1. Module 3 Specific Interventions to Prevent Mother-to-Child Transmission of HIV (PMTCT)

2. Malawi PMTCT Training Package2 Module 3 Objectives  Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.  Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT).  Describe strategies for reducing the risks of MTCT during labour and delivery.

3. Malawi PMTCT Training Package3 Module 3 Objectives (continued)  Discuss the management of women during labour and delivery who are of unknown HIV status.  Describe immediate postpartum care of women with HIV infection.  Explain the need to integrate family planning into community services.  Describe guidelines for immediate newborn care.

4. Malawi PMTCT Training Package4 Unit 1 Implementation of Comprehensive ANC Services

5. Malawi PMTCT Training Package5 Unit 1 Objectives  Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.

6. Malawi PMTCT Training Package6 PMTCT in Antenatal Care (ANC)  ANC improves the health and well-being of mothers and their families.  Integration of PMTCT services into essential ANC services can improve care and pregnancy outcomes for clients.  Antenatal interventions can reduce risk of MTCT

7. Malawi PMTCT Training Package7 Quality RH in context of PMTCT  Comprehensive antenatal services  Routine HIV testing and counselling  ARV prophylaxis or, if eligible, therapy  Safer infant feeding counselling and support  Quality intrapartum care  Quality postpartum care that includes:  Safer infant feeding counselling and support  Family planning services  Follow up care for mother and baby

8. Malawi PMTCT Training Package8 Integrated Essential Package for ANC Services  ANC for HIV-infected pregnant women includes basic services recommended for all pregnant women  Obstetric and medical care for HIV- infected women expanded to address their specific needs

9. Malawi PMTCT Training Package9 Integrated Essential Package for ANC Services (continued)

10. Malawi PMTCT Training Package10 Support Needs of Women with HIV Infection Pregnancy is a stressful time. Support will lead to hope and acceptance. Referrals include:  Food, nutritional counselling & supplementation  Practical necessities  Social and psychological support  Home care & community-based health care  Traditional/herbal healers  Orphan care and support  Care of children with HIV or AIDS

11. Malawi PMTCT Training Package11 Prevention of HIV-Related Conditions Reduce rates if illness, adverse pregnancy outcomes, and death among HIV-infected pregnant women  Women with HIV infection more susceptible to:  TB  Urinary tract infections  Respiratory tract infections  Recurrent vaginal candidiasis  Malaria  Breast conditions  Unhealed episiotomies/caesarean section wounds  Herpes zoster  Puerperal sepsis

12. Malawi PMTCT Training Package12 Maternal Nutrition & MTCT  Nutritional deficiencies can be associated with preterm delivery & increased risk of MTCT  Weight gain during pregnancy is an indicator of mother’s nutritional status

13. Malawi PMTCT Training Package13 Exercise 3.1 Antenatal Care: Case Studies

14. Malawi PMTCT Training Package14 Unit 2 Antiretroviral Prophylaxis and Therapy for PMTCT

15. Malawi PMTCT Training Package15 Unit 2 Objective  Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT)

16. Malawi PMTCT Training Package16 ARV Drugs in PMTCT  Antiretroviral (ARV) drugs hinder replication and mutation of HIV, resulting in less damage to immune system  ARV therapy or prophylaxis reduce risk of MTCT by reducing viral load in mother  ARV drugs can be used for prophylaxis or treatment

17. Malawi PMTCT Training Package17 ARV Drugs in PMTCT (continued)  ARV Therapy: Long-term use of antiretroviral drugs to treat maternal HIV/AIDS to slow progression of disease. ARV therapy also reduces HIV transmission from mother to infant.  ARV Prophylaxis: Short-term use of antiretroviral drugs to reduce HIV transmission from mother to infant. ARV prophylaxis does not treat maternal HIV or provide long-term protection for the infant.

18. Malawi PMTCT Training Package18 Pregnancy & ARV Therapy  Women who are eligible for ARV therapy should be referred to the ARV Clinic.  ARV therapy:  Should begin as soon as possible, but may be delayed until after 1 st trimester  Women on ARV therapy require ongoing care and monitoring in the ANC and ART clinics.

19. Malawi PMTCT Training Package19 ARV Prophylaxis  ARV prophylaxis alone will not protect breastfeeding infants from risk of HIV infection  Single dose Nevirapine (sd-NVP) has been used since inception of programme.  Mother: sd-NVP 200mg at onset of labour  Infant: sd-NVP (6mg) within 72 hours of delivery  Prevent NVP resistance by avoiding multiple doses of NVP to the mother. If the maternal NVP dose is given during false labour, the dose should not be repeated.

20. Malawi PMTCT Training Package20 ARV Prophylaxis  Combination regimens given during pregnancy are more effective but more difficult to administer where infrastructure/access is an issue  The HIV/AIDS Unit is phasing in the regimens at sites with infrastructure  Combination regimens include 2 or 3 of the following drugs:  AZT  NVP  3TC  The recommended regimens are listed in Appendix 3-C

21. Malawi PMTCT Training Package21 Exercise 3.2 Nevirapine Prophylaxis for PMTCT: Case Studies

22. Malawi PMTCT Training Package22 Unit 3 Optimal Management of Women During Labour and Delivery

23. Malawi PMTCT Training Package23 Unit 3 Objectives  Describe strategies for reducing the risks of MTCT during labour and delivery.  Discuss the management of women during labour and delivery who are of unknown HIV status.

24. Malawi PMTCT Training Package24 PMTCT Interventions During Labour & Delivery  Administer ARVs as per guidelines  Use Standard Precautions  Minimize vaginal examinations  Avoid prolonged labour  Avoid routine artificial rupture of membranes  Avoid unnecessary trauma and routine episiotomy  Minimize risk of postpartum haemorrhage  Use safe transfusion practices

25. Malawi PMTCT Training Package25 PMTCT Interventions During Labour & Delivery (continued) Always use Standard Precautions during patient care:  Strict aseptic technique during first stage of labour  Wash hands before & after every procedure  Decontaminate bed, instruments, linens soon after use  Autoclave or high-level disinfection of instruments used for delivery  Use six swab technique for vulval swabbing/vaginal cleansing  Use protective gear, safely dispose sharps & contaminated materials

26. Malawi PMTCT Training Package26 PMTCT Interventions During Labour & Delivery (continued) Minimize vaginal examinations:  Perform vaginal examinations only when necessary  Record all vaginal examinations on partograph

27. Malawi PMTCT Training Package27 PMTCT Interventions During Labour & Delivery (continued) Avoid prolonged labour:  Use partograph to monitor progress of labour  Avoid artificial rupture of membranes  If spontaneous rupture of membranes occurs when not in labour, induce immediately  Augment if in latent phase of labour  Aim to deliver within 4 hours if in active phase of labour  Reinforce pain relief in labour

28. Malawi PMTCT Training Package28 PMTCT Interventions During Labour & Delivery (continued) Avoid unnecessary trauma during delivery:  Avoid invasive procedures  Avoid routine episiotomy  Avoid unnecessary trauma to infant  Minimize use of vacuum extractors  Prevent genital tract/perineal lacerations  Do not give enemas  Do not shave vulva

29. Malawi PMTCT Training Package29 PMTCT Interventions During Labour & Delivery (continued) Minimize risk of postpartum haemorrhage:  Carefully manage all stages of labour to prevent infection & avoid prolonged labour  Actively manage third stage of labour Use safe transfusion practices:  Minimize blood transfusions  Use only blood screened for HIV, hepatitis B, and syphilis

30. Malawi PMTCT Training Package30 Exercise 3.3 Obstetric Practices and HIV: Group Discussion

31. Malawi PMTCT Training Package31 Management of Women with Unknown HIV Status (continued) If a woman presents in: Early labour: Provide HIV information Test unless she refuses Give NVP to woman and infant if she tests HIV+ Late labour (active phase): Defer test until after delivery & before discharge If she test HIV+, give NVP to infant

32. Malawi PMTCT Training Package32 Management of Women with Unknown HIV Status (continued)

33. Malawi PMTCT Training Package33 Exercise 3.4 HIV Testing and ARV Prophylaxis during Labour and Delivery: Case Studies

34. Malawi PMTCT Training Package34 Unit 4 Postpartum Management of Women and Infants

35. Malawi PMTCT Training Package35 Unit 4 Objectives  Describe immediate postpartum care of women with HIV infection.  Explain the need to integrate family planning into community services.  Describe guidelines for immediate newborn care.

36. Malawi PMTCT Training Package36 Immediate and Subsequent Postpartum Care of HIV-Infected Mothers After Delivery  Provide ARV prophylaxis to the infant Before Discharge  Assess Mother  Personal hygiene  Nutritional status  Signs and symptoms of anaemia and infections  Signs of uterine involution  Breast conditions

37. Malawi PMTCT Training Package37 Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued) Before Discharge  Assess Mother (continued)  Urinary tract infections  Episiotomies, caesarean section  Signs of PID and any other infections  Clinical features of HIV or AIDS  Possible side effects of ARVs  Administer Vitamin A and iron supplement

38. Malawi PMTCT Training Package38 Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued) Before Discharge Offer education, counselling, and support for:  Infant feeding, hygiene, re-hydration, umbilicus care, illness  Diet and nutrition  Postpartum infection, including pelvic inflammatory disease (PID)  Anaemia  Community resources  Information on breast and urinary tract infections

39. Malawi PMTCT Training Package39 Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued) Upon Discharge Offer Education, Counselling, Support for:  Follow-up care: both routine (one-week and six-week visits, then monthly check ups) and as needed  Family planning information and services, including information on condom use for dual protection

40. Malawi PMTCT Training Package40 Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued) Upon Discharge Link patients to centers providing the following services:  Postnatal review, dates for one-week and six-week visits  Sexual and reproductive health care, including family planning  Prevention and treatment of HIV-related conditions, inc malaria  Immunizations

41. Malawi PMTCT Training Package41 Immediate and Subsequent Postpartum Care of HIV-Infected Mothers (continued) Upon Discharge (continued) Link patients to centers providing the following services:  Nutritional counselling and support  “Under-five” services  Support groups  HIV treatment, care, and support  Social and psychosocial support  Home-based care

42. Malawi PMTCT Training Package42 Family Planning Family Planning (FP) is a core PMTCT intervention.  FP services integrated into ANC and community health services can minimize HIV/AIDS- related stigma.  FP services includes:  Individual and couples counselling  Continued risk assessment  Early diagnosis and treatment of STIs and HIV/AIDS  Information and skills needed to practise safer sex  Access to contraceptives

43. Malawi PMTCT Training Package43 Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn  Administer NVP prophylaxis as soon as possible but within 72 hours after birth  For home births, child and mother should be seen within 72 hours of delivery:  Assessment  Administration of NVP prophylaxis  Support safer infant feeding.

44. Malawi PMTCT Training Package44 Immediate and Subsequent Postnatal Care of HIV-Exposed Newborn (continued) Make assessments and implement preventive measures:  Infant feeding  Administer ARVs within 72 hours  PCR testing within 48 hours where available  Immunization according to EPI schedule  Side effects of ARV prophylaxis

45. Malawi PMTCT Training Package45 Exercise 3.5 Supporting Postpartum Follow-Up: Group Discussion

46. Malawi PMTCT Training Package46 Module 3: Key Points  The essential package of ANC services includes the basic services recommended for all pregnant women, including HIV testing. However, for women with HIV, obstetric and medical care should be expanded to address the specific needs of women infected with HIV.

47. Malawi PMTCT Training Package47 Module 3: Key Points (continued)  Nutritional assessment, counselling and support are important not only in the antenatal period when good nutrition plays a role in foetal health and PMTCT, but also in the postpartum period, particularly for the breastfeeding mother and for the HIV-exposed or HIV-infected infant and young child.

48. Malawi PMTCT Training Package48 Module 3: Key Points (continued)  ARV therapy is the long-term use of antiretroviral drugs to manage maternal HIV and prevent MTCT; ARV prophylaxis is the short-term use of antiretroviral drugs to reduce MTCT of HIV.

49. Malawi PMTCT Training Package49 Module 3: Key Points (continued)  The HIV/AIDS Unit has phased in the more complex but efficacious WHO-recommended regimen (which include AZT, NVP and, in some instances, 3TC) at sites with adequate infrastructure and human capacity for its delivery. At the same time, expansion of PMTCT to sites with limited infrastructure will be done using single dose Nevirapine (sd-NVP) while steps are taken to build their capacity to deliver the recommended combination regimen.

50. Malawi PMTCT Training Package50 Module 3: Key Points (continued)  The infant ARV prophylaxis regimen is either AZT alone, NVP alone or a combination of AZT and NVP. ARVs should be initiated to the infant as soon as possible after birth but within 72 hours of delivery.  Using safer obstetrical practices can reduce MTCT of HIV in labour and delivery.

51. Malawi PMTCT Training Package51 Module 3: Key Points (continued)  There are national recommendations for testing of women of unknown HIV status in early labour and soon after delivery.  Support for safer infant-feeding practices are a priority in the immediate postpartum period.  Establishing linkages for postpartum follow-up of mother and infant can improve uptake of treatment and support services and reduce HIV- related morbidity and mortality.