National Comprehensive PMTCT/MNCH Integrated Training Manual

National Comprehensive PMTCT/MNCH
Integrated Training Manual
Participant manual
November 2021, MOH, Ethiopia
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1
APPROVAL STATEMENT OF THE MINISTRY
The Federal Ministry of Health of Ethiopia has been working towards standardization and
institutionalization of In –Service Trainings (IST) at national level. As part of this initiative
the ministry developed a national in service training directive and implementation guide for
the health sector. The directive requires all in service- training materials fulfill the standards
set in the implementation Guide to ensure to quality of In –service training material.
Accordingly, the Ministry reviews and approves existing training material based on the IST
Standardization checklist annexed on the IST implementation guide.
As part of the national IST quality control process, this National Comprehensive
PMTCT/MNCH Integrated training package has been reviewed using a standardization
checklist and approved by the Ministry in February 2022.
Assegid Samual Cheru

Human Resource Development Directorate
Director
Ministry of Health, Ethiopia
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ACKNOWLEDGEMENTS
FMOH acknowledges and expresses its deep appreciation for the contributions of the
PMTCT Technical Working Group members, Regional Health Bureaus, health service
providers, PLWHA, Mother Mentors (MSG) organizations, partner organizations, private
organizations and private consultants and PMTCT Tutors who assisted in the development
and revision of this training manual. The Ministry would like to extend its special recognition
for PMTCT Technical Working Group members who were fully involved in the revision of
this training manual.
FMOH extends its deepest gratitude to the experts listed below for their unreserved effort to
realize the training manual.
1 Dr. Meseret Zelalem MoH

2 Meron Abdurahman MoH
3 Aregash Molla MoH
4 Mulu Begna MoH
5 Dr. Zebideru Zewdie MoH/ICAP
6 Takele Yeshiwas MoH
7 Supa Teferi MoH
8 Daba Ejara Madawalabu University
9 Tesfaye Bedru Private consultant
10 Tesema Gebru ORHB
11 Dr. Birhanu Gudeta ARHB
12 Dr. Meaza Damtew ICAP
13 Dr. Abebe Abadi MoH
14 Dr. Mohamed Zidan CDC
15 Dr. Nigist Belayneh UNAIDS
16 Seid Yusuf Arsi University
17. Tolera Geremew MOH
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Acronyms
AIDS Acquired Immuno Deficiency Syndrome MBPC Mother baby pair cohort
ANC Antenatal care MDT Multi-disciplinary team
ART Antiretroviral therapy M&E Monitoring and evaluation
ARV Antiretroviral MNCH Maternal, newborn, and child health
AZT Azidothymidine (Zidovudine) MOH Ministry of Health
BCC Behaviour change communication MRN Medical record number
BCG Bacillus-Calmette-Guerin MSG Mother Support Group
CDC Centers for Disease Control and MTCT Mother-to-child transmission of HIV
Prevention
CD4 Cluster of differentiations 4 NB Newborn
CHWs Community health workers NRTI nucleotide reverse transcriptase inhibitor
C/S Caesarean Section NNRTI Non-nucleotide reverse transcriptase inhibitor
COC Combined oral contraception NVP Nevirapine
CPT Co-trimoxazole preventive therapy OI Opportunistic infections
CQI Continuous quality Improvement OPV Oral Polio Vaccine
CSF Cerebrospinal Fluid PSG Peer support group
3TC Lamivudine PCP Pneumocystis carrini pneumonia
DNA-PCR Di Nucleic Acid Polymerase chain Reaction PCR Polymerase chain reaction
DQA Data Quality Assurance PEP Post-exposure prophylaxis
DBS Died blood spot PI Protease inhibitor
DHS Demographic and Health Surveys PITC Provider-initiated HIV testing and counselling
EDD Expected date of delivery PLHA People living with HIV/AIDS
EAC/S Enhanced Adherence Counselling/Support PMTCT Prevention of mother to child transmission
EDD Expected date of delivery
EID Early Infant Diagnosis PNC Postnatal care
EPI Expanded program of immunization POCS Point of care Com and integrated Services
Pre Exposure HIV Prophylaxis
PrEP
e PNP Enhanced HIV Postnatal prophylaxis RH Reproductive health
EPT Expert Patient-Trainers ( mentor mothers) STI Sexually transmitted infection
EPNP Enhanced postnatal prophylaxis TAT Turn around time
FMOH Federal Ministry of Health TB Tuberculosis

FP Family planning TDF Tenofovir
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GA Gestational age TLD Tenofovir/ Lamivudine/Dalutegravir FDC
GOE Government of Ethiopia TMP-SMZ Trimethoprim-Sulphamethoxazole
HAART Highly active antiretroviral treatment TPHA Trepanomal Hemo Agglutination test
TPT TB Prevention Prophylaxis
HAPCO Federal HIV/AIDS Prevention and TT Tetanus toxoid
Control Office
HBV Hepatitis B Virus UAN Unique ART number
HEI HIV exposed infant UNAIDS Joint United Nations Program on HIV/AIDS
HEW Health extension worker VDRL Venereal disease research laboratory
HF Health facility WLHIV Women Living with HIV
HIV Human immunodeficiency virus WHO World Health Organization
HMIS Health management information system
HTC HIV testing and counselling
HVL High Viral load
INH Isoniazid
IP Infection Prevention
ITN Insecticide-treated bed net
IYCF Infant and young child feeding
L&D Labour and delivery
LMP last menstrual period
LRTI Lower respiratory tract infection
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Contents
Foreword ………………………………………………………………………………………………………………………………………..1
APPROVAL STATEMENT OF THE MINISTRY................................................................................ 2
ACKNOWLEDGEMENTS .................................................................................................................... 3
Acronyms ................................................................................................................................................ 4
List of Tables ......................................................................................................................................... 10
List of Figures ........................................................................................................................................ 11
Introduction to the manual .................................................................................................................... 12
Rationale of revising the course ............................................................................................................ 12
Course syllabus ..................................................................................................................................... 14
Chapter 1: Comprehensive PMTCT Services during ANC .................................................................. 23
1.1. Basics of HIV and Mother to Child Transmission (MTCT) .......................................................... 24
1.1.1. Introduction to HIV and the Immune system ..................................................................... 26
1.1.2. HIV and the Immune System .............................................................................................. 27
1.1.3. Life cycle of HIV ................................................................................................................... 28
1.1.4. CD4 T-cell and HIV Viral Set Point ....................................................................................... 29
1.1.5. HIV infection and disease progression................................................................................ 30
1.1.6. Mother-to-Child Transmission of HIV ................................................................................. 32
1.2: Antenatal Care in the context of HIV ........................................................................................ 43
1.2.1. Introduction to the session .................................................................................................. 43
1.2.2. Essential Elements of Care during Pregnancy .................................................................... 44
1.2.3. Birth Preparedness and Complication readiness plan ......................................................... 49
1.2.4. Practices not recommended during pregnancy ................................................................... 49
1.2.5. Importance of male partner involvement in ANC/PMTCT ................................................ 50
1.3: HIV TESTING AND COUNSELING DURING ANC ............................................................. 52
1.3.1. HIV testing and counseling for pregnant women ............................................................... 53
1.3.2. Provision of pre - test information at ANC setting. ............................................................ 54
1.3.3. The six guiding principles of HTS in the context of PMTCT ............................................. 57
1.3.4. Basic counseling skills ........................................................................................................ 58
1.3.5. The Benefits of HIV Testing and Counseling Services for Women ................................... 59
1.3.6. Disclosure ........................................................................................................................... 60
1.3.7. Integration of HIV testing into antenatal care services ....................................................... 62
1.3.8. Components of HIV testing and counseling ....................................................................... 62
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1.3.9. HIV Rapid Testing .............................................................................................................. 65
1.3.11. Post-Test Counseling ........................................................................................................ 73
1.3.11. Couple counseling ............................................................................................................. 81
1.4: SPECIFIC INTERVENTIONS FOR PMTCT IN THE ANC SETTING .................................. 89
1.4.1. Introduction to the session .................................................................................................. 89
1.4.2. HIV Clinical Review and assessment ................................................................................. 89
1.4.3. Determine WHO clinical stage ........................................................................................... 91
1.4.4. Laboratory ........................................................................................................................... 96
1.4.5. Opportunistic infections and prophylaxis ........................................................................... 97
1.4.6. TB screening guide ............................................................................................................. 98
1.5: CARE AND TREATMENT FOR HIV POSITIVE PREGNANT WOMEN.......................... 109
1.5.1. Introduction to ARVs ........................................................................................................ 109
1.5.2. Monitoring of response to ART ........................................................................................ 116
1.5.3. What to expect in the first months of ART ....................................................................... 117
1.5.4. Monitoring and managing Drug-Drug Interaction ............................................................ 118
1.5.5. Diagnosis of Treatment failure.......................................................................................... 121
1.5.6. Monitoring of women initiated ART ................................................................................ 126
1.5.7. Adherence Preparation and Support for Pregnant Women ............................................... 128
1.5.8. Nutritional support ............................................................................................................ 132
1.5.9. Palliative care .................................................................................................................... 135
1.5.10. Mother support groups for HIV positive pregnant women ............................................ 138
2. PMTCT of Syphilis during ANC ............................................................................................ 139
2.1 Basics of Syphilis and MTCT ..................................................................................................... 139
2.2 Screening for syphilis during ANC ...................................................................................... 143
2.3 Basic Principles for management of syphilis to prevent MTCT of congenital syphilis .... 143
3. PMTCT of Hepatitis B virus...................................................................................................... 146
3.1. Basics of HBV and MTCT ...................................................................................................... 147
3.2 Screening of pregnant women for HBV ................................................................................ 148
3.3 Maternal and infant interventions for PMTCT of HBV .......................................................... 149
Chapter 2: PMTCT IN LABOR AND DELIVERY SETTING.......................................................... 154
2.1. PMTCT Interventions during Labor &Delivery ...................................................................... 155
2.2. STANDARD PRECAUTIONS DURING LABOR AND DELIVERY .................................. 156
2.3 Management of Needle Stick and Other Potential Exposures to HIV in the Workplace .......... 164
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2.4. MANAGEMENT OF LABOUR AND CHILDBIRTH IN THE CONTEXT OF PMTCT........................... 165
2.4.1. HIV Testing Services during Labor ................................................................................. 165
2.4.2. Check for HIV status....................................................................................................... 165
2.4.3. Guiding principles of HIV Testing Services : ................................................................... 166
2.4.4. ARV drug use during Labor and Delivery in different scenarios ....................................... 168
2.4.5. The partograph .................................................................................................................. 169
2.4.6. Safe obstetric practices during labor and delivery for PMTCT ........................................ 179
2.5. IMMEDIATE POSTPARTUM AND NEWBORN CARE ..................................................... 181
2.5.1 Immediate Postpartum care of HIV-infected women................................................. 181
2.5.2 Immediate Postpartum care of women with unknown HIV status ............................ 183
2.5.3. Immediate Newborn ......................................................................................................... 183
2.5.4. Newborn Resuscitation ..................................................................................................... 186
CHAPTER 3: PMTCT IN PNC SETTINGS ................................................................................................ 191
3.1: OVERVIEW OF POST-NATAL CARE IN THE CONTEXT OF HIV .................................................. 191
3.1.1 Interventions to reduce the risk of MTCT of HIV during postnatal period ................ 192
3.1.3 Male involvement in PMTCT during postnatal period ...................................................... 194
3. 2: PMTCT DURING THE FIRST 24HOURS OF CHILDBIRTH ............................................ 195
3.2.1 Assess, classify, and treat the postnatal woman and new born .......................................... 195
3.2.2 HIV Testing Services (HTS) in postnatal care service ......................................................... 198
3.2.3 Postnatal care in the context of HIV infection and for all postnatal women...................... 200
3.2.4 Provide additional care for HIV-positive postnatal women .............................................. 202
3.3: NEWBORN CARE THE FIRST 24 HOURS.......................................................................... 205
3.3.1 Routine newborn care ........................................................................................................ 205
3.3.2 PROVIDE CARE FOR HIV-EXPOSED INFANTS ........................................................ 206
3.3.3 Provide counseling and support on safer infant feeding .................................................... 219
3.4: Family Planning Counseling And Services For HIV Positive Women ................................... 228
3.4.1 Considerations about use of Family Planning Methods by Women Living with HIV ...... 228
3.4.2 Integration of FP service to HIV care including PMTCT .................................................. 229
Chapter 4: Monitoring and Evaluation (M & E) in PMTCT .............................................................. 236
4.1 Introduction to Monitoring &Evaluation and Indicators .......................................................... 237
4.1.1 Monitoring &Evaluationand Indicators ................................................................................. 238
4.2: Recording and reporting of data ............................................................................................. 242
4.2.1 Recording data in cards, registers, and report forms .......................................................... 242
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4.2.2 Reporting: Flow by type and period, channel .................................................................... 261
4.3 PMTCT cohort monitoring ....................................................................................................... 263
4.3.1 Introduction to PMTCT cohort monitoring........................................................................ 263
4.4.2 Maternal PMTCT Cohort Monitoring................................................................................ 268
4.3.3 HIV-EXPOSED INFANT (HEI) PMTCT COHORT ........................................................ 282
4.4: DATA QUALITY.................................................................................................................... 292
4.5 Performance Evaluation using Dashboard and Continuous Quality Improvement (CQI) ...... 294
4.5.1 Performance evaluation using dashboard........................................................................... 294
4.5.2 Performance Evaluation using Continuous Quality improvement (CQI) .......................... 298
REFERENCES ........................................................................................................................................ 308
Annexes ............................................................................................................................................... 310
Chapter 1 annexes ........................................................................................................................... 310
Chapter 3 Annexes .......................................................................................................................... 338
Chapter 4 annexes ........................................................................................................................... 360
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List of Tables
Table 2: Estimated Risk of MTCT of HIV without intervention ............................................................. 32
Table 3: Factors increasing risk of Mother-to-Child transmission of HIV ............................................. 33
Table 4: The antenatal contact schedule .............................................................................................. 43
Table 5: Inconclusive test result interpretation after 14 days .............................................................. 71
Table 6: Checklist for observing counselling sessions for positive test result during role play ............ 80
Table 7: Follow – up after initiation of PrEP ......................................................................................... 86
Table 8:History taking &physical examination. .................................................................................... 90
Table 9: Physical examination for HIV positive pregnant women ........................................................ 91
Table 10: WHO Adolescent and Adult HIV Clinical Staging ................................................................... 93
Table 11: INH prophylaxis and CPT ..................................................................................................... 101
Table 12: Opportunistic infection screening and Management ......................................................... 104
Table 13: Classes and Dosages of Antiretroviral Drugs for Adults and Adolescents and children
currently used in Ethiopia ................................................................................................................... 111
Table 14: Recommended ARV drug regimen in PMTCT...................................................................... 113
Table 15: Summary of sequencing for preferred first, second and third-line ART regimens in pregnant
womena ............................................................................................................................................... 114
Table 16: Recommended laboratory tests for monitoring response to ARVs and its toxicities ......... 116
Table 17: The most likely side effects of TDF/3TC/EFV ...................................................................... 118
Table 18: Examples of common interactions are given below ........................................................... 119
Table 19: Definitions of clinical, immunological and virological failure for the decision to switch ART
regimens ............................................................................................................................................. 122
Table 20: Summary of components of EAS ......................................................................................... 125
Table 21: Symptom/sign screening checklist and possible causes of Symptoms after HAART .......... 126
Table 22: Levels of adherence ............................................................................................................ 129
Table 23: Barriers to adherence and solution .................................................................................... 131
Table 24: Common symptoms from OIs, ARV side effects & complications ...................................... 136
Table 25: Summary of analgesic drugs use for Step-by-Step.............................................................. 138
Table 26: Management of Syphilis positive pregnant mothers .......................................................... 144
Table 27: Treatment of congenital Syphilis in infants......................................................................... 145
Table 28: Treatment of Syphilis for sexual partners ........................................................................... 146
Table 29: Immediate new born problem, care and management ...................................................... 189
Table 30: Maternal and New-born emergencies ................................................................................ 196
Table 31: Routine postpartum care contact ....................................................................................... 198
Table 32: Dosage of NVP and AZT syrup for different age groups ..................................................... 209
Table 33: Immunization schedule for HIV exposed infant .................................................................. 210
Table 34: Follow up visit schedule for HIV exposed infants* ............................................................. 210
Table 35: Dose of CTX for prevention of PCP in infants and children ................................................. 212
Table 36: Normal Development Milestones ....................................................................................... 217
Table 37: Abnormal development that shows delayed acquisition of milestones ............................. 218
Table 38: HIV testing results interpretation in children ................................................................... 225
Table 39: 10 depicting the level of service integration....................................................................... 232
Table 40: Summary of PMTCT cards, forms, registers ........................................................................ 243
Table 41: Key PMTCT indicator elements for health facilities ............................................................ 296
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List of Figures
Figure 1: Classification of the immune system ..................................................................................... 28
Figure 2: Life cycle of HIV ...................................................................................................................... 29
Figure 3: Disease progression pattern among adults ........................................................................... 31
Figure 4: Steps for Condom Use ........................................................................................................... 41
Figure 5: HIV Rapid Test Algorithm for Ethiopia ................................................................................... 70
Figure 6: Dual HV/Syphilis rapid diagnostic test algorithm .................................................................. 72
Figure 7: Couple HIV counselling & testing protocol component structure ......................................... 82
Figure 8: PrEP Screening and Initiation Algorithm ................................................................................ 85
Figure 9: Algorithm for screening TB .................................................................................................... 99
Figure 10: Site of actions for NRTI, NNRTI, and PI .............................................................................. 110
Figure 11: Algorithm for diagnosis and management of treatment failure ....................................... 124
Figure 12: Adult three step analgesics ladder..................................................................................... 137
Figure 13: Algorithm on maternal and infant interventions for prevention of mother-to-child
transmission, and assessment of eligibility of mother for treatment for her own health ................. 151
Figure 14: Steps in hand washing ....................................................................................................... 158
Figure 15: Steps in hand rub ............................................................................................................... 159
Figure 16: Partograph adopted from WHO for use in Ethiopia .......................................................... 172
Figure 17: Help Baby to Breath (Birth/ Neonatal Resuscitation Measures): Post resuscitation care 188
Figure 18: HIV exposed children and HIV negative children and Adolescents <15years of age with
household exposure to PTB cases....................................................................................................... 213
Figure 19: Breast feeding Positions..................................................................................................... 222
Figure 20: Items to consider when conducting a PDSA cycle (Source: Langley et al., 2009) .............. 302
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Introduction to the manual
This National Comprehensive, competency based PMTCT/MNCH participant‘s training
manual includes all essential knowledge, attitude and skills in need to provide essential
services by health care providers. The training manual is prepared to have 1-4 chapters. The
participants are expected to exercise and be competent in how to deliver very essential
services related to PMTCT/EID/ART in MNCH Platform. New developments from the WHO
recommendations on specific areas and experiences from services delivery sites as well as the
mothers under go through PMTCT services are incorporated to enrich the skill station portion
of this training package.
This training takes place using the facilitator‘s guide, different teaching methodologies, HIV
counseling (HTC), laboratory techniques for HIV testing services, DBS collection for HEI,
prescribing ART, and skill stations with expert patient trainers to learn how to deliver caring
and compassionate counseling on treatment adherence HIV exposed infant care and EID and
other services as well as practical attachment in the PMTCT/MNCH/ ART/ sites to produce
competent service provider.
The previous training manual focused on only PMTCT of HIV/AIDS. But the recent PMTCT
guide line includes HIV, Syphilis and HBV. Based on this revision this participant manual is
divided in to four chapters. The first chapter covers basics of HIV, Syphilis, & Hepatitis B
virus and PMTCT interventions during pregnancy, the second chapter addresses PMTCT
services during labor and delivery, the third chapter covers PMTCT interventions for HIV
positive lactating mothers and HIV exposed infants. The last chapter addresses the PMTCT
monitoring and evaluation frameworks including the continuous quality improvement
approach to improve the quality of PMTCT services at MNCH platform.
Rationale of revising the course

The rationale of revising this training course is to include major changes in the PMTCT
training material following the revision of PMTCT guideline based on triple elimination of
mother-to child transmission of HIV, Syphilis, & Hepatitis B virus. As a regard, revising the
PMTCT training materials as per triple elimination is mandatory to capacitate health care
workers on new updates of PMTCT, revised monitoring and evaluation frameworks and
continuous quality improvement approaches. PMTCT/RMNCH/EID/MBPCF and CQI course
is designed all in one to help deliver the services in need in one stop in RMNCH platform.
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This course has more of practical extent that gives emphasis for equity; addresses HIV
exposed infant follow up and improve diagnostic services like DBS collection done in
MNCH unit. Finally the course has MNCH/PMTCT/EID services quality improvement
model theoretical, class room exercise and practical attachment in the health facilities where
the training is provided. These experiences will automatically support the trainees to improve
equality MNCH/PMTCT/ EID services in integrated manner per triple elimination strategy.
Course competencies
The following are the competencies expected to be acquired and executed after the
completion of the training
At the end of this course participants will be able to:
 Provide integrated MNCH/ PMTCT − HIV prevention, care and treatment – in routine
MNCH services.
 Manage the postnatal period within the context of HIV infection
 Provide pretest information for STIs including HIV and MTCT of HIV and Syphilis
 Perform HIV exposed Infant follow up and DBS collection
 Perform family planning counseling for HIV positive women
 Perform partograph plotting and usage to manage delayed births.
 Manage pregnant women diagnosed with Syphilis and treat neonates diagnosed with
Congenital syphilis
 Manage of HBV positive pregnant women and Infant intervention for the prevention of
MTCT of HBV.
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Course syllabus
Course description- This 12 days‘ course designed to equip the participants with the
knowledge, skills and attitude on HIV, Syphilis and Hepatitis B virus prevention, treatment
and care during Pregnancy, labor and delivery and postnatal period. It also maintains the
quality of PMTCT services through application different quality tools and M and E (CQI,
Dashboard, PMTCT cohort monitoring).
Course Goal:
The goal of this course is to produce a pool of competent PMTCT/MNCH service providers,
program managers, supervisors and mentors.
Participant learning objectives
After completing this course the participants will be able to:
- Manage pregnant women for PMTCT interventions at ANC settings
- Manage laboring women for PMTCT interventions at labor and delivery
- Manage postnatal women and HEI for PMTCT interventions at PNC settings
- Monitor and Evaluate PMTCT programs
Training methods and Materials
This course adopts a participatory and interactive approach and is designed to maximize the
involvement of all participants, through:
- Interactive presentation
- Individual reading session and reflection
- Questions and Answer
- Group based learning (group work, Case studies, )
- Think pair share
- Role play
- Facilitator lead Drill
- Video show
- Experience sharing
- Simulation using EPTs
- Demonstration
- Guided clinical practice
- Jigsaw (gallery walk)
- Reading, reflection and discussion
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Training materials
The training packages relevant to deliver the Comprehensive PMTCT/MNCH training are the
following:
National Comprehensive PMTCT/MNCH Training manual

facilitator‘s guide and power point
National PMTCT Guideline
National EMTCT strategy
Participants manual
Checklists for practical attachment
Exercise note book

Pen
Flipchart
Marker
World Health Organization (WHO) HIV clinical staging wall chart
Laminated photos on OIs
Computer and LCD projector, Speaker
Condoms male, female
Penile models
Video clips on female condoms and HIV life cycle
Samples of ARV drugs
Counseling cue card / protocols
Card sorting materials (different OIs color pictures), ARV drug items
NVP and AZT syrup
Syringe of 2ml
HBB models
Video on newborn resuscitation
Copies of plain partograph and answered partograph
Sample of Implants (Jadelle , Implanon ), other FP commodities
Growth Monitoring chart
MUAC tape measure
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Photograph booklet DBS samples
Integrated Antenatal, Labor, Delivery, Newborn, Postnatal care card
HIV exposed infant follow up card
ART Intake form
HIV/ART chronic care follow up form
Transfer out form
ANC Register
L&D Register
PMTCT Register for Health Centers and Hospitals (mother baby pair cohort register)
Postnatal Register
Family Planning Register
DNA PCR specimen tracking logbook
CD4 request forms
Viral load request form
High viral load register and high viral load client follow up form
Retesting register
Maternal and HEI Cohort wall chart
Family based and partner register (ICT Register)
DNA PCR request forms, log book
Monthly DHIS2 reporting forms
Maternal and HEI Cohort reporting form**
Maternal and HEI cohort SOP
PMTCT cohort Job aid
PMTCT appointment & LTFU Tracking logbook***
PMTCT Dashboard ****
PMTCT facility performance indicators follow up form
CQI package checklist all in one
Pencil
Eraser
Sharpener
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Trainee Selection criteria
For basic training,
 Health care provider with at least diploma or first degree in midwifery, Nursing,
Health officer or general practitioner
For training of trainers (TOT),
 Participants will be selected from health facilities, training and higher institutions with
basic training on PMTCT.
Trainer selection criteria
In selecting PMTCT trainers, the following criteria should be considered:
• Those who Participated in the development of this revised the PMCT training material or
• The trainers must have received trainer of trainers (ToT) with basic PMTCT and facilitation
skill training (FST)
Methods of evaluation
Formative Assessment
 Pre course assessment.
 Participant reaction
 Daily evaluation
 Skill assessment of observed practice during roll play, practicum and skill station
Summative Assessment
 End of course evaluation
 Post course knowledge assessment
Certification criteria
- Participants will be certified when they score > 70 % for basic training and more than
80 % for TOT . (50% knowledge and 50 % skill check out exams) and 100%
attendance
Course duration – 12 days
Suggested class size: 25 trainees
Trainer trainee ratio: 1:5 ratios
Corse venue: Accredited CPD centers
CEU: 15
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Course schedule
Date and time Activities/agendas Facilitator Remark

Day One
Monday
8:30 - 9:00 Registration
Welcoming /Opening remark through
9:00 - 9:15
PMTCT/MNCH program coordinator
9:15 - 9:30 Introduction of participants
9:30 - 10:30 Pre test
10:30 – 10:45 Ground role and expectations from the training
10:45 - 11:00 Tea break
11:00 - 11:45 Course Over view and Status MNCH/PMTCT/EID
overview
Chapter 1: PMTCT during Antenatal care
11:45 - 12 :30
Section One: PMTCT of HIV during ANC
12:30 - 1:30 Lunch
1:30 - 3:30 PMTCT of HIV during ANC continued
3:30 - 3:45 Tea Break
5:25-5:30 Daily evaluation
Day Two
PMTCT of HIV during ANC
Tuesday
8:30 - 9:00 Recap:
10:00 - 10:15 Tea break
12:30 - 1:30 Lunch
3:30 - 3:45 Tea break
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Day Three
PMTCT of HIV during ANC continued
Wednesday
8:30-8:40 Recapitulations
8:40- 9:00 PMTCT of HIV during ANC continued
10:00 - 10:15 Tea break
10:15 – 12:30 PMTCT of Syphilis during ANC continued
12:30 - 1:30 Lunch
1:30 - 3:30 PMTCT of Hepatitis B virus
3:30 – 3:45 Tea break
3:45-5:25 PMTCT of Hepatitis B virus continued
Day Four
PMTCT of Hepatitis B virus continued
Thursday
8:40 – 10:00 PMTCT of Hepatitis B virus continued
10:00 - 10:15 Tea Break
10:15 - 12:30 PMTCT of Hepatitis B virus continued
12:30 - 1:30 Lunch
1:30 - 2:30 Chapter Two : Labor and Delivery in PMTCT
2:30 – 3:30 Labor and Delivery in PMTCT continued
3:30- 3:45 Tea break
3:45-5:25 Labor and Delivery in PMTCT continued
Day Five Chapter Two : Labor and Delivery in PMTCT
Friday continued
10:00-10:15 Tea break
12:30-1:30 Lunch
1:30 -3:00 Chapter Three:- PMTCT in PNC setting
3:00-3:15 Tea break
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3:15-5:25 PMTCT in PNC setting continued
5:25-5:30 Daily Evaluation
Day Six Laboratory session
Full day laboratory exercise: HTC and DBS with laboratory

Expert
5:15-5:30 Summary of the day and comments
Day Seven Sunday: PMTCT in PNC setting EPT
Training
Full day PMTCT in PNC setting continued
Day Eight Monday: Skill station with EPTs and M&E in
PMTCT
8:30 – 10:30 Group One:
Skills Station in the class room
With case scenario one through Expert mother
mentors
8:30 - 10:30 Group Two:
Chapter 4. Introduction of M&E in PMTCT
10:30-10:45 Tea break
10:45-12:30 Group One:

Chapter 4. Introduction of M&E in PMTCT
12:30-1:30 Lunch
1:30-3:00 Chapter 4. Recording and reporting data
3:00-3:15 1. Tea Break
3:15 - 5:25 Performance evaluation using dashboard and CQI

5:25-5:30 Daily Evaluation
Day Nine Tuesday Chapter Four- Cohort monitoring and

analysis
8:30-8:40 Recapitulation
8:40-10:00 Maternal Cohort monitoring and analysis

10:00-10:15 Tea break
10:15-12:30 Maternal Cohort monitoring and analysis continued
12:30-1:30 Lunch
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3:00-3:15 Tea break

Day 10 HEI cohort monitoring and analysis

Wednesday
8:30-10:00 HEI cohort monitoring and analysis continued
10:00-10:15 Tea break

12:30-1:30 Lunch
3:00-3:15 Tea break
Day Eleven Field visit

Thursday
8:30 - 12:30 Field visit
12:30 -1:30 Lunch
1:30-3:00 Report write up
3:00-3:15 Tea break
3:15-5:30 Presentation
Day Twelve Revision on Cohort exercises( Friday is last day for

Friday Basic)
8:30 -10:00 Revision on Cohort exercises
10:00-10:15 Tea break
10:15 – 12:30 Revision on Cohort exercises

12:30 - 1:30 Lunch
1:30 - 3:00 Post test
3:00 – 3:15 Tea break
3:15 - 3:30 End course evaluation
3:30 - 5:30 General discussion and closing remark

Day Thirteen Saturday is the last day for TOT
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Full day Facilitation skill( Will be given in the day one)
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Chapter 1: Comprehensive PMTCT Services during ANC
Duration:
Chapter Description
This chapter describes basics of HIV, syphilis and Hepatitis B virus (HBV). It also explain
ANC visits, testing and counseling during ANC, apply the necessary knowledge and skills
on counseling ANC clients ,specific interventions for PMTCT in ANC and care, treatment
and follow up for clients .
Time: 32 hrs.
Enabling Objectives:
By the end of this chapter, participants will be able to:

 Explain the key basic facts of HIV/AIDS and MTCT of HIV, syphilis and HBV
 Apply the necessary steps to provide ANC
 Apply the necessary knowledge and skills on counseling ANC clients for different
health issues
 Demonstrate the skills and competencies to clinically provide specific intervention for
HIV, Syphilis and HBV positive pregnant women in ANC settings
 Implement care, treatment and follow up for HIV, Syphilis and HBV positive
pregnant women.
Chapter Outline
1. PMTCT of HIV during ANC
1.1. Basics of HIV and MTCT
1.2. ANC in the context of HIV
1.3. HIV Testing and Counselling During ANC
1.4. Specific Interventions for PMTCT of HIV in the ANC Setting
1.5. Care, treatment and follow up of HIV positive pregnant women
2. PMTCT of Syphilis during ANC
2.1. Basics of Syphilis and MTCT
2.2. Syphilis screening for pregnant women
2.3. Treatment for pregnant women diagnosed with Syphilis
3. PMTCT of Hepatitis B virus
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3.1. Basics of HBV and MTCT
3.2. Screening of pregnant women for HBV
3.3. Management of HBV positive pregnant women
1.1. Basics of HIV and Mother to Child Transmission (MTCT)

Enabling Objectives
By the end of this session participants will be able to:

• Describe the function of immune system
• Discuss the life cycle of HIV
• Describe the pathophysiology of HIV
• Describe the four prongs of PMTCT.
• List steps for proper condom use and skills on condom negotiation
• List the steps for FP counseling
Allowed time:186 minutes
Exercise 1.1: The Story of Z and H
Group work
Read the story and answer the following question
Time: 15 min
Follow the story while one of the participants reads it aloud and then answer the questions
below the story.
The Story of Z and H
The story starts in 2002. Z is a girl living in one of the big cities of Ethiopia. She just
completed her university education and got married to H. Z family likes H very much.
H owned a shop.
H, a year before marriage
H had frequent business trips. While he was on business trip, he used to go to bar to relax
and have fun. One night, he took alcohol and was in a good mood when he met a girl where
he later spent the night with. He regretted for sleeping with the strange person who is
probably HIV infected and worried for contracting any gent‘s disease.
March 2002
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Z and H got married. It was a beautiful wedding, with a lot of people invited and good food
and drinks. Z and H started to live together, both working in the business.
April 2002
One day, suddenly, Z felt sick. It looked like flu, with fever, sore throat and pains. After
some days, she felt better and started to work again. She did not need any treatment.
Beginning of 2003
A year later, Z got pregnant. Everybody was happy. The first child, S, was born. S was the
pride of the family.
2004, P is born
Their marriage was peaceful and happy, and business was going well. Z got pregnant again
and gave birth to another baby boy, P, in 2004.
However P was not as healthy as his elder brother S. He frequently got sick with fever,
diarrhea and sore mouth. His weight was also low. He had frequent visit to doctor. One day,
the doctor said to Z that the baby had symptoms suggestive of compromised immunity and
counseled her on the HIV test, but she refused the testing. After returning home, did not talk
Z to H about what the doctor said about P.
P‘s condition got worse, and he died in early 2005, and the whole family was disturbed and
grieved by his death.
Almost a year after P’s death (2006), H started to get sick very often. He usually used
different treatments buying by his own. His health never got better like used to be.
The last two months of 2006 were very hard for Z. She was often in a very bad mood, and by
then she had to take care of her sick husband and manage the business alone at the same time.
However her husband‘s condition got worse and he died in late 2006. Z feels more
depressed. Though she is not feeling sick yet, she started realizing that a certain illness has
affected her family. Now she is more concerned about her and her child, S’s health, and starts
worrying more about what will happen to her only child if she dies.
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Answer the following questions:
1. What is the most likely disease that H died of?

2. By whom & how was H infected with this disease?
3. How did Z get infected with this disease?
4. What is the most likely cause of P’s illness and later death?
5. How did P‘s contract the disease?
6. What do you think of S’s status?
7. Why is S free of the illness that killed his father & younger brother?
8. How much time was there between H's initial infection and the year he started to have
serious symptoms?
9. How much time passed between the time H got infected and the time he died?
10. Why was Z sick shortly after marriage?
1.1.1. Introduction to HIV and the Immune system

HIV stands for Human Immunodeficiency Virus which primarily attacks the immune system.
HIV is from a special family of viruses known as retroviruses.
AIDS stands for Acquired Immune Deficiency Syndrome. Patients who are infected with
HIV will develop signs and symptoms as a result of immune depression which collectively
called AIDS.
Modes of HIV transmission:
 Unprotected sexual practice (anal, vaginal, oral) with an infected person
 Transfusion with infected blood or blood products
 The use of needles, syringes, and cutting or perforating objects contaminated by HIV-
infected blood. Sharing contaminated sharp for certain traditional practices; tooth
extraction, uvulectomy, female genital mutilation, circumcision and tattooing.
 MTCT during pregnancy, labor and delivery and breastfeeding from infected women
 Organ transplant from infected donor
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Important: The presence of Sexually Transmitted Infections (STI) increases the risk of
acquiring and transmitting HIV. This is because people with these problems have a higher
concentration of HIV in the genital mucosa and/or transmission of the virus is facilitated due
to the presence of ulcers or openings in the mucosa.
1.1.2. HIV and the Immune System
Introduction to the immune system:
A basic understanding of the anatomy and function of the immune system is helpful in
understanding HIV, which is an infection of the immune cells and organs. The function of the
immune system is to defend our body from invasion by micro-organisms in the environment
through respiration, ingestion or contact with skin and mucous membranes.
The organs where immune cells are produced or stationed are the thymus, bone marrow,
lymph nodes (found along most organs including gastrointestinal tract, respiratory tract, and
reproductive organs), spleen, and liver. The immune system is organized in such a way that
the body is prepared to defend itself immediately as well as in a sustained manner for
ongoing infections.
The immune system protects the body from possibly harmful substances by recognizing and
responding to antigens. Antigens are substances (usually proteins) on the surface of cells,
viruses, fungi, or bacteria. Nonliving substances such as toxins, chemicals, drugs, and foreign
particles can also be antigens. The immune system recognizes and destroys substances that
contain antigens.
INNATE IMMUNITY
Innate, or nonspecific, immunity is the defense system with which you were born. It protects
you against all antigens. Innate immunity involves barriers that keep harmful materials from
entering your body. These barriers form the first line of defense in the immune response. If an
antigen gets past these barriers, it is attacked and destroyed by other parts of the immune
system.
ACQUIRED IMMUNITY
Acquired immunity is immunity that develops with exposure to various antigens. Your
immune system builds a defense against that specific antigen. (Refer to Figure 1 below)
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Figure 1: Classification of the immune system
1.1.3. Life cycle of HIV
Although HIV infects a variety of cells, its main target is the T4-lymphocyte (cluster
of differentiations 4, or CD4). The T cell is a kind of white blood cell that is
responsible for warning the immune system that there are invaders (diseases) in the
body. Once HIV binds to a cell structure, it hides its material inside the cell. This
turns the cell into a sort of HIV factory. The six stages of HIV life cycle are:
1. HIV attaches to the CD4 cell and releases RNA andenzymes.

2. The reverse transcriptase enzyme makes a DNA copy of the viralRNA.
3. New viral DNA integrates into the CD4 cell nucleus using the enzyme integrase.
4. Newviral componentsarethen produced, usingthecell‗s ―machinery‖
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5. The new viral components are, then, assembled together using the enzyme protease
6. Then released as newviruses.
Familiarity with the six stages of the HIV life cycle is essential for understanding the
effects of ARVs onHIV.
Figure 2: Life cycle of HIV
1.1.4. CD4 T-cell and HIV Viral Set Point
HIV attacks many CD4 cells. The infected CD4 cells will first produce many new copies of the
virus and then die. The new copies of HIV will then attack other CD4 cells, which subsequently
will also produce new copies of HIV and then die. This continues; goes on and on: more and
more CD4 cells are destroyed, millions of new more and more new copies of HIV are made, and
new CD4 cells get infected.
HIV infects and destroys the CD4 cells, which are critical to the body‘s defense mechanism.
Consequently, without adequate number of functional CD4 cells, the body is exposed to
infections which it usually would be able to fight off; these conditions are called
opportunistic infections (OIs).
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The extent of immune damage inflicted by HIV is assessed by the CD4 cell count. This can
be counted from a small sample of blood drawn from the infected person. The CD4 count
tells us how strong the immune system is. A CD4 count above 500cells/mm3 indicates that
the immune system is coping well in spite of HIV. However, over time, as the CD4 cells are
progressively destroyed, the CD4 count falls. A low CD4 count tells us the immune system is
getting weaker.
The number of viral copies per cubic mm of blood is called viral load. The viral load
indicates the activity of HIV infection, and hence viral load is another useful blood test to tell
us how much HIV is in the blood. Over time the viral load increases as more and more
viruses are produced, resulting in decreased immune system function and rapid progression to
AIDS.
HIV viral set point: -is the viral load of a person infected with HIV, which stabilizes after a
period of acute HIV infection. The set point is reached after the immune system has
developed specific Cytotoxic T cells and begins to attempt to fight the virus. The higher the
viral load of the set point, the faster the virus will progress to AIDS; the lower the viral load
of the set point, the longer the patient will remain in clinical latency.
Your facilitator will guide you to watch a video clip on viral replication
1.1.5. HIV infection and disease progression

The courses of HIV infection have three stages: primary HIV infection, asymptomatic and
AIDS stage.
Primary HIV infection
The initial stage of HIV infection is called acute sero-conversion, when the patient converts
from a negative antibody-based test result to a positive test result. Most patients seroconvert
within three months after exposure to the virus. During this process, patients often develop
non-specific flu-like symptoms, which do not lead directly to the diagnosis of HIV infection
as they are non-specific. But sometimes, there are no signs or symptoms at all that would
indicate the person has been infected with HIV. These symptoms may include:
• Fever, fatigue, pharyngitis, lymphadenopathy, rash, etc
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Asymptomatic stage/Latent infection
When a person gets infected with the HIV, the virus will start to attack their immune system.
During the first years of infection, the immune system-although weakened a bit by the HIV
virus - still functions quite well. The infected person will have no symptoms, or only minor
symptomslikeskindiseases,alittlelossofweight,orrepeatedsinusitis. A lot of people don‘t know
that they are HIV positive at this stage. Clinical latency period may last an average of 10
years, but some people may progress through this stage faster.
Acquired immune deficiency syndrome (AIDS)
After several years, the person‗s immune system will be very weak; they are
vulnerable to diseases that they could normally fight off. These diseases are called
opportunistic infections (OIs) because they take advantage of a weakened immune
system to cause disease.
Figure 3: Disease progression pattern among adults
Patterns of HIV Disease progression varies among patients

Patterns of HIV disease progression varies among patients because of the viral set
point (serum viral load level at 6 months to one year after acquisition of HIV
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infection) following seroconversion. Accordingly, three types of progression are noted
for adult patients:
 Typical progressors: these account for 90% of individuals who can stay for 8-10 years
before developing symptoms. The viral set point is medium in this group.
 Long-term non-progressors: these account for more than 10% individuals who will
have a stable CD4 count for more than ten years. The viral set point is significantly low in
this group
 Rapid progressors: these account for 5% of individuals who develop AIDS within three
years. Viral set point is high in this group.
NB. This differs in children, children in general are rapid progressors: 30–40% die within
a year, 50% die within 2 years!
1.1.6. Mother-to-Child Transmission of HIV
Mother-to-Child transmission of HIV (MTCT) is the transmission of HIV from an infected

mother to her baby. It can occur during:
 Pregnancy
 Labour and childbirth
 Breastfeeding
MTCT is also referred to as ―vertical transmission‖ or ―perinatal transmission‖. It is the main
cause of HIV infection in children.
Note that not all HIV-positive women will transmit the virus to their child. A summary of
rates of transmission without intervention is provided in table below.
Table 1: Estimated Risk of MTCT of HIV without intervention

Timing Transmission rate without
intervention
During pregnancy 10- 25%
During labor and delivery 35-40%
Overall with breastfeeding up to 6-24 35-40%
Months
Note: Rates of transmission vary because of differences in population characteristics such as
maternal CD4+ counts, RNA viral load, exclusivity and duration of breastfeeding
Source: WHO March 2014 *Supplement to 2013 consolidated guidelines
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1.1.6.1. Factors that increase the risks of MTCT of HIV
The most important risk factor for MTCT of HIV is the amount of HIV virus in the
mother's blood, known as the viral load. The risk of transmission to the infant is
greatest when the mother's viral load is high−which is often the case with recent or
advanced HIV infection. (Refer to table 1.2)
Table 2: Factors increasing risk of Mother-to-Child transmission of HIV

Strong evidence Weak evidence
During pregnancy
 High viral load in the mother  Poor maternal nutritional status
− new infection (viral "spike")  Maternal anemia
− advanced stage of HIV infection  Malaria
(AIDS)  Substance (drug) use or cigarette smoking
 Poor immune status (low CD4 count) during pregnancy
 Sexually transmitted infections (STIs)  External cephalic version
 Certain HIV viral strains  Invasive obstetric procedures
− amniocentesis
− chorionic villus sampling (CVS)
During labour and childbirth

 High viral load in the mother
− new infection (viral "spike")  Chorioamnionitis
 Suctioning newborn
− advanced stage of HIV infection
 Invasive obstetrical procedures
(AIDS)
− Episiotomy
 Vaginal delivery − Early artificial rupture of
 Prolonged rupture of membranes (>4 memberenes
hours)
 Prolonged labour
 Instrumental delivery (forceps or vacuum
extraction)
 Prematurity
 First infant in multiple birth

During breastfeeding
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 High viral load in the mother  Poor maternal nutritional status
− new infection (viral "spike")  Oral disease in the baby (e.g. thrush
− advanced stage of HIV infection or sores)
(AIDS)
 Breastfeeding*
 Mixed feeding (non-exclusive
breastfeeding or non-exclusive
replacement feeding)
 Long duration of breastfeeding
 Mastitis, nipple fissures, breast abscess
* Maternal ART or infant ARV prophylaxis significantly reduces the risks of MTCT of HIV through breastfeeding.
1.1.6.2. Prongs for prevention of Mother-to-Child transmission of HIV

In 2003, WHO launched the four pronged approaches to PMTCT to prevent transmission of
HIV among infants and young children. When implemented properly, these prongs can
reduce the risk of transmission of HIV to less than 5% in breast-feeding infants, and to less
than 2% in non-breast-feeding populations. These prongs are:
A. Prong1: Primary prevention of HIV infection – focuses on keeping people HIV-
negative. Prevention of new infections means that fewer women and men will have HIV
and fewer infants will be exposed to HIV.
 Promote safer and responsible sexual behavior and practices through BCC using
the ―ABC‖ approach:
o A = Abstinence
o B = Be faithful—Be faithful to one HIV-uninfected sexual partner (known sero
status)
o C = Condom use—Use condoms correctly and consistently
o D= Discussion among family members about sexual issues.
 Provide early diagnosis and treatment of sexually transmitted infections

 Make HTS widely available
 Provide Pretest test information
 Adhere to universal precaution procedures for infection prevention (IP) in health
care settings
 Post Exposure Prophylaxis (PEP) following occupational exposure and sexual
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assault as per national guideline
 Promote safer sexual practice among sero-discordant couples; provide ART for
HIV positive partners and pre-Exposure Prevention (PrEP) for negative partners if
eligible.
 Promote early infant male circumcision and Voluntary medical Male circumcision
(VMMC) in settings where male circumcision is not routinely done.
B. Prong 2: Prevention of unintended pregnancies in HIV-positive women – emphasizes
reducing the number of unplanned or unwanted pregnancies. While family planning
will be discussed in details in other sections, we will give some details here in the
context of PMTCT only.
Effective family planning counseling and service is important to help HIV-infected women
prevent unintended pregnancies and space births. It should be conducted sensitively,
maintaining confidentiality and privacy, and must demonstrate respect for clients‘ rights.
Note that all women irrespective of their HIV status should be able to exercise their
reproductive rights freely, whether they choose to plan a pregnancy, space their children‘s
births, or limit childbearing.
FP/HIV services integration is a valuable approach in reducing the unmet needs of both
family planning and HIV care services. Integration of FP/HIV services has several benefits.
 Both direct and indirect costs will be reduced both to the individual and the health
system.
 Maximizes productive use of scarce resources
 Enhanced ability to prevent new HIV infections, especially among infants and youth
 Greater support for dual protection against unintended pregnancy and disease.
The following can serve as a general guidance on information and counseling about fertility
regulation in the context of HIV.
 While women and couples should be free to make their own decisions about
childbearing, counselors should ensure that women are aware of the risks inherent in
any future pregnancies, as well as the risk of passing on the virus during unprotected
sex.
 Counselors should make it clear that even where interventions are available, all
pregnancy carries some risk of HIV transmission from mother to child.
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 The effectiveness of initiating ART during pregnancy (option B+) averts the future
risks of transmitting HIV on successive pregnancies. Women who choose to avoid
pregnancy in the future because of their HIV infection should be offered/referred to
FP services.
 Women who choose replacement infant feeding should also receive advice on
contraception to replace the birth spacing effect of breastfeeding.
 If women choose to bear more children, they should be encouraged to delay the
pregnancy for at least two years.
Counseling on FP should be started in the antenatal period for the following reasons:
 A woman who is HIV-positive needs to understand the risks for herself and her child
if she has other children—both the health risks and the risks of transmitting HIV.
 By providing women with information about FP options during ANC, the woman will
have time to consider her options, talk about options with her partner and family or
friends, and make an informed decision about her choice when she gives birth.
 A woman who has made a decision about a FP choice before giving birth will be
prepared for using the chosen method in the postpartum period to prevent herself from
becoming pregnant again.
 Women should know that after birth, if they have sex and are not exclusively
breastfeeding, they can become pregnant as quickly as four weeks after delivery.
 When ANC is the period FP counselling started, make sure the following points
 Make sure that method choice selection addressed,

 Use sticker to identify the selected FP method on the women card
 Proper referral and linkage communicated accordingly
 Key points to remember while giving Information on FP
• Tailor information to the client‘s needs
• Find out the client‘s need or problem (method in mind? return client?)
• Find out what the client already knows
• Identify information gaps that need to be filled or misconceptions that need to be
corrected
• Personalize information for the client
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• Put information in terms of the client‘s situation
• Help the client understand what the new information means to her or him personally
• Make information understandable
Steps for family planning counseling skill
I. Rapport building
 Greet client with respect

 Make introductions: Identify category of the client—i.e., new, satisfied return,
or dissatisfied return
 Assure confidentiality and privacy
 Explain the need to discuss sensitive and personal issues
II. Exploration
 Explore in depth the client‘s reason for the visit: This information will help
determine the client‘s counseling needs and the focus of the counseling session
New client visit:
 Explore client‘s past experience, current situation, and future RH-related plans
a. Explore client‘s reproductive history
b. Explore client‘s social context, circumstances, and relationships
c. Explore client‘s history of STIs, including HIV
d. Explain STI risk and dual protection, and help the client perceive his or her
risk for contracting and transmitting STIs
 Rule out pregnancy and explore factors related to monthly bleeding, any recent
pregnancy and medical conditions
 Focus your discussion on the method(s) of interest to client
a. Discuss the client‘s preferred method, if any, or
b. Relevant FP options if no method is preferred,
c. Give information as needed, and correct misconceptions
d.
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III. Decision making
1. Identify the options decided by the client
2. Explore relevant options for each decision
3. Help the client weigh the benefits, disadvantages, and consequences of each option
4. Provide information to fill any remaining knowledge gaps
5. Encourage the client to make her own decision
Helping questions the client to reach decision
 Does the client want any more children?

―Permanent vs. temporary methods‖
 How long does the client want to be protected from pregnancy?
―Long-acting vs. short-acting methods‖
 Can the client use and does the client wants to use hormonal methods?
―Hormonal vs. non-hormonal including barrier (condom) methods‖
 Does the client want a method for herself /her partner?
―Male vs. female methods‖
IV. Implementing the decision
a. Assist the client in obtaining and using the FP method chosen

b. Have the client develop skills to use her chosen methods and condoms (as dual
protection)
c. Identify potential barriers that the client might face in implementing her
decision
d. Discuss/Design strategies to overcome the barriers
e. Make a plan for follow-up
Return visit of clients:
Explore the client‘s satisfaction with the current method used
a) Satisfied client
 Confirm correct method use
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 Ask the client about changes in her life style
• Plans about having children,
• STI risk and status
b) Dissatisfied clients:
 Ask for causes of dissatisfaction and discuss possible solutions
• Manage side effects and situation
• Switch methods as needed
Condom for dual protection
Condoms are very useful for both prongs one and two of PMTCT of HIV. With correct and
consistent use, condoms reduce the chance of acquiring or transmitting HIV infection and
STIs as well as prevent unintended pregnancy. If correctly used, condoms provide dual
protection—from infection and pregnancy.
Condom negotiation and insertion
Women need to negotiation on using condoms with their sexual partner. There are many
cultural barriers and challenges for men and women to successfully agree to and routinely use
condoms during intercourse. Disclosure is a key step in successful condom negotiation.
Negotiation involves reaching an agreement on the needs or desires of both parties. It‘s like
bargaining—each person wants to get something without having to give up too much. If you
were buying goods at the market, you might be able to walk away if the terms don‘t meet
your needs; in the case of sex with a regular partner, this is not so easy. Condom negotiation
is important for both HIV-negative and HIV-positive women.
Tips for Skill on Counseling Condom Negotiation
1. It might not be easy to discuss condom use with your partner, and it is good that you
have these steps to ask for advice on how to go about convincing your partner. This is
one of the most important conversations you will have with your partner.
2. It is helpful to think ahead about how you might respond if your partner does not want
to use a condom. You should always remember that is your right to right to demand a
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condom to be used or to decline penetrative sex if your partner will not use a condom.
By using a condom you will also be taking care of your partner.
3. You need to plan ahead and have condom with you if you think you might want to
have sex. Do not relay on your partner to have condom as this might not happen.
4. It is important to discuss using a condom with partner before you start to have sex as
it might be easy to be convinced not to use a condom in the heat of the moment. It is
better to talk about the condom when both of you are relaxed, that way you can have a
frank and honest discussion.
5. Remember that using condom correctly and consistently is key to reducing the risk of
HIV and other STIs.
6. Let us discuss some of the excuses your partner might use for not using the condoms
and some ideas about how to respond if you find yourself pressured to have sex
without a condom (Use annex 1.1 script for condom negation skill)
Techniques/steps on correct use of condoms, both female and male, will be

demonstrated during the training session.
Demonstration Steps on correct use of male condoms
Tips for Use male Condom
 Do not use sharp cutters such as scissors.

 Use a condom every time during any kind of intercourse.
 Use a water-based lubricant. Oil-based lubricant such as oil, hand lotion, or
Vaseline should not be used because they can cause the condom to break
 If you put the condom on upside-down by accident, use a new condom
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
Use a new
condom for
each sex act.
Check package
for date and
damage. Tear
open carefully.
Figure 4: Steps for Condom Use
Female condom
The female condom – also called an internal condom– is a birth control (contraceptive
device that acts as a barrier to keep sperm from entering the uterus. It protects against
pregnancy and sexually transmitting infections. Unlike the male condom it can be inserted
prior to sexual intercourse and does not requires a partner‘s cooperation. The female
condom has a higher failure rate than male condom. Correct and consistent use of female
condom is vital to achieve the level of protection required to prevent unintended pregnancy
and the transmission of HIV and other STIs. (Your facilitator will show you a video on
Female condom demonstration).
C. Prong 3: Prevention of HIV transmission from women living with HIV to their infants –
addresses care for HIV-positive women during pregnancy, labour and childbirth, and
breastfeeding and care for their infants. For example, Provision of ART to a woman
during pregnancy and breastfeeding, and ARV prophylaxis for the infant, can reduce the
risk of the child becoming infected. Details of prong 3 are provided below in the
summary section.
D. Prong 4: Provision of treatment, care, and support to women living with HIV, their
infants, partner, and families is a major continuum of care – including on-going, chronic
care and treatment for HIV-positive pregnant/postpartum women, their HIV positive
infants both during and beyond the PMTCT intervention period. Details of prong 4 are
provided in Chapter 3.
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Session summary: 15 minutes
- HIV primarily attacks the immune system.
- MTCT of HIV occurs during pregnancy, labour and delivery and breast feeding.
- Tailored interventions to address factors that increase MTCT of HIV are key
components of PMTCT service.
- PMTCT Four Prongs Promotes the following strategies
1. Primary prevention of HIV infection (minimizing the transmission of HIV to women)
2. Prevention of unintended pregnancies among women with HIV

 Improving women's access to information, education, sexual and RH services
including FP.
3. Prevention of HIV transmission from mothers with HIV to their infants

a. Increasing women's access to ART
b. Provide ARV prophylaxis for the newborn
c. Ensuring safer delivery procedures
d. Reducing transmission through breastfeeding.
4. Care, support, and treatment for mothers living with HIV, their children, and families (to
improve the health of the mother and the family to the extent possible)
 Prevention and treatment of OI
 ART
 Positive living
 HTS for other family members using family matrix approach and management
 Nutritional supplements
 Social and psychological support
o Peer/mother support groups
o Counseling on( Adherence to treatment, FP, infant feeding and attachment ,
partner testing, disclosure, proper usage of condom …)
These interventions are most effective and are intended to minimize HIV transmission when
they are integrated into existing maternal and child health services
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1.2: Antenatal Care in the context of HIV
After completing this session, participants will be able to:
 Describe the new model of ANC

 Describe essential elements of care during pregnancy
 Describe benefit and approaches of male/partner involvement in PMTCT
interventions
Allowed time: 93 minutes
1.2.1. Introduction to the session

As per the WHO recommendation, the previous four-visit FANC model was replaced by the
new ANC model in 2016, by justifying that in order to reduce perinatal mortality and
improve the pregnancy experience of women, a minimum of eight contacts is required. For
those pregnant women with risks identified, additional contacts may be scheduled as
necessary.
In the current model, the word ―visit‖ is replaced with ―contact‖ as the connotation of the
latter indicates an active connection between a pregnant woman and a health-care provider.
The following table shows the new antenatal contact schedule for pregnant mothers.
Table 3: The antenatal contact schedule

Contacts Gestational age of contact in weeks Appointment schedule
First Trimester
1st Up to 12 After 8 weeks

Second trimester
2nd 20 After 6 weeks
3rd 26 After 4 weeks
Third trimester
43
4th 30 After 4 weeks
41 (if not earlier delivered)
1.2.2. Essential Elements of Care during Pregnancy

 Eight antenatal contacts by a skilled provider—a midwife, nurse or doctor to detect
any problem
 Demonstration of physical examination, vital signs, HEENT abdominal examination,

edema.
 Birth preparedness and complication readiness planning with the family
 Detection and management of coexisting conditions and complications
 HIV testing and counseling (HTS), syphilis and HBV testing.
 Counseling for infant feeding options, family Planning methods, danger signs, STI
prevention and treatment and prevention and treatment of nutritional deficiencies.
 Treatment of diagnosed infection, i.e. HIV, syphilis, gonorrhea, tuberculosis
 Tetanus-diphtheria (Td) vaccine, Iron and folate supplement—for at least 6 months of

pregnancy, 60mg iron and 400 micrograms of folate. (Note: For areas with > 40%
anemia, continue same dosage for three months postpartum)
 Deworming during pregnancy
 Prevention of preeclampsia with calcium supplementation with daily 1.5-2.0 gm oral

elemental calcium starting from 14 weeks of gestation.
o Iodine supplementation(Iodized salt)
o Insecticide-treated net (ITN) utilization for malaria in pregnancy should be

strongly recommended as per national guidelines
 Presumptive treatment for worms and parasites should be provided
44
The following diagnostic tests should be done for all pregnant mothers.
 Hemoglobin (Hb) or hematocrit (HCt), blood group, and Rh
 Urine analysis: Dipstick, microscopy/gram stain
 Tests for HIV, syphilis and HBV.
 Ultrasound before 24 weeks: One ultrasound scan before 24 weeks of gestation (early
ultrasound) is recommended for pregnant women to estimate gestational age, improve
detection of fetal anomalies and multiple pregnancies, placentation, reduce induction
of labor for post-term pregnancy, and improve a woman‘s pregnancy experience.
Specific activities to be performed at each ANC contacts
45
GA in weeks Specific Activities
1st contact Identification, menstrual history, history of present pregnancy, intention

of present pregnancy, past obstetric history, medical history, current
Before or on
medication, gynecological history, nutritional history, social and
12weeks
personal history.
Advise on safer sex
Counsel on need for seven additional ANC visits (more frequent visits if
indicated),
Routinely recommend HIV test (with confidentiality, informed consent,

post-test counseling). If positive:
Do HIV clinical review, clinical staging, CD4, determine WHO clinical

staging
Recommend ART and begin rapid preparation for adherence
Give Co-trimoxazole prophylaxis for HIV positive women with CD4 <350
or clinical stage 3 and 4
Provide TPT for eligible clients.
Counsel on infant feeding options.
Advise on safer sex and use of condoms
Support disclosure and partner testing
Screen for syphilis and HBV; if positive manage as per the PMTCT
guideline.
Tetanus-diphteria 1st dose
Provide three months’ supply of iron folic acid (IFA)
46
Review the documented medical and obstetric history, and laboratory
tests during first contact
20
Ask about the fetal movement
(2nd contact)
Enquire about any new development
Determine the gestational age
Look for the general appearance
Measure the blood pressure and body weight
Look for pallor
Measure the uterine fundal height.
Listen for fetal heartbeat
Perform ultrasound scanning
Provide Calcium and zinc supplements
Provide deworming agent
Administer second dose of Tetanus-diphteria ( 4weeks after Td 1)
Quick check for other danger signs and symptoms
For known HIV positive pregnant women, continue HIV care, treatment
and follow-up. Do Viral load testing if eligible.
Counsel on infant feeding options.
Provide HIV testing, if not tested in the 1st contact; if positive, offer
services listed in the 1st contact.
Screen for syphilis and HBV if not done in the 1st contact.; if positive
manage as per the PMTCT guideline.
26 Conduct same activities as week 20 except for ultrasound scanning
(3rd contact) Conduct urinalysis for proteinuria and urine gram stain
Test for gestational diabetes for high risk pregnant women
47
Retest for HIV who tested negative but have an ongoing risk.
Monitor for adherence on ART
30 Conduct same activities as week 20 except for ultrasound scanning
(4th contact) Retest for HIV who tested negative but have an ongoing risk.
Repeat hemoglobin test
Perform fetal wellbeing assessment if there is a discrepancy between

fundal height and gestational age or if there is a reduction in fetal
movement
34 Repeat all what were done at 30 weeks
(5th contact) Determine fetal presentation
Test urine for proteinuria for high risk women
Do viral load testing
36 Conduct all what were done at 34 weeks’ gestation
(6th contact) Counsel on birth preparedness and complication readiness
Do viral load testing if not done at 34 weeks
38 Inquire any fears, myths, worries, and the like about labor and delivery
(7th contact) Repeat hemoglobin test
Orient her about fetal kick counting
40 Review the fetal kick counting
(8th contact) Repeat all what were done at 38 weeks
Ultrasound scanning for fetal wellbeing assessment
41 Review the fetal kick counting
48
(Last contact for Inform and perform fetal membranes sweeping
earlier not
Ultrasound scanning for fetal wellbeing assessment
delivered)
1.2.3. Birth Preparedness and Complication readiness plan

The pregnant woman, her partner/family and her ANC provider should discuss the woman's
birth preparedness and complication readiness plan. In general,
 Birth preparedness involves preparing for a normal birth, and includes:

o Having a skilled attendant at every birth
o Deciding on the place of delivery
o Having available essential clean items for the mother and baby at birth
o How to get to health facility (including transportation)
o Saving money for emergency transport (in case ambulance is not accessible)
o Preparing support during and after birth (family, friends)
o Arranging a way of communication in emergency situations; and
o Designating a decision maker on her behalf (including giving consent when
she is unable to do that).
 Complication readiness involves preparing for complications, and includes:
o Recognition of warning signs of complications in pregnancy or childbirth
o Designated decision-maker(s)
o Access to emergency funds
o Rapid referral and transport to an emergency obstetric care site.
Keeping pregnant women in the maternity waiting home (MWH) to bridge the geographic gap
of accessing obstetric care during emergency situation is also essential components Birth
preparedness and Complication readiness.
1.2.4. Practices not recommended during pregnancy

 Measurement of maternal height—this is a poor tool for determining cephalo-pelvic
disproportion as maternal height varies among societies.
 Examination of ankle oedema—50-80% of women with normal pregnancies
experience ankle edema and is a non-specific symptom.
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 Examination of fetal position before 36 weeks—the fetal position is not stable
before 36 weeks so position is not of high concern before 36 weeks, but if fetal
position is not vertex after 36 weeks, the woman should be referred.
1.2.5. Importance of male partner involvement in ANC/PMTCT

Efforts towards PMTCT of HIV should be as comprehensive as possible and should
acknowledge that both partners play a significant role in reducing the risk of
transmission of HIV to their child.
In many settings, men‘s involvement has resulted in:
 More uptake of HIV testing and antenatal services
 Better use of PMTCT services by their partners
 Better adherence to PMTCT interventions, such as:
− Taking ARVs ( by both the mother and infant)
− Acceptance of post-test counseling
− Communicating about and practicing safer sex during pregnancy and
breastfeeding
− Delivering the infant in a health facility
− Exclusive breastfeeding, etc
Partner support can help in various ways to lower transmission rates of HIV to a child.
Therefore:
 Couples and partners should be aware of and
supported to use PMTCT services, including HIV
prevention, treatment, care, and routine health
services. Both partners should participate in
decisions that can prevent HIV transmission.
 Couples and partners should be responsible for
safer sex practices all the time, including
throughout pregnancy and breastfeeding.
 Health workers should recommend HIV testing
and counseling to pregnant women and their
partners, and to encourage couples counseling
and testing with mutual disclosure. Partners of
HIV -negative women should also be
50
encouraged to be tested if they have risk.
Both partners should be involved in decisions about and be responsible for implementing
family planning.
Tips on male partner involvement:
Mixes of the following experiences have been found useful in many countries including
Ethiopia to involve male partners and families.
 Community and religious leaders can play an important role in encouraging the father of
the baby to accompany the pregnant woman to antenatal care services. These opinion
leaders may require training so they can correctly explain to community members the
value of male involvement.
 Special services, such as vouchers or written invitations, may increase fathers‘
attendance.
 Community health workers can also inform families and the local community about the
importance of male involvement in pregnancy care.
 Offering couples HIV testing on a routine basis in antenatal care is helpful.
 Strategies to make it easier for men working outside the home to get services, such as
special hours in the evening or weekends.
 Involving men and fathers in antenatal care requires special efforts on the part of health
workers, who may require additional training. Training can help health workers to deal
with difficult situations that can arise, for example when an expectant couple is found to
be sero-discordant.
 Changing social norms and cultural attitudes about father‘s involvement in pregnancy
care may require deliberate efforts over time. However, many countries have found that
increasing involvement of fathers can be effective in improving the health of families.
The value of fathers‘ involvement should be emphasized for all families and all pregnant
women, regardless of HIV status.
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Exercise 1.2: Card sorting exercise on drugs in Pregnancy
Cards box A: Drugs in pregnancy
Individual exercise
Facilitator will guide you through the following
exercise. The objective of this exercise is to
guide you to identify drugs that can be
used/contraindicated during pregnancy.
Time: 5minutes
Vitamin B6 Phenergan Phenobarbital
Paracetamol Mebendazole AZT
3TC Amoxicillin EFV
Co-trimoxazole DTG Tetracycline
Benzyl penicillin injection for Fluconazole TT injection

syphilis
Iron/folate tablets AZT-3TC-DTG AZT-3TC-EFV
TDF-3TC-EFV TDF-3TC-DTG Streptomycin
Rifampicin Ethambutol INH
1.3: HIV TESTING AND COUNSELING DURING ANC

After completion of this session the participants will be able to:
 Define HIV testing and counseling
 Provide pretest information
 Explain the benefits of HIV Testing and counseling Services for Women
 Describe the components of HIV testing and counseling
 Offer couples counseling and HIV testing and with mutual disclosure.
Allowed time: 320 minutes
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1.3.1. HIV testing and counseling for pregnant women
1.3.1.1. Define HIV testing:

HIV testing is a process that determines whether or not a person is infected with HIV.
1.3.1.2. Define HIV counseling:

HIV counseling in the context of PMTCT is a confidential dialogue between women of
childbearing age and their health care providers to help women examine their risk of
acquiring HIV infection before, during, and after pregnancy as well as the risk of transmitting
HIV infection to their children or their partners.
1.3.1.3. Retesting for HIV negative pregnant women

If a pregnant woman is tested negative for HIV during current pregnancy, HIV retesting
should be offered at late pregnancy/delivery or postnatal period based on risk assessment.
The following population categories are also eligible for retesting:
1. Members of sero-discordant couples

2. FSWs (Female sex workers) and other MARPs
3. History of multiple sexual partner
4. History of STIs during this pregnancy
5. Injectable drug users
6. History of potential exposure to HIV
7. Pregnant women with OIs defining illness
8. Occupational exposure or sexually assaulted client
1.3.1.4. Retesting for positives (verification)
All HIV positive pregnant or lactating women should be retested with a second specimen
before initiating ART. The sensitivity and specificity of individual WHO pre-qualified HIV
test kits is high and operational performance in the field, with in validated test algorism has
been shown to be very good in many settings with proper quality assurance measures.
However, if inappropriate tests are used and test kits are used incorrectly, there is a potential
for misclassification of HIV status which even with a very low error rate could bring about a
significant number of misclassified people given the large number of HIV tests conducted at
country level (WHO, 2014). Retesting of pregnant and lactating women who are already on
ART is not recommended. The effect of ART in suppressing viral load replication may
53
extend to suppression of immune response and therefore reduction of antibody production
will be there. Once a person is started on ART low antibody titers make it challenge to
discern whether an individual indeed HIV positive and will lead to potential risks of incorrect
diagnosis.
1.3.2. Provision of pre - test information at ANC setting.

You can provide pre-test information for a group, a couple, or an individual. The group
session is the recommended model for providing pre-test information to antenatal clients,
particularly where the client-to-provider ratio is high. Group information sessions are
efficient, optimize human resources, and allow group interaction. The pre-test session should,
contain at a minimum of the following contents:
o Provide basic information about HIV/AIDS and mother to child transmission
of HIV.
o Reasons for recommending HIV testing, for all pregnant women
o The clinical and preventive benefits of HIV testing
o Available services, both for the woman, her baby, and her partner
o Reassurance that all information will be treated confidentially and will not be
shared with anyone other than health workers directly involved in providing
care for her and her baby
o The right of the woman to decline testing, and that declining testing does not
affect her access to all other services that do not require knowledge of her HIV
status
o Information and support (skills in how to go about it) if the woman opts to
disclose her HIV test result to her partner and encourage her partner to be
tested.
The health worker should also give the woman an opportunity to ask questions or
express anything that concerns her. It is important to discuss the woman‘s concerns,
including those related to disclosure and partner testing.
A client pre-test information session is complemented by using flipcharts, videos, brochures,
posters, and other appropriate job aids to enhance better understanding and facilitate the
decision-making process.
The following is an example of a pre-test information session frame, which a health care
provider can adapt to the specific situation/context of the facility.
54
Sample script for general pretest information:
Introduction:
Welcome, my name is ______. I am a health professional who provides PMTCT here

at this clinic. Today, as part of your visit, we will be discussing HIV, HIV testing and
ways you can protect your health, and the health of your baby and your family.
Impact:
HIV affects families and our community. HIV is an infection that can lead to a serious
illness called AIDS.
Route of transmission:
HIV is mainly transmitted through having unprotected sex with an infected person. A
mother with HIV can also pass HIV to her baby during pregnancy, labor and delivery
and breastfeeding. You can also get HIV when receiving a blood transfusion, if the
blood has not been tested for HIV. And you can also get HIV by sharing sharp objects
such as razor blades or piercing or tattooing equipment that puncture or cut the skin. It
can also be transmitted by sharing needles and syringes to inject drugs or any other
substances. HIV cannot be passed by mosquito bites, sharing food and utensils,
hugging and holding, shaking hands, or sharing toilets.
Diagnosis & benefit of testing:
You cannot tell who has HIV just by looking at a person. The only way to know your
HIV status is by testing. If you are tested and do not have HIV, you will learn how to
protect yourself and your baby from getting HIV. If you are confirmed to be HIV-
positive, you will learn how to get care and treatment and how to lower the chance of
passing HIV to your baby and your partner(s).
Testing process:
Blood test for HIV will be offered as part of the basic services—which includes tests
for Blood Group/Rh, anemia, syphilis and urinalysis for diabetes and other problems;
—you will receive them today. The HIV test is private and confidential; this means
that only health care providers who are caring for you will know your HIV test result
(emphasis on shared confidentiality).
55
You have the right to refuse to any of these tests including HIV testing, but we
strongly recommend you get tested to get all the benefits previously mentioned. We
will take the test for HIV along with the other tests today. The test is done with simple
finger prick test at this (ANC) clinic and the result will be ready within not more than
an hour.
If the test result is negative, it means that you are not infected with HIV. The test does
not determine infection status during window period. If you have risk of getting
infection during the last 3 month, we will repeat another test for you after 3 month.
If your test result is positive, it means you are infected and have the virus in your
blood.
Partner testing:
Your HIV status does not mean the status of your partner. Sometimes couples have
been living together for years and have had children, and yet could still have different
HIV test results. Therefore, it is very important for your partner to get tested for HIV
to determine his HIV status.
Prevention:
Being faithful to one‘s known uninfected partner, correct and consistent use of
condoms, avoiding sharing needles, syringes, and other sharps are some of the ways
to prevent HIV acquisition and transmission.
PMTCT:
For HIV positive woman, avoiding unintended pregnancy using appropriate FP

services; or initiating ARV treatment during pregnancy ordering delivery or during
post-partum while breast feeding; and applying appropriate infant feeding practices
will help to reduce MTCT significantly. Furthermore, these secondary prevention
methods could as well assist in positive living.
Care and Treatment
―If your test result is positive, you we will be provided with the necessary
information, care & support and you will start ART for your own health and to
prevent the risk of transmitting HIV to your baby. If it is negative, you will be
provided with information and advice that will help you stay negative.‖
56
Finally, what questions or concerns do you have? You may probe by asking the
following question:
 Do you understand how one partner can have HIV and the other not have it?
[Suggested response: similar to how you may not get pregnant every time you
have sex, HIV transmission may not happen every time you have sex with an
HIV-positive person. It is not possible to know when HIV will be passed, but
every time you have sex with an HIV-positive person there is a chance that you
could become infected.]
1.3.3. The six guiding principles of HTS in the context of PMTCT

It is important to respect the six core of guiding principles: which are the 6 C's − Consent,
Confidentiality, Counseling, Correct test results, Connections to care and Comfort
 Consent: Informed consent requires that the woman receives clear and accurate
information about HIV, HIV testing procedures, and the care and treatment services
available. Health workers should respect the right of the woman to decline testing.
Verbal consent ids sufficient. In addition, it is essential that all pregnant and lactating
women with HIV are informed that assisted partner service is also voluntary, and that
partners of HIV-positive clients are made aware that HIV testing is voluntarytoo.
 Counseling: HIV testing must be accompanied by appropriate pre-test information and
post-test counseling. All HIV testing services must be accompanied by appropriate and
high- quality post-test counselling, based on HIV test results.
 Correct test results: It is the professional and ethical responsibility of the health
worker to ensure that all women receive correct test results. Internal and external
quality assurance measures including support from reference laboratory is of
paramaunt importance to ensure that people receive correct diagnosis. All pregnant and
lactating women who receive a positive diagnosis should be retested for verification
before ART initiation.
 Connections to care: Health workers caring for pregnant women should ensure that
all women (and their partners if they receive couples testing) receive effective referrals
and linkages to prevention services, care, and treatment.
 Confidentiality: Protecting the confidentiality of the pregnant woman who receives
HIV testing is very important. Shared confidentiality with partner or trusted person and
health care providers are often beneficial to HIV positive women
57
 Comfort: The health worker should assess the woman‘s stage of labour, comfort level,
and need for analgesics. Providers need to show empathy while presenting information
about HIV testing and counseling: explained based on the comfort level of the woman
e.g. between contractions. The health worker should ask the woman to signal for a
pause when a contraction is starting
Tips: Protecting confidentiality
 Discuss HIV testing when the woman is alone and feels safe to answer honestly.
 Confidentiality should be maintained when giving results unless she agrees to have
someone with her.
 Discuss the concept of ―shared confidentiality‖ with health care providers/ trained heath
extension workers with her partner, family members, or other supportive persons in her
life.
 Develop and implement procedures to ensure the confidentiality of how HIV-related test
results are received, recorded, and kept in the antenatal clinic, and to ensure
confidentiality when transferring information to those providing care during labour and
childbirth, and postnatal and newborn care.
1.3.4. Basic counseling skills
Empathizing:
Empathy is the identification with and understanding of another person‘s situation, feelings,
and motives. To empathize is to see the world through the other person‘s eyes and understand
how that person feels. The counselor should listen to the client carefully and try to understand
the client‘s situation and feeling without being judgmental. Empathy should not be confused
with pity or sympathizing.
Active Listening:
The active listener pays attention to what the client says and does, and listens in a way that
shows respect, interest, and empathy. Active listening is more than just hearing what the
client says. It means paying close attention to the content of the message as well as the
feelings and worries that can be expressed through movement, tone of voice, facial
expression, and posture.
58
Open Questioning and Probing:
Open-ended questions elicit more than one-word answers. They often begin with ―how‖,
―what‖, or ―why‖. Such questions encourage the client to express feelings freely and to share
information relevant to the situation. Probing uses questions to help the client express more
clearly. Probing often is necessary when the counselor needs more information about a
client‘s feelings or situation.
Focusing:
Clients often are overwhelmed by many problems, and they can try to address all of their
problems at once. It is important for the counselor and the client to stay focused on the goals
of the counseling session. Counselors might need to refocus or redirect client questions that
can be addressed later in the session. If the client wants to talk about other emotional or
personal issues, the counselor should consider providing referrals for additional support.
Paraphrasing: Is a reflecting statement by the counselor of what a client has said but
restated by the counselor in different words and non-judgmental way. This intended to help
the client know that the counselor is aware of the client‘s perspective.
Correcting Misconceptions
Counselors should provide clients with accurate information and correct misconceptions.
This must be done cautiously so that the client does not feel inadequate or become defensive.
The counselor should acknowledge false information and correct quickly. It is not always
necessary to give detailed explanations of facts
1.3.5. The Benefits of HIV Testing and Counseling Services for Women
Health workers shall explain the benefits of HIV testing for the mother‘s health and for her
child and routinely offer testing for HIV using the opt-out approach with explicit information
on the right she has to decline testing if she decides to do so. Women who refuse testing shall
not be denied any of the services that the facility offers and need support on addressing
reasons for refusing. Some of the benefits of HIV testing in the context of PMTCT includes;
For HIV-negative women
 Helps them remain uninfected
 Helps them to have HIV-free babies
 Help them receive the FP methods of their choice
59
For HIV-positive women:
 Make informed decisions about FP
 Receive appropriate and timely interventions to reduce MTCT including:
o Getting ARV treatment to reduce MTCT
o Infant feeding counseling and support

o Information and counseling on FP
o Prevention of transmission of HIV to her partner
 Receive information on the importance of giving birth in a setting where standard

precautions for infection prevention and safer obstetric practices are implemented
 Secure early access to HIV treatment, care, and support services
 Receive information and counseling on the prevention of HIV transmission to others
 Receive follow-up and ongoing health care for themselves and their HIV-exposed
infants
 Disclose their results to partners and family members and get support
1.3.6. Disclosure
Disclosure is when one partner shares his or her HIV status with another partner
(or any other person). As disclosure is a concern, there are two approaches for
elicitation of partner.
1. Traditional partner testing using client‗s referral- simply the index client takes
responsibility for disclosing their HIV status to partner(s) and encouraging
partner(s) to seek HTS. This is traditionally done with invitation letter or referral
slip.
2. The Innovative Assisted Partner Testing Approach which includes:
 Contract Referral= the index client enters into a ―contract‖ with the provider
whereby the index agrees to disclose his/her HIV status to his/her partner(s) and
refer them to HTS within 14 days. If partner(s) do not access HTS within this
period, in consensus with the index, the provider will contact the elicited
partner(s) directly and offer voluntary HTS.
60
 Provider Referral= with the consent of the index client, the provider directly
contacts the client‗s partner(s) and offers them voluntary HTS while maintaining
the confidentiality of the index client. Disclosure is reserved in this approach.
 Dual Referral= a trained provider sits with the index client and his/her partner
(s) to provide support as the client discloses his/her HIV status. Then the provider
also offers voluntary HTS to the partner(s).
The assisted partner notification services, using provider and/or ―contract referral, is a
particularly effective strategy currently recommended for increasing uptake of partner
testing and identifying and treating new HIV-cases.
While providing counseling on disclosure, providers need to conduct intimate Partner

violence (IPV) - a behavior by an intimate partner that causes physical, sexual, or
psychological harm, including acts of physical aggression, psychological abuse and
controlling behaviors and sexual coercion. As a provider, screen all named partners for IPV
by using the following three standard questions
1. Has [partner‗s name] ever hit, kicked, slapped or otherwise physically hurtyou?
2. Has [partner‗s name] ever threatened to hurtyou?
3. Has [partner‗s name] ever forced you to do something sexually that made
you feel uncomfortable?
If the client answers ―yes‖ to any of the screening questions, the provider should work
with the client to see which notification strategy may be most appropriate. Remember
that provider referral can be done completely anonymously without the client having
to disclose his/ her HIV status to the partner. If the client‗s safety is at risk, then he/
she may not be able to participate in index partner services. Link or refer the client
with IPV to Gender Based Violence (GBV) services.
The following points should also be included in disclosure counseling session:
1. Prioritize what to tell first and what to make next

2. Identifying the person to disclose own HIV status
3. Identifying convenient environment
4. The discussion has to be secret
5. Repeating the key points before starting the discussion
 What to tell, how to tell, when to tell, where to tell and why to tell (4 w and 1 H)
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6. Exercise points to be communicated for disclosure
7. Identify and discuss Points that can be raised by the other person (partner? Mother?
Friends?)
1.3.6.1. Mutual disclosure

Mutual disclosure is when two (or more) partners share their HIV status with one another.
When individuals learn their HIV test results alone, they often bear the burden of disclosing
their HIV status to their partners without assistance from a trained counselor or health care
provider. Couples HIV testing and counseling ensures mutual disclosure of HIV status
between partners. When partners learn their HIV status together, they also agree that
decisions about mutual disclosure to any third parties must be made together. To be effective
mutual disclosure, we need to discuss with the client the 4 W and 1 H which are whom, why,
when, where, and how.
1.3.7. Integration of HIV testing into antenatal care services

The HTS service at MNCH clinics is the key entry point to comprehensive HIV/AIDS
prevention, care, and treatment services for a pregnant, laboring and lactating woman and her
family. As such, it should be provided during ANC, L&D PNC, FP and EPI. This calls for
integration of HIV/AIDs services into the MNCH platform.
1.3.8. Components of HIV testing and counseling

Sample script for individual initial provider encounter in ANC clinic
Component 1 : Notify patient of routine HIV testing ensure

understanding and benefit of testing
Task Suggested Script
Share the findings I have completed examining you and the condition of
of ANC the fetus (your baby) your weight gain, progress of the
examination: fetal growth, and the gestational age . . . (explain the
physical finding)
Notify woman of As you educated in the pretest session in the waiting

routine HIV area our policy is recommend HIV test to all pregnant
testing woman unless you decline. The benefits of HIV testing
62
are………
Ensure Now before I send you for routine ANC laboratory

understanding tests, I want to tell you that unless you decline, I will
and benefit of do HIV testing for you as part of the routine blood
testing tests.
Component 2 : RECOMMEND AND OFFER TESTING
Recommend and In order to help you know your HIV status and take all necessary actions,
offer HIV test we offer HIV testing services to all women as a routine component of
ANC services. And today you will receive this test unless you refuse to get
tested.”
By the way, before we talk more about HIV testing process, have you ever
been tested for HIV?
If patient was tested before and:
Results positive: [Confirm positive results by reviewing any

documentation that the woman may have with her, enroll her for PMTCT,
and continue to the next component.] ―Ok, unless you are already on
HAART, because you are pregnant you will start ART immediately‖
Results negative: [Repeat or confirm HIV test for this pregnancy today.]
If not tested before : continue testing process
Do you have any questions before I proceed?
Component 3A: WOMAN DECLINES OR DEFERS TESTING
Explore and solve “Ok, you have absolute right to refuse, but could you tell me why you
decided not to have an HIV test today?
barriers to testing
How can I help you get ready to take an HIV test? Mothers need to
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know their HIV status when become pregnant that is the only way to
decrease the risk of infecting one’s own baby with HIV.”
[Answer any further questions that a pregnant woman may have or

provide more information that she requests.]
(For a pregnant woman who declined based on a previous negative

HIV test)
“It is still very important that you have an HIV test. I recommend you
repeat the HIV test during this pregnancy so we will have a record of
your results in this clinic.”
(For pregnant woman who has never been tested and still refuses HIV
test)
“I still recommend that you get an HIV test during this pregnancy. If
you do not have HIV, you can be sure that your baby will not be HIV
infected, and also you will protect yourself from becoming infected in
the future.”
“If your result turns HIV-positive, you will be able to get the care and
treatment you need to stay healthy. You will be able to decrease the
risk of HIV infection to your baby or even protect your partner, the
family as a whole, and others.”
Develop plan to “When you return to this clinic for your next pregnancy follow up
return for HIV test visit, we may talk again about HIV testing to see if you are ready to
have the test? Mothers benefit by knowing their HIV status when they
or referral for HIV
become pregnant.”
test
“If you do not want to be tested now here at this clinic, I can give you
a referral to an HIV test site if you would like to go alone or with your
partner.”
“If you do receive a test at a site outside of this clinic, it is important

that you share your results with the health care providers in this clinic
so we can ensure you receive the appropriate care and treatment
during this pregnancy.”
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Thank you(patient’s name), I will see you at your next visit, your next
visit will be on month__/day__/ year __ (specify the date)
N.B. Please make sure specific date (mutually agreed) for the next
appointment is given to the client.
Component 3 B: Pregnant woman agrees to be tested: HIV test preparation
Task Script
Prepare “The test will be done using simple finger prick test, and it takes a
pregnant maximum of an hour to hear the result.”
woman for HIV : Blood is tested by provider as a one stop shopping in the MNCH
platform ( ANC,L&D, postnatal, EPI and FP
testing
“As your blood will be tested here in the clinic. You will need to wait for
some time while I run the test. As soon as the results are available, we
will talk about the test results.”
1.3.9. HIV Rapid Testing

HIV rapid tests are qualitative assays that detect HIV antibodies. Most of them can detect
HIV-1 and HIV-2. HIV testing occurs in a variety of settings outside of the laboratory. The
testing will likely to occur testing and counselling centers (T&C), antenatal care (ANC)
clinics, blood banks, surveillance programs, TB clinics, and sexually transmitted infections
(STIs) clinics.
Advantages of rapid HIV testing include:
 Increase access to prevention (VCT) and interventions (PMTCT)

 Support increased number of testing sites (PITC)
 Same-day diagnosis and counseling
 Easy to use
 Test time under 30 minutes
 Most require no refrigeration
 None or one reagent (a substance used in a chemical reaction to detect or produce
other substances)
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 Minimal or no equipment required
 Minimum technical skill
One advantage of an HIV rapid test is its ability to use whole blood. While HIV rapid tests in
general are considered to be low in complexity, all tests must be appropriately evaluated prior
to use and personnel be properly trained. It is equally important that the test be validated for
use in the environment where testing will occur.
Test procedure 1: Stat-Pak
 Remove the test device and sample pipette from the foil pouch and place it on a flat,
dry surface
 Label the test device with patient name or identification number
 Touch the 5 µL sample loop provided to the specimen, allowing the opening of the
loop to fill with the liquid.
 Holding the sample loop vertically, touch it to the sample pad in the centre of the
SAMPLE (S) well of the device to dispense ~5 µL of sample (serum, plasma or whole
blood) onto the sample pad.
 Invert the Running Buffer bottle and hold it vertically (not at an angle) over the
sample well.
 Add 3 drops (~ 105 µL) of buffer slowly, drop-wise, into the SAMPLE (S) well
 Observe for development of colored bands on the result window
 Read the test result 15 minutes after the addition of the Running Buffer
 Do not read results after 20 minutes.
66
Test interpretation
HIV 1 / 2 Stat-Pak Test Results
Reactive Non-reactive Invalid

2 lines of any intensity appear in 1 line appears in the control area No line appears in the control area.
both the control and test areas. and no line in the test area. Do not report invalid results.
Repeat test with a new test device
even if a line appears in the test
area.
Test procedure 2: Abon
 Allow the test device, buffer and specimen to reach room temperature (15-30 °C)
prior to testing.
 Remove the test device from the foil pouch and use it as soon as possible (within one
hour).
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 Place the test device on a clean and level surface. Label with specimen ID.
 For finger stick whole blood specimens: Take whole blood specimen with a 50 µL
capillary tube until mark line. And add drawn specimen (about 50 µL) on the
specimen well (S) of the test device, then add 2 drops of buffer (approximately 80 µL)
and start the timer.
 Wait for the coloured line(s) to appear.

 Read results at 10 minutes. Do not read results after 20 minutes.
Test interpretation
 Reactive: Two or three distinct coloured lines appear. One line should always appear
in the control line region (C), and another one or two apparent coloured line(s) should
appear in the test line region(s) (T1 and/or T2).
 Note 1: The intensity of the colour in the test line region (T1 and/or T2) will vary but
any shade of colour in the test line region (T1 and/or T2) should be considered
reactive.
 Note 2: Dual infection of HIV-1 and HIV-2 is quite rare.
Test procedure 3: SD-Bioline HIV1/2
 Remove the test device and sample pipette from the foil pouch and place it on a
clean, flat and dry surface
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Using a capillary pipette
 Add 20µl of drawn blood specimen with a 20µl capillary pipette into the sample
well(s). OR, using a micropipette add 10µl of plasma or serum specimen (20µl of
blood specimen) into the sample well(s).
 Add 4 drops of assay diluent vertically into sample well(s).
 Time to result is 10 to 20 minutes. After adding the diluent, read the result after 10
minutes but not more than 20 minutes
 Observe for development of colored bands on the result window and
 Interpret test result at 10-20 minutes. Do not interpret the test results after 20 minutes.
Interpretation
 The presence of two lines as control line (C) and test line 1 (1) within the result
window indicates a positive result for HIV-1.
 The presence of two lines as control line (C) and test line 2 (2) within the result
window indicates a positive result for HIV-2.
 The presence of three lines as control line (C), test line 1 (1) and test line 2 (2) within
the result window indicates a positive result for HIV-1
Ethiopia is currently using serial algorithm (three test algorithm instead of tie-breaker). In
a serial testing algorithm, the samples are tested by a first test. The results of the first test
determine whether additional testing is required.
Test 1 is done using stat-pak, Test 2 using Abon and Test 3 using SD Bioline. When the
first test (T1) is non-reactive, then the final HIV result is negative. When the first test
(T1) is reactive, the result will be tested by a second test (T2); and if the result of the
second test is reactive, then the third test (T3) will be done and if the result is again
69
reactive, the final HIV status will be positive. This test will be repeated at ART clinic for
confirmation.
When the first test is reactive, the result will be tested by a second test; and if the result of
the second test is non-reactive, then repeat both test one (T1) and test two (T2). After
repeating the tests if T1 is reactive and T2 is non-reactive, report HIV negative. After
repeating the tests if T1 is non-reactive and T2 is non-reactive, then report HIV negative.
After repeating the tests if both T1 and T2 are reactive, then conduct test three (T3). If T3
is reactive, report HIV positive. If T3 is non-reactive, report HIV inconclusive and retest
in 14 days.
HIV Rapid Test Algorithm for Ethiopia
Figure 5: HIV Rapid Test Algorithm for Ethiopia
70
Table 4: Inconclusive test result interpretation after 14 days
Previous test result Repeat test result after 14 Report status as
days
A1+, A2+, A3- A1+, A2+, A3- Negative
A1+, A2+, A3- A1+, A2+, A3+ Positive
1.3.10 Dual Detection of HIV and Syphilis for ANC Program
Dual HIV/ syphilis rapid diagnostic tests (RDTs) can be used as the first test for pregnant
women as part of antenatal care (ANC). These simple tests can be used at the point-of-care
and are cost-saving compared to standard testing in ANC. They enable more women to be
diagnosed with HIV and syphilis so that they can access treatment and prevent transmission
to their children.
 Dual/HIV syphilis RDTs detects antibodies to both Treponemal pallidum (TP) (the
cause of syphilis infection) and HIV. Like other RDTs used for HIV alone, they do
not require refrigeration.
 Available products currently do not discriminate between active or past syphilis
infections. This means that, if a person has had syphilis that is treated/resolved, and
treponemal antibodies persist, the dual/HIV syphilis RDT may produce a reactive
result for syphilis.
Advantages of rapid dual HIV/syphilis tests in ANC
 It offers the opportunity to test for both infections with a single finger prick.
 Results are available quickly, enabling many to start either or both HIV treatment and
syphilis treatment with benzathine penicillin.
All women whose dual HIV/syphilis test results include a reactive TP (syphilis) result should
be treated using benzathine penicillin.
1.3.10. Dual HIV/syphilis rapid testing strategy and algorithm for ANC
The testing strategy needed for dual detection of HIV and syphilis (Fig. 1.6) differs from the
recommended strategies for separately testing for HIV or syphilis. It is important not to use
the rapid dual HIV/syphilis test for:
1. Women with HIV taking antiretroviral therapy (ART);
2. Women already diagnosed with and treated for syphilis during their current
pregnancy; and
3. Retesting for HIV
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Perform A1 (HIV/TP)
A1: HIV -, TP- A1: HIV -, TP+ A1: HIV +, TP- A1: HIV +, TP+
A1:HIV -, TP- A1:HIV -, TP+ Report Syphilis positive

________________ ________________
Perform A2 (HIV only) indicative of either
Report HIV Report HIV current or past/resolved
Negative Negative infection
________________ ________________
Report Report
Syphilis Syphilis positive A2: HIV -
Negative A2: HIV +
indicative of
either current or
past/resolved
infection
Perform A3 (HIV only) Repeat A1 (HIV/TP)
A1+,A2+,A3- Repeat A1: Repeat A1:HIV-,TP-

A1+,A2+,A3+ Report HIV or HIV-, TP+
Report HIV HIV+,TP- or HIV+,
inconclusive TP+
Positive Retest in 14
Report days
Syphilis Report Syphilis
Negative Negative
A1:HIV+,TP- or HIV+, TP+ A1:HIV+,TP- or HIV+, TP+

A2:HIV -
A2:HIV -
Repeat A1:HIV+,TP- or HIV+, Repeat A1:HIV-,TP- or HIV-,
TP+
TP+
Report HIV inconclusive Report HIV negative
Retest in 14 days
_____________________
______________________ If A1 or repeat A1 is TP
If A1 or repeat A1 is TP
reactive, report Syphilis
reactive, report Syphilis positive indicative of either
positive indicative of either
current or past/resolved
current or past/resolved infection
infection
____________________________
____________________________ If A1 or repeat A1 is TP non-
If A1 or repeat A1 is TP non-
reactive, Report Syphilis
reactive, Report Syphilis Negative
Negative
Figure 6: Dual HV/Syphilis rapid diagnostic test algorithm
A1: Assay 1, A2: Assay 2, A3: Assay 3, TP: Treponemal pallidum (syphilis).
A1 is a dual HIV/syphilis rapid diagnostic test (RDT)
A2 and A3 (Assay 2 and Assay 3) are HIV RDTs or enzyme immunoassays (EIAs).
When resolving discrepant results, all reactive TP (syphilis) results, including A1: TP+ or
Repeat A1:TP+, should be referred for treatment and further testing according to national
guidelines.
When resolving discrepant results, if A1 and Repeat A1 are both TP (syphilis) nonreactive
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results, report syphilis negative.
1.3.11. Post-Test Counseling

Post-test counseling is an important part of HIV testing, and it should be tailored to
individual test results, risk behavior, and needs. Post-test counseling may be provided to
the woman alone or to the couple together.
The result of HIV testing should always be offered in person in a confidential setting. Along
with the result, appropriate post-test counseling, information or referral should also be
offered.
Component 4: provide HIV negative test result counseling : Inform negative test result
Task Script
Providing the Thank you for waiting.
HIV negative Your HIV test result is now ready.
test results to Your result is negative, Meaning that the test did not detect HIV in your
the pregnant blood.
woman The test result indicates the status you had before 3 months. This type of
test usually does not pick recent infections that are in window period (in
the past three months).
So, I recommend you to have another test after 3 months to confirm your
status if you think that you had any exposure/ risk in the past three
months.
To stay HIV free, it is important to protect yourself from other STIs
including HIV which can be harmful to your baby as well. You may need
to always use condom and seek early treatment if you observe any signs or
symptoms of an infection.
Component 5: Address partner referral and motivate pregnant woman to reduce risk
Motivate HIV infection is common in our community. You need to take steps to ensure
pregnant that you do not become infected in the future.
woman to Knowing your own serostatus does not indicate the status of your partner,
reduce although rare, there is a possibility of being couples with discordant result.
risk. If your partner is HIV-negative, the two of you will need to be faithful to each
73
other. This will protect both of you from getting HIV.
If your partner is HIV-positive or you do not know his status, or if you have
sex with more than one partner, you can protect yourself from HIV by:
 Not having sex until your partner is tested and you find out that he is free
of HIV or
 Using condoms properly every time you have sex.
I would like to make you aware that if you get HIV infection while pregnant or
breastfeeding, the chances of transmitting HIV to your child is much higher
than any other time.
We have condoms available in the clinic, and you are always welcome to take
some.
I can show you how to use condoms correctly. Would you like me to show you
how to use condoms correctly?
[If a woman wants, demonstrate using model, show her the correct way to use
condoms and give necessary instructions. Alternately give handouts on how to
use condoms and how to avoid getting HIV.]
If you think you will have any problems getting your partner to use the
condom, we can offer you advice on how you should negotiate condom use.
Address As you probably know, the fact that you are HIV-negative doesn’t necessarily
partner referral mean that your partner is HIV-negative. Thus, it is strongly advised to ask
your partner get tested.
You are encouraged to bring your partner to this clinic for HIV test or just
refer him so that providers can offer and do HIV testing for him. If you need
any information or referral slip for your partner, here is some information
about where to get HIV testing service and how you can protect yourself from
getting HIV.
I hope you will ask your partner to be tested; if you have difficulty asking your
partner to be tested, we can give you an invitation letter for him to
accompany you in your next visit so as we discuss with him the importance of
being tested.
Thank you for coming in today. I hope that when you come in next time, your
74
partner will have been tested for HIV
Component 6: Provide HIV positive test result counseling: Inform positive test result
Providing the HIV test Thank you for waiting. Your test result is available and your HIV test
results to the pregnant result is positive. This means you are infected with HIV.
woman
[Allow a moment for the patient to absorb the meaning of the result.]
I know how difficult it can be receiving this result—learning that you

Provide support have HIV infection.
It is normal to feel upset and overwhelmed at first.
You need time to adjust to this, but I am confident that in time you will
be able to adjust and cope. Now the services are good, there is
treatment for HIV, people are living healthy life with medication.
Component 7 :Provide HIV clinical care recommendations

Provide HIV clinical Being HIV infected and Pregnant make you in high need of treatment.
care recommendations This helps you that you feel better and live longer; prevent the risk of
MTCT even though you have HIV infection.
Have you heard about treatment for HIV infection, antiretroviral
therapy (ART)?
[If pregnant woman does not know about these medicines, inform her
in brief.]
Our facility provides ARV treatment to all HIV-positive pregnant.
You benefit from ART, because you are pregnant and HIV infected;
you are automatically eligible to start ART, a treatment for life; this
helps both for your own health and protecting the baby from HIV
infection (MTCT). In the meantime, I will do thorough examinations
and request lab investigations for baseline. The baseline lab
investigations are not pre-requisite for initiating ART, rather they use
for follow up of your treatment.
It will be best for you to deliver your baby in a health facility where
you will give birth by skilled birth attendance and receive low risk
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interventions to reduce the risk of MTCT, as well as ARV medication
for the new born.
After delivery, your baby will start ARV prophylaxis immediately and
continue until the age of 12 weeks.
Review woman‘s plan [Discuss a birth preparedness plan: e.g. Planning for transportation?
for delivery securing money for emergency, identifying who shall bring you to the
health facility, who shall decide on emergency, or cover the cost of
transportation, clinical services, etc.]
In case a woman end up to deliver at home:
Both you and the baby have to be examined to make sure all is well.
 [Emphasize to the mother that they shall continue their ART at
the regular time and they shall start giving the infant ARV
prophylaxis immediately after birth and continue up to 12
weeks of age].
Provide ARV “If you accidentally deliver at home, make sure that you come with
prophylaxis your newborn baby to the health facility for the infant ARV prophylaxis
to be started immediately after birth. You need to give ARV
prophylaxis for the baby until 12 weeks of age.”
“The ARV prophylaxis (AZT + NVP) for the baby is safe, is a daily
dose, and it is supplied with a syringe for administration.”
Do you have any questions that I can answer at this time?
When you arrive at the health facility for delivery, please let your
clinician treating you during labour know that you are HIV-positive.
Your baby will also start medication after birth.
Infant feeding As we talked before, there is a risk of your baby getting infected via
counseling breast milk.
We will now discuss some options for you to choose to feed your
newborn baby.
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Counseling on infant feeding Options:
Exclusive breastfeeding for the first 6 months—this is beneficial in
that it is nutritious, easily accessible and has a disease-protective effect
and promotes bonding. If you follow the treatment and advice given
here, you can reduce the chance of passing the virus to the baby. This
is the preferred infant feeding choice in Ethiopia.
Alternative Option
Commercial infant formula—if you are using this option, there is no
risk of virus transmission through breastfeeding, but unless it is given
in a safe way, it carries a higher risk of death in Ethiopia.
From these feeding options you can choose whichever is applicable for
your infant feeding practice. However, there may be situations that
prevent you from continuously practicing your feeding method of
choice, thus alternatives are given to temporarily substitute your
choice.
We will support you in the process of practicing the feeding options
you choose.
Component 8 : Address assisted active partner disclosure and referral
Address disclosure How do you feel about letting your partner know that you are
infected with HIV?
I also want to clarify that your test result does not reflect your
partner’s HIV status. It is important that he also get tested.
[Discuss possible approaches to disclose of HIV status to partner.]
How do you think your partner will react when you tell him about
your being HIV-positive?
Would you be telling your partner about your HIV test result before
coming for the next visit?
What further help do you need to tell your partner about your HIV
test result?
Because HIV can spread through sex, your partner needs to be

77
tested right away to determine if he is also infected.
Your partner can go for HIV testing at the VCT center within the
health facility or other VCT centers around.
Emphasis the importance of partner and family based index case

Discuss partner referral
testing. The prime targets of partner and family based index case
testing service are biological children less than 19 years of age, and
sexual partners (spouse and non-spousal if any).
Do you think you can get your partner in for testing by our next
visit?
[Support patient to refer partner for HIV testing based on partner

notification methods of her choose.
Component 9: Address risk issues and provide referrals

Provide preventive The best way to assure that your partner does not get HIV or any
messages for HIV- other STIs is not to have sex.
positive pregnant women
If you do have sex, you need to use a condom every time. Condoms
will not only protect you from HIV but also from other STIs. We have
condoms available in the clinic and you are welcome to take some.
Where else can you get condoms?
Prevention and early treatment of other STIs will reduce the chance
of spreading them to your partner or your baby.
Do you think you will be able to convince your partner to use a

condom?
[Demonstrate to the patient the use of condoms or provide him/her

with a pamphlet on how to use condoms and how to prevent
transmission of HIV where necessary.]
Lastly, we shall briefly discuss nutrition. Taking a varied and

nutritious diet, including micro-nutrients, is essential for your own
health, as it provides the basis for the production of immune system
78
and delays progression of infection. At the same time, it helps the
fetus to grow and develop well.
I know this has been a very stressful day for you. However, now that
we know you have HIV, we will start on ART and give you
appointment for next visit
Before you leave today, I will give you information about how to get
further support from some organizations within our community.
[Mention some support organizations and provide the patient with
appropriate referrals.]
Most people find it helpful to tell someone about their problems and
get their support. Is there anyone that you can talk to about your
HIV status?
Thank you, (patient’s name) for coming in today.
Exercise 1.3: Role play on testing and counseling for HIV at ANC
Role play
Case scenarios for Post-Test Counselling
Time: 40 minutes
Scenario 1: For HIV-Negative Test Results
W/ro Fethia is 30 years old and 36 weeks pregnant. This is her first pregnancy. She feels
well, and her pregnancy is without incident. She comes to the clinic today for a check-up
before her due date. W/ro Fethia has never been tested for HIV. W/ro Fethia‘s B/P is 120/75
mmHg, and she weighs 45 kilos. All her clinical review is normal.
How would you recommend HIV-testing and counseling to W/ro Fethia today?
The health care provider used the cue card to recommend HIV testing. W/ro Fethia
agreed to be tested for HIV. The nurse did an HIV test which was Negative.
How would you inform Fethia about her HIV test result?
79
Scenario 2: For HIV-Positive Test Results
W/ro Lelise is 35 years old and 20 weeks pregnant. She is Gravida II Para I. She comes to the
clinic for the first time today for a routine check-up. She feels well. She has never been tested
for HIV. She doesn't know her husband's HIV status.
W/ro Lelise‘s B/P is 90/70 mmHg, and she weighs 50 kilos. All her clinical review is normal.
How would you recommend HIV-testing and counseling to Lelise today?
The health care provider used the cue cards to recommend HIV testing. W/ro Lelise agreed to
be tested for HIV. The nurse did the HIV test with finger prick. The HIV test result is
Positive.
How would you inform Lelise about her HIV test result?
Table 5: Checklist for observing counselling sessions for positive test result during role
play
Skills and Specific strategies, statements, behaviors Yes No

techniques () ()
Greets the patient; shakes hands if appropriate

Leans forward when talking
Establishing a Makes eye contact (when appropriate)
relationship
Shows interest in the client
Facial expression indicates caring and interest in the client
Inform the meaning of positive test result
Inform the
positive test
result Allow the moment for the patient to absorb the meaning
Inform the woman about availability of ART drugs to

reduce MTCT of HIV
Lifelong adherence to ART drugs
Provide Discussed the importance of institutional delivery to
clinical care reduce MTCT of HIV
recommendatio Counsel on the importance of infant prophylaxis
ns immediately after birth
Counsel on exclusive breast feeding for the first six
months
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Address Counsel on the disclosure of HIV status to the partner
disclosure and Invitation card provided to bring partner for testing
partner referral
Counsel on the importance of correct and consistent use of
Address risk condom
issues and Counsel on prevention and treatment of STIs
provide
referrals Counsel on taking a varied and nutritious diet
Actively listen to the clients

Uses minimal encouragers such as yes, okay, etc.
Listening Checks to be sure she understands what the patient is
saying
Occasionally sums up patient‘s statements
Avoids over use of closed-ended questions
Questioning Uses open-ended questions to get more in-depth
information from client
Referral and Link the client to PMTCT for re-testing and ART
linkage care, initiation
treatment and
support
1.3.11. Couple counseling
Couples counseling is when two or more partners are counseled followed by testing and
receiving their results together. When couples receive their results together, they can receive
appropriate support and be linked to follow-up services by a counselor, health care provider,
or community-based worker.
Some potential benefits of couples HIV counseling and testing include:
 Individual is not burdened with the need to disclose results and persuade partner to be
tested
 Offer safe environment for couples to discuss risk concerns and issues
 The counselor can help relieve tension and diffuse blame.
 Partners hear information together, enhancing the likelihood of shared understanding.
 Counseling messages are tailored, based on the test results of both partners.
 The counselor creates a safe environment and can help couples talk through difficult
issues that they may not have discussed before.
 Prevention, treatment, and care decisions can be made together.

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 Decisions about family or child testing, as well as family planning, can be made
together
Entire CHCT Protocol

Introduction to Couple Counseling
Option for couple to and Testing & Concurrence to
receive individual Receive Couple Services
VCT services
Explore Couple’s Life-stage and

Reason for Requesting CHCT
Discussion of Couple’s
Risk Issues and Concerns
Couple’s Options for Reducing Risk
Preparation for Testing and

Discussion of Possible Results
Informed Their
Rapid Test Performed Results are the Same
Couple Receives HIV Test Results
Informed Their
Results are Different
Concordant Concordant
Negative Positive Discordant
Risk Reduction Coping and Positive Living – Family Planning Disclosure and
Support HIV Care & Tx and PMTCT Risk Reduction
Overhead 6-9
Figure 7: Couple HIV counselling & testing protocol component structure
Couple counseling skills
 Demonstrate neutrality and non-biased concern for both members of the couple
 Convey respect and regard for the couple‘s relationship/partnership
 Facilitate balanced participation of both partner
 Model appropriate listening and communication skills
 Facilitate dialogue between the couple
 Raise the difficult issues that the couple may need to contend with
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 Mitigate tension and avert blame
Conditions for Receiving CHCT Service
 Voluntary participation of each partner
 Agreement to mutually discuss HIV risk issues and concerns
 Willingness to receive results together
 Commitment to shared confidentiality
 Mutual decisions about disclosure of results
Prevention of HIV transmission in discordant couples

A discordant couple is a couple in which one partner is HIV-positive and one partner is HIV-
negative. It is possible for couples to stay HIV discordant indefinitely if they consistently
practice safer sex using condoms. Treatment for the HIV-positive partner also is highly
effective in reducing the risk of transmission to the HIV- negative partner. Combined
treatment and consistent condom use are likely to offer greater protection than either one
alone. As an additional prevention choice for people at substantial risk of HIV infection (an
incidence of HIV higher than 3 per 100 person-years), oral pre-exposure prophylaxis (PrEP)
should be offered. The target population for PrEP is FSWs and HIV negative partners of
sero-discordant couples. HIV negative partners of sero-discordant couples should be
screened for PrEP eligibility and initiation.
Eligibility criteria for PrEP in HIV Negative Partners of Sero– Discordant Couples
 HIV negative using a rapid antibody test on the day of PrEP initiation
 Substantial risk of HIV infection (any ONE of the following in the past six months):
 Has a known HIV positive sexual partner(s) who is not on ART oron ART for less
than six months and not yet achieved viral suppression or
 If the HIV negative partner has doubts about the effectiveness of the partner‘s
treatment or has other partners besides the HIV-positive partner on treatment, or
 If there is history of partner violence and controlling behaviour.
 Refuses to report risk category but still requests PrEP,
 No contraindications to PrEP medicines (TDF/3TC)
 Willing to give consent for and use PrEP as prescribed, including periodic HIV testing,
safety laboratory testing and enhanced adherence counselling sessions.
 Willing to provide detailed contact information for tracing
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The Exclusion Criteria and Contraindications for PrEP
 HIV infection (rule out HIV infection by testing using the national algorithm at the same
day of PrEP initiation).
 Signs/symptoms of acute HIV infection, with probable recent exposure to HIV.
 Estimated creatinine clearance of less than 60 ml/min (if known).
 Allergy or contraindication to any medicine in the PrEP regimen (TDF or 3TC).
 Presence of Hepatitis B infection (clients with HBsAg Positive test result)
 On MDR-TB treatment.
 Significantly mobile (not planning to be in that town for the next 6 months) persons that
will not be able to attend visits as prescribed, that is clients that will not be in a region
where PrEP can be provided at the next visit or clients that do not have contact
information.
 Unwillingness to use PrEP as prescribed
Follow – Up and Monitoring Of PrEP
 Currently the recommended regimen is TDF/3TC FDC, 1 tablet, orally daily.

Prescription Intervals:
For HIV negative partners of sero - discordant couples, the initial dose will be for one month.
Once the HIV test at 1 month is still negative, provide supply for 3 months and continue the
follow up every 3 months with repeat HIV testing.
84
Figure 8: PrEP Screening and Initiation Algorithm
85
Table 6: Follow – up after initiation of PrEP
Confirmation of HIV Every 3 months. Consider also testing at 1 month
negative status
Address side-effects Every visit.
Brief adherence Every visit.

counselling
Estimated creatinine Every 6 months. Consider more frequently if there is a history

clearance of conditions affecting the kidney, such as diabetes or
hypertension; consider less frequently if age is less than 45,
baseline estimated creatinine clearance more than 90 ml/min,
and weight > 55 kg.
Screening for sexually To diagnose and treat STI (syndromic or diagnostic STI testing,
transmitted infection depending on local guidelines). Every visit.

(STI)
Counseling To assess adherence and provide counselling regarding

effective PrEP use (adherence),
To assess whether the client is still at substantial risk of HIV.
To discuss prevention needs and provide condoms and

lubricants.
To assess fertility intentions and offer contraception or safer
conception counselling.
To assess intimate partner violence and gender based violence.
To assess substance use and mental health issues.
86
Initial follow up will be after a month of initiation and every three months then after.
When should PrEP be stopped or discontinued?
PrEP should be stopped if the client:
 Has a positive HIV test result, then start ART,

 Develops renal disease (refer to the national guideline on comprehensive HIV care and
treatment)
 Has become non - adherent to PrEP (i.e. as per the national definition for adherence, poor
adherence, non – adherence).
 If the client misses 5 or more doses during the month, Enhanced Adherence
Counseling (EAC) will be offered 2 times (once per each visit monthly). If the client
keeps on missing doses, and has poor adherence on three consecutive visits,
providers may consider discontinuing PrEP.
 Does not need or want PrEP,
 No longer meets the eligibility criteria, , index or partner is no more in substantial risk
for HIV infection, i.e., sustained viral suppression of HIV partner,
 If there are safety concerns, where the risks of PrEP use outweigh potential benefits.
After discontinuation of PrEP, there should have to be follow - up testing for HIV after a
month in order to confirm that the client is still HIV negative.
87
Session Summary
True or False
1. Partner/male involvement in maternal and newborn care can help reduce the risks of
MTCT of HIV.
2. All pregnant women should be tested for HIV with or without their consent because, if
HIV-positive, they can transmit the virus to their babies.
3. If a pregnant woman tests negative for HIV she probably is not infected with HIV,
but the test cannot detect very recent infection.
4. All pregnant women are at risk for HIV infection because the pregnancy is the result of
unprotected sex.
5. Confidentiality is less important for pregnant woman because health workers
need to know her HIV status in order to provide PMTCT services.
Short Answers
6. List two reasons that disclosure of HIV status is important for pregnant women
in general.
7. List two benefits for an HIV-positive pregnant woman of knowing her HIV status.
88
1.4: SPECIFIC INTERVENTIONS FOR PMTCT IN THE ANC SETTING
After going through this session, you will be able to:
 Conduct HIV clinical review (physical examination, order investigation) for HIV
positive women.
 Determine clinical staging of HIV positive pregnant women.
 Identify common opportunistic infections in HIV infected pregnant and lactating

women
 Provide TPT and CPT prophylaxis for eligible HIV infected pregnant and lactating
women
Allotted Time: 200 minutes
1.4.1. Introduction to the session

HIV infected women should get comprehensive care and support including ART. This
section briefs the components of clinical care ART.
Assessment of HIV-positive pregnant women consists of the same routine pregnancy-related

review as provided to all pregnant women plus HIV clinical review and assessment. In this
section, we will focus on the HIV clinical assessment.
1.4.2. HIV Clinical Review and assessment

Clinical assessment of the HIV-positive pregnant woman should be performed each time she
comes for antenatal services, for childbirth, and during the postnatal period. It is important to
do a clinical review of pregnant women with HIV at the first antenatal contact and during
each subsequent follow-up contact. Clinical review comprises targeted history taking and
physical examination.
89
Table 7:History taking &physical examination.
1. History 2. Physical Examination (P/E) 6. Assess Family Status
If this is first visit: In all patients: o Forwomen:
Review history. Check record for TB,other · Look for pallor. Ifpallor, o Ask if she is pregnant, ask
opportunistic infections, chronic problems. check for hemoglobin. LMP
For allvisits: · Look forjaundice o If she is not pregnant,ask
 How have youbeen? · Look forthrush. for pregnancyintention
 Have you developed any new symptomsor · Weigh. Calculate weightgain, o Assess for FPneed
problems? or loss. If weight loss, ask o For men:
 Have you had any of the following? If yes, about foodintake. o Ask about pregnancystatus
If any newsymptoms: of theirpartner
evaluate the patient :
· Measure vitalsigns. o Ask for intention to have a
o Cough?
o Nightsweats? · Measure weight, height, head baby
o Fever? circumference andMUAC o Have you disclosed your HIV
o STI signs (For all: genital discharge, sore,dysuria. status to your partner or
· Check for nodes. If >2cm,
For men: scrotal swelling, inguinal swelling. For someonesignificant?
· Look for skinrash.
women: Lower abdominalpain) o Is your partner tested for
· Look for evidence of HIV?
o Diarrhoea?
o Mouth sores? violence. o Are your children testedfor
o New skinrash? · Do further assessmentof HIV?
o Headache? symptoms
o Fatigue? If first visit (also check
o Nausea orvomiting? every 6 months; skip if 7. Review TB status
o Poorappetite? known problem):
o Tingling, numb or painfulfeet/legs? o ActiveTB
o Tell patient you want to
o Any other pain? If yes, assess using WHO o Newlydiagnosed
check hismemory.
stepladder o On antiTB
o Name 3 unrelatedobjects,
o Problems sleeping atnight? o Positive TB screen
o Sexualproblems?
clearly and slowly. Ask
patient to repeatthem: o TB suspected on previous
 Additionally, in childrenask visit, check for sputum
o Unable tofeed
o Can he or sherepeat
them? (Registration result and respond as per
o Difficulty ofbreathing the TBguideline
o Grunting problem?)
If yes, wait 5 minutes and ask o Order sputumexamination
o Legswelling
again, "Can you recall the 3 o Negative TB screen
o Convulsion
o Lethargy/coma objects?" (Recall problem? o GiveTPT/IPT
o Ear pain
3. Laboratory
 Are you sexually active? How manypartners
do you have? Do you usecondoms?
 Have you been feeling sad or unhappy orhave Request relevant laboratory 8. Initiate ART
you lost interest in your normal activities tests as baseline, But this o Do adherencepreparation,
recently? If so assess for depression should not delay ARTinitiation Determinereadiness,
 Have you been feeling scared orfrightened 4.WHO Clinical Staging o Initiate ART as soon as
recently? possible including same day
Determine the WHO Clinical
 Doyoudrink‗tella,‗‗tej,‗‗areke‗,beerorother Stage of your client
ART
alcohol beverage? How many days of a week 9. AdherenceCounseling
do you drink? How much do youdrink? o Conduct ongoing adherence
 Have you needed urgent medical care? If yes, counseling
ask for record/diagnosis. 5.Functional Status 10. PHDP
 Which drugs (anti TB, traditional, ARVs,illicit /Developmental milestone
drugs, etc) are you taking and howoften? Determine the functional status o Give client condoms at
 Assessadherence for adult and Developmental everyvisit
 How are things athome? appropriateness for children o Agree on a prevention goal
for theclient
 What usual physical activities are youdoing?
 Is there anything else you want to talkabout?
90
Table 8: Physical examination for HIV positive pregnant women
Systemic Examination Check for the following findings
Vital signs and Anthropometry  Pulse and Respiratory Rates, BP and Temperature
 MUAC
 Weight, Height
HEENT  Check for Pallor, Jaundice, Oral thrush, Ear discharge,
Tonsillar enlargement, Sinus tenderness
Lymph Glandular System  Check for Enlarged lymph node in the neck and axillae
and groin
Respiratory system  Central Cyanosis
 Check for Air entry and
 Abnormal sounds (Bronchial breath sound, crepitation and
wheezing)
Cardiovascular system  Heart sounds and other abnormal sounds
Gastrointestinal system  Tenderness and/or Guarding
 Mass and Organomegally (e.g. Hepato-splenomegaly)
 Sign of fluid collection (shifting dullness and fluid thrill)
Musculoskeletal system  Tenderness, Abscess collection
Dermatologic  Skin rash
Nervous System  Consciousness
 Orientation to Time, Place and Person
 Meningeal signs, Weakness/paralysis
 Signs of anxiety and /or depression
1.4.3. Determine WHO clinical stage
The criterion for WHO clinical staging for pregnant woman is the same as for any adult. Use
the WHO staging for adolescents and adults − the only modification for pregnant women is
the weight loss criteria in clinical stage 2 and 3. For a pregnant woman, failure to gain weight
during pregnancy may also be considered to be weight loss. (Refer table 1.9 below)
Staging systems for HIV can:
 Help for follow up of HIV positive pregnant/lactating mother who are on ART
91
 Provide a framework for follow-up and clinical management
 Help understand prognosis and guide patient counseling
 Help evaluate whether ARV therapy is working
 Assist with clinical decision-making, including decisions on when to change ARV

therapy.
o Note: clinical staging is not used for ART initiation in HIV positive pregnant and
lactating women but will be used for clinical monitoring after the treatment
initiated.
There are multiple exercises given successively to help you understand the clinical features of
HIV, their significance related to the identifying the magnitude of the illness and treatment.
92
Table 9: WHO Adolescent and Adult HIV Clinical Staging
WHO Clinical WHO Clinical Stage 2 WHO Clinical Stage 3 WHO Clinical Stage 4
Stage 1 (Mild Disease) (Advanced Disease) (Severe Disease/AIDS)
(Asymptomatic)
No symptoms or  Moderate unexplained weight loss  Unexplained severe weight loss  HIV wasting syndrome
only: 5-10%** of presumed or (>10% of presumed or  Pneumocystis (jirovecii) pneumonia
 Persistent measured body weight measured body weight)**
 Recurrent severe bacterial pneumonia
generalized  Sores or cracks around  Unexplained chronic diarrhoea
lips(angular chelitis) for longer than 1 month  Chronic herpes simplex infection (orolabial, genital or anorectal of more
lymphadenop than 1 month‗s duration or visceral at any site)
athy  Papular pruritic eruption  Unexplained persistent fever
 Seborrhoeic demititis (intermittent or constant for  Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
 Herpes zoster longer than 1 month)  Extrapulmonary tuberculosis
 Recurrent upper respiratory  Oral candidiasis  Kaposi sarcoma
infections such as sinusitis or  Oral hairy leukoplakia  Cytomegalovirus infection (retinitis or infection of other organs)
otitis media, tonsillitis,
 Pulmonary tuberculosis  Central nervous system toxoplasmosis
pharyngitis)  HIV encephalopathy
 Recurrent oral ulcers  Severe bacterial infections
(such as pneumonia, empyema,  Extrapulmonary cryptococcosis, including meningitis
 Fungeal nail infection
pyomyositis, bone or joint  Disseminated non-tuberculous mycobacterial infection
infection, meningitis,  Progressive multifocal leukoencephalopathy
bacteraemia)  Chronic cryptosporidiosis
 Acute necrotizing ulcerative  Chronic isosporiasis
stomatitis, gingivitis or
 Disseminated mycosis (extra-pulmonary histoplasmosis,
periodontitis
coccidioidomycosis)
 Unexplained anaemia (<8 g/dl),
 Lymphoma (cerebral or B-cell non-Hodgkin)
 Neutropaenia (<0.5 x 109/l)
 Symptomatic HIV-associated nephropathy or cardiomyopathy
and/or chronic
thrombocytopaenia (<50 x  Recurrent septicaemia (including Non-typhoidal Salmonella)
109/L)  Invasive cervical carcinoma++
 Atypical disseminated leishmaniasis
NB: Most stage 4 conditions should be referred to hospital for diagnosis and treatment. ** Failure to gain weight can be considered as weight loss in pregnant women.
++- cerivical cancer screening have to be done every 2 years for HIV positive women aged 18-49 years
Calculation of wt. loss =initial wt. minus present wt, divided by initial wt. x1
93
Exercise 1.4.
A. Case scenario on diagnoses and management of Fethia and Lelise in the context of PMTCT
Time: 5 minutes
Please read carefully the situation of Fethia and Lelise as narrated below and note the answer on
your exercise book.
The health care provider did post-test counseling, and she

discussed routine ANC services including PMTCT
services. She discussed disclosure and partner testing with
Fethia. She did a clinical review, staging, and sent blood
for a CD4 count.
Following the clinical assessment, thehealth care provider
decided that Fethia is in WHO clinical stage I. Fethia`s
CD4 count is 400. Her hemoglobin is10g/dl.
Which PMTCT interventions would you recommend for
Fethia, today? Why?
The health care provider did post-test counseling with

Lelise. She explained the test result, including the window
period, the importance of remaining negative, and the
danger of new HIV infection during pregnancy and
breastfeeding
Lelisie plans exclusive breastfeeding, and to deliver at the
health center. What counseling should the health care
provider provide for Lelise?
B. Photograph exercises: You will be provided with photographs displaying various clinical
manifestations of HIV. Your job will be identifying the health problem and the clinical stage it
suggests.
Time: 10 minutes
Photo Case study Clinical stage and

label likely diagnosis
A 30 years old with small swelling on the neck. Has
also swelling under the arm pits
B 41 yr. old HIV +ve woman who comes to the
HC having ulcers on the side of mouth
D 37 years old Woman complains of itchy rash
94
over her back
E 50 yrs. old HIV + who comes to the HC due to
rash
F 27 years old HIV positive woman with multiple
sores in her mouth. She says they are painful and
gets them often
G 35 years old HIV positive woman who says she
has lost weight and has whitish debris on her
tongue, the inside of her cheeks, and the back of
her throat
H 41 years old who says he has whitish patch at the
side of his tongue
I 33 years old HIV +ve woman who says that she

has a whitish vaginal discharge. She is frustrated
because she has had it for over a month(
Pregnant women may have it commonly)
J 38 years old HIV +ve woman with painful ulcer
on genitalia. She says she had this for long time
K 47 years old thin man with a mass in his mouth
L 48 years old HIV positive extremely thin woman

with a purple –black rash over her chest.
M 14 years old HIV +ve boy complains of weight
loss and large swelling on the neck
Exercise 1.5. Clinical staging:
 Read the cases below and, for each woman determine the clinical
stage only
 Write the stage number under the column of clinical stage
 When you complete the exercise your facilitator will lead
discussion for correction
 Time allotted: 15 minutes
ART in
Clinical
Cases MNCH Refer
Stage
unit
W/o Leila learned that she was HIV-positive when she has her
first ANC visit at 29 weeks gestation. She is asymptomatic, has
a normal clinical review, and has a normal activity level. CD4
count = 400; hemoglobin = 10.4 gr/dL.
W/o Tirsit learned that she was HIV-positive on her first ANC
visit at 14 weeks gestation; she presented with angular cheilitis;
95
she has a normal activity level; she complains today of
recurrent bronchitis. CD4 count = 320; hemoglobin = 10 gr/dL.
W/o Fatuma learned that she was HIV-positive and pregnant
when she came for care. She is in her first trimester by
estimated dates. She presented with oral thrush; she said that
she is only bedridden almost half of her active life (40% of the
time); and she complained of an unexplained fever for the last
five weeks. CD4 count = 240; hemoglobin = 6.8 gr/dL.
W/o Sinidu finally accepted testing and learned that she was
HIV-positive on her third antenatal visit. She is at 35weeks
gestation; she is asymptomatic and has a normal clinical review;
and she has a normal activity level. CD4 count = 370;
hemoglobin = 10.8 gr/dL.
W/o Beletu learned she was HIV-positive at 12 weeks gestation.

She came for her third ANC visit today at 38weeks gestation;
she presented with oral candidiasis (thrush); said she is
bedridden some times (about 20% of the time); and she
complained of unexplained diarrhea for the last five weeks. CD4
count = 300; hemoglobin = 9 gr/dL.
W/o Tigest is 21 weeks pregnant and has just been tested HIV-
positive. She just finished treatment for pulmonary TB, and she
has no any other abnormal findings. Her hemoglobin is 8.5.
W/o Biya is 29 weeks pregnant and has known she was HIV-
positive since her last pregnancy but did not tell her nurse until
today. She has esophageal thrush and poor weight gain in this
pregnancy. Her hemoglobin is 8.
W/o Wuleta is 18 weeks pregnant. She is doing well and has a

normal clinical review. She is surprised by her positive test and
will bring in her partner soon for a test. Her hemoglobin is 11.
W/o Tirhas is 22 weeks pregnant. She has a normal clinical

review except for many small lymph nodes and a zoster rash.
She just tested positive today and is very upset. She does not
want to travel to the hospital for a CD4 count.
1.4.4. Laboratory
 Tests routinely performed as a standard component of ANC should be ordered as per
ANC protocol.
96
 CD4 count is important to assess severity of HIV infections and monitoring purpose but
there is no need to wait for CD4 count to initiate ART. CD4 should be done as soon as
available for baseline at ART initiation and as necessary for patient monitoring, but this
should not delay the initiation of ART
 Viral load for pregnant and lactating mothers:
o Viral load should be done for newly HIV positive pregnant mothers at 3months of
ART initiation, at 34-36 weeks of GA or delivery at the latest, followed by three
months after delivery and then every 6 months.
o For women already on ART, conduct VL testing at 1st contact at ANC (VL result
conducted in the last 3 months before 1st contact can also be used), at 34-36
weeks of GA or delivery at the latest, followed by three months after delivery and
then every 6months. Details of viral load testing will be discussed in patient
monitoring session.
 Other laboratory tests including Liver/Renal function tests should be ordered only if
clinical symptoms warrant further evaluation.
 If renal or liver function tests confirm underlying renal or hepatic disease, the patient
should be referred to ART clinic for ongoing assessment and management.
1.4.5. Opportunistic infections and prophylaxis

General information
 Opportunistic Infections are common infections which occur in any HIV infected
individual especially when the immunity drops.
 Microorganisms which are usually harmless cause illnesses in an individual whose
immunity is weakened by HIV.
 Bacteria, fungi, protozoa and viruses can cause Opportunistic infections;
 Any system in the body can be affected by opportunistic infections
 Symptoms of opportunistic infections vary mainly according to the affected body system.
For example:
o Infection of respiratory system: usually manifest with cough, difficult breathing
 E.g. Pulmonary Tuberculosis, PCP, etc.
97
o Gastro-intestinal system: usual presenting with diarrhoea.
 E.g. Oral candidiasis, angular cheilitis, etc.
o Central nervous system: usually presenting with severe headache or confusion
 E.g. Toxoplasmosis, Cryptococcosis
o Skin – can manifest with bluish vascular lesions (Kaposi sarcoma), multi-
dermatomal lesions E.g. Herpes zoster, seborrhoea, etc.
1.4.6. TB screening guide

One of the important activities required form you while providing care to an HIV infected
pregnant women is routine screening for tuberculosis.
Questions for TB screening:
Do you have cough currently?
Do you have fever?
Do you have night sweats?
Poor weight gain
Interpretation:
If YES to any one of above symptoms, patient is a TB suspect (we call it screen
positive) and should be further evaluated (see national TB/HIV/Leprosy guideline for
further information).
If NO to all 4 questions (we call it screen negative), patient is candidate for TPT/IPT.
98
Adult or Adolescents ≥15 years living with HIV
Symptoms (any CD4 or ART status )
Current cough
Any fever
Unintentional
weight loss Screen for active TB disease
Any Night sweat
No symptoms suggestive of TB Presence of any one symptom
Assess for contraindication to Investigate for TB and other diseases

3HP
Other diagnosis TB diagnosed

No Contraindication
contraindication to 3HP
Treat as appropriate TB Treatment
Initiate 3HP Assess eligibility for

other TPT regimen
Follow up and consider TPT
once illness resolved
If not eligible:
If eligible: Initiate Defer preventive
alternative therapy until
regimen (6H) contraindication
resolved
Figure 9: Algorithm for screening TB
Tuberculosis preventive therapy (TPT) and Co-trimoxazole preventive therapy (CPT)
Major OI infection can be prevented by prophylactic treatments. In Ethiopia, the most frequently
used prophylactic therapy are TPT against TB and Co-trimoxazole against pneumonia and other
GI infections at PMTCT/MNCH platform. But Patients with active TB should be referred to TB
clinic.
Tuberculosis Preventive Therapy (TPT)
Tuberculosis Preventive Therapy(TPT) is the use of daily isoniazide to sterilize latent TB
infection(LTBI). Thus, TPT is given to individuals with latent infection with Mycobacterium
99
tuberculosis in order to prevent reactivation to activate disease. Screening for exclusion of active
TB in HIV infected persons is the single most step that should preccedthe decision to initiate
TPT.
Studies have shown that providing TPT in eligible individuals does not increase the risk of
developing resistant TB to INH family. The new short course alternative regimens introduced
for TPT are 3HP/weekly isoniazid Plus rifapentine for 3 months, 3HR/Daily rifampicin Plus
isoniazid for 3 months, 6H/ daily isoniazid for 6 months. Daily dose of INH (300mg) for
6months (6H) is preferred option for pregnant women because rifapentine is not currently
indicated for pregnant and lactating women.
Contraindication of TPT
Individuals with any of the following should not receive TPT
 Symptoms compatible with tuberculosis even if the diagnosis yet not confirmed
 Active hepatitis
 Regular alcohol consumption
 Prior allergy or intolerance to isoniazide
 Symptoms of peripheral neuropathy
In addition, rifapentine is not currently indicated for children below 2 years, PLHIV receiving PI
ART regimen, pregnant women and breast-feeding mothers.
NB. Past history of TB and current pregnancy should not be contraindicated for IPT.
Follow up of patients on IPT
Patients on IPT should be given monthly supply of Isonozide for the first three months and three
months‘ supply for the remaining months. During follow up visit:
 Evaluate adherence to prophylaxis and counsel the client

 Evaluate drug toxicity
 Check for sign and symptoms of active tuberculosis or other OIs.
 Stop IPT if active TB is diagnosed and immediately start anti-TB
NB. Repeating INH preventive therapy immediately after the first cycle of IPT or the
provision of IPT immediately after completion of full course of TB therapy is not
recommended.
100
Cotrimoxazole Preventive therapy (CPT)
Initiation of CPT among adults, adolesents, pregnant mothers and children for prevention of
pneumocystis pneumonia, toxoplasmosis, bacterial infections and diarrehea caused by Isispora
belli or cylospora species.
Table 10: INH prophylaxis and CPT

Opportunistic Prophylaxis Remark
Infection
Pulmonary TB Tuberculosis Indication:
preventive  ALL HIV-infected patients without active TB.
therapy(TPT): INH Remember to adjust dosage according to client‘s
300mg/day weight.
(150mg/day if Wt. Be vigilant about overlapping side effects of ARVs
<30kg) x 6 months + and anti-TB drugs.
Pyridoxine 25mg qd Always look up drug-drug interactions when using
anti- TB and ARV.
In an HIV- TB coinfection it is always preferable to
start TB treatment before starting ARV. ARVs can be
started as soon as Anti-TB was tolerated.
Pneumocystis Co-trimoxazole one Indication:
Pneumonia double strength(DS)  WHO Stage III and IV;
 Asymptomatic individuals with CD4 counts below
(PCP) and tablet daily(or 2 single 350
other OIs. strength tabs) Criteria to stop Cotrimoxazole
 Discontinue when clinically stable,
o On ART for at least one year and
o Without any new WHO clinical stage 2, 3
or 4 events with
o Evidence of immune recovery and/ or viral
suppression:
o (i.e., two consecutive CD4 counts >350
101
cells/mm3, 6 month apart or a CD4 count
>350 with VL result <=1,000)
o Dapson is an alternative for clients with
CPT toxicity. Dapsone will contribute to
anaemia in most patients, and causes
haemolytic anaemia in some patients, so
patients should have a baseline Hgb before
starting dapsone and Hgb monitored every
1-2 weeks for the first couple of months.
When dapsone (as a substitute for CPT) is
being used as PCP prophylaxis, it is only
recommended for patients in WHO Stage 4
and/or absolute CD4 count < 200
cells/mm , and should be discontinued once
a patient achieves a sustained CD4 count
of > 200 cells/mm for at least 6 months.
Dapsone is not recommended during
breastfeeding. Available 25mg and 100mg
tabs. For adults 100mg once daily.
 CO-trimoxazole preventive therapy also prevents
Other OI infection such us diarrhea, malaria,
toxoplasmosis and other bacterial infection
102
Exercise1.6. Challenge yourself-Prophylaxis and TB screening:
Read the cases carefully and fill the three columns. You will discuss
with your facilitator at the completion of the exercise.
Time: 8 minutes
No Case Stage TB screen IPT CPT
1 W/o Sinidu finally accepted testing and

learned that she was HIV-positive on her
third antenatal visit. She is at 35weeks
gestation; she is asymptomatic except
having cough of 5 days and has a normal
clinical review; and she has a normal
activity level. CD4 count = 370;
hemoglobin = 10.8 gr/dL.
2 W/o Beletu learned she was HIV-positive at
12 weeks gestation. She came for her third
ANC visit today at 38weeks gestation; she
presented with oral candidiasis (thrush);
said she is bedridden some times (about
20% of the time); and she complained of
unexplained diarrhea and night sweats for
the last five weeks. CD4 count = 300;
hemoglobin = 9 gr/dL.
3 W/o Tigest is 21 weeks pregnant and has

just been tested HIV-positive. She just
finished treatment for pulmonary TB, and
she has no any other abnormal findings. Her
hemoglobin is 8.5.
4 W/o Biya is 29 weeks pregnant and has

known she was HIV-positive since her last
pregnancy but did not tell her nurse until
today. She has esophageal thrush and poor
weight gain in this pregnancy. No other
symptom. Her hemoglobin is 8.
103
Table 11: Opportunistic infection screening and Management
OIs Clinical Presentation Treatment Remark
 Vesicles in one area on one side of body  Keep lesions clean and dry, if patient comes within 48
Herpes Zoster
with intense pain or scars plus shooting to 72 hrs, give acyclovir( 800mg po five times per day
pain. for 7 days/10 mg/kg/dose every 8 hours
 Give pain relief
 If eye involved –needs ophthalmic evaluation
 Vesicular lesion or sores, involving lips and /  Local antiseptics to avoid super infection  Can become
Herpes Simplex
or mouth  If severe ulceration , oral acyclovir 400 mg PO extensive with
 Usually painful 3x/day for 1 week serious mouth
ulcerations
 Peri-anal and/or genital herpes  The response to Acycovir is gratifying if it is done  If > 1 month, stage
in sufficient dose (400mg 4 to 5 X/d) and 4 disease
sufficient duration (10 days to 2 weeks in
moderately severe or severe cases).
 Intensely pruritic discrete, firm papules with  Treat with topical steroid and oral antihistamines;
Pruritic Papular variable stages of development and however it is often refractory to treatment and hence
Eruption predilection for extremities, though they can short course prednisolone may be used.
involve trunk and face.  HAART is often effective.
 Pigmentation, scarring and nodules due to
excoriation.
 Umbilicated and raised lesions usually  May not require therapy; for extensive lesions refer for
Molluscum
involving the face that tends to be very big cryo-therapy
contagiosum
during immune deficiency state.  HAART if eligible
 Painless flat to raised warts over fingers or  Treat with Podophyllin or extensive lesions refer for
Warts/veruccae
genitalia. Cryotherapy.
 In advanced immune deficiency, they tend
to be multiple and exophytic
 Poorly defined erythema. Pus and crust at  Amoxicillin 500mg tid for ten days or erythromycin
Cellulitis
the site plus signs of inflammation 500mg qid if allergic to penicillin.
 Red, tender, warm crusts or small lesions  Clean sores with antiseptic
Impetigo or
 Start Amoxycilline
folliculitis
 Drain pus if fluctuant
 Start cloxacillin if size >4cm or red streaks or tender
nodes or multiple abscesses for 5 days
104
 If allergic to cloxacillin, use erythromycine
 Itching rash with small papules and scratch  Give potent topical steroid
Papular Itching
marks.  Calamine solution
Rash (Prurigo)  Dark spots with pale centers  ART
 Antihistamine
 Generalized red, widespread with small bumps  Stop medications  Drug related itchy
Fixed drug reaction
or blisters; or one or more dark skin areas  Give oral antihistamine skin disorders,
(fixed drug reaction) Cotrimoxazole is a
common cause
 Not OIs , The condition
must be differentiated
from OIs
 Generalized bullous lesion with skin  Stop medication  A rare but fatal
Stevens- Johnson
sloughing, involving mucosal surfaces  Refer URGENTLY to Hospital reaction to ARV's and
Syndrome
including the mouth and the eyes co-trimoxazole
 Not OIs, The condition
must be differentiated
from OIs
Bacterial
 Sudden (3-5 days) onset of cough,  Amoxicillin 500mg tid for ten days
Admission criteria
sputum production, chest pain, chills  In patients with penicillin allergy use erythromycin
Pneumonia  Tachypnea
rigors, fever and/or shortness of breath 500mg qid for the same duration.
(RR>30/minute),
 Chest pain and pleurisy in older  Old age (>70 years),
children and adults  Cyanosis,
 Tachypnea and decreased oxygen  Hypotension, systolic
saturation indicate moderate to sever blood pressure
pneumonia <90mm Hg,
o may consider hospitalizing patients  Multi-lobar
 egophony and pleural effusion on involvement and
examination altered mental status
105
 Sub acute onset of progressive dyspnea,  Trimethoprim 15-25 mg/Kg and sulphamethoxazole 75-
PCP
 Fever, 125mg/kg, three or four times daily for 21 days.
 Non-productive cough,  if patient grows sicker, administration of oxygen is
 Chest discomfort that worsens within days useful.
to weeks.  In severely ill adults with marked respiratory distress
 In children highest incidence is seen prednisolone has to be given simultaneously;
between 2-6 months of age and is o 40mg BID for the first five days then,
characterized by abrupt onset of fever, o 40 mg daily for the next 6 days and
tachypnea, dyspnea and cyanosis. o 20 mg daily until completion of intensive co-
 Presumptive diagnosis of PCP is based on trimoxazole therapy.
clinical judgment  For severe cases of PCP in children provide prednisolone
 Physical examination of the chest may be 2mg/kg per day for the first 7 - 10 days followed by a
normal in mild cases and early presentation. tapering regimen for the next 10 - 14 days.
 Note that the chest X-ray can be normal in  Secondary prophylaxis after completion of the course of
20% of patients. treatment with co-trimoxazole should be started.
 Definitive diagnosis of PCP is based on Alternative regimens for mild to moderate cases of PCP
demonstration of the organism from an include:
induced sputum sample using special stains
like Giemsa or methylamine silver stains, 1.Clindamycin 600 mg qid plus primaquine 15 mg bid
but these tests are not routinely done in
Ethiopia. Or
2.Clindamycin 600 mg qid plus dapsone 100 mg daily
 Inflammation of the gums  Amoxycillin 500mg PO TID for 10 to 14 days
Necrotising
Gingivitis  Extensive and necrotic  Metronidazole 500mg PO BID for 10 to 14 days
 Tooth loss  Debridment is indicated for severe cases
 Anaerobic infection
 White plaques on the buccal mucosa,  Topical therapy with

Oral candidiasis  Clotrimazole oral lonzenges 10 mg 5x/d until
palate, tongue easily scrachable and
bleeding base , or the oropharynx resolution or
 Nystatin 500,000 IU q 6H
- Sucked and retained in the mouth for 20
minutes
- Until 48 hours after symptoms resolve
or
106
 Miconazole oral jel 2% BID for 2-3wks or
 Oral fluconazole 100mg/d for 2wks is considered
drug of choice
 Lesions are described as white corrugated  HAART
Oral hairy painless plaques
leukoplakia  Commonly on lateral aspect of tongue
 Unlike candida, cannot be scraped
 Relatively specific to HIV infection
 Is a multicentric neoplasm consisting of  Majority showed spontaneous regresion with HAART
Oral kaposi multiple vascular nodules appearing in the  Other options- radioterapy,or cryothearapy
sarcoma mucous membranes skin or visera
 Lesions - reddish to purple to brown raised
maqules
 Can Present with oral thrush or alone  Fluconazole 200 mg PO daily for 21 days
Oesophageal
 Dysphagia (difficulty in swallowing) and
candida
odynophagia (painful swallowing) and/or
retrosternal pain
 Focal encephalitis with headache,
Toxoplasma confusion, or motor weakness and fever. First line regimen in Ethiopian context
Gondii  Trimethoprim/sulfamethoxazole 80/400, oral, 4 tablets 12
 Patients may also present with non-focal
Encephalitis hourly for 28 days, followed by 2 tablets 12 hourly for 3
manifestations, including only non-specific
months in adults.
headache and psychiatric symptoms.
 Focal neurological abnormalities may be Alternative regimen
present on physical examination, and  Sulfadiazine, 1-2 gm p.o.q 6h for six weeks or 3
 In the absence of treatment, disease weeks after resolution of lesion PLUS
progression results in seizures, stupor, and  Pyrimethamine Loading dose of 200 mg once,
coma. followed by: Pyrimethamine 50-75 mg/day PLUS
 Folinic acid (Leucovorin): 10-20 mg/d
 Secondary prophylaxis: use co-trimoxazole 960mg
daily for adults
 Subacute meningitis or meningoencephalitis

Cryptococcal Induction phase ( 2 weeks) Requires hospitalization
with fever, malaise, and headache.
meningitis and evaluation by
 Neck stiffness and photophobia, occur in High dose fluconazole- Fluconazole 600 mg twice daily alone physician
only one-quarter to one-third of patients. (In children 12mg/kg/day in two divided doses):
 Some patients experience encephalopathic
symptoms, such as lethargy, altered Consolidation phase (8 weeks)
107
mentation, personality changes, and
memory loss that are usually a result of Fluconazole 800 mg/day, in children 12mg/kg/day)
increased intracranial pressure, thought to Maintenance treatment (or secondary prophylaxis)-
result from impaired cerebrospinal fluid Fluconazole 200 mg daily( in children 6mg/kg/day)
(CSF) absorption.
Alternativein Ethiopian situation
Induction phase ( 2 weeks)
Amphotericin B + fluconazole:
Amphotericin 0.7-1 mg/kg/day + fluconazole 800 mg/day
Consolidation phase (8 weeks)
Fluconazole 400-800 mg/day
Maintenance treatment (or secondary prophylaxis)-
Fluconazole 200 mg daily( in children 6mg/kg/day).
NB:Discontinuation of maintenance treatment (secondary
prophylaxis)
When patients are stable and adherent to ART and anti-fungal
maintenance treatment for at least one year and have a CD4
cell count of greater than or equal to 200 cells/mm3 (two
measurements six months apart).
108
1.5: CARE AND TREATMENT FOR HIV POSITIVE PREGNANT
WOMEN
Time allotted: - 700min
By the end of this section, the participants will be able to:
 Identify classes of ARV drugs,
 Monitor and manage ARV side effects
 Prescribe appropriate ART for HIV positive pregnant women
 Provide adherence counseling and support to HIV positive pregnant women.
 Provide appropriate nutritional assessment,
 Link an HIV infected women to palliative care
1.5.1. Introduction to ARVs

What is ART?
 ART stands for Anti-Retroviral Therapy; the treatment of HIV infected individual with anti-
retroviral drug.
 What is HAART?
o H-Highly, A-Active, A-anti, R-retroviral, T-Therapy
o It is the use of three or more anti-retroviral drugs for the treatment of HIV
infection.
The goal of ART is to suppress the replication and reduce the number of virus in the blood and
increase the number of CD4 as much as possible and finally improve the general health of the
client. Antiretroviral therapy suppress the viral replication to below detectable level, however
the virus can never be eradicated completely from the body; hence the person should take the
drugs lifelong, even if the symptoms have disappeared. Since the virus cannot be eradicated,
safer sex using condom should be practiced.
1.5.1.1. ARV Drugs for Pregnant Women

Classes of Antiretroviral drugs
There are four major classes of ARV drugs available for use in Ethiopia:
109
 The NRTI: This stands for 'Nucleoside and Nucleotide Reverse Transcriptase
Inhibitors'
 The NNRTI: This stands for 'Non-Nucleoside Reverse Transcriptase Inhibitors‘.
 INSTIs: Integrase strand transfer Inhibitors
 The PI: This stands for Protease Inhibitor.
The nucleoside and non-nucleoside inhibitors (NRTI and NNRTI) both have the same
"target." They prevent HIV from entering the infected cell‘s center, so HIV can't start making
new copies.
Integrase strand transfer inhibitors are designed to block the action of integrase, a viral
enzyme that inserts the viral genome into the DNA of the host cell.
Protease inhibitors (PIs): When the central part of the body cell makes parts of the HIV
virus after infection, these parts have to be cut and put together in the right way before the
new HIV copies can leave the cell. Protease inhibitors prevent this ―cutting and putting
together‖ from happening correctly, so the newly produced virus parts cannot leave the
infected cell and infect other cells.
Figure 10: Site of actions for NRTI, NNRTI, and PI
110
Table 12: Classes and Dosages of Antiretroviral Drugs for Adults and Adolescents and
children currently used in Ethiopia
Drug class/ drug Dose a,b
Nucleoside RTIs
Abacavir (ABC) 300 mg twice daily
Lamivudine (3TC) 150 mg twice daily or 300 mg once daily
Zidovudine (ZDV) 300 mg twice daily.
Nucleotide RTI
Tenofovir (TDF) 300 mg once daily
Non-nucleoside RTIs
Efavirenz (EFV) 400 mg once daily or 600 mg once daily
Integrase strand transfer Inhibitors
(INSTIs)
Dolutegravir (DTG) 50 mg once dailye
Raltegravir (RAL) 400mg twice daily
Protease inhibitors
Lopinavir/ ritonavir (LPV/r) 400 mg/ 100 mg twice daily
Atazanavir /ritonavir(ATV/r) 300mg/100 oncedaily
Darunavir/ ritonavir 800 mg + 100 mg once dailyc or
(DRV/r) 600 mg+ 100 mg twice dailyd
a
These dosages are in common clinical use. The dosages in this table were selected on the best available clinical evidence.
Dosages that can be given once daily or twice daily were preferred in order to enhance adherence to therapy. The doses
listed are those for individuals with normal renal and hepatic function. Product-specific information should be consulted for
dose adjustments that may be indicated with renal or hepatic dysfunction or for potential drug interactions with other HIV
and non-HIV medications.
b
Zidovudine, lamivudine, dosages should be adjusted for the Creatinine clearance during renal insufficiency whereas
Tenofovir should be avoided.
c
For individuals with no previous use of protease inhibitors
d
For individuals with previous use of protease inhibitors
e
In case of TB-HIV co-infection, the dose of DTG should be doubled, 50mg BID; DTG should also be used 50mg BID in
third line regimens following exposure ofINSTI.
Combination therapy makes sense for lots of reasons.
1. It takes three drugs to have sustained viral suppression (low level of virus in the
body). HIV makes new copies of itself very rapidly. Everyday billions of new copies of
HIV are made and many infected cells die. Giving a single drug might suppress viral
111
replication for a short period of time but resistance to the drug develops soon. The same
holds true to two drugs regimen and therefore giving two drugs alone for treatment is
strongly discouraged. Whenever ART is given, it is administered as a minimum of three
drugs combination referred as HAART.
2. Antiretroviral drugs from different drug groups attack the virus in different ways.
In the beginning of this chapter, we learned how different anti-HIV drugs attack HIV at
different steps of the process of making copies of itself (first when entering the cell
centre, and then when new copies want to leave the cell). Hitting two targets increases
the chance of stopping HIV and protecting new cells from infection.
3. Combinations of anti-HIV drugs may overcome or delay resistance. Resistance is the
ability of HIV to change its structure in ways that make ARV drugs less effective. HIV
has to make only a single, small change to resist the effects of some drugs. For other
drugs, HIV has to make several changes. When one drug is given by itself, sooner or later
HIV makes the necessary changes to resist that drug. But two drugs are given together; it
takes longer for HIV to make the changes necessary for resistance. When three drugs are
given together, it takes even longer.
1.5.1.2. ART for pregnant women
ART will improve the health of the woman and is the most effective intervention in
decreasing the risk of transmission of HIV to the infant.
All HIV positive pregnant women should be started on ART as soon as possible irrespective
of gestational age, clinical stage and CD4 count. HAART for HIV positive pregnant is
indicated based on WHO programmatic update issued in April 2012, Option B+ (test-and-
treat principle). Once started, a woman should continue taking ART for her entire life.
1st Line ART Regimen for HIV positive pregnant, laboring and lactating women in Ethiopia
with different scenario
1. If a women diagnosed HIV positive at ANC, labor delivery and post natal should be
started TDF/3TC/DTG,(TLD) the fixed dose combination (FDC) as soon as possible
and PMTCT provider should provide ART integrated into ANC, labor and post-
partum care.
2. If the woman is already on ART, when she becomes pregnant, she should be
transferred out from ART and enrolled to PMTCT (in MNCH platform).
112
3. If additional consultation is needed, the client can be referred to ART unit for further
evaluation and management. The client can be referred back to ANC after evaluation
and management.
Table 13: Recommended ARV drug regimen in PMTCT

Scenario:-Diagnosis of HIV and initiation Type of regimen for the woman
of ART at:
ANC (newly identified ) TDF+3TC+ DTG
Intra-partum (L&D), newly identified TDF+3TC+DTG
Postpartum period(newly identified ) TDF+3TC+DTG
Pregnant mother on Pre-ART follow up TDF+3TC+DTG
Already on HAART before pregnancy Continue with the regimen the woman has
started
Justification for Tenofovir (TDF), Lamivudine (3TC) and Dolutegravir (DTG):
 Why is TDF preferred?

o TDF is safe drug with rare side effect and toxicity than other ARVs.
o TDF and 3TC are rarely discontinued due to side effects or toxicity, compared
to the other NRTIs.
 Why DTG?
o More rapid and higher viral suppression
o Higher CD4 cell count recovery rates
o Higher genetic barrier against ARV drug resistance.
o Lower risk of treatment discontinuation and
o Lower potential for drug–drug interactions
113
Table 14: Summary of sequencing for preferred first, second and third-line ART
regimens in pregnant womena
Population Preferred First line Alternative First Special
line circumstances c
Regimens (PFR)
Regimens (AFR) (SC)
Women & adolescent TDF + 3TC + DTG TDF + 3TC + EFV* TDF+3TC+ ATV/r**
girls who have desire (FDC) AZT + 3TC + EFV* AZT+3TC + ATV/r**
for pregnancy or are AZT + 3TC + DTG
pregnant (including
those with TB/HIV
coinfection) b
a
Notes:
 The standard practice should be routine counselling on risk of drugs taken during pregnancy especially in the first
trimester.
 For algorithms for initiating DTG in treatment naïve and for shifting existing first line clients to DTG, refer to the
national ART optimization document
 In the case of suspected treatment failure, consult senior ART clinicians to decide on regiment switch as it may not
be appropriate to do enhanced adherence counselling which may increase risk of viral transmission to the fetus.
 For other conditions related to the ART optimization process, consult the national ART optimization document
b
In case of TB-HIV coinfection, the dose of DTG should be 50mg BID.
c
Special circumstances for those clients who could take neither DTG nor EFV due to contraindication and/or side effects.
*
TDF+3TC+EFV400 (FDC) and TDF+3TC+EFV600 (FDC) can be used interchangeably based on stock availability.
**
WHO recommends ATV/r as alternative first-line when DTG or EFV cannot fit, besides, LPV/r has more side effects and
drug interactions. LPV/r has also pill burden impact. The only concern when using ATV/r as first-line is transmitted
resistance that would affect its use as second-line ARV.
114
Exercise 1.7 & 1.8 Card sorting exercise and drill on decision of treatment site
Now that you have understood staging and treatment for HIV infection from the perspective
of PMTCT, it is imperative to do the following exercises so that you can consolidate your
knowledge and build confidence in managing your clients. Your facilitator will give you
guidance on how to go about the exercise.
Time: 10 minutes
N Clinical situation Decision to tart Remark

o ART at PMTCT
clinic or refer to
ART clinic
1. HIV-positive pregnant, prurigo
only
2. HIV-positive pregnant, zoster only
3. HIV-positive pregnant, oral thrush
and fungal nail infection
4. HIV-positive pregnant, persistent
genital herpes with ulceration for 6
weeks
5. HIV-positive pregnant, TB
lymphadenopathy
6. HIV-positive pregnant, recurrent
mouth ulcers
7. No symptoms or signs
8. Hospitalized with bacterial
pneumonia once
9. No symptoms or signs
10. Hospitalized earlier this year with
Cryptococcus meningitis
11. PCP pneumonia and herpes zoster
12. Recurrent sinusitis
13. Seborrhea rash—very bad
14. Angular cheilitis
15. Three episodes of bacterial
pneumonia in last 6 months
16. Kaposi sarcoma
17. Esophageal thrush
18. Third trimester and has gained no
weight in pregnancy
19. 5 weeks diarrhea despite treatment
20. Very bad gingivitis with small
ulcers
115
1.5.2. Monitoring of response to ART
Patients qualifying for antiretroviral therapy are thoroughly evaluated at baseline and for the
rest of their lives to monitor toxicity, intolerance, response or failure to treatment. Before
ART initiation and thereafter patient readiness and adherence to therapy are always assessed
and necessary support provided. Opportunistic infections including TB, IRIS, and co
morbidities are always looked for and managed.
Table 15: Recommended laboratory tests for monitoring response to ARVs and its
toxicities
Regimen Drugs Monitoring Tests Frequency
First-line TDT/3TC/DTG CD4 Baseline and as necessary for

Regimens patient monitoring
ALT Symptom-directed
Creatinine symptom-directed
HIV viral load test Viral load should be done for
newly HIV positive pregnant
mothers at 3months, at 34-36
weeks of GA or delivery at the
latest, followed by three
months after delivery and then
every 6months.
For women already on ART,
conduct VL testing at 1st
contact at ANC (VL result
conducted in the last 3 months
before 1st contact can also be
used), at 34-36 weeks of GA or
delivery at the latest, followed
by three months after delivery
and then every 6months.
TDF/3TC/EFV CD4 Baseline and as necessary for
patient monitoring
Creatinine symptom-directed
HIV viral load test As indicated above
116
AZT/3TC/EFV Haemoglobin At baseline, 4th, 8th, and 12th
weeks; thereafter
symptom-directed
CD4 count Baseline and as necessary for

patient monitoring
HIV viral load test As indicated above
1.5.3. What to expect in the first months of ART

Although taking ART is a lifelong commitment, the first six months of therapy are especially
important. These complications are commonest when the people starting ART already have
advanced HIV disease with severe immunodeficiency and existing co-infections and/or co-
morbidities, severely low hemoglobin, low body mass index and very low CD4 counts or are
severely malnourished.
Scenarios to look for

- Clinical and immunological improvement and virological suppression
- Opportunistic infections and/or immune reconstitution inflammatory syndrome (IRIS)
may develop
- Early adverse drug reactions, such as drug hypersensitivity, especially in the first three
months of ART.
- Death rates are also highest in the first three months of ART.
1.5.3.1. Monitoring and Management of ARV drug toxicities

Most common toxicities associated with ARVs appear within the first 3-6 months of ART
initiation, therefore it is wise to be vigilant and check for these toxicities in the follow up
visits.
What should be done?
 Establish whether the adverse event is due to ARV drugs, other drugs, or clinical
illness.
 Try to identify the responsible ARV drug.
 Assess the severity using ACTG (AIDS Clinical Trial Group) grading system
Monitoring adverse effects:
117
Side effects to the TDF/3TC/DTG regimen are generally mild, usually most noticed during
the first few weeks of treatment, and tend to disappear by the end of the first month; hence
TDF/3TC/DTG has the lowest rate of switching to an alternative regimen.
The most common side effects of TDF, 3TC, DTG and EFV are summarized in table 17.
Table 16: The most likely side effects of TDF/3TC/EFV

ARV Drug Very Common side effects Potentially Serious side
effects
(Warn patients and suggest ways patient
can manage; Be prepared to manage (Warn patients to seek Care)
when patient seeks care)
Zidovudine Nausea, Diarrhea, Headache, Fatigue Pallor

(AZT)
Muscle pain
Tenofovir Renal insufficiency, Effect

(TDF) on fetal bone
Lamivudine Nausea; Diarrhoea;

(3TC)
DTG Insomnia, dizziness, headache, Nausea, Hepatotoxicity

Diarrhoea, Rash Hypersensitivity reactions
Efavirenz(EVF) Nausea, Diarrhoea, Strange Dreams, Seek care urgently, Yellow

Difficulty Sleeping, Memory problems, Eyes, Psychosis or
Headache; Dizziness confusion, Skin Rash
1.5.4. Monitoring and managing Drug-Drug Interaction

Effect of drugs can be modified by use of another drug (i.e associated drugs gives increase or
decrease in ARV drug levels). HIV positive women may be under treatment for other
conditions besides HIV. Thus it is important that you know what interactions exist between
the groups of drugs that you use to provide effective treatment for your clients. Most of the
drugs are metabolized by kidney and liver.
There are three ways ART drugs may interact with other drugs
118
1. The effects of the drugs on the kidneys andliver
If a patient takes a drug that makes liver work harder, the amount of antiretroviral
drugs in the blood will decrease faster. As a result, the amount of antiretroviral drugs
will be insufficient, which might create resistance to the treatment. If liver starts to
work slowly due to the use of another drug, the amount of antiretroviral drug in the
blood might be too high. In this case, the patient might develop toxic blood levels
leading to side effects.
2. The toxic effects and side effects of the drugs
The risk for side effects increases if two or more drugs that have similar side effects
are given together.
3. The way the drug stop the virus
Some ARV drugs work in exactly the same way to stop the virus. Since they work in
exactly the same way, on the same spot in the CD4 cell, there is no enough space to
work well, and the drugs will not reinforce each other, but block each other.
Whenever prescribing ARVs, check these points:
 Are there any combinations of drugs in the prescription that could cause a drugreaction?
 Are there ARVs that could affect effectiveness of hormonalcontraceptives?
 Check whether the patient is taking other drugs or herbalmedications.
Examples of common interactions are given below.
Table 17: Examples of common interactions are given below

ARV drugs Interacting Key interaction Suggested management
drugs
DTG Carbamazepine, Carbamazepine, Use alternative anticonvulsant agent
Phenobarbital and Phenobarbital and such as valproic acid or gabapentin.
phenytoin decrease OR use EFV instead of DTG
phenytoin
effectiveness of DTG
Polyvalent Polyvalent Cation Use DTG at least 2 hours before or at
products containing Mg, least 6 hours after supplements
cation Al, Fe, Ca and Zn reduces containing polyvalent cations, including
absorption of DTG but not limited to – Fe, Ca, Mg, or Zn
multivitamin supplements; mineral
supplements, cation containing laxatives
and Al, Ca or Mg containing antacids.
Monitor for virological efficacy.
119
Rifampicin Rifampicin increases
metabolism of DTG, Increase the dose of DTG to 50mg BID.
and hence reduces
concentration of DTG
in the
blood.
Metformin DTG increases
metformin levels, Close monitoring of blood sugar.
which may lead to
hypoglycemia.
AZT Ribavirin and Ribavirin decreases Substitute with TDF
pegylated the effect of AZT
interferonalpha-
2a
EFV Estrogen-based Decrease Use alternative or additional
hormonal contraceptive contraceptive methods
contraception effectiveness
Methadone EFV induces Adjust methadone dose as
metabolism and appropriate
decrease level of
methadone
Amodiaquine EFV induces Use an alternative antimalarial
metabolism and agent
decrease level of
Amodiaquine
Boosted Rifampicin Levels of both Substitute rifampicin with
PI (ATV/r, Refampicin and rifabutin
LPV/r) ARVs may be Adjust the PI dose or substitute
decreased with three NRTIs (for children)
Estrogen-based Levels of both Use alternative or additional

hormonal contraceptives & PI contraceptive methods
contraception may be decreased
Methadone Retinovir decreases Adjust methadone

methadone effect- doses as
120
withdrawal syndrome appropriate
Both can cause cardiac
conduction
abnormality
Source: Ethiopian consolidated national guideline for HIV prevention care andtreatment,
FMOH 2020,
Note: Herbal medicines can interact with ARVS and can cause serious harm or may reduce
efficacies of ARVs and other medicines so should not be taken at all.
1.5.5. Diagnosis of Treatment failure

Time: 5 minutes
W/ro Abebech has been diagnosed with HIV 3 years ago. She has
been taking her treatment irregularly for the past 2 years in ART
clinic. Three months ago, she became pregnant and linked to ANC
clinic. Today she presented with severe headache and stiff neck.
With suspicion of meningitis, LP was done and the CSF analysis
revealed Indian ink positive stains.
1. What is wrong with W/ro Abebech?

2. How would you manageher?
 Monitoring individuals receiving ART is important to ensure successful treatment,

identify adherence problems and determine whether and which ART regimens
should be switched in case of treatment failure.
 The value of viral load testing as a more sensitive and early indicator of treatment
failure is increasingly recognized.
 In pregnant women, viral load should be done for newly HIV positive pregnant
mothers at 3months, at 34-36 weeks of GA or delivery at the latest, followed by three
months after delivery and then every 6months.
 For women already on ART, conduct VL testing at 1st contact at ANC (VL result
conducted in the last 3 months before 1st contact can also be used), at 34-36 weeks
121
of GA or delivery at the latest, followed by three months after delivery and then
every 6months in order to detect treatment failure proactively.
 Viral load testing should be used aside from the routine testing whenever there is
clinical or immunologic suspicion of treatment failure.
 The viral load request form should be filled completely before sending it to the
designated laboratory (annex 1.3) and the request and returned result should be
documented on the viral load register (Annex 1.4).
 The cut off point for VL result to say successful treatment is less than or equal to
1,000 copies/ ml. Two consecutive VL results more than 1,000 copies/ ml with EAS
confirm failure of the current treatment regimen.
 Pregnant women with VL 50-1000 copies/ml need to be on EAS in order to reduce
the risk of MTCT of HIV.
 If treatment failure is diagnosed patients should be switched to second line regimen.
A second line regimen is a combination of three ARV drugs (at least two of which
are new to the patient) provided when the first line regimen is no more effective for
that particular patient.
Table 18: Definitions of clinical, immunological and virological failure for the decision
to switch ART regimens
Failure Definition Remark
Virologic Viral load above 1000 copies/mL based This is the earliest sign of
failure on two consecutive viral load failure before manifesting
measurements in 3 months apart, with any of the clinical or
adherence support following the first immunological failure.
viral loadtest An individual must be taking
ART for at least 6 months
before it can be determined
that a regimen has failed. VL
testing should not be done
when there is an acute
infection/fever as there can be
blips of VL. See guidance
below.
Immunologic Adults and adolescents Without concomitant or
failure CD4 count at or below 250 cells/mm3 recent infection to cause a
following clinical failure Or transient decline in the CD4
Persistent CD4 levels below 100 cell count. Persistent is to
cells/mm3 mean at least 2CD4
measurements below the
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threshold.
Current WHO clinical and
immunological criteria have
low sensitivity and positive
predictive value for
identifying individuals with
virologic failure.
Clinical Adults and adolescents It is the last presentation that
failure New or recurrent clinical event comes after immunological &
indicating severe immunodeficiency virological failures.
(WHO clinical stage 4 condition and
certain WHO clinical stage 3 conditions The condition must be
(pulmonary TB and severe bacterial differentiated from immune
infections) may also indicate treatment reconstitution inflammatory
failure) after 6 months of syndrome occurring after
effectivetreatment initiating ART.
a
Note If serial (two or more) CD4 values are available, the rate of decline should be taken into
consideration.
Treatment monitoring algorithm for pregnant and breast-feeding women
Implementation considerations for treatment monitoring of pregnant and breastfeeding
women
Whenever possible, use same-day point-of-care testing for viral load testing of pregnant and
breastfeeding women to expedite the return of results and clinical decision-making. If this is
not available, viral load specimens and results for pregnant and breastfeeding women should
be given priority across the laboratory referral process (including specimen collection, testing
and return of results).
 For all pregnant women, regardless of ART initiation timing: conduct viral load
testing at 34–36 weeks of gestation (or at the latest at delivery) to identify women who
may be at risk of treatment failure and/or may deliver infants at higher risk of
perinatal transmission.
Action: if viral load >1000 copies/ml, follow the treatment monitoring algorithm and provide
enhanced postnatal prophylaxis b for the infant.
In addition:
a) For pregnant women receiving ART before conception: conduct a viral load test at the
first antenatal care visit (or when first presenting) to identify women at increased risk of in
utero transmission.
Action: If viral load >1000 copies/ml, follow treatment monitoring algorithm
b) For pregnant women starting ART during pregnancy: conduct a viral load by three
months after ART initiation to ensure that there has been rapid viral suppression c
Action: If viral load >1000 copies/ml,a follow the treatment monitoring algorithm.
•For all breastfeeding women, regardless of when ART was initiated: conduct a viral load
test three months after delivery and every six months thereafter to detect viraemic episodes
during the postnatal period.
Action: if viral load >1000 copies/ml,a follow the treatment monitoring algorithm, a
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Conduct infant HIV testing immediately and consider reinitiating enhanced postnatal
prophylaxis for the infant. b,e
a. See Fig 1.
b. See the programmatic update on HIV diagnosis and ARV use in HIV-exposed infants (24).
c. If viral load testing is expected to be undertaken in close proximity to the planned viral
load at 34–36 weeks of gestation (see above), the first viral load test can be delayed until
weeks 34–36 of gestation.
d. Conduct same-day testing using point-of-care infant diagnosis, where available, to expedite
the return of results. See subsection 3.1.
e. Consider reinitiating and continuing enhanced postnatal prophylaxis until the results are
returned or same day testing is negative. Begin ART if the infant is diagnosed with HIV (see
the programmatic update on HIV diagnosis and ARV use in HIV-exposed infants (24)).
SOURCE WHO consolidated HIV prevention testing and treatment service delivery
monitoring guideline July 2021
NB. The point of care viral load determination is being implemented targeting pregnant
and lactating women and those who have previous high viral load.
Figure 11: Algorithm for diagnosis and management of treatment failure
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Enhanced Adherence support (EAS)
 Enhanced Adherence Support is important for patients that have unsuppressed VL,
persisted or new immunosuppression, developing new OI or have multiple adherence
barriers. It shall be systematic and with documenting, the interventions provided
during the EAS period.
Table 19: Summary of components of EAS

Enhanced adherence support sessions overview
First Session • Review cognitive, behavioral, emotional and socio-economic barriers to
(When the adherence:
HVL result is - Treatment literacy
received; - Medications: dosage, timing, storage
Day 0) - Side effects
- Motivation
- Mental health screening (screen for depression and other common mental
problems using national mental health assessment tool (Annex 1.5)
• Action:
- Discuss risk reduction (e.g. for substance abuse)
- Discuss patient‘s support systems
- Assist patient to develop adherence plan to address the identified issues.
• Referrals and networking.
Second • Review adherence plan from the first session and discuss any challenges.
Session • Identify other possible gaps and issues emerging.
( 1month/30 • Action
days after the - Assist patient to modify the adherence plan to address the identified
first session) issues.
• Referrals and networking.
Third • Review adherence plan from the first and second session and discuss any
Session (2 challenges.
months/60 • Identify other possible gaps and issues emerging.
days after the • Action
first session) • Assist patient to modify the adherence plan to address the identified issues.
• Decision on repeat VL based on current adherence:
• If the adherence is good, plan repeat VL testing after a month and explain
possible ways forward, emphasizing the role of the patient and the health
facility in terms of strengthening adherence. The EAS may be discontinued
based on the second VL result.
• If adherence challenges persist, plan further monthly EAS sessions before
repeating the VL until adherence is improved. This time additional efforts are
required for the EAS depending on the client‘s situation.
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Fourth • Take the second VL sample for the client showing good adherence.
Session (3 • All efforts should be employed to get the VL result as soon as possible. As
months/90 soon as the VL results received, discuss the result with the patient.
days from • Plan the way forward:
the first 1. If VL is < 50 copies/ml, maintain the current regimen and encourage
session) adherence
2. If VL is 50-1000 copies/ml, continue the current regimen and the
monthly EAS for the next 3 months.
3. If VL is > 1000 copies/ml, switch to appropriate regiment (second or
third line).
There is a checklist to complete at every visit for enhanced adherence support (Annex
1.6). All clients with high VL & on EAS are documented and followed on EAS
register (Annex 1.7).
1.5.6. Monitoring of women initiated ART

All HIV infected individuals require a standard clinical assessment at every visit. Patients
don‘t necessarily volunteer to tell their symptoms; hence active inquiry is required. At each
visit HCW should be checking for:
 HIV related diseases including TB screening questions
 Change in WHO stage; any finding suggesting ART treatment failure
 Drug side effects (ARV, CTX, INH, Anti-TB drugs)
 Adherence to the drugs
Table 20: Symptom/sign screening checklist and possible causes of Symptoms after
HAART
Symptom/sign Possible cause Drug side effects
Weight loss /Body change TB/Malnutrition, Treatment failure Not related to ART
Swollen Glands Persistent generalized Not related to ART
lymphadenopathy (PGL),
Glandular TB, IRIS(TB)
Headache, confusion, Cryptococcal or TB Meningitis, EFV, DTG
Dizziness CNS Toxo, HIV dementia
Mouth Sores White patches: Candidiasis, Ulcers: Co-trimoxazole
Herpes simplex, Angular Cheilitis, hypersensitivity
ulcerative stomatitis NVP (in context of Stevens-
Johnson Syndrome)
Yellow Eyes Viral Hepatitis, Cancer, Alcoholic EFV
Liver Disease, IRIS Hepatitis, INH, Fluconazole,
Malaria, Cancer
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Cough with/without Less than 2 weeks with fever: Not caused by ART
shortness of breath Pneumonia or ?TB,
Greater than Two weeks: TB
Vomiting, Abdominal Acute gastroenteritis; Abdominal 3TC (rarely),Antibiotics
Pain TB
Diarrhoea (< 1 month: Salmonella; E.coli, 3TC (rarely),NVP

HIV),(Blood in stool: Ameba, (rarely),AZT,Antibiotics
Shigella),(> 1 month: HIV OI,
Abdominal TB)
Rash on arm, leg, or Herpes zoster, Fungal skin CTX, NVP, EFV, Fluconazole
Trunk infection, Molluscum-contagiosum,
Scabies
Exercise 1.9: ART Regimens during Pregnancy

Instructions: Fill in the blanks in the table, by answering Yes (Y) or No (N) to each question
asked about the ART regimen.
First-line ART OK in first OK ifPreferred OK during

regimens trimester hemoglobin regimen in breastfeeding
less than 7 pregnancy
TDF-3TC-DTG
AZT-3TC-DTG
TDF-3TC-EFV
AZT-3TC-EFV
Clients follow up schedule:
HIV positive pregnant women who are on ART need to have a regular follow up until mother
baby pair is discharged from the MNCH clinic after 2 years delivery.
Summary the schedule
If diagnosed at •Once found HIV positive, will need at least 8 ANC contacts
ANC:
•If started on ART at 1st contact, schedule return for 2 wks.
•If not started on ART at 1st contact, schedule return for 1 wk.
•Thereafter, schedule monthly for 6 months plus extra contact 2 wks. prior to
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due date, and 6-7 days PP and 6 wks. PP and monthly thereafter through 6th
month post-birth.
•Once stable, schedule every 3 months
If diagnosed If already on ART, PMTCT provider takes over ART management as per above
prior to ANC: schedule.
•If not yet on ART, start TDF-3TC-DTG (1j) and follow above schedule.
TIPS: Good management of side effects includes:

• Discuss very common possible side effects before the person starts the medication.
• Give advice on how to manage minor side effects.
• Warn patients about potentially serious side effects and tell them to seek care urgently if
any serious side effects occur.
• Give immediate attention to side effects and access to the clinic.
• Initiate a discussion about side effects, even if the patient does not mention them
spontaneously.
• Refer the patient to peer-educators.
• Inform the patient not to discontinue ARV drugs due to side effects, without consulting
the care provider.
• Have routine baseline lab tests like Hgb and Creatinine.
1.5.7. Adherence Preparation and Support for Pregnant Women

In the 7 days after diagnosis of HIV infection, pregnant women need to be rapidly prepared
for adherence to ART and given special adherence support in order to get the most benefit
from it. The 5As (Ask, Advise, Agree, Assist, Arrange) are very much useful in order to
prepare for adherence and are good tools to use. Encourage the woman to disclose her status
and help her to identify a treatment supporter (and if possible start preparing the supporter at
the same time). You will need to schedule several visits for education and adherence support
so that the woman can start as soon as possible
There are two kinds of adherence:
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 Adherence to care( Clinical adherence): Regular attendance of patient according
to given appointment
 Drug Adherence: taking prescribe medicines in the right amount on the right time
according to given special advice.
Adherence is crucial for ensuring ARVs maximum effectively and delaying drug resistance.
ARVs do not cure HIV but will stop HIV from multiplying which allows the body‘s defense
system to recover. If ARVs are stopped, the virus will start multiplying again and damage the
immune system. It also learns to evade ARV. So the drug may not work for patients that stop
and start ART again.
There are three levels of adherence: Good, fair and poor (see Table 22 below).
Table 21: Levels of adherence

Grading Percent Missed of 30 doses Missed of 60 doses
Good(G) >95% <2doses <3doses
Fair(F) 85-94% 3-5 doses 3-9doses
Poor(P) <85% > 6doses > 9doses
Note that the patient should not compensate for missed medications inadvertently. It is
strongly recommended that medicines are taken always at around the specific time; however,
in some extreme situation, if a client is not able to take his/her medication on the specified
time, flexibility is possible. That is:
If the client is able to access TDF/3TC/DTG within 12 hours of usual schedule dose, then the
missed dose can be taken; if beyond 12 hours then skip and take the next day dose as per the
schedule.
Continuous Adherence Counseling
Like other patients with HIV, pregnant women need adherence counseling and support. They
need to be rapidly prepared for ART in order to prevent MTCT of HIV as soon as possible.
Starting ART as soon as possible is critical for preventing MTCT. In the past the emphasis
has been on several sessions of adherence preparation for the person starting ARVs, ideally
with a chosen treatment supporter. However, in some settings and especially for pregnant
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women, this may delay initiation of treatment, and even lose women to follow-up. Therefore,
providers should give adherence support and counseling concurrent with the immediate
initiation of therapy, and follow up with ongoing counseling and support as the woman needs.
Encourage the woman to disclose her HIV status and identify her treatment supporter (and if
possible start preparing the supporter at the same time). You will need to schedule several
visits for ongoing education and adherence counseling and support after she has started ARV.
Adherence Advice includes:
 Providing basic information on HIV and its manifestation;

 Clearly stating the benefits and side effects of drugs;
 Identifying when a client should seek urgent help;
 Explaining how medications should be taken;
 Stressing importance of not missing any dose.
The principles of counseling follows by using ‗5As‘ – Assess, Advise, Agree, Assist and
Arrange.(Annex 1.2)
After therapy has begun, it is essential to continue with support for adherence. This should
involve adherence assessments during every visit and emphasize adherence principles to the
patient.
Use adherence supporters, such as mother mentors, case managers, peer educators, if
available.
Continuous involvement of relatives, friends and/or community support personnel is also

essential after addressing confidentiality adequately.
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Table 22: Barriers to adherence and solution
Common barrier Possible cause Possible solutions

 Travelling  Plan before travel
 Alcohol /active drug use  Take extra pills
 Depression /psychiatric  Use reminder cues
illness  Address addiction (alcohol and
Forgot to take pills  living alone and sick drugs)
 Homeless, no family  Enlist family support
support  Treat depression
 Use PLHIV support groups or
religious groups
Wrong attitude -Pills Inadequate knowledge  Adherence preparation ( involving
may not help case managers and peer counselors)
Patient‘s condition  Acute toxicities like  Warn patients about potential short
getting worse while on nausea, vomiting, diarrhea, term toxicities and long term
ART fatigue and skin rashes toxicities and discuss how to manage
 Worsening clinical them if these happen
condition from OIs on  Warn about possibility of IRIS
treatment or already
treated(IRIS)
Felt better, so did not Inadequate knowledge  Provide scientific information and
continue examples
 Ask for family support.
Family prohibit taking  Inadequate knowledge  Family counseling
medication  Incorrect beliefs and  Provide scientific information and
attitudes examples
Did not understand how  Low literacy level ,  Use literacy materials
to take medications Alcohol /active drug use  Use demonstration pills and repeat
 Depression /psychiatric instructions
illness  Ask patient to repeat instructions
 Insufficient time to counsel  Ask family support
 Treat depression
 Address addiction (alcohol and
drugs )
 Living alone  Use PLHIV support groups
 No employment  Register with community base care
Unable to care for self  AIDS dementia/mental programs
illness  Link with NGO support groups
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 Debilitation  Locate family and support
 Identify a friend who could help
Did not want to be seen  Stigma at place of work  Provide counseling
by others when taking  Non-disclosure in the  Support to help with disclosure
medications family
Fear of toxicity  Insufficient treatment  Involve peer educators, Case
preparation managers and adherence supporters.
 Inadequate knowledge  Provide scientific information on
what to expect and how to manage
it.
 Counsel on risks of non-adherence
Tips in achieving optimal drug dose adherence
 Ask at every visit
o Have you had any problems taking your ART

o Were there any days where you cannot manage taking your tablet at the right
time?(weekends, evening, week days)
 Remind every patient at every visit the importance of good adherence
o Initial ART counseling

o Reinforce individual counseling if any signs of poor adherence is noted
o Give practical counseling on how to achieve good adherence
o Include ARVs to a daily routine (e.g. Before washing face or after evening meal)
o Ask families or friends to remind
o Set a daily alarm on cell phone
 Encourage honest dialogue.
o Avoid the impression of ―policing‖ the patient.

o Work with patient to help them achieve good adherence.
 Poor adherence has valid reasons and often can be resolved
1.5.8. Nutritional support

General information:
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 An HIV infected pregnant or lactating woman has two main reasons for increased
nutritional demand.
o The body needs more energy to fight HIV and to compensate for
increased body catabolism due to HIV and related diseases
o A pregnant/lactating woman needs additional nutrients to support fetal
growth development and lactation.
 However, there may be reduced intake due to loss of appetite, oral lesions, and
side-effect of medication, depression, impaired absorption.
 Nutrition related goals for HIV patients may be grouped into three categories:
o Maintain weight or prevent weight loss : prevent disease/ promote
adequate Calorie intake; advice on avoiding practices that negatively
influence food intake and nutrient use
o Improve body composition: by promoting regular exercise to prevent
muscle loss
o Improve immunity and prevent infections by:
– promoting increased micronutrient (vitamin and mineral) intake;
– Encouraging the observation of food safety and handling practices
to prevent food borne illnesses and promoting the use of ARVs to
reduce viral load where necessary and possible.
Nutritional interventions for pregnant women

Nutritional care for HIV +ve pregnant women includes nutritional assessment,
intervention selection, design and follow- up and review.
 Use MUAC instead of
BMI for pregnant and
Nutritional assessment and treatment lactating women
 MUAC 19 - 23CM: Start
Assessment:
therapeutic Feeding (TF)
 Review of dietary history such as appetite, food for Moderate Malnutrition
 MUAC less than 19CM:
habits and stress or depression that may affect eating,
Start Therapeutic feeding
life style practices such as smoking, drinking alcohol for Severe Malnutrition
and caffeine and using drugs that may affect food  If you don‘t have
Therapeutic center you
intake or utilization should refer to where the
service is available.
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 Measurements of body size or proportions such as weight and height ,MUAC
(Anthropometric measurements) for pregnant and lactating women:
 Clinical assessment of symptoms and illnesses associated with HIV/AIDS infection
such as oral thrush and diarrhea, anemia, etc. often appropriate in the absence of
laboratory facilities
 Monitor weight gain during pregnancy; the woman needs to gain at least one kilogram
per month during the second and third trimesters
 Laboratory tests for blood sugar, Hgb, etc.
Management:
Nutrition management of HIV positive pregnant and lactating mothers depends on a
classification of the nutritional status of the mother, other medical conditions and the available
therapeutic or Supplementary food products. The management includes treatment of
malnutrition by prescribing RUTF, supplementary foods and locally available diversified
energy and nutrient dense foods for rehabilitation from malnutrition based on nutrition care
plans. Nutrition care plans are interventions determined based on the mother‘s nutritional
status and health conditions that affect their nutritional needs and absorption/utilization. There
are three nutrition care plans for treatment of malnutrition:
Nutritional Care plan C
Mothers classified as Severe Acute Malnutrition (SAM) with Medical Complication and/or
failed appetite test and those classified as Moderate Acute Malnutrition) MAM with Medical
Complication and/or failed appetite test will be managed at inpatient/stabilization Center
according to the national SAM management guideline. Therefore, should be referred to those
facilities as identified. Pregnant and lactating women classified as SAM without Medical
Complication and passed appetite test will be managed at Outpatient Therapeutic program
(OTP) or PMTCT unit with Ready-to-Use-Therapeutic Food (RUTF) / Plumpynut. Dose and
duration of prescription for outpatient management:
Pregnant and lactating women: 4 sachets per day; maximum for 3 months. Then, transition to
care plans B.
Children: Dosage Based on their weight in kg as indicated on the national SAM management
guideline.
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Nutritional Care Plan B
Pregnant and lactating women classified with MAM and without medical complication and
those transitioned from care plan C will be managed with RUSF/PlumpySup based on the
availability of supply. Otherwise, stress on nutritional counseling on the need to have
additional energy from the locally available foods.
Dose and duration of prescription: Pregnant and lactating women: 2 sachets per day; maximum
for 3 months.
Nutritional Care plan A
 Counsel about reducing energy expenditure, the woman needs to rest during pregnancy
and lactation.
 Health care provider need to encourage the pregnant woman to increase food intake
during pregnancy and lactation, as well as explain to the woman to eat at least one
extra serving of staple food per day during pregnancy and lactation.
 Micronutrient supplements are important during pregnancy and lactation
o Iron prevents and treats anaemia. For prevention, it should be supplemented as

200mg ferrous sulphate once a day as early as possible in pregnancy
o Folate- helps in blood formation and prevents as well as treats anemia. It also
prevents neural tubal defect so that preconception intake of folate is advisable
o Iodine- helps normal physical and mental development of the body; hence
encourage using iodine fortified salt in their meal.
o Vitamin A-keeps the eyes and the skin healthy and protects the body against
infections. Advise the women to take food rich in Vitamin A (meat, fish,
poultry, milk, fruits and vegetables)
 Advice on food intake rich in vitamin C to enhance the absorption of the iron
1.5.9. Palliative care

HIV palliative care: This is an essential component of a comprehensive package of care for
people living with HIV/AIDS because of variety of symptoms they can experience—such as
pain, diarrhea, cough, shortness of breath, nausea, weakness, fatigue, fever, and confusion.
Palliative care is patient and family centered care. It optimizes quality of life by active
participation, prevention, and treatment of suffering. It emphasizes the use of an
interdisciplinary team approach throughout the continuum of the illness, placing critical
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importance on building respectful and trusting relationships. Palliative care addresses physical,
intellectual, emotional, social, and spiritual needs. It facilitates patient autonomy, access to
information, and choice.
Components of palliative care
Essential components of palliative care
 Symptom control  Terminal care
 Effective  Support in bereavement

communication
 Education
 Rehabilitation
 Continuity of care
The continuum of care
The needs of people living with HIV/AIDS fall into four spheres (figure below) all of which
must be addressed by palliative care, within the context of prevention and a supportive policy
and social environment. However, these needs change over time so that the proportion of the
total care given asdisease-modifying/curative treatment (e.g., treatment for an OI, ART) and
the proportion given as palliative treatment (e.g., pain and symptom control) will also vary.
Symptomatic management
ART care providers should assess and manage common symptoms associated with HIV/AIDS
and treatment side effects. Most common symptoms are listed below:
Table 23: Common symptoms from OIs, ARV side effects & complications
Common symptoms from OIs Common ARV side effects & complications
Pain Nausea and vomiting

Dyspnea Diarrhea
GI problems Peripheral neuropathy etc.
Skin and mouth problems
Fever
Neurological disorders
Anxiety, fatigue etc
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Pain Management
Pain is an unpleasant sensory and emotional experience associated with actual or potential
tissue damage or described in terms of such damage. This highlights that pain is not just a
physical sensation but an emotional experience too. In simple words pain is what patient says,
hurts, which gives emphasis on the patient‘s experience.
The concept of total pain refers to the global nature of pain perception not only as a physical
ailment but that it has a psychological, spiritual and social consequence.
Assessment of pain
Pain should be considered as the 5th vital sign. A proper assessment of pain is essential for
successful treatment. Pains could be unrelated to or only indirectly related to the primary
disease and they would need different modalities of treatment.
Grading of pain
Numerical Scale:
It has 0 at one end meaning no pain and 10 at the other end meaning worst imaginable pain.
(No pain) 012 3 4 567 8 910 (Worst possible pain)
Adult three step analgesics ladder
Figure 12: Adult three step analgesics ladder
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Table 24: Summary of analgesic drugs use for Step-by-Step
Drugs Adult dose Remark
Step1 Analgesic of choice during
Acetaminophen/Paracetamol Pregnancy and breast feeding
PO 500-1000mg q hr
Step 1. Ibuprofen Po 400mg q 4-6hrs Use of NSAIDs at about 30 weeks

gestations or later in pregnancy
increases risk of premature closure of
fetal ductus atreriosus.
Avoid use after 30weeks of gestation
and later in pregnancy
Step 1. Diclofenac Po 50mg q 8hrs Use of NSAIDs at about 30 weeks
IM 75mg/3ml 12 hrly gestations or later in pregnancy
increases risk of premature closure of
fetal ductus atreriosus.
Avoid use after 30weeks of gestation
and later in pregnancy
Step 2. Codeine - Po 30-60mg q 4hrs - Persistent use may lead to
max dose 240mg/day dependence and tolerance for the
- IM 30-60mg q 4hrs mother.
- Avoid use in pregnant women during
or immediately prior to labour because
it induced respiratory depression in
neonate.
Step 2 –Tramadol Po 50-100mg q6hrs Avoid prolonged use during pregnancy
Max 400mg/day because it may cause neonatal Opid
IM/IV 50-100Mg q 4- withdrawal syndrome.
6hrs
Step 3. Morphin 2.5-5mg q 4hrs( Dose Avoid prolonged use during pregnancy
can be increased 1.5 because it may cause neonatal Opoid
or doubled after 24hrs withdrawal syndrome.
if pain persists)
1.5.10. Mother support groups for HIV positive pregnant women
The mother support program has seven broad objectives:
 To enhance access to and use of PMTCT services by building strong linkages between
health care providers and peer support networks
 To ensure adherence to ART among pregnant and postpartum women
 To lessen HIV-related stigma and discrimination
 To increase HIV-positive mothers‘ understanding of infant feeding options
 To reduce the incidence of new STIs and HIV among girls and women
 To increase acceptance and use of FP among postpartum women
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 To build linkages with other programs and services that strengthens women‘s health
and decision-making (e.g. nutritional support, income-generating activities, and skills
training).
Mothers-to-mothers, or women-to-women groups help HIV-positive women to demand their
rights and to access appropriate treatment and care. Moreover, they empower the women‘s
negotiation skills which help them to disclose their status to their partners, family members,
and to the community at large; are found to be effective in ensuring initiation of ARVs and
adherence to treatment. And help to link up patient with community care through HDA.
2. PMTCT of Syphilis during ANC
 Basics of Syphilis and MTCT

 Syphilis screening for pregnant women
 Treatment for pregnant women diagnosed with Syphilis
Time allotted: 240 min

Learning Objectives
By the end of this session, participants will be able to:
 Explain the importance of syphilis screening to all pregnant women..
 Manage pregnant women diagnosed with Syphilis
 Identify neonates with congenital syphilis
 Treat neonates diagnosed with Congenital syphilis
Case Scenario Time allotted:- 10minute
A 28 years old 26 weeks pregnant mother comes for ANC and was
screened for syphilis by RPR and she found to be positive for syphilis.
Her HIV test was negative.
 How do you manage this pregnant woman?
 What is the risk if she was left untreated?
 What are the interventions for her new born?
 How do you approach her partner?
Would you recommend to retest for HIV? If so when?
2.1 Basics of Syphilis and MTCT

Syphilis is a systemic disease caused by Trepanoma Palladium. The disease has been divided
in stage based on clinical findings which helps to guide treatment and follow up. HIV and
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syphilis are major public health problems directly affecting women and their newborns, and
indirectly affecting all communities. Without treatment an estimated 50 to 80 percent
pregnancies with syphilis infection result in adverse events, including abortion, fetal death
,neonatal mortality, premature labor, low birth weight and congenital syphilis.
In Ethiopia, syphilis prevalence estimates for women attending ANC ranged from 0.90% to
2.10%, with only an estimated 65.9%(MoH annual performance report, 2019/2020G.C) of
women receiving screening for syphilis. Many women may remain undetected and untreated.
Greater emphasis is therefore needed on the process of screening and effectively treating
mothers, their partners, and their infants affected by syphilis.
Mode of Transmission
Transmission of the disease occurs in the early latent phase (transmission can also occur at the
very early stages and less common during the late latent phase.
 Sexual
Syphilis is transmitted from person to person by direct contact with a syphilitic sore, known as
a chancre.
Transmission of syphilis can occur during vaginal, anal, or oral sex.
 Vertical
Syphilis transmission can also occur between an infected pregnant woman and her unborn
child.
Infection can be transmitted to the baby at any stage of the pregnancy.
The transmission rate is
o 60%-100% during primary and secondary syphilis and

o 40% in early latent syphilis and
o 8% in late latent phase of syphilis.
 Blood-born transmission
Blood donor screening tests for syphilis serological examination is very important.
Note: The syphilis bacteria are fragile. The transmission does not occur through contact with
toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.
Clinical presentation
Syphilis is a sexually transmitted infection that can have multiple different presentations but
also be asymptomatic.
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Primary syphilis
 classically presents as a single painless ulcer or chancre at the site of infection but can
also present with multiple, atypical, or painful lesions.
 Chancres can occur on or around the external genitals (vagina, anus, and rectum) or
around the mouth.
Secondary syphilis
 occur six to eight weeks after the primary ulcer (chancre) and include a generalized
rash (including palms and soles), flu-like symptoms, flat wart-like genital lesions
(condylomata lata), mouth ulcers and patchy hair loss.
Tertiary syphilis
 Occurs many years later and affects skin, bone, heart and nervous system.
 A genital ulcer caused by syphilis will resolve spontaneously within four to six weeks
without treatment; however, the syphilis infection persists, and the ulcer resolving does
not represent cure.
Latent syphilis acquired within the preceding year is referred to as Early latent syphilis; all
other cases of latent syphilis are classified as late latent syphilis or latent syphilis of
unknown duration.
Congenital syphilis
Congenital Syphilis is a significant, under-addressed public health priority. Transmission of T.
pallidum across the placenta from a syphilitic woman to her fetus may occur at any stage of
pregnancy.
 Congenital syphilis can cause:

 Miscarriage (losing the baby during pregnancy),
 Stillbirth (a baby born dead),
 Prematurity (a baby born early),
 Low birth weight, or
 Death shortly after birth(neonatal death)
Note: Up to 40% of babies born to women with untreated syphilis may result in still birth or
neonatal death.
 Congenital Syphilis can have major health impacts on the baby. For example
 Deformed bones,
 Severe anemia (low blood count),
 Enlarged liver and spleen,
 Jaundice (yellowing of the skin or eyes),
 Brain and nerve problems, like blindness or deafness,
 Meningitis, and
 Skin rashes.
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 How Congenital syphilis affects your baby‘s health depends on how long you had
syphilis and if — or when — you got treatment for the infection.
 Transmission can occur during any stage of syphilis; risk is much higher during
primary and secondary syphilis
 Fetal infection can occur during any trimester of pregnancy
 Not all babies born with Congenital Syphilis have signs or symptoms at birth.
 Without treatment, the baby may develop serious problems. Usually, these health
problems develop in the first few weeks after birth, but they can also happen years
later.
 Babies who do not get treatment for Congenital Syphilis and develop symptoms later
on can die from the infection.
 They may also be developmentally delayed or have seizures.
 All neonates born to women who have reactive serologic tests for syphilis should be
examined thoroughly for evidence of congenital syphilis e.g.;
 Jaundice,
 Hepatosplenomegaly,
 Rhinitis,
 Skin rash,
 Pseudo paralysis of an extremity and
 Deformed bones,
Risks for congenital syphilis:
Low risk:
 Mother is treated appropriately >4 weeks before birth

 Treatment completed > 4 weeks before birth
 Mother treated with the correct penicillin regimen for the stage of syphilis
 Maternal 4-fold drop in RPR achieved
 Final RPR titer ≤ 1:4 (VDRL 1:2)
High risk:
situations where infants require further evaluation and treatment at birth include the
following:
• Maternal syphilis not treated or inadequately treated, or treatment inadequately

documented.
• Maternal syphilis treated but with inadequate follow-up or without a satisfactory 4-
fold drop in RPR titer
• Treatment of syphilis in pregnancy with a non-penicillin regimen including
ceftriaxone
• Treatment of the mother < 30 days prior to the birth (maternal treatment unlikely to
have adequately treated the fetus)
• Final RPR titer > 1:4 (VDRL > 1:2)
• Abnormal fetal ultrasound findings
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2.2 Screening for syphilis during ANC
 Screening all pregnant women for Syphilis at the first antenatal care contact is
recommended by WHO.
 Early diagnosis and treatment of Syphilis in pregnant women has been proven as an
effective strategy in the prevention of both adverse outcomes of pregnancy and
Mother-To-Child-Transmission.
 It is important to know what type of test is being used to test for syphilis. Available
syphilis tests are of the RPR type (non-treponemal test). False positive RPR‘s can
occur. It is therefore good practice to confirm any positive RPR with a TPHA/FTA test
(treponemal test).
 TPHA remains positive for life, but an RPR changes in titer in response to treatment or
disease progression. Consider re-infection if the RPR titer increases by four times or
more. Conversely, if a TPHA is used as the first test (as what is used in the HIV-
syphilis combination or standalone syphilis rapid test), the positive result should be
confirmed using an RPR. The RPR will determine if the positive TPHA result indicates
a current active infection or an earlier infection.
 Routine screening of newborn sera or umbilical cord blood is not recommended, as

diagnosis at this time does not prevent symptomatic congenital syphilis in some
newborns.
2.3 Basic Principles for management of syphilis to prevent MTCT of congenital

syphilis
 Most Syphilis-associated deaths could be prevented with a single dose of Benzathine
Penicillin G (BPG).
 BPG is an inexpensive, off-patent drug, and the only antibiotic capable of crossing the
placenta to treat the fetus for Syphilis. As such, it is the only product suitable for the
treatment of pregnant women with Syphilis and to support Elimination of Mother-To-
Child Transmission (EMTCT) of congenital Syphilis.
 Penicillin G is the drug of choice for all stages of syphilis.
 T. pallidum can be killed by very low concentrations of penicillin G, although a long
period of exposure to penicillin is required because of the unusually slow rate of
multiplication of the organism.
 The efficacy of penicillin against syphilis remains undiminished after 70 years of use,
and there is no evidence of penicillin resistance in T. pallidum. In pregnant women
with untreated early syphilis, 70–100% of infants will be infected, with stillbirths in up
to one-third of cases.
 Primary and secondary syphilis are easy to treat with a penicillin injection.
 People who are allergic to penicillin will likely be treated with a different antibiotic,
such as:
o Erythromycin
o Azithromycin (Tabs azithromycin 2G STAT)
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o Ceftriaxone (IM Ceftriaxone 1G OD for 14 days )
Remarks: Although erythromycin and azithromycin treat the pregnant women, they do not
cross the placental barrier completely and as a result the fetus is not treated. It is therefore
necessary to treat the newborn infant soon after delivery.
NB: If the mother was treated with non-penicillin treatment, the baby should be treated as
having congenital syphilis.
Table 25: Management of Syphilis positive pregnant mothers

STAGE Preferred Tx without penicillin allergy Alternative Tx with
penicillin allergy
Early syphilis in Trimester 1 or 2 (up to and including 27 Desensitize and treat
pregnancy weeks): Benzathine benzyl penicillin tetra with penicillin. If
(primary, hydrate 2,400,000 units/4.6 ml intramuscularly desensitization not
secondary, early as a single dose possible use
latent but Erythromycin 500mg
excluding Trimester 3 (from week 28 to term): 6 hourly/PO for 14
neurosyphilis) Benzathine benzyl penicillin tetra hydrate days
2,400,000 units/4.6 ml intramuscularly, on
days 1 and 8 (2 doses)
Late syphilis in Benzathine Benzyl penicillin tetra hydrate Desensitize and treat
pregnancy and 2,400,000 units/4.6 ml weekly on days 1, 8 and with penicillin. If
syphilis of 15 (three doses). desensitization not
unknown duration possible use
(all three If there is any doubt about the time of Erythromycin 500mg
trimesters) acquisition in latent disease, it should be 6 hourly/PO for 28
treated as late latent syphilis. days
Neurosyphilis (all Aqueous crystalline penicillin G (18–24 mU/d Desensitize and treat
trimesters) IV, given as 3–4 mU q4h or continuous With penicillin.
infusion) for 10–14 days; or
Aqueous procaine penicillin G (2.4 mU/d IM)

plus oral probenecid (500 mg qid), both for
10–14 days
Diagnosis and treatment of neonates born to syphilis positive mother
i. Diagnosis of congenital Syphilis in neonates
 The diagnosis of congenital syphilis can be difficult, as maternal Non-treponemal and

Treponemal IgG antibodies can be transferred through the placenta to the fetus,
complicating the interpretation of reactive serologic tests for syphilis in neonates.
 Therefore, treatment decisions frequently must be made on the basis of:-
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 Identification of syphilis in the mother;
 Adequacy of maternal treatment
 Presence of clinical, laboratory, or radiographic evidence of syphilis in the neonate
;( bone abnormalities)
 Presence of neonatal nontreponemal serologic titers (not specific can be maternal)
NB: Any neonate at risk for congenital syphilis should receive a full evaluation and testing for
HIV infection as well.
ii. Treatment of congenital Syphilis in infants
In infants with confirmed congenital syphilis or an infant who are clinically normal, but whose
mothers had untreated syphilis, inadequately treated syphilis (including treatment within 30
days of delivery) or syphilis that was treated with non-penicillin regimens, treat the infant with
aqueous benzyl penicillin or procaine penicillin.
Table 26: Treatment of congenital Syphilis in infants

Scenario Treatment
Infants with Congenital syphilis
 Benzyl penicillin 100 000–150 000 U/kg/day IV for 10–15 days ( IV
50,000 units/kg/dose BID during the first 7 days of life and then TID
thereafter)
OR
 Procaine penicillin 50 000 U/kg/day IM daily for 10–15 days
Infants who are clinically normal
 Benzyl penicillin 100 000–150 000 U/kg/day IV for 10 - 15 days ( IV
50,000 units/kg/dose BID during the first 7 days of life and then TID
but whose mothers had untreated thereafter)
syphilis, inadequately treated
syphilis or syphilis that was OR
treated withnon-penicillin  Procaine penicillin 50 000 U/kg/day IM daily for 10–15days
regimens
NB: If more than 1 day of therapy is missed, the entire course should be restarted.
If a non-penicillin G agent is used, close clinical, serologic, and CSF follow-up is required in
consultation with an expert.
 Neonates with a negative nontreponemal test at birth and whose mothers were
seroreactive at delivery should be retested at 3 months to rule out serologically
negative incubating congenital syphilis at the time of birth.
 Treponemal tests should not be used to evaluate treatment response because the results
are qualitative and passive transfer of maternal IgG treponemal antibody might persist
for at least 15 months.
 Infant treponemal tests can be positive due to passively transferred antibodies but this
should usually disappear by 15 months of age.
 Positive treponemal tests after 18 months is diagnostic of congenital syphilis
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Infants born to mothers with syphilis and HIV require the same evaluation, therapy or
follow-up as is recommended for all infants exposed to syphilis in-utero.
Table 27: Treatment of Syphilis for sexual partners

STAGE Preferred Tx without Alternative Tx with penicillin allergy
penicillin allergy
Primary, CSF normal or not examined: CSF normal or not examined: Tetracycline
secondary, or Penicillin G Benzathine HCl (500 mg PO qid) or
early latent (single dose of 2.4M IU IM) Doxycycline (100 mg PO bid) for 2 weeks
OR CSF abnormal: Treat as neurosyphilis.
Procaine Penicillin 1.2MU
Daily for 10 days CSF
abnormal: Treat as
neurosyphilis.
Late latent (or CSF normal or not examined: CSF normal and patient not infected with
latent Penicillin G Benzathine (2.4 HIV: Tetracycline HCl (500 mg PO qid) or
of unknown mU IM weekly for 3 weeks) Doxycycline (100 mg PO bid) for 4 weeks
duration), CSF abnormal: Treat as CSF normal and patient infected with HIV:
cardiovascular, neurosyphilis. Desensitize and treat with penicillin if
or compliance cannot be assured.
benign tertiary CSF abnormal: Treat as neurosyphilis.
Neurosyphilis Aqueous crystalline penicillin Desensitize and treat with penicillin.
(asymptomatic G (18–24 mU/d IV, given as
or 3–4 mU q4h or continuous
symptomatic) infusion) for 10–14 days; or
Aqueous procaine penicillin G
(2.4 mU/d IM) plus oral
probenecid (500 mg qid), both
for 10–14 days
Session summary
 All pregnant women should be screened for Syhilis at the first ANC contact.
 Syphilis positive pregnant women should be adequately treated for EMTCT of congenital syphilis.
 Treat all partners of pregnant women diagnosed with syphilis.
 Any neonate at risk for congenital syphilis should receive a full evaluation and be
managed as per the standard.
3. PMTCT of Hepatitis B virus

3.1.Basics of HBV and MTCT
3.2.Screening of pregnant women for HBV
3.3.Management of HBV positive pregnant women
146
3.4.Infant intervention for the prevention of MTCT of HBV.
Time allotted: 181min.
Learning objectives
 Explain the importance of Hepatitis B screening to all pregnant women..
 Manage eligible pregnant women diagnosed with Hepatitis B virus
 Discuss infant intervention for the prevention of MTCT of HBV.
W/ro Ak is a 26 years old pregnant woman who comes for ANC at 7

months of pregnancy. She was screened for HBV and found to be
HBsAg positive. She has no other complaints. The following laboratory
test was done.
Viral Load >200,000IU/ml, Ultrasound- normal and ALT is in a normal

range.
Q.1. Is she eligible for long term drug therapy or prophylaxis?
Q.2. How do you monitor the mother status after delivery?
3.1. Basics of HBV and MTCT

Hepatitis B Virus (HBV) is a DNA virus, which causes acute and chronic hepatitis that could
range from asymptomatic carrier states to fulminant liver failure. Acute Hepatitis B virus is
usually self-limited and resolves but in few groups of individuals it may progress. Diagnosis
and treatment of HBV should aim in viral suppression and prevention of complications such as
cirrhosis, and hepatocellular carcinoma and end stage liver disease, and prevention of MTCT.
HBV is prevalent in Ethiopia and based on few studies it has a prevalence of 8-12 %.
A systematic review and meta-analysis of HBV infection among pregnant women in Ethiopia
indicated that the prevalence among the included studies ranges from a minimum of 2.3% in
southern Ethiopia to a maximum of 7.9% in Gambella Hospital. The pooled prevalence of
HBV infection among pregnant women was 4.8%.
Hepatitis B virus causes both acute and chronic infection. If left untreated, chronic HBV
infection can cause liver cirrhosis, liver failure and hepatocellular carcinoma.
147
Acute HBV infection
New onset hepatitis B infection, that may or may not be icteric or symptomatic. Diagnosis is
based on detection of hepatitis B surface antigen (HBsAg) and IgM antibodies to hepatitis B
core antigen (anti HBc). Recovery is accompanied by clearance of HBsAg with sero-
conversion to anti-HBs (antibodies to hepatitis B surface antigen), usually within 3 months.
Chronic HBV infection
Defined as, persistence of hepatitis B surface antigen (HBsAg) for six months or more after
acute infection with HBV.
Transmission of HBV
HBV is transmitted by:-
• Blood and/or body fluids(saliva, menstrual, vaginal and seminal fluids)
from infected individuals,
• Use of contaminated traditional and medical equipments.
• Mother to child
HBV is extremely infectious (about 100 times as infectious as HIV and 10 times more
infectious than Hepatitis C).
3.2 Screening of pregnant women for HBV

All pregnant women should be tested for hepatitis B surface antigen (HBsAg) at least once and
as early as possible particularly in settings with a ≥2% HBsAg seroprevalence in the general
population.
Lab investigation using serological markers for HBV Hepatitis B surface antigen
(HBsAg)
 HBV envelope protein and excess coat particles detectable in the blood in acute and
chronic hepatitis B infection Hepatitis B core antigen (HBcAg).
 HBV core protein: The core protein is coated with HBsAg and therefore not found free
in serum
Hepatitis B e antigen (HBeAg)
 Viral protein found in the high replicative phase of hepatitis B. HBeAg is usually a
marker of high levels of replication with wild- type virus but is not essential for viral
replication.
148
Hepatitis B surface antibody (anti-HBs)
 Antibody to HBsAg: Develops in response to HBV vaccination and during recovery
from acute hepatitis B, denoting past infection and immunity
 Anti-HBe - Antibody to HBeAg: Detected in persons with lower levels of HBV
replication but also in HBeAgnegative disease (i.e. HBV that does not express
HBeAg).
Hepatitis B core antibody (anti-HBc)

 Antibody to hepatitis B core (capsid) protein: Anti-HBc antibodies are not neutralizing
antibodies and are detected in both acute and chronic infection
IgM anti-HBc
 Subclass of anti-HBc. Detected in acute hepatitis B but can be detected by sensitive
assays in active chronic HBV
 IgG anti-HBc :- Subclass of anti-HBc detected in past or current infection
3.3 Maternal and infant interventions for PMTCT of HBV

 Transmission of HBV from mother to child is more common in children born to
women who have a high viral load and/or are positive for the hepatitis B e antigen
(HBeAg).
 It is also recommended to give hepatitis B immune globulin (HBIG)(if available)
shortly after birth for infants born to HBsAg positive mothers(especially if HBeAg
positive or with high HBV DNA).
 Besides, pregnant women tested positive for HBV infection (HBsAg positive) with an
HBV DNA ≥ 5.3 log10 IU/mL (≥ 200,000 IU/mL) has to receive antiviral prophylaxis
to prevent transmission of HBV from mother-to-child.
 Regardless of HBsAg status of the mother during pregnancy, a timely birth dose of
hepatitis B vaccine for the infant has to be given to prevent HBV transmission from the
mother to the child. In contrast, maternal HBIG administration does not provide
additional protection to the infant.
NB. Evidence suggests that the use of antivirals may suppress HBV DNA levels and reduce
transmission of HBV to infants of HBsAg-positive women. Therefore, the use of antiviral
prophylaxis during pregnancy for pregnant women with high HBV DNA levels is essential to
prevent perinatal HBV infection.

149
The following algorithm shows assessment of eligibility for maternal prophylaxis or long term
treatment and interventions for the prevention of MTCT of HBV.
150
HBsAg TESTING IN PREGNANT WOMEN
(using RDT or laboratory-based immunoassay)
HBsAg + HBsAg –
HBV DNA VIRAL LOAD OR HBeAg (if HBV DNA is unavailable)

AND ASSESS FOR CIRRHOSIS
HBV DNA HBV DNA Presence of

<200 000 IU/mL ≥ 200,000 IU/mL cirrhosis
(≥ 5.3 log10 or HBV DNA
or IU/mL) >20 000 IU/mL +
HBeAg negative, or HBeAg persistently
positive, abnormal ALT
without cirrhosis without cirrhosis
NO MATERNAL START MATERNAL START LONG-

TENOFOVIR TENOFOVIR TERM
PROPHYLAXIS PROPHYLAXIS MATERNAL
(from 28 weeks of TENOFOVIR
pregnancy until at TREATMENT AND
DEFER LONG- least birth) MONITOR (as per
TERM National HBV
MATERNAL REASSESS FOR treatment
TENOFOVIR LONG-TERM guidelines)
TREATMENT BUT MATERNAL
MONITOR AND TENOFOVIR
REASSESS TREATMENT
(as per National AFTER DELIVERY
HBV AND
treatment MONITOR (as per
guidelines) National HBV
guidelines)
HEPATITIS B BIRTH DOSE VACCINATION OF THE

INFANT FOLLOWED BY 3 DOSES OF VACCINE
HBIG (if available) FOR INFANTS BORN TO HBsAg POSITIVE MOTHERS

(especially if HBeAg positive or with high HBV DNA)
Figure 13: Algorithm on maternal and infant interventions for prevention of mother-to-
child transmission, and assessment of eligibility of mother for treatment for her own
health
151
4. Management of HBV positive pregnant mothers
5. Prophylaxis and treatment for the mother to prevent mother-to-child

transmission of HBV.
Since the indications for treatment in HBV-infected pregnant women are the same as that for
other adults, all pregnant women should first be assessed for eligibility for long-term treatment
based on their own health needs before initiation of prophylaxis. If not eligible for treatment,
providing prophylaxis with antivirals during the third trimester of pregnancy is effective in
reducing mother-to-child transmission of HBV.
 Pregnant women tested positive for HBV infection (HBsAg positive) with an HBV
DNA ≥ 5.3 log10 IU/mL (≥ 200,000 IU/mL) has to receive tenofovir 300mg daily
prophylaxis from the 28th week of pregnancy until at least birth to prevent mother-to-
child transmission of HBV.
 In settings in which antenatal HBV DNA testing is not available, HBeAg testing
(HBeAg positive) can be used as an alternative to HBV DNA testing to determine
eligibility for tenofovir prophylaxis to prevent mother-to-child transmission of HBV.
 Linking the pregnant or postpartum women to chronic care for long-term maternal
Tenofovir treatment when there is cirrhosis or persistently elevated alanine
aminotransferase plus HBV viral load >=5.3 log10 IU/ml (or > 20,000 IU/ml) or
HBeAg positive.
Exercise 1.10
Case scenario Maternal Maternal long Infant birth

Prophylaxis term treatment vaccine
HBsAg positive pregnant women

with <200,000 IU/ml with no
cirrhosis

with HBV DNA ≥200,000 IU/ml
with no cirrhosis

HBV DNA ≥200,000 IU/ml with
cirrhosis and persistently ALT.
Pregnant women with negative

HBsAg
152
3.3.2 Infant intervention for the prevention of MTCT of HBV.
Birth dose of hepatitis B vaccine:
 Regardless of HBsAg status of the mother during pregnancy, all infants should receive
their first dose of hepatitis B vaccine as soon as possible after birth, preferably within
24 hours, and that the birth dose be followed by three doses of hepatitis B vaccine at
least four weeks apart (at 6th week, 10th week and 14th week of age) to complete the
primary series.
 If available, it is recommended to give single dose hepatitis B immune globulin
(HBIG) shortly after birth for infants born to HBsAg positive mothers (especially if
HBeAg positive or with high HBV DNA).
 Administration of hepatitis B birth dose vaccine within 24 hours of birth should be a

performance indicator for the EMTCT of HBV and reporting and monitoring systems
should be strengthened to improve the quality of data on the birth dose HBV vaccine.
Treatment option for patients with HBV/HIV co-infection
 In HBV/HIV co-infected HIV positive pregnant women, combination ARV therapy

should be initiated with drug containing TDF+3TC (FTC)+DTG
 For HIV/HBV co-infected patients and qualify for treatment of both diseases, oral first
line is first line for those patients with at least 2 drugs having activitiy against HBV like
combination of TDF, FTC/3TC, and DTG.
 The use of lamivudine as a monotherapy in any of these diseases is contraindicated due to
high YMDD resistance
 When switching treatment for patients on ART treatment failure, the regimen that will
continue should have 2 drugs having activity against HBV.
 If TDF associated renal toxicity occurs, the dose of TDF should be adjusted according to
the renal clearance.
Session summary
 All pregnant women should be tested for hepatitis B surface antigen (HBsAg) at least once
and as early as possible particularly in settings with a ≥2% HBsAg seroprevalence in the
general population.
 All eligible HBsAg positive pregnant women should receive either prophylaxis or long
term treatment.
 All newborn should receive HBV birth dose vaccine regardless of maternal HBV status.
153
Chapter 2: PMTCT IN LABOR AND DELIVERY SETTING
Time Allotted - 480 Minutes
Chapter description: - This chapter is designed to equip participants with the necessary
knowledge and skills to provide MTCT interventions, apply standard infection prevention and
control principles and properly manage labor to prevent MTCT
Learning Objectives:
After completing this chapter, the participants will be able to:
- Manage laboring women for PMTCT interventions
Enabling objectives
 Describe PMTCT interventions during labor and delivery
 List principles and practice of standard precautions of infection prevention and control
during labor and delivery
 Demonstrate Management of Labor and Child birth in the context of PMTCT using
partograph
 Describe Immediate Postpartum Care
Chapter outline
2.1. PMTCT interventions during labor and delivery
2.2. Standard Precautions during Labor and Delivery
2.3. Management of Labour and Childbirth
2.4. Immediate Postpartum Care
2.5. Summary
154
2.1. PMTCT Interventions during Labor &Delivery
Time Allocated:- 45 Minute
Enabling objectives
By the end of this session, the participants will be able to:
 Describe PMTCTintervention during labor and
delivery
Individual reflection
1. Reflect the goals of intrapartum care for PMTCT?
2. What are PMTCT interventions during L&D
Time: 10 min
The goal of intrapartum care for PMTCT is to reduce HIV transmission risk by:
 Providing ARV treatment
 Minimizing exposure of fetus to maternal blood and body fluids and
 Supporting safer delivery practices.
Proper diagnosis and monitoring of labor is importance to minimize maternal morbidity and
mortality. In addition, it will also help to prevent risk of MTCT of HIV.
Interventions for PMTCT during L&D include the following:
 Use standard infection prevention practices for all patient care (see Session 2: Standard
Precautions during Labor and Delivery)
 Use of partograph for labor follow-up.
 Continue ARV treatment and dual Prophylaxis as per guideline
 Use safe obstetric practices for PMTCT of HIV
Women whose HIV status is not known need to be tested for HIV and counseled. For newly
diagnosed HIV positive pregnant women should start ART unless the delivery is eminent
within 4 hours. In such cases, she should start ART (TDF +3TC + DTG) immediately
postpartum.
155
2.2. STANDARD PRECAUTIONS DURING LABOR AND DELIVERY
Time Allocated:- 100 Minutes
Enabling objectives
By the end of this session, the participants will be able to:
 Describe standard precautions throughout
labour and childbirth.
 Discuss important principles of universal
precaution and its applications
Introduction
Standard precautions are simple infection control measures that reduce the risk of transmission
of blood-borne pathogens through exposure to blood or body fluids among patients and health
care workers. Standard precautions and standard cleanliness should be adhered to throughout
labor and childbirth. Standard precautions should be followed with every client, regardless of
whether or not the service provider thinks or knows the client might be infected with HIV,
hepatitis or any other transmittable illnesses.
Good infection prevention practices help to:
 Prevent MTCT of HIV by reducing contact with maternal secretions and blood
 Prevent transmission of HIV or other blood-borne infections in the health care
setting.
Group work and presentation

Group1: Hand hygiene principles – presentation and demonstration
Group 2: Use of safe injection techniques, Use sharps disposal
containers,
Group 3: Handling, cleaning, or disposal of instruments safely
Group 4: Use personal protective materials and Handle and dispose of
waste safely:
Time: 30 mine ( 15 for group work and 15 min for presentation)
156
Important principles of infection prevention -
2. 1. Follow general hygiene practices:
 Hand hygiene:
o Hand washing: wet hands and apply soap; rub all surfaces for 40-60 Seconds
rinse hands with running water and dry thoroughly with a single use towel or air
dry your hands;
o Handrubs: (20-30 Seconds, ): apply enough products to cover all areas of the
hands; rub hands until dry. But when hands are visibly soiled, it is preferred to
wash hands.
o Apply waterproof dressing to cover all cuts and abrasions.
 Practice hand hygiene before and after direct contact with patient and procedures.
157
Figure 14: Steps in hand washing
158
Figure 15: Steps in hand rub
159
2.2. Use safe injection techniques:
 Do not recap needles. When recapping is necessary, use the one-handed scoop
technique for recapping needles.
Step 1: Scoop up the cap
Step 2: Push cap firmly down
One-handed scoop technique for recapping needles.

Tips on handling sharps
 Always point the sharp end away from yourself and others.
 Pass sharps (scalpels, blades, lancets, razors, scissors and other sharp instruments) with
the sharp end pointing away from the person receiving. or
 Place the sharp on a designated ―safe zone‖ flat surface or in sterile kidney basin (or
other receiver) where it can then be picked up by the receiving person rather than
passing them hand-to-hand.
 Do not bend, break, manipulate, or remove needles before disposal of syringes.
 Pick up sharps one at a time, and do not pass handfuls of sharp instruments or needles.
2.3. Use sharps disposal containers
Using sharps disposal containers helps prevent injuries from disposable sharps. Sharp
containers should be fitted with a cover and be puncture-proof, leak-proof, and tamper-proof
(i.e. difficult to open or break).
If plastic or metal containers are unavailable or too costly, use containers made of dense
cardboard (cardboard safety boxes) that meet WHO specifications. If cardboard safety boxes
are unavailable, many easily available objects can substitute as sharps containers (Tin with a
lid, thick plastic bottle, heavy-duty plastic box, and heavy-duty cardboard box.)
Recommendations for safe use of sharps containers:
160
 All sharps containers should be clearly marked
―SHARPS‖ and/or have pictorial instructions for
the use and disposal of the container.
 Place sharps containers away from crowded areas and as close as possible to where
the sharps will be used. The placement of the container should be practical (ideally
within arm‘s reach) but unobtrusive. Do not place containers near light switches,
overhead fans, or thermostat controls where people might accidentally put one of their
hands into them.
 Attach containers to walls or other surfaces if possible. Position the containers at a
convenient height so that staff can use and replace them easily.
 Never reuse or recycle sharps materials.
 Mark the containers clearly so that people will not unknowingly use them as garbage
receptacles.
 Avoid shaking a container to settle its contents to make room for more sharps.
 Seal and close containers when ¾ full. Do not fill safety box beyond ¾ full. Once a
sharp‘s container has been closed, do not reopen it.
2.4. Handle, clean, or dispose of instruments safely
 Pass all sharp instruments on to a receiver, rather than hand-to-hand.
 Use needle holders and forceps so as to avoid using your fingers for needle placement
and retrieval.
 Properly process instruments, devices, and equipment used during invasive
procedures—decontaminate, clean, and disinfect or sterilize all devices and equipment.
2.4.1 Steps in Instrument Processing:
1. Cleaning: Efficient cleaning with soap and water is essential prior to disinfection
or sterilization. Cleaning:
 Removes a high proportion of micro-organisms
 Removes contaminants such as dust, soil, salts, and the organic matter that allows
them to adhere to instruments.
2. High-level Disinfection (HLD) - is a process that eliminates all microorganisms
except some bacterial endospores from inanimate objects by boiling, steaming or the
use of chemical disinfectants.
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3. Sterilization - a process that eliminates all microorganisms (bacteria, viruses, fungi and
parasites) including bacterial endospores from inanimate objects by high-pressure steam
(autoclave), dry heat (oven), chemical sterilization or radiation.
2.4.2 Use personal protective materials:
Gloves:
 Wear gloves in all invasive procedures;
 Use gloves during provision of patient care;
 Do not wear gloves away from the bedside, delivery couch, or procedure site; e.g. to
handle phones, chart, to handle clean linen, in hallways or elevators;
 Use heavy duty gloves to clean equipment or patient care supplies;
 Use long, cuffed sterile gloves during manual removal of a placenta;
 Use sterile gloves for any procedure where aseptic technique is required.
 Know which gloves are required for each procedure. This varies whether to use
sterile or clean/disinfected; short or long gloves.
Tips for effective glove use:
 Wear gloves that are the correct size for you.
 Use water-soluble hand lotions and moisturizers often to prevent hands from drying,
cracking, and chapping.
 Avoid oil-based hand lotions or creams as they can damage latex rubber gloves.
 Do not wear rings under gloves.
 Keep fingernails short [less than 3 mm (1/8 inch) beyond the fingertip].
 Store gloves in a place where they are protected from extreme temperature.
Aprons, gowns, masks and eye protection:

 Use masks, eye protection, and gowns (or plastic aprons) when blood or other body
fluids could splash – e.g. while attending second and third stages of labour.
 When possible, wear eye shield during caesarean section and episiotomy suturing.
 Wear a clean, non-sterile, and impermeable plastic apron while attending delivery.
 Ensure gloved hands are held high above the level of the waist and do not come into
contact with the gown.
 After use: Remove soiled gown promptly, perform hand hygiene& dry hands with
towel.
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2.4.3 Handle and dispose of waste safely:
 Use systems for safe waste collection and disposal.
 Collect wastes by type: general waste, medical waste, and hazardous chemical waste
 Materials should be deposited in approved leak-proof materials.
 Delivery couch should be disinfected properly.
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2.3 Management of Needle Stick and Other Potential Exposures to HIV in the
Workplace
Enabling Objectives
- Describe measures after needle stick injury from HIV positive women
- Think Pair and share
- What measure will you take you
encounter needle stick injury while you
are managing clients?
Time: 10 min
When needle stick injuries or other potential exposure to HIV occurs:

 Stop what you are doing and attend the injury.
 If blood or body fluids splash on intact skin, immediately wash the area with water and
soap. If splashed in the face (eye, nose, and mouth) wash with clean water only.
 If a finger prick or a cut occurred during procedures such as suturing, allow the wound
to bleed for few seconds; do not squeeze out the blood, as you squeeze and release your
finger, it produces vacuum and sucks in the virus to your system.
 Wash with soap and water. Use regular wound care. Dry and apply waterproof
dressing, as necessary.
 Topical antiseptics may be used. If the glove is damaged, wash the area with soap and
water, and change the glove.
 Check records for the HIV status of the woman.
Follow the post-exposure prophylaxis (PEP) protocol in Ethiopia. Contact your district.
 Check records for the HIV status of the woman.
 Follow the post-exposure prophylaxis (PEP) protocol in Ethiopia. Contact your district
team if your facility does not have the protocol, necessary supplies, or if no one on
your team has been trained in the management of occupational exposure (someone on
the clinical team should take a PEP short course). Health workers should be
encouraged to report incidents of exposure.
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Case study
A HCWs is working in a very busy labour and delivery unit. She/ is
called to help a colleague with a woman in labor. While She is
administering IM injection of oxytocin, Sheaccidentally punctured by
a needle.
Discussion questions
A. After this occupational exposure, what is the first measure a
HCWs has to take?
B. List each subsequent step according to the PEP protocol
C. How could the HCWs andher colleagues have prevented this
accident?
Time: 10 min
2.4. MANAGEMENT OF LABOUR AND CHILDBIRTH IN THE CONTEXT OF

PMTCT
_Enabling objectives
By the end of this session participants will be able to:
 Conduct HTS during L&D.
 Provide ARV drugs according to the national
guidelines.
 Demonstrate proper use of partograph for
follow-up of women in labor.
 Apply safe obstetric practices during labor and
delivery for PMTCT
2.4.1. HIV Testing Services during Labor

You have already discussed HIV testing and counseling while discussing chapter I. The basic
principles of a routine provider-initiated, opt-out approach also apply for testing and
counseling during labor.
2.4.2. Check for HIV status

Check the woman’s record to be sure the test result is recorded on her card.
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A. If she has been tested and is HIV-positive:
1. Check the woman’s record and ask her if she is taking ART.
2. If she is not taking ART, Initiate ART ,( If yes to Q #1 )
3. Ask her if she disclose her HIV status?
4. If #3 is yes, ask her either husband has tested or not. If not tested inform her to bring
her partner for testing and counselling
5. If Q#3 is no, ask why? and screen for Intimate partner violence (IPV) as part of
partner notification services for HIV (PNS)
6. Tell the mother that you will provide her with ARV drugs during labor and to her
newborn baby as soon as possible after birth.
B. If she has been tested HIV-negative:
 Check to see when the woman was tested for HIV, and recommend repeat HIV testing
if the previous test was done on window period( 6-12 weeks) .
C.If she has not been tested:
Recommend HIV testing and counseling, if appropriate.
HIV testing and counseling should be recommended routinely for all mothers admitted for
labor and delivery with unknown HIV status. If tested positive consider ARV drug and be
linked to HIV care and treatment for herself and for her infant.
2.4.3. Guiding principles of HIV Testing Services :

The guiding principles of provider-initiated testing and counseling (PITC) for HIV are tailored
to the special needs of a woman in labour.
The 5 C's: Consent, Confidentiality, Counseling, Correct test results, and Connections to care
are similar with counseling for HIV during pregnancy (refer to chapter 1 for detail). For the
woman in labour, an additional C is important: Comfort of the woman.
Comfort
The health worker should assess the woman‘s stage of labour, comfort level, and need for
analgesics. Providers need to show empathy while presenting information about HIV testing
and counseling: explained based on the comfort level of the woman e.g. between contractions.
Always consider the woman‘s language and culture and, as needed, must adjust the
terminology used. Make sure the woman understood the information.
Tasks to be considered during couch- counseling:
· Make pre-test messages short & specific,
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· Focus on HIV transmission during L&D
· Explain possible interventions, for the mother & baby
· Provide information, HIV testing and counselling between contractions
· Don‘t give pre test information while managing labour
Task to be completed after delivery
· Before going to post-test counseling, please make sure that the mother is well-rested and
ready to listen to you.
· Ensure the baby has been given first doze of the NVP and AZT prophylaxis.
· Ensure immediate postpartum care has been given to both the mother and her baby.
· Counsel on exclusive breastfeeding or methods of infant feeding of her choice.
· Ensure post-test counseling has been delivered properly and well understood by the
mother.
- Ensure mother receives her first 1month doze
ofART with adequate adherence preparation and
information.
- Ensure mother receives NVP and AZT prophylaxis
for the baby
Case study
Purpose: acquaint yourself with the national and local policies on
testing and counseling in labor.
A labouring mother arrives to the health center with labor pain. This
is her fourth child. She tells you that she has had a good pregnancy.
She has received no antenatal care, and was never tested for HIV. At
this time, her contractions are regular and about 2 minutes apart.
During your examination, you find that her cervix is 7-8 cm dilated.
Q: Considering the national policy on testing and counseling during
L&D, what are your next steps?
Time: 10 min
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2.4.4. ARV drug use during Labor and Delivery in different scenarios
ART reduce the risk of MTCT of HIV by decreasing the viral load in the mother which means
there will be less MTCT of the virus during pregnancy, labor, and delivery, and breast
feeding. .
.A pregnant woman who was on treatment regimen 1e( TDF + 3TC + EFV) during
pregnancyand coming with labor pain should shift to treatment regimen 1J ( TDF + 3TC +
DTG).
HIV positive laboring mother who were not initiated with ARV treatment and newly identified
on coach the treatment should be initiated with 1J treatment regimen.
Case study: ART for Mothers during Labor and Delivery
Purpose: Discuss administration of ART L&DFollow the instruction of your facilitator
Case #1:
A laboring mother arrives at the L&D unit. This is her first pregnancy. Her ANC record
indicates that she was tested during pregnancy and is HIV-positive. Her water broke 4
hours ago, and her contractions are now fewer than 3 minutes apart. Earlier, she received
ARV tablets to take at home. When you examine her, you find that her cervix is 5 cm
dilated.
Q: after providing general labor support, what is your first priority?
Q: If you discover that she has not taken her tablets, what do you do?
Case study #2
Case#2:
A laboring mother arrives at your health centre with labor pain that started 4 hours
ago. This is her first pregnancy. She tested positive for HIV in the second trimester, is
in WHO clinical stage 3, and her last CD4 is 190. She is on TDF-3TC-EFV. Her last
dose was 12 hours before arrival at your health centre in the morning. She does not
want to take the ARV drugs during labour because she is concerned that it might harm
the baby.
Q1: What would you advise her?Q2: Discuss the treatment regimen that the laboring
mother should continue to take
Time: 20 min
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2.4.5. The partograph
1. What is partograph?
2. What are the purposes of managing labor by using partograph
Time: 5 min
A very important way of recognizing prolonged labor, which is a risk factor for MTCT of
HIV. Routinely use the partograph to monitor progress of labor for all women. The partograph
is a graphic recording of the progress of labor and the salient condition of the mother and the
fetus.(Refer to Figure 2.4 for sample of partograph for use in Ethiopia, adopted from WHO) It
serves as an ―early warning system‖ and assists in the early recognition of prolonged and/or
obstructed labor that enable to take decisions as to whether to transfer/referral, augment labor,
or the need for surgical intervention in order to prevent and save lives of both mother and/or
fetus. The partograph has been modified to make it simpler and easier to use. Plotting on the
partograph begins in the active phase of labor when the cervix is 4 cm dilated.
Group work
1. What are the components of a partograph?
2. Describe each component of the partograph
Time: 10 min
Partograph has three components
1. Maternal condition
2. Fetal condition and
3. Progress of labor
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1. Maternal condition
Patient information: Fill out name, gravida, para, hospital number, date and time of
admission, and time of ruptured membranes or time elapsed since rupture of membranes (if
rupture occurred before charting on the partograph began).
- Drugs given: Record any additional drugs given.
- Pulse: Record every 30 minutes and mark with a dot.
- Blood pressure: Record every four hours and mark with arrows.
- Temperature: Record every two hours.
- Protein, acetone and volume: Record when urine is passed.
2. Fetal condition
Fetal heart rate: Record every half hour. The normal rage is between 100 to 180 bpm
Amniotic fluid: Record the color of amniotic fluid at every vaginal examination:
• I: membranes intact
• R: membranes ruptured
• C: membranes ruptured, clear fluid
• M: meconium-stained fluid
• B: blood-stained fluid.
3. Progress of labor
Molding of the fetal head:1. Sutures apposed (+)2. Sutures overlapped but reducible (++)3.
Sutures overlapped and not reducible ( +++)
Cervical dilatation: Assess at every vaginal examination and plot with an ―X‖ mark. Begin
plotting on the partograph at 4 cm. Only begin to use the partograph in active labor, when the
woman is having strong, regular contractions and the cervix is at least 4 cm dilated.
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Descent is assessed by abdominal palpation: It refers to the descent of the fetal head into the
maternal pelvis, and is measured as the part of the head palpable above the symphysis pubis
using a rule five( using five finger bredth) ; recorded as a circle (O) at every abdominal
examination. At 0/5, the fetal head is fully descended into the pelvis and is at the level of the
symphysis pubis.
Alert line: Draw a line starting at 4 cm of cervical dilatation to the point of expected full
dilatation at the rate of 1 cm per hour. If a woman‘s course of labor crosses over the alert line,
the birth attendant caring for her should be alerted that her labor is longer than usual and
consider what interventions might be necessary—transfer if not in a health center with full
emergency obstetric care, rupture of membranes or oxytocin if contractions are inadequate.
Action line: Parallel and four hours to the right of the alert line. If a woman‘s course of labor
crosses over the action line, immediate steps should be taken for delivery (Caesarean section
or forceps/vacuum delivery depending on the position and descent of the baby‘s head) in order
to prevent maternal and neonatal morbidity and mortality.
Hours: Refers to the time elapsed since onset of active phase of labor (observed or
extrapolated)
Time: Record actual time.
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Contractions: Chart every half hour; count the number of contractions in a 10-minute time
period, and their duration in seconds.
• Less than 20 seconds:
• Between 20 and 40 seconds:
• More than 40 seconds: .

Oxytocin: If oxytocin is being used to augment labor, record the amount of oxytocin per
volume of intravenous fluids in drops per minute every 30 minutes.
Figure 16: Partograph adopted from WHO for use in Ethiopia
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The facilitator will take you through the exercise to build your competency on the use of
partograph
Case study: Using the Partograph
Read the two cases below and, for each, answer the questions and plot the information on your partograph forms.
W/ro ―B‖
STEP 1
 W/ro ‗B‘ was admitted at 05.00 on 19.9.2003
 Membranes ruptured 04.00
 Gravida 3, Para 2+0
 Hospital MRN 7886
 On admission the fetal head was 4/5 palpable above the symphysis pubis and the cervix was 2 cm
dilated.
STEP 2
09.00:
 The fetal head is 3/5 palpable above the symphysis pubis.
 The cervix is 5 cm dilated.
 Three contractions in 10 minutes, each lasting 20–40 seconds
 Fetal heart rate (FHR) 120
 Membranes ruptured, amniotic fluid clear
 Sutures of the skull bones are apposed
 Blood pressure 120/70 mmHg
 Temperature 36.8°C
 Pulse 80/minute
 Urine output 200 ml; negative protein and acetone
STEP 3
Plot the following information on the partograph:
09.30 FHR 120, contractions 3/10 each lasting 30 seconds, pulse 80/minute
11.00 FHR 130, contractions 3/10 each lasting 40 seconds, pulse 88/minute, temperature37°C
11.30 FHR 136, contractions 4/10 each lasting 40 seconds, pulse 84/minute, head is 2/5 palpable
13.00 FHR 140, contractions 4/10 each lasting 45 seconds, pulse 90/minute, temperature37°C
13.00:
 The cervix is fully dilated.
 Amniotic fluid clear
 Sutures apposed
 Urine output 150 ml; negative protein and acetone
STEP 4
Q1. Plot all the information given above
Q2. Record on the partograph as she gave birth at 13.20: Spontaneous birth of a live female infant weighing 2,850
g
Time: 20 min
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CASE #2: W/ro ―A‖
STEP 1
W/ro . ―A‖ was admitted at 10.00 on 19.9.2003.
 Membranes intact
 Gravida 1, Para 0+0
 MRN 1443
Record the information above on the partograph, together with the following details:
 The cervix is 4 cm dilated.
 Two contractions in 10 minutes, each lasting less than 20 seconds
 FHR 140
 Membranes intact
 Pulse 80/minute
 Urine output 400 mL; negative protein and acetone
STEP 2
10.30 FHR 140, contractions 2/10 each lasting 15 sec, pulse 90/minute
 The cervix is 4 cm dilated, membranes intact
Q1. What is your diagnosis?
Q2. What action will you take?
STEP 3
14.00 FHR 140, contractions 2/10 each lasting 20 sec, pulse 90/minute, temperature 36.8°C,
blood pressure 100/70 mmHg
14:00:
 Urine output 300 mL; negative protein and acetone
Q3. What is your diagnosis?
Q4. What will you do?
Q5. Plot the following information on the partograph:
14:00:
 The cervix is 4 cm dilated, sutures apposed
 174
Labor augmented with oxytocin 10 units in 500 mL IV fluid at 10 drops per minute
(dpm)
 Membranes artificially ruptured, clear fluid
STEP 4
14.30:
 Two contractions in 10 minutes, each lasting 30 seconds
 Infusion rate increased to 20 dpm
 FHR 140, pulse 90/minute
15.00:
 Three contractions in 10 minutes, each lasting 30 seconds
15:30:
16.00:
 Fetal head 2/5 palpable above the symphysis pubis
 Cervix 6 cm dilated; sutures apposed
 Amniotic fluid clear
16.30:
 Infusion remains at 50 dpm
Q7. What steps would you take?
STEP 5
17.00 FHR 138, pulse 92/minute, contractions 3/10 each lasting 40 sec, maintain at 50 dpm
18:30 FHR 144, pulse 94/minute, contractions 4/10 each lasting 50 sec, maintain at 50 dpm
STEP 6
19.00:
 Fetal head 0/5 palpable above the symphysis pubis
 Four contractions in 10 minutes, each lasting 50 seconds
 Cervix fully dilated
STEP 7
Q9. Record the following information on the partograph:
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19.30:
20.00:
20.10:
 Spontaneous birth of a live male infant weighing 2,654 g
Q10. How long was the active phase of the first stage of labor?
Q11. How long was the second stage of labor?
Q12. Why was labor augmented?
Time: 20 Minutes
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Partograph for CASE 1: W/ro B
177
Partograph forCASE#2: W/ro A
At the
end of
your
exercise
the
Reminder: facilitator will take you through the answers and provide you with an answer sheet
or you will be able to erase the incorrect answer and replaced by the correct one.
178
2.4.6. Safe obstetric practices during labor and delivery for PMTCT
Group work
Discuss the critical obstetric interventions that the HCWs should do during
labor and delivery to prevent HIV transmission from mother to the newborn?
Time: 10 min
Safe obstetric practices that minimize MTCT of HIV during L&D.

Some of the critical interventions are cited below:
Minimize cervical examinations.
 Perform cervical examination with appropriate clean techniques and only when
absolutely necessary (general recommendation is no more often than every 4 hours in
active labor).
Always use partograph and avoid prolonged labor.
Avoid artificial rupture of membranes, unless necessary.
Do not perform routine episiotomy(unless absolutely necessary).
 Minimize the use of forceps or vacuum extractor for delivery unless absolutely
necessary.
Use safe blood transfusion procedures
 Minimize the use of blood transfusions.
 Do not transfuse blood which has not been screened for infections including HIV,
Hepatitis B and C, and malaria.
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Considerations regarding mode of delivery
Vaginal delivery is more likely to increase the risk of MTCT of HIV than elective caesarean
operations in women who have high viral loads. However, the use of Caesarean Section solely
for PMTCT should be carefully considered because there are inherent risks of Caesarean
deliveries such as increased complications of blood loss, infection, anesthesia and longer
hospital stays for both the mother and infant, particularly in low resource settings.
Further, if the mother is taking ARV treatment the HIV transmission is significantly reduced,
even during a normal vaginal delivery. Given the capacity of most of the health facilities in
Ethiopia, routinely offering Caesarean delivery for all HIV-positive pregnant women is not
recommended. In deciding mode of delivery always consider the benefits and risks of vaginal
delivery versus elective Caesarean section, including the safety of the blood supply and the
risk of complications.
If a Caesarean section is necessary for other obstetrical indications (such as fetal intolerance of
labor or hemorrhage), it should not be delayed, irrespective of the woman HIV status and
availability and intake of ARV drugs for HIV positive pregnant woman.
Session Notesfor participants (write key points from the session ( 2.4) in the space
provided below) Time: 10 Minutes
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2.5. IMMEDIATE POSTPARTUM AND NEWBORN CARE
Time Allocated : - 155 Minutes
Enabling objectives
By the end of this session the participants will be able to:
 Describe the components of immediate postpartum care for women with HIV-
infection
 List out the components of immediate postpartum care with unknown HIV status
 Describe the immediate new-born care
2.5.1 Immediate Postpartum care of HIV-infected women

HIV increases the risk of postpartum complications. In HIV-infected mothers, anemia,
puerperal sepsis, and poor wound healing are more common. It is important to recognize and
treat complications, including infections, immediately. Identifying congenital abnormalities
related to anemia such as cleft lip and palate, closed anal orifices‘
Provide continued prevention and care services in the following areas:
 Routine immediate postpartum care, including review of the warning signs as well as
early recognition and treatment or referral according to the national guidelines.
 Ongoing treatment, care, and support for HIV/AIDS including OI prophylaxis,
treatment, and nutritional support
 Treatment and monitoring of TB and malaria
 Assessment of WHO clinical staging.
 Provision of appropriate information about safe infant feeding options before mother
leaves the clinic after childbirth.
 Support the mother‘s choice of feeding options
 Training and observation for proper infant feeding technique of her choice prior to
discharge.
Provide advise / instruction on:
 Perineum care:
- Use plain warm water to clean your perineum.
- Wash your perineum after every visit to the toilet.
- Change sanitary pads / towels frequently to reduce the risk of infection
(Change pads 6 times/day in first week; then 2 times/day).
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- It is normal to bleed for 2 – 4 weeks after the birth but progressively the
amount will decrease.
- More than 2 or 3 pads soaked in 20-30 minutes after delivery or bleeding
increases rather than decreases after delivery should be reported.
- Avoid constipation to minimize discomfort: Fibre in your diet, lots of water to
drink will soften the stools.
 Breast Care
- Breast care includes wearing a good support bra and keeping your breasts clean
and free from infection and skin problems. Nursing pads can be worn inside her
bra to soak up the milk when she is not breast-feeding. These should be
changed often, to keep her nipples clean and dry. She can use a cotton
handkerchief or other cotton squares inside the bra. Avoid pads that are lined
with plastic.
- Counsel and educate the mother about breast self examination
 Waste disposal:
- Disposal of potentially infectious materials such as lochia and blood-stained
sanitary pads as per the national guideline for infection prevetion.
 Family planning
- .limiting and spacing of births should be discussed with every woman
duringANC and reiterated in the immediate postpartum period.
- As much as possible, a woman should be encouraged to make a plan for family
planning (both the method she and her partner plan to use and where/how they
will access it) before leaving the facility after delivery.
- In addition; those family planing method options (e.g. IUCD, EBF, …) decided
to be used before delivery can be initiated during the immediate postpartum
period.
NB: Emphasize on dual methods of FP and further the options of methods will be discussed
in chapter 3
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Case study
W/ro . ―A‖ presented to the L&D ward without having had an HIV test during her pregnancy.
The result of the rapid HIV test result during labor was positive. When the test result told to
W/ro . ―A‖ she became upset but agreed to take the ART for PMTCT. Subsequently, she had
an uneventful labor and delivered a 2.5 kg healthy baby boy. She is determined to breastfeed
her baby boy. It is now two hours after her delivery, and she is resting. Her mother and
husband stayed with her.
a) What postpartum care does she require?
b) What HIV-specific services does she need?
c) What can you accomplish before she leaves the facility in 24 hours?
Time : 10 min
2.5.2 Immediate Postpartum care of women with unknown HIV status

Women whose HIV status is unknown should receive the same components of postpartum care
as women with HIV infection (outlined above). All women should be encouraged to be tested
for HIV and follow the national recommendations for safe infant feeding. HIV testing in the
immediate postpartum period can assist women who tested HIV-positive to:
 Immediate initiate ART for the mother
 Initiate post-exposure prophylaxis for the infant
 Choose the best infant feeding option, and
 Link her to prevention, care and treatment services in the MNCH setting.
The immediate care of newborns exposed to HIV follows standard practice. Regardless of the
mother‘s HIV status, all newborns should be handled with gloves until maternal blood and
secretions are washed off, and the newborns should be kept warm and dry after birth.
2.5.3. Immediate Newborn

Most babies breathe and cry at birth with no help. The care you give immediately after birth is
simple but important and saves life. The immediate assessment of the newborn includes
assessment of vital signs (e.g. color, heart rate, breathing, and temperature and muscle tone) as
the newborn transitions to life outside the womb, as well as an anatomic evaluation for any
congenital abnormalities.
Thermoregulation
Ways of heat loss
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A. EVAPORATION – heat loss through wet skin
This baby will lose heat by evaporation

through a wet skin after birth. Drying and
wrapping OR skin to skin contact plus a hat
is required
B. CONVECTION – heat loss from cooler air circulating around warmer skin particularly
when exposed
This baby is exposed so may lost heat via

conductive air
currents particularly if the room is cool
C. CONDUCTION – heat loss through direct contact with a cold surface (e.g. scales,
unwarmed mattress)
This baby may lose heat by both convection and conduction
via direct contact with cool scales
This baby may lose heat by both convection and

conduction
via direct contact with cool scales
D. RADIATION – heat loss from heat radiating towards a cooler surface (e.g. a cold window,
wall or incubator wall)
184
.
Check for breathing
Check for crying. If the baby is doesn‘t cry check whether breathing has initiated or not and
count respiration for 60 seconds.
Initiate feeding
Starting breastfeeding soon after birth helps mothers provide enough milk later. It also helps
the uterus contract and reduces maternal bleeding.
Cord care
Proper cord cutting, apply chlorhexidine and Keep the cord exposed and dry.
Eye care
Applying medicine (TTC eye ointment or drop) to the inside of the lower lid of both eyes soon
after birth can prevent these infections.
Vit k:
Vitamin K protects babies from serious bleeding that may result in death or brain damage.
Every newborn should be given vitamin K.
Labeling
Put baby tag with the description of mother‘s name, weight of the baby and time of delivery
Weighing
Birth weight identifies babies who may need special care and may be necessary for calculating
drug
doses.
Immunization
Immunizations given during the first week may include BCG, hepatitis B birth dose and oral
polio 0 (OPV0).
Documentation
Document all the service provided.
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Case study
W/ro ―B‖ was diagnosed as HIV-positive during her 1st ANC visit prior to delivery at home. She has
returned to the health center six days after birth.. The baby appears happy, well-hydrated and thriving.
She remains convinced as the baby is not infected with HIV and that the baby is not at risk. In fact, she
did not give the NVP and AZT syrup to the baby because the baby ―didn‘t need it‖ and is
breastfeeding.
a) Is this a typical response in your setting?
b) What services will you offer?
c) What follow-up and referrals are necessary for this mother and her infant?
d) How will you deal with her denial of her diagnosis and risk for her infant?
Time: 15 min
2.5.4. Newborn Resuscitation

Introduction
The first minute after delivery is a ―Golden Minute‖, which means within one minute of birth,
a baby should either be breathing well or should be supported for ventilation with a bag and
mask. The majority (90%) of newborns make the transition from intrauterine to extra-uterine
life without difficulty. However, approximately 10% of the newborns require some assistance
to begin breathing at birth, and only about 1% needs extensive resuscitative measures to
survive.
Always anticipate the need for resuscitation and have a plan to get assistance for every
newborn; especially if the fetus is at higher risk. Timely and correct resuscitation will not only
revive them but will enable them to develop normally. Most will need no further special care
after resuscitation. Functional resuscitation equipment should always be ready and close to the
delivery area since you must start resuscitation within 1 minute of birth.
Three situations require immediate resuscitation:
 No breathing (or gasping, below),
 Cyanosis (blueness) or
 Breathing with difficulty.
ABCs of resuscitation are the same for babies as for adults:
 Airway (position and clear)
 Breathing (stimulate to breathe)
 Circulation (assess the heart rate)
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Steps in newborn resuscitation
In the first 30-60 seconds after birth, every newborn requires the initial steps of newborn care
as stated above. However; if the newborn is not breathing or breathing with difficulty or is
cyanotic by 60 seconds, ventilation with bag and mask should be initiated immediately. The
steps in newborn resuscitation include
Resuscitation using bag and mask:

 Place the newborn on his/her back on a clean, warm surface and keep covered except
for the face and chest.
 Position the head in a slightly extended position to open the airway.
 Clear the airway by suctioning the mouth first and then the nose.
 Place the mask on the baby‘s face so that it covers the chin, mouth and nose.
 Squeeze the bag with two fingers only or with the whole hand, depending on the size of
the bag.
 If the baby‘s chest is rising, ventilate at a rate of 40 breaths per minute, and observe the
chest for an easy rise and fall.
 Ventilate for 1 minute then quickly assess the baby for spontaneous breathing and
color; if breathing is normal and the heart beat is more than 100 bpm, stop ventilating,
give to mother and continue to monitor.
 If the baby is not breathing after 1 minute or is not breathing well, call for help and
improve ventilation (reposition the head, suction and open the mouth, reapply the
mask).
 If the baby‘s heart rate is normal but breathing is less than 30 breaths per minute or
irregular, continue to ventilate for 3-5 minutes until the baby is breathing well; stop
ventilating and monitor baby with mother.
 If the baby is not breathing and the heart rate is normal or slows (less than 80 bpm),
continue ventilation with oxygen if available, organize transfer and refer baby to a
tertiary care centre, if possible.
 If there is no gasping or breathing at all after 20 minutes of ventilation, stop ventilating,
provide emotional support to mother and family.
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Figure 17: Help Baby to Breath (Birth/ Neonatal Resuscitation Measures): Post
resuscitation care
Babies who have required ventilation must be carefully observed, as they are at risk for having
more complications, even after their vital signs have returned to normal. The longer a baby has
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been without breathing spontaneously (apneic), the longer s/he may take to return to a healthy
state.
Care after successful resuscitation: -
• Prevent heat loss:
 Keep the baby skin-to-skin with the mother until the newborn‘s condition is stable.
 Alternatively, place the newborn under a radiant heater.
• Monitor the baby‘s respiratory rate every 15 minutes and observe for other signs of
illness. If signs of breathing difficulties recur or the newborn appears sick, arrange
to transfer the newborn to the most appropriate service for the care of sick newborns.
• Measure the newborn‘s body temperature: If the temperature is less than 36°C,
rewarm the newborn.
• Encourage the mother to begin breastfeeding. A newborn that required resuscitation is at
higher risk of developing hypoglycemia.
Table 28: Immediate new born problem, care and management

Ask, check Look and Sign Classify Treatment
record listen
Is the infant  Is baby  Not breathing Birth Start resuscitation (see to Helping Babies
having not or asphyxia Breathe figure in previous page):
difficulty breathing?  Gasping or  If meconium is present, clear the airway
breathing?  Is baby  Breathing with a suction bulb
gasping? poorly (less  Rub the baby‘s back or foot gently for ten
 Count the than 30 per seconds to stimulate
breaths in minute)  Position the newborn
one  Ventilation using appropriate size mask
minute /self-inflating bag
 Strong cry or No birth  Dry the infant and cover with a warm, dry
 Breathing asphyxia cloth
more than 30  Provide cord care
per minute  Provide eye care
 Give vitamin K, 1mg IM on upper outer
thigh
 Initiate skin-to-skin contact
 Initiate exclusive breastfeeding
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Is the infant  Umbilical  Active Bleeding  Secure umbilical cord for visible bleeding
bleeding stump bleeding from  Vitamin K 1mg IM once if not previously
from the bleeding umbilicus or given
umbilical  Pallor  Sign of shock  Ensure warmth
cord?  Perform blood group/Rh and hemoglobin if
possible
 Refer if bleeding does not stop
 Weight Very Low  Continue with expressed breastfeeding
Gestational  Weigh <1500gm birth  Give vitamin K 0.5mg IM mid-thigh
age the baby  Gestational weight or  Refer urgently
age <32 wks preterm
Weight 1500 to Low birth  Educate mother and initiate Kangaroo
<2500gm OR weight or Mother Care(if less than 2000 gm)
Gestational age preterm  Counsel on optimal breastfeeding
32 -36 weeks  Counsel on prevention of infection
 Give vitamin K 1mg IM on upper outer
thigh
Chapter 2 summary
 Interventions to reduce MTCT of HIV during L&D should be maximized since majority of the
transmissions of HIV occur during this period.
 Using proper infection prevention practices while attending L&D prevents HIV infection to
mothers, newborns, and health care providers.
 Mothers should have access to testing and counseling services during L&D to have an
opportunity for PMTCT services.
 Every health facility with PMTCT services should have ARV drugs available for PMTCT to
improve adherence and significantly reduce MTCT of HIV.
 Always record PMTCT-related information to ensure continuity of care.
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CHAPTER 3: PMTCT IN PNC SETTINGS
Time Allocated: 480 Minutes
Chapter description:
This chapter is designed to equip participants with necessary knowledge and skills on
management of PMTCT intervention in PNC setting
Chapter Objective
By the end of this chapter, participants will be able to
 Integrate HIV comprehensive services in PNC routine care

 Explain care provision during the first 24 hours
 Describe interventions to be provided after the first 24 hours
 Describe FP integration interventions in PNC routine care
Chapter outline
3.1 Overview of the comprehensive post-natal care in the context of HIV
3.2 PMTCT during the first 24 hours
3.3 Newborn care after the first 24 hours
3.4 Family planning counselling in the context of HIV positive women at
PNC settings
3.1: OVERVIEW OF POST-NATAL CARE IN THE CONTEXT OF HIV

Time Allocated - 90 Minutes
Enabling Objective:
By the end of this session, the participants will be
able to: -
 Describe the general concept of intervention to reduce the risk of MTCT in PNC
 Explain the value of integrating HIV care into Post-natal services
 Describe the importance of continuing male partner involvement in PNC setting
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3.1.1 Interventions to reduce the risk of MTCT of HIV during postnatal
period
Pair, Think, Share Exercises
What are the key interventions to reduce the
risk of MTCT of HIV in post-natal care?
Time 3 min
Interventions to reduce the risk of MTCT of HIV during breastfeeding

have two approaches.
A) Reducing exposure of the infant to the virus by:
- ARVs dual prophylaxis for HEIs
- Using a safer infant feeding option. (Exclusive breast feeding (EBF) for the first six
months, including avoid mixed feeding, and early weaning) )
- Aggressively treating oral problems in the infant who is breastfeeding.
- Reinforcement of safe sexual practice and need for dual protection
- Close monitoring for secondary postpartum hemorrhage, which may be more
dangerous
- Early recognition and treatment of infections, including urinary tract infection,
reproductive tract, or obstetric infections (wound infection from C/S or
episiotomy/laceration repair), mastitis and breast abscess and respiratory infection
- Counseling about safe disposal of potentially infectious soiled sanitary pads or other
garments
- Preventing HIV infection in breastfeeding women and their partners.

B) Reducing HIV viral load in breast milk by:
- Providing ART to HIV positive women and ensure viral suppression
- Preventing and aggressively treating cracked nipple and breast infection and any co-
infections in the mother
- Counseling on how to express breast milk in case of engorgement or breast health
problems. Refer if situation is unresolved and use the breast that is not swollen to feed
the baby and seek medical help before it gets worse.
- Reducing factors that lead to progression of HIV-infection in the mother.
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3.1.2 Integrating HIV care into outpatient postnatal services
Individual Reflection
 What are focus areas during postnatal follow-up period?
 What is the appropriate attitude of health care providers towards their
clients in postnatal care services?
Time: 4 minutes
Provision of integrating HIV services, both for the HIV infected mother and HEIs ensures
maximization of HIV services to herself, the exposed infants, and the male partner at single
visits as one shop of services. Traditionally the postnatal period is the period up to 6 weeks
after birth. There are "crucial" moments when contact with the health system/informed
caregiver could be instrumental / Vigilant in identifying and responding to needs and
complications in postnatal women and their babies.
Focus areas during post-natal period
 HIV care and family planning services should be integrated into routine postnatal care.
 If this is not possible, linkages should be developed so that the woman will receive
follow-up of HIV care and family planning services when she needs them.
 Women should be encouraged to return with their babies for routine postnatal follow-up
visits at the 3rd day, the 6th-7th day and at 6 weeks.
 Women and newborns that develop problems need to be assessed and treated as soon as
possible.
 Encourage them to visit HFs more often if they have any concerns, questions, or health
problems. Women need to understand the importance of continued care.
 Women, who give birth at home, should be encouraged to go/return to the health facility
as soon as possible after childbirth within 24 hours.
 Women who give birth at the health facility need to know when to return before
beingdischarged.
 Integration of services support most postnatal women in receiving comprehensive
routine maternal and HIV care at a single visit, and at a single point of care (ensures
principles of one stop shopping services).
 When possible, postnatal visits should be coordinated with infant follow-up visits. This
could prevent delays or missing of receiving essential care, shorten waiting time during
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each follow up visit, and ensure more coordinated care.
 Some discrimination still exists against HIV-positive individuals in deciding to have
children. Health workers caring for HIV-positive persons need to be sensitive to their
own prejudices and be careful to show a caring, motivating, competent,
compassionate, respectful, and non- judgmental attitude.
3.1.3 Male involvement in PMTCT during postnatal period
Individual reflection Exercise

Why is it important to involve male partner during postnatal
period?
Time: 3 Minutes
Efforts towards preventing mother-to-child transmission (PMTCT) of HIV should be as

comprehensive as possible and recognize and support the active involvement of male
partners in PMTCT services. Whenever possible, encourage couples to attend postnatal
care visits together and emphasize the following:
- Male Partners need to be aware of the importance of safer sex practices throughout
pregnancy and breastfeeding.
- Recommend HIV testing and counseling for the woman and her partner.
- Encourage and support assisted active partner disclosure and notifications
- Encourage couple counseling and mutual disclosure.
- Inform both men and women about the risks of MTCT of HIV and services
available to reduce these risks.
Experience in many settings shows that when a male partner is
involved and informed, the woman is more likely to be able to:
- Participate, access, and utilize or actively involved in PMTCT interventions,
including correct and consistent use of condoms during pregnancy and
breastfeeding
- Seek and receive maternal, HEIs care and comprehensive HIV services
- Adhere to her safe infant feeding choice and to routine maternal and HEIs care
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- Able to enroll herself or her partner/s into PrEP.
3. 2: PMTCT DURING THE FIRST 24HOURS OF CHILDBIRTH

Time Allotted 140 Minutes
Enabling Objectives
By the end of this session, participants will be able to: -
- Assess, classify, and treat postnatal women

- Counsel and Offer HIV testing services to postnatal
women and her partner
- Describe postnatal care in the context of HIV
- Describe postnatal care in the context of HBV
- Respond to other observed signs and volunteered
problems in the postnatal period
3.2.1 Assess, classify, and treat the postnatal woman and new born
The postnatal woman should be encouraged to have routine follow up visits in the 1stweek
and at 6 weeks after birth. She should also routinely be counseled on when to seek care
urgently if she or the newborn experiences danger signs. A complete assessment of the
woman and newborn baby should be performed at every postnatal visit.
At each postnatal visit:
1. Check for danger signs.
What are the danger signs during postnatal Period?
Time 2minutes
The general principle of emergency check during postnatal period is the same as during
pregnancy, though some of the emergency conditions in postnatal woman are different from
pregnant women.
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Table 29: Maternal and New-born emergencies
2. Perform postnatal assessment of the woman.

Ask the woman:
- When and where did you give birth?
- How are you feeling?
- Have you had any pain or fever or bleeding since delivery?
- Do you have any problem with passing urine?
- How do your breasts feel?
- How is breastfeeding going?
- Do you have any other concerns?
- Have you discussed family planning with your partner? Have you decided on a
family planning method?
- Have you been tested for HIV before? What were the results?
- Have you been tested for HBV before? What was the result
- Has your partner been tested for HIV? What were the results?
Check records:
- Any complications during pregnancy or delivery?
- HIV status.
- Receiving any treatments, including ART, HBV prophylaxis or treatment?
196
Look, listen, feel:
- Measure blood pressure, pulse, and temperature.
- Look for conjunctival and palmar pallor.
- Look and palpate the woman‘s legs(calves)
- Examine and palpate her breasts
- Feel the uterus:
 Is it hard and round?
- Look at vulva and perineum for:
 cleanliness
 laceration
 swelling
 pus
- Look at pad for bleeding and lochia.
 Does it smell? Is it profuse?
- Ask the woman to feed her baby and assess the feeding, if applicable.
- Ask about and record any medications the woman is on, including ARV drugs.
Give preventive services, advice, and counsel.
There are several measures that should be followed for all postnatal women and some
that will apply to HIV-positive women only.
To all post-natal women, recommend preventive measures, advice, and
counsel
- Encourage couple visit and counseling session.
- Give tetanus toxoid, if due.
- Continue provision of iron/folic acid 1 tablet daily; counsel on adherence and safety
and advice to take the tablets with meal, at night if a once per day dose
- Provide advice and counsel on nutrition and self-care.
- Advise on breast care and for the woman to return immediately if she has any
breast- or breast-feeding problems.
- Advise to stop smoking and avoid alcohol, harmful use of drugs if applicable.
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- Encourage (mother and newborn) sleeping under insecticide-treated bed net (ITN)If
malaria endemic region.
- Counsel on family planning; provide method of the woman‘s choice.
- Offer HIV testing for postnatal women encourage and support partner disclosure and
HIV testing and counseling, if not already done.
Table 30: Routine postpartum care contact

Visit Time
Every woman should be at the health facility for 24hours after delivery
First Contact 3 days (2-3 days)
Second Contact 6-7 days
Third Contact 6 weeks
N.B Encourage woman to bring her partner or family member to at least one
contact
3.2.2 HIV Testing Services (HTS) in postnatal care service
Think Pair Share

1. What would you check about HIV for postnatal women during
PNC?
2. What would you check if she has been tested and is HIV-positive?
3. What would check if she has been tested HIV test negative?
4. What would you do/advise if she has not been tested?
Time 10 minutes
For all postnatal women coming for follow up contact :

Check HIV status:
Check the woman‘s facility record to see if she has been tested for HIV and if the test result
is recorded on the woman‘s maternal card.
And ask the woman:
o Have you had HIV testing and counseling? When? What was the result?
1. If she has been tested and is HIV-positive:

Check the woman‘s record and ask her:
198
- Are you taking any ARV drug?
 If she is on ART, which ARV drugs is she taking? When did she start taking
ART, status of viral load ?
- Assess, counsel and support adherence to ART.
2. If she has been tested HIV-negative:
- Check to see when the woman was tested for HIV and discuss risks of HIV exposure
since the last test (if recent exposure).
- Ask whether she feels confident that she had not been exposed to HIV during the 6
weeks‘ period just prior to the test, or after the test. If there are potential risks for HIV
exposure, in window period or after the test is done, recommend provision of retest
HIV testing and counseling.
3. If she has not been tested:

Offer and recommend HIV testing and counseling as soon as possible.
In all situations,
 Recommend assisted active partner disclosure and partner testing if not already done.
 Recommend couples testing, as appropriate for the woman‘s situation.
 Remind her that even if one partner is HIV-positive, the other may not be. It is
important that both partners are tested.
HIV positive women partner and other family members (All partners &
biological children less than 19 years old) should be strongly addressed for
HTS accordingly using family matrix.
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3.2.3 Postnatal care in the context of HIV infection and for all postnatal
women
Postnatal care for HIV-positive woman includes basic postnatal services recommended for
all postnatal women, PLUS special interventions for the woman's own health and to prevent
mother-to-child transmission (PMTCT) of HIV.
The following healthy practices are necessary for all postnatal women:
- Counseling and support for safe breastfeeding practices.
- To eat two extra variety meal than usual and rest more in the postnatal period and
while breastfeeding.
- To take special care of personal hygiene to prevent infections.
- To be supported to engage in healthy behavior (primary prevention), obtain the
postnatal care they need (care seeking to improve their own health (adherence to
treatment) and that of their baby. These in-turn will reduce some of the risks of
maternal and newborn complications.
- To be supported to know their HIV status by recommending testing and
counseling if it is not yet done.
- To be counseled about family planning options and provided with the method
they choose so they can prevent unintended pregnancies.
- To know how to reduce the risks of acquiring or transmitting HIV infection or other
sexually transmitted infections.
- To be counseled on personal risk reduction, consistent and correct use of condom and
safer sex practices.
- To be supported and encouraged for assisted active partner disclosure and partner
testing including siblings.
All postnatal women, their partner and family, and community members must also know
the danger signs that may arise after childbirth so that help can be sought early and from
the most appropriate place. She also needs to know when to bring her baby in for care if
necessary, between regular visits.
- Maternal : bleeding, fever, foul smelling discharge, abdominal pain, and convulsion
and including
- Newborn: convulsion, abnormal breathing, low or high temperature and bleeding
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Group work Case study 1
W/ro‖ B‖ is 20 years old woman comes to the clinic 24 hours after home
delivery at 38 weeks of gestation. She comes today, because she heard
about ―some medicine ―to prevent the transmission of HIV to her baby.
W/ro‖ B‖ is HIV-positive but did not receive any ARVs during pregnancy
or childbirth.
The baby is exclusively breastfeeding.
The HCWs checked for emergency signs, performed examination, and
classified W/ro‖ B‖ as normal postnatal period. The HCWs recorded that
the clinical review is normal. The baby weighs 3.5kg.
What else would you check about HIV?
The HCWs checked the ANC register and maternal card and noted that
W/ro‖ B‖ had one ANC visit, when tested HIV- positive at 20 weeks of
gestation. She was WHO clinical stage I and her CD4 count was 400
W/ro‖ B‖ didn‘t return for subsequent follow ups and didn't receive ARV
drugs.
Question
How would you manage W/ro‖ B‖ and her baby today?
Time: 10 min
Group work: Case study 2

W/ro ―A‖ is 25 years old woman. She gave birth 4 days ago in
your clinic at 39 weeks of gestation. She has regular follow-up
visits at the HIV clinic and was referred at 20 weeks of gestation
for antenatal care. She has been taking TDF-3TC-DTG for the last
1 years. W/ro ―A‖ is exclusively breastfeeding. She comes today
for follow-up care with her husband who is also HIV-positive.
Questions
How would you manage W/ro ―A‖ and her baby today?
What else would you discuss about HIV care with W/ro ―A‖, her
baby and partner?
Time 10 min
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3.2.4 Provide additional care for HIV-positive postnatal women
What is the benefit of ART provision for HIV positive postnatal
women?
Time 2 minutes
HIV-positive postnatal women need care in addition to the routine postnatal care
provided to all women.
Provision of ART for HIV positive postnatal women can influence disease progression,
HIV viral load, and CD4 counts, all of which influence MTCT of HIV and improves
maternal well-being.
Perform clinical review and WHO staging during each postnatal visit of HIV-positive
woman. The WHO Clinical staging and prophylaxis against OIs are the same for postnatal
women as for HIV-positive adults.
Check if the postnatal woman is on ART
Is the woman on ART or not? If so, look at the regimen and dosage that she is on. Review the
facility register (ANC, and labor and delivery registers) and her HIV care/ART follow-up
form.
1. If the woman is on ART:
- Assess and respond to new signs and symptoms, including ARV drug side-
effects.
- Review the medication with the woman and her treatment supporter if she has
one. Determine if there is an adherence problem, and if there is, address it.
- Ask questions in a respectful, Compassionate, and non-judgmental way that
makes it easier for the woman to answer truth fully.
- Adherence may be difficult in the postnatal period due to physical changes, the
demands of caring for the baby, anxiety related to transmission of HIV to the
baby, or postnatal depression, so the postnatal woman might need extra
adherence support.
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2. If the woman is NOT on ART during the visit:
- Retest at the initiation of ART
- Do clinical staging and CD4 count, where available for baseline.
- Initiate ART immediately after adherence counselling
- Provide continuous adherence counseling and support.
- Screen for OIs at each facility visit.
For all HIV-positive postnatal women:
- Assess TB status during each visit. (Current cough, weight loss, night sweat and
fever)
- Provide chronic HIV care and ensure the woman and her baby continue to receive
care.
- If services are provided at different points of care, coordinate timing of visits as
possible. For example, coordinate visits for postnatal care, HIV care for the woman,
her infant, and partner, and TB care if needed.
- Check if the woman is already on co-trimoxazole prophylaxis. Continue or initiate
co-trimoxazole, if eligible.
- Initiate TPT prophylaxis after excluding active TB (follow the national guideline).
Respond to observed signs and volunteered problems:
- If elevated diastolic blood pressure, give appropriate antihypertensive and refer
urgently to hospital.
- If pallor, check for anemia. If on AZT and has severe anemia (Hgb <7 gm/dl),
discontinue AZT, and change AZT to TDF if on ART. Manage the anemia.
- Advise on safer sex practices and consistent and correct use of condoms to prevent
STIs, including HIV.
- A new HIV infection in a breastfeeding mother increases the risks of MTCT of HIV
due to the high viral load associated with new infection.
- Provide condoms and instruct on correct and consistent use. Many women may
need help preparing to talk with their partners about STI protection, how to use
condoms and safe sex practices.
- Advise the woman that lochia can cause infection in other people and therefore
blood-stained pads/clothes should be disposed safely (IPC Measures).
- Advise when to return to the facility: Advise the woman that she and her baby will
need to return for subsequent postnatal visit in 4-6 weeks.
- Advise on danger signs and when and where to seek medical care urgently.
- Manage breast and breastfeeding problems and any other acute and chronic
problems.
- If a woman is on ART and develops new signs and symptoms: Differentiate
between complications/common problems in the postnatal period and HIV-related
illnesses, ARV drug side-effects, and immune reconstitution syndrome (IRIS).
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- Provide acute care for OIs and other HIV-related conditions, malaria, and manage
drug side-effects as required.
- Advise the postnatal woman to seek care early for any danger signs and infections,
including malaria, TB, or other infections, and STIs. This will help to keep the
mother healthy and provide appropriate care for the baby.
- At the end of the postnatal follow up visits, refer the HIV-positive woman (for
continued HIV care) where she could continue to get HIV care, treatment,
prevention, and support services.
- Provide counseling on family planning or refer to where she goes for counseling.
- Encourage and support the HIV-positive woman on her infant feeding choice. If the
baby is exclusively breast feeding: Arrange for further counseling to prepare for
complementary infant feeding from 6 months of age onwards.
- Provide psychosocial support: Like all persons in chronic care, PLHIV need
continued support and care. This may include counseling and support for both
adherences to medications and for retention in care so that she continues to come
back to the clinic for services.
- An HIV-positive postnatal woman might need additional support if she is
experiencing postnatal depression and is anxious about the HIV status of her baby
and issues surrounding infant feeding. Therefore, encourage her to disclose her HIV
status to family members, her partner, or friends so that she can continue to receive
support at home. Support the woman's infant feeding choice, and advise her on the
importance of HIV care, co-trimoxazole prophylaxis, and HIV testing for her baby.
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3.3: NEWBORN CARE THE FIRST 24 HOURS
Time allocated 160 minutes
Enabling Objective:
By the end of this session, the participants will be
able to-
- Provide routine newborn care
- Provide care for HIV-exposed infants
- Identify HIV-infected infants early
- Describe the guiding principles for safer infant
feeding
3.3.1 Routine newborn care

All newborns should be followed at the health facility for the first 24 hours.
Routine follow-up care for all newborns is recommended at 3rd, 6-7th day,
and 6 weeks.
Provide care:
- Check maternal and newborn record or ask the mother:
 How old is the baby?
 Preterm (less than 37weeks)?
 Breech birth? Difficult birth?
 Resuscitated at birth? Has baby had convulsions?
- Ask the mother: Do you have concerns? How is the baby feeding?
– Assess feeding (for position of the mother, position the baby, breast attachment
and effective suckling)
– Weigh the baby (exercise on weight)
– Check the umbilical cord for bleeding or signs of infection
– Document the HIV status of the mother if known
– Immunize if due, according to national guidelines including HBV birth dose. The
immunization of asymptomatic HIV-infected infants is the same as with non-HIV
infected infants.
– Assess and respond immediately to manage any common problems.
– Always check all young infants for signs of very severe disease and local infection.
A young infant can become sick and die very quickly from serious bacterial
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infections such as pneumonia, sepsis, and meningitis.
– Encourage the mother to seek care immediately if the infant become sick, has
difficulty feeding, or if she suspects any problem.
W/O ―C‖ returned to the postnatal clinic today at 6 weeks after
childbirth. She is still taking ART, and her baby has completed 6
weeks of AZT + NVP. She is exclusively breastfeeding. W/O ―C‖
is worried that her baby might be HIV-infected.
Question
What do you recommend for the baby today? How would you
address W/O A concerns?
Time 10 min

Today W/O ―D‖ returned to the clinic with her baby. She requests
her baby (S) to be tested for HIV. Baby S is 6 weeks old. He is
exclusively breast feeding, and he completed 6weeks of AZT +
NVP. W/O ―D‖ is taking ART. Both, mother, and baby are doing
well. Their clinical review is normal.
Question
What would you recommend today?
Time 10 min
3.3.2 PROVIDE CARE FOR HIV-EXPOSED INFANTS
Infants born to HIV-positive women are called HIV-exposed infants, because

they are exposed to HIV during pregnancy, labor and delivery, or breast-
feeding. HIV- exposed infants may or may not be HIV-infected.
HIV-exposed infants are at increased risk of illness and failure to thrive, even if
they have received antiretroviral prophylaxis or their mother was on ART.
Regular assessment (routine and preventive child health care), early HIV
206
diagnosis and provision of care and treatment are key to ensuring optimal growth
and development−especially during the first 2 years of life.
Interventions
- Prevention of HIV infection in breast feeding women
- Safer infant feeding practices, exclusive breastfeeding for the first 6 months
- Introduce appropriate complementary feeding after 6 months and continue

breastfeeding as the general population.
- ARV prophylaxis to all infants born to HIV-positive women (HIV-exposed
infants), Dual prophylaxis: AZT and NVP. Prophylaxis syrups shall be started
within 1 hour of birth to the HEI. Provide AZT+NVP prophylaxis for the first 6
weeks and continue NVP for the next 6 weeks for a total of 12 weeks for all
HEI.
The best way to prevent breast milk transmission of HIV is by optimal maternal
treatment for the entire duration of exposure. However, infant prophylaxis also
serves for preventing postnatal transmission of HIV. The 2016 WHO ARV
Consolidated Guidelines recommendation a dual regimen of AZT and NVP
which can be extended for up to 12 weeks in breastfeeding infants deemed to be
at high risk of MTCT.
 Ethiopia opted for 12 weeks of prophylaxis: AZT/NVP for the first 6 weeks followed
by NVP alone for the next 6 weeks for all breastfeeding HIV-exposed infants.
 To implement the new recommendation in Ethiopia, key areas (risk stratification,
regimens and formulation and programmatic considerations) were assessed
 Experience of other different countries like Kenya implementation success and
challenge assessed
 The chosen approach includes 6 weeks of AZT &NVP dual therapy, followed by 6
weeks more of NVP alone Because:-
 EDHS 2016 indicates that only 20% of women had their first ANC during the first
trimester
 Most of pregnant women book ANC in 2nd trimester or later
 Risk assessment process (high Vs low) confuses health care providers
 VL access improved but still a problem for pregnant women only 1000 (4%) done
So considering all HEI as risk for ease of regimen standardization
207
Note: Care for children born to HIV-positive women includes routine newborn
care, the same as for non-HIV-exposed infants, and additional care specific for
HIV- exposed infants.
Counselling for HEI ARV prophylaxis
The mother, father, and family members (based on the choice of the mother) will need
careful information and assistance to ensure that the newborn receives the complete
prescribed course of prophylaxis.
When working with mothers and families provide the following information to ensure
adherence to newborn ARV regimen:
– Reasons forgiving ARVs to the newborn: The ARV drugs will reduce risks of
transmission of HIV and completing the entire course of ARVs regimen is
important.
– Explain how to give the syrup. Observe them giving the ARV syrup before
discharge from the maternity facility.
– Respond to any questions and concerns the mother might have about the
newborn ARV regimen.
– Recognize and manage any side-effects.
– Carefully explain the difference between an HIV-exposed infant and an HIV- infected
infant and the importance of regular follow-up visits, age-appropriate HIV testing, and
co-trimoxazole prophylaxis.
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Table 31: Dosage of NVP and AZT syrup for different age groups
Infant age NVP daily dosing Dose in ml AZT daily dose Daily dose in ml
Birth to 6 weeks
Birthweight 2mg/kg 0.2ml/kg 2mg/kg 0.2ml/kg
<2000g daily once once daily twice daily twice daily
Birth weight: 2000- 10 mg 1ml 10mg 1ml
2499g once daily once daily twice daily twice daily
Birth weight 15mg 1.5ml 15mg 1.5ml
>2500 g once daily once daily twice daily twice daily
Age 6 weeks to 12 weeks
Age 6 weeks to 12 20 mg 2ml once daily
weeks once daily or half a 50mg
tablet once daily
Ensure follow-up care of HIV-exposed infants

ARV prophylaxis and other PMTCT interventions reduce the risk of MTCT of HIV, but do
not eliminate it entirely. Thus, staff of maternal and childcare services should identify or
develop services that provide follow-up care and early HIV diagnostic services for HIV-
exposed infants. Arrange for regular follow-up at appropriate settings i.e., ANC & PNC for
all HIV-exposed infants.
Follow-up schedule: In 3 days (3-4 days), (6-7 days), 6 weeks, then monthly for 6
months, then every 3 months until HIV infection is excluded. But also advise the mother to
bring the infant at any time, if there are new signs and symptoms. HIV-exposed infants with
health problems may need more frequent follow-up visits than other infants.
Actions during follow-up visits include the following:
For the mother:
- Do clinical assessments at each visit and reclassify the mother‘s clinical stage if
appropriate.
- Counsel about safer infant feeding practices. Counsel about exclusive breast feeding
- Counsel the mother about her own health (including screening breast for lump and
cervical cancer) and arrange for her continued HIV care and treatment.
Provide routine infant care: This includes
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(1)Monitoring growth and development.
(2) Provide all vaccines including HBV birthing dose according to the national immunization
schedule but avoid live vaccines, e.g., BCG, for symptomatic HIV- infected children; and
(3) Providing vitamin supplements every 6 months beginning at 6 months of age.
Table 32: Immunization schedule for HIV exposed infant

Immunization schedule for infants and children recommended by the
WHO Expanded Program on Immunization
Vaccine Age
Birth 6 10 14wee 9m 15m
BCG X
Oral Polio X X X X
HBV birth dose vaccine X
DPT-HepB-Hib X X X
Pneumococcal vaccine X X X
Inactivated PV X
Rota X X
Measles X X
Infants with symptomatic HIV should not receive BCG vaccine.
Table 33: Follow up visit schedule for HIV exposed infants*

10weeks
14weeks
5months
6months
9months
12month
15month
18month
6weeks
Atbirth
Ageinweeks/mo s
s
nths
History X x x X x X X x x x
Physicalexam X x x X x X X x x x
Growthassessment X x x X x X X x x X
Developmentalasses X x x X x X X x x X
sment
Infantfeedingcounse X x x X x X X x x X
ling
DeterminationofHI *DN Do DNAPCR ifthe testis
AP
Vstat CR
notdoneat6weeks**
Repeat DNA PCR at 9 months
for all HEI DNA PCR negative
at 6 weeks of age and
Do DNA PCR test at any time
if the child is sick (sign and
210
symptoms suggestive of HIV
infection) with negative test
result at 6 weeks
ARV (AZT+ NVP) X

for the first 6 weeks
ARV (NVP alone) X X
for additional 6
weeks
CPT X ContinueuntilHIVisexcluded,andinfantisnolongeratriskfrombr
eastfeeding
TBRiskAssessmen At eachvisit
t
Immunizations X X x x x X
Adherencecounselin X X x x X X x X x X
g
*Thisistheminimum;childrenshouldbeseenmorefrequentlyifclinicallyindicated.
* if the first DNAPCRtestispositive, collect sample for confirmation and start ART
**Iftheinfantisbetween9-12months,firstdoAntibodytestandifpositivedoDBSforDNA
Co-trimoxazole Preventive Therapy (CPT) for HEI

Using pediatric co-trimoxazole in all HIV exposed infants significantly reduces
the rate of PCP and other bacterial infections and in turn reduces infant
morbidity and mortality rates.
- Offer co-trimoxazole prophylaxis at 6 weeks of age; monitor and support

adherence.
- Start co-trimoxazole at 6 weeks of age, or when the HIV-exposed infant is
first seen, if presents later.
- Continue co-trimoxazole prophylaxis if the infant is HIV-infected.
- Discontinue co-trimoxazole prophylaxis if HIV-infection is excluded and
child is no longer breastfeeding.
-
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Table 34: Dose of CTX for prevention of PCP in infants and children
Age Suspension Per Pediatric Single Double
5ml tablet Strength adult Strength
(200/40mg) (100/20mg) tablet adult tablet
(400/80mg) (800/160mg)
< 6mo 2.5 1 tablet 1/4 tablet --
ml
6 mo.- 5yrs 5 ml 2 tablets 1/2tablet --
6-14 yrs. 10 4 tablets 1 tablet 1/2tablet
ml
>14 yrs. -- -- 2 tablets 1 tablet
Provide special care for TB-exposed newborns

- Persons with HIV are at increased risk of having TB disease, due to the immune
suppression caused by HIV. An HIV-positive woman should be assessed for TB during
each visit to the health facility.
- If the mother is diagnosed pulmonary tuberculosis and started treatment less than 2
months before delivery or diagnosed after birth:
- Give the baby 5 mg/kg isoniazid (INH) orally once a day for 6 months to the baby.
- Do not give BCG vaccine at birth. Delay BCG vaccination until INH prophylaxis is
completed or repeat BCG after complete course of Isoniazid Preventive Therapy (IPT).
- Reassure the mother that it is safe to breastfeed the baby.
- Follow up the baby every 2 weeks, or according to national guidelines, to monitor
growth e.g., weight gain.
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Figure 18: HIV exposed children and HIV negative children and Adolescents <15years of
age with household exposure to PTB cases
Growth monitoring & developmental assessment

HIV exposed and HIV infected children need frequent monitoring of growth and development
to detect growth flattening and developmental abnormalities early enough before severe
manifestations occur. The occurrence of growth and developmental abnormality may be an
indication of HIV infection in HIV exposed infants or disease progression in those who are
HIV infected and possibly treatment failure in those who are on HAART.
Components of growth monitoring

- Measuring
 Weight
 Height/length
 Head circumference
- Plotting the measurement on gender appropriate growth curves interpreting the
finding on the growth chart
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To enhance accuracy of weight measurement:
- Use same scale at each visit
- Scales should be zero daily and calibrated weekly
- Infant scales should be used for children <20kg
- Remove all clothing including diaper
- Weigh infants supine and older infants sitting
- Record weight to the nearest 0.1kg
- Record measurement immediately
Measuring length/height
- For children 0-2 years of age measure length:
o Remove shoes when you measure length/height and use two people
o Keep the knees straight and ankles in neutral position when you measure
length
- For children ≥ 2 years of age measure height

o When you measure length, make sure the legs are close to each other and the
heels, the buttock and the back of the head touches the wall or are in straight
line. The child should look straight parallel to the floor.
o Place a ruler or a hard paper on top of the head to perpendicular to the wall to
take the measurement. If there is large hair press gently
o Record measurement of length/height to the nearest 0.5 cm
o Record measurement immediately
Measuring head circumference

Measuring head circumference is an indirect way of measuring brain growth.
HIV affects brain growth directly and is an important cause of acquired microcephaly in
children.
How to measure head circumference?
- Use a non-stretchable plasticized tape
- Place tape at the mid forehead and extend circumferentially to include most
prominent portion of occiput to obtain the greatest volume
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- Record measurement to the nearest 0.5 cm
- Record measurement immediately
Growth chart
A growth chart or curve is a graph that records changes in the child ‗s growth over time
compared to normative growth rates. It is a normative data on weight, height and head
circumference disaggregated by age and sex. Growth chart is an easy and systematic way to
follow CHANGES IN GROWTH OVER TIME for an individual child.
There are a number of growth charts that are used to follow growth of children. WHO
children Growth Charts and CDC Growth Curves are commonly used. These charts are
disaggregated by age and sex and include the following growth curves
Plotting Anthropometric measurements on growth charts (WHO GMC)

- Measure and weigh child using same methodology at each visit
- Using age and sex appropriate charts, plot measurement on the vertical axis against
age on the horizontal axis.
- Compare growth point with previous points
Interpretation of plotting on Growth curves

What is Z-score?
Z-score speak to the general population and address the question - what percentages of the
population are of the same weight and height?
- If a child is on the 0 Z-score for weight for age, it means that 50% of children of the
same age are heavier than this child and 50% weigh less than the child.
- If a child is on the -2 Z-score, the growth chart tells you that the child is small relative
to other children of the same age - 95% of children of the same age are heavier
- If someone is on the +2-Z-score, they are generally a little bit fat. They weigh more
than 95% of children their age.
Refer the Annex3.4WHO Growth chart (Wt/age, Ht or Length/ Age & HC
Assessment of development
Development: pertains to acquisition of various functions and skills with a gradual
change from simple to complex. These spheres of development include language,
psychosocial, fine, and gross motor skills and cognition.
215
Delayed development or loss of milestones may be the first sign of HIV infection in an
infant or young child
- While other causes are possible, abnormal development should raise concerns of
HIV infection
- Infants are at high risk for HIV encephalopathy and severe neurologic disease
- The assessment should include Cognitive, Motor, Language, and Social skills.
How do you assess development?

- Ask
o Parental report on milestones achieved
- Observation
o 12-month-old walks into the examining room, 6-month-old sitting upright in
mothers‘ arms
- Examination
o Neurologic exam, hearing, and vision screen
- Look for Warning signs/red Flags
o early warning signs developmental milestones and interpretation
216
Table 35: Normal Development Milestones
Age Milestones
1 month Turns head when prone, responds to sound, follows moving object
2 months Raises head slightly further when prone and head sustained in plane of body on ventral
suspension, follows moving object 180 degrees, smiles socially, listen to voice and coos
3 months Lifts head and chest when prone; head above plane of body on ventral suspension;
sustained social contact; listen to music; says ―aah,ngah‖
4 months No head lag on pull to sitting position; head steady; reaches and grasps objects and
bring them to mouth, laughs out loud,
5 months Rolls over from stomach to back; imitates speech sounds e.g. makes razzing sounds,
reacts differently to strangers
6 months Sits unsupported briefly, transfers objects from one hand to the other, babbles, reaches
for familiar persons
9 months Pulls to stand, uses finger and thumb to pick up small objects, waves bye-bye, says
mama
12 months Walks with one hand held; imitates actions; releases object to other person on request, a
few words besides ―mama,‖ ―dada‖
15 months Walks alone; crawls upstairs; makes a tower of 3 cubes; follow simple commands; may
name a familiar object
18 months Runs stiffly; walks up stair with one hand held; imitates scribbling; feeds self; uses 10
words; identifies one or more parts of the body
2 years Runs well; walks up and down stairs; circular scribbling; put three words together; often
tells immediate experience
3 years Rides tricycle; stands momentarily on one foot; copies a circle; imitate a cross; knows
age and sex; helps in dressing; washes hands; speech is understandable
4 years Hops on one foot; climbs well; draws a person; tells a story; plays with several children
5 years Skips alternating feet; dresses and undress; names 4 colors; jumps over low obstacles;
ask questions about meaning of words
Source: Nelson Textbook of Pediatrics 17th edition 2004
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Table 36: Abnormal development that shows delayed acquisition of milestones
AGE WARNING SIGNS/Red flags
1 month Does not regard face, no eye contact,, poor suck, floppy
Does not look at you with both eyes at least for a few moments,
2 months
and does not follow with eyes ifyou move your face slowly from
side to side
3 months Does not respond to sound by quieting, no smile
4 months Does not hold head steady for a few moments when you sit him up,
5 months Does not raise head and support weight on arms when in prone
6 months Cannot reach for objects with both hands, Floppy, no response
to sound, Poor social response to people
9 months Unable to sit unsupported,
12monthsmo Unable to bear weight on legs
15 months Does not walk alone, is not using at least one word meaningfully
18 months Does not use at least 3 words, and does not point to what he wants
Individual Exercise
Measuring & labeling weight and height on growth chart
Your facilitator will introduce you to the growth chart of both boys and girls and demonstrate
how to label the weight on to the chart corresponding to the age of the child. You also learn
how to interpret the labeled chart and advise mother/caretaker in line with the weight chart.
Weighing infant:
1. What is the initial step when weighing an infant?
2. What is the second step when weighing an infant?
3. Suppose the available weighing scale is adult type only, what do you do to
know the weight of the infant
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3.3.3 Provide counseling and support on safer infant feeding
All HIV-positive women should receive counseling on infant feeding options as part of
antenatal and postnatal care.
Breast feeding mothers need to know:
- Which breast feeding practices and for how long
o Mothers known to be HIV-infected (HIV exposed infant) should
exclusively breastfeed their infants for the first 6 months of life, introducing
appropriate complementary foods thereafter, and continue breastfeeding as the
general population
o They should take appropriate ARV therapy for themselves and their infants.
o Breastfeeding should then only stop once a nutritionally adequate and safe
diet without breast milk can be provided.
o Mothers who are HIV-negative or of unknown status should

exclusively breastfeed their infants for the first 6 months of life, introducing
appropriate complementary foods thereafter, and continue breastfeeding for
2 years or beyond.
- What to do when a mother decides to stop breastfeeding
o Mothers known to be HIV-positive who decide to stop breast feeding at any
time should stop gradually within one month.
o Stopping breastfeeding abruptly is not advisable.
o When an HIV-positive mother decides to stop breastfeeding at any time, provide
infants with safe, adequate replacement feeds to enable normal growth and
development. All children need complementaryfoodsfrom6 months of age.
In Special Circiumestances , breastfeeding include:
- For infants less than 6 months of age:
o Commercial infant formula milk (As ERFs)
o Home-modified animal milk is not recommended as replacement food before the

first one year.
For children over 6 months of age:

- Commercial infant formula milk
- Meals, including milk-only, other foods and combination of milk and other foods,
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should be provided 4 or 5 times per day.
Key Messages on Optimal Breastfeeding Practices

1. Initiate breastfeeding within the first hour after birth
2. Give colostrum—the first ―natural immunization‖ for the baby
3. Breastfeed on demand, day, and night.
4. Exclusively breast fed until the baby is six months old (exclusive breastfeeding—not
even water—except medications, vitamins, and oral rehydration salts (ORS). Never offer
water, liquids, milk, or foods in breast milk in the first six months as it irritates the gut
and may lead to an increased risk of virus transmission.
5. Start complementary feeding at six months**
6. Practice proper positioning and attachment
7. Seek medical attention if there is a breast problem
8. Mother needs to take two additional meals from locally available food types.
9. Mother needs to take iron and iodized salt.
10. HIV-infected mother needs regular follow-up.
**Complementary feeding should be initiated at six months, and breastfeeding can be
continuing until 12-24 months.
Support mothers to practice proper positioning and attachment
Proper positioning and attachment are critical for safer breastfeeding practices in HIV-infected
infants. Incorrect positioning and attachment can result in nipple cracks and mastitis, which are
associated with increased viral load in the breast milk which in turn will increase the chance of
HIV transmission to the baby. Show proper positioning and attachment
Key Points for Proper Positioning in Breastfeeding

The Mother:
1. Sitting straight with her back supported
2. Relaxed and comfortable position
3. Supported using pillows under the arm or stool for the legs
4. Breast well-supported with her fingers away from the nipple
5. Her fingers against her chest wall below the breast
• Fingers supporting the breast
• Thumb above the breast
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• Fingers not too near the nipple
Positioning: ( Key Points)
1. Head and body in line
2. Held close to the mother‘s body
3. Whole body supported
4. Facing the mother‘s breast
Proper Attachment (Key Points)
1. More areolae should be seen above the baby‘s top lip.
2. Mouth should open wide.
3. Lower lips should be turned outwards.
4. Baby should approach breast, nose to nipple with the chin touching the breast.
Results of poor attachment
 Painful nipples
 Damaged nipples
 Engorgement
 Baby unsatisfied and cries a lot
 Baby feeds frequently and for a long time
 Decreased milk production
 Baby fails to gain weight
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Lying position—this is useful
for nighttime feeding and
when the mother is sick(post-
op).
Sitting position—mother should be

relaxed, with her back supported and
bringing the baby to her breast, not the
breast to the baby.
Figure 19: Breast feeding Positions
222
3.3.4. Testing for HIV-exposed infant
Recommend and agree on HIV testing for the HIV-exposed newborn. Early
diagnosis of HIV infection allows timely initiation of ART. Therefore, recommend and
encourage parents/guardians to have their babies tested for HIV at 6 weeks of age or at first
health care contact thereafter for:
- All children born to HIV-positive woman, breastfeeding from an HIV-positive woman
- All sick children in generalized epidemics where the mother's HIV status is not
known, or the mother is HIV-positive.
There are different kinds of HIV tests, and it is important to understand and be able
to explain to the mother what the different test results mean. Refer to your national guidelines
for infant testing options. Wherever available, dry blood spot (DBS) allows early testing
including those residing in the peripheral locations.
HIV virological tests
HIV virological tests such as DNA or RNA PCR detect the virus itself. The virological
test is done from the age of 6 weeks. It is also used as a confirmatory test for HIV for
children below 18months.
.It is important, to inform the mother early on that infant HIV testing services are available
and when the infant should be tested. Because HIV progresses rapidly in infants and
children, early diagnosis of HIV infection is crucial and Timely interventions in infants are
life- saving. (Refer to annex 3.2: Use of Dried Blood Spots (DBS) for DNA PCR)
HIV antibody (serological) tests

Serological HIV antibody tests including rapid tests detect antibodies, not the virus itself.
Babies of infected mothers are born with antibodies in their blood that have passed from the
mother during pregnancy. During the first months of life, maternal HIV antibodies cannot
be distinguished from those that the infant may have produced. Maternal antibodies can
persist in the child until the age of18 months. This means that serological test in children
under the age of18 months is not a reliable way to check for infection of the child.
The older the child is, the more likely that the positive antibody test indicates the child's
own infection and not that of the mother. For children > 18 months, a positive HIV
antibody test result is interpreted to indicate that the child is HIV-infected.
223
Testing children under18 months of ag
A virological test (PCR) is the only reliable method to determine the child‘s HIV status below
18 months of age. It detects the actual virus in the child‘s blood.
- If PCR or other virological test is available, test from 6 weeks of age

o A POSITIVE result means that the child is infected, as it detects the actual
presence of HIV in the child
o A NEGATIVE result means that child is not infected but could become
infected if they are still breastfeeding.
Serological tests do not determine HIV status in this age group. This is because the test may
detect antibodies that might have passed from them other through the placenta. Therefore, a
positive serological test may only tell you that the child has been exposed to HIV, rather
than that the child is HIV-infected.
- A POSITIVE result means that the child has been exposed to HIV but does not
tell us if the child is infected. Repeat test at 18 months or once breastfeeding has
been discontinued for more than 12 weeks.
- A NEGATIVE result usually means the child is not infected but could become
infected if they are still breastfeeding. A negative testis also useful because it usually
excludes HIV infection from the mother, if the child has not breastfed for more than
12 weeks. Repeat test at18 months or once breastfeeding has been discontinued for
more than 12 weeks.
Testing children 18 months or older and their mothers and discontinue breast feeding
for 12 weeks Use a serological test.
- A POSITIVE result means that the child or mother is infected.
- A NEGATIVE result usually means the child or mother is not infected.
- In a high HIV setting, every child who is sick should be tested for HIV.
Refer to annex 3.3: Algorithm for testing HIV exposed infants
224
Table 37: HIV testing results interpretation in children
HIV testing results interpretation in children

Age HIV testing Interpretation of results Considerations
<18mon HIV antibody If positive, test does not Do DNA PCR test
ths test (rapid HIV reliably confirm HIV infection
test) but shows child has been
exposed to HIV as passive
transfer of maternal
antibodies can cause positive
test results.
If negative and not breastfed
forlast 12 or more weeks, the
baby is neither exposed nor
infected
HIV virological Positive virological test results Take sample for repeat DNA
test(DNA PCR indicate child is infected PCR and Start ART immediately.
using
Negative virological test in an Repeat DNA PCR at 9 months.
DBS/whole
infant with breastfeeding Start ART if result is positive
blood)Used for
implies the child is not after taking sample for
diagnosis in confirmatory DNA PCR.
infected but still exposed
HIV exposed Perform antibody test once
infants and breast feeding is discontinued
young children for 12 weeks or at 18 months
less than 18 of age if repeat PCR test result
months at 9 months is negative.
Negative virological test in an Perform confirmatory
infant NEVER breastfed antibody test at > 18 months
implies the child is most likely of age.
uninfected
>18mon HIV antibody Results valid as for adults If negative and still
ths test .Negative= the child is not breastfeeding–repeat test
infected. once at > 12 weeks after
Positive=the child is infected complete cessation of
breastfeeding.
225
DNA PCR testing should be used to diagnose HIV among infants and children younger
than 18 months of age.
Benefits of the point of care testing, including, but not limited to:
• More rapid testing and timely return of results to caregivers and clinicians.
• Same-day testing and receiving the result.
 Increased retention in the testing-to-treatment cascade
• Increased access to ART and faster initiation
Case study 5
A mother has been on ART (TDF-3TC-DTG) starting from 36
weeks of gestation. In addition, she is taking co-trimoxazole
prophylaxis. She gave birth to a 2 kg girl, at 38 weeks of
pregnancy. She is here today for her postnatal visit at 1 week. She
had chosen to use breast-milk substitute but, upon returning
home, she decided to begin breastfeeding after ―a lot of pressure"
put on her by her mother and mother-in-law, who do not know
that she is HIV-positive. She sometimes provides her baby with
breast milk substitute when she thinks the baby is not being
"satisfied" by her milk. She is complaining today of some nipples
soreness in her right breast. Her temperature is 37.6 ºC.
She had a negative RPR in her first and third trimesters of
pregnancy. Her last hemoglobin, taken at 36 weeks‘ gestation, was
10 g/dl. She is taking iron folate tablet daily. She and her husband
always use condom.
Questions
1. What laboratory tests will you recommend today?
2. How would you counsel this woman about her infant feeding
practice?
3. What advice will you give this mother about her nipple soreness?
4. What would you counsel about disclosure, family index testing
and family planning,
Time: 10 min
Case study 6
A woman comes to your clinic for a postnatal visit 6 weeks after
childbirth. She gave birth at your facility but had not received any
antenatal care. She declined HIV testing during labour but then
agreed to be tested after childbirth.
She is HIV-positive but did not take any ARVs. Her husband does not
know his HIV status. He has come to the clinic with her today at her
request, but you do not know if she has disclosed her HIV status to her
226
husband. She has been exclusively breast feeding, but she plans to go
to work again and does not know if she can continue to exclusively
breastfeed. She has not yet resumed sexual relations since childbirth.
1. What do you do for the HEI?
2. How will you manage her HIV status?
3. What advice would you give for this woman about exclusive
feeding?
4. What advice will you give this woman about disclosure,
family index case testing and family planning?
Time: 10 min
Case study 7
A mother has brought her baby girl for consultation at 1 week of age.
Her birth weight was 2 kg. The mother tells you that the baby was
started AZT 2mg/kg twice per day and NVP 2 mg/kg once per day at
birth and she was told to continue giving it to the baby for 6 weeks. She
wants to stop the AZT + NVP because she thinks it is making her baby
sick. The baby was on exclusive breastfeed, but today she opts for
replacement feeding. Her baby weighs 1.9 kg today and looks well.
The baby has received OPV-0 and BCG at birth.
1. What vaccinations will you give the baby today?
2. How would you advise the mother about administering the AZT +
NVP to her baby?
3. Does the baby need co-trimoxazole prophylaxis today?
4. What would you advise the mother about the baby‘s weight loss?
5. When should this mother bring her baby for HIV-testing?
6. When should the mother bring her baby back for routine follow-up
visit?
Time: 10 min

A mother brought her baby boy for his 6-week visit. His birth weight
was 2.4 kg. Both parents are HIV positive, but neither is taking any
ARV drugs. They plan to use condoms during every sexual act. Her
baby is not taking AZT + NVP. The mother plans to go to work again
but would like to continue exclusive breast feeding. The baby weighs
3.2 kg today. You notice that the baby has oral thrush but otherwise
looks well. You cannot find the baby‘s vaccination record and cannot
see any indication of BCG scar
Questions
1. How would you treat the baby for his HIV exposure?
2. What advice would you give the mother about her baby‘s oral
thrush?
3. What advice would you give the mother about co-trimoxazole
prophylaxis, breastfeeding and baby‘s weight gain?
4. What vaccinations would you offer today?
5. When would you advise the mother to bring her baby for HIV-
227
testing and routine follow-up visit?
Time: 10 min
3.4: Family Planning Counseling And Services For HIV Positive Women
Time Allotted 90 Minutes

Enabling Objective:
By the end of this session, the participants will be able to-
- Discuss post-partum family planning methods
- Describe short and long-acting family planning methods
- Discuss the integration of FP/HIV and STI services at all levels of care
Group Activity
1. List and discuss types of modern SAFP
2. List and discuss types of modern LAFP
3. List and discuss types of modern PPFP for HIV Positive Women
clients (Issues to consider, eligibility …)
Time 10 minutes
3.4.1 Considerations about use of Family Planning Methods by Women Living with HIV
Women living with HIV can use majority of the family planning methods with no
significant side effects. This includes hormonal methods, such as the pill and injectable.
Family planning methods that should not be used by HIV positive women or that needs to be
used with caution : Spermicides or diaphragms/caps with spermicide: these methods should not
be used by women living with HIV/AIDS.
IUDs: Women with HIV or successfully treated AIDS can have an IUD inserted. If a woman
who has an IUD develops HIV infection or an STI, the IUD can stay in place. There is no need
to remove the IUD; just treat the infection. However, IUDs should not be inserted in a woman
with gonorrhea or chlamydia, or if a woman is at high individual risk of these infections.
. Women on ARV or TB medications: Generally, these women can use hormonal

contraceptives (pills or injections) with some exceptions as certain medicationsmay reduce the
effectiveness of the pill and other hormonal contraceptives.If she does not want to use a
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different contraceptive method, she should be encouraged to use condoms along with pills for
extra protection against pregnancy. (refer to annex 3.4):
A woman taking rifampicin or rifabutin: she should not use pills; rather she can use a 3-month
or 2-month injectable (i.e., Depo-Provera or NET-EN). If she does not want to use a different
contraceptive method, she should be encouraged to use condoms along with pills for extra
protection against pregnancy. (refer to annex 3.4).
A woman taking an ARV with ritonavir: she should not use pills; rather she can use a 3-month
or 2-month injectable (i.e.-Provera or NET-EN). If she does not want to use a different
contraceptive method, she should be encouraged to use condoms along with pills for extra
protection against pregnancy. (refer to annex 3.4)
3.4.2 Integration of FP service to HIV care including PMTCT

The integration of family planning (FP) and HIV services is an approach in which both services
are provided together to deliver more comprehensive care to clients and improve sexual and
reproductive health outcomes. By utilizing multiple entry points, effective and efficient
integration of services reduces the time required to get the services. It allows clients of HIV
services to access FP and safe pregnancy services and achieve their fertility intentions more
easily. It includes the delivery of both services at the same time and location as well as referrals
from one service to the other.
Integration refers to the delivery of health services and is therefore one part of a broader set of
linkages between FP and HIV policies, programs, funding, and advocacy. These linkages are
essential to meet the needs of women and their families and to achieve international
development goals, such as an AIDS-free generation and greater access to reproductive health
services.
Health service requirements for Integration and linkage of FP service.

The integration of FP service should be considered in a health facility that have any one or
more of the following services based on the assessment results of availability of physical space,
trained providers, essential equipment, and commodities using the standard assessment tool.
This service must be linked to the next higher level in the absence of services that enable
integration.
a. Child health services (Well baby and sick baby),
b. Immunization,
c. ANC, Labor and–delivery, postnatal care services.
d. CAC
e. HCT, PMTCT and ART service
f. Adult OPD‘s.
g. Adolescent and Youth Health service.
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Strategic considerations for the FP service integration
Pursuing strategically stronger integration of FP with other health services, managers should
consider the following four questions and corresponding activities:
i) Which service areas shall FP integration to be considered?
ii) What type, level, or extent of service integration, if any, is needed?
iii) What steps are needed to establish and sustain high-quality integrated services?
iv) What information is needed to measure program success and inform service
delivery improvement, replication, or scale-up (M&E)?
The above four issues are detailed in the following sections
Potential Service areas on which FP should be integrated
Immunization, under-five clinic, ANC, Labor and delivery, PNC, CAC and medical & surgical
OPD‘swith adequate client flow, infrastructure, and human power can be considered for
integration.
Levels of FP services integration
A ―one-size-fits-all‖ approach to FP and other health services linkages in general, and service
integration, does not exist. Even in countries with greater resources, it is often not feasible for
every facility to offer all contraceptive services in the same place at the same time by the same
provider together with other services. Public and private Health facilities should have to make
decisions about which specific FP and other health care services to integrate, when and where
to integrate them, and the extent to which they should be integrated.
For example, managers of facilities offering RMNCAH-N or HIV care and treatment services
could determine if it is feasible for their health care providers to incorporate FP counselling
into their discussions with clients. They might also provide selected methods (such as
condoms, pills, and injectable), monitor ongoing use, and make referrals for all other methods.
Another facility might offer both HIV counselling and testing and FP services, but in separate
rooms by separate providers.
Managers in this case might determine that the best use of limited resources is to equip the
facility‘s HIV counsellors to screen their clients for risk of unintended pregnancy, offer basic
information about FP, and provide a same-day referral to the FP room if needed. In this
scenario, the FP provider would become responsible for providing appropriate follow-up and
care related to the client‘s FP use.
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At each level of service integration (A, B, C or D), a given type of FP service will be provided.
At level A, FP counselling service (with occasional condom and ECP provision) is provided.
At each successive level, irrespective of the level of the facility (be it health post, health center,
primary hospital, general hospital or referral hospital and their private counterparts); the
activities at the preceding level plus additional services shall be provided as shown in the table
below. For example, if facilities or programs providing Level A functions are not immediately
prepared to provide oral contraceptives for ongoing uses, they may provide emergency
contraceptive pills with referral for ongoing FP management. If the facility or program already
provides oral contraceptives (Level B), it can also offer emergency contraceptive pills.(Table
1).
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Table 38: 10 depicting the level of service integration
Level A Level B Level C Level D
All the following functions provided/performed: All of Level A functions All of Level B functions All of Level C
plus: plus: functions plus:
FP information provided to clients accessing other
health Services. Oral contraceptives pills IUD insertion with Permanent FP
(OCP) with instructions appropriate counselling and (surgical: tubal
Risk assessment for pregnancy and intention for for appropriate use. timing of removal. occlusion, vasectomy)
spacing or limiting. methods with
Injectable with appropriate instructions for self-
Counseling on recommended timing and spacing counselling and schedule
when pregnancy is desired; timing of return to Implants insertion with care and follow-up.
for return visit.
fertility; FP methods (including LAM for appropriate counselling and
postpartum/postnatal clients); FP methods‘ ability to Counselling and referral timing of removal.
prevent STI and HIV infection, method choices for other contraceptive
available and where to access methods not available methods not offered on
on site. site. . Implant or IUD follow-up or
Condoms, with instruction; demonstration on correct refers for follow-up.
use.
Emergency Contraceptive Pills, with instructions for Counselling and referral for
appropriate use. other contraceptive methods
Counselling and referral for other contraceptive not offered on site.
methods not offered on site.
Steps to FP service Integration
STEP 1* STEP 2* STEP 3 STEP 4

STEP 5 Phase in
Identify/refine Assess Build or
Identify
level of program strengthen FP
resources
Integration capacity to systems to methods
to support
that can be support support to expand
integration
adapted FP** new service mix within
program
*Steps 1 and 2 are interchangeable depending on SYSTEMS Resources

-Training -Partnership
Stakeholders‘ pre-existing desires for Level of -Capacity
-Supervision
Integration and linkage to be implemented. -Logistics
-Referral
** Include orientation of stakeholders to staff tasks -Record keeping
and system functions required to support levels -Policy
of integration and linkage
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Individual reflection exercise
(Drill exercise):
1. drug-drug interactions, ARVs, other drugs with FP methods
2. Advantage and disadvantage of some FP methods in the context of HIV)
Time 10 minutes
Pair –Think- Share (Buzz Group Reflection)

For the below cases, Write short answers in the space below for each question
Time 4 minutes
1. An HIV-positive woman comes to your clinic for postnatal visit 2 weeks after childbirth. She
is not breastfeeding and is wondering if she could start a family planning method today. Which
family planning methods are safe for this woman?
2. An HIV-positive woman comes to your clinic,6 weeks after childbirth, for a postnatal
visit. She is exclusively breast feeding, has not yet had her menstrual period. Her baby is
sucking normally, both day and night. She wants to begin having sex and does not want to
become pregnant. What will you advise her about family planning options?
3. An HIV-positive woman comes in for her 1-week postnatal visit. She has TB and is taking
rifampicin. She is not breastfeeding. After much discussion, she and her husband have decided
that they do not want any more children at least for the coming 3 years. Your Patient likes the
progestin-only pills, which she used after her last pregnancy. She is wondering if she could
begin using this method again today. How will you respond?
Individual Skill demonstration

Practice on condom application turn by turn (if not done in CH 1): Refer Steps in Chapter one
Time 20 minutes
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Role Play
Conduct Small & Large group: demonstrate FP counseling in the context of HIV.
Time 30 minutes
CHAPTER 3 SUMMARY
. Interventions to reduce the risk of MTCT of HIV during breastfeeding encompasses
reducing exposure of the infant to the virus and reducing HIV viral load in breast milk
 Integration of services support most postnatal women in receiving comprehensive routine

maternal and HEIs HIV care at a single visit, and at a single point of care (ensures
principles of one stop shopping services).
 Health workers caring for HIV-positive persons need to be sensitive to their own
prejudices and be careful to show a caring,motivating,competent, compassionate,
respectful, and non- judgmental attitude.
 PMTCT should be as comprehensive as possible and recognize and support the active
involvement of male partners in PMTCT services.
 postnatal woman should be encouraged to have routine follow up visits in the 1stweek and
at 6 weeks after birth
 HEIs Prophylaxis syrups shall be started within 1 hour of birth.
 Provide dual AZT+NVP prophylaxis syrups for the first 6 weeks and continue NVP
for the next 6 weeks for a total of 12 weeks for all HEI.
 Virological test (DNA PCR) should be done at the age of 4 to 6 weeks or as soon as
thereafter
 For those tested negative, additional DNA PCR test will be done at 9 month.
 Integration of FP and HIV services is an approach in which both services are provided
together to deliver more comprehensive care and improve sexual and reproductive health
outcomes
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Chapter 4: Monitoring and Evaluation (M & E) in PMTCT
Time allotted: 1420 min

Chapter description
This chapter will equip PMTCT/MNCH health care providers about their critical role in
monitoring and evaluating PMTCT/MNCH programs by using continuous quality improvement,
dash board and PMTCT cohort monitoring.
Enabling Objectives
At the end of this chapter, participants will able to learn:
 Define monitoring, evaluation, indicators, cohort, cohort monitoring and analysis

 Describe the importance of M&E in providing effective public health programs
 Identify the national MNCH/FP/PMTCT program cycle and indicators
 Discuss the purpose of global, national and facility level indicators
 Describe the role of the health care providers and HMIS persons , facility heads/ medical
directors and facility performance Monitoring team (PMT), PMTCT coordinators at all
respective levels
 Describe the HMIS registers, cards, charts and report formats used for MNCH/PMTCT
program
 Discuss how to monitor and analyze PMTCT cohort monitoring for maternal and HEI
out comes
 Describe the dimensions of data quality and define data quality assurance
 Identify gaps in PMTCT care and learn how to take corrective action
 Using the monthly collected data to assess the performance at all level and to improve the
PMTCT service, and utilize data for decision-making and future program planning.
 Address how health management and health facility staffs approach and use quality
improvement methods to focus on the system of care in which they practice.
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Chapter outline
4.1 Introduction to Monitoring & Evaluation and Indicators
4.2 Recording and reporting data
4.3 4.3 Cohort monitoring and analysis
4 4.4 Data Quality
4.6 4.5 Performance Evaluation using dashboard and continuous quality improvement (CQI)
4.1 Introduction to Monitoring &Evaluation and Indicators

Time: 120
Learning Objectives
Participants will able to
 Define monitoring, evaluation and indicator

 Describe the importance of M&E in providing effective PMTCT programs
3. Reflect the importance of M & E for PMTCT?
4. What are PMTCT indicators
Time: 5 min
Maternal, new born and child health (MNCH), including prevention of mother to child
transmission (PMTCT) being one of the most important health sector program, needs to have an
effective M&E system. Data collected from the health management information system (HMIS)
should be used not only for the sake of reporting to a higher level, but also for informed decision-
making at various levels to support continuous service quality improvement. To this effect,
service providers and program managers actively involved in PMTCT/MNCH program should be
equipped with knowledge and skills in M&E.
This session is designed to enable participants to recognize the role of health care service
providers and program managers in monitoring & evaluation and indicators of PMTCT/MNCH
programs.
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This session aims to introduce the HMIS/M&E reporting procedures and tools used for the
MNCH/PMTCT and ensure evidence based decision making.
4.1.1 Monitoring &Evaluationand Indicators

Monitoring - is a systematic process of collection, analyzing and using information to track a
program‘s progress towards realization its intended goal.
Monitoring:
 Involves regular tracking of data of the program,
 Allows the prompt detection and correction of performance problems and there by
improves the quality of health services,
 Assures data quality and accuracy and provides a basis for program evaluation,
 Supports efficient and effective use of program resources.
 Requires standardized variable definitions, case definitions, cards, registers, charts and
forms
 Needs Standardize data recording and reporting
 Should be conducted continuously and systematically
Evaluation: an analysis of program/project data to which measures results and assesses program
impact.
Evaluation:
 Measures trends over time
 Compares observed outcomes to previously established targets
 Identifies program areas that need improvement or changes
 Measures program outcome and impact (program & client)
 Informs decisions about future resource allocation
 Looks at the ―big picture ―
 Should be conducted systematically and periodically
Health Management Information System (HMIS): is a system for collection, compilation and
analysis of routine health service data. It is an important tool in conducting monitoring and
evaluation of health programs such as PMTCT. Regular systematic review of data collected by
HMIS can assist health workers, facility medical directors and Performance Teams, program
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managers, planners, policy makers and other PMTCT stakeholders in evidence-based program
planning and continuous quality improvement...
Health Information System (HIS) is “a system that provides specific information support
to the decision-making process at each level of an organization.” (Hurtubise, 1984)
The purpose of HMIS is to routinely generate quality health information and use that
information for management decisions to improve the performance of health services
delivery.
4.1.2 Indicator
Indicator: is a variable that evaluates status and permit measurement of changes over time.
o Are variables which reveal the health status of a population

o Signal the status or progress towards program implementation
o Signal success or failure in achieving a set objective or goals
o Provide a valid and reliable way to measure achievement, assess performance, and reflect changes
in health status due to an intervention.
o Measure key aspects of program and must therefore be narrowly defined to measure specific
aspects as precisely as possible.
o Demonstrate whether outcomes such as Mother-to-child transmission rate and ART coverage
have changed
o Show whether the program is meeting targets such as the number of pregnant women counseled
and tested for HIV.
o Flag the need for corrective management action
o Evaluate the effectiveness of various interventions or aspects of a program.
o Should be established for each significant program element
o Can be established at the global, national, regional, woreda and facility level.
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Global or worldwide indicators are estimated from national indicators reported by individual
countries to the WHO and other entities. They reflect the current worldwide situation specific to
a given health problem.
The data reported by individual health providers are essential for determining accurate
indicators at the woreda, zonal, regional, national and ultimately global level. Indicator data
provided by the facility and the health providers are the backbone and essential core of any
woreda, zonal, regional, national, or global indicators. Hence; It is important to document data
correctly, promptly, and legibly.
List of PMTCT indicators:
1. Proportion of pregnant women who received 1st antenatal care contact during the current
pregnancy
 Denominator: Total number of expected pregnancies during the reporting period
2. Percentage of pregnant, laboring and lactating women tested for HIV and who know their
results
 Denominator: Total # of estimated pregnant (Eligible ) women during the reporting
period
3. Percentage of HIV positive pregnant, laboring & lactating women identified in the reporting
period (new & known)
 Denominator: Total # pregnant, laboring and lactating women tested for HIV during
the reporting period
4. Percentage of HIV Positive pregnant, laboring and lactating women who received ART at
ANC+L&D+PNC for the first time in the reporting period
 Denominator: Estimated HIV positive pregnant women during the reporting period
5. Percentage of HIV-positive pregnant women who were already on ART when linked to ANC
in the reporting period
 Denominator: Total # of HIV positive pregnant women (New positives plus Known
positives already on ART) during the reporting period
6. Percentage of HIV positive women on HIV care who are using a modern FP method
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 Denominator: # of HIV+ women eligible for modern FP = # of HIV+ women
identified ( those on FP options from ANC/PMTCT, on ART over the total HIV
positive women cumulative )
7. Percentage of infants born to HIV infected women receiving a virological test within 12
months of birth
 Denominator: Total # live births (HEIs) from estimated HIV+ pregnant women
during the reporting period
8. Percentage of Infants born to HIV-infected women started on co-trimoxazole prophylaxis
9. Percentage of infants born to HIV-infected women receiving antiretroviral (ARV) prophylaxis
for prevention of mother-to-child transmission (PMTCT)
10. Percentage of HIV exposed infants receiving HIV confirmatory (Ab) test by 18 months
 Denominator: Total # of live births (HEIs) from estimated(eligible ) HIV+ pregnant
women during the reporting period
11. Percentage of HIV positive pregnant & lactating women whose partner tested for HIV
 Denominator: Total # of HIV Positive pregnant women during the reporting period
12. proportion of pregnant women attending antenatal care tested for Syphilis
Denominator: Total number of pregnant women who attended first ANC visit
13. proportion of pregnant women treated for syphilis
Denominator: Total number of pregnant women tested positive for syphilis
14. Proportion of pregnant women attending antenatal care tested for HBV
Denominator: Total number of pregnant women who attended first ANC visit
15. Proportion of HIV positive women who gave birth at health institution
Denominator: Total # of HIV Positive pregnant women during the reporting period
16. Percentage of HIV positive pregnant & BF women on ART with a suppressed viral load
(<1000 copies/ml) in the reporting period
Denominator: Estimated number of HIV positive pregnant women
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See detail on Annex 4.1
4.2: Recording and reporting of data

Time:- 120 min
Learning objectives
At the end of this session, Participants will:

 Describe the HMIS registers, cards, charts and report formats used for MNCH/PMTCT
program used in facilities
 Understand the purposes of PMTCT cards, registers, charts and formats; and how to
complete them properly, timely, complete and accurate reporting
 Recognize reporting flow, frequency, and channel
 Describe where to find the data to complete these documents; how to record data
properly; and how to assure data quality in PMTCT register
 Describe the responsibilities of health care and HMIS workers, facility managers/
medical directors, and performance team in assuring data quality
4.2.1 Recording data in cards, registers, and report forms

Quality data recording on PMTCT cards, registers, charts and formats is essential to conduct
monitoring and evaluation and to familiarize health care providers with the PMTCT/MNCH-
related reporting, charts and registration formats used at the health facility level. Hence; Health
care providers should
 Understand the data to be collected in PMTCT cards, registers, charts and report forms.
 Record the data on the appropriate form each time they perform a procedure. Example
HIV-positive mother, prescribe ART drugs, receive a test result, provide a referral, or
engage in any other PMTCT/MNCH activity. This includes tally for repeat visits.
 Record all data and requested information on the M&E forms/ registers. When service is
not provided, leave blank.
 Record the data in the same way every time using the same definition, the same rules,
and the same tests for reporting the same piece of information over time. When the tests
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and definitions change because of new treatment guidelines and technologies and when it
is not possible to record the data in the same way; make a note that describes the change.
Table 39: Summary of PMTCT cards, forms, registers

S.N Types Where to get Who completes it
Cards, forms and tools
1 Integrated Antenatal, Labor, At Facility MRN  Provider at ANC/ PMTCT, PNC
Delivery, Newborn, Postnatal unit,
care chart  Provider at L&D
2 HIV exposed infant follow up PMTCT room  Initial at L&D,
card  Provider at ANC/ PMTCT, PNC
3 ART Intake form ART or PMTCT Provider at ANC/ PMTCT, PNC
OPD unit
4 HIV/ART chronic care follow up ART or PMTCT Provider at ANC/PMTCT, PNC unit
form OPD
5 Transfer out form ANC/PMTCT OPD Provider at ANC/PMTCT unit
6 PMTCT Dashboard **** Office of the health  Provider at ANC/PMTCT unit,
facility Head  HMIS focal,
 Performance Improvement team,
7 PMTCT facility performance ANC/ PMTCT Provider at ANC/ PMTCT unit,
indicators follow up form*****
8 Continuous quality improvement ANC/ PMTCT Provider at ANC/ PMTCT unit,
tool (CQI)
Registers
9 ANC Register ANC OPD Provider at ANC unit
10 L&D Register L&D ward Provider at L&D
11 PrEP Register PMTCT Provider at ANC/PMTCT, PNC unit
12 PMTCT Register for Health ANC/PMTCT Provider at ANC/PMTCT, PNC unit,
Centers and Hospitals (mother OPD Provider at L&D unit*
baby pair cohort register)
13 Postnatal Register PNC Ward Provider at PNC unit,
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14 Family Planning Register FP OPD Provider at FP unit,
15 DNA PCR specimen tracking ANC/ PMTCT Provider at ANC/ PMTCT
logbook
16 PMTCT appointment & LTFU ANC/ PMTCT OPD Provider at ANC/ PMTCT unit
Tracking logbook***
17 Index test testing (ICT line ANC/ PMTCT Provider at ANC/ PMTCT
listing register)
18 High viral load register ANC/ PMTCT Provider at ANC/ PMTCT
19 Retest for verification register ANC/ PMTCT Provider at ANC/ PMTCT
Lab request forms

20 CD4 request forms ART/ PMTCT OPD Provider at ANC/PMTCT
21 DNA PCR request forms ANC/PMTCT OPD Provider at ANC/PMTCT
22 Viral load request form ANC/PMTCT OPD Provider at ANC/PMTCT
Reporting forms
23 Monthly HMIS reporting forms ANC/ PMTCT, Provider at ANC/ PMTCT, PNC unit,
PNC , OPD Provider at L&D unit,
L&D, ward
PMTCT cohort tools
24 PMTCT Cohort reporting form** ANC/ PMTCT Provider at ANC/ PMTCT unit,
25 PMTCT SOP ANC/ PMTCT Provider at ANC/ PMTCT unit,
26 PMTCT Cohort wallchart ANC/ PMTCT Provider at ANC/ PMTCT unit,
27 PMTCT job aid ANC/ PMTCT Provider at ANC/ PMTCT unit,

Key:
*Providers at L&D unit are responsible for linking New HIV+ women identified at L&D and already
known to the PMTCT unit. They need to ensure the registration on the PMTCT register including
registration of HEI data including NVP in the MBPCF register,
**The Cohort reporting form is to be completed periodically by ANC/ PMTCT unit,
***The PMTCT appointment and LTFU tracking logbook is to be prepared by the ANC/ PMTCT unit.
HIV+ women missing their appointments or got LTFU will be identified and tracked using the logbook.
****The PMTCT Dashboard is used by managers to follow the PMTCT performance using selected
priority indicators that change through time.
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*****The PMTCT performance indicator is posted at ANC/ PMTCT unit depicting the monthly
achievement against the expectation/ target.
MNCH/ PMTCT related formats & cards:
Participants will be provided with copies of each card, form, & register to be well acquainted with
them.
1. Integrated Antenatal, Labor, Delivery, Newborn & Postnatal care card

 Used to document important information on the woman‘s current pregnancy including
ANC, delivery, and postpartum care data.
 Documents the recording date, the woman‘s medical history, physical examination and
laboratory results.
 Contains data that the provider calculates the gestational age (GA) and estimated date of
delivery (EDD)..
 Contains Data on HIV status, partner testing, TT status, delivery outcome with
intervention; Providers should complete this integrated card at each focused clinical visit.
Data from this card will be transferred & registered on the ANC, PMTCT, L&D and PNC
registers.
2. ART intake form (A & B):
 Contains baseline information for each patient enrolled into HIV care (PMTCT/ART
program).
 this form is filled for all HIV+ women initially at time of enrollment in the
ANC/PMTCT clinic
 Captures socio-demographic information, the patient‘s past and present medical history,
physical examination results, lab results, WHO staging, information on any counseling
sessions, the case management plan and history of treatment – Anti-TB, CPT & IPT.
3. HIV care/ART follow- up form:
 Used to document HIV care progress. The provider should complete this form at every
visit.
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4. HIV Exposed infant follow- up form
 captures all the necessary information/ data on the HEI including the care provided until
the infant is either finally declared HIV free at 18 months of age; or when breastfeeding
stops, or when the infant is determined HIV infected and transferred to ART care &
treatment.
During HEI follow up visits, the provider should document all the basic information required on
the follow-up card
MNCH/PMTCT related Registers:
1. Antenatal Care (ANC) Register

 It Registers all women enrolled in ANC at a health facility and documents the dates and
results of the recommended four ANC visits.
 The service provider enters data at the time of each ANC clinic visit.
 For clients with at least 8 contacts, register the specific information relevant to the
recommended period/ gestational age on the specified space of the register.
 Data for this register can be abstracted from the integrated MNCH card.
Note: Record the first ANC visit of the current pregnancy in the raw where her GA applies at the
time of her visit.
Subsequent repeat visits should be recorded on the respective rows of her initial registration.
Provider should tally repeat (2nd to 4th) ANC visits on respective places of daily tally sheet.
The data that can be extracted from this ANC Register are numbers of First ANC Visits, Fourth
ANC visits, women screened for syphilis, women who received HIV test results and HIV positive
women.
The ANC tally sheet is used to summarize data collected from all four ANC contacts and 8 ANC
contact including syphilis screening.
2. Delivery Register
 lists and summarizes data for all women who gave birth at the facility.
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 provides information on number of deliveries attended, deliveries by type, women who
received HIV test, HIV+ women & outcome of babies & mothers
 includes summary information for calculating delivery indicators.
 The provider completes the Integrated MNCH card at the time-of-service provision, and
transfer data to Delivery Register.
 Documenting date & time of delivery both at the MNCH & Delivery register is very
important.
. Postnatal care (PNC) Register
 lists all clients receiving postnatal services at the health facility.

 . Register includes data for women who received postnatal care at least once in the first
42 days .
 the first PNC visit should occur within the first seven days after delivery.
 The first seven days of PNC care should be disaggregated (1st visit - 3rd day; 2nd visit - 6/7
days; 3rd visit – 6th week). Hence; early PNC visit means visit within the first 7 days.
 The PNC register contains data on Newborn death in the first week of life, HIV tests
performed & HIV+ women.
 The service provider completes the PNC Register at the time of service. information can
be completed by abstracting data from the Integrated MNCH card.
Family Planning Register
 Provides a one-year follow up data for a single client. After the year is completed, the
client is registered again in the same registration book as new.
 HIV+ women shall be linked/ provided with FP service during the postpartum period
preferably at 6th week by MNCH /FP or ANC/PMTCT service providers
 Service providers should complete the register at the time of the FP service visit.
3. PMTCT register
 PMTCT register is to follow HIV positive mothers during pregnancy, labor & breast
feeding & infant born to HIV+ women to provide continuum of HIV care & treatment for
the mothers and baby (HEI) in the MNCH platform until the baby is declared HIV free.
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 Helps follow HEI until serostatus is determined ( seronegative - discharged at max 18
months of age; or HIV infected - referred to ART clinic )
 Helps providers to identify mother-baby cohorts that have been lost-to- follow up and to
act/ intervene- trace.
 Replaces the ART & Pre-ART registers and the HEI follow up register of the ART clinic
 Enable providers to follow HEIs until discharged HIV -free by 18 months of age.
Data elements for the PMTCT register
1.Number of pregnant women tested and who know their results during pregnancy
 Collected from the ANC register during the specified period. It includes those mothers
who already know their HIV+ status (known HIV+), and those mothers who were tested
during this pregnancy and know their HIV status.
2.Number of pregnant women tested and who know their result during labour & delivery:
Collected from delivery register
 Include pregnant women who are tested during L & D and informed of their results; plus
those pregnant women who already knew their sero-positive status (known HIV+) at
delivery.
3.Number of women tested and who know their result during the postpartum period:
 Collected from PNC register

 include lactating/ postpartum women who were tested and who knew their HIV status
after delivery including those with already known seropositive status.
4.Number of women tested positive for HIV:
Collect this number from :1) ANC,2) L&D and 3) PNC registers .
 This number is a summary of all HIV positive clients/mothers identified at ANC, L&D
and PNC, and all those with already known HIV+ status.
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 PMTCT register should contain the exact number of HIV+ women identified in all
service outlets during the reporting period, bringing all HIV+ women into PMTCT follow
up (mother - baby pair cohort register) is very essential.
 Registering them in the booking date and follow the mothers to start ART and the
standard services in the given time through good counseling is expected from PMTCT
service provider.
5.Number of HIV positive pregnant women who received ART to reduce the risk of mother to
child transmission during ANC for the first time:
 Collect this number from the PMTCT register.

 Include HIV+ pregnant women who began ART after they are enrolled in to ANC follow
up and were referred for PMTCT. Do not include HIV+ pregnant women who were
already receiving ART before pregnancy.
child transmission during L&D for the first time:
 Collected from the PMTCT register and includes those HIV+ pregnant women who first
started ART during L&D for PMTCT.
 This number does not include those HIV+ pregnant women already on ART.
child transmission during PNC for the first time:
 is collected from the PMTCT register, and

 includes HIV+ lactating women who first start ART after they are enrolled in to PNC/
PMTCT services for their babies to continue breast feeding.
This does not include those HIV+ lactating women who were already on ART pre-
pregnancy*****.
8. Number of HIV-positive women who got pregnant while on ART & were linked to ANC:
 is collected from the PMTCT register.

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 It includes those HIV+ women who started ART before pregnancy outside of ANC/
PMTCT setup. These mothers are linked to ANC/PMTCT through transfer out format
written from ART unit. The ANC/PMTCT unit will transfer-in her in the integrated
MNCH/PMTCT or MBPCF register and follow her and her HEI for a minimum of 18
months.
The follow up at ANC includes reporting all those newly initiate ART and linked to ANC
through Transfer out every month
9.Number of HIV exposed infants who received HIV test within 2 months of birth, during the
reporting period:

 It includes all infants born to HIV+ women (those newly initiated on ART at PMTCT
clinic and those already on ART when becoming pregnant).
10.Number of HIV exposed infants who received HIV test between 2 and 12 months, during the
reporting period:
 Collect this number from the PMTCT register. It includes all infants born to HIV+
women.
11.Number of infants born to HIV positive women and started on co-trimoxazole prophylaxis
within two months of birth:

 It includes all infants born to HIV+ women.
12.Number of HIV exposed infants who received antiretroviral (ARV) prophylaxis:

 Register these services in ANC unit in the MBPCF register before discharging the mother
in early post natal period or just after delivery.
 labor and delivery service providers or midwives are responsible to perform registering
the data in MBPCF register.
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 it includes all infants born to HIV+ women who received ARV prophylaxis at delivery
and after.
13.Number of HIV infected infants identified early:

 It includes HIV exposed infants at 6 week or anytime soon DNA PCR test result turns
positive.
 Date linked for ART care should be documented in the remark portion of this register
14.Number of HIV infected infants receiving HIV confirmatory (antibody test positive) result by
18 months:
15.Number of HIV exposed infants receiving HIV free confirmatory (antibody test Negative)
result by 18 months:

 It includes all HIV exposed infants who were followed and discharged from the HEI
follow up by 18 months of age.
DataAbstraction/ExtractionforthemonthlyPMTCTservicedeliveryreport:
In order to collect the right data for the monthly report, health care providers need to
know where and how to extract data. DHIS2 data abstraction and extraction principle
will be utilized.
■ For HIV testing abstract data from ANC, L&D & PNC registers.
■ For partner HIV test abstract data from ANC, Land D and PNC registers
■ For Syphilis testing abstract data from ANC registers.
■ For syphilis treatment abstract data from ANC register
■ For HBV testing abstract data from ANC register.
■ For ART uptake, abstract data from MNCH/PMTCT (Mother-Baby-Cohort)
register including new and already on ART,
■ For HBV prophylaxis uptake, data abstract from HBV treatment register
■ For PrEP uptake, abstract data from PrEP register
■ For HBV BD immunization uptake, abstract data from immunization
register
■ For HIV exposed infant related reports, extract data from MNCH/PMTCT
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(Mother-Baby-Pair Cohort register).
Unique ART number comprises of
■ For PMTCT cohort report, extract data
region code/ facility type/ facility
from MNCH/PMTCT (Mother-Baby-Pair Cohort
code/ five digit serial number
register).
unique for the patient.
■ For modern FP utilization report, extract
E.g., UAN- 14/08/001/00023
indicates the 23rd patient newly data from MNCH/PMTCT (Mother-Baby-Cohort
initiated on ART in Zewditu register).
hospital, AA.
Completing the PMTCT Register section by
section
Instruction to complete PMTCT register:
All HIV+ women identified at ANC, L&D & PNC units should be registered in the integrated
MNCH/ PMTCT register(MBPCF register ) the same day. Once HIV positive pregnant/ lactating
women are identified, the provider should ensure respective services are provided for them and
their babies (HEIs) and document it in the patient chart & PMTCT register.
For HIV+ women who start ART at ANC/ PMTCT clinic, the HIV/ ART care & treatment will be
documented on this register. Providers should give five- digit consecutive/ serial numbers
(Unique ART numbers) to those HIV+ women who newly start ART at the PMTCT site. The
source of unique ART number in a facility where PMTCT/ART is collocated is the ART unit.
If a woman is already on HAART; her existing unique ART number is registered on the PMTCT
register and her pregnancy & her baby (HEI) together will be followed in the PMTCT clinic.
Transfer- out format should be used between ART and PMTCT units to reduce data entry in a
duplicated manner.
The critical point to consider here is that; the care & follow-up of the HIV Exposed babies (HEIs)
with their mothers until declared HIV free is the whole point of PMTCT follow up.
For PMTCT only sites, Regional Health Bureaus are responsible for providing facility codes and
unique ART numbers for both public and private facilities, and overseeing the PMTCT services.
Whereas, in a facility where PMTCT and ART services co-exist; the PMTCT unit should take/
reserve unique ART number from the ART clinic so that HIV+ mothers will be transferred to
ART clinic after a 24 month follow up in the PMTCT clinic.
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When compiling reports, differentiate those mothers who start ART for PMTCT purpose at
PMTCT clinic and those who started ART before current pregnancy -as already on ART. This
will avoid double counting HIV+ women who have already been on ART when they come for
PMTCT.
Registration section (Column 1-8): These columns record the demographic characteristics of the
Mother at the time of PMTCT registration. It includes date of registration (DD/MM/YYYY EC
format), medical record number (MRN), name, and dates of registration in the PMTCT program
(booking date, ART initiated date).
ANC section (Column 9-14): These columns record date of last menstrual period (LMP),
estimated date of delivery (EDD), the gestational age in weeks, receipt of ferrous sulphate/folic
acid, syphilis screening results, and selection of infant feeding options. The provider should
estimate the approximate time of delivery -EDD (DD/MM/YYYY, EC) from relevant available
information if the woman does not know her LMP.
Delivery section (column 15-19): These columns record the delivery-related data including date
of delivery (DD/MM/YYYY, EC format), place of delivery, delivery outcome, and whether the
mother received ART during delivery and whether her newborn infant received nevarapine +
Zidovidine (NVP + AZT) prophylaxis.
Post-delivery care section (column 20-24): These columns document whether family planning
counselling occurred post-partum, and the type of contraceptive provided, if any.
HIV care section (column 25-37): These columns document the partner‘s HIV test results. In
addition, these columns document the results of the woman‘s TB screening status. If INH
prophylaxis was provided, record the dates that the patient started and completed INH
prophylaxis. The provider should also record the patient‘s baseline CD4 count, viral load, WHO
clinical stage, and the date that ART was started and the ART regimen used. ART regimens are
coded as follows:
1c = AZT-3TC-NVP
1d = AZT-3TC-EFV
1e = TDF-3TC-EFV
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1f =TDF-FTC-NVP
1g = AZT prophylaxis
1h =NVP prophylaxis
1J=TDF +3TC + DTG
1I =others, specify
HEI follow-up section (column 38-46): These columns document dried blood specimen (DBS)
test results, and whether CTX prophylaxis was administered to the newborn infant, and if the
infant was breastfed.
Mother and infant follow up section (column 47-87): This section is the second page of the
PMTCT register. These columns document data on the mother- baby pair -up to 24 months post-
partum.
The first raw is dedicated for ART follow up of the mother and the second raw is dedicated for
the infant.
In the upper row, document the monthly ART regimen administered to the Mother. At months 6,
12, 18, and 24, document the Mother‘s ART regimen, CD4 counts/ viral load results, and MUAC.
In the lower row, document the medication administered to the infant during each visit. For
example, the infant might be on NVP prophylaxis in the 1st month of life and CPT after one and
half month of life.
Moreover, while documenting on the PMTCT register, consider the following:
 For mothers who start ART with no delay or if already on ART, start entering the regimen
from column 40, i.e., start in the same booking month,
 If the mother had delay in starting ART, count the months delayed and start entering the
regimen leaving equal spaces for months not covered on ART. E.g., if the mother starts ART
2 months after the booking date, start entering under column 42, leaving the missed two
months blank. Note that this shows the missed opportunity even after the mother showed up
to the facility.
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 for the mother identified HIV positive during on coach testing or during labor and delivery
and if again the mother is obtained newly during her PNC example during EPI and in both
cases if both of them started ARVS the same date and month, for the mother: start
registering her ART regimen and NVP prophylaxis for the baby under column 40 and
continue registering her ART regimen and CPT throughout the follow up.
 For HEI who start HEI care & follow up late, start entering/ registering ―NVP/ CPT‖ leaving
the missed month(s) blank.
 After 18 months of post-partum follow up, i.e., Baby discharged HIV free by 18 months, the
Mother will be transferred out from the PMTCT Clinic to the ART clinic in the same facility
or nearby with a standard transfer out (TO) form. However, the Mother can be referred for
follow up/ consultation to the ART Clinic anytime if she develops signs and symptoms of a
stage 3 or 4 opportunistic infection, or if serious ARV drug toxicity occurs, or treatment
failure suspected, or her baby (the HEI) is suspected/ confirmed HIV infected. This needs
close interaction between ANC/PMTCT and ART units for the advantage of the client.
 If the mother or the baby or both are lost to follow-up before the infant‘s final HIV status is
determined (i.e., before 18 months of age or before the cessation of breast-feeding), write
―LTF‖.
 If the mother and baby in pair are transferred to another facility, or if the infant tests positive
for HIV and is linked to treatment & care in pediatric ART clinic (outside the PMTCT site),
write ―TO‖ for transferred out and register the name of the facility where the clients are
transferred out or even for referral cases write the name of the health facility in the remark
column .
 Write ―D‖ if the Infant is dead.
 Write ―DN‖ for Infant Discharged negative at 18 months of age.
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Group work and presentation
Dear participants please read the case-scenarios one by one and exercise
completing the necessary formats and the PMTCT register in particular.
The facilitator may assign you in groups or give you individual
exercises.
Group1: Case 1 (part A & B)
Group 2: Case 1 (part C, D & E)
Group 3: Case 2 (part A, B& C)
Group 4: Case 2 (part D, E& F)
Time: 40 mine ( 30 for group work and 10 min for presentation)
Case 1: Fill out the ANC register for the below client (Client 1):
Part A: Client‘s first visit, Her ANC card number (MRN) is 200056.
Client is 27 years old, presented at the ANC clinic for her first antenatal visit on 10/03/2007. She
didn’t remember her last menstrual period but she said it was 7 months ago, and it was her first
pregnancy. She was tested & counseled for HIV at this visit and her test result is HIV positive.
The nurse subsequently counseled her on the available HIV services, the benefits of PMTCT
service to her and her baby, and on safe infant feeding. The facility does not have the capacity to
run a CD4 test. She reported no gain of weight, she has herpes zoster scar on her right shoulder.
She didn’t have any signs or symptoms of TB or treated for TB. Her basic lab results were
hemoglobin -8 g/dl, BG & Rh - A+, U/A - negative & VDRL - NR.
The nurse categorized her under WHO clinical stage 2.
The nurse prescribed co-trimoxazole and ferrous sulphate for her. Explaining about ART, the
nurse also provided her with a 2 -weeks supply of fixed dose combination ARV drug
(TDF/3TC/DTG ) to take daily. The nurse also counseled her on partner-disclosure, partner
testing and about birth plan; the client agreed to deliver the baby at the facility and she was
appointed to return after 2 weeks for follow-up. She is the 4th women to start ART in the ANC
clinic.
Q1.List down data elements, and fill in client charts followed by the ANC register.
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Part B: Client 1 second visit:
The above client returns to the ANC clinic two weeks later. No significant weight gain. The nurse
counseled her on infant feeding and post-partum family planning options and reviewed her birth
plan too. The client decided to breast feed her baby. The nurse reviewed her card to see how
well she had been adhering to the ART regimen. The client had taken both the ARV and co-
trimoxazole tablets as prescribed. At this visit the client was told to give blood sample for CD4
test. The nurse provided her with additional adherence counseling and support, advised her to
bring her husband for HIV test and gave her a bottle of ARV with appointment to return in 4
weeks.
Q2. Update the relevant sections of the patient chart & ANC register.
Q3. Fill the PMTCT register using information from the 2 visits.
Part C: Client 1 third visit:
The client returned in her 37th week of pregnancy. She had good weight gain. She reported
noticing movement of the fetus. She finally disclosed her status to her husband, told him that she
started taking ART for the baby and asked him for test. He refused the test but approved ART was
good for the baby. The nurse assessed the client and found nothing abnormal except for the
report of missing a single dose of her ARVs and Hgb of 8 g/dl. She had not missed any single
dose from the co-trimoxazole prophylaxis. The nurse was concerned about her Hgb and put her
stall at WHO clinical stage 2. The nurse counseled her on signs of labor & danger signs and
advised her to come to the health facility when she has these signs. She gave her a bottle of
ARVs. The client told the nurse that she would not be able to come to the facility if her husband
went out of town. The nurse reinforced & encouraged her to give birth at a health facility,
continue taking her ART even in labor and provide ARV prophylaxis for the baby. The nurse
promised to attend her delivery & to demonstrate her on how to give NVP for the infant. The
client was appointed around her delivery time.
Q4: Complete the PMTCT register,
Part D: Postpartum
The client managed to give birth at the facility and returned back for PNC after six days. Even
though it was difficult to breastfeed the baby initially, the client gave only breast milk to her
baby. The nurse assured that the baby had got NVP and gave vaccinations. client’s heamoglobin
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turned to 7gm/dl and the nurse gave her iron tablets. After 6 weeks, client returned and the nurse
gave vaccination for the baby, and inserted inplant to her arm following counseling on modern
FP methods. She collected DBS sample and started cotrimoxaxole for the baby.
Client appointed to come back after a month.
Part E: Postpartum (continued)
Unfortunately the DNA PCR result turned out Positive, and client was informed about the result
at the next visit. The Nurse counseled her and transferred out the infant to ART clinic. In fact,
both the mother and infant were referred to ART clinic.
Q5: Update the relevant sections of the PMTCT Register
Case 2: Client 2
Part A: Client 2 first visit: Her ANC card number (MRN ) is 7059328.
Client 2 came for her first ANC visit to your clinic on 13/02/2006. Her LMP was on 28/07/05.
She is 30 weeks pregnant. She was tested HIV-positive at a hospital 8 months ago and has
documentation of her test results on her chart. At that time, she was not enrolled into HIV care
for she was “only visiting temporarily”. However, she has disclosed her status to her partner,
who also tested HIV-positive.
By the time the client came to your clinic, she had on & off intermittent diarrhoea almost for 2
months and had poor weight gain. The nurse put her in WHO clinical stage 3 and enrolled her
into PMTCT and prescribed her fixed dose ARVs, co-trimoxazole and ferrous sulphate. She gave
her adherence counselling and told her to return in a week with a treatment supporter. This
client is the 5th women to start ART in the PMTCT clinic. Her lab result revealed a CD4 count
of 300, haemoglobin- 9 g/dl and nor-reactive VDRL test.
Q6: Fill in all client charts and complete the ANC and PMTCT only register for this client
Part B: Client 2 second visit

This client returned to the ANC clinic as advised by the nurse, she brought her mother on her
second visit. Her urinalysis and stool examinations were not revealing (negative). The client was
cooperative, obedient and listens well; she took her medications as advised. She complains that
she gets tired easily that she associated with the medication. The nurse appointed her after 1
month. She was provided with a bottle of ARVs, blisters of Cotrimpxazole and Fefol.
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Q7: Update the ANC and PMTCT register for client 2.
Part C: Client 2 third visit

This client returned to the clinic after a month as appointed. She took all her ARV drugs and the
diarrhoea stopped shortly after she started the co-trimoxazole. She has no other complaints. She
reported to the nurse that her partner had also started ART. The nursed counseled her on infant
feeding options and discussed about her birth plan. She took her second TT vaccination. She was
appointed after 4 weeks.
Q8: Update the ANC and PMTCT register.
Part D: Client 2 fourth visit

The client returned to the clinic 4 days after her appointment. She came when she left with only
one ARV, claiming that she took all her doses of ARVs as instructed. The nurse encouraged and
counseled her on institutional delivery, exclusive Breast feeding and on benefits of using
immediate post-partum modern FP methods. The nurse reminded her to continue taking her ARVs
while on labor; on ARV prophylaxis for the baby & HIV blood test for the baby before 2 months
of age. She decided to deliver in the facility. She was provided with A bottle of ARVs and blisters
of Co-trimoxazole and appointed after 4 weeks to collect her ARV- refill. . She was expected to
give birth in 2 weeks’ time.
Q9: Update the PMTCT register.
Part E: Post- partum

The client delivered as expected in your facility. She was not stigmatized to inform the midwife
about her taking ARVs. She gave birth to a 2.8kg baby boy. The midwife gave NVP syrup for the
baby. Despite it was difficult and discouraging, she was committed to breastfeeding her baby
since birth. She brought her baby on the 5th day for his first vaccination and for refill. She
returned on the 42nd day together with her baby for vaccination and her PNC. The nurse
evaluated the baby & collected DBS specimen from his foot; stopped the NVP syrup and initiated
him on co-trimoxaxole syrup. She also provided Depo injection on her demand e for the mother. .
The nurse also provided her with a bottle of ARVs, 3 strips of cotrimoxazole and 3 bottles of
cotrimoxazole syrups and appointed her after 1 month reminding her that the result for the baby
would also be ready by then.
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The client came exactly on the appointment day, she heard the blood test result of her baby was
negative, and the follow up and the cotrimoxazole syrup would continue until the baby became
one year old. Client was happy and she chose to continue exclusive breast feeding until 6 month
without adding additional food. She was careful in giving the syrup to the baby & to take ARVs
for herself. The nurse refilled with ARVs, co-trimoxazole tabs & syrup.
Client attended her HIV care and care for her baby visiting the PMTCT nurse monthly until her
baby became 6 months old.
Q10: Update the PMTCT register, both the mother and baby sections.
Part F: Client 2 visit for measles vaccination:
This client came to the clinic 2 days earlier than her appointment. She came for measles
vaccination for her baby. It was more than a month since she stopped breast feeding her baby.
She complained to stop giving cotrimox syrup for the baby for it was getting more difficult & time
taking to administer the syrup in addition she no more breastfed him. Otherwise, both the mother
and baby were in good condition.
The nurse encouraged the client to continue the syrup at least till his birthday when another
blood test is done to confirm free from HIV; provided her with refill ARVs &cotrimox and
appointed her to come back after 3 months.
The nurse noticed on the chart that client missed 3 cycles of Depot injections and asked her if she
took elsewhere. Client was afraid to answer the nurse’s question. It was almost 2 weeks since she
missed her period. She had never suspected the possibility. She did not take any injection after
the initial one. The nurse reassured her and handed her a lab request paper for pregnancy test.
Client took the request paper halfhearted and went out from the clinic.
Q11: Update the PMTCT register,
Q12: What is wrong with this client‘s follow up to the PMTCT service?Discuss on the issues you
identified.
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4.2.2 Reporting: Flow by type and period, channel
Reporting flow
The HMIS report includes data elements regarding the service facilities provide, the disease cases
they treat and administrative data such as human resources, finances and logistics. The data flow
from facilities to FMOH in each month is shown in the diagram below. At each step of reporting,
health officials should review data and evaluate data quality. Regular monitoring will improve
standardization, consistency and quality control.
The reporting channel of public and private health facilities is depicted in the tables below. The
reporting period starts on the 21st of the previous month and ends at the 20th of the reporting
month inclusive (Ethiopian calendar). Facilities shall submit their report to the next level within 5
days, i.e, before the 26th of the reporting month.
For further information & explanation please refer the FMOH HMIS training material, 2018.
Health facilities (public and private) report their performance on the PMTCT program:
 Gather data from individual service delivery units,
 Compile/ Aggregate under standardized Indicator elements, and
 Verify and validate data by PMT/MDT before transmitting to e-record/HMIS
 Transmit the collected data through the HMIS tool that assures standardization, consistency,
and quality control,
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 Submit their HMIS Report to the respective administrative & technical offices monthly,
quarterly and annually.
Administrative health offices (Woreda/Town Health offices, Zonal health departments and
Regional Health Bureaus):
 Monitor facility & program performances using data elements from reports
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4.3 PMTCT cohort monitoring
Time: 960 minutes
Learning Objectives

 Define what cohort and cohort monitoring are
 Explain concepts of PMTCT cohort monitoring.
 Explain maternal and HEI cohort key concepts and outcomes.
 Conceptualize, define and calculate key indicators and outcome measures related to maternal
and HEI cohort monitoring.
 Use Maternal and HEI PMTCT Cohort Monitoring Standard Operating Procedures (SOP)
 Utilize job aid; Maternal and HEI PMTCT follow up card, Cohort monitoring Report Form,
and wall chart
4.3.1 Introduction to PMTCT cohort monitoring
1. What is a cohort?
2. What is cohort monitoring?
Time: 10min
Recent global experiences encourage to move from cross-sectional evaluation towards measuring
impact of all HIV programs, including PMTCT. To that end, programs must routinely monitor
PMTCT outcomes which requires longitudinal monitoring using a cohort approach.
Thus, this training package aims to introduce the PMTCT cohort monitoring tools and procedures
used for the MNCH/PMTCT program to provide detailed step by step instructions on how to
complete these tools; ensure data quality and use routine data to improve performance
management; ensure evidence based decision making and support efforts in continuous quality
improvement (CQI).
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PMTCT Cohort monitoring
A. What is a cohort?
A cohort is a population in which membership is determined entirely by a shared event
What is Cohort monitoring?

Cohort monitoring is a process in which members of a cohort are followed over time in order to
measure an outcome.
Why is PMTCT cohort monitoring important at the facility level?
Can help improve program performance by tracking:
 Client health status

 Quality of care
 Adherence and retention in PMTCT program
 Implementation obstacles at site
 Supplies/stock outs/logistics
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PMTCT cohort monitoring is used to measure the PMTCT intervention outcomes through
longitudinal approach using cohort monitoring tools. The Important PMTCT outcomes are:
 Final status of HIV-exposed infant (most importantly, HIV negative or Positive) and
 Maternal retention on ART (or viral suppression)
 Other PMTCT outcomes: DNA PCR test collected (Early Infant Diagnosis [EID]) by age
2 months.
PMTCT Cascade
Understanding the PMTCT cascade and continuum of care is useful to determine the final
PMTCT outcomes through cohort monitoring.
PMTCT Cascade: cohort outcomes
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Program components or features determining PMTCT cohort monitoring
1. Outcome of interest
Measuring the outcomes of HIV-infected mothers and their exposed infants is necessary to
evaluate and monitor the quality and impact of PMTCT programs. The tools and respective
instructions outlined in this document enable PMTCT providers to measure and understand key
maternal and HEI outcomes at the facility level.
2. Clinical register features
The Integrated MNCH/PMTCT Register captures information on HIV-infected pregnant and

breastfeeding women who enroll into the facility‘s PMTCT program. It contains information
about the mother and HEI over time (longitudinally) from the time of her PMTCT enrollment
until her exit from the facility‘s PMTCT program.
3. Service delivery models—patient and data flow
The PMTCT program is integrated within the MNCH platform and the data source is the PMTCT
cohort register which captures information of both HIV positive pregnant/lactating women and
their HIV exposed infants identified at ANC, labor and delivery and postnatal period. PMTCT
Data collected at facility level needs to follow the national HMIS reporting systems. It is the
responsibility of the PMTCT service provider to ensure that the Maternal and HEI PMTCT
Cohort Report Form and the Maternal and HEI- PMTCT Cohort Wall Chart are accurately
completed within one week of the end of the reporting month.
The four components for each cohort
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For the Maternal cohort
Population: HIV+ pregnant/laboring /breastfeeding mothers in PMTCT program
• Shared event: PMTCT enrollment (Month 0)
• Time points: 3, 6,12 and 24 months
• Outcome: Retention in PMTCT program and viral suppression
Using a cohort approach to monitor HIV+ pregnant, laboring or breastfeeding (BF) women over
time in order to measure their retention in PMTCT* at 3, 6, 12 and 24 months since the Month /
Year of PMTCT enrollment.
For the HIV-exposed infant cohort
• Population: Infants born to HIV+ mothers enrolled in PMTCT program
• Shared event: PMTCT enrollment (Month 0)
• Time points: 12, 18, 24 and 30 months
• Outcomes: final status of HIV-Exposed infant (HIV negative or positive), DNA PCR test
collected (Early Infant Diagnosis [EID]).
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Using a cohort approach to monitor HIV-exposed infants born to HIV+ women in order to
measure their “final” outcome over time.
4.4.2 Maternal PMTCT Cohort Monitoring

The maternal PMTCT cohort monitoring has four components:
1. Population: HIV+ pregnant or breastfeeding women

2. Shared event: maternal PMTCT enrollment (Month/Year) = Month 0
3. Time point: Month 3, Month 6, 12 and Month 24
4. Outcome: maternal retention in PMTCT program and viral suppression
Note:
 The data source for maternal PMTCT cohort monitoring is integrated MNCH/PMTCT
register.
 For HIV+ women not yet on ART, the cohort monitoring assumes ART initiated as soon
as possible upon enrollment in PMTCT
The PMTCT Maternal cohort monitoring is different from the ART cohort monitoring due to the
following reasons;
• Shared event is maternal PMTCT enrollment (NOT ART initiation) at which time the HIV
positive pregnant/lactating women is enrolled to PMTCT program.
• There are 3 categories of HIV+ women at PMTCT enrollment:
1. Already know their HIV+ status AND already on ART
2. Already know their HIV+ status but NOT on ART
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3. Newly diagnosed HIV+ thus NOT on ART yet
Maternal enrollment in PMTCT is the same as Month 0 (month/year (MM/YY)) and it is the time
all the PMTCT clients are enrolled in the PMTCT program. It is the start point for cohort
monitoring. The next month would be Month 1 and so forth.
A. Data Elements Needed to Report Maternal Outcomes:
1. Population
HIV+ pregnant, laboring & BF women registered in the integrated PMTCT register will
comprise of the population for Maternal cohort.
2. Shared event: Maternal enrollment
As defined above Maternal enrollment in PMTCT is the same as Month 0 and this is the time
that all the PMTCT clients enrolled in the PMTCT program.
Month 0: Maternal status data field (refer to the right page of the PMTCT register)
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3.Time Points: Measure the Maternal outcome at 3, 6, 12 and 24 months
Example: see below where you can see the 3 months‘ time point
4.Maternal Outcome:
The “Retention in PMTCT program and viral load suppression” are the desired
outcomes indicated by maternal status ―Alive and on ART‖ (documented by an ART code) For
women not retained in PMTCT, the two other maternal status categories are: lost to follow-up
and known dead
See figure below
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A. Establishing Cohort Size
• The size of the cohort can change at the different time points
• At each time point, the size of the cohort is recalculated and updated
NB: *An HIV-positive pregnant/BF woman from ART clinic who comes for care at a PMTCT
clinic is ENROLLED into PMTCT, NOT TRANSFERRED IN.
B. Calculating cohort size at a time point
C. Original Cohort
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D. Transfer in
HIV+ women may change where they receive PMTCT care
E. Transfer out
HIV+ women may change where they receive PMTCT care or finish PMTCT
Recap: Calculating Net Current Cohort size at a Time Point
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Maternal PMTCT Cohort Monitoring Tools
These tools assist health care providers to conduct cohort monitoring of maternal PMTCT
retention at Months 3, 6, 12 and 24 since maternal enrollment in PMTCT. These tools include;
1. Integrated MNCH/PMTCT Register (data source for Maternal PMTCT Cohort

monitoring)
2. Maternal PMTCT Cohort Report Form
3. Maternal PMTCT Cohort Wall Chart
4. Maternal PMTCT Cohort SOP
5. PMTCT Cohort Monitoring Job Aid

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1. Integrated MNCH/PMTCT Register (data source for Maternal PMTCT Cohort
PURPOSE OF THE INTEGRATED MNCH/PMTCT REGISTER:
The Integrated MNCH/PMTCT Register captures information on HIV-infected pregnant and

breastfeeding women who enroll into the facility‘s PMTCT program. It contains information
about the mother over time (longitudinally) from the time of her PMTCT enrollment until her exit
from the facility‘s PMTCT program. The Register is organized by month/year (MM/YY) of
mother‘s enrollment into the PMTCT program.

This form is used to calculate important outcomes related to retention in the PMTCT program for
a given maternal cohort. Calculation of outcome are done at months 3, 6, 12 and 24 since
maternal PMTCT enrolment. Each maternal PMTCT cohort report form reports on a single
PMTCT maternal cohort in a facility. Information from the maternal PMTCT cohort reporting
form will be used to fill out the facilities maternal PMTCT cohort wall chart.
NB: For procedure in competing the maternal PMTCT cohort reporting form, please refer the
maternal PMTCT cohort monitoring SOP.
The purpose of the reporting form is:
 To calculate maternal outcome (retention in PMTCT program) and other important

maternal status categories at all monitoring time points (Month 3, Month 6, Month 12,
month 24)
There is one Report Form for each Maternal PMTCT Cohort (MM/YY) at a facility
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FEDERAL MINISTRY OF HEALTH OF ETHIOPIA
MATERNAL PMTCT COHORT REPORT FORM FOR THE HEALTH FACILITY
Maternal Enrollment Cohort Month : ______________________ Year:

________________________
Health Facility Name : _____________________________
Region : ________________________________ Woreda :
__________________
Facility type: Health Center Hospital Facility ownership : Public
Private not for profit
Other: ____________________ Private for profit Uniformed
For this maternal cohort, record the number of women enrolled in PMTCT (Month 0). Assess the
following at 3, 6, and 12 months since the mothers’ enrollment into PMTCT.
Materna Maternal Maternal Maternal Maternal
l Cohort Cohort Cohort Cohort Cohort
Fill in the exact Month/Year of the month of mother’s Month Month 3 Month 6 Month 12 Month 24
PMTCT enrollment 0 [mm/yy] [mm/yy] [mm/yy] [mm/yy]
(COHORT MONTH & YEAR = Month 0), and Month [mm/yy]
3, 6, and 12 months since PMTCT enrollment.
Number of HIV-infected women enrolled in

A PMTCT in this facility during this month and year
(Month 0)
UPDATE THE COHORT SIZE
B Total number of Transfer in (TI) since Month 0
C Total number of Transfer out (TO) since Month 0

Number of mothers in the current cohort = Net
D
current cohort (A+B-C)
RECORD MATERNAL OUTCOME
E Mothers Alive and on ART
Lost to F/U (not seen >1 month after scheduled
F
appointment)
G Known dead
CALCULATE MATERNAL RETENTION AND LTF (%)
% of mothers in net current cohort Alive and on
ART
H
[(E/D) x 100% at 3, 6, and 12 months since
PMTCT enrollment]
% of mothers in net current cohort Lost to F/U
I [(F/D) x 100% at 3, 6, and 12 months since
PMTCT enrollment]
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3. Maternal PMTCT cohort SOP
The SOP provides detail instructions and procedures on how to complete the PMTCT cohort
reporting form and wall chart. The SOP instructions outlined in this document enable PMTCT
providers to measure and understand key maternal outcomes at the facility level. Providers are
encouraged to refer to the SOP regularly.
4. Maternal PMTCT Cohort Wall Chart
The purpose of the PMTCT maternal cohort wall chart is to display the facilities PMTCT
maternal outcome information, including maternal retention on ART, loss to follow up and
maternal deaths. It is meant to allow providers to understand the outcomes of the mother in their
PMTCT program. Each maternal PMTCT cohort wall chart displays maternal outcomes of a
single years 12 PMTCT maternal cohorts over time. The wall chart information is the same as
that in the maternal PMTCT cohort reporting forms, including cohort size, maternal outcomes
(mothers alive and on ART, lost to follow up, and known dead), and percentage of women
retained or lost to follow up in the facility PMTCT program.
N.B: For procedure in competing the maternal PMTCT cohort wall chart, please refer the
maternal PMTCT cohort monitoring SOP.
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5. PMTCT Cohort Job Aid
The purpose of the PMTCT Cohort Monitoring Job Aid is to assist providers to identify which
individual monthly cohorts of HIV+ women or HIV-exposed infants (HEIs) should have data
calculated (and entered in Report Forms) for a particular Reporting Month. This Job Aid is used
alongside the Standard Operating Procedures documents for PMTCT Maternal Cohort
Monitoring and for PMTCT HIV-exposed Infant (HEI) Cohort Monitoring, which give
instructions for maternal and HEI cohort reporting.
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Reporting Maternal PMTCT Cohort Outcomes
Reporting month = the last complete month of a follow-up period.
Activities to be performed at each maternal cohort time point
Reporting Point Record the Update the Assess Month 3 Assess Month 6 Assess Month Assess Month 24
Maternal Cohort Size Maternal Maternal Outcome 12 Maternal Maternal
(i.e. time since Original Outcome Outcome Outcome
Cohort
mother‘s PMTCT
enrollment)
Month 0 X -- -- -- --
Month 3 -- X X -- --
Month 6 -- X -- X --
Month 12 -- X -- -- X
Month 24 X X
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Steps used to report on Maternal Cohorts
1. Find the current Reporting Month
2. Identify the cohorts (month/year) that need reports (M3, M6, M12 and M24)
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3. Complete the Report Forms for the proper cohorts
4. Transfer the information to the Wall Chart
Exercise  If the Reporting Month is June 2010EFY, for
Time: 5 min which maternal enrollment cohort would you

assess Month 3 maternal outcome?
 For which maternal enrollment cohort would
you assess Month 6 maternal outcomes?
 For which maternal enrollment cohort would
you assess Month 12 maternal outcomes?
Group exercises on maternal cohort

Time: 235
Exercise 3.1 and 3.2: Using the Maternal PMTCT Cohort Report Form
Purpose: To use data in the register to evaluate maternal outcomes on the Maternal PMTCT
Cohort Report Form
Materials per group: Exercise 3-1 Register page set
Exercise 3-2 Register page set (2 pages long because 12 mothers)
Two blank Maternal PMTCT Cohort Report Forms
Instructions: ―For this exercise, we are going to look at the data retrospectively – looking at all
of the evaluation time points for one cohort (Months 0, 3, 6, 12 and 24 ) and completing all
columns of the Maternal PMTCT Cohort Report Form.
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This exercise will give us good practice looking at all of the different time points. But remember:
when we evaluate cohorts in real life, we will look at the data prospectively in real time (i.e. we
will look at Month 3, 6, 12 and 24 outcomes.
We are going to practice this exercise with two different cohorts from the register. From this
register data, complete the Maternal PMTCT Cohort Report Form. When you are through, we
will discuss the answers as a group, then move on to the HEI cohort.‖
Note: For the maternal cohort, you can complete one month (one column) at a time in small
groups then review the answers to make sure they understand before moving onto the next
column. For the HEI cohort, they can try to complete the entire form and then review the
answers.
Exercise 4:Using the Maternal PMTCT Cohort Report Form and Wall Chart
Purpose: To use data in the register to evaluate maternal outcomes on the Maternal PMTCT
Cohort Report Form, and then transfer that information to the Wall Chart
Materials: One Exercise - 4 Register page set per group
One blank Maternal PMTCT Cohort Report Form per group
One blank maternal wall chart
Instructions: ―For this exercise, we are going to look at the data retrospectively again. This
exercise is similar to Exercise 3, but we are adding one step. First, start by completing the
reporting form just like for exercise 3. Then we will ask for volunteers to transfer that
information to the wall chart.‖
After completing reporting form and reviewing answers as a group, ask participants to gather
around the wall chart. Pre-label the Maternal Cohort Months on the Wall Chart, then ask
participants to find the appropriate month and complete the relevant data fields.
Exercise 5: Using the Job Aid and Maternal PMTCT Cohort tools in real time
Exercise 5a: Using the Job Aid

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Purpose: To practice using the job aid to identify the cohort months that you need to report on
for the given outcome time points (Months 3, 6, 12 and 24 outcomes for the Maternal Cohort)
Materials: One job aid per person
Exercise 5b: Putting it all together - Maternal
Purpose: To report on the appropriate maternal cohort outcomes for a given reporting
month, using the Job Aid and Report Form
Materials per group: One job aid
4 Maternal Report Forms
Exercise 5b Register page sets – 4 cohorts (*Do not distribute these at the
beginning of the exercise)
Instructions: The reporting month in May 2017. It is now early June 2017 and you are
completing your May reports.
Step 1: Decide which cohorts you need to report on & ask a facilitator for the register pages that
you need.
Step 2: Using the register pages that you receive, complete the sections of the Report Form that
are due in reporting month May 2017.
Note: Each small group should get Register page sets for May 2017, Feb 2017, Nov 2016, May
2016.
4.3.3 HIV-EXPOSED INFANT (HEI) PMTCT COHORT

As the country moves towards elimination of MTCT of HIV, stringent monitoring of HIV-
exposedinfants (HEI) whose HIV-infected mothers are enrolled in the PMTCT program becomes
one of the critical elements of the program.
Measuring outcomes of HEI is necessary to evaluate and monitor the quality and impact of
PMTCT programs. HEI will be followed and monitored in groups—or cohorts—based on their
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mothers‘ enrollment (month / year) in the PMTCT program at a facility. Monitoring comprises of
reporting of:
 DNA PCR test (early infant diagnosis [EID]) at Maternal Cohort Months 12 and 18.
 Final outcome status at Maternal Cohort Month 30.
A. HEI Cohort
An HEI PMTCT Cohort is a group of infants whose HIV-infected mothers enrolled in PMTCT
care1 during the same Month / Year. Each year there will be 12 HEI cohorts.
B. Tools for HEI PMTCT cohort monitoring:
 Integrated MNCH/PMTCT Register (data source for HEI PMTCT Cohort monitoring)
 HEI PMTCT Cohort Report Form (to calculate/record outcome information of one HEI
cohort over the monitoring period [Months 12-30])
 SOP for the HEI cohort monitoring
 HEI PMTCT Cohort Wall Chart (displays 1 year of HEI cohort data)
 PMTCT Cohort Monitoring Job Aid (to find which HEI cohorts to report on each month)
C. Data source
The source of HEI PMTCT cohort monitoring is the Integrated MNCH/PMTCT register. This
register is better organized to enroll and monitor HIV positive women and their exposed infants in
pair based on the maternal enrolment month. The simplest and practical tool having a shared
event among HEIs is the month of maternal enrolment.
Hence, the country preferred the month of maternal enrollment as a shared event as mothers in the
same maternal cohort will deliver babies at different times. Mothers in the same maternal cohort
will deliver babies at different times and these babies will be of different ages. (See figure below)
Shared event for HEI = Maternal PMTCT enrollment month/year
1
HIV-infected women can enroll in PMTCT care while pregnant or breastfeeding.
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D. Identifying the cohort
The month/year of enrolment for the mother is found at the top left corner of the register
E. HEI Final outcome
The whole goal of the PMTCT program is to have an HIV-negative baby. But, we know that not
all babies will be negative. Hence, we need to know the final outcome of every baby and ensure
that the goal of our PMTCT program is met.
There are six categories of HEI final outcome.
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1. Discharged negative (DN)
2. Diagnosed positive (P)
3. Lost to F/U (LTFU)
4. Still exposed/breastfeeding (SEBF)
5. Known dead (KD)
6. Transferred out (TO to another PMTCT facility)
When to measure the final outcome?
Month 30 is the time point for measuring final outcome.
Register gathers data through Month 30 (since maternal PMTCT enrollment). Women in Ethiopia
may breastfeed for 18 months or more. To measure final outcome, breastfeeding must be
completely stopped at least for the last six weeks. Therefore Month 30 since mother‘s enrollment
is the last time point in the Register. At Month 30 since mother‘s enrollment, almost all babies
will have weaned from breast feeding and have had the opportunity to have received a final HIV
test.
Secondary HEI outcome of interest
DNA PCR test is the secondary HEI outcome of interest for the HEI PMTCT cohort monitoring.
Early diagnosis of HIV infection using DNA PCR test and enrollment for ART service is an
essential step to prevent morbidity and mortality in HIV infected children. Our guidelines
recommend that infants have DNA PCR test done at 6 weeks of age; however, some infants will
have the test later than 6 weeks of age. Our cohort monitoring process should measure both of
these situations. This means we will measure DNA PCR test collection and report for 2 different
situations:
1. Infant with test collected by 2 months of age

2. Infant with test collected between 2 to 12 months of age
Testing in these two age groups will be measured at Month 12and Month 18since the mother‘s
PMTCT enrollment.
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Lost to Follow/Up: Lost to Follow/Up for HEI is defined as “Infant status” designation for
mothers who have missed their most recent scheduled appointment date by more than one month.
LTFU is important quality indicator in the PMTCT program. Hence, it needs to be followed
regularly.
Time points to measure HEI outcomes and LTFU
There are 4 reporting time points to measure outcomes for each HEI cohort: Months 12, 18, 24
and 30 since mother‘s PMTCT enrollment (Maternal cohort Months 12, 18, 24, and 30). Specific
outcomes are measured at each time point (See Table below).
Reporting Point DNA PCR test DNA PCR test Infant Final outcome
(i.e. time since collected (by age 2 collected Lost to status
mother‘s PMTCT months) (between ages 2 to F/U
enrollment) 12 months)
Month 12 X X X --
Month 18 X X X --
Month 24 -- -- X --
Month 30 -- -- X X
Note:
 These time points (Months 12, 18, 24 and 30) are chosen because the majority of infants
will be old enough to measure the individual outcome of interest
 The reporting point does not correspond to the infant‘s age; rather, it is the month since
the mother’s enrollment into PMTCT.
Identifying Final Outcome: HIV-exposed infant status at Month 30
One of the six categories (refer above) are documented in the right end of the register. Note that
five of the 6 infant status codes are seen on the legend on right page of the Register; the six and
initial test results found on the left page of the register (see table below).
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Infant status*
Indicate NVP for 1st month of life and CPT after 1st month of life
TO for transferred out
LFTU for lost to follow up
D for known dead
DN for Discharged negative infants
P = Diagnosed HIV-positive identified on Left Page under Result DNA PCR or Rapid Test
Possible final outcome 1: Discharged negative (DN)
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Rapid Test Negative (Left Page) and Discharged Negative (DN) on the Right Page
Possible final outcome 2: Positive (P)
The following 3-6 outcome categories are found in the right pages of the cohort register
3. Lost to follow-up (LTFU)
4. CPT (baby still in care and without documentation of final HIV test): should be seen at
Month 29 and/or Month 30
5. Known Dead (D): could appear at any time point
6. Transferred out (TO):could appear at any time point. Double-check for Positive (P). If so,
this TO would be to ART clinic and categorization should be P.
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RIGHT PAGE
NB: To report LTFU there should be at least two consecutive empty boxes from the time point you‘re
measuring
Group exercises on HEI cohort

Time: 240 min
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Exercise 6.1 and 6.2: Using the HEI PMTCT Cohort Report Form
Instructions: ―For this exercise, we are going to look at the data retrospectively – looking at all of
the evaluation time points for one cohort (Month 12, 18, 24, and 30) and completing all columns of
the HEI PMTCT Cohort Report Form.
We are going to practice this exercise with two different cohorts from the register. Register pages
will be provided to you for the first cohort. From this register data, complete the HEI PMTCT
Cohort Report Form. When you are through, we will discuss the answers as a group, then move on to
the 2nd cohort.‖
Materials per group: Exercise 6.1 Register page set
Exercise 6.2 Register page set (2 pages long because 12 mothers)
Two blank HEI PMTCT Cohort Report Forms
Exercise 7:Using the HEI PMTCT Cohort Report Form and Wall Chart
Instructions: ―For this exercise, we are going to look at the data retrospectively again. This
exercise is similar to Exercise 6, but we are adding one step. First, start by completing the reporting
form just like exercise 6. Then, volunteers will transfer that information to the wall chart.‖
After completing reporting form and reviewing answers as a group, participants will gather around
the wall chart. Then, participants will Pre-label the HEI Cohort Months on the Wall Chart, and
participants will find the appropriate month and complete the relevant data fields.
Materials: One Exercise 7 Register page set per group

One blank HEI PMTCT Cohort Report Form per group
One blank HEI wall chart
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Session summary:
Understanding the Maternal and HEI PMTCT Cohort
At this point we have done the following:
1. Reviewed the 4 components of Maternal PMTCT Cohort Monitoring
2. Shown which data elements in the register will help us to:
• Identify maternal cohorts
• Identify the time points of interest (Months on Right page of Register)
• Identify the 3 possible maternal outcomes for women—not just the preferred
outcome (Retention in PMTCT)
3. Shown how to establish cohort size
4. Introduced Maternal PMTCT Cohort Monitoring Tools
• Maternal PMTCT Cohort Report Form
• Maternal PMTCT Cohort Wall Chart
• Maternal PMTCT Cohort Monitoring Standard Operating Procedures (SOP)
• PMTCT Cohort Monitoring Job Aid
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4.4: DATA QUALITY
Time: 60 min
Learning objectives
Participants will:
 Define data quality assurance
 Describe the dimensions of data quality
 Describe why data quality assurance is important for PMTCT
Defining Data quality and data quality assurance
Quality PMTCT data are characterized by accuracy, validity, reliability, confidentiality and
completeness at all forms. In order to assure quality of PMTCT data, the PMTCT service shall
respect good clinical practice, registration of patient data and primary collection and review of
data at the health facility service delivery level.
Dimensions of data Quality
Accuracy: Also known as validity. Accurate PMTCT data are considered correct; the data
measures what it is intended to measure. Accurate data minimizes errors e.g., it minimizes
interviewer bias, and recording, transcription, sampling errors, … to a point of being negligible.
Reliability: The data generated by program information system is based on protocols and
procedures that do not change according to who uses them and when or how often they are used.
The data are reliable because they are measured and collected consistently in a standardized way.
Precision: This means that the data have sufficient detail. For example, an HCT indicator
requires the number of individuals who received HIV counseling and testing and received their
test results, by sex of the individual. An information system lacks precision if it is not designed
to record the sex of the individual who received counseling and testing. Precision is not the same
thing as accuracy. It is possible for reported results to be precise but not accurate.
Completeness: means that an information system from which the results are derived is
appropriately inclusive: it represents the complete list of eligible persons or units and not just a
fraction or sample of the total. A PMTCT indicator is complete when it includes the data from
ANC, L&D & PNC.
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Timeliness: Data are timely when they are documented and reported at the appointed time.
Timeliness is affected by: (1) the rate at which the program information system is updated; (2) the
rate of change of actual program activities; and (3) when the information is actually used or
required.
Integrity: Data have integrity when the system used to generate them is protected from deliberate
bias or manipulation for unacceptable reasons. The PMTCT data shall represent the truth; the
actual practice so that remedial measures can be designed.
Confidentiality: means clients are assured that their data are maintained according to national
and/or international standards; this means that personal data are not disclosed inappropriately, and
data in hard copy and electronic format are treated with appropriate levels of security (e.g.,
PMTCT data are kept in locked cabinets (hard copy) and in password protected files -soft copy).
Data Quality Assurance
PMTCT data quality is assured by periodic review of the recordings and reports generated
through supportive supervision and data quality checks. Key questions to ask during supportive
supervision include:
o Are providers able to record data on the registers and tally sheets appropriately? Do they
record appropriate data on each column/row of registers and tallies?
o Are the data recorded on the registers match with the data reported?
Provide training & develop providers‘ skill to appropriately fill patients‘ records, registers and
reports. Develop their skills in simple calculations of facility indicators for assessing their
performance using the data that they record.
Provide regular feed-back on their performance and the quality of data they have generated
based-on the data they report. Provide verbal /written positive feedback to providers on spot or
during meetings for their good work for maintaining quality data generation.
Health care workers shall know who is accountable for the monitoring activities like
o Reliable and accurate Recording of data ,
o How and when to report information and indicators.
Health care workers contribute to the overall monitoring process to make it as accurate and
reliable as possible by providing feedback about:
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 How the system is working
 Useful methods for sharing information,
 Whether the monitoring tools are easy to complete accurately and reliably and are being
used in a standard manner by everyone.
4.5 Performance Evaluation using Dashboard and Continuous Quality

Improvement (CQI)
Time: 160 min
Learning objectives
 Assess performance at all levels using the monthly collected data and improve the
PMTCT service,
 Utilize data for decision-making and program planning.
 Address how health facility staff and health management approach and use quality
improvement methods to focus on the system of care in which they practice.
4.5.1 Performance evaluation using dashboard

Using M&E Data for Decision-Making and Program Planning
The performance of PMTCT service is checked/ shown with the routine M&E. A functional
M&E system translates raw data into information that will be used at all levels giving clear
accountability for service units & providers and for evidence-based informed decision to improve
the programs.
At health facility level, M&E information shall be analyzed and used in line with the relevant
facility indicators:
 To access the performance of service delivery units, facility and the program as a whole,
 To improve the performance and quality of health service and for program planning.
Facilities shall analyze their PMTCT data/ performance regularly and conduct self-assessments
for selected indicators (monthly, quarterly and annually).
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Group exercises
Time: 15 min
The supervisor reports that MOH has discovered only 65 % of HIV-positive pregnant women
nationwide have received ART in 2020. He writes 65% on the flipchart to emphasize his point.
He continues saying that your health facility is among the lowest, with just 18% of HIV-positive
pregnant women are taking ART, and writes 18% on the flipchart. He called the
PMTCT/MNCH/ART service providers and coordinators for a meeting to find out the reasons.
He points to the group that,According to the national plan your health facility is expected to reach
to 90% and asked why the numbers are so low.
Discuss the following topics in your small group.
What is your interpretation of the monitoring data, i.e., why do you think so few women accept
ART)?
Identify any additional information needed to understand why the performance is so low.
Determine a set of recommendations for your facility to respond to the gap between the
guidelines and the practice.
A member of the group will record the answers on flipchart for presentation to the larger group.
Key PMTCT indicator elements to be monitored at facility level:

Key indicator elements for PMTCT service are important to regularly follow/ monitor the
PMTCT service at health facility level. Providers & focal persons monitor their performance,
identify their gaps that need urgent interventions or close follow up, address root causes and plan
for improvement. At facility/ service delivery point level, PMTCT performance is measured using
the following facility indicators:
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Table 40: Key PMTCT indicator elements for health facilities
DASHBOARD SCORING
Color Percentage and Color and Scoring Definitions
Green: 80%-100% Target achieved or on track
Yellow: 60%-79% Progress but more effort required
Red:<60% Not on track
S. No Variable Description, for the reporting period Number Percentage Score Color
1 Total # of HIV+ pregnant or lactating women that were
enrolled in care in the facility (can be unit specific-
ANC, L&D, PNC)
(ANC + Labor & Delivery + PNC) = PMTCT register
2 # of HIV+ pregnant & lactating women
identified,(New)
3 # of HIV+ women already on ART when coming to
ANC/ L&D/ PNC,
4 Of these, the # and % of HIV+ pregnant/ lactating
women receiving ART (newly initiated on ART and
Already on ART linked with ANC)
5 Proportion of HIV+ women newly initiated on ART,
6 Total # and % of HIV+ pregnant/ lactating women
receiving co-trimoxazole (CTX) according to national
guidelines
7 % of HIV+ pregnant/ lactating women on ART with
viral suppression (<1000ml)
8 Total # and % of HIV+ pregnant/ lactating women -
nutritional assessment done with MUAC
9 Total # and % of Malnourished HIV+ pregnant/
lactating women linked/ provided with nutritional care
10 Total # and % of HIV+ lactating women who received
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FP counselling
11 Total # and % of lactating HIV+ women using modern
FP methods
12 Total # and % of pregnant or lactating HIV+ women
who are labeled LTFU
(missed appointment for more than 31 days)
13 Total # of HIV exposed infants (HEIs) enrolled in care
in the facility
14 Total # and % of HEIs enrolled in care and receiving
NVP + AZT prophylaxis
15 Total # and % of HEIs who had virologic testing for
HIV at 6 to 8 weeks of age
16 Total # and % of HEIs who had virologic testing for
HIV from 2-12 months of age
17 Total # and % of HEIs Antibody testing done for HIV
at 18 months of age to confirm HIV outcome
18 Total # and % of HEIs receiving Co-trimoxazole (CPT)
19 Total # and % of HEIs with a positive virologic test
result
20 Total # and % of HEIs with positive virologic test
result linked to HIV care (initiated ART)
21 Total # and % of male Partners tested & know their
HIV status during the reporting period (ANC/ L&D/
PNC)
22 Total # and % of pregnant women tested for Syphilis
23 Total # and % of pregnant women reactive for Syphilis
test and treated
24 Total # and % of pregnant women tested for HBV
25 Total # and % of pregnant women received HBV
prophylaxis
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Dash board is a tool that shows managers the progress of program performance via selected key
indicators. Hence; selected indicators will be taken as PMTCT dash board monitoring for facility
and program managers at facility Woreda, ZHD, RHB or FMOH levels. The indicators stated on
the dashboard can be modified, expanded or replaced overtime depending on the priority and
degree of improvement.
See Sample Dashboard at Annex 4.14
4.5.2 Performance Evaluation using Continuous Quality improvement (CQI)

Quality Improvement (QI) is an approach to improve the service through the routine use of health
and program data to meet patient and program needs. M&E data provides valuable information
that can be used as part of efforts in continuous quality improvement (CQI). CQI represents one
form of using data generated by M&E system to improve the quality of services.
Purpose: to improve quality of MNCH/PMTCT services through institutionalizing continuous

quality improvement tool in health facilities.
Key Principles of CQI in the Context of MNCH/PMTCT
The CQI of Integrated PMTCT/MNCH care is expected to fulfill the following key principles:
 Address Client satisfaction- Focusing on the needs of HIV+ women to have HIV free baby,
 Follow Scientific approach- to implement new approaches by implementing an improvement
model- measuring →testing change →re-measuring → applying change.
 Apply Team approach- involving the leadership, knowledgeable staff from different
units/work process (laboratory, pharmacy, ART, PMTCT/MNCH etc.). It is also a
complement to involve the community in the team.
Quality improvement activities to improve services shall be integrated into the routine flow of
existing work. This avoids considering CQI activity as a separate program and additional burden
to the routine work. Once the service shows improvement, the system starts functioning more
efficiently and effectively and the tasks become simplified & harmonized further.
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How does CQI work for PMTCT?
In order to implement CQI in PMTCT program, quality improvement initiatives shall be tuned for
the PMTCT service. First define quality PMTCT service and set priorities to identify specific
areas for improvement. Second, set up a system to define & measure performance measurement
methods for improvement and set baseline use of existing data, or collect data that will be used to
monitor successes. Third, establish a Team that identifies the gap between current and expected
level of quality among front line providers and use appropriate method to close the gaps.
As the quality improvement is a team activity, the following are recommended steps a quality
team can do to facilitate quality improvement initiatives in PMTCT service:
Step 1: Understand the process of PMTCT service provided in the clinic clearly articulating the
process, and stating their outputs and outcomes. By doing so, the QI team can list implementation
steps, develop a flow chart and identify potential barriers. The following figure gives an overview
of the general steps taken in a typical MNCH/ PMTCT services.
Step 2: Measure quality standards through selected indicators (or performance measures) for
the quality standard. Once these quality indicators are selected, the QI team will need to collect,
investigate and present the results of their analysis during Multi-Disciplinary Team (MDT)
meetings.
The HMIS indicators for MNCH/PMTCT will be used for measuring performance of
MNCH/PMTCT service delivery at various points. Performance measurement tells what is really
happening, as opposed to what we think is happening. It tells what is being documented in the
clinic records and is available to help with the decision-making of providers who see the patient.
It also tells whether tasks that are supposed to be done are being done, and done well.
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Step 3: Develop a problem statement: Once gaps/ opportunities for improvement are
recognized, the QI team will work on prioritizing for intervention. To prioritize areas of
intervention, consider feasibility, and resource availability that the control QI team has to solve
the problem.
For addressing each of the problems selected, a clear and concise statement that the QI team has
discussed and agreed upon should be used to state the problem in reference. Stating a problem
statement helps the QI team to have a shared vision of the opportunity at hand. Problem statement
shall be blame free and not discussing solutions.
Instead of presenting the Statement of the Problem as ―Women are not tested at ANC because
ANC staff do not offer HIV test. This increases missed opportunities of HIV testing of ANC
attendants.‖ It is better to rewrite as ―Number of ANC attendants that get tested for HIV averages
at 45% of ANC attendants in the months of April – June 2013. This has been stated as one of the
missed opportunities in PMTCT.‖
Step 4: Analyze the root causes of the problem stated, and brainstorm on improvement strategies
to test. Root cause analysis can be done in one of the following ways- Fishbone analysis, The
Five Whys, or Key Driver Diagram.
―Fishbone Analysis‖ using Fishbone Diagram (―Cause & Effect Diagram‖) is used to brainstorm
and map out possible causes of a quality problem. Draw a central line next to the problem we are
working on (a spine), and draw diagonal lines that represent categories of possible causes that the
QI team will brainstorm about. Take the five Ps (patients/clients, providers, policies, processes
and procedures, and place/equipment) as standard branches (bones) as shown in the figure below.
However, it is possible to use different types of groupings applicable to your facility.
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―The Five
Whys‖
method
starts by
stating the
problem
you are
trying to
work on first, and asking a series of whys related to the problem until you get insight on core
causes. The Five Whys can be used along with Fishbone Diagrams to brainstorm on root causes
of a problem. Why low partner testing? Why don‘t partners present? Why not allowed at L&D?
Why policy?
―Key Driver Diagram‖ helps to organize our test ideas in an improvement effort. It lays out the
initial contributors (primary driver or root causes) of a given statement, and then additional
contributors to the contributory itself (secondary drivers or immediate causes). A descriptive test
idea can then be listed with the purpose of testing. The tree-like structure of the diagram assists in
enhancing the development of a predictive thought process.
Once the tree is constructed, the QI team or multidisciplinary team can decide to work on (1) one
test idea towards one set aim, (2) multiple test ideas towards different respective aims, or (3)
multiple test ideas working towards one aim. The driver diagram should be updated throughout an
improvement effort and used to track progress in theory building. Figure below provides a
template of key driver diagram.
Step 5: Develop an aim statement. After declaring the problem and analyzing the root causes of
the stated problem, develop an aim statement articulating the area for improvement, its current
status, and its intended achievements. Aim statements should be Specific, Measurable,
Actionable, Realistic, and Time bound (SMART) as follows.
Step 6: Test and implement the proposed intervention (a test-idea). The test(s) can be several
small tests or one large test of all proposed solutions. The continuous PDSA (Plan-Do-Study-Act)
cycles are one of the tools used to test and implement newly proposed interventions. This is done
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by turning ideas into action and connecting actions taken to learning. Figure 4.1 and the
descriptions below it spell out the details included in each phase of PDSA.
Figure 20: Items to consider when

conducting a PDSA cycle (Source:
Langley et al., 2009)
Implementing CQI at health facility level
Implementing CQI as a provider
All health workers are expected to adhere to the Standard Operating Procedures, standard
protocols and professional ethics to treat patients respectfully and professionally. Providers
trained on PMTCT shall practice what the standard protocol expects and make orientation & on-
job training for co-workers so that the PMTCT service provision fulfills the standard.
The facility led quality assessment checklist (tool) helps each health care provider to check
his/her own actions vis-à-vis the national standard. It summarizes the detail activities (without
which performance might be compromised) of individual service entry points to one key activity
to be scored, which ultimately is captured in the national M&E indicator list.
At every entry point, the minimum quality function will be posted to remind health workers while
providing services. It enables individual providers to self-check and score their performance
observing their own progress. Sixteen key quality result statements are identified along with their
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corresponding sub-activities that are to be counted for scoring each key action. The total
numerator is then added up and compared to denominators sum. The proportion described
in percentage will indicate how much the minimum standards are met at the unit level or at
facility level.
Implementing CQI as a team (Multi-Disciplinary Team (MDT):
As PMTCT service is a team work integrated to the MNCH service, implementing CQI in team
will improve the quality of service, which contributes further to increased uptake of
MNCH/PMTCT services. The minimum quality performance can be assessed using the led
assessment checklist (Annex 2a) and client satisfaction assessment (Annex 2b) to identify areas
for improvement and initiation of CQI process by MDT who are knowledgeable on the respective
service delivery area and scored accordingly. (Please note that this checklist is subject for
modification according to the facility setting).
The use of available data helps identify current gaps that need to be addressed through:
 Asking staff and patients for ideas about what needs to be improved;
 Prioritizing key opportunities for improvement;
 Selecting one specific improvement at a time on which to focus your work.
7.1.1. Facility level
How to use the CQI tools/Facility led assessment checklist
This CQI tool enables facilities to check minimum service standards expected to be implemented
at all service delivery points and can be used as a starting point to identify problems in the health
care system. This tool is meant principally to identify the LTFU cases and missed opportunities in
the provision of PMTCT services particularly drop-outs from the PMTCT cascade services
including HIV exposed infants.
This checklist should be used both by health workers at different PMTCT service points (ANC,
L&D, PNC,) as individual providers and as a team/ MDT (CQI team) or even by external body
(CQA team) to monitor the quality of PMTCT performance in the health facility.
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For example, (1) an individual provider at ANC clinic can check her/ his performance comparing
with the minimum standards of care expected in the unit and strive to improve her/his
performance accordingly; (2) As a team, providers at L&D can use this tool to conduct a baseline
assessment for the PMTCT service rendered at L&D against the standard expected, and agree to
work for improvement, then monitor the changes/ improvements periodically every two weeks;
this can be done by MDT as well. (3) The PMTCT team at Woreda level can also use this tool to
get an external view of the quality of services in a health facility within respective catchment
areas.
The tool has eighteen quality result statements with 50 corresponding check points/actions in
questions for nine service delivery areas. These service areas are: Card Room or Reception, ANC
unit, L&D, PNC, FP, EPI, HEI, pharmacy and laboratory.
Check all the boxes for the ―Checking points‖. Put a tick―‖ mark in the box if the performance
complies with the standard and put ―X‖ mark otherwise. You can decide to mark-up on the
checking points/questions after Observation ―O‖, Interview ―I‖, or Review of Documents ―RD‖.
You can follow the letters in parenthesis next to each checking point to assist you to identify
which approach is better to use for answering the questions. For check points, reviewing relevant
documents is important before deciding. If you find some important findings for the question, you
can write them under the remark column of the table.
For scoring, there is a ―Rank‖ column to put the score for each of the result statements. When
scoring, count the boxes with tick mark only (―‖) and plot the number of ticks as numerator and
the total check points as denominator (―‖ and ―X‖). There is a column labeled as ―M&E
(Quant.) indicators‖. This is meant for writing the corresponding performance indicators of the
health facility/ unit. Once you finish scoring all the check points, go to the last two rows of the
tool to do the aggregate score for the entry points; add all numerators and denominators
separately then calculate the proportion by multiplying the result by 100 to get the percentage.
This helps to compare performance over a period of time and for summarizing performance
numerically.
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Client Exit Interview Check list (Annex 4.15.1) Optional:
This checklist is the center of MNCH/PMTCT quality improvement and assurance for the
Accelerated PMTCT plan and beyond. It is intended to be used by the MDT/CQI team and the
health managers at different levels to understand the quality of service at the health facilities from
the clients/patients perspective. A minimum of four clients who used the health facility for
MNCH/PMTCT services will be interviewed on their exit from the service. It is important to note
that the more clients interviewed, the more reliable the results obtained will be.
Scoring: The response to the first and the last questions on reason for the visit and which service
areas are not satisfactory are meant to specifically identify service areas that require immediate
attention by the health facility. The responses to questions, as per annex 2b, numbered two
through to six are to be scored out of 100. Answers to each of the five questions are given equal
weight, which is 20%. An ―Excellent‖ response will receive a 20 point score; a ―Good‖ response
carries a 15 point score; and a ―Fair‖ response carries a 10 point score. This helps to position the
health facility in respect to client satisfaction and lay the ground to provoke the staff to strengthen
improvement activities.
Roles and responsibilities of MDT /CQI Team at facility level
General understanding: PMTCT service is a team activity that involves different service units.
The MDT is expected to meet twice a month or as per the terms of the health facility. the MDT is
preferably composed of the head of the facility, technical coordinator/ PMTCT focal, and staff
from ANC, L&D, PNC, pharmacy, laboratory, ART program units. The MDT or CQI team
cannot be supervisors; rather they can play the role of supervisor and suggest remedial actions,
assist in skill transfer to improve the clinical work and the health service system in general.
Specific Roles and responsibilities
In order to institute CQI in a PMTCT service set up, it is advisable to start with 2-3 providers well
versed on MNCH/PMTCT service delivery as a sub-team. Orient the team members on the tool &
how to measure clinical performance. The PMTCT focal who compiles the monthly HMIS report
is vital member to participate in the team.
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Dedicate time to conduct an internal periodic quality monitoring supportive supervision in all
MNCH/PMTCT entry units and score quality performance, and stress the importance of complete
documentation to help determine whether or not patients are getting the care they deserve; (use
Annex 4.15.1)
Special emphasis is to be given to Lost to follow-up (LTFU) care during supervision and the
tracing mechanism of HIV positive women (pregnant, lactating…). Conduct and review a client
satisfaction survey monthly Reviewing the quantitative performance monitoring indicators
(M&E) checks: Analyzing the results (from HMIS) vis-à-vis the quality performance checks
Conduct CQI process i.e. measure, testing changes, re-measure, apply the changes and
continually move in a cycle of re-testing changes. All the reviews are undertaken to shape the
service system to improvement.
In order to critically analyze (compare), the following summary checklist could possibly be used
during each MDT/CQI team meeting before starting.
Process checklist Remark

Measure CQI process performance →  Is the CQI process of data gathering conducted
using checklist or other means?
Measure quantitative performance →  Are the current performance monitoring indicators
of MNCH/PMTCT available?
Measure client satisfaction →  Is the client satisfaction survey conducted
currently?
Analysis for the cause of variation  Is the baseline or previous information available?
and plan, do study and act on the  Is the baseline or previous information action plan
next process → available?
 Is the previous MTD report available?
Discuss using the CQI process and develop a plan of action (Annex 4.15.3 Action planning
framework) for self-use and for facility use.
Once the process of CQI is complete, documenting organized ideas using the action plan
framework is important both for implementation and follow-up. The action plan framework
consists of 10 columns. The first 5 columns are used to summarize the different steps gone
through the assessment (study) process until prioritized test action is set. Columns 6 - 8 are for
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planning responsibility, setting time period and resource required. The last two columns are used
to remind and link with the next run of the PDSA cycle. When completing the column‘s cells,
keywords are preferred over long statements (phrases) in any applicable situations. However, it is
advisable to be cautious against the wrong interpretation of some terms/words.
Equally important is record keeping. Making changes resulting in improvement is not a

mechanical process. People are involved and their individual; as well as team efforts should be
clearly noted to be accountable for the changes made and for the feedback loops. Keeping all
records safe and clean will enable use of the findings to guide future actions.
Report compilation and recording: The data generated from CQI process will primarily assist
the facility to take its own action/s as well as serve as reference on the continuous progress
monitoring during the subsequent checks until a comfortable state of actions are obtained. It
could also serve for proposal writing to solicit funds from donors and fill the identified gaps.
Another important value is the documentation of best practices that are identified during the
implementation process.
Session Summary:
• A dashboard is an information management tool that visually tracks, analyzes and
displays key performance indicators and key data points to monitor the health program.
• CQI is a management philosophy which contends that most things can be improved
• An approach to improve the service through the routine use of health and program data to
meet patient and program needs
• The systematic and continuous actions that lead to measurable improvements in health
care services and the health status of targeted patient groups
• Most problems are found in processes, not in people. CQI does not seek to blame, but
rather to improve processes.
• It is possible to achieve continual improvement through small, incremental changes using
the scientific method.
Continuous improvement is most effective when it becomes a natural part of the way
every day work is done
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REFERENCES
Ethiopia AIDS Resource Center (ETHARC). A flipchart to promote PMTCT in Ethiopia. Addis
Ababa, Ethiopia: ETHARC. http://www.etharc.org/resources/download/finish/61/336
Federal HIV/AID Prevention and Control Office (FHAPCO). 2007. Guidelines for management
of opportunistic infections and antiretroviral treatment in adolescents and adults in Ethiopia.
Addis Ababa, Ethiopia: FHAPCO.
http://fitun.etharc.org/resources/guidelinesresources/adultandadolescentguidelines/oi_art_guid
eline.pdf
Federal HIV/AIDS Prevention and Control Office (FHAPCO). 2007. Guidelines for prevention of
mother-to-child transmission of HIV in Ethiopia. Addis Ababa, Ethiopia: FHAPCO.
http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---
ilo_aids/documents/legaldocument/wcms_125389.pdf
Federal Democratic Republic of Ethiopia Ministry of Health (FMOH). 2010. National training
package: provider-initiated HIV testing and counseling: trainer’s manual. Addis Ababa,
Ethiopia: FMOH. http://www.etharc.org/resources/download/finish/33/422
Federal Ministry of Health (FMOH) Ethiopia, Disease Prevention and Control Department. 2004.
Infection prevention guidelines for healthcare facilities in Ethiopia. Addis Ababa, Ethiopia:
FMOH. http://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---
ilo_aids/documents/legaldocument/wcms_125383.pdf
Helping Babies Breath American Academy of Pediatrics 2010
International Training and Education Center on HIV (I-TECH) and Ethiopia Federal Ministry of
Health. 2006. HIV care and ART: A course for physicians. Seattle, WA: I-TECH.
http://www.searchitech.org/itech?page=ff-03-01 (accessed January 10, 2011)
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World Health Organization (WHO) Department of Reproductive Health and Research. 2003.
Managing complications in pregnancy and childbirth: a guide for midwives and doctors.
Geneva, Switzerland: WHO.
World Health Organization (WHO), Department of Reproductive Health and Research. 2002.
WHO antenatal care randomized trial: manual for the implementation for the new model.
Geneva, Switzerland: WHO.
World Health Organization (WHO), Department of Making Pregnancy Safer. 2006. Pregnancy,
childbirth, postpartum and newborn care: a guide for essential practice. Geneva,
Switzerland: WHO. http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf
World Health Organization (WHO), US Centers of Disease Control and Prevention

(CDC).Prevention of mother-to-child transmission of HIV infection: Generic training
package. January 2008. http://www.womenchildrenhiv.org/wchiv?page=pi-60-00 (accessed
January 10, 2011).
UNFPA and EngenderHealth. 2004. HIV prevention in maternal health services: Training guide.
New York: UNFPA and EngenderHealth. http://www.engenderhealth.org/files/pubs/hiv-aids-
stis/hiv_prev_training_gde.pdf (accessed January 10, 2011)
WHO. 2006. Reproductive choices and family planning for people living with HIV: Counselling
tool. Geneva: WHO.
http://www.who.int/reproductivehealth/topics/family_planning/9241595132/en/ (accessed
January 10, 2011)
Refer Basic Emergency Obstetric & Newborn Care (BEMONC) Training Manual, Federal
Democratic Republic of Ethiopia, Ministry of Health the newly updated one
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Annexes
Chapter 1 annexes
Annex 1.1. Responding to Excuses for Not Using Condoms
1. ―I can‘t feel anything when I wear a condom.‖

Possible response: ―I know there‘s a little less sensation, but there‘s not a lot less. Why
don‘t we put a drop of water-based lubricant inside the condom? That‘ll make it feel more
sensitive. Besides if we use a condom I‘ll feel a lot safer and more relaxed, and that will
make sex more enjoyable for both of us.‖
[Note: Lubricants should be water-based.]
2. ―I don‘t need to use a condom. I haven‘t had sex in three months, so I know I don‘t
have any diseases.‖
Possible response: ―That‘s good to know. As far as I know, I‘m disease-free, too. But I‘d
still like to use a condom because either one of us could have an infection and not know
it.‖
3. ―My HIV test was negative.‖
Possible response: “HIV is not the only infection I‘m worried about; there are several
STIs that may not have any visible symptoms even if you are infected. A condom will
help protect us both from getting an STI.‖
4. ―If I have to stop and put it on, I won‘t be in the mood anymore.‖
Possible response: ―I can help you put it on. That way, you‘ll continue to be in the mood,
and we‘ll both be protected.‖
5. ―Condoms are messy, and they smell funny.‖

Possible response: ―It‘s really not that bad. And sex can be a little messy sometimes. But
this way, we‘ll be able to enjoy it and both be protected from HIV and other STIs and
pregnancy.‖
6. ―Let‘s not use condoms just this once.‖

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Possible response: ―No. Once is all it takes to get pregnant or get an infection.‖
7. ―I don‘t have a condom with me.‖

Possible response: ―That‘s okay. I do have.‖
8. ―You never asked me to use a condom before. Are you unfaithful?‖

Possible response: ―No. I just think we made a mistake by never using condoms before.
One of us could have an infection and not know it. It‘s best to be safe.‖
9. ―If you really loved me, you wouldn‘t make me wear one.‖
Possible response: ―Love isn‘t the issue, but getting an STI is. If you really loved me,
you‘d want to protect yourself—and me— from infections and pregnancy so we can be
together and healthy for a long time.‖
10. ―Why are you asking me to wear a condom? Do you think I‘m dirty or something?‖
Possible response: ―It‘s not about being dirty or clean. It‘s about avoiding the risk of
infection and pregnancy.‖
11. ―Condoms don‘t fit me.‖

Possible response: ―Condoms can stretch a lot—in fact, they can stretch to fit over a
person‘s head! So we should be able to find one that fits you.‖
12. ―Why should we use condoms? They just break.‖

Possible response: ―Actually, they told me that condoms are tested before they‘re sent
out—so while they have been known to break, it happens rarely, especially if you know
how to use one correctly, and I do.‖
13. ―What happens if it comes off? It can get lost inside you, and you‘ll get sick, or could
even die. Do you want that?‖
Possible response: ―It‘s impossible for the condom to get lost inside me. If it came off,
it‘d be inside my vagina, and I could just reach in and pull it out.‖
14. ―If you don‘t want to get pregnant, why don‘t you just take the birth control pill?‖
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Possible response: ―Because the birth control pill only protects against pregnancy. The
condom protects against both pregnancy and infections‖ or ―Because I discussed my
options with a doctor, and we decided that condoms are the best method for me to use to
prevent pregnancy.‖
15. ―My religion says that using condoms is wrong.‖

Possible response: ―It might help to talk with one of your religious leaders to find out
their views and make sure that you aren‘t making any false assumptions.‖
16. ―Well, I‘m not going to use a condom, and that‘s it. So let‘s have sex.‖
Possible response: ―No. I‘m not willing to have sex without a condom.‖
17. ―No one else uses them. Why should we be so different?‖

Possible response: ―Because a lot of people who didn‘t use them ended up with HIV.‖
18. ―You‘re a woman. How can you possibly ask me to use a condom? How can I respect
you after this?‖
Possible response: ―You should respect me even more because I am acting responsibly.
I‘m suggesting this because I care about you and respect myself enough to protect myself.
That‘s enough for me.‖
Annex 1.2. The Five ‗A‘s Approach

Using the 5A‘ helps to, delivery of comprehensive MNCH/PMTCT/ART services and improving
quality of training and services as well.
 Assess
 Advise
 Agree
 Assist
 Arrange
ASSESS
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Assess the ANC client‘s plan for today's visit
"Is there anything special about HIV/AIDS or ART or PMTCT you would like to address in
today's session?"
Assess understanding of ARV therapy (ART) for PMTCT
Assessing whether the patient, care givers understand PMTCT/ART/MNCH should include
specific questions. Asking general questions like: "Do you understand everything concerning
antiretroviral therapy/PMTCT?" is not very useful. Most of the patients/care givers will answer
"yes" to this question, even if they do not understand all of it. The best way is to ask questions
that require more than a 'yes' or a 'no' from the patient/care giver.
Questions that make patients/care givers explain in their own words are good to assess their
understanding. It is important to make patients/care givers feel comfortable, not as if they are
taking a test! If a patient has misunderstood or forgotten some information, reassure the
patient/care giver that this is normal and explain once more. Questions that can be asked to assess
the patient's or partners understanding when they come as a couple:
"What do you know about MNCH/ HIV/AIDS / PMTCT/ ART services?‖
If necessary, more specific questions can be used, because big questions such as "what do you
know about HIV/AIDS and ART/PMTCT?" can sometimes overwhelm the patient. In that case,
the patient might say "nothing", though they might know a lot when you ask smaller but specific
questions:
Why do you come to this clinic today?
Do you know about PMTCT services?
What are the benefits of ART?
Does ART cure patients from HIV?
How long do you have to take ART?
Why is it important to come regularly to the health center when you are taking ART?
What do you know about side effects of ART?
Why is it important not to miss a dose when you take ART?
What happens if you do not take ART correctly?
Why is it not good to combine ART with other drugs without consulting the health provider?
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Are you interested in receiving PMTCT and follow up services for you, your baby and the family
members?
ADVICE
"I have some information about HIV/AIDS and ART/PMTCT.. Would you like to hear it?"
Give the patient/ couple advice on the following topics (use the flipchart when this is helpful):
 HIV illness and expected progression (locally adapted, using language your patient
canunderstand).
 Asymptomatic period of some years after infection.
 Opportunistic infections that gradually becomes more serious, because HIV is attacking
the body's defense.
 Explain that in children the progression of disease is often rapid.
 It is good to use drawings or a flipchart to explain these topics:
You can use the story of Alemayehu & Aselef (in Chapter 2) to explain the natural course
of the diseases. Give information about ARV therapy (ART):
 ARVs are: life-saving drugs and their life depend on taking the correct daily dose at the
right time.
 Very strong medicines.
 The pills do not cure HIV—they just control it.
 The pills do not prevent transmission of HIV to others—you must still use condoms and
practice safer sex. The therapy can never eradicate the virus from your body.
 If you forget to take your medicine and remember within four hours, it is OK to take it
then.
 The next dose should be taken at the usual time.
 If you stop you will become ill again (not immediately(, it may take months or even years
as your immunity drops again).
 Possibility of side effects and drug interactions.
 Importance of disclosure of HIV+ status.
 Importance of testing partner and children (see family matrix tool on annex 10).
 Drugs must not be shared with family or friends—patient must take the full dose.
Do not overwhelm the patient/ couples with too much information at once.
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When you give advice, it is necessary to evaluate the patient's confidence and readiness to adopt
the treatment. If you notice the patient/ care giver is not paying attention anymore, or does not
make eye-contact with you anymore, it is good to ask if there is a reason for this. If you have the
impression you have lost the patient's/ care giver‘s attention, it might mean the patient/ is
overwhelmed by the amount of information. Or it could mean the patient is starting to think that
all of this is too difficult for her
AGREE
Before initiating ARV therapy, establish that the patient/ couples is willing and motivated and
agrees to treatment or the care provided
When agreeing with patients to start ART, it is important to check whether the patient is willing
and motivated. The patient is the one that must take the responsibility for taking the medication.
Care worker's impression does not always correspond with the real situation concerning
motivation and adherence.
That is why it is useful to check:
 Has the patient/ couples demonstrated ability to keep appointments and to adhere to other
medications? Whether the patient comes on time on the appointments (check book and
patient chart) and takes other treatments (for example co-trimoxazole prophylaxis)
correctly (ask the patient to repeat how he takes it, count pills).
 Does the patient have a history of non-adherence, for example, a TB defaulter? This
should not exclude this patient, but means that more work is required to prepare for
adherence to ART, infant feeding options, family planning......
 Has the patient disclosed his or her HIV status? If not, encourage the patient to do so.
 Disclosure to at least one person who can be the treatment supporter is important. Overall,
supporting disclosure is important, ask a mentor mothers/ counselor in clinic to help
 Do the patients/ couple want treatment and understand what treatment is for?
 Willingness to come for the required clinic follow-up?
 Is the care giver willing to bring the pregnant, laboring and lactating HIV positive
women/ the child to the clinic for the required follow-up?
 Is the care giver taking her/his treatment or does she/he need it?
ASSIST
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 Explore what is needed to assist the patient/couple with PMTCT/ ART:
 What problems might arise when you follow this plan?"
 What questions do you have about this treatment or how to follow this plan?"
 Help the patient/ caregiver develop the resources/support/arrangements needed for
adherence:
 Ability to come/bring the child/ for required schedule of follow-up. It is crucial to discuss
this in detail. If the patient/care giver lives far away, it is necessary to ask how they will
come. With a family member that has a car? Will the family member be available to come
regularly to the consultation, or if there is an unexpected complication? With public
transport? Will you have money available to pay for public transport?
 Home and work situation that permits taking medications regularly without stigma.
 Some people might be away from home for more than 12 hours a day, and be surrounded
by people all the time. It is important to check whether the patient will be able to cope
with this situation. This means the patient always needs to carry some pills with him (in
apocket), and might need to find a place to take the drugs without others watching.
Perhaps a watch with a discrete alarm is needed to remind them when it's time to take
medication.
 It is important to help the patient figure out routines to set up before starting ART that fit
regular pill-taking with the rest of their life.
 Regular supply: It is important to guarantee a continuous supply of drugs. This is a
substantial commitment. Taking drugs for a limited time or with interruptions will create
resistance. For patients buying their own (other than ARV) drugs, it is important to assess
the viability of their financial resources.
 Supportive family or friends. Stigma and discrimination in the family may be a barrier to
adherence. A family that knows about the diagnosis and are willing to remind the patient
to take the drugs or to support the patient in moments where adherence is difficult can
help support adherence. Mother mentors and ART adherence support groups are very
essential. These can be very important to support adherence.
 Community based organizations may organize these groups or someone on your clinical
team can help your patients set up such groups because treatment supporter—prepare this
316
person: This is a very important person for treatment success. It is important that this
person be prepared for their role, either in the clinic or by a
Community/Group Supporting PMTCT/ART
How to prepare (mother support group):
 Have a meeting with HIV positive mothers who pass through PMTCT services
 Discuss about the need for commitment, confidentiality, knowledge on PMTCT, HIV,
ART and TB, malaria related needs and also emergency resource needs such as money,
help with household, children, which can arise while on treatment).
 Educate on what ―being confidential‖ means.
 Educate on how to remind the patient to take the medicine (and to work out with the
patient how best to do so),
 Be present at the follow-up appointments,
 To accompany patient to support group meeting if possible.
 Educate to prevent his/her burn-out.
 Prepare to provide psychosocial support.
 Request his/her presence at the three preparatory visits prior ART initiation
 Hold treatment supporter meetings at facilities every two weeks to deal with issues facing
 Explain how the PMTCT/MNCH health workers / clinical team can be reached by phone
or any other quick way of consultation if urgent problems with the patient arise.
ARRANGE
 When patient/couple / is ready for ARV therapy, discuss at clinical team meeting, then
make a plan.
 Appointment at least one week or less for PMTCT purpose in a test and treat Option B+
recommendations
Reinforce key messages.
 Arrange an appointment.
 Record the information you gave during this visit on the back of the Treatment Card, so
you can adapt the next consultation.
 Register the data on the mother baby pair cohort register
After completion of this counseling session health workers should be clear with:
317
 Who will be responsible for administration of the drugs ?Refill the drug
 What medication will be given?
 Timing and frequency of medication
 How to administer medication.
 How to measure adherence to care and treatment?
318
Annex 1.3 Viral Load Request Form
319
Annex 1.4 Viral load register
320
Annex 1.5: Mental Health Screening Tool
Brief Mental Health Disorder Symptom Screening Tool for PLHIV and Referral Tool
MRN: __________UniqueART No:_____________Date:__________Patient‘s Name: __________________

This checklist is to assist you in assessing and making a timely referral of the client to the treatment team. All behaviors listed below are important and should be taken seriously;
they are also designed to help you decide if you should refer the client to the treatment team for further assistance. An answer of ―yes‖ to any one of the following questions should
prompt further referral and evaluation by the treatment team or mental health professional. Please put a (√)to indicate a yes answer.
Questions to Identify Depression: In the past 3 months;
(___) Was there ever a time when you felt sad, or depressed for more than 2 weeks in a row?
(___) Was there ever a time lasting more than 2 weeks when you lost interest in most things like hobbies, work, or activities that usually give you pleasure?
Questions to Identify Anxiety: In the past 3 months;
(___) Did you ever have a period lasting more than 1 month when most of the time you felt worried and anxious?
(___) Did you have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy when most people would not be afraid or anxious?
(___) Did you ever have a spell or an attack when for no reason your heart suddenly started to race, you felt faint, or you couldn‘t catch your breath?
Questions to Identify Mania: In the past 3 months;
(___) When not high or intoxicated, did you ever feel extremely energetic, elated or irritable and more talkative than usual that stayed for at least a week?
Questions to Identify Substance Abuse
(___) Have you ever felt the need to cut down on your use of alcohol or drugs?
(___) Has anyone annoyed you by criticizing your use of alcohol or drugs?
(___) Have you ever felt guilty because of something you‘ve done while drinking or using drugs?
(___) Have you ever taken a drink or used drugs to steady your nerves or get over a hangover (eye-opener)? A total of ≥2 may be suggestive of a problem.
Questions to identify suicidal ideation: Since your last visit [or in the last 2 months];
(___) Have you wished you were dead, or wished you could go to sleep and not wake up?
(___) Have you had actual thoughts of killing yourself?(___) Have you ever attempted to harm/kill yourselff?
Questions to Identify Psychosis: Observe or ask families whether the patient (in the last 3 months);
(___) Talking & acting strangely or becoming very quiet and avoid talking.
(___) Claiming to hear voices or see things that other people don‘t.
(___) Being very suspicions, perhaps claiming that other people are trying to harm him/her.
Questions to Identify Dementia: Interview the patient or families whether the patient (in the last 3 months);
(___) Has trouble with memory (___) Has diminished orientation to time, place and person (___)Has diminished executive function.
Questions to Identify Epilepsy:
321
(___) Did you ever have partial or generalized fits [sharp, shaky movements], frothing accompanied by loss of control of bowel or bladder function, sudden loss of consciousness,
and stiff limbs?
Referred by: _______________________ Date: _______________
Feedback (confirm the assessment)

The patient has: (___) Mental Health Disorder (specify) ________________________ (___) Non Mental Health Disorder
Name of clinician: _________________________ Date: _________
322
Annex 1.6. High Viral Load Client Follow-up Form
Name of Health Facility:

1.Patient Information: Name:_______________Age: ___ Sex: M F UAN:________
2. ARV Information Viral Load Results
ARV Regimen Date of initiation: 1stVLresult: ________ c/ml Date:___/___/___
___________ ____/____/____
___________ ____/____/____ Previous VL: _______c/mlDate:___/___/___
___________ ____/____/_____ Date 1st VL result & 1st EAC Session given:___/__/___
3. Give the viral load test result and explain the following to the client
 Viral Load is the number of HIV copies in the blood
 High VL result can be due to poor adherence to medication or can be due to primary
resistance.
 When VL result is high in the blood, the CD4 count decreases, OIs are flare up and disease
progresses.
 High VL can be reduced as a result of good adherence to medication within three months.
Adherence Rate at EAC Session 1

4. Assess current adherence to treatment and >95% 85-94% <85%
document  Good Fair Poor
4.1 How many ARV dose/s do you take/day? <2 dose 3-4 doses >5 doses
Once Twice <3 doses 4-9 doses >9 doses
4.2 Did you miss ARV doses in the past 1month?
Yes No
323
4.3 If Yes, # dose/s you missed? <2 3-4 >5 <3
4-9 >9
5. Explore Medical and Psychosocial Reasons for High VL EAC
5.1 Identify Medical Reasons for High Viral Load Session 1
 Did you take other drugs than ARVs without consulting your physician? (Yes, No),
 If Yes, identify the drug/s, review interaction with ARVs, counsel the client & discontinue
 Have you ever developed recurrent OIs including cough, fever, weight loss, night sweat,
diarrhoea, and vomiting in the past? (Yes, No). If yes, investigate for TB and chronic diarrhea
and manage
 Have you ever developed severe ARV drugs side effects in the past? (Yes, No), If Yes,
investigate and manage for ARVs side effects.
 Have ever taken ART/PMTCT prophylaxis in the past prior to ART initiation?
 (Yes, No), If Yes, suspect primary resistance and consult ART physician
 Did you discontinue your ARV in the past? (Yes, No), If Yes, identify reasons and develop
treatment plan with the client.
 If the client is a child, check proper dosing for weight by reviewing chart and readjust ARV
dosing for weight.
5.2 Identify Psychosocial Reasons for High Viral Load
5.2.1 Cognitive barriers: understanding and expectation -counsel & explain expected
outcomes
 What were the reason/s for missing your ARV dose/s in the past?Identify the reason/s,
counsel and motivate the client to develop medication taking plan.
5.2.2.Socio-economic barriers:lack of social support, disclosure, stigma, &poor living
condition
 Have you disclosed your HIV status to anyone? If No, provide disclosure counseling
and encourage
 Do you have treatment supporter?(Yes, No)If No, counsel to designate treatment
supporter
5.2.3 Behavioural barriers:attitude, motivation, confidence & skills – educate, motivate,
and empower client to manage medication taking and develop reminder
 What do you do to remind yourself to take drugs on time?
 Are you confident to take your ARV openly at home?
324
5.2.4 Psychological/Emotional barriers: common mental illness: depression, PTSD,
substance abuse, and psychosis – link to psychiatric clinic for psychotherapy & treatment
 Have you ever felt sad for more than 2 weeks? Have you ever lost interest in activities
that usually give you pleasure for more than 2 weeks?Have you regularly taken alcohol
or chew Khat?
Rate at Session 2 Rate at Session 3

4. Assess current adherence to treatment >95% 85- <85% >95% 85-94% <85%
and document 94%
Good Fair Poor Good Fair Poor

4.1 How many ARV dose/s do you <2 3-4 <5 <2 3-4 >5
take/day? Once Twice
<3 4-9 >9 <3 4-9 >9
4.2 Did you miss ARV doses in the past one
month? Yes No
4.3 If Yes, dose/s missed? <2 3-4 >5
<3 4-9 >9
5. Explore Medical and Psychosocial Reasons for Date:__/__/__ Date:__/__/__

High VL
5.1 Follow-up status of identified medical EAC Session 2 EAC Session 3
reason/s for High Viral Load


5.2 Follow-up status of identified psychosocial
reasons for High Viral Load
325
5.2.1 Cognitive barriers:


5.2.2 Socio-economic barriers:

5.2.3 Behavioural barriers:


5.2.4 Psychological/Emotional barriers:

Outcome of EAC Sessions:
 Did the patient attend all the appointments? (Yes No) If no, any reason? _______________________
 Major remaining barriers identified after EAC sessions: Behavioral Cognitive Socio-economic
Emotional.___________________________________________________________________
 If patient is defaulted EAC session/s or adherence barriers were not resolved, second Viral Load should be deferred and
EAC extended.
 Share decision with the team.
 Date of collection of 2nd Viral Load:__/__/___,2ndViral Load result:____c/ml Date: ____/____/____
 Your next plan? continue current regimen referring to ART Physician
ART Nurse:_________________________________ Date of final assessment: ____/____/________
Decision by ART physician

What is the plan for this patient? Shifted to Second-line Regimen. continue current regimen
Comment:___________________________________________________________________________
ART Physician:_______________________________________ Date: ____/____/________
326
Annex 1.7 High viral load register
327
Annex 1.8 Re-testing register
328
Annex 1.9 Case Investigation Form
1. Partner and Family based Index Case Testing Case Investigation Form (CIF)
(Index Client form)
A. Facility Information
Region Town Facility Name Name of Service provider
______________________ _______________ ______________________ __________________
B. Index Client Information
Name Father name Grandfather Sex 1. Male Age MRN UAN
2. Female ___ ______ ________
__________ _____________ _____________
Sub city/Zone Woreda Kebele House No
Address: _______________ _______________ ________________ _________________
Phone # (primary): Alternative phone #1: Alternative phone #2:
____________________ ______________________ _______________________
Marital status: 1. Single 2. Married 3. Divorced 4. Separated 5. Widowed 6. Co-habiting
Population group:
1. FSW 2. Long distance drivers 3. Mobile Workers 4. Pregnant Mothers 5. Refugee
6. Prisoner 7. Military 8. Vulnerable Adolescents 9.Others Specify(general population, etc)
C. Reporting Information (Eligibility)
1. HIV new diagnosis 2. PLHIV (known HIV+) with:
Date HIV tested (DD/MM/YYYY) 2.1 Viral Load >1000 copies/mm3
________________________ 2.2 Drop out and returned
2.3 Not yet disclosed to partner
2.4 New partner
2.5 Disclosed but not tested yet
2.6 STI
2.7 Key population( Female sex workers)
D. Interview Information
If offered, (DD/MM/YYYY) If interviewed, (DD/MM/YYYY) If NOT interviewed, Reason:
1. Refused
Date 1st Offered ____________________ Date 1st interview 2.Dead
Date 2ndOffered ____________________ 3. Other (specify):
___________________ Date 2nd interview _______________________
Date 3rd Offered ____________________
___________________ Date 3rd Interview
____________________
Index client is willing to provide name(s) of partner(s).1. Yes 2. No after 3rd interview, what are the reasons for not willing
to provide the name(s)?
If yes, proceed to Page 2

ANNEX1.10 Clinical grading of drug toxicities
Grade 1 Grade 2 Grade 3
Item Mild toxicity Moderate Severe toxicity*

toxicity
Peripheral neuropathy Transient or mild Moderate Marked limitation in

discomfort, no limitation of activity, some
limitation of activity activity, some assistance usually
assistance might required, medical
No medical
be needed intervention/therapy
intervention/treatment
required,
required Non-narcotic
hospitalization
analgesia
possible
required
Severe discomfort
and/or severe
impairment
(decrease or loss of
sensation up to
knees or wrists)
narcotic analgesia
required
Cutaneous/Rash/Dermatitis** Erythema, pruritus Diffuse, Vesiculation or

maculopapular moist desquamation
rash or dry or ulceration*
desquamation
Management Continue ARV substitute Stop ARV and

responsible drug consult experienced
Provide careful
physician
330
clinical monitoring
Consider change of a
single drug if
condition worsens
ANNEX 1.11. Laboratory Grading of Adverse Events in Adults and adolescents (ACTG)
Laboratory Test Abnormalities
Item Grade 1 toxicity Grade 2 Grade 3 Grade 4

toxicity toxicity toxicity
Haemoglobin 8.0-9.4 g/dL 7.0-7.9 g/dL 6.5-6.9 g/dL <6.5 g/dL
Absolute 1,000-1,500 mm3 750-990 mm3 500-749 mm3 <500 mm3
Neutrophil Count
Platelets -75,0000- 99,000 50,000-74,999 20,0000-49,999 <20,000
mm3
ALT 1.25-2.5 X upper 2.5-5 X upper 5.0-10 X upper 10 X upper
normal limit normal limit normal limit normal limit
Bilirubin 1-1.5XULN 1.5-2.5 X ULN 2.5-5 x upper >5 x upper
limits of normal limits of normal
Amylase/lipase 1-1.5XULN 1.5-2 X ULN 2-5 x upper >5x upper limits
limits of normal of normal
Triglycerides * 200-399mg/dL 400-750 mg/dL 751-1200mg/dL >1200mg/dL
Cholesterol * 1.0 –1.3 X Upper 1.3-1.6 X Upper 1.6-2.0 X Upper 2.0 X Upper
normal limit normal limit normal limit normal limit
MANAGEMENT Continue ARV substitute Stop ARV and
responsible drug consult
Repeat test 2
experience
weeks after initial
physician
test and reassess
Lipid imbalances
could be managed
with diet, exercise
and
pharmacologically
with the use of
fibrates.
331
ALWAYS SEEK
EXPERT
ADVICE IN
CASE OF
DOUBT
Annex 1.3 Major types of toxicities associated with ARV drugs and their management.
ARV Major types of Risk factors Suggested Remar
toxicity management k
Drug
ABC Hypersensitivit Substitute with TDF

y reaction. or AZT for first line,
substitute with TDF,
for second line.
ATV/r Electrocardiogr Pre-existing

aphic conduction
Use with caution in
Abnormalities system people with
(PR and QRS disease; preexisting
interval conduction disease
concomitant
prolongation). or who are on
use of other
concomitant drugs
drugs that they may prolong the
may prolong PR or QRS interval
the PR
interval
Indirect Underlying This phenomenon is

hyperbilirubine hepatic clinically benign but
mia disease, potentially
stigmatizing. ,
(clinical HBV and HCV
Substitute with LPV/r
jaundice) co-infection;
only if adherence
Concomitant compromised.
use of
332
hepatotoxic
drugs.
Renal stone History of Substitute with

renal stone. LPV/r.
AZT Anemia, Baseline Avoid use of AZT for

neutropenia anaemia or people with HIV and
severe anemia at
neutropenia
baseline (hemoglobin
CD4 count <7.0 g/dl) as first-line
≤200 therapy.
cells/mm3.
Substitute with TDF
or ABC.
DRV/ Hepatotoxicity Underlying Substitute with ATV/r Usual

r hepatic or LPV/r. When it is adult
disease, HBV used in third-line dose
and HCV ART, limited options of
coinfection; are available. DRV/r
concomitant 600/1
use of 00 mg
hepatotoxic twice
drugs. daily.
Severe skin Sulfonamide For hypersensitivity

and allergy. reactions, substitute
hypersensitivit with another
y reactions. therapeutic class.
DTG* Hepatotoxicity Hepatitis B or If DTG is used in first-

Hypersensitivit C coinfection, line ART, and there
y reactions. Liver disease. are hypersensitivity
reactions, substitute
Weight gain
with another
Hyperglycemia therapeutic class
333
Insomnia (EFV or boosted PIs).
LPV/r Electrocardiogr People with Use with caution in

aphic pre-existing
people with pre-
abnormalities
conduction existing
(PR and QT
system
interval conduction disease
disease;
prolongation, or those on
concomitant
torsade’s de concomitant drugs
use of other
pointes). that
drugs that
may prolong the PR
may prolong
or QRS intervals
the
PR interval,
Congenital
long QT
syndrome,
Hypokalemia
Concomitant
use of drugs If LPV/r is used in
children, substitute
that may with DTG or EFV
prolong the according to age.
QT ATV can be used for
children older than 6
interval
years.
Hepatotoxicity Underlying
If LPV/r is used in
hepatic
second-line ART for
disease
adults, use ATV/r. If
HBV and HCV boosted PIs are
co-infection contraindicated
Concomitant and the person has

use of failed an NNRTI
based first line ART
334
hepatotoxic use DTG or consult
drug specialist
Pancreatitis Advanced HIV

disease
severe Substitute with ATV/r

diarrhea
Risk of Risk factors

prematurity, unknown
Lipoatrophy or
metabolic
syndrome,
dyslipidemia or
pancreatitis
,NVP There are rare Use AZT only

(For reports of
HEIs Hypersensitivit
proph y and
ylaxis hepatotoxicity
)
Persistent Depression or DTG or boosted PI

central other mental
nervous disorder
(previous or
system toxicity
at baseline)
(such
Daytime
EFV as abnormal
dosing
dreams,
depression or
mental
confusion)
335
Hepatotoxicity Underlying
hepatic
disease – HBV
and HCV co-
infection
Concomitant
use of
hepatotoxic
drug
Convulsions History of
seizure
Severe skin Risk factors Use DTG or boosted

Hypersensitivit unknown. PI
y reaction.
Gynecomastia Risk factor Use DTG or boosted

unknown. PI
Chronic kidney Underlying Substitute with AZT

disease, acute renal disease; or ABC.
renal injury,
older age;
Fanconi BMI <18.5 (or
syndrome. body weight
<50 kg); Do not initiate TDF at
eGFR <50 mL/min,
untreated
TDF uncontrolled
diabetes
hypertension,
mellitus;
untreated diabetes,
untreated or presence of renal
hypertension; failure.
Concomitant It is recommended to
use of monitor growth in
nephrotoxic children taking TDF
drugs or a
336
boosted PI. containing regimen.
Decreases in History of
bone mineral osteomalacia
and
Density.
pathological
fracture; risk
factors for
osteoporosis
or bone loss.
Lactic acidosis Prolonged

or severe exposure to
hepatomegaly nucleoside
with steatosis. analogues;
Obesity.
337
Chapter 3 Annexes
Annex 3.1. Danger signs needing immediate Care of the Newborn and women
Assess for emergency signs:
• Newborn not breathing, or is gasping
• Respiratory rate less than 30 breaths per minute
• Low or high body temperature
• Convulsion
• Bleeding or shock.
Ask, Look and Sign Classify Treatment

check listen
record
Is the  Is baby  Not breathing Birth Start resuscitation:
infant not  Gasping asphyxia  Clear the airways
having breathin  Breathing  Rub the baby‘s back for ten
difficulty g? poorly (less seconds
breathing?  Is baby than 30 per  Position the newborn
gasping? minute)  Ventilation using appropriate size
 Count mask /self-inflating bag
the  Strong cry No birth  Provide cord care
breaths  Breathing asphyxia  Provide eye care
in one more than 30  Give vitamin K, 1mg IM on mid-
minute per minute anterior thigh
 Initiate skin-to-skin contact
 Initiate exclusive breastfeeding
Is the  Umbilica  Active Bleeding  Secure umbilical cord for visible
338
infant l stump bleeding from bleeding
bleeding? bleeding umbilicus  Vitamin K 1mg IM once if not
 Pallor  Sign of shock given
 Ensure warmth
 Do BG/Rh and hemoglobin if
possible
 Refer if bleeding does not stop
 Weight Very  Give first dose of gentamycin
Gestational  Weigh <1500gm Low  Continue with expressed
age the baby  Gestational birth breastfeeding
age <32 weeks weight  Give vitamin K 0.5mg IM mid-
or thigh
preterm  Refer urgently
Weight 1500 to Low  Kangaroo Mother Care
<2500gm OR birth  Counsel on optimal breastfeeding
Gestational age weight  Counsel on prevention of infection
32 -36 weeks or  Give vitamin K 1mg IM on mid-
preterm anterior thigh
Ask, check Look and listen Sign Classify Treatment

record
 Count the Any one of the  Give first dose of
Is the breaths in one following signs: intramuscular
infant not minute. Repeat  Not feeding Very Antibiotics
feeding the count if well severe (Ampicillin and
339
(sucking)? more than 60  Convulsions disease gentamycin).
breaths per  Fast breathing  Treat to prevent low
minute. (60 breaths blood sugar
Is the infant  Look for severe per minute or  Advise mother how
having chest in more) to keep the infant
convulsions drawing.  Severe chest warm on the way to
?  Look and listen in drawing the hospital.
for grunting.  Grunting  Refer URGENTLY
 Look at the  Movement to hospital
young infant‘s only when
movements. stimulated or
– Does the infant no movement
move only even when
when stimulated
stimulated?  Fever
– Does the infant (37.5°C* or
not move even above) *
when  Low body
stimulated? temperature
(<35.5°C*)
 Look at the  Red umbilicus Local  Give co-trimoxazole
umbilicus. Is it or draining bacterial or amoxicillin for
red or draining pus infection five days.
pus? OR  Teach mother to
 Look for skin  Skin pustules treat local infection.
340
pustules.  Advise when to
return.
 Measure  Temperature Low  Treat to prevent low
temperature between 35.5 body blood sugar.
(feel for fever, – 36.4o C temperat  Keep baby warm
or low body (both value ure using Kangaroo
temperature) inclusive) Mother Care.
 Refer if temperature
remains the same.
Look for jaundice  Palms and Severe  Warm the baby
 Are the palms soles yellow jaundice (Kangaroo Mother
and soles OR Care)
yellow?  Age <24  Refer
 Is skin on the hours or
face or eyes  Age 14 days
yellow? or more
 Only skin or Jaundice  Advise mother to
eyes yellow give home care.
 Encourage indirect
sunlight and
exclusive and
frequent feeding
 Advice mother
when to return.
341
Maternal Danger Sign
Advise to go to a hospital or health center immediately, day or night, WITHOUT
WAITING, if any of the following signs:
 Vaginal bleeding, Convulsions, Fast or difficult breathing, Fever and too

weak to get out of bed, Severe abdominal pain.
Go to health center as soon as possible if any of the following signs:
Fever, Abdominal pain, Calf pain, redness or swelling, Severe headaches

accompanied, visual disturbances, Edema in hands and face Feels ill, Breasts
swollen, red or tender breasts, or sore nipple, Urine dribbling or pain on
micturition, Pain in the perineum or draining pus, Foul-smelling lochia
342
343
Annex 3.2. Use of Dried Blood Spots (DBS) for DNA PCR
Dried blood spots have been used in newborn screening programs to determine
maternal HIV infection and in research trials to determine HIV subtype. DBS can
be obtained by using blood from a heel-prick in infants or a finger-stick in older
children. This is less traumatic than venipuncture and uses only a small volume of
blood. DBS carries less infective risk than liquid samples and can be stored at
room temperature making them easier to transport to central sites for testing.
Clinic staff members should be trained to collect DBS. Appropriate universal
blood and fluid precautions should be followed.
The health worker‘s job responsibility is:
Collecting valid specimens

Appropriately labeling and storing the specimens until transported for testing
Ensuring records are properly maintained
Avoiding transcription errors.
Steps in DBS (How to Collect, Store, and Transport DBS)
 Prepare the necessary supplies: Blood collection card (filter paper), gloves,
lancet, alcohol, gauze or cotton wool, sealable plastic bags, humidity cards,
and desiccant packs
 Follow standard precaution for handling of blood.
 Clearly label card with appropriate identification number.
 Do not touch circles/sites for blood samples.
 After soaking each circle/site with blood, dry the DBS completely before
packaging (it requires a minimum of three hours to dry).
 Protect the DBS card from sunlight, bugs, cockroaches, and dust.
 When dry, stack the DBS cards between sheets of weighing paper.
 Insert cards into sealable, gas-impermeable plastic bag.
 Add desiccant packets, minimum 10 packets per bag.
 Insert DBS cards into envelope. Include lab requisitions and specimen
delivery checklist, and clearly label the outside of the envelope.
 Send the envelope to the nearest regional laboratory.
Where HIV PCR tests are available, the sample algorithm in Figure 5.3 may be
used.
If DNA PCR test is available, every HIV-exposed infant should have a DNA
PCR test.
o If the HIV DNA PCR result is POSITIVE, the infant is presumed to be

HIV-INFECTED. Repeat DNA-PCR and in the meantime refer these
infants to a pediatric ART treatment center for care and treatment.
If the HIV DNA PCR result is NEGATIVE, the infant is presumed NOT to be
HIV-infected. But if the child develops HIV symptoms (oral thrush,
pneumonia, poor growth, developmental delay, chronic diarrhea) repeat HIV
DNA PCR testing. (NOTE: Breastfeeding infants remain at risk for
acquiring HIV if infant is less than 18 months.)
o If the second HIV DNA PCR result is POSITIVE, the infant is presumed
to be HIV-INFECTED and should be referred to a pediatric ART
treatment center for care and treatment.
o If the second HIV DNA PCR result is NEGATIVE, the infant is

presumed NOT to be HIV-infected
If mother has opted to breastfeed, advise mother to continue exclusive
breastfeeding through 6 months of age, and then to transition to
complementary feeding; breast feeding can be continued up to the age of 24
months. Weaning should be over a period of one month.
6 weeks after stopping breastfeeding for an HIV-exposed infant:
Use the rapid antibody test to test for HIV
o If negative, the infant is presumed NOT to be HIV-infected and may be

discharged from the program and continue routine well childcare.
o If positive, and the infant is less than 18 months of age repeat HIV DNA
PCR test because the maternal antibody can persist until 18 months of
age.
At 18 months of age for an HIV-exposed infant:
Use the rapid antibody test to test for HIV
o If negative and the infant has stopped breast feeding for at least 6 weeks,
the infant is NOT HIV-infected and may be discharged from the program
and continue routine well childcare.
o If positive, the infant is HIV-infected and should be referred to a

pediatric ART treatment center for care and treatment.
If the infant is still breastfeeding, repeat rapid HIV test 6 weeks after weaning.
How to collect DBS

1. Correctly complete all information requested on the laboratory requisition
form.
2. Wash hands and wear powder-free gloves.

3. Confirm identity of infant; write the following information on the DBS filter
paper supplied by the Central Laboratory:
 Infant‘s name
 Unique identifier
 Date of test
 Hospital name
4. Do not allow water, formulae, powder from gloves, antiseptic solutions to

come into contact with filter paper before or after collection of samples since
this will affect the result.
5. Draw an imaginary line from midpoint of the big toe to the heel, and one
from between the 4th and 5th toe to the heel. The arrows indicate safe areas
for puncture site namely X, Y and Z. Do not puncture the back of the heel,
Achilles tendon, or lateral aspect of the big toe.
6. With small infants (<9kg), puncture the heel. Do not puncture the fingers;
there is risk of hitting the bone.
7. Larger infants (>9kg) puncture the heel, if callous is visible, you may use the
medial aspect of the big toe. Do not stick the fingers or small toes; there is
risk of hitting the bone. (This is also true when doing an HIV rapid test. Do
not stick fingers or small toes of small children. Fingers are safe around age
two)
8. Hold the infant‘s foot below the level of the heart; this will help blood flow
more easily.
9. Warm the area, especially if the infant is cold, with a warm moist cloth for
three minutes; this can increase blood flow through the site. The mother can
hold baby‘s foot in her hand, rubbing it gently may help.
10.Clean the area with alcohol, and let it dry for 30 seconds.
11.Using a lancet or heel incision device puncture the site identified as above.
The puncture should be to a depth of less than 2.0mm. Do not use a needle
or scalpel or longer lancet. The lancets are the correct length to puncture
safely without damaging bone.
12.Gently wipe away the first drop of blood with a sterile gauze or clean cotton
ball.
13.Allow another large droplet of blood to form at the puncture site.
14.Gently touch the printed side of the filter paper against the large drop and
allow it to completely fill the circle on the paper. The first drop should fill
the circle. Do not press the paper against the heel.
15.Fill in remaining, at least four, circles in the same manner with successive
drops of blood; one circle is not enough to test. If a circle is poorly done,
move to the next one. Do not apply blood to both sides of the filter paper.
Avoid smearing or touching the spots.
16.If there is not enough blood, you may gently press the area around the
puncture site. Do not ―milk‖ the area, or you will get tissue fluid instead of
blood, and the lab will not be able to test it.
17.Clean the puncture site and press a cotton swab against it until it stops
bleeding. Do not use a bandage.
Drying DBS
18.Once the blood spots have been collected, they need to dry.
19.Do not touch or smear the spots.

20.Place the filter paper on a flat surface or a Schleicher and Schuell cardboard
drying rack and allow to AIR DRY overnight (minimum of three hours).
21.Protect them from sunlight, bugs, and dust.
22.Do not stack, heat, or allow to touch other surfaces during the drying
process. INSUFFICIENT DRYING ADVERSELY AFFECTS TEST
RESULTS.
NB. Drying is the most important process to assure stability of the HIV viral DNA
in the paper. If the DBS is not well dried after staying overnight at room
temperature, the silica contained in the desiccant packets packed together with the
DBS can remove all the remaining moisture.
Packaging DBS
23.Once DBS are completely dry, stack them between sheets of weighing paper
so that DBS cards from different infants are not touching one another.
24.Pack up to 15 DBS cards in a gas-impermeable bag.

25.Add the following items to the bag to preserve the specimens: two desiccant
packs per sample (this will remove any residual moisture from cards and
humidity indicator card (which will indicate the relative humidity inside the
bag).
26.Press as much air out of the bag as possible and seal it shut.
27.The humidity indicator card and the desiccant packs have a color indicator
which changes from blue to pink as humidity increases. All cards and packs
should be replaced with fresh material before they change to a pink color.
NB. Plastic or foil bags used for DBS storage must be gas impermeable. Bags from
grocery stores or other outlets that do not sell scientific supplies are not adequate
and should not be used.
Storage of DBS
28.For storage before transportation to the laboratory, DBS should be kept in

gas impermeable bags with desiccant and humidity indicator cards and
stored at room temperature inside a drawer.
29.Avoid exposing DBS to light. The light and oxygen can react with
hemoglobin-producing active oxygen which can damage the viral
RNA/DNA material.
Transportation of specimens to the laboratory
30.DBS should be transported to the Central Laboratory on the scheduled day.

31.To prepare DBS for transport, remove bagged samples from the drawer and
remove old desiccants. Add fresh desiccants and reseal bag.
32.Use the specimen delivery checklist to verify you have a requisition form for
each DBS.
33.Place the bag of DBS, requisition forms, and the specimen delivery checklist
into a large cardboard or padded envelope, and seal.
34.Label the envelope with
• Your clinic name
• Infant DBS specimens
• Date you are sending to lab

35.Transport the bag by the fastest means possible to the laboratory. AVOID
EXPOSURE TO EXTREMES OF HEAT DURING TRANSPORTATION.
36.If a cooler is available for transport this will protect the samples from short
periods of high temperature.
NB. DBS is considered non-infectious and can be sent inside a letter envelope
without additional bio safety measures.
Annex 3.3: Algorithm for testing of HIV Exposed infants less 18 months of age
HIV-exposed infant or child (4-6 weeks to 18 months)
Conduct DNA PCR a (at 4-6 weeks or

at the earliest opportunity thereafter)
Positive Negative
HIV infection not detected but if infant/child is breastfed the risk

Infant/child is infected of acquiring HIV infection remains until complete cessation of
breastfeeding c
Immediately start ART b Regular clinical monitoring
Repeat DNA PCR to

Conduct DNA PCR b (at 9 months)
Negative Positive
HIV unlikely unless still Infant/child is infected

breastfeeding d
Antibody testing at 18 months of age or 3 months after Immediately start ART b;

cessation of breastfeeding, whichever is later e Repeat DNA PCR to confirm
infection
Note:
• aDNA PCR can be used to diagnose HIV infection as well as to confirm
positive results.
b
• Start ART without delay. At the same time, retest to confirm infection. As
maternal treatment is scaled up and MTCT transmission rates decrease,
false-positive results are expected to increase retesting after a first positive
DNA PCR is hence important to avoid unnecessary treatment, particularly
in settings with lower transmission rates. If the second test is negative, a
third DNA PCR should be performed before interrupting ART.
c
• For children who were never breastfed, additional testing following a
negative DNA PCR at 4–6 weeks is included in this algorithm to account for
potential false-negative DNA PCR results.
d
• The risk of HIV transmission remains as long as breastfeeding continues. If
the 9-month test is conducted earlier than 3 months after cessation of
breastfeeding, infection acquired in the last days of breastfeeding may be
missed. Retesting at 18 months or 3 months after cessation of
breastfeeding (whichever is later) should be carried out for final assessment
of HIV status.
e
• If breastfeeding extends beyond 18 months, the final diagnosis of HIV
status can only be assessed at the end of breastfeeding. If breastfeeding
ends before 18 months, the final diagnosis of HIV status with antibody
testing can only be assessed at 18 months. Antibody testing should be
undertaken at least 3 months after cessation of breastfeeding (to allow for
development of HIV antibodies). For infants younger than 18 months of age
DNA PCR should be performed to confirm infection. If the infant is older
than 18 months, negative antibody testing confirms that the infant is
uninfected; positive antibody testing confirms infant is infected.
Annex 3.4: Growth Monitoring Chart ( wt/Age, Ht/ Age , Head Circumference.
By Gender and Age )
Chapter 4 annexes
Annex4.1:Monthly HMIS service delivery report–PMTCT Indicators
PMTCTIndicators
Maternal indicator
1 PercentageofpregnantandlactatingwomenwhoweretestedforHIVandwhoknowtheirresult
[Numerator:No ofpregnant women testedfor HIV atANC ,L&D, and PNCinthe reportingmonth
Denominator: Estimated number of pregnant womeninthereportingmonth]
1.1 Number of pregnantwomen testedand know theirresult duringpregnancy
1.2 Numberofpregnantwomen testedandknow theirresultduringlabor& delivery
1.3 Numberoflactatingwomentestedandknowtheirresultduringthepostpartumperiod
1.4 Number of womenwho knew their HIVstatus before thecurrent pregnancy (onART)
2 Numberofwomen testedpositivefor HIV(Newlyidentified andalreadyknown )
3 Percentage of HIV Positive pregnant and lactating women who received ART at ANC+L&D+PNC for the first time and who get pregnant
while on ART
[Numerator: Number of HIV positive pregnant and lactating women who received ART at ANC, L&D and PNC for the first time and those
women who get pregnant while on ART & linked to ANC in the reporting period
Denominator: Estimated HIV positive pregnant women in the year]
3.1 Number ofHIVPositivepregnantwhoreceivedARTatANCforthefirsttime
3.2 NumberofHIVpositivePregnantwomenwhoreceivedARTtoreducetheriskofmothertochildtransmissionduringL&Dforthefirsttime
3.3 NumberofHIVpositivelactatingwomenwhoreceivedARTtoreducetheriskofmothertochildtransmissionduringPNCforthefirsttime
3.4 NumberofHIV-positivewomenwhogetpregnantwhileonARTandlinkedtoANC
4 Percentage of HIV infected women using a modern family planning method

[Numerator:No.ofHIVinfectedwomenaged15-49yearsattendingPNC+ARTreportedtheuseofanymethodofmodernfamilyplanning
Denominator:No.ofHIVpositivewomenaged15-49yearsattendingPNC+ARTduringthereportingmonth]
4.1 Number of HIV infected women aged 15-49 reported the use of any method of modern family planning
5 Percentageofpartnersofpregnant,laboringandlactatingwomentestedforHIVduringthereportingmonth
(Numerator:Numberofpartnersofpregnant,laboringandlactatingwomentestedforHIV
Denominator:Totalnumberofpregnant,laboringandlactatingwomentestedforHIV]
5.1 Number ofpartners ofpregnant,laboring andlactatingwomen testedfor HIVwhosetestresultisHIVnegative
5.2 Number ofpartners ofpregnant,laboring andlactatingwomen testedfor HIVwhosetestresultisHIVpositive
6 Percentage of pregnant/breast feeding women who received routine viral load testing
[Numerator:No of HIV positivepregnant/breast feeding women who received routine viral load testing inthe reportingmonth
Denominator:Total number of HIV positive pregnant/breast feeding women inthereportingmonth]
7 Percentage of HIV positive pregnant & BF women with a suppressed viral load (<1000 copies/ml)
[Numerator:No ofHIV positive pregnant & BF women with a suppressed viral load (<1000 copies/ml) inthe reportingmonth
Denominator:Total number of HIV positive pregnant & BF women on ART inthereportingmonth]
8 No/% of pregnant women attending antenatal care tested for HBV
[Numerator:No ofpregnant women testedfor HBV inthe reportingmonth
Denominator:Total number of pregnant women who attended first ANC visitinthereportingmonth]
9 Number of pregnant women who were received prophylaxis for HBV
10 Number % of pregnant women tested for syphilis

[Numerator:No ofpregnant women testedfor syphilis inthe reportingmonth
Denominator:Total number of pregnant women who attended first ANC visit inthereportingmonth]
11 Number of Partners of Syphilis positive pregnant and lactating women who are tested for syphilis
12 Proportion of pregnant women treated for syphilis
[Numerator:No ofpregnant women treatedfor syphilis inthe reportingmonth
Denominator: Total number of pregnant women tested positive for syphilisinthe reportingmonth
13 Proportion of pregnant/breast feeding women who put on 3-month multi-month dispensing (MMD)
[Numerator:Number of pregnant/breast feeding women who put on 3-month multi-month dispensing (MMD)inthe reportingmonth
Denominator: Total Number of HIV positive pregnant/breast feeding women on ART inthe reportingmonth
14 Number of Discordant couples who took PrEP in the PMTCT setting
Infant indicators
15 Percent of infants who received a HBV BD within 24 hours after birth.
[Numerator: No. of infants who received a HBV -BD within 24 hours after birth during the reporting month
Denominator: Total # live births during the reporting period
16 Percent of children under one year of age who have received third dose of pentavalent vaccine
[Numerator: Number of infants who received third dose of pentavalent vaccine during the reporting month (8.1-8.6)
Denominator: Total # live births during the reporting period
17 Percent of Congenital syphilis
[Numerator: No. of infants with of congenital syphilisduring the reporting month
Denominator: Total number of syphilis reactive women during pregnancy
18 Percentage of infants born to HIV infected women receiving a virological test for HIV within 12 months of birth
[Numerator: No. of HIV exposed infants who received an HIV DNA/PCR test within 12 months of birth, during the reporting month
Denominator: Total # live births (HEIs) from estimated HIV+ pregnant women during the reporting period
18.1 NumberofHIVexposedinfantswhoreceivedanHIVDNA/PCRtestwithin2monthsofbirth,duringthereportingperiod
18.2 NumberofHIVexposedinfantsreceivingHIVDNA/PCRtestwithin2monthsofbirthwhosetestresultisHIVnegative
18.3 NumberofHIVexposedinfantsreceivingHIVDNA/PCRtestwithin2monthsofbirthwhosetestresultisHIVpositive
18.4 NumberofHIVexposedinfantswhoreceivedanHIVDNA/PCRtestbetween2to12months,duringthereportingperiod
18.5 NumberofHIVexposedinfantsreceivingHIVDNA/PCRtestwithin2to12monthsofbirthwhosetestresultisHIVNegative
18.6 NumberofHIVexposedinfantsreceivingHIVDNA/PCRtestwithin2to12monthsofbirthwhosetestresultisHIVpositive
19 PercentageofInfantsborntoHIV-infectedwomenstartedco-trimoxazoleprophylaxis withintwomonthsofbirth
Numerator:NumberofinfantsborntoHIVinfectedwomenstartedonco-
trimoxazoleprophylaxiswithintwomonthsofbirthduringthereportingperiod
Denominator:Total # live births (HEIs) from estimated HIV+ pregnant women during the reporting period
20 PercentageofinfantsborntoHIV-infectedwomenreceivingantiretroviral(ARV)prophylaxisforpreventionofmother-to-
childtransmission
[Numerator: Numberof exposed infants received ARV prophylaxis for 12 weeksduring the reporting period
Denominator: Total number of expected live births from HIV positive mothersduring the reporting period
21 PercentageofHIVexposedinfantsreceivingHIVconfirmatory(antibody)testby18months
[Numerator:NoofHIVexposedinfantsreceivingHIVconfirmatory(antibodytest)by18monthsduringthereportingmonth
Denominator:NumberofeligibleHEIduringthereportingmonth
21.1 NumberofHIVexposedinfantsreceivingHIVconfirmatory(antibody)by18months-whosetestresultis Negative
21.2 NumberofHIVexposedinfantsreceivingHIVconfirmatory(antibody)by18months-whosetestresultisPositive
Annex 4.2: Intake form (A & B)
New folder (2)HIV Care/ ART clinic Intake form- A Socio demographics & family care FEDERAL MINISTRY OF ALTH OF
ETHIOPIA
Facility Name_________________ MRN ________ Enrollment date: ___/___/____(DD/MM/YY) Unique ART No. _______ Unit
TB No. ______
Client Name________________________Fathers’Name__________________Garand Fathers’_______________________
For child only:-Mother’s Name: _________________ Place of delivery: O Health facility O Home O Other specify _________
Mode of delivery OSpontaneous vaginalO Cesarean sectionO Other specify __________
CLIENT REFERRAL INFORMATION
From with-in the Facility
O Medical OPD O Pediatric OPD O TB Clinic O MCH (PMTCT) O VCT O Adult IPD
O Pediatric IPD O Other Outpatient specify______
Outside the Facility
O Health Centers O Public Hospital O Private Hospital O NGO/FBO Hospital O Private Clinic O Self-referred O Others
CARE GIVER/EMERGENCY CONTACT INFORMATION

Client reside within the catchments area O Yes O No , if no; Is challenge anticipated to regularly follow in this facility O Yes
Full Name: ________________________ Age: _____Gender: O Male O Female Relation: ___________
Address: Region________ Zone/Sub city_______ Woreda________ Kebele _____ House No.________ Telephone ________
DISCLOSURE AT ENROLLMENT:
Does anyone else know about your/your child‘s HIV Status? O Yes O No
If yes who knows your/your child‘s HIV positive status? OSpouse (Wife/Husband) O Own Child (ren) OParent(s)
O Sibling(s) (Brother(s)/Sister(s) ORelatives O Friends O Others ___________________________
FAMILY MEMBERS(Spouse/Parent and Child/ren/Sibling) HIV STATUS AT ENROLLMENT AND FOLLOW UP Visit
(Enter date for appropriate HIV status in DD/MM/YY format*)
At enrollment At enrollment or follow up visit: update all black fields as status

changed
Family Ag Sex Health status Counsel Tested HIV test Enrolled Started Uniqu
member e (healthy, ed for for Result; NR, R in Care* ART * e ART
chronically ill, HIV* HIV* * #
dead
Spouse/Pare
nt
Child1/Siblin
g
Child2/Siblin
g
Child3/Siblin
g
INSTRUCTIONS:Intake form- A Socio demographics & family care
Note: All but family HIV status fields must be completed at enrollment & all date fields must use Ethiopian calendar in
DD/MM/YY format
Health Facility Name – Health Facility name as registered at the Ministry of Health
Medical Record Number (MRN): Unique individual identifier on medical information provided by facility on folder
Enrollment date: Enter the date client was registered in HIV care using Ethiopian calendar in DD/MM/YY format
Unique ART number: Unique identifier assigned to a client when stating ART. It is composed of region number/
facility type code/ specific facility code /client assigned 5 digit serial numbers starting as 00001
Region Code: 1.Tigray (TG) 2.Afar (AF) 3.Amhara (AM) 4. Oromia (OR) 5. Somali (SO) 6. Benshangul Gumuz (BG)7.
SNNPR (SN) 12. Gambella (GA) 13. Harar (HA) 14. Addis Ababa (AA) 15. Dire Dawa (DD)
Facility Type code: Use 08 for Hospitaland 09 for Health center
Client Name: Enter client‘s given name, Father‘s Name: - Enter client‘s father‘s name. If not known enter NA Grandfather‘s
Name: - Enter client‘s grandfather‘s name. If not known enter NA
For a Child ask and fill Mother name, place and mode of delivery as:
Child‘s; mother Name: Enter client‘s mother if the client is a child <15 years. If clients mother name is not known enter NA
Place and mode of delivery: Mark in appropriate circle that indicate the place and mode of child‘s delivery
Date of Birth: - Use Ethiopian calendar in DD/MM/YYYY format. If only month & year are known, enter 00 for day, if only
year is known, enter 00 for day & 00 for month
Age: - Enter Client‘s current age in years. If Client is less than 5 years old, enter age in months.
Sex: -Mark in the appropriate circle that indicate sex of the client
Marital Status: - Mark in appropriate circle that indicate clients (child‘s care giver) current marital status
Religion: - Mark in appropriate circle that indicate religion of the client
Level of Education: - Mark in appropriate circle that indicate client‘s completed year of schooling
Occupation: Enter what the client‘s current works for living
Client Address: - Enter the current permanent address of the client including; Region, Zone/Sub-city, Wereda , Kebele , House
number as well as telephone number
For clients out of the catchment area of this facility: confirm absence of barriers for regular follow up at this facility including,
time, transport access, transport money
Date confirmed HIV+: Enter test date using Ethiopian calendar in DD/MM/YYYY format; if tested more than once, enter the
most recent one
Type of HIV Test Mark in appropriate circle that indicate the type of test the client took
Client referral information; Mark in appropriate testing point if client linked from with the facility or indicate facility type if
from outside facility
Care giver information: Enter the name, the address & relationship of care giver; to avoid unintended disclosure it is advisable
if care giver is confided client sero-status
Disclosure at enrollment: Does anyone know client HIV Status? Mark appropriate response that indicate clients disclosure
status To who knows clients HIV status:Mark appropriate response that indicate for whom the clients has disclosed
Family members (spouse/parent /child/ren/sibling‘s)
HIV status: at enrolment Mark the relationship, enter the age, sex & health status of client‘s each family members and for those
whose HIV Status is determined indicate the date
At follow up visits: if the status of the clients family member changed enter the date in DD/MM/YY format in the cell
corresponding to the updated status
HIV Care/ ART clinic Intake form-B Past, presenting illness & PHDP FEDERAL MINISTRY OF ALTH OF ETHIOPIA
Facility Name_________________ MRN ___________
PAST OPPORTUNISTIC ILLNESS (OI), PRPHYLAIS AND TREATMENT (MARK ALL THAT APPLY)
Past OI
O Pulmonary TB O TB-Extrapulmonary O Fever (>1 month; unexplained) O Diarrhea (>1 month) O Oral Candidiasis
O pharyngeal candidiasis O Wasting Syndrome O Pneumocystis Carinii Pneumonia O Pneumonia (recurrent) O Cryptococal Meningitis
O Minor Mucocutaneous manifestations O Herpes-simplex(>1month) O Toxoplasmosis (brain) O Kaposi sarcoma
O Other specify_______________________
Past Prophylaxis/Treatment
Cotrimoxazole: Date started _____/______/_____ If stopped; date stopped ____/______/_____
INH: Date started _____/______/______ If completed; date completed ____/______/_____
ARV For PMTCT:- O Yes O No If Yes Health facility:-___________Regimen for mother:______ Regimen for baby:
___________
Lifelong ART/TI:- O Yes O No if yes Regimen: __________ Start date : ____/___ /____ Months on ART Still on Treatment:
O Yes O No
Client STATUS AT ENROLLMENT

VITAL SIGNS:- :- Temp (oC)________ PULSE/HR (/m)__________ BP (mmHg)_________RR (R/m)___________
ANRTOPOMETRY:-Height (cm) _____Weight (kg)_____ BMI (kg/m2)______ for child only; Head circumference (cm): _________
For child; anthropometry interpretation: O Normal weight for age O underweight
FUNCTIONAL Status:- O Working O Ambulatory O Bed ridden

Developmental status (for a child<5) OAppropriate for age O Delay O Regression
PRESENTING SYMPTOM
O Cough O weight Loss __% body wt O Dyspnea O Fever > 1 month O Nightsweat
O Diarrhea O Mental Confusion O STI Symptoms O Dysphagia/ Odynophagia
O Nausea and/or vomiting O Persistent Headaches O Others specify:________________________________________
CLIENT‘S PREGNANCY STATUS at Enrollment:

O Pregnant LMP / / EDD / / O Not Pregnant O Not Applicable
CLIENT GENERAL APPEARANCE OF AT
Enrollment:______________________________________________________________________
System Normal Abnormal Specify Abnormal Finding

HEENT
Lymph nodes
Chest
Heart
Abdomen
Genitourinary System
Musculo-skeletal system
Skin
Nervous System
Physical Examination by system
WHO HIV Clinical Stage at enrollment:________ why: _______________________________
POSITIVE HEALTH DIGNITY AND PREVENTION (PHDP) ISSUE ADDRESSED
Date Basic HIV Prevention:a Positiv Progre Available Education on Why complete Explain What side effects What to do Co
& TB bstinence, e ssion of treatment/ essentials of adherence dose, & how to manage if one forgets ncl
transmission safer sex, living disease prophylaxis ART needed when to dose usi
education, condoms CPT, IPT,FPT take on
INSTRUCTIONS: Intake form- B Past and presenting illness & PHDP
Note: All fields must be completely filled in at enrollment then after should be update accordingly & all date fields must use Ethiopian calendar in DD/MM/YY format
Health Facility Name – Health Facility name as registered at the Ministry of Health
Medical Record Number (MRN): Unique individual identifier on medical information provided by facility on folder
Past Opportunistic Illness (OIs):– Mark all IOs that the patient has experienced before enrollment. Note: that this information can be obtained from the client, medical/lab
recordsor referral form
Past Prophylaxis / Treatment:-
Cotrimoxazole (CTX): If client is on CTX at enrollment enter the start date; using Ethiopian calendar in DD/MM/YYYY
Isoniazid (INH): If client on INH at enrollment enter the start date and if client has completed the INH enter stop date using Ethiopian calendar in DD/MM/YYYY format
ARV for PMTCT: Mark appropriate circle to indicate client exposure to ARV for PMTCTE, if yes enter facility name and the regimen given to the mother and the baby
Lifelong ART/TI: For all transfer in, mark ART status at enrolment, enter the regimen, how long the client was on ART, start date in DD/MM/YY format, & if the client is still
on ART
VITAL SIGNS:- Check and enter the measurement: temperature in OC, Pulse(PR) in rate per minute Blood pressure (BP) in mmHg Respiratory rate (RR) in rate per minute
Anthropometric Measurement:- measure and enter: Height in cm, Weight in kg, body mass index (BMI) in KG/ M2
Functional Status:- Assess & mark appropriate circle: Working if able to perform usual work in & out of house, Ambulatory if Able to perform activities of daily living but
not able to work Bedridden(B)=not able to perform activities of daily living
Developmental status for children <5 years:- A= Appropriate if a child has attained milestones for age: Delay: if the child failure to attain milestones for age Regression: loss
of what has been attained for age
Presenting Symptom: Ask and mark all the symptoms that the e client complain to have at enrolment
Client‘s pregnancy status at enrolment: If pregnant enter Date of last Menstrual Period (LMP) & Expected Date of Delivery (EDD) otherwise mark appropriate circle
Client general appearance at enrollment: Assess and describe the general prance of the clients in the space provided
Physical Examination: Assess and mark appropriate physical finding category for each system; and describe all abnormal findings
WHO HIV Clinical Stage: Assess and stage the clients; enter the criteria (from past /presenting finding) used to put the client on a particular WHO clinical stage; listed below
WHO HIV Clinical Stage 1:
-Clinically Asymptomatic Client -Persistent Generalized Lymphadenopathy (PGL)
-Minor Mucocutaneous Manifestations - Herpes Zoster - 5-10% body weight loss - Recurrent upper respiratory tract infection
- Oral Candidiasis -Unexplained Chronic Diarrhea (>1 month) - >10% of Body Weight loss - Oral Hairy Leukoplakia
- Unexplained Prolonged Fever (>1 month) - Pulmonary Tuberculosis - Bacterial Pneumoni Unexplained anemia (<8g/dl),
neutropaenia (<0.5x109/l) and/or chronic thrombocytopaenia (<50 x 109/L)-Other Severe Bacterial Infections (eg. pyomyositis)
WHO HIV Clinical Stage4:
- Extrapulmonary Tuberculosis -HIV Wasting Syndrome - Atypical Mycobacteriosis -Candidiasis (Esophagus, Trachea, Bronchi or Lungs)
- Crytococcosis Extrapulmonary - Cryptosporidiosis with Diarrhea (>1 month duration) -Herpes Simplex (mucocutaneous >1 month, or visceral - CMV Disease (other
than liver, spleen, lymph nodes) -HIV Encephalopathy - Karposi‘s Sarcoma
- Lymphoma - PML - Mycosis, Disseminated (i.e. Histoplasma, Coccidioides) - Pneumocystis Carinii Pneumonia (PCP) - Salmonella Septicemia, Non-typhoid -
Toxoplasmosis of the CNS - Symptomatic HIV-associated - Invasive cervical carcinoma
- nephropathy or cardiomyopathy - Atypical disseminated leishmaniasis
POSITIVE HEALTH DIGNITY AND PREVENTION PHDP) ISSUE ADDRESSED
Enter the date of adherence counseling in DD/MM/YY format and mark all issues raised and dressed during PHDP counseling
Annex 4.3: Follow up card
HIV CARE/ART FOLLOW-UPFORM FEDERAL MINISTRYOFHEALTH
FacilityName____________________________________________________ Name:
______________________________________ Age _________years(MonthsforChildren <5years) Sex M F 
Address:Region Woreda/SubcityKebele___________ HouseNo.___________Telephone _____________ t Unique

__________________________DateconfirmedHIV+ (Retesting): //(DD/MM/YY)
Typeof HIVTest RapidHIVtests DNA/PCR(forchildren)Client readiness: (date client is ready)//(DD/MM/YY)Height(Adult)in cm: _______
Pregnan Funct Xpert Cx Ca screening, Co- Assess&co
Adverse event for TB Treatment /TB Prophylaxis

Treatment unsel Client
cystatus ional MTB/RIF( trimoxazol ARVdrugs sets HIV
/FP Statu & referral e forARV
preventi
1) Adherence
method s Preventive on plan
W,A, LF-LAM(2) therapy
B
Fluconazole preventive therapy( FPT)

BMI ( MUAC forpregnant woman or
Hgb.
medications/ or nutritional
NextVisit
(Say- Yes/No and specify drug)

ALT/
Management of cervical lesions
Assessed &Managed for pain

TB Treatment / TBProphylaxis
If child Length/ Height/ Head
AST/ Date
Type of Cx Ca Screening (0-6)
Referral Cx Ca screening &

dd/mm/yy
Developmental Milestone
Cr/
Circumferencefor <3years
CD4 /mm or % if<5 Yrs.

WHO Stage (1-4 / T1- T4
OIs/ HIVrelatedcancers
supplements dispensed
CrAg
Disclosure for Children

Weight (Kg) Edema+/-
management (0-4)
Reason for change

Adherence (G,F,P)
Adherence (G,F,P)
(Dispensed Dose)
VL
Monthson ART
TB Screen- P/N
Follow up
Dispense dose
result
bedridden)
S/ date Why Dispens
3
Result P/N
Side effect
US dd/mm/yy (copies/
Sent (√)
Fair or e Dose/
drugs
(A.D.R)
(0-4)) ml)
Poor? code
Months on ART Pregnancy Status /Family Planning Functional status Eligibility
S/US Method
S=Scheduled US=Unscheduled Duration in months since initiation of ART: P = Pregnant (If pregnant, give estimated W=Working (able to perform usual ELIGIBLE date(dd/mm/yy) when patient is medically eligible for
due date (EDD)) work in or out of the house, harvest, go ART
0 = ART Initiation date PMTCT = Referred to PMTCT & indicate
TB SCREEN to school or, for children, normal WHY ELIGIBLE (Note reasons why patient eligible for ART)
1 week = 1 week linkage (enter code in the space 1. Clinically only
SCREEN FOR TB AT EVERY VISIT activities or playing)
2 weeks = 2 weeks provided on the header) 2. CD4 count
Adult & Adolescent A=Ambulatory (able to perform
3 weeks = 3 weeks WP = want to become pregnant 3. Transfer in (TI)
1. Current Cough? activities of daily living)
1 = 1 month No FP = not pregnant & is not using any 4. Other( like TB, HBV, Pregnancy)
2. Fever?
3. Night sweats? 2= 2 months FP methods B=Bedridden (not able to perform
4. Weight loss? FP= On Family Planning (enter code): activities of daily living)
P= (Positive screen)-Yes to any of If Pre-ART, leave this column blank 1= Condoms
the above---Evaluate for TB. Pain Assessment & Management 2= Oral contraceptive pills DEVELOPMENTAL MILESTONES FOR ELIGIBLE AND READY
N=(Negative screen)-No to all 3= Injectables/implantable hormones Enter the date (dd/mm/yy) when patient is medically eligible
Assess for Pain & Manage as CHILD
questions above---assess for IPT 4=Diaphragm/cervical cap and ready (counseled for adherence) for ART
NP=no pain Code as: A= Appropriate :D= Delay: R=
eligibility 5=Intrauterine device
S1=WHO Step 1 Regression
TB=Currently on AntiTB 6=Vasectomy/tubal legation Client Set HIV Prevention Plan
Children 0-14 years old
S2=WHO step 2
7= Abstinence (no sex) Sitting without support …….3 to 9
S3=WHO step 3
1. Current Cough ___________________________ months
Nutritional Status(adults ) D= Agreed to Disclose to partner/ family / friend,
2. Fever Length /height/ HC Standing with assistance……5 to 11
BMI MUAC PT=planned to bring partner for testing,
3. Weight loss or poor weight gain Measure length / height in cm for months
(for non pregnant / non (for pregnant/ ChT= agreed to bring children for testing,
4. Contact history with TB patient
post partum) postpartum
children younger than 14 years at Hands and knees crawling ….6 to13 SSex= discussed & agreed to practice safer sex
P=(Positive screen)-Yes to any one EVERY visit
1= Not malnourished /bedridden) months SubU=Decides to avoid or decrease Substance use
of the four---evaluate for TB Measure head circumference in cm for
N=(Negative screen)-No to all four---
(>18.5 ) 1=Not malnourished ( Walking with assistance ….7 to 14 ASS= Assessed for STI
>22cm) children younger than 3 years of age at
months SRX=client managed for STI
assess for eligibility to IPT 2=Moderate malnutrition 2=Moderate EVERY visit
TB= Currently on AntitTB (16 -18.5) malnutrition Standing alone…….8 to 17 months
3=Severe malnutrition (<
16)
(19-22cm)
Walking alone……. 9 to 18 months
3=Severe malnutrition
(<19 cm for pregnant Delay: failure to attain milestones for
2
*BMI=wt/(ht) and postpartum /< age
18cm for bedridden) Regression: loss of what has been
attained for age
Nutritional Status (Children ) Nutritional Status (Older children &
adolescents )
W/H BMI for age(5-18yrs)
1=Normal/appropriate (> -1 Z score) 1=Normal/appropriate ( > -2 Z score)
2=Mild (< -1 and > -2 Z score) 2=Mild (< -1 and > -2 Z score)
3=MAM (< -2 and > -3 Z score) 3=Moderate malnutrition (< -2 and > -3 Z
4=SAM (< -3 Z score) score)
4=Severe malnutrition (< -3 Z score)
*BMI for age for older children and
adolescents.
TB PROPHYLAXIS/TREATMENT ADHERENCE SIDE EFFECTS REASONS FOR STOPPING REGIMEN DISPENSE DOSE/REGIMEN CODE
INH1-6=Currently on INH Estimate adherence using the table below: 1. No side effects STOP = Stopped ART Note the Number of doses of treatment dispensed / Regimen
prophylaxis (Number refers to Adherence % missed doses: 2. Nausea code
If STOP, In why column, note reason:
months on INH) 3. Diarrhea
4. Fatigue 1 Toxicity/side effects
INHC=Completed treatment % (of 30 (of 60 Adult 1st Line Child 1st Line Regimens
5. Headache 2 Pregnancy
INH dc=discontinued for any reason doses) doses) Regimens 4a =d4T+3TC+NVP
6. numbness/ tingling/pain 3 Treatment failure
TB RX 1-8 =Currently on AntiTB G(good) > ≤2 ≤3 7. Rash 1a =d4T+3TC+NVP 4b = d4T+3TC+EFV
(numbers refer to months on Rx) 95% doses doses 8. Anemia 4 Poor adherence 1b =d4T+3TC+EFV 4c = AZT+3TC+NVP
TB RX dc=discontinued TB Rx for F(fair) 85- 3-5 3-9 9. Abdominal pain 5 Illness, hospitalization 1c=AZT+3TC+NVP 4d = AZT+3TC+EFV
any reason 10. Jaundice 6 Drugs out of stock
94% doses doses 1d=AZT+3TC+EFV 4e=AZT+3TC+LPV/r*
TB Rx C=Completed anti TB Rx 11. Fat changes
P(poor) <85% ≥6 >9 12. dizzy, anxiety, nightmare, 7 Patient lack finances 1e=TDF+3TC+EFV 4f= d4T+3TC+LPV/r*
OI/Opportunistic cancers doses doses 8 Other patient decision 1f=TDF+3TC+NVP 4g = Others, specify
depression
13. other 9 Planned treatment interruption 1g =Others, specify (ABC+3TC+EFV,ABC+3TC
NOI= No OI or Opportunistic cancer
If Fair or Poor adherence, in why column note (TDF+FTC+EFV, +NVP, ABC+3TC+AZT
Z=Zoster 10.Other nd
reason: ABC+3TC+EFV, ABC+3TC+NVP Child 2 Line Regimens
BP=Bacterial Pneumonia REASONS FOR REGIMEN CHANGE & ABC+3TC+AZT) 5a = ABC+ddI+LPV/r
1. Toxicity/Side effects
PTB= Pulmonary Tuberculosis 5b= ABC+3TC+LPV/r
2. Share with others 1. Toxicity/Side effects
EPTB= Extra pulmonary tuberculosis 3. Forgot nd
Adult 2 Line Regimens: 5c=other
2. Pregnancy
T= oral,esophageal candidiasis 4. Felt better 3. Risk of pregnancy 2a =ABC +ddI +LPV/r
Ulcers-mouth, genital, 5. Too ill 4. Due to new TB 2b= TDF+ddI+ LPV/r * Regimen of choice for HIV
DC or DA=Diarrhea Chronic/Acute 6. Stigma, discloser 5. New drug available
2c= TDF+3TC+LPV/r infected infants who are
PCP=Pneumocystis pneumonia 7. Drug stock out 6. Drug stock out
8. Lost/ran out of pills 2d=AZT+3TC+LPV/r exposed to NVP for PMTCT
CT= CNS Toxoplasmosis 7. Other
9. Delivery/travel problems 8. Clinical failure 2e= Other
CM=Cryptococcal Meningitis 10. Inability to pay 9. Immunologic failure
NHL=NonHodgkins Lymphoma 11. Alcohol 10. Virologic failure
KS=Kaposi’s Sarcoma 12. Depression
CCa=Cervical cancer 13. Other
nd
O=Other In the follow-up date, in 2 column if one of the options below applies, use the row next to the last visit to enter the appropriate information
TO = transferred out LOST= not seen since>/=1 months DROP= last to follow- up for >3 month DEAD
Annex 4.4: HIV exposed infant follow up card
Annex 4.5: DNA PCR sample collection request form
Annex 4.6: Partner and family based ICT case investigation form
Annex 4.7: MotherBabyPairPMTCTRegister
Annex 4.7.1: Instructions for integrated MNCH/PMTCT register
Region Write the region where the facility is located

Zone/Sub-City /Woreda Write theZone/Sub-City /Woredawhere the facility is located.
Name of Health Facility Write the name of the health facility
Register begin date Write the date of the first entry in the register, written as (EC) Day / Month / Year (DD/MM/YY)
Register end date Write the date of the last entry in the register, written as (EC) Day / Month Year(DD/MM/YY)
Col.No Data Element Description
1. S. N. Sequential serial number in registration book, beginning with 1 for the first client in the cohort.
2. Mother's name write name of the mother
3. MRN Write Unique individual identifier for mother used on medical Information folder, for HC and hospital.
4. ART unique ID number Record the existing Unique ART number or assign one during initiation. A unique ART number should be assigned to
clients initiated on ART at MNCH clinic. This includes: region number / facility type code / specific facility code /
client assigned number.
Region number: the following code numbers are used:
Tigray:- 01 SNNPR:- 07
Afar:- 02 Gambella :- 12
Amhara:- 03 Harar :- 13
Oromia:- 04 Addis Ababa :- 14
Somali:- 05 Dire Dawa :- 15
Benishangul Gummuz :-06 Sidama :-
Facility type code: Hospital =08
Health Center = 09
Each HC / hospital in each region is coded with three digits starting from 001. These specific facility codes are assumed
to be given by regions together with federal, which means it is pre coded and given to each facility centrally.
Patient assigned number: A 5 digit number unique within the facility; the first pregnant woman to start ART in the
clinic will be given 00001. Example Unique ART No. 01/08/001/00001
5. Age Age of the woman in years, Document the clients age in the column,
6. Booking Date Booking date is the first date for Maternal enrollment in PMTCT. If the mother starts ART in the PMTCT clinic in the
same day, this date will be the same with ART start date. But for mothers who had already started ART, the booking
date will be entered and as a result the date will be different from ART initiated date
7. Newly diagnosed & started on ART Write ―1‖ for the women who are diagnosed and started on ART during ANC for the first time.
write code (1=ANC; 2=L&D; 3=post partum) Write ―2‖ for the women who are diagnosed and started on ART during at L&D for the first time.
Write ―3‖ for the women who are diagnosed and started on ART during PNC for the first time.
8. Known HIV + write code (1=On ART at entry; Write ―1‖ for woman who was started on ART before PMTCT entry.
2=Not on ART) Write ―2‖ for known HIV + women was not started ART before PMTCT entry .
9. LNMP Write the date (DD/MM/YY) of the last normal menstrual period.
10. EDD Write the Expected date (DD/MM/YY) of delivery.
11. Gestational age (GA) in weeks Write the gestational age (GA) in weeks.
12. Ferrous Sulfate/Folic Acid Provided(Y/N) Write ―Y‖ if ferrous sulphate / folic acid is provided
Write ―N‖ if ferrous sulphate / folic acid is not provided
13. Syphilis test result (R/NR/ND) Write ―R‖ if the syphilis test result is Reactive,
Write ― N‖ if the syphilis test result is not Reactive
Write ―ND‖ if syphilis test is not done.
14. Selected Infant Feeding option (EBF, ERF, MF) Write ―EBF‖ if the mother selects exclusive breast feeding.
Write ―ERF‖ if the mother selects exclusive replacement feeding.
Write ―MF‖ if the mother selects mixed feeding.
15. Date of delivery Write the date the mother gave birth E.C. (DD/MM/YY)
16. Sex of Infant ( M/F ) Write ― M‖ if the Infant is Male or Write ―F‖ if the Infant is Female
17. Place of Delivery (write code) Write code for Place of Delivery
1= same facility, 2= another health facility 3= home delivery.
18. Delivery Outcome (LB,SB) Write ―LB‖ if delivery outcome is Live Birth or Write ―SB‖ if delivery outcome is Still birth.
19. ART Taken During Labor (Y/N) Write ―Y‖ if the woman took ART during delivery or ― N‖ if the women didn‘t take ART during delivery
20. Infant Received ARV Prophylaxis (AZT + NVP Write ―Y‖ Infant Received ARV Prophylaxis (AZT + NVP for the 1st 6 weeks) & (NVP only for the next 6 weeks)
for the 1st 6 weeks) & (NVP only for the next 6 total 12 weeks , I not write ―N
weeks) total 12 weeks (Y/N)
21. Family Planning Counseled(Y/N) Write ―Y‖ if the mother is counseled on family planning or ―N‖ if the mother is not counseled on family planning.
22. Tick (√) if client is new acceptor at the time of registration. A new acceptor is someone who has not received a
New acceptor (√) contraceptive method from a recognized Provider before registration.*
23. Tick (√) if client is repeat acceptor at the time of registration.
Repeat acceptor (√) A repeat acceptor is someone who is not a new acceptor; in other words, a repeat acceptor has received a contraceptive
method from a recognized Provide before registration.
24. Contraceptive provided (write abbreviation) Write abbreviation of modern contraceptive methods a client chose. See the abbreviation on the register.
25. HIV testing accepted ( √) Tick ( √) if the partner/husband accepts testing for HIV
26. Partner tested (P/N/ND) Write ―P‖ if test result is positive, Write ― N‖ if the test result is negative, Write ―ND‖ if partner test is not done.
27. Write the selected from the following list of target population category. An individual should be assigned to only one
category that best describes him/her.
Partner Target population Category write code A= Female Commercial Sex workers , B= Long distance drivers, C= Mobile/Daily Laborers, D= Prisoners, E= OVC,
F= Children of PLHIV, G= Partners of PLHIV,
H= Other MARPS, I= General population
28. HIV Positive partner Linked to ART Tick (√) if the partner is positive and linked to ART.
29. TB symptom screening (P/N/ND) Write the mother‘s TB symptom screening result as ―P‖ for Positive, ―N‖ for Negative and ―ND‖ for test not done
30. Date INH prophylaxis started Write the date as E.C(DD/MM/YY) INH prophylaxis is initiated.
31. Date TB Rx started/Unit TB Number Write the date as E.C(DD/MM/YY) TB Rx is initiated on the upper row and unit TB Number in lower row.
32. Initial CD4 count(Value/ND) Write initial mother‘s CD4 count value as a baseline for newly enrolled mothers in PMTCT after initiating ART as soon
as possible. For those mothers who are already on ART during enrollment, the most recent CD4 count value has to be
documented or write ND if CD4 count is not done
33. WHO Clinical Stage Write mother‘s WHO clinical stage.
34. Maternal CPT started (Y/N) Write ―Y‖ if mother started CPT prophylaxis or Write ―N‖ if mother didn‘t start CPT prophylaxis.
35. Date ART initiated Write ART start date on which ART was started and could be the same as booking date for those clients newly started
ART.
36. Initial ART Regimen (write Code) Write the code for the regimen that patient has started. This is found at the bottom of the ART register.
37. Infant's MRN Write the medical record number of the HIV exposed infant
38. Date of HEI enrollment to PMTCT Write date of the HIV Exposed Infant (HEI) enrolled in PMTCT cohort
39. Infant Received NVP write code (1=For 6 wks Write ―1‖ if the Infant Received NVP for 6 weeks.
2=For 12 wks 3=not provided) Write ―2‖ if the Infant Received NVP for 12 weeks.
Write ―3‖ if the Infant is not provided NVP.
40. Infant Received NVP(DD/MM/YY) Write the date AZT + NVP was initiated as ( DD/MM/YY)
41. Infant feeding practice within the first 6 months Write ―EBF‖ if exclusive breastfeeding; ―ERF‖ if replacement feeding; ―MF‖ if mixed feeding.
(EBF/ ERF/ MF) Provider should refer the patient follow up card, ask the mother ―what, how did she feed her baby every time she comes
for follow up (Complete this at 6th month of infant age) to document the status
42. Age in wks Started CPT Write age in weeks when the infant initiated Cotrimoxazole prophylaxis.
43. Age in months DNA/PCR test done (MM) Write age in months DNA/PCR test done.
44. Result of DNA/ PCR(P/N) Write ―P‖ if positive or ―N‖ if negative.
45. Rapid HIV-AB test result(P/N) Write ―P‖ if HIV-AB test result is positive or ―N‖ if HIV-AB test result is negative
46. Remarks Write important patient related issues not incorporated in the list of data elements.
Right Side of the page (48-87)
Month ―0" in the Right Page is the initial month and year (MM/YY) that the mothers are enrolled in PMTCT service. This is the shared event for
Month " 0" in the Right Page maternal cohort monitoring and analysis of the maternal outcome such as retention and viral load suppression a well as others.
Maternal enrolment to PMTCT cohort (MM ,YY) is also the shared event for HEI PMTCT Cohort
TO,TI ,LTF Write transfer out (TO), transfer in (TI) and lost to follow up (LTF) in the column and row (cell) corresponding to each client followed in the cohort
when the situation takes place. –Fill out a formal TO format for clients who is transferring to other PMTCT and ART sites.
Write TI for clients transferred out from other PMTCT sites and who came with formal TO.
N.B. Clients coming from ART clinics are not considered as TI. These clients are considered as newly enrolled to PMTCT cohort for the purpose of
the current pregnancy. Write LTF in the cell for mother miss their appointment for more than two months.
Cohort follow up for the Fill the status of mother and infant in each visit using the codes mentioned and write their sums every months at the bottom of each column
Maternal and HEI PMTCT Write maternal viral load result at 3 months of ART initiation for newly started ART then put the result every 6 months in the lower row.
cohort If viral load is <1,000 copies per ml, write un detectable ; otherwise write detectable or >1000 copies /ml.
Cohort follow up for the Maternal and HEI PMTCT cohort
Arrows For data elements related with "Maternal Status",
 Put the total number of retained /alive & On ART
 Put the total number of ―LTF‖
 Put the total number of "TO"
 Put the total number of mothers with detectable Viral load >1000 copies
 Put the total number of mothers Malnourished
 Put the number of deaths.
For data elements related with "Infant status",
 Put the total number of infants Still on BF /Exposed
 Put the total number of positive infants ―LTF‖
 Put the total number of Discharged negative infants
 Put the total number of positive infants
 Put the total number of "TO"
Put the number of infant died.
Annex4.7.2: LeftSide
Annex4.7.3:.RightSide
Annex 4.8: DNA PCR log book
Annex 4.9: PrEP register
INSTRUCTION FOR PrEP REGISTER
Register (HC/Clinic/Hospital- PrEP Reg) kepq`qqqt in ARTroom /KP Clinic, and completed by the ART data clerk, based on PrEP facility record
forms and tally sheets.
Location information to be completed at front of register:
Write month and year (EC) at top of page.
Region Write the region where the ART center with PrEP Service is located
Woreda / Sub-City Write the woreda/sub-city where the ART center with PrEP Service is located
Name of Health Facility Write the name of the health facility where the ART center with PrEP Service is located
S. N Datum Comments
1. Serial number write sequential number in the row column
2. PrEP start date Write the date client started PrEP as E.C. (DD/MM/YY)
3. MRN/UIC Unique individual identifier used on medical information folder, for Public HC/ hospital and UIC for drop-in center
4. Name in full (individual, Write the patient‘s first name in the upper space and father‘s and grandfather‘s name in the lower space
father, grandfather)
5. Age Write the clients Age in year
6. Sex M=male, F=Female
7& Target groups Tick under column 6 if the client is HIV negative discordant couples or
8 Tick under column 7 if the client is FSW
9 Client‘s Write Client‘s woreda or Kebele in the above space and clients‘ phone number or house number in the lower space
woreda/kebele/Phone
number/House number
Initial Visit
10 HIV Test date Write the initial date a client tested in the above space and HIV test result in the lower space P=positive, N=Negative
11 Date client received Write the date client received HIV test results as E.C. (DD/MM/YY)
results
12 Creatinine (eGFR) Write the estimated eGFR result
(optional)
13. STI Screening with Write ‗Y‘ if the client is screened for STI or ‗N‘ for if the client is not screened for STI in the above space and if the
Syndrome client is screened positive. write code (STI syndromes: U=Urethral discharge / G=Genital ulcers / V=Vaginal discharge
/ L=Lower abdominal pain / S=Scrotal swelling / I=Inguinal bubo / O=Other-specify) in the lower space
14. Hepatitis B surface Write ‗Y‘ if the client is tested or ‗N‘ if the client is not tested in the above space and write ‗P‘ if the test result is
Antigen test positive or ‗N‘ if the test result is negative
15 Pregnancy status Write ‗P‘ if the client is pregnant or ‗NP‘ if the client is not pregnant or NA if Not applicable in the above space and if
the client is not pregnant and using FP Method write the Family planning code (FP= On Family Planning (enter
code):1= Condoms, 2= Oral contraceptive pills, 3=Injectable/implantable hormones, 4=Diaphragm/cervical cap,
5=Intrauterine device, 6=Vasectomy/tubal legation, 7= Abstinence (no sex) in the lower space
16 Number of Tablets Write number of tablets prescribed
Follow up Visit -1
17 Date Write follow up date as E.C. (DD/MM/YY)
18 & 19 HIV Re-testing result Write the date HIV retested under the date column and HIV test result ‗P‘ for positive or ‗N‘ for negative under HIV
test result column
20 Side effect Write the code of side effects as ( A= Abdominal pain/ S=Skin rash/ Nau=Nausea/ V=Vomiting/ D=Diarrhea/
F=Fatigue/ H=Headache/ L = Enlarged lymph nodes and/ R= Fever / O=Other-specify)
21 Adherence Write ‗G‘ for good adherence if the client missed 4 or less than 4 tablets or ‗P‘ for poor adherence if client missed more
than 5 and above tablet or dose in one month
22 Follow up Status If the client is on treatment write number of tablets prescribed, if transferred out other facility write T0, if the client
died while on treatment write ‘D‘ and if the client lost from follow up for more than one month write LTFU
23 STI Screening with Write ‗Y‘ if the client is screened for STI or ‗N‘ for if the client is not screened for STI in the above space and if the
Syndrome client is screened positive in the lower space. write code (STI syndromes: U=Urethral discharge / G=Genital ulcers /
V=Vaginal discharge / L=Lower abdominal pain / S=Scrotal swelling / I=Inguinal bubo / O=Other-specify)
23-79 For Follow up visit- 2 and above use the instruction commented under Follow up visit -1(serial number 15-21)
80` Stopped PrEP Write the date client stop PrEP as E.C. (DD/MM/YY) in the above space and write the code reasons for stopped
(H=Tested HIV+/R=No longer at substantial risk/S=side effects/Specify any other reasons) in the lower space
Annex 4.10 : Retesting register
Other important tools/registers used in PMTCT setting
 Index case testing (ICT) tracking register

 Lost to follow up (LT/FU) tracing register
 Appointment calendar Register
 Recency testing register
 Integrated ANC, L&D, PNC register
 Family planning register
 Mental Health integration screening tools
 Referral forms
Annex 4.11: SOP: MATERNAL PMTCT COHORT MONITORING OF MATERNAL RETENTION IN CARE
Ethiopia will monitor the retention of HIV-infected women enrolled in PMTCT programs in its facilities. Pregnant/breastfeeding women in the
facility PMTCT program will be followed and monitored in groups—or cohorts--based on the month and year of their enrollment in the PMTCT
program. Retention of each cohort in the facility PMTCT program will be reported 3, 6, and 12 months since the mother‘s PMTCT enrollment.
PURPOSE OF THIS DOCUMENT:
This document gives step-by-step instructions on how to:
1) Construct a Maternal PMTCT Cohort
2) Analyze the retention of Maternal PMTCT Cohorts in the PMTCT program at different time points
SCOPE OF THIS DOCUMENT:
Measuring the outcomes of HIV-infected mothers is necessary to evaluate and monitor the quality and impact of PMTCT programs. The
tools and respective instructions outlined in this document enable PMTCT providers to measure and understand key maternal outcomes at
the facility level.
MATERNAL COHORT DEFINITION:
The maternal cohort includes the HIV+ pregnant and breastfeeding women enrolled in the PMTCT program during a given month/year
(MM/YY). Each year there will be 12 maternal cohorts.
KEY MATERNAL COHORT OUTCOMES THAT IS MEASURED:
The maternal outcome measured is maternal retention in the PMTCT program. It is measured at three time points—at 3, 6, and 12 months
since the month of PMTCT enrolment--and will be calculated on the Maternal PMTCT Cohort Report Form.Maternal Loss to follow-
up will also be tracked.
TOOLS USED IN MATERNAL PMTCT COHORT MONITORING:
 Integrated MNCH/PMTCT Register (data source for Maternal PMTCT Cohort monitoring)
 Maternal PMTCT Cohort Report Form
 Maternal PMTCT Cohort Wall Chart
 PMTCT Cohort Monitoring Job Aid
RESPONSIBILITIES:
It is the responsibility of the PMTCT health care provider to ensure that the Maternal PMTCT Cohort Report Form and the Maternal
PMTCT Cohort Wall Chart are accurately completed within one week of the end of the reporting month.
OVERVIEW OF EACH OF THE TOOLS USED FOR MATERNAL COHORT MONITORING
1. Integrated MNCH/PMTCT Register = DATA SOURCE for maternal PMTCT cohort monitoring
TheIntegrated MNCH/PMTCT Register captures information on HIV-infected pregnant and breastfeeding women who enroll into the
facility‘s PMTCT program. It contains information about the mother over time (longitudinally) from the time of her PMTCT enrollment
until her exit from the facility‘s PMTCT program.
HOW IS THE Integrated MNCH/PMTCTRegisterORGANIZED?
The Register is organized by month/year (MM/YY) of mother‘s enrollment into the PMTCT program.
 Each page is devoted to HIV+ women who enroll in the facility‘s PMTCT program during a single month/year (a cohort).
 Each page of the Register has 7 rows, which allows for documentation of 7 HIV+ women. Facilities that enroll more than 7 HIV+
pregnant or breastfeeding women in a given month continue entering women that month‘s cohort on the following page. (Thus, in
facilities with higher PMTCT volume, a single cohort may be listed on more than one page of the Register).
 Each cohort should be started on a fresh page, even if the previous page is not full (i.e., less than 7 PMTCT enrollees).
PROCEDURE: WHO AND WHEN TO ENTER WOMEN IN THEIntegrated MNCH/PMTCT Register?
All HIV+ pregnant or breastfeeding women enrolled in the facility‘s PMTCT program should be entered in the Register. This includes
women who are:
1. Newly diagnosed HIV+
2. Known HIV+ before pregnancy
HIV+ pregnant or breastfeeding women should be entered in the facility‘s Register when they enter the facility‘s PMTCT program even if
ART has not yet been initiated.
PURPOSE OF THE MATERNAL PMTCT COHORT REPORT FORM:
This form is used to calculate important outcomes related to retention in the PMTCT program for a given maternal cohort. Calculations of
outcomes are done at Months 3, 6, and 12 since maternal PMTCT enrollment. Each Maternal PMTCT Cohort Report Form reports on a
single PMTCT maternal cohort in a facility.
Information from the Maternal PMTCT Cohort Report Form will be used to fill out the facility‘s Maternal PMTCT Cohort Wall Chart.
HOW IS THE Maternal PMTCT Cohort Report FormORGANIZED?
Each Maternal PMTCT Cohort Report Form reports information on one maternal PMTCT enrollment cohort (month/year) at a health facility.
PROCEDURE FOR COMPLETING THE Maternal PMTCT Cohort Report Form:
1. For the reporting month, use the PMTCT Cohort Monitoring Job Aid to identify which maternal enrollment cohorts (MM/YY) should be
evaluated (Months 3, 6, and 12 since PMTCT enrollment).
2. Please refer to Tables 1 and 2 (below) for instructions on how to complete the Maternal PMTCT Cohort Report Form.
 Table 1defines key terms and provides guidelines to identify situations and outcomes needed to complete the Maternal PMTCT
Cohort Report Form.
 Table 2 provides detailed instructions about how to complete the Maternal PMTCT Cohort Report Form. For each maternal cohort,
this includes:
o Calculation of the initial (Month 0) cohort size
o At three time points (Months 3, 6, and 12 since enrollment):
– Cohort size is updated
– Maternal outcomes are recorded, and
– Maternal retention and lost to follow-up are calculated
MATERIALS MANAGEMENT AND STORAGE:
File Maternal PMTCT Cohort Report Forms in a clearly labeled binder in a secure location. Each binder should have 12 report forms in
active use per calendar year. Completed report forms (all data entered through 12 months of follow-up) may be filed in an archive section
of the binder.
Key terms, definitions, and practical guidelines to identify situations and outcomes needed to complete the Maternal PMTCT Cohort
Report Form
Key Term Definition Practical guidelines:
How this would appear in the
Integrated MNCH/PMTCT Register
Month 0 The month of enrollment in the PMTCT program for the On the Integrated MNCH/PMTCT Register (Left page):
HIV+ mother ―Month 0‖ is the ―PMTCT Register: Cohort: Month‖ (top of
page) = mother‘s PMTCT registration ―Booking Date‖
month
Transfer In (TI) Mother who changes her ongoing care to the PMTCT No official data field or code for ―TI‖ in the Integrated
program at a new facilityfrom another facility‘s PMTCT MNCH/PMTCT Register. The following information may
program where she was previously enrolled and followed. assist in identifying TI :
 At the new facility, a TI mother would be expected to be
IMPORTANT: The HIV+ pregnant or breastfeeding women entered at the bottom of a Register cohort page (because
who comes to a facility PMTCT program from an adult she is assigned same MM/YY PMTCT enrollment
ART clinic is considered newly enrolled in PMTCT. cohort as at her previous facility).
She is not considered as a TI.  ―TI‖ or ―transferred in‖ may/may not be written in the
body of the Register (either page) or in the comments.
 No maternal status is listed in Month 0 but status is
reported in subsequent months in the Integrated
MNCH/PMTCT Register (Right page).
 The facility ―Booking Date‖ (Column 6) would likely be
after the cohort month in the Integrated
MNCH/PMTCT Register (Left page).
 Checks () may be placed in ―maternal status‖ boxes
before her transfer; this would reflect services elsewhere
during the months before mother‘s transfer to the
current facility
Transfer Out Mother who officially transfers her care out of a facility‘s ―TO‖ or ―transferred out‖ written in the Integrated
(TO) PMTCT program. Her transfer could be to: MNCH/PMTCT Register (Right page).
1. Another PMTCT facility
-OR-
2. Adult ART clinic (exit from PMTCT program)
Net current The number of mothers currently being followed in the Net current cohort is calculated in a given reporting month
cohort facility‘s PMTCT program. =
Number of mothers in the original cohort (Month 0) plus the
total number TI since Month 0, minus the total number TO
since Month 0.
MATERNAL The most current documented ―maternal status‖ (Alive and Determine the maternal statusfor each mother in the cohort.
OUTCOME on ART, Lost to Follow-Up, or Known Dead) for the To do this, look across her row to identify those who
STATUS: mother at the time of reporting. transferred in (from other PMTCT facilities), those who
transferred out, and current maternal outcome for the
reporting period. If no maternal status is documented in the
column for the reporting month, find the last documented
outcome in the Integrated MNCH/PMTCT Register (Right
page)
Alive and Maternal status designation for mothers who attended the ―Alive and on ART‖ is documented by an ART regimen
on ART clinic and received ART ANDdid not miss their most recent code (e.g., ―1C‖ or ―1E‖ or ―1F‖) recorded in the maternal
scheduled appointment by more than one month. status row of the Integrated MNCH/PMTCT Register
(Right page).
Lost to Follow- Maternal status designation for mothers who have missed ―LTF‖ could be determined in the Integrated
Up (LTF) their most recent scheduled appointment date by more than MNCH/PMTCT Register (Right page), by either:
one month A. Maternal status = ―LTF‖ or ―lost‖ written in
-OR-
B. Blank boxes for the two most recent consecutive
months
Known Maternal status designation for mothers who died at any ―D‖ or ―died‖ written in the Integrated MNCH/PMTCT
dead time after PMTCT program enrollment—by report or Register (Right page).
verified in writing
Completing thePMTCT Maternal Cohort Report Form
Steps to complete the Maternal PMTCT Cohort Report Form

Month 0
ORIGINAL 1. Write the name of the month and year in the Month 0 column.
COHORT 2. Count the number of mothers with any maternal status reported in Column 40 (Month 0). Enter this number into Row A (Month 0).
Month 3
1. Write the name of month and year in Month 3 column.
UPDATE 2. Count the total number of Transfer Ins (TI) since Month 0. Enter the TI number in the box for Row B, (Month 3).
COHORT SIZE 3. Count the total number of Transfer Outs (TO) since Month 0. Enter the TO number in the box for Row C (Month 3).
4. Calculate the number of mothers in the current cohort (net current cohort) = Row A (Month 0) plus Row B (Month 3) minus Row C (Month 3).
*For Month 3 maternal outcomes, look at Columns 40–43 in Integrated MNCH/PMTCT Register (Right page). Determine the maternal status for each mother in the cohort.
5. Count the number of mothers with each outcome (Alive and on ART, Lost to F/U, and Known Dead) at Month 3. Use the definitions in Table 1 above.
RECORD
6. Enter the value for number of mothers with each outcome as follows:
MATERNAL
OUTCOMES a) Alive and on ART: Enter number on Row E (Month 3).
b) Lost to F/U (LTF): Enter number on Row F (Month 3).
c) Known dead: Enter number on Row G (Month 3).
CALCULATE % *Calculate percent of mothers Retained (Alive and on ART ) and Lost to Follow-Up at Month 3, using the following formulas:
RETAINED & LTF 7. Percentage (%) Retained = # Alive and on ART / net current mother cohort x 100% = Row E (Month 3) / Row D (Month 3) x 100%. Enter number on Row H (Month 3).
8. Percentage (%) Lost to Follow-Up (LTF) = # Lost to Follow-Up / Net current mother cohort x 100% = Row F (Month 3) / Row D ( Month 3) x 100%.
Instructions for Month 6 and Month 12 on next page
Completing the Maternal PMTCT Cohort Report Form(continued)

Month 6
4. Calculate the number of mothers in the current cohort (net current cohort) = Row A (Month 0) plus Row B (Month 6) minus Row C (Month 6).
*For Month 6 maternal outcomes, look at Columns 40–46 in Integrated MNCH/PMTCT Register (Right page): Determine the maternal status for each mother in the cohort.
RECORD
MATERNAL
RETAINED
& LTF
7. Percentage (%) Retained = # Alive and on ART / Net current mother cohort x 100% = Row E (Month 6) / Row D (Month 6) x 100%. Enter number on Row H (Month 6).
Month 12
4. Calculate the number of mothers in the current cohort (Net current cohort) = Row A (Month 0) plus Row B (Month 12) minus Row C (Month 12).
*For Month 12 maternal outcomes, look at Columns 40–54 in Integrated MNCH/PMTCT Register (Right page): Determine the maternal status for each mother in the cohort.
RECORD
MATERNAL
RETAINED & LTF 7. Percentage (%) Retained= # Alive and on ART / Net current mother cohort x 100% = Row E (Month 12) / Row D (Month 12) x 100%. Enter number on Row H (Month 12).
Examples of special situations and how to interpret them for Maternal PMTCT Cohort Report Form
Situation Interpretation/ Recommended Action

Mother‘s enrollment information is  Mother is enrolled in the PMTCT program and should be counted as part of the cohort for Month 0,
entered in Cohort Register (Left), but even if no maternal status is documented. This typically occurs when a mother is enrolled in the
Cohort Register (Right) is blank (no PMTCT program but not started on ART.
maternal status recorded).  If she does not return to clinic for >1 month after her most recent scheduled appointment, she is
categorized as Lost to Follow-Up.
Mother transfers in from another Mother presents at health facility and claims to have been enrolled in another PMTCT program at a different
PMTCT facility without official facility. Verify her PMTCT enrollment month/year by 1) asking the mother; and 2) confirming with the
documentation. original PMTCT facility via a phone call. Using her PMTCT enrollment cohort month/year, mother is
categorized as a Transfer In. If you are unable to verify mother‘s original PMTCT enrollment month, enter
her as a new enrollment in the current cohort month.
In Cohort Register (Right), you notice The maternal status may not have been accurately entered in the Cohort Register (Right). To determine if the
two consecutive blank boxes in the mother was LTF OR if she was scheduled for a multi-month appointment, check the Appointment Register
―Month‖ columns. You know that the or Patient‘s File to verify the schedule appointment date.
mother-infant pair is stable and suspect  Mother is LTF if she did not return to clinic for >1 month after her most recent scheduled appointment.
and they were given a 3-month return Document that she is LTF in the Cohort Register (Right).
appointment.  Mother is ―Alive and on ART‖ if she was scheduled for a multi-month appointment (e.g., every 3
months). Document her regimen code/drug in the appropriate months leading up to her next scheduled
visit.
In Cohort Register (Right), Mother is assumed to have transferred out to adult ART clinic and exited the PMTCT program since there is
―Miscarriage― or ―Stillbirth‖ is written in no risk of mother-to-child transmission. Her maternal status should be documented as ―TO‖ in Cohort
the maternal status box. Register (Right).
In Cohort Register (Right), ―Other  This indicates that the mother has become pregnant again.
Pregnancy‖ is written in the maternal  She should exit her current PMTCT cohort with her maternal status documented as ―TO.‖
status box, with no further However, the provider should ensure that the HIV-exposed infant is followed until final outcome.
documentation in subsequent boxes.  The mother should enter a new PMTCT cohort for her current pregnancy.
A row in the Cohort Register (Left and Two possibilities:
Right) has no mother entered but has an 1. Infant with caregiver who is not the mother (and mother never enrolled in PMTCT). This infant
entry for a baby would be entered by the dates of its enrollment in PMTCT services.
2. Infant is likely a twin. Hopefully this will be written in the comments section of the Register. Could
also confirm if there is a mother-infant pair in the same cohort with an infant delivered on the same
day.
Maternal PMTCT Cohort Wall Chart
PURPOSE OF THE PMTCT Maternal Cohort Wall Chart:
The purpose of thePMTCT Maternal Cohort Wall Chartis to display the facility‘s PMTCT maternal outcome information, including
maternal retention on ART, loss to follow-up, and maternal deaths. It is meant to allow providers to understand the outcomes of the
mothers in their PMTCT program.
HOW IS THE Maternal PMTCT Cohort Report FormORGANIZED?
Each Maternal PMTCT Cohort Wall Chartdisplays maternal outcomes of a single year‘s 12 PMTCT maternal cohorts over time.
The Wall Chart information is the same as that in the Maternal PMTCT Cohort Report Forms, including cohort size, maternal outcomes
(mothers Alive and on ART, Lost to Follow-up, and Known Dead), and percentage of women retained or lost to follow-up in the facility
PMTCT program.
PROCEDURE FOR COMPLETING THE Maternal PMTCT Cohort Wall Chart:
1. Write the name of month and year for Months 0, 3, 6, and 12 into the appropriate columns on the Wall Chart for the individual
monthly cohorts.
2. Each month, copy data from the Maternal PMTCT Cohort Report Forms that were completed that Wall Chart information is taken
month into the appropriate cohort and reporting month sections of the Maternal PMTCT Cohort Wall directly from the Maternal
Chart. This will be the values from Rows A–I for the respective cohorts that were just evaluated for PMTCT Cohort Report Forms
that were completed that
Month 0, 3, 6, or 12.
month.
Maternal PMTCT Cohort Wall Chart should be displayed on the wall in the PMTCT clinic.
Each Wall Chart reflects the outcomes of a single year‘s 12 individual monthly PMTCT maternal cohorts. There may be up to 2 Wall
Charts in active use at any time. Once all cohorts on a Wall Chart have data completed through Month 12, the Wall Chart may be
removed from display and stored in a secure location.
REMINDER:
At Month 12, begin to enter information for the HIV-exposed infant in the
HIV-exposed Infant (HEI) PMTCT Cohort Report Form.

Annex 4.12: SOP:HIV-EXPOSED INFANT (HEI) PMTCT COHORT MONITORING OF EARLY INFANT DIAGNOSIS & OUTCOME STATUS*
Ethiopia will monitor HIV-exposed infants (HEI) whose HIV-infected mothers are enrolled in the PMTCT program. These infants will be
followed and monitored in groups—or cohorts—based on theirmothers‘ enrollment (month / year) in the PMTCT program at a facility.
Ethiopia will monitor:
DNA PCR test collection (early infant diagnosis [EID]) will be reported at Maternal Cohort Months 12 and 18.
HEI outcome status will be reported at Maternal CohortMonth 30.2
PURPOSE OF THIS DOCUMENT:
This document gives step-by-step instructions on how to:
1) Construct a HEI PMTCT Cohort
2) Analyze DNA PCR test collection for HEIs

at different time points
3) Analyze HEI outcome status at Month 30
SCOPE OF THIS DOCUMENT:
Measuring outcomes of HEI is necessary to evaluate and monitor the quality and impact of PMTCT programs. The tools and instructions
outlined in this document enable PMTCT providers to measure and understand key HEI outcomes at the facility level.
* Measured at Month 30 since maternal PMTCT enrollment
2
HEI loss to follow-up will be reported at 4 time points: Maternal Cohort Months 12, 18, 24, and 30.
HEI COHORT DEFINITION:
A HEI PMTCT Cohort is a group of infants whose HIV-infected mothers enrolled in PMTCT care3 during the same Month / Year.
Each year there will be 12 HEI cohorts.
TOOLS USED IN HEI PMTCT COHORT MONITORING:
 Integrated MNCH/PMTCT Register (data source for HEI PMTCT Cohort monitoring)
 HEI PMTCT Cohort Report Form (to calculate/record outcome information of one HEI cohort over the monitoring period [Months 12-
30])
 HEI PMTCT Cohort Wall Chart (displays 1 year of HEI cohort data)
 PMTCT Cohort Monitoring Job Aid (to find which HEI cohorts to report on each month)
KEY HEI COHORT OUTCOMES MEASURED:
Two key outcomes will be calculated on the HEI PMTCT Cohort Report Form.
1) DNA PCR test collection-- by 2 months of age, and between 2 and 12 months of age -- (reported at Maternal Cohort Months 12 and
18);
2) HEI outcome status (reported at Maternal Cohort Month 30).
In addition to these outcomes, Lost to Follow-up of infants will be measured to show program performance (reported at Maternal Cohort
Months 12, 18, 24, and 30).
TIME POINTS TO MEASURE THE HEI COHORT OUTCOMES:
3
HIV-infected women can enroll in PMTCT while pregnant or breastfeeding.
There are 4 reporting time points to measure outcomes for each HEI cohort: Months 12, 18, 24 and 30 since mother‘s PMTCT enrollment
(Maternal cohort Months 12, 18, 24, and 30). Specific outcomes are measured at each time point (See Table1a below).
Table 1a. Time points to measure specific HEI outcomes

REMEMBER, that the
reporting point does not DNA PCR DNA PCR test
Reporting Point
correspond to the test collected- collected-- Infant Lost HEI outcome
(i.e. time since
infant’s age. Rather, it is -by 2 months between 2 and 12 to F/U status
the monthsince the mother‘s PMTCT enrollment)
of age months of age
mother’senrollment
Month 12 X X X --
into PMTCT.
Month 18 X X X --
Month 24 -- -- X --
Month 30 -- -- X X
These time points (Months 12, 18, 24 and 30) are chosen because the majority of infants will be old enough to measure the individual
outcome of interest
RESPONSIBILITIES:
The PMTCT health care provider is responsible for the completion of the HEI PMTCT Cohort Report Form and the HEI PMTCT
Cohort Wall Chart within one week of the end of the reporting month.
OVERVIEW OF EACH OF THE TOOLS USED FOR HEI COHORT MONITORING
2. Integrated MNCH/PMTCT Register = DATA SOURCE for HEI PMTCT cohort monitoring
The Integrated MNCH/PMTCT Register captures information on all HIV+ mothers enrolled in the facility‘s PMTCT
program and their infants (HEIs). The Register contains information about these mother-infant pairs over time (longitudinally)
until the outcome status of the HEI is determined, or until 30 months after the mother‘s enrollment into PMTCT, whichever
occurs first.
Information for the HEI PMTCT Cohort Report Form and Wall Chart come from the Integrated MNCH/PMTCT Register.
HOW IS THE Integrated MNCH/PMTCTRegisterORGANIZED?
The Register is organized by date (month/year [MM/YY]) of the mother‘s enrollment into the PMTCT program. The Register
allows follow-up of the mother-infant pair for as long as 30 months after the mother‘s PMTCT enrollment. The information
about the mother-infant pairs is entered across both pages of the open Register.
 Each page of the Register has 7 rows, which allows for documentation of 7 mother-infant pairs across both pages of an
open Register.
 All HIV+ pregnant/breastfeeding women entered on a page of the Integrated MNCH/PMTCT Register would have
enrolled in the PMTCT program in the same month/year (MM/YY).
PROCEDURE: WHO AND WHEN TO ENTER HEI IN THEIntegrated MNCH/PMTCT Register?
All HIV+ pregnant/ breastfeeding women enrolled in the facility‘s PMTCT program should be entered in the Register.
Information about their infants is added to the Register for the first time when the HEI is brought to the clinic for his/her first visit.
 Infant information is first added to the register (on the same row as the infant‘s HIV+ mother) when he/she is brought for PMTCT
services at the facility, preferably at 4–6 weeks of age. Remember, the months in the register where infant information appears are not
the infant‘s age; they are the months since the mother‘s enrollment in PMTCT.
 If more than 7 HIV+ pregnant/breastfeeding women enroll in PMTCT at a facility in a single month continue, a second page (the
following page) is used to continue to enter women in that month‘s cohort.
 So, information on a single cohort may be listed on more than one page of the Register at facilities with higher PMTCT volume.
 At least one row

* TRANSFER IN: Which page should HEIs(mother-infant pairs) who TI be entered in the Register?
must be left blank at the end of
When an infant (and HIV+ mother) transfer to a new PMTCT facility, the mother-infant pair should be entered
each month to allow space to
in the Integrated MNCH/PMTCT Register in the month/year of her original enrollment into the PMTCT program
(if known and confirmed). enter a mother-infant pair that
transfers in from another
If month of original PMTCT enrollment is not known/confirmed (unofficial transfer without referral form),
enter the mother-infant pair into the Integrated MNCH/PMTCT Registerin month of transfer. PMTCT facility and is in that
MM/YY cohort.
 Each new month‘s cohort should be started on a fresh page, even if the previous page is not full (i.e., less than 7 PMTCT enrollees).
REMEMBER:
A HEI cohort includes infants of HIV+ mothers who enrolled in a facility’s PMTCT program during the same month/year (MM/YY).
The HEI cohorts are grouped by the month/year of their mother’s PMTCT enrollment, NOT by their ages).
2. HEI PMTCT Cohort Report Form
PURPOSE OF THE HEI PMTCT COHORT REPORT FORM:
This form is used to calculate outcomes of infants in HEI cohorts at certain time points.
Information from the HEI PMTCT Cohort Report Form is used to fill out the facility‘s HEI PMTCT Cohort Wall Chart.
HOW IS THE HEI PMTCT Cohort Report FormORGANIZED?
The HEI PMTCT Cohort Report Form reports outcome information at certain time points (maternal cohort Months 12, 18,
24, and 30) for a single HEI PMTCT cohort in a facility.
WHEN DOES HEI COHORT REPORTING BEGIN?
Reporting of outcomesfor HEI cohortsbegins at Month 12 since the MM/YY of maternal enrollment in PMTCT (maternal
cohort Month 12).
PROCEDURE FOR COMPLETING THE HEI PMTCT Cohort Report Form:
3. For the reporting month, use the PMTCT Cohort Monitoring Job Aid to identify which HEI cohorts should be evaluated.
(Remember: HEI cohorts are grouped by MM/YY of mothers‘ PMTCT enrollment; HEI reporting is done at Months 12, 18,
24, and 30 since mother‘s PMTCT enrollment).
4. Please refer to Tables 1b, 2, 3, and 4 (below) for instructions on how to complete the HEI PMTCT Cohort Report Form.
 Table 1bdefines key terms and provides guidelines to identify situations and outcomes needed to complete the HEI
PMTCT Cohort Report Form.
 Table 2 provides detailed instructions about how to complete the HEI PMTCT Cohort Report Form. For each HEI cohort,
this includes calculation of:
o Cohort size at Months 12, 18, 24, and 30 (since maternal PMTCT enrollment) and each of the outcomes listed in Table
1a.
 Table 3gives the steps to identify the HEI outcomes, which are reported on the HEI PMTCT Cohort Report Form at the
maternal cohort Month 30 time point.
 Table 4 lists examples of special situations and how to interpret them for completing the HEI PMTCT Cohort Report
Form.
File HEI PMTCT Cohort Report Forms in a clearly labeled binder in a secure location. Each binder should have 12 Report
Forms in active use per calendar year. Completed HEI PMTCT Cohort Report Forms (i.e., reports with HEI data entered
through Month 30 since maternal PMTCT enrollment) may be filed in an archive section of the binder.
Table 1b. Key terms, definitions, and practical guidelines to identify situations and outcomes needed to complete the HEI PMTCT Cohort
Report Form (part 1 of 3)

Month 0 The month/year of HEI mother‘s enrollment Found on the Integrated MNCH/PMTCT Register (Left page):
into the PMTCT program ―Month 0‖ is listed in ―PMTCT Register: Cohort: Month‖ (top
of page). It is the month/ year of the mother‘s PMTCT
registration ―Booking Date‖.
Month 12 12 months after the mother‘s PMTCT This is the first time point that a HEI outcome will be measured
enrollment and reported. Found on the Integrated MNCH/PMTCT
Register (Left page) under ―M12‖.
Transfer In (TI) HEIs (and their mothers) already enrolled in No official data field or code for ―TI‖ in the Integrated
a PMTCT program elsewhere, who transfer MNCH/PMTCT Register. The following information may
(change primary location of where to receive assist in identifying TIs:
care) into this facility.  At the new facility, a TI infant (and his/her HIV+ mother)
would be expected to be entered at the bottom of a Register
cohort page (because she is assigned same MM/YY
PMTCT enrollment cohort as at her previous facility).
 ―TI‖ or ―transferred in‖ may/may not be written in the body
of the Register (either page) or in the comments.
 No maternal status is listed in Month 0 but status is
reported in subsequent months in the Integrated
MNCH/PMTCT Register (Right page).
 The facility maternal ―Booking Date‖ (Column 6) would
likely be after the cohort month in the Integrated
IMPORTANT: The HIV+ pregnant or MNCH/PMTCT Register (Left page).
breastfeeding women who comes to a  Checks () may be placed in the mother‘s ―maternal
facility PMTCT program from an adult ART status‖ boxes (Left page) for the months before her transfer
clinic is considered newly enrolled in to the current facility; this would reflect that she received
PMTCT. She is not considered as a TI. services elsewhere during the months before mother-infant
pair transferred.

Transfer Out (TO) HEI (and HIV+ mother) who officially transfer care ―TO‖ or ―transferred out‖ may be written in the Integrated
out of a facility‘s PMTCT program. Her transfer MNCH/PMTCT Register (Right page).
could be to:
3. Another PMTCT facility
-OR-
4. Adult ART clinic (exit from PMTCT program)
Present Cohort The HEIs whose mothers began as original cohort Present Cohort is calculated in a given reporting month =
for HEIs members plus HEIs whose mothers TI (i.e., were in Number of HEIs whose mothers were in the original cohort
same MM/YY cohort at another PMTCT facility) (Month 0) plus the total number of HEIs whose mothers TI to
that cohort since Month 0.
NOTE: For HEIs Transfer Out is an outcome. TOs
are not considered when updating HEI the Present
Cohort numbers.
DNA PCR test Blood specimen collected from the HEI for a The ―DNA PCR test collected‖ outcome is calculated for each
collected virologic HIV test (dried blood spot [DBS] cohort at Month 12 and Month 18 months since mother‘s
specimen)—best done at 4–6 weeks of age. PMTCT enrollment. (The outcome is divided into tests collected
by 2 months of age and tests collected between 2 –12 months of
age.)
HEI There are 6 possible outcome status categories for Each of the 6 possible outcomes is identified in different ways in
OUTCOME HEIs at Month 30 since maternal PMTCT the Integrated MNCH/PMTCT Register. This is described in
STATUS at enrollment: Table 1c.
MONTH 30 since 1. Discharged Negative (DN) Each HEI will be assigned only one outcome.
maternal PMTCT 2. Diagnosed Positive (DP)
enrollment 3. Lost to follow-up (LTF)
NOTE: HEIs who test HIV positive and are linked to ART
4. Still exposed/breastfeeding (CPT)
5. Known Dead (D) care, should be designated as “P” (not “TO”) when
6. Transfer Out (TO) calculating the Final Outcome Status indicator.

HEI
OUTCOME STATUS
(cont‘):
Discharged negative (DN) Rapid HIV-AB test result is negative and the
infant has a ―DN‖ designation in the
Diagnosed positive HEIs who test HIV positive, either with DNA
(P) PCR or with a Rapid HIV test, at any point
during the PMTCT follow-up period.
Lost to Follow-Up “Infant status” designation for mothers who ―LTF‖ may be determined in the Integrated
(LTF) have missed their most recent scheduled MNCH/PMTCT Register (Right page), by either:
appointment date by more than one month C. “Infant status” = ―LTF‖ or ―lost‖ written
-OR-
D. If the boxes for the two most recent consecutive
months are left blank
This procedure is used for identifying HEIs who are

“LTF” at any of the reporting time points--Months 12,
18, 24, or 30 (and have not returned to care).
Still exposed/breastfeeding HEIs with ―CPT‖ designation at Month 30
(CPT) since mother‘s PMTCT enrollment (end of the
follow-up period)
Known Maternal status designation for mothers who ―D‖ or ―died‖ written in the Integrated MNCH/PMTCT
Dead died at any time after PMTCT program Register (Right page).
(D) enrollment—by report or verified in writing
Transfer Out HEIs who transfer out of this PMTCT facility
(TO) to receive care at another PMTCT facility.
Table 2. Instructions on how to complete theHEI PMTCT Cohort Report Form(part 1 of 2)
Steps to complete the HIV-exposed Infant (HEI) PMTCT Cohort Report Form for each HEI cohort (at Months 12, 18, 24,and 30 after maternal PMTCT enrollment)
Month 12
* At the top of the Report Form:
COHORT (MM/YY)
& FACILITY INFO
1. Write the name of the month and year of the maternal PMTCT enrollment month (Maternal Cohort Month 0) for this HEI cohort.
2. Fill out the information about the Health Facility and its location.
REPORTING MONTH 3. Write the name and year of Month 12 for this HEI cohort in the "Maternal Cohort Month 12" column.
COHORT 4. Count the number of HEIs born to the HIV+ mothers enrolled in PMTCT at your facility in Maternal Cohort Month 0. Enter this number into Row A (Month 12)
SIZE 5. Enter Row A (Month 12) number into Row C (Month 12)
LOST TO FOLLOW-UP 6. Count the number of HEIs lost to follow-up by Month 12. Enter this number into Row D (Month 12)
7. Count the number of HEIs that had DNA PCR tests collected by 2 months of ageby time point Month 12. Enter this number into Row E (Month 12) #
DNA PCR 8. Calculate the percentage of HEIs with DNA PCR tests collected by 2 months of age = Row E (Month 12) # / Row C (Month 12) * 100%
COLLECTED 9. Count the number of HEIs that had DNA PCR tests collected between 2–12 months of age by Month 12. Enter this number into Row F (Month 12) #
10. Calculate the percentage of HEIs with DNA PCR tests collected between 2–12 months of age = Row F (Month 12) # / Row C (Month 12) * 100%
Month 18
REPORTING MONTH 1. Write the name and year of Month 18 in the "Maternal Cohort Month 18" column.
2. Write the total number of HEIs in this cohort that have transferred into (TI) your facility's PMTCT program since Month 0. Enter this number into Row B (Month 18)
UPDATE COHORT
3. Add the number of HEIs born to mothers who enrolled in PMTCT at your facility plus the number of HEI that TI since Month 12 = Row A (Month 12) + Row B (Month
SIZE
18).
LOST TO FOLLOW-UP 4. Count the number of HEIs lost to follow-up at Month 18. Enter this number into Row D (Month 18)
8. Count the number of HEIs that had DNA PCR tests collected by 2 months of ageby time point Month 18. Enter this number into Row E (Month 18) #
DNA PCR 9. Calculate the percentage of HEIs with DNA PCR tests collected by 2 months of age = Row E (Month 18) # / Row C (Month 18) * 100%
COLLECTED 10. Count the number of HEIs that had DNA PCR tests collected between 2–12 months of ageby Month 18. Enter this number into Row F (Month 18) #
11. Calculate the percentage of HEIs with DNA PCR tests collected between 2–12 months of age = Row F (Month 18) # / Row C (Month 18) * 100%
Instructions for Month 24 and Month 30 on next page

Table 2. Instructions on how to complete theHEI PMTCT Cohort Report Form(part 2 of 2)
Month 24
2. Write the total number of HEIs in this cohort that have transferred into (TI) your facility's PMTCT program since Month 12. Enter this number into Row B (Month 24)
UPDATE COHORT
SIZE
3. Add the number of HEIs born to mothers who enrolled in PMTCT at your facility plus the number of HEI that TI since Month 0 =
Row A (Month 12) + Row B (Month 24). Enter this number into Row C (Month 24)
LOST TO FOLLOW-UP 4. Count the number of HEIs lost to follow-up at Month 24. Enter this number into Row D (Month 24)
Month 30
UPDATE COHORT 2. Write the total number of HEIs in this cohort that have transferred into (TI) your facility's PMTCT program since Month 0. Enter this number into Row B (Month 30)
SIZE 3. Add the number of HEIs in original cohort plus the number of TIs since Month 12 = Row A (Month 12) + Row B (Month 30). Enter this number into Row C (Month 30)
* Count the number of HEIs with each outcome by Month 30: See Table 3 for instructions about how to assign final outcomes.
4. Discharged negative ( DN) by Month 30. Enter this number into Row G (Month 30) #
5. Diagnosed positive (P). Enter this number into Row H (Month 30) #
HEI OUTCOMES
6. Lost to follow-up (LTF). Enter this number into Row I (Month 30) #
#
7. Still exposed/breastfeeding (CPT). Enter this number into Row J (Month 30) #
8. Known dead (D). Enter this number into Row K (Month 30) #
9. Transferred out (TO to another PMTCT facility--NOT to ART clinic). Enter this number into Row L (Month 30) #
* Calculate percentages (%) of HEIs by Month 30:
10. Discharged negative (DN) = Row G (Month 30) # / Row C (Month 30) * 100%. Enter this percentage into Row G (Month 30) %
11. Diagnosed positive (P) = Row H (Month 30) # / Row C (Month 30) * 100%. Enter this percentage into Row H (Month 30) %
HEI OUTCOMES 12. Lost to follow-up ( LTF) = Row I (Month 30) # / Row C (Month 30) * 100%. Enter this percentage into Row I (Month 30) %
% 13. Still exposed/breastfeeding (CPT) = Row J (Month 30) # / Row C (Month 30) * 100%. Enter this percentage into Row J (Month 30) %
14. Known dead (D) = Row K (Month 30) # / Row C (Month 30) * 100%. Enter this percentage into Row K (Month 30) %
15. Transferred out (TO to another PMTCT facility--NOT to ART clinic) = Row L (Month 30) # / Row C (Month 30) * 100%.
Enter this percentage into Row L (Month 30) %
Table 1c. Steps to identify the six possible HEI OUTCOMES at Month 30 for each HEI cohort.
***Each HEI will be given only one Outcome***
Steps to identify HEI Outcomes

HEI Outcome Status STEP 1. STEP 2.
Right Cohort Register Page Left Cohort Register Page Comment
Look back from Month 30 to Month 0 Confirm ―DN‖ status with
1. Discharged negative (DN) and count # of HEIs with Infant Status ―N‖ HIV test results in ---
―DN‖ Columns 37 and 38
If infant has been diagnosed HIV+
Diagnosed positive (―P‖), report this HEI as ―P‖,
2. --- ―P‖ in Columns 37 OR 38 even if ―TO‖ or ―LTF‖ is also
(P)
written on Right Page
Providers must tell mothers
Still Count # of HEIs with most recent
that CPT babies will need HIV
3. exposed/breastfeeding Infant Status as ―CPT‖ at Month 29 ---
testing after breastfeeding is
(CPT) or Month 30 (Columns 78, 79)
completed
Look back from Month 30 to Month
Known dead Count infants regardless of
4. 0 and count # of HEIs with Infant ---
(D) HIV status
Status ―D‖
Transfer out (TO) Look back from Month 30 to Month
5. to another facility--NOT 0 and count the # of HEIs with last --- ---
to ART clinic) recorded Infant Status ―TO‖
Look back from Month 30 to Month NOTE:
0 and count # of HEIs: A HEI may be LTF and then
 With Infant Status ―LTF‖ who return to clinic for care later.
Final Lost to F/U never returned for care--OR-- A HEI who has a ―LTF‖
6. ---
(LTF)  Who missed most recent outcome, never returned to
scheduled appointment by more care after being designated
than one month and never LTF.
returned for care
Table 4. Examples of special situations and how to interpret them for completing the HEI PMTCT Cohort Report Form.
Situation Interpretation/ Recommended Action

HEI whose mother transfers in from Mother presents at health facility and claims to have been enrolled in another PMTCT program at a different
another PMTCT facility without official facility. Verify her PMTCT enrollment month/year by:
documentation. 1) asking the mother and
2) calling the original PMTCT facility to confirm
Using her PMTCT enrollment cohort month/year, mother is categorized as a Transfer In.
If you are unable to verify mother‘s original PMTCT enrollment month, enter her as a new enrollment in
the present cohort month. Her infant will be in the HEI cohort with the same maternal enrollment cohort
month/year.
In Cohort Register (Right), you notice The maternal status may not have been properly entered in the Cohort Register (Right).
two consecutive blank boxes in the most To determine if the HEI (and the HIV+ mother) are LTF OR if they were scheduled for a multi-month
recent ―Month‖ columns. appointment, check the Appointment Register or Patient‘s File to verify the scheduled appointment date--
even if you believe that the mother-infant pair is stable and suspect and they were given a 3-month return
appointment.
 If HEI (and mother) did not return to clinic for >1 month after her most recent scheduled
appointment, then both are LTF. Document that the HEI (and mother) are LTF in the Cohort Register
(Right).
 If HEI (and mother) are scheduled for a multi-month appointment (e.g., every 3 months) and have
not missed that appointment, then the HEI (and mother) are NOT LTF. Document HEI CPT (and
mother‘s ART regimen code) in the appropriate months leading up to the HEI‘s next scheduled visit.
In Cohort Register (Right), ―Other  This indicates that the mother has become pregnant again.
Pregnancy‖ is written in the maternal  The mother should exit her current PMTCT cohort with her maternal status documented as ―TO.‖
status box, with no further  The provider should ensure that the HIV-exposed infant is followed until determination of the HEI
documentation in subsequent boxes, but outcome, which is measured at Month 30 since the maternal PMTCT enrollment.
the HEI information continues.
A row in the Cohort Register (Left and Two possible reasons for this situation:
Right) has no mother entered but has 3. HEI is with caregiver who is not the mother (and mother never enrolled in PMTCT). This infant
HEI information documented would be entered in the HEI cohort of the month/year that he/she was first seen for PMTCT
services.
4. HEI may be a twin. Hopefully this will be written in the comments section of the Register.
Look to see if there is a mother-infant pair in the same cohort with an infant that was delivered on
the same day as the HEI without maternal information.
3. HEI PMTCT Cohort Wall Chart
PURPOSE OF THE HEI PMTCT Cohort Wall Chart:
The purpose of theHEI PMTCT Cohort Wall Chart is to display the facility‘s PMTCT HEI outcome information, including HEI Outcome
and DNA PCR test collection, and loss to follow-up data. It is meant to allow providers to understand the outcomes of the HEIs in their
PMTCT program.
HOW IS THE HEI PMTCT Cohort Wall Chart ORGANIZED?
Each HEI PMTCT Cohort Wall Chart displays information for 12 HEI cohorts (1 year of HEI cohorts).
The outcomes at each of 4 time points for every HEI cohort are displayed. When HEI cohort monitoring is functioning for some time,
there may be 3 HEI PMTCT Cohort Wall Charts active at one time.
Information from HEI PMTCT Cohort Report Form used to complete the HEI PMTCT Cohort Wall Chart.
 Some of the HEI PMTCT Cohort Wall Chartinformation is the same as on HEI PMTCT Cohort Report Form, including
original cohort size, TI, present cohort size, and some lost to follow-up numbers but, unlike the Report Form outcome
information is shown as percentages.
 Outcomes that are entered on the HEI PMTCT Cohort Wall Chart are:
o 1) DNA PCR test collection by 2 months of age, and between 2–12 months of age;
o 2) HEI Outcomes, displayed as percent of cohort that are Discharged
Negative; HIV Positive; and lost to follow up measured at Month 30. HEI PMTCT CohortWall Chart
This information shows the impact of the facility PMTCT program. information is taken directly or
calculated from the HEI PMTCT Cohort
PROCEDURE FOR COMPLETING THE HEI PMTCT Cohort Wall Chart:
Report Forms.
 Remember: The mother‘s PMTCT enrollment month/year (Month 0) defines the particular HEI cohort.
 On any given month, you will report on outcomes for 4 separate HEI cohorts—those at Months 12, 18, 24, and 30 (since maternal
PMTCT enrollment).
 Each month, upon completing the 4 appropriate PMTCT HEI Cohort Reporting Forms, transfer the newly-figured information
promptly to the HEI Cohort Monitoring Wall Chart.
3. Write the name of month and year for Months 12, 18, 24, and 30 into the appropriate columns on the Wall Chart for each of the
individual monthly cohorts.
4. Each month, copy the data from the HEI PMTCT Cohort Report Forms that were completed that month into the appropriate cohort
and reporting month sections of the HEI PMTCT Cohort Wall Chart: Values from Report FormsRows A–D for the HEI cohorts that
just had outcomes measured at Month 12, 18, 24, and 30 into the corresponding boxes on theWall Chart.
5. At Month 18, calculate the percentage of the infants in the cohort that had:
a. DNA PCR test collection by 2 months of age by entering data from Report Forms Rows E (Month 18) / Rows C (Month 18) X
100% = [E/C x 100%].
b. DNA PCR test collection between 2–12 months of age by entering data from Report Forms Rows F (Month 18) / Rows C
(Month 18) X 100% = [F/C x 100%].
6. At Month 30, calculate the percentage of the infants in the cohort that had the following HEI Outcomes:
a. Discharged HIV Negative by entering data from Report Form Row G (Month 30) / Row C (Month 30) X 100% = [G/C x 100%].
b. Diagnosed HIV Positive by entering data from Report Form Row H (Month 30) / Row C (Month 30) X 100% = [H/C x 100%].
c. Lost to Follow-up by entering data from Report Form Row I (Month 30) / Row C (Month 30) X 100% = [I/C x 100%].
File HEI PMTCT Cohort Report Forms in a clearly labeled binder in a secure location. Each binder should have 12 report forms in active
use per calendar year. Completed report forms (all data entered through Month 30) may be filed in an archive section of the binder.
HEI PMTCT Cohort Wall Chart should be displayed on the wall in the PMTCT clinic. Once all cohorts have data completed through
Month 30, the wall chart may be removed from display and stored in a secure location.
Annex 4.13: PMTCT Cohort Monitoring Job Aid
Purpose:
 The purpose of the PMTCT Cohort Monitoring Job Aid is to assist providers to identify which individual monthly cohorts of HIV+
women or HIV-exposed infants (HEIs) should have data calculated (and entered in Report Forms) for a particular Reporting Month.
 This Job Aid is used alongside the Standard Operating Procedures documents for PMTCT Maternal Cohort Monitoring and for PMTCT
HIV-exposed Infant (HEI) Cohort Monitoring, which give instructions for maternal and HEI cohort reporting.
Reporting Month:
 The Reporting Month is defined as the last complete month of a follow-up period.
 The PMTCT Maternal and HEI Reporting Forms will be completed early in the month after the Reporting Month. For example, the
Report Form for Reporting Month January should be completed early in February.
Example: 3-month reporting for an October cohort:
3-month follow-up period*
Month 0 Month 1 Month 2 Month 3 Month 4

Oct Nov Dec Jan Feb
Month 0 = Complete
Reporting
Month of mother’s PMTCT Month 3
Month
enrollment
*3-month follow-up period includes 3 full months of data (Months 1–3). The starting point is in Month 0.
Time points for maternal cohorts and for HEI cohorts reporting:
 For each maternal cohort, information is reported for 3, 6, and 12 months after the mother‘s PMTCT enrollment.
 For each HEI cohort, information is reported for at 12, 18, 24, and 30 months after the mother‘s PMTCT enrollment.
The Ethiopian PMTCT cohort monitoring tools may be introduced in time for the May 2017 reporting month. (Maternal and HEI Report Forms for
May reporting month would be completed in early June). Please use the following instructions to understand which specific cohorts should have
information reported for particular reporting months.
INSTRUCTIONS:
As PMTCT cohort monitoring is rolled out/implemented, we will evaluate register data from the maternal and HEI cohorts that enrolled in the
PMTCT program 12 months before the implementation of cohort monitoring tools (e.g., May 2016, if May 2017 is the first PMTCT cohort
monitoring reporting month).
The tables below (pages 3 and 4) show which cohorts will be evaluated for each reporting month. Complete reports for the following reporting
months [GREY CELLS], complete the designated monthly outcomes [GREEN CELLS] for maternal and/or HEI cohorts [WHITE CELLS]:
In summary, for the following reporting months:
 May 2017 – Oct 2017: Complete 3, 6, and 12 month maternal outcomes, and the 12 month HEI outcome
 Nov 2017-Apr 2018: Complete 3, 6, and 12 maternal outcomes, and the 12 and 18 month HEI outcomes
 May 2018- Oct 2018: Complete 3, 6, and 12 maternal outcomes , and the 12, 18 and 24 month HEI outcomes
 Nov 2018 onward: Complete 3, 6, and 12 maternal outcomes , and the 12, 18, 24 and 30 month HEI outcomes
Steps to report on Maternal and HEI Cohorts:1. Find the current reporting month
2. Identify the cohort months that you need to report on
3. Complete reporting forms and wall chart
REPORTING MATERNAL OUTCOMES
May
Reporting Month Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018
2017
Mother‘s PMTCT Enrollment Month (Month 0)
Record the Original Cohort Size for: May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018
Assess Month 3 Maternal Outcome for: Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018
Assess Month 6 Maternal Outcome for: Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017 May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017
Assess Month 12 Maternal Outcome for: May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017
REPORTING HEI INDICATORS*
May
2017
Assess Month 12 Infant Indicators for: May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Apr 2017
Assess Month 18 Infant Indicators for: Nov 2015 Dec 2015 Jan 2016 Feb 2016 Mar 2016 Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016
* Infant indicators are assessed at 12, 18, 24 and 30 months since Mother‘s PMTCT Enrollment
Steps to report on Maternal and HEI Cohorts: 1. Find the current reporting month
2. Identify the cohort months that you need to report on
3. Complete reporting forms and wall chart

REPORTING MATERNAL OUTCOMES
May
2018
Record the Original Cohort Size for: May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 2019
Assess Month 3 Maternal Outcome for: Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018 Nov 2018 Dec 2018 Jan 2019
Assess Month 6 Maternal Outcome for: Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018 May 2018 Jun 2018 Jul 2018 Aug 2018 Sep 2018 Oct 2018
Assess Month 12 Maternal Outcome for: May 2017 Jun 2017 Jul 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 Apr 2018
REPORTING HEI INDICATORS*
May
2018
* Infant indicators are assessed at 12, 18, 24 and 30 months since Mother‘s PMTCT Enrollment
Annex.4.14: National PMTCT dashboard for monitoring MNCH/PMTCT/ EID Performances at all levels
DASHBOARD SCORING
Colour Percentage and Colour and Scoring Definitions
Green: 80%-100% Target achieved or on track
Yellow: 60%-79% Progress but more effort
required
Red:<60% Not on track
Year ----------- Annual Regional Performance
Remark
Quarter
Quarter
Quarter
Quarter
Score in
Eligible
color
4tth
Indicators
3
Mothers needing PMTCT (expected number of HIV
positive pregnant women)
Expected number of pregnancies
Number of pregnant women tested and know their

HIV result during pregnancy
Number of pregnant women tested and know their

HIV result during labour & delivery
Number of women tested and know their HIV result

during the postpartum period
Total Tested
Number of new HIV positive women during ANC, L&D

and Postpartum
Total number of pregnant women tested for syphilis
Total number of Reactive pregnant women treated for

syphilis
Total number of pregnant women tested for HBV
Total number of Reactive pregnant women treated for HBV
Number of HIV positive women who gave birth at health

institution
Number of HIV positive women who received ART to

reduce the risk of mother to child transmission during ANC
for the first time
Number of HIV positive Pregnant women who received

ART to reduce the risk of mother to child transmission
during L&D for the first time
Number of HIV positive lactating women who received

ART to reduce the risk of mother to child transmission
during PNC for the first time
Number of women with known HIV positive status

attending ANC, delivery and postpartum for new pregnancy
linked from ART
Total on ART
Number of HIV exposed infants who received a virological

HIV test within 12 Months of birth
Number of HIV exposed infants who received a virological HIV

test within 12 Months of birth Positive (PMTCT)
Number of HIV exposed infants who received ARV

prophylaxis (PMTCT)
Number of partners of pregnant, laboring and lactating

women tested for HIV and know their results
Number of partners of pregnant, laboring and lactating

women whose test result is HIV positive
Example for National Annual Plan from the Eligible

Note: Dash board is used at Woreda / zone / Region and National level
 Dashboard Scoring is done by color. Help to monitor PMTCT performances at each level quarterly
 If the percent of performance indicator is above 80 to 95%: Green
 If the percent of performance indicator is between 60-79%: Yellow
 If the percent of performance indicator is less than 60%: Red
Annex 4.15: Continuous quality improvement (CQI )TOOL
FACILITY LED ASSESSEMET OF PMTCT SERVICE
Region: ___________________Health facility: ______________Date: _______/_________/_______
S. Servic Intervention Result Check points Scoring M&E (Quantitative Re
N e area statements (Use observation(O) or/and interview(I) Defined indicators) ma
or/and review of documents(RD)) in # rk
1 Card Post reminder Card room with Reminder notice posted (O)
Room (statement notice posted on ---of----
or ―Priority for visible place Clerk gives priority for pregnant and
Recepti pregnant and lactating women(O/I)
on lactating
women‖)
2 Presence of Cue card and
Health workers utilization/application for PMTCT(o) # of pregnant
Use of Cue card Complied to TC Client informed about availability of women tested and
standards interventions to reduce MTCT(I) ---of--- know their result
Privacy assured (O)
HIV testing conducted using the national
testing algorithm(O)
ANC Syphilis testing as a routine(I,RD)
unit Syphilis test positives management
(I,RD)
HBV testing as a routine(I,RD)
HBV test positives prophylaxis (I,RD)
3 Prevention and Pregnant --of--- # of pregnant
treatment of iron mothers  Lab testing for Hemoglobin/ Hematocrit women tested for
deficiency screened and conducted (RD) anaemia,
anaemia in treated for % # of pregnant
pregnancy anaemia  Iron supplementation provided (RD) women who
received Iron
supplementation
4 Male friendly Male partners Woman informed on the necessity of
MNCH services involvement in partner testing(I) # of male partners
the MNCH entry Invitation sent to PW‘s partners to attend ---of-- tested
points clinic‘s session (I, RD)
Family testing using family matrix (O,I
)
HCT service provided to PW
partners(I,RD)
5 Recording and Records are All HMIS forms available (O)
reporting complete and Maternal & HEI cohort report forms
kept (Record available (O) ---of--
Keeping) Maternal & HEI cohort wall chart
available (O)
Completeness of records (O, RD)
Records properly handled(cabinets, room
locked) (O)
Transfer in and transfer out sheet has
been presnt & completed well(O,I,RD)
6 Availing Clinical Attendance tool in place for easy # of pregnant
Attendance Attendance book reference(O) ---of---- women LTFU care;
register to track in place (patient
LTFU tracking system Proper application of tracing tool (O,RD)
available?)
TOTAL SCORE --of
7 Clinical service PMTCT service Trained health worker assigned(O, I) # PW+ provided
related to available 24 Basic L&D equipment available with ART during
PMTCT open hours for (delivery coach, delivery set, maternity ANC, L&D & PNC;
round the clock labouring bed…) and ready for use(O) ---of---- # of HEI received
(24/7) women ART for the mother (I/O) ARV for PMTCT
ARV prophylaxis for newborn
available(RD/O)
Check for Expiry date for all ARVS (O)
Job aids related to PMTCT in place(O)
8 Client informed about availability of # of women TC
L&D Health workers interventions to reduce MTCT(I) during L&D and
unit Use of Cue card Complied to CT Privacy assured(O) know their status
standards HIV testing conducted using the national ---of----
testing algorithm(O, RD)
HCT service provided to delivering
women partners (I,RD)
9 Male friendly Male partners Woman informed on the necessity of # of male partner
MNCH services involvement in partner testing(I) tested at L&D(the
the MNCH entry Invitation sent to PW‘s partners to attend ---of--- denominator is the #
points clinic‘s session (I, RD) of ANC HTC )
HCT service provided to PW partners
(I,RD)
presence of personal protective
Infection Use of standard equipment for delivery service available
prevention during precautions (O, I )
labor and Presence of instrument cleaning & ---of---
delivery processing set up been present (O,I)
clean ,neat delivery room(O)
Hand hygiene practice & procedure
posted (O)
10 HIV positive Standard referral forms are available
Linking cases to mothers linked and used(O, RD) # of mothers linked
PMTCT/ANC for to care, support Service directory available(O, RD) ---of---- to treatment, Care
Rx, care and and treatment  Referral and feedback forms are &Support to ANC
support services properly documented (O, RD) unit
 HEIs put on NVP Prophylaxis and # of HEIs put on
linked to MBPCF(I,O,RD) NVP
TOTAL SCORE ---of-
S. Service Intervention Result Check points Scoring M&E Remark

N area statements (Use observation(O) or/and Defined in (Quantitative
interview(I) or/and review of # indicators)
documents(RD))
11 Availing regular standard services open Provide standard PNC as per the # of HIV+
services during all clinic regularly guidelines for mother-infant pairs(O, mothers
hours during all RD) received at
clinic hours Counseled on BF and care for HIV ---of---- least one
exposed infant(O, RD) PNC
Offer HCT if not done already(RD) services; #
PNC/EP Job aids available(O) of HEI on BF
I/HEI received
unit daily NVP
for PMTCT
12 Making MNCH services Male partners Woman informed on the necessity # of male
Male friendly involved in the of partner testing(I) partners
MNCH entry Invitation sent to women‘s partners ---of---- tested for
points to attend clinic‘s session(RD) HIV in PNC
HTC service provided to women
partners (RD)
13 Use of dual protection HIV positive Different options for FP methods # HIV
(contraception and women counseled and demonstrated, stressed +Women
consistent use of condom) received dual on dual protection(O,I, RD) ---of---- provided
Prevention Job aids available (O) with PP FP
counseling methods
14 HIV positive standard HIV/AIDS referral forms # of HIV
Linking clients to care mothers linked are available and used (O,RD) positive
and support to care, support Service directory available(O, RD) ---of---- women and
and treatment Referral and feedback forms are newborn
services properly documented(O,RD) linked to
treatment,
C&S
15 FP Use of dual protection HIV positive Different options for FP methods ---of---- # of HIV
(contraception and women counseled and demonstrated, stressed Positive
consistent use of condom) received on dual protection (O,I,RD) women who
counselling on different FP options are are on FP
dual protection available(O)
Job aids available(O)
TOTAL SCORE __of__
S. Service Intervention Result Check points Scoring M&E Remark

N area statements (Use observation(O) or/and Defined in (Quantitative
interview(I) or/and review of # indicators)
documents(RD))
16 EID HEI diagnosed Postal office receives DBS sample ---of---- # of infants
within 5 days after collection(I) tested with
DBS test turn round time DNA PCR
<1month(I) and know
Tracing of clients to inform status their status
(RD,I)
17 ART Referral linkage Referral Transfer in and transfer out sheet # of mothers
system among has been presnt & completed linked b/n
ART and well(O,I,RD) ART &
PMTCT  Team work among PMTCT and --of---- PMTCT
ART provider (I,O)
Referral slip used for pre-ART
clients linked for PMTCT (O/I)
Laborat Establish functional drug Functional PMTCT logistics and supply
18 ory and supplies system L&S mgt. management conform with the # of health
Pharmac system national drug policy and ---of---- facilities
y store regulations(O) with stock-
and Regular update of drug and supplies outs in the
dispensa stock balance(RD) last three
ry Early request (one month)of refill months
prior to stock out of medical and
supplies(RD)
Reagent for syphilis test available
(O,I ,RD)
RPR/VDRL test performed for
ANCs(I,RD)
 Quality assurance performed(HTC,
DBS) (I, RD)
19 Regular meeting conducted every 2
PMTCT Existing system for Best practices weeks to capture lessons learnt and
/ MCH monitoring and and challenges challenges for decision making ---of----
coordina documenting best documented (verified by minutes)(RD)
tion practices CQI recording formats and M&E
service tools available (O,RD)
Timely report and feedback
provided to challenges including
logistics and supplies issues(RD)
TOTAL SCORE ---of---
GRAND TOTAL SCORE ---of---
Note: These are not the only quality indicating checks. However, these are considered basics to start up identifying problems of
PMTCT services. The health facility can possibly generate information to from other source to identify problems/challenges/gaps and
run the process of PDSA.
Annex 4.15.1: Sample of Clients‘ Exit Interview Questionnaire

Instruction: Hello, I would like to ask your permission to be part of an assessment about how you felt about the services you received
in today‘s visit to this health facility. This is to better understand how services can be improved. You are kindly requested to respond
to the questions honestly.
Thank you. Let‘s begin now. Answer questions with a tick against the corresponding response that matches.
S/# Items/questions Responses
1. Reason for your visit □ ANC/PMTCT
□ Delivery Service
□ Post natal care
□Other (specify)
Excellent Good Fair Remark
2 In general, how do you feel about the waiting time?
3 How do you feel about the time given for consultation by the health
provider?
4 How do you rate the assistance of the health provider to make you
understand the recommendations that you need to follow?
5 How well do you think your privacy was respected and maintained
during your visit?
6 Generally, how do you rate your satisfaction with the services you
received today?
7 If fairly satisfied, which service(s) do you think need(s) improvement? □ART
□ PMTCT /ANC
□ L&D
□ Postnatal/FP
□Card room,
□Pharmacy
□Laboratory
□ other (specify)
These are all the questions. Thank you for your time and your valuable information.
ANNEX 4.15.2: Action Plan Framework
Name of facility: ______________________ Date: ____/_____/_______
ACTION PLAN
R/N GAP IN INDICATOR Possible Action Responsible Support Timeline Evaluate/ action
THE cause taken PERSON Required lesson for the
(Result (intended (d/m/y)
CHECK learned next
area #) Target) (key (Test
POINTS cycle
causes) action) (Study)
(problem
statement)
P1: I: C1: □Modify

□Expand
P2: T: C2:
□Drop
Annex 4.15.3: Tips for Practical Attachment Facility Visit
1. Introduce to facility head and management team about the objective of this facility visit
Objective
 Implementing follow up of CQI and plan of action to be done in the facility
 Introduction dash board
 Introduce clinical and systemic mentoring of PMTCT/HIV exposed infants
431
 Identify the level of involvement of mother mentors for PMTCT through interview,
observation and discussion with MNCH/PMTCT coordinator and mother mentors
including document review
2. Visiting
 First visit all areas of key PMTCT Implementing areas in group
(ANC,L&D,PNC,EPI,F/P, Adult and pediatric ART, Pharmacy and Laboratory)
3. Clinical Case Review
 Select 6 cards among PMTCT clients and 3 new and 3transferred from ART to ANC
 Review findings and actions performed
 Put tally accordingly and sum for the cards you reviewed
S.N Activity Description Done Not Done Finding and Action

Assessment of FP and documented FP options
WHO clinical Starting
CD4 follow up after 6 months
Viral load done after one year
ART initiation and Re-filling at ANC
TB screening
Referral for TB suspect
INH prophylaxis for TB negatives
CPT prophylaxis
STI screening and management
Nutritional assessment and management
Adherence monitoring and counselling
Disclosure counselling
Family Index Client Finding or use of family matrix
Children identified HIV positive through the use of
family matrix
4. Clinical case review for HEI Case review for HEI
See 3-5 HIV exposed infant card and review and put tally accordingly
S.N Activity Description Done Not Done Finding

1 NVP + AZT prophylaxis provided and registered in the
MBPC register at a time of delivery
2 CPT started at 6 weeks
3 DBS at 6 weeks, results registered
4 Ab confirmatory test done at 18 months
5 Growth Monitoring & Developments Assessment
6 Vaccination/ EPI
7 Infant feeding selected and current status
8 Other care of exposed infant
432
5. Key tasks
A. Perform facility led assessment tool
B. Explaining How to use dash board
C. Doing action plan of health facility with PMTCT team and facility head
D. Summary report on:-
 General view of Facility MNCH/PMTCT performance: strengths, gaps
identified and areas of improvement specific to the facility
 Total Performance & gap of the health facility
 Document any challenges related to MNCH/PMTCT services.
Format for practical attachment– Trainee‘s assignment to Health facilities
S.N NAME OF THE PARTICAIPANTS‘ NAME OF HEALTH FAILITY TEAM LEADER
433

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National Comprehensive PMTCT/MNCH

Integrated Training Manual

Assegid Samual Cheru

1 Dr. Meseret Zelalem MoH

FMOH Federal Ministry of Health TB Tuberculosis

Rationale of revising the course

National Comprehensive PMTCT/MNCH Training manual

Exercise note book

Date and time Activities/agendas Facilitator Remark

3:00-3:15 Tea break

5:25-5:30 Daily Evaluation

Day Six Laboratory session

Full day laboratory exercise: HTC and DBS with laboratory

10:45-12:30 Group One:

1:30-3:00 Chapter 4. Recording and reporting data

3:00-3:15 1. Tea Break

3:15 - 5:25 Performance evaluation using dashboard and CQI

Day Nine Tuesday Chapter Four- Cohort monitoring and

8:40-10:00 Maternal Cohort monitoring and analysis

3:15-5:25 Maternal Cohort monitoring and analysis continued

Day 10 HEI cohort monitoring and analysis

10:15-12:30 HEI cohort monitoring and analysis continued

Day Eleven Field visit

3:00-3:15 Tea break

Day Twelve Revision on Cohort exercises( Friday is last day for

10:15 – 12:30 Revision on Cohort exercises

3:30 - 5:30 General discussion and closing remark

By the end of this chapter, participants will be able to:

1.1. Basics of HIV and Mother to Child Transmission (MTCT)

By the end of this session participants will be able to:

Exercise 1.1: The Story of Z and H

The Story of Z and H

H, a year before marriage

1. What is the most likely disease that H died of?

1.1.1. Introduction to HIV and the Immune system

Modes of HIV transmission:

 Unprotected sexual practice (anal, vaginal, oral) with an infected person

 Transfusion with infected blood or blood products

 Organ transplant from infected donor

1.1.2. HIV and the Immune System

Introduction to the immune system:

1.1.3. Life cycle of HIV

1. HIV attaches to the CD4 cell and releases RNA andenzymes.

Figure 2: Life cycle of HIV

1.1.4. CD4 T-cell and HIV Viral Set Point

1.1.5. HIV infection and disease progression

Primary HIV infection

• Fever, fatigue, pharyngitis, lymphadenopathy, rash, etc

Figure 3: Disease progression pattern among adults

Patterns of HIV Disease progression varies among patients

1.1.6. Mother-to-Child Transmission of HIV

Mother-to-Child transmission of HIV (MTCT) is the transmission of HIV from an infected

Table 1: Estimated Risk of MTCT of HIV without intervention

Table 2: Factors increasing risk of Mother-to-Child transmission of HIV

During labour and childbirth

1.1.6.2. Prongs for prevention of Mother-to-Child transmission of HIV

 Provide early diagnosis and treatment of sexually transmitted infections

 Make sure that method choice selection addressed,

Steps for family planning counseling skill

 Greet client with respect

New client visit:

b. Explore client‘s social context, circumstances, and relationships

c. Explore client‘s history of STIs, including HIV