HIV stands for Human Immunodeficiency Virus and can be transmitted through sexual contact, blood transmission, or from mother to child. There are two types of HIV, HIV-1 being more prevalent. HIV progresses to AIDS by weakening the immune system over time. Prevention of mother-to-child transmission (PMTCT) aims to prevent HIV transmission from mother to child during pregnancy, birth, or breastfeeding through testing, treatment, and replacement feeding. Antiretroviral therapy can suppress HIV and slow disease progression.

1. HIV AND PREVENTION OF MOTHER-TO-CHILD
TRANSMISSION (PMTCT)
By Gebremaryam T.

2. Cont…
HIV stands for Human Immunodeficiency Virus.
• Human: Infecting human beings
• Immunodeficiency: Decrease or weakness in
the body’s ability to fight off infections and
illnesses
• Virus: A pathogen having the ability to
replicate only Inside a living cell

3. Types of HIV Virus
There are two types of HIV virus:
• HIV 1 is most common in sub-Saharan Africa and throughout the
world. HIV 1 can be divided into groups M, N, and O.
 The pandemic is dominated by Group M, which is composed of
subtypes A – J.
• HIV 2 is most often found in West Central Africa, parts of Europe and
India.
Both produce the same patterns of illness. Both are RNA viruses
with single strand of genetic materials.
HIV 2 causes a slower progression of disease than HIV 1.
It is important for tests to detect the HIV subtypes that are present in
the region.
• Otherwise, testing may lead to false negative results.

4. Structure of HIV cell

5. Cont…
• Like all viruses, HIV virus is made up of 2 main
elements:
 the external envelope, and
 the internal core.
• Core p24
• RNA Reverse Transcriptase
• Envelope
• HIV is in a family of viruses called retrovirus

6. AIDS stands for:
Acquired: To come into possession of
something new
Immune Deficiency: Decrease or weakness in
the body’s ability to fight off infections and
illnesses Syndrome: A group of signs and
symptoms that occur together and
characterize a particular abnormality
AIDS is the final stage of the disease caused by
infection with the virus.

7. Cont…
• HIV is the virus that causes AIDS. Not
everyone who is infected with HIV has AIDS.
• AIDS is the result of progression of HIV
Infection. Anyone infected with HIV, although
healthy, can still transmit the virus to another
person.
• HIV infection leads to a weakened immune
system. This makes a person with HIV
vulnerable to infections.

8. Cont…
• AIDS results when HIV infection progresses to
an advanced stage, damaging the immune
system to a point at which the body can no
longer fight illness..
• Drugs treat HIV and AIDS are called antiretro
virals (ARVs).
• They prevent the virus from replicating and
slow the progress of the disease.

9. 9
Modes of HIV Transmission
• Sexual intercourse
• Accidental exposure to blood/blood
products (e.g., blood transfusions, shared
needles, contaminated instruments)
• Mother to child during:
– pregnancy
– birth
– breastfeeding

10. 10
HIV Transmission Through Sexual
Contact
• Of every 100 HIV infected adults, 75-85
have been infected through unprotected
intercourse
– 70% of these infections are from heterosexual
intercourse
• STDs, especially ulcerative lesions in
genitalia, increase risk of transmission
Source: UNAIDS/WHO 1996.

11. HIV Transmission from Mother to
Infant
• Antenatal
– In utero by transplacental passage
• Intranatal
– Exposure to maternal blood and vaginal secretions
during labor and delivery
• Postnatal
– Postpartum through breastfeeding

12. 12
HIV Transmission
HIV cannot be transmitted by:
– Casual person to person contact at home or work
or in social or public places
– Food, air, water
– Insect/mosquito bites
– Coughing, sneezing, spitting
– Shaking hands, touching, dry kissing
– Swimming pools, toilets, etc.

13. 13
Women and HIV
Social Risk Factors
– Illiteracy
– Lack of awareness of preventive measures
Biological risk factors
– Twice as easy for women to contract HIV from men
– Physiology of women (e.g., menstruation, intercourse)
– Pregnancy-associated conditions (e.g., anemia, menorrhagia
and hemorrhage) increase the need for blood transfusion
Economic
Cultural
Behavioral factors

14. 14
HIV and Contraception
• Contraception with protection
– Male condom (latex and vinyl)
– Female condom
– Nonoxynol-9 (antiviral spermicidal cream)1
– Diaphragm1
• Methods appropriate for use by women with
HIV. They should use a condom for their
partner’s protection.
– Hormonals (COCs, Implants)
– Voluntary sterilization
1Partial protection if used without condom

15. 15
Effect of AIDS on Pregnancy
• Infertility
• Repeated abortions
• Prematurity
• Intrauterine growth retardation
• Stillbirths
• Congenital abnormalities
• Embryopathies

16. BENEFITS TO HIV TESTING
• Early counseling and treatment of hiv
infection
• Ability to make decisions regarding pregnancy
• Implementation of strategies to attempt to
prevent transmission to fetus
WHO SHOULD WE SCREEN
• ALL: pregnant women
• TARGETED TESTING FAILS TO IDENTIFY A
SUBSTANTIAL PROPORTION OF HIV POSITIVE
WOMEN

17. HIV infection can be measured in
terms of:
• The amount of virus circulating in the body –
called the viral load
• The amount of antigen – p24 antigen
circulating in the body
• Proteins or cells that protect the body against
infection – IgG and IgM antibodies, and CD4
cells

18. Measuring human response to HIV
infection: B and T cells
• T and B cells are types of white blood cells called
lymphocytes that provide protection against
infection.
• B cells are responsible for producing antibodies.
• There are three types of T cells.
 Helper T-Cells (also called CD4+ cells) help
other cells destroy infective organisms.
 Suppressor T-Cells (also called CD8+ cells)
suppress the activity of other lymphocytes so
they don’t destroy normal tissue.

19. Cont…..
• Killer T-Cells (also called cytotoxic T
lymphocytes, or CTLs, and are another kind of
or CD8+ cell)
recognize and destroy abnormal or infected
cells.
Over a period of time, HIV infects and kills
white blood cells called CD4 lymphocytes or
(T cells), leaving the body unable to fight off
certain kinds of infections.

21. Window period
• the phase when individual infected with HIV,
but antibody levels are not detectable.
• One may test false-negative for HIV
antibodies, and can still pass the virus to
others during this period.
• What occurs during the window period is
called seroconversion:

22. Cont…
• Seroconversion” is a term used to describe the
change from non-detectable to detectable
antibody levels.
• Specimen may test initially non-reactive, but
change to testing reactive after a certain time
period.
• Seroconversion occurs generally 3-8 weeks
after the initial infection

23. Disease Progression

24. progression may be delayed by:
• Prevention and early treatment of
opportunistic infections (OIs)
• Antiretroviral therapy
• Positive living

25. The HIV Life Cycle
1 . Binding and Fusion
HIV begins its life cycle when it binds to a CD4
receptor and one of two co-receptors on the
surface of a CD4+ T-lymphocyte.
The virus then fuses with the host cell. After
fusion, the virus releases RNA, its genetic
material, into the host cell

26. Life cycle cont…
2 . Reverse Transcription:
An HIV enzyme called reverse transcriptase
converts the singlestranded HIV RNA to
double-stranded HIV DNA

27. Life cycle cont…
3 . Integration:
The newly formed HIV DNA enters the host
cell's nucleus, where an HIV enzyme called
integrase "hides" the HIV DNA within the host
cell's own DNA.
The integrated HIV DNA is called provirus. The
provirus may remain inactive for several years,
producing few or no new copies of HIV

28. Life cycle cont…
4 . Transcription
When the host cell receives a signal to
become active, the provirus uses a host
enzyme called RNA polymerase to create
copies of the HIV genomic material, as well as
shorter strands of RNA called messenger RNA
(mRNA). The mRNA is used as a blueprint to
make long chains of HIV proteins

29. Life cycle cont…
5 . Assembly
An HIV enzyme called protease cuts the long
chains of HIV proteins into smaller individual
proteins. As the smaller HIV proteins come
together with copies of HIV's RNA genetic
material, a new virus particle is assembled

30. Life cycle cont…
6 . Budding:
The newly assembled virus pushes out ("buds") from
the host cell.
During budding, the new virus steals part of the cell's
outer envelope.
This envelope, which acts as a covering, is studded with
protein/sugar combinations called HIV glycoprotein.
These HIV glycoprotein are necessary for the virus to
bind CD4 and co receptors.
The new copies of HIV can now move on to infect other
cells

31. WHO Staging System
for HIV in Adults and Adolescents
Clinical stage I
• Asymptomatic
• Persistent generalized lymphadenopathy
Performance scale 1: asymptomatic, normal
activity

32. Clinical Stage 2
Recurrent bacterial RTI (two or more in any six-month
period)Symptom complex, e.g. unilateral face pain with
nasal discharge (sinusitis) or painful swollen eardrum
(otitis media), cough with purulent sputum
(bronchitis), sore throat (pharyngitis).
Two or more documented occurrences of antibiotic
responsive URTI.
Herpes zoster
Painful rash of small fluid filled blisters in distribution of a
nerve supply, can be hemorrhagic on erythematous
background, and does not cross midline. Current or in
the last two years. Severe or frequently recurrent
herpes zoster is usually associated with more advanced
HIV disease.

33. Stage 2 cont…
Angular cheilitis
• Splits or cracks on lips at the angle of the
mouth with depigmentation, usually responds
to antifungal treatment but may recur. Also
common in nutritional deficiency, e.g. of B
vitamins.
• Recurrent oral ulcerations occurring twice or
more in six months Aphthous ulceration,
typically with a halo of inflammation and a
yellow-grey pseudomembrane.

34. Papular pruritic eruptions
• Papular pruritic vesicular lesions. Also common in
uninfected adults. Note: scabies and obvious insect
bites should be excluded.
Seborrhoeic dermatitis
Itchy scaly skin condition, particularly affecting scalp,
face, upper trunk and perineum. Also common in
uninfected adults.
Fungal nail infections of fingers
Fungal paronychia (painful red and swollen nail bed) or
onycholysis (separation of the nail from the nail bed) of
the fingernails. Also common in uninfected adults.
Proximal white subungual onchomycosis is uncommon
without immunodeficiency.

35. Clinical Stage 3
• Unexplained chronic diarrhoea for longer than
one month Chronic diarrhoea.
• Unexplained persistent fever (intermittent or
constant and for longer than one month)Reports
of fever or night sweats for more than one
month, either intermittent or constant with
reported lack of response to antibiotics or
antimalarials. No other obvious foci of disease
reported or found on examination.

36. Cont….
• Oral candidiasis Persistent creamy white to
yellow soft small plaques on red or normally
colored mucosa which can often be scraped
off (pseudo membranous), or red patches on
tongue, palate or lining of mouth, usually
painful or tender (erythematous form), not
responding to local antifungal treatment.

37. Stage 3….
• Oral hairy leukoplakia Fine small linear patches
on lateral borders of the tongue, generally
bilaterally, which do not scrape off.
• Acute necrotizing ulcerative
• gingivitis or necrotizing ulcerative periodontitis
Severe pain, ulcerated gingival papillae, loosening
of teeth, spontaneous bleeding, bad odour, and
rapid loss of bone and/or soft tissue.
• Unexplained anaemia (<8g/dl), neutropenia
(<1000/mm3) or thrombocytopenia (<50 000/
mm3) for more than one month

38. Stage four
• Extrapulmonary/disseminated TB
• Systemic illness usually with prolonged fever,
night sweats, weakness and weight loss.
• Clinical features of organs involved, e.g. focal
lymphadenopathy, cold abscess, sterile pyuria,
pericarditis, ascites, pleural effusion, meningitis,
arthritis, CXR may reveal diffuse uniformly
distributed small miliary shadows Response to
standard anti-TB treatment in one month.

39. Stage four cont…
• Kaposi’s sarcoma Typical appearance in skin or
oropharynx of persistent, initially flat, patches
with a pink or blood-bruise colour, skin lesions
that usually develop into nodules. Can be
confused clinically with bacillary angiomatosis,
non-Hodgkin lymphoma and cutaneous fungal or
bacterial infections.
• CMV (retinitis or CMV infection of an organ other
than liver, spleen or lymph nodes)
• Retinitis only.

40. Stage four cont…
• CNS toxoplasmosis Fever, headache, focal
neurological signs, convulsions.
• Rapid response (within 10 days) to high-dose co-trimoxazole,
or pyrimethamine and sulphadiazine
or clindamycin.
• Cryptococcal meningitis or other
extrapulmonary Cryptococcus infection
Meningitis: usually subacute, fever with
increasing severe headache, meningism,
confusion, behavioural changes.
• Responds to antifungal therapy.

41. Cont…
• HIV encephalopathy Clinical finding of
disabling cognitive and/or motor dysfunction
interfering with activities of daily living,
progressing over weeks or months in the
absence of a concurrent illness or condition
other than HIV infection which might explain
the findings. Sever HSV
© Slice of Life and Suzanne S. Stensaas

42. Clinical management
Clinical events pre-ART Action
• Stage 1 No action required
• Stage 2 Requires cotrimoxazole
• Stage 3 Or Stage 4
Requires cotrimoxazole if not already started
Consider ART

43. Diagnosis
• ELISA test with a sensitivity of >99.5 percent.
• Western blot or immuno fluorescence assay (IFA),
both of which have high specificity.
• According to the Centers for Disease Control and
Prevention, antibody can be detected in most patients
within 1 month of infection, and thus, antibody
serotesting may not exclude early infection.
• For acute primary HIV infection, identification of viral
p24 core antigen or viral RNA or DNA is possible. False-positive
confirmatory results are rare

44. Dx cont…
• “rapid” HIV test performed to women with
limited prenatal care or with undocumented HIV
status.
These tests can detect HIV antibody in 60
minutes or less and have sensitivities and
specificities comparable with those of
conventional ELISAs.
A negative rapid test result does not need to be
confirmed.
A positive rapid test result should be confirmed
with a Western blot or IFA test.

45. Pharmacology

46. Classes of Antiretrovirals
• NRTIs
– Nucleoside reverse transcriptase inhibitors
– Nucleotide reverse transcriptase inhibitors (NtRTI)
• NNRTIs – non-nucleoside reverse transcriptase
inhibitors
• PIs – protease inhibitors
• Fusion Inhibitors and entry inhibitors
Enfuvirtide
Maraviroc
46

47. ARVs and the HIV Lifecycle
47

48. Nucleoside Reverse
Transcriptase Inhibitors (NRTIs)
48
RNA DNA
Nucleus
Host Cell

49. Types of NRTIs
• Zidovudine (AZT)
• Stavudine (d4T)
• Lamivudine (3TC)
• Didanosine (ddI)
• Abacavir (ABC)
• Zalcitabine (ddC)
• Emtricitabine (FTC)
• Tenofovir (TDF)-Nucleotide RTI
49

50. Non-Nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
50

51. Non-Nucleoside Reverse
Transcriptase Inhibitors
• NNRTIs
– Nevirapine (NVP)
– Efavirenz (EFV)
– dilavirdine
51

52. Protease Inhibitors (PIs)
52
DNA
Host Cell

53. Protease Inhibitors (2)
• Lopinavir + Ritonavir
• Nelfinavir
• Saquinavir-HGC
• Indinavir
• Fosamprenavir
• Atazanavir
• Ritonavir
53

54. Antiretroviral Drugs
First Line Second Line
AZT or d4T
and
3TC
and
NVP or EFV
ABC, TDF, or AZT
and
ddI
and
Lop/r, SQV/r, NFV,
IND/r
54

55. 2003 vs. 2005 WHO Guidelines
55

56. PMTCT
• PMTCT is a term used to describe a package of
services comprehensive cares intended to reduce
the risk of mother-to-child transmission of HIV in
intrauterine, labor and delivery, post partum and
breast feeding.
• With out intervention the risk of MTCT is 20-45%

57. • approximately 600,000 HIV-infected infants are
born every year–at least 1,600 every day–in
resource-constrained countries.
• Transmission occurs during pregnancy, labor and
delivery, and breastfeeding.
• The rate of mother to child transmission has
been reduced to less than 5 percent among the
limited number of HIV-infected women in
developed countries.

58. • high rates are largely due to the
lack of access to:
–HIV voluntary counseling and testing
– replacement feeding
–selective caesarean section
–antiretroviral drug therapy

59. 59
AIDS and Infants
• Symptoms generally develop by 6 months of
age
– Diarrhea
– Failure to thrive
• Most of these children die before their second
birthday
• Children born to HIV-infected parents are
likely to become orphans

60. Reducing pediatric HIV infection and
disease involves three stages:
• preventing HIV infection among women of
childbearing age
• preventing unwanted pregnancy among HIV-positive
women
• preventing mother to child transmission
during pregnancy, labor and delivery, and
breastfeeding

61. Risk factors for MTCT; contd…
Obstetrical
• Prolonged rupture of
membrane (longer
than 4 hours)
• Mode of delivery
• Intrapartum
hemorrhage
• Obstetrical procedures
• Invasive fetal
monitoring
Fetal
• Prematurity
• Genetic
• Multiple pregnancy
Infant
• Breastfeeding
• Gastrointestinal tract
factors
• Immature immune
system
61

62. PMTCT….
Estimated Risk of MTCT
Timing Transmission Rate Without Any
Interventions
• During pregnancy 5-10%
• During labor and delivery 10-15%
• During breastfeeding 5-20%
• Overall without breastfeeding 15-25%
• Overall with breastfeeding to six months 20-35%
• Overall with breastfeeding to 18-24 months 30-45%
Note: Rates vary because of differences in population
characteristics such as maternal CD4+ cell counts, RNA
viral load and duration of breastfeeding.

63. PMTCT with Antiretroviral drugs
All pregnant and breastfeeding women infected with
HIV should initiate triple ART, which should be
maintained for life long.

64. EVOLUTION OF WHO PMTCT ARV RECOMMENDATIONS
2001 2004 2006 2010 Launch
July 2013
PMTCT
4 weeks AZT;
AZT+ 3TC, or
SD NVP
AZT from 28
wks + SD NVP
AZT from 28wks
+ sdNVP
+AZT/3TC 7days
Option A
(AZT +infant NVP)
Option B
(triple ARVs)
Option B or B+
Moving to ART
for all PW/BF
ART
No
recommendation
CD4 <200 CD4 <200 CD4 <350 CD4 <500
Move towards: more effective ARV drugs, extending coverage
throughout MTCT risk period, and ART for the mother’s health

65. When to Start ART

66. Rationale: Shift from Option A to B+ or B
BENEFITS FOR MOTHER AND CHILD BENEFITS FOR PROGRAM DELIVERY &
PUBLIC HEALTH
Ensures all ART eligible women initiate
treatment
Reduction in number of steps along PMTCT
cascade
Prevents MTCT in future pregnancies Same regimen for all adults (including
pregnant women)
Potential health benefits of early ART for
non-eligible women
Simplification of services for all adults
Reduces potential risks from treatment
interruption
Simplification of messaging
Improves adherence with once daily, single
pill regimen
Protects against transmission in discordant
couples
Reduces sexual transmission of HIV Cost effective
Major issue now is not “when to start” or “what to start” but “whether to stop”

67. Programmatic considerations for B+
• Initiate all HIV+ pregnant and breastfeeding women on ART
• Operational and programmatic advantages to lifelong ART for
pregnant and breastfeeding women (“B+”), particularly in settings
with:
– Generalized epidemics
– High fertility (though need to strengthen FP)
– Long duration of breastfeeding
– Limited access to CD4 to determine ART eligibility
– High partner serodiscordance rates

68. ARVs and breastfeeding
2013 (no change from 2010)
National agencies should decide between promoting mothers with HIV to either
breastfeed and receive ARV interventions or to avoid all breastfeeding
Where the national choice is to promote BF, mothers whose infants are HIV
uninfected or of unknown HIV status should:
• exclusively breastfeed their infants for the first six months of life
• introduce appropriate complementary foods thereafter, and continue
breastfeeding for the first 12 months of life
• breastfeeding should then only stop once a nutritionally adequate and safe diet
without breast-milk can be provided
(strong recommendation, high-quality evidence for the first 6 months;
low-quality evidence for the recommendation of 12 months)

69. Summary of Changes in Recommendations:
What to Start in Adults
FIRST-LINE REGIMENS (PREFERRED ARV REGIMENS)
TARGET
POPULATION
2010 ART GUIDELINES 2013 ART GUIDELINES
STRENGTH &
QUALITY OF
EVIDENCE
HIV+ ARV-NAIVE
ADULTS
AZT or TDF + 3TC (or
FTC) + EFV or NVP
TDF + 3TC (or FTC) + EFV
(as fixed-dose combination)
Strong,
moderate-quality
evidence
HIV+ ARV-NAIVE
PREGNANT
WOMEN
AZT + 3TC + NVP or
EFV
HIV/TB
CO-INFECTION
AZT or TDF + 3TC (or
FTC) + EFV
HIV/HBV
CO-INFECTION
TDF + 3TC (or FTC) +
EFV

70. QUESTION ???
• What points are important when
counseling a pregnant women with HIV?
72

71. Ante natal care
• ANC allows interaction between the health
facility and sexually active women to:
– provide information on HIV
– promote safer sex practices,
– provide opportunity for the pregnant woman to know
her HIV status
– Identify and treat STIs
– Advice on use of ITN
• Provides opportunities to discuss the
interventions for reducing the risk of MTCT
73

72. Counseling HIV positive pregnant
women???
• Effect of pregnancy on HIV infection
• Effect of HIV on pregnancy outcome
• Risk of transmission to fetus and infant
• Treatment options in pregnancy
• Interventions to prevent mother to infant
transmission
• Infant feeding options
• Disclosure of results to partner
• Need for follow up of mother and child
• Future fertility and contraceptive options
74

73. Question
• What measures can you take during antenatal
care (ANC) of an HIV-positive woman to
reduce the risk of transmission of HIV?
75

74. Antenatal interventions to reduce
MTCT
• HIV testing and counseling services
• Behavior change communication:
– Sexual
– Injection drug use
– Alcohol use and smoking
• Prevention of new infections in pregnancy
• Identification and treatment of STIs (genital
ulcers and abnormal vaginal discharge)
• Use ITN for malaria prevention
76

75. Antenatal interventions to reduce
MTCT contd
• Prevention and treatment of anemia (balanced
diet and nutritional supplementation)
• Avoiding invasive testing procedures in
pregnancy
– Amniocentesis
– Chorionic villus sampling
– External cephalic version
• Multivitamin supplementation
• Tetanus toxoid immunization
77

76. Antenatal interventions to reduce
MTCT contd
• Antiretroviral Treatment
– Initiate HAART to all HIV positive pregnant women identified
according to the national guideline (option B+):
• During pregnancy
• In labour
• Postpartum
(ART’s should be provided to the mother for her health as well as
for the health of the baby.)
• Physical examination to detect any signs of HIV-related
illness
78

77. Antenatal interventions to reduce
MTCT cont’d
• Use ITN for malaria prevention
• Mebendazole at first visit in areas of high
worm prevalence
• Isoniazid (INH) prophylaxis for tuberculosis
(TB) if indicated
• Pneumocystis carinii pneumonia (PCP)
prophylaxis, in women with clinical signs of
AIDS or CD4 counts of below 200 mm3
• Psychological support
79

78. QUESTION ???
• What measures can you take during labor and
delivery to reduce the risk of transmission of
HIV?
80

79. Intrapartum interventions to reduce
MTCT
• Application of good infection prevention
practices during pelvic examinations and
delivery
• Avoiding unnecessary artificial rupture of
membranes
• Avoiding prolonged labour and prolonged
rupture of membranes
81

80. Intrapartum interventions to reduce
MTCT contd
• Avoid unnecessary trauma during
delivery:
–Unnecessary episiotomy
–Forceps delivery
–Vacuum extraction
82

81. Vaginal versus Caesarean
Risk
concern
Vaginal Caesarean
Blood loss - Increased
Infection -
Increased in HIV+ women;
antibiotic prophylaxis
recommended
MTCT
No evidence of
increased MTCT with
ARV Rx and
adequate viral load
Reduces risk of MTCT if
performed before labor
onset
Mortality - Increased
Resource
issues -
Requires greater resources
(supplies, equipment, staff)
83

82. Intrapartum interventions to reduce
MTCT (cont.)
• Minimize risk of PPH (to protect mother’s
health and decrease provider exposure to
blood)
– Active management of 3rd stage
• Administer oxytocin immediately after delivery
• Controlled cord traction
• Check for contraction of the uterus
– Repair any genital tract lacerations
– Make sure placenta is complete
84

83. HARRT regimen to HIV +pregnant
women
• Initiate HAART to all HIV women identified
during pregnancy, labour and postpartum
period as follows
– TDF, 3TC, and EFV ( single tab combination one
tablet daily)
ARV for New born :
Daily Neverapiine for six weeks
85

84. Feeding options for the HIV exposed infant
“A little bit of this and a little bit of
that is not best for the baby! ”
Avoid mixed feeding !
86
Exclusive
breast
Feeding
Exclusive
formula
Feeding

85. Breastfeeding
• Exclusive breastfeeding should be encouraged
among all women regardless of HIV status
• For HIV free survival, all women for whom
replacement feeding is not acceptable,
feasible, affordable, sustainable and safe
(AFASS) should be encouraged to exclusively
breastfeed their infant for six months
• A woman should be supported in her infant
feeding decision; the choice is hers
87

86. Ongoing care
• HARRT is initiated for HIV positive mothers in
ANC will continue during post partum period
until graduated from PMTCT services
• All HIV infected mothers should be linked to
care and support to help keep them in the
best health possible
88

87. Fig. 6.1: PMTCT as an Entry Point for Care and
Support
Palliative care
Income support
PMTCT
Planning for
the future
(including FP)
Psychosocial
support
Basic clinical care
(mother, infant)
Prevention and Rx
of OIs
Access to ARVs
Nutritional
Support
89

88. Newborn
• Irrespective of the HIV status handle with
gloves until maternal blood and secretions
have been washed off
• Avoid hypothermia
• Give antiretroviral agents according to the
recommendation ( Neverapiine for six weeks),
if available
• Watch for anaemia
• Follow up infant for infection
90

89. Immediate care of the neonate
• Cut cord under cover of a lightly wrapped
gauze swab, to prevent blood spurting.
• Handle all babies regardless of the mother’s
HIV status with gloves until maternal blood
and secretions are washed off.
• All babies irrespective of HIV status should be
kept warm post-delivery.
91

90. Immediate care of the neonate (cont)
• Do not suction the newborn with a
nasogastric (NG) tube unless there has been
meconium-stained liquid.
• Where suctioning is required:
– use a mechanical suction unit (at a pressure
below 100mm Hg) or bulb suction, if possible,
rather than the mouth operated suction. Do not
use the bulb syringe for another baby before high
level disinfection done .
• Attach the baby to the mother’s breast only if
the mother has made a prior decision to
breastfeed.
92

91. Immediate care of the neonate (cont)
• If the mother has decided not to breastfeed, place the
baby on the mother’s body for skin-to-skin contact.
Provision should be made to provide the mother with
infant formula
• Vitamin K should be administered as per national
guidelines
• BCG should be administered according to the
national/WHO immunization guideline.
• Antibiotic or 1% silver nitrate eye ointment should be
administered as prophylaxis against ophthalmia
neonatorum according to the national/WHO
immunization guideline. 93

92. QUESTION ???
• What breastfeeding issues must be
considered when helping an HIV-positive
mother to decide whether or not to
breastfeed?
94

93. Breastfeeding Issues
• Warmth for newborn
• Nutrition for newborn
• Protection against other infections
• Risk of HIV transmission
• Contraception for mother
• AFASS - the mother who is infected with HIV
should breastfeed unless replacement feeding is
acceptable, feasible, affordable, safe, and
sustainable (AFASS).
95

94. Breastfeeding Recommendations
• If the woman is:
– HIV-positive and chooses to breastfeed, promote
exclusive breastfeeding for 6 months
– HIV-negative or does not know her HIV status,
promote exclusive breastfeeding for 6 months
– HIV-positive, meets AFASS criteria, and chooses
to use replacement feedings, counsel on the safe
and appropriate use of formula
– HIV-positive and chooses to breastfeed, promote
exclusive breastfeeding for 6 months
96

95. Goals of FP for HIV infected women
• Prevention of unintended pregnancy
• Appropriate child spacing to reduce
maternal and infant morbidity and
mortality
97

96. Special considerations for choosing FP
method
• Effectiveness
• Safety/side effects
• Effect on HIV transmission or progression
• Effect on STI transmission or acquisition
• Ease of use
• Non-contraceptive benefits
• Potential interactions with other medications
98

97. CONDOMS and HIV
99
Pregnancy!
STDs!
HIV
re-infection!
Male or female condoms
combine protection from...

98. Key take-away points
• Women with HIV infection require focused
antenatal care provided in accordance with
national protocols.
• HIV can be transmitted from an infected
mother to her child during pregnancy, labour
and delivery, or through breastfeeding.
• Antiretroviral therapy regimens reduce the risk
of MTCT and improve maternal survival in
both breastfeeding and non-breastfeeding
women.
100

99. Key take-away points (cont.)
• Women should be monitored for signs or
symptoms of progressive HIV/AIDS, and
opportunistic infections, particularly
tuberculosis (TB).
• Exclusive breastfeeding should be
recommended to reduce the risk of MTCT
during the postnatal period unless the mother
chose to give Replacement feeding .
• Decisions about infant feeding options should
be made before delivery.
101

100. HIV FREE SERVIVAL
WITH THE HELP OF
COMPITENT MIDWIFES