THE SOUTH AFRICAN ANTIRETROVIRALTREATMENT GUIDELINES 2013

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1 THE SOUTH AFRICAN ANTIRETROVIRALTREATMENT GUIDELINES 2013 PMTCT GUIDELINES: REVISED MARCH 2013 Versin March

2 TABLE OF CONTENTS: 1. Executive summary 3 2. PMTCT prcesses and gals f interventin 5 3. Keeping wmen and children healthy and imprving their quality f life and reducing mrtality Prvider initiated cunseling and testing fr wmen and infants Rutine clinical care fr HIV psitive pregnant wmen Regimens Establishing exclusive breastfeeding Mther infant fllw up 44 Versin March

3 CHAPTER 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 2010 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 Rutine TB symptm screening at each visit with TB investigatin r referral fr TB investigatins if symptm screen psitive. 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 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, initiated sn after birth and cntinued fr 6 weeks. 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. Versin March

4 Testing f all HIV-expsed infants at any age frm birth if symptmatic f HIV including all premature and lw birth weight infants wh are expected t have a higher incidence f transmissin. Strengthening f cmmunity-based husehld and dr-t-dr activities t educate and enhance the utilizatin rates and effectiveness f health prgrams. Versin March

5 CHAPTER 2 PMTCT PROCESSES AND GOALS OF INTERVENTION The PMTCT prgramme reaches ut t all wmen befre pregnancy, during pregnancy, thrugh labur and delivery and thrugh the pst natal perid up t a perid f 18 mnths. The prgramme aims t result in healthy mthers and HIV-uninfected infants. The screening and referral fr TB management in this ppulatin is als addressed. Figure 1: Summary f PMTCT Prcesses The belw flw diagram highlights the varius cmpnents in the PMTCT prgram with management as per HIV status f the wman and HIV expsure fr infants 2.1 ALL WOMEN IN THE REPRODUCTIVE AGE GROUP Gals f interventins: Imprve the quality f sexual and reprductive health services Imprve access t family planning services Imprve access t safer sex ptins Prevent transmissin f HIV infectin Imprve access t HCT services t knw HIV status 2.2. ANTENATAL CARE Gals f interventins: Imprve the quality f the mther s health and prevent mrtality Identify wmen wh are HIV-psitive including thse wh may ser-cnvert during pregnancy Ensure ALL wmen enter the PMTCT prgramme If HIV-infected then require prmpt prvisin f ARVs and further cunselling If HIV-uninfected require specific cunselling and advice n repeat testing every 3 mnths after a negative test, and/r at 32 weeks, labur and thrugh breastfeeding every 3 mnths ALL wmen t have TB screening Versin March

6 Prevent mther-t-child transmissin f HIV Prvide ART, as sn as HIV psitive status knwn, in pregnancy fr maternal health and t reduce HIV transmissin t the baby 2.3 LABOUR AND DELIVERY Gals f interventins: Prvide HIV cunselling and testing services t all wmen with unknwn status Identify HIV-psitive wmen Prvide adequate PMTCT cverage Screen fr TB in all wmen irrespective f HIV-status Cntinuity f care with prphylactic and treatment antiretrviral regimens Initiate nenates brn t HIV-psitive mthers with antiretrviral prphylaxis immediately at birth Establish safe infant feeding practices supprting exclusive breastfeeding and kangar mther care fr all mthers and infants 2.4 POSTNATAL FOLLOW-UP OF MOTHER AND INFANT Gals f interventins: Prvide fllw-up pst-partum care including a pstnatal visit within 3 6 days fr mther and baby 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 f HIV fr HIV-expsed infants Screen and where indicated exclude TB in mthers and infants Reduce pstnatal HIV transmissin thrugh breastfeeding Identify all HIV-expsed infants as early. This means a PCR HIV test fr all symptmatic infants* anytime after birth and at 6 weeks (fr asymptmatic infants) at rutine EPI 6 week visit. (* Symptmatic Infants any infants displaying the fllwing failing t thrive (includes LBW), haematlgical abnrmality like anaemia r thrmbcytpaenia, cngenital pneumnia, pneumnia, hepatsplenmegaly, extensive ral candidiasis, significant lymphadenpathy, any OIs) Identify all HIV-infected infants and start ART prmptly (within 7 days) 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 and 6 weeks pst breast feeding test. All HIV-infected individuals shuld have prvisin f TB screening, INH prphylaxis, CTX prphylaxis, nutritinal and psychscial supprt, cervical cancer screening, family planning ptins, mnitring f CD4 cell cunt and, clinical staging. Mthers f unknwn HIV status r wh are HIV negative shuld be tested fr HIV test at 6 weeks, 3 mnths, 9 mnths and ne year pstpartum, particularly if they are breast Versin March

7 feeding. Nte at initial PICT in the ANC, mthers wuld be cnsenting nce fr the prtcl f initial and repeated HIV testing thrughut HIV expsure s as t ensure that this is efficiently dne withut any requirement fr further cunselling unless indicated. Versin March

8 Figure 2: PMTCT Algrithm 1: fr all wmen wh are newly diagnsed as HIV psitive anytime during pregnancy AND wmen wh enter ANC with knwn HIV psitive status and nt yet n ART. First antenatal visit : HIV-psitive nt n ART (knwn and newly diagnsed) Histry & clinical assessment including fr TB & WHO staging, Blds sent fr creatinine, CD4 If n active psychiatric illness r histry f renal disease Start FDC (TDF, FTC/3TC, EFV) same day 1 week later : Review results f CD4, serum creatinine If serum creatinine 85 µml/l Check CD4 cunts, WHO staging CD4 350 r stage 3/4 CD4>350 r stage 1/2 If active psychiatric illness r histry f renal disease Start AZT 300mg same day (prvided Hb >7g/dL) If serum creatinine >85 µml/l: see Figure 4 frfurther management f pregnant wmen n AZT see figure 3 Cntinue FDC as lifelng treatment Cntinue FDC as prphylaxis thrugh antenatal, labur and delivery, pstnatal till ne week after cmplete cessatin f breastfeeding Versin March

9 Figure 3 : PMTCT algrithm 2: Initiatin f antiretrvirals during pregnancy in wmen with active psychiatric illness r histry f renal disease If active psychiatric illness r histry f renal disease Start AZT 300mg same day Histry, clinical assessment, WHO staging Blds sent fr serum creatinine, CD4 Rutine antenatal care (including urine dipstix, Hb, RPR) 1 week later Review results f CD4, serum creatinine If serum creatinine 85 µml/l Check CD4 cunts, WHO staging If serum creatinine > 85 µml/l: see Figure 4 CD4 350 r stage 3/4 CD4>350 r stage 1/2 Requires alternate triple-drug regimen fr lifelng treatment per adult guidelines TDF+ FTC+ NVP Use LPV/RTV in wmen with CD4 cunts > 250cells/mm 3 Cntinue AZT prphylaxis thrughut pregnancy Intrapartum: Prvide AZT 3 hurly during labur, Stat Dse NVP + TDF/FTC Versin March

10 Figure 4: PMTCT algrithm 3: Initiatin f antiretrvirals during pregnancy in wmen with serum creatinine > 85 µml/l: If serum creatinine > 85 µml/l (referred t ART Clinic) Check CD4 cunts, WHO staging CD4 350 r stage 3/4 CD4>350 r stage 1/2 Requires alternate triple-drug regimen fr lifelng treatment per adult guidelines: AZT+ 3TC+ EFV If haemglbin <7g/dl AZT is cntraindicated. Use ABC r D4T instead f AZT. Cntinue AZT prphylaxis thrughut pregnancy Intrapartum: Prvide AZT 3 hurly during labur, STAT dse : NVP + TDF/FTC Versin March

11 PMTCT Algrithm 4: fr all wmen wh are newly diagnsed any time during the pstnatal perid. Any pstnatal visit: newly diagnsed HIV psitive: Histry & clinical assessment including fr TB & WHO staging, Blds sent fr creatinine, CD4 Please see algrithm 1 fr further managmeent f mther. If n active psychiatric illness r histry f renal disease: Start FDC (TDF, FTC/3TC, EFV) same day and Check status f infant feeding, If currently breastfeeding the baby Check baby HIV status (PCR test befre 18 mnths, and rapid HIV test after 18 mnths); Maternal blds sent fr creatinine, CD4, assess fr active psychiatric illness. 1 week later : Review results f Maternal CD4, serum creatinine If serum creatinine 85 µml/l Check CD4 cunts, WHO staging CD4 350 r stage 3/4 CD4>350 r stage 1/2 If serum creatinine >85 µml/l: see Figure 4 In case f expsure t BF at any time during the pst natal perid Check baby HIV status (PCR) Return in 1 week t review results Infant t be given NVP syrup fr 7 days and return fr PCR test results within 7 days Baby PCR Psitive: initiate Treatment Baby PCR Negative: Cntinue NVP fr 6 weeks Baby PCR Negative: if PCR has been dne anytime befre 6 weeks, and is negative, please repeat PCR at 6 weeks Baby PCR Psitive:initiate treatment Cntinue FDC as lifelng treatment Cntinue FDC as prphylaxis thrugh pstnatal till ne week after cmplete cessatin f breastfeeding Versin March

12 CHAPTER 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. Have a TB symptm screen at each visit with further TB investigatins if any f the screening questins are psitive. Be encuraged t invlve partners r spuses in caring fr the pregnancy. Be cunselled n safer sex and prvided with cndms and discuss future family planning ptins. Be cunselled n safe infant feeding ptins and assisted in making an apprpriate feeding chice. Be infrmed that breastfeeding is the preferred ptin. 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, flate and calcium 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 a triple-drug antiretrviral regimen as an FDC at the first antenatal visit, whether newly diagnsed r knwn t be living with HIV but nt n ART. This is t prevent mther-t-child transmissin f HIV and t reduce maternal mrbidity and mrtality. The duratin f regimen is determined by CD4 cunts, (> 350 cells/mm3 t receive FDC till 1 week after cessatin f breast feeding cessatin and < 350 cells/mm3 t cntinue lifelng treatment) Be ffered apprpriate PCP and assessed fr eligibility fr TB preventive therapy with isniazid. Be cunselled n safer sex, family planning, pstnatal cntraceptin and partner testing. Wmen wh are put n FDC in their pregnancy (either fr her wn health r fr PMTCT) shuld be mnitred and managed, where pssible, by the same prvider in the same facility thrugh antenatal and pst natal perid until the end f breastfeeding. Please nte: these wmen will be managed by NIMART trained nurses and midwives and shuld be referred if required (in case f adverse events/cmplicatins) t an ART site with a dctr fr further management. Versin March

13 Wmen wh test HIV-negative anytime during antenatal, labur r pstnatal perids are still cnsidered part f the PMTCT prgramme and 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 12 weeks after the initial HIV test is negative and/r at 32 weeks r later gestatin perids r in the labur ward, at the 6 week pst natal visit, at 3, 6 and 12 mnths during breast feeding t detect thse wh may have ser-cnverted during pregnancy. They shuld have a symptm screen fr TB at each visit. 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. They shuld have a symptm screen fr TB at each visit. Wmen wh initially test negative and subsequently test psitive during pregnancy shuld be initiated n FDC n same day f diagnsis. Further management as per figure 2 n page 8. Unbked wmen reprting in labur shuld be cunselled and tested fr HIV during the first stage f labur, and if psitive given a single dse f NVP and TDF and FTC and 3 hurly AZT until delivery. Pstdelivery, start FDC and d rutine tests (creatinine and CD4) and manage as per figure 2 n page 8. Please nte: All infants brn t HIV psitive mthers: start NVP as sn after birth as pssible (within 72 hurs pstdelivery) and cntinue fr 6 weeks. Infants f HIV infected wmen nt n ART (treatment r prphylaxis) wh are breastfeeding shuld cntinue daily NVP until ne week after cessatin f breast feeding. Please nte: n wman shuld leave the delivery site with unknwn HIV status. All wmen wh test psitive during labur and delivery need t start FDC and return after 1 week fr review f CD4 and creatinine results at the clinic (nt at delivery site). Further management f these wmen is based n creatinine and CD4 test results and is as per figure 2 n page 8. Wmen tested pstdelivery: cunselling and testing shuld be ffered t all wmen with unknwn HIV status r thse wh tested negative 6 weeks prir t delivery as sn as pssible. If the mther tests psitive, the infant shuld be initiated nt NVP as sn as pssible, the mther shuld be cunselled n feeding ptins and cunselled abut infant testing. If the mther intends t breastfeed her baby, the FDC shuld be initiated fr the mther, WHO staging dne, and CD4 cell cunt and creatinine taken prir t discharge with a fllw up visit scheduled within ne week. Further management as per figure 2 n page 8. NB: 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 Versin March

14 wmen and infants. This entails thrugh cmpletin f the Rad- t-health Bklet (RTHB Pages 7 & 8), particularly as it relates t HIV. The RTHB is a health recrd f essential infrmatin relating t and influencing the health utcmes f a child that begins frm birth and cntinues int early childhd. It is imperative that healthcare wrkers are diligent in cmpleting this recrd at every pint that an infant and yung child is seen at a health facility. Infrmatin regarding HIV expsure and PMTCT interventins are CRITICAL fr the cntinued management f mthers and infants. Versin March

15 CHAPTER 4 PROVIDER-INITIATED COUNSELLING AND TESTING FOR WOMEN AND INFANTS 4.1 OVERVIEW All wmen attending antenatal care (bth first-time attendees and wmen attending fllw-up 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 with anther test type. 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. Versin March

16 Figure 5: Prvider-initiated cunselling and testing Grup Infrmatin Sessin (Previusly called grup cunselling) 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 Cunselling Pst-Test Cunselling, 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. Versin March

17 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 Emphasis that bth partners need testing 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 and INH prphylaxis and antiretrviral therapy Advantages f breastfeeding as well as measures t reduce risk f transmissin via this rute 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 Imprtance f bringing infant in fr attentin and testing prir t 6 weeks if any suspicin Imprtance and relevance f the Rad T Health Bklets 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. Treatment will be prvided fr all wmen living with HIV until 1 week after breast feeding cessatin. Onging treatment is determined by CD4 cell cunt and clinical stage and cnditin f the wman. Versin March

18 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 fr current test and subsequent tests in pregnancy 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 and serum creatinine, if the rapid HIV tests are psitive. 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, intra partum and pst partum every 3 mnths 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 Versin March

19 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, serum creatinine and TB screening shuld fllw the HIV test and shuld be dne at the same visit and wmen asked t return in 7 days fr the results. 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. Versin March

20 Figure 6: 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 POSITIVE / NEGATIVE DEPENDENT ON ELISA RESULT Versin March

21 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: Risks fr HIV transmissin 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 TB symptms 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 infectin 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 Versin March

22 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, have their CD4 cell cunt and creatinine checked and be screened fr TB preferably n the same day as the cnfirmatin f their HIVpsitive status. All wmen living with HIV shuld be initiated n ART (FDC) n the same day. 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 Shwn the RTHB and infrmed f the benefits and need fr this dcument 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. Versin March

23 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 after 12 weeks f an initial negative HIV test, and/r 32 weeks r later gestatin, at the time f delivery and 6 weeks, 3, 6, 9 and 12 mnths after delivery. 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. Shwn the RTHB and infrmed f the benefits and need fr this dcument 4.4 TESTING ALGORITHM FOR INFANTS The belw diagrams shw the testing algrithms fr infants < 18 mnths f age, and infants > 18 mnths f age. Versin March

24 Versin March

25 CHAPTER 5 ROUTINE CLINICAL CARE FOR HIV-POSITIVE PREGNANT WOMEN HIV psitive pregnant wmen require all cmpnents f rutine antenatal, labur and delivery and pst natal care. These include: irn and flate supplementatin; haemglbin testing; the prvisin f antiretrviral drugs fr prphylaxis and/r treatment; the diagnsis, preventin and management f pprtunistic infectins including TB; the mdificatin f bstetric practices, especially during labur and delivery; cunselling n infant feeding, safer sex, family planning, and cntraceptin. 5.1 ANTENATAL MANAGEMENT INITIAL ASSESSMENT At their first antenatal clinic visit all HIV psitive wmen shuld underg have the fllwing,: 1 Rutine testing fr Haemglbin, Rh, RPR 2 CD4 cell cunt 3 HIV clinical staging 4 Clinical screening fr TB and STIs 5 Clinical & labratry screening fr renal disease, including serum creatinine 6 Screening fr active psychiatric illness 7 Initiatin f antiretrviral prphylaxis and/r treatment CD4 CELL COUNT CD4 cell cunt testing shuld be dne at the first antenatal visit, but initiatin f an antiretrviral regimen shuld nt be delayed fr the CD4 cell cunt r ther investigatins. Labratry turnarund times fr CD4 cell cunts shuld be under ne week. CD4 results are nt required befre initiatin f a triple-drug antiretrviral regimen. Hwever CD4 results shuld be reviewed at the next antenatal visit t decide whether triple-drug antiretrvirals are t be given as prphylaxis until ne week after cessatin f breastfeeding r as lifelng therapy and whether the wmen requires c-trimxazle prphylaxis. Versin March

26 HIV CLINICAL STAGING Clinical assessment and staging f all HIV psitive wmen shuld be cnducted at their first antenatal visit. CLINICAL & LABORATORY SCREENING FOR RENAL DISEASE Use f tenfvir is cntraindicated in individuals with renal disease. Renal disease is uncmmn in HIV-infected pregnant wmen. At the first antenatal visit, wmen at increased risk f renal disease may be identified thrugh a pre-pregnancy histry f diabetes r hypertensin, a previus kidney cnditin requiring hspitalizatin, r 2+ prteinuria n urine dipstix. At the first antenatal visit, bld fr serum creatinine testing shuld be sent tgether with CD4 cell cunt and ther blds. Serum creatinine results shuld be available within ne week, and may be needed t adjust antiretrviral medicatins. A serum creatinine f >85 µml/l is cnsidered abnrmal in pregnancy (ther methds f estimating renal functin, including estimated glmelurlar filatratin rate frm the Cckrft-Gault equatin, are inaccurate in pregnancy). CLINICAL SCREENING FOR TUBERCULOSIS Active TB disease is cmmn in wmen living with HIV. All pregnant wmen shuld be actively screened fr TB symptms.. If an HIV psitive patient has symptms suggestive f TB, a sputum specimen must be cllected fr GeneXpert testing, and the TB Xpert diagnstic algrithm fllwed. Althugh it is imprtant t investigate patients fr TB befre starting ART, in mst pregnant patients initiatin f ART prphylaxis r lifelng treatment shuld nt be delayed fr TB investigatins. The healthcare prvider shuld suspect TB in a wman living with HIV if any f the fllwing 4 symptms are present: 1 Current cugh f any duratin. 2 Fever 3 Night sweats 4 Weight lss r pr weight gain Any wman living with HIV wh has nne f these symptms can be cnsidered fr eligibility fr isniazid preventive therapy by perfrming a tuberculin skin test (TST). CLINICAL SCREENING FOR NEUROPSYCHIATRIC ILLNESS Use f efavirenz is cntraindicated in individuals with active psychiatric illness. In practice, any wman with an active psychiatric illness shuld nt receive an efavrienz-cntaining antiretrviral regimen withut cnsultatin. Mild depressin is nt a cntraindicatin t efavirenz. Versin March

27 INITIATION OF ANTIRETROVIRAL PROPHYLAXIS OR TREATMENT It is imprtant t avid unnecessary delays in initiating antiretrviral medicatins during pregnancy and all HIV-infected pregnant wmen shuld receive antiretrviral prphylaxis r treatment frm their first antenatal visit regardless f gestatinal age. Under the revised guidelines, the first-chice ARV regimen fr prphylaxis and lifelng treatment are the same (TDF+3TC/FTC+EFV, ideally as an FDC). As a result, unless there is a cntraindicatin t TDF+3TC/FTC+EFV, all wmen can start this regimen as an FDC, at the first antenatal clinic visit. Identifying wmen wh are eligible fr lifelng treatment early in pregnancy is imprtant t ensure adequate cunselling. All 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 TDF+3TC/FTC+EFV thrughut pregnancy until 1 week after cessatin f breastfeeding t reduce mther-t-child transmissin. In wmen fr whm TDF+FTC+EFV is cntraindicated, AZT during pregnancy and intrapartum is the alternative antiretrviral regimen with extended daily infant NVP until breast feeding cessatin. 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. As per the adult guidelines, TDF+3TC/FTC+EFV is the preferred regimen fr lifelng antiretrviral therapy unless cntraindicated due t active psychiatric illness r renal disease. Nte that eligibility fr lifelng antiretrviral treatment may be determined at the first antenatal visit (based n clinical staging) r at a later antenatal visit when CD4 cell cunt results are reviewed. ANTIRETROVIRAL PROPHYLAXIS HIV psitive pregnant wmen wh are nt eligible fr lifelng ART are given an antiretrviral regimen fr prphylaxis t reduce mther-t-child transmissin. The maternal prphylaxis regimen is: TDF+3TC/FTC+EFV (ideally as a fixed drug cmbinatin tablet, FDC) taken nce daily, frm the first antenatal visit. This regimen is cntinued during labur and delivery, and int the pstpartum perid thrughut the perid f breastfeeding until ne week f breastfeeding cessatin. In wmen with a cntraindicatin t TDF+3TC/FTC+EFV (eg, renal disease r psychatric illness), antenatal AZT shuld be initiated frm the first antenatal visit, unless labratry findings indicate that the mther is severely anaemic (i.e. Hb<8g/dl). Irn and flate supplementatin shuld be prvided t all antenatal wmen rutinely. Versin March

28 Antiretrviral prphylaxis shuld be dispensed at regular intervals frm the antenatal clinic setting. 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 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 cunt f 350cell/mm3 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. Mnitring fr treatment failure and txicity shuld fllw the recmmendatins in the adult ART guidelines. Antiretrviral treatment fr pregnant wmen shuld be initiated in the antenatal clinic and dispensed regularly thrughut pregnancy and pstpartum. Wmen n lifelng ART wh becme pregnant cntinue with treatment as per adult ARV guidelines (including thse n secnd line regimens). A viral lad test shuld be perfrmed by the HIV clinic as sn as pregnancy is diagnsed. Onging adherence advice is recmmended regardless f result. If the viral lad is high, apprpriate interventins t imprve adherence and r diagnse resistance with apprpriate regimen change is imprtant. If the VL is high, the wmen shuld be referred back t the HIV clinic fr apprpriate management. Wmen wh initially test negative and subsequently test psitive during pregnancy shuld be initiated nt TDF+3TC/FTC+EFV as an FDC immediately. A CD4 cell cunt and serum creatinine shuld be taken, clinical staging and TB screening dne. As fr ther wmen starting TDF+3TC/FTC+EFV, serum creatinine shuld be reviewed within ne week t determine the safety f lng-term tenfvir use, and CD4 cell cunt shuld be reviewed t determine the need fr prphylaxis versus lifelng antiretrviral therapy. TUBERCULOSIS DISEASE Tuberculsis is a WHO stage 3 disease and as such, HIV psitive pregnant wmen with active TB disease qualify fr lifelng ART regardless f CD4 cell cunt. HIV psitive wmen with TB disease shuld be initiated n TB treatment alng with AZT prphylaxis. Lifelng antiretrviral therapy (typically TDF+FTC/3TC+EFV) shuld replace AZT prphylaxis apprximately 2 weeks after the start f TB therapy. The early intrductin f ART increases the risk f TB assciated immune recnstitutin inflammatry syndrme (TB IRIS). Patients shuld be cunselled regarding TB IRIS and staff shuld be alert t the symptms f TB IRIS as per adult guidelines. Initiatin f ART shuld nt be delayed while waiting fr the results f TB investigatins. 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. Versin March

29 Isniazid Preventive Therapy (IPT) All HIV psitive pregnant wmen shuld underg a symptm screen fr TB at each visit. If they have n cugh, fever, night sweats r weight lss they shuld be cnsidered fr a TST (tuberculin skin test) and if this is psitive started n IPT (isniazid preventive therapy) nce stable n ART. If the wman is n lifelng ART IPT shuld be cntinued fr 36 mnths. If the wman is n prphylactic ART IPT shuld be cntinued fr 12 mnths nly. If TST cannt be perfrmed IPT shuld be deferred until TST can be perfrmed. IPT shuld nly be started nce the patient is stable n ART. OI PROPHYLAXIS Fr wmen with CD4 <200 cells/mm 3 r WHO stage 3/4 disease: start C-trimxazle 80/400mg, 2 tablets daily until CD4 >200 cells/mm 3. ANAEMIA A wman is said t be anaemic when her haemglbin level is belw 11g/dl, but treatment usually nly ccurs when haemglbin is belw 10g/dl. An Hb < 7g/dl is a severe anaemia. Anaemic wmen have an increased risk f pregnancy cmplicatins, including death. If anaemia is crrected, the wman wuld be able t better withstand the cmplicatins f haemrrhage and sepsis. Anaemia is a very cmmn cnditin, and is mre cmmn in wmen infected with HIV. Screening fr anaemia Measure haemglbin level at first ANC visit, at 32 weeks gestatinal age and near time f delivery (36 weeks gestatinal age) Lk fr cnjunctival pallr Lk fr palmar pallr Ask pregnant wmen at each visit: d yu tire easily r get shrt f breath ding rutine tasks? What immediate actin shuld be taken if there is anaemia? If Hb <7g/dl: start supplementatin f ferrus sulphate (FeSO4) 1 tablet three times a day and flate 5mg daily and send bld t the labratry fr a full bld cunt (FBC) (see belw). Hb between 7 and 10g/dl: FeS4 1 tablet three times daily and fllw them 2 weekly and check Hb. If Hb is 10 and 11g/dl, give FeS4 ne tablet twice a day and check Hb again 4 weeks later. All wmen shuld be cunselled n the imprtance f taking their tablets and nutritinal advice shuld be given. Hw t prevent anaemia: Versin March

30 All pregnant wmen shuld receive ferrus sulphate mg (1 tablet) daily, and flic acid 5 mg (1 tablet) daily thrughut their pregnancy. If Hb<7g/dl: Bld needs t be sent t the labratry fr a Full Bld Cunt (FBC) and the wmen referred. Irn deficiency is likely if: the FBC shws a lw mean crpuscular vlume (MCV <80fl)) (micrcytic anaemia) with nrmal white cell cunt (WCC) and platelets. Treatment: Irn supplementatin if nt due t anther cause such as an inherited haemglbinpathy Flate deficiency is likely if: there is a high MCV (>115fl) and nrmal WCC and platelets Treatment: flic acid supplementatin In wmen infected with HIV, it is cmmn t have a mixed picture, indicative f chrnic disease. If the WCC, platelets and Hb are all decreased, the patient has a pancytpenia and shuld be referred t a hspital. If the patient is symptmatic (shrt f breath at rest r mild exertin, edema, syncpe), she shuld be referred t a hspital immediately. RENAL DISEASE At the first antenatal visit, wmen identified thrugh their histry as being at increased risk f renal disease, r wh have 2+ prteinuria n urine dipstix, shuld nt receive a tenfvircntaining regimen withut prir review f serum creatinine results. These wmen shuld start AZT immediately and return fr review f CD4 cell cunt and serum creatinine within ne week. Wmen wh have a nrmal serum creatinine ( 85 µml/l) shuld switch frm AZT t TDF+FTC/3TC+EFV immediately Wmen wh have an elevated serum creatinine (>85 µml/l) shuld be managed accrding t their eligibility fr lifelng antiretrviral therapy based n CD4 cell cunt and clinical staging: Wmen wh d nt require lifelng antiretrviral therapy can cntinue AZT prphylaxis thrughut pregnancy and their infant shuld receive daily NVP until breast feeding cessatin Wmen wh require lifelng antiretrviral therapy shuld be managed accrding t adult guidelines fr lifelng antiretrviral therapy (and receive a triple-drug antiretrviral regimen that des nt cntain tenfvir, eg, AZT+3TC+EFV). Fr wmen wh start a TDF+3TC+EFV at their first antenatal visit, a serum creatinine >85 µml/l indicates the need t stp this regimen immediately. The CD4 cell cunt and clinical staging shuld be reviewed t identify the best antiretrviral ptin fr these wmen: Versin March

31 Wmen wh are nt eligible fr lifelng antiretrviral therapy can be switched t AZT prphylaxis Wmen wh require lifelng antiretrviral therapy shuld be managed accrding t adult guidelines fr lifelng antiretrviral therapy (and receive a triple-drug antiretrviral regimen that des nt cntain tenfvir, AZT with 3TC+EFV). Fr wmen taking TDF+FTC/3TC+EFV wh develp renal cmplicatins during pregnancy, the regimen shuld be stpped if repeated serum creatinine exceeds 85 µml/l. In these instances, AZT shuld be used in the place f TDF+FTC/3TC+EFV fr wmen wh are nt eligible fr lifelng antiretrviral therapy. In wmen wh are eligible fr lifelng antiretrviral therapy, an alternate triple-drug regimen shuld be prescribed per adult antiretrviral guidelines. PSYCHIATRIC ILLNESS Wmen identified as having active psychiatric illness at the first antenatal visit shuld start AZT immediately and return fr review f CD4 cell cunt within ne week. Wmen determined t be eligible fr lifelng antiretrviral therapy based n CD4 cell cunt <350 r clinical staging shuld be managed accrding t adult guidelines fr lifelng antiretrviral therapy (eg, substituting NVP r Lpinavir/ritnavir fr EFV). Wmen wh require prphylaxis nly shuld cntinue t receive AZT twice daily thrughut pregnancy. HEPATITIS B INFECTION TDF and 3TC/FTC are bth active against Hepatitis B. When available, Hepatitis B surface antigen testing shuld be cnducted in wmen befre stpping TDF+3TC/FTC+EFV prphylaxis. If a wman has evidence f hepatitis B infectin, she qualifies fr lifelng ART treatment and must remain n TDF + 3TC/FTC t prevent a hepatitis flare if ARVs stpped. LABORATORY MONITORING FOR ANTIRETROVIRAL PROPHYLAXIS OR TREATMENT Fllwing initiatin f TDF+3TC/FTC+EFV fr prphylaxis r treatment, all wmen require serum creatinine testing after 3 mnths, 6 mnths and 12 mnths. Because standard methds fr the estimatin f glmelular filtratin rate are inaccurate in pregnancy, serum creatinine values <85µml/L shuld be cnsidered nrmal befre delivery. After delivery, interpretatin f serum creatinine values shuld be based n the mdified Ccrft-Gault equatin per adult antiretrviral guidelines. All wmen wh are nt eligible fr lifelng ART during pregnancy (and receive antiretrvirals as prphylaxis) shuld have a repeat CD4 cell cunt 6 mnths after the end f maternal antiretrviral use. In the case f wmen taking TDF+3TC/FTC+EFV thrughut breastfeeding, this means a CD4 cell cunt 6 mnths after the end f breastfeeding. Versin March

32 All wmen wh receive AZT fr prphylaxis (because TDF+FTC+EFV is cntraindicated) require regular (see table belw) haemglbin mnitring during pregnancy. All wmen wh receive TDF+FTC+EFV r anther triple-drug regimen fr antiretrviral treatment require standard mnitring per adult antiretrviral guidelines, including Viral Lad testing 6 mnths and 12 mnths after initiatin and CD4 cell cunt 12 mnths after initiatin. Fr wmen taking Mnitring if n lifelng therapy Mnitring if n prphylaxis nly TDF+3TC/FTC+EFV(FDC) Creatinine at 3, 6 and 12 mnths pst-initiatin Creatinine at 3, 6 and 12 mnths pst-initiatin Viral Lad at 6 and 12 mnths pst-initiatin; CD4 at 12 mnths pst-initiatin AZT nly Haemglbin 1, 2, 3 and 6 mnths pst-initiatin Other triple-drug regiments Per adult ARV guidelines 5.2 INTRAPARTUM MANAGEMENT The wman s HIV 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 OR TREATMENT All HIV-psitive wmen wh started TDF+3TC/FTC+EFV r anther triple-drug regimen during the antenatal perid shuld cntinue t receive this regimen thrughut labur and delivery. Fr wmen wh received AZT during pregnancy (ie, with a cntraindicatin t TDF+3TC/FTC+EFV and nt eligible fr lifelng ART) AZT shuld be given 3-hurly during labur with a single dse f nevirapine (NVP) and stat dse f TDF+FTC at nset f labur. WOMEN NEWLY DIAGNOSED HIV POSITIVE DURING LABOUR Wmen wh are newly diagnsed as HIV psitive during labur shuld receive a single dse f NVP and TDF+FTC and 3 hurly AZT. Fr wmen wh plan t breastfeed, the regimen TDF+3TC/FTC+EFV shuld be initiated (with CD4 cell cunt and serum creatinine testing cnducted) as sn as pssible thereafter. INTRAPARTUM SPECIAL CIRCUMSTANCES Caesarean sectins shuld be perfrmed fr bstetric indicatins and are nt recmmended t reduce mther-t-child transmissin. Wmen wh initiated TDF+3TC/FTC+EFV during the antenatal perid shuld cntinue this regimen thrughut the intrapartum perid and treatment shuld nt be mitted. In the case f an emergency Caesarean sectin in a wman Versin March

33 wh is nt already n an antiretrviral regimen fr prphylaxis r treatment, ensure that the wman receives single dse NVP + 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 POSTDELIVERY 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, almst immediately. All infants shuld start feeding (exclusive breastfeeding is recmmended). Initiate HIV-expsed infants n NVP prphylaxis immediately after birth r very sn after (within 72 hurs windw). Befre leaving the health facility immediately pstpartum: All wmen must be cunselled n the nging risk f HIV transmissin t the infant thrugh breastfeeding, and the need fr maternal antiretrviral use fr prphylaxis and/r treatment, as well as infant prphylaxis. All wmen taking TDF+3TC/FTC+EFV shuld have at least 6 weeks supply f medicatins and shuld knw the name and lcatin f the health facility where they can receive additinal medicatins, as well as the prcedures fr this nging care. All wmen shuld have 6 weeks supply f daily NVP prphylaxis fr their newbrns. All wmen, whether n antiretrviral prphylaxis r treatment, and their infants shuld receive fllw-up at the health facility within the first 3 t 6 days pstpartum, and shuld be seen again at the health facility at 6 weeks pstpartum. In rder fr the recmmendatin abve t be fllwed thrugh crrectly all RTHBs (Rad T Health Bklets) need t be crrectly cmpleted prir t discharge with all relevant infrmatin regarding HIV expsure and PMTCT recrded fr ALL babies n pages 7 & 8 f the RTHB. This is a manadatry requirement and NOT ptinal. Infants shuld be vaccinated per EPI guidelines. BCG vaccine must be given unless the mther has active TB and has been n treatment fr less than 2 mnths prir t Versin March

34 delivery. If the mther has active TB, the infant must be screened fr cngenital TB* and INH prphylaxis r TB treatment started as apprpriate (per Natinal TB guidelines) and BCG vaccinatin deferred. Infant testing shuld be dne at 6 weeks (see sectin n infant testing). Cntraceptin and cervical screening shuld be discussed and ffered t all wmen after delivery befre discharge and at subsequent visits Onging psychscial supprt shuld address the fllwing: Maternal adherence t antiretrviral regimen TDF+3TC/FTC+EFV regardless f whether this is fr prphylaxis r treatment Adherence t infant daily nevirapine prphylaxis fr 6 weeks Safe infant feeding, including exclusive breastfeeding Scial security issues Child health Psitive preventin fr HIV & AIDS STOPPING MATERNAL PROPHYLAXIS Wmen wh initiated TDF+FTC+EFV (FDC) fr prphylaxis during pregnancy r immediately pstpartum shuld cntinue this regimen until 1 week after the cessatin f all breastfeeding. Prir t discntinuatin hepatitis B infectin shuld be excluded and HIV staging, including screening fr TB disease, cmpleted. Wmen with stage 3 r 4 disease r hepatitis B infectin shuld cntinue ART lifelng. Repeat CD4 cell cunts shuld be dne in case the last CD4 cunt was dne mre than 12 mnths ag. INFANT PROPHYLAXIS Antiretrviral prphylaxis given immediately r 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. Infants brn t HIV-psitive wmen shuld receive daily nevirapine fr 6 weeks, with dsing determined as fllws: If birth weight 2500 grams: 15mg If birth weight grams: 10mg If birth weight <2500 grams: 2mg/kg Versin March

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