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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
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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 ofacquiring HIV from their mothers.
More than 90% of women attending ANC are tested
for HIV, while in the general adult population only23.4% are tested, showing that stigma is still highlyprevalent (Zambia Sexual Behaviour Survey, 2009)
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The plan to scale up PMTCT
services includes: MaintainingANC utilization above90 percent
Improving acceptance oftesting to 100 percent
Improving adherence to antiretroviral (ARV)therapy by HIV positive women to 90 percent,and
Increasing the proportion of women delivered byskilled health workers to 70 percent.
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Objectives of the next five year PMTCT Scale upplan Virtual Elimination of MTCT of HIV
To reduce the risk of transmission ofMTCT of HIVto 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 centby 2015.
To provide antiretroviral therapyto at least 95
per cent ofHIV-positive children in need oftreatment by 2015.
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Zambia(Population 13.5 million)
Number of PLWHA: 1, 100, 000
Adults 15 49 yrs HIV prevalence rate: 14.3%
Children 0 - 14 yrs living with HIV: 80,000 - 120, 000(95,000, UNICEF 2007)
Antenatal HIV Prevalence 16.4%
Perinatally exposed infants per year: ~ 80,000 infants
Infants born with HIV per year(without PMTCT): ~ 28,000 infants
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Counseling and Testing Group Health Education
PITC / VCT
Family Centered Approach Couple Counseling
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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 HIVnegative pregnant women, every 4 weeks. Ensure every woman has atleast three doses before delivery. All pregnant mothers must use ITNs
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ANC cont. Cotrimoxazole prophylaxis: for all HIV positive women starting
in the second trimester
Fansidar and Cotrimoxazole are not given in the first trimesterbecause both drugs have anti-folate properties that will causefoetal malformations.
TB clinical screening in HIV infected mothers with historytaking, examination and sputum smear if indicated. If diagnosed
positive, refer for appropriate TB care.
Promoting and supporting couple counselling, partnerdisclosure and male involvement in ANC.
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WHOs 4-Prong Approach to PMTCT
September 2007 Edition 3 Module 8: ART in Special Populations 10
Uninfected
Parents to be
HIV infected
woman
Pregnant HIV
infected woman
HIV infected
infant
I. Primary preventionof HIV
II. Prevention of
unintended
pregnancy
III. Prevention of
MTCT
AIDS and
Death
IV. Linkage to Care
and Support
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Timing of MTCT
Labor/Delivery PostnatalAntenatal
5-10% 5-10%10-20%
Increases to 10-20% if
breastfeeding is prolonged
beyond 6 months
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Pregnant Women Treating pregnant women with ARV therapy to
prevent transmission of the virus to the foetus is apriority.
All pregnant women that are HIV positive shouldbe on HAART ifclinical (WHO) or CD4 criteriaare met.
If found ineligible for HAART she should beinitiated on short course therapy as outlined below
Short-term ARV therapy does not treat maternaldisease
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Orientation to New ART Protocols 2010 13
Criteria for PMTCT interventions
(Eligibility Criteria)
Provide HAART Provide Short Course ARVs
CD4 < 350 / mm3 > 350 / mm3
Clinical Criteria only
(CD4 not available) Stage 3 or 4 (any CD4a
) Stage 1 or 2
a If CD4 >350 then initiate ART with EFV plus 2 NRTIs
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rop y ax s ase on2010 guidelines (Option A)
Course Antenatal
Mother
Intrapartum
Mother
Postnatal
Mother
Postnatal
All exposed infants
From 14 weeks of
pregnancy
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
twice daily for
7 days
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 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 .
For women
presenting in 3rd
trimester
AZT 300mg BD
until delivery
Continue Combivir stat dose
of 1 tablet at onset of labour
and 1 tablet every 12hours
until delivery.
NVP 200mg single dose at
onset of labour
Combivir1
tablet BD for 7
days
Breastfeeding infant:
i)NVP at birth and daily until one
week after all exposure to breast
milk
ii)Start Cotrimoxazole from 6
weeks until a week after all
exposure to breast milk has ended.
Non-breastfeeding infant:
i)Commercial milk formulaii)NVP at birth and for 6 weeks.
iii Start co-trimoxazole until
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ART prophylaxis 2010 cont.For womanwho has not
received
prophylaxis
antenatally
Combivir 1 tablet atonset of labour and 1
tablet every 12hours
until delivery.
NVP 200mg single
dose at onset of
labour
Combivir1 BDfor 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.
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Extended simplified infant NVP dosing
recommendationsInfant age NVP daily dosing
Birth - 6 weeks
Birth weight 2,000 - 2,499 gram
Birth weight >2,500 gram
10 mg once daily (1ml)
15 mg once daily (1.5mls)
>6 weeks to 6 months 20 mg once daily (2mls)
>6 to 9 months 30 mg once daily (3mls)
>9 months to end of BF 40 mg once daily (4mls)
Low birth weight infants should receiveweight-specific dosing, suggested starting
dose is 2 mg/kg once daily.
Therapeutic drug monitoring is
recommended. * Adapted from: Mirochnick
M. et. al. [2006].
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HAART in Pregnancy Preferred regimen isAZT, 3TC and NVP
Use EFV in women with CD4 above 350 andafter the 1st trimester
If NVP hypersensitivity occurs substitute NVPwith EFV
Alternative regimen TDF, FTC/3TC and NVP/EFVABC, FTC/3TC and NVP/EFV
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EFV in Pregnancy If gestational age greater than 14 weeks continue
with Efavirenz
If less than 14 weeks, Efavirenz has been associatedwith neural tube defects therefore consider CD4count; If CD4 250 consider triple nucleoside therapywith AZT/3TC/ABC (if unable to monitor ALT)
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TDF in Pregnancy 2010 guidelines recommend TDF based regimen as
alternative regimen to AZT based regimen
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Algorithm for Care of the HIV positive pregnant
Woman based on 2010 WHO Recommendations
fig 2.1, pg 13
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Infant feeding options
September 2007 Edition 3 Module 8: ART in Special Populations 21
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Infant feeding Recommendations Breastfeeding is protected, promoted and supported. (See
annex IV on the 10 steps of breastfeeding)All mothersregardless of HIV status should exclusively breastfeed
up to 6 months and thereafter continuebreastfeeding up to at least 12 months, with timely,adequate and safe complementary feeding.
HIV positive mothers are encouraged to breastfeed for 12months with use ofextended 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 tobreastfeeding has ended.
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Care and Support to HIV+ Mothers, Children and their
families
Apply family centred approach to HIV testing, careand treatment
Promote adherence to extended NVP and co-trimoxazole prophylaxis.
Encourage and support couples counselling and maleinvolvement
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HIV testing for the infant All HIVexposed infants receiving extended NVP
prophylaxis should have a PCRat 6 weeks and at 6months.
An antibody test at 12 months and 18 months or aftercessation of breastfeeding.
If a health worker identifies a sick child or one who isfailing to thrive an HIV test must be done. ( ProviderInitiated Testing & Counselling - PITC)
A PCR test may be done, regardless of breastfeeding, if thechild presents with symptoms of HIV at less than 18
months of age.(see pg 25 of PMTCT guidelines)
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Nevirapine Prophylaxis If the mother is breastfeeding the infant must be given
NVP at birth and daily until one week after all exposure tobreast milk has ended.
If the mother is on HAART or not breastfeeding, the babymust be given NVP at birth and daily for 6 weeks.
Observe the infant for NVP sensitivity which may presentas a generalised skin rash.
If a baby is receiving extended NVP and tests HIV positiveby PCR, stop NVP prophylaxis and immediately refer
to paediatric ART clinic.
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Co-trimoxazole Administration in HIV Exposed
infants
weight Daily dose Child tablet(each tab = 100mgsulfamethoxazole,
and 20mgtrimethoprim)
(100mls) bottlesneeded per month
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Summary of recommendations for discontinuing
primary co-trimoxazole prophylaxisTarget population RecommendationsTarget population Recommendations
HIV Exposed children Discontinue co-trimoxazole afterHIV infection is excluded
Infants and children living with HIV Maintain on co-trimoxazole until theage of 5 years irrespective of clinicaland immune response (At 5 yearsfollow adult guidelines)
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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 andAIDS.
Supporting adherence to treatment (ARVs and cotrimoxazole) Sensitization of community to the importance of HIV care
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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 newbornbaby are taken to the health facility for medical assessment, timelyadministration 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 checkupsand services
Record keeping and data entry at both facility and community level
Referrals and linkages to appropriate community-based groups such asPLHIV, peer support groups, post-test clubs, legal services, churches,faith-based organisations, legal counsellors and organisations whichpromote Income Generating Activities (IGAs).
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Global Fund PMTCT Indicators
1. No of HIV- infected pregnant women receivedAntiretroviral drugs
2. No of HIV- infected pregnant women assessed foreligibility
3. No of infants born to HIV- infected women, who arebreast feeding and covered by an antiretroviral drug
4. No of infants receiving a virological test (DBS) within2 months
5. No of infants started on co-trimoxazole within 2months
6. No of pregnant women who know their HIV status
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CHAZ 2010 PMTCT
ACHIEVEMENTSIndicator 1 3,226 against 5,875 (55%)
Indicator 2 2,012 against 5,875 (34%)
Indicator 3 1,796 against 4,700 (38%)Indicator 4 1,739 against 4,700 (37%)
Indicator 5 3,012 against 4,113 (73%)
Indicator 6 11,153 against 15,765 (71%)
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Global Fund PMTCT Indicators -
IDEALY1. No of pregnant women who know their HIV status
2. No of HIV- infected pregnant women assessed foreligibility
3. No of HIV- infected pregnant women receivedAntiretroviral drugs
4. No of infants born to HIV- infected women, who are
breast feeding and covered by an antiretroviral drug5. of infants receiving a virological test (DBS) within 2
6. No of infants started on contrimoxazole within 2months
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CHAZ PMTCT Program Challenges
Mothers/babies lost to follow
CHIs not sending reports on timeData collected is not accurateSome indicators are new and CHIs
are not yet oriented.Delayed or non receipt of DBSresults
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Are we together?
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Thank You
Questions?????