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Republic of Namibia
MINISTRY OF HEALTH AND SOCIAL SERVICES
GUIDELINES FOR THE PREVENTION OF
MOTHER-TO-CHILD TRANSMISSION OF HIV
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Guidelines for PMTCT in Namibia
Republic of Namibia
MINISTRY OF HEALTH AND SOCIAL SERVICES
GUIDELINES FOR THE PREVENTION OF
MOTHER-TO-CHILD TRANSMISSION OF HIV
Directorates: Primary Health Care and Special Programmes
Divisions: Family Health and Health Sector
Private Bag 13198
Windhoek
Tel 061 203 2272/2731
Fax 061 224 155
First Edition
December 2004
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Guidelines for PMTCT in Namibia
PREFACE
HIV/AIDS poses the greatest threat to individual and family survival. HIV can be
silently transmitted from HIV-positive pregnant women to their babies during
pregnancy, labour and delivery, or through breastfeeding. Approximately 90% of
HIV infection among children is acquired through this mode of transmission.
According to several epidemiological studies which were carried out in Africa, close
to 20% of children born to HIV positive mothers acquire the infection vertically.
The World Health Organization estimates that the rates of transmission ranges
from 13 to 32% in developed countries and between 25 to 48% in developing
countries. Most of these children eventually die during infancy and early childhood.
The Declaration of Commitment adopted by the United Nations General Assembly
Special Session on HIV/AIDS commits Member States to reduce the proportion of
infants infected with HIV and to provide information, counselling and other
prevention services to pregnant women during antenatal visits. Administration of
antiretroviral medicines during pregnancy is associated with a marked reduction in
HIV transmission from the mother to her baby. The Government of the Republic of
Namibia has introduced a national programme for the prevention of mother to child
transmission of HIV. Out of more than 500 babies who were born to HIV positive
mothers at Katutura and Oshakati hospitals and who received Nevirapine
according to schedule, only 4 babies tested HIV positive after 18 months of follow
up, which represents 0.8% prevalence ratio.
The cornerstone of a successful PMTCT programme is a high rate of HIV testing
among pregnant women in order to identify those who are positive and at risk of
transmitting the virus to their babies. HIV testing should be routinely provided at
the first antenatal visit or at any other opportunity to all pregnant women who
accept it. Health care workers should strongly promote routine counselling and
testing for pregnant women and their partners. Family members should support
the expectant mother to receive counselling and testing in order to protect the
unborn child. Studies elsewhere, and experiences in some regions in Namibia,
have shown that most women actually desire testing in order to protect their
babies, but unfortunately they often fear the stigma and rejection if they were to
test positive. Quality counselling and support is essential and the Ministry is
working with its partners to introduce community counsellors to assist health care
workers with meeting the large demand. The Ministry is also working with the
laboratory services to introduce same-day HIV testing results to reduce the waiting
time and to increase the proportion of pregnant women who receive their results.
As indicated in these guidelines, wherever possible, HIV-positive pregnant women
who have a CD4 count ≤ 300/mm3 or have a WHO stage III or IV disease should
receive a combination of three antiretroviral medicines as care for them in the long
term. Otherwise, the HIV-positive pregnant women will receive a single dose of
Nevirapine at the onset of labour and a single dose to the baby after birth. Safe
obstetrical practices as outlined in these guidelines should also be followed. All
health professionals caring for pregnant women should undergo the Ministry’s
established PMTCT training to be able to implement these guidelines in a
competent manner.
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Guidelines for PMTCT in Namibia
Infant nutrition is also a critical component of PMTCT. All pregnant women should
be counselled on infant feeding regardless of their HIV status. Breastfeeding is still
the best feeding option for mothers who test HIV-negative, or for those who do not
know their HIV status. Feeding options for HIV-positive mothers are described in
the guidelines.
The development of these comprehensive PMTCT Guidelines required the
collaboration of individuals, agencies, and organisations. The Ministry of Health
and Social Services wishes to recognise the contributions of the Department of
Obstetrics and Gynaecology and the Department of Paediatrics at Katutura
Hospital, the Directorates of Primary Health Care and Special Programmes, DED,
GTZ, the Franco-Namibia Co-operation, UNICEF, USAID/FHI and the Centres for
Disease Control. Guidelines developed by other agencies and African countries
served as useful reference materials. These guidelines are for both the public and
private sectors and I urge all doctors, nurses, and other health professionals to
familiarise themselves with the content of these guidelines to be able to assist their
clients.
Dr. K. Shangula
Permanent Secretary
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Guidelines for PMTCT in Namibia
TABLE OF CONTENTS
PREFACE ........................................................................................................................................... III
Table of Contents ................................................................................................................................ v
List of Tables ...................................................................................................................................... vi
List of Figures ..................................................................................................................................... vi
List of Abbreviations ...........................................................................................................................vii
CHAPTER 1: BACKGROUND ............................................................................................................ 1
1.1 Introduction .................................................................................................................................... 1
1.2 Magnitude of HIV Infection during Pregnancy in Namibia ............................................................. 2
1.3 Risk of Mother-to-Child Transmission of HIV ................................................................................ 3
1.4 The Benefits of the PMTCT .......................................................................................................... 5
1.5 Interventions to Prevent Mother-To-Child Transmission of HIV .................................................... 5
CHAPTER 2: PREVENTION OF HIV INFECTION AND UNINTENDED PREGNANCIES ................ 6
2.1 Prevention of STIs / HIV ................................................................................................................ 6
2.2. Prevention of Unintended Pregnancies ........................................................................................ 6
CHAPTER 3: ROUTINE COUNSELLING AND TESTING (RCT) ...................................................... 8
3.1 Benefits of Counselling and Testing for HIV .................................................................................. 8
3.2 Counselling .................................................................................................................................... 9
3.3 Testing for HIV Infection in Pregnancy ........................................................................................ 11
CHAPTER 4: MODIFICATION OF ROUTINE CARE DURING PREGNANCY, LABOUR, DELIVERY
AND THE POSTNATAL PERIOD FOR HIV-POSITIVE WOMEN. .................................................... 13
4.1 Management of the Known HIV-positive Woman during Pregnancy .......................................... 13
4.2 Management of the HIV-positive Woman during Labour and Delivery ...................................... 16
4.4 Care of HIV-positive Women After Delivery ................................................................................ 19
CHAPTER 5 : MANAGEMENT OF THE HIV-EXPOSED NEW-BORN ............................................ 20
5.1 Management of the Newborn in the Early Postnatal Period ....................................................... 20
5.2 Infant Feeding Options ................................................................................................................ 20
5.3 Management of Breastfeeding .................................................................................................... 24
5.4 Introducing Complementary Feeding 6 – 12 months ................................................................. 24
5.5 Clinical Management of the HIV exposed Newborn .................................................................... 25
5.6 Diagnosis of HIV Infection in Children ......................................................................................... 25
CHAPTER 6: MANAGEMENT OF ANTIRETROVIRAL DRUGS DURING PREGNANCY,
INTRAPARTUM AND POSTPARTUM .............................................................................................. 27
6.1 Overview of Antiretroviral (ARV) Drug Use for PMTCT............................................................... 27
6.2 Management of ARV Drugs in Pregnancy According to Clinical Scenarios ............................... 29
6.3 Monitoring of Pregnant Women Placed on HAART .................................................................... 31
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Guidelines for PMTCT in Namibia
CHAPTER 7: PROGRAMME MANAGEMENT OF PMTCT .............................................................. 34
7.1 Promotion of PMTCT through Communication Strategies .......................................................... 34
7.2 Organisation and Administration ................................................................................................. 34
7.3 Monitoring, Evaluation and Reporting ......................................................................................... 36
REFERENCES .................................................................................................................................. 39
LIST OF APPENDICES
APPENDIX I.
TREND IN HIV PREVALENCE AMONG PREGNANT WOMEN BY BY SENTINEL
SITES 1992-2004 .................................................................................................. 41
APPENDIX II.
HIV PREVALENCE IN PREGNANT WOMEN BY AGE GROUP………………….41
APPENDIX III. TESTING FOR HIV INFECTION IN PREGNANCY… .................... ……………….42
APPENDIX IV
WHO STAGING SYSTEM FOR HIV INFECTION AND DISEASE IN ADULTS
AND ADOLESCENTS……………………………………….................................... 44
APPENDIX V.
ORAL ARV SHORT COURSE REGIMENS FOR PMTCT ………………………...45
APPENDIX VI. CONSENT / RELEASE FORM……………………………….…..............................46
APPENDIX VIII. CONSENT/RELEASE FORM TO BE TESTED AND TO PROVIDE NEVIRAPINE
TO A NEW BORN ................................................................................................. 47
List of tables
TABLE 1.
TABLE 2.
TABLE 3.
TABLE 4.
TABLE 5.
TABLE 6.
TABLE 7.
TABLE 8.
TABLE 9.
ESTIMATED NUMBER OF INFANTS INFECTED WITH HIV PER YEAR (MOHSS). ... 3
TRANSMISSION PATTERNS IN BREASTFEEDING AND NON-BREASTFEEDING
POPULATIONS IN THE ABSENCE OF ANTI-RETROVIRAL (ARV) DRUG
INTERVENTION ............................................................................................................. 4
FACTORS INCREASING OR AFFECTING MOTHER-TO-CHILD TRANSMISSION OF
HIV .................................................................................................................................. 4
EFFICACY OF VARIOUS PMTCT INTERVENTIONS……………………......................5
REQUIREMENTS AND COSTS OF INFANT FORMULA FOR THE FIRST SIX
MONTHS………………………………………………………………………………………23
BABY’S MINIMUM REQUIREMENTS WHILE USING MODIFIED COW’S AND
GOAT’S MILK ............................................................................................................... 24
DOSAGES OF NEVIRAPINE SUSPENSION ............................................................... 25
RECOMMENDED DOSES OF CO-TRIMOXAZOLE FOR PCP PROPHYLAXIS ........ 25
RECOMMENDATION FOR ARV THERAPY IN HIV-POSITIVE PREGNANT WOMEN
WITH TUBERCULOSIS ............................................................................................. 32
List of figures
FIGURE 1
FIGURE 2
FIGURE 3
FIGURE 4
FIGURE 5
TREND IN HIV PREVALENCE AMONG PREGNANT WOMEN IN NAMIBIA, 19922004……………………………................................................................................ …….2
RISK OF OF MOTHER-TO-CHILD TRANSMISSION DURING DIFFERENT STAGES
OF PREGNANCY .......................................................................................................... 3
DIAGNOSIS OF HIV INFECTION IN INFANT ............................................................. 26
ALGORITHM FOR USE OF ARV DRUGS FOR HAART OR PMTCT IN PREGNANT
WOMEN ....................................................................................................................... 28
PMTCT RECORD-KEEPING AND REPORTING SYSTEM ........................................ 38
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Guidelines for PMTCT in Namibia
LIST OF ABBREVIATIONS
AIDS
Acquired immunodeficiency virus
ALT
Alanine amino transferase
ANC
Antenatal care
AROM
Artificial rupture of membranes
ART
Anti-retroviral therapy
ARV
Anti-retroviral
CDC
Communicable Disease Clinic
CMV
Cytomegalovirus
DNA
Deoxyribonucleic acid
ECV
External cephalic version
EFV
Efavirenz
ELISA
Enzyme Linked Immunosorbent Assay
FBC
Full blood count
HAART
Highly active anti-retroviral therapy
Hb
Haemoglobin
HBsAg
Hepatitis B surface antigen
HBV
Hepatitis B virus
HIS
Health Information System
HIV
Human Immuno Deficiency Virus
HW
Health worker
ICU
Intensive care unit
IM
Intramuscular
IMCI
Integrated Management of Childhood Illnesses
IMR
Infant Mortality Rate
IPT
Isoniazid Preventive Therapy
IUCD
Intrauterine contraceptive device
IV
Intravenous
KJ
Kilo Joule
NGO
Non Governmental Organisation
NIP
Namibian Institute of Pathology
NRTI
Nucleoside reverse transcriptase inhibitor
NNRTI
Non-nucleoside reverse transcriptase inhibitor
PCP
Pneumocystis carinii pneumonia
PCR
Polymerase chain reaction
PI
Protease Inhibitor
PLWHA
People living with HIV/AIDS
PML
Progressive multifocal leukoencephalopathy
PMTCT
Prevention of Mother-to-Child Transmission
PNC
Post natal care
PO
By mouth
QID
Four times per day
RCT
Routine Counselling and Testing
RNA
Ribonucleic acid
ROM
Rupture of membranes
RPR
Rapid Plasma reagin
STD
Sexually Transmitted Disease
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Guidelines for PMTCT in Namibia
STIs
TB
TBA
TDS
TOT
ULN
UNAIDS
VCT
VDRL
WBC
WHO
Sexually Transmitted Infections
Tuberculosis
Traditional Birth Attendant
Three times per day
Trainer of Trainers
Upper limit of normal
Joint United Nations Programme on AIDS
Voluntary Counselling and Testing
Venereal Disease Research Laboratory
White blood count
World Health Organisation
Acronym of drugs
3TC
ABC
AZT
D4T
ddC
DdI
DMPA
IDV
IDV/r
LPV
LPV/r
NFV
NVP
RTV
SQV (hgc)
SQV (sgc)
SQV/r
TDF
ZDV
Lamivudine
Abacavir
Zidovudine
Stavudine
Zalcitabine
Didanosine
Depo-Medroxyprogesterone Acetate
Indinavir
Indinavir + Ritonavir
Lopinavir
Lopinavir + Ritonavir
Nelfinavir
Nevirapine
Ritonavir
Saquinavir, hard gel
Saquinavir, soft gel
Saquinavir + Ritonavir
Tenofovir
Zidovudine
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Guidelines for PMTCT in Namibia
CHAPTER 1
BACKGROUND
1.1.
Introduction
During 2002, UNAIDS estimates that approximately 800,000 children acquired HIV
infection world-wide through mother-to-child transmission, including 720,000 in subSaharan Africa. This translates into approximately 2,200 new infections in children per
day. As of 2002, UNAIDS estimated that 3.2 million children under 15 years of age were
living with HIV/AIDS, and 2.4 million of these resided in Sub-Saharan Africa. An
estimated 610,000 children died world-wide in 2002 from AIDS alone. The situation with
respect to mother-to-child transmission of HIV clearly poses a global public health
emergency, particularly in Sub-Saharan Africa.
The most common mode of HIV transmission in children is vertical infection from an HIV
positive woman to her child during pregnancy, labour and delivery, or through
breastfeeding. It has been established that the use of antiretroviral medicines reduces
the proportion of children who become infected vertically to 3% and below. It should
however be noted that in children born to HIV positive mothers, the maternally acquired
HIV antibodies may persist for up to 18 months. Therefore a positive HIV antibody test in
a baby younger than 18 months may represent exposure to maternal infection rather
than infection of the baby.
Prevention of Mother to Child Transmission of HIV includes four main strategies:
i.
Primary prevention of HIV in women of reproductive age;
ii.
Prevention of unintended pregnancy in HIV-infected women;
iii.
Prevention of mother-to-child transmission through the use of antiretroviral
(ARV) drugs and other practices;
iv.
Provision of comprehensive care to HIV infected women, partners, and children.
In spite of the increasing availability and feasibility of using ARV drugs, numerous
challenges must be addressed in order for PMTCT services to be effective. They include:
i.
Capacity to provide routine HIV counselling and testing to all pregnant women
early in antenatal care.
ii.
Making counselling services available in antenatal clinic for pre, post and on
going counselling.
iii.
Providing the most appropriate and the most effective ARV drug regimen to
qualifying pregnant women.
iv.
Promoting breastfeeding in the general population and supporting infant feeding
options for HIV positive mothers to reduce transmission through breastfeeding.
v.
Training a large number of health professionals in order to sustain PMTCT
services.
The purpose of these PMTCT guidelines is to:
i.
Provide the basis for a national standard of care to prevent mother-to-child
transmission in all health facilities.
ii.
Sensitise health service providers and other stakeholders involved in PMTCT to
issues that are important to the success of the programme.
iii.
Promote the importance of PMTCT services and networking amongst all those
involved in the care of pregnant women and family members.
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Guidelines for PMTCT in Namibia
iv.
v.
Equip health workers with essential knowledge and information on counselling,
infant feeding, obstetric care, laboratory services, ARV drugs, programme
management, and monitoring and evaluation process of the programme.
Mobilise community support, and active participation for the successful
implementation of the programme. Therefore, appropriate information needs to
be disseminated for the public to understand the benefits of the PMTCT.
These guidelines are complemented by other MOHSS documents, which health workers
should consult for more in-depth information and guidance, they include:
i.
The National Strategic Plan on HIV/AIDS, Medium Term Plan III, 2004-2009.
ii.
The Namibian Reproductive Health Policy, 2002.
iii.
Guidelines for Counselling of HIV/AIDS and Sexually Transmitted Diseases,
2001.
iv.
Clinical Management of HIV/AIDS, 2001.
v.
Guidelines for ARV Therapy, 2003.
vi.
Guidelines in confidentiality, testing and notification, 2001.
vii.
National VCT Guidelines, 2004.
viii.
Infant and Young Child Feeding, National Guidelines for Health Professionals,
(Draft).
ix.
National Policy on Infant and Young Child Feeding, 2003.
x.
Food and Nutrition Guidelines for Namibia, 2000.
xi.
Nutritional Management in HIV/AIDS; A Resource Guide for Health Workers,
2003.
xii.
TB Guidelines, 2004.
xiii.
National policy and guidelines for malaria control, 1995.
1.2.
Prevalence of HIV infection in pregnancy in Namibia
In 2004, the national HIV prevalence ratio amongst pregnant women was 19.8%, ranging
from 9% in Opuwo to 43% in Katima Mulilo across the 24 sentinel sites.
Figure 1. Trend in HIV prevalence ratio among pregnant women, 1992 – 2004
HIV Prevalance (%)
25
17.4
20
19.3
22
19.8
15.4
15
8.4
10
4.2
5
0
1992
1994
1996
1998
2000
2002
2004
Year
Figure 1 shows the trend over time in the proportion of pregnant women who tested HIVpositive in Namibia from 1992 to 2004. HIV surveillance has been conducted every two
years amongst pregnant women in Namibia since 1992 using the same standardised
methodology.
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Guidelines for PMTCT in Namibia
1.3.
Risk of Mother-to-Child Transmission of HIV
In the absence of antiretroviral medicines and with breastfeeding, published estimated
ratio of mother-to-child transmission (MTCT) of HIV range from 21% to 43% in various
African settings. An estimate of the magnitude of transmission to newborns in Namibia
per year is summarised in Table 1. Each year an estimated 4,620 newborns acquire HIV
infection as a result of mother-to-child transmission.
Table 1. Estimated number of infants infected with HIV per year (MOHSS)
Population (Census 2001)
1.8 million
Births per annum, 2002 (estimated HIS 2001)
70,000
HIV prevalence in mothers, 2002
22%
Total number of births to HIV-positive mothers at risk of MTCT,
assuming no multiple pregnancy
15,400
Number of new-born infected with HIV during 2002 in Namibia,
assuming a 30% risk of transmission and no intervention provided
4620
As depicted in Figure 2 most transmission takes place during labour and delivery,
followed by transmission in the uterus and through breastfeeding, depending on
duration. The greater risk of transmission around labour and delivery is due to the
increased exposure of the new-born to HIV-contaminated blood and body fluids. Also,
the longer the child is breastfed, the greater the risk of HIV transmission.
Figure 2. Risk of mother-to-child transmission during the stages of pregnancy
Risk of MTCT, if the mother is breastfeeding and not receiving ARV
Antenatal
Labour and Delivery
Early Postpartum,
0-6 months
Late Postpartum,
6-24 months
Risk of Transmission:
5-10%
10-20%
5-20%
Source: Adapted from Guidelines for Anti-Retroviral Therapy, MOHSS, 2003
The estimated risk of HIV transmission to exposed new-borns, assuming no intervention
is as follow:
 5-10% during pregnancy,
 10-20% during labour and delivery, and
 5-20% from breastfeeding depending on the duration.
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Guidelines for PMTCT in Namibia
Without any PMTCT intervention, for every 300 children born to HIV-infected women,
about 100 will become infected. Of those 100 children infected about 16 would have
acquired HIV during pregnancy, 50 during labour and delivery and 34 after delivery
through prolonged breastfeeding. In the absence of ARV medicines intervention,
transmission patterns and risks vary between breastfeeding infants, depending on
duration of breastfeeding, and non-breastfeeding infants as shown in Table 2.
Table 2. Transmission patterns in breastfeeding and non-breastfeeding
populations in the absence of anti-retroviral (ARV) medicines intervention
Transmission ratio %
HIV transmission by
stages
No
Breastfeeding
Breastfeeding
breastfeeding
for 6 months
for 18-24
months
During pregnancy
5-10%
5-10%
5-10%
During labour
10-20%
10-20%
10-20%
Early (first 2 months)
5-10%
5-10%
Late (after 2 months)
1-5%
5-10%
25-35%
30-45%
Through breastfeeding
Overall
15-30%
Source: de Cock K.M. et al (2000)
Though transmission can occur at any stage, the main factors that increase the risk of
mother-to-child transmission are summarised in Table 3 below.
Table 3. Factors increasing or affecting mother-to-child transmission of HIV
Obstetrical
Maternal
Foetus/New-born
Viral
 Episiotomy
 High viral load
 Prematurity
 Viral resistance?
 Invasive monitoring
 Low CD4 count
 Multiple births
 Viral subtype?
 Mode of delivery
 Advanced disease
 Breastfeeding
 ROM > 4 hours
 Poor nutrition
 Mixed feeding
 Intrapartum
 Breast condition or
 Immature gastro
haemorrhage
disease
intestinal tract
 Instrumental delivery
 STIs
 Genetic factors
 Chorio-amniocentesis
 New HIV infection
 Immature immune
 Illicit substance abuse
 Vit A deficiency
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Guidelines for PMTCT in Namibia
1.4.
Benefits of the PMTCT
PMTCT provides several benefits at the societal, household, and individual levels:
i. Reduces suffering from HIV/AIDS in children and those affected.
ii. Decreases the burden on the household and health system, by decreasing the
number of HIV infected children.
iii. Provides a linkage to early and comprehensive HIV/AIDS care for the mother,
partner, and child, including ARV therapy.
iv. Counselling, testing, access to ARV therapy and community sensitisation can also
contribute to reduce stigma in society.
v. Promotes behaviour change, e.g., use of dual methods of family planning, improved
attendance for antenatal care, improved infant feeding practices.
vi. Provides opportunity to plan for the future, for example infant feeding options.
vii. Gives an opportunity to improve, expand health services and to strengthen health
infrastructure.
1.5.
Interventions to prevent mother-to-child transmission of HIV
Table 4.
Efficacy of various PMTCT interventions
Intervention
No intervention
No breastfeeding
Short-course with one ARV, but breastfeeding
Short-course with one ARV, but no
breastfeeding
Short course with 2 ARV, but no breastfeeding
3 ARV drugs, no breastfeeding
3 ARV drugs but breastfeeding
Risk of Transmission
30 to 45%
20 to 25%
15 to 25%
5 to 15%
5%
1%
Unknown
A number of clinical trials in Sub-Saharan Africa have demonstrated the efficacy of
various short-course ARV drug regimens for PMTCT. Generally speaking, the more
ARV drugs are given to the pregnant woman and her HIV exposed newborn, the lower
the risk of transmission. However, simplicity of use, potential toxicity, and cost are also
important considerations in selecting drug regimens, which is why single-dose
Nevirapine (SD-NVP) serves as the standard for PMTCT in Namibia.
The advantages of single-dose Nevirapine to the mother and exposed new-born include:




It is simple to administer, making it a more feasible option in resource-limited
settings.
Nevirapine is rapidly absorbed by the gastrointestinal tract and is readily
transferred across the placenta to provide protection to the baby.
A single dose of Nevirapine results in a rapid decline in maternal viral load and is
long-acting.
There are virtually no side effects from single-dose Nevirapine to the mother and
exposed newborn, and its safety is now well-demonstrated.
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Guidelines for PMTCT in Namibia
CHAPTER 2
PREVENTION OF HIV INFECTION AND UNINTENDED PREGNANCIES
2.1.
Prevention of sexually transmitted infections (STIs) including HIV
2.1.1. Behavioural change communication.
Preventing HIV infection in women will contribute significantly to the prevention of HIV
transmission to infants and young children. HIV prevention programmes will need to be
directed to all women and their partners. Behavioural change communication towards
the ABC (abstinence, be faithful and use condoms) should make particular efforts to
reach young people, the future parents.
2.1.2. Voluntary counselling and testing (VCT) services.
VCT plays an important role in HIV prevention through detection of HIV, risk reduction,
and counselling of couples. Providing accessible VCT services is therefore an effective
strategy to decrease primary HIV infection.
2.1.3. Treatment of Sexually Transmitted Infections.
Human immunodeficiency virus is passed from one person to another more easily when
one or both people are infected with another STI. The STIs that are particularly
important in this interaction are chancroid, chlamydia, gonorrhoea, syphilis,
trichomoniasis, genital herpes and granuloma inguinale. Depending on which infection it
is, these STIs can make it two to nine times more likely that someone will be infected
with HIV when exposed to the virus. Rapid treatment of STIs reduces the risk of
acquiring additional infections and infecting other people. Referral of sexual partners for
treatment is essential for the interruption of re-infection. The Syndromic Approach
adapted by the Namibian Government is well suited for primary health care services and
for rural clinics because it does not require laboratory services. People with STIs can get
care right in their own community. Appropriate counselling and treatment of STIs also
improves the use of condoms, changing risky sexual behaviour, accepting HIV testing
and convincing their partner to seek treatment.
2.2.
Prevention of Unintended Pregnancies
2.2.1 Family planning services
Family planning programmes in Namibia have made significant progress in the provision
of contraception to reduce unintended pregnancies. Most HIV-infected women in
resource-limited countries are unaware of their sero-status. Being HIV infected can
influence a woman’s and partner’s choices about pregnancy. Therefore, family planning
services need to be strengthened so that all women, including those infected, can
receive support and services to prevent unintended pregnancies.
Sexually transmitted infections, including HIV, remain a matter of concern to the
MOHSS. Therefore, prevention of these infections must be reinforced in the context of
comprehensive reproductive health, including family planning and sexual health. The
concept of “dual protection” against STIs/HIV and unintended pregnancy should be
actively promoted.
To promote dual protection, health workers should provide
information on methods to prevent unintended pregnancies as well as on STIs and HIV.
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Guidelines for PMTCT in Namibia
“Dual protection” is defined as the simultaneous prevention of STI/HIV infection and
unintended pregnancy through the use of condoms.
Informed choice on contraception must include the recognition and acknowledgement
that many methods are effective against pregnancy, yet offer no protection against STIs
or HIV infection. Informed choice must include information that correct and consistent
condom use prevents HIV and STIs, but is also a highly effective contraceptive. Condom
use combined with another contraceptive method further helps to prevent pregnancy.
Dual protection is particularly important for anyone who is sexually active and is not
planning a pregnancy with a partner of unknown HIV status, or with anyone who is in an
HIV discordant relationship.
The operationalization of dual protection requires a number of actions, including:
i. maximising the integration of family planning and STI/HIV prevention services;
ii. ensuring widespread availability of male and female condoms at service delivery
points, and other outlets;
iii. development of adolescent friendly reproductive health services;
iv. male involvement in reproductive health;
v. appropriate introduction of female condoms into reproductive health programmes;
vi. Promotion of dual protection in antenatal and postnatal services.
2.2.2. Contraceptive considerations when female patients are on ARV therapy
Women known to be infected with HIV should receive essential care and support
services, including family planning and other reproductive health services, so that they
can make informed decisions about their future reproductive lives.
For all male and female patients receiving ARV therapy, the use of barrier methods is
recommended to reduce the risk of transmission of HIV and other sexually transmitted
infections.
Most ARV drugs lower blood concentration of estrogens. Therefore, women on ARV
therapy should not use oral contraceptives.
Suitable contraceptive methods for women on ARV therapy are:
 Inject able Progestagen

Barrier methods (female and male condoms)

Emergency contraception

Sterilization

Contraceptive implants
A short course ARV regimen for PMTCT will not have an effect on the woman’s postpartum contraceptive options.
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Guidelines for PMTCT in Namibia
CHAPTER 3
ROUTINE COUNSELLING AND TESTING (RCT)
3.1. Benefits of counselling and testing for HIV
In Namibia HIV infection has emerged as the most important factor contributing to adult
and child morbidity and mortality. According to the 2004 sentinel sero-survey, 1 in 5
pregnant women is infected with HIV. Life-saving interventions are now available to
prevent mother-to-child transmission and prolong survival of people living with HIV/AIDS.
Therefore, all pregnant women should be routinely counselled and tested for HIV
infection at their first ANC visit, and their sexual partner(s) should be encouraged to be
tested as well.
Most pregnant woman will test HIV negative, which offers an opportunity to counsel them
on risk reduction for the prevention of HIV infection. Knowing the HIV status of the
partner is also critical. HIV-negative women with an HIV-positive partner are at high risk
for HIV infection. Conversely, if the woman is HIV-positive, the partner may be HIV
negative. These two are examples of discordant couples. Discordant couples have
unique and complex needs in terms of on-going counselling and support.
RCT has become increasingly important in national and international prevention and care
efforts. Knowledge of HIV status can be a motivating force for HIV-positive and negative
people alike to adopt safer sexual behaviour, which enables sero-positive people to
prevent their sexual partners from getting infected, and those who test negative to
remain negative. Counsellors could be midwives, doctors, nurses, religious workers,
community members, friends, family, members of AIDS organisations and people living
with HIV/AIDS. Guidelines for counselling exist; refer to them for the definition, the
objectives, the process of counselling, training and the skills required.
RCT is the cornerstone of all interventions to reduce mother-to-child transmission
(MTCT) of HIV. In the PMTCT programme, pre-test, post-test, and on-going counselling
are offered to all pregnant women and postpartum women and their partners and
families. Routine counselling and testing in the antenatal clinic is different from VCT in
several aspects:
In VCT the client seeks the service for the specific purpose of learning their HIV serostatus and to receive counselling regarding the results as well as other information about
HIV infection and AIDS. This testing is done anonymously, or the names of the clients
are known but kept confidential. In the ANC the pregnant woman is seeking medical care
to ensure the health of her baby and herself. HIV testing and counselling is at best a
secondary purpose for seeking care. Therefore, routine counselling and testing in
the antenatal clinic should be provided by the health worker to all pregnant
mothers as part of a routine comprehensive package of care.
It is the responsibility of the staff at the antenatal clinics at all levels to provide
information and support to pregnant women regarding their HIV status. This has the
effect of de-stigmatizing HIV testing, which indirectly, reduces stigma of HIV in the health
care setting. The benefits of HIV routine counselling and testing in the ANC are
described below:
8
Guidelines for PMTCT in Namibia
Benefits of routine counselling and voluntary testing for HIV in ANC services
Box 1.
 Making counselling and testing a routine ANC service (offered to every
ANC client) can help reduce the stigma associated with both VCT and
HIV infection.
 Counselling and testing offered at ANC clinics may be more acceptable
to pregnant women compared to VCT centres that serve both men and
women.
 Counselling and testing services based in antenatal clinics can reach a
high percentage of pregnant women.
 When women come for follow-up visits to antenatal clinics, they can be
given answers to different HIV-related questions at various stages of
the pregnancy.
 Offering counselling and testing within the clinic/health centre will help
to integrate HIV/AIDS programmes with other forms of health care,
such as treatment of STIs and other infections, nutrition support, and
family planning.
 For women who are found to be HIV-positive, counselling and testing
at the health centre can help to ensure that they are referred for other
interventions (treatment of STIs, TB and opportunistic infection
prophylaxis, ARV prophylaxis, infant feeding counselling).
 For women who are found to be HIV-negative, safe sexual behaviour
(or primary prevention of HIV) can be reinforced.
Adapted from Preble and Piwoz, 2001
3.2.
Counselling
3.2.1. Pre-test counselling for all pregnant women.
For all pregnant women, education and counselling about health and health risks is an
essential part of quality care. The following topics can be covered in group or individual
counselling:
 Personal hygiene
 Maternal nutrition
 Family planning
 Prevention and treatment of STIs
 Prevention and treatment of TB and other opportunistic diseases
 Information on HIV transmission and prevention
 Routine counselling and voluntary testing for HIV
 Sharing results with partners
 ARV medicines for PMTCT and for therapy
 Baby care and infant feeding options
No pregnant woman who refuses HIV testing should be tested. All the pregnant
women who accept to be tested will sign a Consent Form, while those who refuse will
sign a Release Form.
9
Guidelines for PMTCT in Namibia
3.2.2. Post-test counselling if HIV-negative
 Women should understand the meaning of a negative test and the window period.
Those who wish to have a repeat test should be given this opportunity.
 Discuss risks of couples having discordant HIV results and review disclosure
plans; counsel couple or partner if not tested together.
 Provide counselling on primary prevention of HIV infection and the importance of
remaining negative. Counsel the client on the development of an individual risk
reduction plan to remain negative.
 HIV-negative women should be advised to breastfeed in order to promote good
health and nutrition for her infant.
 Review other aspects of pregnancy care and self-care (nutrition, hygiene, malaria,
immunisations, etc.).
 Schedule next visit.
3.2.3. Post-test counselling if HIV-positive
Counselling of mothers who are informed for the first time that they are HIV-infected may
require more than one session. It is important to establish rapport that will encourage the
client to feel comfortable at return visits, ideally seeing the same nurse or counsellor. At
each visit check if the information on HIV/AIDS is well understood and promote safer
sex. The following topics are important on which to counsel HIV-infected women.
A.





B.





The meaning of positive results (having HIV infection)
Coping with feelings of shock, loss.
Difference between HIV and AIDS.
Infection prevention and care.
PMTCT through ongoing care and ARV medicines for the mother and baby.
Living positively.
Sharing results with partner
Discuss whom to tell the result. Nearly all people who learn their HIV results
disclose these results to someone else.
Discuss couple discordance and the importance of having partner(s) tested.
Since HIV is a sexually transmitted disease, it is especially important for their
partners also to be counselled and tested, since the partner may or may not be
infected.
Discuss support systems at home and in the community.
Discuss return visit or referral for couple or partner to VCT.
Discuss safer sex: abstinence, being faithful to partner of known HIV status and
condom use to prevent re-infection and protect partner(s).
C.
PMTCT interventions
General information should be given about PMCT interventions at each visit:
 Explain the need for additional clinical evaluation and laboratory tests to check if
she is eligible for HAART, co-trimoxazole prophylaxis and/or isoniazid preventive
therapy.
 Explain the regime of Nevirapine for mother and baby.
 Give the mother Nevirapine to take home at 32 weeks, in case the mother is
delayed in travelling to the hospital or in case she delivers at home.
 For Nevirapine, emphasize the importance of taking the tablet at the onset of
labour.
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Guidelines for PMTCT in Namibia

D.
Instruct the mother to bring the baby to the clinic immediately if she has delivered
at home.





Nutrition for mother and infant
Healthy food for the mother.
Benefits of breastfeeding and the risk of MTCT.
Risks and benefits of replacement feeding for HIV-exposed infants.
Acceptability, feasibility, safety and affordability of replacement feeding.
Exclusive breastfeeding for four months and abrupt stopping.



Issues on Family Planning
Information about making decisions on future fertility.
Information on contraceptive options.
Drug interactions between antiretroviral drugs and contraceptives.
E.
F.
Support groups
Link the women and family members to local AIDS support groups (NGOs, community
based organisations, church organisations, home based care groups), including support
groups of other people living with HIV/AIDS. Health institutions should collaborate with
AIDS support groups and utilise their services including peer counselling. Linking HIVpositive women and family members to these groups is important for:
 Reducing fear, ignorance and stigma surrounding HIV.
 Reducing the potential for domestic violence.
 Stimulating a community response in those living positively with HIV/AIDS.
 Contributing to an environment supportive of safer sexual behaviour.
G.






Planning for the future
Living with uncertainty due to a chronic illness and planning for the future.
Be aware of the need for ongoing HIV care, opportunistic infection prevention and
treatment.
Be aware of the life long increased risk of tuberculosis and the importance of early
diagnosis and treatment.
The criteria for the start of the ARV therapy, benefits and risks involved.
Importance of drug adherence.
Referral to the closest Communicable Disease Clinic.
3.3. Testing for HIV infection in pregnancy
The only way to know whether or not a person is infected with HIV is to take an HIV test.
The role of HIV testing in this programme is that of determining the sero-status of
pregnant women, their partners, and babies born to HIV-infected mothers. It is important
to note that results are needed in a timely manner in order to intervene. For women who
give consent, HIV testing should be performed routinely like the other tests performed at
the ANC (Rhesus, full blood count, haemoglobin, syphilis test).
3.3.1.



Types of HIV tests related to the management of HIV/AIDS.
HIV antibody tests
ELISA tests
Simple/rapid HIV
Rapid HIV tests are accurate, simple to perform and provide results immediately.
11
Guidelines for PMTCT in Namibia
For a pregnant woman arriving late in pregnancy, early in labour or immediately post
partum, the rapid test is the only option to get a HIV result in time to intervene effectively
for PMTCT.
3.3.2. Rapid HIV Testing
According to the NIP, two different rapid HIV tests should be performed concurrently on a
finger-stick blood sample and results reported as follows:
 If both tests are positive – report positive.
 If both tests are negative – report negative.
 If the tests are discordant (1 positive and 1 negative), or if the results cannot be
interpreted, then perform a third test as tie breaker or send a specimen to the
NIP for ELISA testing.
Only trained health professionals or trained community counsellors should perform these
tests in the context of a quality control assurance programme.
3.3.3 Blood sample collection
It is important to remember universal body fluid precautions to prevent blood-borne
transmission of HIV and other pathogens. Precautionary measures include the following:
 Wear gloves.
 Cover your sores with a plaster.
 Wash your hands with soap or disinfectant in case of contact with blood.
 Wash your hands after taking the blood.
 Be careful when you manipulate used needles or sharp instruments.
 Never re-cap used needles!
 Put the used needle in the disposal box.
 Keep the work environment clean and disinfected before and after the work.
 Collect the appropriate amount of blood for ELISA or rapid tests, CD4 count and
any other laboratory examination to be done (refer to NIP guidelines for the
amounts needed).
 Seal the blood containers well and label them before forwarding them to the
testing site.
12
Guidelines for PMTCT in Namibia
CHAPTER 4
MODIFICATION OF ROUTINE CARE DURING PREGNANCY, LABOUR, DELIVERY
AND POST-NATAL PERIOD FOR HIV-POSITIVE WOMEN
4.1 Management of known HIV-positive woman during pregnancy
4.1.1. Nutrition for an HIV-positive pregnant mother.
The health of a woman influences her fertility as well the health of the baby. A wellnourished mother will ensure a well-nourished foetus and newborn infant, and improve
breast milk production. All HIV-infected patients need information on a healthy diet and
nutritional support. During pregnancy every woman has an altered immune system. It is
even more important for pregnant women who have HIV to eat a balanced healthy diet.
Balanced diet during pregnancy
Eating a variety of foods ensures that the body gets all the nutrients that it needs. A
healthy diet for the pregnant women will ensure appropriate foetal growth and organ
development. In later pregnancy when women have difficulties eating a full meal at one
time, frequent eating of smaller portions and healthy snacks are good options.
Energy is the capacity of a body to do work. All of a person’s energy is derived from the
plant and animal food they eat. The energy value depends mainly on the carbohydrates,
proteins and fats contained in food. The daily Kilo Joule (KJ) required in pregnancy are
9000-10500. Carbohydrates are the main source of energy for the body. The most
common forms of carbohydrates are starches such as maize, mahangu, rice and wheat
and starchy roots such as potatoes and sweet potatoes. They are cheap, easy to find
and should form the base of every diet. Unrefined cereals are rich in micro nutriments,
which help strengthen the immune system. Proteins play an important role in enhancing
the body’s defence system. Nuts, meats and legumes should be taken in combination
with cereals. Fats are a concentrated source of energy and are therefore needed in
smaller amounts. Besides providing energy for the body, fats are needed for building
cells and absorbing and using vitamins. Vitamins and Minerals become increasingly
important when the immune system is weakened. They can be found in dark green leafy
vegetables, yellow and orange fruits, sweet potatoes, pumpkins, carrots, avocados and
tomatoes.
Nutritional guidance for all pregnant women
Box 2.
Every day, the pregnant women should consume the following food:
 Milk products e.g. yoghurt, omaere, fresh milk and omootekwa (different
names in indigenous languages applicable as well).
 Meat, fish, eggs, or/and beans interchangeably and at regular daily
intervals.
 Fruit and vegetables, e.g. orange, spinach, pumpkins, and apples.
 Bread and cereals, interchangeably and at regular daily intervals.
 Lots of liquid, e.g. water, oshikundu, and fresh juice.
 Alcohol intake is prohibited.
Other types of food and liquid may be consumed in line with cultural preferences and
practice.
13
Guidelines for PMTCT in Namibia
Precautions to prevent or minimise food or waterborne diseases, recommended
for pregnant women living with HIV/AIDS.
 Eat food that is well cooked and not contaminated.
 Never leave raw or cooked meat, poultry, fish and shellfish outside a refrigerator
for more than 1 hour.
 Uncooked meat should not be in contact with other foodstuff. Knives and all the
instruments should be washed after contact with uncooked foodstuff.
 Raw food should be stored separately from cooked food.
 A person living with HIV/AIDS should not drink water directly from lakes, ponds,
and rivers, due to the risk of acquiring various water-borne diseases, for example
cryptosporidiosis, giardiasis and others.
4.1.2. Routine antenatal care
When a woman who is known to be HIV-positive becomes pregnant, or is diagnosed as
being HIV-positive during pregnancy, her obstetric and medical care will need to be
strengthened and modified. All routine ANC supplies and vaccinations for example iron,
multivitamin, folic acid, tetanus toxoid should be provided. Sexually transmitted
infections should be treated following MOHSS syndromic management guidelines.
The schedule for follow up of the HIV-positive women is the same as in routine ANC.
 From 0 to 28 weeks: follow-up visit monthly
 From 28 to 36 weeks: follow-up visit every 2 weeks
 From 36 weeks: follow-up visit every week
Additional visits will not be required for obstetric reasons, although the HIV positive
pregnant woman may need to attend further counselling sessions or for complications
related to her HIV status.
When possible procedures, such as chorionic villus sampling, amniocentesis or
cordocentesis and external cephalic version (ECV), should be avoided because they
may carry a risk of HIV transmission to the foetus.
Medical evaluation for opportunistic infections
At the initial and at subsequent visits, a review of HIV-related symptoms and
determination of WHO staging should be done with focus on the following HIV-related
signs and symptoms.
 Persistent diarrhoea;
 Fever;
 Respiratory infections;
 Signs of TB;
 Oral and vaginal candidiasis;
 Lymphadenopathy;
 Herpes zoster;
 Other skin conditions can be common in HIV-infected persons;
 Other sexually transmitted infections;
 Poor weight gain, weight loss, or wasting in pregnancy are a poor prognostic sign
of HIV infection.
14
Guidelines for PMTCT in Namibia
TB and bacterial respiratory infections are common in HIV-positive individuals. All HIVinfected pregnant women should be screened for active TB and further evaluated if they
have any of the following signs and symptoms.
 Cough,
 Fever,
 Weight loss,
 Night sweats.
In case of illness, the nurse should refer the pregnant women to the medical officer for
further evaluation.
Laboratory investigations for HIV-positive pregnant women
All HIV positive pregnant women should have the normal routine tests. In addition, CD4
count and the Hepatitis B surface antigen should be performed if not done previously as
a baseline.
Prophylactic treatment
Prophylaxis in HIV-positive pregnant women may include:
 Pregamal
 Multivitamin supplementation
 Tetanus toxoid immunisation
 Intermittent Preventive Treatment (IPT) during first and second pregnancies for
women living in malarious areas. Sulphadoxine-pyrimethamine should be given in
two doses. The first dose should be given after quickening and the second one at
least four weeks apart up to 36 weeks of pregnancy.
 Cotrimoxazole prophylaxis after the first trimester if her CD4 count is below 300.
 Pregnant women should be encouraged to sleep under impregnated mosquito
nets.
 Isoniazid Preventive Therapy (IPT) to treat latent TB infection is recommended for
HIV-infected pregnant women as long as there is no evidence of active TB and
they have not received IPT before.
Who should get IPT
Who should not get IPT
Pregnant women HIV infected with none Any HIV infected pregnant woman
of the following signs or symptoms of TB.
with any of the following signs or
symptoms.

No fever

Loss of weight

No cough

Fever

No night sweats

Cough

No significant lymphadenopathy

Night sweats

No active liver disease (jaundice)

Lymphadenopathy

Has not received IPT before or TB

Liver disease (jaundice)
treatment in the previous year

TB treatment in the previous
year
NB: Isoniazid is safe to administer during pregnancy and breastfeeding.
15
Guidelines for PMTCT in Namibia
HIV related illnesses in pregnant women
HIV related illnesses in pregnant women are treated in the same way as in non-pregnant
women. The patient should be referred to a doctor familiar with HIV care and pregnancy.
Tuberculosis is the most significant common disease and should be managed and
treated in accordance with TB treatment protocols. However, the management of TB
and ARV treatment in pregnant women is complex. HIV-positive women may have other
sexually transmitted infections that will require treatment. Urinary tract infection and
respiratory infections are more common in HIV-positive women and may require
antibiotic therapy. Vaginal candidiasis may be recurrent and should be treated with local
antifungal preparations. Oral and/or oesophageal candidiasis should be treated with
fluconazole and/or local anti-fungal preparations.
Antiretroviral therapy for the mother
If the pregnant woman meets the criteria for antiretroviral therapy, she should be put on
treatment. In order to prevent the transmission of HIV to the unborn baby, a single dose
of Nevirapine 200mg should be given to the mother to take home in last trimester (32
weeks) for self-administration at the onset of labour.
Partner involvement
Counselling, testing and, if indicated, treatment is advocated for all partners of HIVpositive pregnant women. When possible the HIV follow-up of the pregnant woman and
her partner should be done simultaneously. Repeated counselling sessions will support
the family in the feeding option chosen.
Counselling for lifestyle and behaviour change
Unprotected sex in the presence of STIs during pregnancy may be associated with an
increased risk of HIV transmission to the baby. Women and their partners should be
encouraged to reduce risk of transmission to the child and partner by using condoms.
Smoking, alcohol and drug use should be discouraged.
Follow-up for HIV-positive pregnant women
HIV-infected pregnant women with CD4 more than 300/mm3 and asymptomatic need to
be followed-up routinely at their ANC appointments. They should be monitored for
symptoms of disease progression. CD4 count should be repeated every 6 months.
Pregnant women with CD4 less than 300/ mm3 or WHO stage III or IV should be referred
to the Communicable Disease Clinic for ARV therapy where they will receive monthly
follow up. Prevention and treatment of opportunistic diseases and infections are
important priorities for care at all stages of HIV disease.
4.2.
Management of the HIV-positive woman during labour and delivery
4.2.1. Universal precautions
Women with HIV infection should not be isolated from other women in labour. Universal
precautions should be used by health workers on all women in labour irrespective of their
HIV status.
16
Guidelines for PMTCT in Namibia
Remember to follow universal precautions in all women.
Box 3.
•
Reduce needle stick injuries, do not recap needles.
•
Wash hands with soap and water after contact with blood and body fluids.
•
Wear gloves during operations and delivery or any invasive procedures.
•
Cover your own broken skin or open wounds.
•
Wear impermeable plastic apron when conducting delivery.
•
Wear eye shields/goggles during operations and deliveries.
4.2.2. Specific intrapartum interventions
Management of labour in all known HIV positive women
i. Midwives should confirm the HIV status of all women who are admitted to the labour
ward by checking the records and/or by asking the mother whether she has been
tested for HIV infection. The management of those who are HIV-positive is
discussed below.
ii. Labour management should follow normal obstetric guidelines in most respects.
Analgesia should be given in labour, if required and epidural analgesia is not
contraindicated.
iii. Proper and consistent use of the partogramme in the monitoring progress of labour
will improve the management and reduce the risk of prolonged labour in all women.
iv. Emotional support during labour is important for all women, and may be even more
necessary for an HIV-positive woman who is concerned about her condition and the
risk of transmission to the child. This may be made worse by her fear of
stigmatisation and discrimination by medical staff, her partner or family members.
v. Whenever possible, during labour, HIV-positive women should have the option to
have a companion of their choice present who knows their HIV status and who can
provide supportive companionship.
vi. Labour ward staff should be sensitive to the fears and concerns of the HIV-positive
mother about her HIV status.
Management of normal vaginal deliveries
Vaginal cleansing with Hibitane (chlorhexidine 0.25%) solution reduces the risk of
puerperal and neonatal sepsis. It may also have some effect on HIV transmission where
membranes are ruptured for more than 4 hours. After every vaginal examination, the
birth canal is wiped with gauze or cotton wool, soaked in Hibitane solution. The number
of vaginal examinations should be kept to minimum required. Where induction of labour
is indicated, membranes should be left intact for as long as possible because prolonged
rupture of membranes is associated with increased risk of transmission. Artificial
Rupture of Membranes (AROM) of more than four (4) hours duration is associated with
an increased risk of HIV transmission. Therefore, it should be reserved for women with
foetal distress or abnormal progress. Episiotomies should be used only for specific
obstetric indications. Delivery should be conducted using standard practice while
avoiding unnecessary trauma or prolongation of the second stage.
17
Guidelines for PMTCT in Namibia
Management of deliveries by Caesarean Section (CS).
Caesarean Sections can reduce the risk of MTCT compared to vaginal delivery.
However, it carries the risk of surgical complications, such as infections and slow healing
of wound. Caesarean Sections should only be performed for standard obstetric
indications.
Activities to consider when performing a safe delivery
Box 4.

Perform vaginal cleansing with Hibitane (chlorhexidine 0.25%).

Avoid episiotomies unless absolutely necessary.

If assisted delivery is required it should involve as little trauma as possible.
Clamp cord immediately after baby is delivered and avoid milking the cord.

Cut cord under cover of a lightly wrapped gauze swab to avoid blood
spurting.
4.2.3. Management of ARV medicines for HIV-positive women in labour.
ARV medicines are effective in reducing transmission of HIV from the mother to the baby
when used appropriately.
In Chapter 6, the different clinical scenarios and
recommendations for use of ARV drugs are described. If the pregnant woman does not
qualify for ART she, should be given single-dose Nevirapine (SD-NVP) to reduce the risk
of transmission to the baby. During the last trimester (32 weeks), the mother should
receive 1 tablet of Nevirapine (200 mg each) to take home and to be taken at the onset
of labour and report to the nearest health facility. If more than 48 hours have past
since the first Nevirapine dose and she is in labour, then Nevirapine single-dose
should be repeated.
SD-NVP is most effective when given at the onset of labour. Upon admission to the
labour ward, the midwife should ask whether the HIV-positive pregnant woman received
a dose of Nevirapine during antenatal care and whether she took it before admission. If
she did not take Nevirapine prior to admission and is in labour, a stat single-dose of
Nevirapine 200 mg orally should be given immediately. In the case of elective
Caesarean Section, a single-dose should be given 2 to 6 hours prior to the procedure.
If the mother is HIV-negative with an HIV-positive partner, neither she nor
the new-born are to receive Nevirapine. Mother to child transmission of
HIV can only occur if the mother is HIV-infected.
4.3.
Management of women with unknown HIV status when in delivery or
postpartum.
It is common for women with unknown status, such as unbooked cases, to present to the
health facility in active labour. In such cases the health worker should counsel the
mother about the need to know her HIV status. The benefit of Nevirapine to prevent the
HIV transmission from the possible HIV infected mother to the child should be explained,
and the possibility to reduce transmission by providing Nevirapine to the new born,
should also be explained. If she agrees to be tested she should sign a consent form for
18
Guidelines for PMTCT in Namibia
HIV testing and giving NVP to the baby. When the test results are known she should be
counselled accordingly.
4.4.
Care of HIV-positive women after delivery
The postnatal period remains without complications in the majority of cases. However,
HIV positive women are prone to infection in the postnatal period. Once infection is
suspected intervention should be promptly instituted.
Information on possible
complications should be given before discharge.
Decision on infant feeding is best made before delivery. Infant feeding options should be
reviewed and support should be provided on the choice made. Information on
contraception options should be given and services provided. The use of barrier
methods (male or female condom) is recommended to reduce the risk of transmission of
HIV and other sexually transmitted infections.
An additional highly effective
contraceptive method is recommended to minimise the risk of unintended pregnancies.
Women whose HIV status is not known should be offered counselling and testing in the
immediate postnatal period once the patient has been stabilised. The patient needs to
be reviewed 6 weeks after delivery for a PAP smear and possible referral to the relevant
unit for ongoing clinical and laboratory evaluation and monitoring.
Further counselling and support will be needed. Women and their partners should be
referred to community-based organisations or other support groups available.
19
Guidelines for PMTCT in Namibia
CHAPTER 5
MANAGEMENT OF THE HIV-EXPOSED NEWBORN
5.1.
Management of the Newborn in the Early Postnatal Period
5.1.1. All babies should be handled with gloves and wiped with towel or surgical cloth
and washed with water and gentle soap.
5.1.2. Avoid suction in most newborns. If suction is required do it gently and use a
mechanical suction unit (at a pressure below 100mmHg) or a bulb suction and not
a mouth-suctioning device.
5.1.3. Cut the cord under the cover of lightly wrapped gauze.
5.1.4. All babies, irrespective of their HIV status should be kept warm after delivery.
5.1.5. Assessment of the newborn including the determination of the birth weight, length,
head circumference and eye care are done as usual.
5.1.6. Vitamin K, BCG, polio immunisation should be given according to the
recommendations for all newborns. Injections should be given only after bathing.
5.1.7. Infant should receive 1% tetracycline eye ointment or 1% silver nitrate eye drop as
prophylaxis against ophthalmia neonatorum.
5.1.8. Skin to skin contact with the mother should be established in all babies, even if the
mother is not intending to breastfeed.
5.1.9. Breastfeeding should commence at once if the mother has decided to breastfeed.
5.1.10. Solid waste e.g. dressings and placenta, should be properly disposed of.
5.2.
Infant Feeding Options
The objective of health services should be to prevent HIV transmission through
breastfeeding and optimize nutrition for the HIV exposed newborn while continuing to
protect, promote and support breastfeeding as the best choice of infant feeding for
women who are HIV negative and women who do not know their HIV status. Meeting
this objective requires:
 Organising counselling services,
 Strengthening ANC services,
 Providing infant feeding counselling for all pregnant women during ANC and
mothers post partum,
 Facilitating access to replacement feeding1 where appropriate,
 Preventing any “spill over “ effect of replacement feeding to those who are HIVnegative and of unknown status,
 Preventing commercial pressures of artificial feeding and,
 Providing appropriate follow-up care and support for HIV-positive women and their
children, particularly up to the age of two years.
1 Replacement feeding is defined as the process of feeding a child who is not receiving any breast milk with a diet that provides all
the nutrients the child needs. During the first six months this should be with a suitable breast milk substitute-commercial formula or
fresh cows or goats milk with vitamins and minerals supplements. After six months it should preferably be with a suitable breast milk
substitute, and complementarily prepared and nutrient – enriched family foods, given three times a day. If suitable breast milk
substitutes are not available, appropriately prepared family foods be further enriched and given five times a day.
20
Guidelines for PMTCT in Namibia
5.2.1 Feeding recommendations for HIV negative women
Exclusive and sustained breastfeeding means breastfeeding with no any other feeding
for the first four months of life for the baby, which is followed by the introduction of
complementary foods at six months with continued breastfeeding up to 2 years and
beyond. This feeding pattern is recommended for all mothers who are HIV negative and
those who do not know their sero-status. Health workers are required to assist mothers
with appropriate breastfeeding techniques and management of breastfeeding problems.
Exclusive and sustained breastfeeding is recommended for all children of women
whose HIV-status is negative or unknown.
5.2.2. Feeding recommendations for HIV-positive women
Breastfeeding is normally the best way to feed an infant. However, if a mother is infected
with HIV, it is preferable to replace breast milk to reduce the risk of HIV transmission to
her infant. Breastfeeding is a preventable mode of HIV transmission to infants and there
is an urgent need to educate, counsel and support women and families so that they can
make decisions about how best to feed infants in the context of HIV. Mothers who are
HIV-positive but choose to breastfeed can reduce the risk of transmission to their infants
by modifying breastfeeding.
HIV infection is an acceptable medical reason for feeding milk other than breast milk.
Health workers and counsellors should help HIV infected pregnant and lactating women
who choose not to breastfeed to identify safe, affordable, sustainable, feasible and
acceptable alternatives to breast milk. The risk of replacement feeding should be less
than the potential risk of HIV transmission through infected breast milk, so that infant
illness and death from other causes do not increase; otherwise there is no advantage in
replacement feeding. Replacement feeding in the case of HIV is applied to mothers
known to be HIV positive and is not a violation of the “baby and mother friendly initiative”
guidelines or the Code of Marketing of breast milk substitutes.
A.
Exclusive breastfeeding from birth to four months and abrupt stopping
An HIV positive mother may choose to breastfeed her baby if she considers it to be the
best way of feeding. If the mother chooses this method of feeding, she requires support
and encouragement. The baby should be breastfed on demand at least 8 to 12 times in
24 hours including night feeds. Exclusive breastfeeding provides the best infant nutrition
for growth and development. Giving the baby any drinks, water or foods other than
breast milk and use of pacifiers or dummies or artificial teats interferes with exclusive
breastfeeding. In addition, it may cause gut infection and irritation that will the baby more
susceptible to HIV transmission.
How to achieve exclusive breastfeeding
 Teach the mother the importance of exclusive breastfeeding during antenatal
care.
 Initiate breastfeeding within ½ an hour of birth with skin-to-skin contact.
 Show mothers how to correctly position and attach their babies to the breast.
 Teach the importance of breastfeeding on demand, rooming-in and night feeds.
 Teach and show mothers how to express and feed breast milk.
 Teach mothers about the dangers of using bottles, artificial teats, dummies and
cups with spouts.
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Guidelines for PMTCT in Namibia
How to help mothers to achieve early and abrupt stopping
Stopping breastfeeding early reduces the risk of transmission of HIV by reducing the
length of time the infant is exposed to the virus in breast milk. Before a mother stops
breastfeeding abruptly, she needs counselling about replacement feeding and
support for her decision. This counselling should begin in the post partum period.
It should include the following points:
 Finding a regular supply of another kind of milk. It is important that she does not
mix formula and breast milk as this might increase the risk of HIV transmission.
 Milking her breasts to dry up without engorgement.
 Ensuring continuing physical contact with her baby without giving in to the
pressure to breastfeed
 How to cup feed her baby.
B.
Replacement feeding (infant formula, cows and goats milk)
Replacement feeding can be an option of choice provided it is acceptable, affordable,
sustainable, feasible and safe. Commercial infant formula is already modified but cow's
and goat's milk for the first 6 months needs to be modified. The baby on exclusive
replacement feeding needs water.
How to achieve exclusive replacement feeding
Exclusive replacement feeding is more difficult than exclusive breastfeeding. Therefore
mothers should be taught:
 the dangers of mixed feeding;
 how to prepare infant formula;
 How to correctly and safely modify cow’s or goat’s milk.
Commercial Infant formula
Safe formula feeding is expensive. This option should be considered by the HIV-positive
mother when:
 Formula feeding is acceptable and affordable in the social context.
 The family has reliable access to a sufficient supply of commercial infant formula
for at least 6 months. The cost given in Table 5 does not include the cost of
utensils and fuel needed for the preparation.
 The family has resources, including clean water, fuel for food preparation,
utensils, skills and time to prepare commercial infant formula accurately and
hygienically.
 The mother should be educated about the dangers of diarrhoea and how to treat
dehydration with ORS.
 The family has access to an optimal environment, including sanitation and safe
water.
Table 5: Requirements and costs of infant formula for the first six months.
Age (Months)
Quantity
First month
Second month
Third month onwards
TOTAL
2.5 kg (5 tins)
3.0 kg (6 tins)
4.0 kg (8 tins)
22
Cost N$
(500 gm tins at 30 N$)
30 x 5 = 150.00
30 x 6 = 180.00
30 x 8 = 240.00
570.00
Guidelines for PMTCT in Namibia
Preparation of Infant Formula
Mothers should be advised to follow all the instructions given for preparation and mixing
of the formula:
 Wash hands with clean water and soap before preparation.
 Use clean utensils washed in soap and water and kept covered.
 Boil water for 5 minutes and cool to room temperature before mixing.
 Make sure the water and the powder is correctly measured.
 Mix powder and water well.
 Prepare only one feed at a time.
 Use a cup to feed the baby, hold the baby close to foster bonding.
 Discard left over feed.
The mother should be advised on the following:
 Not store prepared feed in a thermos, because this will help bacteria to multiply.
 Always check the expiry date on the tin.
 Store infant formula in cool and dry place.
 Follow the manufacturer’s instructions on the infant formula label in order to
ensure safe preparation of formula. This option requires a lot of support.
Preparation of modified cow’s and goat’s milk
Modified animal milk is another option for infant feeding but in Namibia fresh cow’s and
goat’s milk may not be available all year round. The only milk reliably available is “Long
Life” milk, which is more expensive in comparison to fresh cow’s milk. In addition,
modification of animal milk is more complicated than preparation of infant formula, which
is already modified. Furthermore, there is a need to provide supplements in the form of
vitamins and minerals. After six months the baby can be given full strength milk.
Animal milk contains twice as much protein and about six times as much mineral salts
than human milk. In addition, it has less carbohydrate content than breast milk. It is
therefore difficult for an infant’s immature kidney to excrete the extra waste. Unmodified
milk may lead to illness including convulsions. To make it safer for the baby less than 6
months it should be modified by diluting it with water to reduce protein and minerals and
boiled to make the protein more digestible. Sugar should be added to increase the
energy content. The baby should also be given multi-vitamin supplements to prevent
micronutrient deficiency.
Follow the following steps to prepare the milk feeds:
 Wash hands with clean water and soap before preparation.
 Use clean utensils washed in soap and warm water and kept covered.
 Boil water for 5 minutes and cool to room temperature before mixing.
 Boil milk to the boiling point and cool it to room temperature
 Measure the correct amount of water, milk and sugar.
 Mix well.
 Use a cup and a spoon to feed the baby.
 Hold the baby while feeding.
 Discard left over milk.
23
Guidelines for PMTCT in Namibia
Table 6: Baby’s minimum requirements while using modified cow’s and goat’s
milk.
150 ml/kg of
body weight
per day
Average weight
st
1 month
3 kg
2nd month
4 kg
rd
3 month
5 kg
th
4 month
5 kg
5th month
6 kg
th
6 month
6 kg
Age
(months)
Dilution:
100ml milk +50ml water +
(2 teaspoons) sugar = 150 ml
Milk
320 ml
420 ml
480 ml
480 ml
600 ml
600 ml
Water
160 ml
210 ml
240 ml
240 ml
300 ml
300 ml
Sugar
32 g
42 g
48 g
48 g
60 g
60 g
Total
volume/day
Approximate
number of
feeds
480 ml
640 ml
720 ml
720 ml
900 ml
900 ml
8 x 60 ml
7 x 90 ml
6 x 120 ml
6 x 120 ml
6 x 150 ml
6 x 150 ml
The baby requires about 92 litres for the first six months as the actual intake. The cost is
± N$7.00 per litre x 92 = N$644. Like in the case of infant formula, this cost does not
include the cost of utensils and fuel for preparation. After six months the baby can be
given full strength milk. Offer the baby clean water to drink 2-3 times a day to avoid
constipation.
5.3. Management of Breastfeeding
For breastfeeding to be successful the following issues should be explained and/or
shown to mothers. It is ideal to do this during antenatal period and reinforce after
delivery.
 Correct positioning and attachment.
 Importance of early initiation of breastfeeding immediately after birth.
 Frequency and duration of breastfeeding 8 to 12 times including night feeds.
 Importance of exclusive breastfeeding.
 The importance of breastfeeding on demand and rooming in.
 Dangers of mixed feeding.
5.4. Introducing complementary feeding 6-12 months
It is recommended that solids be introduced at 6 months for both breastfed and
replacement fed babies. The first food to be introduced is the household staple energy
food. The consistency and frequency of solid food is very important:
Answering the following questions will assist health workers in advising the mother to do
the right thing:
When? From 6 months.
What? Household staple energy food.
How? Gradually by spoon.
How often + How much? Once a day on the first day, increase amount and frequency
gradually up to 2 times a day until 9 months.
What consistence? Soft and smooth, but not watery.
When and How?
 At 9 months, gradually introduce well-mashed fruits and vegetable one spoon of
one food at a time
 Increase as the child is becoming used to the food.
 Add other food e.g. soft meat, fish, chicken, egg (only yellow).
 Enrich staple food with oil, fats and sugar.
 Increase the amount, consistency and frequency up to 5 times per day at 1 year,.
24
Guidelines for PMTCT in Namibia
5.5. Clinical Management of the HIV-exposed Newborn
The child should be monitored closely and in case of clinical signs of HIV infection
referred to Communicable Disease Clinic (CDC).
5.5.1 Management of ARV medicines.
The newborn of an HIV-infected mother should receive single-dose of Nevirapine 2
mg/kg between 12-72 hours after delivery if the mother has received Nevirapine at least
2 hours before delivery. If an HIV-infected mother has not received Nevirapine during
labour and presents with her new-born baby, the following is recommended:
Table 7.
Weight
<1.5 kg
<2kg
2-3kg
3-4
>4kg
Dosages of Nevirapine suspension
Nevirapine (mg)
Nevirapine suspension (10 mg/ml)
Adjust the dose according to 2mg/kg
4 mg
0,4 ml
6 mg
0,6 ml
8 mg
0,8 ml
10 mg
1,0 ml
5.5.2. Prophylaxis for Opportunistic Infections
Pneumocystis carinii pneumonia (PCP) is the leading cause of HIV related mortality in
infants, therefore PCP prophylaxis is recommended for all HIV-exposed infants
beginning at the age of 6 weeks. Indications for stopping PCP prophylaxis are:
i. HIV infection excluded;
ii. HIV infected children, over 1 year, on ARV drugs, with CD4>20% for 3 to 6 months.
Table 8.
Recommended doses of co-trimoxazole for PCP prophylaxis
Age
Co-trimoxazole dosage
Six weeks to five months
2.5 ml once daily on Mondays, Wednesdays and
Fridays.
Six months to six years
5 ml once daily on Mondays, Wednesdays and
Fridays.


All HIV exposed contacts under 5 years who are exposed to a TB patient having a
positive AFB sputum smear are eligible for Isoniazid Preventive Therapy (IPT).
The infant should be seen at the first scheduled immunisation visit at 6 weeks,
followed by monthly visits until 6 months of age.
5.6. Diagnosis of HIV Infection in Children
Maternal HIV antibodies pass through the placenta during pregnancy. Therefore
children born to HIV-positive mothers may have a positive HIV antibody test. Passively
transferred maternal HIV antibody may persist for up to 18 months. The current
minimum standard in Namibia is to use an HIV antibody test to diagnose HIV infection in
HIV exposed children. All babies born to HIV infected mothers should be tested regularly
for HIV in accordance with the Protocol for PMTCT. Polymerase Chain Reaction (PCR)
tests, which detect viral RNA or DNA rather than maternal antibodies can be used when
become available. PCR should be performed after the end of the breastfeeding, or if
clinically indicated according to the flow chart below.
25
Guidelines for PMTCT in Namibia
Diagnosis of HIV infection in infants
Infant
No
Yes
Breastfed?
1 ELISA or 2 rapid (1)
HIV tests at 18 months
(2)
1 ELISA or 2 rapid (1) HIV tests
at 9 and 12 months
2 Positives
tests
1 positive test
and 1 negative
2 negatives
tests
Positive
eee
Negative
The child is
HIV Positive
The child is
HIV negative
e
test
Antibody test at 18 months
HIV result
Positive
The child is HIV
Negative
HIV
result
Negative
The child is HIV
Positive.
26
Guidelines for PMTCT in Namibia
CHAPTER 6
MANAGEMENT OF ANTIRETROVIRAL
INTRAPARTUM, AND POSTPARTUM
6.1.
MEDICINES
DURING
PREGNANCY,
Overview of Antiretroviral Drug Use for PMTCT
There are essentially three types of ARV medicines used in Namibia.
Nucleoside Analogue Reverse Transcriptase Inhibitors (NRTIs)
These medicines inhibit the transcription of viral RNA into DNA, which is necessary for
reproduction of the virus. They include zidovidine (AZT) and lamivudine (3TC); the best
studied and most widely used NRTIs for PMTCT. Stavudine (d4T) and didanosine (ddI)
are also commonly used NRTIs in long term ARV therapy, but not in short course for
PMTCT.
Non-Nucleoside Analogue Transcriptase Inhibitors (NNRTIs)
These are of a chemically different class than NRTIs but also inhibit transcription of viral
RNA into DNA. They include nevirapine (NVP) and efavirenz (EFV). Nevirapine is
widely used and well studied for PMTCT, but efavirenz should not be given to
pregnant women due to potential teratogenicity.
Protease inhibitors (PIs)
They act on the viral enzyme that cuts long chains of amino acids into smaller proteins.
Protease inhibitors are used for long-term ARV therapy, not as a component of shortcourse ARV drug regimens for PMTCT.
ARV medicines should be administered to HIV-positive pregnant women for purposes of
PMTCT and/or therapy under the following clinical scenarios.
Scenario 1
Continuation of Highly Active Antiretroviral Therapy (HAART) during pregnancy.
Scenario 2
Initiation of HAART during pregnancy for women who have WHO stage III or IV disease
or CD4 below 300/mm3, but have not yet been started on antiretroviral therapy.
Scenario 3
HIV-infected pregnant women who do not qualify for ART and their exposed newborn
should receive a recommended short course of antiretroviral medicine regimen for
PMTCT.
Scenario 4
ARV drug prophylaxis for the HIV-exposed newborn, when the mother did not receive
any antiretroviral drug.
27
Guidelines for PMTCT in Namibia
Fig. 4. Algorithm for use of ARV Drugs for HAART or PMTCT in Pregnant Women
First ANC Visit
HIV routine
counselling
and voluntary
testing
YES
Known HIV
positive
NO
NO
HIV
Result
HIV
Negative
YES
Receiving
HAART
YES
HIV
Positive
Counsel on HIV
prevention and
` promote
breastfeeding
Home delivery
and mother did
not take NVP
Counselling,
clinical and
laboratory
assessment,included.
CD4
NO
WHO clinical
stage III / IV or
CD4<300
cells/mm3
Scenario 1
Continue HAART, but
discontinue or switch if
 On EFV , or
 On ddI/d4T, or
 Severe toxicity or side
effects (vomiting)
YES
Assess for medical
contraindications.
Scenario 4
Scenario 3
Scenario 2
NVP 2 mg/kg to
new-born STAT
Second dose after
48-72 hours
NVP 200 mg at
onset of labour and
2 mg/kg to newborn at 12-72 h
Start therapy with
NVP+AZT+3TC
Or if Hb<7
NVP+d4T+3TC
(1)
Regular follow-up counselling and clinical follow-up of mother and infant
(1) - For those on TB treatment, special regimen is
required, see Section 6.3.2
EFV=efavirenz ddI=didanosine
d4T=stavudine NVP=nevirapine
AZT=zidovudine
3TC=lamivudine
28
Guidelines for PMTCT in Namibia
6.2
Management of ARV Drugs in Pregnancy According to Clinical Scenarios
6.2.1. Scenario 1
HIV infected pregnant women already on HAART during current pregnancy
HAART regimens in pregnant women achieve efficacy for PMTCT through significant
reductions in maternal viral load. For women already receiving HAART and who become
pregnant, continuation of HAART with a recommended regimen for pregnant women is
the best option for mother and child. Not all HAART regimens, however, are safe or
recommended in pregnant women.
All recommended regimens consist of two nucleosides and a potent third drug to
complement it. Because some patients will not tolerate the recommended first line
therapy, clinicians providing HAART should be familiar with the various regimens.
The most widely used ARV therapy regimens in pregnant women include zidovudinelamividine (AZT/3TC), in combination with nevirapine (NVP), or nelfinavir, or
lopinavir/ritonavir (LPV/R), or saquinavir/ritonavir.
These combinations are
recommended by WHO.
The combination of stavudine-didanosine (d4T/ddl) should not be used in pregnant
women due to the increased risk of lactic acidosis.
Efavirenz (EFV) should not be used in pregnant women due to the potential teratogenic
effects on the foetus.
Pregnant women who
lopinavir/ritonavir (LPV/r).

cannot
tolerate
nevirapine
(NVP)
should
be
given
Women on HAART should be counselled about potential risks and benefits of
continuing therapy during the first trimester. If therapy is discontinued during the first
trimester, stop all medicines at once and restart all the same medicines
simultaneously in the second trimester as long as the medicines are not
contraindicated in pregnancy. If the pregnancy is identified during the second
trimester, continue with treatment.
Consult a specialist physician if HAART in a pregnant woman needs to be
switched or interrupted.
6.2.2. Scenario 2
HIV-positive pregnant women who have not received prior antiretroviral therapy but
needs it for their own health
For HIV-positive pregnant women who have not received ARV therapy, follow Figure 4 to
determine if she qualifies for ARV therapy. The use of ARV therapy during pregnancy,
when indicated, will improve the health of the mother and substantially decrease the risk
of transmission of HIV to the infant. If she does not qualify for ARV therapy, she should
receive a short course ARV regiment for PMTCT.
Pregnant women should be started on ARV therapy if they meet the following criteria:
29
Guidelines for PMTCT in Namibia



WHO stage III or IV HIV disease irrespective of CD4 cell count;
WHO stages I or II, with a CD4 cell count below 300/mm³,
Social criteria,which include the following:
~ Lived in a stable residence for the past 3 months;
~ Are not acutely abusing alcohol or other substances;
~ Have access to the Communicable Disease Clinic for follow-up;
~ Patient is committed to long-term ARV therapy, adherence to treatment,
practising safer sex, and allowing home visits if indicated;
~Patient has identified someone at home, in the community, or at the workplace to
serve as a therapy supporter.
The first-line regimen for HIV-positive pregnant women who do not have active
TB and meet the eligibility criteria for HAART is
zidovudine-lamivudine-nevirapine
(AZT-3TC-NVP).
The dosages for the first-line HAART regimen in pregnant women are:
i. Zidovudine (AZT) 300 mg twice daily. Monitor haemoglobin levels.
ii. Lamivudine (3TC) 150 mg twice daily.
iii. Nevirapine (NVP) 200 mg daily x 14 days, then twice daily. Monitor alanine amino
transferase (ALT).
HAART should be started in the second trimester unless the patient is severely ill, in
which case therapy should be started as soon as possible. Prior to initiation of therapy,
assessment for medical contraindications to regimen must be done.
ARV drugs should be continued as usual during labour and the post partum period.
Women who are put on HAART should be observed for evidence of ARV medicine
toxicity, in particular Nevirapine-related liver toxicity and skin rash. Zidovudine (AZT)
should not be used in women with Hb≤7 g/l. They should receive stavudine (d4T/20mg)
twice daily as well as appropriate management of underlying causes of anaemia.
6.2.3 Scenario 3
HIV infected pregnant women who do not qualify for ARV therapy or HIV-infected
pregnant women in labour who have received no ARV medicines drugs during
pregnancy
HIV positive pregnant women, who are not yet eligible for ARV therapy on the basis of
their disease status should be offered a short course ARV regimen for PMTCT.
HIV-positive pregnant women, who do not meet the eligibility criteria for ARV
therapy or are in labour and have received no ARV therapy before, should
receive SD-NVP at the onset of labour. The baby should receive a SD-NVP.
30
Guidelines for PMTCT in Namibia
6.2.4 Scenario 4
Infants born to HIV infected mothers who received no ARV medicines during pregnancy
or labour
If an HIV infected mother, for some reasons, has not received Nevirapine during labour
and presents with her new-born baby, the following is recommended:
*
Newborns who present less than 24 hrs of age should receive a dose of
Nevirapine syrup and a second dose at 48-72 hrs.
*
New-borns who present more than 24 hrs of age but less than 72 hours of age
should receive a single dose of NVP syrup.
*
New-borns who present more than 72 hours of age do not benefit from PMTCT
prophylaxis and should not receive Nevirapine.
6.3
Monitoring of pregnant women placed on HAART
6.3.1. Clinical monitoring for pregnant women placed on HAART
Baseline clinical assessment
The baseline medical history should include essential demographic characteristics; the
past medical history including major illnesses, hospitalisations and surgeries, the length
of time since the diagnosis of HIV infection, current medications and review of
symptoms. The baseline physical examination should include vital signs, weight, and
detailing of any abnormalities of the eyes, oropharynx, lymph nodes, lungs, heart,
abdomen, extremities, nervous system and genital tract.
Once ART has commenced, a reasonable schedule for clinical monitoring includes
follow-up visits at two, four, and six weeks after initiation and a minimum of every two
months thereafter for clinical and laboratory monitoring. Monthly visits to trained staff,
which can be combined with drug dispensing, are encouraged so as to monitor and
reinforce adherence and identify problems requiring referral. At each visit, inquiries
regarding adherence to treatment, any new symptoms that may be related to drug side
effects, HIV disease progression or opportunistic infections should be made.
Clinical monitoring for toxicities and effectiveness of ARV medicines in pregnant
women
Patients should be informed about the symptoms of ARV medicines side effects/toxicities
and should be educated regarding the need to seek care. Clinical evaluation of the
effectiveness of ART is important. The basic parameters examined and documented
should include:
~ the patient’s perception of how he/she is doing on therapy;
~ changes in body weight over the course of therapy;
~ signs of immune reconstitution syndromes.
~ HIV-related disease progression.
~ signs of drug toxicities.
~ decrease in symptoms of HIV disease and an improved quality of life.
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Guidelines for PMTCT in Namibia
Baseline laboratory assessment
Baseline laboratory assessment for HIV-infected pregnant women prior to starting ARV
therapy:
 HIV
 CD4 count
 FBC
 RPR
 HBs Ag (Hepatitis B surface Antigen)
 ALT
 Creatinine
 Blood glucose
6.3.2 Management of pregnant HIV-positive women with concurrent diseases.
Tuberculosis
It is preferable that pregnant women with TB disease complete their TB therapy prior to
beginning ARV medicines for therapy or PMTCT. However, they will need to be started
while still on TB treatment if they are in the last trimester of pregnancy because there is
high risk of HIV disease progression and death during the period of TB treatment.
Normally, in cases where a person needs TB and HIV therapy concurrently, first line
therapy options include efavirenz (EFV) plus zidovudine-lamivudine (AZT/3TC) or
stavudine/lamivudine (d4T/3TC). However, efavirenz (EFV) should not be used during
the first trimester of pregnancy. Except for SQV/r, PIs are also not recommended during
TB treatment with rifampicin due to their interactions with the latter drug. Therefore, the
regimen of choice for pregnant women with AIDS and TB is AZT-3TC saquinavir/ritonavir
(SQR/R) or abacavir (ABC), or efavirenz. Nevirapine (NVP) should only be use if there is
no alternative, considering the hepatotoxicity of Nevirapine and the effect of rifampicin on
reducing serum levels of NVP.
Table 9: Recommendation for ARV therapy in HIV-positive pregnant women with
Tuberculosis
Situation
Pulmonary
>200mm³
Recommendations for PMTCT and HAART
TB and CD4 Treat TB. Monitor CD4 counts. Give only
short-course regimen for PMTCT.
Start TB treatment. Start ART after 2 months
of TB therapy and if in 2nd trimester of
Pulmonary TB and CD4 50pregnancy
use
zidovudine-lamivudine
200/mm³
(AZT/3TC) plus saquinavir/ritonavir (SQV/R) or
efavirenz.
Start TB therapy. Evaluation at 2 weeks, and
Pulmonary TB and CD4
start HAART as soon as TB therapy is
<50/mm²
tolerated using AZT-3TC-SQV/r or efavirenz if
Or extra pulmonary TB
in 2nd trimester.
Hepatitis B Virus (HBV)
Limited studies have shown that there is a high prevalence of HBV among Namibians
with HIV. Among patients with effective HAART, liver disease is one of the most
common complications due to hepatotoxicity of many HAART regimens as well as
accelerated liver damage following immune reconstitution. Two ARV drugs for HIV have
32
Guidelines for PMTCT in Namibia
also shown antiviral effect on HBV. These drugs are lamivudine and tenofovir. The
combination of these drugs reduces the development of viral resistance of HBV. Among
the NNRTIs, efavirenz is the best tolerated and nelfinavir is the best tolerated PI. All
ARV drugs are potentially hepatotoxic. Ritonavir and nevirapine should especially be
avoided in patients with chronic active hepatitis B.
Renal Failure
In patients with renal failure dosages need to be adjusted for some medicines on the
basis of creatinine clearance. Consult with a specialist physician before starting HAART
in a patient with renal failure or when renal failure develops in a patient on HAART.
Tenofovir can cause franconi’s Syndrome. This is asymptomatic and can be monitored
by checking for proteinuria and elevated creatinine. In the following circumstance,
consult a specialist.
 Failure of first line therapy;
 Discordant couples considering having children;
 Combined pathologies (hepatitis, renal failure, diabetes, neoplasia, etc) ;
 Severe drug toxicities;
 Pregnant women receiving any other treatment than the recommended regimens.
33
Guidelines for PMTCT in Namibia
CHAPTER 7
PROGRAMME MANAGEMENT OF PMTCT
7.1.
Promotion of PMTCT through communication strategies
Communication is a key component to empower individuals and communities to support
behaviour change including the utilization of PMTCT services. Communication plays a
vital role in changing knowledge in mother to child transmission (MTCT) of HIV as well as
influencing values, social norms and correct understanding of MTCT. There is therefore
a need to provide adequate information to women/families on safe pregnancy, delivery
and newborn/infant care and to promote access to key services. There is also need to
address beliefs and harmful community practices which place women at risk, and affect
their access to information, services, and support. Communication operates through
three main strategies:
Programme communication (behaviour change communication) for changes in
knowledge, attitude and practices of specific key social groups. Activities focus on
strengthening programmes for women, their male partners, families and peers by
developing their skills, confidence and to challenge harmful norms. Health workers
should use interpersonal communication and counselling skills to support women and
their male partners. PMTCT and HIV messages could be disseminated through Maternal
and child health services, including, Family Planning, ANC, PNC, and Under Fives.
Social mobilisation for wider participation and ownership of community leaders and
groups of people.
Activities include raising awareness through campaigns or
establishing support groups or strengthening links between groups. It is done through
the use of community networks to encourage community support and action.
Advocacy is to raise political will and social leadership commitment. Activities focus on
developing new policies or laws to protect vulnerable individuals or increase their access
to services. It may also include sourcing support from politicians and policy makers.
7.2.
Organisation and Administration
7.2.1. Infrastructure.
It is useful to consider the issue of systems and health care infrastructure in terms of
three dimensions:
 Human resources
 Physical infrastructure
 Management infrastructure
Human Resource
The presence and availability of adequate human resource is the most important
ingredient of a successful PMTCT programme. The term “human resource” incorporates
staffing levels, staffing mix and staff competencies and motivation.
34
Guidelines for PMTCT in Namibia
Staffing levels
Services that run with inadequate staff do not run well. In all health facilities, the PMTCT
programme entails an increase in workload and clinical responsibilities. If this additional
workload is not compensated by additional staff, this can result in stress and possibly
deterioration in the overall quality of care provided. In Namibia it was therefore decided
to strengthen the introduction of the PMTCT programme by the recruitment of community
counsellors to assist with the counselling. PMTCT is integrated into routine ANC care
and should be provided by all nurses, not specialized staff.
The minimum staffing levels for PMTCT counselling should be based on the following
norms: Initial pre- and post-test counselling – an average of 60 minutes total per client;
follow up counselling and support - an average of 30 minutes per visit on two separate
occasions for HIV-positive women; a maximum of 8 clients seen per day for pre and
post-test counselling per counsellor.
Staff mix
It is important to note that a comprehensive PMTCT programme requires a mix of clinic
nurses, midwives, counsellors, obstetric and paediatric staff and doctors playing
complementary roles. Community counsellors are a critical element of the PMTCT
programme.
They need to work in close collaboration with professional staff.
Operational links between PMTCT services with welfare and nutrition staff is important to
provide post-partum care and support of mothers with HIV and their children.
Staff competencies, morale and motivation
Training and human capacity development is critical for the development of adequate
staff competencies, morale and motivation. A pool of experts and trainers with the
commitment and time to provide training is needed in each region.
In terms of training content, there is a need to balance the focus on HIV counselling and
testing with more training on infant feeding and child health. Off-site, formal classroombased training needs to be complemented with more on-site, in-service training with a
focus on skills development, local problem solving and on changing attitudes towards
HIV.
A strategy, to ensure that HIV counselling, PMTCT and infant feeding is taught
thoroughly and effectively in all under-graduate nurse and medical training institutions,
must be developed and implemented immediately.
Management infrastructure
Good management and a functional Regional Management Team (RMT) in collaboration
with the Regional AIDS Co-ordination Committee (RACOC) is a key factor determining
the success, efficiency, effectiveness and sustainability of the PMTCT programme.
Senior managers and effective multi-sectoral committees are important for integrating the
programme horizontally across the departments and creating an enabling environment
for programmatic staff. Strong technical capacity and the presence of experienced
clinicians with a commitment to HIV within the regional PMTCT management structures
are also important components of regional capacity.
At the local level, effective and integrated management is required at district level. The
active involvement of the DCC, local medical staff, HIS managers, hospital matrons and
PHC supervisors are equally important.
35
Guidelines for PMTCT in Namibia
NGOs are important potential role-players in the recruitment, training, remuneration,
support and supervision of community counsellors. A more pro-active development of
new NGOs and PLWHA support groups is suggested. It is necessary to improve the
capacity to work with NGOs efficiently, effectively and in the spirit of partnership.
Physical infrastructure
The importance of physical infrastructure is reflected in two ways. First of all, an
inadequate physical space and privacy hampers the ability of facilities to provide
adequate counselling and HIV testing services. It may therefore be necessary to expand
or renovate facilities. In many of the rural sites, the difficulties and expense of simply
getting to health facilities that provide antenatal, delivery and post-natal care remain a
major barrier to adequate coverage of health services including PMTCT services as well
as to adequate continuity of care. Improvements in access to care will improve PMTCT
coverage.
7.2.2. Integration of PMTCT into routine services
HIV-positive pregnant women should be followed up at the antenatal clinic. Women who
are not eligible for ARV therapy should receive Nevirapine from the antenatal clinic to
take home during the third trimester. Pregnant women who are eligible for ART should
be referred to the Communicable Disease Clinic (CDC) for the assessment, follow-up
and counselling. Where CDC has not yet been established the client must be referred
the nearest CDC. Counsellors should be available at the ANC to ensure the HIV
counselling and the regular follow up of the pregnant woman and her partner.
Nevirapine will be dispensed from the antenatal clinic for purposes of PMTCT.
7.3.
Monitoring, Evaluation and Reporting
7.3.1 Supportive supervision
Without regular support and supervision of front-line staff, the positive impact of training
is not sustained. Support and supervision, as well as organising peer support groups, is
required to help prevent staff burn-out. Providing effective and appropriate support and
supervision to front-line staff is a highly skilled job that should be part of a human
resource development plan.
7.3.2. Monitoring and Evaluation (M&E)
Monitoring means tracking the key elements of programme performance on a regular
basis (inputs, activities, results). Evaluation is the periodic assessment of the change in
targeted results that can be attributed to the programme intervention, or the analysis of
inputs and activities to determine their contribution to results. Monitoring and evaluation
helps programme implementers to:
 Determine the extent to which the programme is on track and to make any needed
corrections accordingly;
 Make informed decisions regarding operations management and service delivery;
 Ensure the most effective and efficient use of resources; and
 Evaluate the extent to which the programme/project is having or has had the
desired impact.
Effective M&E is based on a clear, logical pathway of results, in which results at one
level are expected to flow towards results at the next level, leading to the achievement of
the overall goal. If there are gaps in the logic, the pathway will not flow towards the
required results. The major levels are inputs, outputs outcomes and impacts
36
Guidelines for PMTCT in Namibia
7.3.3. Indicators
The indicators in the UNGASS M&E and the National Strategic Plan on HIV//AIDS in
Namibia framework will help in monitoring progress. While the aim is not to measure
progress at every step, the proposed indicators constitute parameters for the monitoring
of progress at all levels. Since it is not realistic to develop indicators for all possible
areas of action and programming, indicators have been developed for those areas where
particular emphasis is called for, and where progress needs to be measured:
 No. of health facilities providing PMTCT
 No. of health workers trained in PMTCT
 No. of TOTs for PMTCT
 No. of pregnant women starting ANC
 % pregnant women pre-test counselled
 % pregnant women post-test counselled
 % pregnant women tested for HIV
 % pregnant women tested HIV-positive
 % women who have received Nevirapine
 % babies who have received Nevirapine
 % HIV-infected infants born to HIV-infected mothers
 % pregnant women receiving a complete course of antiretroviral prophylaxis to
reduce the risk of MTCT.
 % of HIV+ women who choose to exclusively breastfeed for 4 months
 % HIV+ women who choose replacement feeding
7.3.4 PMTCT record-keeping and reporting
Prevention of mother-to-child transmission (PMTCT) of HIV is an integral part of the
existing Maternal and Child Health service. In addition to preventing HIV infection from
HIV-positive mothers to their newborns, it also aims at improving ANC services in
general. Monitoring of the intervention is indeed not intended to introduce a new system
of recording and reporting. Instead, it intends to improve the existing recording and
reporting system through addition of some new components/variables to be recorded
and providing for means of data storage and analysis in the hospitals delivering the
service. The PMTCT record-keeping and reporting system consists of the following
elements:
 The Antenatal Clinic Register and the Maternity Register have been updated to
include HIV status and PMTCT information.
 The 2 facility-based Monthly Report Forms which are aggregated from the
antenatal and maternity registers and submitted to the HIS office.
 The computerised PMTCT database at the district, regional, and national level.
37
Guidelines for PMTCT in Namibia
Figure 5.
PMTCT record keeping and reporting system
Data Collection and Reporting Procedure
Health Facility
ANC Register
Maternity (L&D) Register
ANC Monthly Summary Form
Maternity (L&D) Monthly Summary Form
District / Regional Office
Feedback
National Office
Data
Processing
Analysis
Forward flow:
Feedback
Feedback:
The following steps assist programme managers in optimizing the use of data:
 collect good-quality data by completing ANC and labour and delivery registers
accurately
 Compile monthly summary reports: Form 1 for ANC statistics and Form 2 for
labour and delivery statistics.
 Identify the different end-users, and present and package the data according to
their needs.
 Setup mechanisms for an efficient data analysis and utilization at each level.
 Provide feedback to clinics and health centres, DCCs, RMTs as well as
ART/PMTCT management committees.
Results of the analysis of routinely collected data will help the hospital management and
health staff to identify, in a timely manner, the problems occurring in their health facility
regarding the above three dimensions of the intervention, namely availability of essential
resources, utilisation of services and adherence. When problems are identified,
managers and the health staff will rationally conduct analysis of the identified problems
with stakeholders and plan for possible solutions.
38
Guidelines for PMTCT in Namibia
References
1. Government of the Republic of Namibia, Guidelines for the Use of Anti-retroviral
Therapy. Ministry of Health and Social Services, May 2003.
2. Government of the Republic of Namibia, National Guidelines on Clinical Management
of HIV Disease ad AIDS. Ministry of Health and Social Services, Namibia, July 2001
3. MOHSS, 2004: Preliminary results of 2004 Sentinel Sero Survey.
4. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in
Persons Infected with Human Immunodeficiency Virus. November 28, 2001. Available
at http://www.aids-ed.org and http://cdc.gov/mmwr.
5. Public Health Service Task Force Recommendations for the Use of Antiretroviral
Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to
Reduce Perinatal HIV-1 Transmission in the United States. The Living Document:
February 4, 2002. Available at http://www.aids-ed.org and http://hivatis.org.
6. World Health Organization, Prevention Of Mother-To-Child Transmission Of HIV:
Selection And Use
Of Nevirapine; Technical Notes; Geneva 2001
WHO/HIV_AIDS/2001.3, WHO/RHR/01.21
7. WHO; Exploring common ground: STI and FP activities; Ref. WHO/RHR/01.20;
http://www.who.int/reproductive-health/publications/RHR_01_20/abstract.en.html
8. WHO; Prevention of HIV in Infants and Young Children; Review of Evidence and
WHO’s Activities; WHO/HIV/2002.08
9. Health Systems Trust for the national Department of Health, Interim Findings on the
national PMTCT Pilot Sites - Lessons and Recommendations; South Africa, June
2002; http://www.hst.org.za
10. Family Health International, Institute for HIV/AIDS, Baseline Assessment Tools For
Preventing Mother-To-Child Transmission (PMTCT) of HIV; August 2003; www.fhi.org
11. WHO: Increasing Access to HIV testing and Counselling, report of a WHO
consultation. 19 – 21 November 2002.
12. Republic of Kenya, National Guidelines for Prevention of Mother to Child HIV/AIDS
Transmission
13. WHO: (draft) Antiretroviral drugs and the prevention of mother-to-child transmission
of HIV infection in resource-constrained settings, recommendations for use, 2004
Revision.
39
Guidelines for PMTCT in Namibia
Appendix I
Table 1.Trend in HIV prevalence ratio among pregnant women by sentinel site,
1992-2004
Sentinel site
Katima Mulilo
Oshakati
Grootfontein
Onandjokwe
Katutura Hospital
Oshikuku
Walvis Bay
Tsumeb
Otjiwarongo
Uutapi
Rundu
Nyangana
Andara
Engela
Nankudu
Keetmanshoop
Swakopmund
Gobabis
Mariental
Rehoboth
Opuwo
Windhoek C.H.
Luderitz
Outjo
Overall
1992
14%
4%
4%
2%
1994
25%
14%
9%
8%
7%
1996
24%
22%
1998
29%
34%
2000
33%
28%
17%
16%
21%
23%
29%
23%
31%
21%
28%
16%
18%
14%
10%
16%
17%
13%
7%
15%
9%
2002
43%
30%
30%
28%
27%
27%
25%
25%
25%
23%
22%
22%
21%
19%
16%
16%
16%
13%
12%
10%
9%
22.0%
9%
7%
6%
2%
7%
8%
5%
11%
18%
8%
7%
17%
3%
3%
1%
4%
6%
14%
16%
15%
23%
18%
17%
22%
9%
10%
9%
7%
4.2%
8.4%
15.4%
17.4%
19.3%
3%
35
15
2004
43%
25%
28%
22%
24%
27%
26%
16%
17%
17%
21%
15%
18%
18%
19%
16%
28%
14%
11%
14%
9%
10%
22%
12%
19.8%
Sourse: MOHSS.
This table shows the trend over time in the proportion of pregnant women who tested
HIV-positive by sentinel survey site. HIV surveillance has been conducted in alternate
years amongst pregnant women in Namibia since 1992 using the same standardized
methodology. The number of sentinel sites was increased from 18 to 21 in 2002 to
improve survey quality.
Appendix II
Table 2.
HIV prevalence ratio in pregnant women by age-group
Age group
(years)
13 - 19
20 – 24
25 – 29
30 – 34
35 – 39
40 – 44
45+
Overall
Source: MOHSS
Negative.
677
1092
771
536
293
114
20
3503
Positive.
74
251
269
163
93
14
3
867
40
Total
751
1343
1040
699
386
128
23
4370
Prevalence
9.9%
18.7%
25.9%
23.3%
24.1%
10.9%
13.0%
19.8%
95% CI
7.9 – 12.3
16.7 – 20.9
23.2 – 28.7
20.3 – 26.7
20.0 – 28.7
6.1 – 17.7
2.8 – 33.6
18.7 – 21.1
Guidelines for PMTCT in Namibia
Appendix III
TESTING FOR HIV INFECTION IN PREGNANCY
Types of HIV tests Related to HIV Management:
1.
HIV antibody tests:
Most commonly available HIV tests detect antibodies against HIV. They do not detect the
virus itself. Detectable antibodies against the HIV take from 1-3 months to develop after
HIV infection occurs. This time period is known as the window period. HIV antibody tests
are sometimes false positive, therefore, the laboratory routinely confirms with a second
antibody test.
2.
ELISA tests (Enzyme-Linked Immuno abSorbent Assay):
These are the most efficient tests for testing large numbers per day, but require
laboratory facilities with expensive equipment, maintenance, staff and a reliable power
supply. In Namibia, they are used for blood safety and diagnosis because they are very
sensitive (false negative tests are rare). A positive ELISA test result needs to be
confirmed with a second ELISA test using a different test kit, in order to diagnose HIV
infection conclusively. ELISA tests are also used to run quality assurance programmes
for rapid HIV tests.
3.
Simple/rapid HIV tests:
These tests utilise serum or a small whole blood sample from a finger prick. Like ELISA,
the rapid test determines whether there are HIV antibodies in a person’s blood. It gives
only two results, positive or negative. This simplifies interpretation by the provider. They
are a type of ELISA test built into an absorbent strip where the serum passes over a test
and control line. They do not require special equipment or highly trained staff and they
are as accurate as the routine ELISA tests. Simple/rapid tests will usually give results in
less than 30 minutes and are easy to perform.
Quality control for rapid testing
As with any laboratory test, quality control is also important to establish and maintain for
rapid HIV testing. Such a programme will help to detect any substandard tests as a result
of manufacturing errors, poor storage conditions, or user error. It is recommended that
each facility performing rapid testing should:
~ Ensure that any staff performing rapid HIV testing has been trained and certified
by the NIP to perform the test.
~ Maintain a log book of rapid test results which lists date of the test, results for test
1 and test 2, any tie-breaker test results, any ELISA results if performed,
comments, and signature of the person who performed the test.
~ On 1-2 days per month, collect an additional specimen for ELISA testing in
addition to rapid testing and submit to the NIP.
4.
HIV antigen and viral test:
These tests measure components of the virus itself and often quantify the amount of the
virus in the blood stream. These tests are useful for:
~ Diagnosing HIV infection in the window period, before HIV antibodies have
formed.
~ Diagnosing HIV infection in infants. All infants have maternal antibodies present
and so will test positive for HIV antibodies. Only those infected with HIV will have
the virus itself found. DNA PCR could be used for HIV1.
41
Guidelines for PMTCT in Namibia
~ Monitoring efficacy of ARV treatment: if effective, the viral
amount/quantity of virus in the blood) should drop when on treatment.
load
(or
5.
HIV RNA by PCR:
This is a good tool for measuring disease progression and response to therapy. The level
of plasma HIV-1 RNA is clearly a useful indicator of the response to ART in individual
patients. A baseline viral load is not required for initiating therapy, but it serves as a
useful baseline marker for response to therapy. In fully adherent patients, viral load is
likely to reach undetectable levels in 70-80% of the patients after 4 to 6 months. This is
therefore an appropriate time to assess therapy effectiveness. The viral load test detects
levels between 400-750,000 copies/ml. Depending on resources this test can be
regularly repeated or when treatment failure is suspected. However, due to its high cost
and limited availability in resource constrained settings, it is not presently recommended
in these guidelines as a required monitoring tool for managing ARV therapy. In the
absence of viral load monitoring treatment failure will need to be assessed
immunologically and clinically, rather than virologically.
6.
CD4+ lymphocyte cell count:
HIV targets lymphocytes having a receptor on their surface known as “CD4”, destroys
them, and thereby creates immunodeficiency. As the CD4 count progressively declines,
immunodeficiency becomes progressively worse and opportunistic disease occurs. A
CD4 count is only performed on patients with HIV infection. Available in Namibia, the
“CD4 count” is the best measure of immune function in a patient with HIV infection and is
measured using flow cytometer equipment in the laboratory. CD4+ lymphocyte counts
are one of the most useful and reliable ways of assessing whether an HIV-positive
patient should start ART and they are also extremely important in the assessment of the
effectiveness of ART. An increase of >100 CD4 cells/mm3 in the first 6-12 months is
typically seen in an ART adherent patient. Higher elevations can be seen and the
response often continues in subsequent years in individuals who are maximally
virologically suppressed. Immunologic failure on therapy can also be assessed by CD4+
cell counts.
42
Guidelines for PMTCT in Namibia
Appendix IV
WHO STAGING SYSTEM FOR HIV INFECTION AND DISEASE IN ADULTS AND
ADOLESCENTS
Clinical Stage I:
 Asymptomatic
 Persistent generalized lymphadenopathy (PGL).
Performance scale 1: Asymptomatic, normal activity.
Clinical Stage II:
 Weight loss, < 10 % of body weight.
 Minor mucocutaneous manifestations (seborrheic dermatitis, prurigo, fungal
nail infections.
 Recurrent oral ulcerations, angular cheilitis.
 Herpes Zoster, within the last 5 years.
 Recurrent upper respiratory tract infections (i.e., bacterial sinusitis).
And/or Performance scale 2: symptomatic, normal activity.
Clinical Stage III:
 Weight loss, > 10 % of body weight.
 Unexplained chronic diarrhoea, > 1 month.
 Unexplained prolonged fever (intermittent or constant), > 1 month.
 Oral candidiasis (thrush).
 Oral hairy leukoplakia.
 Pulmonary tuberculosis, within the past year.
 Severe bacterial infections (i.e., pneumonia, pyomyositis).
And/or Performance scale 3: bed-ridden, < 50% of the day during the last month.
Clinical Stage IV:
 HIV wasting syndrome, as defined by CDC1.
 Pneumocystis carinii pneumonia.
 Toxoplasmosis of the brain.
 Cryptosporidiosis with diarrhoea, > 1 month.
 Cryptococcosis, extrapulmonary.
 Cytomegalovirus (CMV) disease of an organ other than liver, spleen or lymph
nodes.
 Herpes simplex virus (HSV) infection, mucocutaneous > 1 month, or visceral
any duration.
 Progressive multifocal leukoencephalopathy (PML).
 Any disseminated endemic mycosis (i.e. histoplasmosis, coccidioidomycosis).
 Candidiasis of the oesophagus, trachea, bronchi or lungs.
 Atypical mycobacteriosis, disseminated.
 Non-typhoid Salmonella septicaemia.
 Extrapulmonary tuberculosis.
 Lymphoma.
 Kaposi’s sarcoma (KS).
 HIV encephalopathy, as defined by CDC2.
And/or Performance scale 4: bed-ridden, > 50 % of the day during the last month.
43
Guidelines for PMTCT in Namibia
Appendix V
ORAL ARV SHORT-COURSE REGIMENS FOR PMTCT
Alternative regimens (not for use in the public sector)
For use in public
health facilities.
Drug
For the mother
Pregnancy Labour
200 mg
onset
Nevirapine
(NVP)
None
Zidovudine
300mg
Q12h at 28- 300mg Q3h
36 wks
Postpartum Neonatal
at
None
2mg/kg at 12-72 hrs
(e.g., a 3 kg new-born
should receive 0.6 ml
of
a
10
mg/ml
suspension)
300mg Q12
4mg/kg Q12h x 7 days
x 7 days
AZT 4mg/kg Q12h x 7
days
AZT 300mg AZT 300mg
Zidovudine Q12h at 28 Q3h NVP200 None
Nevirapine
-35 wks
mg at onset
(AZT + NVP)
AZT 300mg
Zidovudine – 300/150mg
Q3h
Lamivudine
Q12h at 36
3TC 150mg
(AZT + 3TC)
weeks
Q12h
at 32 weeks
AZT
300
Zidovudine – bd
Continue all
Lamivudine - 3TC150mg
medications,
Nevirapine
bd
change AZT
AZT+3TC+NV NVP 200mg
Q3h
P
od for 2 wks
then bd
NVP 2mg/kg at 12-72
hrs
(e.g., a 3 kg new-born
should receive 0.6 ml
of
a
10
mg/ml
suspension)
300/150mg AZT4mg/kg,
Q12h
x 3TC 2mg/kg Q12h x
7days
7days
Continue
entire
SD-NVP 2mg/kg at 12regimen for
72 hours
3
days
postpartum
AZT dose adjustment for IV dosage (1.5mg/kg/12 hours) and premature infants
(2mg/kg/12hours)
44
Guidelines for PMTCT in Namibia
Appendix VI
CONSENT / RELEASE FORM
FOR PREGNANT WOMEN
IN ANC
Name:
_________________________________________________
Physical address
_________________________________________________
Phone
_______________________
Hereby confirm that
1. I have been counselled
2. I understand the implications of the tests
3. I want to be tested for HIV
4. I refuse to be tested for HIV before my delivery
Signed at _________________________
Date
_________________________
Signature of the pregnant women:
_____________________________
Signature of the counsellor:
_____________________________
45
Guidelines for PMTCT in Namibia
Appendix VII
Consent / release form to be tested and to provide Nevirapine to a new born
CONSENT / RELEASE FORM
FOR PREGNANT WOMEN IN ANC
Name:
________________________________________________
Physical address
_________________________________________________
Phone:
_________________________________________________
Hereby confirm that:
1. I have been counselled
2. I understand the implications of the tests
3. I want to be tested for HIV
4. I refuse to be tested for HIV before my delivery
5. I want my baby receive 1 or 2 doses of nevirapine
according to the medical indication
Signed at _________________
Date
_________________
Signature of the pregnant women:
__________________________________
Signature of the nurse:
__________________________________
46
Guidelines for PMTCT in Namibia
Printed with support from the US Presidential
Emergency Plan for AIDS Relief
47