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8/3/2019 2 PMTCT-Slides Jan 2011
http://slidepdf.com/reader/full/2-pmtct-slides-jan-2011 1/22
WHO 2010 guidelines and
country level guidelines onantiretroviral drugs for
treatment pregnant women and
preventing HIV infection ininfants
8/3/2019 2 PMTCT-Slides Jan 2011
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Acknowledgments
EGPAF acknowledges the World Health
Organization for sharing these slides, which
have been adapted for use by (Facilitator
please add the name of the person whoadapted these slides).
All guidelines available at:
http://www.who.int/hiv/en/
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Contents
These slides include:
1. An overview of the WHO revision process
2. The revised WHO guidelines on ARVs for PMTCT.
3. Country-specific guidelines on ARVs for
PMTCT.4. General discussion points,
implementation challenges, and a quiz to
test your knowledge.
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WHO REVISION PROCESS
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Prioritise Problems, establish panel, questions
Systematic Reviews
Evidence Profiles
Relative importance of outcomes
Overall quality of evidence
Benefit ± downside evaluation
Strength of recommendation
Implementation and evaluation of guidelines
Guideline development process
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Preparation
~ one year of activities«
Systematic reviews
Evidence profiles
Feasibility assessment
Costing projections
PLHIV consultations Drug safety profiles
Peer consultations
Use of the GRADEmethod (seewww.gradeworkinggroup.o
rg/)
2010 update
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PMTCT Study Results and GuidelinesRevisions
USA & Europe
Thailand
Africa
1998
Bangkok
AP/IP AZT
1998
Abidjan
AP/IP AZT
1999
HIVNET 012
Sd-NVP
2002
DITRAME+1
AZT+NVP
2003
DITRAME+1.1
AZT/3TC+NVP
2004
PHPT-2
AZT+NVP
1994
ACTG 076
1999
PETRA
AZT
/3TC
2009
Mma Bana
AZT/3TC/LPV-r
AZT/3TC/ABC
2009
Kesho Bora
AZT+3TC+sd-NVP
2009
PEPI-Malawi
6 wks NVP-infant
2000
PHPT
AZT
T r a n s m i s s i o n ( % )
0
5
10
15
20
25
30
35
WHO
recommendations
first issued
1st revision of
WHO
guidelines
2nd revision of
WHO
guidelines
2010 revision
2009
B AN
Maternal ARV
vs infant NVP 6
m
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REVISED WHOGUIDELINES
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Antiretrovirals in pregnancy
The PMTCT recommendations refer to two key
approaches:
Life-long ART for HIV-infected pregnant womenin need of treatment
Prophylaxis, or the short-term provision of
ARVs, to prevent HIV transmission from motherto child, for women who don·t require
treatment for their own health
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WHO Key recommendations
1. Earlier ART for a larger group of HIV+ pregnantwomen to benefit both the health of the motherand prevent HIV transmission to her child duringpregnancy
2. Longer provision of ARV prophylaxis for HIV+pregnant women who do not need ART for theirown health to reduce the risk of HIV transmissionfrom mother to child
3. Provision of ARVs to the mother or child toreduce the risk of HIV transmission during thebreastfeeding period
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Antiretroviral therapy (ART)
CD4 cell count available
CD4 < 350 cell/mm3 CD4 > 350 cell/mm3
ART
Regardless of
clinical stage
ART
If symptomatic
(stage 3 or 4)
WHO clinical stage
Stage 1 ARV prophylaxis
Stage 2 ARV prophylaxis
Stage 3 ART
Stage 4 ART
Start ART as soon as feasible regardless of gestational
age and continue for life long
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ART for mother & prophylaxis forexposed infants
Mother
Preferred
AZT + 3TC + NVP or
AZT + 3TC + EFV
Alternative TDF + 3TC (or FTC) + NVP or
TDF + 3TC (or FTC) + EFV
Exposed infants (mothers on ART)
All infants
NVP for 4-6 weeks or
AZT for 4-6 weeks
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13
Benef it and impact of ART in eligiblepregnant women
Pregnant women with CD4 < 350 cells/mm3:
About 40% of HIV+ pregnant women
Account for > 75% of MTCT risk
Account for >80% of postpartum transmission
Account for 85% of maternal deaths within 2years of delivery
Have strong benefit from initiating ART formaternal health and PMTCT during pregnancy,labour and delivery and breastfeeding
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ARV prophylaxis to preventMTCT
For w omen not eligible f or ART or
unknow n eligibility
Beginning as early as 14 weeks of
gestation (2nd trimester) or as soon as
possible thereafter
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ARV prophylaxis to give to non-eligible pregnant women
2 possible options:
A) Maternal AZT, or
B) Maternal triple ARV prophylaxis
And for the breastfeeding mother:
Provision of ARVs to the child OR the motherto reduce risk of HIV transmission during
breastfeeding (if breastfeeding is best infant
feeding option)
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Prophylaxis optionsOption A Option B
Mother
Antepartum AZT (from 14 weeks)
sd-NVP at onset of labour*
AZT + 3TC during labour & delivery*
AZT + 3TC for 7 days postpartum*
Mother
Triple ARV (from 14 wks until one wk
after all exposure to breast milk has ended)
AZT + 3TC + LPV-r
AZT + 3TC + ABC
AZT + 3TC + EFV
TDF + 3TC (or FTC) + EFV
Infant
Breastfeeding population
Daily NVP (from birth until one wk after
all exposure to breast milk had ended)
Non-breastfeeding population
Sd-NVP + daily AZT for 4-6 weeks
OR
Daily NVP for 4-6 weeks
Infant
All exposed infants
AZT for 4-6 weeks OR NVP for 4-6 weeks
*sd-NVP and AZT+3TC can be omitted if mother receives > 4 wks AZT antepartum
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Option A or Option B?
Both recommended options A and B providesignificant reduction of the MTCT risk
There are advantages and disadvantages of
both options, in terms of feasibility, acceptabilityand safety for mothers and infants, as well as
cost
The choice for a preferred option should bemade at a country level, after considering these
advantages and disadvantages
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REVISED COUNTRYGUIDELINES
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Steps on Guidelines Adaptation and Implementationat Country Level
Establishment of the National Advisory Committee
Evidence Assessment (considering the globalrecommendations)
Situational Assessment (coverage, populations, treatmenteligibility criteria, lab, delivery & procurement capacities,training needs)
Adaptation (feasibility & costing evaluations)
Decision Making & Prioritization
M&E plan
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Current Status of Guidelines Adaption/Option Choice andImplementation in {Insert your country name here}
Facilitator, please include country-specific
choice, guideline summary, and
modifications
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Discussion Question Guide
Do you feel the option chosen is appropriate for your country
context? Why or why not?
Discuss monitoring and evaluation of the revised PMTCT guidelines:
are there any modifications that should be made to existing forms,
registers, or data review processes?
Discuss possible barriers to implementation of the revised PMTCT guidelines and proposed solutions to these barriers.
Discuss existing community or facility-based efforts to increase
demand, access, and adherence to PMTCT, and how these might
be upscaled.
Discuss existing efforts to reach more HIV-exposed children with ARVs for PMTCT, in particular those mother-baby pairs missed by
PMTCT programs, and how these efforts might be upscaled.
Discuss how to integrate PMTCT services with other service
delivery points.
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Group Quiz Questions
Instructions: Please break into your small
groups and answer the following questions
together:
Facilitator please add questions as
appropriate.