Prevention of Parent To Child Transmission PPTCT

1. Prevention of
Parent-to-Child Transmission
(PPTCT)
PPTCT Overview

2. Session Objectives
By the end of the session, the participants will be
able to discuss:
•Describe NACO’s four-pronged strategy for PPTCT
•Understand the factors that influence PTCT
•Understand interventions to reduce PTCT
•Discuss measures to overcome PPTCT issues in a
resource-restricted setting
PPTCT Overview
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3. Routes of Transmission of HIV
NACO Annual Report 2009-2010
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PPTCT Overview

4. HIV and Women in India
PPTCT Overview
Indicator Number
Number of women who are HIV infected
in India and % of total
0.9 million (38%)
Number of annual pregnancies in India27 million
Estimated number of HIV positive
pregnancies (2009)
43,000
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5. •Primary prevention of HIV among women of
childbearing age
•Preventing unintended pregnancies among women
living with HIV
•Preventing HIV transmission from a woman living
with HIV to her infant
•Providing appropriate treatment, care and support to
women living with HIV and their children and
families
PPTCT Overview PPTCT Overview
NACO’s 4-Pronged PPTCT Strategy
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6. Risk of HIV Transmission
Transmission
Rate
During pregnancy 5-10%
During labour and delivery 10-15%
During breastfeeding 5-20%
Overall without breastfeeding 15-25%
Overall with breastfeeding to six months 20-35%
Overall with breastfeeding to 18-24 months 30-45%
Source: WHO
PPTCT Overview
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Estimated Risk and Timing of PTCT
in the Absence of Interventions

7. •What are the factors that influence mother-
to-child transmission risk ?
PPTCT Overview
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Risk of HIV Transmission

8. •High viral load
•HIV subtype
•Resistant strains
•Advanced clinical stage
•Concurrent STI
•Recent infection
•Viral, bacterial and parasitic (esp. malaria) placental
infection
•Malnourishment
PPTCT Overview
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Maternal Risk Factors
Influencing PTCT

9. •Uterine manipulation
(amnio, external cephalic version)
•Prolonged rupture of the membranes (>4 hours)
•Placental Disruption (abruption, chorioamnionitis)
•Intrapartum haemorrhage
•Invasive foetal monitoring (scalp electrode/scalp blood
sampling)
•Invasive delivery techniques: episiotomies, forceps,
use of metal cups for vacuum deliveries
•Vaginal delivery vs. caesarean section
PPTCT Overview
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Obstetrical Risk Factors
Influencing PTCT

10. •Immature Immune System
–Preterm baby
•Low birth weight (<2.5kg)
•First infant of multiple birth
•Altered skin integrity
•Immature GI tract
•Genetic susceptibility
–HLA genotype
–CCR5 karyotype deletion
PPTCT Overview
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Infant Risk Factors Influencing PTCT

11. •Mother is infected with HIV while breastfeeding
•Breast pathologies (cracked nipples, mastitis, or
engorgement)
•Advanced HIV disease in the mother
•Poor maternal nutrition
•Mouth sores or an inflamed GI tract in baby
•Mixed feeding: Breast milk along with other foods
•Prolonged breast feeding (6-18 months)
PPTCT Overview
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Infant Feeding Risk Factors
Influencing PTCT

12. Interventions During Pregnancy
•Primary prevention of HIV in childbearing women
•Provide HIV information to ALL pregnant women
•Antenatal visits are opportunity for PPTCT
•Prevention of unwanted pregnancy in HIV-positive
women
•Prevention of PTCT through ART (to mother and
baby)
•Safe obstetric practices
PPTCT Overview
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13. PPTCT Overview
Interventions During
Labour and Delivery
1.Minimise 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)
4.Avoid unnecessary trauma during delivery
–Use non-invasive foetal monitoring
–Avoid invasive procedures, such as using scalp electrodes or
scalp sampling
–Avoid routine episiotomy
–Minimise the use of forceps or vacuum extractors
–Uterine manipulation - amnio, external cephalic version (ECV)
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14. •Do not use suction unless absolutely necessary
–If suction is a must, 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
•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
PPTCT Overview
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Interventions During
Labour and Delivery

15. •Caesarean section performed before the onset of labour or
membrane rupture has been associated with reduced HIV
Transmission from Mother to Child
•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
•In India, normal vaginal delivery is recommended unless
the woman has obstetric reasons (like foetal distress,
obstructed labour, etc) for a C-section
•Use of ART can reduce risk of PTCT better and with less
risk than a C-section
PPTCT Overview
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Considerations
Regarding Mode of Delivery

16. •Observe for signs and symptoms of HIV infection
•All HIV exposed infants should receive
cotrimoxazole at 4-6 weeks of age
•Follow standard immunisation schedule
•Routine well baby visits
•DNA PCR
•18-month visit for HIV testing
PPTCT Overview
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Interventions During Infancy

17. •Exclusive breastfeeding
•Support good breast health and hygiene
•Replacement feeding – if Affordable, Feasible,
Acceptable, Sustainable and Safe (AFASS)
•Avoiding addition of supplements or mixed feeding
which enhance HIV transmission
Discussions with mothers about the above must
consider personal, familial and cultural concerns
PPTCT Overview
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Interventions for
Safer Infant Feeding

18. Outcome of various Feeding options
PPTCT Overview
BMJ, 2001, 322:3; bmj.com
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19. PPTCT Overview
Anti Retroviral prophylaxis
and therapy
• ARV prophylaxis: Short-term use of antiretroviral
drugs to reduce HIV transmission from mother-to-
infant
• ARV therapy: Long-term use of antiretroviral drugs to
treat maternal HIV and for PPTCT
• ARVs during pregnancy decrease the HIV viral
load in the mother’s blood, thus lowering the
chance of her infant to get exposed to the virus
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20. Intervention
Risk of Mother-to-Child
HIV Transmission
No ARV, breastfeeding 30-45%
No ARV, No breastfeeding 20-25%
Short course with 1 ARV,
breastfeeding
15-25%
Short course with 1 ARV,
No breastfeeding
5-15%
Short course with 2 ARVs,
no breastfeeding
5%
3 ARVs (ART), no breastfeeding 1%
2 ARVs, breastfeeding unknown
3 ARVs (ART), breastfeeding unknown
Source: WHO
PPTCT Overview
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ARV Interventions

21. Antiretroviral Prophylaxis:
Monotherapy
•Nevirapine (NACO Guidelines)
–Mother - Single dose NVP 200mg onset of
labour
–Baby - Syrup NVP 2mg/kg within 72 hours
of delivery
•Revised NACO Guidelines will be in place
shortly
PPTCT Overview
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22. •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 NEVIRAPINE
(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
partogramme or medical record to avoid accidental
repeat dosing
PPTCT Overview
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ARV prophylaxis during Labour &
Delivery for HIV-infected Women

23. What are the challenges of using single
dose Nevirapine for prophylaxis ?
PPTCT Overview
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Discussion Question

24. WHO
Clinical Staging
CD4 (cells/cu.mm)
I and II Start ART at CD4 Count <350
III and IVStart ART irrespective of CD4 Count
Strict Monitoring of Adverse effects of Nevirapine is
needed if CD4 count is >250
PPTCT Overview
ART in Pregnancy
Guidelines for initiation of ART (2010)
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25. First line Regimens for
Pregnant Women Eligible for ART
•AZT/3TC/NVP is the preferred regimen
•Stavudine to be given in the place of Zidovudine in
those having low haemoglobin (<9G%)
•Women with contraindications to NVP
(hepatotoxicity and rash) can be given EFV
•Avoid Efavirenz during First Trimester of Pregnancy
(teratogenic in first trimester)
•Efavirenz to be used with caution and with
“thorough” counselling of the risks to foetus
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26. Can we give NVP based ART
to a woman who has had
single dose-NVP for PPTCT?
PPTCT Overview
NACO ART guidelines 2007; CID 2008; 46: 622-4.
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Discussion question

27. NACO’s Key Principles (1)
•ART is only one component of PPTCT
•Selection of ART is based on:
•Effective regimen available for treatment of
maternal disease
•Teratogenic potential of the drugs should
pregnancy occur
•Provide ART to pregnant women based on national
guidelines
PPTCT Overview
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28. NACO’s Key Principles (2)
•Offer pregnant women the most efficacious PPTCT
regimens
•Simple and effective regimens should be used in
order to expand coverage and benefit more people
•Simple ARV with NVP should be considered as short
term alternative until changes in national health
system takes place
PPTCT Overview
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29. Case Study 1
25 year-old patient, primigravida at 20 weeks gestation:
–Diagnosed as HIV-positive at the antenatal
outpatient department
–ART facilities available
1.What ARV regimen is appropriate for this patient?
2.What other services will this patient need?
PPTCT Overview
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30. Case Study 2
An unregistered primagravida patient:
–Admitted with labour pains for 2 hours
–Rapid test for HIV is positive
1.What ARV regimen is appropriate for this patient?
2.What other services will this patient need?
PPTCT Overview
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31. Case Study 3
A pregnant woman, in the first trimester,
comes with CD4 cell count of 176
1.Does this woman need ART?
2.How will you manage this pregnant woman?
3.If the woman is also suffering from pulmonary TB,
how will you manage?
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PPTCT Overview

32. Challenges to Implementing
Interventions to Prevent PTCT
•A significant proportion of deliveries continue to be
unsupervised Home deliveries in many states
•Many of the hospital deliveries still remain
uncovered by PPTCT for different reasons
•Most of the private institutional deliveries are not
covered by PPTCT
•Gaps in initiating early ART for the eligible HIV
positive pregnant mothers
•Infant feeding practices / options for HIV exposed
infants: varied perceptions, opinions and advices
PPTCT Overview
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33. Key Points
•PTCT risk is affected by four factors:
–Maternal
–Obstetrical
–Infant
–Infant feeding
•Appropriate interventions and ART can reduce PTCT
risk
•ARV prophylaxis, safer obstetric and infant feeding
practices are effective interventions to reduce PTCT
PPTCT Overview
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