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A presentation made to the year five MBChB students of Makerere University College of Health Sciences on the 18th of September 2014.
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PMTCT of HIV and MTCT PlusNkeramahame Juvenal, MBChB (MUK)
Outline
• Definitions
• MTCT of HIV
• Burden of MTCT
• History of PMTCT of HIV
• Option B+
• EMTCT
Definitions
HIV infection - presence of HIV virus in blood without necessarily having symptoms or signs of disease
HIV disease - presence of signs and symptoms due to infection with HIV AIDS – clinical syndrome suggestive of advanced HIV infection MTCT – when the HIV virus is passed from the mother to her child during
pregnancy, birth or breastfeeding PMTCT – the package of services given to women to prevent acquisition of
HIV and/or reduce risk of MTCT PMTCT Plus – provision of ART and support to HIV infected mothers, their
babies and family members to ensure proper nurturing, care and protection of the child
eMTCT – Uganda’s strategy for virtual elimination of MTCT using option B+
MTCT of HIV
• About 30-35% of HIV-infected mothers with infect their babies if no intervention.
• Peripartum HIV transmission can be reduced to under 5% in resource limited settings using a feasible ART regimen
• B/F causes about 1/3 – ½ all infant HIV infections and reducing postnatal transmission through B/F, whilst maintaining child survival, is an urgent priority.
• Evidence highlights the impact of breastfeeding duration & pattern, and hazards associated with the avoidance of breastfeeding in different settings
• About 90% of HIV-infected children in SSA acquire HIV through MTCT
MTCT
MTCT can occur
• during pregnancy
• during delivery or
• through breastfeeding
Rates of MTCT….Decock et al., JAMA, 2000,283:1175-1182
Time of transmission Absolute transmission rate (%)
During pregnancy 5-10
During labour and delivery 10-20
During breast feeding 5-20
Overall without b/feeding 15-30
Overall with b/feeding through 6 months 25-35
Overall with b/feeding through 18 -24 months 30-45
Burden of MTCT
• Annually about 25,000 to 40,000 babies get HIV infection in Uganda.
• 0.6% U5s are infected with HIV
• Over 90% of HIV infected children acquire it from MTCT
• In Uganda, 66% of the HIV infected children do not survive to celebrate their 3rd birthday with no intervention
Risk factors for MTCT
Source: WHO, CDC Prevention of Mother to Child Transmissionof HIV Generic Training Package, July 2008
Maternal and neonatal factors that may increase the risk of HIV transmission
Pregnancy Labour and delivery Breastfeeding
High maternal viral load (new infection or advanced AIDS)
Viral, bacterial, or parasitic placental infections, such as Malaria
Sexually transmitted infections (STIs)
Low CD4+ count Virulent HIV strain
High maternal viral load Prolonged rupture of
membranes for >4 hours Prolonged labour Vaginal delivery Assisted vaginal delivery Invasive delivery procedures
(e.g. episiotomy, artificial rupture of membranes)
Chorioamnionitis (fromuntreated STI or otherinfection)
Preterm delivery Low birth weight
High maternal viral load Long duration of breastfeeding Mixed feeding (giving water,
other liquids, or solid foods in addition to breastfeeding)
Breast abscesses, nipplefissures, mastitis
Oral disease in the baby (e.g. thrush or sores)
History of PMTCT
PMTCT is a dynamic and rapidly changing field.
2010 WHO Guidelines
Option A
Treatment or prophylaxis dependent on CD4 count
CD4 ≤350 or WHO stage 3 or 4 regardless of CD4 count:
Life-long ART
CD4 >350, and WHO stages 1 and 2:
Antenatal and intrapartum prophylaxis (AZT, sdNVP, TDF/FTC)
Extended infant NVP syrup for BF infants
Option B
All HIV infected pregnant women initiated on
ART regardless of CD4 count
CD4 ≤350, or WHO stage 3 or 4
life-long ART
CD4 ≤350, or WHO stage 3 or 4
life-long ART
CD4 >350 and WHO stages 1 and 2, stop
ART after delivery if FF, or after cessation
of BF if BF
2012 WHO ProgrammaticUpdateOption B+
Life-long ART for all HIV infected
pregnant women regardless of CD4 count
Advantages of Option B+
Simplification of PMTCT regimen requirements
No need for CD4 count to determine eligibility
Extended protection from MTCT in future pregnancies from conception
Strong & continuing prevention benefit against sexual transmission in serodiscordant couples/partners
Improved benefit for the woman’s health in between pregnancies
Simple community message; start ARVs, continue for life
Interventions in PMTCT
HIV testing and counselling during ANC, labour and delivery and postpartum
Provision of antiretroviral (ARV) drugs to mother and infant
Modified safer obstetric practices e.g elective c/section
Infant feeding information, counselling and support
Modified infant feeding practices
Referrals to comprehensive treatment, care and social support for mothers and families with HIV infection
Specific interventions
WHO Clinical staging of HIV disease.
Initiate ART treatment as soon as possible during pregnancy labour/delivery and through BF and for the entire life of the women
Special ART adherence counseling for treatment as prevention
Special support and follow up of discordant couples
Linkage to ART center for lifelong chronic care using referral system
Infant feeding counseling and support based on knowledge of HIV status
Maternal nutrition including assessment, counseling and support
Specific interventions
Co-trimoxazole prophylaxis
Malaria prevention and treatment
Additional counseling and provision of family planning services
TB screening and treatment
Counsel on other prevention interventions, such as safe drinking water
Supportive care, including, psycho social support, adherence support, and palliative care including pain and symptom management
Provide outreach services for clients and family members unable to come back for routine follow up.
De-worming
Counseling and referral for women with history of harmful alcohol or drug use
Effectiveness of PMTCT
ARV prophylaxis in labour alone reduces MTCT in B/F popn by 41-47% after SVD
If ARV prophylaxis is started in the last month of preg, reduction is by up to 63%
Current recommendations of ART started early can reduce MTCT to <2%
Breastfeeding a major source of MTCT can be addressed by use of ART during B/F
Comprehensive Approach Of PMTCT
1. Primary prevention
• ABC-mutual faithfulness
• access to condoms
• HCT
• Prevention and early treatment of STIs
• Counselling for HIV negative men and women
• Male circumcision
• Prevention of blood-to-blood transmission
Comprehensive approach to PMTCT….
2. Prevention of unintended pregnancies among women who are HIV-infected
• Address FP and contraceptive needs of the woman
3. Prevention of HIV transmission from women infected with HIV to their Infants
• HCT
• ART to mother and infant
• Modified obstetric practices
• Modified infant feeding practices
• Infant feeding information, counselling and support
• Referrals to comprehensive treatment, care and social support for mothers and families affected
Comprehensive approach to PMTCT….
4. Provision of treatment, care and support to women infected with HIV, their infants and their families
To promote long-term care of women who are HIV-infected and their families
Care and treatment with ARV therapy for the long-term health of women and families.
Symptom management
Prevention and treatment of HIV-related conditions
Reproductive health care, including family planning and contraception counselling
Nutritional support
Psychosocial and community support
Palliative care, if indicate
Barriers to universal access to PMTCT Weak healthcare systems, including inadequate antenatal care (ANC)
Limited access to pre-test counselling, either because systems are not in place or providers are not routinely offering testing
Lack of effective coordination to oversee implementation
Inadequate community engagement
Stigma and discrimination
Lack of awareness that HIV can be passed from mother-to-child
Inadequate access to ARV therapy or prophylaxis
“Universal Access” is the idea that everyone has a right to the prevention, care, support and treatment related to HIV and AIDS.
REFERENCES
Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice, De Cock et al, JAMA 283(9), March 2000
World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a
public health approach, 2010 version
World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:recommendations for a public health approach, June 2013.
World Health Organization. Prevention of Mother-to-Child Transmission of HIV: Generic Training Package, January 2008
World Health Organization. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Programmatic update, 2012
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