1

Learning Objectives

Describe the new 2010 Zambia PMTCT guidelines Describe the new ART options for the Prevention of Mother to Child transmission (PMTCT) List the antiretroviral drugs that should be used in pregnancy Describe recommendations for infant feeding for HIV-positive and negative women Describe follow-up of HIV exposed infants

Zambia Antenatal HIV Prevalence

Currently the antenatal HIV prevalence among

pregnant women is 16.4%. With 500,000 580,000 women delivering annually, approximately 80,000 infants born are at risk of acquiring HIV from their mothers. More than 90% of women attending ANC are tested for HIV, while in the general adult population only 23.4% are tested, showing that stigma is still highly prevalent (Zambia Sexual Behaviour Survey, 2009)

The plan to scale up PMTCT services includes:

Maintaining ANC utilization above 90 percent
Improving acceptance of testing to 100 percent Improving adherence to antiretroviral (ARV)

therapy by HIV positive women to 90 percent, and Increasing the proportion of women delivered by skilled health workers to 70 percent.

Objectives of the next five year PMTCT Scale up plan Virtual Elimination of MTCT of HIV
To reduce the risk of transmission of MTCT of HIV to less than 5 per cent by 2015. To reduce the unmet need for family planning by 50 per cent from the current levels of 27 per cent

by 2015. To provide antiretroviral therapy to at least 95 per cent of HIV-positive children in need of treatment by 2015.

Zambia
(Population 13.5 million)
Number of PLWHA: Adults 15 49 yrs HIV prevalence rate: Children 0 - 14 yrs living with HIV:

1, 100, 000 14.3% 80,000 - 120, 000 (95,000, UNICEF 2007) 16.4% ~ 80,000 infants

Antenatal HIV Prevalence

Perinatally exposed infants per year:

Infants born with HIV per year(without PMTCT):

~ 28,000 infants

Counseling and Testing

Group Health Education
PITC / VCT Family Centered Approach Couple Counseling

ANC Care
Clinical screening and examination: BP, urinalysis, and weight

measurement
Detection and effective treatment of STIs Prevention, detection and treatment of anaemia (Hb, Systematic de-

worming, Ferrous Sulphate and Folic acid)

Multi-vitamin supplementation for the prevention of low birth weight Counselling about infant feeding options IPT with SP for malaria prophylaxis, from second trimester for HIV

negative pregnant women, every 4 weeks. Ensure every woman has at least three doses before delivery. All pregnant mothers must use ITNs

ANC cont.
Cotrimoxazole prophylaxis: for all HIV positive women starting

in the second trimester

Fansidar and Cotrimoxazole are not given in the first trimester

because both drugs have anti-folate properties that will cause foetal malformations.

TB clinical screening in HIV infected mothers with history

taking, examination and sputum smear if indicated. If diagnosed positive, refer for appropriate TB care. disclosure and male involvement in ANC.

Promoting and supporting couple counselling, partner

WHOs 4-Prong Approach to PMTCT

I. Primary prevention of HIV

Uninfected Parents to be

HIV infected woman II. Prevention of unintended pregnancy

Pregnant HIV infected woman

III. Prevention of MTCT HIV infected infant

IV. Linkage to Care and Support

AIDS and Death

September 2007 Edition 3

Module 8: ART in Special Populations

10

Timing of MTCT
Antenatal

Labor/Delivery

Postnatal

5-10%

10-20%

5-10%

Increases to 10-20% if breastfeeding is prolonged beyond 6 months

September 2007 Edition 3 Module 8: ART in Special Populations 11

Pregnant Women
Treating pregnant women with ARV therapy to prevent transmission of the virus to the foetus is a priority. All pregnant women that are HIV positive should be on HAART if clinical (WHO) or CD4 criteria are met. If found ineligible for HAART she should be initiated on short course therapy as outlined below Short-term ARV therapy does not treat maternal disease
September 2007 Edition 3 Module 8: ART in Special Populations 12

Criteria for PMTCT interventions (Eligibility Criteria)

Provide HAART CD4 Clinical Criteria only (CD4 not available) < 350 / mm3 Provide Short Course ARVs > 350 / mm3

Stage 3 or 4 (any CD4a)

Stage 1 or 2

If CD4 >350 then initiate ART with EFV plus 2 NRTIs

Orientation to New ART Protocols 2010

13

Course

ARV Prophylaxis based on WHO 2010 guidelines (Option A)

Antenatal Mother Intrapartum Mother Postnatal Mother Postnatal All exposed infants AZT 300mg BD starting at 14 weeks or as soon as possible thereafter until delivery Combivir 1 tablet every 12hours until delivery. NVP 200mg single dose at onset of labour Combivir 1 tab Breastfeeding infant: twice daily for i)NVP at birth and daily until one 7 days week after all exposure to breast milk ii)Start co-trimoxazole from 6 weeks until a week after all exposure to breast milk and HIV infection is ruled out. Non-breastfeeding infant: i)Commercial milk formula ii)NVP at birth and for 6 weeks. iii) Start co-trimoxazole until PCR results are confirmed negative . Continue Combivir stat dose Combivir1 Breastfeeding infant: of 1 tablet at onset of labour tablet BD for 7 i)NVP at birth and daily until one and 1 tablet every 12hours days week after all exposure to breast until delivery. milk NVP 200mg single dose at ii)Start Cotrimoxazole from 6 onset of labour weeks until a week after all exposure to breast milk has ended. Non-breastfeeding infant: i)Commercial milk formula ii)NVP at birth and for 6 weeks. iii) Start co-trimoxazole until

From 14 weeks of pregnancy

For women presenting in 3rd trimester

AZT 300mg BD until delivery

ART prophylaxis 2010 cont.

For woman who has not received prophylaxis antenatally Combivir 1 tablet at onset of labour and 1 tablet every 12hours until delivery. NVP 200mg single dose at onset of labour Combivir1 BD for 7 days Check eligibility for HAART Breastfeeding infant: i)NVP at birth and daily until one week after all exposure to breast milk ii)Start co-trimoxazole from 6 weeks until a week after all exposure to breast milk has ended. Non-breastfeeding infant: i)Commercial milk formula ii)NVP at birth and for 6 weeks. iii) Start co-trimoxazole until PCR results are known.

Mother who is on HAART or eligible for HAART

Continue HAART or start HAART

Continue HAART

Continue HAART Breastfeeding Infant: i)NVP for 6 weeks, Non-breastfeeding infant: i)Commercial milk formula ii)NVP at birth and for 6 weeks. iii) Start co-trimoxazole until PCR results are known.

Extended simplified infant NVP dosing recommendations

Infant age Birth - 6 weeks Birth weight 2,000 - 2,499 gram Birth weight >2,500 gram >6 weeks to 6 months NVP daily dosing 10 mg once daily (1ml) 15 mg once daily (1.5mls) 20 mg once daily (2mls)

>6 to 9 months
>9 months to end of BF

30 mg once daily (3mls)

40 mg once daily (4mls)

Low birth weight infants should receive weight-specific dosing, suggested starting dose is 2 mg/kg once daily. Therapeutic drug monitoring is recommended. * Adapted from: Mirochnick M. et. al. [2006].

HAART in Pregnancy
Preferred regimen is AZT, 3TC and NVP
Use EFV in women with CD4 above 350 and after the 1st trimester If NVP hypersensitivity occurs substitute NVP with EFV Alternative regimen TDF, FTC/3TC and NVP/EFV ABC, FTC/3TC and NVP/EFV

September 2007 Edition 3

Module 8: ART in Special Populations

17

EFV in Pregnancy
If gestational age greater than 14 weeks continue with Efavirenz If less than 14 weeks, Efavirenz has been associated with neural tube defects therefore consider CD4 count;
If CD4 <250 switch to Nevirapine if CD4 250350 switch to nevirapine, monitor ALT if CD4 count > 250 consider triple nucleoside therapy

with AZT/3TC/ABC (if unable to monitor ALT)

September 2007 Edition 3

Module 8: ART in Special Populations

18

TDF in Pregnancy
2010 guidelines recommend TDF based regimen as

alternative regimen to AZT based regimen

September 2007 Edition 3

Module 8: ART in Special Populations

19

Algorithm for Care of the HIV positive pregnant Woman based on 2010 WHO Recommendations fig 2.1, pg 13

Infant feeding options

September 2007 Edition 3

Module 8: ART in Special Populations

21

Infant feeding Recommendations

Breastfeeding is protected, promoted and supported. (See

annex IV on the 10 steps of breastfeeding) All mothers regardless of HIV status should exclusively breastfeed up to 6 months and thereafter continue breastfeeding up to at least 12 months, with timely, adequate and safe complementary feeding. HIV positive mothers are encouraged to breastfeed for 12 months with use of extended daily NVP prophylaxis for infants until one week after the end of breastfeeding. All breastfeeding HIV negative women are encouraged to get an HIV test every 3 months until all exposure to breastfeeding has ended.
September 2007 Edition 3 Module 8: ART in Special Populations 22

Care and Support to HIV+ Mothers, Children and their families

Apply family centred approach to HIV testing, care

and treatment Promote adherence to extended NVP and cotrimoxazole prophylaxis. Encourage and support couples counselling and male involvement

HIV testing for the infant

All HIV exposed infants receiving extended NVP

prophylaxis should have a PCR at 6 weeks and at 6 months. An antibody test at 12 months and 18 months or after cessation of breastfeeding. If a health worker identifies a sick child or one who is failing to thrive an HIV test must be done. ( Provider Initiated Testing & Counselling - PITC) A PCR test may be done, regardless of breastfeeding, if the child presents with symptoms of HIV at less than 18 months of age. (see pg 25 of PMTCT guidelines)

 If the mother is breastfeeding the infant must be given

Nevirapine Prophylaxis

NVP at birth and daily until one week after all exposure to breast milk has ended. If the mother is on HAART or not breastfeeding, the baby must be given NVP at birth and daily for 6 weeks. Observe the infant for NVP sensitivity which may present as a generalised skin rash. If a baby is receiving extended NVP and tests HIV positive by PCR, stop NVP prophylaxis and immediately refer to paediatric ART clinic.

Co-trimoxazole Administration in HIV Exposed infants

weight Daily dose Child tablet (100mls) bottles (each tab = 100mg needed per month sulfamethoxazole, and 20mg trimethoprim) One child tablet mixed with feed or small amt of feed Two child tablets 1

<6months or <5kg

2.5mls

6mths to 5yrs, or 5 to 15kg

5mls

Summary of recommendations for discontinuing primary co-trimoxazole prophylaxis

Target population
Target population HIV Exposed children

Recommendations

Recommendations Discontinue co-trimoxazole after HIV infection is excluded Maintain on co-trimoxazole until the age of 5 years irrespective of clinical and immune response (At 5 years follow adult guidelines)

Infants and children living with HIV

Role of Community Healthcare Providers in PMTCT (1)

Encourage pregnant women in their community to go for early

booking by 14 weeks Encourage women to deliver in facilities Encouraging couple counselling and testing for HIV Encourage and support disclosure Perform group education, testing and counselling On-going psychosocial counselling Reducing stigma and discrimination associated with HIV and AIDS. Supporting adherence to treatment (ARVs and cotrimoxazole) Sensitization of community to the importance of HIV care

Role of Community Healthcare Providers in PMTCT (2)

Promote Male involvement in PMTCT In the event of a home delivery, ensure that the mother and newborn

baby are taken to the health facility for medical assessment, timely administration of ARVs and immunizations. Support breastfeeding and extended NVP prophylaxis Promotion of retention of mother-baby pairs in the programme Encourage and support women to come back for postnatal checkups and services Record keeping and data entry at both facility and community level Referrals and linkages to appropriate community-based groups such as PLHIV, peer support groups, post-test clubs, legal services, churches, faith-based organisations, legal counsellors and organisations which promote Income Generating Activities (IGAs).

Global Fund PMTCT Indicators

1. 2. 3. 4.

5.
6.

No of HIV- infected pregnant women received Antiretroviral drugs No of HIV- infected pregnant women assessed for eligibility No of infants born to HIV- infected women, who are breast feeding and covered by an antiretroviral drug No of infants receiving a virological test (DBS) within 2 months No of infants started on co-trimoxazole within 2 months No of pregnant women who know their HIV status

CHAZ 2010 PMTCT ACHIEVEMENTS

Indicator 1 Indicator 2 Indicator 3 Indicator 4 Indicator 5 Indicator 6 3,226 against 5,875 (55%) 2,012 against 5,875 (34%) 1,796 against 4,700 (38%) 1,739 against 4,700 (37%) 3,012 against 4,113 (73%) 11,153 against 15,765 (71%)

Global Fund PMTCT Indicators IDEALY

1. No of pregnant women who know their HIV status 2. No of HIV- infected pregnant women assessed for eligibility 3. No of HIV- infected pregnant women received Antiretroviral drugs 4. No of infants born to HIV- infected women, who are breast feeding and covered by an antiretroviral drug 5. of infants receiving a virological test (DBS) within 2 6. No of infants started on contrimoxazole within 2 months

CHAZ PMTCT Program Challenges

Mothers/babies lost to follow CHIs not sending reports on time Data collected is not accurate Some indicators are new and CHIs are not yet oriented. Delayed or non receipt of DBS results

Are we together?

September 2007 Edition 3

Module 8: ART in Special Populations

34

Thank You Questions?????