PRE-TEST

• 1.Regargind latest guideline on initiation of ARV start at CD4 of

• A. <200cc/ml

• B.>200cc/ml

• C..<350cc/ml

• D.<500cc/ml

• E. non of the above

• 2.Best ARVs combination for PMTCT should contain at least

• A. AZT

• B. 3TC

• C.TDF

• D.LPV/r

• E. NVP

• 3.Best option advocated by the WHO IS

• A.Option a

• B. Option b

• C.Option c

• D. Option a+

• E. option b+

• 4. Factors associated with MTCH include

• A.low viral load

• B.infections

• C. prolong rupture of membranes

• D.cracked nipples

• E. antepartum haemorrhage

• 5.concerning choice of ARVs for PMTCT

• A.NVP should be avoided in the first trimester

• B.EFZ can be use in the first trimester

• C.NVP is safe in TB/HIV Co infection

• D.AZT IS unsafe throughout pregnancy

• E. EFZ Is teratogenic hence avoid in 1st trimester

CURRENT TREND IN MANAGEMENT OF

MATERNAL TO CHILD TRANSMISSION OF HIV

BY DR ZAINAB ABDULAZEEZ UMAR

DEPARTMENT OF FAMILY MEDICINE

SYNOPSIS

• OBJECTIVES

• INTRODUCTION

• SCOPE OF HIV

• MTCT

• PMTCT

• HAART AND PMTCT

• INFANTS FEEDING

• CONCLUSION

• REFERENCES

LEARNING OBJECTIVES

• To become familiar with factors affecting the transmission of HIV

from mother-to-child

• To become familiar with interventions to prevent the transmission of HIV from mother-to-child

• To be familiar with current guidelines in managing MTCT

INTRODUCTION

• HIV the aetiological agents of AIDS have been identified as HIV-1 and HIV-2. These viruses belong to the Lentivirus group of Retroviridae family.

• HIV continues to be a major global public health issue, having claimed more than 36 million lives so far.

• The Human Immunodeficiency Virus (HIV) targets the immune system and weakens people's surveillance and defense systems against infections and some types of cancer.

• As the virus destroys and impairs the function of immune cells, infected individuals gradually become immunodeficient

• Immunodeficiency results in increased susceptibility to a wide range of infections and diseases that people with healthy immune systems can fight off

• . The most advanced stage of HIV infection is Acquired Immunodeficiency Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the individual

• . AIDS is defined by the development of certain cancers, infections, or other severe clinical manifestations

• The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called mother-to-child transmission.

• In the absence of any interventions transmission rates range from 15-45%.

• This rate can be reduced to levels below 5% with effective interventions.

• These can be achieved by setting global norms and standards for HIV prevention, care and treatment of pregnant women, mothers and their children,

•SCOPE OF HIV

WHO – HIV department | January 19, 2014|

The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information.

Regional HIV and AIDS statistics and features 2012

TOTAL 35.3 million[32.2 million – 38.8 million]

2.3 million[1.9 million – 2.7 million]

Adults and children newly infected with

HIV

Adults and children living with HIV

Sub-Saharan Africa

Middle East and North Africa

South and South-East Asia

East Asia

Latin America

Caribbean

Eastern Europe and Central Asia

Western and Central Europe

North America

Oceania

25.0 million[23.5 million – 26.6 million]

3.9 million[2.9 million – 5.2 million]

1.5 million[1.2 million – 1.9 million]

1.3 million[1.0 million – 1.7 million]

1.3 million[980 000 – 1.9 million]

1.6 million[1.4 million – 1.8 million]

270 000[160 000 – 440 000]

86 000[57 000 – 150 000]

130 000[89 000 – 190 000]

48 000[15 000 – 100 000]

260 000[200 000 – 380 000]

880 000[650 000 – 1.2 million]

250 000[220 000 – 280 000]

860 000[800 000 – 930 000]

51 000[43 000 – 59 000]

32 000[22 000 – 47 000]

81 000[34 000 – 160 000]

12 000[9400 – 14 000]

29 000[25 000 – 35 000]

2100[1500 – 2700]

1.6 million[1.4 million – 1.9 million]

Adult & child deaths due to AIDS

1.2 million[1.1 million – 1.3 million]

220 000[150 000 – 310 000]

52 000[35 000 – 75 000]

91 000[66 000 – 120 000]

20 000[16 000 – 27 000]

17 000[12 000 – 26 000]

41 000[25 000 – 64 000]

11 000[9400 – 14 000]

7600[6900 – 8300]

1200[<1000 – 1800]

0.8%[0.7% - 0.9%]

Adult prevalence (15‒49) [%]

4.7%[4.4% – 5.0%]

0.3%[0.2% – 0.4%]

0.4%[0.3% – 0.5%]

0.7%[0.6% – 1.0%]

0.5%[0.4% – 0.8%]

0.1%[0.1% – 0.2%]

<0.1%[<0.1% – 0.1%]

1.0%[0.9% – 1.1%]

0.2%[0.2% – 0.2%]

0.2%[0.2% – 0.3%]

with nearly 1 in every 20 adults living with HIV. 69% of all people living with HIV are living in this region.

New HIV infections have fallen by 33% since 2001.

, down from 3.4 New HIV infections among children have declined by 52% since 2001.

SCOPE IN NIGERIA

• HIV Prevalence in Nigeria is 4.6%

• Nigeria now has the second highest number of plwhiv in the world after South Africa.

• Over 90% of HIV infection in children are as a result of MTCT.

• An estimated 220,000 exposed children born each year.

• Without PMTCT about 88,000(40%) of these are infected.

• With PMTCT about 2% (4,400) infected.

• Nigeria has 30% of the global burden of MTCT.

SCOPE IN KANO

In 2009 with 372 HIV infected pregnant women detected out of 3470 ANC clients

There were 4922 deliveries out of which 125 were HIV positive, giving a prevalence rate of 2.54%.

the transmission rate from mother to child amongst those who accessed PMTCT services was about 2-3 % .

SCOPE OF HIV/AIDS IN WOMEN

HIV spreads rapidly, particularly among young women.

These women are in their most productive and reproductive years.

There are various factors that make women vulnerable to HIV infection, These factors include: Biological factors Socio-cultural factors

BIOLOGICAL FACTORS

• Women have larger surface area of the genital mucosa

• Semen infected with HIV contains higher concentrations of virus than vaginal fluid.

• Young women have immature cervix and scanty vaginal secretion hence barrier to infection is reduced

• Women become more vulnerable again after menopause

• Tearing and bleeding during intercourse further increased predisposition to infection. This can occur during rough vagina sex, anal sex, dry sex or rape

• Untreated STIs multiplies the risk of HIV infection by 300-400%.

SOCIO-CULTURAL FACTORS

• Economic and societal approved dependency on men

• Rights of women are abused and often violated.

• Condom use by stable partners is often frowned at.

• Cultural practices often expose women to multiple partners e.g polygamy, widow inheritance, wife hospitality

• Gender inequalities which negatively impacts on and their effect on seeking care and prevention efforts

• Burden of being the care provider in the home may supercede the need to care for herself

Mother to Child Transmission of HIV Infection

MOTHER-TO-CHILD TRANSMISSION

MTCT of HIV can occur during:• Pregnancy• Labour and delivery• Breastfeeding

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

25–40 infants will be HIV-infected

5–10 infants infected during

pregnancy

About 15 infants

infected during labour and delivery

5–15 infants infected during breast-feeding

• Pregnancy ---------- (5 - 10%)

• Delivery ------- (10 -15%)

• Breastfeeding ----- (10 - 15%)

Timing of Transmission: Targeting Prevention (In an Untreated Non-Breastfeeding Population, Total Transmission Rate is up to 25%)

RISK FACTORS FOR MTCT

Pregnancy

•High maternal viral load

•Infection

•STIs

•Malnutrition

•Haemorrhage

Labour and Delivery

•High maternal viral load

•Prolonged rupture of membranes

•Invasive delivery procedures

•Chorioamnionitis

Breastfeeding

•High maternal viral load

•Duration

•Early mixed feeding

•Breast fissures, infections

•Poor maternal nutrition

•Oral disease in infant

PMTCT

Prevention

Of

Mother

To

Child

Transmission

• Best practice for antenatal, intrapartum and postpartum care of the HIV-positive mother to reduce mother-to-child transmission

ELEMENTS OF A SUCCESSFUL PROGRAMME FOR PREVENTION OF HIV INFECTION IN INFANTS AND YOUNG CHILDREN

• Element 1 Primary prevention of HIV infections

• Element 2 Prevention of unintended pregnancies among women infected with HIV

• Element 3 Prevention of HIV transmission from women infected with HIV to their infants

• Element 4 Provision of treatment, care and support to women infected with HIV, their infants and their families

ABCs of primary HIV prevention for parents-to-be:

A = Abstain B = Be faithful to one HIV-uninfected partner C = Condom use – use condoms consistently and correctly

Adapt approach to local culture and target groups at risk

ELEMENT 1: PREVENTION OF PRIMARY HIV INFECTION

• Access to counselling and referral for family planning

• Safe, consistent, effective contraception

ELEMENT 2: PREVENTION OF UNINTENDED PREGNANCIES AMONG WOMEN INFECTED WITH HIV

Core Interventions

• HIV testing and counselling

• Antiretrovirals

• Safer delivery practices

• Safer infant-feeding practices

Combination interventions can reduce the MTCT rate to as low as 2% in the absence of breastfeeding.

ELEMENT 3: PREVENTION OF HIV TRANSMISSION FROM WOMEN INFECTED WITH HIV TO THEIR INFANTS

• Prevention and treatment of OIs

• ARV treatment

• Treatment of symptoms

• Palliative care

• Nutritional support

• Reproductive healthcare

• Psychosocial and community support

ELEMENT 4: TREATMENT, CARE AND SUPPORT FOR WOMEN INFECTED WITH HIV AND THEIR FAMILIES

SPECIFIC INTERVENTIONS TO REDUCE MOTHER-TO-CHILD TRANSMISSION

• HIV testing and coucelling in pregnancy• Antenatal care• Antiretroviral agents• Obstetric interventions

• Avoid amniotomy• Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood

sampling• Restrict episiotomy• Elective cesarean section• Remember infection prevention practices

• Newborn feeding: Breast milk vs. formula34

TESTING AND COUNSELING FOR PMTCT

• Offered in the following settings• Antenatal care• Labour and delivery• Postnatal• Family planning and other services

• Information offered are the following:• HIV Infection and mode of transmission• Safer sex practices• Prevention and treatment of sexually transmitted infections (STIs)• Prevention of HIV in infants and young children including interventions for PMTCT• HIV testing, post-test counseling, and follow-up services

• INFORMATIO OFFERED TO HIV +VES (POST TEST)

• Antiretroviral treatment/prophylaxis• Infant-feeding counseling and support• Information and counseling on family planning• Receive education on the importance of delivering in a setting where universal precautions and

safer obstetric practices are implemented. • Secure early access to HIV treatment, care and support services. • Receive information and counseling on the prevention of HIV transmission to others. • Receive follow-up and ongoing health care for themselves and their HIV-exposed infants. • Disclose their results to partners and family members.

LAB. TESTING FOR HIV INFECTIONS

• Detectable components or products of viral infection for diagnosis• Antibodies-

• Rapid tests

• ELISA(reactive/non-reactive),

• Western blot (positive, negative, Indeterminate.)

• Antigen- antigen P24

• Nucleic acid- polymerase chain reaction

• Whole(viable)virus- viral culture

LABORATORY TESTING(4)

CD4 lymphocyte count.

• Normal laboratory ranges 500-1400/mm.• Most useful for assessing immune function. • Degree of immuno-suppression determines staging of HIV infection, recommendations for ARV and prophylaxis

against OIs.

Viral Load estimation• goal is to reduce viral load to undetectable (<400 copies/mL)

OTHER TESTS: BASELINE LABS TESTS

• FBC (anemia with ZDU)

• LFTs (mitochondrial disease with NRTI, elevated ALT w/ NNRTI and PI)

• amylase (pancreatitis with NRTI)

• early 1-hr OGT (GDM with PI)

• creatinine

• Hep B & C, CMV, toxo

ANTENATAL CARE

• Most HIV-infected women will be asymptomatic• Watch for signs/symptoms of AIDS and pregnancy-related complications• Treat STDs and other coinfections• Counsel against unprotected intercourse• Avoid invasive procedures and external cephalic version• Give antiretroviral agents• Counsel about nutrition

HIV and Pregnancy 40

Clinical Stage 1

Asymptomatic

Clinical Stage 2

Mild Disease

Stage 3 Advanced Disease Stage 4 Severe Disease (AIDS)

No symptoms or only: Persistent generalized lymphadenopathy

Weight loss 5-10%** Sores or cracks around

lips (angular cheilitis) Itching rash

(seborrhoea or prurigo)

Herpes zoster Recurrent upper

respiratory infections such as sinusitis or otitis

Weight loss > 10%** Oral thrush (or hairy

leukoplakia) More than 1 month: Diarrhoea or Unexplained fever Severe bacterial

infections (pneumonia, muscle infection, etc)

Pulmonary TB TB lymphadenopathy

HIV wasting syndrome Oesophageal thrush More than 1 month: Herpes simplex

ulcerations Recurrent severe

pneumonia within 6 months

Lymphoma* Kaposi sarcoma Invasive cervical cancer* CMV retinitis* Pneumocystis pneumonia Extrapulmonary TB* Toxoplasma* Cryptococcal meningitis* Visceral leishmaniasis*

If CD4 < 350 Cotrimoxazole & INH prophylaxis

If CD4 < 350 Cotrimoxazole & INH prophylaxis

Cotrimoxazole & INH prophylaxis

Cotrimoxazole & INH prophylaxis

Consider ART if CD4 < 350 Consider ART if CD4 < 350 ART ART

WH O A D U LT H IV C L IN IC A L S T A G IN G

Principles of ARV useStrict adherence critical but a challenge in pregnancyARVs have side effects that need clinical and lab

monitoringBeware of drug interactionsResistance may develop if adherence is not excellent or

if drug interactions affect drug levels, resistance may occurResistance may be spread to baby and to partner

With excellent adherence and monitoring, risks of ARV are minimised and benefits are maximised

HIV IN PREGNANCY: DRUG TREATMENT

• The goal in pregnancy is to reduce viral load to undetectable to minimize perinatal transmission.

• However, the woman should be counselled and willing to adhere to the regimen

• She should be counselled on the risks and benefits of the ARVs

Evolution of the efficacy of the ARV prophylaxis: 1994-2004

0

5

10

15

20

25

30

35

None &BF

None noBF

NVP &BF

AZT36wks &

BF

AZT36wksno BF

AZT28wksno BF

AZT28wks +NVP no

BF

HAARTno BF

HAART+ C-S no

BF

% Transmission

Tran

smis

sion

Rat

e (%

)

NRTI NNRTI PI

Nucleoside reverse transcriptase inhibitors (NsRTI)

Nucleotide reverse transcriptase inhibitor (NtRTI)

Non-nucleoside reverse transcriptase inhibitors (NNRTI)

Protease Inhibitors (PI)

zidovudine (AZT) lamivudine (3TC)abacavir (ABC)emtricitabine (FTC) stavudine (d4T)

tenofovir disoproxil fumarate (TDF)

nevirapine (NVP)efavirenz (EFV)

saquinavir (SQV) ritonavir (RTV), as booster* indinavir (IDV) nelfinavir (NFV) lopinavir (LPV)

THE DIFFERENT ANTIRETROVIRAL DRUGS

OTHERS

Fusion Inhibitor Enfuvirtide (ENF, T-20)

CCR5 Antagonist Maraviroc (MVC)

Integrase Inhibitor Raltegravir (RAL)

• A first-line regimen is a combination of drugs that will be used in a patient who has no prior ART experience. This means that the patient has never taken ARV drugs before.

• Most commonly, a first-line regimen will consist of two NsRTI's and one NNRTI.

• Many patients will eventually develop failure of therapy: the first-line therapy will not be effective anymore (often because the drugs were not taken correctly). In that case, the doctor may decide to switch to a second-line regimen.

• Usually, the second-line regimen will consist of 2 NRTI + 1 PI.

FIRST - LINE AND SECOND-LINE REGIMEN

ART should be initiated in all pregnant women based on the following criteria.

• CD4 count of less than or equal to 350 irrespective of WHO clinical staging.

• WHO stages III and IV irrespective of CD4 cell count.• Nigerian guideline Recognizes pregnancy as an indication for

prophylactic ART irrespective of CD4 count, viral loads or clinical staging

ART INITIATION

Women With CD4 Count above 350 Cells/mm3

Women With CD4 Count beloW 350 Cells/mm3

ChilD receives

option a During pregnancy: AZT starting as early as 14 weeks of pregnancy At delivery: single-dose NVP and first dose of AZT/3TC After delivery: daily AZT/3TC through 7 days postpartum

Triple ARVs started as soon as diagnosed and continued for life

Daily prophylaxis (NVP) from birth until 1 week after all breastfeeding has finished; or, if not breastfeeding or if mother is on treatment, through age 4–6 week

Option b Triple ARVs starting as early as 14 weeks of pregnancy continued through childbirth (if not breastfeeding) or until 1 week after all breastfeeding has finished

Daily prophylaxis (NVP or AZT) from birth through age 4–6 weeks regardless of infant feeding method

Option b+ Triple ARVs started as soon as diagnosed and continued for life

Advantages of Option B+• Further simplification of regimen and service delivery (One regimen See

and Treat) • Harmonization with ART programmes (TDF + 3TC or FTC + EFV as first

line regardless of CD4 count)• Protection against mother-to-child transmission in future pregnancies• Continuing prevention benefit against sexual transmission to

serodiscordant partners• Avoiding stopping and starting of ARV drugs• HBV Co-infection therapy

CHOICE OF ARV”S IN PREGNANCY

Combination regimens, usually including 2 NRTIs with either a NNRTI or 1 or more protease inhibitors (PIs) are recommended

AZT + 3TC + EFV/NVPAZT + 3TC (or FTC) + EFV/NVP

AZT + 3TC + LPV/rAZT + 3TC + ABCTDF + 3TC (or FTC) + EFV/NVP

NOTE

Nevirapine is avoided in women with CD4 count >250. EFV is avoided in the first trimester

• Any pregnancy regimen should include ZDT unless contraindicated

• Combination HAART (3 drugs) is associated with vertical transmission rates of <2% and is considered standard of care (regardless of VL or CD4+)

• Safety of HAART in pregnancy is reassuring

• Continue drugs during labor

NEW RECOMMENDATIONS IN WHO ART GUIDELINES (2013)

• • Earlier initiation of ART (CD4 ≤ 500)

• • 1) Immediate ART for children below 5 years

• • 2) Harmonization of ART across populations (e.g., adults and pregnant women, B/B+) and age groups

• • 3) Simplified, fewer, and less toxic 1st line regimens (TDF/3TC/EFV)

• • 4) Improved patient monitoring to support adherence and detect failure (increased use of VL)

• • 5) Recommend task shifting, decentralization, and integration

TARGETS FOR E-MTCT

CLINICAL SCENARIO 1:PREGNANT WOMAN HAS RECEIVED ARV MEDICATION IN THE PAST BUT IS NOT CURRENTLY ON ANY MEDICATION

• the choice of regimen may vary according to the history of prior use, the indication for stopping treatment in the past, gestational age, and resistance testing

• if there is no resistance to the drugs, ARV(HAART) can be used again, but avoid drugs with teratogenic potential or adverse maternal effects.

• Commence ARVS as soon as possible(AZT+3TC+NVP/EFZ) OR TDF

CLINICAL SCENARIO II:PATIENT WHO IS ON A HAART REGIMEN PRESENTS FOR PRENATAL CARE

• continuing her treatment during the first trimester is reasonable,• Zidovudine should be a component of the regimen whenever

possible • provided that care is taken to avoid medications that are

contraindicated in early pregnancy

CLINICAL SCENARIO III:ARV NAÏVE HIV-INFECTED PREGNANT WOMAN

• 1.In facility with capacity to provide and monitor triple ARV

• HAART should be started as soon as possible, including during the first trimester.

• Infant:dly NVP irrespective of feeding option

CONT IIIB• 2.In facility with limited capacity to provide &

monitor triple ARVSThe following ARV prophylactic regimen is

recommended: Zidovudine from 14 weeks gestation.Sd NVP at onset of labourAZT+3TC during labour and deliveryAZT+3TC for 7 days post partum

PROPHYLAXIS FOR PMTCT CLINICAL SETTING IIIB :THE INFANT

• A For breastfeeding infants: Commence daily NVP and continue until one week after cessation of all breastfeeding.

• B For non-Breastfeeding infants: Give daily NVP for 6 weeks only

CLINICAL SCENARIO IV:HIV +VE DIAGNOSED IN LABOR

1. For facilities with capacity to provide and monitor Triple ARV medication:

Mother Commence triple ARV prophylaxis during labour and continue thru bf2. For facilities with limited capacity (on–site or by linkage) to provide and monitor triple ARV

medication.

Mother:

• Intrapartum:

sdNVP + ZDV + 3TC as soon as diagnosis is made in labour.

• Post partum:

ZDV + 3TC for 7 days

• Determine if mother is eligible (within 5 days of delivery) for HAART

Infant:

• Mother breastfeeding not commenced on HAART:

Give daily NVP to infants from birth until one week after cessation of all breastfeeding

• Mother breastfeeding (eventually commenced on HAART) Give daily NVP to infants from birth and continue until six weeks after maternal

commencement of HAART

• Mother not breastfeeding: Give daily NVP to infants from birth until 6 weeks of age.

CLINICAL SETTING VRECOMMENDATIONS FOR PREGNANT HIV-SEROPOSITIVE MOTHERS WHO PRESENT AFTER DELIVERY

If mother chooses to breastfeed, recommend HAART (follow guidelines for HAART eligible mothers)

If mother chooses to formula feed, determine if mother is eligible for HAART for her own disease,

Infant :give sdnvp and then for 6 wks

CLINICAL SETTING VI: HIV-INFECTED WOMAN WITH ACTIVE TB

• Delay ARV treatment until second trimester, if possible.

Treatment regimens: These are in decreasing order of preference

• If treatment is initiated in second trimester EFV (800mg) + 2NRTIs

ZDV + 3TC + Abacavir

2 NRTIs + Ritonavir-boosted PI* (Saquinavir/r or Lopinavir/r) ZDV + 3TC + Tenofovir

Change rifampin to low dose rifabutin

INFANTS:Prophylactic INH from birth (5mg/Kg once daily) until six (6) months of age

WHO PROGRAMMATIC UPDATE APRIL 2012

• Option B+: – Triple ARV drugs to all HIV-infected pregnant women beginning

in the antenatal clinic setting and continuing this therapy for all of these women for life.

• Now being considered by the PMTCT Task Team

NATIONAL RECOMMENDATIONS 2010INFANTS

• HIV+ Mothers ( whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life.

Breastfeeding should then only stop once a nutritionally adequate and safe diet without breast milk can be provided.

When HIV-infected mothers decide to stop breastfeeding (at any time) they should do so gradually within one month

: MONITORING OF THERAPY • Check viral load, CD4+, LFTs, FBC every trimester• Consider change of therapy if viral load still detectable in 3-6

months• Exclude adherence problems

• Is she taking her meds??

• Baseline ARV resistance testing • HAART naïve (new) cases• HAART re-starts• if suboptimal viral suppression

CARE IN LABOUR AND DELIVERY

• AVOID ARM/FETAL SCALP PROCEDURES/ECV• UNIVERSAL PRECAUTIONS SHOULD BE APPLIED• AVOID ROUTINE EPISIOTOMY• FORCEPS PREFERABLE TO VACUUM• ELECTIVE C/S BENEFICIAL• Elective Caesarean section (C/S) reduces the risk of MTCT

by at least 50% compare with vaginal delivery

• Following delivery, avoid milking the cord. • The baby should be thoroughly dried, and any remaining maternal

blood and amniotic fluid should be removed.• Vigorous suctioning of the infant’s mouth and pharynx should be

avoided• Vaginal cleansing using disinfectants such as chlorhexidine where

SVD is anticipated.• Use partogram to monitor labour progress.• Determine mother’s feeding choice

INFANT FEEDING OPTIONS

Allow mother to take decision by her self after counselling.Exclusive Breast feeding

1 Support mother, put baby to breast immediately, exclusive, proper position & attachment, feed on demand2 Modification of BF a Early cessation- stop by 6 mths.b Expressing & heat treating BM.c Wet nursing- not advisable.

• EXCLUSIVE FORMULAR FEEDING

A- acceptable.

F- feasible.

A- affordable.

S- sustainable.

S- safe.

Types –commercial infant formula & home made modified animal milk.

COMPREHENSIVE POSTPARTUM CARE AND SUPPORT

Components of comprehensive care include the following medical and supportive care services:• Primary, obstetric, paediatric and HIV specialty care• Family planning services• Immunization/prophylaxis against OIs• Mental health services• Substance-abuse treatment• Coordination of care through case management for the woman, her children, and other

family members.

Support services should include case management childcare, respite care, assistance with basic life needs (eg. housing, food,

and transportation), and legal and advocacy services. Continuity of antiretroviral treatment must be

ensured.

ROLE OF FAMILY PHYSICIAN

• HIV IS ONE DISEASE THAT ALLOWS THE FAMILY PHYSICIAN TO PRACTICE WITH ALL HIS SKILLS

-COUNSELING\EDUCATING

-PERSONALISED CARE

-CONTINOUS CARE

-FAMILY CARE

-TEAM WORK\REFERRAL ETC

CONCLUSION

PMTCT is a success story in HIV prevention.A proper understanding of the basic principles of HIV

and ARV use is all that is necessary to achieve this success.

The implementation of the core PMTCT interventions based on these principles will reduce MTCT from 40% to about 2%.

THANK YOU FOR YOUR ATTENTION

REFERENCES

• British HIV Association guidelines for the management of HIV infection in pregnant women 2012

• National guidelines on PMTCT 2010

• National guidelines on PMTCT 2012

• H Galadanci et al Outcome of deliveries among HIV +ve mothers at AKTH – NJM 2006.

• Infant feeding in HIV – generic training manual.

• Expanding and Simplifying Treatment for Pregnant Women Living with HIV

• HIV in pregnancy www.medscape.com/hiv in pregnancy

• WHO Guideline on PMTCT

• AITT option b+ Toolkit 2013 expanding and simplifying treatment for pregnant women www.emtct.iatt.org

• V Mangiaterra WHO: Global plan to eliminate MTCT of HIV 2013