Session: 3 The four pronged approach to comprehensive prevention of HIV in infants and young children Dr.Pushpalatha, Assistant Professor, Dept of Pediatrics, Dept of Pediatrics, Vani Vilas Hospital, Bangalore.

Although PPTCT Programs often focus on ARV prophylaxis, a comprehensive approach to the prevention of HIV infection in infants and young children consists of Although PPTCT Programs often focus on ARV prophylaxis, a comprehensive approach to the prevention of HIV infection in infants and young children consists of 4 elements 4 elements

The four-pronged approach

HIV will not be passed on to children in parents-to-be are not infected. HIV will not be passed on to children in parents-to-be are not infected. Decreasing the number of HIV infected mothers is the most effective way of reducing MTCT Decreasing the number of HIV infected mothers is the most effective way of reducing MTCT Prevention of primary HIV infection

Safe and responsible sexual behavior and practices – the ABC approach Safe and responsible sexual behavior and practices – the ABC approach A=abstinenceA=abstinence B=be faithful to one partnerB=be faithful to one partner C=condom use, correctly and consistentlyC=condom use, correctly and consistently Prevention of primary HIV infection- strategies Increasing new HIV infection-from husbands to wives. Needs behavioural changes and education to safer sex practices. Factors contributing to women’s vulnerability to HIV are Poverty,lack of information,abuse,violence. BCC –aim to change the risky behaviour

 PROVIDE EARLY DIAGNOSIS AND TREATMENT OF STI’s  PROVIDE ACCESS TO CONDOMS  PROVIDE SUITABLE COUNSELLING FOR HIV NEGATIVE WOMEN  MAKE HIV TESTING AND COUNSELLING WIDELY AVAILABLE

The four-pronged approach

Women who know that they are HIV infected can avoid unintended pregnancies Women who know that they are HIV infected can avoid unintended pregnancies Family planning counseling for such women and their partners is critical. Family planning counseling for such women and their partners is critical. Providing safe and effective contraception and high quality reproductive health counseling contributes to informed decision making about pregnancy choices. Providing safe and effective contraception and high quality reproductive health counseling contributes to informed decision making about pregnancy choices. Prevention of unintended pregnancies among HIV infected women

The four-pronged approach

PPTCT refers to specific program to identify HIV infected pregnant women and to provide them with effective interventions to reduce MTCT PPTCT refers to specific program to identify HIV infected pregnant women and to provide them with effective interventions to reduce MTCT The most important risk factor for MTCT is the VIRAL LOAD. High viral load is seen with recent HIV infection or with advanced HIV/AIDS The most important risk factor for MTCT is the VIRAL LOAD. High viral load is seen with recent HIV infection or with advanced HIV/AIDS Prevention of HIV transmission from HIV infected women to their infants

ANC for the HIV infected woman includes basic prenatal care that emphasizes identifying and treating HIV related diseases ANC for the HIV infected woman includes basic prenatal care that emphasizes identifying and treating HIV related diseases ARV prophylaxis for the mother and infant decreases the risk of MTCT during labor. ARV prophylaxis for the mother and infant decreases the risk of MTCT during labor. However, ARV prophylaxis does not decrease the long term risk of transmission during breastfeeding. However, ARV prophylaxis does not decrease the long term risk of transmission during breastfeeding.

PPTCT core interventions PPTCT core interventions HIV testing and counseling HIV testing and counseling ARV prophylaxis ARV prophylaxis Safer delivery practices Safer delivery practices Safer infant feeding practices Safer infant feeding practices How these interventions work How these interventions work Identifies HIV infected women Identifies HIV infected women Reduced maternal viral load during pregnancy Reduced maternal viral load during pregnancy Reduced infant exposure to the virus during labor Reduced infant exposure to the virus during labor Reduced infant exposure to the virus through safer feeding options Reduced infant exposure to the virus through safer feeding options

Ways to reduce MTCT HIV testing and counseling HIV testing and counseling Early MTP- when safe and acceptable to the woman Early MTP- when safe and acceptable to the woman ARV prophylaxis ARV prophylaxis Elective Cesarean section when safe and feasible. Elective Cesarean section when safe and feasible. Safer obstetrical procedures. Safer obstetrical procedures. Infant feeding counseling for safer infant feeding practices. Infant feeding counseling for safer infant feeding practices.

ARV prophylaxis ARV prophylaxis, given to a HIV positive pregnant woman does not confer long term benefit to the woman herself ARV prophylaxis, given to a HIV positive pregnant woman does not confer long term benefit to the woman herself With advanced HIV –combined ARV prophlaxis and treatment With advanced HIV –combined ARV prophlaxis and treatment

ARV prophylaxis In industrialized countries – In industrialized countries – triple drug ARV,triple drug ARV, No breastfeeding,No breastfeeding, Elective LSCS- rate of MTCT is 2% Elective LSCS- rate of MTCT is 2% ARV prophylaxis can reduce MTCT by 40-70%. Current regimens prevent infection only during early breast feeding period. ARV prophylaxis can reduce MTCT by 40-70%. Current regimens prevent infection only during early breast feeding period.

Partner involvement in PPTCT Both partners need to be aware of the importance of the safe sex through out pregnancy and breastfeeding. Both partners need to be aware of the importance of the safe sex through out pregnancy and breastfeeding. Both partners should be counseled and tested for HIV Both partners should be counseled and tested for HIV Both partners should be made aware of and provided with PPTCT interventions. Both partners should be made aware of and provided with PPTCT interventions.

The four-pronged approach

Medical care and social support are important in helping these women Medical care and social support are important in helping these women We need to address concerns about their own health and the that of their children and families We need to address concerns about their own health and the that of their children and families If a woman is assured of this, she is more likely to accept counseling and testing and if infected, interventions to reduce MTCT If a woman is assured of this, she is more likely to accept counseling and testing and if infected, interventions to reduce MTCT Provision of treatment, care and support to HIV infected women, their children and their families

HIV related treatment, care and support services for women Prevention and treatment of opportunistic infections Prevention and treatment of opportunistic infections ARV treatment ARV treatment Palliative and non-ARV care Palliative and non-ARV care Nutritional support Nutritional support Reproductive health care including family planning and counseling Reproductive health care including family planning and counseling Psychosocial and community support Psychosocial and community support

Care and support of the HIV exposed infant and child These children have a higher risk of illness and malnutrition. These children have a higher risk of illness and malnutrition. They may be infected with HIV and may become ill even when adequate health care and nutrition are provided They may be infected with HIV and may become ill even when adequate health care and nutrition are provided Those who do not receive breast feeding lack its protective benefits against gastroenteritis, respiratory infections and other complications Those who do not receive breast feeding lack its protective benefits against gastroenteritis, respiratory infections and other complications If mother is ill, she may be unable to give adequate care If mother is ill, she may be unable to give adequate care The family may be economically vulnerable due to AIDS related illness and deaths among adults The family may be economically vulnerable due to AIDS related illness and deaths among adults

Nutritional support for HIV exposed infant or child Supporting the mother’s chosen infant feeding option Supporting the mother’s chosen infant feeding option Providing education on hydration and early reporting of diarrhea Providing education on hydration and early reporting of diarrhea Monitoring for growth and development Monitoring for growth and development Monitoring for signs of infection that can alter feeding patterns Monitoring for signs of infection that can alter feeding patterns Regular follow-up during first 2 years of life, including immunizations and HIV testing Regular follow-up during first 2 years of life, including immunizations and HIV testing