1. Prevention of Mother-To-Child
Transmission of HIV(PMTCT)

2. Epidemiology
• Of 33.4 million people living with HIV/AIDS
worldwide, 15.7 million are women(2007)
• About 90% of HIV +ve women reside in subSaharan Africa.
• In Ethiopia HIV prevalence in women is 4%,
accounting to 55%.

3. • MTCT is the most significant source of HIV
infection in children below the age of 15
years.
• Sub-Saharan Africa is home to 90% of the
world’s HIV-infected children.

4. Reasons for high rate of HIV infection in
women include:
• Biologic
• Gender
• Social and Economic

5. Definition:
• MTCT is HIV-infection transmission from
mother-to-child during:
• Pregnancy
• Labor and delivery
• Breastfeeding
• PMTCT is a term used to describe a package of
services intended to reduce the risk of
mother-to-child transmission of HIV.

6. Effect of pregnancy on HIV infection
• Pregnancy suppresses the immune function in
both HIV-infected and non-infected women.
• BUT pregnancy does not seem to have an
effect on the progression of HIV disease.

7. Effect of HIV on pregnancy
(besides the MTCT)
•
•
•
•
•
Increased risk of spontaneous abortions
Increased risk of stillbirth
Increased risk of pre-term deliveries
risk of low birth weight infants
Increased risk of bacterial pneumonia, urinary tract
infections and other illnesses
• Increased risk of postnatal infections
– Advanced stages of HIV disease tend to have more complications
during pregnancy, delivery and in the postpartum period particularly if
they are not receiving proper care.

8. Objectives of PMTCT
Prevention of
 Promot access to ART
 Reduce new pediatric
unwanted
hiv infection
pregnancies  Promote access of
(Family Planning) HIV exposed infants
to care
 Promote the timely
treatment and care
Primary
to preserve the family
HIV prevention
unit and reducing the
number of orphans.

9. Goals of PMTCT
• Uncomplicated pregnancy
• Healthy, uninfected infant
• Healthy mother who has not compromised
her future options for HIV therapy

10. Risk of transmission without intervention
Without intervention, the overall MTCT rate is
approximately 20–45%.

11. Risk factors associated with increased
overall risk of MTCT
1)
2)
3)
4)
Maternal Factors
Infant factors
Obstetric and Delivery Practices
Infant feeding factors

13. National Strategies for PMTCT
• Primary prevention of HIV in childbearing
women
• Prevention of unintended pregnancy in HIVpositive women
• Prevention of transmission from HIV+ women
to their infants
• Treatment, care and support of women
infected with HIV, their infants and their
families

15. Element 1: Prevention of Primary HIV Infection
1-Promote safer and responsible sexual
behaviour and practices
2-Address factors that make girls and women
especially vulnerable to HIV infection and that
limit their access to care as well as male
involvement in PMTCT
3-Use community education

16. 4-Promote male involvement in HIV/AIDS
prevention at all levels
5-Provide early diagnosis and treatment of STIs
6-Provide HIV counselling and testing to all
adults and adolescents

17. Element 2: Prevention of Unintended Pregnancies Among
Women who are HIV-Infected
1. Effective family planning
• Prevents unintended pregnancies
• women who are HIV-infected protect their own
health while taking care of their families.
• Respect for clients’ rights: every
woman, regardless of her HIV status, has the right
to make a free and informed decision about
whether and when she becomes pregnant
• Most methods of contraception are safe for use
by women with HIV.

18. 2-Encourage dual protection
3-Provide integrated HIV and STI services at all
levels of care
4-Provide full information about the possibility
of transmitting HIV to a child
5-Offer information about prevention and
referral for HIV counselling and testing
6-Counsel men and women who know they are
positive, assisting them to make well-informed
decisions

20. HIV-Positive Women Who Intend to
Become Pregnant
1-Give Accurate Information on Risk of MTCT
and Ensure Informed Decision to Conceive
2-Provide ART for eligible HIV infected women, if
not already on treatment and ARVs for PMTCT
for those who are not eligible for ART.

21. 3-Maintain the Best Possible Health and Nutritional
Status
-Good nutritional support
-iron, folate, &Zn supplementation at least
3months prior to pregnancy
-malaria prevention
-prevention &screening of STIs before
pregnancy
-prophylaxis & Tx of OIs
-avoid pregnancy till 6months after recovery
from any chronic infections

22. Element 3: Prevention of HIV Transmission from
Women Infected with HIV to their Infants

23. Antenatal Care
HIV Counselling and Testing during Antenatal
Care
All women coming for ANC, labour, delivery and
post partum follow-up including child health
care shall be told that their routine laboratory
check up includes HIV testing unless they say
“NO”. The right to say “no” shall be clearly
communicated.

24. Additional Antenatal Care Needs for HIVpositive Women
Additional history and clinical examination for HIVpositive pregnant women:
1. Past history of HIV-related illness and HAART
2. Duration of known HIV-positive status
3. Assessment for symptoms of AIDS and HIV of
other children and partner
4. Any medications for HIV-related illness taken
since beginning of pregnancy
5. Any potential factor that can hamper the
adherence to ARV (alcohol use,)

25. Additional laboratory assessment of HIVpositive pregnant women.
o Screening CD4 count/percentage is routinely
recommended.
o diagnose opportunistic infections.
o Antiretroviral therapy
o All HIV-positive women should be routinely
assessed for ART eligibility and initiated on
HAART if eligible.

26. Prophylaxis and treatment for opportunistic
infections:
o Provide routine TMP-SMT prophylaxis for all
HIV-infected pregnant women with clinical
stage 2, 3, 4 disease or CD4 count below or
equal to 350 /mm3
Tuberculosis (TB):
o Screen all HIV-positive pregnant women for TB
o Link TB positive pregnant and post natal
women to TB clinic
o Screen all clients with cough of more than two
weeks for TB according to national guidelines.

27. Malaria:
o Insecticide treated bed nets
o Anti malarial prophylaxis for those at risk
Chloroquine 300mg/wk or
Chloroquine 300mg/wk + proguanil 200mg/d
Short course ARV prophylaxis to reduce MTCT
during pregnancy
Infant Care
Counselling on signs and symptoms of
HIV/AIDS disease progression
Partners and family

28. Intra partum care: Labour and Delivery
Intra partum care and infection prevention include:

Essential obstetric care for all mothers
– A skilled attendant
– Early identification of danger signs
 Safe delivery practices and avoiding invasive
procedures when possible
–
–
–
–
No AROM
No routine episiotomy
Avoid vacuum extraction and forceps if possible
Limit vx examination during labour
 Safe delivery practices designed to protect health
workers, mothers, family members, and babies.

29. HIV testing and counseling during labour
As up to two thirds of pregnant women attend
health facilities for the first time in labour, HIV
testing and counselling should be offered
routinely for all mothers admitted for delivery

30. Post partum care
• Postpartum care at six hours, six days and six
weeks for all women and newborns.
• Additionally:
– Continue on HAART if patient is eligible (if on
HAART while pregnant)
– Commence on HAART if patient is eligible (if
HAART was not started while pregnant)

31. Newborn and Postnatal Care
o Routine measures
o ARV Prophylaxis to all infants born to HIV-positive
mothers to prevent MTCT

32. The PMTCT recommendations refer to
two key approaches:
Antiretroviral drugs decrease viral replication, Viral
load & reduce the risk of MTCT of HIV
1. Life-long ART for HIV-infected pregnant women
in need of treatment.
2. Prophylaxis, or the short-term provision of
ARVs, to prevent HIV transmission from mother to
child, for women who don’t require treatment for
their own health

33. When is ART indicated
1. WHO Stage III or IV disease irrespective of
CD4 cell count
2. All women with CD4 of less than or equal to
350 per mm3 irrespective of clinical staging.
When to start ART in pregnancy
HIV-infected pregnant women in need of ART for
their own health should start ART as soon as
feasible regardless of gestational age and continue
throughout pregnancy, childbirth, breastfeeding (if
breastfeeding), and thereafter.

35. ART for mother & prophylaxis for
exposed Infants
Mother
Preferred
• AZT + 3TC + NVP or
• AZT + 3TC + EFV
Alternative
• TDF (Tenofovir disoproxil fumoarate)+ 3TC (or FTC (emticitabine) )+ NVP
or
• TDF + 3TC (or FTC) + EFV
Exposed infants (mothers on ART)
All infants
• NVP or
• AZT

36. ARV treatment and prophylaxis
Three possible options

37. Option A
Option B
Mother
Antepartum AZT (from 14 weeks)
sd-NVP at onset of labor
AZT + 3TC during labor & delivery
AZT + 3TC for 7 days postpartum
Mother
Triple ARV (from 14 weeks until one week after
all exposure to breast milk has ended)
AZT + 3TC + LPV-r
AZT + 3TC + ABC
AZT + 3TC + EFV
TDF + 3TC (or FTC) + EFV
Prophylaxis options
Infant
Infant
Breastfeeding population
All exposed infants
Daily NVP (from birth until one week after AZT for 4-6 weeks OR
all exposure to breast milk had ended)
NVP for 4-6 weeks
Non-breastfeeding population
Sd-NVP + daily AZT for 4-6 weeks OR
Daily NVP for 4-6 weeks

38. Option B+ Same for treatment and
prophylaxis :
Mother
Regardless of CD4 count, triple ARVs
starting as soon as diagnosed, continued for
life
 Infant
Daily NVP or AZT from birth through age 4–
6 weeks regardless of infant feeding method
b
c

39. • The FMOH opted from option A of the 2010
WHO PMTCT recommendations

40. First line HAART regimens for eligible
pregnant women in Ethiopia
AZT + 3TC + NVP for life given as follows:
• Start as soon as possible even in first trimester
• Note that NVP requires a graduated dose
increase:
• Give 200 mg once a day for 14 days, then
increase to 200 mg twice a day
• Give 3TC- 150mg and AZT- 300mg po twice daily
• can be dispended as a fixed dose preparation
• Continue ART through out
pregnancy, childbirth,, breastfeeding and
thereafter for life.

41. ARV prophylaxis for Non eligible
pregnant women
• AZT (Zidovudine) - 300 mg twice daily - starting at
14 weeks of pregnancy and thereafter
• AZT (Zidovudine) – 600mg at the onset of labor +
NVP 200mg single dose + 3TC (Lamivudine)
150mg every 12 hours until delivery
• Post partum Prophylaxis
AZT 300mg + 3TC 150mg 2 times a day for 7days
Infant
Single dose NVP (2mgkg) with AZT (4mgkg bid) for
7days

42. Option B+ ADVANTAGES
• further simplification of PMTCT programme
requirements.
• extended protection from mother-to-child
transmission in future pregnancies from
conception
a strong and continuing prevention benefit
against sexual transmission in serodiscordant
couples and partners

43. • likely benefit to the woman’s health of earlier
treatment and avoiding the risks of stopping
and starting triple ARVs, especially in settings
with high fertility; and

44. • a simple message to communities that, once
ART is started, it is taken for life.

45. Challenges and questions for B+
• ARV adherence and retention in care
• concerns about HIV drug resistance with
longterm use of ART when initiated in early
HIV disease, safety of increased ARV exposure
for the fetus/infant, acceptability and equity.

46. References
• Ethiopia Ministry Of Health, 2007. Guidelines For
Prevention Of Mother-To-Child Transmission Of HIV
In Ethiopia.
• WHO, 2010. Anti Retroviral Drugs For Treating
Pregnant Women And Preventing HIV Infection In
Infants.
• Ethiopia Ministry Of Health, 2011. Guidelines For
Prevention Of Mother-To-Child Transmission Of HIV
In Ethiopia.
• WHO, 2012. Programmatic update. Use of
Antiretroviral Drugs for Treating Pregnant Women
and Preventing HIV Infection in Infants.
• Ethiopia Ministry Of Health, 2010. Management
Protocol On Selected Obstetric Topics.