Module 2

1. Module 2 Overview of HIV Prevention in Mothers, Infants, and Young Children

2. Module Objectives • Discuss the epidemiology of MTCT in Malawi • Discuss biological, social, and cultural factors explaining women’s vulnerability to HIV infection. • Define mother-to-child transmission of HV infection (MTCT). • Explain the factors that influence the transmission of HIV from mother to child. Malawi PMTCT Training Package

3. Module Objectives (continued) • Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children. • Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children. Malawi PMTCT Training Package

4. Unit 1 HIV in Malawi Malawi PMTCT Training Package

5. Unit 1 Objectives • Discuss the epidemiology of MTCT in Malawi. • Discuss biological, social and cultural factors explaining women’s vulnerability to HIV infection. Malawi PMTCT Training Package

6. HIV Infection Rates • HIV can spread rapidly • Some African countries with previously low HIV infection rates among pregnant women now have high infection rates. • For example, in Swaziland HIV prevalence among pregnant women increased greatly: • 4% in 1992 • 34% in 2000 • 43% in 2004 • HIV epidemic in Malawi has not exhausted its potential for growth. Malawi PMTCT Training Package

7. HIV Infection Rates • 400,000 AIDS orphans in Malawi. • The number or orphans is increasing by 60,000/year. • The death rate for adults aged 15-49 has tripled since 1990. • The number of tuberculosis cases is triple what it would have been. Malawi PMTCT Training Package

8. Exercise 2.1 Epidemiology of HIV: Interactive Discussion Malawi PMTCT Training Package

9. Gender & HIV • In Malawi, women (aged 15-24) are more than two times as likely to be HIV-infected than men. • Biological, social, cultural factors contribute to increased vulnerability of women to HIV infection. • Awareness of these factors is first step in addressing gender and HIV issues. Malawi PMTCT Training Package

10. Factors Increasing Vulnerability of Women to HIV Infection Socio-cultural factors • Educational level • Inability to negotiate safer sex • Trauma & bleeding during sex • Sex with older men • Exchanging sex for necessities of survival • Lack of access to information on HIV and STIs Malawi PMTCT Training Package

11. Factors Increasing Vulnerability of Women to HIV Infection (continued) Biological factors : • Cervical cells (Langerhans cells) may provide portal of entry for HIV. • Vulva/vaginal inflammation or ulceration • Silent/undiagnosed STIs & PID • Sexual intercourse during menstruation Malawi PMTCT Training Package

12. Factors that Influence Sexual Behaviour of Men Socio-cultural factors: • Failure to seek care for HIV/STIs • Culturally accepted practice of having multiple sex partners • Ego-driven behaviours to display manhood • Peer pressure to conform to unsafe sex practices Malawi PMTCT Training Package

13. Factors Affecting Both Sexes • Lack of information on sexuality and physical development • Lack of skills to negotiate safer sex • Limited access to health services: • Testing and counselling • Risk reduction • Testing/treatment of STIs Malawi PMTCT Training Package

14. Exercise 2.2 Local HIV-Related Terminology: Interactive Discussion Malawi PMTCT Training Package

15. Unit 2 Mother-to-Child Transmission of HIV Infection Malawi PMTCT Training Package

16. Unit 2 Objectives • Define mother-to-child transmission of HV infection (MTCT). • Explain the factors that influence the transmission of HIV from mother to child. Malawi PMTCT Training Package

17. Mother-to-Child Transmission (MTCT) Definition: • Transmission of HIV from a mother to her baby during pregnancy, labour, delivery, and breastfeeding. • Also called vertical transmission or perinatal transmission • “MTCT” does not attach blame to mother Malawi PMTCT Training Package

18. When can MTCT occur? Timing of MTCT: • During pregnancy • During labour and delivery • During breastfeeding Malawi PMTCT Training Package

19. Rates and Timing of MTCT • Without intervention, 25%-50% of babies born to HIV-infected women will be HIV-infected. • Most transmission occurs during labour and delivery • Substantial risk of transmission also exists during breastfeeding Malawi PMTCT Training Package

20. 50 to 75 infants will not be HIV-infected 100 infants born to HIV-infected women who breastfeed, without any interventions 25 to 50 infants will be HIV-infected 10-20 infants infected during labour and delivery 10-20 infants infected during breast-feeding 5–10 infants infected during pregnancy HIV Outcomes of Infants Born to Women Infected with HIV Malawi PMTCT Training Package

21. Maternal Factors Associated with Increased Risk of HIV Transmission Malawi PMTCT Training Package

22. Summary of PMTCT Interventions Malawi PMTCT Training Package

23. Effect of Pregnancy on HIV Effect of pregnancy on HIV infection: • Immune function is suppressed during pregnancy. • Studies show little effect of pregnancy on HIV progression in asymptomatic HIV-infected women • African women in late stage disease found to have more complications during pregnancy, labour and delivery, and postpartum period. Malawi PMTCT Training Package

24. Effect of HIV on Pregnancy Pregnancy-related complications for women with HIV include: • Increased risk of spontaneous abortions • Double the rate of pre-term deliveries • Increased risk of having LBW infant • Increased risk of stillbirths • Increased risk of bacterial pneumonia, urinary tract and other postnatal infections Malawi PMTCT Training Package

25. Unit 3 Comprehensive Approach to Prevention of HIV Infection in Infants and Young Children Malawi PMTCT Training Package

26. Unit 3 Objectives • Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children Malawi PMTCT Training Package

27. Comprehensive Approach to PMTCT • HIV prevention efforts reach fewer than one in five people at risk • Four elements of comprehensive approach to PMTCT target different populations Malawi PMTCT Training Package

28. Comprehensive Approach to PMTCT: Four Elements • Element 1: Primary Prevention of HIV infection • Element 2: Prevention of unintended pregnancies among women 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 Malawi PMTCT Training Package

29. Comprehensive Approach to PMTCT: Four Elements (continued) • Using Element 3 alone only reduces HIV transmission to infants by 2%-12% • Prevention of primary HIV infection in women (Element 1) and unintended pregnancies among HIV-infected women (Element 2) decreases proportion of infants infected by 35%-45%. Malawi PMTCT Training Package

30. Element 1: Primary Prevention of HIV Infection Primary prevention is the most effective way to control spread of HIV. • Behaviour change interventions (BCI) • Prevention and treatment of STIs • Testing and counselling • Promotion and provision of condoms • Prevention of HIV in young people Malawi PMTCT Training Package

31. Behaviour Change Intervention (BCI) • Backbone of primary prevention of MTCT of HIV • Three main strategies used in BCI: • Communication for behaviour change • Social mobilization • Advocacy Malawi PMTCT Training Package

32. Primary Prevention Prevention and early treatment of STIs • Presence of STIs generally increases risk of HIV infection • HIV infection tends to increase severity of STIs Importance of testing and counselling • Entry point or “gateway” into HIV-related prevention and care services, including PMTCT services and family planning Malawi PMTCT Training Package

33. Primary Prevention Promotion and provision of condoms • Consistent and correct condom use can prevent STIs, HIV and unintended pregnancies Prevention of HIV in young people • Provide information about HIV and AIDS • Teach “life skills” Malawi PMTCT Training Package

34. Exercise 2.3 Supporting Condom Use: Discussion and Demonstration Malawi PMTCT Training Package

35. Exercise 2.4 The Handshake Game: Interactive Game Malawi PMTCT Training Package

36. Element 2:Prevention of Unintended Pregnancies among Women who are HIV-infected • Family planning integral part of Malawi Safe Motherhood Initiative • Access to contraceptives • Early diagnosis and treatment of STIs, including HIV • Continued health promotion, risk reduction and family planning advice; including sex education, complete with information about how condoms provide dual protection against both pregnancy and STIs, including HIV. Malawi PMTCT Training Package

37. Element 2: Common Contraceptive Options Malawi PMTCT Training Package

38. Element 3:Prevention of HIV Transmission from Women to their Infants Core PMTCT Interventions • HIV testing and counselling • ARV prophylaxis or therapy • Safer obstetric practices • Infant feeding counselling and support Malawi PMTCT Training Package

39. Element 3 (continued) Partner involvement in PMTCT • Both partners responsible for safer sex during and after pregnancy. • Both partners should be tested and counselled for HIV. • Both partners responsible for child feeding. Malawi PMTCT Training Package

40. Element 3 (continued) ARV prophylaxis and therapy for mother • ARV prophylaxis refers to ARV drugs given to mother and infant for PMTCT • No long-term benefits to mother from ARV prophylaxis • Pregnant women, with advanced HIV infection may receive ARV therapy • CD4 count or clinical staging according to WHO guidelines to determine eligibility for ARV therapy Malawi PMTCT Training Package

41. Element 4:Provision of Treatment, Care, and Support to Women Infected with HIV, their Infants, Children and Families Treatment, care, and support services for women • Prevention and treatment of opportunistic infections e.g. cotrimoxazole preventative therapy • ARV therapy (at ARV clinics) • Treatment of symptoms • Nutritional support • Reproductive health care (including family planning services) • Psychosocial and community support • Palliative care Malawi PMTCT Training Package

42. Element 4 (continued) Treatment, care and support of infants and children who are HIV-exposed • Infants and children who are HIV-exposed require regular follow-up care, especially during the first 2 years of life • Care should include: • Cotrimoxazole preventive therapy • Screening, diagnosis and treatment of tuberculosis • Immunizations • HIV testing • Ongoing monitoring of feeding, nutritional status, growth, and development Malawi PMTCT Training Package

43. Unit 4 Role of Maternal and Child Health Services and Reproductive Health Services for the Prevention of HIV Infection in Infants and Young Children Malawi PMTCT Training Package

44. Unit 4 Objective • Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children Malawi PMTCT Training Package

45. Maternal and Child Health (MCH) Services • PMTCT services most effective when integrated into RH and MCH services • Antenatal care most common entry point into PMTCT services • MCH services facilitate PMTCT • RHU facilitates PMTCT • HIV/AIDS Unit facilitates PMTCT Malawi PMTCT Training Package

46. Comprehensive PMTCT Services • Group pre-test HIV-related education & routine testing • Individual counselling • Partner involvement • Community mobilization • Family planning services • Post-test counselling, including infant feeding counselling • Nutrition counselling and supplements • ARV prophylaxis or clinical staging & referral to ART clinics • Follow-up care Malawi PMTCT Training Package

47. Module 2: Key Points • Approximately 80,000 women/year in Malawi need PMTCT services to prevent passing HIV to their infants • Young women in Malawi are 2.2 times more likely to be HIV-infected than young men. This is due to biological, social, and cultural factors. • The overall MTCT of HIV rate is approximately 40% without intervention. Malawi PMTCT Training Package

48. Module 2: Key Points (continued) • Effective PMTCT services provide access to interventions that can significantly reduce the rate of MTCT. • Because ARV prophylaxis alone does not treat the mother’s infection, ongoing care and ARV therapy (if eligible) is needed. Malawi PMTCT Training Package

49. Module 2: Key Points (continued) • The four elements of a comprehensive PMTCT programme effectively reduce MTCT of HIV: • Primary prevention of HIV infection • Prevention of unintended pregnancies in women infected with HIV • Prevention of HIV transmission from women infected with HIV to their infants • Provision of treatment, care and support to women infected with HIV, their infants, and their families Malawi PMTCT Training Package

50. Module 2: Key Points (continued) • MCH, especially ANC services are an entry point to the range of services that provide treatment, care, and support to the woman who is HIV-infected and her family. • Linkages to community services can enhance treatment, care, and support. Malawi PMTCT Training Package