CHAZ PMTCT Orientation (2) Revised

7/31/2019 CHAZ PMTCT Orientation (2) Revised

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Learning Objectives Describe the new 2010 Zambia PMTCT guidelines Describe the new ART options for the Prevention of

Mother to Child transmission (PMTCT) List the antiretroviral drugs that should be used in

pregnancy Describe recommendations for infant feeding for

HIV-positive and negative women Describe follow-up of HIV exposed infants

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Zambia Antenatal HIV Prevalence Currently the antenatal HIV prevalence among

pregnant women is 16.4%.

With 500,000 580,000 women delivering annually,approximately 80,000 infants born are at risk ofacquiring HIV from their mothers.

More than 90% of women attending ANC are tested

for HIV, while in the general adult population only23.4% are tested, showing that stigma is still highlyprevalent (Zambia Sexual Behaviour Survey, 2009)


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The plan to scale up PMTCT

services includes: MaintainingANC utilization above90 percent

Improving acceptance oftesting to 100 percent

Improving adherence to antiretroviral (ARV)therapy by HIV positive women to 90 percent,and

Increasing the proportion of women delivered byskilled health workers to 70 percent.


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Objectives of the next five year PMTCT Scale upplan Virtual Elimination of MTCT of HIV

To reduce the risk of transmission ofMTCT of HIVto less than 5 per cent by 2015.

To reduce the unmet need for family planning by

50 per cent from the current levels of 27 per centby 2015.

To provide antiretroviral therapyto at least 95

per cent ofHIV-positive children in need oftreatment by 2015.


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Zambia(Population 13.5 million)

Number of PLWHA: 1, 100, 000

Adults 15 49 yrs HIV prevalence rate: 14.3%

Children 0 - 14 yrs living with HIV: 80,000 - 120, 000(95,000, UNICEF 2007)

Antenatal HIV Prevalence 16.4%

Perinatally exposed infants per year: ~ 80,000 infants

Infants born with HIV per year(without PMTCT): ~ 28,000 infants


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Counseling and Testing Group Health Education

PITC / VCT

Family Centered Approach Couple Counseling


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ANC Care Clinical screening and examination: BP, urinalysis, and weight

measurement

Detection and effective treatment of STIs

Prevention, detection and treatment of anaemia (Hb, Systematic de-

worming, Ferrous Sulphate and Folic acid)

Multi-vitamin supplementation for the prevention of low birth weight

Counselling about infant feeding options

IPT with SP for malaria prophylaxis, from second trimester for HIVnegative pregnant women, every 4 weeks. Ensure every woman has atleast three doses before delivery. All pregnant mothers must use ITNs


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ANC cont. Cotrimoxazole prophylaxis: for all HIV positive women starting

in the second trimester

Fansidar and Cotrimoxazole are not given in the first trimesterbecause both drugs have anti-folate properties that will causefoetal malformations.

TB clinical screening in HIV infected mothers with historytaking, examination and sputum smear if indicated. If diagnosed

positive, refer for appropriate TB care.

Promoting and supporting couple counselling, partnerdisclosure and male involvement in ANC.


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WHOs 4-Prong Approach to PMTCT

September 2007 Edition 3 Module 8: ART in Special Populations 10

Uninfected

Parents to be

HIV infected

woman

Pregnant HIV

infected woman

HIV infected

infant

I. Primary preventionof HIV

II. Prevention of

unintended

pregnancy

III. Prevention of

MTCT

AIDS and

Death

IV. Linkage to Care

and Support


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Timing of MTCT

Labor/Delivery PostnatalAntenatal

5-10% 5-10%10-20%

Increases to 10-20% if

breastfeeding is prolonged

beyond 6 months


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Pregnant Women Treating pregnant women with ARV therapy to

prevent transmission of the virus to the foetus is apriority.

All pregnant women that are HIV positive shouldbe on HAART ifclinical (WHO) or CD4 criteriaare met.

If found ineligible for HAART she should beinitiated on short course therapy as outlined below

Short-term ARV therapy does not treat maternaldisease



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Orientation to New ART Protocols 2010 13

Criteria for PMTCT interventions

(Eligibility Criteria)

Provide HAART Provide Short Course ARVs

CD4 < 350 / mm3 > 350 / mm3

Clinical Criteria only

(CD4 not available) Stage 3 or 4 (any CD4a

) Stage 1 or 2

a If CD4 >350 then initiate ART with EFV plus 2 NRTIs


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rop y ax s ase on2010 guidelines (Option A)

Course Antenatal

Mother

Intrapartum

Mother

Postnatal

Mother

Postnatal

All exposed infants

From 14 weeks of

pregnancy

AZT 300mg BD starting

at 14 weeks or as soon as

possible thereafter until

delivery

Combivir 1 tablet every

12hours until delivery.

NVP 200mg single dose at

onset of labour

Combivir 1 tab

twice daily for

7 days

Breastfeeding infant:

i)NVP at birth and daily until one

week after all exposure to breast

milk

ii)Start co-trimoxazole from 6

weeks until a week after all

exposure to breast milk and HIV

infection is ruled out.Non-breastfeeding infant:

i)Commercial milk formula

ii)NVP at birth and for 6 weeks.

iii) Start co-trimoxazole until

PCR results are confirmed

negative .

For women

presenting in 3rd

trimester

AZT 300mg BD

until delivery

Continue Combivir stat dose

of 1 tablet at onset of labour

and 1 tablet every 12hours

until delivery.

NVP 200mg single dose at

onset of labour

Combivir1

tablet BD for 7

days

Breastfeeding infant:

i)NVP at birth and daily until one

week after all exposure to breast

milk

ii)Start Cotrimoxazole from 6

weeks until a week after all

exposure to breast milk has ended.

Non-breastfeeding infant:

i)Commercial milk formulaii)NVP at birth and for 6 weeks.

iii Start co-trimoxazole until


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ART prophylaxis 2010 cont.For womanwho has not

received

prophylaxis

antenatally

Combivir 1 tablet atonset of labour and 1

tablet every 12hours

until delivery.

NVP 200mg single

dose at onset of

labour

Combivir1 BDfor 7 days

Check eligibility

for HAART

Breastfeeding infant:i)NVP at birth and daily until one week

after all exposure to breast milk

ii)Start co-trimoxazole from 6 weeks until

a week after all exposure to breast milk has

ended.




iii) Start co-trimoxazole until PCR results

are known.

Mother

who is on

HAART or

eligible for

HAART

Continue HAART or

start HAART

Continue HAART Continue HAART Breastfeeding Infant:

i)NVP for 6 weeks,




iii) Start co-trimoxazole until PCR results

are known.


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Extended simplified infant NVP dosing

recommendationsInfant age NVP daily dosing

Birth - 6 weeks

Birth weight 2,000 - 2,499 gram

Birth weight >2,500 gram

10 mg once daily (1ml)

15 mg once daily (1.5mls)

>6 weeks to 6 months 20 mg once daily (2mls)

>6 to 9 months 30 mg once daily (3mls)

>9 months to end of BF 40 mg once daily (4mls)

Low birth weight infants should receiveweight-specific dosing, suggested starting

dose is 2 mg/kg once daily.

Therapeutic drug monitoring is

recommended. * Adapted from: Mirochnick

M. et. al. [2006].


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HAART in Pregnancy Preferred regimen isAZT, 3TC and NVP

Use EFV in women with CD4 above 350 andafter the 1st trimester

If NVP hypersensitivity occurs substitute NVPwith EFV

Alternative regimen TDF, FTC/3TC and NVP/EFVABC, FTC/3TC and NVP/EFV



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EFV in Pregnancy If gestational age greater than 14 weeks continue

with Efavirenz

If less than 14 weeks, Efavirenz has been associatedwith neural tube defects therefore consider CD4count; If CD4 250 consider triple nucleoside therapywith AZT/3TC/ABC (if unable to monitor ALT)



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TDF in Pregnancy 2010 guidelines recommend TDF based regimen as

alternative regimen to AZT based regimen



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Algorithm for Care of the HIV positive pregnant

Woman based on 2010 WHO Recommendations

fig 2.1, pg 13


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Infant feeding options



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Infant feeding Recommendations Breastfeeding is protected, promoted and supported. (See

annex IV on the 10 steps of breastfeeding)All mothersregardless of HIV status should exclusively breastfeed

up to 6 months and thereafter continuebreastfeeding up to at least 12 months, with timely,adequate and safe complementary feeding.

HIV positive mothers are encouraged to breastfeed for 12months with use ofextended daily NVP prophylaxis for

infants until one week after the end of breastfeeding. All breastfeeding HIV negative women are encouraged to

get an HIV test every 3 months until all exposure tobreastfeeding has ended.



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Care and Support to HIV+ Mothers, Children and their

families

Apply family centred approach to HIV testing, careand treatment

Promote adherence to extended NVP and co-trimoxazole prophylaxis.

Encourage and support couples counselling and maleinvolvement


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HIV testing for the infant All HIVexposed infants receiving extended NVP

prophylaxis should have a PCRat 6 weeks and at 6months.

An antibody test at 12 months and 18 months or aftercessation of breastfeeding.

If a health worker identifies a sick child or one who isfailing to thrive an HIV test must be done. ( ProviderInitiated Testing & Counselling - PITC)

A PCR test may be done, regardless of breastfeeding, if thechild presents with symptoms of HIV at less than 18

months of age.(see pg 25 of PMTCT guidelines)


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Nevirapine Prophylaxis If the mother is breastfeeding the infant must be given

NVP at birth and daily until one week after all exposure tobreast milk has ended.

If the mother is on HAART or not breastfeeding, the babymust be given NVP at birth and daily for 6 weeks.

Observe the infant for NVP sensitivity which may presentas a generalised skin rash.

If a baby is receiving extended NVP and tests HIV positiveby PCR, stop NVP prophylaxis and immediately refer

to paediatric ART clinic.


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Co-trimoxazole Administration in HIV Exposed

infants

weight Daily dose Child tablet(each tab = 100mgsulfamethoxazole,

and 20mgtrimethoprim)

(100mls) bottlesneeded per month


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Summary of recommendations for discontinuing

primary co-trimoxazole prophylaxisTarget population RecommendationsTarget population Recommendations

HIV Exposed children Discontinue co-trimoxazole afterHIV infection is excluded

Infants and children living with HIV Maintain on co-trimoxazole until theage of 5 years irrespective of clinicaland immune response (At 5 yearsfollow adult guidelines)


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Role of Community Healthcare Providers in PMTCT (1) Encourage pregnant women in their community to go for early

booking by 14 weeks Encourage women to deliver in facilities

Encouraging couple counselling and testing for HIV

Encourage and support disclosure

Perform group education, testing and counselling On-going psychosocial counselling

Reducing stigma and discrimination associated with HIV andAIDS.

Supporting adherence to treatment (ARVs and cotrimoxazole) Sensitization of community to the importance of HIV care


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Role of Community Healthcare

Providers in PMTCT (2) Promote Male involvement in PMTCT

In the event of a home delivery, ensure that the mother and newbornbaby are taken to the health facility for medical assessment, timelyadministration of ARVs and immunizations.

Support breastfeeding and extended NVP prophylaxis Promotion of retention of mother-baby pairs in the programme

Encourage and support women to come back for postnatal checkupsand services

Record keeping and data entry at both facility and community level

Referrals and linkages to appropriate community-based groups such asPLHIV, peer support groups, post-test clubs, legal services, churches,faith-based organisations, legal counsellors and organisations whichpromote Income Generating Activities (IGAs).


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Global Fund PMTCT Indicators

1. No of HIV- infected pregnant women receivedAntiretroviral drugs

2. No of HIV- infected pregnant women assessed foreligibility

3. No of infants born to HIV- infected women, who arebreast feeding and covered by an antiretroviral drug

4. No of infants receiving a virological test (DBS) within2 months

5. No of infants started on co-trimoxazole within 2months

6. No of pregnant women who know their HIV status


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CHAZ 2010 PMTCT

ACHIEVEMENTSIndicator 1 3,226 against 5,875 (55%)

Indicator 2 2,012 against 5,875 (34%)

Indicator 3 1,796 against 4,700 (38%)Indicator 4 1,739 against 4,700 (37%)




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Global Fund PMTCT Indicators -

IDEALY1. No of pregnant women who know their HIV status

2. No of HIV- infected pregnant women assessed foreligibility

3. No of HIV- infected pregnant women receivedAntiretroviral drugs

4. No of infants born to HIV- infected women, who are

breast feeding and covered by an antiretroviral drug5. of infants receiving a virological test (DBS) within 2

6. No of infants started on contrimoxazole within 2months


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CHAZ PMTCT Program Challenges

Mothers/babies lost to follow

CHIs not sending reports on timeData collected is not accurateSome indicators are new and CHIs

are not yet oriented.Delayed or non receipt of DBSresults


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Are we together?



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Thank You

Questions?????

Documents

CHAZ PMTCT Orientation (2) Revised