negativepartner.
33

34. FAMILY PLANNING AND HIV INTEGRATED SERVICES
•Integrating family planning (FP) and HIV servicesimproves
access to contraceptive choices while ensuring that HIV-positive
women can prevent unintended pregnancies and plan for safer
conception.
Why Integrate Family Planning and HIV Services?
•Prevents unintended pregnanciesamong HIV-positive women.
•Reduces risk of mother-to-child transmission (MTCT).
•Improves adherence to HIV treatment and ART outcomes.
•Enhances access to dual protection(contraceptives + STI/HIV
prevention).

35. Key Integrated Services:
•Contraceptive Counseling:Discussing FP options, including
effectiveness and ARV interactions.
•HIV Testing and ART Initiation:Ensuring all women know their
HIV status.
•Dual Method Use:Promoting condoms alongside hormonal or
long-term contraception.
•Postpartum Family Planning:Offering FP methods after delivery
or abortion to prevent unplanned pregnancies.
•Cervical Cancer Screening:Since HIV increases the risk of
cervical cancer, screening should be routine.

36. Assessing ChildbearingReadiness
A health worker in Uganda welcomes a pregnant
couple into a clinic in "Caring Completely," a DISH
Projectvideo.
© 1996 Center for Communication Programs, Courtesy
ofPhotoshare
Supporting PLHIV and their partners to discuss their childbearing needs and readiness in a non-judgmental
manner will help them make their own best decisions. Partners might not always agree or feel free to express
their own desires, readiness and/or concerns without support. Facilitating a conversation between partners and
offering education and interventions will lead to the best outcomes. The goal is to determine if both partners are
comfortableandconfidentabouttheirreadinesstohaveachild.Wheneverpossiblebothmembersofthe couple
shouldbepresentto considerthefollowingquestions:
1.Do both partners know each other’s HIV status? Do they need help with
disclosure? (Offer Assisted Partner Notification asneeded.)
2.What is each partner’s current health status? Is HIV-positivepartner’s
viral load suppressed? Is HIV-negative partner onPrEP?
3.How long have they been together? Any relationshipissues?
4.How many children does each partner currently have? What is thehealth
status of eachchild?
5.Do both partners desire to have achild?
6.How did each come to their childbearingdecision?
7.Why do they want to have a childnow?
8.What family support is there for trying for achild?
9.What family support is there for raising thechild?
10.After considering all of these issues, what do they want todo?
CH 4: Safer Conception Counselling andsupport
47
4836

37. Safer Conception Counselling andsupport
Things to consider
•Disclosure
•Couples’
•communication
•Risk of transmission of HIV / STIs to partner and infant
•ART eligible partner(s) stabilized on optimal therapy prior to conception
attempts and has undetectable viral load (when testing is available)
•Identification and management of co-morbidities
•PrEPfor HIV-negative partner
•Baseline fertility assessment

38. Timed UnprotectedIntercourse
1.Determine woman’s fertile period using ovulation calendar (example below). Free on-line phone
apps arealso available.
2.Couple has unprotected sex ONLYduring the 3 days that the woman is ovulating and most
fertile.
3.Condoms are use during all other days of the month.
1Period
starts
2 3 4 5 6 7
8 9 10 11 12 13Possibly
fertile
14Most
fertile
15 Possibly
fertile
16 17 18 19 20 21
22 23 24 25 26 27 28
29Period
starts
30
How to determine a woman’s fertile period: A woman is most fertile 14 days before her period starts and
may possibly be fertile the day before and after. The average woman has a 28-day cycle, but many are
longer or shorter. Have women track their cycles for a couples of months to determine length and
regularity. Then help women count the number of days between the time one period starts and the time
the next starts to find out how long their cycle are. Then mark a calendar for the day they expect their next
period and count back 14days.Thisisthedaythattheyaremostlikelytogetpregnant.
CH 4: Safer Conception Counselling andsupport
49
5038

39. Educational Tool: Timed UnprotectedIntercourse
50
2
0
3 7
1 Periodstarts 2 3 4 5 6 7
8 9 10 1 13 Possiblyfertile14 Mostfertile
15 Possiblyfertile 16 17 18 19 2 21
22 2 24 25 26 2 28
29 Periodstarts 30
CH 4: Safer Conception Counselling andsupport
39

40. Basic Principles of Prevention of Mother-
to-Child Transmission (PMTCT)
•PMTCT (Prevention of Mother-to-Child Transmission) is a strategy
aimed at reducing the risk of HIV transmission from an HIV-positive
mother to her baby during pregnancy, childbirth, and
breastfeeding. The goal is to eliminate pediatric HIVand ensure
the mother’s health.
THE FOUR PILLARS OF PMTCT/ PILLARS
1. Primary Prevention of HIV in Women of Reproductive Age
•Ensuring women do not acquire HIV before or during pregnancy.
•Providing HIV testing, risk assessment, and PrEP(Pre-Exposure
Prophylaxis).
•Encouraging condom use and behavior change interventions.

41. 2. Preventing Unintended Pregnancies Among HIV-Positive Women
•Offering family planning and contraceptive services.
•Ensuring HIV-positive women have access to safe reproductive choices.
•Providing counseling on contraceptive options and ART interactions.
3. Preventing HIV Transmission from Mother to Child
•Early initiation of Antiretroviral Therapy (ART)to suppress the mother’s
viral load.
•Providing safe delivery practicesto reduce exposure.
•Promoting safe infant feeding practices(exclusive breastfeeding or
formula feeding).
4. Providing Care, Treatment, and Support for HIV-Positive Mothers,
Infants, and Families
•Ensuring postnatal follow-upfor both mother and child.
•Providing early infant HIV testing (EID)at 6 weeks and regular check-ups.
•Supporting adherence to ART and promoting psychosocial well-being.

42. KEY STRATEGIES IN PMTCT
•HIV Testing & Counseling (HTC):All pregnant women should be tested for HIV
and receive counseling.
•Antiretroviral Therapy (ART):All HIV-positive pregnant women should be on
lifelong ART (Option B+).
•Safe Delivery Practices:Avoid prolonged labor, artificial rupture of
membranes, and unnecessary invasive procedures.
•Infant Prophylaxis:Newborns receive antiretroviral prophylaxis (e.g.,
Nevirapine) to prevent HIV transmission.
•Early Infant Diagnosis (EID):PCR testing at 6 weeks and repeated follow-ups to
ensure early detection and treatment.
•Infant Feeding Counseling:Exclusive breastfeeding for 6 months with ART or
safe formula feeding.

43. PREVENTION OF MOTHER TO CHILD HIV
TRANSIMISSION (PMTCT)
•HIV Testing and Counseling (HTC)
•All pregnant women should be tested early in pregnancy.
•Partner testing and index testing encouraged.
•Antiretroviral Therapy (ART) for the Mother
•All HIV-positive pregnant women should start lifelong ART (Option B+).
•ART reduces viral load to undetectable levels (U=U).
•Safe Labor and Delivery Practices
•Avoid prolonged rupture of membranes.
•Minimize invasive procedures (episiotomy, forceps).
•Encourage C-section if viral load is high.

44. •Infant Prophylaxis
•All HIV-exposed infants should receive Nevirapinefor 6–12 weeks.
•Early Infant Diagnosis (EID) with PCR at 6 weeks.
•Safe Infant Feeding Practices
•Exclusive breastfeeding for 6 monthswith maternal ART or
•Formula feedingif it is affordable and safe.
•Avoid mixed feeding as it damages the infant’s gut and increases HIV
risk.
•Postnatal Follow-up and Treatment
•Regular viral load monitoringfor mothers.
•Follow-up testing for infants at 6 weeks, 6 months, and 12 months.
•If infant is HIV-positive, initiate ART immediately.

45. FACTORS AFFECTING PMTCT (PREVENTION OF
MOTHER-TO-CHILD TRANSMISSION OF HIV)
1. MATERNAL FACTORS
??????Viral Load and ART Adherence
•High maternal viral loadincreases the risk of transmission.
•Poor adherence to ARTleads to treatment failure and drug resistance.
•Late initiation of ARTin pregnancy increases transmission risk.
??????CD4 Count and Disease Stage
•Low CD4 count (<200 cells/mm³) weakens the immune system, increasing
MTCT risk.
•Advanced HIV stage (AIDS) increases the likelihood of vertical transmission.

46. ??????Co-infections and Poor Health
•Sexually transmitted infections (STIs)(e.g., syphilis, herpes)
increase the risk.
•Tuberculosis (TB) and malariaworsen maternal health and immune
suppression.
•Malnutrition and anemiareduce the body’s ability to fight
infections.
??????Breastfeeding Practices
•Mixed feeding(breastfeeding + formula/solid foods) damages the
infant’s gut, increasing HIV transmission risk.
•Extended breastfeedingwithout maternal ART increases postnatal
transmission.

47. 2. INFANT FACTORS
??????Prematurity and Low Birth Weight
•Preterm babies have immature immune systems, making them more
vulnerable.
??????Failure to Receive Infant Prophylaxis
•If the baby does not receive Nevirapineor AZT (Zidovudine)within 6
hours after birth, the risk increases.
??????Delayed Early Infant Diagnosis (EID)
•PCR testing at 6 weeksis essential for early detection and treatment.
•Late diagnosis leads to delayed ART initiation and increased mortality.

48. 3. HEALTH SYSTEM FACTORS
??????HIV Testing and Linkage to Care
•Lack of early HIV testing during pregnancymeans missed
opportunities for intervention.
•Weak referral and follow-up systems lead to poor retention in
PMTCT programs.
??????Availability and Accessibility of PMTCT Services
•Shortages of ARVs, HIV test kits, and lab facilitieshinder
effective PMTCT.
•Long distances to health facilities limit access to antenatal care
(ANC).

49. ??????Skilled Health Workforce
•Lack of trained healthcare workersaffects service
delivery.
•Poor counseling on ART adherence and safe
feedingimpacts PMTCT success.
??????Delivery Practices
•Prolonged labor or rupture of membranes (>4
hours)increases HIV exposure.
•Lack of C-section servicesfor high-risk mothers
increases intrapartumtransmission.

50. 4. SOCIO-ECONOMIC AND CULTURAL FACTOR
??????Stigma and Discrimination
•Fear of disclosureprevents women from accessing HIV care.
•Social rejection discourages ART adherence.
??????Lack of Male Partner Involvement
•Male partners influence decision-making on HIV testing and ART adherence.
•Low male engagement leads to poor retention in care.
??????Economic Barriers
•Poverty limits accessto health facilities and transportation.
•Formula feeding may not be an option due to cost and availability.
??????Traditional and Cultural Beliefs
•Some communities promote traditional birth attendantsover skilled health workers.
•Cultural breastfeeding practices(e.g., early introduction of other foods) increase MTCT risk.

51. POSITIVE LIVING IN HIV MANAGEMENT
•Positive livingrefers to adopting a healthy lifestyle, mindset, and
behaviorsthat help people living with HIV (PLHIV) lead long,
fulfilling liveswhile managing their condition effectively.
•It focuses on physical health, mental well-being, adherence to
treatment, and social support.
1. Adherence to Antiretroviral Therapy (ART)
??????Taking ART consistently and correctlyreduces viral load to
undetectable levels (U=U).
??????Prevents drug resistance and improves life expectancy.
??????Helps PLHIV stay healthy and prevents transmissionto partners.

52. 2. Healthy Nutrition and Lifestyle
??????Eating a balanced dietstrengthens the immune system and
reduces opportunistic infections.
??????Regular exerciseimproves energy levels, heart health, and mental
well-being.
??????Avoiding alcohol, smoking, and drug usereduces complications.
3. Mental Health and Emotional Well-being
??????Counseling and peer supporthelp manage anxiety, depression, and
stigma.
??????Engaging in stress management techniqueslike meditation and
physical activity.
??????Seeking professional mental health carewhen needed.

53. 4. Preventing Opportunistic Infections (OIs)
??????Taking prophylaxis (e.g., Cotrimoxazolefor bacterial infections)
prevents severe infections.
??????Getting vaccinations(Hepatitis B, HPV, Pneumonia) to protect
against common diseases.
??????Practicing good hygiene(clean water, handwashing) to prevent
infections.
5. Safe Sexual and Reproductive Health
??????Consistent condom useprevents HIV transmission and STIs.
??????Accessing family planning and safer conception methodsfor HIV-
positive couples.
??????Regular screening for STIs and cervical cancerin women.

54. 6. Social Support and Disclosure
??????Joining PLHIV support groupsto share experiences and
encouragement.
??????Educating family and community to reduce stigma and
discrimination.
??????Seeking help from counselors and peer educatorswhen needed.
7. Economic Empowerment and Productivity
??????Encouraging education, employment, and income-generating
activities.
??????Learning new skillsfor self-reliance and improved quality of life.
??????Accessing social welfare programsfor PLHIV where available.

55. 8. Regular Medical Check-Ups and Monitoring
??????Routine viral load testingensures ART
effectiveness.
??????Screening for non-communicable diseases
(diabetes, hypertension, cancer).
??????Regular mental health and nutritional
assessments

56. Why Practice Positive Living?
1. Improves Health and Longevity
??????Taking ART consistentlysuppresses the virus, preventing HIV from progressing
to AIDS.
??????Reduces the risk of opportunistic infections (TB, pneumonia, candidiasis, etc.).
??????Helps maintain a strong immune system, promoting overall well-being.
2. Prevents HIV Transmission
??????Achieving an undetectable viral load (U=U)means HIV cannot be transmitted
to sexual partners.
??????Practicing safe sex (consistent condom use, PrEPfor partners)reduces new
infections.
??????Safer conception and PMTCT services protect babies from HIV transmission

57. 3. Enhances Mental and Emotional Well-being
•??????Reduces stress, anxiety, and depressionlinked to HIV stigma and
discrimination.
??????Engaging in support groups and counselingbuilds confidence and
self-acceptance.
??????Helps PLHIV maintain positive relationships and a hopeful
outlook on life.
4. Boosts Energy and Physical Strength
•??????Good nutrition and regular exercisehelp manage weight,
maintain strength, and prevent other illnesses.
??????Staying active and productiveimproves mood and overall well-
being.
??????Avoiding harmful substances (alcohol, smoking, and drug use)
prevents complications.

58. 5. Strengthens Social and Family Support
??????Open communication and disclosurehelp build trust with loved
ones.
??????Reduces social isolationby engaging with peer support groups.
??????Encourages acceptance and reduced stigmawithin families and
communities.
6. Increases Economic Stability and Self-Sufficiency
??????Encourages education, employment, and financial independence.
??????Ensures PLHIV continue working and contributing to their
families.
??????Reduces economic burden by preventing costly hospitalizations
due to HIV-related complications.

59. 7. Ensures Safe Sexual and Reproductive Health
??????Helps PLHIV make informed family planning and reproductive
health choices.
??????Encourages safe conception optionsfor HIV-positive couples.
??????Ensures regular screening for STIs, cervical cancer, and other
health risks.
8. Contributes to Ending HIV/AIDS
•??????Reduced HIV transmissionmeans fewer new infections in the
community.
??????Increases ART adherence, leading to better public health
outcomes.
??????Supports global efforts to end the HIV epidemic.

60. CH.5: Minimum Service Package forPLHIV(1)
ServiceArea Service Description
Clinical evaluation
and monitoring of
HIV disease
•Clinical evaluation and monitoring to ascertain the WHOclinical stage of disease
and excludecomorbidities.
Antiretroviraltherapy •ARTinitiationattheearliestopportunityinallpeoplewithconfirmedHIV
infection, regardless of clinical stage or CD4 cellcount
Nutritionservices Nutrition assessment, counseling and support(NACS)
Opportunistic
infection
screening,
prevention, and
management
•Cotrimoxazoleprophylaxis
•INH prophylaxis ifeligible
•Screen and manage OIs like TB and cryptococcalinfection
Screening and
treatment of
co-
morbidities
•Screen and manage NCDsincluding:
oHypertension
oDiabetes
oDyslipidemias
oMental health (especiallydepression)
Sexual and
reproductive
health services
•Screening and management of sexually transmittedinfections
•Family planning and pre-conceptionservices
•Early identification of pregnant mothers and linkage toANC
•Facility delivery and postnatalcare
•Cervical and breast cancerscreening 60

61. CH.5:
M
inimum Service Package forPLHIV
(2)
70
ServiceArea ServiceDescription
Adherence
counseling
•Adherence preparation, monitoring andsupport
Psychosocialsupport
and palliativecare
•Assessment for family and communitysupport
•Assessment for stigma anddiscrimination
•Linkage to a psychosocial supportgroups
•Assessment for socialchallenges
•Referral for palliative care whenrequired.
Orphans and
vulnerable
children (OVC)
•Assessment forvulnerability
•HIV testing for familymembers
•Referral and linkage to aCBO/CDO
•Nutrition assessment, counseling andsupport
•ART initiation for HIV-positive children and theircaretakers
For details of OVC care, refer to the SPPI, Ministry of Labor, Gender, and
Social Development
Positive
health,
dignity and
prevention
•Supported disclosure of HIV status to family and significantothers
•Active partner and family tracing for HIVtesting
•Education, distribution and promotion ofcondoms
•Family planning/contraceptive counseling andservices
•STI screening, prevention and treatmentservices
•Routine ART adherencecounseling
61