Preventing Maternal to Child

Transmission of HIV

(PMTCT)

-- Dec 2010

HIV Services at Mae Tao Clinic

Objectives for this Training

Explain basic HIV/AIDS information.

Present information about HIV transmission and

prevention.

Describe benefits and risks of HIV screening for

pregnant women

Describe the stages of the PMTCT program

PMTCT Counseling Knowledge Quiz

List the Ways in Which HIV Infection Is Transmitted

Unprotected sex with an infected person.

From an infected mother to her infant before birth,

during birth, or during breastfeeding.

Blood transfusion in areas where blood is not

screened.

Blood-to-blood transmission.

Injection drug use.

Accidental exposure to needles or sharps.

What Body Fluids Contain High Concentrations of HIV?

Blood

Semen

Vaginal secretions

Breast milk

What Specific Part of the Human Body Does HIV Attack and What Is the

Result?

HIV infects the immune system,

specifically the CD4 cells.

Over time, the weakened immune system

has a progressively more difficult time

fighting infections.

If 100 Women Who Were HIV Infected Gave Birth to 100 Babies and They All

Breastfed Their Babies and None of Them Received Any Treatment, How

Many Babies on Average Would Become Infected With HIV at 1 Year of

Age?

Mother to Child Transmission

100 infants born to HIV-infected women who breastfeed,

Without any interventions

60 to 75 infants

will not be HIV

infected

25 to 40 infants will be HIV infected

5-10 infants

infected

during

pregnancy

About 15

infants

infected

during

labour and

delivery

5-15

infants

infected

during

breastfeed

ing

Name at Least 4 Interventions That Are Universal Precautions.

Wash hands after any direct contact with patients.

Do not recap needles.

Dispose of needles and sharps safely in puncture-

proof containers.

Wear gloves

Promptly and carefully clean up spills of blood and

other body fluids.

2 Reasons Why an HIV Positive Woman May Choose to Breastfeed

To avoid stigma

To maintain denial of her HIV status

To comfort the infant in an easy way

To save money if she cannot afford milk

powder and cannot get it another way.

To accommodate family pressure

What Is Specifically Measured in an HIV Screening Test?

Antibodies

What Does “Window Period” Mean?

This is the period between initial infection

and the time when the HIV test can detect

the antibodies.

People infected with HIV usually develop

antibodies 4 to 6 weeks after infection but it

may take as long as 3 months.

What 2 Factors Increase the Risk of Transmitting Infection to the Baby

During Pregnancy

New HIV infection during pregnancy

Malaria or any other infection that goes to

the placenta

STI

Maternal malnutrition

Advanced or late-stage AIDS

Name 1 Symptom Associated With HIV Infection in the Infant or Child.

Low weight and failure to gain weight

Pneumonia

Lymphadenopathy

Diarrhea

TB

HIV and AIDS Overview

HIV and AIDS

Human Immunodeficiency Virus

H = Human

I = Immunodeficiency

V = Virus

HIV and AIDS

Acquired ImmunoDeficiency Syndrome

A = not inherited

I = immune system

D = deficiency – inability to protect against illness

S = syndrome, a group of symptoms or illnesses

that occur as a result of HIV infection

CD4 The average person has between 800 & 1500

CD4 cells per cubic millimetre of blood

The immune system helps fight diseases

Disease CD4 Disease

KILLS DISEASE

IMMUNE

SYSTEM

ATTACKS DISEASE

T Cells (CD4 Cells) =

Part of body’s immune system

Transmission of HIV

HIV is transmitted by

Direct contact with infected blood

Sexual contact: oral, anal or vaginal

Direct contact with semen or vaginal and cervical secretions

Mothers infected with HIV to infants during pregnancy, delivery and breastfeeding

Coughing, sneezing

Insect bites

Touching, hugging

Water, food

Kissing

Public baths/pools

Transmission of HIV

HIV cannot be transmitted by:

Toilets

Handshakes

Work or school contact

Telephones

Cups, glasses,

plates, or other utensils

Women are 3 times more easily infected than males!

The vagina is more susceptible to lesions allowing the virus to pass into the body, and semen can remain in the body for up to three days.

Worldwide 75% of HIV is transmitted sexually.

¾ of infections are through heterosexual sex and ¼ are homosexual sex.

Are Some People More Susceptible to HIV?

Are Some People More Susceptible to HIV?

People with STIs are up to 10 times more at risk as many of the STI will result in cuts and open sores giving the HIV more chance to enter the body.

HIV Animation

Natural History of HIV Infection

Severity of illness is determined by amount of virus in the body (increasing viral load) and the degree of immune suppression (decreasing CD4 count).

Higher the viral load, the sooner immune suppression occurs.

When does HIV become AIDS?

1500 to 800 CD4 - Average healthy person

Below 500 CD4 - HIV+ person at risk from

Opportunistic Infections

200 CD4 Person is considered to have AIDS

CD4

COUNT

! In many developing countries they are unable to conduct the

difficult CD4 count tests. In these countries AIDS is

diagnosed by looking at the symptoms that the person has.

26

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Module 1

Draft

_______________Head__________________

Toxoplasmosis (Toxo)

Cryptococcal meningitis

_______________Eyes__________________

Cytomegalovirus (CMV)

___________Mouth and Throat__________

Candidiasis (Yeast)

________________Lungs________________

Pneumocystis carinii pneumonia (PCP)

Tuberculosis (TB)

Histoplasmosis

_________________Gut_________________

Cytomegalovirus (CMV)

Cryptosporidiosis

Mycobacterium avium complex (MAC)

________________Skin_________________

Herpes simplex

Shingles

_______________Genitals______________

Genital herpes

Human papillomavirus (HPV)

Vaginal candidiasis (Yeast)

HIV-Related Opportunistic Infections

PMTCT Program

PMTCT Strategies

Prevention of primary HIV infection

Prevention of unintended pregnancies among

women infected with HIV

Prevention of mother to child transmission

Providing treatment, care and support to

women who are HIV infected, their infants,

and their families

HIV Prevalence at Mae Tao Clinic

Insert

Percent of ANC clients testing

positive

0.00

0.50

1.00

1.50

2.00

2.50

1999 2000 2001 2002 2003 2004 2005 2006 2007

Pregnant Women

4,545 seen in ANC in 2007

3,421 (75.3%) tested for HIV in 2007

1,124 (24.7%) not tested

53 (1.55%) tested positive

for HIV

3368 (98.45%)

tested negative

+1 patients diagnosed elsewhere

54 patients enrolled in PMTCT in 2007

13 (24.07%) lost to follow-up

11 (20.37%)

pending

delivery at

< 28 weeks

as of 1/18/2008

27 (50%) received AZT

antepartum

Assume 1.55%

HIV rate

17.42 (1.55%)

hypothetical HIV

positive

1106.58

(98.45%) not

hypothetically

HIV positive

1089.43

(98.45%)

Hypothetical

HIV Negative

17.15 (1.55%)

Hypothetical

HIV Positive

(seroconversion

during pregnancy)

5.38 (30.9%)

Hypothetical

HIV infected

infants

12.04 (69.1%)

Hypothetical

Non HIV

infected infants

4.02 (30.9%)

Hypothetical

HIV Positive

infants

8.98 (69.1%)

Hypothetical

HIV Negative

infected infants

52.20 (1.55%)

Hypothetical

HIV Positive

(seroconversion

during pregnancy)

3315.80

(98.45%)

Hypothetical

HIV

Negative

5.30 (30.9%)

Hypothetical

HIV Positive

Infants

12.09 (69.1%)

Hypothetical

HIV Negative

Infants

2 (3.70%)

received

NVP at

delivery, no

AZT

antepartum

1 ( 1.85%)

patient given

wrong result and

thus not enrolled

in program until

after delivery

4 (14.8%)

pending

delivery as of

1/18/2008

23 (85.2%)

delivered as

of 1/18/2008

Outcomes for ANC Screening in 2007

Antenatal Care for PMTCT

Extensive post-test counseling

Includes partner, STI, GBV, TB screening, VDRL,

Hepatitis B, discrimination, work)

Home-based care and/or other Support Networks

World Vision, METRO

Mae Sot hospital

Ultrasound, repeat HIV testing with ELISA)

Start daily dose of AZT at 28 weeks gestation

Labour and Delivery

Delivery at Mae Sot Hospital

Before rupture of membranes

Normal (vaginal) or Cesarean

Post partum tubal ligation available

Intrapartum Medicine

Nevirapine, Lamivudine, AZT

Post-Partum

Continue medication and personal care

Family Planning

Baby to start 1-3 drug therapy

Baby HIV test at 12 months of age is

important

Infant Feeding choice

Types of Infant Feeding

1. Breastfeed exclusively

Except for medicine and vitamins

2. Replacement feeding – milk formula

3. Mixed feeding

Both breast milk and formula

Mixed feeding should be avoided - it increases the risk of HIV infection, diarrhea and other infections

Formula Feeding Is OK When It Is:

Acceptable

– no stigma

Feasible

– mother can correctly prepare it

Affordable

– can pay for cost (incl. travel)

Sustainable

Will not switch back to breast milk

Safe

Clean water, cups, bottles

Breast Feeding

Give breast milk for first few months only

then switch to other foods

About 6 months

No Breast milk if mother has

new HIV infection

AIDS or Opportunistic Infections

Explain what a positive HIV test means to a

client.

Explain what a negative HIV test means.

Case 1

20 year old G1 P0 at 3 months gestation.

No previous ANC.

She comes by herself.

Complains of diarrhea for 2 weeks and weight loss, weakness.

Exam shows bruises on her face, chest and legs.

Case 1

She tells you her husband beats her and told her to get an abortion when he found out she was pregnant.

Her HIV test is reactive.

How do you counsel her?

What services should she receive?

Case 2

22 year old G1 P0 admitted to RH IPD for septic induced abortion at 2½ months gestation.

She is not married.

She has worked in a brothel for 3 months and plans to continue there.

Her HIV test is reactive.

How do you counsel her?

What services should she receive?

Case 3

34 yr old G4 P1+2 at 6 months gestation comes for

her first ANC visit.

Her husband is working in Bangkok. He is not the

father of this baby. He does not know she is

pregnant and sends her money every month.

Her HIV test is reactive.

How do you counsel her?

PMTCT Goals for 2008: Goal 1

90 percent or more of all ANC clients will be screened for HIV (and Hepatitis B and VDRL).

Women will be tested at the first ANC visit

Repeat testing will be done in the third trimester for women at high risk for infection

New STI

Partner positive

Other risk factors

PMTCT Goals for 2008: Goal 2

All HIV infected ANC clients will have a peer counselor to meet with throughout pregnancy and afterwards either through Home-based Care or at RH OPD.

Each session will include education about HIV transmission, ARV’s, infant feeding, and risk reduction practices.

PMTCT Goals for 2008: Goals 3 & 4

All HIV infected clients will be referred to

Mae Sot Hospital for CD4 count and if

eligible full ARV therapy through the

migrant ARV program.

All data forms on ANC HIV infected clients

will be complete, accurate, and prompt.