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PRE-TEST • 1.Regargind latest guideline on initiation of ARV start at CD4 of • A. <200cc/ml • B.>200cc/ml • C..<350cc/ml • D.<500cc/ml • E. non of the above • 2.Best ARVs combination for PMTCT should contain at least • A. AZT • B. 3TC • C.TDF • D.LPV/r • E. NVP • 3.Best option advocated by the WHO IS • A.Option a • B. Option b • C.Option c • D. Option a+ • E. option b+ • 4. Factors associated with MTCH include • A.low viral load • B.infections • C. prolong rupture of membranes • D.cracked nipples • E. antepartum haemorrhage • 5.concerning choice of ARVs for PMTCT • A.NVP should be avoided in the first trimester • B.EFZ can be use in the first trimester • C.NVP is safe in TB/HIV Co infection • D.AZT IS unsafe throughout pregnancy • E. EFZ Is teratogenic hence avoid in 1st trimester CURRENT TREND IN MANAGEMENT OF MATERNAL TO CHILD TRANSMISSION OF HIV BY DR ZAINAB ABDULAZEEZ UMAR DEPARTMENT OF FAMILY MEDICINE SYNOPSIS • • • • • • • • • OBJECTIVES INTRODUCTION SCOPE OF HIV MTCT PMTCT HAART AND PMTCT INFANTS FEEDING CONCLUSION REFERENCES LEARNING OBJECTIVES • To become familiar with factors affecting the transmission of HIV from mother-to-child • To become familiar with interventions to prevent the transmission of HIV from mother-to-child • To be familiar with current guidelines in managing MTCT INTRODUCTION • HIV the aetiological agents of AIDS have been identified as HIV-1 and HIV-2. These viruses belong to the Lentivirus group of Retroviridae family. • HIV continues to be a major global public health issue, having claimed more than 36 million lives so far. • The Human Immunodeficiency Virus (HIV) targets the immune system and weakens people's surveillance and defense systems against infections and some types of cancer. • As the virus destroys and impairs the function of immune cells, infected individuals gradually become immunodeficient • Immunodeficiency results in increased susceptibility to a wide range of infections and diseases that people with healthy immune systems can fight off • . The most advanced stage of HIV infection is Acquired Immunodeficiency Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the individual • . AIDS is defined by the development of certain cancers, infections, or other severe clinical manifestations • The transmission of HIV from an HIV-positive mother to her child during pregnancy, labour, delivery or breastfeeding is called mother-to-child transmission. • In the absence of any interventions transmission rates range from 15-45%. • This rate can be reduced to levels below 5% with effective interventions. • These can be achieved by setting global norms and standards for HIV prevention, care and treatment of pregnant women, mothers and their children, •SCOPE OF HIV Regional HIV and AIDS statistics and features 2012 25.0 million Adults and children newly infected with HIV 1.6 million [23.5 million – 26.6 million] [1.4 million – 1.8 million] Adults and children living with HIV Sub-Saharan Africa Middle East and North Africa South and South-East Asia East Asia Latin America Caribbean Eastern Europe and Central Asia Western and Central Europe North America Oceania TOTAL Adult prevalence (15‒49) [%] 4.7% 1.2 million [4.4% – 5.0%] [1.1 million – 1.3 million] 260 000 32 000 0.1% 17 000 [200 000 – 380 000] [22 000 – 47 000] [0.1% – 0.2%] [12 000 – 26 000] 3.9 million 270 000 0.3% 220 000 [2.9 million – 5.2 million] [160 000 – 440 000] [0.2% – 0.4%] [150 000 – 310 000] 880 000 81 000 <0.1% 41 000 [650 000 – 1.2 million] [34 000 – 160 000] [<0.1% – 0.1%] [25 000 – 64 000] 1.5 million 86 000 0.4% 52 000 [1.2 million – 1.9 million] [57 000 – 150 000] [0.3% – 0.5%] [35 000 – 75 000] 250 000 12 000 1.0% 11 000 [220 000 – 280 000] [9400 – 14 000] [0.9% – 1.1%] [9400 – 14 000] 1.3 million 130 000 0.7% 91 000 [1.0 million – 1.7 million] [89 000 – 190 000] [0.6% – 1.0%] [66 000 – 120 000] 860 000 29 000 0.2% 7600 [800 000 – 930 000] [25 000 – 35 000] [0.2% – 0.2%] [6900 – 8300] 1.3 million 48 000 0.5% 20 000 [980 000 – 1.9 million] [15 000 – 100 000] [0.4% – 0.8%] [16 000 – 27 000] 51 000 2100 0.2% 1200 [43 000 – 59 000] [1500 – 2700] [0.2% – 0.3%] [<1000 – 1800] 35.3 million 2.3 million 0.8% 1.6 million [32.2 million – 38.8 million] [1.9 million – 2.7 million] [0.7% - 0.9%] [1.4 million – 1.9 million] The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information. | Adult & child deaths due to AIDS WHO – HIV department | January 19, 2014 with nearly 1 in every 20 adults living with HIV. 69% of all people living with HIV are living in this region. New HIV infections have fallen by 33% since 2001. , down from 3.4 New HIV infections among children have declined by 52% since 2001. SCOPE IN NIGERIA • • HIV Prevalence in Nigeria is 4.6% Nigeria now has the second highest number of plwhiv in the world after South Africa. • Over 90% of HIV infection in children are as a result of MTCT. • An estimated 220,000 exposed children born each year. • Without PMTCT about 88,000(40%) of these are infected. • With PMTCT about 2% (4,400) infected. • Nigeria has 30% of the global burden of MTCT. SCOPE IN KANO In 2009 with 372 HIV infected pregnant women detected out of 3470 ANC clients There were 4922 deliveries out of which 125 were HIV positive, giving a prevalence rate of 2.54%. the transmission rate from mother to child amongst those who accessed PMTCT services was about 2-3 % . SCOPE OF HIV/AIDS IN WOMEN HIV spreads rapidly, particularly among young women. These women are in their most productive and reproductive years. There are various factors that make women vulnerable to HIV infection, These factors include: Biological factors Socio-cultural factors BIOLOGICAL FACTORS • Women have larger surface area of the genital mucosa • Semen infected with HIV contains higher concentrations of virus than vaginal fluid. • Young women have immature cervix and scanty vaginal secretion hence barrier to infection is reduced • Women become more vulnerable again after menopause • Tearing and bleeding during intercourse further increased predisposition to infection. This can occur during rough vagina sex, anal sex, dry sex or rape • Untreated STIs multiplies the risk of HIV infection by 300-400%. SOCIO-CULTURAL FACTORS • Economic and societal approved dependency on men • Rights of women are abused and often violated. • Condom use by stable partners is often frowned at. • Cultural practices often expose women to multiple partners e.g polygamy, widow inheritance, wife hospitality • Gender inequalities which negatively impacts on and their effect on seeking care and prevention efforts • Burden of being the care provider in the home may supercede the need to care for herself Mother to Child Transmission of HIV Infection MOTHER-TO-CHILD TRANSMISSION MTCT of HIV can occur during: • Pregnancy • Labour and delivery • Breastfeeding MOTHER-TO-CHILD TRANSMISSION 100 infants born to HIV-infected women who breastfeed, without any interventions 5–10 infants infected during pregnancy About 15 infants infected during labour and delivery 25–40 infants will be HIV-infected 60 to 75 infants will not be HIV-infected 5–15 infants infected during breast-feeding Timing of Transmission: Targeting Prevention (In an Untreated Non-Breastfeeding Population, Total Transmission Rate is up to 25%) • Pregnancy ---------- (5 - 10%) • Delivery ------- (10 -15%) • Breastfeeding ----- (10 - 15%) RISK FACTORS FOR MTCT Pregnancy Labour and Delivery Breastfeeding •High maternal viral load •High maternal viral load •High maternal viral load •Infection •Duration •STIs •Prolonged rupture of membranes •Malnutrition •Invasive delivery procedures •Haemorrhage •Chorioamnionitis •Early mixed feeding •Breast fissures, infections •Poor maternal nutrition •Oral disease in infant PMTCT Prevention Of Mother To Child Transmission • Best practice for antenatal, intrapartum and postpartum care of the HIV-positive mother to reduce mother-to-child transmission ELEMENTS OF A SUCCESSFUL PROGRAMME FOR PREVENTION OF HIV INFECTION IN INFANTS AND YOUNG CHILDREN • Element 1 Primary prevention of HIV infections • Element 2 Prevention of unintended pregnancies among women infected with HIV • Element 3 Prevention of HIV transmission from women infected with HIV to their infants • Element 4 Provision of treatment, care and support to women infected with HIV, their infants and their families ELEMENT 1: PREVENTION OF PRIMARY HIV INFECTION ABCs of primary HIV prevention for parents-to-be: A = Abstain B = Be faithful to one HIV-uninfected partner C = Condom use – use condoms consistently and correctly Adapt approach to local culture and target groups at risk ELEMENT 2: PREVENTION OF UNINTENDED PREGNANCIES AMONG WOMEN INFECTED WITH HIV • Access to counselling and referral for family planning • Safe, consistent, effective contraception ELEMENT 3: PREVENTION OF HIV TRANSMISSION FROM WOMEN INFECTED WITH HIV TO THEIR INFANTS Core Interventions • HIV testing and counselling • Antiretrovirals • Safer delivery practices • Safer infant-feeding practices Combination interventions can reduce the MTCT rate to as low as 2% in the absence of breastfeeding. ELEMENT 4: TREATMENT, CARE AND SUPPORT FOR WOMEN INFECTED WITH HIV AND THEIR FAMILIES • Prevention and treatment of OIs • ARV treatment • Treatment of symptoms • Palliative care • Nutritional support • Reproductive healthcare • Psychosocial and community support SPECIFIC INTERVENTIONS TO REDUCE MOTHER-TOCHILD TRANSMISSION • • • • HIV testing and coucelling in pregnancy Antenatal care Antiretroviral agents Obstetric interventions • Avoid amniotomy • Avoid procedures: Forceps/vacuum extractor, scalp electrode, scalp blood sampling • Restrict episiotomy • Elective cesarean section • Remember infection prevention practices 34 • Newborn feeding: Breast milk vs. formula TESTING AND COUNSELING FOR PMTCT • Offered in the following settings • • • • • Antenatal care Labour and delivery Postnatal Family planning and other services Information offered are the following: • HIV Infection and mode of transmission • Safer sex practices • Prevention and treatment of sexually transmitted infections (STIs) • Prevention of HIV in infants and young children including interventions for PMTCT • HIV testing, post-test counseling, and follow-up services • INFORMATIO OFFERED TO HIV +VES (POST TEST) • Antiretroviral treatment/prophylaxis • Infant-feeding counseling and support • Information and counseling on family planning • Receive education on the importance of delivering in a setting where universal precautions and safer obstetric practices are implemented. • Secure early access to HIV treatment, care and support services. • Receive information and counseling on the prevention of HIV transmission to others. • Receive follow-up and ongoing health care for themselves and their HIV-exposed infants. • Disclose their results to partners and family members. LAB. TESTING FOR HIV INFECTIONS • Detectable components or products of viral infection for diagnosis • Antibodies• Rapid tests • ELISA(reactive/non-reactive), • Western blot (positive, negative, Indeterminate.) • Antigen- antigen P24 • Nucleic acid- polymerase chain reaction • Whole(viable)virus- viral culture LABORATORY TESTING(4) CD4 lymphocyte count. • Normal laboratory ranges 500-1400/mm. • Most useful for assessing immune function. • Degree of immuno-suppression determines staging of HIV infection, recommendations for ARV and prophylaxis against OIs. Viral Load estimation • • goal is to reduce viral load to undetectable (<400 copies/mL) OTHER TESTS: BASELINE LABS TESTS • FBC (anemia with ZDU) • LFTs (mitochondrial disease with NRTI, elevated ALT w/ NNRTI and PI) • amylase (pancreatitis with NRTI) • early 1-hr OGT (GDM with PI) • creatinine • Hep B & C, CMV, toxo ANTENATAL CARE • • • • • • • Most HIV-infected women will be asymptomatic Watch for signs/symptoms of AIDS and pregnancy-related complications Treat STDs and other coinfections Counsel against unprotected intercourse Avoid invasive procedures and external cephalic version Give antiretroviral agents Counsel about nutrition HIV and Pregnancy 40 Clinical Stage 1 Clinical Stage 2 Asymptomatic Mild Disease No symptoms or only: Persistent generalized lymphadenopathy Weight loss 5-10%** Sores or cracks around lips (angular cheilitis) Itching rash (seborrhoea or prurigo) Herpes zoster Recurrent upper respiratory infections such as sinusitis or otitis Stage 3 Advanced Disease Stage 4 Severe Disease (AIDS) Weight loss > 10%** Oral thrush (or hairy leukoplakia) More than 1 month: Diarrhoea or Unexplained fever Severe bacterial infections (pneumonia, muscle infection, etc) Pulmonary TB TB lymphadenopathy HIV wasting syndrome Oesophageal thrush More than 1 month: Herpes simplex ulcerations Recurrent severe pneumonia within 6 months Lymphoma* Kaposi sarcoma Invasive cervical cancer* CMV retinitis* Pneumocystis pneumonia Extrapulmonary TB* Toxoplasma* Cryptococcal meningitis* Visceral leishmaniasis* If CD4 < 350 Cotrimoxazole & INH prophylaxis If CD4 < 350 Cotrimoxazole & INH prophylaxis Cotrimoxazole & INH prophylaxis Cotrimoxazole & INH prophylaxis Consider ART if CD4 < 350 Consider ART if CD4 < 350 ART ART Strict adherence critical but a challenge in pregnancy ARVs have side effects that need clinical and lab monitoring Beware of drug interactions Resistance may develop if adherence is not excellent or if drug interactions affect drug levels, resistance may occur Resistance may be spread to baby and to partner With excellent adherence and monitoring, risks of ARV are minimised and benefits are maximised HIV IN PREGNANCY: DRUG TREATMENT • The goal in pregnancy is to reduce viral load to undetectable to minimize perinatal transmission. • However, the woman should be counselled and willing to adhere to the regimen • She should be counselled on the risks and benefits of the ARVs Evolution of the efficacy of the ARV prophylaxis: 1994-2004 % Transmission Transmission Rate (%) 35 30 25 20 15 10 5 0 None & None no NVP & BF BF BF AZT AZT 36wks & 36wks no BF BF AZT 28wks no BF HAART HAART AZT 28wks + no BF + C-S no BF NVP no BF THE DIFFERENT ANTIRETROVIRAL DRUGS NRTI Nucleoside transcriptase (NsRTI) NNRTI reverse Nucleotide inhibitors transcriptase (NtRTI) zidovudine (AZT) lamivudine (3TC) abacavir (ABC) emtricitabine stavudine (d4T) reverse Non-nucleoside reverse Protease Inhibitors (PI) inhibitor transcriptase inhibitors (NNRTI) tenofovir disoproxil nevirapine (NVP) fumarate (TDF) efavirenz (EFV) (FTC) PI saquinavir (SQV) ritonavir (RTV), as booster* indinavir (IDV) nelfinavir (NFV) lopinavir (LPV) OTHERS Fusion Inhibitor Enfuvirtide (ENF, T-20) CCR5 Antagonist Maraviroc (MVC) Integrase Inhibitor Raltegravir (RAL) FIRST - LINE AND SECOND-LINE REGIMEN • A first-line regimen is a combination of drugs that will be used in a patient who has no prior ART experience. This means that the patient has never taken ARV drugs before. • Most commonly, a first-line regimen will consist of two NsRTI's and one NNRTI. • Many patients will eventually develop failure of therapy: the first-line therapy will not be effective anymore (often because the drugs were not taken correctly). In that case, the doctor may decide to switch to a second-line regimen. • Usually, the second-line regimen will consist of 2 NRTI + 1 PI. ART INITIATION ART should be initiated in all pregnant women based on the following criteria. • CD4 count of less than or equal to 350 irrespective of WHO clinical staging. • WHO stages III and IV irrespective of CD4 cell count. • Nigerian guideline Recognizes pregnancy as an indication for prophylactic ART irrespective of CD4 count, viral loads or clinical staging Women With CD4 Count above 350 Cells/mm3 Women With CD4 Count beloW 350 Cells/mm3 ChilD receives option a During pregnancy: AZT Triple ARVs started as starting as early as 14 soon as diagnosed and weeks of pregnancy At continued for life delivery: single-dose NVP and first dose of AZT/3TC After delivery: daily AZT/3TC through 7 days postpartum Daily prophylaxis (NVP) from birth until 1 week after all breastfeeding has finished; or, if not breastfeeding or if mother is on treatment, through age 4–6 week Option b Triple ARVs starting as early as 14 weeks of pregnancy continued through childbirth (if not breastfeeding) or until 1 week after all breastfeeding has finished Daily prophylaxis (NVP or AZT) from birth through age 4–6 weeks regardless of infant feeding method Option b+ Triple ARVs started as soon as diagnosed and continued for life Advantages of Option B+ • Further simplification of regimen and service delivery (One regimen See • • • • • and Treat) Harmonization with ART programmes (TDF + 3TC or FTC + EFV as first line regardless of CD4 count) Protection against mother-to-child transmission in future pregnancies Continuing prevention benefit against sexual transmission to serodiscordant partners Avoiding stopping and starting of ARV drugs HBV Co-infection therapy CHOICE OF ARV”S IN PREGNANCY Combination regimens, usually including 2 NRTIs with either a NNRTI or 1 or more protease inhibitors (PIs) are recommended AZT + 3TC + EFV/NVP AZT + 3TC (or FTC) + EFV/NVP AZT + 3TC + LPV/r AZT + 3TC + ABC TDF + 3TC (or FTC) + EFV/NVP NOTE Nevirapine is avoided in women with CD4 count >250. EFV is avoided in the first trimester • Any pregnancy regimen should include ZDT unless contraindicated • Combination HAART (3 drugs) is associated with vertical transmission rates of <2% and is considered standard of care (regardless of VL or CD4+) • Safety of HAART in pregnancy is reassuring • Continue drugs during labor NEW RECOMMENDATIONS IN WHO ART GUIDELINES (2013) • • Earlier initiation of ART (CD4 ≤ 500) • • 1) Immediate ART for children below 5 years • • 2) Harmonization of ART across populations (e.g., adults and pregnant women, B/B+) and age groups • • 3) Simplified, fewer, and less toxic 1st line regimens (TDF/3TC/EFV) • • 4) Improved patient monitoring to support adherence and detect failure (increased use of VL) • • 5) Recommend task shifting, decentralization, and integration TARGETS FOR E-MTCT CLINICAL SCENARIO 1:PREGNANT WOMAN HAS RECEIVED ARV MEDICATION IN THE PAST BUT IS NOT CURRENTLY ON ANY MEDICATION • the choice of regimen may vary according to the history of prior use, the indication for stopping treatment in the past, gestational age, and resistance testing • if there is no resistance to the drugs, ARV(HAART) can be used again, but avoid drugs with teratogenic potential or adverse maternal effects. • Commence ARVS as soon as possible(AZT+3TC+NVP/EFZ) OR TDF CLINICAL SCENARIO II:PATIENT WHO IS ON A HAART REGIMEN PRESENTS FOR PRENATAL CARE • continuing her treatment during the first trimester is reasonable, • Zidovudine should be a component of the regimen whenever possible • provided that care is taken to avoid medications that are contraindicated in early pregnancy CLINICAL SCENARIO III:ARV NAÏVE HIV-INFECTED PREGNANT WOMAN • 1.In facility with capacity to provide and monitor triple ARV • HAART should be started as soon as possible, including during the first trimester. • Infant:dly NVP irrespective of feeding option CONT IIIB • 2.In facility with limited capacity to provide & monitor triple ARVS The following ARV prophylactic regimen is recommended: Zidovudine from 14 weeks gestation. Sd NVP at onset of labour AZT+3TC during labour and delivery AZT+3TC for 7 days post partum PROPHYLAXIS FOR PMTCT CLINICAL SETTING IIIB : THE INFANT • A For breastfeeding infants: Commence daily NVP and continue until one week after cessation of all breastfeeding. • B For non-Breastfeeding infants: Give daily NVP for 6 weeks only CLINICAL SCENARIO IV:HIV +VE DIAGNOSED IN LABOR 1. For facilities with capacity to provide and monitor Triple ARV medication: Mother Commence triple ARV prophylaxis during labour and continue thru bf 2. For facilities with limited capacity (on–site or by linkage) to provide and monitor triple ARV medication. Mother: • Intrapartum: sdNVP + ZDV + 3TC as soon as diagnosis is made in labour. • Post partum: ZDV + 3TC for 7 days • Determine if mother is eligible (within 5 days of delivery) for HAART Infant: • Mother breastfeeding not commenced on HAART: Give daily NVP to infants from birth until one week after cessation of all breastfeeding • Mother breastfeeding (eventually commenced on HAART) Give daily NVP to infants from birth and continue until six weeks after maternal commencement of HAART • Mother not breastfeeding: Give daily NVP to infants from birth until 6 weeks of age. CLINICAL SETTING V RECOMMENDATIONS FOR PREGNANT HIV-SEROPOSITIVE MOTHERS WHO PRESENT AFTER DELIVERY If mother chooses to breastfeed, recommend HAART (follow guidelines for HAART eligible mothers) If mother chooses to formula feed, determine if mother is eligible for HAART for her own disease, Infant :give sdnvp and then for 6 wks CLINICAL SETTING VI: HIV-INFECTED WOMAN WITH ACTIVE TB • Delay ARV treatment until second trimester, if possible. Treatment regimens: These are in decreasing order of preference • If treatment is initiated in second trimester EFV (800mg) + 2NRTIs ZDV + 3TC + Abacavir 2 NRTIs + Ritonavir-boosted PI* (Saquinavir/r or Lopinavir/r) ZDV + 3TC + Tenofovir Change rifampin to low dose rifabutin INFANTS:Prophylactic INH from birth (5mg/Kg once daily) until six (6) months of age WHO PROGRAMMATIC UPDATE APRIL 2012 • Option B+: – Triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting and continuing this therapy for all of these women for life. • Now being considered by the PMTCT Task Team NATIONAL RECOMMENDATIONS 2010 INFANTS • HIV+ Mothers ( whose infants are HIV uninfected or of unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life, introducing 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. When HIV-infected mothers decide to stop breastfeeding (at any time) they should do so gradually within one month : MONITORING OF THERAPY • Check viral load, CD4+, LFTs, FBC every trimester • Consider change of therapy if viral load still detectable in 3-6 months • Exclude adherence problems • Is she taking her meds?? • Baseline ARV resistance testing • HAART naïve (new) cases • HAART re-starts • if suboptimal viral suppression CARE IN LABOUR AND DELIVERY • • • • • AVOID ARM/FETAL SCALP PROCEDURES/ECV UNIVERSAL PRECAUTIONS SHOULD BE APPLIED AVOID ROUTINE EPISIOTOMY FORCEPS PREFERABLE TO VACUUM ELECTIVE C/S BENEFICIAL • Elective Caesarean section (C/S) reduces the risk of MTCT by at least 50% compare with vaginal delivery • Following delivery, avoid milking the cord. • The baby should be thoroughly dried, and any remaining maternal blood and amniotic fluid should be removed. • Vigorous suctioning of the infant’s mouth and pharynx should be avoided • Vaginal cleansing using disinfectants such as chlorhexidine where SVD is anticipated. • Use partogram to monitor labour progress. • Determine mother’s feeding choice INFANT FEEDING OPTIONS Allow mother to take decision by her self after counselling. Exclusive Breast feeding 1 Support mother, put baby to breast immediately, exclusive, proper position & attachment, feed on demand 2 Modification of BF a Early cessation- stop by 6 mths. b Expressing & heat treating BM. c Wet nursing- not advisable. • EXCLUSIVE FORMULAR FEEDING A- acceptable. F- feasible. A- affordable. S- sustainable. S- safe. Types –commercial infant formula & home made modified animal milk. COMPREHENSIVE POSTPARTUM CARE AND SUPPORT Components of comprehensive care include the following medical and supportive care services: • • • • • • Primary, obstetric, paediatric and HIV specialty care Family planning services Immunization/prophylaxis against OIs Mental health services Substance-abuse treatment Coordination of care through case management for the woman, her children, and other family members. Support services should include case management childcare, respite care, assistance with basic life needs (eg. housing, food, and transportation), and legal and advocacy services. Continuity of antiretroviral treatment must be ensured. ROLE OF FAMILY PHYSICIAN • HIV IS ONE DISEASE THAT ALLOWS THE FAMILY PHYSICIAN TO PRACTICE WITH ALL HIS SKILLS -COUNSELING\EDUCATING -PERSONALISED CARE -CONTINOUS CARE -FAMILY CARE -TEAM WORK\REFERRAL ETC CONCLUSION PMTCT is a success story in HIV prevention. A proper understanding of the basic principles of HIV and ARV use is all that is necessary to achieve this success. The implementation of the core PMTCT interventions based on these principles will reduce MTCT from 40% to about 2%. REFERENCES • British HIV Association guidelines for the management of HIV infection in pregnant women 2012 • National guidelines on PMTCT 2010 • National guidelines on PMTCT 2012 • H Galadanci et al Outcome of deliveries among HIV +ve mothers at AKTH – NJM 2006. • Infant feeding in HIV – generic training manual. • Expanding and Simplifying Treatment for Pregnant Women Living with HIV • HIV in pregnancy www.medscape.com/hiv in pregnancy • WHO Guideline on PMTCT • AITT option b+ Toolkit 2013 expanding and simplifying treatment for pregnant women www.emtct.iatt.org • V Mangiaterra WHO: Global plan to eliminate MTCT of HIV 2013