PMTCT guidelines

As PMTCT program is part of our care and support program and mother to child
transmission is very important part of prevention and care and support program and it is
preventable and this guideline aims to provide guidance to assist the health care providers
including medical officers, PMTCT nurses, nurses and counselors. This guideline based
upon the WHO and NAP guidelines and it will facilitate the selection and provision of
ARV for pregnant women and babies, either for their own health or prophylaxis of
prevention of mother to child transmission.

Strategic Approach

Prevention of mother to child transmission has four main prongs of strategy to prevent
HIV infection in infants and children, however , it is also indeed to free HIV infection in
all reproductive aged women.

1. Primary prevention of HIV infection among women of reproductive age

2. Prevention of unintended pregnancies among women living with HIV
3. Prevention of HIV transmission from mothers living with HIV to their infants
4. Care, treatment and support for mothers living with HIV, their children and families

All four components must be implemented in order to optimize the effectiveness of

programmes and reach the overall goal of improving maternal and child health in the
context of HIV.

How can it benefit to mothers and infants

Most children living with HIV acquire the infection through mother to child transmission
(MTCT) ,which can occur during pregnancy, labor and delivery and during breast
feeding. In the absence of any intervention the risk of transmission reach 15-30 % in the
absent of breast feeding and breast feeding can add the risk another 5-20% more to a total
of 20-45 %.

The risk of mother to child transmission can be reduced by 50% with the admistration of
single dose nevirapine to mother and baby during delivery, and it can be further reduced
to below 2 % by more potent and systematic antiretroviral prophylaxis (pARV) during
pregnancy, labor to mother and in the first weeks of life to infant followed by complete
avoidance of breast feeding.
Risk factors

Some factors determine the rate of transmission of mother to child as follow:

During pregnancy

High maternal viral load( new or advance HIV infection)

Viral, bacterial and parasitic placental infection (especially malaria)
Sexually transmitted infections

During labor and delivery

High maternal viral load(new and advance HIV/AIDS)

Rupture of membranes for more than 4 hours before labor begins
Invasive delivery procedures (Vacuum, forceps, episiotomy)
First infant in a multiple birth
Chorioamniontitis (Inflammation of membranes covering the fetus)

During breast feeding

High maternal viral load

Duration of breast feeding
Early mix feeding of infant( breast milk with replacement feeding)
Maternal nutrition status
Infant oral diseases ( thrush or mouth sores)

Safe delivery

Interventions that reduce MTCT risk in labor and delivery include:

Universal precaution
Minimal use of cervical examinations
Avoidance of - prolong labor
-routine rupture of membranes
- Unnecessary trauma such as episiotomies and fetal scalp monitoring

Minimize risk of postnatal hemorrhage

Safe transfusion practices

Regarding mode of delivery, elective caesarean section, when performed before the onset
of labor or membrane rupture, has been associated with reduced MTCT.However, it
needs to be considered individually that the benefits and risks of vaginal delivery versus
elective caesarean section, including the safety of the blood supply and risk of
complications from operation. Moreover, we have to consider whether it could be
accessible, feasible and affordable to all pregnant mothers.

ARV prophylaxis for PMTCT

ARV prophylaxis for PMCT depends on different conditions and different scenarios of
pregnant women living with HIV.

1. Women who become pregnant while receiving HAART

2. pregnant women with indication for HAART
3. pregnant women not yet indicated for HAART ( pART for preventing HIV
transmission to infant)
4. Women living with HIV who are in labor and who have not yet received
pARV
5. ARV prophylaxis for preventing HIV infection in Infants
-born to women living with HIV in pregnancy
- born to women living with HIV who have not yet received ARV drugs during
pregnancy or labor

1. Women who become pregnant while receiving HAART

For those who are on HAART become pregnant, the treatment should be continued
unless she is on EFV based regimen and in first trimester of pregnancy. In that case NVP
should be substituted for EFV, because of its teratogenicity effect. Alternatively, a triple
NRTIs or PI based regimen could be used. Women who are receiving EFV and it is in
second or third trimester of pregnancy can continue the same current regimen. It should
be noted that EFV is not an indication for abortion.
Infant born to women who are receiving antiretroviral therapy should receive AZT 4 mg
per kg for 7 days just after delivery ( within 72 hour).
2. Pregnant women with indications for HAART

For pregnant women living with HIV who meet the clinical and immunological criteria
for HAART should be started as soon as practicable after meeting the same procedures as
women who are not pregnant.
Such conditions and procedures should be followed as pre ART counseling, clinical and
laboratory monitoring and assessing are very important procedure for the pregnant
women own health and for her infant. Women need to informed in advance and aware of
potential benefits and implications of beginning ART both for their own health and for
fetuses/

Recommendation for initiating ARV treatment in pregnant women based on clinical stage
and availability of immunological makers

WHO clinical stage CD4 testing not available CD4 testing available
Stage 1 Do not treat Treat if CD 4 cell count <200
cells /mm2
Or <350cells /mm

Stage 2 Do not treat Same as above

Stage 3 Treat Treat if CD4 cell count <350
cells /mm2 or irrespective of CD4
count
Stage 4 Treat Treat irrespective of CD4 cell count
Despite the fact that WHO launched rapid advice on PMCT, we have to follow the NAP
guideline 2007 till it is updated by NAP.

The main purpose of this recommendation is to address the health of pregnant women
herself. The additional benefits of providing ART to these pregnant women are
1. Substancially reducing the risk of MTCT, and
2. Minimizing the consequences of resistance to NVP from the use of Sd-NVP containing
pARV for the prevention of MTCT.

The preferred regimen is : AZT(300mg)+3TC(150mg) +NVP(200mg)

In women with CD4 more than 250, NVP used should be with close monitoring of
clinical symptoms and, where available, hepatic transminase enzyme during first 12
weeks of therpy.This includes informing the woman about symptoms for which she
should seek care urgently such as yellow eyes, skin rashes, fever and abdominal pain.
EFV should only be used during first trimester of pregnancy if the potential benefit
justifies the potential risk to the fetus, such as in a pregnant woman without any other
therapeutic options.

If there is no access to ARV treatment for pregnant women, recommend to follow the
recommendation for pregnant women who does not meet indication for HAART as
follow.

For infant AZT 4mg per kg for 7 days is recommended if mother received ART for more
than 4 weeks antenatal and if not AZT for 4 weeks rather than 1 week should be
provided.

3. Pregnant women with no indication for ARV treatment (pARV for prevention of
HIV transmission to the infant)

Single dose NVP is the simplest regimen to administer but due to less effective and at
high risk of resistance to NVP it is rarely used nowadays. Therefore, we have to follow
recommendation of AZT/3TC tail.

This refer to starting AZT 300mg at 28 weeks of gestation follow by AZT and 3TC with
Sd-NVP 200 mg at onset of labor and AZT 300 mg +3TC 150 mg BID for 7 days .As
we used NNRTI Sd –NVP , we will follow AZT+3TC for 7 days to reduce the
development of resistance of NVP.

For infant NVP 2 mg per kg birth weight and AZT 4 mg per kg BID for 7 days. However,
for mother who received AZT for less than 4 weeks during pregnancy, increase the
duration of AZT for infant for 4 weeks.

pARV should be started as much possible as we can prevent when some pregnant women
accessed very late to PMCT services.

For pregnant women who presenting late in pregnancy or during labour

Women with indication for ART who present very late in pregnancy should be started on
ART irrespective of the gestational age of pregnancy after complete pre ART counseling
and clinical and hematological assessments .If however, it is not possible to begin
treatment prior to delivery, pARV should be given while plans are made to start ARV for
the mother as soon as possible after delivery. If Sd –NVP is used women should,
whenever possible, receive AZT+3TC intrapertum and for 7 days postpartum to reduce
development of resistance of NVP.However, if only Sd-NVP is available it should be
used.

If women do not meet the indication to receive ART ,it is better to start pARV as early as
possible according to their gestational age and labour state for late accessed women.

4. Women living with HIV who are in labor and who have not yet received pARV

Many women in these circumstances may only have been identified as being HIV
infected during labour.Particular efforts are needed to ensure that they receive HIV
related care services including clinical and immunological assessments to determine their
eligibility for ART as part of post partum follow up care.

The recommended regimen for preventing MTCT among women in labour who have not
received antenatal ARV prophylaxis consists of Sd-NVP+ AZT and 3TC intrapartum,
and 7 days tail of AZT+3TC for mother postpartum .For the infant Sd –NVP and AZT for
4 weeks .

5.ARV prophylaxis for preventing HIV infection in Infants

pARV for infant born to mother who received ARV prophylaxis antenatal and
intrapartum is described as above with Sd-NVP 2 mg per kg just after delivery and AZT
4 mg per kg BID for 7 day or 4 weeks according to duration of mother received antenatal
prophylaxis.

Sd-NVP immediately after delivery and AZT for 4 weeks are recommended for infant
born to mother living with HIV who has not received any ARV prophylaxis, because this
regimen results in a greater reduction in transmission than no treatment or just Sd-NVP.It
is strongly recommended to start immediately after delivery or within 12 hours after
delivery, if possible.

Check lists for MOs

Make sure patient or client is pregnant.

If patient is newly enrolled to program, on the day of registered
- history taking including PMCT history and LMP
- clinical staging including OI screening and treatment
- Cotrimoxazole prophylaxis if eligible
- Screening for TB, malaria and STD and treatment
- Safer sex practice with partner
- Plan to do USG , CD4 and other lab investigations as soon as possible (make
priority)
- Refer to food program
- If gestational age is in late second and third trimester plan to refer to CWH
for safe delivery after thorough counseling
- Refer to PMCT nurses to register and further counseling and management
- If patient is from SKK or TTY plan to appoint to meet with PMCT nurses

For PMCT counseling

- Psychosocial support and encourage patient
- make sure who will be disclosed for care
- having consent to home visit
- important of CD4 testing
- counseling for PMTCT ( explain about PMCT, prophylaxis and so on)
- Safe delivery ( options and help them choose –what will be the most
acceptable ,feasible and realistic and convenient for patients)
- Partner involvement and safer sex practice with partners
- Introduction for infant feeding