Continuing Care for Mothers, Children, and Families Following Prevention of Mother-to-Child Transmission of HIV (PMTCT)

1. Continuing Care for Mothers, Children, and FamiliesFollowing Prevention of Mother-to-Child Transmission of HIV (PMTCT) Programmes

2. Objectives for this Module • Describe comprehensive HIV care for women, children, and their families. • Understand the basic principles and purpose of family-centred care. • Identify and strategically address gaps in the provision of comprehensive HIV care for women, children, and their families.

3. Objectives for this Module • Recognize common signs and symptoms of HIV in infants and young children. • Understand the importance of male involvement in PMTCT and HIV programmes and be able to suggest creative strategies to encourage their participation. • Describe the difference between linkages and referrals.

4. Objectives for this Module • Improve referral practices between PMTCT and HIV care and treatment programmes. • Discuss retention strategies for keeping women and their families in care. • practise problem-solving skills to address social issues affecting a client’s capacity to follow-up with care and treatment.

5. Session 1 Introduction to Comprehensive Care for Mothers, Children, and Families

6. Objectives of Session 1 • Describe comprehensive HIV care for women, children, and their families. • Understand the basic principles and purpose of family-centred care. • Identify and strategically address gaps in the provision of comprehensive HIV care for women, children, and their families.

7. Objectives of Session 1 • Recognize common signs and symptoms of HIV in infants and young children. • Understand the importance of male involvement in PMTCT and HIV programmes and be able to suggest creative strategies to encourage their participation.

8. Introductory Presentation PMTCT and HIV Careand Treatment Programmes

9. Large Group Discussion • Barriers to accessing HIV-related treatment, care, and support • Role of a PMTCT healthcare worker in comprehensive care

10. Role of PMTCT Healthcare Workers in HIV Care & Treatment • Assess client needs • Recognize clinical symptoms • Understand when to refer • Establish and maintain referral and linkage systems • Participate in client case management • Advocate for comprehensive care needs

11. Comprehensive Managementof a Person with HIV • Shared responsibility for client: • Multi-disciplinary team • Community • Family • Client themselves

12. Components of comprehensive treatment, care, and support • For mother and partner • For child • For family

13. Comprehensive Carefor Mother and Partner • HIV testing for partner • ARV therapy assessment and referral • Screening, prevention, and treatment of HIV-related conditions • Counselling and support on adherence and nutrition • Psychosocial and spiritual support

14. Comprehensive Carefor Mother and Partner • Information, counselling, and support on infant feeding • Safer sex and family planning • Referral to community organizations • Disclosure counselling and support • Palliative care, when indicated • Drug and alcohol counselling and treatment

15. Comprehensive Carefor Child • ARV therapy assessment and referral • Screening, prevention, and treatment of HIV-related infections • Growth and development monitoring • Immunizations • HIV diagnosis by laboratory test or presumptive diagnosis

16. Comprehensive Carefor Child • HIV education (as appropriate) • Psychosocial support • Disclosure counselling (as appropriate) • Links and relationships with community service organizations and agencies to promote continuity of care

17. Comprehensive Carefor Family • HIV testing for older children • Adherence counselling • Links and relationships with community service organizations and agencies to promote continuity of care • HIV education • Psychosocial and spiritual support

18. Comprehensive Carefor Family • Referrals and links to domestic violence organizations • Bereavement counselling • Social support services • Legal advice and services • Employment, income-generation activities

19. Family-centred Care Family-centred care recognizes all persons who function as family members, as identified by the person living with HIV infection.

20. Goals of Family-based Care • Decrease morbidity and mortality • Improve the quality-of-life for HIV-infected women, children, and their families • Reduce transmission of HIV through secondary prevention counselling and education

21. Opportunities to Reach Families within PMTCT Programmes • HIV counselling and testing for all sexual partners • Family-focused adherenceand disclosure counselling • Mechanisms to reach family members during appointments • Postpartum • MCH • Paediatric

22. Discussion Question • How has the role of PMTCT healthcare workers expanded? • Discuss how healthcare workers feel about this expanded role. ?

23. Postpartum Care forHIV-infected Mothers • Best practices in postpartum care include: • Mechanism to communicate mother’s ANC and L&D history to postpartum nursing staff • Mechanisms to target mothers who miss ANC appointments • Community resources to locate and link mothers to care Review Appendix A – “Checklist for Postpartum Visit for HIV-infected Women and HIV-exposed Newborns”

24. Exercise 1 Facilitating Referrals between PMTCT and HIV Care and Treatmentlarge group discussion

25. Follow-up Care of theHIV-exposed Infant • Follows best practices applied to all infants and children • Assessment of growth, nutrition, and development • Vaccines • Full physical exam focusing on identification of HIV-related infections • Cotrimoxazole prophylaxis at 4-6 weeks of age Review Appendices B and C “Infant/Young Child Follow-up Visits” “Monitoring Growth, Nutrition, and Development of HIV-exposed Infants and Children”

26. Diagnosis of HIV Infectionin Infants • Immune system of HIV-infected children immature • Close follow-up and diagnosis critical to saving children’s lives • 1/3rd die by 1 year old • ½ die by 2 years of age • Diagnosis using clinical symptoms or HIV testing

27. Diagnostic Testing of HIV-exposed Infants and Young Children • Caribbean guidelines recommend HIV DNA PCR viral testing be performed for HIV-exposed infants starting at 6-8 weeks of age. • HIV antibody tests may be difficult to interpret in children less than 18 months of age due to the presence of maternal antibodies to HIV. • HIV antibody tests can be used to diagnose HIV infection in children 18 months of age and older. Always refer to national guidelines and algorithms

28. Recognizing HIV Infectionin Children • All healthcare workers working with infants and children: • Identify the signs and symptoms of HIV-infection • Provide or refer for HIV diagnostic testing and HIV care and treatment

29. Suspecting HIV Infectionin a Child • All infants/children born to mothers with unknown HIV status should be considered at risk • Encourage and support testing for all mothers • Refer to healthcare team specializing in HIV care if HIV infection is suspected

30. Risk factors for HIV if Mother’s HIV Status is Unknown • Mother has symptoms of HIV or another STI If mother is diagnosed with HIV, all of her children need to be tested

31. Common Signs and Symptomsof HIV infection in Infants/Children • Low weight and/or growth failure • Lymphoid interstitial pneumonia (LIP) • Hepatosplenomegaly • Pneumonias, including PCP • Oral candidiasis (thrush)

32. Common Signs and Symptomsof HIV infection in Infants/Children Digital clubbing from lymphoid interstitial pneumonia Severe wasting/malnourishment

33. Common Signs and Symptoms of HIV infection in Infants/Children • Lymphadenopathy • Parotid gland swelling • Recurrent ear infections • Persistent diarrhoea — for more than one week • Tuberculosis Review Table 2:“Clinical conditions or signs of HIV infection in a child who is HIV-exposed”

34. PCP pneumonia Common Signs and Symptoms of HIV infection in Infants/Children Oral thrush

35. Growth and HIV Infection • Growth failure reported in as many of 50% of HIV-infected children • Growth failure defined as the persistent and unexplained decline or levelling-off in weight and the speed of growth despite adequate nutrition.

36. Growth and HIV Infection • Growth monitoring and nutritional assessment performed for all for HIV-exposed and infected children. • Poor growth may be one of the first indicators of HIV infection in children. See Appendix C – Monitoring Growth, Nutrition, and Development of HIV-exposed Infants and Children

37. Exercise 2 Clinical Presentation of HIVin Infants and Childrenlarge group discussion & case studies

38. Male Partners and HIVPrevention, Care, Treatment,and Support • Men have the power to alter the HIV epidemic in Caribbean • Can prevent HIV transmission to their partners • Can seek/support HIV care and treatment for self and families

39. Men and HIV Risk • Culturally acceptable to fathermultiple children with different partners • Multiple sex partners • Work migration • Expectations of “manhood” • Risky behaviors • Drug use • Paying for sex • Men expected to determine when, where, and how couples have sex

40. Barriers to Safe Sexfor Couples • Misinformation about condoms • Clumsy • Reduction of sexual pleasure • Belief that contraception is a woman’s responsibility • Marriage not necessarily equated with mutual faithfulness

41. Barriers to Safe Sexfor Couples • For women: • Difficulty of negotiating for safer sex • Fear of reprisal if condoms requested • Stigma against homosexuality • High risk sex may not be disclosed to female partners

42. Discussion Questions • How can we encourage men to be more involved in the health of their families? • As healthcare workers what can we do to encourage the involvement of men?

43. The Evolving Role of Men • Male involvement in ANC increases rates of PMTCT uptake. • Involving men in the health of the family involves challenging beliefs about traditional roles.

44. Strategies to Include Men in HIV Prevention, Care, & Treatment • Offer HIV counselling and testing at flexible times • Promote HIV counselling and testing where men gather • Sporting events • Workplace

45. Strategies to Include Men in HIV Prevention, Care, & Treatment • Involve male role models • Support for HIV prevention efforts that target norms of masculinity • Adopt policies at health facilities that normalize male attendance • Provide family planning counselling to couples See Appendix F – “Family Planning in the Context of HIV Infection”

46. Session 2 Linkages, Referrals, andRetention Strategies

47. Objectives of Session 2 • Describe the difference between linkages and referrals. • Discuss retention strategies for keeping women and their families in care. • Improve referral practices between PMTCT and HIV care and treatment programmes. • Practise problem-solving skills to address social issues affecting a client’s capacity to follow-up with care and treatment.

48. Introduction to Linkagesand Referrals • Both HIV-infected and uninfected women benefit from referrals to services outside of PMTCT programmes. • Linkages provide a “seamless” continuum of care as if there were a single entity delivering a range of services.

49. Linkages • Formal networks between organizations or agencies • Facilitate the referral of the client and her family for services • Foster a sense of joint purpose and joint achievement for healthcare workers

50. PMTCT Linkages PMTCT programmes should be linked to: • Tertiary referral hospitals, district hospitals, and peripheral health facilities • Other government organizations e.g., schools, social welfare agencies, and local government • Communities they serve • Non-governmental and faith-based community organizations • Private doctors and healthcare providers