PMTCT MANUAL by mikeholy


									            PMTCT +
 Integrating Treatment into the
  Prevention of Mother-to-Child
      Transmission of HIV

          PMTCT+ MANUAL

Implementation Guidelines for
    Health Care Workers

        National HIV/STI Programme

             Ministry of Health


           Revised March 2005

One of the priorities for the National HIV/AIDS/STI Control programme
is to strengthen the treatment, care and support of persons living with

Approximately 1.5-2% of Antenatal Clinic attendants are estimated to
be HIV positive, with Mother to Child Transmission occurring in
approximately 25% of these births, either during the actual
pregnancy, 20%–25%, through maternal-fetal exchange of blood,
during labour and delivery (intrapartum), 60%–70%, by contact of the
infant’s skin or mucous membranes with infected blood or other
maternal secretions and after delivery (postpartum), 10%–15%
through breast-feeding. With appropriate interventions Mother to Child
Transmission can be reduced from 25% to below 5%.
An opportunity is therefore missed whenever a woman of childbearing
age is

  unaware of her HIV status or her risk for HIV or
  when an HIV-infected pregnant woman
     a) does not receive prenatal care,
     b) is not offered HIV testing,
     c) is unable to obtain HIV testing,
     d) is not offered chemoprophylaxis,
     e) is unable to obtain chemoprophylaxis, or
     f) does not complete the chemoprophylaxis regimen.

               Mother-to-Child Transmission
               Prevention (PMTCT) Strategies

Primary Prevention

The first interventions in Mother-to-Child Transmission (MTCT) are the
prevention of new infections in women of childbearing age and the
prevention of unintended pregnancies in HIV infected females.

These interventions include:

    Empowering women with knowledge and skills to prevent
     HIV/STI transmission
    Promoting safer sex behaviour (correct and consistent use of
     condom and reduction of the number of sexual partners)
    Promoting use of an effective Family Planning method e.g. Tubal
     Ligation, Depo Provera Oral Contraceptives or Norplant
    Early Diagnosis and Complete Treatment of Sexually
     Transmitted Infections (STIs)

Secondary Prevention

These interventions are aimed at preventing transmission of HIV from
each infected woman to her unborn child and include:

   Ensuring that HIV infected females and their partners make
    informed reproductive choices.
   The use of anti-retroviral (ARV) drugs: Highly Active
    Antiretroviral therapy (HAART), Zidovudine (ZDV) short course,
    Nevirapine (NVP) single dose or combination therapy.
   Obstetrical interventions such as avoidance of invasive
    procedures (e.g. Episiotomy and Artificial Rupture of
    Membranes, Fetal Scalp Monitoring, and interventions to prevent
    prolonged labour.
   Ensuring that all HIV-infected mothers receive counselling about
    the risks and benefits of various infant feeding options and
    specific guidance in selecting the option most likely to be
    suitable for their situation.
   When replacement feeding is acceptable, feasible, affordable,
    sustainable and safe, it is recommended that HIV-infected
    mothers avoid all breastfeeding

The major factors that limit compliance of patients to prevent MTCT

   Lack of confidence that health care workers will maintain
   The perception that they (patients) will be victimized and
    discriminated against by health care workers due to the stigma
    associated with the disease.

Each patient/client must therefore be assessed and a plan developed
based on the particular needs and circumstances for continued

Therapeutic Interventions

Each of the following regimes has been proven to reduce significantly
the risk of mother-to-child transmission and may be utilized as

   Triple therapy utilizing HAART regime where indicated.
   A short course of AZT given 300 mg orally twice daily starting
    between 28- 36 weeks of gestation and 300 mg orally
    intrapartum every 3 hours as well as to the new born at 4mg/kg
    every twelve hours for either one or up to six weeks.
   A single (200 mg) dose of Nevirapine (NVP) given at the onset of
    labour to the mother and 2mg/ kg body weight Nevirapine
    suspension given to the infant within the first 72 hours after

The effect of ARVs in reducing the transmission appears to be partly
through the reduction of maternal viral load and also by acting as post
exposure prophylaxis to the infant.

     Voluntary Counselling and Testing (VCT)
All pregnant women presenting to the health institution for antenatal
care will be offered confidential counselling, and will be tested for HIV
with an informed oral consent.

Trained counsellors will conduct counselling. Each pregnant mother
will be counselled before and after the HIV test is done. Pre-test
counselling maybe carried out in groups.

Pre and Post-Test Counselling Goals

Counselling and Voluntary HIV Testing helps women and men who
may be considering building or expanding their families to:

    Make choices to reduce their risks of HIV infection and
     transmission-both to others and to the infants of pregnant, HIV-
     positive women
    Make informed choices about contraception and condom use

    Discuss HIV status and testing with their partner(s)

Pregnant Women Who Test HIV Negative

Counselling provides an opportunity for the patient/client who has
received a negative result following the HIV test to:

    Make choices to reduce her risks of HIV infection in the future
     (including talking to partners about testing, decreasing the
     number of partners, etc.)

    Understand and maintain safer sex behaviour (including condom
     use) in order to prevent HIV infection in the future

Pregnant Women Who Test HIV Positive

Counselling provides an opportunity for the patient/client who has
received a positive result following an HIV test to:

    React to an HIV-positive result and receive empathy and support
     from a counsellor

    Commence HAART therpy for her own health or Choose
     Nevirapine and/or AZT prophylaxis for MTCT prevention.

   Understand infant     feeding   options   and    choose      the   most
    appropriate one.

   Learn more about HIV infection and its implications for her

   Prepare to talk to her partner about her HIV status and discuss
    HIV testing

   Make informed choices about sexual behaviour (abstinence,
    partner reduction and condom use) and future fertility, including
    tubal ligation or other long-term method such as Depo Provera,
    Norplant etc.

   Be prepared for the follow up during pregnancy and delivery

The Role of Group Education
Group education provides antenatal clients with the essential
information about HIV/AIDS so counsellors can focus on counselling
instead of educating their clients. Group education can be conducted
by a staff member, volunteer or a community peer educator. The
following topics are covered in group education sessions.

   What is HIV/AIDS

   National statistics about HIV/AIDS

   Local myths and misperceptions

   Routes of HIV transmission

   HIV risk behaviours

   Relationship of sexually        transmitted     infections    to    HIV
    transmission and infection

   How to prevent HIV infection

   How to decrease risks of HIV, including talking to partners about

   Explain basic principles of the HIV test and procedure.

   Mother-to-child transmission

   Explain the benefits of Mother to Child Transmission Prevention

   Availability of VCT

   Special care and services for HIV-positive women

Pre-test Counselling
The counsellor should:

   Assess the knowledge of the expectant mother on HIV/AIDS and
    provide basic information about HIV infection.

   Explain basic principles of the HIV test and procedure.

   Explain the benefits of Mother to Child Transmission Prevention

   Emphasize that the test is voluntary and confidential.

   Assist individual to assess risk status and develop a plan of
    action to reduce risk.

   Empower individual to make informed choices on methods of

   Obtain informed oral consent.

Post-test Counselling
Negative Result
The counsellor should:

   Provide HIV test result clearly and simply

   Inform her that a test should be repeated in subsequent
    pregnancies or three months from when she was last at risk
    (when applicable).


   Assist each patient/client to develop a risk reduction plan.

   Assist individual to identify who will support them in their plan to
    reduce their risks

   Discuss HIV transmission and prevention methods.

   Empower individual to talk with her partner about her HIV result
    and HIV testing

   Demonstrate the proper use of condoms.

Positive Result
The counsellor should:

   Provide test result clearly and simply

   Assist the client to identify sources of support and provide
    necessary referrals

        o Discuss obtaining needed medical care, family planning
          options, testing for sexually transmitted diseases and TB

        o Give information      on   the     options   of   antiretroviral

        o Give   information    on   the    advantages    and
          disadvantages of breastfeeding and Breast Milk
          Substitutes(BMS) including the respective risks

        o Discuss with the mother issues around feasibility,
          acceptability, affordability, safety and sustainability
          of Breast Milk Substitutes

        o Demonstrate to the mother how to safely prepare
          and feed infant with BMS

        o Refer the mother to the Nutrition Clinic

   Empower client to share her HIV status with her partner and
    discuss protecting future partners

   Discuss how to reduce her risks and protect others in the future

   Give emotional support.

A Notification form must be completed and submitted to the
Medical Officer of Health for the Parish (in sealed envelope
marked confidential)

                   HIV Testing in Jamaica

HIV tests should be administered with pre and post-test counselling
and informed oral consent. In addition, routine HIV & Syphilis testing
should be offered to all pregnant women.

One of two methods of HIV testing may be used

    HIV Rapid Test done on site.

Regular blood sample sent to the lab for ELISA.

HIV testing should be administered with pre and post-test
counselling and informed oral consent.

ELISA HIV antibody tests or a “Rapid Test” will be conducted using the
blood specimen collected. Six millilitre (6 ml) of venous blood will be
drawn from the subject at the routine ANC clinic. The samples will be
collected and sent to an appropriate Laboratory within the respective
region. Standard testing procedures for screening and confirmation
will be used to determine the HIV status.

 In the Case of a Rapid Test the Laboratory Technical Assistant (LTA)
or designated individual on site will carry out the test. A sample
should still be sent to the regional lab or NPHL for confirmation or
quality control as required.

All test results will be made available to the referring institution and to
the patient within two weeks of testing. Priority will be given to HIV
positive results which should be sent immediately to the institution for
early identification, follow up and treatment as per guidelines. The
positive results should also be sent directly to the Medical Officer of
Health – MO (H) - of each parish to ensure that confidentiality is
maintained. The MO (H) should inform the Contact Investigator and
the Senior Public Health Nurse in the institution (shared
confidentiality). A list of HIV positive individuals should also be
provided promptly to relevant secondary care facilities.

                   The HIV Positive Woman
                         (See MCH Manual)

 Initial Evaluation of the HIV Infected Pregnant Woman

When the diagnosis of HIV infection is made at antenatal screening,
the patient should be evaluated both by:
    1. Doctor at the HIV Treatment Centre;
    2. Doctor/Obstetrician at the High Risk Clinic.

The main aim is staging of the disease, based upon which a
comprehensive multidiscipliany management plan for both pregnancy
and beyond will be developed. Multidisciplinary management must
include nutritional counseling and psycho- social support (see
treatment manual).

   Refer the HIV positive mother to the nearest treatment center
    for multidisciplinary care.

        o High Risk Obstetric Clinic

        o Specialist medical/ HIV clinic
N.B. Health care providers are reminded to complete the
antenatal record card making strict documentation of all
procedures inclusive of counselling anti retroviral drugs and
method of testing.      Clients HIV results must also be
documented on the card as C13 Pos using the same coloured
ink as all other notations (the HIV results must not be
highlighted in red).

              Guidelines For HIV Relevant Assessment

                            History Taking
Attention must be paid to the following:

Maintaining confidentiality- the doctor or nurse taking the history
must ensure that the patient’s details are kept private by:
   discussing only with those who need to know
   Treating patient in a non discriminatory manner

                            General Health
      General well-being
      Constitutional symptoms
      Past Medical History (especially history of previous sexually
       transmitted infections)
      Immunization status- specifically HepatitisB, pneumococcus,

                             Drug History
      Medication and dosage of prescription and non prescription
      Drug use (Cigarettes, crack, cocaine, alcohol, marijuana etc.)

                            Sexual History
Establish a rapport with the patient, and integrate these questions at
the appropriate time.

   1. Sexual practices
        – number and gender of partners,
        – type of sexual contact (oral, genital, anal)
        – any sexual contact with commercial sex workers

   2. Partner Notification
Sexual contacts need to be identified and arrangements made for
them to be counseled and tested or contact traced (while preserving
confidentiality of information source). Refer Patient to Contact

   3. Previous STDs – dates and diagnoses

     4. Contraceptive use – ask about condom usage, and other forms
        of family planning being used.

                        Past Obstetric/Gynaecological History

     o No of previous pregnancies and complications
     o Route of Delivery
     o L.M.P., menarche, menorrhagia dysmenorrhea, Pap smear

                                    Family History
        Medical illnesses including TB, hypertension, diabetes mellitus
        Other HIV positive family members
        Availability of friend and/or family support

                                Occupational History
     Increased risk for opportunistic infections
          - travel
          - occupation (e.g. farming, pet shop workers), hobbies
          - pets
          - crowds
          - hospitals
          - financial support
          - employment status
          - ability to function at work

                                 Review of systems

General: fatigue, weight loss, lymphadenopathy, wasting

GI               R.S           CVS             CNS                  GU

Oral lesions     SOB            palpitations   anxiety              dysuria
Diarrhoea        chest pain                    depression            rash
Dysphagia        cough                         headache             urinary freq.
Vomiting         nasal stuffiness              neck pain            discharge
Odynophagia      postnasal drip                visual disturbance


Itching, sores

                 Comprehensive Physical Examination

   Change in weight, height, fever, pallor
   Oral cavity for evidence of ulcers, thrush, poor dentition, gingival
     Dermatologic examination includes the entire skin and mucous
      membranes, taking particular note of conditions such as herpes
      zoster, folliculitis, seborrheic eczema, severe tinea corporis,
      abscesses, straightening and thinning of hair
     Examine all lymph node areas noting any enlargements and
     Eyes: fundoscopy
     ENT
     Chest examination: CVS, RS
     Abdominal examination, look for hepatosplenomegaly
     Obstetric examination : Fundal height, lie presentation
     Rectal/genital examination noting the presence of peri-
      anal/genital herpes or genital warts,
         o pelvic examination with Pap smear
                 Do cervical assessment
                 Note vaginal discharge and cervical erosions.
     CNS: paralysis, monoparesis, hemiparesis, cranial nerve
     M/S looking for wasting, arthropathy

                       Laboratory Evaluation

Must do:
Routine pregnancy scrren including:
   CBC (Hb, WBC, diff, plat.);
   Urinalysis;
   CD4 Count (all HIV positive patients must have a CD4

Should do:
   HBsAg
   Renal Function tests (urea, creatinine, electrolytes and
   LFTs, serum proteins, Alb., Glob. on initiating treatment

   Serum lipids
   Glucose
   Pap smear
   Viral Load

   Antenatal Follow-up at High Risk Obstetric Clinic

Midwives/Obstetrician/Attending Physician:.
   Advise the mother not to miss any of her prenatal appointments

   Routine appointments should be once per month until seven
    months and every two weeks until 36 weeks then every week
    until the baby is born or as necessary. Appointments to the high
    risk clinic, however, may be determined by the Patient’s status
    and frequency of visits decided by the attending clinicians.

   Advise the mother about healthy nutrition and meals and refer
    her to the Nutritionist/Nutrition Assistant.

   Advise the pregnant woman to avoid smoking and alcoholic

   Advise the client to bring her antenatal card at the time of labour
    and to indicate her status to the attending Midwife to allow for
    administration of antiretroviral drugs for PMTCT

   Remind the patient that there is an intrapartum component to
    the AZT regime and that she should point this out to the
    attending midwife.

   Reinforce    information on    the  advantages   and
    disadvantages of breastfeeding and BMS including the
    respective risks.

   If she chooses not to breastfeed, demonstrate to the
    mother how to safely prepare and feed BMS.

   If she chooses to breastfeed, demonstrate to the mother
    good breastfeeding techniques to help prevent and treat
    breast problems (e.g. cracked nipples, mastitis) that can
    increase the risk of HIV-transmission.

   Remind her to ask the maternity ward nurse to give
    medication to her baby before discharge.

   Fully involve the relevant spouse in the antenatal management
    of the patient. (Encourage mother to bring her partner to the

    Give the mother adequate supply of AZT to serve at least one
     week past the next visit date plus a single dose of Nevirapine to
     take at the onset of labour.

                 Antiretroviral Therapy (ARV)

Guidelines for commencing treatment with
Antiretroviral therapy.

(See Medical Management Manual)

Antiretroviral therapy reduces the incidence of opportunistic infections
and significantly increases quality of life and life expectancy among
people living with HIV/AIDS.

When to start
      All women with clinical AIDS
      Women with a CD4 count of 200/mm3 or less
      Women with CD4 levels between 200 and 350/mm3,
           o Doctor should assess when to start therapy, by looking at
             the presence of clinical features

Women diagnosed in pregnancy who meet the above criteria and
require antiretrovirals for their own health should begin a combination
regime. This should be compatible with the PMTCT regime. If they do
not require ARV’s for their own health then one of the following
recommended regimes for PMTCT prophylaxis should be offered.

Option A

Women with CD4 Counts above 250

AZT given as below

       Start ZDV 300 mg bid at 28 weeks gestation (or as soon as
       possible thereafter) and continued for one week after delivery.


       ZDV 300 mg PO every 3 hours from onset of labour until


       Single dose Neviarapine at onset of labour.
       Do not continue 3-hourly dosing for longer than 24 hours.

       To Infants AZT as follows

       ZDV 4 mg/kg (0.4 ml/kg) Po every 12 hours for six weeks

       Premature (<34 wk EGA) infant dosage: 2 mg/kg Po q 12 hr for
       2 weeks then 3 mg/kg Po q 12 hr for four weeks

Option B (Women presenting very late in Pregnancy, after 38
weeks or during labour).

Administration to the mother of a single dose 200 mg of Nevirapine
tablet by mouth at the onset of labour.

   1. The administration of 2mg/kg of Nevirapine suspension to the
      newborn infant of HIV positive mother within the first 72 hours
      after birth but preferable within the first 24 hours.


   2. The administration of two doses of Nevirapine 24 hours apart
      within 72 hours after birth to the Infant if the Mother received
      her Nevirapine within 2 hours of delivery.

Option C

For women with CD4 count below 250

Commence therapy at end of first trimester with

Zidovudine/Lamivudine plus (Nevirapine or Nelfinavir)
(The Mother’s intra partum doses should be given to her to
keep at 36 weeks’ gestation. This action helps to ensure
prompt compliance at the onset of labour.)

For ZDV:
     (Dispense initial 5-week supply, then 4-week supply every
     4 weeks (so patient has enough to continue for 1 week if
     appt missed or for dosing during labour)


AZT should be continued for six weeks in the infants and for
one week post delivery in the mothers

Infants whose mothers received NVP can also be given AZT for
4 weeks as outlined above.

Infants whose mothers received AZT should be given AZT as

Infants of HIV+ mothers who received neither Nevirapine nor
AZT should be given AZT for six weeks.

Discontinue antiretroviral in the mother’s one week      post
delivery (If treatment not indicated). If treatment indicated
(AIDS or CD4 below 200) patient should be placed on three
ARV Drugs.

Patient should be appropriately counselled on how to correctly take
medication and maintain high levels of compliance.


For women who present at the time of labour without previously
accessing HIV counselling and testing, diagnosis at the time of labour
and delivery is still important point of entry for both preventive and
treatment services

      Offer counselling and rapid testing during labour.

      Offer maternal single dose nevirapine prophylaxis to women
       testing positive and AZT at above doses to infant.

      If delivery imminent, omit maternal dose and administer infant
       dose as soon as possible after birth. Continue for 6 weeks

      If not enough time, offer counselling and rapid testing shortly
       after delivery followed by postpartum AZT to the infant if Mother
       is positive.

Women known to be positive who have not received ARV prophylaxis
antepartum should be offered nevirapine as per regime.

●     Women should be referred to the Treatment Centre for
follow up post delivery.
As access to ARV treatment becomes more widely available and
women not only live longer, but take advantage of their reproductive
potential, two further Clinical Scenarios will have to be considered.


Although there are concerns relating to potential effects of ARV
drugs on the developing fetus, suspending treatment during the first
trimester is not recommended.
In the first trimester, EFV should be avoided and replaced by NVP, NFV
or Lopinovir/r because of a possible risk of central nervous system
birth defects.

Pregnancy-associated nausea and vomiting may affect a woman’s
ability to adhere to ARV treatment and occasionally require that
treatment be temporarily discontinued. If treatment is discontinued, all
ARV drugs should be stopped simultaneously and restarted together to
decrease the risk of developing drug resistance.
ARV treatment with the full regimen should continue during labour.

Infants born to women receiving ARV treatment should receive:

    o ZDV for six weeks

Recommendations on HIV and infant feeding are unchanged for
women receiving ARV treatment.


Recommended first - line ARV regimens for women who may
become pregnant and who have indications for starting ARV treatment
             1. ZDV +3TC +(NVP/Nelfinavir/Kaletra)
             2. d4T +3TC +(NVP/Nelfinavir/Kaletra)

       The choice of ARV regimen for women with the potential to
        become pregnant must consider the possibility that the ARV
        drugs may be received during the first trimester: before
        pregnancy is recognized and during the period of organogenesis.
       Drugs such as efavirenz that are potentially teratogenic should
        be avoided if effective contraception cannot be ensured.

Adverse Effects
The most clinically important reported adverse events associated with
chronic dosing of Nevirapine (Viramune) for the treatment of HIV
infection are rash, increasing fever, nausea, and headache. Cases of
hypersenstivity reactions have also been observed.

The most frequently reported adverse events related to Viramune in
paediatric patients were similar to those observed in adults with the
exception of granulocytopenia, which was more commonly observed in

Adverse events related to AZT include bone marrow suppression,
anaemia, myopathy, lactic acidosis and severe hepatomegaly. Other
more common side effects included; fever, headache, nausea,
vomiting, anorexia, taste perversions, myalgia, insomnia and rash.

         Modification of Obstetrical Practice
Practice Universal Precautions

   Remember to give intra-partum AZT as per above outlined

   Avoid Artificial Rupture of Membrane and consider shortening
    labour if possible. Artificial Rupture of Membranes (ARM) should
    be delayed until the cervix is 6 cm or more dilated if progress of
    labour is adequate.

   Rupture of membranes of more than four hours should be
    avoided as much as possible because of the increased risk of HIV
    transmission to the child.

   Caesarean sections should be used for obstetrical indications and
    not primarily to reduce MTCT.

   Episiotomy should be avoided unless absolutely necessary.

   Avoid unnecessary invasive procedures.

   Clamp the umbilical cord immediately after birth.

   Use scissors to cut umbilical cord not a scalpel.

   Cleanse the baby immediately after birth (use soap and water).

   Exercise special care in handling placenta

   Breast-feeding    should be avoided and infant formula made
     available to those who cannot afford to buy.

Post Delivery Follow Up

Immediate Postpartum care

After delivery and before discharge, a senior qualified clinician
will examine mother and baby and an examination form filled.

Routine postnatal care of the mother and child care education should
be provided.

Reinforce nutritional advice particularly with emphasis on a balanced
diet and preparation of safe food.

 Reinforce information on the advantages and disadvantages of
breastfeeding and BMS including the respective risks. (Support
should be given to the mothers who choose NOT to breast feed
the baby to implement this and formula provided as required).

Advise to apply cold compress on the breast and not to express breast
milk - leave the breast unstimulated and well-supported (Try to avoid
lactation suppression drugs, though they may be necessary)
Instruct about proper perineal care and safe handling of lochia and
blood stained sanitary pads.
         o Wrap pads in plastic bags
         o Wash underwear with bleach

Advise to be aware of symptoms and signs of postpartum infections
occuring in the chest, urinary tract episiotomy or caesarean section

6 weeks postpartum

Assess mother infant pair in routine manner.

Ensure follow-up for HIV care by clinician.

Refer to nearest Treatment Centre for assessment.

Refer for ongoing gynaecological care and follow up as women
infected with HIV need
        Counseling and psychological support,
        Advice on condom use (male and female)
        Advice on family planning not limited to only permanent
            o Dual protection to prevent and reduce further HIV
                infection, STI’s and pregnancy
            o IUCD’s can be used with standard cautions
            o Hormonal contraception with oestrogen may be less
                effective with ARV’s
        Screening for cervical neoplasia, which has a higher incidence
         in HIV positive women and presents at a more advanced
         stage of disease.

     More aggressive therapy for gynaecological infections that
      may be more severe.
Infants born to HIV- Positive Mothers

      1. AZT

         Begin ZDV 4 mg/kg (0.4 ml/kg) p.o. every 12 hours for six

         Premature (<34 wk EGA) infant dosage: 2 mg/kg p.o. q 12
         hr for 2 weeks then 3 mg/kg p.o. q 12 hr

         IV dosage
         Term: 1.5 mg/kg IV q 6 hr

         Premature <34 weeks EGA: 1.5 mg/kg q 12 hr X 2 weeks,
         then 1.5 mg/kg q 8 hr.

         Note That AZT should be continued for six weeks

         Infants whose mothers received NVP should be
         given AZT within72 hrs after birth.

         Infants whose mothers received AZT should be given
         AZT as above.

         Infants of HIV+ mothers who received neither
         Nevirapine nor AZT should be given AZT for 4 – 6

         Refer to specialist Paediatric Clinic at HIV Treatment

      2. Should be referred to the Paediatrician or most senior
         available clinician for review prior to or at discharge and a
         docket started for the child.

      3. Should visit the postnatal clinic/hospital at 6 weeks of age,
         and at three and five months for routine medical care
         including immunizations and growth monitoring and PCR

        4. A blood sample should be collected from infants of HIV
           positive mothers at 6 weeks and 3 months of age and sent
           to the National Public Health Laboratory
           (NPHL) to determine HIV status Ensure that the mother
           is adequately counselled about the meaning of each test

At scheduled visits, to the child health clinics, the Doctor or Nurse
practitioner must conduct a physical examination and monitor adverse
events as well as document infant feeding patterns, neonatal, and
infant morbidity and mortality.

Baseline Follow up: Fever, failure to thrive, diarrhoea, thrush,
recurrent or multiple infections, cough, swollen lymph nodes,
developmental delays.

Physical     Examination:    temperature,   weight,    height,    head
circumference, (use growth chart) Skin eruptions, ears, nose and
throat infections, abdominal organs enlargement, febrile illnesses and
chest infections.

 Patient must be referred to the Paediatrician if symptomatic.

Infant Feeding

Mothers should be counselled about the benefits and risk of HIV
transmission through breastfeeding.        The benefits and risks
associated with breast milk substitutes must be explained.

Mothers who are HIV positive should also be cautioned about the
dangers of combining breastfeeding and breast milk substitutes.

The programme provides replacement feeding for at least six months
to babies of HIV positive mothers who choose not to breastfeed. The
infant needs about 150 ml of milk per kg of body weight per day.

Formula Requirements
Age in Months      Weight in kg      Approx. amount Approx. number
                                     of formula per of feeds
                                     24 hours

1                  3                 450 ml            8 * 60 ml

2                  4                 600 ml            7 * 90 ml

3                  5                 750 ml            6 *120 ml

4                  5.5               750 ml            6 *120 ml

5                  6                 900 ml            6 *150 ml

6                  6.5               900 ml            6 *150 ml

     The mother should be provided with the first portion of the
      replacement feeding supply (enough to last her eight weeks)
      on her last antenatal visit.
     The infant should be referred to the nutrition clinic for growth
      monitoring and follow-up.
     Infants with any medical problems or complaints should be
      referred to a Paediatrician/clinician.
     The Nutritionists in the parish need to teach the mother hygienic
      preparation of replacement feeds prior to and after delivery.
     The mother needs to know how to feed her infant from a cup.
      (See annex)
     Because of the risk of HIV, once the replacement feeding has
      begun, no breastfeeds at all should be given.
Other Pregnancy Outcomes

    A pregnancy, which ended without a live birth, needs to be
    recorded and reported on the obstetric record form.

    If outcome is foetal death, needs to be recorded

    Long-term contraceptive and counselling should be offered to the

Childhood Immunization

Routine Childhood immunizations are NOT hazardous to children born
to an HIV positive mother. Immunizations should be administered
according to National EPI guidelines.
 Asymptomatic children should receive the same immunization as all
other children. However:
    Infants with HIV infection should be vaccinated with Inactivated
      Polio Vaccine (IPV) rather than OPV.
    BCG is not recommended for symptomatic HIV infected
    IPV should also be used to immunize household contacts of a
      child with HIV infection.

Vaccine Schedule for HIV Exposed Infants

Vaccine            Asymtomatic        Symptomatic      Optimal timing
                    HIV               HIV              Of
                   Infection          Infection        Immunization
BCG                Yes                No               Birth
DPT                Yes                Yes              6,10, 14 weeks
OPV                Yes                No               6,10, 14 weeks
IPV                Yes                Yes              6,10, 14 weeks
MMR                Yes                Yes              10-12 months
Hepatitis B        Yes                Yes              As for uninfected individuals
Tetanus Toxoid     Yes                Yes              As for uninfected individuals
DT                 Yes                Yes              5 Doses
Influenza          Yes                Yes              As for uninfected individuals
Pneumovax          Yes                Yes              As for uninfected individuals
Note that BCG Vaccine is given at birth and must be given unless the infant
is symptomatic.

Programme Implementation
Health Team

This programme is being implemented as an intricate part of the
existing MCH services and will be guided by the same principles that
now obtains.

The Medical Officers of Health MO (H) s, of each Parish/District will be
the coordinators and supervisors of the programme at the field level. A
parish team of health workers include:

Public     Health      Nurse,     Midwife,     Contact      Investigator,
Nutritionist/Nutrition Assistant, Obstetrician, Paediatrician, Medical
officer at Hospitals, Health Educator, District Medical Officer or Nurse
Practitioner, Laboratory Technologist or Technicians, Pharmacist,
Hospital Matron or Sister. All will participate in the implementation of
the programme under the technical guidance of the Regional Technical
Director and the National Task Force.

The Parish MO (H) and health team responsibilities include ensuring:

    Confidential counselling of pregnant mothers.

    Blood collection, storage and transportation of specimens for HIV

    Distribution of medication and infant replacement feeding where

    Review and ensure documentation of the mother and child follow

    Collection and maintenance of records and documentation as per
     the guidelines.

    Selection of health workers for training.

    Programme, Implementation, Monitoring & Evaluation

This programme will be implemented as an integral part of the existing
family health services utilizing the same structures procedures and

The National Task Force, the National HIV/STI Prevention and Control
Programme and Family Health Services will provide guidance.

Monitoring Indicators

    Number of training workshops held and number of health
     workers trained.

 Percentage of ARMs performed per delivery sites per month from
  maternity record.

 Number of ANC women seen by health centre by month.

 Percentage of ANC women tested for HIV.

 Proportion of ANC women who tested HIV-positive.

 Proportion of pregnant women who tested HIV-positive and
  agreed to take Nevirapine or AZT.

 Proportion of pregnant women who are on AZT at the onset of

 Proportion of pregnant women receiving Nevirapine.

 Proportion of women/children returning for reviews at 4, 6
  weeks, 2 months, 4 months, 5 months, 6 months, 9 months, 12
  months and 18 months.

 Proportion of infants of HIV-positive women who grow according
  to standard curve.

 Prevalence of HIV infection among infants of HIV-positive

 Morbidity rates among infants of HIV-positive mothers.

 Number of Pre and Post test counselling sessions held.

 Proportion of children receiving exclusive BMS, mixed
  feeding or exclusive breastmilk

 Mother to child transmission rate as determined at 12 months of
  age of the baby.

For additional information, please contact any of the following

     Dr. Kevin Harvey
     Coordinator, Treatment, Care and Support
     for Persons Living with HIV/AIDS
     Ministry of Health
     2-4 King Street
     Tel: 9671100 Ext. 2611
     Fax. 967-1280

     Dr. Nadine Johnson
     Consultant and Lecturer
     Department of OBGYN
     University of the West Indies
     Mona Kingston 7

     2-4 KING STREET
      Direct (876) 948-1542
     FAX (876)967-1643

     Dr. Michelle Harris
     Regional Technical Director
     South-East Regional Health Authority
     25 Dominica Drive
     Kingston 5
     Telephone: 754-3440, 3441
     Fax: 926-4019

    Dr. Michele Roofe
    Regional Technical Director
    North–East Regional Health Authority
    Ocean Village Plaza
    Shop # 34-37
    Ocho Rios, St. Ann
    Telephone: 795-3107
    Fax: 795-2747

    Dr. Alex. Konstantinov
    Regional Technical Director
    Western Regional Health Authority
    c/o Cornwall Regional Hospital
    P.O. Box 900
    Montego Bay, St. James
    Telephone: 952-1124
    Fax: 952-4074

    Dr. Michael Coombs
    Regional Technical Director
    Eagle Financial Building
    5 Ward Avenue
    Mandeville, Manchester
    Telephone: 625-0612,0613
    Fax: 962-8233

    Telephone: 967-3830, 967-3764
    Toll free:  1-888-991-4444




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