A presentation made to the year five MBChB students of Makerere University College of Health Sciences on the 18th of September 2014.

1. PMTCT of HIV and MTCT Plus
Nkeramahame Juvenal, MBChB (MUK)

2. Outline
• Definitions
• MTCT of HIV
• Burden of MTCT
• History of PMTCT of HIV
• Option B+
• EMTCT

3. Definitions
 HIV infection - presence of HIV virus in blood without necessarily having
symptoms or signs of disease
 HIV disease - presence of signs and symptoms due to infection with HIV
 AIDS – clinical syndrome suggestive of advanced HIV infection
 MTCT – when the HIV virus is passed from the mother to her child during
pregnancy, birth or breastfeeding
 PMTCT – the package of services given to women to prevent acquisition of
HIV and/or reduce risk of MTCT
 PMTCT Plus – provision of ART and support to HIV infected mothers, their
babies and family members to ensure proper nurturing, care and
protection of the child
 eMTCT – Uganda’s strategy for virtual elimination of MTCT using option B+

4. MTCT of HIV
• About 30-35% of HIV-infected mothers with infect their babies if no
intervention.
• Peripartum HIV transmission can be reduced to under 5% in resource
limited settings using a feasible ART regimen
• B/F causes about 1/3 – ½ all infant HIV infections and reducing
postnatal transmission through B/F, whilst maintaining child survival,
is an urgent priority.
• Evidence highlights the impact of breastfeeding duration & pattern,
and hazards associated with the avoidance of breastfeeding in
different settings
• About 90% of HIV-infected children in SSA acquire HIV through MTCT

5. MTCT
MTCT can occur
• during pregnancy
• during delivery or
• through breastfeeding

6. Rates of MTCT….Decock et al., JAMA, 2000,283:1175-1182
Time of transmission Absolute transmission rate (%)
During pregnancy 5-10
During labour and delivery 10-20
During breast feeding 5-20
Overall without b/feeding 15-30
Overall with b/feeding through 6 months 25-35
Overall with b/feeding through 18 -24 months 30-45

7. Burden of MTCT
• Annually about 25,000 to 40,000 babies get HIV infection in Uganda.
• 0.6% U5s are infected with HIV
• Over 90% of HIV infected children acquire it from MTCT
• In Uganda, 66% of the HIV infected children do not survive to
celebrate their 3rd birthday with no intervention

8. Risk factors for MTCT
Source: WHO, CDC Prevention of Mother to Child Transmissionof HIV Generic Training Package, July 2008
Maternal and neonatal factors that may increase the risk of HIV transmission
Pregnancy Labour and delivery Breastfeeding
 High maternal viral load (new
infection or advanced AIDS)
 Viral, bacterial, or parasitic
placental infections, such as
Malaria
 Sexually transmitted infections
(STIs)
 Low CD4+ count
 Virulent HIV strain
 High maternal viral load
 Prolonged rupture of
membranes for >4 hours
 Prolonged labour
 Vaginal delivery
 Assisted vaginal delivery
 Invasive delivery procedures
(e.g. episiotomy, artificial
rupture of membranes)
 Chorioamnionitis (from
untreated STI or other
infection)
 Preterm delivery
 Low birth weight
 High maternal viral load
 Long duration of breastfeeding
 Mixed feeding (giving water,
other liquids, or solid foods in
addition to breastfeeding)
 Breast abscesses, nipple
fissures, mastitis
 Oral disease in the baby (e.g.
thrush or sores)

9. History of PMTCT
PMTCT is a dynamic and rapidly changing field.
2010 WHO Guidelines
Option A
Treatment or prophylaxis dependent on CD4 count
 CD4 ≤350 or WHO stage 3 or 4 regardless of CD4 count:
Life-long ART
 CD4 >350, and WHO stages 1 and 2:
Antenatal and intrapartum prophylaxis (AZT, sdNVP, TDF/FTC)
Extended infant NVP syrup for BF infants

10. Option B
All HIV infected pregnant women initiated on
ART regardless of CD4 count
 CD4 ≤350, or WHO stage 3 or 4
life-long ART
 CD4 ≤350, or WHO stage 3 or 4
life-long ART
 CD4 >350 and WHO stages 1 and 2, stop
ART after delivery if FF, or after cessation
of BF if BF

12. 2012 WHO Programmatic
Update
Option B+
Life-long ART for all HIV infected
pregnant women regardless of CD4 count

15. Advantages of Option B+
 Simplification of PMTCT regimen requirements
 No need for CD4 count to determine eligibility
 Extended protection from MTCT in future pregnancies from
conception
 Strong & continuing prevention benefit against sexual transmission in
serodiscordant couples/partners
 Improved benefit for the woman’s health in between pregnancies
 Simple community message; start ARVs, continue for life

16. Interventions in PMTCT
 HIV testing and counselling during ANC, labour and delivery and
postpartum
 Provision of antiretroviral (ARV) drugs to mother and infant
 Modified safer obstetric practices e.g elective c/section
 Infant feeding information, counselling and support
 Modified infant feeding practices
 Referrals to comprehensive treatment, care and social support for
mothers and families with HIV infection

17. Specific interventions
 WHO Clinical staging of HIV disease.
 Initiate ART treatment as soon as possible during pregnancy labour
/delivery and through BF and for the entire life of the women
 Special ART adherence counseling for treatment as prevention
 Special support and follow up of discordant couples
 Linkage to ART center for lifelong chronic care using referral system
 Infant feeding counseling and support based on knowledge of HIV
status
 Maternal nutrition including assessment, counseling and support

18. Specific interventions
 Co-trimoxazole prophylaxis
 Malaria prevention and treatment
 Additional counseling and provision of family planning services
 TB screening and treatment
 Counsel on other prevention interventions, such as safe drinking water
 Supportive care, including, psycho social support, adherence support, and
palliative care including pain and symptom management
 Provide outreach services for clients and family members unable to come back
for routine follow up.
 De-worming
 Counseling and referral for women with history of harmful alcohol or drug use

19. Effectiveness of PMTCT
 ARV prophylaxis in labour alone reduces MTCT in B/F popn by 41-47%
after SVD
 If ARV prophylaxis is started in the last month of preg, reduction is by
up to 63%
 Current recommendations of ART started early can reduce MTCT to
<2%
 Breastfeeding a major source of MTCT can be addressed by use of
ART during B/F

20. Comprehensive Approach Of PMTCT
1. Primary prevention
• ABC-mutual faithfulness
• access to condoms
• HCT
• Prevention and early treatment of STIs
• Counselling for HIV negative men and women
• Male circumcision
• Prevention of blood-to-blood transmission

21. Comprehensive approach to PMTCT….
2. Prevention of unintended pregnancies among women who are HIV-infected
• Address FP and contraceptive needs of the woman
3. Prevention of HIV transmission from women infected with HIV to their Infants
• HCT
• ART to mother and infant
• Modified obstetric practices
• Modified infant feeding practices
• Infant feeding information, counselling and support
• Referrals to comprehensive treatment, care and social support for mothers and
families affected

22. Comprehensive approach to PMTCT….
4. Provision of treatment, care and support to women infected with HIV,
their infants and their families
To promote long-term care of women who are HIV-infected and their families
 Care and treatment with ARV therapy for the long-term health of women and families.
 Symptom management
 Prevention and treatment of HIV-related conditions
 Reproductive health care, including family planning and contraception counselling
 Nutritional support
 Psychosocial and community support
 Palliative care, if indicate

23. Barriers to universal access to PMTCT
Weak healthcare systems, including inadequate antenatal care (ANC)
 Limited access to pre-test counselling, either because systems are not
in place or providers are not routinely offering testing
 Lack of effective coordination to oversee implementation
 Inadequate community engagement
 Stigma and discrimination
 Lack of awareness that HIV can be passed from mother-to-child
 Inadequate access to ARV therapy or prophylaxis
“Universal Access” is the idea that everyone has a right to the prevention, care, support and treatment
related to HIV and AIDS.

24. REFERENCES
Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice, De Cock et al, JAMA
283(9), March 2000
World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a
public health approach, 2010 version
World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:
recommendations for a public health approach, June 2013.
World Health Organization. Prevention of Mother-to-Child Transmission of HIV: Generic Training Package, January 2008
World Health Organization. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Programmatic
update, 2012