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Module 3
Specific Interventions to Prevent Mother-to-Child
Transmission of HIV (PMTCT)
Malawi PMTCT Training Package 2
Module 3 Objectives
Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.
Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT).
Describe strategies for reducing the risks of MTCT during labour and delivery.
Malawi PMTCT Training Package 3
Module 3 Objectives (continued)
Discuss the management of women during labour and delivery who are of unknown HIV status.
Describe immediate postpartum care of women with HIV infection.
Explain the need to integrate family planning into community services.
Describe guidelines for immediate newborn care.
Malawi PMTCT Training Package 4
Unit 1
Implementation of Comprehensive ANC Services
Malawi PMTCT Training Package 5
Unit 1 Objectives
Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.
Malawi PMTCT Training Package 6
PMTCT in Antenatal Care (ANC)
ANC improves the health and well-being of mothers and their families.
Integration of PMTCT services into essential ANC services can improve care and pregnancy outcomes for clients.
Antenatal interventions can reduce risk of MTCT
Malawi PMTCT Training Package 7
Quality RH in context of PMTCT
Comprehensive antenatal services Routine HIV testing and counselling ARV prophylaxis or, if eligible, therapy Safer infant feeding counselling and support
Quality intrapartum care Quality postpartum care that includes:
Safer infant feeding counselling and support Family planning services Follow up care for mother and baby
Malawi PMTCT Training Package 8
Integrated Essential Package for ANC Services
ANC for HIV-infected pregnant women includes basic services recommended for all pregnant women
Obstetric and medical care for HIV-infected women expanded to address their specific needs
Malawi PMTCT Training Package 9
Integrated Essential Package for ANC Services (continued)
Client history History of present
pregnancy Social history Physical exam and vital
signs Lab tests STI screening
HIV-related conditions o Tuberculosis o Malaria
Immunizations ARV prophylaxis and/or
therapy Nutritional assessment,
counselling, and support Health education Infant feeding
counselling
Malawi PMTCT Training Package 10
Support Needs of Women with HIV Infection
Pregnancy is a stressful time. Support will lead to hope and acceptance.
Referrals include: Food, nutritional counselling & supplementation Practical necessities Social and psychological support Home care & community-based health care Traditional/herbal healers Orphan care and support Care of children with HIV or AIDS
Malawi PMTCT Training Package 11
Prevention of HIV-Related Conditions
Reduce rates if illness, adverse pregnancy outcomes, and death among HIV-infected pregnant women
Women with HIV infection more susceptible to: TB Urinary tract infections Respiratory tract infections Recurrent vaginal candidiasis Malaria Breast conditions Unhealed episiotomies/caesarean section wounds Herpes zoster Puerperal sepsis
Malawi PMTCT Training Package 12
Maternal Nutrition & MTCT
Nutritional deficiencies can be associated with preterm delivery & increased risk of MTCT
Weight gain during pregnancy is an indicator of mother’s nutritional status
Women’s pre-pregnancy weight Recommended weight gain (kg) Normal 11.5- 18.0
Underweight 12.5-18.0 Overweight 7.0-11.5
Malawi PMTCT Training Package 13
Exercise 3.1
Antenatal Care:
Case Studies
Malawi PMTCT Training Package 14
Unit 2
Antiretroviral Prophylaxis and Therapy for PMTCT
Malawi PMTCT Training Package 15
Unit 2 Objective
Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT)
Malawi PMTCT Training Package 16
ARV Drugs in PMTCT
Antiretroviral (ARV) drugs hinder replication and mutation of HIV, resulting in less damage to immune system
ARV therapy or prophylaxis reduce risk of MTCT by reducing viral load in mother
ARV drugs can be used for prophylaxis or treatment
Malawi PMTCT Training Package 17
ARV Drugs in PMTCT (continued)
ARV Therapy: Long-term use of antiretroviral drugs to treat maternal HIV/AIDS to slow progression of disease. ARV therapy also reduces HIV transmission from mother to infant.
ARV Prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant. ARV prophylaxis does not treat maternal HIV or provide long-term protection for the infant.
Malawi PMTCT Training Package 18
Pregnancy & ARV Therapy
Women who are eligible for ARV therapy should be referred to the ARV Clinic.
ARV therapy: Should begin as soon as possible, but may be
delayed until after 1st trimester Women on ARV therapy require ongoing
care and monitoring in the ANC and ART clinics.
Malawi PMTCT Training Package 19
ARV Prophylaxis
ARV prophylaxis alone will not protect breastfeeding infants from risk of HIV infection
Single dose Nevirapine (sd-NVP) has been used since inception of programme. Mother: sd-NVP 200mg at onset of labour Infant: sd-NVP (6mg) within 72 hours of delivery
Prevent NVP resistance by avoiding multiple doses of NVP to the mother. If the maternal NVP dose is given during false labour, the dose should not be repeated.
Malawi PMTCT Training Package 20
ARV Prophylaxis
Combination regimens given during pregnancy are more effective but more difficult to administer where infrastructure/access is an issue
The HIV/AIDS Unit is phasing in the regimens at sites with infrastructure
Combination regimens include 2 or 3 of the following drugs: AZT NVP 3TC
The recommended regimens are listed in Appendix 3-C
Malawi PMTCT Training Package 21
Exercise 3.2
Nevirapine Prophylaxis for PMTCT: Case Studies
Malawi PMTCT Training Package 22
Unit 3
Optimal Management of Women During Labour and
Delivery
Malawi PMTCT Training Package 23
Unit 3 Objectives
Describe strategies for reducing the risks of MTCT during labour and delivery.
Discuss the management of women during labour and delivery who are of unknown HIV status.
Malawi PMTCT Training Package 24
PMTCT Interventions During Labour & Delivery
Administer ARVs as per guidelines Use Standard Precautions Minimize vaginal examinations Avoid prolonged labour Avoid routine artificial rupture of membranes Avoid unnecessary trauma and routine
episiotomy Minimize risk of postpartum haemorrhage Use safe transfusion practices
Malawi PMTCT Training Package 25
PMTCT Interventions During Labour & Delivery (continued)
Always use Standard Precautions during patient care:
Strict aseptic technique during first stage of labour Wash hands before & after every procedure Decontaminate bed, instruments, linens soon after use Autoclave or high-level disinfection of instruments
used for delivery Use six swab technique for vulval swabbing/vaginal
cleansing Use protective gear, safely dispose sharps &
contaminated materials
Malawi PMTCT Training Package 26
PMTCT Interventions During Labour & Delivery (continued)
Minimize vaginal examinations: Perform vaginal examinations only when
necessary Record all vaginal examinations on
partograph
Malawi PMTCT Training Package 27
PMTCT Interventions During Labour & Delivery (continued)
Avoid prolonged labour: Use partograph to monitor progress of labour Avoid artificial rupture of membranes If spontaneous rupture of membranes occurs
when not in labour, induce immediately Augment if in latent phase of labour Aim to deliver within 4 hours if in active phase
of labour Reinforce pain relief in labour
Malawi PMTCT Training Package 28
PMTCT Interventions During Labour & Delivery (continued)
Avoid unnecessary trauma during delivery: Avoid invasive procedures Avoid routine episiotomy Avoid unnecessary trauma to infant Minimize use of vacuum extractors Prevent genital tract/perineal lacerations Do not give enemas Do not shave vulva
Malawi PMTCT Training Package 29
PMTCT Interventions During Labour & Delivery (continued)
Minimize risk of postpartum haemorrhage: Carefully manage all stages of labour to prevent
infection & avoid prolonged labour Actively manage third stage of labour
Use safe transfusion practices: Minimize blood transfusions Use only blood screened for HIV, hepatitis B,
and syphilis
Malawi PMTCT Training Package 30
Exercise 3.3
Obstetric Practices and HIV: Group Discussion
Malawi PMTCT Training Package 31
Management of Women with Unknown HIV Status (continued)
If a woman presents in:
Early labour:
• Provide HIV information
• Test unless she refuses
• Give NVP to woman and infant if she tests HIV+
Late labour (active phase):
• Defer test until after delivery & before discharge
• If she test HIV+, give NVP to infant
Malawi PMTCT Training Package 32
Management of Women with Unknown HIV Status (continued)
Pre-test information checklist for use in labour and delivery
HIV is the virus that causes AIDS.
HIV can be transmitted from mother to infant
HIV testing can help determine HIV status and need for interventions.
A positive rapid HIV test result must be confirmed.
HIV testing is strongly recommended.
Medicines are available for PMTCT.
Care will be provided regardless of testing decision.
Post-test counselling following delivery, with referral for follow-up services, is required for all HIV-positive mothers and their infants.
Malawi PMTCT Training Package 33
Exercise 3.4
HIV Testing and ARV Prophylaxis during Labour and Delivery:
Case Studies
Malawi PMTCT Training Package 34
Unit 4
Postpartum Management of Women and Infants
Malawi PMTCT Training Package 35
Unit 4 Objectives
Describe immediate postpartum care of women with HIV infection.
Explain the need to integrate family planning into community services.
Describe guidelines for immediate newborn care.
Malawi PMTCT Training Package 36
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers
After Delivery Provide ARV prophylaxis to the infant
Before Discharge Assess Mother
Personal hygiene Nutritional status Signs and symptoms of anaemia and infections Signs of uterine involution Breast conditions
Malawi PMTCT Training Package 37
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)
Before Discharge Assess Mother (continued)
Urinary tract infections Episiotomies, caesarean section Signs of PID and any other infections Clinical features of HIV or AIDS Possible side effects of ARVs
Administer Vitamin A and iron supplement
Malawi PMTCT Training Package 38
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)
Before DischargeOffer education, counselling, and support for: Infant feeding, hygiene, re-hydration, umbilicus
care, illness Diet and nutrition Postpartum infection, including pelvic
inflammatory disease (PID) Anaemia Community resources Information on breast and urinary tract
infections
Malawi PMTCT Training Package 39
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)
Upon Discharge
Offer Education, Counselling, Support for: Follow-up care: both routine (one-week
and six-week visits, then monthly check ups) and as needed
Family planning information and services, including information on condom use for dual protection
Malawi PMTCT Training Package 40
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)
Upon DischargeLink patients to centers providing the following services: Postnatal review, dates for one-week and six-week
visits Sexual and reproductive health care, including family
planning Prevention and treatment of HIV-related conditions, inc
malaria Immunizations
Malawi PMTCT Training Package 41
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)
Upon Discharge (continued)
Link patients to centers providing the following services: Nutritional counselling and support “Under-five” services Support groups HIV treatment, care, and support Social and psychosocial support Home-based care
Malawi PMTCT Training Package 42
Family Planning
Family Planning (FP) is a core PMTCT intervention. FP services integrated into ANC and community
health services can minimize HIV/AIDS- related stigma.
FP services includes: Individual and couples counselling Continued risk assessment Early diagnosis and treatment of STIs and HIV/AIDS Information and skills needed to practise safer sex Access to contraceptives
Malawi PMTCT Training Package 43
Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn
Administer NVP prophylaxis as soon as possible but within 72 hours after birth
For home births, child and mother should be seen within 72 hours of delivery: Assessment Administration of NVP prophylaxis Support safer infant feeding.
Malawi PMTCT Training Package 44
Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn (continued)
Make assessments and implement preventive measures:
Infant feeding Administer ARVs within 72 hours PCR testing within 48 hours where available Immunization according to EPI schedule Side effects of ARV prophylaxis
Malawi PMTCT Training Package 45
Exercise 3.5
Supporting Postpartum
Follow-Up:
Group Discussion
Malawi PMTCT Training Package 46
Module 3: Key Points
The essential package of ANC services includes the basic services recommended for all pregnant women, including HIV testing. However, for women with HIV, obstetric and medical care should be expanded to address the specific needs of women infected with HIV.
Malawi PMTCT Training Package 47
Module 3: Key Points (continued)
Nutritional assessment, counselling and support are important not only in the antenatal period when good nutrition plays a role in foetal health and PMTCT, but also in the postpartum period, particularly for the breastfeeding mother and for the HIV-exposed or HIV-infected infant and young child.
Malawi PMTCT Training Package 48
Module 3: Key Points (continued)
ARV therapy is the long-term use of antiretroviral drugs to manage maternal HIV and prevent MTCT; ARV prophylaxis is the short-term use of antiretroviral drugs to reduce MTCT of HIV.
Malawi PMTCT Training Package 49
Module 3: Key Points (continued)
The HIV/AIDS Unit has phased in the more complex but efficacious WHO-recommended regimen (which include AZT, NVP and, in some instances, 3TC) at sites with adequate infrastructure and human capacity for its delivery. At the same time, expansion of PMTCT to sites with limited infrastructure will be done using single dose Nevirapine (sd-NVP) while steps are taken to build their capacity to deliver the recommended combination regimen.
Malawi PMTCT Training Package 50
Module 3: Key Points (continued)
The infant ARV prophylaxis regimen is either AZT alone, NVP alone or a combination of AZT and NVP. ARVs should be initiated to the infant as soon as possible after birth but within 72 hours of delivery.
Using safer obstetrical practices can reduce MTCT of HIV in labour and delivery.
Malawi PMTCT Training Package 51
Module 3: Key Points (continued)
There are national recommendations for testing of women of unknown HIV status in early labour and soon after delivery.
Support for safer infant-feeding practices are a priority in the immediate postpartum period.
Establishing linkages for postpartum follow-up of mother and infant can improve uptake of treatment and support services and reduce HIV-related morbidity and mortality.