Prevention of Mother to Child Transmission of HIV (PMTCT) Guidelines

Chapter 6: Prevention of Mother to Child Transmission of HIV Outline HIV Testing Introductio and Re- Maternal n to PMTCT Testing in ART MNCH HIV Viral load Exposed EID monitoring Inf...

Chapter 6: Prevention of Mother to Child Transmission of HIV Outline HIV Testing Introductio and Re- Maternal n to PMTCT Testing in ART MNCH HIV Viral load Exposed EID monitoring Infant Algorithm in PBFW Prophylaxis  Introductio n Mother to child transmission (MTCT) of HIV is an important contributor of HIV transmission (>90% of new infections in children). Approximately 60% of those MTCT transmissions occur during the antenatal period or labor and delivery. The remaining 40% of acquired infections are attributed to breastfeeding Other Means of Transmission Blood transfusions, blood products and organ/tissue transplants Contaminated needles Scarification marks Sexual intercourse Factors Affecting MTCT (Maternal) High maternal HIV RNA level Low maternal CD4 count Chorioamnionitis Maternal vitamin A deficiency and malnutrition Co exciting sexually transmitted disease Interpartum hemorrhage Artificial rapture of membranes Rapture of membranes >4hours Fetal scalp monitoring Episiotomy  Risk is 14% if sero conversion occurs before birth Risk is 29% if during breastfeeding Highest in the first 6 months of life but continues throughout breastfeeding Transmission Transmission risk increased by - Seroconversion during breastfeeding Through - Mastitis/breast abscess Breastfeeding - Bleeding nipples - High plasma viral load - Oral thrush in baby - Mixed feeding (including breast milk)  The aim of ‘elimination’ is to have an MTCT rate of HIV of less than 5% in breast-feeding communities (for non-breastfed populations MTCT rate < 2%). Introductio The national PMTCT targets: n cntd HIV and Syphilis Antenatal Syphilis ART Treatment care testing coverage coverage coverage coverage (in ANC) (in ANC) ≥ 95% (in ANC) ≥95% ≥95% ≥ 95% UN Strategic Framework for Prevention of HIV Infection in Infants and Young Children Prong 3 Prong 2 Prong 1 Prevention Prevention of of mother- Primary Prevention unintended to-child HIV of HIV pregnancies transmissio n Prong 4 Provision of care and support for HIV-infected 8 women, their children and their families  HIV testing services in pregnant and breastfeeding women The dual HIV and syphilis rapid diagnostic test is recommended as the first test in the HIV testing algorithm for pregnant women in antenatal care. Health workers should retest previously HIV-negative pregnant and breastfeeding women as follows: At ANC booking (ideally first trimester of pregnancy) 32 weeks (or at any contact after 32 weeks including labour and delivery) 6 weeks post-natal In antenatal 6 monthly during the breastfeeding care settings, period couples and partners should be offered voluntary HIV testing services with support for mutual disclosure.  All HIV-positive pregnant and breastfeeding women should initiate lifelong ART: TREAT ALL Maternal Same day ART initiation irrespective of their CD4 count or WHO clinical stage; ART Treatment is lifelong  1st and 2nd line ART regimens for pregnant and lactating women Pregnant and 1st line 2nd line therapy Lactating therapy women Preferred TDF + 3TC+ If TDF was used as first line, use Option DTG AZT plus 3TC plus ATV/r or LPV/r If AZT was used as first line, use TDF plus 3TC plus ATV/r or LPV/r Alternative TDF + 3TC + If TDF was used as first line, use Options EFV400 AZT plus 3TC plus DTG If AZT was used as first line, use  VIRAL LOAD MONITORING IN PBFW Whenever possible, utilize same-day point-of-care (POC) testing for viral load testing If not available, viral load specimens and results for pregnant and breastfeeding women should be prioritized across the laboratory referral process (including specimen collection, testing, and results return) e.g., use of red stickers for priority specimens. Adherence counselling should be provided at all ANC and post-natal visits to ensure viral suppression is maintained throughout pregnancy and breastfeeding.  Viral Load Monitoring Algorithm for Pregnant Women Not Yet on ART or Newly Diagnosed HIV Positive  Viral Load Monitoring Algorithm for Pregnant Women Already on ART Viral Load Monitoring Algorithm in Breastfeeding Women (Regardless of When ART was started)  Viral undetectability - viral load equal to or less than 50 copies/mL Individuals with low-level viremia: > 50 to < 1000 copies, maintain ARV regimen, enhance adherence counselling and repeat viral load testing after one month. Viral Load Virological failure -Viral load above 1000 copies/mL based on two consecutive viral load Monitoring measurements three months apart, with adherence support following the first viral load test. N.B. If Maternal Viral load >1000 copies/mL: conduct infant HIV testing immediately and initiate triple ARVs for postnatal prophylaxis (AZT+3TC+NVP) for 12 weeks Follow-up HIV test results for the infant promptly and if positive initiate infant on ART with ABC+3TC+pDTG 2016 HIV Exposed Infant Prophylaxis Recommendations According to the 2016 guidelines, VL testing during pregnancy and breastfeeding period and the duration of maternal ART is needed to stratify HIV exposed infants as either high risk or low risk. It is important not to use a “one size fits all” for infant prophylaxis as infants are not all at the same risk for HIV transmission. A high-risk infant is defined as follows: An infant whose mother has a high viral load >1000copies/ml during the last 4 weeks before delivery An infant born to HIV infected woman who has received less than 4 weeks of ART at the time of delivery An infant born to a newly diagnosed HIV infected woman during labor, delivery and postpartum (Incident HIV infection) An infant whose mother has advanced HIV disease (in the absence of a VL result) All infants who do not meet the criteria for ‘high-risk’ infants are classified as ‘low-risk’ infants.  2016 Guideline Recommendation for ARV Prophylaxis ARV Prophylaxis – New Recommendation! All HIV-exposed infants should receive triple ARVs for post-partum prophylaxis for 12 weeks. Regimen for triple ARVs for post-natal prophylaxis will be AZT+3TC+NVP It is important to perform a NAT prior to starting the triple regimen, and if the result is not available immediately, at least collect a specimen as interpretation of later testing will be difficult. The results of any future tests will be influenced by the ARVs on board.  Cotrimoxazole Prophylaxis All HIV-exposed infants should receive cotrimoxazole prophylaxis at 6 weeks of age (or at their first encounter with the health system if this happens after age 6 weeks) Cotrimoxazole is stopped after the period of risk and final confirmation of negative HIV status. Final negative status is defined as a negative rapid HIV test at 18-months or 3 months after breastfeeding ends if breastfed longer than 18 months. If an HIV exposed infant tests HIV positive at any time point, they continue to receive cotrimoxazole prophylaxis Infant feeding in the context of HIV The MOHCC promotes, supports, and protects breastfeeding because it is the first and best investment for a child’s nutrition and health. Appropriate feeding methods including their advantages and disadvantages should be explained to all mothers to allow them to make an informed decision. Mothers who choose to breastfeed are advised to Exclusively breastfeed their infants for the first 6 months of life, introducing adequate and appropriate nutritious complementary foods at 6 months, with continued breastfeeding up to 24 months and beyond. Avoid mixed feeding within the first 6 months (feeding infants with breast milk and other fluids, and semi-solid or solid foods)  Zimbabwe is a breastfeeding Conditions country with ……………..women who chose not to breastfeed needed to should meet the conditions needed to safely formula feed safely exclusively breastfeed for the Formula first 6 months Feed  HIV-infected mothers may consider expressing breast milk as an interim feeding strategy: In special circumstances such as when the infant is born with low birth weight or is otherwise ill in the neonatal period and unable to breastfeed. Infant When the mother is unwell and temporarily unable to breastfeed or has a temporary breast health problem such as mastitis. feeding in Expressing breastmilk should also be taught to mothers to assist mothers to the context stop breastfeeding. Breastfeeding mothers who decide to stop breastfeeding at any time should of HIV stop gradually within one month. Abrupt cessation of breastfeeding is not advised. Breastfeeding mothers should be counselled on how to solve common difficulties, such as sore nipples, perceptions of “insufficient milk,” breast engorgement, manual expression, and storage of breast milk. Breastfeeding mothers are advised to immediately seek treatment for mastitis, cracked nipples, infant mouth lesions, and thrush to decrease the risk of MTCT. Breastfeeding mothers should be counselled on adequate and nutritious appropriate complementary foods that must be introduced to the infants’ diet beginning at 6 months as per the Zimbabwe  All infants with unknown or uncertain HIV exposure being seen in health-care Early Infant facilities at or around birth or at the first postnatal visit (usually 4–6 weeks) or other Diagnosis child health visit should have their HIV exposure status ascertained. This can be of HIV done by: Asking if the mother knows she is HIV positive or is on ART Checking the handheld child health card for information on maternal HIV status The HIV exposure status of a child less than 18 months of age should be ascertained by testing the mother Early Infant Diagnosis of HIV All babies of HIV-infected mothers are born with maternal anti-HIV antibodies that are passed on to them trans-placentally. These antibodies start to wane from about 4 months, and by 18 months have cleared off completely. Due to the presence of these maternal antibodies, HIV antibody tests in infants under the age of 18 months cannot be used to definitively diagnose HIV infection. Definitive Diagnosis of HIV infection in children less than 18 months requires testing for the virus itself (called virologic testing, or Nucleic Acid Testing - NAT). Infants with an initial positive virological test result should be commenced on ART without any delay and, at the same time, a second specimen should be collected to confirm the initial positive virological test result. N.B Immediate initiation of ART saves lives and should not be delayed while waiting for the results of the confirmatory test. In case the second NAT result is negative (i.e discordant results) , a third NAT should be performed before ART interruption.  In case the 3rd NAT is negative some factors The child should be should NOT when Follow-up considered assessingplan patient havefor ART interruption: should be agreed signs/symptoms upon with Early Infant suggestive of HIV caregiver(s) and Diagnosis infection HCW of HIV The infant should be followed up for a minimum of 8 months after interruption of ART. Where possible, both early infant diagnosis (EID) (qualitative) and VL (quantitative) tests should be performed at 4 weeks, 4 months, and 8 months after ART interruption. (WHO 2021 guidelines)  Summary Key Changes Revised Infant Use of Point-of-Care Prophylaxis Revised Viral Load Viral Load and recommendations – testing algorithm Early Infant Triple ARVs for all for PBFW Diagnosis testing HIV Exposed for priority groups Infants Final outcome at 18 Revised EID months or three Algorithm – Nucleic months after Acid Test at birth, 6 stopping weeks, 9 months breastfeeding