PMTCT
Objectives of this Presentation
• Definition of mother to child transmission
• To describe the global response to PMTCT
• To implement the essential programmatic
components of PMTCT
– The four pillars of PMTCT
– The elements of the PMTCT cascade or sequence
– PMTCT /Sexual Reproductive Health (SRH) integration
• To implement evidence based solutions to address
the challenge of retention in PMTCT programmes
Mother-to-child transmission of HIV
• The transmission of HIV from a HIV-positive
mother to her child during pregnancy, labour,
delivery or breastfeeding is called mother-to-
child transmission.
• In the absence of any intervention,
transmission rates range from 15% to 45%.
This rate can be reduced to below 5% with
effective interventions during the periods of
pregnancy, labor, delivery and breastfeeding.
In the absence of breast-feeding, an estimated
50 to 70% of transmissions occur around the
time of delivery, with the remainder occurring in
utero.
WHO advises that all pregnant and
breastfeeding women should receive ART
irrespective of clinical stage of disease or CD4
count.
Risk Factors for MTCT
Maternal Factors:
• High maternal viral load
• Low CD4 count
• Advanced maternal disease
• Viral or parasitic placental infections during
pregnancy, labour and childbirth
• Maternal malnutrition ( including iron and folate,
vitamin A, and zinc deficiencies)
• Nipple fissures, cracks, mastitis and breast abscess
Infant factors
• First infant in multiple birth
• Preterm low birth weight
• Duration of breastfeeding
• Mixed feeding
• Oral diseases in child
HIV prevention strategies
1. Condom use
2. Education
3. HIV prevention for key population
4. HIV post exposure prophylaxis
5. Male circumcision
6. New HIV prevention technologies
7. Prevention of mother to child transmission
8. Social and behavior change
Global PMTCT Coverage
77% coverage of ART in PMTCT
29% Nigeria
95% South Africa
Souce WHO Global Health Sector Response to HIV 2000-2015
The four pillars of PMTCT ?
4. Keeping mum ,
3. Testing and
1 dad and any
2. Family Planning ARV Intervention
Primary positive baby alive
for mum and baby
prevention as well
Pillar 1 : Primary prevention of HIV
• 8 elements of prevention in antenatal and postnata
care ( WHO 2017)
– HIV testing
– HIV TESTING SERVISES for all sexual and drug injecting
partners
– Partner referral for ART if HIV positive
– Male partner referral for voluntary medical male
circumcision (VMMC)
– STI screening and management
– Condom promotion
– Risk reduction counselling
– Offer, start or continue Pre-exposure propylacses (PreP)
Primary prevention in pregnancy
in context of Pre-exposure
Prophylaxis
Who to prioritise for PreP
• Assessment of ongoing risk ( risk scores may be used)
– Unknown partner status in high prevalence
settings
– HIV positive partner not on ART or with unknown
viral load
– Current STI including syphilis
– High risk exposures ( female sex work ; injecting
drug use)
Pillar 2: Family Planning
• All HIV positive women should have access to family
planning and should be given a choice of methods
• FP services should be integrated into ART clinics and
provided as a one stop service
• For stable HIV clients receiving a differentiated model of
ART refill, provision for FP must be made – ideally
through use of a long lasting method or community
delivery of FP
• Women should also be encouraged to “ plan their
families” – aiming to conceive when they are well and
their viral load is suppressed
Cont…..
• Longs acting methods are preferred
– IUDs and IUS devices can be safely used by HIV positive
women
– Progestogen injections can be safely used – refer to local
guidelines for frequency of use
• Oral combined contraceptives should not be used in
combination with Non-Nucleotide Reverse Transcriptase
Inhibitors NNRTIs
• There is some evidence that the effectiveness of implants
may be reduced when used in combination with EFV based
regimens. However where supply of other forms of
contraception may be limited this may remain an acceptable
option.
• Use of condoms should be advised with all contraception
methods
Pillar 3: The PMTCT cascade/prosess
Attending Community awareness to increase ANC attendance early
ANC Use of pregnancy tests at community level
Exposed
HAART HAART HAART
Testing antenatal Delivery Postnatal
baby follow
up
HIV Testing and Re-testing
• All pregnant women with unknown or negative status should
be tested at their first antenatal visit
• Re-testing of HIV negative women is then recommended in
the third trimester , at delivery ( depending on timing of
previous test) and regularly ( 6 mthly ) during breast feeding
• Re-testing identifies sero-convertors and is an opportunity to
re-identify those lost to follow up
• Where to re-test postnatally to catch these women? Re-
testing may be integrated into EPI
• In low prevalence settings the frequency of re-testing should
be adapted
Antiretroviral Interventions for PMTCT: The
Mother
• All HIV positive women should be started on
lifelong TDF 3TC EFV when diagnosed
antenataly, at delivery or postnataly
Strategies to support maternal
retention in PMTCT
• Integration of PMTCT and SRH(sexual and
reproductive health) Services: ante-natally, at
delivery and postnatally ( mother infant pair
clinics/ family approach)
• Quality counselling and adherence support
• Peer to peer support – “ Mother Mentors”
• Male involvement – invitation letters
• Community engagement and awareness
Patient Tracing
Identification of missed appointments Communication to tracer
Tracer communicates back to Tracer calls or visits patient
Viral Load Monitoring in PMTCT
• WHO does not currently make any different recommendation
regarding the timing or frequency of VL testing in PMTCT
– For clients already on ART to perform a VLT at first
antenatal visit if previous VLT more than 3-6 months ago
– For newly initiated clients to perform the first VLT at 3
months
– For women initiating ART to perform the first VLT earlier
( mth 3 on ART)
– To increase frequency of VLT during pregnancy and breast
feeding to 6 monthly
Management of the exposed
infant
Antiretroviral prophylaxis for the
exposed infant
• The choice of antiretroviral prophylaxis for the exposed
infant will depend on whether the infant is classified as
high or low risk
• WHO defines a high risk HIV exposed baby to be born to
mother
– born to women with established HIV infection who have received less than
four weeks of ART at the time of delivery, OR
– born to women with established HIV infection with VL >1000 copies/mL in
the four weeks before delivery, if VL available, OR
– born to women with incident HIV infection during pregnancy or
breastfeeding, OR
– identified for the first time during the postpartum period, with or without a
negative HIV test prenatally
con….
• Low risk babies should • High risk babies should
receive receive
– If breastfeeding 6 weeks – dual prophylaxis with
of infant prophylaxis daily AZT and NVP for 6
with daily NVP weeks whether they are
– If having replacement breast or formula fed
feeding they should – Breast fed high risk
receive 4-6 weeks of infants should continue
daily NVP ( or twice NVP or AZT alone for a
daily AZT) further 6 weeks
prophylaxis for the exposed infant
• All exposed infants should start cotrimoxazole
prophylaxis at 6 weeks
• Cotrimoxazole prophylaxis is stopped once
negative HIV status is confirmed 12 weeks
after cessation of breastfeeding
HIV testing of exposed infants
• All exposed infants should be tested between 4-6 weeks using
nucleic acid testing ( NAT)
• If tested negative at birth exposed infants should be re-tested
at 6 weeks
• Exposed infants are then re-tested with antibody test at 9
months , 3 mths after cessation of breast feeding and at any
time the child presents with symptoms suggestive of HIV.
END
