EMTCT AND INFANT FEEDING

EMTCT

Principle objectives of EMTCT programme:

• Maximally reduce the risk of vertical transmission

• Improve maternal & infant survival

TO ACHIEVE HIV FREE SURVIVAL

Key Concepts in Vertical Transmission

• Transmission can occur during pregnancy,

labour and delivery, and postpartum during
breastfeeding
• Not all infants born to HIV+ women will acquire
HIV infection
(estimated risk 24 - 45% without any
intervention)
• Current EMTCT interventions can reduce the
risk of transmission to 1.5 % - 5%
 Timing of MTCT
Early Postpartum
Early Antenatal (0-1 mo)
(<28 wks)
Late Postpartum

Labour and
Delivery

Late Antenatal 1-6 mos 6-24 mos

(28 wks to labour)

0% 20% 40% 60% 80% 100%

Proportion of infections
 Factors influencing MTCT

• 1. Maternal Factors

 High viral load

 Low CD4 count
 Other infections – STI, TB etc
 Maternal IDU
 ART given during pregnancy, labour &
delivery & bf significantly decrease VT risk (&
can reduce maternal morbidity & mortality)
 Factors Influencing MTCT

2. Obstetrical Factors
• Length of ruptured membranes/chorioamnionitis
• Vaginal delivery
• Invasive procedures & difficult delivery

3. Infant Factors
• Prematurity
• 1ST twin
• Breast feeding
 EMTCT Interventions

EMTCT must be in the context of a

continuum of care:
• Women’s health
• Antenatal care
• Labour and delivery
• Post-natal care
 EMTCT

1. Women’s health - the 4 pillars of EMTCT

• Primary prevention of HIV

• Prevention of unintended pregnancy
• ART for HIV infected women
• Provision of care for women & their children
(MNCH services – EID, CMZ prophylaxis etc)
 EMTCT

2. Antenatal Care
• Comprehensive antenatal services – incl. nutrition
counselling & support
• Information on HIV infection & EMTCT
• Routine HTC & repeat testing during pregnancy
• CD4 cell count no longer mandatory for ART
initiation
• Life-long ART (option B +)
• Infant feeding counselling
• Male involvement
 VL Monitoring During Pregnancy
ART experienced pregnant women at 1st ANC visit

• Check the most recent VL result

• If no VL within the last 6 months, do the test
• If unsuppressed
oOffer intensive adherence counselling
oRepeat VL in 3 months & follow VL algorithm
• If suppressed
oRepeat VL testing between 32 & 36 weeks of
pregnancy & every 6 months while breast-
feeding
 Option B+ Regimen
Option B+
Mother
• Triple ART to all HIV positive pregnant and breastfeeding women

•TDF + 3TC + EFV

(FDC 1 tab PO OD)

Infant
All exposed infants
•NVP for 6 weeks
Birth weight < 2500g 10mg PO OD
Birth weight > 2500g 15mg PO OD
 EMTCT

3. Labour and delivery

Optimal obstetric practices including:
• Avoid PROM
• Avoid assisted instrumental delivery
• Avoid invasive monitoring procedures
• Avoid episiotomy & prematurity
• Only suction infant when msl & baby is floppy
• Wipe the neonate carefully at birth
 Care of the Mother-Baby Pair

Ask about …
Adherence to ART
Breastfeeding
Cotrimoxazole prophylaxis
Disclosure and Dad’s HIV status & ART
Early Infant Diagnosis and link to ART
Family Planning
Growth monitoring and EPI status
Happiness
Evolution of WHO PMTCT ARV Guidelines
Over Time As New Evidence Becomes Available

September 2015

2001 2004 2006 2010 2013 2015

Treatment No rec ART if CD4 ART if CD4 ART if CD4 ART if CD4 ART
<200 <200 <350 <500 regardless of
CD4
PMTCT 4 weeks AZT from 28 AZT from 28 Option A Option B Life-long
AZT; AZT+ wks + sdNVP wks + AZT/sdNVP + ART preg/BF ART for all
3TC; sdNVP + infant NVP if BF Option B+ pregnant
or SD NVP AZT/3TC 7d Option B Life-long women
ART preg/BF ART
 HIV Exposed Infants (HEI)
High risk infant:
• An infant whose mother with a VL >1000 in last 4
weeks prior to delivery
• An infant born to HIV+ve woman who has
received < 8 weeks of ART at the time of delivery
• An infant born to a newly diagnosed HIV+ve
woman (labour, delivery & postpartum - incident
HIV infection)

All other infants are classified as ‘low-risk’ infants

 ART Prophylaxis for HEI

High Risk Infants Low Risk Infants

Breast-fed Breast-fed
twice daily AZT + daily daily NVP for
NVP for 12 weeks 6 weeks

Formula-fed Formula-fed
twice daily AZT + daily NVP daily NVP
for 6 weeks for 6 weeks
 Early Infant Diagnosis
• Birth testing (DNA PCR) for all HIV-Exposed
Infants & ART commencement for all +ve
neonates
• ALWAYS retest & confirm results with repeat
PCR but retesting should not delay ART
initiation
• Babies who test negative at birth or not tested
MUST be tested at 6 weeks
• Don’t forget 6 weeks post-weaning test!
Where are We in the Plan to Eliminate New
Pediatric HIV Infection?
Major Progress in Preventing Perinatal Infection in Past Decade

But we have not yet

reached the goal of global
elimination of MTCT 1.6 million pediatric
infections averted

~400 new pediatric

Infections every day!
In 2015, still 150,000 new
pediatric HIV infections 2015 goal
<40,000

70% decrease in new pediatric infections

since 2000
 2016 UNAIDS/WHO
“Super Fast-Track” Targets for
Children, Adolescents and
Young Women
• Start Free: Reduce new HIV infections among children to <40,000
by 2018 & <20,000 by 2020, and 95% of HIV+ pregnant women to
receive life-long antiretroviral therapy by 2018.

• Stay Free: Reduce the number of new infections among

adolescents & young women to <100,000 by 2020 and to reach 25
million men with voluntary male circumcision services by 2020,
with a focus on young men ages 15-29 years.

• AIDS-Free: Antiretroviral treatment services to reach 1.6 million

children <15 years and 1.2 million adolescents 15-19 years by
2018, or 95% coverage for children.
New HIV Infections in Children and % Pregnant Women
Receiving ARV for PMTCT 2005-2015
And Fast-Track Goals
95%
life-long
ART
80%
any ARV
for PMTCT

150,000

40,000
20,000

2015 2018 2020

ONE YEAR FROM NOW
Six-Week and Final MTCT Rates by Country, 2015
21 Global Plan countries have ↓ MTCT from 22.4% in 2009 to 8.9.% in 2015

These 7 countries
would be <5%
Significant impact of
without
postnatal infection,
postnatal tx accounting for >50% of
all new pediatric infections -
including Malawi.
the “first” B+ country
(since 2011)!
5 countries
<5% MTCT
WHO goal
 Where are New Infections Occurring?
Distribution of New HIV Infections Among Children, Global, 2015
10 countries
Nigeria alone had 15% new
account
Nigeria infections in 2015 & only
for >70% of
15%
21% ↓ MTCT since 2009 (vs
new
>60% other priority countries)
infections
29%
South Africa
13%

4% 8%
5% India
8/10 countries
Zimbabwe 6%
5% have IMPAACT sites
5% 5% 5%
Malawi
Zambia Mozambique

Tanzania Kenya
Uganda
% Women Receiving ARVs (Prophylaxis or
Treatment) for PMTCT by Priority Country, 2015
Still countries struggling 6 additional countries 6 countries met
with <50% coverage had >80% pregnant Global Plan goal of >90%
including Nigeria with women on ARV pregnant women on ARV
large # HIV-infected
Zimbabwe PMTCT Programme

The Zimbabwe National PMTCT programme:

• 3 pilot sites in 1999
• 1,560 ANC sites providing PMTCT services out
of a total of 1,643 health care facilities country
wide (95%). 2012
• 93 % of HIV-positive pregnant women received
ART in 2012 compared to 86% in 2011.
• The PCR positivity has been declining steadily
over the years, from 14% in 2010, to 7% in
2012
 Zimbabwe PMTCT Programme

• 90% pregnant women attend ANC

• 65% attend 4 or more ANC visits
• 65% live births take place in health facilities
• MMR 555/100 000 (26% attributable to
HIV/AIDS)
• < 5 years MR 84/1000 (21 - 41% attributable to
H/A)
• 48% exclusive breastfeeding rate
The following issues are central to
effective eMTCT...
• Coverage
– Community mobilisation for ANC
– eMTCT services at all 1,560 health facilities
• Retention
– Patient returns for refills
– No logistic or operational failures
• Adherence
– Patient swallows >90% of doses
• Prevention of new infections in young women
 Nyasha

• Nyasha (24yrs) tests positive for HIV during the

labour and delivery of her second child.
• She had tested negative for HIV when booking
for ANC at EGA 24/40.
• Her male partner subsequently admits that he
tested HIV-positive when he started TB
treatment 3 months ago, but couldn’t bring
himself to disclose his status to anyone.
 Nyasha

• Would you consider Nyasha’s risk of HIV

transmission to the baby low, medium or high?
Explain your answer
• How would you manage this family?
• Explain your management of Nyasha, her
partner, the infant
 Sarudzai

• Sarudzai (23yrs, P0G1) tests positive for HIV in

pregnancy at EGA 38/40, begins the Option B+
regimen and goes on to deliver a live baby boy
2 weeks later, who initiates breastfeeding well.
• She presents to you in casualty 3 weeks after
delivery with a 2 day history of fever, severe
cramping lower abdominal pain and worsening
backache
 Sarudzai

• You note that she is short, of borderline

nutritional status, has generalised
lymphadenopathy and planar warts over her
forehead and forearms
• She has a temperature of 39’C, mild pallor,
tachycardia, normal BP
• Abdomen is tender to palpation, HOF 12/40,
scanty bloody vaginal discharge with no clots,
os admits 1 finger
 Sarudzai

• What is your differential diagnosis?

• What additional history is needed for optimal HIV
case management?
• Outline your management in casualty.
 Sarudzai

• She has an USS that reveals fluid in the Pouch

of Douglas and she is managed as a case of
puerperal sepsis, discharged and returns for the
6 week postnatal review.
• Her prior condition has resolved, but she has
not been sleeping well since delivery, has pains
all over the body that come and go, feels very
tired, has no appetite for food and is worried
that the child has not gained weight well
 Sarudzai

• She declines contraception, as her in-laws took her

husband away from her, as he tested HIV negative
at work 4 months before delivery, although they
permit him to visit her during the day from time to
time
• She and her husband don’t understand this, as she
was a virgin when she married this man, and she
confirms they are still in love
• The baby was tested for HIV during the mother’s
hospitalisation and you have the result in her notes
– it is positive.
 Sarudzai

• How would you manage :

• Sarudzai’s new symptoms?
• Contraception?
• Her child
• How could Sarudzai have contracted HIV?
 Rudo

• Rudo (22yrs) has a male partner with HIV

infection, diagnosed recently when being
counselled for medical male circumcision.
• She reveals this to you when she brings their
thriving breastfed 14 week old first born child
(5.2kg) for a routine check-up.

• How would you manage Rudo and her infant?

 Tsitsi

• Tsitsi (27yr) started the Option B+ regimen in

ANC at EGA 28/40 of pregnancy just over 20
months ago.
• She comes to the clinic with her thriving 18
month old child (11.5kg), who stopped
breastfeeding 4 months ago. She and the infant
are asymptomatic.

• How would you manage Tsitsi and her baby?

 Tsitsi

• You review Tsitsi’s laboratory results from 2

weeks before:
VISIT CD4 count Viral Load
(cells/uL) (copies/mL)

28/40 ANC 395 4,668

38/40 ANC 435 679
6 months 700 <40
12 months 748 <40
18 months 690 1,287
 Tsitsi

• What could explain the trends noted in the blood

results?
• Outline your management approach
 Shamiso

• Shamiso (22 yrs) is admitted to hospital after a

suicide attempt last night, having drunk rat poison
when lodging at a friend’s house
• Her friend tells you that the husband discovered
syringes in their room earlier that day and realised
that Shamiso was giving ART to their 4-month old
first born child, Dylan
• He threw her out of the marital home after she
admitted that she had tested positive for HIV in
pregnancy and the infant’s test at 6wks was also
positive
 Shamiso

• List the themes raised by Shamiso’s story.

• What additional history is required to optimise
HIV-related care for this family
• List who should be included in Shamiso’s case
management team
 Infant feeding

www.newlandsclinic.org.zw Zimbabwe
 Infant feeding issues in MTCT-
breastfeeding
Breast milk
• is species specific
• is nutritionally balanced
• easily digestible
• contains anti-infective factors (IgA) & cells
• clean, affordable & accessible
• benefits the mother & her infant
 Child Survival & Breastfeeding

Optimal breastfeeding of infants under two years

of age has the greatest potential impact on
child survival of all preventive interventions,
with the potential to prevent over 800,000
deaths (13% of all deaths) in children under
five in the developing world (Lancet 2013).
 Child Survival & Breastfeeding

• Breastfed children have at least six times

greater chance of survival in the early months
than non-breastfed children.

• An exclusively breastfed child is 14 times less

likely to die in the first six months than a non-
breastfed child, and breastfeeding drastically
reduces deaths from acute respiratory infection
and diarrhoea, two major child killers (Lancet
2008).
 Breast Milk and HIV

• HIV is found both within cells & free in breast

milk
• Virus in breast milk correlates with level of
circulating virus. The higher the viral load the
more likely the infant will become infected
through breastfeeding
• HIV has created great confusion among health
workers about the merits of BF for the HIV+
mother.
Factors Which Increase Transmission of
HIV Through Breast Milk
• Cracked nipples
• Breast abscesses
• Mastitis - clinical & sub-clinical
• Viral load, low immunity, new infection
• Mixed feeding (breast milk + other milk)
• Prolonged breastfeeding
• Prematurity
• Oral/intestinal lesions in the infant
 To Breastfeed or not to Breastfeed

• Exclusive breastfeeding is threatened by the

HIV epidemic, but it remains an unfailing anchor
of child survival.(WHO 2000)

• Exclusive breastfeeding for the first 6 months

for the majority of HIV-infected mothers who are
poor reflects the optimum balance between
advantages and disadvantages.(WHO 2000)
 When the Infant is HIV-infected

If infants & young children are

known to be HIV+, mothers are
strongly encouraged to exclusively
BF for the first 6 months of life &
continue BF as per the
recommendations for the general
population (2 years).
Zimbabwe Infant Feeding Guidelines - 1
• Infections and malnutrition remain a major
cause of infant morbidity & mortality
• Bf is the most effective strategy for improving
the health & chances of infant survival
• The majority of pregnant women are HIV-ve, bf
should be supported/encouraged for all women
• Health workers should encourage VCT before
conception & also in the pre, intra, &
postpartum periods
Zimbabwe Infant Feeding Guidelines - 2

The current guiding principle is that “breastfeeding

should continue to be encouraged unless there are
viable options to ensure appropriate infant & child
feeding for women who know they are HIV
positive.”

(Zimbabwe Ministry of Health and Child Welfare, National Nutrition Unit, 2005)
Conditions Needed to Safely Formula Feed

• Safe water/sanitation at household & community level

• Mother/caregiver can provide enough infant formula to
support normal growth & development of infant
• Mother/caregiver can prepare infant formula cleanly &
often enough so that it is safe
• Mother/caregiver can exclusively give infant formula
for the 1st 6 months
• Family is supportive
• Mother/caregiver can access comprehensive child
health care services
Let us work together to
eliminate paediatric HIV from
Zimbabwe....

It is possible!!