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Module 3

Module 3. Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT). Module Objectives. Describe the difference between ARV therapy and ARV prophylaxis List the criteria for starting pregnant women on ARV therapy List the recommended ARV drugs for PMTCT

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Module 3

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  1. Module 3 Specific Interventions for the Prevention of Mother-to-Child Transmission of HIV (PMTCT)

  2. Module Objectives • Describe the difference between ARV therapy and ARV prophylaxis • List the criteria for starting pregnant women on ARV therapy • List the recommended ARV drugs for PMTCT • Understand the antenatal management of women infected with HIV and women of unknown HIV status PMTCT Generic Training Package Module 3, Slide 2

  3. Module Objectives (Continued) • Explain the management of labour and delivery for women infected with HIV and women of unknown HIV status • Describe postpartum care of women infected with HIV and women of unknown HIV status • Describe the care of infants born to mothers who are HIV-infected and infants born to women of unknown HIV status PMTCT Generic Training Package Module 3, Slide 3

  4. Session 1 Antiretroviral Therapy and Antiretroviral Prophylaxis for PMTCT PMTCT Generic Training Package Module 3, Slide 4

  5. Session 1 Objectives • Describe the difference between ARV therapy and ARV prophylaxis • List the criteria for starting pregnant women on ARV therapy • List the recommended ARV drugs for PMTCT PMTCT Generic Training Package Module 3, Slide 5

  6. ARV Therapy and ARV Prophylaxis What is the difference between ARV therapy and ARV prophylaxis? PMTCT Generic Training Package Module 3, Slide 6

  7. ARV Therapy and ARV Prophylaxis • ARV therapy:Long-term use of antiretroviral drugs to treat maternal HIV and for PMTCT • ARV prophylaxis:Short-term use of antiretroviral drugs to reduce HIV transmission from mother-to-infant PMTCT Generic Training Package Module 3, Slide 7

  8. Antiretroviral (ARV) Therapy • Improves the health of women • Decreases the risk of transmitting HIV to infant • Pregnant women who are HIV-infected and who are eligible for antiretroviral (ARV) therapy should receive treatment according to national or WHO guidelines. ARV • Is provided by PMTCT programmes or by referral to HIV care and treatment clinic PMTCT Generic Training Package Module 3, Slide 8

  9. Starting ARV Therapy:WHO Recommendations • If CD4 count is not available: • Treat all symptomatic patients at WHO Stages 3 and 4 • When to start ARVs is based on symptoms of HIV infection and, where available, laboratory test results. • See Table 3.1 PMTCT Generic Training Package Module 3, Slide 9

  10. Starting ARV Therapy:WHO Recommendations (Continued) • If CD4 count is available: • Treat all patients with CD4 counts <200 cells/mm3 • Treat all HIV-infected pregnant women in Stage 3 whose CD4 count is <350 cells/mm3 • Consider treatment for the non-pregnant in Stage 3 if CD4 count is < 350 cells/mm3 PMTCT Generic Training Package Module 3, Slide 10

  11. Becoming Pregnant while on ARV Therapy WHO recommendations: • Continue to take ARV therapy throughout pregnancy, labour, delivery and postpartum • Infants born to mothers on ARV therapy should receive one week of ARV prophylaxis with AZT • If a woman is on efavirenz (EFV) as a part of her ARV therapy and becomes pregnant: • Substitute NVP for EFV if pregnancy if recognized during 1st trimester • Continue EFV if recognized during 2nd or 3rd trimester • See Appendix 3-A for more information on managing ARV therapy during pregnancy PMTCT Generic Training Package Module 3, Slide 11

  12. Starting ARV Therapy during Pregnancy • A pregnant woman eligible for ARV therapy based on national or international guidelines should start treatment as soon aspossible, even during the 1st trimester • All ARV drugs are associated with some toxicity • The risk for a pregnant woman and her child from ARV therapy varies and is dependent on the: • Stage of pregnancy • Duration of therapy • Number of drugs used PMTCT Generic Training Package Module 3, Slide 12

  13. First-line ARV Therapy for Pregnant Women • Pregnant women should be closely monitored for toxicity, including hepatitis, from NVP during the first 12 weeks of therapy WHO Recommendation:Zidovudine (AZT) + lamivudine (3TC) + nevirapine (NVP) PMTCT Generic Training Package Module 3, Slide 13

  14. Commonly Used ARV drugs for PMTCT PMTCT Generic Training Package Module 3, Slide 14

  15. Delaying Start of ARV Therapy • Delaying the start of ARV therapy can be considered if a pregnant woman: • Suffers frequently from nausea, a common side effect of some ARVs • Is in her first trimester and concerned about the effects of ARVs on the developing fetus • HOWEVER, if a woman’s clinical or immune status suggests she is severely ill, the benefits of early ARV therapy outweigh any potential risk tothe fetus PMTCT Generic Training Package Module 3, Slide 15

  16. HIV-Infected Pregnant Woman with TB • First priority is to treat the TB • With careful clinical management, a pregnant woman can be treated for both HIV and TB • Drugs need to be monitored very closely to avoid interactions and side effects • See Appendix 3-A for more information on managing an HIV-infected pregnant woman with TB PMTCT Generic Training Package Module 3, Slide 16

  17. ARV Prophylaxis • All HIV-infected pregnant women who are noteligible for ARV therapy should be offered ARV prophylaxis for PMTCT PMTCT Generic Training Package Module 3, Slide 17

  18. ARV Prophylaxis for PMTCT:WHO Recommendations • Use combination regimens of AZT, 3TC and a single dose of NVP because they: • Are more effective in preventing MTCT • Can reduce viral resistance • See Appendix 3-B for the WHO recommended PMTCT ARV regimens PMTCT Generic Training Package Module 3, Slide 18

  19. Viral Resistance and ARVs • HIV can mutate or change so it becomes resistant to specific ARV drugs — whether used for therapy or prophylaxis • When viral resistance occurs, these ARV drugs are no longer as effective • Additional information on viral resistance can be found in Module 7 PMTCT Generic Training Package Module 3, Slide 19

  20. WHO Recommendations on Single-dose NVP • Resistance can develop when a single dose of NVP is given during labour • Single dose NVP is the minimum recommended regimen where capacity is limited; should only be used where other options not available • Single-dose NVP is given to a mother at the onset of labour and to her infant as soon as possible after delivery • Specific obstacles to delivering more effective combination regimens should be identified and actions taken to address them PMTCT Generic Training Package Module 3, Slide 20

  21. Session 2 Antenatal Management of Women Infected with HIV and Women of Unknown HIV Status PMTCT Generic Training Package Module 3, Slide 21

  22. Session 2 Objectives • Understand the antenatal management of women infected with HIV and women of unknown HIV status PMTCT Generic Training Package Module 3, Slide 22

  23. Antenatal Care • ANC improves the general health and well-being of mothers and their families • Good maternal healthcare not only improves pregnancy outcomes, but also helps women with HIV stay healthy longer PMTCT Generic Training Package Module 3, Slide 23

  24. Integrating PMTCT Servicesinto MCH Programmes Integrating PMTCT and MCH programmes ensures that: • PMTCT programmes have access to MCH patients • PMTCT services benefit from the expertise and experience of HCWs working in MCH services • PMTCT services are normalized as a part of care PMTCT Generic Training Package Module 3, Slide 24

  25. PMTCT Services in MCH Care • Health information and education • Education about HIV and HIV prevention including safer sex • HIV testing and counselling • Partner HIV testing and counselling, including couple counselling, either on-site or by referral • ARV therapy or ARV prophylaxis (ARV therapy may be provided either on-site or by referral) PMTCT Generic Training Package Module 3, Slide 25

  26. PMTCT Services in MCH Care (Continued) • Treatment, care & support for HIV infection • Information on infant feeding options, counselling and support • Screening, prevention and treatment of opportunistic infections and other HIV-related conditions • Co-trimoxazole prophylaxis against PCP, malaria and other infections • Diagnosis and treatment of sexually transmitted infections (STIs) PMTCT Generic Training Package Module 3, Slide 26

  27. Role of HIV Testing in PMTCT • HIV testing and counselling is the critical initial step to provide healthcare workers (HCWs) with the opportunity to offer PMTCT services PMTCT Generic Training Package Module 3, Slide 27

  28. ANC Services for HIV-infected Women • Include all of the basic services (e.g., services for all pregnant women regardless of HIV infection status) • In addition, an HIV-infected pregnant woman has other care and support needs(outlined in Table 3.2). The PMTCT interventions in this module are primarily in reference to women infected with HIV-1 • See Appendix 3-C for more information about PMTCT and HIV-2 PMTCT Generic Training Package Module 3, Slide 28

  29. Common Infections inHIV-Infected Women • Women with HIV are susceptible to opportunistic infections, HIV-related infections and other common infections because their immune systems are not working well • All infections can increase the risk of MTCT • HCWs should follow national guidelines for prophylaxis and treatment of all infections that can affect HIV patients • Effective prevention reduces rates of illness and death among HIV-infected pregnant women PMTCT Generic Training Package Module 3, Slide 29

  30. Common Infections in HIV-infected Women (Continued) • Opportunistic infections: • Tuberculosis • Pneumocystis pneumonia (PCP) • HIV-related infections: • Recurrent vaginal candidiasis • Other common infections: • Sexually transmitted infections (STIs) • Urinary tract infections • Respiratory infections • Malaria, where prevalent PMTCT Generic Training Package Module 3, Slide 30

  31. Common Infections inHIV-Infected Women (Continued) • Co-trimoxazole prophylaxis prevents common infections: • PCP pneumonia • Other bacterial pneumonias • Malaria • Toxoplasmosis • Certain causes of diarrhoea • Co-trimoxazole prophylaxis is likely to improve overall pregnancy outcomes • See Module 7 for more information on PCP prophylaxis PMTCT Generic Training Package Module 3, Slide 31

  32. Psychosocial & CommunitySupport • Pregnant women with HIV may have concerns about the health of the baby, their own health and disclosure of their status • HCWs should assess how much support an HIV-infected woman is receiving from family and friends • Where available, HCWs should refer HIV-infected pregnant women to organizations that provide support PMTCT Generic Training Package Module 3, Slide 32

  33. Patient history Physical exam, vital signs Lab tests Nutritional assessment & counselling STI screening TB and malaria assessment and treatment OI and malaria prophylaxis Tetanus immunization ARV therapy/ prophylaxis Infant feeding Counselling on safer pregnancy, HIV danger signs Partners/family (testing, support) Effective contraception planning ANC Services for HIV-Infected Women (Table 3.2) PMTCT Generic Training Package Module 3, Slide 33

  34. Exercise 3.1 Antenatal care: case studies PMTCT Generic Training Package Module 3, Slide 34

  35. Session 3 Management of Women Infected with HIV and Women of Unknown HIV Status during Labour and Delivery PMTCT Generic Training Package Module 3, Slide 35

  36. Session 3 Objectives • Explain the management of labour and delivery in women infected with HIV and women of unknown HIV status PMTCT Generic Training Package Module 3, Slide 36

  37. PMTCT During Labour & Delivery • Labour and delivery (L&D) practices for HIV-infected women should follow standard obstetric practices, set forth by national and international standards PMTCT Generic Training Package Module 3, Slide 37

  38. PMTCT During Labour & Delivery (Continued) • Standard obstetric practices include Standard Precautions: • Wearing protective gear • Using and disposing of sharps safely • Sterilizing equipment and safely disposing of contaminated materials PMTCT Generic Training Package Module 3, Slide 38

  39. Standard Precautions in L&D • Reduce the risk of transmission of blood-borne pathogens from the patient to the HCW • Used when caring for all patients, regardless of diagnosis or presumed HIV infection status • Because of risk of contact with blood, use of Standard Precautions is particularly important during delivery • Discussed in greater detail in Module 8 PMTCT Generic Training Package Module 3, Slide 39

  40. Labour & Delivery for HIV-infected Women • Administer ARV therapy or ARV prophylaxis during labour according to national guidelines to reduce maternal viral load and provide protection to the infant • Avoid repeat dosing of single-dose NVP (e.g., in the case of false labour) as this can cause viral resistance • Ensure that a woman is in true labour before administering a single-dose of NVP • Document NVP administration clearly on a patient’s partogram or medical record to avoid accidental repeat dosing PMTCT Generic Training Package Module 3, Slide 40

  41. PMTCT during L&D • Minimize vaginal examinations • Avoid prolonged labour • Consider using oxytocin to shorten labour when appropriate • Avoid premature rupture of membranes • Use partogram to measure labour • Avoid artificial rupture of membranes (unless necessary) PMTCT Generic Training Package Module 3, Slide 41

  42. PMTCT during L&D (Continued) • Avoid unnecessary trauma during delivery. • Use non-invasive fetal monitoring • Avoid invasive procedures, such as using scalp electrodes or scalp sampling • Avoid routine episiotomy • Minimize the use of forceps or vacuum extractors PMTCT Generic Training Package Module 3, Slide 42

  43. PMTCT during L&D (Continued) • Minimize risk of postpartum haemorrhage • Actively manage the third stage of labour • Give oxytocin immediately after delivery • Use controlled cord traction • Perform uterine massage • Carefully repair genital tract lacerations • Carefully remove all products of conception PMTCT Generic Training Package Module 3, Slide 43

  44. PMTCT during L&D (Continued) • Use safe blood transfusion practices • Minimize use of blood transfusions • Use only blood screened for HIV and, when available, screened for syphilis, malaria and hepatitis B and C PMTCT Generic Training Package Module 3, Slide 44

  45. Considerations RegardingMode of Delivery • Caesarean section performed before the onset of labour or membrane rupture has been associated with reduced MTCT Elective Caesarean, along with safer infant feeding practices and ARV therapy or ARV prophylaxis, has greatly reduced the rate of MTCT in countries where this procedure is safe and available PMTCT Generic Training Package Module 3, Slide 45

  46. Considerations Regarding Mode of Delivery (continued) • The risk of elective Caesarean for PMTCT should be assessed carefully in the context of factors such as: • Risk of post-operative complications • Safety of the blood supply • Cost PMTCT Generic Training Package Module 3, Slide 46

  47. HIV Testing during Labour • Testing during labour is the last opportunity before childbirth to identify women infected with HIV • A woman of unknown HIV status at labour should be offered HIV testing and counselling • ARV prophylaxis, when initiated during labour for the woman and just after birth for the infant, can reduce MTCT by as much as 50% • See Module 5 for additional information on HIV testing during labour PMTCT Generic Training Package Module 3, Slide 47

  48. Exercise 3.2 Labour & delivery ARV prophylaxis: case studies PMTCT Generic Training Package Module 3, Slide 48

  49. Session 4 Postpartum Care of Women Infected with HIV and Women of Unknown HIV Status PMTCT Generic Training Package Module 3, Slide 49

  50. Session 4 Objectives • Describe postpartum care of women infected with HIV and women of unknown HIV status PMTCT Generic Training Package Module 3, Slide 50

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