1. Module 3 Antenatal Care for PMTCT Ministry of Health/HAPCO, Ethiopia

2. 4 Sections Section One Focused ANC Section Two Introduction to PMTCT Section Three HIV testing & counseling during ANC Section Four Clinical care for HIV positive women. Section five for HIV positive pregnant women

3. Module objectives: Explain focused antenatal care Describe the components of a comprehensive approach to the prevention of mother to child transmission of HIV Describe Counseling and Testing during ANC Describe clinical care for HIV positive pregnant women Describe ARVs for pregnant women

4. FANC What is FANC & what is the time schedule for FANC? What is the routine care & preventive therapy we provide at ANC?

5. Section 1 Focused ANC

6. Approach of focused ANC: Every pregnancy is “at risk" Ensure that we use ANC as an opportunity to detect and treat existing problems Ensure that the services are available to respond to obstetric emergencies when they occur Prepare women and their families for the eventuality of an emergency

7. Focused ANC: Four antenatal visits are recommended  As early as possible in pregnancy  4-6 months  8 months  9 months Content for the first visit should be carried out for all women at first contact with the clinic, regardless of gestational age

8. Focused ANC Women who have chronic illnesses detected may require more visits than others If an HIV-infected woman is eligible for ART, she will require additional visits for rapid adherence preparation and support and to provide infant feeding counseling and additional psychosocial support.

9. Essential elements of care: Birth preparedness and complication readiness planning with family Detection and management of coexisting conditions and complications HIV-Testing and counselling Counseling for breast feeding options, family planning, danger signs, HIV/STI and nutrition Treatment of any diagnosed infection, i.e. Syphilis, Gonorrhea tuberculosis

10. Essential elements of care Tetanus toxoid (2 doses) Iron and folate- for 6 months of pregnancy (60mg Iron and 400 mcg of folate, for areas with > 40% anemia) and continue same dosage for 3 months postpartum Iodine supplementation in selected populations Malaria prevention as per national guidelines with ITN

11. What is your opinion on the following issues  Numerous visits-.  Measurement of maternal height- Examination of Ankle Edema-  Examination of fetal position before 36 weeks-

12. Causes of maternal death What are the main causes of maternal death & how do you avert them?

13. Reduction of maternal death through ANC: Haemorrhage  Iron/folate supplementation, measurement of HCT and Blood typing, malaria prevention, availability of blood for transfusion Preeclampsia /eclampsia  BP measurement, warning signs, urine for protein, rapid referral and treatment with Mag sulphate Obstructed labour  Fundal height measurement, fetal lie after 36 weeks, use of partograph in labor and rapid referral for prolonged labor

14. Reduction of maternal death through ANC: Puerperal sepsis  Treatment of STIs, plan for safe/clean delivery, two doses of tetanus toxoid, PMTCT and ARV if indicated Complications of unsafe abortion  Post abortion care, family planning

15. Birth preparedness plan What do you mean by birth preparedness plan? What birth preparedness plan are specific to HIV positive pregnant women?

16. Birth Preparedness Plan Discussion of safest place for delivery with a skilled attendant and complication readiness HIV+ women should be advised to deliver in a health facility, and to go to the facility whenever labor starts or her water breaks  The HIV+ woman must remember to bring her ARV drugs to the facility.

17. If home birth is the only option for an HIV+ woman, the health worker should: Be certain ARV drugs are available for the woman and her newborn Provide careful instructions on how to take the ARV drugs. Arrange for a treatment supporter,TBA or CHW of her choice to help with ART or ARV prophylaxis at home.

18. Section 2 Introduction to PMTCT

19. Learning Objectives Explain how MTCT of HIV occurs. Describe the four pronged approach for PMTCT. Describe factors that increase the risk of MTCT of HIV & interventions which can reduce the risk.

20. Mother to Child Transmission of HIV During pregnancy 5-10% During labor/delivery10-20% During breastfeeding5-20% Overall without breastfeeding15-30% Overall with b’feeding for 6 mo25-35% Overall with b’feeding 18-24 mo30-45%

21. 4 strategies of PMTCT: Primary prevention of HIV infection  minimizing the transmission of HIV to women Prevention of unintended pregnancies among women with HIV  Improving women's access to information, education, sexual and reproductive health services including family planning.

22. 4 strategies of PMTCT Prevention of HIV transmission from mothers with HIV to their infants  Increasing women's access to ART, providing antiretroviral treatment during labour, ensuring safer delivery procedures and reducing transmission through breastfeeding. Care, support and treatment for mothers living with HIV, their children and families  to improve the health of the other and the family to the extent possible

23. Factors that increase the risk of MTCT of HIV during pregnancy: STRONG EVIDENCE High viral load new infection (primary infection) advanced disease: clinical AIDS Poor immune status (low CD4 count) STIs Malaria( Placental infection) Certain HIV-viral strains High viral load-- new infection (primary infection) or advanced disease: clinical AIDS Poor immune status (low CD4 count) STIs Malaria( Placental infection) Certain HIV-viral strains

24. Factors that increase the risk of MTCT of HIV during pregnancy: WEAKER EVIDENCE Poor maternal nutritional status Anemia Substance (drug) use or cigarette smoking during pregnancy External cephalic version Invasive obstetrical procedures Amniocentesis, chorionic villus sampling

25. Factors that increase the risk of MTCT of HIV during labor/delivery: STRONG EVIDENCE: High viral load (from recent infection or advanced disease/clinical AIDS) Prematurity Vaginal delivery Prolonged rupture of membranes (more than 4 hours) Prolonged labour Instrumental delivery (forceps or vacuum extraction) First infant in multiple birth

26. Factors that increase the risk of MTCT of HIV during labor/delivery: WEAKER EVIDENCE: Chorio-amnionitis Suctioning newborn unless necessary for thick meconium or to resuscitate Invasive obstetrical procedures  Episiotomy  Artificial rupture of membranes

27. Factors that increase transmission of HIV during breastfeeding: STRONG EVIDENCE Breastfeeding with early mixed feeding Mixed feeding (non-exclusive breastfeeding or non-exclusive replacement feeding) Long duration of breastfeeding Mastitis, nipple fissures, breast abscess Oral disease in the baby (e.g. thrush or sores) New infection in mother while breastfeeding

28. Factors that increase transmission of HIV during breastfeeding: WEAKER EVIDENCE  Poor maternal nutritional status

29. Interventions which reduce the risk of MTCT during ANC ARV drugs to mother which decrease the viral load in the mother. Detection & treatment of anaemia,malaria,STIs.

30. Male partner involvement What is the importance of male partner involvement in PMTCT?

31. Importance of male/partner involvement in PMTCT interventions: Use of condom during pregnancy & lactation. Acceptance of maternal HIV services. More decision power for infant feeding choices. ARV adherence & Compliance. Economic empowerment. Family union in HIV support.

32. Section 3 HIV Counseling and Testing during ANC

33. Learning objectives Explain the principles for routine offer of HIV testing & counseling during pregnancy. Describe how to manage women who opt out from HIV testing.

34. HIV testing should be offered routinely for all pregnant women Pre-test information is given for a group,a couple or an individual at ANC THEN hiv testing is offered routinely. Post-test counseling may be provided to the woman alone, or the couple together. An HIV positive pregnant woman needs extra post test counseling & support. If an HIV- woman is at high risk, she should be offered testing again in the 3 rd trimester Managing women who choose to “opt out”  Allow her to express concerns  Take extra time  Re-offer HIV testing at every visit  Provide referral and take home information

35. Routine HIV TESTING What do you think is the advantage of routine HIV testing? How do you keep confidentiality?

36. Exercise A

37. Section 4 Clinical care for the HIV+ pregnant woman

38. Learning objectives Recognize medical eligibility for ART in pregnant women. Identify clinical & immunologic staging. Recognize when to refer clients.

39. Medical eligibility for ART in pregnant women: If CD4 is available:  WHO Clinical Stage 4- give ART regardless of CD4 count  WHO Clinical Stage 3 - give ART if CD4 less than 350  WHO Clinical Stage 1 or 2, give ART if CD4 less than 200 IF CD4 is NOT available:  All women who are WHO Clinical Stage 3 or 4 are eligible for ART  In WHO Clinical Stage 2, the woman is medically eligible for ART if total lymphocyte count (TLC) is less than 1200/mm3 in facilities where there is no CD4

40. Differences between medical eligibility for ART in pregnant vs. non-pregnant clients:  Pregnant women in clinical stage 3 with CD4 count less than 350 are eligible for ART. While this is only true for non-pregnant adults and adolescents with pulmonary TB or severe bacterial infection).  Highest priority for CD4 testing should be given to pregnant women, where limited numbers of individuals are able to access CD4 count. This will provide opportunity to initiate ART for all women who are medically eligible.

41. ANC ANC provided to HIV positive women should also include clinical review,Clinical staging,CD4 &HGB.

42. WHO clinical staging Stage1 Asymptomatic Stage2 Mild disease Stage3 Advanced disease Stage4 Severe disease

43. Exercise Drill on ART & ARV prophylaxis. Exercise B clinical staging & need for ARTor ARV prophylaxis

44. Section 5 ARV for pregnant women

45. Learning objectives Describe the different options of ARVs in use for PMTCT. Describe the preparations for adherence & support.

46. ARV ARV prophylaxis. ART

47. ARV prophylaxis Pregnant women who are not yet eligible for ART should be offered ARV prophylaxis to reduce the risk of MTCT of HIV All infants born to HIV-infected women should receive a course of ARV drugs as post-exposure prophylaxis.

48. Current regimen for ARV prophylaxis: For the mother- zidovudine (AZT 300mg) twice daily from 28 weeks of pregnancy, or as soon as feasible their after antenatally. Intrapartum AZT 600mg at the onset of labour plus single dose Nevirapin 200mg po and 3TC 150mg Bid for 7 days. Postpartum: AZT 300mg Bid and 3TC 150mg Bid for 7 days. For the infant- Single dose nevirapine (2mg/kg) +AZT (4mg/kg) Bid for 7 days. If mother received less than 4 weeks of AZT AZT dose for the infant should be extended for 4 weeks.

49. A note about ARV prophylaxis:  Short-term ARV prophylaxis for PMTCT does not treat maternal HIV immuno-suppression and therefore does not provide long-term benefits to the health of the woman. For this reason, women should be regularly assessed for ART eligibility.  ARV prophylaxis does not provide long-term protection for the infant

50. Exercise C True or False

51. ART regimen during pregnancy: Preferred regimen - AZT-3TC-NVP if the CD4 count is less than 250. In patients with moderate to severe anaemia, D4T+3TC+NVP can be used alternatively. Avoid use of EFV during first trimester pregnancy BUT when the benefit of early therapy outweighs any potential foetal risks, ARV therapy should be instituted at any time of gestation. If the CD4 count is 250 – 350 (and the woman qualifies for ARVs, then it is better to use EFV (rather than NVP) after the first trimester.

52. Special considerations for ARV use in pregnancy In advanced HIV disease the benefits of ART in the first trimester outweighs the potential risk to the unborn child If the woman is already on ART before becoming pregnant, continue ART Avoid EFV in the first trimester as may be associated with birth defects in the fetus.  If a woman is already on ARV including EFV change her to NVP until she finishes the first trimester (200mg NVP BID).

53. Special considerations for ARV use in pregnancy If the ARV regimen includes Nevirapine (NVP) and CD4 is greater than 250, there is an increased risk of severe Nevirapine-related rash and liver toxicity.  After the first timester, change to EFV regimen OR  Monitor carefully, with transaminiases if possible for signs of liver toxicity determine transaminase level at base line 2-4wks,8wks & 12 wks. Do not give ddl-d4T combination any time during pregnancy

54. Anemia in pregnancy: Anaemia is a common  May be due to poor iron stores, infection with malaria and hookworm. HIV infection itself, cotrimoxazole prophylaxis and AZT AZT can cause a very rapid fall in haemoglobin.  if the ARV regimen contains AZT, obtain haemoglobin before initiation and, at 4th, 8th and 12th weeks after initiation.  If the woman’s haemoglobin is less than 7 grams/dL, do not start AZT, and if already on AZT, substitute d4T for AZT

55. Exercise D ART regimens in pregnancy True or False.

56. Adherence Preparation What is the importance of rapid adherence preparation? How is adherence preparation in pregnant women different from non pregnant women & what are some of the challenges?

57. During labor: Mother on ART during antenatal care: Continue regular schedule of ART every 12 hours (no additional prophylaxis) Mother on ARV prophylaxis (or no ARV drugs during antenatal care): AZT 600 mg (two tablets of 300 mg) once (Note that the woman may have already taken this dose at home at the onset of labour - ask her and record) PLUS Single dose NVP 200 mg (not necessary to give if mother was on AZT for >4 weeks ) PLUS 3TC 150 mg at the onset of labour or soon thereafter and continue with 3TC 150 mg every 12 hours until delivery

58. After delivery: Mother on ART during antenatal care: Continue regular schedule of ART. Mother on ARV prophylaxis or ARV Started only during Labor: 3TC 150 mg plus AZT 300 mg — twice daily for 7 days

59. For the newborn: The newborn should receive the first dose of ARV prophylaxis as soon as possible after childbirth. If possible, before the newborn leaves the delivery room.

60. Take home messages Every pregnant woman should attend, at least, four focused ANC visits in order to detect and treat existing illnesses including HIV. Every woman should have birth preparedness and complication readiness plan to reduce maternal sickness and death Pregnant women are at increased risk for HIV and other STIs: if infected will compromise their health and that of their fetus

61. Take Home Message Involving men in reproductive health and family planning has great impact on the increasing acceptance of condom use and practice of safer sex to avoid infection Prioritize pregnant women for ART to promote HIV free child survival Women have the right to be informed about the availability and accessibility of ARVs, and options of care and support at any point during their pregnancy