New Pmtct Protocol
Transcript of New Pmtct Protocol
New PMTCT protocol(to start in mid september 2010)
BackgroundElimination of vertical transmission (GOAL) Possibility of New standard of quality care
and interventions for low and middle income countries Avoid high child mortality rate after 6months. Protection of children through breastfeeding
What is currently done
What is new
Advantages of the new protocol on Infant feedingChance for the child to continue benefiting
from breastfeeding(breast milk),No need to stop breastfeeding early. Increase mother-baby contact (affection) Avoid infant mortality rate due to malnutrition especially after 6 month when mothers was told to stop breastfeeding. Protected breastfeeding with ARVs.
Comparison of the current and the new protocols for non eligible womenCurrentMono therapy (AZT) Short period (3
NewTriple therapy (TDF
month) Starting period : 28 weeks Non protected breastfeeding
based) Long period (2 years) Starting period : 14 weeks Protected breastfeeding
I.PMTCT Protocol1. HIV + pregnant women eligibles to ART for their
own health.All women with CD4 500 are not
eligibles to ART. Start tripletherapy at 14 weeks of pregnancy up to the weaning time. The recommended period of breastfeeding is 18 months . The regimen:Tenofovir 300mg + Lamivudine 300mg et Efavirenz 600mg :(TDF + 3TC + EFV )
I. PMTCT Protocol(cont)4. HIV+ pregnant women previously exposed to single dose of NVP will receive : Tenofovir 300mg + Lamivudine 300mg
+Lopinavir/Ritonavir (Kaletra) 250mg(TDF + 3TC + Lop/r)
NB: ARV prophylaxis will be stopped one week after weaning.
5.HIV + pregnant women with renal failure. Regimen: Abacavir 300mg+ Lamivudine 150 mg + Efavirenz 600mg:(ABC+ 3TC + EFV)
I.PMTCT Protocol(cont)Women with renal failure and who had
been previously exposed to Sd NVP will receive: Abacavir 300mg+ Lamivudine 150 mg +Lopinavir/Ritonavir (Kaletra)250mg (ABC+ 3TC + Kaletra) NB:
Follow up of the renal funtion is
very important. ARV prophylaxis will stop one week after weaning.
I.PMTCT Protocol(cont)6.HIV + pregnant women coming late for ANC: above 34 weeks of pregnancy Start TDF + 3TC + EFV after renal function test (Creatinine) without waiting for CD4 count result. After CD4 count result: CD4 500/mm3: continue the same regimen up to the weaning time (one week after weaning).
I. PMTCT Protocol(cont). HIV - pregnant women in discordant couple . HIV testing after every 3 months and7
during labor. If still
Sd TDF+3TC+EFV then continue TDF+3TC during one week after delivery.
HIV negative ,she will receive during labor:
If HIV positive: CFR to above section (Care
and treatment for HIV+ pregnant women)
Children from discordant couples would take
daily NVP up to weaning time (one week after weaning). If the women turns POSITIVE during breastfeeding period, she should start ARV tripletherapy and the child should continue daily Nevirapine(NVP) for 6 weeks
I.PMTCT Protocol(cont) Prophylaxis to HIV exposed infants Breasfeeding and non-
breastfeeding children. Daily Nevirapine (NVP) syrup for 6 weeks.
New protocol SUMMARY
SCENARIOS CD4500 Coming >34 weeks of pregnancy-labor
REGIMENS MOTHERS TDF+3TC+NVP TDF+3TC+EFV TDF+3TC+EFV TDF+3TC+EFV
DURATION For life From 14 weeks of pregnancy - for life From 14 weeks of pregnancy - weaning Start immediately then adjust the TTT after CD4 count result. Depends on the CD4 count.
Previously exposed to Sd TDF+3TC+Lop/r(Kaletra) NVP HIV negative in discordant Testing every 3 months couple and at labor. If still HIV -:Sd TDF+3TC+EFV then TDF+3TC for 1 week If turns HIV +:triple therapy according to CD4 count results CHILDREN Born to HIV + mother Daily NVP
Birth6 weeks of life
Follow up of HIV +woman on ARV prophylaxis.After initiation of ARV prophylaxis: Control of liver (ALAT) and renal (Creatinine) function tests at1month (M1), 3 months (M3) and at 6 months (M6) for women on tripletherapy. In case of toxicity to NVP or suspicion : transfer for medical advise. In case of toxicity to NVP in 1st term of pregnancy replace with kaletra and at 2nd term replace with EFV. CD4 count control will be done every 6months for allwomen on tripletherapy
II.Follow-up of HIV exposed infants.Biological PCR at 6 weeks Serology at 9 and18 months.
Growth monitoring and nutrition
status
18months:Weigh,height,neurological evaluation,infection. Nutritional status. Medical Cotrimoxazole : start at 6 weeks up to definitive HIV negative status. If the child turns HIV positive: transfert to pediatric care and treatment.
Monthly up to
PCR 6 semaines. Si la PCR 1 est ngative, continuer le suivi et faire
une srologie 9 mois. Si la PCR 1 est positive, confirmer par une 2me PCR mais en mme temps dbuter la PEC en donnant les ARVS chez lenfant en attendant la PCR de confirmation (car le rsultat de la PCR de confirmation peut trainer). Si la PCR de confirmation revient ngative, refaire une
3me PCR pour reconfirmer: Si la 3 me PCR de reconfirmation revient ngative: donc erreur de la PCR1, stopper la PEC pdiatrique dj initie et faire la srologie 9 mois. Si la 3 me PCR de reconfirmation revient positive, continuer la PEC pdiatrique dj initie et rfrer dans le service de PEC ARV pdiatrique. Si la PCR de confirmation revient positive, continuer la PEC pdiatrique dj initie et rfrer dans le service de PEC ARV pdiatrique.
Srologie 9 moisTout enfant avec une PCR 1 ngative ou si la PCR na pas t disponible le test de srologie sera fait comme suit et selon lalgorithme national:Le test de srologie 9 mois. Si la srologie est positive, confirmer par une PCR (car possibilit de la prsence des anticorps maternels), si la PCR de confirmation est positive rfrer en PEC (pdiatrique). Si la srologie 9 mois est ngative, continuer la prise en charge en cours et refaire une dernire srologie 18 mois.
Srologie 18 moisSi la srologie est positive, confirmer par
une PCR. Si la PCR est galement positive, lenfant est dclar positif et est transfr en prise en charge (pdiatrique) Si la srologie 18 mois est ngative et que lenfant ne tte plus, il est directement dclare ngatif et sort du programme. NB: Pour les enfants qui sont allaits au del de 16 mois, la srologie sera faite un mois et demi aprs larrt complet de lallaitement.
Medical Follow up.Le Cotrimoxazole doit tre donn
systmatiquement chaque enfant n de mre sropositive partir de 6 semaines de vie. Cest ce mme moment que lenfant doit aussi bnficier de la 1re PCR (DBS) et de la 2me vaccination. La dure du traitement dpendra de la confirmation du rsultat ngatif de la PCR ou de la srologique VIH chez lenfant. Et si le rsultat est confirm positif, lenfant sera rfr dans le service de prise en charge pdiatrique.
III.Family plannig.Start counseling on FP during
pregnancy. Integration of FP and HIV(especially PMTCT)services. Avail and provide FP methodes :especially long term methods. Promote and encourage dual protection.
Questions & Answers
(1)Duration of BF maximal or minimal (for
Rwanda PMTCT program)
R/18 months is the recommended maximum
duration of breastfeeding but mothers can wean their infants even before this period if the AFASS conditions are met. All this breastfeeding period is protected by ARVs.
Procedures of weaning : R/ The mother should stop breastfeeding gradually; this should take a period of 1 month. She will start the gradually process from 17 month maximum. Counseling will be provided to the mother to make sure that she had completely stop breastfeeding. She need to understand that after declaring that she had stopped breastfeeding she will no longer receive the treatment for protection of her child.
(2)Time to test the children:R/ Ideal is to do PCR/DBS at 6 weeks but if
not done PCR will be done at the first visit between 6 weeks and 9 months or in case of clinical indication. Serology at 9 months. Serology at 18months for all the children weaned up to 16 months but for children weaned after 16 months, the serology will be done 6 weeks after complet weaning.When to stop ARVs prophylaxis for
mothers?R/ ARVs will be stoped ONE WEEK after
Follow up of women: where?
and how?
R/ Where: For full package HF: i twill be done in PMTCT/C&T services. For PMTCT stand aloneit will be done in PMTCT services. R/How: Entry point for PMTCT is ANC, dossier is done lab
tests taken, drugs refilling every month, clinical assessment and ANC visits.
Criteria of readiness of sites to
implement new protocol:
R/Trained staff (task shifting/decentralized
training) Refresher training (with the support of partners and district Hospitals) Drug requisition tools available on site and
If a woman is already on current
protocol, what will be done when the new one starts?R/ For the non eligible woman, shift to
tripletherapy after assessing the liver and the renal functions. For the eligible already on tripletherapie: dont change the regimen unless this is side effect. The women has to continue the same regimen.
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