Objectives. Outline. Section 1: Interaction between HIV and pregnancy. Effects of HIV on Pregnancy. Section 2: Mother-to-Child-Transmission (MTCT)

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1 Objectives Prevention of Mother-to-Child Transmission (PMTCT) Teen Club Community Partners Training Programme By the end of the session participants will be able to: 1. Identify factors affecting the transmission of HIV from mother to child 2. Describe the interventions to prevent the transmission of HIV from mother to child including: Drugs used in PMTCT The PMTCT protocol Outline Interaction between HIV and pregnancy Mother to child transmission (MTCT) Factors affecting MTCT Interventions to prevent MTCT Effects of HIV on Pregnancy Increased risk: Premature delivery Intrauterine Growth Restriction Baby is born smaller than anticipated Stillbirth Infections Baby born dead Sexually transmitted infections, pneumonias, Urinary tract infections, Opportunistic Infections pregnancy Ectopic *NO increased risk of congenital anomalies. Section 1: Interaction between HIV and pregnancy Section 2: Mother-to-Child-Transmission (MTCT) Breast feeders VS NON-breast feeders 1

2 Timing of Transmission: Targeting Prevention (In an Untreated Breastfeeding Population, Total Transmission Rate is up to 40%) Pregnancy (5-10%) Timing of Transmission: Targeting Prevention (In an Untreated Non-Breastfeeding Population, Total Transmission Rate is up to 25%) Pregnancy (5-10%) Delivery (10-15%) Breastfeeding (10-15%) Delivery (10-15%) Section 3: Factors Affecting Transmission 1. Maternal 2. Obstetric 3. Fetal 4. Infant Maternal Factors Increasing the Risk of Transmission High Viral Load Acute infection Advanced Disease Impaired immunologic status (low CD4) Impaired nutritional status High risk behavior (STIs) Obstetric Factors Increasing the Risk of Transmission Prolonged rupture of membranes (> 4 hrs) Intrapartum hemorrhage Invasive obstetrical procedures - Amniocentesis - Invasive fetal monitoring - Forceps Fetal Factors Increasing the Risk of Transmission Prematurity Multiple fetuses First born with increased risk compared to subsequently delivered infant(s). 2

3 Infant Factors Increasing the Risk of Transmission Breastfeeding Mixed breast feeding Exclusive breast feeding Oral Thrush Prematurity Section 4: Prevention of Mother-to-Child Transmission (PMTCT) 1. Antiretroviral Medications (ARVs) --Treatment (HAART) --Prophylaxis 2. Modifying Obstetric Practices 3. Modifying Infant Feeding Practices ARVs & PMTCT: General Principles ARVs reduce transmission Lower viral load AZT is most studied By itself has PMTCT effects independent of its effect on viral load AZT, NVP, & 3TC considered safest ARVs for MTCT can be administered as part of: 1. Maternal treatment program (HAART) 2. Maternal / infant prophylaxis program HAART & PMTCT: The Botswana National ARV Program (HAART) In Botswana, eligibility for HAART is the same for non-pregnant and pregnant adults: a. CD4 count <250, or b. History of an AIDS-defining illness HAART: Advantages in Pregnancy VERY low transmission rates (<2%). Use of multiple medications decreases the risk of developing resistance. HAART has PMTCT effects independent of its effect on viral load. HAART should be given to ALL pregnant women who qualify for treatment. Prophylaxis & PMTCT : Non-Treatment Programs for the Prevention of Mother-to-Child Transmission Regimens of short course ARVs given to reduce transmission of HIV from a mother to her baby. Such regimens do NOT treat the mother s HIV infection. 3

4 Botswana National Program for PMTCT PREGNANCY L&D INFANT INTERVENTIONS HAART, if qualifies, or AZT beginning at 28 weeks Mother AZT: NVP: AZT +/- NVP AZT (4w) + NVP Ante-natally (from 28 weeks): 300mg orally q 12 hrs From onset of labour until delivery: 300mg orally q 3 hrs (maximal dose 1500mg) Single-dose (200mg) at onset of labour upon admission to L&D, if not previously on AZT 4 wks Infant AZT: From birth to 4 weeks of life: 4 mg/kg every 12 hours NVP: Single-dose (2mg / kg) immediately after delivery Infant Formula Provision for up to 12 months of life Botswana National Program for PMTCT PMTCT protocol for mothers identified positive only in labor: Single-dose NVP 200mg and AZT q3h per protocol. If infant is premature, AZT dose is 2mg/kg q12h for 4 weeks. If unable to take AZT PO, then administer per NG tube (no IV AZT). If mother is unable to take AZT orally during labor, give IV: 2mg/kg loading dose, followed by 1mg/kg every hour until delivery. Obstetric Practices and PMTCT: Avoid artificial rupture of membranes. Minimize interval between rupture of membranes and delivery. Avoid invasive procedures / instrumented deliveries, whenever possible. - If instruments required, use plastic suction cups. Avoid episiotomy, whenever possible. Perform vaginal cleansing. Infant Feeding Practices and MTCT Infant Feeding Recommendations (1) First Best: Exclusive formula feeding: when clean water, patient education, and safe methods of formula preparation are available. -- Babies in this strategy should NEVER receive breast milk. -- Supplemental liquids (water, juice) and solids (tsabana, cereal) may be introduced at 6 months of age. Infant Feeding Recommendations (2) Second Best: Exclusive Breast feeding -- Mixed breast feeding is NOT recommended at any time. -- In babies completely weaned supplemental liquids (water, juice) and solids (tsabana, cereal) may be introduced at 6 months of age. 4

5 WHO / UNICEF / UNAIDS (2000) Women should be empowered to make fully informed decisions regarding infant feeding. Women who have access to clean water and formula should be encouraged to exclusively formula feed. Overall, an informed mother is in the best position to decide how to feed her infant(s). Reproductive Choices and HIV National Guidelines recognize the desire of HIV-infected couples (discordant and concordant) to have children: - Couples should be counseled about adoption. - Intercourse for conception should be confined to the fertile period. - Couples must be informed about risks of unprotected sex. ARVs and Potential Impact on Mother-to Child Transmission in Botswana ~40,000 deliveries / year 35% of pregnant women HIV (+) 14,160 babies born to infected mothers / year Without any intervention: 5,660 HIV (+) babies / yr With prophylaxis and exclusive FF: 1770 HIV (+) babies / yr With HAART and exclusive FF: 283 HIV (+) babies / yr The program(s) are available, we just need to see that they get into the community! Empowering the M in MTCT Education / Reinforce benefits of VCT (voluntary counseling & testing) & MTCT Strengthen existing counseling services lay counselors group counseling followed by individual counseling Peer counseling Family / Male involvement Increase access to preventative treatments Increase access to HAART Discussion question! As a community OVC and Palliative care provider: Summary MTCT of HIV-1 can occur during pregnancy, delivery, or through breast milk. Untreated MTCT rates range from 15-40%. What do you consider to be your role in the PMTCT program? Maternal, obstetric, fetal, and infant factors contribute to the risk of MTCT. MTCT can be reduced with the use of ARVs & by modifying obstetric and infant feeding practices. 5

6 Thank you Thank you to all our Partners 6