Prevention of Mother-To-Child Transmission of HIV(PMTCT)

Epidemiology

• Of 33.4 million people living with HIV/AIDS worldwide, 15.7 million are women(2007)

• About 90% of HIV +ve women reside in sub-Saharan Africa.

• In Ethiopia HIV prevalence in women is 4%, accounting to 55%.

• MTCT is the most significant source of HIV infection in children below the age of 15 years.

• Sub-Saharan Africa is home to 90% of the world’s HIV-infected children.

Reasons for high rate of HIV infection in women include:

•Biologic

•Gender

• Social and Economic

Definition:

• MTCT is HIV-infection transmission from mother-to-child during:

• Pregnancy

• Labor and delivery

• Breastfeeding

• PMTCT is a term used to describe a package of services intended to reduce the risk of mother-to-child transmission of HIV.

Effect of pregnancy on HIV infection

• Pregnancy suppresses the immune function in both HIV-infected and non-infected women.

• BUT pregnancy does not seem to have an effect on the progression of HIV disease.

Effect of HIV on pregnancy(besides the MTCT)

• Increased risk of spontaneous abortions

• Increased risk of stillbirth

• Increased risk of pre-term deliveries

• risk of low birth weight infants

• Increased risk of bacterial pneumonia, urinary tract infections and other illnesses

• Increased risk of postnatal infections– Advanced stages of HIV disease tend to have more complications

during pregnancy, delivery and in the postpartum period particularly if they are not receiving proper care.

Objectives of PMTCT

Primary HIV prevention

Prevention of

unwantedpregnancies

(Family Planning)

Promot access to ART Reduce new pediatric

hiv infection Promote access of

HIV exposed infants to care

Promote the timely treatment and care to preserve the family unit and reducing the number of orphans.

Goals of PMTCT

• Uncomplicated pregnancy

• Healthy, uninfected infant

• Healthy mother who has not compromised her future options for HIV therapy

Risk of transmission without intervention

Without intervention, the overall MTCT rate is approximately 20–45%.

Risk factors associated with increased overall risk of MTCT

1) Maternal Factors

2) Infant factors

3) Obstetric and Delivery Practices

4) Infant feeding factors

National Strategies for PMTCT

• Primary prevention of HIV in childbearing women

• Prevention of unintended pregnancy in HIV-positive women

• Prevention of transmission from HIV+ women to their infants

• Treatment, care and support of women infected with HIV, their infants and their families

Element 1: Prevention of Primary HIV Infection

1-Promote safer and responsible sexual behaviour and practices

2-Address factors that make girls and women especially vulnerable to HIV infection and that limit their access to care as well as male involvement in PMTCT

3-Use community education

4-Promote male involvement in HIV/AIDS prevention at all levels

5-Provide early diagnosis and treatment of STIs

6-Provide HIV counselling and testing to all adults and adolescents

Element 2: Prevention of Unintended Pregnancies Among Women who are HIV-Infected

1. Effective family planning• Prevents unintended pregnancies• women who are HIV-infected protect their own

health while taking care of their families.• Respect for clients’ rights: every

woman, regardless of her HIV status, has the right to make a free and informed decision about whether and when she becomes pregnant

• Most methods of contraception are safe for use by women with HIV.

2-Encourage dual protection

3-Provide integrated HIV and STI services at all levels of care

4-Provide full information about the possibility of transmitting HIV to a child

5-Offer information about prevention and referral for HIV counselling and testing

6-Counsel men and women who know they are positive, assisting them to make well-informed decisions

HIV-Positive Women Who Intend to Become Pregnant

1-Give Accurate Information on Risk of MTCT and Ensure Informed Decision to Conceive

2-Provide ART for eligible HIV infected women, if not already on treatment and ARVs for PMTCT for those who are not eligible for ART.

3-Maintain the Best Possible Health and Nutritional Status

-Good nutritional support

-iron, folate, &Zn supplementation at least 3months prior to pregnancy

-malaria prevention

-prevention &screening of STIs before pregnancy

-prophylaxis & Tx of OIs

-avoid pregnancy till 6months after recovery from any chronic infections

Element 3: Prevention of HIV Transmission from Women Infected with HIV to their Infants

Antenatal Care HIV Counselling and Testing during Antenatal

Care

All women coming for ANC, labour, delivery and post partum follow-up including child health care shall be told that their routine laboratory check up includes HIV testing unless they say “NO”. The right to say “no” shall be clearly communicated.

Additional Antenatal Care Needs for HIV-positive Women

Additional history and clinical examination for HIV-positive pregnant women:

1. Past history of HIV-related illness and HAART

2. Duration of known HIV-positive status

3. Assessment for symptoms of AIDS and HIV of other children and partner

4. Any medications for HIV-related illness taken since beginning of pregnancy

5. Any potential factor that can hamper the adherence to ARV (alcohol use,)

Additional laboratory assessment of HIV-positive pregnant women.

o Screening CD4 count/percentage is routinely recommended.

o diagnose opportunistic infections.

o Antiretroviral therapy

o All HIV-positive women should be routinelyassessed for ART eligibility and initiated onHAART if eligible.

Prophylaxis and treatment for opportunistic infections:

o Provide routine TMP-SMT prophylaxis for all HIV-infected pregnant women with clinical stage 2, 3, 4 disease or CD4 count below or equal to 350 /mm3

Tuberculosis (TB):

o Screen all HIV-positive pregnant women for TB

o Link TB positive pregnant and post natal women to TB clinic

o Screen all clients with cough of more than two weeks for TB according to national guidelines.

Malaria:

o Insecticide treated bed nets

o Anti malarial prophylaxis for those at riskChloroquine 300mg/wk orChloroquine 300mg/wk + proguanil 200mg/d

Short course ARV prophylaxis to reduce MTCT during pregnancy

Infant Care

Counselling on signs and symptoms of HIV/AIDS disease progression

Partners and family

Intra partum care: Labour and DeliveryIntra partum care and infection prevention include:

Essential obstetric care for all mothers– A skilled attendant

– Early identification of danger signs

Safe delivery practices and avoiding invasive procedures when possible – No AROM– No routine episiotomy– Avoid vacuum extraction and forceps if possible– Limit vx examination during labour

Safe delivery practices designed to protect health workers, mothers, family members, and babies.

HIV testing and counseling during labour

As up to two thirds of pregnant women attend health facilities for the first time in labour, HIV testing and counselling should be offered routinely for all mothers admitted for delivery

Post partum care• Postpartum care at six hours, six days and six

weeks for all women and newborns.

• Additionally:

– Continue on HAART if patient is eligible (if on HAART while pregnant)

– Commence on HAART if patient is eligible (if HAART was not started while pregnant)

Newborn and Postnatal Careo Routine measures

o ARV Prophylaxis to all infants born to HIV-positive

mothers to prevent MTCT

The PMTCT recommendations refer to two key approaches:

Antiretroviral drugs decrease viral replication, Viral load & reduce the risk of MTCT of HIV

1. Life-long ART for HIV-infected pregnant women in need of treatment.

2. Prophylaxis, or the short-term provision of ARVs, to prevent HIV transmission from mother to child, for women who don’t require treatment for their own health

When is ART indicated

1. WHO Stage III or IV disease irrespective of CD4 cell count 2. All women with CD4 of less than or equal to

350 per mm3 irrespective of clinical staging. When to start ART in pregnancy

HIV-infected pregnant women in need of ART for their own health should start ART as soon as feasible regardless of gestational age and continue throughout pregnancy, childbirth, breastfeeding (if breastfeeding), and thereafter.

ART for mother & prophylaxis for exposed Infants

Mother

Preferred

• AZT + 3TC + NVP or

• AZT + 3TC + EFV

Alternative

• TDF (Tenofovir disoproxil fumoarate)+ 3TC (or FTC (emticitabine) )+ NVP

or

• TDF + 3TC (or FTC) + EFV

Exposed infants (mothers on ART)

All infants

• NVP or

• AZT

ARV treatment and prophylaxis

Three possible options

Prophylaxis optionsOption A Option B

MotherAntepartum AZT (from 14 weeks)sd-NVP at onset of laborAZT + 3TC during labor & deliveryAZT + 3TC for 7 days postpartum

MotherTriple ARV (from 14 weeks until one week after all exposure to breast milk has ended)AZT + 3TC + LPV-r AZT + 3TC + ABCAZT + 3TC + EFVTDF + 3TC (or FTC) + EFV

InfantBreastfeeding populationDaily NVP (from birth until one week after all exposure to breast milk had ended)Non-breastfeeding populationSd-NVP + daily AZT for 4-6 weeks ORDaily NVP for 4-6 weeks

InfantAll exposed infantsAZT for 4-6 weeks ORNVP for 4-6 weeks

Option B+ Same for treatment and prophylaxisb:

Mother

Regardless of CD4 count, triple ARVs starting as soon as diagnosed,ccontinued for life

Infant

Daily NVP or AZT from birth through age 4–6 weeks regardless of infant feeding method

• The FMOH opted from option A of the 2010 WHO PMTCT recommendations

First line HAART regimens for eligible pregnant women in Ethiopia

AZT + 3TC + NVP for life given as follows:• Start as soon as possible even in first trimester• Note that NVP requires a graduated dose

increase: • Give 200 mg once a day for 14 days, then

increase to 200 mg twice a day• Give 3TC- 150mg and AZT- 300mg po twice daily• can be dispended as a fixed dose preparation• Continue ART through out

pregnancy, childbirth,, breastfeeding and thereafter for life.

ARV prophylaxis for Non eligible pregnant women

• AZT (Zidovudine) - 300 mg twice daily - starting at 14 weeks of pregnancy and thereafter

• AZT (Zidovudine) – 600mg at the onset of labor + NVP 200mg single dose + 3TC (Lamivudine) 150mg every 12 hours until delivery

• Post partum ProphylaxisAZT 300mg + 3TC 150mg 2 times a day for 7days

InfantSingle dose NVP (2mg\kg) with AZT (4mg\kg bid) for 7days

Option B+ ADVANTAGES

• further simplification of PMTCT programmerequirements.

• extended protection from mother-to-child transmission in future pregnancies from conception a strong and continuing prevention benefit against sexual transmission in serodiscordantcouples and partners

• likely benefit to the woman’s health of earlier treatment and avoiding the risks of stopping and starting triple ARVs, especially in settings with high fertility; and

• a simple message to communities that, once ART is started, it is taken for life.

Challenges and questions for B+

• ARV adherence and retention in care

• concerns about HIV drug resistance with longterm use of ART when initiated in early HIV disease, safety of increased ARV exposure for the fetus/infant, acceptability and equity.

References • Ethiopia Ministry Of Health, 2007. Guidelines For

Prevention Of Mother-To-Child Transmission Of HIV In Ethiopia.

• WHO, 2010. Anti Retroviral Drugs For Treating Pregnant Women And Preventing HIV Infection In Infants.

• Ethiopia Ministry Of Health, 2011. Guidelines For Prevention Of Mother-To-Child Transmission Of HIV In Ethiopia.

• WHO, 2012. Programmatic update. Use of Antiretroviral Drugs for Treating Pregnant Women and Preventing HIV Infection in Infants.

• Ethiopia Ministry Of Health, 2010. Management Protocol On Selected Obstetric Topics.