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Module 3. Specific Interventions to Prevent Mother-to-Child Transmission of HIV (PMTCT). Module 3 Objectives. Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.

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module 3

Module 3

Specific Interventions to Prevent Mother-to-Child Transmission of HIV (PMTCT)

module 3 objectives
Module 3 Objectives
  • Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.
  • Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT).
  • Describe strategies for reducing the risks of MTCT during labour and delivery.

Malawi PMTCT Training Package

module 3 objectives continued
Module 3 Objectives (continued)
  • Discuss the management of women during labour and delivery who are of unknown HIV status.
  • Describe immediate postpartum care of women with HIV infection.
  • Explain the need to integrate family planning into community services.
  • Describe guidelines for immediate newborn care.

Malawi PMTCT Training Package

unit 1
Unit 1

Implementation of Comprehensive ANC Services

Malawi PMTCT Training Package

unit 1 objectives
Unit 1 Objectives
  • Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.

Malawi PMTCT Training Package

pmtct in antenatal care anc
PMTCT in Antenatal Care (ANC)
  • ANC improves the health and well-being of mothers and their families.
  • Integration of PMTCT services into essential ANC services can improve care and pregnancy outcomes for clients.
  • Antenatal interventions can reduce risk of MTCT

Malawi PMTCT Training Package

quality rh in context of pmtct
Quality RH in context of PMTCT
  • Comprehensive antenatal services
    • Routine HIV testing and counselling
    • ARV prophylaxis or, if eligible, therapy
    • Safer infant feeding counselling and support
  • Quality intrapartum care
  • Quality postpartum care that includes:
    • Safer infant feeding counselling and support
    • Family planning services
    • Follow up care for mother and baby

Malawi PMTCT Training Package

integrated essential package for anc services
Integrated Essential Package for ANC Services
  • ANC for HIV-infected pregnant women includes basic services recommended for all pregnant women
  • Obstetric and medical care for HIV-infected women expanded to address their specific needs

Malawi PMTCT Training Package

support needs of women with hiv infection
Support Needs of Women with HIV Infection

Pregnancy is a stressful time. Support will lead to hope and acceptance.

Referrals include:

  • Food, nutritional counselling & supplementation
  • Practical necessities
  • Social and psychological support
  • Home care & community-based health care
  • Traditional/herbal healers
  • Orphan care and support
  • Care of children with HIV or AIDS

Malawi PMTCT Training Package

prevention of hiv related conditions
Prevention of HIV-Related Conditions

Reduce rates if illness, adverse pregnancy outcomes, and death among HIV-infected pregnant women

  • Women with HIV infection more susceptible to:
    • TB
    • Urinary tract infections
    • Respiratory tract infections
    • Recurrent vaginal candidiasis
    • Malaria
    • Breast conditions
    • Unhealed episiotomies/caesarean section wounds
    • Herpes zoster
    • Puerperal sepsis

Malawi PMTCT Training Package

maternal nutrition mtct
Maternal Nutrition & MTCT
  • Nutritional deficiencies can be associated with preterm delivery & increased risk of MTCT
  • Weight gain during pregnancy is an indicator of mother’s nutritional status

Malawi PMTCT Training Package

exercise 3 1
Exercise 3.1

Antenatal Care:

Case Studies

Malawi PMTCT Training Package

unit 2
Unit 2

Antiretroviral Prophylaxis and Therapy for PMTCT

Malawi PMTCT Training Package

unit 2 objective
Unit 2 Objective
  • Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT)

Malawi PMTCT Training Package

arv drugs in pmtct
ARV Drugs in PMTCT
  • Antiretroviral (ARV) drugs hinder replication and mutation of HIV, resulting in less damage to immune system
  • ARV therapy or prophylaxis reduce risk of MTCT by reducing viral load in mother
  • ARV drugs can be used for prophylaxis or treatment

Malawi PMTCT Training Package

arv drugs in pmtct continued
ARV Drugs in PMTCT (continued)
  • ARV Therapy: Long-term use of antiretroviral drugs to treat maternal HIV/AIDS to slow progression of disease. ARV therapy also reduces HIV transmission from mother to infant.
  • ARV Prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant. ARV prophylaxis does not treat maternal HIV or provide long-term protection for the infant.

Malawi PMTCT Training Package

pregnancy arv therapy
Pregnancy & ARV Therapy
  • Women who are eligible for ARV therapy should be referred to the ARV Clinic.
  • ARV therapy:
    • Should begin as soon as possible, but may be delayed until after 1st trimester
    • Women on ARV therapy require ongoing care and monitoring in the ANC and ART clinics.

Malawi PMTCT Training Package

arv prophylaxis
ARV Prophylaxis
  • ARV prophylaxis alone will not protect breastfeeding infants from risk of HIV infection
  • Single dose Nevirapine (sd-NVP) has been used since inception of programme.
    • Mother: sd-NVP 200mg at onset of labour
    • Infant: sd-NVP (6mg) within 72 hours of delivery
  • Prevent NVP resistance by avoiding multiple doses of NVP to the mother. If the maternal NVP dose is given during false labour, the dose should not be repeated.

Malawi PMTCT Training Package

arv prophylaxis1
ARV Prophylaxis
  • Combination regimens given during pregnancy are more effective but more difficult to administer where infrastructure/access is an issue
  • The HIV/AIDS Unit is phasing in the regimens at sites with infrastructure
  • Combination regimens include 2 or 3 of the following drugs:
    • AZT
    • NVP
    • 3TC
  • The recommended regimens are listed in Appendix 3-C

Malawi PMTCT Training Package

exercise 3 2
Exercise 3.2

Nevirapine Prophylaxis for PMTCT: Case Studies

Malawi PMTCT Training Package

unit 3
Unit 3

Optimal Management of Women During Labour and Delivery

Malawi PMTCT Training Package

unit 3 objectives
Unit 3 Objectives
  • Describe strategies for reducing the risks of MTCT during labour and delivery.
  • Discuss the management of women during labour and delivery who are of unknown HIV status.

Malawi PMTCT Training Package

pmtct interventions during labour delivery
PMTCT Interventions During Labour & Delivery
  • Administer ARVs as per guidelines
  • Use Standard Precautions
  • Minimize vaginal examinations
  • Avoid prolonged labour
  • Avoid routine artificial rupture of membranes
  • Avoid unnecessary trauma and routine episiotomy
  • Minimize risk of postpartum haemorrhage
  • Use safe transfusion practices

Malawi PMTCT Training Package

pmtct interventions during labour delivery continued
PMTCT Interventions During Labour & Delivery (continued)

Always use Standard Precautions during patient care:

  • Strict aseptic technique during first stage of labour
  • Wash hands before & after every procedure
  • Decontaminate bed, instruments, linens soon after use
  • Autoclave or high-level disinfection of instruments used for delivery
  • Use six swab technique for vulval swabbing/vaginal cleansing
  • Use protective gear, safely dispose sharps & contaminated materials

Malawi PMTCT Training Package

pmtct interventions during labour delivery continued1
PMTCT Interventions During Labour & Delivery (continued)

Minimize vaginal examinations:

  • Perform vaginal examinations only when necessary
  • Record all vaginal examinations on partograph

Malawi PMTCT Training Package

pmtct interventions during labour delivery continued2
PMTCT Interventions During Labour & Delivery (continued)

Avoid prolonged labour:

  • Use partograph to monitor progress of labour
  • Avoid artificial rupture of membranes
  • If spontaneous rupture of membranes occurs when not in labour, induce immediately
  • Augment if in latent phase of labour
  • Aim to deliver within 4 hours if in active phase of labour
  • Reinforce pain relief in labour

Malawi PMTCT Training Package

pmtct interventions during labour delivery continued3
PMTCT Interventions During Labour & Delivery (continued)

Avoid unnecessary trauma during delivery:

  • Avoid invasive procedures
  • Avoid routine episiotomy
  • Avoid unnecessary trauma to infant
  • Minimize use of vacuum extractors
  • Prevent genital tract/perineal lacerations
  • Do not give enemas
  • Do not shave vulva

Malawi PMTCT Training Package

pmtct interventions during labour delivery continued4
PMTCT Interventions During Labour & Delivery (continued)

Minimize risk of postpartum haemorrhage:

  • Carefully manage all stages of labour to prevent infection & avoid prolonged labour
  • Actively manage third stage of labour

Use safe transfusion practices:

  • Minimize blood transfusions
  • Use only blood screened for HIV, hepatitis B, and syphilis

Malawi PMTCT Training Package

exercise 3 3
Exercise 3.3

Obstetric Practices and HIV: Group Discussion

Malawi PMTCT Training Package

management of women with unknown hiv status continued
Management of Women with Unknown HIV Status (continued)

If a woman presents in:

  • Early labour:
  • Provide HIV information
  • Test unless she refuses
  • Give NVP to woman and infant if she tests HIV+
  • Late labour (active phase):
  • Defer test until after delivery & before discharge
  • If she test HIV+, give NVP to infant

Malawi PMTCT Training Package

exercise 3 4
Exercise 3.4

HIV Testing and ARV Prophylaxis during Labour and Delivery:

Case Studies

Malawi PMTCT Training Package

unit 4
Unit 4

Postpartum Management of Women and Infants

Malawi PMTCT Training Package

unit 4 objectives
Unit 4 Objectives
  • Describe immediate postpartum care of women with HIV infection.
  • Explain the need to integrate family planning into community services.
  • Describe guidelines for immediate newborn care.

Malawi PMTCT Training Package

immediate and subsequent postpartum care of hiv infected mothers
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers

After Delivery

  • Provide ARV prophylaxis to the infant

Before Discharge

  • Assess Mother
    • Personal hygiene
    • Nutritional status
    • Signs and symptoms of anaemia and infections
    • Signs of uterine involution
    • Breast conditions

Malawi PMTCT Training Package

immediate and subsequent postpartum care of hiv infected mothers continued
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Before Discharge

  • Assess Mother (continued)
    • Urinary tract infections
    • Episiotomies, caesarean section
    • Signs of PID and any other infections
    • Clinical features of HIV or AIDS
    • Possible side effects of ARVs
  • Administer Vitamin A and iron supplement

Malawi PMTCT Training Package

immediate and subsequent postpartum care of hiv infected mothers continued1
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Before Discharge

Offer education, counselling, and support for:

  • Infant feeding, hygiene, re-hydration, umbilicus care, illness
  • Diet and nutrition
  • Postpartum infection, including pelvic inflammatory disease (PID)
  • Anaemia
  • Community resources
  • Information on breast and urinary tract infections

Malawi PMTCT Training Package

immediate and subsequent postpartum care of hiv infected mothers continued2
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Upon Discharge

Offer Education, Counselling, Support for:

  • Follow-up care: both routine (one-week and six-week visits, then monthly check ups) and as needed
  • Family planning information and services, including information on condom use for dual protection

Malawi PMTCT Training Package

immediate and subsequent postpartum care of hiv infected mothers continued3
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Upon Discharge

Link patients to centers providing the following services:

  • Postnatal review, dates for one-week and six-week visits
  • Sexual and reproductive health care, including family planning
  • Prevention and treatment of HIV-related conditions, inc malaria
  • Immunizations

Malawi PMTCT Training Package

immediate and subsequent postpartum care of hiv infected mothers continued4
Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued)

Upon Discharge (continued)

Link patients to centers providing the following services:

  • Nutritional counselling and support
  • “Under-five” services
  • Support groups
  • HIV treatment, care, and support
  • Social and psychosocial support
  • Home-based care

Malawi PMTCT Training Package

family planning
Family Planning

Family Planning (FP) is a core PMTCT intervention.

  • FP services integrated into ANC and community health services can minimize HIV/AIDS- related stigma.
  • FP services includes:
    • Individual and couples counselling
    • Continued risk assessment
    • Early diagnosis and treatment of STIs and HIV/AIDS
    • Information and skills needed to practise safer sex
    • Access to contraceptives

Malawi PMTCT Training Package

immediate and subsequent postnatal care of hiv exposed newborn
Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn
  • Administer NVP prophylaxis as soon as possible but within 72 hours after birth
  • For home births, child and mother should be seen within 72 hours of delivery:
    • Assessment
    • Administration of NVP prophylaxis
    • Support safer infant feeding.

Malawi PMTCT Training Package

immediate and subsequent postnatal care of hiv exposed newborn continued
Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn (continued)

Make assessments and implement preventive measures:

  • Infant feeding
  • Administer ARVs within 72 hours
  • PCR testing within 48 hours where available
  • Immunization according to EPI schedule
  • Side effects of ARV prophylaxis

Malawi PMTCT Training Package

exercise 3 5
Exercise 3.5

Supporting Postpartum

Follow-Up:

Group Discussion

Malawi PMTCT Training Package

module 3 key points
Module 3: Key Points
  • The essential package of ANC services includes the basic services recommended for all pregnant women, including HIV testing. However, for women with HIV, obstetric and medical care should be expanded to address the specific needs of women infected with HIV.

Malawi PMTCT Training Package

module 3 key points continued
Module 3: Key Points (continued)
  • Nutritional assessment, counselling and support are important not only in the antenatal period when good nutrition plays a role in foetal health and PMTCT, but also in the postpartum period, particularly for the breastfeeding mother and for the HIV-exposed or HIV-infected infant and young child.

Malawi PMTCT Training Package

module 3 key points continued1
Module 3: Key Points (continued)
  • ARV therapy is the long-term use of antiretroviral drugs to manage maternal HIV and prevent MTCT; ARV prophylaxis is the short-term use of antiretroviral drugs to reduce MTCT of HIV.

Malawi PMTCT Training Package

module 3 key points continued2
Module 3: Key Points (continued)
  • The HIV/AIDS Unit has phased in the more complex but efficacious WHO-recommended regimen (which include AZT, NVP and, in some instances, 3TC) at sites with adequate infrastructure and human capacity for its delivery. At the same time, expansion of PMTCT to sites with limited infrastructure will be done using single dose Nevirapine (sd-NVP) while steps are taken to build their capacity to deliver the recommended combination regimen.

Malawi PMTCT Training Package

module 3 key points continued3
Module 3: Key Points (continued)
  • The infant ARV prophylaxis regimen is either AZT alone, NVP alone or a combination of AZT and NVP. ARVs should be initiated to the infant as soon as possible after birth but within 72 hours of delivery.
  • Using safer obstetrical practices can reduce MTCT of HIV in labour and delivery.

Malawi PMTCT Training Package

module 3 key points continued4
Module 3: Key Points (continued)
  • There are national recommendations for testing of women of unknown HIV status in early labour and soon after delivery.
  • Support for safer infant-feeding practices are a priority in the immediate postpartum period.
  • Establishing linkages for postpartum follow-up of mother and infant can improve uptake of treatment and support services and reduce HIV-related morbidity and mortality.

Malawi PMTCT Training Package