Session 6 PMTCT udom-chas presentation .pptx

Prevention of mother to child

1. Session 6: PMTCT

2. Learning Objectives (1) By the end of this session, participants will be able to: Describe basic facts on mother-to-child transmission of HIV Identify the factors that enhance HIV transmission from mother to child Describe the four elements of a comprehensive approach to preventing HIV infection in infants and young children Describe PMTCT services in Tanzania

3. Activity: Brainstorming What do you know about Mother to child transmission (MTCT) of HIV?”

4. Basic Facts on MTCT (1): Definition MTCT is the transmission of HIV from an HIV-infected mother to her baby that can occur during: Pregnancy (Maternal) 10-15% Labour and Delivery (L&D) 10-15% Breastfeeding (post-partum) 5-20% Total MTCT transmission rate without intervention in Tanzania is 25-50%

5. Basic Facts on MTCT (2) “MTCT” attaches no blame or stigma to the woman who gives birth to a child who is HIV-infected “MTCT” of HIV should not obscure the fact that HIV may be introduced into a family by either the woman or her sexual partner

6. Factors that Enhance HIV Transmission from Mother to Child Viral factors Maternal factors Obstetric factors Foetal factors Postnatal factors

7. Factors that Enhance HIV Transmission from Mother to Child Viral factors Virulence of transmitted strain (some strains may be stronger than others)

8. Factors that Enhance HIV Transmission from Mother to Child Maternal factors High Viral Load (during acute HIV infection and advanced AIDS stage) Immunosuppression Impaired nutritional status High risk behavior may lead to maternal re-infection The presence of abruptio-placenta or chorioamnionitis Presence of diseases such as TB, malaria or STIs such as syphilis, chancroid, and bacterial vaginosis

9. Factors that Enhance HIV Transmission from Mother to Child Obstetric Factors Chorioamnionitis (from untreated STIs or other infections),routine episiotomy, invasive procedures; Intra-partum haemorrhage is associated with increased HIV transmission to the infant Obstetric procedures like early rupture of membranes, routine episiotomies, vacuum delivery or forceps delivery are associated with increased transmission

10. Factors that Enhance HIV Transmission from Mother to Child Foetal factors Pre-maturity Twin or multiple pregnancy ( First born has increased risk compared to subsequently delivered infants) Individual genetic susceptibility

11. Factors that Enhance HIV Transmission from Mother to Child Postnatal Factors Breast conditions (mastitis, breast abscess, nipple cracks) Pattern of infant feeding (breast feeding, mixed feeding) Infant infections (oral thrush, gastritis) Herpes genitalis

12. PMTCT in Tanzania (1) The World Health Organization launched option B+ in 2012 and is the main approach to PMTCT The main aim of option B+ is to simplify and harmonize treatment ( prio to this different guidelines had been issued by WHO) Tanzania adopted option B+ in 2013 Although the Global Plan had great successes, Tanzania’s target of having < 5% (MTCT) by 2020 was not achieved (By 2020 MTCT In Tanzania – 19.7%)

13. PMTCT in Tanzania (2) In lowering rate of MTCT it is important to involve HIV positive mothers in all stages of pregnancy Peers and expert clients are also crucial source of information as there is shortage of HCP Mothers enrolled to PMTCT should have current knowledge (Health belief model proposes that people will take action toward health goals if they are aware of the benefits, requirements and perceived control)

14. PMTCT in Tanzania (3) There are guidelines for PMTCT that outline the services and counselling steps mothers should receive. Elements of PMTCT, such as points of transmission, appear to be well known to mothers, however others like prevention methods, time of child testing, and optimal infant feeding practices are not well known

15. Brainstorming What are the four elements in a comprehensive approach to PMTCT?

16. 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 amongst 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.

17. 1 st Element:Primary Prevention of HIV (1) HCPs at RCH clinics should ensure that HTS is offered to all women of childbearing age, their partners, and children whose mothers are HIV positive or mothers with unknown status. Sexually active women and men should be encouraged to use safer sex practices. All HCPs should emphasize early diagnosis and treatment of STIs in their practices.

18. Primary Prevention of HIV (2) HIV testing services First test at first ANC Visit Second test in 3 rd Trimester (32-36weeks), if missed to be done at L&D or PNC(<42days) Third test to be done 3 months after delivery Fourth test to be done 6 months after delivery Fifth test to be done annually or with each pregnancy

19. 2 nd Element: Preventing Unintended Pregnancies Family planning counselling contributes to informed decision-making about pregnancy choices and is critical for preventing unintended pregnancies among HIV positive women Dual protection is the simultaneous prevention of Sexual transmitted infections (including HIV) and unwanted pregnancy).

20. 3 rd Element: Prevention of vertical transmission HIV testing services identifies women with HIV ARV treatment: Reduces maternal viral load Safer delivery practices: Reduces infant exposure to HIV virus during labour and delivery Prophylaxis and EID for HEI Counselling and support on safer infant-feeding practices: Reduces infant exposure after birth

21. 4 th Element: Treatment, Care, and Support Women assured of treatment and care are more likely to accept HIV testing and counselling: If HIV-positive, they are more likely to accept interventions to reduce MTCT Long-term medical care and social support are important for women living with HIV and AIDS and their families HIV Exposed Infants and children require regular follow-up care Provide assessment and nutritional support

22. ART for Pregnant and Lactating Mothers ART should be initiated immediately to all HIV infected pregnant women ART leads to very low transmission rates (<2%) by rapidly lowering mothers HVL TDF +3TC+DTG(TLD)is the preferred due to rapid lowering of viral load and less toxicity, If not tolerated give TDF+3TC+ EFV(TLE) Women on second and third line ART should continue with their current regimen

23. ART Monitoring for PBFW For newly diagnosed PBFW check HVL 3 months after initiation of ART, re-check every 6 months For PBFW already on ART check HVL at first ANC visit, re-check every 6 months Check CD4 at baseline then every 6 months till is above 350 cell/mm3 LFT and RFT at baseline then every 6 months

24. OIs Prophylaxis For Pregnant Women and HIV Exposed Infants Cotrimoxazole tablets 960mg daily is given to all pregnant women with CD4 cell count ≤350 cells/mm 3 Start Cotrimoxazole Syrup for HEI at the age of 6 weeks and continue until confirmed HIV negative TPT Pre-emptive cryptococcal

25. Antiretroviral Prophylaxis for HEI Reduces the chances of the HIV-exposed infant from getting infected with HIV from the mother in the postpartum period Infant prophylaxis is most effective when initiated as soon as possible (preferably within 6 – 12 hours) after delivery.

26. HIV Exposed Infant care Administer NVP syrup immediately after birth to all HIV exposed infants and continue until six weeks of age Give high-risk infant enhanced postnatal prophylaxis ( ePNP ) for a total of 12 weeks

27. HEI Risk Categories High risk group: these are infants with increased risk of transmission. It includes i nfants born to:- Women diagnosed HIV positive during pregnancy, delivery or breastfeeding Women known to be HIV positive but not yet on ART W omen known to be HIV positive or already on ART but with high viral load (≥50copies/ml). Low risk group: these are with low risk of transmission. It includes i nfants born to:- Women already on ART with HVL of <50 copies/ml within three months of pregnancy.

28. Antiretroviral Prophylaxis for HIV Exposed infant Low risk High risk FDC of AZT/3TC/NVP has been phased out therefore it is recommended to use AZT/3TC (60/30mg) +NVP(Suspension)

29. HEI Care Test At birth for high risk babies After six weeks take the second test Ensures infant testing three months after cessation of breast-feeding and a confirmatory testing at 18 months of age Facilitates early initiation of ART for HIV infected children Exclusive breast feeding should be emphasize for six months before adding complementary feeds

30. Discussion What is the current trend of MTCT in the facilities? What is observed among mothers regarding means of transmission and ways to prevent HIV to the babies?

31. Case Study C.P.M had adherence counselling after being diagnosed with HIV infection at a GA of 14 weeks. She used ART in pregnancy and delivered spontaneously vaginally in a HF and NVP syrup prophylaxis was given to her baby. The baby is 4 months old,EBF and is growing accordingly. She seeks advise because wants to stop EBF.

32. Questions for Catty How would you advise C.P.M on her request Will you like to discuss the related complications on formula milk to her baby What issues apart from BF would you advise.

33. Questions or comments on this session? Chapter 4: HIV Prevention Service for Adolescents

34. Key points MTCT can occur during pregnancy, labour & delivery, or breastfeeding Maternal, obstetric, fetal, and infant factors contribute to the risk of MTCT MTCT can be reduced through the correct use of ARVs treatment to the mother and prophylaxis to the infant