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PMTCT
By Katya de Oliveira
What is PMTCT?
PMTCT is an intervention to ensure that no child is born with HIV. It is an essential step to ensuring an AIDS free generation. The PMTCT initiative provides drugs, counseling and psychological support to help mothers safeguard their infants against the virus.
Guidelines and Objectives
General Objectives
General Objectives
» Ensure timely HIV diagnosis, management, treatment and
initiation of ARVs for treatment for all eligible populations to achieve best health
outcomes in the most cost-efficient manner
» Contribute to strengthening of the health sector’s capacity to deliver high-quality integrated health and wellness services
» Implement cascade management and ensure continuity of care
» Provide standardised and simplified less toxic treatment, which is harmonised amongst pregnant women, breastfeeding mothers, adolescents
and adults in both the private and public sector
» Simplify guidance for health workers to improve the quality of HIV care for all people living with HIV and HIV-exposed infants
» Prevent new infections and reduce AIDS-related deaths among children, adolescents and adults
Specific Objectives
Specific Objectives
» Promote viral load testing as a preferred approach
for monitoring ART success and diagnosing treatment
failure
» Provide lifelong ART for all pregnant and breastfeeding women living with HIV
» Initiate ART earlier at a CD4 count threshold of 500 cells/µl
» Prioritise initiation of patients with CD4 count of ≤350 cells/µl, severe HIV disease and HIV/TB co-infection
» Strengthen retention in care and adherence to ART
» Reinforce phasing out of d4T in first-line regimens
» Ensure that HIV and TB services are provided as part of integrated maternal and child health, and sexual and reproductive health services
» Test all HIV-exposed and symptomatic children and initiate ART in all children under <5 years of age who are HIV-positive
PMTCT- An Evolution
PMTCT- An Evolution
1998–1999: a PMTCT programme was started ...
1998–1999: a PMTCT programme was started at two midwife obstetric units in Khayelitsha, Cape Town by the Western Cape Department of Health, despite the lack of a national policy.
2000: thirteenth international HIV conference, Durban. Da...
2000: thirteenth international HIV conference, Durban. Data presented indicated that antiretroviral drug regimens were effective in reducing mother-to-child transmission.
2001: the South African Ministry of Health endorsed t...
2001: the South African Ministry of Health endorsed the establishment of two research sites in each of the nine provinces for a period of 2 years to understand better the operational challenges of introducing antiretrovirals during pregnancy to reduce mother-to-child transmission.
2001: this policy was challenged in the courts. In December 2001, the government was ordered by the court to develop a fully capable and effective national programme to reduce mother-to-child transmission by the following year.
2001: this policy was challenged in the courts. In Decemb...
2002: the government challenged the court order, but was unsuccessful. The PMTCT programme commenced.
2002: the government challenged the court order, b...
2003: the government published a new operational plan for treating and caring for those infected with HIV. The plan included increased provision of nevirapine, the extension of treatment to all HIV-infected pregnant mothers and their children and the expansion of related health-care services, such as voluntary counselling and testing.
2003: the government published a new operation...
2004: introduction of comprehensive care management and treatment of HIV-infected individuals. Pregnant women with a CD4+ T-cell count < 200 cells/mm3 became eligible for HAART.
2004: introduction of comprehensive ca...
2008: the Department of Health updated the PMT...
2008: the Department of Health updated the PMTCT policy to include:
dual prophylaxis with azidothymidine and nevirapine from 28 weeks’ gestation
dual prophylaxis with azidothymidine and nevirapi...
nevirapine treatment for pregnant women during labour and for their babies within 72 hours of delivery
nevirapine treatment for pregnant women duri...
HAART for pregnant women with a CD4+ T-cell count < 200 cells/mm
HAART for pregnant women with a CD4+ T-ce...
2008: the Minister of Health launched the national PMTCT accelerated plan (A-plan) which aimed to reduce mother-to-child transmission of HIV from 12% in 2008 to less than 5% by 2011, in accordance with the National Strategic Plan 2007–2011
2008: the Minister of Health launched t...
2009: President Zuma’s speech on World AIDS Day outlined changes to be implemented in 2010. This gave a clear indication that the political leadership required to address the scale of the problem was available.
2009: President Zuma’s speech on World AIDS Day outlin...
2010: the Department of Health revised the PMT...
2010: the Department of Health revised the PMTCT policy again to include lifelong HAART for HIV-positive women with a CD4+ T-cell count ≤ 350 cells/mm3 and dual ART from 14 weeks onwards in the pregnancy for HIV-positive women with a CD4+ T-cell count > 350 cells/mm3, in line with option A of World Health Organization guidelines.17 Infant prophylaxis was daily nevirapine for 6 weeks for all infants. Daily nevirapine was continued for all breastfeeding infants whose mothers were not on HAART, to reduce postnatal transmission.
2011: following a national conference on breastfeeding, the Minister of Health endorsed a policy that breastfeeding should be exclusively used at public health facilities, with formula milk being reserved for when there are medical indications, and that the provision of free formula milk should be phased out.
2011: following a national conference on breastfeedi...
2011: in line with a call from global agencies, the Departme...
2011: in line with a call from global agencies, the Department of Health developed a national action framework for eliminating mother-to-child transmission of HIV.
Relevance
Relevance
In 2011, an estimated 70.4% of maternal deaths in South Africa were associated with HIV infection
Half of all deaths of children younger than 5 years in 2011 were also associated with HIV
Therefore, the success of PMTCT is critical for reducing maternal and child mortality and morbidity.
Current Protocol
MOM
HIV Testing
HIV Testing
When to test:
» Every 3 months throughout pregnancy
» At labour/delivery
» At the 6 week EPI visit
» Every 3 months throughout breastfeeding
Initiation of ART
Initiation of ART
Initiate lifelong ART in ALL pregnant or breastfeeding women on the same day of diagnosis regardless of CD4 count
All unbooked women who test positive during labour should be given prophylactic ART during labour and initiated on lifelong ART before being discharged
Emphasise exclusive breastfeeding for the first 6 months, with complementary feeding only from 6 months and breastfeeding continued until 12 months
Starting ARVs
Starting ARVs
Already on ARVs
Already on ARVs
Untested in Labour
Untested in Labour
Postpartum Newly Diagnosed
Postpartum Newly Diagnosed
Baby
Treated Mom
Untreated Mom
Untreated Mom
High Risk Mom
High Risk Mom
Breastfeeding Mother Diagnosed with HIV
Breastfeeding Mother Diagnosed with HIV
Unknown Maternal Status
Unknown Maternal Status
Follow Up
Follow Up
Summary:
Summary:
Virologically supressed mom: NVP @ birth + daily x 6 weeks
Untreated/ineffectively Rx: NVP ASAP + daily x 6 weeks
High rish mom: AZT+ NVP at birth + for 6 weeks
Postpartum HIV+ mom: AZT+ NVP @ birth then for 12 weeks
If PCR -ve stop AZT
Only stop NVP if mom on Rx for 12 week
Unknown maternal status: NVP stat --> if PCR + then NVP 6 weeks
Dosing
Are We Successful?
Are We Successful?
Reduction in transmission
Transmission has been reduced from 3.5% in 2010 to 2.7% in 2011
Reduction in transmission
Examples
Example 1
Example 1
A 16 year old mom P0G1, presents to casualty in labour, unbooked and delivers a prem baby with Apgars of 7, 8, 9
Mom unaware of her status, says she doesn’t want to keep the baby and refuses to be tested for HIV
*What tests would we do on baby if mom allows baby to be tested?
*How will we manage baby?
Answer:
*Start NVP immediately and do a PCR
*If positive continue NVP daily for 6 weeks and do a PCR
*If negative stop NVP
Example 2
Example 2
A 6 Month old baby RVD exposed, completed 6 weeks NVP, PCRs at Birth and 10/52 negative
*Mom on FDC for past 10 years compliant on treatment and virally suppressed. Wants to know if she can continue Breast feeding?
*What advice would you give?
Answer:
*Mom can continue to breastfeed up to one year
*PCR at 6 weeks post cessation of BF
*VCT/ELISA at 18 months
References
References
*SA HIV Society: http://www.sahivsoc.org/Files/ART%20Guidelines%2015052015.pdf
*WHO: http://www.who.int/bulletin/volumes/91/1/12-106807/en/
*https://www.avert.org/professionals/hiv-programming/prevention/prevention-mother-child
*Dr Mwala PPT on Prevention of Mother to child transmission (PMTCT) - HIV