prevention of mother to child transmission new guidelines kenya

1. PMTCT
PRESENTER:
KISIANGANI ISAAC
MORACHA KEVIN
MODERATOR:
PROF NYANDIKO

2. INTRODUCTION
• Mother-to-child transmission (MTCT) of HIV,
also called perinatal or vertical transmission,
occurs when HIV is spread from an HIV+
woman to her baby during pregnancy, labor
and delivery or breastfeeding.

3. • Overall incidence without intervention is 15 to 45%
distributed over:
– Antenatal period
– The labor and delivery period
– Breastfeeding
• Around 15-30% of babies born to HIV positive women will
become infected with HIV during pregnancy and delivery.
• A further 5-20% will become infected through
breastfeeding.
• This rate can be reduced to levels below 5% with effective
interventions.

4. INTRODUCTION
• The global community has committed itself to
accelerate progress for the prevention of
mother-to-child HIV transmission (PMTCT)
through an initiative with the goal to eliminate
new pediatric HIV infections by 2015 and
improve maternal, newborn and child survival
and health in the context of HIV.

5. INTRODUCTION
• In order to reduce MTCT, all pregnant women
should have access to:
– free or low-cost prenatal care
– voluntary HIV testing and counseling.
– If a pregnant woman is HIV+, access to ARV treatment
both to treat HIV and improve her own health, and to
decrease the chances of HIV infection in her infant.
• Treatment options for preventing MTCT include
giving antiretroviral drugs to the mother after the
first trimester of pregnancy and during labor, and
to her infant for the first 12 wks of life

6. EPIDEMIOLOGY
• The World Health Organization (WHO) estimated
that >35.3 million persons worldwide were living
with HIV infection at the end of 2012, including
3.3 million children <15 years of age.
• More than 95% of HIV+ women in the world live
in developing countries and most HIV+ children
are born in developing countries.
• In 2012, almost 2.3 million people acquired HIV
260,000 were <15 years and 1.6 million died,
including 210,000 children.

7. • Kenya National AIDS/STI Control Programme
(NASCOP) estimates that there were 1.55
million babies born in 2011 in Kenya and that
as many as 6.3% of pregnant women in Kenya
were living with HIV/ AIDS.
• In Kenya, an estimated 37,000 to 42,000
infants are infected with HIV annually due to
mother-to-child transmission.

8. • Overall, 0.9% of children aged 18 months to
14 years were infected with HIV. This
corresponds to an estimated 104,000 children
infected with HIV nationwide.
• Note that this estimate does not include
children younger than 18 months of age and
children in North Eastern region. (KAIS 2012)

9. Risks of MTCT
Factors affecting risk of MTCT are:
• Maternal- Obstetric, Post partum B/Feeding
• Fetal and infant.

10. Maternal factors
• Advanced Disease
• Low CD4
• High plasma viral load
• During acute HIV infection – early disease
• During end stage disease
• AIDS diagnosis/advanced HIV disease
• High viral load genital secretions
• Vitamin A deficiency
• Malaria
• Behavioral factors; multiple sex partners
• Anemia, sexually transmitted diseases,
chorioamnionitis

11. Obstetric factors
• PROM >4 hrs, risk increases by the hour (4%)
• Episiotomy
• Instrumental delivery; forces, vacuum
• Invasive fetal monitoring
• external cephalic version
• Cord Milking/Delayed clumping
• Prolonged labor
• Transmission during labor and delivery occurs
when the infant sucks or aspirates cervical
secretions that contain HIV, or when there are
other mucous membrane exposure.

12. Fetal/infant factors
• Prematurity <37 weeks
• Lesions on skin and mucous membranes
• Trauma in birth canal
• Oral disease in the infant: oral ulcers or thrush

13. Postpartum Breastfeeding
Risk in postpartum breastfeeding influenced by:-
• Pattern; mixed increases risk
• Breast disease; cracked nipples, mastitis,
breast engorgement, breast abscess
• Longer duration of exposure or prolonged
breastfeeding

14. PILLARS OF PMTCT
• Preventing HIV infection among prospective
parents
• Avoiding unwanted pregnancies among HIV
positive women
• Preventing the transmission of HIV from HIV
positive mothers to their infants during
pregnancy, labor, delivery and breastfeeding.
• Care and support of women, children and
families infected and affected by HIV and AIDS

15. Primary prevention
• Abstinence
• Being faithful to one uninfected person
• Right condom use
• HIV testing and counselling;
– provider initiated
– patient initiated
• Pre exposure prophylaxis
• Post exposure prophylaxis
• Careful use and disposal of sharp objects
• Screening of blood before transfusion

16. Family planning
o Emergency contraception.
o Barrier methods: Female and male condoms
provide protection against STIs and reduce
the risk of HIV transmission
o Lactational Amenorrhoea Method (LAM)
o Hormonal contraception
o Intra-uterine contraceptive devices (IUCDs)
o Surgical methods
o Fertility Awareness Based methods : use of
Standard Days Method or Calendar method
should have regular menstrual cycles.

17. MTCT interventions
ANTENATAL
o Group education: Include information on four ANC visits, breastfeeding,
personal hygiene, birth preparedness, danger signs, prevention of
complications, skilled birth attendance, family planning, immunization
schedule, post-natal care and HIV and AIDS management.
• Client history: Obtain routine data including medical, obstetric, and
psychosocial history. Determine drug history, known allergies. Physical
examination: Include vital signs, inspection, auscultation and palpation,
breast Examination
• Abdominal and genital examination: Include inspection, palpation, fetal
auscultation, speculum and bimanual examinations, where indicated, STI
screening, cervical cancer screening(VIA)ANC Profile: Routine tests for
syphilis, Hb, blood group and Rhesus factor, urinalysis

18. RECOMMENDATIONS
Testing and counseling for PG and B/F women:
• All to be tested and counseled during their 1st ANC
visit. Repeat after 3mo for those who test –ve
• All B/Fng women who tested –ve during ANC or status
unknown should also test.
• All PG and B/Fng women who opt-out or decline
testing during 1st clinic visit should be offered
counseling and testing in subsequent visit(s)
• Offer testing and counseling to all spouses/ sexual
partners of HIV infected PG and B/Fng women.

19. RECOMMENDATIONS
HIV testing and counseling of infants and
children <18mo:
• HIV exposure status of all infants should be
established at the 6-week immunization visit
or at 1st contact thereafter ,using maternal
medical information.
• Conduct HIV Ab testing for mother or children
<18mo age of unknown status to establish
their HIV exposure status.

20. • All HIV –exposed infants should be offered
routine DNA PCR testing at the 6-week
immunization visit, or at the earliest
opportunity for infants seen after 6 weeks age
•Infants with an initial positive HIV DNA PCR
results should be presumed to be HIV infected
and started on ART in line with national
guidelines.

21. Testing and counseling of children >18mo:
• Conduct testing and counseling for all children
presenting to the health facility irrespective of
reason for their visit to the facility.
• Testing and counseling for all children of HIV
infected adults ASAP, within 1mo of
confirming the HIV + status of adult.

22. Disclosure of status to HIV = children and
adolescents:
• Health Service Providers should support and
advise caregivers to initiate disclosure of HIV
status to the HIV infected child preferably
from age of 6 Years
• Full Disclosure should occur when the child is
developmentally ready ideally by 10 years
(Before adolescence)

23. ARV in pregnancy
• All HIV-infected pregnant women should be counseled
on comprehensive HIV care including use of ARVs for
their own health and for PMTCT.
• All HIV-infected pregnant women should have their HIV
disease staged
• All HIV-infected pregnant women should have baseline
laboratory and other necessary diagnostic evaluations
• OI prophylaxis & micronutrient supplementation

24. • ARV are used for:
– Treatment: All HIV-infected pregnant women
should start ART as soon as possible. HIV-infected
pregnant women already on ART before becoming
pregnant should continue ART.
– Prophylaxis:
• Option A
• Option B
• Option B+

25. • A once-daily fixed-dose combination of TDF +
3TC (or FTC) + EFV is recommended as first-line
ART in pregnant and breastfeeding
women, including pregnant women in the first
trimester of pregnancy and women of
childbearing age.
• The recommendation applies both to lifelong
treatment and to ART initiated for PMTCT and
then stopped

26. INTRAPARTUM:
• Minimize vaginal examinations.
• Use aseptic techniques in conducting delivery.
• Avoid routine artificial rupture of membranes
(ARM).
• Avoid prolonged labor by use of a partograph.
• Avoid unnecessary trauma during delivery.
• Minimize the risk of postpartum hemorrhage.
• Use safe blood transfusion practices.

27. i) No ARVs taken in pregnancy?
Mother in early labor (up to 1 hour before delivery)
• Mother: Intrapartum period; Give mother NVP
at onset of labor
• Postpartum: Start on TDF+3TC+EFV
Infant:
• Breastfeeding infant :Daily NVP 2mg/kg from
birth until 1 week after all exposure to breast
milk has ended
• Non-breastfeeding infant : NVP for 12 weeks

28. ii) Mother received HAART in Pregnancy
• Continue the HAART regimen through
labor and delivery and post partum
period
• Give infant Nevirapine syrup as above
• Link the mother baby pair to chronic HIV
care in the post partum period

29. Mode of delivery:
• Elective caesarean section (CS) reduces the
risk of HIV MTCT as compared to vaginal
delivery if the viral load is >1000 copies per
ml, but may not be available in many settings.

30. • IMMEDIATE POSTPARTUM
• Support infant feeding options. For all HIV negative women, women
of unknown HIV status and HIV positive mothers opting for
exclusive breastfeeding, initiate breastfeeding within half hour of
birth.
• Identification of complications in mother and newborn - manage
and/or refer appropriately
• Routine postpartum care: blood pressure measurement; breast
examination; examination of the uterus, the perineum and lochia.
Ensure regular passage of urine and proper hygiene to prevent
infection; checking for signs of anemia, fever and tachycardia and
Vitamin A supplementation

31. • All babies should receive their routine immunization
(OPV and BCG) in their first hours of life
• Support exclusive breastfeeding (with cover of ARVs)
until six months unless the mother has been counseled
on replacement feeding and meets the AFASS criteria.
• Initiate/continue Cotrimoxazole for all HIV positive
women
• For the newly diagnosed, perform WHO Staging, CD4
Count and treat/refer for ART appropriately.
• For mothers on ART/HAART; continue with treatment

32. MTCT interventions
LATE POSTPARTUM
• Breast care in breastfeeding mothers
• Encourage daily cleaning of the breasts and avoiding the application
of lotions.
• Treat maternal vaginal candidiasis and infant oral candidiasis.
• Educate mother on optimal breast feeding technique including
exclusive breastfeeding.
• Educate the mother on breast care to prevent complications
(cracking and engorgement).
• Express and heat treat the milk if breast has mastitis or abscess.

33. • Breast care in non breastfeeding mothers
• Should wear a good supporting brassiere day and night.
• Give analgesics for pain.
• Initiate contraception within 4 weeks of delivery
• Lochia:
• Put emphasis on good perineal hygiene and proper handling
of body fluids.
• Avoid contaminating the baby with body fluids or with
bedding soiled with lochia.
• Sharing of beds by mothers in the hospital should be
discouraged.
• Caesarean Section
• Broad spectrum antibiotics should be used routinely after CS.

34. • Essential maternal education and follow-up
• Monitor for breast and pelvic infection at all post natal clinic visits.
• Educate on prompt health seeking behavior.
• Health education on hygiene, lochia and breast care.
• contraception
• Care, support and treatment for HIV positive mother and child:
– Counselling.
– OI prophylaxis and treatment.
– Link to support groups and assessment of the need for ART.
– Early infant diagnosis (EID) should be provided at six weeks and
thereafter

35. ARV prophylaxis for HIV exposed
infants
1. Mother Dx with HIV during pregnancy at any
gestation, labor , delivery and immediate
post-partum irrespective of feeding option?
– Immediately initiate NVP prophylaxis for 12wks.
– Do HIV PCR test
– Initiate Rx if infant is infected

36. 2. Infant identified as HIV exposed after birth
(through infant or maternal HIV antibody
testing) and is breastfeeding?
– Initiate NVP prophylaxis
– Do HIV PCR test
– If +ve initiate ART and stop NVP prophylaxis
– If –ve CT NVP up to 12 weeks

37. 3. Infant identified as HIV exposed after birth
(through infant or maternal HIV antibody
testing) and is not breastfeeding/ on
replacement feeding?
– Do HIV PCR test
– -ve? No drug for prophylaxis
– +ve? Initiate ART

38. 4. Mother receiving ART but interrupts ART
regimen while breastfeeding (such as toxicity
stock-outs or refusal to continue)?
– Initiate NVP until 12wks after maternal ART is
restarted or until 1wk after B/Fng has ended if
mother does not restart ART
– Do HIV PCR test to infant

39. INFANT FEEDING IN HIV
a) Exclusive breast feeding for 6mths -is advisable,
unless replacement feeding is AFASS for them and
their infants before that time.
b) Exclusive replacement Feeding -should be AFASS
C) Complementary foods- If the conditions for
replacement feeding are still not met for 6 mo then,
ct b/f with additional complementary feeding 1st
12mo

40. Care and follow up of children of HIV-infected
mothers
• All HIV exposed infants should be seen in the health
care facility within two weeks of delivery.
• For all HIV exposed infants, monthly follow up visits are
recommended beginning at six weeks through 2 years.
• Where possible, visits should be linked to the
immunization and growth monitoring visits.
• All HIV exposed infants should be started on co-trimoxazole
prophylaxis from 6 weeks of age.

41. REFERENCES
• Rapid advice guidelines June 2014
• Summary of new recommendations 2013.
• http://nascop.or.ke/prevention_of_mother_to
_child.php