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									           Module 2



Overview of HIV Prevention in
 Mothers, Infants and Young
          Children
                           Module Objectives

 Provide an overview of mother-to-child transmission of
  HIV (MTCT)
 Identify factors that increase the risk of MTCT
 Describe the four elements of a comprehensive
  approach to prevention of HIV infection in infants and
  young children




PMTCT Generic Training Package                      Module 2, Slide 2
                      Module Objectives     (Continued)




 Provide examples of each of the four elements
 Describe the role of maternal and child health (MCH)
  services in the prevention of HIV infection in infants and
  young children




PMTCT Generic Training Package                            Module 2, Slide 3
                                 Session 1

         Introduction to Mother-to-Child
               Transmission of HIV




PMTCT Generic Training Package               Module 2, Slide 4
                         Session 1 Objectives

 Provide an overview of mother-to-child transmission of
  HIV (MTCT)
 Identify factors that increase the risk of MTCT




PMTCT Generic Training Package                      Module 2, Slide 5
                                 MTCT

 Mother-to-child transmission of HIV (MTCT) is the
  transmission of HIV from an infected mother to her baby
  during pregnancy, labour and delivery and
  breastfeeding
 Also known as “vertical transmission” or “perinatal
  transmission”
 Most children with HIV acquired the virus through MTCT



PMTCT Generic Training Package                    Module 2, Slide 6
                                 PMTCT

 PMTCT: common term for programmes,
  services and interventions whose goal is to
  reduce the risk of MTCT




PMTCT Generic Training Package           Module 2, Slide 7
                                 PMTCT   (Continued)




 PMTCT services include:
       HIV testing and counselling during ANC, labour and
        delivery and postpartum
       Provision of ARV drugs to mother and infant
       Safer delivery practices
       Infant feeding information, counselling and support
       Referrals to comprehensive treatment, care and social
        support for mothers and families with HIV infection



PMTCT Generic Training Package                         Module 2, Slide 8
                                 Universal Access

 The idea that everyone has a right to the
  prevention, care, support and treatment related
  to HIV and AIDS




PMTCT Generic Training Package                      Module 2, Slide 9
                     Access to PMTCT

        UNICEF PMTCT Report Card 2005 Findings:
         In 2005, only 11% of women in 58 countries
       surveyed received PMTCT counselling and less
                than 10% were tested for HIV

       In 2006, less than 10% of pregnant women who
      tested HIV-positive worldwide received ARV drugs
                          for PMTCT


PMTCT Generic Training Package                  Module 2, Slide 10
                Barriers to Universal Access to
                            PMTCT
 Weak healthcare systems,        Stigma and discrimination
  inadequate ANC
                                  Lack of awareness that HIV
 Limited access to pre-test       can be passed from mother-
  counselling                      to-child
 Lack of effective               Inadequate access to ARV
  coordination to oversee          therapy or prophylaxis
  implementation
 Inadequate community
  engagement

PMTCT Generic Training Package                      Module 2, Slide 11
                         Scale-up of PMTCT

 Scale-up of PMTCT services is essential
       To avoid new infections among children
       As part of the strategy to realize the vision of an
          HIV-free and AIDS-free generation




PMTCT Generic Training Package                      Module 2, Slide 12
                                 Exercise 2.1
         Local HIV Terminology: Discussion




PMTCT Generic Training Package                  Module 2, Slide 13
                                 MTCT: Overview

 The term “MTCT” attaches no blame or stigma to a
  woman who gives birth to a child who is HIV-infected
 Does not suggest deliberate transmission by mother,
  who is often unaware of her own infection status and
  unfamiliar with how HIV is passed from mother-to-child




PMTCT Generic Training Package                    Module 2, Slide 14
                           MTCT: Overview   (Continued)




 The term should not hide this fact: either the woman or
  her sexual partner may introduce HIV into a family—and
  both of them share responsibility for preventing
  transmission to the infant




PMTCT Generic Training Package                       Module 2, Slide 15
                        MTCT Overview   (Continued)




 MTCT can occur during
       Pregnancy
       Labour and delivery
       Breastfeeding


Without intervention, the overall MTCT rate is 20-45%




PMTCT Generic Training Package                        Module 2, Slide 16
                       MTCT Overview    (Continued)




 Risk of transmission during breastfeeding depends on:
       Use of safer breastfeeding
        practices (e.g., avoidance of
        mixed feeding)
       Duration of breastfeeding




PMTCT Generic Training Package                        Module 2, Slide 17
                        MTCT Overview   (Continued)




 With breastfeeding to six months
  overall transmission rate is 20-35%
 With breastfeeding to 18-24 months
  overall transmission rate increases to 30-45%




PMTCT Generic Training Package                        Module 2, Slide 18
                HIV-Exposed Infant Outcomes

100 infants born to HIV-infected                      55–80 infants will
women who breastfeed, without                            not be HIV-
       any interventions                                  infected

     5-10                          10-15             5-20
   infants                        infants          infants
  infected                       infected         infected
   during                         during           during
 pregnancy                        labour           breast-
                                    and           feeding
                                 delivery


             20-45 infants will be HIV-infected

PMTCT Generic Training Package                               Module 2, Slide 19
                                 Reducing MTCT

           MTCT can be reduced by 40-70% through
                 core PMTCT interventions

 In industrialized countries the rate of MTCT has been
  reduced to 2%




PMTCT Generic Training Package                   Module 2, Slide 20
                  Transmission Risk Factors




        What are the risk factors for MTCT?




PMTCT Generic Training Package           Module 2, Slide 21
                  Transmission Risk Factors


       The most important risk factor for MTCT is the
        amount of HIV in the mother's blood. This is
                  known as the viral load

 Risk of transmission to infant is highest when mother’s
  viral load is high, e.g. in:
       Recent HIV infection
       Advanced AIDS

PMTCT Generic Training Package                   Module 2, Slide 22
             Transmission Risk Factors              (Continued)




During Pregnancy:
1. High maternal viral load (new infection or advanced
   AIDS)
2. Viral, bacterial, or parasitic placental infections, such
   as malaria
3. Sexually transmitted infections (STIs)




PMTCT Generic Training Package                     Module 2, Slide 23
             Transmission Risk Factors               (Continued)




During Labour and Delivery:
1. High maternal viral load (new infection or advanced AIDS)
2. Rupture of membranes for more than 4 hours
3. Invasive delivery procedures that increase contact with
   mother's infected blood or body fluid
4. Chorioamnionitis
5. Preterm delivery
6. Low birthweight


PMTCT Generic Training Package                      Module 2, Slide 24
             Transmission Risk Factors             (Continued)




During Breastfeeding:
1. High maternal viral load (new infection or advanced
   AIDS)
2. Duration of breastfeeding
3. Mixed feeding (giving water, other liquids, or solid
   foods in addition to breastfeeding)
4. Breast abscesses, nipple fissures, mastitis
5. Oral disease in the baby (e.g. thrush or sores)

PMTCT Generic Training Package                    Module 2, Slide 25
                         HIV and Pregnancy

Effect of pregnancy on HIV infection:
       Pregnancy suppresses immune function in both
        HIV-infected and non-infected women
       Studies have shown that pregnancy does not seem
        to have an effect on progression of HIV disease




PMTCT Generic Training Package                Module 2, Slide 26
                Effect of HIV on Pregnancy

 More complications, including increased risk of:
       Spontaneous abortions and still birth
       Stillbirth
       Pre-term deliveries
       Low birth weight infants
       Bacterial pneumonia, UTI and other illnesses
       Postnatal infections

 It is critical that pregnant women with HIV get the
  best possible ANC and postpartum care

PMTCT Generic Training Package                         Module 2, Slide 27
                                 Session 2



      Comprehensive Approach to
   Prevention of HIV Infection in Infants
           and Young Children



PMTCT Generic Training Package               Module 2, Slide 28
                       Session 2 Objectives

 Describe the four elements of a comprehensive
  approach to prevention of HIV infection in infants and
  young children
 Provide examples of each of the four elements




PMTCT Generic Training Package                    Module 2, Slide 29
               Comprehensive Approach to Preventing HIV
                 Infection in Infants and Young Children


 To significantly reduce MTCT and achieve targets,
  PMTCT must be viewed as a comprehensive public
  health approach
 Focus is on:
       Women with HIV and their partners, children and
        families
       Parents-to-be whose HIV status is unknown or who
        have tested HIV-negative


PMTCT Generic Training Package                      Module 2, Slide 30
                         Four Elements of a
                       Comprehensive Approach
                     Element              Target Population
   Primary prevention                    Women and men who
                                          are sexually active
   Prevention of unintended              HIV-infected women
    pregnancies among women infected
    with HIV
   Prevention of HIV transmission from   HIV-infected women
    women with HIV to their infants
   Provision of treatment, care and      HIV-infected women,
    support to women with HIV, their      their children and
    infants and families                  families

PMTCT Generic Training Package                      Module 2, Slide 31
                            Elements 1 and 2

 Elements 1 and 2 are the most effective ways to
  prevent MTCT
       Element 1: Prevention of HIV infection in all women
        and men.
            Also called “primary prevention”

       Element 2: Prevention of unintended pregnancy
        among women infected with HIV



PMTCT Generic Training Package                   Module 2, Slide 32
                          Elements 1 and 2          (Continued)




           Elements 1 and 2 are beneficial to women
          and can decrease the percentage of infants
           who become infected with HIV by 35% to
                   45% in many countries


                                 See Appendix 2-A


PMTCT Generic Training Package                              Module 2, Slide 33
                          Element 1:
                   Primary Prevention of HIV
 Primary prevention: most effective way of controlling
  the spread of HIV
 Must continue to be a major part of every
  comprehensive country response to HIV




PMTCT Generic Training Package                 Module 2, Slide 34
                       Element 1:
              Primary Prevention of HIV                     (Continued)




 “ABC”: an HIV primary prevention strategy
       A = Abstain
       B = Be faithful to one partner
            also called “mutual faithfulness” or “mutual monogamy”

       C = Use condoms correctly and consistently
          (every time)



PMTCT Generic Training Package                             Module 2, Slide 35
                Primary Prevention: Issues for
                          Women
 Especially for young women, successful implementation
  of the “ABCs” may require support
 Factors contributing to women’s vulnerability to HIV
  include poverty, culturally defined roles, lack of
  information, abuse, violence, coercion by men and the
  inability to negotiate safer sex
 HCWs can help women address these challenges
  through education, support and community linkages

PMTCT Generic Training Package                 Module 2, Slide 36
                           Mutual Faithfulness

 Mutual faithfulness is effective when:
       Both partners are HIV-negative and have no other risk of
        HIV infection
       Both partners are HIV-positive

 If one is HIV-positive and the other HIV-negative then
  mutual faithfulness must be combined with condom use
  to be effective



PMTCT Generic Training Package                        Module 2, Slide 37
                             Condom Access

 Male and female condoms, when used correctly and
  consistently, can help prevent:
       HIV transmission
       STIs
       Unintended pregnancy

 PMTCT programmes should make male and female
  condoms available



PMTCT Generic Training Package               Module 2, Slide 38
              Condom Access: HCW’s Role

 HCWs should:
       Provide clients with information
        on how to use condoms
       Support client who is
        negotiating with partner
        for safer sex
       Promote joint responsibility for
        preventing the transmission of HIV

PMTCT Generic Training Package               Module 2, Slide 39
             STIs: Prevention & Early Treatment

 STIs affect HIV and vice versa
       Having other STIs increases the risk of HIV
        infection
       HIV infection tends to make an STI more
        severe and less responsive to conventional
        treatment




PMTCT Generic Training Package                 Module 2, Slide 40
               STIs: Prevention & Early Treatment
                                 (Continued)




 Early diagnosis and treatment of STIs: Can reduce
  incidence of HIV in general population by about 40%



 STI treatment services present an opportunity to provide
  information on HIV infection & MTCT and to refer for
                 testing and counselling




PMTCT Generic Training Package                 Module 2, Slide 41
                 HIV Testing and Counselling

                              HIV screening or diagnostic HIV
                               testing and counselling should be:
                                  Routinely offered to clients attending
                                   in-patient and community-based
                                   services, e.g.: Hospital, ANC, family
                                   planning, STI and post-delivery settings
                                  Widely available and, where
                                   necessary, re-oriented to meet young
                                   people’s needs



PMTCT Generic Training Package                                 Module 2, Slide 42
               Counselling for HIV-Negatives

 Can be a powerful tool to:
            Encourage adoption of safer sex practices
            Encourage partner HIV testing
            Discuss family planning
 Provides patients the opportunity to learn how to protect
  themselves and their infants from HIV infection



PMTCT Generic Training Package                     Module 2, Slide 43
                            Male Circumcision

 WHO and UNAIDS recommend male circumcision be
  available in countries highly affected by HIV
       Recent studies show that male circumcision reduces risk
        of heterosexually acquired HIV infection in men by ~60%

 Should be performed by trained providers only in
  sanitary settings with adequate equipment and
  counselling




PMTCT Generic Training Package                       Module 2, Slide 44
                       Male Circumcision         (Continued)




 Counselling of men and partners necessary to prevent:
       developing false sense of safety
       engaging in high-risk behaviours (could undermine partial
        protection provided by male circumcision)

 Male circumcision does not provide complete protection
  against HIV: circumcised men must continue to use
  other forms of protection from HIV, such as condoms



PMTCT Generic Training Package                            Module 2, Slide 45
                  Blood-to-Blood Transfusion

 Screen all blood and blood
  products for HIV according to
  national guidelines
 Follow Standard Precautions
  (including Universal Precautions)
  in the clinic setting




PMTCT Generic Training Package           Module 2, Slide 46
                                 Exercise 2.2
      HIV and STI handshake: group game




PMTCT Generic Training Package                  Module 2, Slide 47
                      Element 2: Preventing
                     Unintended Pregnancies
 Family planning saves lives and enhances the health
  status of women and their families
 The cost of infection and child deaths averted through
  family planning is substantially less than the cost of
  child death averted through the 3rd and 4th elements
 Family planning provides intrinsic benefits by helping
  women avoid unintended pregnancy and, in effect,
  saving lives and enhancing the health status of women
  and their families

PMTCT Generic Training Package                  Module 2, Slide 48
                  Element 2: Preventing
               Unintended Pregnancies                  (Continued)




 Unintended pregnancies are avoidable
 Family planning counselling helps women and/or
  couples to:
      Prevent unintended pregnancies
      Discuss condoms and condom use: dual protection
       against unintended pregnancy and STIs
      Get emergency contraceptive services
      Get referrals to providers of care, treatment and support



PMTCT Generic Training Package                         Module 2, Slide 49
                      Effective Family Planning

 Prevents unintended pregnancies
 Spaces births
 Helps women who are HIV-infected protect their
  own health while taking care of their families




PMTCT Generic Training Package              Module 2, Slide 50
               Effective Family Planning      (Continued)




 It is important that pregnant women practise
  safer sex:
      Pregnant women are at a higher risk of acquiring
       HIV than non-pregnant women, and
      Pregnant women who are newly infected are
       more likely to pass HIV to their infants




PMTCT Generic Training Package                Module 2, Slide 51
                   Family Planning Counselling

 Should be conducted with particular sensitivity, in
  private
 Must demonstrate respect for clients’ rights




PMTCT Generic Training Package                   Module 2, Slide 52
                   Family Planning Counselling
                                 (Continued)




 Every woman, regardless of her HIV status, has the
  right to make a free and informed decision about
      Whether and when she becomes pregnant
      Whether to use contraception
      Which method to use

 Where possible, encourage women to include their
  partners in family planning counselling sessions



PMTCT Generic Training Package                 Module 2, Slide 53
                   Family Planning Counselling
                                     (Continued)




 3 steps to family planning counselling with an HIV-
  infected women:
      Step 1: Discuss HIV and pregnancy
      Step 2: Support the client to select a contraceptive method
      Step 3: Discuss HIV and fertility




PMTCT Generic Training Package                            Module 2, Slide 54
                   Family Planning Counselling
                                      (Continued)




Step 1: Discuss HIV and pregnancy, including the
   following points:
          Pregnancy does not accelerate HIV progression
          Pregnant HIV-infected women should attend ANC, take
           advantage of available PMTCT interventions and get
           care and treatment
          Consider the realities of caring for and raising a child,
           particularly if the child is unwell or even HIV-infected




PMTCT Generic Training Package                             Module 2, Slide 55
                Family Planning Counselling
                                 (Continued)




Step 2: Support the client to select a contraceptive
   method
    Condoms                       LAM
    Hormonal contraceptives       Sterilization
    IUDs


    Most methods of contraception are
     safe for use by women with HIV
    Condoms are important as dual protection

PMTCT Generic Training Package                      Module 2, Slide 56
                       Contraceptive Methods

Step 2 (continued):

Hormonal contraceptives, are highly effective but:
      HCWs should counsel women about possible
       interactions between hormonal contraceptives and
       ARV drugs. The use of a back-up method like a
       condom is recommended.
      Women taking rifampicin for tuberculosis usually
       need to use a back-up method of contraception like
       condoms.

PMTCT Generic Training Package                  Module 2, Slide 57
                       Contraceptive Methods
                                 (Continued)




Step 2 (continued):
 IUDs can be used by asymptomatic or mildly
  symptomatic women; they are not recommended for
  women with advanced HIV who are not on ARV
  therapy
 Spermicides, or diaphragm with spermicides
  should not be used
 Fertility awareness-based methods are unreliable
  and should not be used

PMTCT Generic Training Package                 Module 2, Slide 58
                       Contraceptive Methods
                                  (Continued)




Step 2 (continued):
 Lactational amenorrhea method (LAM) should only
  be used by women who
      (i) are less than 6 months postpartum
      (ii) are exclusively breastfeeding, and
      (iii) have not resumed menstruating
 Sterilization is effective for women with HIV



PMTCT Generic Training Package                    Module 2, Slide 59
                 Family Planning Counselling
                                 (Continued)




Step 3: Discuss HIV and fertility
    HIV may reduce fertility by as much as 40% but ARV
     therapy increases fertility
    Ensure that couples are aware of possibility of fertility
     returning
    Emphasize family planning




PMTCT Generic Training Package                       Module 2, Slide 60
                           Element 3: PMTCT

 PMTCT programmes:
     Identify pregnant women with HIV
     Provide HIV-infected pregnant women with
      interventions for PMTCT




PMTCT Generic Training Package                Module 2, Slide 61
             Element 3: PMTCT Interventions

              Intervention                       These interventions work by…
HIV testing and counselling during ANC,          Providing information about HIV,
labour and delivery and postpartum                PMTCT, safer sex
(individual, couple, group)
                                                 Identifying women infected with HIV
Provision of antiretroviral (ARV) drugs to   Reducing maternal viral load
mother and infant
Safer delivery practices                     Reducing infant exposure to maternal
                                             blood
Infant feeding information, counselling      Reducing infant exposure to the virus in
and support                                  breast milk
Referrals to comprehensive treatment,        Ensuring the woman and her family have
care and social support for mothers and      access to life-saving care, treatment and
families with HIV infection                  support services

 PMTCT Generic Training Package                                        Module 2, Slide 62
                Partner Involvement in PMTCT

 PMTCT interventions should be based on the
  principle that both mothers and fathers have an
  effect on HIV transmission to the infant

    Involving both men and women in all 4 elements
            is vital to the success of PMTCT




PMTCT Generic Training Package              Module 2, Slide 63
                Partner Involvement in PMTCT
                                  (Continued)




 Both partners should be:
       Participating in decisions about preventing HIV
        transmission
       Playing an important role in using family planning
        methods
       Getting tested and counselled for HIV




PMTCT Generic Training Package                         Module 2, Slide 64
                Partner Involvement in PMTCT
                                 (Continued)




 Both partners should be:
       Responsible for safer sex during pregnancy,
        breastfeeding
       Getting information about PMTCT services from HCWs
       Responsible for choosing a safer infant feeding method

 A partner’s support is valuable for seeking and
  participating in HIV-related care, treatment and support



PMTCT Generic Training Package                        Module 2, Slide 65
               Element 4: Treatment, Care
                     and Support

 Medical care and social support are important
  for women living with HIV, enabling them to
  address concerns about their own health and
  the health and future of their children and
  families




PMTCT Generic Training Package           Module 2, Slide 66
                                 Linkages to Care

 Linkages to long-term treatment, care, support services
  are critical. Such services include:
       ARV therapy
       Symptom management
       Prevention and treatment of HIV-related conditions
       Reproductive health care: family planning and
        contraception counselling
       Nutritional support
       Psychosocial and community support
       Palliative care, if indicated

PMTCT Generic Training Package                          Module 2, Slide 67
          Linkages for HIV-Exposed Infants
                    and Children
 Infants and children born to HIV-infected mothers
  require regular follow-up care, especially during the
  first two years of life
       Immunizations
       Prophylaxis for Pneumocystis pneumonia, other
        common infections
       HIV testing
       Monitoring of feeding, nutrition, growth and development



PMTCT Generic Training Package                       Module 2, Slide 68
                     Linkages for HIV-Exposed
                      Infants and Children             (Continued)




 Linkage essential for HIV-exposed children as they
  are at higher risk for illness and malnutrition:
       May be infected with HIV and become ill—even with
        adequate healthcare and nutrition
       If receiving replacement feeding, may be at risk of
        infections and malnutrition
       If mother is ill, she may have difficulty caring for her
        children




PMTCT Generic Training Package                             Module 2, Slide 69
                                 Session 3



     Role of Maternal and Child Health
       Services in the Prevention of
HIV Infection in Infants and Young Children



PMTCT Generic Training Package               Module 2, Slide 70
                        Session 3 Objectives

 Describe the role of maternal and child health (MCH)
  services in the prevention of HIV infection in infants and
  young children




PMTCT Generic Training Package                    Module 2, Slide 71
                        Integrating PMTCT into
                             MCH Services
 Access to comprehensive MCH services is central to
  efforts to reduce HIV in infants and young children
 PMTCT programmes need to be integrated into existing
  MCH care

         ANC is the most common entry point for a
            pregnant woman into the healthcare
        system; enrolment should ensure access to
              necessary PMTCT interventions


PMTCT Generic Training Package                 Module 2, Slide 72
              Comprehensive MCH Services

 Structure usually includes services such as:
       ANC
       Immunization programmes for infants and
        children
       Postpartum care
 Comprehensive approach likely to strengthen maternal,
  infant and family care


PMTCT Generic Training Package                   Module 2, Slide 73
                        Role of Comprehensive
                            MCH Services
 Provide comprehensive ANC       Provide core PMTCT
  care                             interventions
 Prevent primary infection in    Provide education about
  parents-to-be                    prevention, early recognition
                                   of STIs
 Provide family planning
  services to HIV-infected        Provide or refer to STI care
  couples and women of             and treatment
  childbearing age of
  unknown HIV status              Offer or refer for primary
                                   care of adults and children
 Educate women and their
  partners about reducing the
  risk of MTCT

PMTCT Generic Training Package                       Module 2, Slide 74
                        Role of Comprehensive
                         MCH Services      (Continued)



 Refer women and families to health and community
  services for palliative care, psychosocial and spiritual
  support, economic assistance
 Educate patients about how to recognize symptoms of
  opportunistic infections and measures they can take to
  prevent such infections
 Educate patients about how to recognize early signs
  and symptoms of HIV infection in the infant or child


PMTCT Generic Training Package                           Module 2, Slide 75
                                 Key Points

 Risk of MTCT without intervention is 20–45%
 Effective PMTCT programmes provide access to
  interventions that can significantly reduce the rate of
  MTCT
 Risk of transmission to the infant is highest when the
  mother’s viral load is high. Two of the main reasons that
  a mother may have a high viral load are: recent HIV
  infection and advanced AIDS


PMTCT Generic Training Package                     Module 2, Slide 76
                                 Key Points   (Continued)




 A comprehensive approach is needed to prevent HIV
  infection in infants, young children. The four elements of
  the comprehensive approach to PMTCT are:
       Primary prevention of HIV infection
       Prevention of unintended pregnancies among women
        infected with HIV
       Prevention of HIV transmission from women infected
        with HIV to their infants
       Provision of treatment, care and support to women
        infected with HIV, their infants and their families


PMTCT Generic Training Package                              Module 2, Slide 77
                                 Key Points   (Continued)




 MCH services, especially ANC care, are an
  entry point into the range of services required to
  meet the needs of HIV-infected women and
  their families




PMTCT Generic Training Package                              Module 2, Slide 78

								
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