Download integrated prevention of mother-to

Ministry of Health
NATIONAL PROTOCOL GUIDELINES
INTEGRATED PREVENTION OF
MOTHER-TO-CHILD
TRANSMISSION OF HIV/AIDS
NAC
ZAMBIA
2008
FOREWORD
PMTCT services are now offered in all the 72 districts in the nine Provinces of Zambia, from the pilot
phase seven years ago, the country is in the phase of expansion and as of January,2008 :678
facilities were implementing PMTCT. The programme is currently meeting 39% of the need, which is
one of the fastest increasing and comparatively high performance within the region. Expansion and
consolidation is ongoing with support from partners, mostly the Global Fund, UN Agencies, UNITAID
and PEPFAR and the country is set for higher targets. Mother to child transmission (MTCT) of HIV is
by far the largest source of HIV infection in children below the age of 15 years. According to
UNAIDS estimates, more than 90% of children who acquire the disease through Mother to child
transmission acquire the virus before birth, during birth or through breastfeeding.
HIV is the most serious threat to the development agenda in Zambia and the country is one of the
most heavily affected countries in the sub-region with the prevalence of 14.3% (DHS 2007) for
adults aged 15 to 49 years. Furthermore it is estimated that 1.1million Zambians are infected with
HIV of which 130,000 are children. HIV disease progression in children is faster and about 30% of
these children need to be on ARVs since they have progressed their HIV status to AIDS. Without any
intervention, one third of children born with HIV will die by their first and a half by their second
birthday. The prevalence rate of HIV ranges from 25-35% in urban areas and 8-16% in rural areas.
Women are disproportionately affected and the prevalence rate among pregnant women in
antenatal settings is 16.4% (ZANCSSR 2006). With about 500,000 deliveries every year and an
estimated 16% prevalence among pregnant women, Zambia is expected to have around 88,000 HIV
positive pregnant women delivering each year and with a transmission rate of 30 to 40% it is
expected that 28,000 babies are born HIV positive each year if no interventions are undertaken to
prevent mother-to-child transmission of HIV. To achieve the 4th and 5th Millennium Development
Goals (MDGs) Zambia a rapid response to scale up PMTCT is needed and this why the Zambia
government and cooperating partners have placed HIV as one of the top development agenda.
The goal of PMTCT programme in Zambia is to eliminate HIV infection in children and this second
edition, PMTCT guidelines have been produced to guide health care workers in the
implementation of PMTCT taking into consideration the incorporated new global PMTCT strategy by
the Inter-agency Task Team (IATT) as well as the recent World Health Organization (WHO) PMTCT
guidelines that promote treatment of pregnant women and prevention of HIV infection in resource
limited settings. These guidelines aim for significant improvements in care and delivery needed for
pregnant women and their children in the context of PMTCT including increased access to primary
prevention and family planning services, greater integration of PMTCT services into antenatal care
(ANC) settings, the use of more efficacious regimens to prevent transmission, greater access to
highly active antiretroviral treatment (HAART) for mothers eligible for treatment, and greater access
on the part of mothers and children to cotrimoxazole prophylaxis to ward off opportunistic
infections. In addition, early infant diagnosis (EID) methods that ensure that those children infected
despite these interventions have prompt access to HIV care and treatment.
This document has been mainly written for use by health care providers at the health facility and
district managers for PMTCT programming.
Brian Chituwo MP
Honourable Minister of Health.
2
ACKNOWLEDGEMENTS
Dr. V. Mukonka
Director Public Health and Research
Ministry of Health
3
Table of Contents
Foreword
2
Acknowledgements
3
Abbreviations
5
Introduction
6
Chapter 1 : Testing and Counselling
8
Chapter 2 : Antenatal Care
12
Chapter 3 : Intrapartum Care
16
Chapter 4 : Immediate Post Natal Care and Neonatal Care
18
Chapter 5: Postnatal Check-up
26
Chapter 6 : Follow-Up Pediatric HIV Care and Long Term support to Mothers
26
Chapter 7 : Care for Health Workers and Community Health Providers
37
Chapter 8 : Monitoring and Evaluation
38
Annex I : Nevirapine Baby Dose Preparation
42
Annex II : Antenatal Care Flowchart with orphan model
43
Annex III : Sources of Iron and other Nutrients and their Absorption
44
Annex IV : Amounts of Foods to Offer for Complimentary Feeding
46
Annex V : Positive Living with PLWHA
47
Annex VI : WHO Staging System for HIV Infection and Disease
49
Annex VII : Clinical Situations and Recommendations
56
Annex VIII : 10 Steps to Successful Breastfeeding
58
References
59
4
Abbreviations
3TC
Lamivudine
ANC
Antenatal care
ARV
Antiretroviral drugs
AZT
Zidovudine
BD
Bi-daily
DHS
Demographic and Health Survey
ELISA
Enzyme-Linked Immunosorbent Assay
HAART
Highly Active Antiretroviral Therapy
HB
Haemoglobin
HIV
Human Immunodeficiency Virus
HMIS
Health Management Information System
IGA
Income generating activities
INH
Isoniazide
IU
International Unit
IYCF
Infant and Young Child Feeding
MNCH
Maternal, Neonatal and Child Health
MTCT
Mother to Child Transmission of HIV/AIDS
NVP
Nevirapine
NGO
Non Governmental Organisation
PCP
Pnemocystis Jiroveci Pneumonia
PITC
Provider Initiated Testing and Counselling
PLHIV
People Living with HIV
PMTCT
Prevention of Mother-to-Child Transmission
RPR
Rapid Plasma Reactive - Syphilis test kit
STI
Sexually Transmitted Infections
TB
Tuberculosis
TT
Tetanus toxoid
UNICEF
United Nations Children's Fund
WHO
World Health Organisation
ZBSS
Zambia Sexual Behaviour Survey
ZDV
Zidovudine
5
Introduction
The 2004 Sentinel Surveillance survey indicate that the overall HIV prevalence for pregnant women
aged 15–49 years from the 23 sentinel surveillance sites tracked in 2004 was 18.7%. The mean HIV
prevalence at the urban sites was 25% and 11.8% for rural sites. HIV prevalence among 15–19year-olds was 11.6% (8.7% for rural sites and 14.6% for urban sites).
Without provision of prevention of Mother-to-Child transmission services, an estimated 40,000 out of
the 500,000 babies born annually will acquire HIV infection.
The implementation of prevention of Mother-to-Child transmission of HIV programmes, has yielded
positive results in developed and developing countries. The Zambian programme will have a
significant impact on childhood HIV infection and the increasing mortality trends by scaling up
prevention of Mother-to-Child transmission of HIV services to all Maternal, Neonatal and Child
Health (MNCH) services in the country, with introduction of more efficacious regimens and initiation
of testing and counselling by providers.
Scaling up includes maintaining ANC utilization above 90 percent, improving acceptance of testing to
70 percent, and acceptance, adherence to ARV therapy by HIV positive women to 75 percent, and
improving the number of deliveries attended by a skilled and trained health worker. The goals of the
National Prevention of Mother-to-Child Transmission of HIV Strategic Framework are:
1. To contribute to the improvement in child survival and development through reduction of HIV
related infant and childhood morbidity and mortality.
2. To contribute to the decrease in maternal mortality through the strengthening of antenatal,
delivery and postpartum care services.
3. To contribute to the improvement of the length and quality of life of HIV positive women and
their families through the provision of care and support services.
The Zambia National prevention of Mother-to-Child transmission of HIV programme uses a fourprong approach in prevention of Mother-to-Child transmission of HIV adopted from WHO
recommendations. Major components include primary prevention of HIV among young people,
women and men, prevention of unwanted pregnancies among HIV positive women, prevention of
HIV transmission from infected mothers to their babies, and care and support to HIV infected
families.
Expected Outcomes are:
•
•
•
Strengthening of primary prevention of HIV and STIs among women of childbearing age and
their children.
Decreased maternal, infant and under-five morbidity and mortality through improved service
delivery of antenatal, delivery and postpartum services.
Increased access to contraceptives, double protection, VCT and ARVs.
6
•
•
•
Increased access to community based care and support services for those infected or affected by
HIV and AIDS.
Increased health workers capacity to implement integrated reproductive health, HIV/AIDS
prevention and care services.
Increased community capacity to prevent and manage HIV/AIDS issues, particularly prevention of
Mother-to-Child transmission of HIV.
7
CHAPTER ONE
Testing and Counselling
The first step in the prevention of Mother-to-Child transmission of HIV programme is for all pregnant
women to know their HIV status. The Zambia National prevention of Mother-to-Child transmission
of HIV Programme uses an opt-out approach. The opt-out approach means that HIV testing is
part of the routine laboratory processes undertaken during all pregnancies. (See Annex II: Ante
natal Care Flow Chart with Opt out model).
Opt-out: HIV test is routinely recommended and provided to each patient. As with any
medical procedure, the client may decline to undertake the test
The woman does not have to sign a consent form but only needs to be fully informed of the test. It
is recommended that, testing and counselling for HIV, is done prior to other antenatal procedures.
The blood should be collected at the point of service and results for HIV given the same day. If tests
are done in the MNCH 10% of the samples should be sent to the laboratory for quality control
and quality assurance on a monthly basis.
HIV Counselling
People who have been trained in prevention of Mother-to-Child transmission of HIV should offer
counselling. However, as prevention of Mother-to-Child transmission of HIV is integrated in MNCH,
and services are scaled up countrywide, more people who have been mentored by those trained in
prevention of Mother-to-Child transmission of HIV should provide services.
Group Health Education, in the context of prevention of Mother-to-Child transmission of HIV also
used as group counselling, is the main means of giving information, education and communication
in the MNCH. It is meant to be interactive with the clients, to enable clarifying of as many issues and
questions as possible. GHE can be conducted by trained counsellors, students, volunteers and other
appropriate service providers.
Individual pre-test counselling is reserved only for those who have further issues to clarify, or those
who have declined the test, in order to probe further the possible reasons for declining the test,
offer support and make arrangements for opportunities to test.
Clients proceed to have the HIV test done, as well as the syphilis and HB.
At the booking visit and subsequent ones, all pregnant women should receive prenatal care and
health information that include counselling and testing, and information on Mother-to-Child
transmission of HIV, through both group education/discussion sessions as the mainstay of
information exchange.
8
Pregnant women who tested HIV negative early in pregnancy should be offered an opportunity to
re-test later during the third trimester or soon after delivery.
Elements in Group Health Education (GHE)
1.
HIV transmission and how to prevent it.
2.
Mother-to-Child transmission of HIV and programme measures to reduce it.
3.
HIV testing process and the fact that an HIV test is an integral part of care for pregnant
women, as interventions are available to care for the mother and baby.
4.
Importance of encouraging husband/partners to come for counselling and testing. Different
culturally appropriate initiatives may be taken in different settings to encourage male partner
involvement.
5.
Explanation on confidentiality and shared confidentiality.
6.
Explanation on the importance of disclosure.
7.
A negative result may mean that they are in the window period and will need to be retested
after 3 months and information should be provided on how to stay negative.
8.
The importance of having HIV negative pregnant women to be re-tested later in the third
semester.
9.
A positive result means that the mother has HIV and there is a risk that the mother will
transmit the virus to her baby either during pregnancy, labour or delivery, however, effective
preventive and care interventions are available including ARVs
10. HIV testing for the baby of the HIV positive mother, as well as other members of the family.
11. Information on the anti-retroviral therapy (ART) programme for mothers and children.
Provide time to answer questions and clarify any information that the audience may not be clear
with. Attention should also be paid to recapping or summarising the prevention of Mother-to-Child
transmission of HIV programme and its benefits. Individual pre-test counselling may be reserved
for those women who have further questions or are not clear.
HIV Testing
The women are then individually guided to where their HIV testing and ANC service package will be
done, unless she has declined.
The person trained in rapid HIV testing takes blood samples and when indicated, could also at the
same time perform other tests like RPR, and HB applying National Algorithms for testing. If there is
a laboratory and a trained laboratory technician at your station, then use these facilities.
•
If the first rapid test is negative, the woman is considered HIV negative. If the first rapid test is
positive, a second rapid test is done using a different test kit. If both tests are positive, the
woman is HIV positive. If the first test is positive and the second test is negative, the woman is
HIV indeterminate. If her HIV status is indeterminate, and a tie breaker test is not available at
9
the facility then a blood sample must be sent to the nearest district laboratory for re-testing. The
tie breaker test being used in Zambia is the BioLine test.
•
After the test has been performed, the service provider enters the results in prevention of
Mother-to-Child transmission of HIV register and/or the Laboratory HIV Test Register.
The register is kept confidential and always remains on site. Test results are given during the
post-test counselling session.
•
The major benefit of the rapid test is that it can be done in a short space of time and therefore
the woman should go home with her results the same day. Women should not be sent home
without their HIV test results. They should receive their HIV test results the same day.
HIV Post-test Counselling
•
All women and their partners, regardless of their HIV status should receive post-test counselling
in line with the post-test counselling format provided during the counsellor’s training.
•
If a woman or her partner tested HIV negative, she should receive post- test counselling on how
to maintain the HIV negative status, with a focus on her health, safer sexual practices, and the
high risk of transmission to her baby should she become infected during pregnancy or breastfeeding. The window period should be explained once more and she should receive routine
antenatal care. It should be emphasized that she will need to be re-tested after 3 months or
towards the end of her pregnancy or soon after delivery, depending on which comes first.
•
If a woman or her partner is tested HIV positive, they are informed about prevention of Motherto-Child transmission of HIV and offered an opportunity to join the programme.
•
All HIV positive women and their partners should be clinically tested for CD4 count or clinically
staged using the WHO staging criteria and based on eligibility criteria, referred to the ART
programme. If the facility is unable to provide this service, they should be referred to the
referral facility where they will be clinically assessed for HAART eligibility. Clients who qualify for
HAART will be offered all other components of the MTCT programme except the short-course
ARVs. All HIV positive women should also receive routine antenatal care. Clients that do not
qualify for HAART should be registered in the Pre-ART register, and followed up using national
guidelines. Where CD4 Count is not available, the WHO clinical criteria should be used to stage.
During post-test counselling and over the next visits, the newly diagnosed HIV positive woman is
also provided with:
•
Ongoing counselling which includes: emotional support, assessment of coping, information about
existing peer-support groups, appropriate referrals for support and information around positive
living (See annex V for more information about positive living).
•
Information about HIV disease, potential health problems and the importance of clinical care for
HIV disease
10
•
Information about the ART programme
•
Information about the MTCT Programme and medicines that are offered including potential side
effects
•
Counselling about partner identification and disclosure, stigma and discrimination and shared
confidentiality. For clients who qualify for prevention of Mother-to-Child transmission of HIV
provide anti retroviral drugs as according to the guidelines.
•
All regimens are administered by mouth. Paediatric formulations are used for all infant
regimens. Efforts must be made to monitor for side effects and support maternal and infant
adherence.
•
Remind the mothers that may deliver at home about ARV doses for herself at the beginning of
labour, and for the baby within 72hours of birth, preferably as soon as possible after delivery.
Request that she goes to the health facility within 72 hours after delivery for the NVP and AZT
syrup baby doses and for immunization.
•
Infant feeding counselling immediately after post test counselling if they can cope otherwise an
appointment should be scheduled.
•
All women should receive information about husband/partner testing.
•
HIV results and the post-test counselling session are recorded in the Counselling Register.
11
CHAPTER TWO
Antenatal Care
Antenatal care aims at making pregnancy and delivery a safe experience for the mother. It is also
intended to build the foundation for the delivery of a healthy baby.
Antenatal Care Services
These are meant for all pregnant women who should attend at least four visits of focused antenatal
care schedules for:
•
Clinical screening and examination, monitoring of blood pressure, urinalysis, and
compulsory weight measurement at every visit.
•
Active detection and effective treatment of STIs (RPR for screening and Benzathine
Penicillin as treatment). If RPR is done and found negative in the first trimester, repeat at
36 weeks gestation. The repeat of RPR test could be combined with a repeat HIV testing
for women found HIV negative earlier in pregnancy.
•
Prevention, detection and treatment of anaemia should be strengthened in line with Safe
Motherhood guidelines. This should include determination of HB at baseline and
subsequent visits. Systematic de-worming should also be provided together with Ferrous
Sulphate and Folic acid.
•
Intermittent Presumptive Treatment (IPT) with sulphadoxine-pyremethamine for malaria
prophylaxis should be given starting in the second trimester. The IPT should be
administered at least after every 4 weeks, although it can also be given even after 8
weeks. It should be ensured that, a woman has at least three doses before delivery.
However it should be noted that a woman receiving Cotrimoxazole prophylaxis should not
receive IPT. Encourage the use of impregnated mosquito nets by ALL pregnant mothers.
•
Multi-vitamin supplementation for the prevention of low birth weight to all antenatal
attendees.
•
Counselling about infant feeding options including the health benefits and risks of
breastfeeding and replacement feeding.
•
Information about safer sex during pregnancy, breastfeeding, and double protection in
the long-term. This should go with promotion and provision of condoms for all couples to
use at all times during pregnancy and breastfeeding.
•
Tuberculosis (TB) clinical screening in HIV infected mothers with history taking,
examination and sputum smear if indicated. If diagnosed positive, refer for appropriate TB
care.
12
As soon as the woman reaches 28 weeks of pregnancy, or soon after, provide short-course ZDV
therapy.
•
At the first visit after confirming the mother is HIV positive, the woman can be given her
single NVP dose to take home so she can take it at the onset of labour. Where blister packs
are available she may be given the full course of drugs for her to take during antenatal,
labour, delivery and in the postpartum period. How ever it needs to be emphasized that she
will need to be seen every four weeks for review. At these visits asses adherence and other
issues such as disclosure, side effects and testing of other family members. These visits can
also be used to reinforce messages such as infant feeding, family planning, early infant HIV
testing and other aspects of continuum of care. She will also be given the babies NVP dose at
the 32 visit to be taken soon after birth and she should be advised on safe sex.
Between 1st ANC
contact and 28 Weeks
28 Weeks
32 Weeks 36 Weeks On-set of
labour
At birth
Ensure the following are done:
1. HIV, RPR, HB & CD4 tests
are done
2. Eligibility for HAART is
determined
3. Counselling on ARVs and
IYFC is conducted
Administer AZT
on-site and
dispense for the
next 4 weeks
Dispense
AZT+3TC(for
intake during
labour) &
Nevirapine
(for the baby)
Dispense
Nevirapine
Check
adherence
and drug
stocks
Dispense
AZT+3TC
Ensure that counselling on ARV
adherence and IYFC is
conducted at every visit
•
If the woman loses her medication give her a repeat dose but if she takes her NVP too early
due to false labour, do not give her a repeat dose.
•
All pregnant women, especially those on the prevention of Mother-to-Child transmission of
HIV programme are encouraged to deliver at the health facility.
•
All Pregnant women meeting the criteria for HAART should be treated starting from second
trimester. Those on HAART prior to pregnancy should continue through out pregnancy.
However, if the regimen contains Efavirenz (EFV), discuss with the mother the possibility of
exchanging this drug as it has been associated with teratogenicity. Otherwise the mother is
encouraged to continue with the same regimen.
•
If possible the woman should be advised to deliver in a health facility. Where that is not
possible the woman should be advised to take the ARVs prescribed but even then the health
provider should check the woman’s HB before delivery.
Based on the individual needs of the mother we need to plan for their care (including frequency of
visit)
13
Anti-Retroviral Prophylaxis Regimens to Prevent Mother to Child Transmission
Course
Antenatal
Recommended
for
pregnant
women
presenting at 28
weeks pregnancy or
earlier. This is the
preferred regimen
Mother:
ZDV 300mg
Twice
a
day
starting at 28
weeks or as soon
as
possible
thereafter
Intrapartum
Postnatal
Mother:
3TC / ZDV (150/300) start
dose of 2 tablets at onset of
labour and 1 tablet every 12
hours until delivery.
Infant:
NVP 2mg/kg oral suspension
immediately after birth and
ZDV 4mg/kg twice a day for 7
days starting immediately
after birth.
NVP 200mg single-dose
onset of labour.
at
Mother:
3TC/ ZDV (150/300)1 tablet
twice a day for 7 days
Regimen
for
pregnant
women
who has received
less than 4 weeks of
AZT
or
HAART
before delivery.
Mother:
3TC/ ZDV(150/300) start dose
of 2 tablets at onset of labour
and 1 tablet every 12 hours until
delivery
NVP 200mg single-dose at onset
of labour.
Infant:
NVP 2 mg/kg oral suspension
immediately after birth and ZDV 4
mg/kg twice a day for 28 days.
Regimen for mother
who has received no
ARV prophylaxis.
Mother
3TC/ ZDV (150/300)start dose
of 2 tablets at onset of labour
and 1 tablet every 12 hours until
delivery.
NVP 200 mg single-dose at onset
of labour.
Infant:
NVP 2 mg/kg as soon as possible
after delivery and
ZDV 4 mg/kg twice a day for 28
days.
Mother
3TC/ ZDV 1 tablet twice a day for
7 days
Where combination None
regimen
not
available.
Mother:
Infant:
Single-dose NVP 200 mg at onset NVP 2mg/kg oral suspension
of labour.
immediately after birth.
If the mother did
not
receive
any
A R V s
f o r
prophylaxis
and
baby is seen soon
after delivery.
Mother
3TC/ ZDV (150/300)1 tablet twice
a day for 7 days
Infant:
NVP 2 mg/kg as soon as possible
after delivery and
ZDV 4 mg/kg twice a day for 28
days.
Source: Generic Training Package, Pocket Guide, WHO, 2004
•
•
Prophylactic ARVs should be dispensed within MNCH
When referred for HAART pregnant women should be given priority for assessment given that
there is a limited period within which the opportunity to avert HIV transmission to the unborn
baby can be fully utilized.
14
•
•
Where Combivir is not available, continue with Zidovudine ******
The use of NVP alone is discouraged unless there are no other options.********
15
CHAPTER THREE
Intrapartum Care
This involves the modification of midwifery and obstetrical practices for the HIV positive woman to
reduce the risk of HIV transmission to the infant. Although elective caesarean section (prior to
labour) is of value, it is not practically feasible to be routinely offered in Zambia.
However, the following obstetrical practices should be applied to reduce the risk of HIV transmission
to the infant:
•
Avoiding episiotomy unless medically indicated.
•
Avoiding routine rupture of membranes unless medically indicated.
•
Avoiding unnecessary suctioning of the neonate as well as other invasive procedures such as
intrauterine scalp monitoring.
Short Course ARV During Delivery
NVP 200mg to the mother at onset of labour and single dose 2mg/kg syrup for the baby
within 72 hours of birth
3TC/ZDV Start dose of 2 tablets for the mother at onset of labour, 1 tablet every 12
hours until delivery, then 1 tablet twice a day for 7 days and 4mg/kg of ZDV twice a day
for 7 days for baby
In addition to labour ward routine activities, the following should be observed:
•
Upon admission, the midwife inquires if the woman took the short course ARV at home.
•
If the patient is found to be in labour or to have ruptured membranes but did not take any short
course ARV at home, she should be given NVP and 3TC/ZDV dose immediately.
If the patient does not have the ARVS given to her previously at the health facility, she must be
given doses from the Health centre stocks.
NVP should not re-dispensed, when taken in false labour, however if lost or forgotten it can be redispensed.
In the case of false labour, if the patient is evaluated before she has taken her Nevirapine, she
should be sent home to await more active labour. She should be instructed to continue with AZT
and to take her Nevirapine with the onset of stronger and more regular contractions, or upon
rupture of membranes. For ruptured membranes, if with fever and/or greater than four hours, give
antibiotics.
16
If the patient is evaluated after she has taken her Nevirapine and the 600mg ZDV, but found not to
be in true labour, and not to have ruptured membranes, she should not be given another dose of
NVP, however for ZDV, the patient should take the usual dose of 300mg after 12 hrs, and continue
with the twice a day regimen. When labour starts, she should move on to3TC/ZDV start dose of 2
tablets then 1 tablet every 12 hours, until delivery.
1. Women can be given NVP at any time during the first stage of labour. It is only too late to give
NVP to the woman if the baby’s delivery is imminent i.e. if the head is crowning.
2. A woman on HAART should continue the HAART regimen and should not be dispensed ARVs
for prevention of Mother-to-Child transmission of HIV Prophylaxis.
3. If a mother knows she is HIV positive at delivery but is not in the prevention of Mother-to-Child
transmission of HIV programme, she should be given NVP and 3TC/ZDV as well as NVP and ZDV for
the baby as long as she has been counselled about the prevention of Mother-to-Child transmission of
HIV programme, including infant feeding practices and the importance of care, follow-up and HIV
testing for the baby.
For a mother who has not taken ARVs or only receives NVP and 3TC/ZDV during labour
or the mother tests positive soon after delivery, the baby should be given:
NVP dose immediately after birth AND ZDV 4mg/kg twice daily for 28 days starting
immediately after birth
If the woman does not know her HIV status and presents in early labour, she should be offered
Counselling and Testing and if found positive, spelt out protocol should be followed in giving care.
First Stage
Strictly keep membranes intact for as long as possible to prolong rupture unless otherwise medically
indicated.
Use aseptic techniques including vaginal cleansing with 0.5% chlorhexidine with each vaginal
examination.
Second Stage
Avoid invasive procedures i.e. episiotomies and instrumental deliveries unless absolutely necessary.
17
CHAPTER FOUR
Immediate Post-natal Care and Neonatal Care
This refers to the package of services provided to the mother and the infant before they leave the
health facility (6 to 48 hours after delivery).
The following checklist can serve as a guide to the health care provider to ensure the package of
care is complete:
•
ARVs for the postnatal period
•
Revisit time
•
Hb check
•
Next scheduled visit
•
Danger signs that the mother should look out for
•
Look out for opportunistic infections
•
Cotrimoxazole prophylaxis for women with a CD4 count less than 350.
The package of care for the Newborn is outlined below:
Nevirapine syrup dose:
• If a baby weighs 2 kg or more (>2000g) = give 0.6 ml (6 mg).
• If a baby weighs less than 2 kg, dose Nevirapine by baby weigth = > give 0.2 ml/kg (2 mg/kg).
ZDV syrup dose:
• 4 mg/kg twice daily for 7 days.
Anti-Retroviral Therapy for the Newborns
Nevirapine is given to the baby between 4 and 72 hours after delivery.
If the baby vomits the drugs within one hour of taking them, a second dose should be given and the
baby observed for another one hour. A third dose should not be given.
As earlier stated, if the mother did not take Nevirapine or took her dose of Nevirapine less than two
hours prior to delivery, the baby should get the start dose of Nevirapine and the ZDV syrup twice a
day for 28 days.
If the baby of an HIV positive mother in the prevention of Mother-to-Child transmission of HIV
programme is born at home or outside the health facility, and presents to the clinic within 72 hours
of delivery, and it is established that the mother took ARVs at the onset of labour, Nevirapine and
ZVD should be given to baby as per regular doses for the baby. The mother should also be given
ZDV/3TC for 7 days after delivery. This should be noted in all Registers including Under 5
Card.
18
If the baby of an HIV positive mother, in the prevention of Mother-to-Child transmission of HIV
programme is born at home or outside the health facility, and presents to the clinic within 72 hours
of delivery, and you establish that the mother did not take ARVs at the onset of labour, the baby
should get the start dose of Nevirapine and the ZDV syrup twice a day for 28 days. This should be
noted in the Registers and Under 5 Card.
If the baby of an HIV positive mother who is not in the prevention of Mother-to-Child transmission
of HIV programme is born at home or outside the health facility, and presents to the clinic within 72
hours of delivery, the baby should get the start dose of Nevirapine and the ZDV syrup twice a day
for 28 days. This should be noted in the Registers and Under 5 Card.
NOTE: All information on the HIV status and ARVs dispensed as well as follow up should
be recorded in Registers and Under 5 Cards.
Immunization for the Newborns
All babies should receive their routine immunization (OPV0 and BCG) in their first hours of life. OPV0
can be given as suggested, or any time up to 14th day of birth.
Feeding Practices
In Zambia, breastfeeding should continue to be protected, promoted and supported.
For mothers who are HIV negative, or who are of unknown status, exclusive breastfeeding for 6
months and thereafter continued breastfeeding up to 24 months or beyond with timely, adequate
and safe complementary feeding is recommended.
All pregnant women should routinely be tested for HIV and all breastfeeding HIV negative women as
well as those of unknown status should be encouraged to regularly take an HIV test( during the
pregnancy and breast feeding period).
Infant Feeding Options (0-6months) when a Mother is HIV Positive
There are only two main infant feeding options when the mother is HIV positive. These are:
•
Exclusive breastfeeding – This means giving a baby only breast milk, and no other liquids or
solids, not even water unless medically indicated. This means that exclusive breastfeeding is
recommended for HIV-infected women for the first six months of life unless replacement feeding
is acceptable, feasible, affordable, sustainable and safe for them and their infants before that
time.
•
Exclusive replacement feeding – This is the process of feeding a child who is not
breastfeeding with a diet that provides all the nutrients the child needs until the child is fully fed
19
on family foods. The infant feeding recommendation in this category is infant formula.
Other infant feeding options in special situations include:
•
Heat Treated Expressed Breast milk- This means that a mother expresses breast milk and heats
it so that the HIV present in breast milk is destroyed making it safe to feed the infant. This
may be used during the transition period from breastfeeding. Heat-treatment reduces the level
of some anti-infective components of breast milk. However heat-treated breast milk remains
superior to breast-milk substitutes.
•
Wet nursing –This refers to breastfeeding by another woman, who is HIV-negative. This may
only be considered in special situations such as in case of an orphaned infant and the family can
not meet AFASS. The wet nurse should be tested every three months. The wet-nurse will also
need to protect herself from HIV infection the entire time that she is breastfeeding. In
addition, the wet-nurse should be available to feed the baby on demand, both day and
night.
She should also receive counselling about how to prevent cracked nipples, breast infections
and engorgement. If a baby is already infected with HIV, there may be a very small chance
that he can pass the virus to the wet-nurse through breastfeeding. The wet-nurse needs to
know about this small risk and avoid breastfeeding while the baby has oral thrush or she
has cracked nipples and can express breast milk during this period to give by cup.
NOTE: Home modified animal milk is no longer a recommendation. This is in view of not
only concerns on the safety of preparation of feeds and storage, but also due to its
nutritional inadequacies (micro nutrients and essential fatty acids). Therefore, it is not
part of the guidelines.
Feeding Options when the Infant is Tested (0-6months) with PCR (Early
Infant Diagnosis)
What are the recommendations?
•
Breastfeeding mothers of infants and young children who are known to be HIV-infected should
be encouraged to continue breastfeeding.
•
If an infant tests HIV negative and is breastfeeding, counsel the mother & reassess AFASS
•
If the infant’s HIV status is unknown, encourage mother to use earlier chosen option pending
results.
Mode of feeding for replacement feeding
How should replacement feeding be given to an infant?
20
•
By cup and spoon.
•
Baby should be fed on fresh feed every time.
•
The transition from breastfeeding should be within 2-3 days to 3wks (transition period).
Abrupt
weaning is not recommended.
Feeding of Infants Born to HIV Positive Mothers after 6months
What should a breastfeeding mother do after 6months?
•
At six months, if replacement feeding is still not acceptable, feasible, affordable, sustainable and
safe, continuation of breastfeeding with additional complementary foods is recommended, while
the mother and baby continue to be regularly assessed. All breastfeeding should stop once a
nutritionally adequate and safe diet without breast milk can be provided.
•
The transition from breastfeeding should be within 2-3 days to 3wks (transition period).
Abrupt
weaning is not recommended.
•
The mother’s Cd4 count should be assessed every 3months where the service is available so that
mothers are initiated on HAART if less than 350.
Complementary feeding: This means giving other foods in addition to breastfeeding. This should
start after the first 6 completed months (see annex IV for details).
Making the Transition from Exclusive Breastfeeding to Exclusive Replacement Feeding
While a mother is breastfeeding, teach her baby to drink expressed, unheated, breast milk
from a cup. This milk may be heat-treated to destroy the HIV. Once the baby is drinking
comfortably, replace one breastfeed with one cup-feed using expressed breast milk.
Increase the frequency of cup-feeding every few days and reduce the frequency of
breastfeeding. Ask an adult family member to help cup-feed the baby.
Stop putting her baby to the breast completely as soon as she and her baby are accustomed
to frequent cup-feeding. From this point on, it is best to heat-treat her breast milk.
If her baby is only receiving milk, check that he is passing enough urine - at least six wet
nappies in every 24-hour period. This means that he is getting enough milk.
Gradually replace the expressed breast milk with formula (if below 6months) or whole
animal milk if above 6months.
If her baby needs to suck, give a clean finger instead of the breast.
To avoid breast engorgement (swelling) express a little milk whenever her breasts feel too
full. This will help her to feel more comfortable. Use cold compresses to reduce the
inflammation. Wear a firm bra to prevent breast discomfort. Do not begin breastfeeding
21
again once she has stopped. If she does, she can increase the chances of passing HIV to her
baby. If her breasts become engorged, express the milk by hand and discard it.
Begin using the family planning method of her choice, if she has not already done so, as
soon as she starts reducing breastfeeds.
Infant feeding counselling flow charts
Counselling for Infant Feeding in Relation to HIV
Pregnant or recently-delivered woman in
contact with the health services
Unknown HIV status
Tested negative
Encourage Testing
Tested positive
Counsel on infant feeding;
discuss options available
Counsel and encourage breastfeeding
Infant Feeding Options from 0-6 Months for HIV+ Women
Infant feeding options from 0-6 months
Exclusive breastfeeding
Replacement feeding when
AFASS:
Infant formula
Other breastmilk options:
• Expression and heat treatment
• Wet-nursing (breastfeeding by
an HIV negative woman)
22
1. During the group education, breastfeeding should be promoted while encouraging mothers to
test for HIV. Health workers should explain that once a mother has had an HIV test and her
result is positive, she should discuss with a health worker on how to feed her baby.
2. Infant feeding options should not be discussed in the group education but rather with an HIV
positive mother individually.
3. During the individual counselling for infant feeding the health worker should discuss the benefits
and risks of each of the two main options (exclusive breastfeeding and exclusive replacement
feeding i.e. is infant formula). It is important to ensure that AFASS is explored so that the client
makes an informed decision. If the mother requires more time to make up her mind or consult
the spouse, then make an appointment for a later discussion.
4. After the mother has received infant feeding counselling and has decided the feeding method it
is important for the health worker to demonstrate how best that method can be practiced. This
maybe done during a follow up appointment.
Infant Feeding Follow-Up
Whatever the feeding decision, health workers should follow-up all HIV-exposed infants, and
continue to offer infant feeding counselling and support, particularly at key points when feeding
decisions may be reconsidered.
Infant feeding counselling, support and follow up should be provided:
•
•
•
During pregnancy- First and follow up Antenatal Natal Care visits
At Delivery
During post natal – At 6days, 6weeks and thereafter every month until 24 months of age
Health workers should identify and establish community support to refer mothers for follow up. This
may be support on psychosocial and/or feeding issues. It is important that mother support groups
are strengthened in this regard. Traditional birth Attendants, community Health Workers, Home
Based Care Givers are some of the community based agents that can integrate infant feeding
support as part of their activities.
Feeding the Sick Child
Feeding a sick child is critical. HIV positive children are more likely to fall sick frequently. Sick
children need to eat small frequent meals to enhance recovery. Breastfed infants and young children
should continue breastfeeding during the period of sickness.
The IMCI strategy is critical in enhancing optimal feeding for sick children
Baby Friendly Hospital Initiative (BFHI) and Compliance to the Marketing
of Breastmilk Substitute’s Legislation
Like all other health facilities providing care for infants and mothers, all prevention of Mother-toChild transmission of HIV sites should implement the Baby Friendly Hospital Initiative (BFHI).
23
The DHMT should ensure that all sites comply with the legislation that regulates the marketing of
breast milk substitutes (Food and Drugs Act, Marketing of Breast milk Substitutes, 2006 Legislation).
This legislation aims at ensuring that mothers make an informed decision regarding the use of
breast milk substitutes rather than on the basis of commercial pressure
The revised and expanded BFHI includes the 10 steps to successful breast feeding and 3 additional
(Refer to annex VIII):
Care for the Mother
1. A high dose of Vitamin A (200, 000 IU) supplementation for the mother after delivery should be
given.
2. Promotion and provision of male or female condoms for use irrespective of one’s HIV status.
3. Counselling on family planning for HIV positive mothers including use of condoms and risk of
pregnancy in non-breastfeeding mothers.
4. Nutrition counselling and support especially for HIV positive mothers.
5. Personal hygiene especially after episiotomy.
Role of Traditional Birth Attendant (TBA)
TBAs can play an important role in the delivery of quality prevention of Mother-to-Child transmission
of HIV services. They can help in referring pregnant women to antenatal care services and
contribute to follow-up of women in the community enrolled in the programme. District health
teams should therefore organize prevention of Mother-to-Child transmission of HIV training for TBAs
to equip them with basic knowledge and skills related to HIV, AIDS and prevention of Mother-toChild transmission of HIV using the revised Community Lay Counsellor Training Programme of
2007. After training, health facility teams should provide support and oversee TBA activities.
Trained TBAs can, and are expected to help with the following:
•
Identifying all pregnant women in their catchment areas in the community.
•
Encourage women to deliver in facilities
•
Referring pregnant women to ANC and encouraging counselling and testing for HIV.
•
Perform group education, testing and counselling
•
Packaging and selling of clean delivery kits (CDKs).
•
Reducing stigma associated with HIV and AIDS.
•
Supporting adherence to short-course ARVs and ensure that these are taken at the onset of
labour.
•
Ensure that the newborn baby is taken to the health facility for medical assessment, timely
administration of short-course ARV syrups for those on the PMTCT programme, and for
immunization.
24
•
Encourage Cotrimoxazole initiation and intake
•
Support optimum infant feeding practices
•
Encourage and support women to come back for postnatal check ups and services, especially if a
mother is HIV positive.
•
Data entry: The TBAs may be equipped with skills to assist in data entry in registers at the
facility as part of the task shifting initiative. They should be also encouraged to record and report
using their tools. These may be exercise books or community registers and submitted to their
respective support facilities. Health centres need to support the community efforts including the
TBAs and facilitate referrals from the community.
25
CHAPTER FIVE
Post-Natal Check-ups
The purpose of this is to ascertain the health status of the mother and the baby. It is also an
opportunity to do the following:
•
Initiate family planning
•
Continue with immunisation.
•
Provide nutrition counselling, both for the mother and child
•
Monitoring the baby’s growth
•
Starting PCP prophylactic treatment for the baby.
At these visits, the following should be emphasised:
•
Double protection using condom and any other family planning method for couples irrespective
of their HIV status.
•
Growth monitoring for all infants and nutrition counselling for all mothers.
•
Feeding decisions to be reinforced and supported. Mothers and partners should be referred to a
local mother support group.
•
Monitoring of adverse ARV drug reaction both in mothers and babies.
•
Breast conditions should be identified early and treated accordingly.
•
Appointment for HIV testing of the baby.
Home Deliveries
•
All women who deliver at home should be encouraged to visit health facilities within 72 hours of
delivery by TBAs, other community volunteers and health workers. This is to ensure mothers
enrolled onto the programme have access to ARV treatment for their babies, and to access OPV
0 and BCG vaccinations and to go for both postnatal check ups.
•
Birth Attendants have a key role to play by ensuring a clean and safe delivery, as well as timely
referral to the nearest health centre.
26
CHAPTER SIX
Follow-up: Paediatric HIV Care and Long Term Support to Mothers
All babies who are born to HIV positive mothers are HIV-exposed. A large component of the
paediatric aspect of prevention of Mother-to-Child transmission of HIV is implemented in the underfive clinics during the first 18 months of the baby’s life as part of routine care. The paediatric
component of MTCT includes:
•
Monitoring adherence to chosen infant feeding practice and provision of necessary support. HIV
positive mothers who opted for breastfeeding should be supported during safe transition.
•
Dispensing of Cotrimoxazole to prevent Pneumocystis Jiroveci Pneumonia (PCP) and other
opportunistic infections from 6 weeks of age.
•
Frequent clinical visits to monitor for clinical signs of HIV infection and provide routine paediatric
care including immunisations.
•
HIV testing and referral to HAART for positive babies. See table below for schedule of HIV
testing in babies.
HIV positive mothers should also be monitored at all baby contacts including during immunization
HIV Testing
For babies with access to Infant HIV Diagnosis, do PCR at 6weeks as demonstrated in
the flow chart below.
For babies with no access to Early Infant HIV Diagnosis, test the baby at 12 months
with re-testing of babies at 18 months using rapid antibody tests. It should be noted
that for as long as the baby continues to breast feed he/she remains at risk of
contracting HIV infection.
and clinic visits.
Referral mechanisms and procedures for babies and mothers needing additional clinical care
•
should be determined. Mothers should be provided with appropriate patient education materials.
•
An expanded role for trained community counsellors might be considered: community
counsellors could provide on-going counselling for mothers, follow-up of defaulters, and
sensitization of community to the importance of HIV testing.
•
HIV testing for the brothers and sisters of HIV exposed infants as well as children presenting
with clinical signs of HIV infection through the counselling and testing services, may be
considered. Partners or husbands of HIV positive women should also be offered HIV testing.
27
Pneumocystis Jiroveci (PCP) Prophylaxis with Cotrimoxazole for babies
•
PCP is the leading killer of HIV infected babies. Primary prophylaxis against Pneumocystis Jiroveci
should therefore be provided through the use of oral Cotrimoxazole suspension for at least the
first year of life.
•
Cotrimoxazole is given to all HIV-exposed babies i.e. all babies born from HIV positive
mother’s starting at six weeks of life and continues until at least 12 months if the baby still
tests HIV positive.
•
Cotrimoxazole can be stopped if the baby tests HIV negative and is not breastfeeding.
•
Cotrimoxazole can also be stopped if the baby is HIV positive but has no symptoms and is doing
well at 12 months, or better still, has CD4 ≥ 25%. (Check WHO recommendation).
•
Cotrimoxazole is continued beyond 12 months if the baby is HIV positive and has symptoms of
WHO Stage 2 HIV disease or worse.
•
If Cotrimoxazole has been given for treatment of PCP then it should be given as prophylaxis for
life.
•
Cotrimoxazole is dosed by weight, and given daily. The following table demonstrates the once
daily Cotrimoxazole dosage.
Cotrimoxazole Administration in HIV Exposed infants
Weight
Daily Dose
(100ml) Bottles
needed per month
< 5kg
5 ml
0.5
5-9.9 kg
7.5 ml
1
10-14.9 kg
10ml
1.5
15-19.9 kg
15 ml (1.5 tabs)
2
> 20 kg
20ml (2tabs)
2.5
The following are points to note with Cotrimoxazole administration:
•
Allergic reactions are rare but can present as generalized body rashes. If a rash occurs, refer
baby the same day, to an experienced HIV clinician for evaluation and possible switching to
Dapsone (2 mg/kg daily).
•
A blistering rash involving skin, mouth, red eyes (if scabies or impetigo are ruled-out), is a
medical emergency. Cotrimoxazole is stopped and the baby should immediately be referred to a
District or tertiary hospital where switching to Dapsone may be required.
28
•
Medicine is kept in a cool place and refrigerated if possible. Mothers are asked to bring the
baby’s medicine bottle to each clinic visit so compliance can be assessed.
•
Dispensing of Cotrimoxazole to mothers should be made as easy as possible with consideration
being given to fast-tracking the distribution in a well coordinated manner with routine
immunization visits, starting at six weeks. Cotrimoxazole administration is documented in the
Under-five register and Under-five card.
Clinical Evaluation and Follow-Up of Babies
All children should be registered at birth, and protected from violence, abuse and neglect. Followups on HIV exposed babies should be frequent. Nurses and other health workers should educate
mothers and other care-givers on the importance of the following:
•
Prompt screening and seeking treatment and management of opportunistic infections.
•
Adequate basic hygiene, both personal and environmental.
•
Nutritional education for caretakers and communities.
•
Promotion of the use of Insecticide Treated Nets for children.
•
Parent and community education for prompt treatment of illness as per IMCI guidelines.
•
Community education for integrated approach to Early Childhood Development, which creates a
foundation of support for children, their caregivers, and the community
MNCH nurses should see babies at one and six weeks and then every four to six weeks, coordinated
with the immunisation schedule. The suggested visit schedule for the first 24 months of life is:
•
Weeks: 6, 10 and 14.
•
Months: every month up to 24 months.
This schedule can be increased if and when need arises.
Adherence to growth monitoring and promotion should be emphasized, in addition to early referral
for any growth faltering children born to HIV infected women. Growth faltering is one of the earliest
signs of HIV/AIDS infection or tuberculosis.
At monitoring visits, the MNCH nurse should assess the following clinical conditions:
•
Growth faltering.
•
Oral thrush or sores and nappy rash.
29
•
Fevers, if the baby is floppy or irritable.
•
Asks about inter-current illnesses
•
Ask about diarrhoea and coughs
•
Asks about TB contacts.
If they are present, the baby is referred to the HIV clinician, or to District Hospital.
The Health worker also assesses:
•
The mother’s coping and general health. He/she encourages clinic visits for the mother, and
participation in support groups.
•
Feeding practices and problems
•
Adherence to Cotrimoxazole
•
Adherence to immunizations, as per paediatric schedules.
•
The need for de-worming treatment should also be emphasised and considered every six months
starting at one year of age using Mebendazole.
Diagnostic Testing of Infant and Young Children Exposed to HIV
HIV diagnosis in infancy is essential component of the continuum of care for perinatally exposed
infants. HIV can be diagnosed in adults by testing blood for antibodies to HIV. In children, however,
an antibody test is not effective, because the mother’s maternal antibodies are passed to the child
as a natural means of protection while the infant is developing its own immune system. As a result,
antibody tests for infants may yield false positive results for up to 18 months. Because ARV
prophylaxis reduces but does not eliminate MTCT, health care providers should identify or develop
services that provide follow-up care and HIV diagnostic services for infants and young children of
mothers infected with HIV. PCR testing is able to identify the virus in the infants’ blood with
accuracy from one month of age and beyond making PCR an appropriate intervention for early
infant diagnosis.
If a child exposed to HIV develops signs or symptoms of HIV infection, early diagnosis and
intervention is critical.
HIV viral assays in infants
Viral assays that detect HIV in the infant's blood, such as the DNA or RNA PCR test, may be used to
diagnose HIV infection in infants at a younger age than antibody testing. Early diagnosis of HIV
allows the provider to promptly initiate counselling about methods of infant feeding and facilitates
early clinical care for the infant who is HIV-infected.
A viral assay can be performed from age 6 weeks to allow decisions related to ARV treatment and
care. Where virological testing is available, the sample algorithm in Figure 6.3 may be used. A viral
test may be done, regardless of breastfeeding, if the child presents with symptoms of HIV at less
than 18 months of age.
30
HIV diagnosis in infants and young children less than 18 months with viral assay
Non-breastfeeding Infant
Breastfeeding Infant
Virology test from 6 weeks
or older
Positive test
Virology test from 6 weeks or older
Negative test
Positive test
Negative test
.
Child is HIV
infected
Refer for
treatment, care
and support
Child is NOT
HIV-infected
Child is HIV
infected
Refer for
treatment,
care and
support
Repeat test at least 6
weeks after complete
cessation of
breastfeeding
Positive Antibody
test
Negative
Antibody test
Child is HIVinfected
Child is NOT
infected
Refer for
treatment,
care and
support
31
Importance of Early Diagnosis of HIV
•
Early diagnosis reduces infant mortality
•
Early diagnosis enables us to give more appropriate counselling
•
Early diagnosis reduces stress for families – uncertainty of not knowing
Eligibility Criteria for PCR
•
Mother must have tested positive to HIV rapid test during her pregnancy (meaning that the infant
is HIV-exposed)
***In the rare event that the mothers HIV status is not known and is not available for HIV testing and
the infant tests positive to a rapid HIV test then such an infant should under go a PCR test.
•
And child must be under 18 months
What Pre-test Information Should Be Given Before PCR?
Inform the mother/caregiver of the following:
•
The importance of the test (and of knowing the child’s status as soon as possible)
•
The test is done on all babies under 18 months who test positive on the rapid test
•
It is possible that the child may be infected even if the mother took ARV prophylaxis or HAART
•
Inform mother that free ongoing care and ARV therapy are now available for all infants with HIV
•
Prepare her for the possible outcomes of the PCR test by reviewing all the possibilities (positive or
negative)
•
Tell mother when test results will be available
Post-test Counselling After PCR
•
As with all HIV testing, post-test counselling following PCR is extremely important
•
Post-test counselling should be:
•
•
thorough
•
supportive
•
accurate
General principles of all post-test counselling apply
32
Interpretation of results
For children who are not breastfeeding, at age 6 weeks:
•
If a DNA PCR test is positive, the child is HIV-infected.
•
If a DNA PCR is negative, the child is not HIV-infected.
For children who are breastfeeding, at age of 6 weeks:
•
If a DNA PCR test is positive, the child is considered HIV-infected.
•
If a DNA PCR test is negative, repeat viral assay 6 weeks after complete cessation of
breastfeeding.
•
If a DNA PCR test is negative 6 weeks after complete cessation of breastfeeding, the child is not
HIV-infected.
•
If a DNA PCR test is positive 6 weeks after complete cessation of breastfeeding, the child is HIVinfected.
Post-test Counselling for a Positive PCR Result
Inform the mother/caregiver of the following:
•
Tell her that her baby has HIV
•
Tell her the baby needs to see a doctor as soon as possible
•
Tell her the baby will continue to take Cotrimoxazole
•
If the mother is breastfeeding, tell her to continue to breastfeed
•
With treatment, the baby can have a healthy childhood
•
Answer any questions she may have
Post-test Counselling for a Negative PCR Result
Breastfed baby:
Exclusively Breastfed baby:
Explain that the baby didn’t get HIV during pregnancy or childbirth; however the baby is still at risk
to have gotten HIV in the last 6 weeks of exposure to breastfeeding and for as long as
breastfeeding continues. Important to give mother appropriate infant feeding counselling to
minimize his/her risk of infection as below:
•
Reassess AFASS and ascertain whether the mother will be able to change to exclusive
33
replacement feeding
•
If yes explain to the mother how she can best transition the baby from exclusive breast
feeding to exclusive replacement feeding with minimal risk. It is important to note that even
if the mother chooses to change to exclusive replacement feeding, there still remains a risk
that the baby may have been infected during the last 6 weeks of breastfeeding and the virus
cannot yet be detected. Therefore the baby will require a repeat test at 12 and 18 months
according to the national schedule.
•
If no then emphasize to the mother the importance of breastfeeding exclusively up to 6
months. Tell mother/caregiver she’ll need to bring the baby back for a repeat HIV test:
•
12 months old, 18 months old AND 3 months post last breast milk feed
•
Also that if the child falls ill she is to return immediately for HIV testing according to
the national algorithm
Emphasize to the mother that mixed feeding at an early age may increase the infant’s chance of
becoming infected with HIV while breastfeeding.
Formula-fed Baby
Note: The HIV test cannot tell:
•
•
•
If a person has AIDS
How the person became infected with the virus
How long the person has been living with the virus
Reminder about the Window Period!
After a person is infected with HIV, there is a period of time when s/he will not test
positive for HIV but can infect other people. This is called the window period, and it can
last from several weeks to 3 months. This window period exists because the tests show
the presence of antibodies to HIV, which are not present immediately when someone is
infected; it takes time (up to 3 months) for the person to develop antibodies in
detectable quantities.
A patient who has received a negative test result but recently engaged in a behaviour
that put him/her at risk for HIV infection should consider retesting in 3 months.
For example, if the patient had unprotected sex on May 15 and was tested on
June 3, s/he may want to be tested again after August 15.
34
•
Inform the mother/caregiver the baby does not have HIV
•
Tell her she can stop giving the baby Cotrimoxazole
•
Inform the mother she should not practice mixed feeding.
•
Answer any questions she may have.
The test used to diagnose babies born to HIV-infected mothers, Polymerase Chain Reaction (PCR),
tests directly for HIV DNA rather than the HIV antibody. Traditionally, the test requires a liquid blood
sample, which if taken in a rural area and transported to a testing facility, needs to be kept
refrigerated. Samples for PCR testing can be either liquid or dry blood. For health facilities that are
near PCR centres may send their PCR samples as liquid blood samples while those facilities that are
distant may send their PCR samples as dry blood samples. The Dried Blood Spots (DBS) using filter
paper card method are easy to prepare and can be stored and transported to testing facilities
without refrigeration. Infants can be tested using PCR as early as six weeks of age. PCR testing using
DBS has been proven to be as effective as PCR using liquid blood samples. The filter paper card
method facilitates easier transportation of the specimens to the centralized HIV DNA PCR testing
centres as dry blood spots (DBS). DBS specimens can be transported by mail or other carriers from
all areas around the country.
Collecting DBS samples is easier than collecting whole blood samples. It involves spotting small
quantities of blood on specially designed filter paper using a heel or toe prick method.
Where there is no access to early infant diagnosis then Antibody testing can be done at 12 and 18
months as outlined below:
•
All babies should be tested at 12 months using the rapid HIV testing method as for adults.
Blood can be obtained via heel sticks.
•
At 18 months an HIV negative test means the baby is uninfected-unless the baby is being breastfed. An HIV negative baby can be “graduated” from the MTCT programme.
•
For babies with a positive HIV test at 12 months, parents should be told that this may be a “false
positive” result because some babies are slow in clearing their maternal antibodies. Thus, such
babies will need to be re-tested at 18 months.
•
Babies testing positive at 12 months are entered into the Special register and under 5 cards to
facilitate further follow-up.
•
At 18 months, all remaining HIV positive babies should be re-tested.
By 18 months, all
uninfected babies will test HIV negative and HIV infected babies will test HIV
positive. An HIV positive test for a baby who is 18 months or older confirms HIV infection.
•
Breast-fed babies can contract the infection from breast milk. All breastfed babies even if testing
negative at 12 or 18 months, should be re-tested 3 months after weaning off from breast-milk in
35
cases where breast-feeding has continued for longer.
•
All test results should be recorded in the Special register and Under 5 cards.
Long Term Support for HIV Positive Mothers after the Delivery Period
As much as possible, a comprehensive package of care and support should be provided to HIV
positive women and their families. At 6 week review of the mother and baby, or when mother
brings baby for vaccination, refer mother back to the HIV clinician for further follow up.
This support should include:
•
Pneumocystis Jiroveci Pneumonia prophylaxis with Cotrimoxazole as per national guidelines.
•
Prompt screening, treatment and management of opportunistic infection.
•
Good referral networks for mothers to access all care available to HIV infected people including
HAART if applicable through the ARV programme.
•
Psycho-social support to mothers and their families: Referrals should be made to communitybased groups such as PLHIV, peer support groups, post-test clubs, legal services, churches, and
faith-based organisations and legal counsellors. Income Generating Activities (IGAs) have the
potential to promote sustainability of the programme. This is an area that should be continually
advocated for and promoted.
•
When making referrals, women should be given the name of the organisation, an address, and a
contact person. A short referral note should also be provided.
•
Continued education and counselling of mothers and their partners on vital aspects of prevention
of Mother-to-Child transmission of HIV.
Issues to address should include the risks of HIV
positive women getting pregnant, medical care, good nutrition, infant feeding, and prevention of
STIs as well as promotion of safer sex practices.
36
CHAPTER SEVEN
Care for Health Workers and Community Health Providers
Use Universal Infection Prevention Precautions when handling all patients.
Post-Exposure Prophylaxis (PEP)
•
Immediately wash with soap and water, any wound or skin site in contact with infected blood or
fluid, then irrigate with sterile physiological saline or mild disinfectant.
•
Rinse eyes or exposed mucous membrane thoroughly with clear water or saline.
•
Report immediately to the person in-charge of PEP and follow national PEP protocol.
Care for HIV infected Staff
•
Encourage testing for all staff and confidentiality
•
Create a supportive environment for HIV prevention and care among staff.
37
CHAPTER EIGHT
Monitoring and Evaluation
Monthly prevention of Mother-to-Child transmission of HIV reports will be prepared from Health
facilities through the prevention of Mother-to-Child transmission of HIV/VCT data management
system which is sent to the DHO. The DHO in turn submits consolidated prevention of Mother-toChild transmission of HIV district reports quarterly to the Provincial Health Office Data Management
Specialist who in turn submit provincial reports to the Ministry of Health. Data Management
Specialists and Clinical Care Specialists should provide support supervision to health facilities
implementing prevention of Mother-to-Child transmission of HIV.
Prevention of Mother-to-Child transmission of HIV information is entered in mothers’ antenatal
cards, Integrated prevention of Mother-to-Child transmission of HIV and VCT registers, prevention of
Mother-to-Child transmission of HIV Delivery registers; Under 5 cards and Under 5 registers; PreART and ART registers. The current minimum standard indicators to be monitored on a quarterly
basis are as in table 5 below.
Prevention of Mother-to-Child Transmission of HIV and Paediatric HIV Care
Indicators
Safe Motherhood
Antenatal 1st visit before 20 weeks
•
•
Antenatal 1st visit 20 weeks or later
•
Antenatal 1st visits total
•
Antenatal follow-up visits
Prevention of Mother-to-Child Transmission
Counselling & Testing
• Antenatal client tested at 1st antenatal visit
•
Antenatal client tested at follow-up antenatal visit
•
Antenatal client with known HIV positive status
•
Antenatal client HIV positive new case
•
Antenatal client collecting HIV test results
•
Antenatal client male partner counselled
•
Antenatal client male partner tested for HIV
Post-test Services
• Referred for Pre ART from PMTCT
•
Opting for 6 months EBF at 1st visit
38
PMTCT Deliveries
• Live Births HIV exposed
Prophylaxis
• ARV prophylaxis mono therapy to woman
•
ARV prophylaxis dual therapy to woman
•
ARV prophylaxis HAART to woman
•
ARV prophylaxis mono therapy to baby
•
ARV prophylaxis dual therapy to baby
•
Cotrimoxazole started by baby within two months
Follow up
• Live birth HIV exposed 1 month ago
•
Live birth HIV exposed 12 months ago
•
Live birth HIV exposed 18 months ago
•
HIV test to HIV-exposed baby at 6 weeks
•
HIV test to HIV-exposed baby at 12 months
•
HIV test to HIV-exposed baby at 18 months
•
HIV test positive at 6 weeks new case
•
HIV test positive at 12 months new case
•
HIV test positive at 18 months new case
Some information is also collected in the Pre-ART and ART registers and likewise compiled monthly
in the HMIS HIA form for monthly submission as listed below:
Antiretroviral Therapy
Pre ART registration total new case
• Pre ART registration from Counselling and Testing
•
Pre ART registration from PMTCT
•
Pre ART registration from TB
•
Pre ART registration from other sources
Eligibility of ART
• Patients eligible for ART this month
Initiated on ART
• ART initiated <12 months male
39
•
ART initiated <12 months female
•
ART initiated 12–59 months male
•
ART initiated 12–59 months female
•
ART initiated 5-14 years male
•
ART initiated 5-14 years female
•
ART initiated >14 years male
•
ART initiated >14 years female
ART Initiated New Cases
And
Cumulative ART initiated in this clinic
ART initiated in pregnant women
ART initiated in TB HIV positive patient
ART follow up
ART current count 0 – 14 years
ART current count > 14 years
40
Reporting System Flow Chart
Health Center
Safe Motherhood
Registers
Counselling
Register
Labour Ward
Register
Under 5 Register
Monthly Submissionto MNCH Coordinator
and DHIO at District level
Quarterly
Reports
District AIDS Task
Force (DATF)
Clinical Care
Specialist / Data
Manager
Provincial AIDS Task
Force (PATF)
MOH
Quarterly Summary
NAC
Quarterly Summary
Regional Summary
Global Prevention of Mother to Child of HIV program
update by region and by country
41
Annexes
Annex I: Nevirapine Baby Dose Preparation:
Nevirapine Baby Dose Preparation:
The oral suspension does not require mixing.
Gently shake the Viramune®
suspension by inverting the bottle several times. The bottle should not be shaken vigorously.
The dose should be administered using a calibrated oral syringe. A hypodermic syringe may also
be used for oral administration if the needle has been removed. The syringe should hold a
maximum total volume of 3 ml or less to ensure accuracy.
Ideally, a new syringe should be used for each patient. Used syringes should be discarded to
avoid contamination of the Viramune® multiple dose bottle and the spread of infections
between patients.
Since multiple patients will receive medication from the same bottle of Viramune®, the suspension
should be measured by pouring a small amount into a cup. The suspension should then be
drawn into the oral syringe and administered orally. The remainder of the Viramune® in the
cup should not be returned to the bottle and should be discarded. To avoid contamination,
the syringe should not be placed directly into the bottle.
Viramune® suspension does contain preservative to minimize the possibility of harmful microbial
growth in the open bottle.
Nevirapine Syrup Storage:
The bottle should be recapped and tightly sealed immediately following each use.
The bottle should be stored at 15oC-30oC (59oF-86oF) or room temperature
The bottle should be labelled with the date on which it was opened. Based on results from a
retrospective analysis of clinical samples returned from a MTCT prevention trial conducted in
Africa, open bottles have an in-use life of 12 months from the date of opening, not to exceed
the shelf-life expiration date printed on the bottle. Bottles should be discarded after this time.
SOURCE: Briefing note on HIV/AIDS and products required for prevention of Mother-to-Child
transmission of HIV, UNICEF – Copenhagen, March 2002
42
Annex II - Antenatal Care Flow Chart with opt-out model
Pregnant Women Present for booking
Health Education followed by Group Counselling
Counselling Register
Opt Out of HIV Testing
Takes Rapid Test
Proceed with booking and encourage
testing at a later date
1st and 2nd Test Positive
= HIV Positive
1st Test Positive, 2nd Test Negative =
Indeterminate
1st Negative =
HIV Negative
Indeterminate: to reference Laboratory
Blood Test
Register
Positive
Negative
Blood Test
Register
Post Test Counselling
Post Test Counselling
Counselling Register
Counselling Register
Inform re: MTCT
Proceed with Booking
Offer ARV
No to ARV: Mark
Antenatal Card
Yes to ARV
Do Retest
later in
Pregnancy
Adherence Counselling
Referel to:
Post Test
Clubs,
Health
Education,
Mark Antenatal Card
Proceed with Booking
Proceed with Booking
Repeat Info re: MTCT
Labour Ward and Under Register
43
Referrals to:
1. Treatment of Opportunistic
infections
2. Psychosocial counselling services
3. Post test clubs and peer-support
groups (NZP+ for example)
4. Nutrition education and support
Annex III - Sources of Iron and other Nutrients and their absorption.
Pregnant and lactating women need many different nutrients for growth and development, to
provide energy and to keep healthy. The following foods are good sources of iron zinc and vitamin
A.
Sources of Iron and its absorption:
The amount of iron that is absorbed from food depends on:
•
The amount of iron in the food
•
The type of iron (iron from meat and fish is better absorbed than iron from plants, milk and
eggs)
•
The types of other foods present in the same meal (some promote iron absorption and others
interfere).
•
Whether there is presence of anaemia (more iron is absorbed if anaemic).
Examples of Foods high in Iron
High iron, good absorption
High Iron poor absorption
Liver of all kinds
Other organs/offal, especially red organs and blood
Flesh of animals, especially red meats
Flesh of birds, especially dark meat
Foods fortified with iron such as infant formula
Egg yolk
Pulses
Dark-green leaves
The amount of iron absorbed from eggs, milk and plant foods is:
•
Increased by eating at the same meal:
•
Foods rich in vitamin C
•
Flesh and organs/offals of animals, birds
•
Fish
•
Decreased by drinking
•
Teas and coffee
Eating foods rich in vitamin C at the same meal is the best way to improve the absorption of iron
from eggs, milk and plant foods. Foods rich in Vitamin C include guava, mango, orange and other
citrus fruits, paw-paw and pineapple
Sources of Zinc:
•
Liver and offal of all kinds
44
•
Foods prepared with blood
•
Flesh of animals, birds and fish
•
Egg yolk
Sources of Vitamin A:
•
Breast milk
•
Liver of all kinds
•
Egg yolk
•
Orange-coloured fruits: mango, paw-paw, passion fruit (but not oranges). The darker the colour,
the more vitamin A
•
Orange-coloured vegetables – carrot, pumpkin, yellow sweet potato, red/orange peppers (but
not tomatoes). The darker the colour, the more vitamin A
•
Dark-green leaves – spinach, cassava leaves, sweet potato leaves (kalembula), pumpkin leaves
(chibwabwa). The darker the green the more vitamin A.
Sources of Vitamin C: (Cooking destroys some vitamin C)
•
Fresh fruit – guava, lemon, oranges, paw-paw, banana, passion fruit, mangoes
•
Tomatoes, peppers
•
Green leaves and vegetables – spinach, cassava leaves, sweet potato leaves, cabbage, broccoli,
cauliflower
•
Fresh starchy roots and fruits are good sources if large amounts are eaten_ potato, sweet
potato.
Sources of Calcium:
•
Milk and milk products – cheese, yoghurt
•
Fish eaten with bones – small whole fish, pounded dried fish (kapenta), canned fish
45
Annex IV: Amounts of Foods to Offer for Complimentary Feeding
AMOUNTS
OF
FOODS TO OFFER –COMPLEMENTARY FEEDING
Age
Texture
Frequency
Amount of food an
average child will usually
eat at each meal
Start with thick porridge,
well mashed foods
2-3 meals per day plus
frequent breastfeeds
Start with 2-3 tablespoonfuls
per feed
continue with mashed
family foods
Depending on the child's
appetite 1-2 snacks may
be offered
increasing gradually to
Finely chopped or mashed
foods, and foods that
baby can pick up
3-4 meals plus
breastfeeds
Depending on the child's
appetite 1-2 snacks may
be offered
1/2 of a 250 ml cup/bowl
Family foods, chopped or
mashed if necessary
3-4 meals plus
breastfeeds
Depending on the child's
appetite 1-2 snacks may
be offered
3/4 to 1 250 ml cup/bowl
6-8 months
9-11 months
12-23 months
½ of a 250 ml cup
If baby is not breastfed, give in addition: 1-2 cups of milk per day, and 1-2 extra meals per day.
46
Annex V – Positive living for PLHIV
People with HIV can live full and healthy lives if they take care of themselves and access treatment.
Nurses and community health workers/counsellors should do the following:
Advise how to prevent other infections
•
Avoid STIs and re-infection with other strains of HIV
•
Use safe and chlorinated drinking water – drink boiled water or tea when possible
•
Store water in container which prevents contamination ( use spigot, do not dip
hand or used
cup into the water)
•
Eat well cooked food
•
Wash fruits and vegetables with chlorinated water especially for lettuce)
•
Practice good hand washing – especially after toilet of themselves or others. Caregivers and
patient should wash hands often: after using toilet; before preparing food, after sneeze or
cough, after touching your genitals, after handling garbage, after touching any blood, semen,
vaginal fluids and faeces
•
HIV patients should have a local antiseptic (such as gentian violet or chlorhexidine) at home to
apply to minor wounds after washing.
•
Use insecticide-treated bed net to prevent malaria
•
Give advice to seek treatment early for any ailments
Encourage physical activity as appropriate
•
Help patient develop his or her own programme.
•
Exercise can make the person feel better and maintain muscle tone.
•
Physical activity is important to prevent weight loss.
•
It stimulates appetite
•
Reduces nausea
•
Improves functioning of the digestive system
•
Strengthen muscles
47
Advise to avoid harmful or ineffective expensive treatment or food supplements
•
If there is any treatment other than what has been prescribed by a health professional such as
ARVs then a health worker should be consulted.
•
Whether other medication is been taken it is very important to remain adherent to the ARVs to
prevent the setting in of resistance and treatment failure.
Additional Advise on Nutrition
•
Food to stimulate weight gain should have high protein, fat and carbohydrate content and
include: avocados, coconut, full-cream milk powder, yoghurt or sour milk, soya products,
cheese, meat, fish, chicken, ground nuts, nuts and seeds, dried fruit, egg, beans, lentils,
potatoes, sweet potatoes, bananas, cassava, millet, sorghum, oats, rice, wheat, and maize
•
Avoid refined sugar and sweets as these increase the risk of dental and oral problems
•
Some tips to facilitate adequate intake and digestion of food: squeeze fresh lemon juice over
fatty foods like meat, chicken and nuts
•
Add the grated skin of oranges and lemons to fatty foods
•
To help digest meat, eat papaya with the meat
•
Eat many small meals a day and chew food well
•
Drink between meals not with meals
•
Eat fermented or sour foods such as sour milk, sour porridge etc.
•
Avoid excessive alcohol/drugs.
Have peer demonstrate preparation of nutritious food.
48
Annex VI: WHO Staging System for HIV Infection and Disease
WHO Staging—Adults and Adolescents
Clinical Stage 1
• Asymptomatic
•
Persistent generalized lymphadenopathy
Clinical Stage 2
1
2
• Moderate unexplained weight loss (under 10% of presumed or measured body weight)
•
Recurrent respiratory tract infections (sinusitis, tonsillitis, otitis media, pharyngitis)
•
Herpes zoster
•
Angular cheilitis
•
Recurrent oral ulceration
•
Papular pruritic eruptions
•
Seborrhoeic dermatitis
•
Fungal nail infections
Clinical Stage 3
1
2
• Unexplained severe weight loss (over 10% of presumed or measured body weight)
•
Unexplained1 chronic Candidia for longer than one month
•
Unexplained1 persistent fever (intermittent or constant for longer than one month)
•
Persistent oral Candidiasis
•
Oral hairy leukoplakia
•
Pulmonary tuberculosis
•
Severe bacterial infections (e.g. pneumonia, empyema, pyomyositis, bone or joint infection,
meningitis, bacteraemia)
•
Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
•
Unexplained1 anaemia (below 8 g/dl ), neutropenia (below 0.5 x 109/l) and/or chronic
thrombocytopenia (below 50 x 109 /l)
WHCLINIC AND ADOLESCENTS
49
Clinical Stage 4
• HIV wasting syndrome
•
Pneumocystis pneumonia
•
Recurrent severe bacterial pneumonia
•
Chronic herpes simplex infection (orolabial, genital or anorectal of more than
•
one month’s duration or visceral at any site)
•
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)
•
Extrapulmonary tuberculosis
•
Kaposi sarcoma
•
Cytomegalovirus infection (retinitis or infection of other organs)
•
Central nervous system toxoplasmosis
•
HIV encephalopathy
•
Extrapulmonary cryptococcosis including meningitis
•
Disseminated non-tuberculous mycobacteria infection
•
Progressive multifocal leukoencephalopathy
•
Chronic cryptosporidiosis
•
Chronic isosporiasis
•
Disseminated mycosis (extrapulmonary histoplasmosis, coccidiomycosis)
•
Recurrent septicaemia (including non-typhoidal Salmonella)
•
Lymphoma (cerebral or B cell non-Hodgkin)
•
Invasive cervical carcinoma
•
Atypical disseminated leishmaniasis
•
Symptomatic HIV-associated nephropathy or HIV-associated cardiomyopathy
1 Unexplained refers to where the condition is not explained by other conditions.
2 Assessment of body weight among pregnant woman needs to consider the expected weight gain of pregnancy.
Source: Revised WHO clinical staging and immunological classification of HIV and case definition of HIV for surveillance
2006
50
Immunological staging of HIV infection
Clinical staging can be used effectively without access to CD4 or other laboratory testing. However,
CD4 testing is useful for determining the degree of immunocompromise, and where CD4 facilities
are available should be used to support and reinforce clinical decision-making. Data on CD4 levels
are not a prerequisite for starting HAART and should only be used in conjunction with clinical stage.
Table 2 presents CD4 levels in relation to the severity of immunosuppression.
For clinical purposes long term prognosis has been shown to be related to the nadir or lowest-ever
value of CD4. It should be noted that the immunological staging of disease reverses with successful
HAART.
CD4 levels in relation to the severity of immunosuppression
Not considered to have
significant immunosuppression
>500/mm3
Evidence of mild immunosuppression
350−499/mm3
Evidence of advanced immunosuppression
200−349/mm3
Evidence of severe immunosuppression
<200/mm3
Implications for clinical and immunological criteria for initiating HAART
in adults and adolescents
There is strong evidence for the clinical benefit of HAART in adults with advanced HIV/AIDS as
determined clinically or immunologically. The precise clinical and or immunological criteria for
initiating HAART is usually outlined in national treatment guidelines. Existing WHO recommendations
are provided on a WHO web site (2).
Clinical and immunological criteria for initiating HAART
in adults and adolescents
Clinical stage
HAART
4
Treat.
3
Consider treatment: CD4, if available, can guide the
urgency with which HAART should be started.
1 or 2
Only if CD4 < 350/mm3.
51
CD4 can be used to monitor responses to treatment, although they are not essential. Absolute CD4
values also fluctuate with intercurrent illness and with physiological and test variability, so the trend
over two or three repeated measurements is usually more informative than individual values. Note:
that during the course of acute HIV infection the CD4 count may reach very low levels and then
recover.
WHO Staging—Infants and Children
Guidelines for Antiretroviral Therapy of HIV infection in Infants and Children: Towards universal
access
WHO staging for children with established HIV infection
(on the following page)
52
Clinical Stage 1
Asymptomatic
Persistent generalized lymphadenopathy
Clinical stage 2
Unexplained persistent hepatosplenomegaly
Papular pruritic eruptions
Extensive wart virus infection
Extensive molluscum contagiosum
Recurrent oral ulcerations
Unexplained persistent parotid enlargement
Lineal gingival erythema
Herpes zoster
Recurrent or chronic upper respiratory tract infection (otitis media, otorrhea, sinusitis, tonsillitis) Fungal nail infections
Clinical stage 3
Unexplained moderate malnutrition not adequately responding to standard therapy Unexplained persistent diarrhea
(14 days or more )
Unexplained persistent fever (above 37.5 intermittent or constant, for longer than one month) Persistent oral Candida
(outside first 6-8 weeks of life) Oral hairyleukoplakia
Acute necrotizi ng ulcerative gingivitis/periodontitis Lymph node TB
Pulmonary tuberculosis
Severe recurrent presumed bacterial pneumonia Symptomatic lymphoid interstitial pneumonitis
Chronic HIV-associated lung disease including bronchiectasis
Unexplained anemia (<8g/dl ), neutropenia (<05 x 109) or chronic thrombocytopenia (<50 x 109/l3)
Clinical stage 4
Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy Pneumocystis
pneumonia
Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding
pneumonia)
Chronic herpes simplex infection; (orolabial or cutaneous >one month' s duration or visceral at any site)
Extra pulmonary tuberculosis
Kaposi sarcoma
Esophageal candidacies (or Candida of trachea, bronchi or lungs)
Central nervous system toxoplasmosis (outside the neonatal period)
HIV encephalopathy
Cytomegalovirus (CMV) infection; retinitis or CMV infection affecting another organ, with onset at age >1 month.
Extra pulmonary cryptococcosis including meningitis
Disseminated endemic mycosis (extra pulmonary histoplasmosis, coccidiomycosis, penicilliosis) Chronic
Cryptosporidiosis
Chronic Isosporiasis
Disseminated non-tuberculous mycobacteria infection
Acquired HIV-associated rectal fistula
Cerebral or B cell non-Hodgkin lymphoma
Progressive mu ltifocal leukoencephalopathy
HIV-associated cardiomyopathy or HIV-associated nephropathy
Notes:
• Diagnosis of HIV infection according to recommendations in Section IV
• All clinical events or conditions referred to are described in Part B of this Annex
53
Immunological categories for paediatric HIV infection
Immunological staging for children is also possible. The absolute CD4 count and the percentage
values in healthy infants who are not infected with HIV are considerably higher than those observed
in uninfected adults, and slowly decline to adult values by the age of 6 years. In considering
absolute counts or percentages, therefore, age must be taken into account as a variable. The
absolute CD4 count associated with a specific level of immunosuppression tend to change with age,
whereas the CD4 percentage related to immunological damage does not vary as much. Currently,
therefore, the measurement of the CD4 percentage is recommended in younger children. CD4
testing is not essential for the initiation of HAART, and should only be used in conjunction with
clinical stage. As for adults, immunological staging assists clinical decision-making and provides a
link with monitoring and surveillance definitions. It is usually reversed by successful HAART.
CD4 levels in relation to the severity of immunosuppression
Age
Immune status
Up to 12 months
Not considered to
immunosuppression
>25%
>500/mm3
25−34%
20−24%
350−499/
mm3
a d v a n c e d 20−24%
15−19%
200−349/
mm3
<15%
<200/mm3
have
significant >35%
Evidence of mild immunosuppression
Evidence
of
immunosuppression
13
-59 5 years or
months
over
Evidence of severe immunosuppression
<20%
Implications for clinical and immunological criteria for initiating HAART
Although there are concerns about the early use of HAART in asymptomatic infants, all children with
stage 3 or stage 4 disease (advanced HIV defined clinically) should start HAART following discussion
with their families. There is very strong evidence for the clinical benefit of HAART in children with
advanced HIV/AIDS. For older children some clinical conditions, e.g. LIP, appear to have a more
stable clinical course, although there are few data on cohorts from African settings. Because of the
revisions in clinical staging these recommendations should replace those provided in the 2003 WHO
reference guide (2).
54
Clinical and immunological criteria for initiating HAART in infants and children
Clinical stages
4
Presumptive stage 4
3
1 and 2
HAART
Treat
Treat
Consider treatment for all ages. Children aged under
2 years usually require HAART.
CD4 %, if available should be used to guide decisions
on HAART
Usually only where CD4 available.
Under 12 months:
13-59 months :
5 years or over
CD4 % <20
CD4 % <15
CD4 < 200/mm3
Note: Co-trimoxazole prophylaxis
should be given to all HIVexposed infants until HIV infection
is definitively excluded, to all
symptomatic HIV-infected
children and to asymptomatic
children with immunological
evidence of immunosuppression
CD4 can be used to monitor responses to treatment, although it is not essential. Absolute CD4
values also fluctuate with intercurrent illness and with physiological and test variability, so the trend
over two or three repeated measurements is usually more informative than individual values.
55
Annex VII: Clinical situations and recommendations for the use of antiretroviral drugs
in pregnant women and women of child-bearing potential in resource-constrained
settings
Clinical Situation
Recommendation
A:
HIV-infected First-line regimens: D4T + 3TC + NVP or ZDV + 3TC + NVP
women
with Efavirenz (EFV) should be avoided in women of childbearing age, unless effective contraception
indications
for can be assured. Exclude pregnancy before starting treatment with EFV.
initiating
ARV
treatment1 who may
become pregnant
B:
HIV-infected
women receiving ARV
treatment
who
become pregnant
Women
Continue the current ARV regimen2 unless it contains EFV. If it does, substitution with a NVP or
a PI should be considered if in the 1st trimester.
Continue the same ARV regimen during the intrapartum period and after delivery.
Infants
If born to women receiving either 1st or 2nd-line ARV regimens: 1-week ZDV and single dose
NVP.
C:
HIV-infected
pregnant women with
indications for ARV
treatment1
Women
Follow the treatment guidelines as for non-pregnant adults except that EFV should not be given
in the 1st trimester.
First line regimensD4T + 3TC + NVP or ZDV + 3TC + NVP
Consider delaying therapy until after the 1st trimester, although in severely ill women the
benefits of early therapy clearly outweigh the potential risks.
Infants
1-week ZDV and single-dose NVP.
D: HIV-infected
First-choice regimen: ZDV/ NVP & ZDV/3TC/
pregnant women
Women
without indications for
ARV treatment1
ZDV starting at 28 weeks or as soon as possible thereafter. Then give 3TC and ZDV in labour
and for 7 days after delivery. In addition, women should receive single-dose NVP at the onset
of labour.
Infants
Single-dose NVP and 1-week ZDV3
Alternative regimen: ZDV + 3TC (For women presenting late in pregnancy)
Women
ZDV + 3TC starting at 36 weeks or as soon as possible thereafter. Continue in labour and for 1
week postpartum.
Infants
1-week ZDV+3TC
E:
HIV-infected Follow the recommendations in Situation D, but preferably use the most efficacious regimen
pregnant women with that is available and feasible.
indications for starting
ARV treatment1 but
treatment is not yet
available
56
Clinical Situation
Recommendation
F:
HIV-infected •
pregnant women with •
active tuberculosis
•
G: Pregnant women
of
unknown
HIV
status at the time of
labour or women in
labour known to be
HIV-infected
who
have not received ARV
drugs before labour
If ARV treatment is initiated, consider4: (ZDV or d4T) + 3TC + SQV/r.
If treatment is initiated in the 3rd trimester (ZDV or d4T) + 3TC +EFV can be considered.
If ARV treatment is not initiated, follow the recommendations in Situation D.
If there is time, offer HIV testing and counselling to women of unknown status and if positive,
initiate intrapartum ARV prophylaxis.
Women
Single-dose NVP. If in advanced labour do not give the dose but follow the recommendations in
Situation H as outlined below:
ZDV + 3TC in labour and 1-week ZDV + 3TC postpartum
Infants
1-week ZDV+3TC
If there is insufficient time for HIV testing and counselling during labour, then offer testing and
counselling as soon as possible postpartum. Follow the recommendations in Situation H for
women testing positive postpartum.
H: Infants born to Infants
HIV-infected women Single-dose NVP as soon as possible after birth and 4-weeks ZDV
who have not received If the regimen is started more than 2 days after birth, it is unlikely to be effective.
any ARV drugs or who
received less than 4
weeks of ARVs in
pregnancy.
1
WHO recommendations for initiating ARV treatment in HIV-infected adolescents and adults. If CD4 testing is
available it is recommended to offer ARV treatment to patients with: WHO Stage IV disease irrespective of CD4 cell
count, WHO Stage III disease with consideration of using CD4 cell counts less than 350 106 cells/L to assist decisionmaking and WHO Stage I and II disease in the presence of a CD4 cell count less than 200 106 cells/L. If CD4 testing is
unavailable, it is recommended to offer ARV treatment to patients with WHO Stage III and IV disease irrespective of
total lymphocyte count or WHO Stage II disease with a total lymphocyte count less than 1200 106 cells/L.
2
Conduct clinical and laboratory monitoring as outlined in the 2003 revised WHO treatment
guidelines.
3
Continuing the infant on ZDV for four to six weeks can be considered if the woman received
antepartum ARV drugs for less than four weeks.
4
ABC can be used in place of SQV/r; however, experience with ABC during pregnancy is limited. In the rifampicinfree continuation phase of tuberculosis treatment, an NVP-containing ARV regimen can be initiated.
57
Annex VIII: 10 Steps To Successful Breastfeeding
Step one
• Have a written infant feeding policy that is routinely communicated to all health staff
Step two
• Train all health care staff in skills necessary to implement this policy
Step three
• Inform all pregnant women about the benefits and management of breastfeeding
Step four
• Help mothers initiate breastfeeding within an hour of birth
Step five
• Show mothers how to breastfeed and how to maintain lactation, even if they should be
separated from their infants
Step six
• Give newborn infants no food or drink other than breast milk, unless medically indicated
Step seven
• Practice rooming-in: allow mothers and infants to remain together 24 hours a day
Step eight
• Encourage breastfeeding on demand
Step nine
• Give no artificial teats or pacifiers* to breastfeeding infants
Step ten
• Foster the establishment of breastfeeding support groups and refer mothers to them on
discharge from hospital or clinic
In Addition:
• Comply to the Marketing of breast milk substitutes legislation and the international Code
• Encourage all pregnant women to test for HIV and provide them appropriate support on
infant feeding
• Promote Mother Friendly Care practices
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References
1. Chronic HIV Care with ARV Therapy, Integrated Management of Adolescent and Adult Illness,
Interim Guidelines for First-level Facility Health Workers, WHO, January 2004.
2. Complementary Feeding: Family Foods for Breastfed Children, WHO, 2000.
3. Counselling Mothers on Infant Feeding for the Prevention of Mother to Child Transmission of
HIV, Regional Centre for Quality of Health Care, March 2003
4. HIV and Infant Feeding: A Guide for Health Care Managers and Supervisors, WHO/UNICEF/
UNAIDS, 1998
5. Antiretroviral drugs and the Prevention of Mother To Child Transmission of HIV Infection in
resource limited settings- Recommendations for a Public Health Approach (2005 Revision)-WHO.
6. Moss, W. et al, 2003, Immunization of Children at Risk of Infection with Human Immunodeficiency
Virus
7. Nutrition Essentials: A Guide for Health Managers, WHO, 1999.
8. Piwoz E. et al, Early Breastfeeding Cessation as an Option for Reducing Postnatal Transmission of
HIV in Africa
9. Prevention of Mother-to-Child transmission of HIV, Full Protocol, March 2002, Department of
Health, Provincial Administration of the Western Cape, South-Africa.
10. WHO Complementary feeding, Annex 1: Good Sources of Important Nutrients
11. Zambia Demographic & Health Survey 2001-2002
12. Zambia Sentinel Surveillance Trends
13. Interim WHO Clinical Staging of HIV/AIDS and HIV/AIDS case definition for Surveillance
14. Zambian Guidelines for Antiretroviral Therapy of HIV infection in Infants and Children 2007 –
Ministry of Health Zambia
15. Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents. New HAART Protocols
May 2007 – Ministry of Health Zambia
16. Infant and Young Child Feeding : An Integrated Course- 2005- World Health Organisation
17. HIV and Infant Feeding :Consensus Statement 2006- World Health Organisation
18. HIV and Infant Feeding Framework- United Nations
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NOTE: HIVAIDS is a dynamic field. As thus, the management protocols will be updated on a regular
basis, as need arises. Should you have any question on this protocol or would like to provide any
feedback, please send your comments/questions to:
National prevention of Mother-to-Child transmission of HIV Coordinator
Ministry of Health
Ndeke House
P.O. Box 32588
Lusaka
Tel: (1) 253179/81/82
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