Prevention of Mother to child transmission - PMTCT.ppt

1. Prevention of Mother-to-Child
Transmission of HIV
Samson Mvandal

2. Outline
• Background on pediatric HIV transmission
• Principals of PMTCT
• Maternal PMTCT Regimens
• HIV-Exposed Infant Management

3. Definition
• PMTCT: prevention of mother-to-child transmission
• HIV-Exposed Infant: baby born to a woman who is
HIV-infected
• Prophylaxis: giving a medication to prevent a
disease/condition from occurring
• Treatment/Therapy: giving a medication to control
or treat a disease/condition that a patient has

4. Paediatric HIV - Epidemiology
• In 2012 2.3 million people were newly infected with HIV
- 550,000 newly infected children
• In 2017, 180,000 children become HIV positive,
• More than 90% of pediatric HIV infections are acquired
vertically
• Without diagnosis and treatment 30% die before age 1 and
50% before 2 years
• Children who acquired HIV from their mother declined from
18% in 2010 to 10% in 2017(UNAIDS 2018)

5. Maternal-Child-Transmission
Vertical Transmission of HIV
• Children acquire HIV infection from their mothers
During pregnancy
At labor and delivery
Through breastfeeding

6. Without any interventions,
what percentage of infants
born to HIV infected
women will become
infected?

7. Exposed child without intervention
• 10-15% become infected during pregnancy
• 10-15% become infected at labor and delivery
• 5-20% infected through breastfeeding

8. How do we intervene it?
• Prior PMTCT strategies reduce MTCT to about 15%
• More aggressive PMTCT measures could allow this to
be decreased to 5%
• If an HIV-exposed infant is given ART within the first 12
weeks of life, they are 75% less likely to die from an
AIDS-related illness.(UNAID 2014)
NB: If the mother and child will use Nevirapine and mother
only breastfeeding her child, the risk of having HIV will
decrease.

9. Factors affecting mother to child
transmission
• HIV Viral Load (> 50/UL of blood)
Acute Infection
Advanced Disease
• Low CD4
• Poor nutritional status
• Inter-current STIs
• Placental Infections (malaria, chorioamnionitis)

10. Factors affecting mother to child transmission
• Prolonged rupture of
membranes (more than 4
hours)
• Premature rupture of
membrane
• Obstetric procedures
• Preterm delivery
• Low birth weight
• Breast inflammation during
breastfeeding
• Duration of breastfeeding
• Mixed feeding
• Oral thrush or ulcerations
in breastfeeding infants
• Bloody amniotic fluid
• Hemorrhage in labour

11. Goals of Tanzania’s PMTCT Program
• Increasing proportion of pregnant women and breast
feeding to know their HIV status and HIV +ve to receive
ARVs
• Ensure access to care and treatment for mother and
babies living with HIV
• 90% reduction of new infant infections by 2030
• Mother-to-child transmission rate less than 5%
• At least 90% of all HIV-Exposed infants alive and
uninfected at 2 years of age

12. PMTCT Overview
 4 elements of a comprehensive approach to PMTCT;
1. – Primary prevention of HIV among women of
childbearing age and their partners
2. – Prevention of unintended pregnancies among
women living with HIV
3. – Prevention of vertical transmission of HIV from
mothers to their infants
4. – Provision of treatment, care and support to women
living with HIV and their partners, infants, and families

13. Primary prevention of HIV among women
of childbearing age and their partners
All women and their partners should know their HIV
status
• HIV testing and counseling
Encourage safer sex practices
• Condom use
• Reduction of number of sexual partners
• Remain faithful to sexual partner
• STI prevention and treatment

14. Prevent unintended pregnancies among
women living with HIV
Provide family planning counseling
• HIV-Infected woman who do not wish to get
pregnant should use 2 methods for contraception
-Barrier method
– condom use

15. Prevention of vertical transmission of HIV from
mothers to their infants
HIV-testing and Counseling for all Pregnant women
• Identifies HIV-positive women who require services
Antiretroviral Drugs
• Maternal ARVs decrease viral load and exposure of
infant to HIV
• Infant ARVs provide protection during and after
exposure to HIV (prophylaxis)
Safer Delivery Practices
Safer Infant Feeding Practices

16. PMTCT – Anti-retroviral Drugs
2010 WHO Recommendations for PMTCT
• Eligible HIV-positive pregnant women should start
ART
WHO Stage 3 or WHO Stage 4
CD4 < 350
• Women not eligible to start ART would receive
prophylaxis
Option A: accepted by Tanzania
Option B

17. PMTCT- Antiretroviral Drugs
2010 WHO Recommendations for PMTCT
• Option A
Women not eligible for ART receive prophylaxis
during pregnancy with:
-AZT twice daily
-sdNVP at onset of labor
-AZT + 3TC twice daily at onset of labor for 7 days
• Option B
Triple drug prophylaxis during pregnancy

18. According to STG & NEMLIT 2021
• Available alternative first line ART regimen includes;
TDF+ FTC+EFV 600mg (FDC)
OR
ABC+3TC+ EFV 600mg or DTG
OR
AZT+3TC+EFV 600mg or DTG

19. PMTCT- Antiretroviral Drugs
Malawi developed Option B+ which has now been
approved by WHO and recently accepted in Tanzania
• Option B+: ALL HIV-positive pregnant and
breastfeeding women should be started on ART for
lifelong therapy, regardless of WHO Stage or CD4
count.

20. PMTCT- Infant Regimens
Administer NVP immediate after birth to all HIV
exposed infant and continue until to 6 weeks of age
• Mother on ART
Infant NVP once daily for 6 weeks
• For high risk infants
Duo prophylaxis containing NVP syrup (once daily) and
AZT syrup (twice daily) for the first 6 weeks of life, then
continue with daily NVP alone up to 12 weeks of life

21. PMTCT- Infant Regimens…….
• Infant prophylaxis is most effective when given as
soon as possible after birth, preferably within 6–12
hours
• HIV exposed infants identified beyond the age of 4
weeks should not be given ARV prophylaxis

22. NPV Dosing Guideline For Infants
Infant Age NVP daily dosing
Birth to 6 weeks
• Birth weight 2000-2499g 10mg (1ml) once daily
• Birth weight > 2500g 15mg (1.5ml) once daily
> 6 weeks – 6 months 20mg once daily
>6 months – 9 months 30mg once daily
>9 months to end of BF 40mg once daily

23. NPV Dosing Guideline For Infants….
• Low birth weight infants <2000g should receive mg/kg
dosing; suggested starting dose is 2mg/kg once daily
(STG & NEMLIT 2021)

24. PMTCT – Safer Delivery Practices
• Minimize vaginal examinations
• Avoid
‐Prolonged labor
‐Artificial rupture of membranes
‐Trauma

25. PMTCT–Safer Infant Feeding Practices
Definitions
• Exclusive breastfeeding
-Providing ONLY breastmilk to an infant (no water, porridge, etc)
• Replacement feeding
-Providing another source of nutrition to an infant other than breastmilk,
ie infant formula
• Mixed feeding
-For child less than 6 months of age, giving both breastmilk and
additional foods
• Complementary Feeding
-For child older than 6 months of age, giving both breastmilk and
additional foods

26. PMTCT – Safer Infant Feeding Practices
• 2010 WHO Infant Feeding Recommendations
Exclusive Breastfeeding for ALL infants for the 1st
6 months of life
After 6 months of age, continue breastfeeding, but
add additional foods into the diet
Complementary feeding until 1 year, then wean
HIV-negative or HIV-unknown infants
HIV-positive infants may continue BF until 2 years
or longer

27. Benefits of Breastfeeding
• Optimal nutrition for infants
• Decreased infections from respiratory and diarrheal
illnesses
• Improved survival, especially in the first 6 months of life
• Affordable

28. Risks of Breastfeeding
 Ongoing exposure to HIV-infection through breastfeeding
‐Decreased with exclusive breastfeeding

29. How to Make Breastfeeding Safer
• Child
-Timely treatment of thrush and other oral lesions
• Mother
‐Appropriate breast care and timely treatment of
mastitis or infection
‐Breastfeeding mothers should have recent CD4
‐Eligible mothers should be on ART

30. How to Make Breastfeeding Safer
 ...safer, and successful!
• Education about nutritional requirements of lactating
mothers– and support if available
• Proper lactation management and support
• Supportive environment in hospitals and clinics
(“Baby Friendly”)
• Early identification of problems
• Promotion of condom use

31. Benefits of Replacement Feeding
• No risk of HIV transmission to the infant
• Other family members able to help feed infant,
especially if mother is working

32. Disadvantages of Replacement Feeding
 No protective antibodies
Increased risk of infection, especially diarrheal
and respiratory infections
Malnutrition
Especially if formula not properly prepared
 Cost
 Preparation time/supplies needed
 People may wonder why woman not breastfeeding

33. How to Make Replacement Feeding
Safer
• Boil and cool water before each use
• Caregivers should wash their hands and the child’s
face/hands with soap before preparing or giving feeds
• Feed with cup or spoon, not a bottle with a nipple

34. How to Make Replacement Feeding
Safer
• Caregivers need instruction on how to appropriately mix
formula
• Give anticipatory guidance about diarrhea
‐Danger signs
‐How to treat diarrhea
‐Provide ORS

35. Provision of treatment, care and support
to women living with HIV and their
partners, infants, and families
• Routine antenatal care
• Partner testing and counseling
• Referral to CTC for services for family members
• Linkage to community support services

36. Summary
• PMTCT works
• Guidelines are changing

37. References
• Tanzania National Guidelines on PMTCT, 2017
• Antiretroviral Drugs for Treating Pregnant Women and
Preventing HIV Infections in Infants. WHO 2010.
• Triple antiretroviral compared with zidovudine and single-dose
NVP prophylaxis during pregnancy and breastfeeding for
prevention of mother to child transmission. Lancet Inf. Dis. Jan
2011.
• TANZANIA GUIDELINE FOR PEDIATRIC AIDS TREATMENT.
• STG & NEMLIT 2021
• UNAID, 2018

38. Thank You for Listening