PMTCT and Baby-Friendly Initiatives

Tariro Mahonde
Mary Macheso
Tapiwa Maoni
Kelvin Makwinja
Supervisor: Professor V. Mwapasa
Outline

1. Burden and trend of pediatric HIV infection and HIV related death,
globally and in Malawi
2. Modes of transmission of pediatric HIV
3. Timing on HIV MTCT in breastfeeding and non-breastfeeding
populations
4. Risk and protective factors for HIV MTCT
Outline continued

5. World Health Organization's goal and strategy for elimination of

HIV MTCT and extent of strategy implementation in Malawi
6. Major changes in HIV PMTCT regimens in Malawi from ARV
prophylaxis to Option B+.
7. Major implementation challenges with the current eMTCT strategy
and possible solutions
Burden of HIV

• Globally 1.4 million children (<15 years old) live with HIV .
• 87% of these children live in Sub-Saharan Africa
• 76 000 died from HIV related causes
• 66% of children knew their HIV status, 57% of children living with HIV
globally were receiving antiretroviral treatment and 48% had a suppressed
viral load
• Everyday about 685 children became infected with HIV
• 250 children died from AIDS related causes
Burden of HIV continued
• In 2023, there was a 10 % mother-to-child HIV transmission rate,
including perinatal and postnatal infections
• 120 000 new infections
• 2030 target for elimination of MTCT is <50,000 annual infections
 Global number of annual new infections among
children aged 0-14

Number
of new
infections

Years
Number of new HIV infections among children by
source of infection globally in 2023

Number of new
HIV infections
 Global number of AIDS-related deaths among
children aged 0–14 years

Number of
AIDS related
deaths

Year
Number of children aged 0-19 years living
with HIV in Sub-Saharan Africa in 2023

Number of children living with HIV

Number of annual new HIV infections in
children and adolescence in Malawi
Number of
new
infections

Years
Number of children and adolescence living with
Malawi

Number of
children and
adolescence
living with
HIV

Years
Number of AIDS-related deaths in Malawi

Number of
AIDS-related
deaths

Years
Modes of paediatric HIV transmission

• Mother to child transmission ( accounts for 95% of MTCT)

• Pregnancy
• Childbirth
• breastfeeding
• Unprotected sexual contact with an HIV infected person
• Sexual abuse
• Blood contamination during blood transfusion
• Less common modes
• Sharing of blood contaminated items during traditional/cultural processes
OVERALL MTCT PERCENTAGE IN BREAST-
AND NON-BREASTFEDERS
 RISK FACTORS FOR MTCT
1. ANTENATALLY
• High viral load
• Low CD4 count for advanced AIDS
• STIs: genital ulcer disease including HSV2 and syphilis
• Advanced maternal disease with immunosuppression and
malnutrition
2. BEHAVIOURAL FACTORS
• Illicit drug use during pregnancy
• Frequency of unprotected sexual intercourse during pregnancy
• Number of sex partners during pregnancy
RISK FACTORS FOR MTCT CONT…
3.INTRAPARTUM
• Prolonged labor
• Preterm rapture of membranes
• Assisted vaginal deliveries, episiotomy
4.POSTNATALLY
• Prematurity
• Infant feeding practices: breastfeeding, mixed feeding,
premastication
• Oral infant diseases
• Breast abscesses, nipple fissures, mastitis
• Poor maternal nutrition status
PROTECTIVE FACTORS FOR MTCT

• HIV1 (genetics)
• Maternal nutrition
• Viral suppression
• Caesarean delivery
• Maternal high CD4 count
• Good sexual practices
• Early antenatal visits
• Post exposure prophylaxis
PMTCT vs eMTCT

Elimination of infections: Reduction to zero of the incidence of infection caused by a

specific agent in a defined geographical area as a result of deliberate efforts;
continued measures to prevent re-establishment of transmission are required.
-CDC
WHO goals for eliminating HIV MTCT

• Target: Reduce new HIV infections among children to less than 50 per
100,000 live births by 2030.

• Transmission Rate: Achieve a mother-to-child transmission rate of

HIV below 5% in breastfeeding populations and below 2% in non-
breastfeeding populations.
Malawi goals for e-MTCT
•
Reduce the MTCT rate at the end of the breastfeeding period from 7.6% to less
than 5% by 2025.

• Reduce the case rate of new paediatric HIV infections due to MTCT from 715
cases/100,000 live births to less than 350 cases/100,000 live births by 2025.

• Reduce the estimated number of new infections among children less than 15 years
old from 4,300 in 2016 to less than 1,000 in 2025.
Malawi objectives for eMTCT goals

• Maintain ART coverage of at least 95% among HIV-positive pregnant and

postpartum women.

• Reduce unmet need for family planning among HIV+ postpartum women to less
than 10%.

• Achieve the 90-90-90 targets among infants born to HIV positive women.

• Achieve HIV screening coverage of at least 80% among spouses/partners of

pregnant or postpartum women
WHO Strategies for e-MTCT

• Prong 1:Prevention of HIV among women of reproductive age within

services related to reproductive health such as antenatal care,
postpartum and postnatal care and other health and HIV service
delivery points, including working with community structures.

• Prong 2:Providing appropriate counselling and support, and

contraceptives, to women living with HIV to meet their unmet needs
for family planning and spacing of births, and to optimize health
outcomes for these women and their children.
WHO Strategies for e-MTCT continued

• Prong 3:For pregnant women living with HIV, ensure HIV testing and
counselling and access to the antiretroviral drugs needed to prevent
HIV infection from being passed on to their babies during pregnancy,
delivery and breastfeeding.

• Prong 4:HIV care, treatment and support for women, children living
with HIV and their families.
Four prongs/strategies of PMTCT

Prong 1:Primary prevention of HIV in the general population

Prong 2: Preventing unintended pregnancies among women living with
HIV
Prong 3: Preventing HIV transmission from women living with HIV to
their infants
Prong 4: Providing appropriate treatment, care, and support to mothers
living with HIV and their children and families.
Prong 1:Primary prevention of HIV in the general
population
•Behaviour change communication to reduce risky sexual contacts
•Provision of condoms
•Voluntary medical male circumcision for HIV negative men
•Scale-up of HIV testing in high-yield settings for early diagnosis and
ART referral
•ART provision for all HIV infected adults and children, (regardless of
CD4 count and/or clinical stage)
•Viral load monitoring and timely switch to 2nd or 3rd line for patients
on ART
•PrEP & PEP
Prong 2: Preventing unintended pregnancies among
women living with HIV
• Provider initiated family planning in ART clinics
• Intensify SBCC to increase demand for and uptake of SRH and HIV
prevention services by AGYW
• Promote integration of SRHR and HIV services in service delivery
clinics
• Increase access and service delivery points
Prong 3: Preventing HIV transmission from women
living with HIV to their infants
•Provider initiated testing at MNCH settings for early HIV diagnosis
and ART initiation
•Initiation of lifelong ART for all HIV infected pregnant and
breastfeeding women
•Safe obstetric practices
•Provision of exposed infant with HIV prophylaxis with 2P or
Nevirapine
•Infant feeding advice to reduce the risk of transmission through
breastmilk
Major changes in HIV PMTCT regimens

• To achieve prong 3 for PMTCT a lot of drugs were used over the years
from ARV prophylaxis in 2008 till now:
Key points
AZT - Zidovudine
3TC - Lamivudine
NVP - Niverapine
sdNVP - Single dose Niverapine
ARV Prophylaxis in 2008

• AZT was to be given to mothers from 28 weeks

• Then a sdNVP and AZT/3TC was given during labor until 1 week
after delivery
• NVP syrup was given to the infant for 1 week or more depending on
the duration of exposure of the mother to ARVs
Rationale of the changes

• Simplify delivery of PMTCT services

• Accelerate the reduction of HIV transmission in Malawi
• Strengthening of linkages between reproductive health and ART
programmes
• Protection against MTCT in future pregnancies
• Avoiding Stopping and Restarting ART
• Reduced risk of resistance to ART drugs
• Reduced the possibility of ART defaulters or even lost to follow up
Comparison of options A , B & B+
OPTION ADVANTAGE DISADVANTAGE
A Reduction of MTCT Requires baseline CD4
Infant NVP until stopping breastfeeding
B Did not require CD4 count test ART stopped after breastfeeding
NVP was given up to 6wks Increased risk of HIV transmission
Lack of compliance with breast feeding advice
B+ Increase ART coverage High rate of loss to follow up of mom and baby
Avoids stopping and restarting Increased number of defaulters
ART

Did not require CD4 count

Simplified integration of services
Prong 4: Treatment, care, and support to mothers
living with HIV ,their children and families.
• Integrating HIV clinical services
• Routine ascertainment of HIV exposure status for children under 24
months
• Preventive services for HIV patients
• Cotrimoxazole preventive therapy (CPT)
• TB Preventive Therapy (TPT)
• Management of non-communicable diseases
• Special treatment support for children and adolescents
Recommended infant care and child feeding
Infant feeding practices

• In high income settings replacement feeding is safe , affordable ,

culturally accepted and hence recommended
• In low income settings where resource limitations exist WHO
recommends HIV infected women to breast feed while the mother or
infant receives ART/ prophylaxis
• Breast feeding contraindicated in presence of mastitis
• HIV transmission is lower with exclusive breast feeding rather than
mixed feeding
• Pre-mastication is a risk factor for HIV transmission
Routine ascertainment of HIV exposure/infection in
children under 24 months in Malawi
Paediatric HIV diagnosis methods and their
challenges
DIAGNOSTIC METHOD CHALLENGE
DNA-PCR • Limited laboratory infrastructure,
equipment and trained personnel
• Difficulty transporting samples from
rural areas to the laboratory
• High losses to follow-up of HIV
exposed infants
Rapid antibody test • Not reliable in breastfeeding children
• Does not provide viral load
information
• Need for other confirmatory tests to
rule out false positives
eMTCT implementation challenges and possible
solutions
Prong 1 Challenges Solutions to prong 1
• Negative socio-cultural factors  Develop and implement campaigns on:
 Behaviour change communication,
 universal and targeted HIV Testing
• Stigma and discrimination and Counselling
 ART adherence
 Increased use of male and female
• Poor awareness of eMTCT programmes condoms, PEP and

• Insufficient HIV testing coverage of male  HIV self-test to male partners

partners  Male partner involvement in ANC and
PITC for them
eMTCT implementation challenges and possible
solutions
Prong 2 Challenges Solutions to prong 2

High proportion of unintended pregnancies • Scale up integration of family planning

in HIV-positive women
services with other SRH/HIV service to
expand coverage
• Intensify counselling and provision of
wide range of family planning methods to
HIV positive women
eMTCT implementation challenges and possible
solutions
Prong 3 Challenges Prong 3 Solutions
• Late presentation to ANC, delaying of • Disseminate information on eMTCT to
HIV testing and linkage to ART the community and train health workers.
• More children getting infected during • Provision of infant HIV prophylaxis with
breastfeeding than during the pregnancy 2P or Nevirapine and lifelong ART for
period all HIV infected pregnant and
breastfeeding women
• Unsafe obstetric practices i.e. TBAs • Safe obstetric practices
• Lack of routine viral hepatitis screening • HIV, syphilis and hepatitis B status
and stock-outs of syphilis test kits in ascertainment at prenatal and perinatal
ANC
eMTCT implementation challenges and possible
solutions cont’d

Prong 4 challenges:. Prong 4 solutions:

• The low uptake of ART among  Routine ascertainment of HIV
children living with HIV exposure status for children under 24
months
• Suboptimal ART regimen for children  Scale up care, treatment and support
• Underdiagnosis of HIV-related for HIV-infected women and their
diseases and opportunistic infections children and families
• Limited service integration, mainly Integrating HIV clinical services and
because of infrastructure challenges mother/infant follow-up
and staff shortages
Retention of mother-infant care in eMTCT

• This is attributed in large part to sub optimal adherence and retention of

mother-infant pairs after childbirth
• For countries to achieve the retention in eMTCT
• Mothers and their infants must remain in care throughout the cessation of
breastfeeding and beyond
Summary
References

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