Module 3 Specific Interventions to Prevent Mother-to-Child Transmission of HIV (PMTCT)

Module 3

Specific Interventions to Prevent Mother-to-Child

Transmission of HIV (PMTCT)

Malawi PMTCT Training Package 2

Module 3 Objectives

Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.

Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT).

Describe strategies for reducing the risks of MTCT during labour and delivery.

Malawi PMTCT Training Package 3

Module 3 Objectives (continued)

Discuss the management of women during labour and delivery who are of unknown HIV status.

Describe immediate postpartum care of women with HIV infection.

Explain the need to integrate family planning into community services.

Describe guidelines for immediate newborn care.

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Unit 1

Implementation of Comprehensive ANC Services

Malawi PMTCT Training Package 5

Unit 1 Objectives

Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.

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PMTCT in Antenatal Care (ANC)

ANC improves the health and well-being of mothers and their families.

Integration of PMTCT services into essential ANC services can improve care and pregnancy outcomes for clients.

Antenatal interventions can reduce risk of MTCT

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Quality RH in context of PMTCT

Comprehensive antenatal services Routine HIV testing and counselling ARV prophylaxis or, if eligible, therapy Safer infant feeding counselling and support

Quality intrapartum care Quality postpartum care that includes:

Safer infant feeding counselling and support Family planning services Follow up care for mother and baby

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Integrated Essential Package for ANC Services

ANC for HIV-infected pregnant women includes basic services recommended for all pregnant women

Obstetric and medical care for HIV-infected women expanded to address their specific needs

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Integrated Essential Package for ANC Services (continued)

Client history History of present

pregnancy Social history Physical exam and vital

signs Lab tests STI screening

HIV-related conditions o Tuberculosis o Malaria

Immunizations ARV prophylaxis and/or

therapy Nutritional assessment,

counselling, and support Health education Infant feeding

counselling

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Support Needs of Women with HIV Infection

Pregnancy is a stressful time. Support will lead to hope and acceptance.

Referrals include: Food, nutritional counselling & supplementation Practical necessities Social and psychological support Home care & community-based health care Traditional/herbal healers Orphan care and support Care of children with HIV or AIDS

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Prevention of HIV-Related Conditions

Reduce rates if illness, adverse pregnancy outcomes, and death among HIV-infected pregnant women

Women with HIV infection more susceptible to: TB Urinary tract infections Respiratory tract infections Recurrent vaginal candidiasis Malaria Breast conditions Unhealed episiotomies/caesarean section wounds Herpes zoster Puerperal sepsis

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Maternal Nutrition & MTCT

Nutritional deficiencies can be associated with preterm delivery & increased risk of MTCT

Weight gain during pregnancy is an indicator of mother’s nutritional status

Women’s pre-pregnancy weight Recommended weight gain (kg) Normal 11.5- 18.0

Underweight 12.5-18.0 Overweight 7.0-11.5

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Exercise 3.1

Antenatal Care:

Case Studies

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Unit 2

Antiretroviral Prophylaxis and Therapy for PMTCT

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Unit 2 Objective

Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT)

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ARV Drugs in PMTCT

Antiretroviral (ARV) drugs hinder replication and mutation of HIV, resulting in less damage to immune system

ARV therapy or prophylaxis reduce risk of MTCT by reducing viral load in mother

ARV drugs can be used for prophylaxis or treatment

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ARV Drugs in PMTCT (continued)

ARV Therapy: Long-term use of antiretroviral drugs to treat maternal HIV/AIDS to slow progression of disease. ARV therapy also reduces HIV transmission from mother to infant.

ARV Prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant. ARV prophylaxis does not treat maternal HIV or provide long-term protection for the infant.

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Pregnancy & ARV Therapy

Women who are eligible for ARV therapy should be referred to the ARV Clinic.

ARV therapy: Should begin as soon as possible, but may be

delayed until after 1st trimester Women on ARV therapy require ongoing

care and monitoring in the ANC and ART clinics.

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ARV Prophylaxis

ARV prophylaxis alone will not protect breastfeeding infants from risk of HIV infection

Single dose Nevirapine (sd-NVP) has been used since inception of programme. Mother: sd-NVP 200mg at onset of labour Infant: sd-NVP (6mg) within 72 hours of delivery

Prevent NVP resistance by avoiding multiple doses of NVP to the mother. If the maternal NVP dose is given during false labour, the dose should not be repeated.

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ARV Prophylaxis

Combination regimens given during pregnancy are more effective but more difficult to administer where infrastructure/access is an issue

The HIV/AIDS Unit is phasing in the regimens at sites with infrastructure

Combination regimens include 2 or 3 of the following drugs: AZT NVP 3TC

The recommended regimens are listed in Appendix 3-C

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Exercise 3.2

Nevirapine Prophylaxis for PMTCT: Case Studies

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Unit 3

Optimal Management of Women During Labour and

Delivery

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Unit 3 Objectives

Describe strategies for reducing the risks of MTCT during labour and delivery.

Discuss the management of women during labour and delivery who are of unknown HIV status.

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PMTCT Interventions During Labour & Delivery

Administer ARVs as per guidelines Use Standard Precautions Minimize vaginal examinations Avoid prolonged labour Avoid routine artificial rupture of membranes Avoid unnecessary trauma and routine

episiotomy Minimize risk of postpartum haemorrhage Use safe transfusion practices

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PMTCT Interventions During Labour & Delivery (continued)

Always use Standard Precautions during patient care:

Strict aseptic technique during first stage of labour Wash hands before & after every procedure Decontaminate bed, instruments, linens soon after use Autoclave or high-level disinfection of instruments

used for delivery Use six swab technique for vulval swabbing/vaginal

cleansing Use protective gear, safely dispose sharps &

contaminated materials

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PMTCT Interventions During Labour & Delivery (continued)

Minimize vaginal examinations: Perform vaginal examinations only when

necessary Record all vaginal examinations on

partograph

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PMTCT Interventions During Labour & Delivery (continued)

Avoid prolonged labour: Use partograph to monitor progress of labour Avoid artificial rupture of membranes If spontaneous rupture of membranes occurs

when not in labour, induce immediately Augment if in latent phase of labour Aim to deliver within 4 hours if in active phase

of labour Reinforce pain relief in labour

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PMTCT Interventions During Labour & Delivery (continued)

Avoid unnecessary trauma during delivery: Avoid invasive procedures Avoid routine episiotomy Avoid unnecessary trauma to infant Minimize use of vacuum extractors Prevent genital tract/perineal lacerations Do not give enemas Do not shave vulva

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PMTCT Interventions During Labour & Delivery (continued)

Minimize risk of postpartum haemorrhage: Carefully manage all stages of labour to prevent

infection & avoid prolonged labour Actively manage third stage of labour

Use safe transfusion practices: Minimize blood transfusions Use only blood screened for HIV, hepatitis B,

and syphilis

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Exercise 3.3

Obstetric Practices and HIV: Group Discussion

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Management of Women with Unknown HIV Status (continued)

If a woman presents in:

Early labour:

• Provide HIV information

• Test unless she refuses

• Give NVP to woman and infant if she tests HIV+

Late labour (active phase):

• Defer test until after delivery & before discharge

• If she test HIV+, give NVP to infant

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Management of Women with Unknown HIV Status (continued)

Pre-test information checklist for use in labour and delivery

HIV is the virus that causes AIDS.

HIV can be transmitted from mother to infant

HIV testing can help determine HIV status and need for interventions.

A positive rapid HIV test result must be confirmed.

HIV testing is strongly recommended.

Medicines are available for PMTCT.

Care will be provided regardless of testing decision.

Post-test counselling following delivery, with referral for follow-up services, is required for all HIV-positive mothers and their infants.

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Exercise 3.4

HIV Testing and ARV Prophylaxis during Labour and Delivery:

Case Studies

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Unit 4

Postpartum Management of Women and Infants

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Unit 4 Objectives

Describe immediate postpartum care of women with HIV infection.

Explain the need to integrate family planning into community services.

Describe guidelines for immediate newborn care.

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Immediate and Subsequent Postpartum Care of HIV-Infected Mothers

After Delivery Provide ARV prophylaxis to the infant

Before Discharge Assess Mother

Personal hygiene Nutritional status Signs and symptoms of anaemia and infections Signs of uterine involution Breast conditions

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Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Before Discharge Assess Mother (continued)

Urinary tract infections Episiotomies, caesarean section Signs of PID and any other infections Clinical features of HIV or AIDS Possible side effects of ARVs

Administer Vitamin A and iron supplement

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Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Before DischargeOffer education, counselling, and support for: Infant feeding, hygiene, re-hydration, umbilicus

care, illness Diet and nutrition Postpartum infection, including pelvic

inflammatory disease (PID) Anaemia Community resources Information on breast and urinary tract

infections

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Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Upon Discharge

Offer Education, Counselling, Support for: Follow-up care: both routine (one-week

and six-week visits, then monthly check ups) and as needed

Family planning information and services, including information on condom use for dual protection

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Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Upon DischargeLink patients to centers providing the following services: Postnatal review, dates for one-week and six-week

visits Sexual and reproductive health care, including family

planning Prevention and treatment of HIV-related conditions, inc

malaria Immunizations

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Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Upon Discharge (continued)

Link patients to centers providing the following services: Nutritional counselling and support “Under-five” services Support groups HIV treatment, care, and support Social and psychosocial support Home-based care

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Family Planning

Family Planning (FP) is a core PMTCT intervention. FP services integrated into ANC and community

health services can minimize HIV/AIDS- related stigma.

FP services includes: Individual and couples counselling Continued risk assessment Early diagnosis and treatment of STIs and HIV/AIDS Information and skills needed to practise safer sex Access to contraceptives

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Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn

Administer NVP prophylaxis as soon as possible but within 72 hours after birth

For home births, child and mother should be seen within 72 hours of delivery: Assessment Administration of NVP prophylaxis Support safer infant feeding.

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Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn (continued)

Make assessments and implement preventive measures:

Infant feeding Administer ARVs within 72 hours PCR testing within 48 hours where available Immunization according to EPI schedule Side effects of ARV prophylaxis

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Exercise 3.5

Supporting Postpartum

Follow-Up:

Group Discussion

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Module 3: Key Points

The essential package of ANC services includes the basic services recommended for all pregnant women, including HIV testing. However, for women with HIV, obstetric and medical care should be expanded to address the specific needs of women infected with HIV.

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Module 3: Key Points (continued)

Nutritional assessment, counselling and support are important not only in the antenatal period when good nutrition plays a role in foetal health and PMTCT, but also in the postpartum period, particularly for the breastfeeding mother and for the HIV-exposed or HIV-infected infant and young child.

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Module 3: Key Points (continued)

ARV therapy is the long-term use of antiretroviral drugs to manage maternal HIV and prevent MTCT; ARV prophylaxis is the short-term use of antiretroviral drugs to reduce MTCT of HIV.

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Module 3: Key Points (continued)

The HIV/AIDS Unit has phased in the more complex but efficacious WHO-recommended regimen (which include AZT, NVP and, in some instances, 3TC) at sites with adequate infrastructure and human capacity for its delivery. At the same time, expansion of PMTCT to sites with limited infrastructure will be done using single dose Nevirapine (sd-NVP) while steps are taken to build their capacity to deliver the recommended combination regimen.

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Module 3: Key Points (continued)

The infant ARV prophylaxis regimen is either AZT alone, NVP alone or a combination of AZT and NVP. ARVs should be initiated to the infant as soon as possible after birth but within 72 hours of delivery.

Using safer obstetrical practices can reduce MTCT of HIV in labour and delivery.

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Module 3: Key Points (continued)

There are national recommendations for testing of women of unknown HIV status in early labour and soon after delivery.

Support for safer infant-feeding practices are a priority in the immediate postpartum period.

Establishing linkages for postpartum follow-up of mother and infant can improve uptake of treatment and support services and reduce HIV-related morbidity and mortality.