Prevention of

Parent-to-Child Transmission

(PPTCT)

PPTCT Overview

Session Objectives

By the end of the session, the participants will be able to discuss:

• Describe NACO’s four-pronged strategy for PPTCT

• Understand the factors that influence PTCT

• Understand interventions to reduce PTCT

• Discuss measures to overcome PPTCT issues in a resource-restricted setting

PPTCT Overview 2

Routes of Transmission of HIV

NACO Annual Report 2009-2010

3PPTCT Overview

HIV and Women in India

PPTCT Overview

Indicator Number

Number of women who are HIV infected in India and % of total

0.9 million (38%)

Number of annual pregnancies in India 27 million

Estimated number of HIV positive pregnancies (2009)

43,000

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• Primary prevention of HIV among women of childbearing age

• Preventing unintended pregnancies among women living with HIV

• Preventing HIV transmission from a woman living with HIV to her infant

• Providing appropriate treatment, care and support to women living with HIV and their children and families

PPTCT Overview PPTCT Overview

NACO’s 4-Pronged PPTCT Strategy

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Risk of HIV TransmissionTransmission

Rate

During pregnancy 5-10%

During labour and delivery 10-15%

During breastfeeding 5-20%

Overall without breastfeeding 15-25%

Overall with breastfeeding to six months 20-35%

Overall with breastfeeding to 18-24 months 30-45%

Source: WHO

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Estimated Risk and Timing of PTCT in the Absence of Interventions

• What are the factors that influence mother-to-child transmission risk ?

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Risk of HIV Transmission

• High viral load

• HIV subtype

• Resistant strains

• Advanced clinical stage

• Concurrent STI

• Recent infection• Viral, bacterial and parasitic (esp. malaria) placental

infection

• MalnourishmentPPTCT Overview 8

Maternal Risk Factors Influencing PTCT

• Uterine manipulation (amnio, external cephalic version)

• Prolonged rupture of the membranes (>4 hours)

• Placental Disruption (abruption, chorioamnionitis)

• Intrapartum haemorrhage

• Invasive foetal monitoring (scalp electrode/scalp blood sampling)

• Invasive delivery techniques: episiotomies, forceps, use of metal cups for vacuum deliveries

• Vaginal delivery vs. caesarean sectionPPTCT Overview 9

Obstetrical Risk Factors Influencing PTCT

• Immature Immune System

– Preterm baby

• Low birth weight (<2.5kg)

• First infant of multiple birth

• Altered skin integrity

• Immature GI tract

• Genetic susceptibility

– HLA genotype

– CCR5 karyotype deletion

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Infant Risk Factors Influencing PTCT

• Mother is infected with HIV while breastfeeding

• Breast pathologies (cracked nipples, mastitis, or engorgement)

• Advanced HIV disease in the mother

• Poor maternal nutrition

• Mouth sores or an inflamed GI tract in baby

• Mixed feeding: Breast milk along with other foods

• Prolonged breast feeding (6-18 months)

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Infant Feeding Risk Factors Influencing PTCT

Interventions During Pregnancy

• Primary prevention of HIV in childbearing women

• Provide HIV information to ALL pregnant women

• Antenatal visits are opportunity for PPTCT

• Prevention of unwanted pregnancy in HIV-positive women

• Prevention of PTCT through ART (to mother and baby)

• Safe obstetric practices

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PPTCT Overview

Interventions During Labour and Delivery

1. Minimise vaginal examinations 2. Avoid prolonged labour

– Consider using oxytocin to shorten labour when appropriate

3. Avoid premature rupture of membranes – Use partogram to measure labour– Avoid artificial rupture of membranes (unless necessary)

4. Avoid unnecessary trauma during delivery– Use non-invasive foetal monitoring– Avoid invasive procedures, such as using scalp electrodes or

scalp sampling– Avoid routine episiotomy– Minimise the use of forceps or vacuum extractors– Uterine manipulation - amnio, external cephalic version (ECV)

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• Do not use suction unless absolutely necessary – If suction is a must, use either mechanical suction at

<100 mm Hg pressure or bulb suction, rather than mouth-operated suction

• Clamp cord after it stops pulsating and after giving the mother oxytocin

• For all infants: – When head is delivered wipe infant’s face with gauze

or cloth

– After infant is completely delivered, thoroughly wipe dry with a towel and transfer to the mother

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Interventions During Labour and Delivery

• Caesarean section performed before the onset of labour or membrane rupture has been associated with reduced HIV Transmission from Mother to Child

• The risk of elective Caesarean for PMTCT should be assessed carefully in the context of factors such as:– Risk of post-operative complications

– Safety of the blood supply

– Cost

• In India, normal vaginal delivery is recommended unless the woman has obstetric reasons (like foetal distress, obstructed labour, etc) for a C-section

• Use of ART can reduce risk of PTCT better and with less risk than a C-section

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Considerations Regarding Mode of Delivery

• Observe for signs and symptoms of HIV infection

• All HIV exposed infants should receive cotrimoxazole at 4-6 weeks of age

• Follow standard immunisation schedule

• Routine well baby visits

• DNA PCR

• 18-month visit for HIV testing

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Interventions During Infancy

• Exclusive breastfeeding

• Support good breast health and hygiene

• Replacement feeding – if Affordable, Feasible, Acceptable, Sustainable and Safe (AFASS)

• Avoiding addition of supplements or mixed feeding which enhance HIV transmission

Discussions with mothers about the above mustconsider personal, familial and cultural concerns

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Interventions for Safer Infant Feeding

Outcome of various Feeding options

PPTCT Overview BMJ, 2001, 322:3; bmj.com

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PPTCT Overview

Anti Retroviral prophylaxis and therapy

• ARV prophylaxis: Short-term use of antiretroviral

drugs to reduce HIV transmission from mother-to-

infant

• ARV therapy: Long-term use of antiretroviral drugs to

treat maternal HIV and for PPTCT• ARVs during pregnancy decrease the HIV viral

load in the mother’s blood, thus lowering the

chance of her infant to get exposed to the virus

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Intervention Risk of Mother-to-Child HIV Transmission

No ARV, breastfeeding 30-45%

No ARV, No breastfeeding 20-25%

Short course with 1 ARV, breastfeeding

15-25%

Short course with 1 ARV, No breastfeeding

5-15%

Short course with 2 ARVs, no breastfeeding

5%

3 ARVs (ART), no breastfeeding 1%

2 ARVs, breastfeeding unknown

3 ARVs (ART), breastfeeding unknown

Source: WHOPPTCT Overview 20

ARV Interventions

Antiretroviral Prophylaxis: Monotherapy

• Nevirapine (NACO Guidelines)

– Mother - Single dose NVP 200mg onset of labour

– Baby - Syrup NVP 2mg/kg within 72 hours of delivery

• Revised NACO Guidelines will be in place shortly

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• Administer ARV therapy or ARV prophylaxis during labour according to national guidelines to reduce maternal viral load and provide protection to the infant

• Avoid repeat dosing of single-dose NEVIRAPINE (e.g., in the case of false labour), as this can cause viral resistance

– Ensure that a woman is in true labour before administering a single-dose of NVP

– Document NVP administration clearly on a patient’s partogramme or medical record to avoid accidental repeat dosing

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ARV prophylaxis during Labour & Delivery for HIV-infected Women

What are the challenges of using single

dose Nevirapine for prophylaxis ?

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Discussion Question

WHO

Clinical StagingCD4 (cells/cu.mm)

I and II Start ART at CD4 Count <350

III and IV Start ART irrespective of CD4 Count

Strict Monitoring of Adverse effects of Nevirapine is needed if CD4 count is >250

PPTCT Overview

ART in PregnancyGuidelines for initiation of ART (2010)

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First line Regimens for Pregnant Women Eligible for ART

• AZT/3TC/NVP is the preferred regimen

• Stavudine to be given in the place of Zidovudine in those having low haemoglobin (<9G%)

• Women with contraindications to NVP (hepatotoxicity and rash) can be given EFV

• Avoid Efavirenz during First Trimester of Pregnancy (teratogenic in first trimester)

• Efavirenz to be used with caution and with “thorough” counselling of the risks to foetus

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Can we give NVP based ART

to a woman who has had

single dose-NVP for PPTCT?

PPTCT Overview

NACO ART guidelines 2007; CID 2008; 46: 622-4.

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Discussion question

NACO’s Key Principles (1)

• ART is only one component of PPTCT

• Selection of ART is based on:

• Effective regimen available for treatment of maternal disease

• Teratogenic potential of the drugs should pregnancy occur

• Provide ART to pregnant women based on national guidelines

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NACO’s Key Principles (2)

• Offer pregnant women the most efficacious PPTCT regimens

• Simple and effective regimens should be used in order to expand coverage and benefit more people

• Simple ARV with NVP should be considered as short term alternative until changes in national health system takes place

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Case Study 1

25 year-old patient, primigravida at 20 weeks gestation:

– Diagnosed as HIV-positive at the antenatal outpatient department

– ART facilities available

1. What ARV regimen is appropriate for this patient?

2. What other services will this patient need?

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Case Study 2

An unregistered primagravida patient:

– Admitted with labour pains for 2 hours

– Rapid test for HIV is positive

1. What ARV regimen is appropriate for this patient?

2. What other services will this patient need?

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Case Study 3

A pregnant woman, in the first trimester, comes with CD4 cell count of 176

1. Does this woman need ART?

2. How will you manage this pregnant woman?

3. If the woman is also suffering from pulmonary TB, how will you manage?

31PPTCT Overview

Challenges to Implementing Interventions to Prevent PTCT

• A significant proportion of deliveries continue to be unsupervised Home deliveries in many states

• Many of the hospital deliveries still remain uncovered by PPTCT for different reasons

• Most of the private institutional deliveries are not covered by PPTCT

• Gaps in initiating early ART for the eligible HIV positive pregnant mothers

• Infant feeding practices / options for HIV exposed infants: varied perceptions, opinions and advices

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Key Points• PTCT risk is affected by four factors:

– Maternal

– Obstetrical

– Infant

– Infant feeding

• Appropriate interventions and ART can reduce PTCT risk

• ARV prophylaxis, safer obstetric and infant feeding practices are effective interventions to reduce PTCT

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