PMTCT

1. PMTCT KING DAVID 12 APRIL 2010 BY:MRS SIWUNDLA

2. BACKGROUND • Entry to PMTCT services involves HCT • HCT is an entry point to comprehensive continuum of care • Encourages and supports formal collaboration between the public, private and NGO sectors • Ensures that people who test HIV negative are encouraged and motivated to maintain their negative status

3. Continue • Those who test + are supported in living long healthy lives through positive health seeking behaviors and the appropriate service hence PMTCT

4. Pilot phase 2001 – 2 sites Guidelines developed in 2000 Comprehensive package Based on single-dose Nevirapine (sdNVP) 1st report on resistance- 60% at 6 weeks- May 2004 Further resistance data – wanes after 6 months Research – Dual therapy 2008 Approval of CCMT guidelines on 5 February 2010 Update of PMTCT guidelines – Access of ART for pregnant women Improved efficacy outcomes Eradication of HIV in infants Towards an HIV free South Africa Continue

5. New guidelines are an update to the National PMTCT policy and guidelines AIMS Ensure primary prevention of HIV among women of childbearing age Integration of PMTCT interventions into BANC, SRH, STI, Child and Adolescent Health, CCMT, Maternal and TB services Strengthening postnatal care Providing an expanded package of PMTCT services 4 pronged approach Prevention of primary HIV infection Prevention of unwanted pregnancies in all women of child bearing age. Prevention of mother to child transmission Treatment, care and support NEW GUIDELINES

6. To strengthen the implementation of the Comprehensive Plan To contribute to the overall NSP prevention goal of reducing HIV incidence rate by 50% in SA by 2011. To keep women and children healthy and improve the quality of their life thus reduce mortality Specific PMTCT objectives (in NSP) Broaden existing PMTCT services to include related services and target groups – Integration Scale up and improve quality of PMTCT to reduce MTCT to less than 5% Specific targets as per NSP Further to be informed by practical provincial business plans OBJECTIVES

7. Package of services Routine offer of counselling and testing Provision of PICT in the context of BANC Involvement of partner and family – comprehensive approach Provision of appropriate regimens for PMTCT and quality of mother’s life Provision of other appropriate treatments Prophylaxis Opportunistic infections EXPANDED PMTCT

8. Provision of psychosocial support to HIV positive women Quality, individualised counselling on safe infant feeding EBF EFF Strengthened obstetrical practices to reduce MTCT ARV prophylaxis to infants Integrated follow up of exposed infants – IMCI strategy Early HIV infant testing – PCR at 6 weeks Strengthening of community based household and door to door activities EXPANDED PMTCT

9. Early booking All to receive information about HIV in a group - Couple counselling and testing Routinely offering CT to all Provider Initiated Counselling and testing Consent- written and/or verbal Blood specimens to include for rapid HIV and CD4 (same day) Clinical staging ENROLMENT OF WOMEN

10. Discordant Sent for ELISA All to receive post-test counselling Offer CT at all subsequent visits to those who refused Ongoing individualised counselling to HIV positive Repeat test at 32 weeks if initially HIV negative Window period Post-test new infections ENROLMENT OF WOMEN

11. Counselling on safe sex and provision of condoms Encourage partner disclosure and testing Family planning ART Prophylaxis at 14 weeks or later (If no indication clinically and CD4 unavailable, initiate AZT while awaiting CD4 results) or ART lifelong to all that are eligible (within two weeks) Alanin Aminotransferase (ALT) baseline for women to be initiated on NVP consisting regimen FBC (Hb) for women to be initiated on AZT Creatinine Clearance for women initiated on TDF HepbAg CLINICAL CARE OF HIV POSITIVE WOMEN

12. Cotrimoxazole WHO Stage III and IV CD4 <350 (Results in 5-7 days) TB screening and treatment (Screen for TB before initiating ART lifelong – drug interaction) OI management according to guidelines Micronutrient supplements Dietary advice Safe infant feeding-counselling Assess all women for eligibility at subsequent visit CLINICAL CARE OF HIV POSITIVE WOMEN

13. Feeding to maximize survival and prevent MTCT Counsel all HIV positive women on safe feeding Either exclusive replacement feeding or exclusive breast feeding Mixed feeding strongly discouraged Exclusive breastfeeding recommended for 1st 6 months of life Mothers on ART lifelong may continue breast feeding for the 1st 12 months of life Mothers not on ART lifelong may stop Breastfeeding at any time but weaning should be gradual during one month while baby is still on NVP Complementary foods from 6 months Provision of uninterrupted supply of free formula for at least 6 months Support feeding option (psychological and practical) SAFE INFANT FEEDING

14. As per IMCI guidelines All HIV exposed infants to receive NVP daily for 6 weeks All HIV exposed infants to have PCR (dry blood spot) test at 6 weeks and commence cotrimoxazole Infants testing positive for PCR should have a confirmatory viral load and urgently referred for inintiation of ART Stop cotrimoxaxole if test is negative and infant no longer on breast Above 18 months - HIV antibody test Breastfed infants retested 6 weeks after cessation of breastfeeding INFANT FOLLOW - UP

15. Early ANC booking – as soon as misses period Benefits of CT Primary HIV Prevention Male and partner involvement Safe infant feeding The PMTCT package Adherence and support Where to access all relevant services? Importance of follow up COMMUNICATION AND SOCIAL MOBILISATION

16. Challenges • Verticalization of the program • Circumcision versus condom use • NVP misuse

17. Recommendation • To strengthen the services in support of the PMTCT program at district level and sub district level

18. THANK YOU