Prevention of Mother-to-child Transmission(PMTCT)

2011

Ashraf CoovadiaDepartment Of Paediatrics & Child HealthRahima Moosa Mother and Child Hospital

University of The Witwatersrand

Overview

Statistics Timing of Transmission Risk Factors for MTCT History of pMTCT Interventions Revised SA pMTCT policy 2010

Antenatal Prevalence - SA

Antenatal Prevalence - SA

Just under a third of pregnant women (29.3%) in South Africa are HIV Positive

One out of four babies (25%) born to all HIV positive mothers will acquire HIV from their mother ( if no intervention is offered )

That means at least 75% of babies are uninfected at birth!

Mother to Child Transmission

Background

55% of all HIV-1 positive adults are women of child bearing age.

Seroprevalence rates among pregnant women exceeds 30% in many urban populations in sub-Saharan Africa

MTCT Rates

~10 - 30% in non-breastfeeding population of HIV-1 positive women in more developed countries

25 -45% in breast-feeding populations in Africa

intrapartum67%

in utero33%

Timing of transmission in Non breast-feeding

Transmission in Children

breastfeeding30%

intrapartum60%

in utero10%

Timing of transmission Breastfeeding

Pregnancy Labour and Delivery Breastfeeding

High maternal VL

Placental infection

STIs

Maternal malnutrition

High maternal VL

ROM >4 hours before

labour begins

Invasive delivery

procedures

First infant in

multiple birth

Chorioamnionitis

High maternal VL

Duration of

breastfeeding

Early mixed feeding

Breast abscesses,

nipple fissures,

mastitis

Poor maternal

nutritional status

Oral disease in the

baby

Risk Factors for MTCT

History of PMTCT and ARV interventions

ACTG 076 1994, AZT to mother from 2nd trimester,

IV during labour and delivery, 6 weeks to infant; transmission reduced from 25%-8%

Shorter course therapies sought Thai regimen PETRA

HIVNET 012 Nevirapine one dose to mother and one

dose to baby (transmission reduced to 13%)

What did we know and when did we know it? Perinatal HIV Clinical Trial Results

1994 U.S. AZT Trial ACTG 076• 67% reduction in transmission

1998 Thai Bangkok short AP/IP AZT trial

• 50% reduction in transmission

1998 Cote d‘Ivoire short AP/IP AZT trials

• 37% reduction in transmission (breastfeeding)

1999 PETRA AZT/3TC trial (6 wk results)• 50% reduction with longest arm. • 38% reduction with the IP/PP arm

1999 Uganda 2-dose IP/PP NVP trial (HIVNET 012)• 47% reduction in transmission (breastfeeding)

1994 2004

2000 ThailandLong vs short AZT regimens

• 4% TR in LL (non BF)

2002 Cote d’Ivoire DITRAME +

• 6.2% TR with AZT & IP/PP NVP

2004 Thailand PHPT• 1.9% AZT + NVP

2003 DITRAME + 1201.1• 4.7% TR with AZT/3TC &

IP/PP NVP

MTCT: The four-pronged strategy

• Primary prevention of HIV in parents-to-be

• Prevention of unwanted pregnancies

• Prevention of transmission from HIV-infected mother to infant

• Appropriate treatment and care

Interventions

Before conceptionPrimary prevention of HIV in parents-to-bePrevention of unwanted pregnancies AntenatalIdentification of women requiring HAART or PMTCT ARV

courseAvoidance of unprotected sex with HIV+ partner PeripartumGood obstetric practiceElective Caesarian sectionARV – Nevirapine given in labour PostnatalAvoidance of breastfeeding – where safe, feasible,

acceptable

Standard ANC procedure Group pre-test counselling – PMTCT information

Individual counselling

Obtain verbal consent and proceed to test

Test results Post-test counselling and further PMTCT

information

Screening HIV test

Screening positiveScreening Negative

NegativeConfirmatory HIV test

Confirmatory positive

Confirmatory negative

NB! Retest at 32 weeks or ( 6 weeks after initial test )

Final result positive

Indeterminate

Send for HIV ELISA

Indeterminate Elisa send for PCR DNA test (diagnostic PCR)

Positive /Negative final result

Screening HIV test

Staging – highly simplified

Stage 1 - healthy

Stage 2 – skin conditions

Stage 3 – oral conditions and pulmonary TB

Stage 4 – other opportunistic infections

Zidovudine (AZT)

Dual therapy – antenatal AZT and intrapartum sd-NVP – introduced in February 2008

Addition of antenatal AZT further decreases transmission to 5%

Timing of initiation of AZT changed now to be in line with new WHO guidelines – from 14 weeks gestation

AZT cont...

According to president Zuma’s mandate on 1 December 2009, AZT for PMTCT should be

started from 14 weeks of pregnancy instead of 28 weeks

All HIV-infected pregnant women seen at antenatal clinics at 14 weeks of pregnancy and above must be started on AZT while awaiting CD4 cell count result

AZT cont... If the CD4 cell count is above 350

cells/mm3, AZT is continued until labour begins.

During labour, sd-NVP is issued in labour ward together with AZT 300mg 3 hourly until delivery. The women is then given TDF + FTC (acts as the tail cover)

If the CD4 cell count is less than 350 cells/mm3, the pregnant woman qualifies for ART).

AZT is stopped once ART is started, no additional AZT during labour nor tail required.

AZT AND ANAEMIA IN PREGNANCY

Anaemia is common in pregnancy Various causes: nutritional (iron deficiency),

HIV-related are common

AZT may exacerbate an existing anaemia, or cause the haemoglobin to drop

Prescribe adequate doses of haematinics – for all women and advise on how to take iron

Haemoglobin monitoring

Hb ≥ 11g/dl Ferrous Sulphate 200mg daily/Folic acid 5mg daily

Iron Supplementation

Hb >8g/dl <10g/dl Ferrous Sulphate 200mg tds/Folic acid 5mg daily

Hb <8g/dl Ferrous sulphate 200mg tds/Folic acid 5mg daily Urgent referral for investigation

For women on AZT 4 weekly Hb monitoring Consider initiating ART

Haematinics and monitoring (BANC)

Repeat Hb weekly

<14 weeks

>14weeks

Stage 3, 4 (any gestation)

Stage 3, 4 (any gestation)

Return1 week,ART/AZT from 14weeks

Start AZT results 1

week

Refer for anaemia start AZT when Hb >8

AZT immediately refer for ART

Hb, TB screen,CD4, Stage, Start FeSO4 and Folic Acid

1st Visit – HIV Infected

Hb > 8

Hb < 8

Management in labour

Single dose Nevirapine + AZT 300mg 3 hourly

To reduce intrapartum transmission (esp. unbooked mothers presenting in labour)

Reduces transmission to around 10% by 6 weeks testing

TDF + FTC stat after delivery

Combination therapy reduces resistance due to sdNVP

AZT started at 1st visit

Subsequent ANC visits

Check CD4 cell count resultALT if abnormal – HebBSagU&E + Weight (creatinine clearance)

CD4 ≤ 350 or stage 3 & 4

CD4 > 350Stage 1 & 2

Same day referral to ARV clinic for ART, AZT stopped once ARTinitiated

AZT 300 mg 12 hourlyGive 4 weeks supply

ANCBooking

Case finding do a CD4 cell count

Less than 14 weeks

(NVP,TDF,3TC)

Continue AZT

CD4 <350

HIV stagingCD4 result within 1weekStart AZT from 14 weeks

From 14 weeks,

•initiate ART

(EFV,TDF,3TC)

CD4 < 350

CD4>350

PMTCT and ART initiations NEW

PMTCT and ART initiation outline:

1. ANC booking visit2. Rapid HIV test positive3. HIV staging and CD4 cell count 4. Gestational age from 14 wks to 42 wks -

initiate AZT same same day5. CD4 count result within 1 week6. A. CD4 >350 – continue AZT B. CD4: <350 or stage 3 or 4 – initiate ART:

TDF, 3TC and NVP/EFVTDF, 3TC and NVP/EFV

Labour and delivery

Minimize number of PV exams to decrease risk of infection

Avoid prolonged labour

Avoid artificial rupture of membranes

Avoid traumatic vaginal delivery

Labour and delivery

Avoid routine episiotomy

Suction baby only when indicated, i.e. no routine suctioning

Wipe baby clean immediately after delivery to remove blood & liquor

HIV infectedmother on PMTCT regimen or no treatment

NVP statAZT 300mg 3 hourly during labour

Infant NVP 6 weeks*Delivery

Tail cover FTC/TDF stat dose post delivery

At onset of labour

HIV infectedmother on ART

Continue ART regimen 12

hourly throughout

labour

Mother continueART lifelong

At onset of labour NEW

Caesarian section

Routine C/S for HIV neither indicated nor feasible in government hospitals.

Elective C/S (Obstetric indication): give sd NVP at least 4 hours before

surgery If patient on ART, continue medication

at usual times Emergency C/S, antiretroviral treatment /

prophylaxis should be given stat Tail cover post C/S

Feeding practices

SAFE FEEDING PRACTICES For all HIV positive women Either exclusive replacement feeding

or exclusive breast feeding AFASS must be assessed on an individual

basis

Feeding choices for HIV infected women

Mixed feeding strongly discouraged BREAST FEEDING: exclusive breastfeeding

recommended for 1st 6 months of life . If she wants to stop at 6 months AFASS must

be reassessed Cessation of breastfeeding before 6 months

not recommended. Introduce complementary foods from 6 months in addition to continuing with breastfeeding

Feeding choices for HIV infected women

REPLACEMENT FEEDING: If women chose not to breast feed, exclusive formula feeding (i.e. no breast milk) should be practiced

Provision of free formula for at least 6 months Complementary foods should be introduced from 6 months

If the mother is known to be HIV positive – the infant is referred to as HIV EXPOSED

If the mother is known to be HIV positive – the infant is referred to as HIV EXPOSED

AVOID MISLABELINGAVOID MISLABELING

Post natal care

All women of unknown HIV status should be offered HIV testing and

counseling prior to discharge All HIV exposed infants to receive NVP daily for

6 weeks *All abandoned infants considered to be in their

first 72 hours of life, provide NVP daily for six weeks or until HIV ELISA confirms no HIV exposure

IdentifyHIV -exposed infant

6 weeks:Start CTXDo PCR Stop NVP

Prompt referral for

ART. Continue CTX

Switch to EBF if possible

PCR

PCR positive

PCR negative

*HIV negativeStop CTX

Exclusive formula fed

.

Stop infant NVP at 6 weeks

Continue infant NVP until breastfeeding cessation or max 1year

Infants of Breastfeeding mothers

VENOUSCAPILLARY

Blood collection

V

1ml

500 ul(0.5 ml)

PCR Positive

Do Viral load on separate

blood sample

Repeat DNA PCR

Initiate ART while waiting for VL

results

VL ≥ 10000 copies/ml(4log)

Continue ART

Confirm HIV infection in infants

.

VL ≤10000 copies/ml

Testing breastfed infants

6 week PCR (as for all HIV-exposed infants) BEFORE breastfeeding is stopped, do HIV

test: if positive, continue breastfeeding, refer for initiation if negative, stop breastfeeding

AFTER breastfeeding is stopped, do HIV test: if positive, try to re-initiate breastfeeding

refer for initiation if negative, currently HIV-uninfected

" All HIV-exposed infants should have a rapid test at 18 months to confirm their status unless they are already on ART"

Rapid test at 18 months

The provision of a “tail” to prevent Nevirapine resistance for women receiving sdNVP in labour

Dispensing daily NVP to the baby for 6 weeks (instead of AZT).

For breastfed infants NVP continues daily for 1 week after breastfeeding stops preferably no more than 12 months if mother not on ART.

pMTCT and feeding choices

HIV is present and transmitted via breast milk

Formula feeding is difficult in many areas especially rural

Women should be fully informed about choices and supported in their decision by health care workers (WHO)

Exclusive Breastfeeding (for 4 months)

BENEFITS Optimal nutrition Saves time, money

and effort Reduced exposure

to germs Better immunity Less allergy Socially acceptable Bonding

RISKS Transmits HIV

Exclusive Formula feeding

BENEFITS No transmission

of HIV through breast milk

RISKS Cost- may have

higher risk of poor growth

Infectious diseases, such as diarrhoea and pneumonia if hygiene, sanitation and access to clean water is poor

PMTCT RATES

Of all HIV Infected Women

75 % HIV Negative Babies

25 % HIV Infected BabiesWhere no intervention

> 95% HIV Negative Babies !

< 5% Infected

Take Home Messages All women have a right to receive PMTCT All babies have a right to be protected through

PMTCT Testing of all women is key to the realization of

these rights Provision of appropriate and timely

interventions is critical to diminishing MTCT risk Feeding choice needs to be an informed one Paediatric Diagnosis is a key component of

PMTCT Paediatric HIV is ERADICABLE