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Dr KABERA Ren Family Physician

Background Objectives Guidelines References

Tuesday, December 31, 2013

AIDS is a pandemic threat to Public Health Rwanda: countrywide 200.000 people living with HIV/AIDS3 The prevalence is 3% (DHS 2010) and 4.7% among pregnant women (UNAIDS 2009)3. Kabutare : Prevalence of HIV among pregnant women is 2.9 % -Among 1258 pregnant women 36 were infected with HIV (July 2012- Dec 2012)5
Tuesday, December 31, 2013

PMTCT: Prevention of Mother to child transmission of HIV Rwanda: April 1999 ,TRAC with support from UNICEF in Kicukiro Health Center Zidovudine from 28wks to birth ,the cost was expensive (800 US $) HIVNet012 regimen: NVP at labor and Newborn, the resistance raised attention (monotherapy) Dec 2005 ,Tritherapy HAARTs protocol initiation Nov 2009,WHO adopted new recommendations, Breastfeeding 1999 to 2009 :1 site to 366 sites of PMTCT
Tuesday, December 31, 2013

The clinical prevention of HIV in Rwanda includes six components: 1. Voluntary counseling and testing of HIV (VCT). 2. Prevention of mother-to-child transmission of HIV (PMTCT). 3. Prevention among HIV-positive individuals. 4. HIV prevention among high-risk groups. 5. Provider-initiated testing of HIV. 6. Male circumcision.
Tuesday, December 31, 2013

Primary prevention of HIV, especially among women of child-bearing age. Integration of PMTCT interventions with basic antenatal care Strengthening postnatal care for the motherbaby pair. Provision of an expanded package of PMTCT

Tuesday, December 31, 2013

The primary prevention of HIV infection in future parents. The prevention of HIV transmission from the infected mother to her child. The prevention of unwanted pregnancies among HIV-positive women. Comprehensive care and treatment of the infected woman, her child, and her family.
Tuesday, December 31, 2013

HIV-positive pregnant women HIV+ eligible for ARV(CD4 <350,WHO Clin. Stg 3,4) HIV+ CD4 350-500 HIV+ CD4 >500 HIV+ NVP exposure (Single dose) HIV+ Renal impairment HIV+ >34 weeks HIV-negative in discordant couple ARV for Children exposed to HIV
Tuesday, December 31, 2013

HIV-positive pregnant women eligible for ARV treatment CD4 count < 350 WHO clinical stage of 3 or 4 TDF 300 + 3TC 300 + NVP 200 Dosage Initiation phase 14 D : TDF+3TC 1Tab OD and NVP 1Tab OD Maintenance phase TDF+3TC 1Tab OD and NVP 1Tab BD
Tuesday, December 31, 2013

HIV-positive pregnant women eligible for ARV Treatment - CD4 :350 - 500 They will receive triple therapy from the 14th week for life . Their regimes are the same as those of noneligible women mentioned below. Dosage : TDF+ 3TC+ EFV 1Tab OD

Tuesday, December 31, 2013

HIV-positive pregnant women non-eligible for ARV treatment - CD4 >500 Any woman with a CD4 count > 500 is noneligible for ARV treatment for life. Triple therapy from the 14th week of gestation until one week after weaning. The recommended duration of breastfeeding is 18 months. Dosage :TDF 300+3TC 300+ EFV 600 1tab OD
Tuesday, December 31, 2013

HIV-positive pregnant women with prior exposure to single-dose Nevirapine From previous pregnancy Dosage :TDF 300 + 3TC 300 1Tab OD Kaletra 250 2Tab BD

Tuesday, December 31, 2013

HIV-positive pregnant women with impaired renal function ABC300 1 Tab BD + 3TC 150 BD + EFV 600 OD (N) HIV-positive pregnant women with impaired renal function with single dose of NVP exp ABC300 1Tab BD +3TC 150 BD+ Kaletra 250 2Tab BD
Tuesday, December 31, 2013

HIV-positive pregnant women arriving late: after 34 weeks of gestation TDF300 + 3TC300 + EFV600 1 Tab OD treatment after a renal assessment (Creatinine) o If the CD4 count < 500/ mm3, the woman is eligible for ARV treatment and will continue the treatment for life. o If the CD4 count > 500/ mm3, she will continue the same treatment until one week after the cessation of breastfeeding.
Tuesday, December 31, 2013

HIV-negative pregnant women in a serodiscordant couple HIV every three months, as well as at the onset of labor. If she is shown to be HIV-positive: refer to the section on care for HIV positive pregnant women (see above). If she remains HIV-negative, she will receive during labor a single dose of TDF + 3TC + EFV and continue with TDF + 3TC (one combined tablet per day) for one week after delivery Prophylaxis in Children: NVP syrup until weaning
Tuesday, December 31, 2013

All children born to HIV-positive mothers, whether the mothers breastfeed or not, will receive Nevirapine (NVP) syrup during the first six weeks of life.

Tuesday, December 31, 2013

Follow up of women taking prophylaxis After initiating ARV prophylaxis, Liver function tests (ALAT) and renal function tests (Creatinine) (M1),(M3),(M6) for women on triple therapy. NVP toxicity before the end of her first trimester, replace NVP Kaletra. NVP toxicity after first trimester, replace NVP EFV. CD4 counts every six months for women on HAARTs Monitoring the nutritional status
Tuesday, December 31, 2013

Ensure that every patient is in possession of a referral card and check their serologic status, as well as the ARVs prescribed for cases diagnosed HIV-positive. Systematically propose an HIV test to every woman who comes to the delivery room not knowing her HIV status. For all pregnant women who tested HIV-positive during ANC or in the delivery room, or who have an HIV-positive partner, ensure that they are given ARVs and enrolled in the follow-up program for PLWHIV. Give advice on family planning.
Tuesday, December 31, 2013

Artificial rupture of membranes Vaginal examinations Episiotomy Induced labor Tying the umbilical cord Aspirating the newborns nostrils with a suction tube

Tuesday, December 31, 2013

Vaginal disinfection: Vaginal disinfection with 0.25% Chlorhexidine solution Disinfection of the newborn: Immediately after birth, it is recommended that the child be wiped with 0.25% Chlorhexidine solution

Tuesday, December 31, 2013

Biological follow up PCR: 6wks If negative do serology at 9mo If positive (+--) do HIV test at 9mo (+-+) HAARTs (++) HAARTs HIV Test: 9 Mo (+) PCR (+) HAARTs (-) do HIV Test at 18 Mo 18 Mo (+) PCR (+) HAARTs (-) Declared Negative
Tuesday, December 31, 2013

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Clinical Update on Prevention of Maternal to Child Transmission of HIV WHO Guidance 2009-2010 National standards and guidelines for the clinical prevention of HIV Rwanda.2011 Rwanda-Demographic Health Survey. 2010 National guidelines for comprehensive care of people living with HIV in Rwanda.2011 R. Kabera, L. King. The Prevalence of HIV Infection among Pregnant Women at Kabutare District Hospital Rwanda. East and Central African Journal of Surgery. November/December 2013 Vol. 18 (3)

Tuesday, December 31, 2013