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					PMTCT

In 2004 one million, ten thousand children were born in South Africa. Of these
37 000 were HIV positive at birth and another 26 000 became HIV positive
through breastfeeding.

How do we stop this happening? The answer is called prevention of mother-to-
child transmission, which we know as PMTCT.



CHAPTER ONE: WHAT IS PMTCT?

- Reducing mother to child transmission was an early benefit of antiretrovirals; a
  pregnant mother can protect her child from HIV using antiretroviral drugs.


Discussion points:

    •    What does PMTCT stand for?

    •    What can we use to reduce the risk of transmission of HIV from a mother
         to her baby?




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CHAPTER TWO: RATES OF MOTHER- TO- CHILD TRANSMISSION
WITHOUT TREATMENT.

- The mother to child transmission rate for some one not using any antiretrovirals
  is about 30%. That means if 100 pregnant women go to the clinic and are
  tested HIV positive, without ARVs like nevirapine, approximately 30 babies will
  be born HIV positive.

- Mother to child transmission of HIV during pregnancy (called in-utero) is
  unusual. Of the 30 babies with HIV only about 5 will be infected babies during
  pregnancy the rest will be infected during delivery or labour.

- Babies can also become infected through breastfeeding.

- Those are the different times at which mothers can pass HIV on to their babies.

- An intervention with single dose nevirapine can mean only about 15 out of 100
  mothers will pass HIV on to their babies during delivery. If nevirapine is taken
  together with AZT (given to mothers from 28 weeks of pregnancy) - like in the
  Western Cape - the number of mothers who can infect their babies with HIV will
  drop to only ONE mother out of a 100. ***This should be at least 2% PC


Summary:

         About 30 out of 100 babies during pregnancy or delivery.

         Of these 5-10 out of 100 babies will be infected in the womb during
         pregnancy.

         About 20 out of 100 babies will be infected during delivery.

         10-20 /100 babies will be infected by breast milk when mixed or breast
         feeding.

         25-50 out of 100 babies will not be infected.




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Discussion points:

    •    Untreated, approximately how many babies out of 100 will become HIV
         positive during pregnancy or delivery?

    •    What about breastfeeding?

    •    What if a mother receives single dose nevirapine?

    •    What about AZT and nevirapine?



CHAPTER THREE: RATES OF MOTHER- TO- CHILD TRANSMISSION WITH
TREATMENT

- As we heard, if a pregnant woman is given single dose nevirapine to prevent
  her baby from infection, out of the 100 HIV positive pregnant women only 15
  mothers will pass the HIV on to their babies during labour.

- In the Western Cape they are now taking nevirapine together with AZT. These
   two together limit the chances of a mother infecting her baby with HIV during
   pregnancy. The chances are so limited that out of a 100 HIV positive pregnant
   mothers as few as two babies will be born with HIV.

- So as we’ve heard just a single dose of nevirapine can reduce the chance of
  passing HIV to your baby during labour by half but AZT and nevirapine together
  can reduce the chances a whole lot more.


Summary

         About 15/100 babies will be infected during labour with nevirapine only

         About 2/100 with nevirapine and AZT


Discussion point:

    •    Are women receiving AZT and nevirapine for PMTCT in South Africa?




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CHAPTER FOUR: HOW BABIES GET HIV

- During pregnancy if the mother’s viral load is high and if her CD4 cell count is
  extremely low, a baby is more likely to be infected. Also if an HIV positive
  mother develops opportunistic infections.

- An HIV positive mother’s breast milk also contains HIV. If a baby is fed with
  breast milk, the baby might get infected with HIV through breast feeding.


Summary:

         Babies get infected during pregnancy

         The risk is increased if the mother develops OIs during pregnancy

         Babies get infected while breastfeeding or mix- feeding.


Discussion points:

    •    What can increase the risk of a baby being infected during pregnancy and
         delivery?

    •    How else can a baby become infected?




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CHAPTER FIVE: WHEN TO START PMTCT TREATMENT

If we do not have a period for more than a month, we should go for a pregnancy
test. If we are pregnant, it's important to book quickly with an ante-natal clinic. If
we book late, we could actually miss the opportunity to benefit from PMTCT if we
are HIV positive.

Pregnant Women with CD4 Count Below 200

- If your CD4 cell count is below 200, it means you must start on ARVs for your
   own HIV. In this case you are not going to take only a single dose of nevirapine
   during labour (or AZT for the last part of your pregnancy and nevirapine during
   labour) you are going to take the ARVs for the rest of your life as you need
   treatment for your own health.

- A mother’s treatment with ARVs will mean that there will be a very low risk of
  transmitting HIV to her baby.

Pregnant Women with CD4 Count Above 200

- If you still have plenty of CD4 cells - over 200 – it is important that you know the
  perfect time at which you can start taking ARVs.

- If you take nevirapine with a high CD4 count, the nevirapine can sometimes
  cause liver damage. So that is why it is not recommended for treatment when
  your CD4 count is still high. There is not a risk to your liver from single dose
  nevirapine with a high CD4 count.

- On the 28th week of your pregnancy you will be given nevirapine to take home
  (because no one knows exactly when you are going to go into labour). You
  must take the nevirapine when you feel like you are going to give birth soon.
  Then go to the clinic to give birth, after you’ve taken the pill.

- If for any reason you did not get the nevirapine in advance, you must tell the
   nurses that you are in labour and you are HIV positive so that they can give you
   the pill while you are still in labour.

- After you have given birth, your baby will also have to take the nevirapine but it
  will be in liquid form, not a pill. The nevirapine must be given to the baby within
  three days of being born.




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Pregnant Women with CD4 Count Above 200 Using AZT and Nevirapine

- You can also take AZT and nevirapine which is much more effective than
  nevirapine only.

- You must start taking AZT twice a day from the 28th week of pregnancy, until
  you go into labour.

- You will also take a single dose of nevirapine at the start of labour.

- The baby must also be given AZT daily from birth for seven days as well as a
  single dose of Nevirapine within 3 days of birth.

- In South Africa we started our PMTCT programmes using single dose
   nevirapine only. As PMTCT is much more effective when you use both AZT and
   nevirapine, this strategy was introduced in the Western Cape.

- It is recommended that both drugs be used nationwide. Currently in 2006 each
   province is taking its own decision on implementing AZT and nevirapine.

- As HIV/AIDS activists and advocates, we need to demand that AZT and
  nevirapine be made available to all HIV positive pregnant women - that do not
  need treatment for their own health - in all government clinics and hospitals.


Summary

         If your CD4 cell count is above 200, you must start on PMTCT
         programme.

         If your CD4 cell count is below 200, you must start on ARVs for life.

         At week 28 of your pregnancy you will be given nevirapine to take when
         you go into labour.

         Within 3 days after your baby is born, he or she must get a dose of
         nevirapine syrup.

         Take AZT twice a day from the 34th ??? week of pregnancy.

         The baby must also take AZT from birth for 7 days.

         AZT must be made available in all government clinics.




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Discussion points:

    •    What care and treatment should you receive if you have a low CD4 count
         (below 200) and are pregnant?

    •    What if your CD4 count is above 200?

    •    What PMTCT strategy is better than single dose nevirapine in this case?

    •    In which province is this strategy being used?




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CHAPTER SIX: BREAST VERSES BOTTLE

- An HIV positive mother has HIV in her breast milk. The lining of a baby’s
  stomach and gut are very, very sensitive. Anything other than breast milk, even
  water or medicine, may irritate the gut, and make it possible for the baby to
  absorb the HIV in the mother’s milk.

- It is considered safer to either breastfeed or bottle feed a baby rather than
   mixed feed.

- Mixed feeding is a problem for HIV transmission because when a mother is
  formula feeding to a child the gut may be damaged and that allows the virus
  through. That is why women are recommended to exclusively breastfeed if they
  decide that they are going to breastfeed.

- If they decide to formula feed then it is safer to exclusively formula feed.

- If you choose formula feeding over breast milk you will be given the formula
   milk called Perlagon to give to the baby when you leave the clinic.

- After six weeks you will come back to the clinic and your baby will be given
  bactrim (or cotrimoxazole). Babies are given cotrimoxazole syrup. It protects
  them against infection.

- If you are using the formula milk, you must make sure that you read the
   instructions on the package. Be aware of how much milk you are supposed to
   be giving your baby.

- It is also important to keep the feeing equipment (including the mixing cup, the
   spoon and bottle) very clean. You can put them in boiling water to kill all the
   germs.

- It's very important that mothers have a clear understanding of the issues
   involved in deciding on breast or formula feeding. Government protocol says
   that mothers must make their own decision about breast or formula feeding,
   once they clearly understand the issues.

- If you have reliable access to clean water and it is easy to get formula, formula
   feeding is definitely safest. But if you do not have access to clean water, dirty
   water could cause diarrhoea, which could harm the baby.

- There are some social pressures to breastfeed, as well as nutritional and
  emotional advantages.

- But most women find it difficult to breastfeed exclusively.




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Summary

         HIV positive mothers have HIV in their breast milk.

         New-born babies have sensitive stomachs.

         Breast milk does not irritate babies’ stomachs.

         Anything besides breast milk even water or medicine can irritate baby’s
         stomachs.

         If stomach lining is infected, they can get HIV from breast milk.

         Do not mix- feed your baby.

         Safest way to feed your baby is formula feed.

         It becomes risky when access to clean water is difficult.

         Mother’s milk is best helps mother- to- child bonding.

         There is always some risk of transmission


Discussion points:

    •    Why is breast feeding risky for HIV positive mothers?

    •    What feeding strategy is more risky?

    •    What is the safest way to feed a baby to prevent MTCT through
         breastfeeding?

    •    What are some of the things that could make formula feeding difficult?




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CHAPTER SEVEN: WHEN TO TEST YOUR BABY FOR HIV

- Make sure you and your child go for all of your check ups at your local clinic.
  Speak to your health care worker about any concerns that you may have.

- Using the normal antibody test for HIV means that babies can only be tested
  from nine months. This is because a new baby will share his or her mother’s
  antibodies whether the baby is HIV positive or negative, so an antibody test
  may show false positive result before 9 months.

- With the antibody test, the baby would have to be tested again at 110 months
  and only then we can be completely sure that the bay is not infected with HIV.

- This is a long time to wait.

- The PCR test responds to the presence of the virus itself and not to antibodies.
  This test can be used when the baby is 3 months old. If the mother has chosen
  exclusive breast feeding, then the PCR test must be repeated at 6 months.

- Currently the PCR test is only available in the Western Cape and some
  hospitals in Gauteng.

- HIV/AIDS activists need to demand that the PCR test be made available in all
  government clinics and hospitals.


Summary

         The PCR test should be used when the baby is 3 months old.

         Repeat the PCR test at 6 months if exclusive breastfeeding.

         The PCR test must be made available in all government hospitals and
         clinics.


Discussion points

    •    Why do all babies born to HIV positive mothers test positive with the HIV
         antibody test whether they are positive or negative?

    •    How old does a baby need to be before we can be completely sure of the
         antibody test results?

    •    What other test can we use?

    •    What are the advantages?




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In 2003 (most recent figures????), in South Africa, the number of health
facilities providing PMTCT increased from 20% to 53%, but the health
department has not recently released figures on how many mothers are getting
PMTCT. Nor are there yet any plans to extend PMTCT with AZT and nevirapine
together to the rest of the country.

Currently all the procedures in the PMTCT programme, such follow-up after birth,
need strengthening. Because AZT-Nevirapine will stop a lot more babies from
becoming positive, and because 18 months is too long to wait to find out if your
baby is HIV positive.




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