CLINICAL GUIDELINES: PMTCT (Prevention of Mother-to- Child Transmission)

Transcription

1 CLINICAL GUIDELINES: PMTCT (Preventin f Mther-t- Child Transmissin) 2010 Natinal Department f Health, Suth Africa; Suth African Natinal AIDS Cuncil

2 FOREWORD It is with pleasure that I present the revised PMTCT Guidelines. Gvernment has adpted a new utcmes based apprach t accelerate attainment f the bjectives utlined in the Medium Term Strategic Framewrk (MTSF) One f the bjectives is t imprve the health prfile f all Suth Africans. The 10 pint plan f the Health Sectr is aimed at creating a well functining health system capable f prducing imprved health utcmes. Pririty seven f the 10 pint plan is t accelerate implementatin f the HIV&AIDS plan and the reductin f mrtality due t TB and assciated diseases. On Wrld AIDS Day, 2009, the Hnurable President Jacb Zuma annunced new interventins t imprve antiretrviral therapy (ART) access fr pririty grups in rder t decrease the disease burden, t address maternal and child mrtality, and t imprve life expectancy. Based n the Presidential annuncements, all HIV psitive pregnant wmen with a CD4 cunt 350/mm 3 will cmmence lifelng ART earlier, r less furthermre, prphylaxis ART treatment will be started earlier, at 14 weeks pregnancy, fr wmen wh are nt eligible fr lifelng ART. Fr the first time, HIV psitive wmen can safely breastfeed their children prvided the child is taking ARV s during the breastfeeding perid. This dcument serves as a new guide t health practitiners with regard t the cmprehensive management f pregnant wmen wh are HIV psitive. It is f paramunt imprtance t nte that PMTCT has the ptential t be the engine fr strengthening delivery f cmprehensive, integrated health care. The guideline therefre, prmtes the integratin f PMTCT with maternal, newbrn and child health prvisin f, ART, family planning, STI and TB services. The many cmments frm and the invlvement f internal and external stakehlders is appreciated and has cntributed significantly t the finalizatin f these guidelines. I wuld like t thank all wh cntributed t the develpment f these guidelines despite their busy schedules. DR AARON MOTSOALEDI MINISTER OF HEALTH DATE: 1

3 ABBREVIATIONS AND ACRONYMS 3TC ANC AIDS ALT ART ARV ART AZT BANC BF BFHI BBA CCMT CHW s CTX DNA d4t ECD EBF EFF EFV EPI FTC HAART HCW HIV IMCI LPV/r MTCT NHA NHC NSP NVP PEP PCP PCR PICT Lamivudine Antenatal Care Acquired Immune Deficiency Syndrme Alanine Amintransferase Antiretrviral Therapy Antiretrviral Antiretrviral Therapy Zidvudine Basic Antenatal Care Breast Feeding Baby Friendly Hspital Initiative Brn Befre Arrival (t delivery unit) Cmprehensive Care Management and Treatment fr HIV and AIDS Cmmunity Health Wrkers Ctrimxazle Dexyribnucleic Acid Stavudine Early Childhd Develpment Exclusive Breastfeeding Exclusive Frmula Feeding Efavirenz Expanded Prgramme n Immunisatin Emtracitabine Highly Active Antiretrviral Therapy Health Care Wrker Human Immundeficiency virus Integrated Management f Childhd Illness Lpinvir/ritnavir Mther-t-Child Transmissin f HIV Natinal Health Act Natinal Health Cuncil Natinal Strategic Plan Nevirapine Pst-Expsure Prphylaxis Pneumcystis jirveci Pneumnia Plymerase Chain Reactin Prvider-Initiated HIV Cunselling and Testing 2

4 PMTCT PNC RF RTHC sdnvp SRH TC TDF UNAIDS UNICEF VCT WHA WHO Preventin f Mther-t-Child Transmissin f HIV Pstnatal Care Replacement Feeding Rad t Health Chart Single-Dse Nevirapine Sexual and Reprductive Health Testing and Cunselling Tenfvir United Natins Prgramme n HIV/AIDS United Natins Children s Fund Vluntary Cunselling and Testing Wrld Health Assembly Wrld Health Organisatin 3

5 DEFINITIONS Breast milk substitute Any fd r drink marketed r therwise representing a partial r ttal replacement fr breast milk, whether r nt suitable fr that purpse. Cmmercial infant frmula A cmmercial prduct that meets the applicable Cdex standard fr infant frmula, fllw-up frmula, and infant r fllw-up frmula fr special dietary r medical purpses. Cmplementary fds Refers t any fdstuff, whether in slid r semi-slid frm, given t an infant after the age f 6 mnths as part f the transitinal prcess in which an infant learns t eat fd apprpriate fr his r her develpmental stage, while cntinuing t breastfeed r be fed with cmmercial frmula. Cup feeding The act f feeding an infant r child using a cup, regardless f what the cup cntains. Exclusive breastfeeding r exclusive breast milk feeding Feeding practice in which an infant receives nly breast milk and n ther liquids r slids, including water, but may receive drps r syrups cnsisting f vitamins, mineral supplements, r medicines that are deemed necessary and essential fr the child. When expressed milk is given, the preferred term is breast milk feeding. Exclusive frmula feeding Feeding practice in which infants receive n breast milk, but receive a diet that prvides adequate nutrients until the age at which they can be exclusively fed family fds. During the first 6 mnths f life, frmula feeding requires a suitable cmmercial frmula. After 6 mnths, cmplementary fds shuld be intrduced. Health care persnnel Health care prviders and health care wrkers. Health care prvider Any persn prviding health services in terms f any law, including in terms f the: Allied Health Prfessins Act, 1982 (Act N.63 f 1982) Health Prfessins Act, 1974 (Act N. 56 f 1974) Nursing Act, 1978 (Act N. 53 f 1974) Pharmacy Act, 1974 (Act N. 53 f 1974) and Dental Technicians Act, 1978 (Act N. 19 f 1979) 4

6 Health care wrker Any persn wh is invlved in the prvisin f health services t a user, but is nt a health care prvider as defined abve. This includes lay cunsellrs and cmmunity caregivers. HIV-expsed infant: Infant brn t an HIV-psitive wman. HIV-negative Refers t peple wh have taken an HIV test with a negative result and knw their result. HIV-psitive Refers t peple wh have taken an HIV test with a psitive result and knw their result. HIV status unknwn Refers t peple wh have nt taken an HIV test r wh d nt knw the result f their test. Infant A persn frm birth t 12 mnths f age. Micrnutrients Micrnutrients are natural substances fund in small amunts in fd (e.g. vitamins and minerals), as cmpared with macrnutrients (e.g. prtein, fats and carbhydrates), which are fund in larger amunts. Mixed feeding Feeding breast milk as well as ther milks (including cmmercial frmula r hme prepared milk), fds, r liquids. Mther-t-child transmissin Transmissin f HIV frm an HIV-psitive wman t her child during pregnancy, delivery, r breastfeeding. The term is used because the immediate surce f the infectin is the mther, and des nt imply blame n the mther. Nutritinal status An individual s state as determined by anthrpmetric measures (height, weight, circumference etc.), bichemical measures f nutrients r their by-prducts in bld and urine, a physical (clinical) examinatin, and a dietary assessment and analysis. Nutritinal supplements Fd- and / r nutrient- supplements given in additin t fd available at hme. Prvider-initiated cunselling and testing (PICT) A rutine, pt-ut prcess in which health care persnnel ffer grup infrmatin and HIV-testing, 5

7 with the patient / client always retaining the ptin t decline. The patient / client als receives pst-refusal cunselling r pst-test cunselling. Replacement feeding Feeding f infants wh are receiving n breast milk with a diet that prvides adequate nutrients until the age at which they can be exclusively fed n full family fds. During the first 6 mnths f life, frmula feeding shuld be with a suitable cmmercial frmula. After 6 mnths, cmplementary fds shuld be intrduced. Safe infant feeding Feeding practices that wuld lead t a healthy, well-grwn, able, live, HIV-free child wh has n underlying mrbidity resulting frm incrrect feeding practices. 6

8 TABLE OF CONTENTS FOREWORD... 1 ABBREVIATIONS AND ACRONYMS... 2 DEFINITIONS EXECUTIVE SUMMARY PMTCT PROCESSES AND GOALS OF INTERVENTION ANTENATAL CARE LABOUR AND DELIVERY POSTNATAL FOLLOW-UP OF MOTHER AND INFANT KEEPING WOMEN AND CHILDREN HEALTHY AND IMPROVING THEIR QUALITY OF LIFE AND REDUCING MORTALITY PROVIDER-INITIATED COUNSELLING AND TESTING OVERVIEW TESTING ALGORITHM FOR PREGNANT WOMEN POST-TEST COUNSELLING ROUTINE CLINICAL CARE FOR HIV-POSITIVE PREGNANT WOMEN ANTENATAL MANAGEMENT INITIAL ASSESSMENT ANITRETROVIRAL PROPHYLAXIS LIFELONG ANTIRETROVIRAL TREATMENT SPECIAL CIRCUMSTANCES: INTRAPARTUM MANAGEMENT ANTIRETROVIRAL PROPHYLAXIS ANTIRETROVIRAL TREATMENT INTRAPARTUM SPECIAL CIRCUMSTANCES SAFE DELIVERY TECHNIQUES POSTNATAL CARE CARE OF HIV-POSITIVE WOMEN AND THEIR INFANTS IN THE IMMEDIATE POST- DELIVERY PERIOD ANTIRETROVIRAL PROPHYLAXIS INFANT PROPHYLAXIS REGIMENS ESTABLISHING SAFE INFANT FEEDING PRACTICES BACKGROUND INFANT FOLLOW-UP REFERENCES Tables and Figures Figure 1: Summary f PMTCT Prcesses Figure 2: PMTCT Algrithm Figure 3: Infants wh are exclusively frmula fed Figure 4: Infants wh are exclusively breastfed whse mthers are n lifelng ART Figure 5: Infants wh are exclusively breastfed whse mthers are NOT n lifelng ART Figure 6: All mthers at scheduled check-up, 6 weeks pst-partum Figure 7: Prvider-initiated cunselling and testing Figure 8: Algrithm fr HIV testing:

9 1. EXECUTIVE SUMMARY This dcument is an update f the natinal PMTCT Plicy and Guidelines. It aims t prvide cntinued guidance twards a reductin in the vertical transmissin f HIV, building n wrk dne since the inceptin f the prgramme and the 2008 Plicy and Guidelines dcument. In line with the internatinal standards fr a cmprehensive strategy, the PMTCT plicy recgnises that in rder t prevent HIV amng wmen and children, the fur elements f PMTCT are integral. These include: Primary preventin f HIV, especially amng wmen f childbearing age; Preventing unintended pregnancies amng wmen living with HIV; Preventing HIV transmissin frm a wman living with HIV t her infant; and Prviding apprpriate treatment, care, and supprt t wmen living with HIV and their children and families. The Natinal PMTCT prgramme aims t ensure: Primary preventin f HIV, especially amng wmen f child-bearing age. Integratin f PMTCT interventins with basic antenatal care (BANC), sexual and reprductive health (SRH), Child and Adlescent Health, CCMT and TB services. Strengthening pstnatal care fr the mther-baby pair. Prvisin f an expanded package f PMTCT services, including: Rutine ffer f HIV cunselling and testing fr all pregnant wmen attending antenatal care Prvisin f prvider-initiated cunselling and testing services in the cntext f PMTCT, in facilities ffering rutine antenatal care. Invlvement f the partner and the family in rder t ensure a cmprehensive apprach. Prvisin f apprpriate regimens t prevent mther-t-child transmissin f HIV accrding t the risk prfile based n the HIV test, CD4 cell cunt, and clinical staging. Prvisin f ther apprpriate treatments, such as thse fr pprtunistic infectins (OI) management and nutritinal supprt. Prvisin f psychscial supprt t HIV-psitive pregnant wmen. Prvisin f quality, bjective, and individualized cunselling n safe infant feeding practices (as defined in this dcument) fr HIV-psitive wmen in health facilities ffering rutine ANC services, thrugh trained lay cunsellrs and health care prfessinals. Strengthened bstetric practices which reduce MTCT. Prvisin f antiretrviral prphylaxis t infants. 8

10 Integrated fllw-up f infants brn t HIV-psitive wmen thrugh rutine child health services and the Integrated Management f Childhd Illness (IMCI) Strategy. Early infant HIV testing using HIV DNA-PCR at 6 weeks f age fr all infants brn t HIV-psitive wmen (integrated with the EPI 6-week visit), irrespective f feeding ptin. Strengthening f cmmunity-based husehld and dr-t-dr activities t educate and enhance the utilizatin rates and effectiveness f health prgrams. 9

11 2. PMTCT PROCESSES AND GOALS OF INTERVENTION Figure 1: Summary f PMTCT Prcesses Antenatal Care Labur & Delivery Pstnatal Care 2.1 ANTENATAL CARE Gals f interventins: Imprve the quality f the mther s health and prevent mrtality Identify wmen wh are HIV-psitive Ensure HIV-psitive wmen enter the PMTCT prgramme Prevent mther-t-child transmissin Prvide AZT frm 14 weeks f pregnancy r lifelng ART as sn as pssible, depending n a mther s clinical indicatins 2.2 LABOUR AND DELIVERY Gals f interventins: Identify HIV-psitive wmen Prvide adequate PMTCT cverage Cntinuity f care f prphylactic and treatment antiretrviral regimens Reduce maternal nevirapine resistance Initiate nenates brn t HIV-psitive mthers with antiretrviral prphylaxis immediately at birth 10

12 Figure 2: PMTCT Algrithm HIV infected Mther n AZT regimen r n treatment At nset f labur sdnvp AZT 3hrly till delivery Pst- Delivery Single Dses TDF + FTC Infant: NVP fr 6 weeks r fr duratin f breast feeding Mther: Assess need fr lifelng ART befre discharge Mther n lifelng ART Cntinue ART regimen thrughut labur Infant: NVP fr 6 weeks Mther: Cntinue n lifelng ART All wmen f unknwn HIV status shuld be ffered HIV testing and cunselling befre discharge, preferably prir t, r immediately after, delivery t ensure that the baby gets antiretrviral prphylaxis if the test is HIV psitive. All abandned infants judged t be in their first 72 hurs f life shuld be given NVP as sn as pssible and then daily fr six weeks, r until rapid testing f the mther r infant cnfirms the absence f HIV expsure Breastfed infants whse mthers are nt n lifelng ART shuld cntinue NVP beynd 6 weeks f age until all cessatin f breastfeeding 2.3 POSTNATAL FOLLOW-UP OF MOTHER AND INFANT Gals f interventins: Prvide fllw-up pst-partum care including a pstnatal visit within 3 days Imprve the quality f the mther s health and reduce mrtality by including family planning cunselling and cervical cancer screening where applicable Prvide pst-expsure prphylaxis fr infants 11

13 Reduce pstnatal HIV transmissin thrugh breastfeeding Identify all HIV-expsed infants Reduce mrtality in HIV-expsed infants Identify all HIV-psitive infants and start ART early Figure 3: Infants wh are exclusively frmula fed IDENTIFY HIV-expsed infant 6 weeks: EPI -Start CTX -D PCR -Discntinue infant NVP -Safe infant feeding cunseling and supprt PCR PCR negative PCR psitive HIV Negative Stp CTX Rapid HIV at 18 mnths Prmpt referral fr ART Cntinue infant CTX Cnfirm status with Viral Lad Figure 4: Infants wh are breastfed whse mthers are n lifelng ART IDENTIFY HIVexpsed infant 6 weeks: EPI -Start CTX -D PCR -Discntinue infant NVP -Safe infant feeding cunseling and supprt PCR PCR negative PCR psitive Cntinue EBF fr 6 mnths Cntinue infant CTX until BF stpped and infant negative Repeat HIV test 6-weeks pstcessatin f BF Rapid HIV at 18 mnths Prmpt referral fr ART Cnfirm status with viral lad Cntinue BF fr 2 years Cntinue infant CTX 12

14 Figure 5: Infants wh are exclusively breastfed whse mthers are NOT n lifelng ART IDENTIFY HIVexpsed infant 6 weeks: EPI -Start CTX -D PCR -Cntinue infant NVP PCR negative PCR Cntinue EBF fr 6 mnths Cntinue infant NVP until BF stpped Cntinue infant CTX until BF stpped and infant negative Repeat HIV test 6 weeks after cessatin f BF PCR psitive PCR psitive PCR negative Prmpt referral fr ART Cnfirm status with viral lad Cntinue BF fr 2 years Cntinue infant CTX Stp infant NVP HIV negative Stp CTX Rapid HIV test at 18 mnths NB: All HIV-expsed infants nt n ART shuld have a rapid test at 18 mnths f age t cnfirm HIV status cnferred by the 6-week PCR test. Figure 6: All mthers at scheduled check-up, 6 weeks pst-partum Identify HIVinfected mther On lifelng ART? N -CD4 -Clinical staging -TB screening CD4 >200 Refer fr *Wellness Services and family planning Yes Supprt and mnitr adherence Ensure referred t PHC fr nging ART Discuss family planning Encurage infant testing CD4 < 200 r WHO 3 r 4 Urgently refer fr lifelng ART * Wellness Services entails fllw-up f HIV-infected individuals nt yet n ART and includes: prvisin f TB screening, INH prphylaxis, CTX prphylaxis, nutritinal and psychscial supprt, cervical cancer screening, mnitring f CD4 cell cunt, clinical staging and preparedness fr ART. Mthers f unknwn HIV status r wh are HIV negative shuld be ffered an HIV test during pstnatal care visits. 13

15 3. KEEPING WOMEN AND CHILDREN HEALTHY AND IMPROVING THEIR QUALITY OF LIFE AND REDUCING MORTALITY All pregnant wmen shuld: Be encuraged t bk early int antenatal care, as sn as they believe they are r are cnfirmed t be pregnant. Receive rutine antenatal care, including micrnutrient supplementatin. Be ffered infrmatin n the availability f PMTCT interventins during all health care cnsultatins. Be rutinely ffered HIV cunselling and testing and encurage partner r spuse testing. Be encuraged t invlve partners r spuses in caring fr the pregnancy. Be cunselled n safer sex and prvided with cndms. Be cunselled n safe infant feeding ptins and assisted in making an apprpriate feeding chice. Be supprted n the chice f infant feeding at all times. All pregnant wmen wh are HIV-psitive shuld: Receive rutine antenatal care, including irn and flate supplementatin. Be ffered infrmatin n the availability f PMTCT interventins at all health care cnsultatins, and nt nly when visiting the antenatal clinic. Be clinically staged and have a CD4 cell cunt taken n the same day as the HIV test is dne, and preferably at the first ANC visit (r at the earliest pprtunity). Be screened fr TB, in line with the BANC. Be screened and treated swiftly fr syphilis and ther STIs, in line with BANC. Receive regimens t prevent mther-t-child transmissin f HIV (PMTCT regimen) OR lifelng ART if CD4 cell cunt <350 cells/mm 3 (ART regimen). Be ffered apprpriate PCP and TB preventin prphylaxis. Be cunselled n safer sex, family planning, pstnatal cntraceptin and partner testing. Wmen wh start lifelng ART in their pregnancy shuld be mnitred and managed, where pssible, by the same prvider in the same facility. They shuld receive fllw-up frm an antenatal healthcare wrker until at least 6 weeks pstpartum, befre being referred fr nging care t an apprpriate facility. Wmen wh test HIV-negative shuld receive pst-test cunselling and cunselling n risk reductin interventins including invlvement f partners r spuses, fcusing mainly n hw t maintain their HIV-negative status. They shuld cntinue t receive rutine antenatal care, and shuld be encuraged t use cndms. They shuld be ffered a repeat HIV test at r arund 32 weeks gestatin, t detect thse wh may have ser-cnverted during pregnancy. 14

16 Wmen wh chse nt t be tested shuld receive individual pst-refusal cunselling and be ffered HIV testing at every subsequent visit in a nn cercive manner during the antenatal perid. They shuld als be ffered an HIV test at the nset f labur; if this is nt pssible, they shuld be ffered testing shrtly after childbirth. Wmen wh initially test negative and subsequently test psitive during pregnancy shuld be given a CD4cell cunt test, clinically staged, and initiated nt AZT whilst awaiting the CD4 cell cunt result. If the result is CD4 is 350 r less the wman must cmmence lifelng ART within 2 weeks. If the CD4 is mre than 350, then she cntinues n AZT. Unbked wmen reprting in labur shuld be cunselled and tested fr HIV during the first stage f labur and ffered a PMTCT interventin as per guidelines. If this is nt pssible, cunselling and testing shuld be ffered after delivery. If the mther tests psitive, the infant shuld be initiated nt NVP, the mther shuld be cunselled n feeding ptins and cunselled abut infant testing. The mther must be staged and a CD4 cell cunt taken prir t discharge with a fllw up visit scheduled within ne week. If eligible fr ART (CD4 f 350 r less r WHO stage 3 r 4) she shuld cmmence lifelng ART within 2 weeks. Infrmatin n a patient s HIV status, PMTCT r ART regimen, and CD4 cell cunt shuld be shared between health care persnnel at all levels f the health service, while respecting the cnfidentiality f wmen and children. This is called shared cnfidentiality amngst health care wrkers, and is essential fr maintaining cntinuity f care amng wmen and infants. This entails thrugh cmpletin f the Rad- t-health Card, particularly as it relates t HIV. 15

17 4. PROVIDER-INITIATED COUNSELLING AND TESTING 4.1 OVERVIEW All wmen attending antenatal care (bth first-time attendees and wmen attending fllwup visits) shuld be given rutine infrmatin abut HIV testing and the PMTCT prgramme. The initial infrmatin n HIV and its transmissin shuld be given in a Grup Infrmatin Sessin. Thereafter, all wmen wh have nt previusly been tested r thse wh require repeat testing shuld meet with a cunsellr, nurse, r midwife fr a ne n ne Individual Infrmatin Sessin. At the individual infrmatin sessin, each wman shuld be infrmed f the rutine HIV testing prcedure and shuld be given the pprtunity t ask further questins. The wman shuld then be ffered an HIV test and asked t prvide verbal cnsent t the testing. A wman may refuse an HIV test ( pt-ut ). Wmen wh pt-ut f HIV testing shuld be ffered pst-refusal cunselling t explre the reasns fr this chice, address any misunderstandings, and encurage her t recnsider her decisin nt t test, but withut applying undue pressure. These wmen shuld be ffered rutine HIV testing at each subsequent clinic visit. Infrmatin shuld be ffered befre the testing prcedure and cunselling shuld ccur after the test results are prvided. All wmen wh test HIV psitive shuld have their HIV status cnfirmed using a secnd rapid HIV test. Pst-test cunselling shuld be ffered t bth HIV psitive and HIV negative wmen; HIV psitive wmen shuld nly be cunselled after a secnd rapid HIV test has been perfrmed t cnfirm a psitive HIV status. The flw chart belw summarises the prcesses invlved in prvider-initiated cunselling and testing. 16

18 Figure 7: Prvider-initiated cunselling and testing Grup Infrmatin Sessin (Previusly called grup cunseling) Individual infrmatin sessin fr each wman and an ffer t test Agree t test Refuse t test HIV NEGATIVE HIV POSITIVE (cnfirm by 2 nd rapid HIV test) Pst-Refusal Cunseling Pst-Test Cunseling, Infrmatin and Supprt Same day CD4 cell cunt and TB screening Clinical staging Cntinuus PICT with each visit Details f what infrmatin shuld be prvided during pre-test and individual infrmatin sessins are cntained in the bxes belw. PRE-TEST GROUP INFORMATION SESSION Staff shuld cnduct a general grup infrmatin sessin n HIV and PMTCT-related issues fr all wmen cming fr first r repeat antenatal visits. A grup infrmatin sessin shuld include the fllwing key cmpnents: Benefits t the wman Infrmatin abut HIV transmissin and hw t prevent it as an individual and as a cuple Infrmatin abut the HIV testing prcess Emphasis n the imprtance f early access t antiretrviral therapy, fr the mther s wn health Infrmatin abut the high mrtality due t HIV& AIDS Infrmatin that maternal deaths are preventable, and that PMTCT is ne such effrt 17

19 Benefits t the fetus and infant: Infrmatin abut mther-t-child transmissin f HIV and pssible measures t reduce this Infrmatin n interventins that can keep HIV-expsed infants healthy, such as ctrimxazle prphylaxis and antiretrviral therapy Assurance n cnfidentiality, a discussin f shared cnfidentiality, and cuple cunselling Emphasis n the need fr PCR testing at 6 weeks pst-partum and its benefits Emphasis n the imprtance f adherence t prphylaxis r treatment The grup infrmatin sessin shuld prvide further infrmatin n the prgramme, and include the fact that HIV testing is a necessary step fr enrlment int the PMTCT prgramme, unless a wman s status is already knwn t be psitive. Furthermre, CD4 cell cunt and clinical staging are imprtant fr clinical decisin making. INDIVIDUAL INFORMATION SESSION An individual infrmatin sessin shuld be available t all pregnant wmen fllwing the grup infrmatin sessin. This shuld instil a psitive fcus and acceptance n the client s side. The cmpnents f the individual infrmatin sessin include: An assessment f whether the infrmatin prvided in the grup sessin has been understd Answers t any remaining questins, with an aim t clarify any misunderstanding A discussin f the way frward and the treatment ptins within the PMTCT interventin Verbal cnsent fr HIV testing 4.2 TESTING ALGORITHM FOR PREGNANT WOMEN Testing must be seen as a key entry pint t accessing HIV care and PMTCT services. Ensure that the testing algrithm utlined in the HCT Plicy is fllwed. HIV testing f wmen shuld ccur as part f the first antenatal encunter. Enugh bld shuld be cllected fr rutine antenatal screenings including haemglbin, Rhesus factr, and syphilis tests as well as a rapid HIV test and CD4 cell cunt, if required. 18

20 At the time this rutine bld sample is drawn, a rapid HIV test shuld be dne using either a drp f bld frm the venepuncture site r a finger prick. If the test is negative and the wman is asymptmatic, she is cnsidered t be HIV negative. Wmen wh test HIV negative shuld be ffered a repeat HIV test frm 32 weeks gestatin t detect late ser-cnversin r late infectin. If the rapid HIV test is psitive, a secnd cnfirmatry HIV test shuld be dne utilizing bld frm a secnd finger prick and anther rapid HIV test kit (frm a different supplier). The wman shuld be present when this cnfirmatry test is dne. A client is HIV psitive nly if the secnd cnfirmatry rapid test is als psitive. If the results are discrdant (i.e. the first rapid HIV test is psitive and the secnd rapid HIV test is negative), a specimen f bld shuld be cllected and a labratry ELISA test cnducted. The wman must be asked t return fr the HIV ELISA test results urgently (ideally within a week). The healthcare prvider shuld explain the reasn fr the labratry test t the client. Fr wmen wh missed the pprtunity t be tested at the first antenatal visit, the testing algrithm shuld be fllwed whenever cnsent is given and testing ccurs. The CD4 cell cunt and TB screening shuld fllw the HIV test and shuld be dne at the same visit. Prfessinal nursing staff and lay cunsellrs r cmmunity health wrkers (CHWs) in the facility shuld be trained t perfrm the rapid HIV tests, fllwing specific manufacturer s instructins and quality cntrl prtcls. 19

21 Figure 8: Algrithm fr HIV testing: SCREENING HIV TEST Rapid HIV test SCREENING RESULT POSITIVE SCREENING RESULT NEGATIVE CONFIRMATORY HIV TEST Rapid HIV test FINAL RESULT NEGATIVE CONFIRMATORY RESULT POSITIVE CONFIRMATORY RESULT NEGATIVE FINAL RESULT POSITIVE INDETERMINATE SEND FOR HIV ELISA INDETERMINATE ELISA SEND FOR p24 OR DNA PCR HIV ELISA RESULT POSITIVE / NEGATIVE ELISA FINAL RESULT 20

22 4.3 POST-TEST COUNSELLING All HIV psitive and HIV negative wmen shuld receive pst-test cunselling. The bx belw summarises the infrmatin that shuld be prvided during pst-test cunselling. POST-TEST COUNSELLING FOR ALL WOMEN REGARDLESS OF HIV STATUS Pst-test cunselling sessins shuld include infrmatin n: HIV transmissin risks Safe sex and the availability and use f cndms Cntraceptin and future fertility Treatment ptins MTCT and HIV and pssible interventins (ART, revised bstetric practices) Partner testing Safe infant feeding ptins fr HIV psitive wmen Infant prphylaxis Infant feeding cunselling fr HIV negative wmen Stigma Referral t supprt services All wmen regardless f their HIV status must receive pst-test cunselling. The cmpnent f pst test cunselling fr all wmen shuld include: One-n-ne interactin with clients Prvide HIV test results as sn as pssible after testing Give the results clearly in a manner that des nt instil fear r anxiety Deal with the feelings arising frm psitive and negative results Discuss preventin f infectins and the "windw perid" Identify and help with the wman's immediate cncerns Discuss what supprt the wman has and needs Discuss with whm the client may want t share the results Discuss the imprtance f partner testing Discuss the benefits f disclsure Identify what difficulties the client fresees and hw t deal with them Educate and encurage safer sexual practices; prvide cndms Encurage the wman t ask questins Prvide infrmatin n a healthy lifestyle, medical fllw-up, and lcal supprt systems Prvide nging fllw up and cunselling 21

23 Details f what infrmatin t discuss during pst-test cunselling fr all wmen, and tpics specific t HIV psitive and HIV negative wmen, are listed in the bxes belw. Identify what difficulties the client fresees and hw t deal with them Educate and encurage safer sexual practices; prvide cndms Encurage the wman t ask questins Prvide infrmatin n a healthy lifestyle, medical fllw-up, and lcal supprt systems Encurage disclsure Prvide nging fllw up and cunselling POST-TEST COUNSELLING ISSUES FOR HIV POSITIVE WOMEN All HIV-psitive wmen shuld be clinically staged and have their CD4 cell cunt checked and be screened fr TB preferably n the same day as the cnfirmatin f their HIV-psitive status. Wmen wh have WHO clinical stage 3 r 4 disease shuld be initiated n lifelng ART as sn as pssible. The pst-test cunselling sessin fr wmen wh are HIV psitive shuld have the fllwing key cmpnents cvered ver a number f cunselling sessins, which may nt ccur all n the same day: Infrmatin abut antiretrviral therapy, the side effects f the medicatin, and where t reprt these Cunselling n safe infant feeding ptins Cunselling n expsure t stigma Infrmatin and cunselling n cntraceptin and future family planning Infrmatin abut safer sexual practices during pregnancy and in the lng-term Infrmatin n and referral t supprt services and psitive living Infrmatin n disclsure HIV psitive wmen shuld be ffered cunselling at every subsequent antenatal care visit, r earlier if the wman r cunsellr deems this necessary t assist her with cping and thinking thrugh the cnsequences f her diagnsis. Wmen shuld be encuraged t jin a supprt grup. Wmen requiring additinal supprt shuld be referred t a scial wrker r psychlgist. If cunsellrs identify cmplex issues that they are unable t handle, they shuld refer the client t a scial wrker r psychlgist. 22

24 POST-TEST COUNSELLING FOR HIV NEGATIVE WOMEN HIV negative wmen shuld be ffered rutine antenatal services, as stipulated in the DOH Guidelines fr Maternity Care in Suth Africa. A repeat HIV test is dne frm 32 weeks gestatin. HIV-negative wmen shuld be cunselled n: Preventin and risk reductin behaviur (the risk f transmissin frm mther t child is particularly high fr wmen infected with HIV during pregnancy) Safe sexual practices The high risk f transmissin f HIV t her infant, if newly infected during pregnancy r breastfeeding The benefits f exclusive breastfeeding fr the first 6 mnths and cntinued breastfeeding thereafter and intrductin f cmplementary fds. 23

25 5. ROUTINE CLINICAL CARE FOR HIV-POSITIVE PREGNANT WOMEN HIV psitive pregnant wmen require all cmpnents f rutine antenatal care. These include: irn and flate supplementatin; the prvisin f antiretrviral drugs fr prphylaxis and treatment; the preventin and management f pprtunistic infectins; the mdificatin f bstetric practices, especially during labur and delivery; integrating HIV management, especially 3-hurly AZT int the partgram as part f labur management; cunselling n infant feeding ptins; and cunselling n safer sex, family planning, and cntraceptin. 5.1 ANTENATAL MANAGEMENT INITIAL ASSESSMENT At their first antenatal clinic visit all HIV psitive wmen shuld have the fllwing, in additin t rutine antenatal prcedures: 1. CD4 cell cunt 2. HIV clinical staging 3. Clinical screening fr TB and STIs 4. Alamine Amintransferase 5. Initiatin f antiretrviral prphylaxis r treatment CD4 CELL COUNT The fllw-up date must be ne week after the CD4 cell cunt has been taken t ensure prmpt initiatin f lifelng ART if eligible. Labratry turnarund times fr CD4 cell cunts shuld be under ne week. Wmen wh d nt return fr CD4 cell cunt results shuld be actively traced and advised t return fr their results. HIV CLINICAL STAGING Clinical assessment and staging f all HIV-psitive wmen shuld be cnducted at their first antenatal visit. CLINICAL SCREENING FOR TUBERCULOSIS C-infectin with TB and HIV is cmmn. If an HIV psitive patient has symptms suggestive f TB, tw sputum specimens shuld be cllected fr smear micrscpy and a TB culture. It is very imprtant t investigate patients fr tuberculsis befre starting ART. The healthcare prvider shuld suspect TB if tw r mre f the fllwing are present: 24

26 1. Cugh >2 weeks 2. Sputum prductin, which may ccasinally be bld stained 3. Fever >2 weeks 4. Drenching night sweats >2 weeks 5. Unexplained weight lss ( 1.5 kg ver the past 4 weeks r pr weight gain during pregnancy) 6. Lss f appetite, malaise, r tiredness 7. Shrtness f breath r chest pains ALT A baseline ALT t measure liver functin shuld be dne befre administering NVP. INITIATION OF ANTIRETROVIRAL THERAPY It is imprtant t avid unnecessary delays in initiating lifelng ART. Pregnant wmen shuld be staged t determine indicatin fr ARV treatment r prphylaxis, accrding t WHO clinical staging and CD4 cell cunt. The fllwing eligibility criteria apply fr pregnant mthers: Wmen with a CD4 cell cunt f mre than 350 cells/ mm 3 and WHO stage 1 and 2 disease shuld receive antiretrviral prphylaxis with AZT t reduce mther-t-child transmissin. Wmen with a CD4 cell cunt f 350 cells/ mm 3 r less WHO clinical stage 3 r 4 shuld receive lifelng antiretrviral treatment, bth fr their wn health and t reduce the likelihd f mther-t-child transmissin. ANITRETROVIRAL PROPHYLAXIS HIV psitive pregnant wmen wh are nt eligible fr lifelng ART are given a PMTCT regimen fr prphylaxis t reduce mther-t-child transmissin. The regimen includes antenatal, intrapartum, and pstnatal cmpnents. The maternal PMTCT regimen is: Antenatal Zidvudine (AZT) frm 14 weeks; Intrapartum single-dse Nevirapine (sdnvp), 3 hurly AZT, and Pstdelivery single dses f Tenfvir (TDF) + Emtracitabine (FTC) Antenatal AZT shuld be initiated frm 14 weeks gestatin r as sn as pssible thereafter, unless labratry findings indicate that the mther is severely anaemic (i.e. Hb<8g/dl) r if the wman is clinically pale. Irn and flate supplementatin shuld be prvided t all antenatal wmen rutinely. Wmen shuld return mnthly fr AZT. LIFELONG ANTIRETROVIRAL TREATMENT HIV psitive pregnant wmen eligible fr lifelng ART shuld start lifelng ART as early as pssible and cntinue thrughut pregnancy, delivery, and fr the rest f their lives. Lifelng ART 25

27 benefits maternal health and cntributes t maternal survival and reduces mther-t-child transmissin. Initiatin f ART is recmmended fr all HIV psitive pregnant wmen with CD4 cell cunt f 350 r less, irrespective f WHO clinical staging, and fr all HIV-psitive pregnant wmen in WHO clinical stage 3 r 4, regardless f CD4 cell cunt and wmen c-infected with TB/HIV. Pregnant wmen initiated n lifelng ART shuld be seen tw weeks after ART initiatin and then mnthly. Mnitring fr treatment failure and txicity shuld fllw the recmmendatins in the adult ART guidelines. Wmen n lifelng ART wh becme pregnant cntinue with treatment as per adult ARV guidelines (including thse n secnd line regimens). In cases in which a wman is taking an EFVcntaining regimen, EFV shuld be substituted with NVP nly if she is still in the first trimester. Wmen wh initially test negative and subsequently test psitive during pregnancy shuld be initiated nt AZT immediately. A CD4 cell cunt shuld be taken, clinical staging and TB screening dne, and lifelng ART cmmenced if eligible. If CD4 is 350 r mre then the mther shuld cntinue with AZT. SPECIAL CIRCUMSTANCES: TUBERCULOSIS INFECTION Tuberculsis is a stage WHO 3 disease and as such, TB-infected pregnant wmen, regardless f CD4 cell cunt, qualify fr ART. TB treatment shuld be priritised prir t initiating lifelng ART. If CD4 > 250 cells/mm 3 : Start ART nly after patient has stabilised n TB treatment (2-8 weeks after starting treatment) and initiate ART frm 12 weeks gestatin nwards If CD4 < 250 cells/mm 3 : Start ART nly after patient has stabilised n TB treatment (2-8 weeks after starting treatment). If severe mrbidity r very lw CD4 cunt (< 50 cells/mm3): Start ART after 2 weeks f TB treatment Pregnant wmen wh develp TB while n lifelng ART shuld cntinue their existing ART regimen, unless they are taking LPV/r. In this case, the LPV/r dse shuld be dubled HEPATITIS B INFECTION Tw antiretrviral agents with activity against hepatitis B shuld be used t cntrl bth HIV and hepatitis B. TDF and 3TC/FTC have activity against hepatitis B, and it is recmmended that TDF shuld substitute fr D4T in these c-infected patients. 26

28 5.2 INTRAPARTUM MANAGEMENT The wman s serstatus shuld be recrded in the maternity register. Health care wrkers shuld check the wman s dcumented HIV status and details f the antiretrviral drugs received during pregnancy. If her HIV status is unknwn and she is in the first stage f labur, HIV testing and cunselling shuld be prvided. If this is nt pssible prir t delivery, then HIV testing and cunselling shuld be prvided as sn as pssible after delivery. ANTIRETROVIRAL PROPHYLAXIS HIV-psitive wmen wh are nt n lifelng ART shuld receive AZT 3-hurly and sdnvp, and a single dse f TDF+FTC pst-delivery. ANTIRETROVIRAL TREATMENT Wmen wh are n lifelng ART shuld cntinue their regimen thrughut labur and delivery. They d nt require additinal intrapartum sdnvp r 3hurly AZT r pst-delivery TDF and FTC. INTRAPARTUM SPECIAL CIRCUMSTANCES Caesarean sectins shuld be perfrmed fr bstetric indicatins and are nt recmmended t reduce mther-t-child transmissin. Fr planned (elective) Caesarean sectins, antiretrviral prphylaxis (sdnvp + TDF + FTC) shuld ideally be given fur hurs prir t the prcedure. Wmen wh are n lifelng ART shuld cntinue their standard ART regimen. In the case f an emergency Caesarean sectin, ensure that the wman receives sdnvp + TDF + FTC prphylaxis prir t the prcedure. All HIV-psitive wmen wh underg Caesarean sectins shuld receive prphylactic antibitics. 5.3 SAFE DELIVERY TECHNIQUES MTCT risk is increased by prlnged rupture f membranes, assisted instrumental delivery, invasive mnitring prcedures, episitmy, and prematurity. Only suctin the baby s nse and airway when there is mecnium-stained liqur. 5.4 POSTNATAL CARE CARE OF HIV-POSITIVE WOMEN AND THEIR INFANTS IN THE IMMEDIATE POST- DELIVERY PERIOD Within an hur f delivery: Infants brn t HIV-psitive wmen shuld receive skin-t-skin cntact with their mthers, regardless f the mther s infant feeding chice. 27

29 All infants shuld start feeding (exclusive breastfeeding n demand r exclusive frmula feeding). Initiate HIV-expsed infants n NVP prphylaxis immediately after birth If the mther has nt made a decisin abut feeding yet, she shuld be cunselled n infant feeding. All wmen, whether n ART r nt, and their infants shuld receive fllw-up at the health facility within the first 3 days pstpartum, and shuld be seen again at the health facility prir t 6 weeks pstpartum. Thereafter, fllw-up shuld ccur at the well-infant clinics, as per the IMCI guidelines. Infant testing shuld be dne at 6 weeks (see sectin n infant testing). Cntraceptin shuld be discussed and ffered t all wmen after delivery and at subsequent visits Onging psychscial supprt shuld address the fllwing: Infant feeding chice and practice Scial security issues Child health Psitive preventin fr HIV & AIDS ANTIRETROVIRAL PROPHYLAXIS There is high mrbidity and mrtality f HIV psitive wmen in the pstpartum perid. Therefre, wmen wh are nt n ART shuld be assessed fr lifelng ART eligibility by ding a CD4 cunt test. If the wman is fund t be eligible she shuld cmmence lifelng ART within 2 weeks. Supprt fr wmen initiated n lifelng ART during pregnancy is particularly imprtant in the pstnatal perid. Apprpriate referral fr nging care must be ensured. INFANT PROPHYLAXIS Antiretrviral prphylaxis given sn after birth t all HIV-expsed infants is effective in reducing mther-t-child transmissin whether maternal ARVs are received r nt, and frms the basis f a pst-expsure prphylaxis strategy. Infant antiretrviral prphylaxis is als highly effective in reducing transmissin thrugh breast milk. Ideally, all infants brn t HIV-psitive wmen shuld receive skin-t-skin cntact with their mthers, regardless f the mther s feeding chice. Infants brn t HIV-psitive wmen shuld receive daily nevirapine fr 6 weeks, with dsing determined as fllws: If birth weight 2.5kg: 15mg If birth weight < 2.5kg: 10mg Infant prphylaxis shuld be initiated as sn as pssible after delivery. 28

30 ABANDONED INFANTS shuld receive NVP as sn as pssible (<72 hurs) after birth and cntinued until HIV-expsure status has been determined, using a rapid test r an HIV ELISA test. If the infant has been HIV-expsed, NVP shuld cntinue until 6 weeks f age and fllwed by a PCR at 6 weeks. IF MATERNAL STATUS IS UNKNOWN, including cases in which the mther is indispsed (due t severe illness, cma, mental illness, r death), the infants shuld receive NVP and have an HIV test (ELISA r e rapid test) t infrm further management f the infant. WHERE THE MOTHER IS KNOWN TO BE HIV-POSITIVE, BUT SHE REFUSES ANY ARV PROPHYLAXIS FOR THE INFANT, a cunsellr must intervene t explain the risks f mther-t-child transmissin and the benefits f antiretrviral therapy. Shuld this cunselling fail t cnvince the mther t adpt infant prphylaxis, the mther shuld then be infrmed f the infant s right t receive prtectin frm acquiring HIV. The healthcare wrker shuld cnsult the head f the facility and, with his r her permissin, prvide the necessary treatment in the best interest f the infant. In all actins cncerning children, the best interests f the child shall be a primary cnsideratin (Children s Act, N 38 f 2005). 29

31 6. REGIMENS Table 1: Standardised natinal ART and ARV regimens fr wmen wh are HIV psitive and pregnant and their infants Maternal regimens Wman Regimen Cmment Eligible fr lifelng ART (i.e. CD4 < 350 r WHO clinical stage 3 r 4) Currently n lifelng ART Cntraindicatin t TDF (renal disease) TDF + 3TC/FTC + NVP Cntinue ART AZT+ 3TC + NVP Start lifelng ART within 2 weeks Substitute EFV with NVP if in first 12 weeks f pregnancy Nt eligible fr ART i.e. CD4 > 350 and WHO stage 1 r 2 Unbked and presents in labur AZT frm 14 weeks sdnvp + AZT 3hrly in labur TDF + FTC single dse (stat) pstdelivery sdnvp + AZT 3hrly in labur TDF + FTC single dse pst-delivery Assess maternal ART eligibility befre discharge Table 2: Infant Regimens Infant regimens Infant Regimen Cmment Mther n lifelng ART NVP at birth and then daily fr 6 weeks irrespective f infant feeding chice Mther n PMTCT regimen NVP at birth and then daily fr 6 weeks cntinued as lng as any breastfeeding If frmula fed baby can stp NVP at 6 weeks Mther did nt get any ARV befre r during NVP as sn as pssible and daily fr at least 6 weeks cntinued as lng as any Assess ART eligibility fr the mther within 2 weeks delivery breastfeeding Unknwn maternal status because rphaned r abandned Give NVP immediately* Test infant with rapid HIV test. If psitive cntinue NVP fr 6 weeks. If negative discntinue NVP Fllw up 6 week HIV DNA PCR * If rapid HIV test can be dne within 2 hurs, then wait fr HIV result befre cmmencing NVP 30

32 Table 3: ARV Adult Dsing Guide Drug Dsage Ntes TDF (Tenfvir) 300mg daily Tenfvir is cntraindicated in creatinine clearance f <50ml/min d4t (Stavudine) 30mg 12hrly p All adult patients nw receive 30mg regardless f weight 3TC (Lamivudine) 150mg 12 hurly p OR 300mg daily FTC (Emtracitabine) 200mg daily NVP (Nevirapine) 200mg dly p X 2 weeks then Shuld be used with cautin with TB 200mg 12 hurly p treatment Fr PMTCT purpses single dse (sdnvp) is used as a 200mg tablet given nce. EFV (Efavirenz) 600mg ncte Avid in first trimester f pregnancy Kaletra (lpinavir 133.3mg /ritnavir 33.3mg) Aluvia (lpinavir 200mg /ritnavir 50mg) 3 tabs 12 hurly (Lp400mg/Rit100mg) 2 tabs 12 hurly (Lp400mg/Rit100mg) *Dses and frequency will remain the same when used intrapartum and psychiatric cnditins Preferably taken with fd. Bsting required with TB treatment Stre in a cl place Preferably taken with fd. Bsting required with TB treatment AZT (Zidvudine) 300mg 12 hurly p Avid if severe anaemia (Hb <8g/dl) Table 4: NVP Infant Dsing Guide Drug Birth Weight Dse Quantity NVP syrup (10mg/ml) Birth t 6 weeks 10mg/d 1ml <2.5kg birth weight Birth t 6 weeks 15mg/d 1.5ml 2.5kg birth weight Fr all: 6 weeks t 6 mnths 20mg/d 2ml 6 mnths t 9 mnths 30mg/d 3ml 9 mnths t end BF 40mg/d 4ml 31

33 7. ESTABLISHING SAFE INFANT FEEDING PRACTICES 7.1 BACKGROUND The Suth African natinal PMTCT prgramme adpts an apprach t infant feeding that maximizes child survival, nt nly the avidance f HIV transmissin. The Suth African Infant and Yung Child Feeding Plicy, its implementatin guidelines, and the Baby Friendly Hspital Initiative (BFHI) in particular, the ten steps t safe infant feeding utlined in the BFHI shuld be fllwed t facilitate feeding supprt fr HIV-psitive and HIV-negative wmen. All mthers wh are knwn t be HIV-infected either n lifelng ART r nt, wh exclusively breastfeed their infants shuld d s fr 6 mnths, intrduce apprpriate cmplementary fds thereafter, and cntinue breastfeeding fr the first12 mnths f life. Mthers wh are knwn t be HIV-infected, and nt n lifelng ART, wh decide t stp breastfeeding at any time shuld d s gradually during ne mnth whilst the baby cntinues t receive daily NVP and shuld cntinue fr ne week after all breastfeeding has stpped. PRINCIPLES OF SAFE INFANT FEEDING Health care persnnel, lay cunsellrs, and cmmunity caregivers shuld receive standardized training n infant feeding, cunselling, and HIV. Trained health care persnnel shuld prvide high quality, unambiguus, and unbiased infrmatin abut risks f HIV transmissin thrugh breastfeeding, ART prphylaxis t reduce this risk, and risks f replacement feeding. Cunselling n infant feeding must cmmence after the first pst-test cunselling sessin in pregnancy. Infant feeding shuld be discussed with wmen at every antenatal visit. Mixed feeding during the 1 st 6 mnths f life shuld be strngly discuraged as it increases the risk f childhd infectins. Mass mbilizatin and cmmunicatin n infant feeding and HIV shuld be dne thrugh mass media, including distributin f infrmatin educatin cmmunicatin (IEC) materials and cmmunity-based activities. In an attempt t ptimise child survival, HIV-psitive pregnant wmen shuld be fasttracked fr lifelng ART r PMTCT regimens in rder t keep them healthy and reduce MTCT. HIV-negative wmen At every antenatal visit, HIV-negative wmen r wmen f unknwn HIV status shuld be advised t exclusively breastfeed their babies during the first 6 mnths f life and cntinue breastfeeding fr at least 2 years. Every effrt shuld be made t have all pregnant wmen 32

34 HIV tested and retested as utlined in the testing sectin f this dcument. HIV-psitive wmen At every antenatal visit, HIV-psitive wmen shuld be cunselled n safe infant feeding. Each pregnant HIV-psitive wman shuld receive at least fur antenatal cunselling sessins n infant feeding and ARV prphylaxis. Pstnatal supprt fr infant feeding During the pstnatal perid, mther-infant pairs shuld have a fllw-up visit within 3 days after delivery t review feeding practices, check breast health, maternal health and child health, and prvide general supprt. All HIV-psitive infants shuld cntinue breastfeeding fr at least 2 years. Frmula feeding HIV-psitive wmen: Free cmmercial infant frmula will be prvided t infants fr at least 6 mnths. Wmen shuld receive practical supprt, including demnstratins n hw t safely prepare frmula and feed the infant. At 6 mnths f age, infants with r at risk f pr grwth shuld be referred fr cntinued nutritinal mnitring and dietary assistance. An apprpriate frmula milk prduct fr the infant s age and circumstances shuld be chsen. Infants weighing <2 kg shuld receive a special lw birth weight frmula until the infant weighs at least 2 kg; thereafter infant frmula fr a term infant can be given. A sy prtein based frmula shuld nt be given t an infant <2kg. All health care wrkers caring fr mthers, infants, and yung children shuld fully adhere with all the prvisins f the Internatinal Cde f Marketing f Breast Milk Substitutes and its subsequent reslutins, which will be superseded by the Suth African Regulatins relating t Fdstuffs fr Infants, Yung Children, and Children nce they are prmulgated. These regulatins have been adapted t allw fr infant feeding in the cntext f HIV. In cases in which cmmercial frmula is prvided free f charge at health facilities, managers, supervisrs, and health care persnnel shuld ensure an uninterrupted supply at clinic level. A reliable prcurement and distributin system shuld be put in place. 33

35 Fr mthers wh have chsen t avid all breastfeeding: Frmula feeding mthers require supprt at every well child / rutine visit, every immunizatin visit, and every sick child visit t facilitate and supprt exclusive frmula feeding. Frmula milk preparatin shuld be demnstrated at the first pstnatal visit and as needed thereafter, and discussed at every visit. Health care persnnel shuld: Prvide clear guidance regarding the vlume and frequency f feeding needed at each age. Discuss the dangers assciated with bttle-feeding and hw bttles shuld be cared fr, if used. Discuss and demnstrate cup feeding as a recmmended alternative t bttle-feeding. Discuss hme supprt fr aviding breastfeeding ensure that the wman has a supprter utside the health facility t help her avid all breastfeeding. 34

36 8. INFANT FOLLOW-UP Prir t discharge, ntes shuld be written n the Rad-t-Health chart t indicate whether the infant has received ARVs and what feeding chice the mther has made. This will ptimise infant prphylaxis, imprve the infant s access t apprpriate care, and reduce mrbidity and mrtality. Infants shuld receive fllw-up visits accrding t the IMCI clinical case management guidelines, including: Weekly visits during the first mnth f life Mnthly visits thereafter, until the age f twelve mnths Three-mnthly visits between the age f 12 mnths and tw years f age unless the child is ill; in this case they shuld be seen mre ften During the first pst-delivery visit: All HIV-expsed infants shuld receive NVP daily fr 6 weeks. If the infant is frmula fed, the health care wrker shuld check the methd f cleaning utensils and preparing frmula. Frmula preparatin shuld be demnstrated after cunselling when wmen have chsen nt t breastfeed. Demnstratin (t ensure safe and crrect preparatin) is essential fr HIV-psitive wmen. If the infant is breastfed, the pattern f feeding, attachment, and psitining and the mther s breast health must be checked. HIV-expsed infants shuld be tested fr HIV at 6 weeks f age, r befre 6 weeks f age if they are sick (see sectin n HIV testing). NVP t be stpped at 6 weeks in infants: Wh are frmula fed, Whse mthers are n lifelng ART Wh are diagnsed as HIV infected. ALL HIV-expsed infants cmmence CTX prphylaxis at 6 weeks f age. All infants identified as being HIV psitive shuld have a cnfirmatry viral lad and be referred fr urgent ART initiatin. Early ART shuld be initiated in all HIV psitive infants. HIV-expsed infants shuld be fllwed up AT LEAST mnthly in the first year f life and every three mnths thereafter, regardless f their methd f feeding. Infants clinically suspected f having HIV shuld be tested fr HIV, regardless f their age. 35