PREVENTION OF MOTHER TO CHILD TRANSMISSION OF HIV

DR. IHEKAIKE/ DR. NEPYIL

1

9/12/2023

PRESENTERS

2

9/12/2023

OUTLINE

3

9/12/2023

INTRODUCTION

4

9/12/2023

Human Immune Deficiency Virus�

• Human Immune Deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) is a major public health problem globally, with more than 36.7 million people estimated to be living with HIV.
• The sub-Saharan region of Africa has a disproportionately high number of persons infected with HIV.
• The high infection rates are prevalent in both adults and children

​

5

9/12/2023

What is PMTCT?�

• Prevention of Mother to Child Transmission (PMTCT) is a commonly used terminology for preventing the transmission of HIV virus from pregnant mothers to their infants
• It refers to the set of programs/interventions designed to identify the pregnant mothers with HIV and provide them with effective interventions to prevent mother to child transmission (MTCT)
• MTCT is a burning issue in HIV and AIDS as 90% of new cases of HIV in infants and children’s are due to MTCT
• Mother to child transmission of HIV virus may occur at three different points. They are:
• During Pregnancy
• During Labour and delivery
• During breastfeeding

​

​

​

6

9/12/2023

• Globally, new paediatric HIV infections decreased from 270 000 (230 000-330 000) in 2009 to 160 000 (110 000-260 000) in 2018, with only an 8% decline in the last 2 years.
• More than 90% of these children were infected through mother-to-child transmission (MTCT).
• Without intervention, the risk of transmission is 15-30% in non-breastfeeding populations.
• Breastfeeding by an infected mother increases the risk by 5-20% to an overall transmission rate of 20-45%.

​

7

9/12/2023

• Effective prevention of mother-to-child transmission (PMTCT) has reduced HIV transmission to < 1%.
• The systematic implementation of these protocols has made paediatric infection an increasingly rare problem in contexts where adequate health care is accessible.
• In the 21 African priority countries in the Global Plan, which accounts for over 90% of all HIV-infected pregnant women and new infections among children globally, ART coverage in HIV-infected pregnant women increased to 82% (62-95%) in 2018.

​

8

9/12/2023

Locally…

• According to the National Agency for the Control of AIDS (NACA), Nigeria has more HIV-infected babies than anywhere in the world. In 2016, Nigeria accounted for 37,000 of the world’s 160,000 new cases of babies born with HIV.
•  However, since 2017, an estimated 94.9% of infants exposed to HIV by their mothers have been saved from infection through the implementation of the PMTCT intervention under the National AIDS and Sexually Transmitted Infection Control Programme(NASCP) and across the 36 States and Federal Capital Territory, there are a total of 6,301 PMTCT sites.

9

9/12/2023

• First introduced in 2001 in Nigeria, the overall goal of the PMTCT is to contribute to the reduction of HIV and AIDS incidences. The national PMTCT aims (as set out in the National HIV/AIDS Strategic plan 2017-2021) at ensuring at least 95% of all HIV positive pregnant women and HIV exposed infants have access to effective antiretroviral (ARV) prophylaxis by 2021.
• It also aims at ensuring at least 80% of HIV positive pregnant women have access to quality infant feeding counselling and 95% HIV exposed infants have access to Early Infant Diagnosis (EID), (Source: NACA Factsheet 2016 – updated 2019).

​

10

9/12/2023

PATHOGENESIS OF MOTHER TO CHILD TRANSMISSION

11

9/12/2023

Mother-to-child-transmission of HIV(MTCT) is the most prevalent source of pediatric infection. This is through the vertical transmission from the infected mother to infant.

• Antepartum (Transplacentally).
• Intrapartum (During labour and delivery).
• Postpartum (Breastfeeding).

​

12

9/12/2023

MTCT transplacentally; This can occur as early as 8 weeks of gestation, others can occur during the third trimester. In utero transmission ca occur if the placenta is damaged and blood from the mother transfers into the blood circulation of the fetus. Chorioamnionitis has been linked with damage to the placenta and increased HIV transmission risk.

​

13

9/12/2023

14

9/12/2023

MTCT DURING LABOUR.

• During childbirth, the child can be exposed to virus from the woman’s blood and other fluids.

15

9/12/2023

MTCT VIA BREASTFEEDING

Infected cells and cell-free virus are found in breast milk-more in mature milk than in colostrums. Although maternal ART substantially reduces the risk of transmission through breast milk. WHO recommends that mothers living with HIV breast feed exclusively for the first 6months of life and continue breast feeding for at least 12 months with the addition of complementary foods.

​

​

16

9/12/2023

ELEMENTS OF PMTCT/ PREVENTION OF MTCT OF HIV

17

9/12/2023

1. Primary prevention of HIV infection in women of reproductive age and their partners.

​

• 2) Prevention of unintended pregnancies among HIV positive women.

​

• 3) Prevention of HIV transmission from infected mothers to their infants.

​

• 4)Provision of appropriate treatment, care and support to HIV infected mothers, their infants and family

​

​

18

9/12/2023

PRIMARY PREVENTION OF HIV INFECTION IN WOMEN OF REPRODUCTIVE AGE AND THEIR PARTNERS

• Prevention is primarily using the ABC approach to enhance safer and responsible sexual behavior and practices.

​

1. Abstinence- refraining from having sexual intercourse until viral load is well controlled and until marriage.

​

• Be faithful- be faithful to one partner

​

• Condom use- using condoms correctly and consistently during sexual intercourse.

19

9/12/2023

• Other ways to prevent transmission include;

​

1. Provision of early diagnosis and treatment of STIs;

Early diagnosis and treatment of STIs can reduce the incidence of HIV in the general public by about 40%

2. Making HIV testing and counseling widely available

HIV testing and counseling of HIV negative women ,if made available to all women of child bearing age reduces the risk of transmission as PMTCT

​

​

20

9/12/2023

PREVENTION OF UNINTENDED PREGNANCY AMONG HIV POSITIVE WOMEN

• Solely the responsibility of government and health services to provide HIV positive women and their partners with comprehensive information about the risks associated with child bearing as part of routine information about HIV an AIDS.

​

​

• Providing good quality , user friendly and easily accessible family planning services to enable HIV positive women who want to avoid pregnancy .

​

21

9/12/2023

• Promoting dual method of contraception for protection from HIV,STIs and unplanned pregnancies.

​

• Offering contraceptives to all HIV positive mothers in immediate postpartum unintended pregnancies.

​

22

9/12/2023

PREVENTION OF HIV TRANSMISSION FROM INFECTED MOTHERS TO THEIR CHILDREN

• 1. Antiretroviral Therapy (ART) for the Mother:
• • Initiate HIV-infected pregnant women on lifelong antiretroviral therapy (ART) as soon as diagnosed, regardless of CD4 count or clinical stage.
• • Ensure strict adherence to ART throughout pregnancy, labor, delivery, and breastfeeding, as per national guidelines.

​

23

9/12/2023

• 2. Antiretroviral Prophylaxis for the Infant:
• • Administer antiretroviral drugs to the infant as prophylaxis, starting within hours to days after birth, and continuing for a specific duration as recommended.
• • The choice of antiretroviral prophylaxis regimen may depend on factors like the mother’s viral load and infants risk.
• 3. Safe Obstetric Practices:
• • Encourage pregnant women to deliver in healthcare facilities where skilled birth attendants can provide appropriate care.
• • Avoid procedures like invasive monitoring or unnecessary episiotomy, which may increase the risk of transmission during delivery.

​

24

9/12/2023

• 4. Safe Infant Feeding Practices:
• • Promote exclusive breastfeeding for the first six months of life, combined with maternal ART.
• • Advise against mixed feeding (breast milk and other liquids/foods) to reduce the risk of transmission
• • Support mothers who choose formula feeding with access to safe and clean water and infant formula.

​

• 5. Early Infant Diagnosis (EID):
• • Conduct early infant diagnosis (EID) using PCR or other approved methods, typically within the first six weeks of life, and repeat at specific intervals.
• • Initiate antiretroviral treatment for infants who test positive as soon as possible.

​

25

9/12/2023

• 6. Counseling and Education:
• • Provide counseling and education to HIV-infected pregnant women about PMTCT, including the importance of ART adherence, safe delivery practices, and infant feeding options.
• • Offer information about the benefits of HIV testing and ART for partners and family members
• .7. Family Planning:
• • Encourage family planning and reproductive health services for women living with HIV, helping them make informed choices about future pregnancies.

​

26

9/12/2023

Care and support to HIV infected mothers and family.

• 1.Medical Care for HIV-Infected Mothers:
• •Initiate and maintain antiretroviral therapy (ART) as per national guidelines
• .•Regularly monitor the mother’s CD4 count, viral load, and overall health.
• • Address any opportunistic infections or complications promptly.
• 2. Psychosocial Support:
• •Offer counseling and emotional support to help mothers cope with the psychological and emotional challenges of living with HIV.
• •Create a safe and nonjudgmental environment where mothers can discuss their feelings, concerns, and fears.

​

27

9/12/2023

• 3. Medication Adherence Support:
• •Provide education and support to ensure mothers adhere to their ART regimen consistently.
• •Address any barriers to adherence, such as side effects or logistical challenges.
• 4.Nutritional Support:
• • Promote a balanced diet and provide nutritional counseling to maintain the mother’s health and strengthen her immune system.
• • Address any nutritional deficiencies or concerns.

​

28

9/12/2023

For the family

• 1. Psychosocial Support: Offer psychosocial support to the entire family to address the emotional and psychological impact of HIV. This can include individual and group counseling.
• 2. Education and Awareness: Provide education about HIV transmission, prevention, and stigma reduction for family members. Encourage open communication within the family.
• 3. Family Planning: Offer family planning services and counseling to help the family make informed choices about having additional children while minimizing the risk of HIV transmission.

​

29

9/12/2023

• 4. Community Support: Connect the family to local support groups and community organizations that can provide additional assistance and reduce isolation.
• 5. Linkage to Social Services: Assist the family in accessing social services like housing, food assistance, and childcare, as needed.
• 6. Regular Monitoring: Continuously monitor the health and well-being of the family members, ensuring they adhere to treatment plans and stay connected to care.

​

30

9/12/2023

NUTRITION IN HIV EXPOSED CHILDREN

31

9/12/2023

INFANT FEEDING IN THE CONTEXT OF HIV

32

9/12/2023

INFANT FEEDING IN THE CONTEXT OF HIV

• Nutrition is essential for child survival.
• Malnutrition is a common condition in HIV infected children and is a major contributor to morbidity and mortality in this population. HIV infection can result in nutritional deficiencies, growth failure and developmental delay.
• Malnutrition itself results in decreased immune function and greater susceptibility to infections thus accelerating disease progression. Malnutrition makes HIV infection worse and HIV worsens malnutrition.

​

33

9/12/2023

GOALS OF NUTRITION MANAGEMENT FOR HIV EXPOSED AND INFECTED INFANTS

• Provide nutritional counselling to caregivers.
• Encourage exclusive breastfeeding for infants less than 6months.
• Introduction of complementary foods in infants beginning at 6months.
• Stop breastfeeding at the age of 12 months or soon after as appropriate.
• Maintaining adequate nutritional support during periods of illness

34

9/12/2023

BREASTFEEDING AND HIV INFECTION

• Breastfeeding is one of the most important child survival strategies.
• However, HIV can be transmitted through breast milk. Exclusive breastfeeding from birth in the presence of maternal ART contributes to HIV free survival in exposed infants. This avoids the risk and complexities associated with replacement feeding.
• It is recommended that health care providers counsel and support HIV positive mother to breastfeed her infant. Both mother and baby must however receive ARV prophylaxis or treatment as appropriate.

​

35

9/12/2023

• However women who choose not to breastfeed or have medical contraindications should be counseled and supported in their decision.
• After 6 months breast milk only is not enough for adequate nutritional support of the infant. Complementary food should be introduced such as fruits, high protein foods and soft prepared foods and green leafy vegetables.

​

36

9/12/2023

WHEN TO STOP BREASTFEEDING

• HIV-infected women who decide to stop breastfeeding should gradually wean over one month.

​

• Mother of infant on ARV prophylaxis should continue prophylaxis for one week after complete cessation of breastfeeding. At this time infants should be provided with safe and adequate complementary foods to enable growth and development.

​

​

37

9/12/2023

MICRONUTRIENT SUPPLEMENTS

• All HIV infected children should receive micronutrients as follows;
• Single dose vitamin A supplementation every 6 months between ages 6months and 59 months of age as per the guidelines
• For uninfected children;
• <6 months -50,000IU
• 6-12months 100,000IU
• 12months -5years -200,000IU

​

38

9/12/2023

• Zinc supplements;
• <2 years 10mg b.d *14 days
• >2 years 20mg b.d *14bdays
• Iron supplements;
• 3-6mg/kg/day as required
• Folate supplements;
• <4 months 2.5 mg/day
• >4 months 5mg/day
• Multivitamins; B6, B12, C, E

​

NOTE: de-worming albendazole oral, 400 mg single dose every 6 months after the first year of life.

​

​

39

9/12/2023

GROWTH MONITORING AND NUTRITIONAL ASSESSMENT

• Regular and careful assessment of a child’s growth helps monitor HIV disease progression, identify complications early and offer the opportunity to intervene. Growth faltering may occur even before the emergence of opportunistic infections or other symptoms.
• Growth monitoring include;
• History; feeding history( types and amounts of food taken, frequency of meals, problems with feeding), potential cause of malnutrition, assess for any major changes in child’s circumstances, check mother’s health and her care of other children.

​

40

9/12/2023

• Anthropometry;
• Measuring of weight, height or length at every encounter with child and comparing with the age and sex appropriate WHO Z score card.
• Measurement of mid-upper arm circumference and occipito-frontal circumference.
• Using the modified wellcome classification chart or other growth charts.
• Complete physical examination and appropriate laboratory assessments should be performed.

​

41

9/12/2023

PMTCT REGIMENS

42

9/12/2023

ARV THERAPY IN PREGNANCY AND PMTCT

High maternal viral load is a major risk factor for MTCT of HIV.

This supports the idea that the risk of transmission is most related to the baby`s overall exposure to the virus.

Therefore, reducing maternal viral load by ARVs is an effective way to prevent MTCT.

Pregnancy in HIV positive women is an absolute indication for ART.

ART should be initiated in all HIV pregnant and breastfeeding women regardless of gestational age, WHO clinical stage and at any CD4+ cell count and continued for life.

​

43

9/12/2023

• There are several ARV drugs that can be used in various combinations and regimens.
• Common drugs used are: Zidovudine(AZT), lamivudine(3TC), Nevirapine(NVP), tenofovir(TDF), Efavarine(EFV), Emtricitabine(FTC), Abacavir(ABC).

44

9/12/2023

ARVs THAT SHOULD BE AVOIDED IN PREGNANCY

EFAVIRENZ

May be teratogenic during first trimester (but not an indication for abortion)

TENOFOVIR

Bone demineralization but benefits outweigh risks

​

45

9/12/2023

• PMTCT ARV recommendations refer to two key approaches :
• Lifelong ART for HIV-positive pregnant women in need of the treatment.
• Prophylaxis, or short-term provision of ARV’s to prevent transmission from mother to child; during pregnancy, during breastfeeding(if it is the best option for the infant )

46

9/12/2023

ART for HIV+ pregnant women

• Mothers in need of ART for their own health should get life long treatment
• Initiate ART in pregnant women with CD4 count ≤350 regardless of clinical stage
• Initiate ART in clinical stage 3 and 4 if CD4 not available
• Start as soon as feasible
• CD4 count is important in making decision on ART eligibility

47

9/12/2023

48

9/12/2023

2. ARV prophylaxis to prevent MTCT

• For women not eligible for ART or unknown eligibility
• Begin as early as 14 weeks gestation (2^nd trimester) or as soon as possible thereafter
• The two main options are
• Maternal AZT or
• Maternal triple ARV prophylaxis

and for breastfeeding mothers provision of ARVS to the child or mother to reduce risk of HIV transmission during breastfeeding (if breast feeding is the only option )

49

9/12/2023

50

9/12/2023

2. ARV prophylaxis to prevent MTCT

• For women not eligible for ART or unknown eligibility
• Begin as early as 14 weeks gestation (2^nd trimester) or as soon as possible thereafter
• The two main options are
• Maternal AZT or
• Maternal triple ARV prophylaxis

and for breastfeeding mothers provision of ARVS to the child or mother to reduce risk of HIV transmission during breastfeeding (if breast feeding is the only option )

​

51

9/12/2023

52

9/12/2023

ARV prophylaxis options

Dosage of the ARV

Mother:

• Can be given as AZT 300mg or 600mg, 3TC 150mg, NVP 200mg

Child:

• NVP 6mg, AZT 4mg/kg

​

53

9/12/2023

54

9/12/2023

Special concerns of drugs for PMTCT

• Nevirapine(NVP) toxicity in woman with high CD4
• Ongoing concerns of NVP resistance
• Efavirenz(EFZ) teratogenicity in first month of gestation
• Zidovudine(AZT) and anemia
• Tenofovir and bone demineralization
• Cost

55

9/12/2023

SUMMARY

• Mother to child transmission can occur during, pregnancy, labor, delivery and breastfeeding.
• There are several PMTCT strategies include HIV counseling & testing, safe obstetrics, ART, postpartum continuum care for mother and child .
• There are numerous barriers to a successful PMTCT program in our environment ,and they include ;poor health care systems, lack of effective coordination to oversee implementation, lack of awareness that HIV can be passed from mother to child ,inadequate access to ARV therapy or prophylaxis and many more.

56

9/12/2023

CONCLUSION

• Mother to child transmission is a key health issue in Nigeria and intervention programs such as the PMTCT programs are important in reducing spread of diseases from mother to child and minimizing both mortality and morbidity .

​

57

9/12/2023

References

• Pediatrics and child health in a tropical region Azubike & Nkanginieme 3^rd edition chapter 58 pages 608-611

​

• https://slideplayer.com/amp/7334295/
• https://www.aidsmap.com/news/nov-2009/new-who-guidelines-pmtct-and-infant-feeding

58

9/12/2023

59

9/12/2023

Thank you