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					Focus Area One: Prevention of mother to child transmission of HIV (PMTCT)
1. Definition and description
A woman with HIV can transmit the virus to her infant either during pregnancy, labour or after
childbirth via breastfeeding. Several factors are associated with a higher risk of transmission,
including the amount of virus in the mother (viral load) and CD4 cell count. Without treatment,
the chance of transmitting HIV from a mother to a baby is somewhere between 12 and 25% in
resource rich settings, and between 20 and 45% in resource poor settings. It is greatly influenced
by whether the child is breastfed. In 1994, a controlled clinical trial demonstrated that treatment
with a drug called AZT (Zidovudine) during pregnancy, delivery and to the infant after birth can
reduce the risk of mother-to-child transmission of HIV by two thirds. Subsequent studies
reported that other treatment courses with AZT and other antiretroviral drugs could also reduce
the likelihood of infection of the infant. One trial in Uganda demonstrated significant reductions
in HIV transmission simply by giving a single dose of Nevirapine to the mother at the start of
labour and to her infant within 72 hours of childbirth. This simple and inexpensive approach
allowed resource poor countries to design and implement programmes for the prevention of
mother-to-child transmission. At present only 9% of HIV positive women in resource poor
countries are able to have treatment with anti-retroviral drugs (ARVs)1. A notable exception is
Botswana where an estimated 90% of HIV positive pregnant women are enrolled in the PMTCT
programme2. Unfortunately in many countries the majority of pregnant women have no antenatal
care and no opportunity to deliver with a trained birth attendant, let alone receive HIV testing
and ARVs.

1.1 Prevention of mother to child transmission and prevention of unwanted pregnancy
will almost eliminate HIV infection in children. Some Tearfund partners have adopted the
broader definition of PPTCT (prevention of parent to child transmission) rather than PMTCT
(prevention of mother to child transmission). This recognises that women alone cannot prevent
transmission of HIV to their children; a woman can have been infected by her partner and so
both parents have responsibilities for their unborn child. Experience has shown that many
women refuse HIV testing or abandon medical care because they fear revealing their HIV status
to husbands. Testing of both parents, by increasing the knowledge and understanding of the
man, allows him to take increased responsibility for his own health and for that of his wife or
other sexual partner and family3. It also allows the burden of anxiety, decisions as to disclosure
to other family members, decisions over treatment, infant feeding and future care to be shared
between the man and the woman.

Due to the decreased immune state of pregnancy, pregnant women have a greater risk of being
infected with HIV. New HIV infections are associated with a very high viral load and so there is
a higher risk of transmission of the virus to the unborn child or the breastfeeding infant when a
woman is recently infected. Therefore the child of an HIV negative mother is not free from risk
while the mother is at risk of new HIV infection. This means that the pregnant or breastfeeding
woman and her sexual partner need to continue to protect themselves from infection: in
particular if her partner is HIV positive, active means of protection (condoms or abstinence)
need to be taken.

Tearfund’s strategic response to HIV has an integrated approach to the PMTCT4. Linked areas
are covered in the following documents: behaviour change among children and young people
(focus area 5); access to treatment (focus area 3); stigma and discrimination (focus area 4); and
impact mitigation (focus area 2).

1.2 Anti-retroviral therapy
There are different options recommended for prevention of mother to child transmission:
     When combination ARVs are not available Nevirapine as a single oral tablet is taken by
        the HIV positive pregnant woman at the onset of labour. This is followed by Nevirapine
        syrup which is given to the newborn infant within 72 hours of delivery. The Nevirapine
        syrups needs to be refrigerated and therefore is likely to be best provided at a health
     Where combination ARVs5 are available the pregnant woman will take a combination of
        anti-retroviral drugs as indicated by the CD4 count and clinical stage of HIV and AIDS,
        and the stage of pregnancy. Combination ARVs will also be provided to her newborn
        infant for one to four weeks.

Availability of ARVs and the regimen recommended will vary between countries and are
regularly updated. Tearfund partners should only implement PMTCT programmes in
consultation with, and subject to approval from, the appropriate National HIV and AIDS
Programme and local medical advisers.

1.3 Infant feeding: Breastfeeding can transmit HIV, but there is increasing evidence that
exclusive breastfeeding up to the age of six months gives newborn babies and infants in the
developing world their greatest chance of survival and is widely acceptable 8,9. Exclusive
breastfeeding is associated with a lower risk of transmission of HIV infection compared with
mixed feeding (providing breast milk along with bottled milk or other foods). Bottle feeding has
the economic cost of purchase of infant milk formula; the difficulty of mixing formula to the
correct strength, and of having clean water for mixing formula and washing utensils, and
therefore gives an increased risk of diarrhoeal illness and death. In some communities, stopping
breastfeeding after six months or bottle feeding may be associated with stigma because these may
brand the mother as having HIV. The HIV positive women should receive counselling and have
her skills built to enable her to make an informed choice and overcome stigma. The various
factors involved in the choice of infant feeding will vary between countries and it is
important for Tearfund partners to discuss infant feeding and the recommended
regimens with their National HIV and AIDS Programme and local medical advisers.

1.4 Care of HIV exposed children up until 18 months of age should include Cotrimoxazole
prophylaxis from six weeks old, and CD4 counts and commencement of ART when clinically
indicated5. Before the age of 18 months, routine HIV blood antibody testing cannot distinguish
the HIV status of the infant from that of the mother because the infant may still have antibodies
received from the mother at the time of birth.

2. NGO Code of good practice in HIV10
The Code calls for NGOs to provide, or advocate for access to, PMTCT services. PMTCT
includes the specific interventions of ARVs and counselling on infant feeding. There needs to be
comprehensive networking between different sectors to ensure that pregnant women can access
these. It is also stated that PMTCT needs to extend to contraception, prevention of HIV,
prevention and treatment of other sexually transmitted diseases, and antenatal care.

3. Guidelines for practice
3.1 What would this mean for the person living with HIV
 Pregnant women and their partners will have the opportunity for counselling and testing for
    HIV. If they are found to be HIV positive they will receive advice about the most
    appropriate treatment available to reduce the risk of transmission to their unborn child and
    to protect their own health. They will receive counselling related to infant feeding options
    and support following their decision. If one of the partners is found to be HIV negative they
    will be informed of the risk of acquiring HIV when pregnant or breastfeeding and
    understand the way to protect themselves from infection, including the need for condom
 Children of an HIV positive mother will receive early prophylaxis with Cotrimoxazole,
    testing for HIV at 18 months of age and be monitored clinically and with CD4 counts tests
    to monitor beginning treatment with ARVs.
 Women will have the option of using contraception to prevent having a child.

3.2 What should Tearfund-supported projects implemented by partners cover?
 Link with national government AIDS programme and receive regular updated advice about
    national guidelines and good practice.
 Support local and national efforts to improve access to, and quality of, existing obstetric care.
 Provide education about PMTCT to government midwives, traditional birth attendants and
    other women in the community who are active in women’s health care, and to link up
    PMTCT work with work on maternal and child health (e.g. clinics for children under the age
    of five, family planning clinics, antenatal clinics)3.
   Involve community members in PMTCT, such as men, church leaders, lay volunteers3.
   Provide confidential and voluntary HIV testing and counselling to all couples3 and single
    women. This should include:
         o Pre-test counselling for groups or individuals. There should be discussion about risk
              factors and education to reduce risk and ensure that the woman and her partner
              understand the test and implications of a positive result.
         o Post-test counselling when both partners are HIV positive. Ensure that the woman
              and her partner understand the test result, and are provided with emotional support
              and follow up which includes referral to ARV/PMTCT services.
         o Post-test counselling when one or both of the couple are HIV negative. This should
              advise the woman and her partner that the woman is at increased risk of acquiring
              HIV infection when pregnant or breastfeeding, and, if newly infected, is at greater
              chance of transmitting the virus to their unborn or breastfeeding child.
   For pregnant women who are HIV positive:
         o Enrol in a PMTCT5 programme.
         o Receive Cotrimoxazole while following local guidelines.
         o Support for health clinic attendance (which may include assistance with
              transportation and repeated advocacy for free care)
   Discuss infant feeding3, including the choice of exclusive breastfeeding or replacement
    feeding, and support mothers in their choice. Provide education about nutritional and locally
    appropriate feeding after six months.
   Ensure safer delivery3,5 through encouraging regular antenatal care and attendance at health
    centres for delivery, where blood contact between mother and child and birth attendants can
    be reduced, and ARVs for the newborn child may be available.
   Infants born to HIV positive mothers5:
          Give Cotrimoxazole prophylaxis from six weeks of age
          Provide mothers with counselling related to feeding and nutrition
          Immunise the child following the national protocol (EPI)
          Advocate for children to access CD4 counts and ARVs3.
          HIV testing at 18 months
              o Children who are HIV positive should be followed up to ensure regular health
                  clinic attendance and adherence to ARV treatment programme
              o Children who are HIV negative are still at risk of inadequate nutrition due to the
                  illness of their mothers, and should have regular growth monitoring.
   Following delivery HIV positive mothers should be:
              o given access to advice and means to access contraceptive services.
              o empowered with negotiation skills to enable them to have more control over
                  their sexual activityy
              o referred to an ARV clinic to continue treatment and followed up by the

4. How can people living with HIV be involved?
HIV positive women who have had a child and taken treatment for PMTCT are a strong
resource for counselling pregnant women for VCT, providing education before ARV,
encouraging longer term adherence and for counselling on infant feeding and stigma reduction.
As part of a homecare network they are able to participate in the full range of homecare services,
with the added strength of speaking from direct experience.
Greater involvement of people living with HIV and AIDS should be encouraged at all levels of
the organisation and programmes with the aim being to obtain representation in each of the
following categories: target audience; contributors; speakers; implementers; experts and decision
makers9. It is crucial that women are actively encouraged to participate. The level and extent of
PLHA involvement in the organisation will depend on access to treatment, other responsibilities
such as family and income generation, and on the climate of discrimination.
5. Understanding the gender dimensions within the area
It is important that the potential risks to women of disclosure of positive HIV status to sexual
partners and family are recognised.
       If an HIV positive woman is at risk of domestic violence, sexual abuse or being thrown
         out of the home, she is unlikely to wish to be tested. Care needs to be taken to avoid
         putting pressure on women to be tested against their will.
       Ill treatment of the mother will compromise the survival of her children.
       If a pregnant woman is taking ARVs or is bottle-feeding where community expectations
         are that mothers will breastfeed, it may not be possible for her to hide her HIV status.
       Where disclosure is inevitable and women risk abusive treatment, sheltered care may
         need to be made available. Involvement of human rights organisations and legal
         advocacy may be required.

6. Relationship to homecare
Through their network of community contacts and knowledge about HIV transmission and
treatment services, home based care givers are able to support all aspects of PMTCT including:
      Encourage pregnant women to access antenatal care and HIV testing.
      Provide support for the HIV pregnant woman in her family and community, in
        particular with issues relating to disclosure of HIV status and adherence to medication.
      Respond with referral to appropriate agencies in the event of abusive situations.
      Provide support in the chosen infant feeding method.
      Encourage health clinic attendance of mother, father and child for follow-up after birth.

7. Key indicators
Baseline measurement of the following indicators should be part of project planning and be
included in the initial proposal submitted to Tearfund. This may be carried out by the partner
organisation or rely on information gathered by other agencies within the target community.
      % of HIV positive pregnant women receiving a complete course, from at least 28 weeks
         of gestation, of ART prophylaxis to reduce the risk of MTCT
      % of pregnant mothers receiving :
    a) an HIV test
    b) the % of HIV infected mothers receiving a CD4
    c) the % of HIV infected mothers receiving ARVs because of a low CD4 count
    d) the % of HIV infected mother receiving comprehensive counselling re breastfeeding
    options, according to WHO guidelines
      Infant feeding outcomes for infants of HIV positive mothers:
              o Percentage exclusively breastfed until they are six months old.
              o Incidence of diarrhoeal disease and death (for those receiving infant milk
      Percentage of all mothers who received PMTCT and whose infants are still receiving
         follow-up at two years old and accessing CD4 counts and ARV services if available.

Reference List:
    1. Veneman A. Achieving Millennium Development Goal 4. Comment. Lancet; 368:1044-1046;
        statistic quoted from
    2. HIV & AIDS Treatment in Practice Newsletter. HIV treatment for mothers and children in
        Botswana: lessons from a dynamic program. #76 October 20 th 2006
    3. Focused Church based action for PMTCT: case studies of Tearfund partner PMTCT
        programmes. Draft document. Lead Author: Dr. Rena Downing. October 2006. Document
        available on request from Tearfund UK.
    4. Making a difference. Tearfund’s strategic response to the AIDS pandemic. July 2006
    5. Chronic HIV Care with ARV therapy and prevention. Integrated management of adolescent and
        adult illness; Integrated management of childhood illness. Interim guidelines for health workers at
        health centre of district hospital outpatient clinic. World Health Organisation. July 2006. Available
    6. Handbook of HIV Medicine. Oxford University Press, Southern Africa. 5 th Edition 2005.
        Chapter 34 (Infant Feeding), Chapter 41 (Prevention of mother to child transmission of HIV).
    7. HIV Management Course: University of the Witwatersrand, South Africa. November 2005
8.  Coovadia HM, Rollins NC, Bland RM, e t al. Mother to child transmission of HIV-1 infection
    during exclusive breastfeeding in theh first 6 months of life: an intervention cohort study. Lancet
9. WHO and HIV and infant feeding technical consultation. October 2006. Consensus Statement.
10. Renewing our voice: Code of good practice for NGOs responding to HIV/AIDS 2004. Julia
    Cabassi, David Wilson. Distributed by Oxfam GB.