Draft National PMTCT Guidelines - RSS 2016

MINISTRY OF HEALTH
GOVERNMENT OF SOUTH SUDAN
Revised Guidelines for the Prevention of Mother-

to Child Transmission and Early Infant Diagnosis
of HIV using option B+
Third edition December 2016
Table of Contents
CHAPTER ONE: INTRODUCTION AND BACKGROUND............................................................11
1.1 Introduction...............................................................................................................................11
1.2. Background and contexts........................................................................................................11
1.3 Rationale For The Guidelines..................................................................................................11
1.4 Objectives Of The Guidelines..................................................................................................11
1.5 The Guideline Review Process................................................................................................12
1.6 The scope and structure of the guidelines...................................................................................12
1.7 The intended users of the guidelines...........................................................................................13
CHAPTER TWO : OVERVIEW OF HIV/AIDS AND MTCT IN SOUTH SUDAN........................14
2.1. Introduction................................................................................................................................14
2.2.The HIV/AIDS Epidemic in South Sudan........................................................................................14
Figure 1: South Sudan ANC Sentinel Surveillance 2012.....................................................................14
2.3 The burden of Mother to Child Transmission of HIV in south sudan............................................15
2.4 Risk of transmission without intervention...................................................................................15
Figure 2: Risk of HIV transmission when there is no PMTCT intervention..........................................16
2.5 Factors that determine HIV transmission.....................................................................................16
Table 1: Factors increasing risk of mother-to-child transmission of HIV.............................................16
CHAPTER THREE : STRATEGIC FRAMEWORK FOR ELIMINATION OF MOTHER TO CHILD
TRANSMISSION OF HIV IN SOUTH SUDAN..................................................................................19
3.1 Introduction...............................................................................................................................19
3.2. Program Goal and objectives..................................................................................................19
3.2.1 Program Goal......................................................................................................................................19
3.2.2. Strategic objectives............................................................................................................................19
3.3 Comprehensive Approach To PMTCT...................................................................................20
3.4 EMTCT Program Component Expected Results.................................................................21
3.4.1 Planned Program component Level Results.......................................................................21
3.4.2 Intermediate (Output) Results..........................................................................................................22
3.5 Comprehensive EMTCT Package of interventions...............................................................23
3.6 . PROGRAM IMPLEMENTATION APPROACHES.....................................................................23
3.6.1 Upstream Interventions to create an enabling environment............................................23
3.6.2. Downstream Service delivery interventions......................................................................23
3.6.3 Health Facility based EMTCT interventions...................................................................................23
3.6.4. Community led EMTCT interventions...............................................................................24
3.6.4.1 Basic Package Of Community EMTCT Services..............................................................24
3.6.4.2. Establishing Community EMTCT Services.....................................................................25
3.7 PMTCT Interventions in Humanitarian Settings.................................................................26
3.7.1 Introduction..............................................................................................................................26
3.7.2. Why EMTCT In Humanitarian Settings ?..........................................................................26
3.7.3 Basic Principles of Humanitarian Response..................................................................................26
3.7.4 The basic package of RH/PMTCT to deliver in humatarian settings..............................27
3.7.5 Minimum initial package of RH/STI/HIV/AIDS Services............................................................27
3.7.6 Post crisis Package of RH/STI/HIV/AIDS services......................................................................27
CHAPTER 4: PREVENTION OF HIV IN ADOLESCENTS ,YOUTH AND WOMEN OF CHILD
BEARING AGE.......................................................................................................................................28
4.1 INTRODUCTION:...........................................................................................................................28
4.2 BEHAVIORAL CHANGE AND RISK REDUCTION INTERVENTIONS...................................................28
4.3 BIOMEDICAL PREVENTION INTERVENTIONS................................................................................30
4.3.1 SAFE MALE CIRCUMCISION (SMC).........................................................................................................30
4.3.2 POST EXPOSURE PROPHYLAXIS.............................................................................................................31
4.3.3 ORAL PRE-EXPOSURE PROPHYLAXIS (PREP)..........................................................................................33
4.4 STRUCTURAL INTERVENTIONS.....................................................................................................34
3.4.1 PREVENTION AND MANAGEMENT OF GENDER BASED VIOLENCE........................................................34
CHAPTER 5 : HIV TESTING SERVICES FOR PREGNANT WOMEN AND INFANTS...............36
5.1 Introduction.................................................................................................................................36
5.2 The purpose of HIV testing services.............................................................................................36
5.3 Principles of HIV Testing Services (HTS)...............................................................................37
Recommendation:...........................................................................................................................37
5.4 Approaches to HIV testing and counselling..........................................................................37
5.4.1 FACILITY-BASED APPROACHES..................................................................................................38
5.4.1.1. Provider-initiated approach:.........................................................................................................38
Recommendation...............................................................................................................................38
5.4.1.2. Diagnostic testing:.................................................................................................................39
5.4.2. Community HIV Testing Approaches................................................................................39
5.4.3 Workplace-Based HIV Testing services...............................................................................39
5.5 HIV testing technologies..............................................................................................................40
5.5.1. Rapid HIV tests.....................................................................................................................................40
5.5.2 ELISA.....................................................................................................................................................40
5.6 HIV Testing Services Protocols..............................................................................................41
HTS service provision should follow the steps described in Table 1 below. 4.3 The Provider Initiated testing
and counselling Process.....................................................................................................................41
5.6.1 Pre-test Information:.................................................................................................................42
5.6.2 HIV Testing Process...........................................................................................................................42
5.6.2.1 The Hiv Testing Algorithm For Persons Aged 18 Months And Above........................43
Figure 4: Serial HIV Testing Algorithm for persons above 18 months of age......................................43
5.6.2.3.HIV TESTING ALGORITHM FOR INFANTS AND CHILDREN BELOW 18 MONTHS OF AGE.....................44
5.6.3 Post-test counselling:...............................................................................................................45
Post test counselling process.............................................................................................................45
Recommendation:..............................................................................................................................46
5.7 Pregnant women who opt out of HIV testing:..............................................................................46
Recommendation:..............................................................................................................................47
5.8 Partner testing:............................................................................................................................47
Recommendation:..............................................................................................................................47
5.9 Counselling discordant couples:...................................................................................................47
Information about discordant couples.........................................................................................48
5.10 RE-TESTING FOR HIV..................................................................................................................48
5.10.1 Re-testing for HIV positive people before ART initiation.....................................................................48
5.10.2 Re-testing for HIV-Positive Infants.......................................................................................................48
5.10.3 Re-testing for HIV-Negative Individuals...............................................................................................49
5.10.4 Repeat HIV test during pregnancy...........................................................................................49
Recommendation...............................................................................................................................50
5.11 HIV testing during breastfeeding:..............................................................................................50
5.12 Testing of children of pregnant and breastfeeding women for HIV............................................50
Recommendation:..............................................................................................................................51
5.13 LINKAGE FROM HIV TESTING TO HIV PREVENTION, CARE, AND TREATMENT............................51
5.14 INTER-....................................................................................................................................................52
FACILITY LINKAGES.........................................................................................................................................52
5.14 QUALITY ASSURANCE IN HIV TESTING AND COUNSELING.........................................................52
CHAPTER 6: PREVENTION OF AIDS RELATED DISEASES AND CO-MORBIDITIES..............53
6.1 Introduction...............................................................................................................................53
6.2 Package of services for prevention of HIV infections and co-morbidities...................54
6.2. 1 Septrin prophylaxis...................................................................................................................54
5.1.1 Side effects to septrin ...........................................................................................................................55
Table 3: Grading ofseptrin allergic reactions:.....................................................................................55
Table 4: Desensitization of septrin allergic reactions:........................................................................56
Recommendations:............................................................................................................................57
6.2.2. Prevention of Tuberculosis......................................................................................................57
6.2.2.1 Intensified TB case finding.................................................................................................................58
Screening for TB disease among PWHIV.....................................................................................58
6.2.2 Isoniazid Preventive Therapy (IPT)........................................................................................................59
6.2.3 Infection control of Tuberculosis...........................................................................................................60
6.3. Prevention of malnutrition in pregnant and breastfeeding women living with HIV.....................61
6.3.1 Routine Nutrition Education and Counselling.......................................................................................61
6.3.2 Nutritional assessment.........................................................................................................................62
6.3.3 Food safety:...........................................................................................................................................62
6.4 Prevention of disease through WASH practices...........................................................................63
6.4.1Safe drinking water................................................................................................................................63
6.4.2 Hand washing........................................................................................................................................63
6.4. 3 Excreta Management...........................................................................................................................64
6.4.4 WASH activities at health facilities........................................................................................................64
6.4.5 Prevention of malaria............................................................................................................................64
6.4.6 Use of condoms....................................................................................................................................65
CHAPTER 7: PREPARATION FOR ART AND CHRONIC CARE...................................................65
7.1 Introduction..............................................................................................................................65
7.2 Treatment of illness:.....................................................................................................................66
7.3 Pre ART Laboratory tests..............................................................................................................66
7.3.1 Screening for syphilis............................................................................................................................66
Recommendation:...........................................................................................................................67
7.3.2 CD4 testing............................................................................................................................................67
Recommendation:..............................................................................................................................67
7.3.3 Hemoglobin concentration...................................................................................................................67
7.3.4 Urine Dipstick:.......................................................................................................................................67
7.4 Counseling and psychosocial support......................................................................................................68
CHAPTER 8. ANTIRETROVIRAL THERAPY FOR POSITIVE MOTHERS...................................68
8.1 Introduction.................................................................................................................................68
8.2 Antiretroviral drugs:.....................................................................................................................68
8.3 When to start treatment..............................................................................................................69
Recommendation:..............................................................................................................................69
8.3.1. Challenges of providing ART for all pregnant and breastfeeding women.............................................70
8.4 Recommended regimen:..............................................................................................................71
8.5 Pregnancy during HIV care or treatment......................................................................................72
8.6 ART for TB/HIV co-infection.........................................................................................................72
8.7 ART for partners of women and other adults...............................................................................73
8.8 What to expect when ART is started............................................................................................73
8.8.1 Immune reconstitution inflammatory syndrome (IRIS).........................................................................73
8.8.2 Side effects of ARVs...............................................................................................................................74
8.9 Transition from option A to B+ the current recommendations:...................................................77
CHAPTER 9: ADHERENCE TO ART AND RETENTION IN CARE:.............................................77
9.1 Introduction.................................................................................................................................77
9.2 Definition of Adherence...............................................................................................................77
9.3 Advantages of adherence to ART and retention in care...............................................................77
9.4 Causes of poor adherence to ART and retention in care:.............................................................78
9.5 Assessment of adherence to ART and retention in care...............................................................79
9.5.1. Assessing adherence to ART.................................................................................................................79
9.5.2 Assessing retention in care....................................................................................................................79
Recommendation:..............................................................................................................................80
9.6 Strategies to enhance adherence to ART and retention in care...................................................80
9.6.1.1Medication Adherence Counselling....................................................................................................80
9.6.2 Managing substance use and mental health.........................................................................................80
9.6.3. Reminders and cues.............................................................................................................................80
9.6.4 Peer support.........................................................................................................................................80
9.6.5 A supportive environment....................................................................................................................81
9.6.6 Food/Social Support:.............................................................................................................................81
9.6.7 Decentralisation of ART.........................................................................................................................81
9.6.8 Shortening waiting time at health facilities...........................................................................................82
CHAPTER 10: CHRONIC CARE FOR POSITIVE MOTHERS AND CHILDREN.........................83
10.1 Introduction...............................................................................................................................83
10.2 What is good chronic care?........................................................................................................83
10.3 Principles of chronic care:..........................................................................................................83
10.4 Recommendation:......................................................................................................................85
CHAPTER 11: PROVIDER INITIATED FAMILY PLANNING FOR PLHIV...................................86
11.1 Introduction...............................................................................................................................86
11.2. Reasons for unmet need for family planning............................................................................86
11.3 Meeting family planning needs:.................................................................................................87
11.4 Family planning methods for women living with HIV.................................................................88
Table 6: Short term family planning methods............................................................................88
Table 6: Long-term family planning methods.....................................................................................89
11.5 Women living with HIV who wish to get pregnant:....................................................................89
11.5.1 Counselling for HIV-positive client desiring a pregnancy.....................................................................90
CHAPTER 12. IDENTIFICATION ,CARE AND FOLLOW-UP OF HIV EXPOSED INFANTS...91
12.1 Introduction.............................................................................................................................91
12.2 Identification of HIV-exposed Infants.........................................................................................91
Recommendation...............................................................................................................................92
12.3 ARV prophylaxis for HIV exposed Infants...................................................................................92
12.4 Services for HIV exposed infants......................................................................................................92
12.5 Basic care to HIV exposed infants...............................................................................................93
12.6 Testing HIV exposed infants:......................................................................................................94
12.7 Care for TB-exposed infants:..................................................................................................................95
12.8 Septrin prophylaxis for the baby............................................................................................................95
12.9 HIV-exposed infant follow-up schedule.............................................................................96
CHAPTER 13. INFANT AND YOUNG CHILD FEEDING COUNSELLING WITHIN THE CONTEXT
OF HIV.....................................................................................................................................................98
13.1 Introduction...............................................................................................................................98
13.2 for exclusive Breast Feeding.................................................................................................99
13.3 How to make a decision to stop breastfeeding after 12 months........................................99
13.4 Essential Behaviours for complementary feeding....................................................................100
CHAPTER 14: CREATING AND STRENGTHENING ENABLING ENVIRONMENT FOR EMTCT.
102
14.1 Introduction.............................................................................................................................102
14.2 .Reduction of stigma and discrimination in health facilities.....................................................102
14.3 Strategies to reduce stigma..................................................................................................102
14.4 Male partner engagement:......................................................................................................103
14.4.1 1Strategies for male involvement:....................................................................................................103
14.5 Elimination of gender based violence:................................................................................................104
14.6 Peer support........................................................................................................................................105
CHAPTER 15: INTEGRATION OF PMTCT INTO MCH SERVICES:...........................................107
15.1 Introduction...........................................................................................................................107
15.2 Rationale for integration of services...................................................................................107
15.3 Approaches to INTEGRATING EMTCT AND MNCH SERVICES....................................................108
15.3.1 Integration Of PMTCT Into Routine ANC..............................................................................108
Flow chart of services offered to pregnant women during ANC......................................................109
15.3 Birth preparedness...................................................................................................................109
15.4 Integration of PMTCT into services for Labour, Delivery and Immediate postpartum period.. 111
15.4.1 Interventions for PMTCT during labour and delivery...........................................................111
15.4.2 Interventions in the immediate post partum period:............................................................113
15.4.3 Interventions at discharge.....................................................................................................113
15.5 PMTCT services for breastfeeding mothers..............................................................................114
Table 10: Interventions at the postnatal visit for all women............................................................115
15.6 Breastfeeding women living with HIV......................................................................................116
CHAPTER 16 STANDARD PRECAUTIONS FOR INFECTION CONTROL IN HEALTH CARE
SETTINGS..............................................................................................................................................118
16.1. Introduction..........................................................................................................................118
16.2.1 Proper hand hygiene.............................................................................................................118
16.2.2. Use safe injection techniques...............................................................................................118
16.2.3. 119
Handle and clean instruments safely...............................................................................................119
16.3. Handle and dispose sharps safely...........................................................................................119
16.3.1 Use sharps disposal containers.........................................................................................................119
16.5.1 Use personal protective materials.........................................................................................120
16.5.2 Aprons, gowns, masks and eye protection............................................................................122
16.6 Prevent and clean up splashes and spills.................................................................................122
16.7 Handle and dispose of waste safely.........................................................................................123
16.8 Manage needle sticks or other workplace exposures to HIV...........................................123
CHAPTER 17 : PMTCT PROGRAM MANAGEMENT AND COORDINATION.......................125
17.1. Introduction..........................................................................................................................125
17.2 Rationale for effective Program Management system......................................................125
17.3 The Organizational Structure For PMCT Program Management...................................125
17.4 .Roles and responsibilities of Program management Structures.....................................126
17.4.1. National level PMTCT program Management Teams..............................................................126
17.4.2 State Level PMTCT program management functions...............................................................126
17.4.3 Roles of the County Health department and Management Team............................................126
17.4.5 The Roles of Health facility level Management Team..................................................127
17.4.6 Roles of Community based PMCT program management team............................................128
17.5 Coordination of PMTCT Program interventions..........................................................128
17.5.1 The Rationale for strengthened coordination mechanisms...................................................129
17.5.2 Strategies to improve EMTCT program coordination............................................................129
CHAPTER 18 : MANAGING HUMAN RESOURCE EMTCT........................................................132
18.1 Introduction.............................................................................................................................132
18.2 Why invest in HRH for EMTCT?...........................................................................................132
18.3 Basic principles underpinning HRH management..................................................................132
18.4 The HRH requirements for EMTCT at the facility level.....................................................132
18.5 Planning and managing HRH requirements for EMTCT.......................................................134
18.6 Recommended PMTCT training packages...............................................................................134
18.7 Team Management at the health facility level..........................................................................135
18.8 Monitoring and reporting on health workforce performance...................................................135
CHAPTER 19.PMTCT OPTION B+ SUPPLIES AND LOGISTICS CHAIN MANAGEMENT SYSTEMS
136
19.1 Introduction...........................................................................................................................136
19.2 Purpose of PMTCT supplies chain management system.................................................136
19.3. Principles of a sound PEMTCT Supplies and logistics system.......................................137
19.4. The PEMTCT Supplies and Logistics Cycle......................................................................137
19.4.1. Selection Of Health Products At The Facility.................................................................137
19.4.2 Quantification And Forecasting.......................................................................................138
19.4.3. Ordering Of Supplies And Medicines.......................................................................................138
19.4.4 Sources Of ARVs Medicines And Health Supplies...................................................................138
19.4.5 Preparing Bi-Monthly Orders And Reports................................................................................138
19.4.6 Submitting The Bi-Monthly Order...............................................................................................139
19.5. Stock Redistribution.............................................................................................................139
19.6 Rational Medicines Use........................................................................................................139
19.6.1 Principles Of Rational Medicines Use.........................................................................................139
19.6.2. Rational Prescribing......................................................................................................................139
19.6.3. Rational Dispensing..........................................................................................................139
19.7 Distribution Of Medicines To Patients...............................................................................140
19.8 Guidance For Stock Management At Health Facility........................................................140
19.9 Pharmacovigilance................................................................................................................140
19.10 PMTCT Supplies and Logistics information management............................................140
CHAPTER 20: PMTCT PROGRAM MONITORING AND EVALUATION MECHANISM........140
20.1 Introduction...........................................................................................................................140
20.2 The purpose of the Monitoring and Evaluation mechanism...........................................141
20.3 Program Monitoring and evaluation Indicators................................................................141
20.4 PMTCT Program Data Management..................................................................................142
19.4.1 Indicators For Routine Monitoring..............................................................................................142
20.4.2 Data collection................................................................................................................................142
20.4.3 PMTCT Data analysis and Reporting.............................................................................143
20.4.4 Data Flow........................................................................................................................................144
20.5 Strategic Information Dissemination and use..........................................................................144
20.6 Special studies and surveys......................................................................................................144
20.7 Other Data Sources...........................................................................................................................145
20.8 New Considerations For Routine Monitoring...............................................................................145
20.9. HIV Drug Resistance Monitoring..................................................................................................145
20.10 Routine Supervision And Data Auditing.....................................................................................145
20.11 RESEARCH AND EVALUATION.................................................................................................145
20.12 DATA USE................................................................................................................................145
21. ANNEXES............................................................................................................................................146
CHAPTER ONE: INTRODUCTION AND BACKGROUND
1.1 Introduction
These are national guidelines for use of antiretroviral drugs for prevention and treatment of HIV in
pregnant women ,lactating mothers and HIV exposed babies based on the 2013 WHO
recommendations .
1.2. Background and contexts

In 2013 the world health organization(WHO) released consolidated guidelines for prevention and
lifelong treatment /AIDS of HIV in pregnant women and lactating mothers for virtual eliminating of
mother to child transmission of HIV also referred to as option B plus (+) .Countries with high burden of
HIV/AIDS are expected to review, update and align their national PMTCT policy guidelines ,strategies
,programs and services to the WHO PMTCT option B+ as the global community strives to achieve a
world free from HIV/AIDS by 2030 .
South Sudan is a young nation emerging from protracted civil war that has impacted heavily on the
health system as evidenced by poor health indicators and low coverage of supply side indicators. The
country also is resource constrained in terms of staffing levels. On the other hand the Government of
South Sudan is committed to the global goal of eliminating mother to child transmission of HIV.
The ministry of health of GOSS is reported to have adopted the WHO PMTCT Option B+ in 2015. The
Ministry of Health (MoH) has vested interests in the quality and effective uptake of the comprehensive
PMTCT program interventions. It is upon this background that necessary policies ,strategies and
implementation tools need to be updated to fit the context of South Sudan.
1.3 Rationale For The Guidelines

There is need to have updated national PMTCT program implementation guidelines to support the
Ministry of Health and partners at all levels of the national health care system in scale up of PMTCT
option B+ services integrated into maternal ,new born and child health services at both facility and
community levels within the context of the primary health care system .
1.4 Objectives Of The Guidelines
These guidelines are intended:
1.4.1 .To provide guidance and planning and programming for national interventions for virtual
elimination of mother to child transmission of HIV using the four prong approach
1.4.2 To provide a standardized and simplified guide on use of antiretroviral drugs for treatment and
prevention of HIV in HIV positive pregnant women ,breast feeding mothers and their HIV exposed
babies
1.4.3 To ensure timely initiation of ARVs for HIV treatment and prevention in pregnant HIV positive
women and breast feeding mothers .
1.4.4. To improve clinical outcomes, promote adherence and improved retention of patients in care o
Strengthen health systems to support service delivery in the continuum of care
1.4.5. To serve as a training tool and reference material for health service providers, program managers,
and people living with HIV.
o developing an oversight system holds implementing partners accountable for service delivery.
1.5 The Guideline Review Process

The document was reviewed and updated through a consultative and participatory process with inputs
and contribution from key stakeholders that included the South sudan AIDS commission ,National
Ministry of Health UN agencies and programs, civil society organizations ,decentralized entities from
the state and county levels and representatives of persons living wit HIV/AIDS .
1.6 The scope and structure of the guidelines

The revised guidelines have 19 chapters which highlighted below :
Chapter 1 describes the background, rationale, objectives of the guidelines and the target audience
Chapter 2 and 3 provides an overview of HIV/AIDS and frameworks for Elimination of Mother to Child
HIV transmission, a central component in the continuum of care for women living with HIV to reduce
the burden of HIV in the paediatric population.
Chapter 4 provides guidance on primary prevention of HIV as the first prong in the comprehensive
EMTCT program package . Prevention remains the cornerstone in HIV control in the absence of a cure.
Chapter 5 covers HIV testing services (HTs), a key strategic entry point to prevention, treatment, care
and support services.
Chapter 6 provides guidance on the prevention for positives looks at Chronic HIV care which enables
early ART eligibility assessment and timely initiation of treatment, as well as access to interventions
aimed at preventing further HIV transmission, and prevention of opportunistic infections and co-
morbidities.
Chapters 7 and 8 cover preparations for ART and Antiretroviral Therapy, the goal of which is to suppress
viral replication, reduce CD4 cell destruction, restore the immune system thereby reducing HIV-related
illness and improving quality of life.
Chapters 9 and 10 provides guidance on adherence to ART retention to care and chronic care for
positive pregnant women and lactating mothers .
Chapter 11 provides guidance on provider initiated family planning (prong 2) for HIV positive women
for dual protection .
Chapter 12 look at care for exposed infants and HIV infection in children which tends to follow a more
aggressive course than in adults. Children are therefore given a special section highlighting some of the
unique features of care in this population. Recommendations on Infant and Young Child Feeding are
covered in Chapter 13.
Chapter 14 provides guidance on measures to create an enabling environment for prevention

,treatment and care for positive pregnant women ,lactating mothers and HIV exposed infant at both
facility and community levels .
Chapter 15 covers integration of EMTCT services to Reproductive ,maternal and child health services
across the continuum of care .
Chapter 16 highlights universal precautions for infection control at both facility and community EMTCT
service delivery points .
Chapters 17,18 and 19 highlight health systems to support scale up of EMTCT option B+ service delivery
including program management , Human Resource, Supply Chain Management and Monitoring and
Evaluation requirements .
1.7 The intended users of the guidelines

These guidelines are intended for use by national ,state ,county and community based HIV/AIDS and
PMTCT program managers ,supervisors and service providers .The same guidelines will also be useful
for the following audiences :
Clinicians and other health service providers
Program managers of the national HIV program, the TB program, laboratory services, MCNH
and reproductive health programs, commodity supply chain management for HIV related
commodities Researchers
Development partner agencies that support the national programme .
CHAPTER TWO : OVERVIEW OF HIV/AIDS AND MTCT IN SOUTH SUDAN

2.1. Introduction
Chapter two provides an overview of the HIV epidemic ,burden of mother to child transmission (MTCT)
of HIV and current status of the national PMTCT program response efforts in south sudan as a basis for
updating the National Guidelines .
2.2.The HIV/AIDS Epidemic in South Sudan

The 2012 antenatal Care (ANC) sentinel surveillance put the national HIV prevalence at 2.6% ranging
from 0.3% in Aweil Civil Hospital (Northern Bahr Ghazal) to 14% in Ezo primary health care centre
(Western Equatoria). The figure below shows the geographical variation of HIV prevalence based on
South Sudan ANC sentinel surveillance 2012.
Figure 1: South Sudan ANC Sentinel Surveillance 2012
Much as the HIV/AIDS pandemic is considered to be generalized, albeit some areas are described as hot
spots especially along the borders with Democratic Republic of Congo (DRC), South Sudan and Kenya.
Approximately 184,000 people are living with HIV (170,000 adults and 14,000 children under 15 years
of age) in 2015. An estimated 15,000 new infections occur annually. Surveillance showed marked
heterogeneity of the epidemic, with significant differences between sites with lowest and highest
prevalence.
It is estimated that 15,400 deaths have occurred due to HIV/AIDS of 14,000 are adults and 1,400
children under 14 years of age .To control this epidemic, it is crucial to prevent new infections.
2.3 The burden of Mother to Child Transmission of HIV in south sudan
According to UNAID (April 2016) ,the HIV prevalence among pregnant women is estimated at
2.9 per cent. With about 585,000 expected pregnancies in 2016 ,this translated to about
17,530 pregnant women living with HIV/AIDS in south Sudan and about 5000 HIV exposed
babies . HIV positive pregnant women are at risk of transmitting HIV to their babies during
pregnancy, birth or through breast feeding. Well over 90% of new HIV infections among
infants and young children occur through mother to child transmission (MTCT) of HIV; this
mode of transmission is responsible for 21% of all new HIV infections in South Sudan.
Table showing expected numbers of HIV positive pregnant women and exposed babies .
Population group Percentage (%) Numbers
Total population 100% 11,425,377
Women of child bearing age (15-49) 22% 2,500,000
Expected pregnant women 5% 585,0000
Expected HIV positive pregnant women 3% 17,500
Expected HIV+ deliveries/exposed infants 4.4% 14,000
However, the overall risk of MTCT of HIV can be reduced to less than 2% by a package of
evidence-based interventions. This package is now the standard of care in most high income
countries; the implementation of this package has led to the virtual elimination of new HIV
cases among children. Even in resource-constrained countries such as South Sudan, simple
and less expensive combinations of antiretroviral preventive regimens can reduce
significantly the risk of mother to child transmission.
Paediatric HIV/AIDS continues to pose a challenge in the sub region. On average less than
20% of the children exposed to HIV access services for early infant diagnosis of HIV ,care and
treatment. In addition few health facilities provide Paediatric HIV/AIDS cares services.
Furthermore inadequate community mobilization and education to support Paediatric care
impacts on linkage to care for infected children. The number of implementers and Health
facilities providing child and adolescent friendly services including reproductive issues for
children remain limited to less than 30% in the region
2.4 Risk of transmission without intervention

Without intervention, the overall MTCT rate is approximately 35% ranging from 20 to
45%.Even when women living with HIV receive no PMTCT interventions, most of the children
they give birth to are not HIV-infected. However since we do not know which children will be
free from infection, all children of women living with HIV need to be tested to HIV.
16
Figure 2: Risk of HIV transmission when there is no PMTCT intervention.
100 infants born to HIV-infected women who breastfeed, 5580 infants

without any interventions will not be HIV-
infected
510 infants
infected 1015 520
infants
during infants infected
pregnancy infected during
during breast-
labour feeding
and
delivery
2045 infants will be HIV-infected
2.5 Factors that determine HIV transmission

The most important factor that determines MTCT of HIV is the amount of HIV virus in the
mother's blood, known as the viral load. The chance of HIV transmission is greatest when
the mother's viral load is high which is often the case with recent or advanced HIV
infection. Some of the factors that determine HIV transmission are the same and some are
different during pregnancy, labour and childbirth, and breastfeeding.
Table 1: Factors increasing risk of mother-to-child transmission of HIV

High quality evidence Low quality evidence
During pregnancy
High viral load in the mother (new infection Poor maternal nutritional status
&advanced stage of HIV infection/AIDS)
Maternal anaemia
Poor immune status (low CD4 count)
Malaria
Sexually transmitted infections (STIs)
Substance (drug) use or cigarette smoking during
Certain HIV viral strains pregnancy
External cephalic version
During labour and childbirth
17
High viral load in the mother (new infection Suctioning newborn
Invasive obstetrical procedures (episiotomy, early
Vaginal delivery artificial rupture of membranes)
Prolonged rupture of membranes (>4 hours)
Prolonged labour
Instrumental delivery (forceps or vacuum

extraction)
Prematurity
First infant in multiple birth
During breastfeeding
High viral load in the mother (new infection Poor maternal nutritional status
Oral disease in the baby (e.g. thrush or sores)
Breastfeeding
Mixed feeding (non-exclusive breastfeeding or non-

exclusive replacement feeding)
Long duration of breastfeeding
Mastitis, cracked nipples, breast abscess
2.5. The current status of Prevention of Mother to Child Transmission of HIV program
The program for prevention of mother to child transmission of HIV (PMTCT) is thought to
have started in South Sudan in 2006. Therefore, prevention of Mother to Child transmission
of HIV (PMTCT) is one of the priorities for the government of the Republic of South Sudan
(RSS .In South Sudan, an estimated 400, 000 pregnant women need counselling and testing,
to determine their HIV status, of which 8000 are living with HIV.
The MOH-led HIV/AIDS programme has established over 1105 HIV Testing and Counselling
(HTC) sites,73 sites providing PMTCT services , 55 health facilities providing PMTCT option B+
services ,and XXX HIV treatment centres in South Sudan taking care of about 8,000 clients
(about 5% are children) with close to 2,500 on Antiretroviral Therapy (ART) over that are
integrated into existing health care systems.
18
By 2015, about 35,000 pregnant women who visited ANC were counseled and tested for HIV,
445 received ARVs to prevent transmission of HIV and 201 infants exposed to HIV
transmission were placed on prophylaxis. The PMTCT guidelines have been developed,
mother-to-mother support groups established and sensitization of the community on PMTCT
is being carried out.
Although the number of women and babies receiving PMTCT services has been on the
increase since then, there is still a huge number of pregnant and breastfeeding women
living with HIV who are transmitting HIV to their babies because they have not been tested
for HIV and given antiretroviral drugs (ARVs) to prevent MTCT of HIV.
2.6 Bottleneck to current PMTCT program interventions.
Main challenges include low levels of knowledge about HIV/AIDS, multiple concurrent sexual
partners, poverty, low school enrolment a
The coverage of PMTCT services is very low. The PMTCT sites are not adequate and it is
unclear if the distribution of facilities providing PMTCT is mapped to areas of highest
population density and HIV prevalence. Only 11% of health facilities providing MNCH
services were offering PMTCT services to pregnant women.
Knowledge of mother to child transmission of HIV among women and men is very low. Only
15% of women have knowledge of mother to child transmission of HIV according to the
South Sudan household survey of 2010.
Uptake of ANC services is also very low. The number pregnant women who make at least
one visit to the ANC remains low with only 11.5% finally delivered in health facilities 1. There
is a very poor tracking system and outreach services for the 81% of pregnant women who
delivered at home2.
A referral system from the primary health care facilities State to tertiary hospitals, which
provide a continuum of PMTCT/ART/HTC services, is largely weak.
There is limited follow up of HIV positive women and their babies, and a low rate of ANC
return visits and health facility deliveries, often leading to loss of clients/babies.
There is poor availability of CD4 testing which contributes to the inability to determine the
pregnant women are eligible for treatment. Additionally, inadequate funding has meant that
PMTCT commodities needed are procured through emergency funding mechanisms.
There is no Early Infant Diagnosis mechanism in place to facilitate better follow-up of

exposed infants.
1
South Sudan Household Survey, 2010
2
South Sudan Household Survey, 2010
19
Poor data quality in the PMTCT programme leading to lack of information on the quality of
PMTCT services being provided, including regimens being provided.
CHAPTER THREE : STRATEGIC FRAMEWORK FOR ELIMINATION OF

MOTHER TO CHILD TRANSMISSION OF HIV IN SOUTH SUDAN
3.1 Introduction
Elimination of Mother to Child transmission of HIV (PMTCT) is one of the priorities for the
government of the Republic of South Sudan (RSS .In South Sudan, an estimated 400, 000
pregnant women need counselling and testing, to determine their HIV status, of which 8000
are living with HIV.
3.2. Program Goal and objectives

3.2.1 Program Goal
To eliminate New HIV Infections Among Children and Keeping their Mothers Alive by 2025 .
3.2.2. Strategic objectives

Based on the goal and also the bottleneck analysis conducted, the following strategic
objectives are set to scale up PMTCT services in South Sudan:
1. To create an enabling policy and practice environment for elimination of HIV/AIDS in

south sudan by 2030.
2. To increase demand for services for primary prevention of HIV in women and men of
reproductive age from xx to 90% in south sudan by 2030.
3. To improve access to and uptake of quality MNCH and PMTCT services for pregnant,
lactating women ,children and families
4. To build capacity of health care workers for provision of quality skilled care and
ensure their employment, deployment and retention;
5. To improve and maintain infrastructure and equipment for delivery of quality MNCH
and PMTCT services at all levels in collaboration with other ongoing initiatives;
20
6. To create demand and increase access to and utilization of MNCH and PMTCT
through establishing community involvement initiatives and linkage mechanisms to
health facilities;
7. To strengthen logistics management system and commodity security;
8. To strengthen systems for Monitoring and Evaluation of PMTCT and promote the
generation, dissemination and use of information for evidence based planning and
decision making.
3.3 Comprehensive Approach To PMTCT.

To significantly reduce MTCT and achieve the global and national targets, PMTCT should be
implemented as a comprehensive public health approach focusing not only on women with
HIV, but also their partners as well as parents-to-be whose HIV status is unknown or who
have tested HIV-negative.
The comprehensive approach includes the four elements listed in the table below:
Table 2: Elements of comprehensive PMTCT
Four elements of a comprehensive approach to preventing HIV infection in infants and young
children
Element Target population Additional information
Element 1: Women and men This element aims to prevent men and women
who are sexually from ever contracting HIV. If new HIV infections
Primary
active are prevented, fewer women will have HIV and
prevention of HIV
fewer infants will be exposed to HIV. Interventions
infection
for primary prevention of HIV infection include:
ABC* approach, HIV Counselling and testing, safe
male circumcision, treatment of sexually
transmitted infections and safe blood transfusion.
Element 2: Women living This element addresses the long term family
Prevention of with HIV planning and contraceptive needs of women living
unintended with HIV.
pregnancies
among women
infected with HIV
Element 3: Women living This element focuses on:

Prevention of HIV with HIV
Access to HIV testing and counselling during ANC,
transmission from
labour and delivery and the postpartum period
women infected
with HIV to their
21
infants Provision of ARV drugs to mother and infant
Safer delivery practices to decrease the risk of

infant exposure to HIV
Infant feeding information, counselling and

support for safer practices
This also includes community outreach and efforts

to support partner involvement and testing.
Element 4: Women living This element addresses the treatment, care and
with HIV and support needs of HIV-infected women, their
Provision of
families children and families.
treatment, care
and support to
women infected
with HIV, their
infants and their
families
*ABC refers to Abstinence, Be faithful Condom use
3.4 EMTCT Program Component Expected Results
3.4.1 Planned Program component Level Results
By 2021 , the following program results should have been achieved :
Prong Targets
Prong1 Primary 50% reduction in HIV incidence among women 15-24 years
prevention
Prong 2 Family 50% reduction in unmet need for FP among all women in high-
planning burden countries for PMTCT
Prong 3 MTCT 90% reduction in estimated number of new infant
infections and a MTCT rate of less than 5%
22
Prong 4 HIV-free At least 90% of all infants born to women living with HIV, alive and
survival HIV uninfected to the age of 2 years
Prong 4 Treatment At least 90% of eligible pregnant women living with HIV are
receiving antiretroviral therapy for their own health
3.4.2 Intermediate (Output) Results

EMTCT services scaled up to all PHCCs and above and in at least 50% of the PHCUs
90% of all pregnant women attending ANC counselled, tested and given HIV results
At least 70% of the male partners of pregnant and lactating women counselled,
tested for HIV
ARVs for PMTCT option B+ provided according to recommended guidelines to 90% of

all infected pregnant and lactating women
ARVs for PMTCT option B+ provided according to recommended guidelines provided

to at least 90% of all exposed infants
90% of all pregnant and lactating mothers provided IYCF counselling
Co-trimoxazole prophylaxis provided to 90% of HIV exposed infants from 6 weeks of

age
DNA PCR test provided to 90% of all HIV exposed infants
90% of eligible HIV positive pregnant and lactating mothers initiated on HAART for
life
90% of HIV infected infants identified through EID linked to HAART for life
50% reduction in HIV incidence among women 15-24 years
50% reduction in unmet need for FP among all women in high-burden countries for
PMTCT
90% reduction in estimated number of new infant infections and a MTCT rate of less
than 5%
At least 90% of all infants born to women living with HIV, alive and HIV uninfected to
the age of 2 years
At least 90% of eligible pregnant women living with HIV are receiving antiretroviral
therapy for their own health.
23
3.5 Comprehensive EMTCT Package of interventions
To prevent mother to child transmission of HIV, the United Nations recommends a
comprehensive approach that includes the following four components or prongs:
1. Primary prevention of HIV infection among women of childbearing age;
2. Preventing unintended pregnancies among women living with HIV;
3. Preventing HIV transmission from a woman living with HIV to her infant; and
4. Providing appropriate treatment, care and support to mothers living with HIV and
their children and families
3.6 . Program Implementation Approaches

3.6.1 Upstream Interventions to create an enabling environment
Enabling Legal and regulatory framework for EMTCT
National policy and implementation guidelines for EMTC
National strategic and investment plan for EMTC
National financing mechanism for scale up
National human resources for health plan for RH/MCH/EMTCT
Capacity building and training strategy
National procurement and supplies management system EMTCT commodities
Strategic partnerships and alliances and coordination mechanism
National strategic information management system
3.6.2. Downstream Service delivery interventions
3.6.3 Health Facility based EMTCT interventions
a) Prevention of HIV in adolescents ,youth and women of WCBA
Using a combination of behaviour change and risk reduction ,biomedical and structural preventive
interventions :
IEC/BCC materials and messages
Condon promotion and distribution
STI prevention and management
24
Prevention and treatment of GBV
Male medical circumcision
a. Prevention of early and unwanted pregnancies
Adolescent sexual reproductive health services
MCH /Family planning services
b. PMTCT services
HCT services
IYCFC
ARVs for prevention
HAART, treatment and care for HIV in pregnant ,lactating mothers and family
Prevention of opportunistic infections
HAART for life long treatment and care
Chronic care
3.6.4. Community led EMTCT interventions
Community EMTCT is the provision of EMTCT services by formal (trained health personnel)
or informal care providers such as VHTs, Linkage facilitators, Peer Educators, PHLIV networks,
family members and other stakeholders outside the health facility settings usually within
communities.
The purpose of establishing community EMTCT services is to engage the community inorder
to successfully implement, scale and utilize EMTCT services and attain better EMTCT
outcomes. All PMTCT implementing sites should establish a network of community-based
structures and systems within their catchment area to support the health facility deliver a
minimum package of community-based EMTCT services.
3.6.4.1 Basic Package Of Community EMTCT Services

The basic package of community EMTCT services includes;
Health education and advocacy for EMTCT services.

Community sensitization and mobilization for reproductive health and EMTCT services
Identification, counseling, and referral of pregnant/ lactating mothers for a
comprehensive ANC services, skilled delivery, EMTCT services for mother and baby, Post
Natal Care, IYCFC, Early infant diagnosis, and FP.
25
Identification of partners of pregnant women and the HIV-exposed infants in
communities and referring them together with the mother for HTS and other services in
the facility.
Addressing social and behavioural factors that affect uptake of PMTCT services including
stigma, disclosure, discrimination, etc
Providing adherence support.
Support on Follow-up, linkage, tracking of identified mothers, their exposed infants, and
partners.
Community ART and cotrimoxazole refills.
Provision of psychosocial support through Family Support Groups
Provide outreaches/Home based HTS for male partners
Promote family care, treatment & support
This package should be delivered using continuous quality improvement approaches and
monitored using a well-defined M&E structure.
3.6.4.2. Establishing Community EMTCT Services.
PMTCT sites should do the following inorder to establish community EMTCT services;
a). Establish partnership and Networks with acommunity-based organization, NGOS and
'networks of PLHIVfor community service delivery.This can be done by;
Conducting community mapping of resources, identify referral trigger factors, develop

referral directories and support documentation of referral processes.
Connecting with the Community Development Officers, CBO, FBO, NGOs and networks
of PLHIV and other networks involved in community-based EMTCT and meeting to agree
oncommon objective and agenda.
Establishing and strengthening of comprehensive referral network systems and

coordination of two-way referrals between community and health facilities.Also,
establish mechanisms for assessing performance of these systems
Promoting: Integration of EMTCT into reproductive health, MCH, and other programs
Partnership with thecommunity to provide human resources for health in MCH/ EMTCT.
Identification of and collaboration with relevant sectors for community empowerment

and economic strengthening activities to reduce gender inequalities as well as increase
womens access to assets
b). Identify, training and facilitate community health workers
Community health workers in the catchment area should be identified, trained and
facilitated to implement the community EMTCT minimum package.
26
c). Establish coordination mechanism.
Each health facility should establish a mechanism for coordinating with the community
structures.Communication channels between the partners should be open, and health
facilities can organize regular meetings to assess performance.
3.7 PMTCT Interventions in Humanitarian Settings

3.7.1 Introduction
The humanitarian situation in South Sudan has deteriorated since December 15th 2013 when a fight
between armed forces and the opposition erupted. Consequently the gains achieved in provision of
social services have been disrupted affecting 4.5 million people 3including women and children. It is
estimated about 730,000 people have been internally displaced and more than 75,000 are seeking
refuge in eight UN bases4.The ongoing conflict will have further impact on the existing challenges in
the health sector and in particular the bottlenecks identified as the part of the development of this
plan.
3.7.2. Why EMTCT In Humanitarian Settings ?

It has been documented that conflicts further aggravate the risk of HIV and on the other hand
affects negatively PLHIV. Women of reproductive age may become more vulnerable to unprotected
sex and rape may be used as a weapon. Disruption of ARVs and drugs for OIs may occur due to
difficulties in accessing treatment facilities. Therefore it is against this background, the PMTCT
strategies have to be implemented following the guidelines for addressing HIV in humanitarian
situation5.
3.7.3 Basic Principles of Humanitarian Response
The provision of EMTCT services integrated to reproductive and child health services should be
guided by the Humanitarian principles of :
Humanity : The purpose of humanitarian action is to protect life and health and ensure
respect for human being .
Neutrality : Humanitarian actors must not take sides in hostilities or engage in

controversies of a political, racial,religious or ideological nature.
Impartiality : Humanitarian action must be carried out on the basis of need alone, giving
priority to the most urgent cases of distress and making no distinctions on the basis of
nationality, race, gender, religious belief, class or political opinions .
Independency: Humanitarian action must be autonomous from the political, economic,

military or other objectives that any actor may hold with regard to areas where humanitarian
action is being implemented.
39
South Sudan Crisis Response Plan. Jan-March 2014
410
UNICEF 2014.South Sudan Humanitarian Situation Report.Sitrep #9
511
IASC 2010. Guidelines for Addressing HIV in Humanitarian Settings
27
Do no harm :What so ever you do should be in the best interest of beneficiaries .
3.7.4 The basic package of RH/PMTCT to deliver in humatarian settings

The following activities constitute minimal initial response and have been adapted from the
guidelines to suit South Sudan context. The minimal initial response may be implemented for
six months and extended as appropriate until the situation improves. This set of activities
aim to sustain basic services and should be prioritized in UN bases and primary health care
facilities that are still running and near IDPs
3.7.5 Minimum initial package of RH/STI/HIV/AIDS Services

Establish HIV awareness and community support team that will constitute community
health workers and aid workers. The team should use appropriate channels of
communications such as word of mouth and existing print to materials to raise
awareness on HIV prevention, testing, MNCH/PMTCT service utilization and male
involvement
Purchase essential supplies that include delivery kits, ARVs, OIs drugs, HIV tests,
Syphilis tests, Hb tests and good quality male condoms.
Utilize community health and aid workers to distribute male condoms free of charge
Provide free and easily accessible contraceptives such as pills,condoms ,injectales for
women of child bearing age .
Offer testing and counselling services to all pregnant women
Identify known HIV positive pregnant women and continue ART preferably switching to
option B+
Provide ARV treatment for mothers and children already taking ARVs including for
PMTCT as soon as possible.
Provide care, treatment and support for HIV exposed infants
Provide clean delivery kits to visibly pregnant women and birth attendants with an
explanation on how to use them.
Provide infant feeding guidance to HIV positive mothers
Establish a referral system to manage obstetric emergencies, including transport and
communications systems, access to obstetric care and safe blood in the event of a
transfusion.
3.7.6 Post crisis Package of RH/STI/HIV/AIDS services
Should the humanitarian situation improve; a refocus on addressing bottlenecks as defined

in the chapters above and in annex will be required. The bottlenecks should be addressed
as the expanded response from the minimal initial response. The approach should be to
improve first on the existing infrastructure before scaling up and eventually create a platform
for eMTCT in post-crisis scenarios.
The comprehensive package of EMTCT services integrated with RH services in post crisis
settings should include but not limited to :
Providing comprehensive STI and HIV prevention and treatment services ,including
STI surveillance systems .
28
Continue providing comprehensive HIV prevention services using multiple prongs
including Post exposure prophylaxis for cases of rape (SGBV) .
Collaborate in establishing and providing comprehensive HIV /AIDS prevention
,treatment ,care and support for PLHA .
Strengthening health systems and referral networks for RH/STI/HIV/AIDS services .
CHAPTER 4: PREVENTION OF HIV IN ADOLESCENTS ,YOUTH AND

WOMEN OF CHILD BEARING AGE
4.1 INTRODUCTION:
The HIV epidemic In South is driven by multiple behavioural, biomedical and structural
factors. There is thus no single HIV prevention intervention that is sufficient to prevent all
HIV transmissions. The country, therefore, needs to adopt a combination HIV prevention
approach which uses a mix of biomedical, behavioural and structural interventions to meet
the HIV prevention needs of the population so as to have the greatest possible impact on
reducing new infections. This chapter will provide guidance on how to implement
interventions that reduce the acquisition of new infections among HIV-uninfected youth and
adults, key and priority populations.
4.2 BEHAVIORAL CHANGE AND RISK REDUCTION INTERVENTIONS

The priority of the behavioural interventions is to delay sexual debut, eliminate unsafe sex,
reduce multiple, especially concurrent sexual partnerships and discourage cross-
generational and transactional sex. See Table 1 for services for behavioural and risk
reduction.
Table 1: Services for behavioral change and risk reduction
Area Guidance
Service delivery Each health facility/program should have a focal person for HIV prevention.
All staff offering prevention services need to be trained including training in
GSD
Peer-led model for priority and key populations is recommended
Outreaches for key and priority populations is recommended
Job aides to support standardization for quality assurance
Linkage and follow-up between facility and community
29
Area Guidance
Risk Offer HTS to sexually active clients who have not tested in the last 12
assessment for months or had unprotected sex in last three months.
client Assess sexual behaviour of the client (ask if condoms are used, frequency,
thenumber of partners, transactional/ sex work). If client involved in
transactional/sex work encourage correct and consistent condom use
Discuss knowledge of partner status about sexual behaviour
Assess for STIs and link to treatment
Discuss sexual and reproductive health services and link to services as
appropriate
Provide Socio- Discuss delay onset of sexual debuts in children and adolescents
Behavioural (Abstinence);
Change Discuss correct and consistent condom use; offer condoms as appropriate
Communication Discourage multiple, concurrent sexual partnerships to promote
(SBCC) link to faithfulness with a partner of known status;
services as Discourage cross-generational and transactional sex
Discourage risky cultural practices such as widow inheritance, and wife
appropriate;
replacement and childhood marriages.
Identify, refer and link clients to other available facility and community
programs
Assess for violence, (physical, emotional, sexual-) if sexual, assess if client
was raped and act immediately (see section forGBV case management)
and section for PEP
Condom Discuss condom use as an option for risk reduction
promotion and Discuss barriers to condom use
provision Clarify any questions and dispel myths around condoms
Demonstrate how to use condoms
Allow the client to role play
Practice how to introduce condoms in relationship
Provide condoms to client
4.3 BIOMEDICAL PREVENTION INTERVENTIONS

The key biomedical interventions include PMTCT, Safe Male Circumcision, ART, PEP, PrEP,
blood transfusion safety, and STI screening and treatment, especially for Key populations.
This section will discuss SMC, PEP, and PrEP. Other interventions will be discussed in other
chapters: EMTCTchapter , ARTchapter Error: Reference source not found and STI screening
and treatment section Error: Reference source not found
4.3.1 SAFE MALE CIRCUMCISION (SMC)

Male circumcision is the surgical removal of the foreskin of the penis. SMC reduces the risk
of HIV acquisition among circumcised men by approximately 60%.Table 2below describes
process involved in providing SMC
30
Table 2: Process of providing safe male circumcision
Process Description
Priority groups All males in reproductive age group

for SMC Adolescent boys
Recommended Conventional Surgery using the dorsal slit method

methods for WHO pre-qualified devices
SMC
Eligibility Screen for STIs: If STIs are present defer the circumcision and treat the
Screeningfor STIs.SeeError: Reference source not found
Tetanus Immunization Status: All persons undergoing circumcision should
SMC have at least two documented doses of TT vaccination given at least
28days apart and not more than 6-months. If there is no evidence of TT
differ SMC and refer for TT
Penile abnormalities: If there are any penile abnormalities, refer for
specialist care
Bleeding disorders: If there is ahistory of bleeding disorders, differ SMC
and refer.
Existence of chronic disease conditions such as Diabetes, hypertension:
Differ SMC and refer
Consent/Assent Clients 18 years and above should consent before SMC.
For adolescents <18 years, assent and parental/legal guardian consent are
required
HIV testing All SMC clients should be offered HTS, though clients may opt out. A
positive HIV test is not a contraindication to circumcision. Initiate ART in
Men and adolescents who test positive.
Follow up after Following conventionalsurgery; At 48 hours, seven days and at six weeks
SMC Follow-up of device circumcision: should follow device used.
4.3.2 POST EXPOSURE PROPHYLAXIS

Definition: Post-exposure prophylaxis(PEP) is the short-term use of ARVs to reduce the
likelihood of acquiring HIV infection after potential occupational or non-occupation
exposure.
Types of Exposure:
Occupational exposures occur in the health care setting and include sharps and
needlestick injuries or splashes of body fluids to the skin and mucous membranes.
31
Non-occupational exposures include unprotected sex, exposure following assault like in
rape & defilement, road traffic accidents and injuries at construction sites where
exposure to body fluids occur.
Steps in assessing a potential PEP recipient
Health facilities providing PEP must have trained healthcare workers on infection prevention
and control, and management of PEP. The healthcare workers should use the steps inTable 3
to assess clients for PEP eligibility and provide PEP.
Table 3: Steps for providing pre-exposure prophylaxis (PEP)
Step Description
Step 1: Clinical Conduct a rapid assessment of the client to assess exposure and risk and
assessment provide immediate care.
and providing
Occupation exposure:
first aid
After a needle stick or sharp injury
Do not squeeze or rub the injury site

Wash the site immediately with soap or mild disinfectant (chlorhexidine
gluconate solution)
Use antiseptic hand rub/ gel if no running water
Dont use strong irritating antiseptics (like bleach or iodine)
After a splash of blood or body fluids in contact with intact skin
Wash the area immediately

Use antiseptic hand rub/ gel if no running water
Dont use strong irritating antiseptics (like bleach or iodine) for exposure
specific injuries, refer to the PEP Guidelines
Step 2: Provide PEP when:
Eligibility
exposure occurred within the past 72 hours; and
assessment:
the exposed individual is not infected with HIV; and
the source is HIV-infected or has unknown HIV status or high risk
Do not provide PEP when:
The exposed individual is already HIV positive;

When the source is established to be HIV negative; and exposure to bodily
fluids that does not pose a significant risk: tears, non-blood-stained saliva,
urine, and sweat.
Exposed people who decline an HIV test
Step Description
32
Step 3: Counsel on
Counseling
the risk of HIV from the exposure
and support
Risks and benefits of PEP
Side effects of ARVs. Error: Reference source not found
Provide enhanced adherence counseling if PEP if prescribed
Link for further support for sexual assault cases.
Step 4: PEP should be started as early as possible not beyond 72 hrs. of exposure.
Prescription: For recommended regimens
Adults : TDF+3TC+ATV/r
Children: ABC+3TC+LPV/r
A complete course of PEP should run for 28 days
Do not delay the first doses because of lack of baseline HIV Test.
Document the event and patient management in the PEP register. Ensure
confidentiality of patient data.
Step 5: To monitor adherence and manage side effects
Provide Perform follow-up HIV testing after three months after exposure.
follow-up If HIV infected
o Provide counseling and link to HIV clinic for care and treatment
o If HIV-uninfected, provide HIV prevention education/risk reduction
Discontinue PEP after 28 days.
4.3.3 ORAL PRE-EXPOSURE PROPHYLAXIS (PREP)
Definition: PrEP is the use of ARV drugs by people who are not infected with HIV to block
the acquisition of HIV.
Where will PrEP services be offered?
PrEP will be offered in sites with funded demonstration and special pilot projects. This
guidance is, therefore, for those sites. Because of commodity gaps, PrEP is not to be rolled
out in all public health facilities yet. Table 4 describes processes involved in offering PrEP.
Table 4:The Process of providing Pre-Exposure Prophylaxis (PrEP)
Process Description
Eligibility of PrEP provides an effective additional biomedical prevention option for HIV-
PrEP negative people at substantial risk of HIV. These include people who:
Have multiple sexual partners

Engage in transactional sex including sex workers
Use or abuse of injectable drugs and alcohol
Have had more than one episode of an STI within the last twelve months
33
Discordant couples, especially if the HIV positive partner is not on ART or has
been on ART for less than six months.
Recurrent users of PEP-(3 consecutive cycles of PEP)
Individuals who engage in anal sex.
Key populations who are unable and or unwilling to achieve consistent use of
condoms
These risk factors are likely to be more prevalent in populations such as sex
workers, fisher folk, long distance truck drivers, men who have sex with men
(MSM) and, uniformed forces and adolescents and young women engaged in
transactional sex.
Screening for After meeting the eligibility criteria, the following screening tests should be done
PrEP before initiating PrEP.
eligibility
Confirm HIV-negative status
Rule out acute HIV infection
Assess for hepatitis B infection
Assess for contra-indications to TDF/FTC
Steps to Provide risk-reduction and PrEP medication adherence counseling,
Initiation of
Provide condoms and education on their use.
PrEP
Initiate a medication adherence plan
Prescribe a once-daily pill of TDF (300mg) and FTC (200mg).
Initially, provide a 1-month TDF/FTC prescription (1 tablet orally, daily)
together with a 1-month follow-up date.
Counsel client on side effects of TDF/FTC
Follow-up / After the initial visit, subsequent clinic visits should be every three months
Monitoring Perform an HIV antibody test every three monthsand document negative HIV
clients on status
PrEP For women, perform a pregnancy test based on clinical history
Review the patients understanding of PrEP, any barriers to adherence,
tolerance to the medication as well as any side effects
Review the patients risk exposure profile and perform risk reduction
counseling
Evaluate and support PrEP adherence at each clinic visit
Evaluate the patient for any symptoms of STI s at every visit and treat as
needed
Guidance on Its a personal Choice
discontinuing Changed life situations resulting in lowered risk of HIV acquisition
PrEP Intolerable toxicities and side effects
Chronic non-adherence to the prescribed dosing regimen despite efforts to
improve daily pill taking
Acquisition of HIV infection
34
4.4 STRUCTURAL INTERVENTIONS
3.4.1 PREVENTION AND MANAGEMENT OF GENDER BASED VIOLENCE

Gender-based violence (GBV) has the potential to increase the risk to acquiring HIV. Also,
for those on treatment, GBV can negatively affect retention and ART adherence of clients
leading to poor treatment outcomes. Screening for, preventing and responding to GBV
promptly will reduce the risk of HIV infection and may improve treatment outcomes of
those at risk for GBV.
Clients should, therefore, be assessed for GBV at least once every six months as part of
the HIV program.
Service delivery points recommended for GBV screening include: OPD, ANC/MCH, and
IPD
Every site providing GBV services and post-violence care, should have the following:
A written algorithm with steps of active case identification and follow-up
At least one staff trained to provide post-violence care
A focal point for GBV services at each facility
Provide PEP
Table 5 below describes the minimum package ofpost-rape care services and child
protection after GBV.
Table 5: Minimum package for post-rape care services
Health facilities should provide the following clinical services as part of post-rape care:
Initial assessment of the client

Rapid HIV testing and referral to care and treatment ifHIV-infected
Post-exposure prophylaxis (PEP) for HIV see section
STI screening/testing and treatmentsee sectionError: Reference source not found
Forensic interviews and examinations
Emergency contraception, where legal and according to national guidelines if person reached
within the first 72 hours
Counseling
The health facility should also identify, refer and link clients to non-clinical services.
Some of the services include the following:
Long term psycho-social support

Legal counseling
Police- investigations, restraining orders
Child protection services (e.g. emergency out of family care, reintegration into family care when
possible, permanent options when reintegration into family impossible)
Economic empowerment
35
Emergency shelters
Long-term case management
Reporting: Health facilities should use HMIS 105 to report GBV
4.4 .Recommendations :
Primary prevention of HIV is a key component in the efforts for virtual elimination of
mother to child transmission of HIV is South Sudan .Therefore all policy makers,
program planners, managers, supervisors and providers at all levels have to ensure a
balanced approach to HIV prevention ,treatment ,care and support ,without too
much biases towards test and treat interventions .
CHAPTER 5 : HIV TESTING SERVICES FOR PREGNANT WOMEN AND

INFANTS
5.1 Introduction
This section describes guidelines for provision of HIV counselling and testing services in
reproductive and child health services at both facility and community levels. HIV testing is an
entry point to HIV prevention, care, treatment, and support services. By 2015, only xx% of
the estimated xxx million HIV-positive persons in South Sudan knew their HIV sero-status,
and xxx% of these were receiving anti-retroviral treatment (MoH, 2015). To improve access
and efficiency, HIV testing services (HTS) should be made available to all pregnant and
lactating mothers and their children and families using cost-effective and high-impact
approaches. HTS service delivery includes a range of activities and services that are
36
described in the pathway in Error: Reference source not foundbelow. Health workers should
use this guidance alongside the national HTS policy and implementation guidelines (2016).
5.2 The purpose of HIV testing services

Antenatal care settings are important entry points for pregnant women and their partners to
learn about their HIV status and receive HIV prevention, care, and treatment services. Early
identification of HIV infection through testing and counselling plays a central role in the
ability to provide the needed HIV services during pregnancy, childbirth, and breastfeeding.
Early identification will enable women and their partners to gain the maximum benefit for
their own health and for preventing HIV transmission to their infants.
The aim of HIV Testing services (HTS) is to diagnose HIV early and correctly inorder to guide
scale-up of high impact interventions. To improve access and efficiency, HIV testing services
(HTS) should be made available to all persons at risk of HIV infection using cost-effective and
high-impact approaches. HTS service delivery includes a range of activities and services that
are described in the pathway in Error: Reference source not foundbelow.
Recommending HIV testing should be on the first contact during antenatal care or
breastfeeding women in order to ensure that as many women as possible receive HIV-
related information and services. It is important that the woman receives the test result on
same day. This helps to increase the proportion of women who receive their test results and
minimize any delay before necessary interventions.
Figure 2: HTS pathway
5.3 Principles of HIV Testing Services (HTS)

HTS delivery should be non-discriminatory and offered using a human rights approach that
observes the 5Cs- that is Confidentiality, Consent, Counselling, Correct Test result and
Connection to appropriate services. These principles are described below.
37
4.3.1 Confidentiality; all providers should ensure privacy during HTS provision. All
information discussed with clients should not be disclosed to another person without
the clients consent.
4.3.2 Consent; all persons should consent to HTS. In situations where consent cannot be
obtained, the parent or guardian (of a child), next of kin, or legally authorized person
should consent. Counseling; all persons accessing HTS should be provided with
quality counseling before and after testing.
4.3.3 Correct test result; HTS providers should adhere to the national testing algorithm and
MUST ensure that clients receive correct HIV test results.
4.3.4 Connect to other services;providers should link HTS clients to appropriate HIV
prevention, treatment,care and support services.
4.3.5 Comfort:The health worker should assess the womans stage of labour, comfort level,
and need for analgesics. HCWs need to show empathy while presenting information
about HIV testing and counselling: the content should be short, to the point, and
explained based in the comfort level of the woman e.g. between contractions.
Recommendation:
In all cases of counseling adults, the five core guiding principles should be respected. These
are: Consent, Confidentiality, Counselling, Correct test results, and Connections to care. In
the case of women in labour another C for Comfort is required.
5.4 Approaches to HIV testing and counselling

To improve access and efficiency of HTS, a mix of health facility and community-based
approaches should be utilized.
5.4.1 FACILITY-BASED APPROACHES

Facility based HTS approaches include Provider-initiated testing service and voluntary
counseling and testing.
5.4.1.1. Provider-initiated approach:

In the provider-initiated approach, HIV testing is offered as a routine part of standard care
much like syphilis screening in ANC. This approach, also referred to as opt-out,allows all
women to beprovided with pre-test information, tested for HIV and counselled unless they
specifically decline to be tested or opt-out. The provider-initiated approach emphasizes
that HIV testing is an expected part of care (ANC, L&D and/or post-delivery). However,
testing is still voluntary under the provider-initiated approachthe client has a right to
decline testing.In the client-initiated (also referred to as voluntary counselling and testing
(VCT)approach, the client also receives information about HIV testing. After receiving the
information, it is up to the client to request for HIV testing.
The provider-initiated approach is recommended for HIV testing and counselling in the ANC,
L&D and post-delivery settings. Provider-initiated testing helps normalize HIV testing and
makes the test a standard component of ANC, L&D and post-delivery care. It has been
shown to increase the number of women who test for HIV.
38
Recommendation
Provider-initiated HIV testing and counselling (PITC) with rapid tests and same day results
should be recommended to all women whose HIV-infection status is not known during
antenatal care, child birth and breastfeeding.
Under this approach, HTS should be initiated by the health worker as part of standard health
care.Health workers should prioritize PITC for patients at maternal and child health clinic,
adult and pediatricpatient wards, TB clinics, family planning clinics, STI clinics, nutrition
units, clinics managing survivors of sexual abuse and in HIV care clinics. They should also
assess all patients at OPD for HTS eligibility. PITC will be offered as an opt out HTS service.
5.4.1.2 Routine HIV testing:

This should be carried out for individuals likely to pause a risk of HIV infection to others. The
following individuals shall be prioritized for routine HIV testing; Pregnant and breastfeeding
women, Partners of pregnant and breastfeeding women,blood, and body tissue or organ
donors. Individuals tested using this approach should be given an opportunity to know their
HIV status.
5.4.1.3 . Voluntary HIV Counselling and Testing (VCT)

Also called Client-Initiated HIV Testing and Counselling (CITC), is where individuals and
couples seek HIV testing services on their own. These clients should receive HIV testing and
counseling from any certified HTS entry point in the facility.
5.4.1.2. Diagnostic testing:

This should be carried out on individuals as deemed necessary by the attending health care
team with the purpose of better patient management. Such situations will include patient is
symptomatic patients, unconscious patients, mentally ill patients and very sick patients, etc.
5.4.2. Community HIV Testing Approaches

Community-based HTS approached are either Index client contact tracing, outreach or work-
based HTS.
5.4.2.1 Index client contact tracing

In this approach, the index client is used to help identify the subsequent clients for testing.
Index client contact tracing is done either through snowball approach or home-based HTC.
Home-Based HIV Testing and Counselling (HBHTC)

Home-Based HIV Testing and Counseling (HBHTC) is where HTS is provided in a home
setting through an index HIV client invitation or a door- to- door approach. Index-client
HBHTC should be prioritizedfor household members of all HIV-positive individuals in care
as well as confirmed and presumptive Tuberculosis patients.
Snowballing approach:In this approach, the HTS team works with the index client to
invite other members of the group for HTS. This approach is recommended for use
among sex workers and men who have sex with men.
39
5.4.2 Outreach HTS
This approach should target priority populations that otherwise have limited access to HTS
services (see section on target populations below). Outreach HTS can be;
Door-to-door HIV testing may be implemented ONLY in high HIV prevalence settings
or communities for key populations such as the fisher folk, hotspots for Sex Workers.
Or
HTS integrated into health outreaches like immunization or VMMC
Conducting HTS outreachesin locations frequented by target populations like key
population hotspots, sporting events or workplaces.Theseoutreaches could include
moonlight testing and mobile clinics.
5.4.3 Workplace-Based HIV Testing services

This approach gives opportunities to employees, their families, and communities to access
HTS services in the workplace. Workplace HIV testing should be confidential, delivered in a
safe environment and should not be abused. The HTS provider at the workplace should
ensure that all clients diagnosed with HIV are effectively linked to HIV care, treatment and
support services. Disclosure of HIV serostatus is at the discretion of the employee.
5.5 HIV testing technologies

HIV tests detect antibodies or antigens associated with HIV in whole blood, saliva, or urine.
Blood sampling is the most common method of testing. The results of different tests can be
combined to confirm HIV test results. When properly administered, HIV tests offer a high
degree of accuracy. However, those who administer or handle the HIV tests must be trained
so that accuracy is preserved.
Shortly after infection with HIV, the body starts to make antibodies to fight the virus. It may
take 4 to 6 weeks, but occasionally takes up to 3 months for these antibodies to become
detectable in the blood. During this time, a person can still transmit the virus to others, even
if he or she looks and feels completely healthy.
Rapid HIV tests and the ELISA (enzyme-linked immunosorbent assay) are the most
commonly used antibody tests in PMTCT settings.
5.5.1. Rapid HIV tests

Rapid HIV tests give accurate results within 20-40 minutes, allowing clients to receive their
test results on the same day the sample is taken and do not require a laboratory. All rapid
HIV tests have the following characteristics:
Can be done in the clinic setting (e.g., the antenatal clinic, VCT centre or in L&D)
Highly accurate when performed correctly
40
Usually performed on serum or whole blood (either by finger prick or venous
sample); there are some rapid HIV tests that can be used on saliva
Can be done on a single specimen with no batching required
HCWs can be trained to perform the tests
Some rapid tests do not require special equipment, electricity or refrigeration.
Although most rapid tests can detect HIV-1 and HIV-2, they usually do not differentiate
between the two types of HIV. This is significant for PMTCT programmes in places where
HIV-2 is common because nevirapine (NVP), which is used for both ARV therapy and
prophylaxis, is not effective against HIV-2. In places where HIV-2 is common, different testing
procedures are needed to screen for HIV-1 and HIV-2 and to distinguish between them.
5.5.2 ELISA
The ELISA is also used to identify antibodies to HIV in blood, urine or saliva. Generally, a
blood specimen is drawn and sent to a laboratory for testing by technicians.
The limitations of the ELISA are:
Tests must be done in batches of 4090 specimens.
Positive results must be confirmed either with another ELISA (using a test kit from a
different manufacturer) or by Western blot, another antibody test. Both confirmatory
tests can be done on the initial blood specimen.
Results may take several days to weeks and women may not return for results or may
give birth before results are ready.
Laboratories and trained technicians are required.
Test is sensitive to temperature and requires refrigeration.
Test requires that reagents (the chemicals needed to process the test) are available at
all times.
5.6 HIV Testing Services Protocols

HTS service provision should follow the steps described in Table 6 below. 4.3 The Provider
Initiated testing and counselling Process
Table 6: HIV testing provision steps/protocol
Step Activity Description
41
1. Pre-test information Help the client/patient to know the ways HIV is transmitted
giving and counseling and basic HIV preventive measures, benefits of HIV testing,
possible test results and services available, consent and
confidentiality; individual risk assessment, and fill the HTS
card. Allow clients/patients to ask questions.
2. HIV Testing Refer to the HIV testing algorithms for the different age
groups (Section and below).
3. Post- test counseling Assess readiness to receive results, give results simply;
(individual /couple) address concerns, disclosure and partner testing, risk
reduction, provide information about basic HIV care and ART
care; complete the HTS card and HTS register.
4. Linkage to other Provide information about services referred for; fill the
services Triplicate referral form; when enrolled, enter the patients
pre-ART enrolment number into the HTS register.
5.6.1 Pre-test Information:

Pre-test information can be given for a group, a couple, or an individual. Group sessions are
the recommended model for providing pre-test information clients for ANC clients because
they are usually many in number. It also allows group discussion. This should be given as part
of the general health education talks offered regularly.
The pre-test session should, at a minimum, contain:
Reasons for recommending HIV testing, for all pregnant and breastfeeding women
The clinical and preventive benefits of HIV testing and ART
Available services, both for the woman, her baby, and her partner.
Reassurance that all information will be confidential and will not be shared with anyone
other than health workers directly involved in providing care for a woman and her baby.
The right of a woman to decline testing, and that declining testing does not affect her access
to all other services that do not require knowledge of her HIV status.
That testing will be done right away to all those who do not know their HIV status
The available support for women who would like to disclose to their partners or tested as a
couple.
Gender based violence related to HIV testing and treatment
42
Discordance (see information for discordant couples)
The health worker should also give women an opportunity to ask questions or express
anything of their concern. It is important to address their concerns, including those related
to disclosure and partner testing.
5.6.2 HIV Testing Process

In order to test a person for HIV infection, a HCW must handle the testing devices properly.
The following are important points to be observed:
Infection control and Standard Precautions
Proper labelling
Proper specimen collection procedures
Required volume per test
Proper reagents per test
Correct timing per test
Interpretation of results
Proper record-keeping
Proper disposal procedures
5.6.2.1 The Hiv Testing Algorithm For Persons Aged 18 Months And Above
The HIV testing algorithm for persons aged 18 months and above is in Figure 3 below.
When using this algorithm in children 18 months and above who are still breastfeeding; If
the final status is negative, another test should be repeated six weeks after cessation of
breastfeeding
Figure 3: Serial HIV Testing Algorithm for persons above 18 months of age.
The recommended testing algorithm follows the following steps:-
A blood sample is taken and tested once using the initial rapid test.
If this first test result is non-reactive it is said to be HIV-negative, there is no need to

perform a second test; the result is given to the client as HIV-negative.
If the first test result is reactive or positive, the blood sample is tested again using a
different brand of rapid HIV test:
If the second test is reactive, the result is given to the client as HIV-positive.
43
If the second test is negative, a third test known as a tiebreaker is performed; the
result of the tiebreaker is the final HIV result.
Figure
Note: RSS- MOH; First Test- Determine, Second Test-UNIGOLD,
Tie- breaker Test-.
In the L&D setting, a single positive rapid test is adequate to start ARV prophylaxis for the
woman during labour and for the infant upon delivery. The test should be repeated and the
result confirmed after delivery.
5.6.2.3.HIV TESTING ALGORITHM FOR INFANTS AND CHILDREN BELOW 18 MONTHS OF

AGE
A Virological test (DNA PCR) is the recommended test for determining the HIV status in
infants and children below 18 months of age. The sample for testing should be collected
using dried blood spot (DBS) specimens.
The 1st DNA-PCR test should be done at six weeks of age or the earliest opportunity
thereafter.Interpretation of the results and further testing are guided by the testing
algorithm in Figure 4 below.
A POSITIVE DNA PCR test result indicates that the child is HIV-infected.
All infants with a positive DNA/PCR test results should be initiated on ART, and another
blood sample is collected on the day of ART initiation to confirm the positive DNA/PCR HIV
test result.
44
A NEGATIVE 1st DNA PCR test result means that child is not infected, but could become
infected if they are still breastfeeding. Infants testing HIV negative on DNA/PCR should be re-
tested six weeks upon cessation of breastfeeding.
Infants with negative 2nd DNA/PCR test should have a final rapid antibody test performed at
18 months.
Figure 4: HIV Testing Algorithm for children <18months age
Interpreting HIV Antibody Tests: It is important for the HCW to clearly convey the meaning
of a positive or negative HIV test result. A positive HIV test (one that has been confirmed by
more than one reactive test) means that antibodies to HIV are present in a person's body
and that the person is infected with the virus. HCWs must communicate to the client that a
positive HIV test confirms infection with HIV. It does not mean that the client has AIDSthe
advanced stage of HIV infection when a person becomes sick. Most people with HIV
infection are healthy for most of the time they are infected.
A negative test results can mean one of two things:Either the person is not infected with HIV
or the person is infected with the virus but the body has not had enough time to make a
detectable amount of antibodies
5.6.3 Post-test counselling:

Post-test counselling is an important part of HIV testing, and it should be tailored to
individual test results, risk behaviour, and needs. Post-test counselling may be provided to
the woman alone or to the couple together. For women tested in labour, post test
counseling should be done when she is comfortable even if this is after giving birth.
45
Post test counselling process
Explain the HIV test result. In case of pregnant women, it is recommended that all pregnant
women who test negative the first time during pregnancy have a repeat test after 3 months.
Provide information on how to prevent HIV transmission, including MTCT of HIV.
Discuss options for safer sex practices and support clients' informed decision.
Provide condoms or information on how to get and use them. Explain that condom use
during pregnancy is not contraception but is a way to protect both the mother and the baby
from sexually transmitted infections, including HIV.
Encourage and support disclosure and partner testing.
Encourage joining peer support group in available
Discuss family planning after giving birth
For HIV Positive women: Extra post-test counselling and support will be required on
initiation of ART. She needs counselling to understand the benefits of taking ART to reduce
MTCT of HIV and maintain her health. She should also be supported to disclose her HIV
status to her partner and to encourage her partner to get tested.
For HIV-negative women, the post-test counselling should provide information on how to
prevent HIV infection. A new HIV infection during pregnancy or while breastfeeding has a
high risk of MTCT due to the high viral load. The woman should know that her test result
does not tell if her partner has HIV. It is possible for her and her partner to have different HIV
test results, even if she has been having sex for a long time with her partner. To protect
herself and her baby from HIV, her partner should also get an HIV test.
Recommendation:
All women tested for HIV during pregnancy, child birth and breastfeeding should go through
pre and post counseling guided by the 5 principles of counselling. HCWs should ensure that
women in labour are comfortable during pre and post test counseling.
5.7 Pregnant women who opt out of HIV testing:

If a woman declines HIV testing after pre-test counselling, a HCW should spend extra time
with her to find out the reason, and see if she needs support. The following are some
considerations:
Some women might be afraid of HIV testing, they might not want to know their HIV status,
might not want to discuss the results with their partner or anyone else, or they might not
want to think their baby is at any risk.
46
Some women might not realize that they are at risk, and that pregnancy is a result of
unprotected sex carries risks of sexually transmitted infections, including HIV.
Stigma and discrimination against HIV-positive pregnant or breastfeeding women and are
known to be living with HIV, is a problem in South Sudan. Counseling pregnant and
breastfeeding women and their partners about the benefits of knowing their HIV status for
themselves and their baby can usually help them to overcome fear of stigma, discrimination,
and other barriers.
Allowing pregnant women to express their concerns is very important. Fear of bad outcomes
following disclosure is common, and this could be aggravated by the low socio-economic
status that women experience in South Sudan. However, research in other countries has
shown that most women who disclose report positive outcomes, support, and
understanding from their partners. When counselling, it is important to assist women in
evaluating the chances of unpleasant outcomes, and help them make a plan to minimize
these outcomes. Also, offer to speak to other family members if the woman decides to bring
them.
Recommendation:
If a woman declines HIV testing at her first counseling session, testing at subsequent visits
should be explored and recommended.
5.8 Partner testing:

Couples and partners should be aware of and supported to use PMTCT services, including
HIV prevention, treatment, and care, and routine health services. Both partners should
participate in decisions that can prevent HIV transmission. In countries neighboring South
Sudan such as Kenya and Uganda, 50% of HIV positive persons have an HIV negative
partner.The majority of people living in stable relationships are unaware of their partner's
status, and many people with an HIV-positive partner are not aware of their own status.
Many people living with HIV assume their partner is also infected and do not understand the
potential for discordant results. Thus, it is important that HIV testing and counselling is
routinely recommended to the partner of the pregnant or breastfeeding woman irrespective
of the test result of the woman. Whenever possible, partners should be counselled and
tested together. When individuals learn their HIV test results alone, they often bear the
burden of disclosing their HIV status to their partners without assistance from a trained
counsellor or health care provider. Couples HIV testing and counselling ensures mutual
disclosure of HIV status between partners. When partners learn their HIV status together,
they also agree that decisions about mutual disclosure to any third parties must be made
together. Partner testing enhances early initiation and adherence to interventions for
PMTCT, care and treatment of mothers and their partners and infants.
47
Recommendation:
HIV testing with counselling should be recommended for partners of HIV negative or positive
pregnant and breast feeding women. Couple HIV testing and counselling with mutual
disclosure of HIV status between partners should be encouraged.
5.9 Counselling discordant couples:

A discordant couple is one in which one partner is HIV-positive and one partner is HIV-
negative. In Western Equatoria, the state with the highest prevalence in South Sudan,
discordance was reported as common. When discordance is established, it can be a highly
emotional issue. Often there are accusations of infidelity and betrayal. HIV positive women
in discordant couples are likely to face gender-based violence, divorce and separation.
Discordant results need to be handled carefully. Couples and at times HCWs may have
misconceptions about discordance. Some of the misconceptions are that the negative
person may have a hidden infection not detected by HIV tests, or is immune to HIV or
protected by supernatural powers etc. HCWs need to have a clear understanding of
discordance so as to provide couples with clear and accurate information. The
misconceptions need to be explored and challenged.
Prevention of HIV-transmission among discordant couples depends on appropriate

counseling, use of condoms and treatment for the HIV-positive partner. Alcohol use has
been associated with unprotected sex among serodiscordant couples and should be
addressed in counseling of discordant couples. All people testing for HIV need to be
informed about discordance. This information may be given during pre/posttest counseling
and also as required.
Information about discordant couples

HIV discordance is common
Couples can remain discordant for a long time
HIV discordance is not necessarily a sign of sex outside marriage
HIV is not transmitted at every sexual encounter but chances of transmission increase over
time with more sexual encounters.
The HIV-negative partner is not immune to HIV infection
HIV-negative partner in a discordant relationship is at a very high risk of getting HIV infection
Prevention of HIV transmission in discordant couples is possible.
48
5.10 RE-TESTING FOR HIV
5.10.1 Re-testing for HIV positive people before ART initiation
All HIV positive individuals should be re-tested for HIV before initiating ART.Re-testing should
be performed by a different tester using the approvednational HIV testing algorithm at the
ART initiation site/care point.
5.10.2 Re-testing for HIV-Positive Infants

All babies testing HIV positive at the first or second DNA PCR HIV testing should be re-tested
for HIV. The DBS sample should be collectedon the day the childis initiated on treatment.
5.10.3 Re-testing for HIV-Negative Individuals

The following population categories should be re-tested for HIV as summarized in Table 7
below;
Table 7: Categories of HIV-Negative persons to re-test at specified time-points

s/no Population category When to re-test
1. Individuals exposed to HIV Four weeks after testing

within four weeks before HIV
testing
2. Key Populations Every 3 Months
3. HIV negative Partners in Every three months

discordant couples
4. Pregnant women 1st trimester/1st ANC Visit, then in the 3rd

Trimester/during labor and delivery
5. Breastfeeding Women Every three months until three months after

cessation of breastfeeding
6. Confirmed and presumptive TB Four weeks after testing

Patients
7. PEP clients At one month,three month and 6 months after

completing the PEP course.
8. PrEP As per the new guidelines

P
9. STI patients Four weeks after testing
10. HIV-Exposed Infants(HEIs) Six weeks upon cessation of breastfeeding
11. INCONCLUSIVE Results 14 days after the last test
49
5.10.4 Repeat HIV test during pregnancy
It is recommended that all pregnant women be tested for HIV infection as early as possible
in their pregnancy. Women who test early in pregnancy will require another HIV test after 3
months to identify women who were in the window period when the first HIV test was done.
However, with newer rapid tests, the window period is very brief. Therefore, the most
important reason for repeat testing is to identify women who got infected during pregnancy.
Newly infected women have a high viral load which increases the chances of MTCT of HIV.
Recommendation
HIV-negative pregnant and breastfeeding women should have a repeat HIV testing and
counseling every 3 months.
5.11 HIV testing during breastfeeding:

More than one in three HIV infections in children occurs during breastfeeding if prolonged
up to 2 years.
Figure 3: Vertical transmission through breastfeeding
Any breastfeeding child whose mothers HIV-infection status is unknown is at risk of HIV-
infection if not infected already. Once identified, uninfected breastfeeding infants of women
living with HIV can receive interventions for PMTCT. Those infected can receive ART early
enough to enhance their chances of survival. Breastfeeding mothers with unknown HIV-
infection status can be identified in clinics for immunisation, well children, family planning,
and nutrition and well as paediatric inpatient wards etc. However one entry point where
breastfeeding women routinely attend is the immunisation clinic. Women coming for
immunisation for the first time should be asked to bring their ANC cards and their testing
50
information transferred from the ANC card to the immunisation card of the baby. PITC
should be offered to women who were not tested during ANC.
5.12 Testing of children of pregnant and breastfeeding women for HIV.

HIV is a family disease. Whenever a pregnant or breastfeeding woman is identified as living
with HIV for the first time, it is important not only to test her sexual partner but also all her
children. This is because she may have given birth to some or all her children while living
with HIV. Some of them could be HIV infected. HIV makes children ill and kills faster than in
adults. It is therefore very important to identify those who may be HIV-infected early and
start them on treatment. Children are minors and will require the permission (consent) of
parents or guardians to be tested for HIV. Antibody tests can only be used if the child is 18
months or older. Testing of children less than 18 months is discusses under management of
HIV-exposed infants in section 3
Recommendation:
All children of pregnant or breastfeeding women living with HIV should recommended for
PITC.
5.13 LINKAGE FROM HIV TESTING TO HIV PREVENTION, CARE, AND TREATMENT
Linkage refers to the act of connecting individuals that have tested for HIV from one service
point to another. Linkageis successful if the patient/client receives the services referred to
receive. For all clients who test HIV positive, linkage should occur within seven days (within
the same facility) and 30 days for those referred to another facility. We highly recommend
theuse of lay providers (community and facility-based) as linkage facilitators. The process of
linkage within the same health facility is described inFigure 5 below:
Figure 5: Internal Linkage Facilitation Steps.
51
Provide results accurately
Provide information about care available at facility and
elsewhere in catchment area
Describe the next care and treatment steps
Discuss the benefits of early treatment initiation and cons
of delayed treatment
Identify and address any barriers to linkage
Post-Test
Involve the patient in the decision making process
Counselling regarding care and treatment
Fill in client card and include referral notes
Fill in the triplicate referral form
Introduce and hand the patient to a linkage facilitator
If same day linkage is not possible-book an appointment
for the client at the clinic and follow to ensure the patient
attends
Linkage Facilitator escorts client to ART Clinic with the linkage

forms
Patient to the
Handover client to responsible staff at that clinic
HIV clinic The Linkage facilitator ensures that the client is enrolled within
seven(7) days
Register the patient in the pre-ART register

Open and HIV/ART card/ file for the patient
Offer ART preparatory counselling
Conduct baseline investigations
If the patient is ready to start ART and baseline investigations
Enrolling at are normal- start ART
HIV Clinic Coordinate care and provide integrated care, e.g TB/HIV
treatment, Mother-baby pair receiving care together
Continue discussion on disclosure and psychosocial support
Discuss and make an appropriate appointment with the
patient
5.14 INTER-
FACILITY LINKAGES
Inter-facility linkage refers to connecting a newly diagnosed patient at another facility for HIV
treatment, care, and support services. The referring facility should track (follow-up) all HIV-
positive patients referred to other facilities and ensure they are enrolledin care within 30
days, using the follow-up/tracking schedule described inTable 8below.
Table 8: Schedule for follow up/ Tracking inter-facility linkages
Timeline Action
Day 1(referral A client diagnosed HIV positive and referred to thepreferred facility.
day)
52
Linkage facilitator documents clients contacts.
Linkage facilitator obtains clients consent for home visiting.
Linkage facilitator introduces theclient to community health worker.
Week 1 Linkage Facilitator calls Client or the contact in the health facility
where the client was referred to. If client reached, document
complete linkage.
Week 2 If the client didnt reach the facility by week 1, the Community Health
Worker (HHP) visits Clients home to remind about the referral.
Week 3 Linkage Facilitator Calls Client or Facility contact to confirm if the

HHP/BHT visit to clients home made any impact. If client reached,
document complete linkage.
If theclient didnt reach, the linkage facilitator visits clients home to

discuss reasons for the clients failure to reach the referral point.
Week 4 Linkage Facilitator Calls Client or Facility X to confirm if client reached.

If yes, document linkage as complete. If no, document as Lost.
5.14 QUALITY ASSURANCE IN HIV TESTING AND COUNSELING

HIV Testing Services should be deliveredaccording to national standards. The main quality
assurance issues in HTS service delivery are:
HTS should be performed by trained and certified providers. Providers should be

assessed annually for competency.
SOPs should be followed at all times.
HTS data quality (data collection, analysis, reporting).
Internal and external HIV quality control processes performed including supervision.
53
CHAPTER 6: PREVENTION OF AIDS RELATED DISEASES AND CO-
MORBIDITIES
6.1 Introduction
Pregnant and breastfeeding women living with HIV need interventions to prevent diseases
so as to live a good quality life and ensure healthy new-born babies. In addition, acute Illnesses are
likely to increase the viral load and also lead to premature and low birth weight babies thereby
increasing the chances of MTCT of HIV. At each visit, during antenatal and post natal care, women
living with HIV should be assessed for any illness and offered interventions for prevention of disease.
In this chapter we describe some of the key interventions for disease prevention and health
promotion.
6.2 Package of services for prevention of HIV infections and co-

morbidities
This is a package of high impact; low cost interventions for prevention of common HIV
related opportunistic infections and co-morbidities. It has been proven to iimprove the
quality of life and well being of persons living with HIV ,even in the absence of antiretroviral
treatment .The package for disease prevention should include at least the following:-
Septrin prophylaxis
TB counselling, screening and prophylaxis;
Prevention of malnutrition;
Water, sanitation and hygiene
Malaria prevention.
Prevention with positives
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6.2. 1 Septrin prophylaxis
Septrin prophylaxis is useful in prevention of number diseases among PLWHIV. It prevents
deaths and hospitalisations from diseases such as pneumonia, toxoplasmosis, diarrhoea,
malaria etc. For pregnant women, septrin prophylaxis may also have indirect benefits for
neonatal and infant health in addition to its direct benefits for maternal health. In a Zambian
study, when septrin was provided to pregnant women with CD4 cells less than 200cells/mm 3
there were significant improvements in birth outcomes; with reductions in prematurity and
new born deaths6. All pregnant and breastfeeding women living with HIV should be started
on septrin prophylaxis. Pregnant women living with HIV can start taking septrin prophylaxis
at any gestational age.
Figure 4: Septrin dosage in adults and children7
5.1.1 Side effects to septrin .

Side effects to septrin prophylaxis are not common. The commonest side effect is an allergic
reaction. When an allergic reaction to septrin develops, septrin can be substituted with
dapsone (100mg daily) or septrin desensitization may be attempted. However, dapsone is
less effective than septrin in preventing diseases. It is therefore desirable to attempt
desensitization to Septrin among individuals with a previous non-severe reaction, before
substituting dapsone . Septrin desensitization should not be attempted among individuals
with a previous severe (grade 4) reaction to septrin or other sulfa-containing drugs.
Desensitization can be attempted two weeks after a non-severe (grade 3 or less) septrin
reaction that has resulted in a temporary interruption ofprophylaxis.Septrin desensitization
has been shown to be successful in most individuals with previous hypersensitivity and
rarely causes serious reactions. It is recommended to commence an antihistamine regimen
of choice one day prior to starting the regimen and to continue daily until completing the
dose escalation. If a severe reaction occurs, the desensitization regimen is terminated. If a
minor reaction occurs, repeat the same step for an additional day. If the reaction subsides,
advance to the next step; if the reaction worsens, the desensitization regimen is terminated.
6
Walter J, et al. Reduction in preterm delivery and neonatal mortality after the
introduction of antenatal cotrimoxazole prophylaxis among HIV-infected women with
low CD4 cell counts. J Infect Dis 2006;194:1510-1518.
7
http://www.aidstar-one.com/sites/default/files/AIDSTAR-One_Co-trimoxazole_CHW_Job_Aid_updated.pdf
(accessed on 4th November 2013)
55
Table 3: Grading ofseptrin allergic reactions:
Grade Clinical description Recommendation
GRADE 1 Erythema Continue septrin prophylaxis with careful and

repeated observation and follow-up. Provide
symptomatic treatment such as antihistamines if
available.
GRADE 2 Diffuse maculopapular rash, Continue septrin prophylaxis with careful and
dry desquamation repeated observation and follow-up. Provide
symptomatic treatment, such as antihistamines if
available
GRADE 3 Vasiculation, mucosal Septrin prophylaxis should be discontinued until the

ulceration advance event has completely resolved (usually 2
weeks) and then reintroduction or desensitization
can be considered.
GRADE Exfoliative dermatitis, Steven Septrin should be permanently discontinued

Johnson syndrome, erythema
4
multiforme, moist
desquamation
Table 4: Desensitization of septrin allergic reactions:

Day 1 Antihistamine
Day 2 Antihistamine + 2 mls of septrin syrup *
Day 3 Antihistamine + 4 mls of septrin syrup*
Day 4 Antihistamine + 6 mls of septrin syrup*
Day 5 Antihistamine + 8 mls of septrinsuyrup*
Day 6 Antihistamine +One single strength septrin tablet
(400 mg sulfamethoxazole + 80 mg trimethoprim)
Day 7 Antihistamine +Two single- strength or one double- strength tablet septrin
tablet (800 mg sulfamethoxazole + 160 mg trimethoprim)
*septrin oral syrup is 40 mg trimethoprim + 200 mg sulfamethoxazole per 5 ml.
Septrin prophylaxis should also be discontinued if the PLWHIV develops jaundice (yellow
eyes), severe anaemia, severe pancytopaenia.Septrin should not be given in patients who
56
are known to be allergic to sulfa drugs; have severe liver disease, severe renal disease or
glucose-6-phosphate dehydrogenase (G6PD) deficiency.
Figure 5: septrin side effects8
Recommendations:
All pregnant and breastfeeding women living with HIV should be started and on septrin
prophylaxis and continued indefinitely. Septrin prophylaxis during pregnancy should be
started at any stage of pregnancy.
6.2.2. Prevention of Tuberculosis

PLWHIV have a greatly increased risk of acquiring tuberculosis (TB). The risk of developing TB
is more than 20 times greater in people living with HIV than among those who do not have
8
http://www.aidstar-one.com/sites/default/files/AIDSTAR-One_Co-trimoxazole_CHW_Job_Aid_updated.pdf
(accessed on 4th November 2013)
57
HIV infection.TB is responsible for more than a quarter of deaths in PLWHIV. It is common
for many people to be infected with the TB germ but never develop the TB disease (this is
referred to as latent TB or TB infection). In TB disease (also called active TB), the patient
has signs and symptoms (fever, weight loss, cough etc.) that increasingly become worse with
time. In latent TB on the on the hand, the patient has no signs or symptoms and one could
live with it without any problems. TB disease is infectious latent TB is not. A case of TB does
not refer to a person with latent TB (TB infection) but to TB disease. Latent TB does not
necessarily become TB disease. However, HIV infection increases the risk of latent TB
becoming TB disease.
In addition to direct effects of TB disease on pregnant and breastfeeding women living with
HIV, TB disease also has an impact on pregnancy outcomes. Pregnant women with un-
treated TB disease are more likely to give birth to babies that are premature or of low birth
weight. Among pregnant women with TB disease, there is also an increased risk that the
baby will be infected with TB before and after birth, and develop active TB disease. When a
pregnant woman is co-infected with HIV, TB increases the risk of vertical transmission of HIV
to the unborn child.
In order to prevent TB disease among pregnant and breast feeding women living with HIV, all
health care facilities and HCWs providing services to PLWHIV should implement the three Is
strategy i.e. Intensified Case Finding (ICF), Isoniazid Preventive Therapy (IPT) and Infection
control whenever PLWHIV present to health facilities.
6.2.2.1 Intensified TB case finding

Intensified case finding is the use of a clinical algorithm to find out PLWHIV who may have TB
disease (and therefore requires further investigation) and those who are less likely to have
TB disease and requires preventive therapy. At every visit, a HCW should find out if a
PLWHIV has any one of the following symptoms: - cough for any duration, fever for any
duration, night sweats, weight loss or in the case of pregnant women, failure to gain weight.
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Screening for TB disease among PWHIV9.
Ask if a PLWHIV has any ONE of the following currently:
Cough for any duration

Fever for any duration
Night sweats
Weight loss OR failure to gain weight in pregnancy
NO to ALL the questions rules out TB

YES to any of the questions. Do sputum
smear microscopy of 2 specimens for START IPT
AFB and other investigations.
6.2.2 Isoniazid Preventive Therapy (IPT).

All PLWHIV without any of the symptoms above are unlikely to have TB disease and should
be given isoniazid (INH) for six months to prevent future development of TB disease. This is
called Isoniazid Preventive Therapy (IPT). It is important to be sure that the PLWHIV does not
have TB disease before giving IPT. The clinical algorithm is very good at identifying PLWHIV
who are unlikely to have TB disease. However, the clinical algorithm, on its own, it cannot
identify those with TB disease but will identify those who need further investigations.
Household and close contacts of persons with TB disease should be prioritized for clinical
evaluation of TB and those with no TB disease receive IPT. IPT is more effective in those with
a positive tuberculin skin test (TST) than those with an unknown or negative test. It is
therefore recommended that the TST should be used where possible. However, TST should
not be a requirement for initiating IPT. Another perceived barrier to commencing IPT is the
fear that individuals may develop drug resistant TB following IPT. It has been shown that
drug-resistant TB rates are not raised among those who develop TB following IPT, compared
to those expected of people living with HIVIPT is recommended for all children living with
parents or care takers with TB disease. All individuals with HIV receiving IPT should be
evaluated monthly. At each monthly visit, a patient on ITP should be assessed for TB
symptoms (cough, fever, night sweats, and weight loss), side effects of INH (hepatitis,
9
www.cdc.gov/tb/topic/globaltb/screening.htm
59
neuropathy, and rash), and adherence. If a person on IPT develops TB symptoms, IPT should
be stopped and promptly evaluated for TB. Contraindications to IPT include: active hepatitis
(acute or chronic), regular and heavy alcohol consumption and symptoms of peripheral
neuropathy. Past history of TB disease and current pregnancy should not be
contraindications for starting IPT.The recommended dose of isoniazid is 5 mg/kg daily for six
months, up to a maximum dose of 300 mg daily. If TB disease is diagnosed, a combination of
drugs following the national guidelines should be used. Streptomycin should be avoided in
pregnant and breastfeeding women as it may cause damage to the ears of newborns.
However, streptomycin may be used in severe forms of TB disease such as TB meningitis
even in pregnant and breastfeeding women.
6.2.3 Infection control of Tuberculosis

People living with HIV (including health care workers who may also have HIV infection) are at
a risk of catching TB from fellow clients coming to health facilities with TB disease. It is
therefore important to institute effective measures to control TB transmission in health
facilities. TB infection control practices should also be instituted in other congregate settings
(prisons, refugee camps etc.). TB infection control practices include personal, administrative,
and environmental controls as well as health worker surveillance. Communities and the
general public need to be well informed about these practices. Some intervention may not
be feasible in the resource context of South Sudan but most can easily be implemented.
To prevent transmission of TB in health facilities and other congested places, the following
are required:-
Separation of patients with suspected or confirmed TB
Adequate ventilation in clinics for people with HIV or TB.
Use of protective wear e.g. masks for HCWs that come into close contact with TB patients
e.g. lab personnel.
Advise everyone, especially people with HIV or TB to use cough etiquette (cough in a hand or
piece of cloth.)
People with HIV should sleep alone.
Recommendations:
Pregnant and breastfeeding women living with HIV should be screened for TB disease with a
clinical algorithm and those who do not report any one of the symptoms of current cough,
fever, weight loss10 or night sweats are unlikely to have active TB disease and should be
10
Poor weight gain is defined as reported weight loss, or very low weight (weight-for-age
less than 3 z-score), or underweight (weight-for-age less than 2 z-score), or confirmed
weight loss (>5%) since the last visit, or growth curve flattening
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offered IPT. Those who report any one of the symptoms of current cough, fever, weight loss
or night sweats may have active TB disease and should be evaluated for TB disease and
other diseases
Pregnant and breastfeeding women living with HIV who have an unknown or positive TST
status and are unlikely to have active TB disease should receive at least six months of IPT as
part of a comprehensive package of HIV care. IPT should be given to such individuals
irrespective of the degree of immunosuppression, and also to those on ART, those who have
previously been treated for TB.
6.3. Prevention of malnutrition in pregnant and breastfeeding women living with HIV.
Good maternal nutrition during pregnancy and lactation is essential to ensure good health
for mothers and the survival and development of their children. HIV increases the risk of
under nutrition in HIV-infected pregnant and lactating women and malnutrition is associated
with faster HIV-disease progression.
Energy, protein, and various micronutrient requirements increase during pregnancy to

ensure foetal growth and development, and milk production. HIV can cause nutrient loss,
malabsorption, and increased energy needs, further jeopardizing nutritional status. For all
women, improving nutritional status before and during pregnancy can help ensure adequate
gestational weight gain and decrease the risk of premature delivery and low birth weight.
For HIV-infected women, adequate nutritional status may reduce vertical transmission by
affecting several maternal or foetal and infant risk factors for transmission.
Components of nutrition care and support include nutrition assessment and counselling,
micronutrient supplementation, food provision (if needed), food safety and hygiene,
psychosocial support, and referral to other services.
6.3.1 Routine Nutrition Education and Counselling

Pregnant and breastfeeding women living with HIV should receive nutritional education and
counselling at every ANC visit and all postpartum follow-up visits. The content of these
sessions includes:
Mothers-to-be and new mothers should get additional rest, especially during the third
trimester of pregnancy and soon after giving birth respectively.
Accurate information regarding cultural foods and traditional therapies and practices that
are beneficial or harmful during pregnancy and lactation.
Eat a well-balanced diet that includes a variety of fresh foods, based on what is locally
available and affordable. Make starches the basis of the meal. Eat proteins with every meal;
include a mixture of non-animal proteins. Eat fruits and vegetables every day if possible.
Try to eat small meals frequently
61
Iron and folic acid supplementation during pregnancy and Vitamin A within the last eight
weeks of delivery
Drink at least eight glasses of clean water each day
Take multivitamins daily
Practice good food hygiene to avoid food-borne illness
use iodised salt to prevent iodine deficiency
Give advice on how to manage diarrhoea, nausea, vomiting, loss of appetite, and mouth and
throat problems, which may prevent weight gain and affect the womans nutritional status.
6.3.2 Nutritional assessment

Pregnant women are expected to have adequate weight gain of at least 1 kg/month in the
2nd and 3rd trimesters. Mid upper arm circumference (MUAC) should be used to assess
nutritional status in pregnant and breastfeeding women instead of the body mass index
(BMI). MUAC of less than 22 should be managed as moderate malnutrition and MUAC less
than 19 cm as severe malnutrition.
6.3.3 Food safety:

The figure7: Five keys to food safety.
62
Recommendations:
All pregnant and breastfeeding women living with HIV should receive education and
counselling on nutrition.
All pregnant and breastfeeding women should have their nutrition status assessed at every
routine visit.
Iron, folic acid and vitamin A should be given to pregnant and breastfeeding women living
with HIV according to national guidelines.
6.4 Prevention of disease through WASH practices.

Pregnant and breastfeeding women living with HIV should be informed and also supportedto
make behaviour changes required to avoid disease through improved water, sanitation and
hygiene (WASH) practices. WASH is the use of proper practices with water, cleanliness, and
waste disposal to reduce disease transmission or acquisition. This is particularly important
for PLHIV because of the weakened immunity. It is also important for their family members
of PLHIV. WASH should be applied at home and in health facilities. Important components of
WASH at home are:
Safe water for drinking
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Frequent, correct hand washing
Better latrines and/or safe excreta disposal
These WASH practices are particularly important for the prevention of water borne disease
such as typhoid, dysentery, diarrhoea etc. Diarrhoea affects 90% of HIV-positive people and
results in significant morbidity and mortality. Diarrheal illness in HIV-positive patients can
interfere with the absorption of antiretroviral drugs and essential nutrients, further
exacerbating HIV infection and illness. WASH practices can reduce diarrhoea by 25 to 65%.
6.4.1Safe drinking water

Drinking water should be stored separately from water used for other purposes. Drinking
water should be boiled or disinfected using a chlorine solution/tablet (e.g. water guard) and
stored safely. Storage should be in narrow-mouth container (e.g. Jerry can) with a cover. For
serving, water should be poured into a glass or cup. Hands are not to be dipped into the
water. The container for storing drinking water should be regularly washed with soap and
hot water.
6.4.2 Hand washing

Hands should be washed regularly at critical times when diseases could be transmitted or
acquired. Hands should be washed with water and soap or wood ash before eating or
cooking, after using or cleaning a toilet/latrine, after cleaning a babys bottom, and disposing
of waste. If running water is not available, a tippy tap could be used for hand washing. An
example of a toppy tap is shown below:
6.4. 3 Excreta Management

People in the community should be encouraged to build and use latrines (toilets) for safe
disposal of excreta so it does not become a source of contamination, particularly for the
drinking water.
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6.4.4 WASH activities at health facilities
By promoting WASH activities, health facilities provide a positive example to the community.
Health facilities should have a sufficient number of clean, functional latrines/toilets for
patient/caregivers and health care providers; facilities for hand washing and systems for
managing hospital waste. Latrines should be appropriately constructed and designed to be
safe and secure for children, the elderly, and disabled, pregnant, and very sick people. Toilets
and latrines can be equipped to meet the specific needs of PLHIV and patients with
disabilities by simple additions and design modifications. Toilets should be easy to clean and
cleaned regularly. Some PLHIV need frequent use of latrines/toilets because of related
diarrhoea, but they may have difficulties using very dirty latrines/toilets.
6.4.5 Prevention of malaria

Malaria is common in South Sudan and pregnant women and children under 5 years of age
are more likely to get malaria. Malaria can be prevented by sleeping under a mosquito net or
residual indoor spraying. It is recommended that all pregnant women should receive malaria
prophylaxis in the form of intermittent presumptive treatment with fansidar. If the woman is
already receiving septrin prophylaxis, she does not need to take intermittent presumptive
therapy. If a woman has been receiving intermittent preventive treatment for malaria or
septrin prophylaxis, a treatment for acute malarial illness that does not include fansidar
should be recommended.
6.4.6 Use of condoms

Safer sex and use of condoms for HIV infected and discordant couples are essential to
protect against STIs and prevent the transmission/acquisition of HIV infection.
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CHAPTER 7: PREPARATION FOR ART AND CHRONIC CARE
7.1 Introduction
It has been mentioned above that ART for PMTCT is an emergency; it needs to be started as soon as
possible. However, in all patients, it is important to prepare the patient before starting ART. The
minimum pre-ART package includes:-
Treatment of all concurrent illness
Laboratory tests
Counseling and psychosocial support
7.2 Treatment of illness:

Because of the weakened immunity, PLWHIV are more likely to get sick. Compared to people
with no HIV-infection, PLWHIV will get common infections more frequently, presenting more
aggressively and responding poorly to treatment and or rare opportunistic infections. In
addition to prevention, these acute infections need to be treated urgently.
Pregnant and breastfeeding women living with HIV need to be treated for any concurrent
illness before starting on ART. This helps the woman to avoid taking many medications at
once. When ART is started while taking other medications, it may be difficult to find out
which one is causing side effects in case they develop.
Once ART has been started it is alright to add other medications if needed to treat any new
infections. It is important to note that some diseases are part of HIV disease (e.g. skin rash)
and can only go away when ART is started.
7.3 Pre ART Laboratory tests

The most important tests to be done for pregnant and breastfeeding women starting ART
are CD4 count, hemoglobin concentration, syphilis antibody test and urine dipstick. With the
66
exception of CD4 counts, the other tests are done routinely for pregnant and breastfeeding
women.
7.3.1 Screening for syphilis

In South Sudan, syphilis is very common. In 2012, based on sentinel antenatal surveillance,
the national prevalence was more than 3 times that of HIV (8.3% for syphilis compared to
2.6% for HIV). The syphilis bacterium can infect the baby of a woman during her pregnancy.
All pregnant women should be tested for syphilis at the first prenatal visit preferably
together with HIV test. The syphilis screening test should be repeated during the third
trimester (28 to 32 weeks gestation) and at delivery in women who are previously untested,
or had a positive screening test in the first trimester.
Depending on how long a pregnant woman has been infected, she may have a high risk of
having a stillbirth (a baby born dead) or of giving birth to a baby who dies shortly after birth;
untreated syphilis in pregnant women results in infant death in up to 40 per cent of cases.
Any woman who delivers a stillborn infant after 20 weeks gestation should also be tested for
syphilis.
An infected baby born alive may not have any signs or symptoms of disease. However, if not
treated immediately, the baby may develop serious problems within a few weeks. Untreated
babies may become developmentally delayed, have seizures, or die. All babies born to
mothers who test positive for syphilis during pregnancy should be screened for syphilis and
examined thoroughly for evidence of congenital syphilis.
Genital sores caused by syphilis make it easier to transmit and acquire HIV infection sexually.
Syphilis also causes an increase in the viral load in pregnant mother living with HIV which in
turn increases the chances of MTCT.
Treatment of pregnant women with penicillin is very effective in preventing mother-to-child

transmission of syphilis.
Recommendation: Concurrent illnesses should be treated first before starting ART for
pregnant and breastfeeding women.
7.3.2 CD4 testing

Although CD4 testing is not required to initiate ART in pregnant and breastfeeding women,
it is still essential in the management of all PLWHIV in South Sudan. It is important to obtain
a CD4 count as soon an HIV-positive test is confirmed (baseline) and every 6-month while on
ART. The baseline CD4 count is not a precondition to initiate ART for PMTCT and can be
provided at a later visit. If CD4 testing is not available at the health facility initiating ART,
women should be clearly advised on how to get the test. This may be by transporting blood
samples to where testing can be done or referring the woman to another facility for CD4
quantification.
67
Recommendation:
All pregnant and breastfeeding women living with HIV should have a CD4 test as soon as
possible after they are identified and every 6 months while on treatment. The baseline CD4
count result is not a precondition to start ART and can be provided later
7.3.3 Hemoglobin concentration

Low hemoglobin concentration is common in pregnant and breastfeeding women in South
Sudan. Essential care includes the routine prevention, detection and treatment of anemia
and its causes for all pregnant and breast feeding woman including those living with HIV. If
the hemoglobin concentration cannot be tested in the laboratory, it should be assessed
clinically. If the hemoglobin concentration is lower than 7 g/dl or the woman has severe
pallor on clinical examination, AZT should not be used but other ARV drugs can be used in
addition to treatment of anemia. An AZT-containing regimen requires continuous monitoring
for anemia.
7.3.4 Urine Dipstick:

A dipstick urinalysis helps to find out is the woman has diabetes or urinary tract infection
(UTI) or kidney damage. Tenofovir (TDF), an ARV drug common in the first line regimen, can
damage the kidney or make it worse
7.4 Counseling and psychosocial support.

Before ART is started, it is important to have a detailed discussion with PLWHIV about their
willingness and readiness to initiate ART. In order to make informed choice, they need to
know about the ARV drug regimen, dosage and scheduling, the likely benefits and possible
side effects and the required follow-up and monitoring visits. The choice to accept or decline
ART ultimately lies with the individual person, and if they choose to defer initiation, ART can
be offered again at subsequent visits. If there are problems with mental health or substance
that are major barriers to adherence, appropriate support should be provided, and
readiness to initiate ART should be reassessed later. A wide range of patient information
materials as well as community and peer support can help the persons readiness and
decision to start therapy. People starting treatment should understand that the first ART
regimen offers the best opportunity for effective viral suppression and immune recovery,
and that successful ART requires them to take the medications exactly as prescribed. They
should be advised that many adverse effects are temporary or may be treated, or that
substitutions can often be made for problematic ARV drugs. People receiving ART should
also be asked regularly about any other medications they take, including herbal remedies
and nutritional supplements.
People receiving ART need to understand that, while the ARV drugs reduce the risk of HIV
transmission, they cannot be relied on to prevent other people from acquiring infection.
They should be given advice on safer sex (including condom use), to prevent transmitting
HIV to a partner.
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CHAPTER 8. ANTIRETROVIRAL THERAPY FOR POSITIVE MOTHERS
8.1 Introduction
One of the key changes in the revised guidelines is the use of antiretroviral drugs not only for
prevention of HIV but also for life long treatment of HIV positive pregnant women ,breast
feeding mothers and HIV positive children ,young persons and men for their own health .This
section provides guidance on the use of antiretroviral drugs for treatment and prevention .
8.2 Antiretroviral drugs:

HIV is a retrovirus. So, drugs against HIV are called anti-retroviral (ARV) drugs. There are
5groups of antiretroviral drugs. They attack the virus in different ways. The different groups
are Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI), Non-Nucleoside
Reverse Transcriptase Inhibitors (NNRTI), Protease Inhibitors (PIs), fusion inhibitors and an
integrase inhibitor. The table below shows most the different drugs and the groups they
belong to. It is important to note that one ARV drug may be called different names
depending on the manufacturer. For example zidovudine is also known as Retrovir from GSK,
Zidovir from Cipla, Viro-Z from Ranbaxy etc. In addition, more than one ARV drug may be
combined into one pill. For example tenofovir, emitricitabine and efavirenz are combined
into one pill called atripla.
Table of antiretroviral drugs recommended for PMTCT
A combination of 3 different ARV drugs is necessary for effective treatment of HIV and
PMTCT. Three drugs are more effective because they attach the virus from different areas. If
only one or two drugs are used, the virus quickly develops resistance to the ARV drugs. The
combination of 3 different antiretroviral drugs is called Anti-Retroviral Therapy (ART). ART
works by limiting viral multiplication thereby bringing down the viral load. When the viral
load comes down, the CD4 count build up again and offers protection to the body. ART
prevents MTCT by reducing the viral load in blood and breast milk.
A first-line regimen is a combination of ARV drugs that will be used in a patient who has no
prior ART experience. This means the patient never took ART before. Most commonly, a first-
line regimen will consist of two NRTIs and one NNRTI. Some patients will develop failure of
therapy: the first-line therapy will not be effective anymore. Often, this is because the drugs
were not taken correctly. In that case, the patient may be switched to a second-line regimen.
Usually, the second-line regimen will consist of 2 NRTIs and one PI.Even second-line regimen
can fail, if not taken well. The first line regimen offers the best chance of viral suppression
and immune recovery. Viral suppression depends on when ART is started. When ART is
started early in the disease, viral suppression is achieved earlier and faster and maintained
69
longer than when it is started late. The table below shows some of the common ARVs, adult
doses, side effects, major side effects and food restrictions
8.3 When to start treatment.
Recommendation:
All women living with HIV identified during pregnancy, labour or while breastfeeding should
be started on ART for life irrespective of CD4 counts or WHO clinical stage.
This is an important new recommendation in these guidelines. Previously, ART was started in
pregnant and breastfeeding women depending on the level of the CD4 count or WHO clinical
stage. Because of the challenges of CD4 testing and WHO clinical staging, fewer pregnant
and breastfeeding women living with HIV received ART. This new recommendation
simplifies the use of ARVs for PMTCT for providers, clients and service delivery. It is
simplified for providers because (a) only a positive HIV test is required to initiate ART and
most MCH clinics and HCWs can do an HIV test and should therefore be able to initiate ART
for PMTCT and (b) only one regimen and dose is prescribed during pregnancy, labor and
delivery and breastfeeding (c) the same regimen and dose is prescribed as first line for other
PLWHIV (d) there is no need to find out when breastfeeding stops so as to stop prophylaxis.
It is simplified for the client because the same ARV drug and dose is taken while pregnant,
giving birth, breastfeeding and thereafter. This is even better when it is one pill once a day.
This reduces the number of unique activities that a pregnant or breastfeeding woman living
with HIV has to do differently from the rest in order to avoid MTCT of HIV. Finally, it
simplifies operations and service delivery for PMTCT because procurement, supply chain
management, training, monitoring and evaluation around one first line regimen for most
PLWHIV are much easier. Simplification enhances coverage and equity. It enables more
health facilities and HCWs, including those in hard-to-reach areas and populations, to offer
PMTCT services to pregnant and breastfeeding women. In addition to simplification and the
expected expansion of ART for PMTCT, this recommendation has a number of other
advantages:
Treating all pregnant and breastfeeding women living with HIV irrespective of immune status
allows early initiation of ART. This prevents further disease progression in the mother. As a
result, maternal HIV-related deaths, opportunistic infections, and TB are reduced. This has a
direct impact on survival of their children. When mothers survive, their children are also
more likely to survive and be healthy.
ART significantly reduces MTCT of HIV by reducing viral load in blood and breast milk. This
makes breastfeeding relatively safer and women living with HIV can breastfeed their babies
longer. This contributes to AIDS free survival of HIV-exposed infants.
ART reduces sexual HIV transmission to HIV negative partners in sero-discordant couples.
70
8.3.1. Challenges of providing ART for all pregnant and breastfeeding women.
The recommendation to offers ART to all pregnant and breastfeeding women irrespective of
CD4 count or WHO clinical stage has a number of challenges. These include:-
Cost: ART for all pregnant and breastfeeding women living with HIV is costlybecause more
ARV drugs, other consumables, staff, infrastructure etc. will be required. However, it is
expected that the increased cost will be compensated for by the benefits of having more
women accessing ART early and being healthy, and fewer HEIs getting infected. The cost of
medications should be balanced with the cost of failure to prevent MTCT of HIV. The new
recommendation may be more costly but still cost-effective. It is also expected for these ARV
drugs are likely to get cheaper with time.
Toxicity and resistance: The longer a person is on ART, the more side effects are expected to
develop and the higher the chances of developing resistance. By initiating ART early and
being on it for life, PLWHIV are likely to accumulate more side effects of and resistance to
ART.
Redirection of resources away from non-pregnant women with CD4 less than 350: Adults
living with HIV and CD4 count less than 350 cells/mm 3 need ART as a matter of priority.
Treating all pregnant and breastfeeding women should not deprive them of treatment.
Retention: Another challenge for lifelong treatment is to ensure adherence to care and
treatment. Therefore there is a need invest more resources and HCWs more effort and time
in ensuring that women starting on ART are retained in care and on treatment.
Declining treatment: There is a possibility that some women may not agree with the idea of
lifelong treatment when they do not need it for their own health especially when they look
and feel healthy.
8.4 Recommended regimen:

The first line regimen recommended for all eligible PLWHIV should also be used in pregnant
and breastfeeding women living with HIV. Currently the recommended regimens are:
zidovudine (AZT) or tenofovir (TDF) PLUS lamivudine (3TC) or emitricitabine (FTC) PLUS
efavirenz (EFV) or nevirapine.Stavidine (d4T) has been part of the first line but the Ministry
of Health is in the process of having it replaced with either AZT or TDF.
Nevirapine and pregnancy: Some studies have shown a slightly increased risk of nevirapine
related skin rash and liver disease when it is given to pregnant women with CD4 counts
higher than 250cells/mm3. However, a systematic review11 of the risk of NVP-associated
toxicity in pregnant women suggests that the frequency of adverse events is elevated but no
higher than that observed in the general adult population. The authors of the review
concluded: the findings of this reviewsuggest that there is little evidence to justify
11
Ford N et al. Adverse events associated with nevirapine use in pregnancy: a systematic review and meta-
analysis. AIDS 27, online edition. DOI: 10.1097/QAD.0b013e32835e0752, 2013.
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discrimination according to pregnancy status when using nevirapine as part of combination
antiretroviral therapy. Despite this, the overall frequency of side-effects associated with
nevirapine was high and the authors suggested that where possible, the use of alternative
drugs with better overall toxicity profiles such as efavirenz should be considered. Such
considerations are all the more important in resource-limited settings where capacity for
toxicity monitoring remains limited. NVP has other drawbacks. It requires lead-in dosing for
initial use and it is not available as a fixed dose combination with TDF+3TC (or FTC). As a
result, South Sudan Ministry of Health plans to replace NVP with EFV in its first line regimens
for all patients. However, in circumstances where NVP is still in use as part of combination
therapy, it is not justifiable to withhold it from pregnant women on the basis of increased
chances of side effects. When NVP is used in any patient, it is essential to look out for
possible side effects.
Efavirenz in pregnancy:Initially, there were concerns about case reports associating efavirenz
with birth defects. However, according World Health Organization 12, evaluation of
prospectively collected data is reassuring; an updated systematic review and meta-analysis
including the Antiretroviral Pregnancy Registry, reported out comes for 1502 live births to
women receiving EFV in the first trimester and found no increase in overall birth defects and
no elevated signal for EFV compared with other ARV exposure in pregnancy. They
concluded as follows . the clearbenefits of this regimen (TDF/FTC/EFV) for
pregnantandbreastfeeding women (and women of childbearing potential) outweigh the
potential risks.
It is often said that starting ART is not an emergency because PLWHIV need to be prepared
and get ready for lifelong ART before initiation. This is largely true for those starting ART for
their own health. However, in pregnancy and breastfeeding women living with HIV, ART is
also for PMTCT. The earlier ART is started the higher the chances of preventing MTCT. In
South Sudan where women book for ANC late, attend few ANC visits and the majority give
birth at home, a HCW has a narrow window of opportunity in which to intervene. It is
therefore important that pregnant and breastfeeding women should be started on ART as
soon as possible, within the first 2 weeks the HIV diagnosis is made. This requires HCWs to
expedite the preparation and counseling of these women as matter of priority.
8.5 Pregnancy during HIV care or treatment

Some women may get pregnant while attending the ART clinic either in the pre-ART stage or
on ART. If she is pre-ART, she should start first line ART as soon as she is identified to be
pregnant irrespective of clinical stage or CD4 countand should continue for life. However, if a
woman gets pregnant while on ART, she should continue with the regimen she has been
using even if this is different from what is provided in the MCH. Pregnant women should also
be referred to an antenatal clinic for care of the pregnancy. The referral note should indicate
12
WHO 2013.Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:
recommendations for a public health approach.
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the ART she is taking. She should choose to either continue receiving ART from the ART clinic
or from the antenatal clinic. HCWs in the ART clinic need to be conversant with PMTCT.
8.6 ART for TB/HIV co-infection

PLWHIV are more likely to have tuberculosis. If a pregnant or breastfeeding woman living
with HIV is also found to have TB before starting ART, it is preferable not to initiate treatment
for HIV and TB simultaneously. TB treatment should be started first and ART started later
(after 2-8 weeks) when the patient is stable on anti-TB drugs. The advantages of this
approach are:-
Minimises confusion about which drugs to take when.
In case of side effects, a HCW is more likely to find out the offending drug.
Minimises pill burden.
Limits the risk of immune reconstitution inflammatory syndrome (IRIS).
Increases adherence.
Rifampicin reduces the serum level of NVP and some protease inhibitors. Efavirenz levels at
standard doses remain largely unaffected by rifampicin and so it is the preferred
NNRTI.Treatment for TB is the same for pregnant women and women who are not pregnant,
with the only exception that in second-line treatment streptomycin (except for meningeal
infections) should be avoided in pregnancy due to the risk of ototoxicity (harmful effects on
the organs or nerves concerned with hearing and balance) on the foetus or breastfeeding
due to potential for serious adverse reactions in nursing infants. However, it critical to bear
in mind that starting ART for PMTCT needs to be expedited.
8.7 ART for partners of women and other adults

It is important to note that men and women who are not pregnant, in labour or
breastfeeding need to be assessed for eligibility before starting ART. Treatment can only be
started if they are eligible on the basis of a CD4 count or WHO clinical stage. The only
exception is in a discordant relationship where theHIV-positive member of a discordant
couple should be started on lifelong ART irrespective of CD4 count or WHO clinical stage so
as to prevent HIV transmission to an HIV-negative partner.
Recommendations:
Pregnant and breastfeeding women and those in labour and child birth should be initiated
on the first line regimen. Preference is given to TDF/FTC/EFV fixed dose combination.
ART for PMTCT is an emergency. ART should be started soon after as HIV-infection is
confirmed. Preparations of women for ART should be expedited.
All women living with HIV who get pregnant while on ART should continue with the same
ART regimen they were using before getting pregnant.
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An HIV-positive member of a discordant couple should be started on lifelong ART
irrespective of CD4 count or WHO clinical stage so as to prevent HIV transmission to an HIV-
negative partner.
In TB-HIV co-infection, antituberculosis treatment should be initiated first, followed by ART

as soon as possible within the first 8 weeks of treatment. Efavirenz should be used as the
preferred NNRTI in patients starting ART while on antituberculosis treatment.
8.8 What to expect when ART is started

When ART is started, after several months of treatment and adherence, the viral load is
suppressed and this leads to clinical and immunological improvement (increased CD4 count).
In the first few months (usually about three) however, some negative events may occur.
Often, these are due to the immune reconstitution inflammatory syndrome (IRIS) and or side
effects of ART. Some side effects occur much later.
8.8.1 Immune reconstitution inflammatory syndrome (IRIS)

This is a spectrum of clinical signs and symptoms thought to be associated with immune
recovery brought about by a response to ART. It occurs among 1030% of the people
initiating ART, usually within the first 48 weeks after initiating therapy. It may present in two
different ways: paradoxical IRIS, when an opportunistic infection or tumour diagnosed
before ART initially responds to treatment but then deteriorates after ART starts; or
unmasking IRIS, in which initiating ART triggers disease that is not clinically apparent before
ART. IRIS is a diagnosis by exclusion. It should be considered only when the presentation
cannot be explained by a new infection, expected course of a known infection or drug
toxicity. The most serious forms of paradoxical IRIS are for TB, cryptococcosis, Kaposis
sarcoma and herpes zoster. BCG vaccineassociated IRIS (localized and systemic) may occur
in infants. PLWHIV who are most likely to get IRIS are those who at initiation of ART have a
low CD4+ cell count (<50 cells/mm3), disseminated opportunistic infections or tumours or
have been on treatment for opportunistic infections for a short duration. IRIS is generally
self-limiting, and interruption of ART is rarely indicated, but people may need to be
reassured in the face of protracted symptoms to prevent discontinuation of or poor
adherence to ART. The most important steps to reduce the development of IRIS include:
earlier HIV diagnosis and initiation of ART before CD4 decline to below 200 cells/mm 3;
improved screening for opportunistic infections before ART, especially TB and cryptococcus ;
and optimal management of opportunistic infections before initiating ART. Most pregnant
and breastfeeding women have high CD4 counts at the time of starting ART and are
therefore unlikely to develop IRIS.
8.8.2 Side effects of ARVs

Approximately 80 per cent of pregnant and breastfeeding women on ART will experience
some side-effects. This is similar to the percentage of people using ARV drugs who are not
pregnant or breastfeeding. Most side-effects are minor; they include nausea, feeling tired,
and diarrhoea. In rare instances, however, they can be very serious.
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The side-effects of ARV drugs that are most likely to be confused with or even combined
with pregnancy-related problems or complications such as nausea and vomiting, headache,
fatigue, pallor/anaemia, fever, jaundice, abdominal/flank pain, cough/difficult breathing, and
depression.
Table 5: Side effects of ART in pregnant and breastfeeding women and their management.
Response
Signs or symptoms Special additional considerations in managing pregnant or breastfeeding
women are in italics.
Nausea or vomiting Take the drugs with food. If on AZT, reassure the patient that this is
common, and usually self-limited. Treat symptomatically (. If it persists
for more than 2 weeks or worsens, call for advice or refer.
This is a common pregnancy-related problem in the first 14 weeks of

gestation. Morning sickness can be made worse by nausea from ARV
drugs. If no response to dietary changes and no other signs or
symptoms, try vitamin B6 (25 mg 3-4 times daily, not to exceed 100
mg/day). If no response and vomiting interferes with ART or fluid intake,
give phenergan IM or rectally. If no response, consult or refer.
Headache Assess for meningitis Measure BP, If diastolic BP >90 mm Hg, consider
pre-eclampsia
If on AZT or EFV, reassure that this is common and usually self-limited. If

it persists more than 2 weeks or worsens, consult or refer.
Give paracetamol if no underlying problem.
Diarrhoea Hydrate, prevent dehydration. Reassure patient that, if due to ARV, it will
improve in a few weeks. Follow up in 2 weeks. If not improved, call for
advice or refer.
Fatigue Consider anaemia, especially if on AZT. Check for pallor and check
haemoglobin. If it is due to anaemia and the HB level is <7 g/dl, then
stop AZT if on ART prophylaxis. If on ART, replace AZT with TDF. Manage
the anaemia. If not because of the anaemia, fatigue commonly lasts 4 to
6 weeks especially when starting AZT. If severe or longer than this,
consult/refer. Pregnancy is a common cause of fatigue but it is important
to think of other causes.
Pallor: anaemia Measure haemoglobin. If severe pallor or pallor with other signs of
severe anaemia or very low haemoglobin (<7 g/dl), stop AZT if on ARV
prophylaxis and refer/consult with a clinician. If on ART, replace AZT with
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Response
Signs or symptoms Special additional considerations in managing pregnant or breastfeeding
women are in italics.
TDF.
Make sure any patient with anaemia is given iron/folate tablets,

mebendazole tablets (if not given in the last 6 months), and malaria
treatment, if at risk.
Anxiety, This may be due to efavirenz. Give EFV in the evening before bed;
nightmares, counsel and support (usually lasts <3 weeks). Call for advice or refer if
depression, suicidal severe depression, suicidal, or psychosis. Initial difficult time can be
ideas managed with amitriptyline at bedtime.
Consider depression during pregnancy, and postnatal depression in the

first weeks after birth.
Blue/black nails Reassure, no danger. Common with AZT.
Rash If on nevirapine or abacavir or septrin, assess carefully. Call for advice. If

generalized or peeling or with mucous membrane involvement, stop all
the ARV drugs and septrin and refer to hospital.
If a pregnant woman is on nevirapine, a new rash is likely due to this and

may indicate a life-threatening situation. Pregnancy-related rashes are
rare and this diagnosis is made clinically. Any pregnant woman with
unrelenting pruritus should be evaluated by an experienced clinician.
Fever Check for common causes of fever. This could be due to side-effect of
the ARV drugs, an opportunistic or other new infection, or immune
reconstitution syndrome (IRIS). Treatment of IRIS requires an
experienced clinician.
Yellow eyes Stop all medications.

(jaundice)
Jaundice in pregnancy can be caused by many diseases, some of which
can be fatal if not managed urgently and correctly. All pregnant women
with jaundice should have an urgent evaluation by an experienced
clinician and a liver function test done
Abdominal or flank Abdominal or flank pain: consider abruptio placenta, labour, and
pain conditions more common in pregnant women such as pyelonephritis.
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This condition requires an experienced clinician.
Tingling, numb or If new or worse on treatment, consult or refer. Patient on d4T-3TC-NVP

painful feet/legs or should have the d4T discontinued; substitute AZT if no anaemia (check
hands haemoglobin before starting AZT).
Cough or difficult This could be an opportunistic infection or IRIS or side-effect of the ARV
breathing drugs (i.e. lactic acidosis). Treatment requires an experienced clinician.
In pregnancy or postnatal, consider severe anaemia, cardiac failure,
respiratory infection, and pulmonary embolus.
Changes in fat Discuss carefully with your patient can she/he accept it? Counsel and
distribution educate the patient. This can lead to poor treatment adherence.
In patients on Consider abacavir hypersensitivity syndrome, a life threatening situation.

abacavir: Fever, Discontinue abacavir immediately and forever if hypersensitivity
fatigue, rash, sore syndrome is suspected.Abacavir should not be started in a patient who
throat, or shortness has history of abacavir hypersensitivity syndrome.
of breath
Patients on Refer if suspected kidney problem. If possible determine serum urea and
tenofovir creatinine levels. If abnormal, consult or refer.
8.9 Transition from option A to B+ the current recommendations:

When a facility begins implementing the new recommendations, transition from OPTION A
should occur as follows:-
Women on AZT should start ART (three drugs) at the next facility visit without a gap.
Having started on ART, women should not swallow single dose NVP they may have been
given to take home.
Women arriving in labour after swallowing AZT should not be given AZT/3TC but ARTStart all
breastfeeding HIV infected women on ART (even if they have taken one of the previous
PMTCT prophylaxis regimens during pregnancy and/or delivery
Bring back any remaining ARVs to the clinic.
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CHAPTER 9: ADHERENCE TO ART AND RETENTION IN CARE:
9.1 Introduction
9.2 Definition of Adherence

Adherence to treatment is the ability to take ART drugs at the times, frequencies, and under
specified conditions as prescribed by a HCW. Retention in care is the ability to come for
clinical visits as recommended by a HCW. In the case of pregnant and breastfeeding women
living with HIV, retention in care refers not only to HIV/AIDS care but also to services offered
during pregnancy and breastfeeding. Some people may be adherent to treatment but miss
clinic appointments. On the other hand, patients who miss routine visits may be taking
medications as prescribed. Both adherence to ART and retention in care are essential if
pregnant and breastfeeding women living with HIV are to use health services successfully for
PMTCT, for their own health and that of their new born babies
9.3 Advantages of adherence to ART and retention in care.

When ART drugs are taken as prescribed, they are more effective in stopping viral
multiplication and keeping the viral load very low. When the viral load is very low, the
chances of MTCT of HIV are also very low. In addition, the CD4 count raises and protests the
body from opportunistic infections. On the other hand, non-adherence to ART results in
inconsistent drug levels in blood which allows continuous viral multiplication. Viral
multiplication in the presence of sub-therapeutic ARV drug levels in blood increases the
chances for the formation of viral variants resistant to the currently prescribed medication.
When the virus develops resistance, it cannot be suppressed by the prescribed ARV drugs
and the viral load raises thereby increasing the chances of MTCT as well as causing a decline
in CD4 counts and body immunity in general. Low adherence to treatment is associated with
higher hospitalization rates, productivity loss, disease progression, and death. When drug
resistance develops patients need to be moved to second line ARV drugs which are more
expensive. Drug-resistant virus can also be transmitted from mother to child and to a sexual
partner. Low adherence to ART has negative implications for programs and patients; and
may result in transmission of drug resistant viruses. Once a client has started ART, adherence
to treatment and retention in care are the most important factors for treatment success.
9.4 Causes of poor adherence to ART and retention in care:

A number of factors are associated with poor adherence to treatment and retention in care.
These include:
Psychosocial (e.g. depression, stigma, substance/alcohol abuse)
Socio economic (e.g. cost of transport, food insecurity, lower literacy)
Poor access (e.g. long waiting times, cost of medication, transport costs)
Environmental (e.g. client-provider relationship, support services)
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Community (e.g. lack of awareness, stigma) etc.
Pill burden and concurrent opportunistic infections may also interfere with adherence to
treatment.
Stock outs.If the medications are not available at health facilities, adherence is likely to be
poor.
The pregnancy and breastfeeding period presents challenges that may affect treatment
adherence. Pregnancy-related conditions such as nausea and vomiting may negatively affect
treatment adherence. Other challenges during this period may include dealing with the
diagnosis of HIV infection (many women learn about their HIV infection during routine
screening during pregnancy); concerns about how ART affects the health of the foetus; pill
burden; the number of clinic visits during pregnancy; fear of disclosure of HIV status to
partners; long waiting times at clinics; and lack of follow-up and transfer to other clinics after
delivery. A number of studies suggest that women are less likely to adhere to medication
and be retained in care postpartum than when pregnant. Therefore it is important to
maximise interventions for adherence during pregnancy.
9.5 Assessment of adherence to ART and retention in care

It is important for HCWs to routinely assess adherence to ART and retention in care. Reasons
for poor adherence and missed appointments need to be established so that PLWHIV can be
given support to address the challenges. Methods for assessing adherence include:-
9.5.1. Assessing adherence to ART.

Adherence to ART can be assessed using patient self-report, pill count or pharmacy refill
records.
Patient self-report:Asking PLWHIV or their caregivers how many doses of ARV drugs they
have missed since the last visit (or within a specified number of days in the past) can help to
estimate non-adherence. However, although this method is commonly used, people may not
remember missed doses accurately or may not report missed doses because they do not
want to be criticised by HCWs. Counselling on the importance of documenting ARV drug
doses and an environment that promotes and enables honest reporting of non-adherence
are critical components of monitoring adherence to ART in routine care settings.
Pill count: Counting the remaining pills in bottles during routine heath care visits may help to
assess adherence. However, some people may throw away tablets prior to visiting health
facilities, leading to overestimated adherence. Although unannounced visits at peoples
homes could lead to more accurate estimates, this approach poses financial, logistical and
ethical challenges.
Pharmacy refill records: Pharmacy refill records provide information on when PLWHIV picked
their ARV drugs. When they obtain pharmacy refills at irregular intervals, this may indicate
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non-adherence to ART; however people may still pick up their medications whenever they
come for routine care without swallowing the medications as prescribed. This behaviour
could lead health care providers to overestimate adherence by solely using pharmacy refill
records.
None of these common methods is very accurate, but can still be used. This is better than
not making any attempt to assess adherence of PLWHIV on ART.
9.5.2 Assessing retention in care

To monitor retention in care, reliable patient tracking and tracing systems are used to
identify patients who have missed visits or are lost to follow-up (have not turned up for
more than 3 months). The simplest way is for health facilities to use an appointment register
where return dates of patients are recorded. On clinic days, a comparison is made of the
clients who turned up and the ones expected. A list of those who did not show up is made
and used to call or trace them. Mobile text messages (SMS) can be used to remind PLWHIV
not to miss their appointments and also inform those who have missed their appointments.
The usefulness of text messages in reducing non-adherence has been well established and is
recommended by the WHO 2013 consolidated guidelines.
Recommendation:
Mobile phone text messages could be considered as a reminder tool for promoting
adherence to ART as part of a package of adherence interventions.
9.6 Strategies to enhance adherence to ART and retention in care

No single intervention will ensure adherence to ART for all clients at all times. There is need
for a combination of interventions. Below are some of the interventions but not all.
Depending on the circumstances, the health facilities can innovate and use what works best.
9.6.1.1Medication Adherence Counselling

Medication adherence counselling can improve the knowledge and understanding patients
have about their disease. Adherence counselling should be provided both before and after
initiation of ART to pregnant and breastfeeding women living with HIV as well as their
partners and treatment supporters where possible. Preparatory counselling should first
assess the PLHIVs readiness to start ART. Early and on-going education to women and their
treatment supporters should emphasize the importance of adherence for PMTCT and for the
health of the mother. Consequences of non-adherence such as MTCT of HIV, increase in viral
load and development of resistance, decrease in CD4 cells and immune function, disease
progression should also be discussed.
9.6.2 Managing substance use and mental health.

Improving well-being of PLHIV by treating depression and managing substance use disorders
(e.g. excessive alcohol intake) can improve adherence to ART. Where feasible, HCWs should
screen PLWHIV for depression especially those with poor adherence to ART. Depression may
also occur as part of the postpartum complications.
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9.6.3. Reminders and cues
One of the common reasons for poor adherence is I forgot. In order to address
forgetfulness, PLWHIV would benefit from reminders to take their medications. At an
individual level, clients may use alarms on watches or cell phones, diaries and calendars
9.6.4 Peer support

Peer support relies on a friend or family member to help the patient to take medications
regularly as well as providing some social and logistical support. This would include
reminding the patient to take their medication on time, offering encouragement to keep
going, helping to keep clinic appointments, and providing emotional support. The use of
treatment supporters is relatively low cost and limits risks of forced disclosure because the
patient selects his or her own treatment supporter. In some programs, a PLWHIV can only
start ART when she has a treatment supporter. Although this may enhance adherence, it
may also delay starting ART for PMTCT in pregnant and breastfeeding women. Delay in
starting ART for PMTCT increases the chances for MTCT of HIV. If a treatment supporter is
not readily available, a compromise may be to start ART and then allow the woman brings a
treatment supporter later.
9.6.5 A supportive environment

A supportive environment is essential for PLWHIV to gain trust in the health system and
participate actively in their own care. When they find poor customer care, they are less likely
to come back. Health facilities need to implement the principles of good chronic care. HCWs
should avoid being judgemental and ensure 100% confidentiality. That way, patients will feel
free to share with a health care worker their challenges and together look for solutions.
HCWs should be available on days when PLWHIV attend clinics.
9.6.6 Food/Social Support:

Competing demands of family expenses have been found to affect treatment adherence
negatively. Improving access to food, clean water, sanitation, education, and economic
opportunities may help to improve adherence. PLWHIV should be linked with organisations
offering social/food support in the community.
9.6.7 Decentralisation of ART

When ART services are located far away from where PLWHIV live, adherence to care and
treatment can be compromised. People living in rural areas are usually affected by this
problem. In order to address this challenge, decentralisation of ART services to lower health
centres as well as establishing outreaches in the community should be considered. The main
challenge for decentralisation of ART is the insufficient human resources for health.Health
care personnel remain insufficient in South Sudan. Although the long term solution is to
train more health workers, in the interim, clinical tasks can be shared and shifted to ensure
that PLWHIV receive services. Task shifting is where some clinical work usually done by
clinicians or doctors is shifted to nurses and some of the work usually done by nurses is
shifted to non-medical people such as mentor mothers or expert patients. Task shifting
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improves access to ART at sites without physicians (such as PHCCs). Even in hospitals with
physicians/clinicians, task shifting allows physicians to spend more time managing more
complex clinical conditions such as treatment of confections, side effects or treatment
failure. Fortunately, the new recommendations have simplified ART for PMTCT so that it can
be provided by nurses and midwives at health centres.
In order to give guidance on task shifting, the WHO consolidated guidelines of 2013, made
the following evidence-based recommendations.
Recommendations:
Trained non-physician clinicians, midwives and nurses can initiate first-line ART
Trained non-physician clinicians, midwives and nurses can maintain ART
Trained and supervised community health workers can dispense ART between regular
clinical visits
Initiation of ART includes assessment for ART eligibility (based on clinical and/or
immunological criteria); assessment for opportunistic infections; adherence counselling; and
the prescribing of first-line ART. Maintenance of ART includes on-going clinical assessment;
monitoring for toxicity, treatment failure (clinical, immunological and virological) and
opportunistic and other co-infections; adherence counselling; and the further prescribing of
ART. Dispensing ART includes assessment for any new signs and symptoms, adherence
monitoring and support and dispensing medication to patients who are already on ART
between regular clinic visits.
Rationale and supporting evidence:Because there are often strong concerns about the
ability of different cadres of health workers to offer ART, we include the rational and
supporting evidence. The supporting evidence is contained in this quotation from the 2013
WHO consolidated guidelines.
The systematic review identified three randomized trials and six observational studies
addressing task shifting. Overall, the data showed no difference in mortality and losses to
care when nurses or non-physician clinicians initiate or maintain people on ART or when
community health workers maintain people on ART, relative to physicians providing this
care. The quality of care in these studies was ensured by (1) providing training, mentoring,
supervision and support for nurses, non-physician clinicians and community health workers
(2) ensuring clear indications for patient referral; (3) implementing referral systems and (4)
implementing monitoring and evaluation systems. Patient education could help people and
their families understand that care provided by nurses and community health workers is not
of lower quality than that provided by physicians. Shifting the initiation and maintenance of
ART to adequately trained and supervised nurses and community health workers may
enable substantial cost savings through (1) the ability to decentralize care to primary care
facilities; (2) lower overhead costs for delivering quality care (with comparable or better
82
outcomes) by nurses, non-physician clinicians and community health workers compared
with physicians; and (3) decreased facility and utility costs (if care is being delivered in health
facilities complemented with community-level services). Therefore, nurses and non-
physician clinicians (clinical officers) can in initiate and maintain ART if they are well trained,
mentored and supervised. They also need to be able facilitated to consult more competent
colleagues.
9.6.8 Shortening waiting time at health facilities

Another barrier that compromises retention in care is longer waiting times at health
facilities. Some (not all) of the strategies to reduce waiting time at a health facility include
the following:-
Separating patients who need to see a HCW from those who have only come to pick drugs.
Giving PLWHIV who are stable on ART and have good adherence a 3-monthly supply of ARV
drugs.
Scheduling some specific patients to come in the afternoon when there may be fewer
patients.
CHAPTER 10: CHRONIC CARE FOR POSITIVE MOTHERS AND CHILDREN

10.1 Introduction
HIV/AIDS is an incurable disease. It is chronic. When PLWHIV are identified, they need care
and treatment for the rest of their lives. To ensure a good quality of life, health facilities
need to provide effective chronic care to pregnant and breastfeeding women living with HIV.
Health facilities usually provide acute care. Acute care includes the management of the
common illnesses such as bacterial infections, skin, and neurological and mental health
problems. Some of these acute problems may be HIV related. Because most health care
systems developed in response to acute problems, they are designed to address urgent
health care needs and to diagnose, relieve symptoms, and expect cure. PLWHIV need both
acute and chronic care but they are organised differently.
10.2 What is good chronic care?

Good chronic care recognizes the fact that the patient must understand and learn to manage
his or her own chronic condition. HIV infection and its slow progression to AIDS require
much education and support to give patients the skills to manage themselves. Although the
clinical team and others at home and in the community can help, it is the patient that needs
to learn to cope with their infection, to disclose to those that they trusts in order to get
further help, to learn to practice prevention and positive living, and to understand and use
prophylaxis and ART and other treatments.
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10.3 Principles of chronic care:
There are 10 principles that a HCW should always apply so as to provide good chronic care.
Treatment partnership with a client: A partnership is an informal agreement between HCW

and client to work together in an agreed way toward an agreed goal. In case of children who
are too young to advocate for themselves, a partnership is built with the parents or
guardians etc. In a partnership both parties share responsibility for the care and treatment.
Each partner knows what role he or she plays. Partners treat each other with respect. One
partner does not have all the power to make decisions.
Focus on a clients concerns and priorities: It is important to find out and address why the
client has come to a health facility. Sometimes, by focusing only on the obvious signs or
symptoms of illness, the real reason that has brought the client to the clinic is missed.
Use the 5 AsAssess, Advise, Agree, Assist, Arrange.
Assess: Assess the patients goals for this consultation. Assess the patient physically and
psychologically, adherence, social support etc. Find out the reasons behind the findings.
Advise: This includes recommending the treatments to the patient, educating the patient,
and preparing the patient for self-management. It is important to discuss the options, not to
just tell the patient what to do. It is also important to evaluate how ready the patient is to
adopt the treatment.
Agree: Agree means that the patient understands, wants and agrees to the treatment plan.
This is a step we often skip! It may be logical to skip this step during emergency care for
trauma or a very sick patient. They have come (or been brought) for care and are too sick for
a discussion or to make a choice. For young children needing acute care, we try to tell them
what is happening but we often do not ask for their agreement (and would still treat them
even if they screamed no which they often do). However, chronic care is not an
emergency. For chronic care, AGREE is the key step in the process since it is the basis for
forming a partnership with the patient and supporting good patient self-management.
Assist: This includes treatments (medication and other treatments), advice and counselling,
but also help that you can provide the patient in terms of skills to carry out the treatments
or to overcome barriers. An important way to assist the patient is to get other help, by
linking to available support in the community or to peer support groups or involving
someone to help support them in their treatment. Usually we (and the patients) focus only
on the pills or the injection. There is much more that is needed than this for good chronic
care, especially for lifelong treatments like ARV therapy. Even the best plans for treatment
often run into problems. When the patient returns, they may need more assistance to solve
problems and overcome obstacles. We often assist the patient only with treatments and skip
other ways of assisting that may be as important.
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Arrange: A definite follow-up, scheduling a group appointment, arranging how the
medication can be picked up on the next visit, and recording what happened on the visit are
all parts of arrange.
Support client self-management.PLWHIV need to assume ownership of their own care.

Clients with chronic conditions, such as HIV, experience better treatment outcomes when
they are more involved.This is called self-management. Self-management means the patient
taking responsibility for their own health care.The patient takes responsibility for taking
medication (such as septrin or ARV drugs) and makes choices on lifestyle issues that protect
or damage their health. He or she makes choices on how to practice safer sex, use condoms,
and prevent sexually transmitted infections and undesired pregnancies. Self-management
does not just happen. It is not always automatic. It needs to be nurtured. The following
actions can support clients self-management:-
Help clients understand the options and the consequences of their decisions.
Find out regularly how well the clients are managing themselves
Appreciate and giving encouragement on the positive choices.
Provide support with the challenges. Avoid blaming clients. Patients are more interested in
their own wellbeing than anybody else.
Promoting self-management requires a good relationship between the care team and the
patient that the patient trusts and believes in. To take on this role a patient needs to be
supported and highly motivated.
Work as a clinical team (and hold team meetings).Chronic care requires the skills of different
cadres of medical workers. Teamwork between different HCWs at a health facility is essential
for providing good chronic HIV care to clients. It can also be helpful when providing acute
care to clients. The team should be inclusive of various cadres of health care workers such as
lay health workers, nurses, clinicians, pharmacy staff, and doctors where available. Each
team member is responsible for building their own skill set, as well as contributing to the
education of other team members. The team should be aware of their limits, and should
practice active referral of clients to other clinical stations in the facility, or even to other
facilities if required. A person from a different health facility may be incorporated into a
team. His/her participation may be on clinic days for example or through consultation on
phone etc.
Use written information. Written information helps the HCW to remember the treatment
plan, monitor and evaluate progress, remember when its time for a follow-up appointment
and facilitate response to missed appointments etc. This includes registers, treatment plans,
patient calendars, treatment cards. Patients should have a written or pictorial summary of
the plan to take home and a self-monitoring tool such as a calendar or chart.
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Organise proactive follow-up.
In chronic care, follow-up visits are arranged in advance. The patient is expected to a see a
health worker regularly whether the patient is sick or not. This is unlike acute care where the
patient only comes to see a HCW when s/he is sick.
Involve "expert patients", peer educators and support staff.
Link the patient to community-based resources and support.
Ensure continuity of care.
10.4 Recommendation:
All facilities offering ART for pregnant and breastfeeding women living with HIV should
establish a system for good chronic care.
CHAPTER 11: PROVIDER INITIATED FAMILY PLANNING FOR PLHIV

11.1 Introduction
Family planning (FP) is one of the strategies to prevent vertical transmission of HIV from
mother to child. By reducing the number of unplanned pregnancies in women living with
HIV, family planning reduces the number of infants exposed to HIV and therefore MTCT of
HIV. In addition to MTCT of HIV, unplanned pregnancies expose women to risks of pregnancy
and labour such as post-partum haemorrhage etc. as well as death. Spacing of pregnancies
gives a mother enough time to recover from effects of pregnancy, labour and delivery and
leads to improved quality of life of the woman and family. Family planning can improves
family wellbeing, because the couples with fewer and or well-spaced children are better able
to provide them with adequate food, clothing, housing and education.
It has been estimated that in order to virtually eliminate MTCT of HIV in resource poor
countries, unmet need for family planning must be eliminated first.Unmet need for family
planning is defined as whena woman would not like to get pregnant soon or at all but is not
using a family planning method. This means:-
Some women with HIV not using FP would NOT like to get pregnant (have unmet need for
FP)
Some women with HIV not using contraception would like to get pregnant (have no unmet
need for FP)
11.2. Reasons for unmet need for family planning.

Countries of Sub-Saharan Africa including South Sudan, where the burden of HIV is greatest
also have a high unmet need for family planning. Women living with HIV having unmet need
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for family planning may get unplanned pregnancies and some of their children get HIV-
infected.A study by US CDC in South Sudanfound that unwanted pregnancies may account
for almost a quarter of all HIV-positive infants 13.Unmet need for family planning exist
because :-
They lack adequate information about FP methods
They are concerned about perceived side effects
There are objections to FP from a spouse, community, religion, HCWs etc.
The FP method of choice is not available or is obtained far from where they live.
11.3 Meeting family planning needs:

Pregnant, breastfeeding and other women living with HIV should be routinely counselled on
family planning when come for routine antenatal, postnatal or ART services. HCWs need the
skills and knowledge on how to best to communicate with women living with HIV about
family planning. The following steps are suggested to enable PLWHIV make informed
choices about family planning:
First, women should be given information on family planning. (Apply principles of BCC) They
need to know the types of family planning methods, advantages and side effects. The
common misconceptions need to be identified and challenged. It should be clear that the
reproductive choices of a woman, regardless of HIV status, will be respected and
safeguarded. They should also know that women living with HIV who wish to have children
will be supported. Breastfeeding women will need information about methods that are
appropriate for both her HIV-positive status and for a postnatal woman. If she is not
exclusively breastfeeding, she could become pregnant again as soon as 4 weeks after
childbirth. She should start using a family planning method as soon as she can, and before
she starts sexual activity again. If she is exclusively breastfeeding she should start another
family planning method before 6 months after childbirth. Women also need information on
the advantages of dual protection and also how to negotiate for condom use.
The initial information giving could be in a group counselling session for pregnant and
breastfeeding women.
Secondly, all women should be offered family planning on a one-to-one basis. For
breastfeeding women living with HIV, this may be at the EID care point, in the family
planning clinic or in the ART clinic. All these facilities should be able to provide family
planning services. This provider initiated family planning is by asking 3 questions in a non-
judgemental manner. These are:-
Would you like to have more children?
13
(Hladik et al., 2008a).
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If YES: find out soon or in future. If she wants more children offer counselling on PMTCT. If
she is already on ART, emphasize adherence. If she is not on ART (see section on women
desiring pregnancy)
If she wants to avoid or delay pregnancy ask: Are you currently using any method to delay or
avoid pregnancy?
If yes: find out if it is MODERN or TRADITIONAL. If traditional, counsel about modern

methods of family planning.
If NO ask: Would you like to start using any method NOW?
If NO: find out why and offer support and or counsel accordingly.
If YES, provide the method she would like to use or refer accordingly.
11.4 Family planning methods for women living with HIV

Women living with HIV are advised to use dual method (Condom and another contraceptive
method). The condom prevents re-infection with other HIV strains or STIs. Women with HIV
can use most methods of family planning. The latest WHO guidelines confirm that these
methods are safe for HIV-positive women, and those who are at risk of HIV. 14This includes
hormonal methods, such as the pill, IUD and injections. However, PLWHIV should not use:-
Spermicides, or diaphragms or caps with spermicide
Women taking a TB drug rifampicin or an ARV with ritonavir should not use pills.
Table 6: Short term family planning methods.

Common
Effectiveness (pregnancies Considerations if
Method How to use side-
per 100 women) HIV-positive
effects
Male Use every Highly effective when used None Condoms are
condom time you correctly each time the only
have sex (2 pregnancies/ year) contraceptive
method that
Less effective as commonly
protects against STIs
used (15 pregnancies/year)
and HIV
14
Medical eligibility criteria for contraceptive use, WHO, 2009.
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Common
Effectiveness (pregnancies Considerations if
Method How to use side-
per 100 women) HIV-positive
effects
Female Use every Effective when used None Condoms are

condom time you correctly each time(5 the only
have sex pregnancies/year) contraceptive
method that
protects against STIs
used(21 pregnancies/year)
and HIV
Oral Take a pill Highly effective when used Menstrual HIV-positive women
contracepti every day correctly(<1 pregnancy changes, and women on ART
ve pills /year) spotting, should use pills in
headaches combination with
, nausea condoms (dual
protection)
Injectables Get an Highly effective when used Spotting HIV-positive women

injection correctly initially, and women on ART
every 1, 2, (<1 pregnancy/year) then no should use
or 3 months bleeding injectables in
combination with
condoms (dual
protection)
Emergency Take within Reduces chances of Nausea Not as effective as

contracepti 5 days after pregnancy from that one other methods for
ve pills condom act of unprotected sex to regular use
breakage/ 1/4 or 1/8 of chances if not
other used
unprotecte
d sex
Table 6: Long-term family planning methods.
Implant, IUD, Provide long-term, highly effective contraception (<1 pregnancy per 100
vasectomy, women per year) and can be used by women with HIV.
female
Vasectomy and female sterilization are permanent methods, for couples
sterilization
or women who know they will not want more children.
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Use in combination with condoms for dual protection.
These methods require a procedure performed by health care provider.
11.5 Women living with HIV who wish to get pregnant:

Many men and women living with HIV desire to have children although many clients may
feel uncomfortable discussing it with HCWs. By asking the 3 questions above, women in
wishing to get pregnant will be identified. Reproduction is a basic human right, and for many
women having a child is part of their life plan. Indeed, in many parts of Africa being without
a child attracts significant stigma.
The reproductive health needs of PLWHIV should always be supported if well advised.
Unfortunately, some HCWs hold very negative attitudes to this and many do not have the
skills or knowledge to offer the required support. Because of the negative attitude and lack
of support from HCWs, when women living with HIV get pregnant, they find it hard to come
back to the same health facilities or HCWs.This may result in MTCT and or complications to
mother and/ or baby. If the 3 questions are routinely asked to breastfeeding women living
with HIV, those wishing to have more children will be identified. They will also induce a client
to discuss this rather sensitive issue.
11.5.1 Counselling for HIV-positive client desiring a pregnancy

First, explore what clients know about HIV transmission and conception
Secondly give them information about the risks:
Having unprotected sex means a client may transmit HIV and STIs to an HIV negative partner
or can acquire STIs or new strains of HIV that make their disease advance more quickly.
The risk of MTCT is always there. In the absence of ART, the risk of MTCT of HIV is about
35%. This means that about 1 of every 3 of HIV-positive women pass virus to their baby.
With ART transmission can be as low as 5% but it is not completely eliminated.
Finally, the client needs to understand the recommendations: These are:-
Voluntary partner testing and mutual disclosure. If the partner is sero-negative, the couple
should understand the risk for HIV transmission.
The woman should get appropriate care and treatment of any infections
The woman should be on ART through pregnancy, labour and delivery and breast feeding. If
the woman is not on ART already, she should start ART for at least 4 months before having
unprotected sex for purposes of conception. The four months is to ensure a very low viral
load at conception.
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The woman should give birth in a health facility and the baby receives ARV prophylaxis at
birth.
Mother should adhere to the infant feeding recommendations.
In some resource rich countries or private health facilities, artificial insemination may be
available to help discordant couples reduce or eliminate the risk of transmission. This is
usually very costly.
CHAPTER 12. IDENTIFICATION ,CARE AND FOLLOW-UP OF HIV

EXPOSED INFANTS
12.1 Introduction
HIV- exposed infants (HEIs) refers to children born to women living with HIV whose HIV
infection status is not known. For program purposes, they should also be less than 18
months of age or above 18 months and still breastfeeding. HEIs could be HIV infected or not.
It is important to identify the HEIs, who are HIV infected so that they are started on ART. HIV
infected infants have very fast disease progression. Without treatment, one out of every two
children infected at birth die by two years of age. In order to establish their HIV-infection
status, which may take some time because it requires DNA PCR or the infant is still
breastfeeding and exposed to HIV infection, HEI need to be identified and followed up.
12.2 Identification of HIV-exposed Infants

A system is required to ensure that all HEIs in a health facility and in the community are
identified,registered at the EID care point. The EID care point is mainly for records purposes
since it is expected that care of HEI will be part of the routine services in the MCH. HEIs can
be identified by testing mothers or babies. The most common service areas to identify HEI
are during pregnancy, breastfeeding and when sick children are brought to hospital.
Pregnant women:Pregnant women identified as HIV-infected during ANC should be referred

to the EID care point for registration before they give birth. They should be informed about
the services of the EID care point and asked to bring their new-born children at the EID care
point at 6 weeks of age.
Breastfeeding mothers: Breastfeeding women routinely come to the MCH clinic for child
immunisation or other services such as family planning. When a breastfeeding mother
comes for these services, the HCW should check on the chart of the mother or baby to find
out if the mother was tested during pregnancy.For mothers tested during ANC, the testing
information is transferred from the mother to baby card. For mothers who did not test or
tested but have no record or tested more than 3 months before, PITC with opt out using
rapid antibody tests is offered. The mother or baby may be tested.If the mother tests HIV-
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positive then she is HIV-infected and the baby is HIV exposed. Whether the mother acquired
HIV after giving birth, as long as the infant is breastfeeding then the infant is HIV-exposed. A
child of any age, born to an HIV-infected mother, who tests HIV-negative with antibody test
but is still breastfeeding should also be regarded HIV-exposed and is registered at the EID
care point for follow-up.
Sick and or malnourished children: Where possible, PITC for sick and/or malnourished
children should be implemented. If this is not feasible, then children in the outpatient
department (OPD) or hospitalised with diseases suggestive of HIV-infection should be tested
for HIV using rapid antibody tests. Those testing positive and are less than 18 months and or
still breastfeeding are HIV-exposed. In order to determine if a child has an infection
suggestive of HIV, it is important to note that the diseases that HIV-infected children
commonly suffer from are similar to those that commonly affect HIV-uninfected children.
Whether HIV-infected or not, children in South Sudan will often present with fever (usually
malaria), diarrhoea, pneumonia, malnutrition or a combination of these. However, HIV-
infected children are more likely to get sick often and their sicknesses tend to be more
severe, prolonged and respond poorly to usual treatment. In addition however, HIV-infected
children are more likely to have rare opportunistic diseases such as pneumocystis (carinii)
jiroveci pneumonia (PCP), cryptococcal meningitis, Kaposis sarcoma etc. They are also called
HIV-related diseases. Therefore, HIV infection should be suspected in a child with
recurrent /prolonged common infections or an opportunistic infection. Common symptoms
and signs suggestive of HIV include: severe malnutrition, oral candidiasis, generalized skin
rashes, generalized swollen lymph nodes, recurrent severe pneumonia, recurrent or
persisting diarrhea, herpes zoster, chronic discharging ear, persistent nasal discharge
(sinusitis), recurrent/persistent fevers, delayed mile stones, small head and Kaposis sarcoma
Recommendation
Infants with signs or symptoms suggestive of HIV infection should undergo HIV serological
testing and, if positive (reactive), referred to the EID care point.
12.3 ARV prophylaxis for HIV exposed Infants

Children born to women living with HIV need ARV prophylaxis for PMTCT at birth or
whenever identified if they are still breastfeeding. At birth, all HEI should be given NVP
prophylaxis for 4-6 weeks. HEI may also be identifiedduringbreastfeeding either because no
HIV test was done during pregnancy or a pregnant woman with HIV gave birth at home or in
a facility without PMTCT e.g. a private midwife.When an HEI is identified during
breastfeeding, the infantshould be examined clinically for HIV infection and a sample taken
off for DNA PCR. Those who are not HIV-infected should also be given prophylaxis with NVP
for 4-6 weeks. Those who are infected should be started on ART.
12.4 Services for HIV exposed infants

EID care point: All facilities offering PMTCT should establish a point in the MCH that will keep
the records of HEIs such as registers, clinical charts, appointment book, and materials for
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DNA PCR etc. Sample collection for DNA PCR is done here and results for DNA PCR are also
sent here.
Registration of HEIs (including pregnant women with HIV). All HEI should be registered at the
EID care point.
Provide information to pregnant and breastfeeding women living with HIV (and or other care
givers) about the services HEIs require on registration and subsequent visits. The information
should cover:-
The need for HIV testing to rule out HIV infection from the time of registration until the end
of breast feeding. Most of the HEI are uninfected but those infected need to be identified
early and started on treatment.
Explain the importance of regular follow-up visits, and prophylaxis with septrin. Septrin
prevents malaria, pneumonia and diarrhoea in HEIs.
Reasons for and how to give NVP to the newborn: NVP will reduce risks of transmission of
HIV, and completing the entire course of NVP regimen is important. Ensure the mother
giving the NVP syrup correctly.
Initial DNA PCR test. As soon as an HEI is registered with the EID care point, a DBS sample is
collected and transported to the laboratory for testing. Results from the laboratory are sent
back to the EID care point and given to the mother or care giver. The EID care point
coordinates the whole of this process.
HIV antibody testing: From 9 months, an HIV antibody test should be done and if it is
positive and the child is sick, ART should be started and a confirmatory HIV antibody test
should be done after 18 months of age. If it is positive after 18 months, ART continues, it is
negative ART stops.
12.5 Basic care to HIV exposed infants

This includes:-
Routine childhood immunizations.
Assessment of growth: regular measurement of weight, length, mid-upper arm

circumference and plotting on a growth chart. Growth failure may be a sign of HIV
disease.
Clinical assessments for signs and symptoms of disease and treatment. If signs and
symptoms suggestive of HIV disease are present and the infant fulfils the criteria for
presumptive clinical diagnosis of severe HIV disease, ART should be started and
diagnosis confirmed later after 18 months.
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Developmental assessments for evidence of delay. If an HEI has developmental delay,
with no other obvious reason, may have HIV encephalopathy. ART should be started
and diagnosis confirmed after 18 months.
Provide septrin prophylaxis to the baby.
Provide ARV prophylaxis to the baby if it is still required
Provide vitamin A supplements every 6 months beginning at 6 months of age.
Provide INH prophylaxis for the TB-exposed infants without TB disease.
Provide counselling so that the mother practices exclusive infant breastfeeding for
the first 6 months of age and appropriate complementary feeding from 6 months of
age, breastfeeding up to 12 months and weaning when she has a safe and
nutritionally adequate substitute to breast milk.
Link HIV-infected children to ART clinic if it is separate.
Final HIV test. All HEIs should have a final test, 6 weeks after stopping all
breastfeeding.
Care and treatment for the mother including Septrin prophylaxis and ART.
12.6 Testing HIV exposed infants:

Unlike adults, antibody tests cannot be used conclusively to determine the HIV-infection
status of children less than 18 months of age because most of them still have antibodies
from the mother. To establish HIV infection in these children, tests that detect the virus itself
(virological tests) are used.
The common virological test used to test for HIV in exposed infants is DNA PCR. DNA PCR is
a complicated test that can only be done in specialized laboratories. It is believed South
Sudan will have such a laboratory in the near future. Blood samples for DNA PCR are taken
off from an HEI onto a piece of filter paper. The samples are then dried (dry blood spots or
DBS) and sent to the testing laboratory. DBS for DNA PCR should be taken off when the HEI is
4-6 weeks of age or as soon as is identified before 18 months of age. When it is not possible
to do a DNA PCR fast enough or not at all, two strategies can be used to identify HIV-infected
earlier than 18 months.
At any age: Presumptive clinical diagnosis of severe HIV disease:It is possible to use clinical
signs and symptoms in a sick HEI to make a diagnosis. This is called presumptive clinical
diagnosis of severe HIV disease. It is not conclusive but can be used to start ART. A
presumptive clinical diagnosis should only be made with the intention of starting ART i.e. in
a child who is so sick that he/she needs treatment urgently. To make a presumptive clinical
diagnosis of severe HIV disease, the child should have:
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HIV antibody positive AND
Either an AIDS indicator condition OR
at least two of the following: oral thrush, severe pneumonia, or severe sepsis.
Two other factors supporting the presumptive diagnosis of severe HIV disease in an HIV-
positive infant would be a CD4 cell count of less than 20% and either advanced maternal
HIV disease or recent HIV-related maternal death.
From 9 -18 months: The child is still HIV antibody positive and sick.
Although 18 months is taken to be the age at which all the HEIs have no more maternal
antibodies, most of HEI will have lost maternal antibodies by 9 months of age. In the
absence of DNA PCR if an HEI
12.7 Care for TB-exposed infants:

Persons with HIV are at increased risk of having TB disease, due to the immune-suppression
caused by HIV. An HIV-positive woman should be assessed for TB during each visit to the
health facility. If the mother is diagnosed with pulmonary tuberculosis and started treatment
less than 2 months before delivery or diagnosed after birth, the baby should receive INH
prophylaxis.
The baby should be given 5mg/kg isoniazid (INH) orally once a day for 6 months (1 tablet =
200mg) to the baby.For TB-exposed newborns at birth, BCG vaccine should not be given. It
should be delayed until INH prophylaxis is completed, or BCG should be repeated after
complete course of Isoniazid Preventive Therapy (IPT). The mother should be reassured that
it is safe to breastfeed the mother.
12.8 Septrin prophylaxis for the baby

Septrin prophylaxis should be started at 4-6 weeks of age, or when the HIV-exposed infant is
first seen, if presents later.
Septrin prophylaxis should be continued if the infant is HIV-infected.
Septrin prophylaxis should be discontinued if HIV-infection is excluded and child is no longer

breastfeeding.
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12.9 HIV-exposed infant follow-up schedule.
Recommendations:
All HIV-exposed infants should be registered at the EID care point where their DBS for DNA
PCR will be collected and results provided .
HIV-exposed infants have DNA PCR at six weeks of age or at the earliest opportunity
Positive virological testing at any age will be considered indicative of HIV infection, but a
repeat virological test or HIV antibody testing (after 18 months of age) needs to be done to
confirm HIV infection.
Breastfeeding infants: window period of six weeks required before negative virological test
results can be assumed to reliably indicate HIV infection status after the complete cessation
of breastfeeding.
Children testing HIV anti-body testing at the age of 9 months or more and are sick will be
considered as HIV infected and started on treatment, but needs to be confirmed by repeat
antibody testing after the age of 18 months
Definitive HIV diagnosis in children aged 18 months and more can be made with HIV
antibody tests, including rapid antibody tests (3 test algorithm)
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If virological testing is not available, presumptive clinical diagnosis accompanied by HIV
antibody testing should be used to identify timely infants in need of potentially life-saving
ART
Protocol for testing HIV-exposed infants;
Alogarithm of HIV-testing in Adults
Alogarthm of HIV testing in children older than 18 months.
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CHAPTER 13. INFANT AND YOUNG CHILD FEEDING COUNSELLING
WITHIN THE CONTEXT OF HIV
13.1 Introduction
Infant feeding practices have a major impact on child health and survival. Infant feeding
refers to breastfeeding and complementary feeding. Complementary feeding starts at 6
months of age. Breastfeeding has many benefits for the baby. For example, the baby
receives antibodies from the mother to protect him/her against common diseases. Breast-
milk also contains growth factors and the correct balance of nutrients that aid development
of the baby. And, as a result of protective factors, death from diarrhoea, respiratory disease,
and pneumonia are less common among breastfed babies. Thus, breastfeeding is critical for
survival of the infant.
However, in the context of HIV infection, infant feeding is a challenge. Despite the many
benefits of breastfeeding, a mother who is HIV-positive can pass on HIV to her baby through
breastfeeding. In developed countries, women living with HIV may choose not to breastfeed
at all and instead use infant formula (replacement feeding). However, this has been found to
be dangerous for the majority in poorer countries of sub Saharan Africa because most
families cannot afford safe replacement feeding. It is important to note that there have
been various recommendations for breastfeeding and as a result there is a lot of confusion
among health workers in this area.In these guidelines, the breastfeeding recommendation is:
Mothers known to be infected with HIV (and whose infants are HIV uninfected or of
unknown HIV status) should exclusively breastfeed their infants for the first 6 months of life,
introducing appropriate complementary foods thereafter, and continue breastfeeding for the
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first 12 months of life. Breastfeeding should then only stop once a nutritionally adequate
and safe diet without breast-milk can be provided.
13.2 for exclusive Breast Feeding

The justification of this guidance is based on three reasons.
First, WHO recommends that: National health authorities should decide which feeding
practices will be adopted nationally for HIV-positive mothers and their babies, that is
whether:
To adopt breastfeeding with ART to reduce transmission OR
To avoid breastfeeding completely.
In the case of South Sudan, the choice is to adopt breastfeeding with ART to reduce
transmission.
Secondly, WHO also recommends breastfeeding for 12 months because the maximum
benefit of breastfeeding in preventing mortality from diarrhoea, pneumonia and
malnutrition is in the first 12 months of life.
Thirdly, although the risk of HIV transmission is always there, it is much lower in
breastfeeding women living with HIV on ART especially if it is started during pregnancy and
with good adherence. The 6 week NVP prophylaxis that HEI receive at birth or whenever
they are identified also contributes to prophylaxis. However, HCWs and breast feeding
women should be aware that the key to avoiding HIV transmission is adherence to ART in
the mother.
At every routine visit, breastfeeding women living with HIV need counseling on infant
feeding. They need to be informed on:-
The fact that breast feeding always has a risk for HIV transmission at any time. This risk can
be minimized by exclusive breast feeding for the first 6 months and adherence to ART during
pregnancy and breastfeeding. Mixed feeding increases the chances of HIV transmission as
well as diseases such diarrhea and malnutrition. Poor adherence to ART increases the
chances of HIV transmission through breast milk.
13.3 How to make a decision to stop breastfeeding after 12 months.

Correct positioning of children to avoid sore nipples and having them treated when they
develop.
How to provide optimal complementary food using the locally available ingredients
Essential behaviors for exclusive breastfeeding
Essential behaviors for complementary feeding.
99
Counseling of mothers without enough breast milk
Essential behaviours for exclusive breastfeeding.
A mother practices optimal breastfeeding during the first six months when she:
Initiates breastfeeding within one hour of birth.
Feeds the colostrum to the baby.
Positions and attaches the infant correctly at the breast.
Breastfeeds on demand.
Breastfeeds frequently during the day.
Breastfeeds during the night.
Offers second breast after infant empties the first.
Gives only breast milk; gives no water or teas or any other liquids or foods.
Continues breastfeeding when she is sick.
Increases breastfeeding frequency during and after infants illness, including diarrhoea.
Seeks help from a trained health worker or counsellor if she has problems with
breastfeeding.
Eats sufficient nutritious foods herself and takes supplements as recommended by the
health provider
13.4 Essential Behaviours for complementary feeding
A mother practices optimal complementary feeding during the period 6-23m of the
infants life when she:
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Starts feeding additional foods to the child at the age of 6 months.
Starts with soft or mushy foods at first that are age appropriate and are not too thin or
thick, and gradually shifts to foods of a solid consistency if the child is ready.
Continues breastfeeding up to two years of age or beyond.
Offers solid or semi-solid foods 2-3 times per days when child is between 6-8 months of
age, and 3-4 times per day after that, and offers nutritious snacks 1 or 2 times per day, as
desired.
Offers a variety of foods, from all the food groups (grains, roots and tubers, legumes and
nuts, animal source foods and fruits and vegetables) and increases in variety and quantity
as the child grows.
Practices good hygiene in preparation and storage of complementary foods (including

washing hands before and using clean water and utensils).
Continues breastfeeding and feeding complementary foods during illness.
Gives the child iron-rich foods such as animal source foods or iron supplements if iron-rich
foods are less available.
Uses feeding times for interacting with the child, to teach and stimulate social
development as well as encourage the child to eat.
CHAPTER 14: CREATING AND STRENGTHENING ENABLING

ENVIRONMENT FOR EMTCT.
14.1 Introduction
If PMTCT services are to be utilised by the majority of pregnant and breastfeeding women,
there is need for an environment that encourages them to know their HIV infection status
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and supports those who test positive to receive care and treatment. In this section, we
discuss some of the strategies that can be used to create such an environment. They include:
reduction of stigma and discrimination, male engagement, elimination of gender based
violence and peer support groups.
14.2 .Reduction of stigma and discrimination in health facilities

Stigma refers to reduction of that persons status in the eyes of society because of who s/he
is. Discrimination is when a person is being treated unfairly and unjustly on the basis of
belonging or being perceived to belong to a particular group. Stigma leads to discrimination
and discrimination reinforces stigma. Stigma and discrimination related to HIV exists in many
communities and health facilities of South Sudan. We concentrate on stigma and
discrimination in health facilities where HCWs, for whom these guidelines are intended, can
make a difference. When stigma and discrimination exists, pregnant and breastfeeding
women would rather not test, least they are HIV- positive and are stigmatised. Without
testing HIV positive women are likely to transit infection to their children and or partners.
Stigma and discrimination also contributes to the loss from care and treatment of those who
test HIV positive. From the clients perspective, it adds psychological distress to her burden
of illness. For the HCW, who has a responsibility to care for all patients including PLWHIV, it
is clearly unethical.
HCWs can contribute to reduction of stigma in the community and are primarily responsible
for making sure there is no stigma in health facilities. Some of the actions that could be
stigmatising in health facilities include:-blaming PLWHIV; treating them differently; breaching
confidentiality by sharing results or testing with HIV without consent. Stigma and
discrimination is more likely in health care facilities where HCWs have inadequate
information about HIV transmission and have unjustifiable fear about acquiring HIV by
casual contact with PLWHIV or have judgemental attitudes about how PLHIV acquired HIV.
14.3 Strategies to reduce stigma

To avoid stigma and discrimination in health care facilities, HCWs need to:-
Be knowledgeable on how HIV can and cannot be transmitted. HIV cannot be

transmitted by casual contact.
Practice standard precaution practices for HIV prevention
Have access to post exposure prophylaxis.
Know that PLWHIV have a right to confidentiality, dignity, privacy and safety.
Follow clearly laid out standards for HIV testing that include informed consent.
Re-examine their attitudes towards PLWHIV.
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Protect the clients right to privacy by ensuring that voices cannot be heard during
counselling or history taking.
Protect the clients right to confidentiality by keeping record secured.
Avoid separation of PLHIV from other patients.
Avoid using gloves for physical examination of PLHIV unless there is likelihood of
exposure to blood of body fluids.
Treat PLWHIV in the same way they would be treated if they were in a similar
situation.
Avoid verbal and non-verbal communication that would portray scorn, disgust or
disrespect (facial expressions, hand expressions when touching a clients clothes or
utensils etc. Examples of stigmatising language include AIDS victim, AIDS carrier, HIV
is a death sentence etc. An example of non-stigmatising language is person living
with HIV or positive living.
Welcome all clients with warmth, a smile, a kind word and genuine interest in who
they are and their circumstances.
14.4 Male partner engagement:

Involving male partners in reproductive health services increase the uptake of couple
counselling and disclosure of HIV status (see section on couple counselling). This would
make it possible to provide services to HIV-negative couples and discordant couples, as well
as care and treatment for HIV-positive couples and their families. Male involvement could
enhance partner support for follow-up care for HIV-positive pregnant and breastfeeding
women and HIV-exposed infants, including ARV adherence, improved adherence to infant
feeding methods, and early management of HIV-exposed infants. It could also eliminate
harmful consequences faced by women who seek PMTCT services such as stigmatization and
gender-based violence. Moreover, male involvement in PMTCT services could address the
healthcare needs and responsibilities of men, providing them with positive male norms, and
linking them to other healthcare services
14.4.1 1Strategies for male involvement:

Different countries and programs have used different strategies to enhance male
involvement. These have included a combination of some of the following:
Using invitation letters. Men are invited to come to health care facilities through their
partners. The invitation letter may be written by a prominent person in the
community or health workers.
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Community mobilisation for male involvement using IEC materials, media,
community leaders, community health workers etc.
Establishing fathers support groups at MCH clinics.
Giving priority to couples.
In Rwanda, male involvement has been implemented at a national level. It is within the
PMTCT guidelines. Mayors contracts with the president of the republic include ANC, PMTCT
and partner testing. Performance based financing for clinic staff include partner testing.
14.5 Elimination of gender based violence:

Violence against women means any act of gender-based violence that results in, or is likely
to result in, physical, sexual or psychological harm or suffering to women, including threats
of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or
private life. Violence against women shall be understood to encompass, but not be limited
to, the following: Physical, sexual and psychological violence occurring in the family,
including battering, sexual abuse of female children in the household, dowry-related
violence, marital rape, female genital mutilation and other traditional practices harmful to
women, on-spousal violence and violence related to exploitation; physical, sexual and
psychological violence occurring within the general community, including rape, sexual abuse,
sexual harassment and intimidation at work, in educational institutions and elsewhere,
trafficking in women and forced prostitution; physical, sexual and psychological violence
perpetrated or condoned by the State, wherever it occurs15.
Gender-based violence (GBV) is both a cause and consequence of HIV infection. Violence or
the fear of violence can pose formidable barriers to PMTCT services. GBV is a barrier to
women getting tested, disclosing their status to partners, adhering to treatment regimens,
and seeking antenatal care.
In both HIV and GBV, women are particularly vulnerable as a result of the unequal power
relationships based on gender and reinforced by political and economic systems. Both need
to be addressed by comprehensive and multi-sectoral approaches.
HCW can make a contribution to make GBV less and not more. Just like stigma, the health
care facilities can inadvertently contribute to GBV if sufficient care is not taken. One the
most important principle HCWs should observe is do no harm. HCWs should provide
PMTCT services in a way that will not put pregnant and breastfeeding women in danger of
GBV.
15
Declaration on the Elimination of Violence against Women. Proceedings of the 85th Plenary Meeting.
Geneva: United
Nations General Assembly, Dec. 20, 1993.
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Health professionals may inadvertently put women at risk if they are uninformed or
unprepared.
For example, providers can unwittingly cause harm by:
Expressing negative attitudes to clients about women who are beaten or raped e.g.:-
Husbands have the right to use physical violence against their wives
Women like to be treated with violence
Sexual violence by men against women is normal and harmless
Discussing a womans injuries in a consultation room that can be overheard by a

potentially violent spouse standing outside.
Breaching confidentially by sharing information about pregnancy, abortion, STIs, HIV

or sexual abuse with another family member without the womans consent.
Another strategy to minimise GBV is meaningful engagement of people living with HIV
(PLHIV), in particular women living with HIV and GBV survivors. Involving PLHIV, specifically
women living with HIV, in program planning, implementation, and evaluation allows
programs to build on direct experience and tailor services to individuals and the contexts in
which they are offered.
It has been suggested that PMTCT services should routinely screen for GBV but this depends
on whether the facility has the required capacity. A clinic is not ready for routine screening
of GBV until it can ensure:-
Clients privacy, safety, and confidentiality.
Providers have appropriate attitudes and skills.
Providers have something to offer women. Providers may have nothing to offer
women in terms of services when adequate referral services do not exist either in the
clinic or in the community
Even when there isnt much to offer GBV victims, all HCWs can ensure that the health care
facilities do not inadvertently contribute to GBV.
14.6 Peer support

Peer support groups exist in different forms with different names. However the principle is
the same. It involves recruiting, training, employing, and supporting mothers living with HIV
(mentor mothers) to support, educate, and inspire HIV-positive pregnant women and new
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mothers to access and adhere to PMTCT interventions and prevent HIV transmission to their
babies.
Peer support is based on the premise that no one understands the realities of living with
HIV/AIDS better than someone who has been living with and managing it every day. Because
they are coping with the daily challenges of HIV/AIDS, mentor mothers have the power to
serve as important role models. Mentor mothers can help individuals cope with their HIV
diagnosis and resulting grief, provide opportunities for people to share feelings, receive
helpful ideas, reframe negative thoughts, change harmful behaviours, develop a sense of
stability and hope, and adhere to health routines. The effectiveness of peer support is often
associated with a positive form of peer pressure which can motivate a person to pursue
things previously thought to be impossible. Peer support services serve a uniquely important
role within the HIV/AIDS service system in general and PMTCT in particular.
In addition to being HIV positive, a peer supporter should be willing to be a mentor, to

disclose HIV status with peers and having gone through the PMTCT experience.
They are given training on PMTCT and reproductive health and then integrated at the health
care facility as members of the health care team. They provide group health education, one-
on-one and couples education, facilitate support groups, follow up with HIV clients who have
missed clinic visits and conduct referrals. They encourage pregnant and breastfeeding
women to test for HIV. They provide psychosocial support and counselling to those who test
HIV positive so that they adhere to PMTCT services. They urge mothers to bring their new
born babies back to clinics for doctors visits, immunization, and early infant diagnosis of
HIV; and talk to women about the recommended techniques for feeding their babies. An
example of what they discuss is shown in the table below from Intrahealth in Ethiopia.
Discussion topics16
Psychosocial
-How to disclose HIV status to partners and others
-Confronting stigma and discrimination
-Living positively
-Gender violence
HIV Care: Mother
-The PMTCT process
16
IntraHealth International. Mothers support groups in Ethiopia. A peer support model to address the needs of women
living with HIV.
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-Antiretroviral therapy for mothers
HIV Care: Infant
-Infant feeding options and family nutrition
-Antiretroviral therapy for infants
Reproductive Health
-Family planning and prevention of unintended pregnancies
-Safer sexual practices
CHAPTER 15: INTEGRATION OF PMTCT INTO MCH SERVICES:
15.1 Introduction
Integration of PMTCT into MCH means delivery of both services together on the same
patient visit by the same health worker or clinical team. The opposite of integration is
vertical programs, where PMTCT services are offered by specific HCWs different from those
offering MCH services.
15.2 Rationale for integration of services

Advantages of integration are:-
Avoids HIV-related stigma because MCH and HIV services are offered in the same area
and by the same HCWs.
Avoids missed opportunities for key interventions.
Makes visits more efficient for the patient (avoids costly, time consuming, multiple visits
by the patient and his/her family);
Makes visits more efficient for the clinical team, particularly at health centre level;
Reduces waiting times during a visit.
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15.3 Approaches to INTEGRATING EMTCT AND MNCH SERVICES
EMTCT interventions should be integrated into the MNCH services which include but not
limited to the ANC, Labor and Delivery, Post Natal Care, Sick child clinic and YCC. The section
defines the services offered in respective EMTCT prongs in the respective parts of the MNCH
services continuum; before pregnancy, antenatal, labour and delivery, postnatal&
community. See Figure 6
Figure 6: The EMTCT continuum of services
Community EMTCT
These two examples show how integration works:
(1) the health information messages pregnant women receive in morning in the waiting area
also includes pre-test counselling as well as information on the services available for
pregnant women with or without HIV.
(2) Blood for syphilis, haemoglobin concentration determination, HIV, malaria etc. is take off
at the same time. However, integration should always ensure confidentiality.
15.3.1 Integration Of PMTCT Into Routine ANC.

All pregnant women require high quality antenatal care to be able to go through pregnancy
safely and deliver healthy babies. In addition, high quality ANC contributes to PMTCT. For
example, prevention of malaria and anaemia reduces the risk of prematurity and low birth
weight. Both are risk factors for MTCT of HIV.
Four antenatal visits are recommended for a healthy woman with a normal pregnancy,
scheduled at specific times in the pregnancy to deliver the essential interventions during
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antenatal care. HIV-positive pregnant women usually require more visits than HIV-negative
pregnant women. HIV-positive pregnant woman on ART will require additional visits for
additional counselling and support.These guidelines recommend monthly ANC visits for
pregnant women on ART. Most of the services are the same for all pregnant women whether
HIV positive or negative pregnant.An essential package of integrated antenatal care services
is shown in the table below.
Flow chart of services offered to pregnant women during ANC.

HOME
Discusses with partner about HIV disclosure

Discusses with partner about birth preparedness
Has/plans personal savings and can access in case of need
Recognizes these danger signs require going to a health
facility immediately. Knows where to go in case of
emergency.Knows who the blood donor is
HEALTH FACILITY (1): TRIAGE; Check and

act for the following emergencies:-
Difficult breathing
Shock
HEALTH FACILITY 5:RECORDS Vaginal bleeding
Severe abdominal pain
Fill in registers, mother cards, appointment Dangerous fever
books Labour
Other danger sign
HEALTH FACILITY (2): PROVIDE GROUP

HEALTH FACILITY 4: CLINICAL ASSESSMENT INFORMATION
&MANAGEMENT
15.3 Birth preparedness. This covers pre-test counselling for HIV
Preparing for birth should be done during antenatal care. All pregnant
ALL WOMEN: women
and other should
topics such as:- be
encouraged to give birth in health facilities with a skilled attendant. However, in RSS, only
Weight and assessment of nutrition status, Services available during ANC
13.6%pressure
Blood of women give birth in health facilities. This is likely to be trueforServices
pregnant women
for HIV+ women
Palpation
living with HIV
of the abdomen, NeedSome
especially with challenges of poor access to health facilities. women
to attend at least 4 visits.
Respond to observed signs and volunteered Nutrition in pregnancy
may plan to give birth in a health facility but for various reasons may end up giving birth at
problems. Male partner engagement
home or
Provide TT, with
Iron / afolic
TBA.acid,Either way,
Fansidar andany
bed pregnant woman who may not giveFamily
birthplanning
in a health
nets
facility should ensure the following:- Prevention of diseases.
One-on-one discussions & counselling on HIV Birth preparedness
(post-test) family planning, male partner Danger signs
Have a delivery kit and understand how to use it.
engagement,birth preparedness and WASH interventions
complication readiness.
WOMEN Ensure
WITH HIV:there is a clean delivery surface for birth.
Ensure
WHO thestaging,
clinical attendant washes her/his hand with clean water and soap before and after
Screening for HEALTH FACILITY 3: LABORATORY
touching theTBmother
with ITP and
if no baby.
TB disease,
Septrin prophylaxis, ART (may give for 3 TESTS
months if the woman is near term),
Adherence counselling & infant feeding Blood for HIV, CD4 (if required)
counselling, 109 HB and syphilis, hepatitis etc.
Linkage with peer supporters. Urinalysis
The birth attendant should also keep her/his nails short.
When the baby is delivered, he/she should be placed on the mothers chest with skin-to-skin
contact and the eyes wiped using a clean cloth for each eye.
Use the ties and razor blade from the disposable delivery kit to tie and cut the cord.
Dry the baby after cutting the cord.
Wipe clean but do not bathe the baby until at least 6 hours after birth.
Wait for the placenta to deliver on its own.
Someone stays with themother for the first 24 hours.
Keep the mother and baby warm. Dress or wrap the baby, including the babys head.
Dispose of the placenta in a correct, safe, and culturally appropriate manner (burn or bury).
AVOID local medications to hasten labour.
AVOID inserting any substances into the vagina during labour or after childbirth.
AVOID pushing on the abdomen during labour or deliver.
AVOID other relevant harmful local practices and use helpful local practices.
UDERSTAND the danger signs in the mother and the baby. If the mother or baby has any of
danger signs, she/they must go to the health facility immediately, day or night, WITHOUT
any delay. The danger include: waterbreaks and not in labour after 6 hours, labour
pain/contractions continue for more than 12 hours, vaginal bleeding before childbirth or
heavy bleeding after delivery (pad cloth soaked in less than 5 minutes), placenta not
expelled 1 hour after delivery, signs of infection on the baby, baby is not able to feed or is
very small.
Aware of when to return for follow-up care after childbirth.
In addition a pregnant woman living with HIV who may give birth at home should be
prepared as follows:
Take home enough ART medications for her treatment during labour, delivery and
postpartum period. A three months supply near term should be considered.
Continue with the ART she is taking and the same schedule, during labour, delivery and
postpartum.
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Take home the ARV medicine (NVP) for the HEI prophylaxis during pregnancy and give
prophylaxis to the baby as soon after birth as possible. If she does not have the NVP at birth,
she should bring the new born to the health facility or send someone to collect the medicine
soon after birth within 72 hours.
Disclose to someone she trusts who can give her the necessary support during labour,
childbirth, and the postnatal period.
Recording PMTCT and ANC data: (to be added after revision of the data tools is complete)
15.4 Integration of PMTCT into services for Labour, Delivery and Immediate postpartum
period.
Labour and delivery is a very important period for PMTCT. Although this period is shorter
compared to pregnancy or breastfeeding, it poses the greatest risk for transmission of HIV
from the mother to the child. In the absence of any intervention, 10 to 20 per cent of
exposed infants becoming infected at this time. It is therefore important to establish the HIV
status of women prior to, or during labour and delivery and provide interventions aimed at
reducing the risk of transmission in this critical period. With appropriate interventions, the
risk of MTCT can be reduced significantly.
15.4.1 Interventions for PMTCT during labour and delivery

PITC for all women in labour with unknown HIV-infection status.
ART for women who are HIV-positive. If the woman is already receiving ART, the same
regimen and schedule should continue.
Quality care during labour, delivery and immediate postpartum: Quality care and
management duringlabour, delivery and immediate postpartum period reduces illness and
mortality in all women (whether HIV infected or not) and their new-borns. For women living
with HIV in particular, quality services contribute to PMTCT. In addition, health workers are
also protected from blood borne infections (including HIV). The following are components of
quality care during labour, delivery and immediate postpartum that contributes to PMTCT:-
Adherence to standard precaution practices.
Detection and management infections.
Prevention of prolonged labour by recognizing and managing unsatisfactory progress

early by using the partograph. Preventing prolonged labour can reduce risks of MTCT
of HIV by minimizing the number of hours the baby is exposed to maternal blood and
secretions in the birth canal during labour.
Avoiding invasive foetal monitoring to assess need for early intervention will also
reduce MTCT of HIV.
Minimize vaginal examinations of the cervix.
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Minimise vaginal examination of the cervix: Vaginal examinations should only be performed
when absolutely necessary and with an appropriate clean technique. Limiting vaginal
examinations increases womens comfort during labour and reduces the risk of infection. It
may also reduce the risk of MTCT of HIV by minimizing introduction of maternal infection
into the uterus and minimizing potential trauma to the vagina caused during examination.
Routine (artificial) rupture of membranes should be avoided. Risk of MTCT increases with
the duration of ruptured membranes, therefore, artificial rupture of membranes should only
be performed when absolutely necessary. Limiting the time between rupture of membranes
and birth reduces the baby's contact with maternal blood and secretions thus may help
reduce MTCT of HIV. If augmentation of labour is necessary due to prolonged labour, the
woman should be referred to a facility where this can be carried out safely. If capacity is
available and rupture is prolonged, oxytocin drip may be used to augment labour and to
shorten duration of labour and duration of ruptured membranes.
Perform active management of the third stage: Active management is very important to
prevent postpartum haemorrhage. Postpartum haemorrhage may increase the risk of MTCT
of HIV due to increased possibility of potential exposure of the newborn to maternal blood
when there is a large PPH. Active management of the third stage involves 3 important
components:
Give oxytocin 10 IU intramuscularly within 1 minute following the birth of the baby, after the
presence of multiple pregnancies has been excluded.
Deliver the placenta using controlled cord traction: Await a strong uterine contraction (23
minutes), and then deliver the placenta using controlled cord traction. Place side of one
hand above symphysis pubis with palm facing towards the mothers umbilicus, and apply
counter-traction to the uterus. At the same time, apply steady, sustained controlled cord
traction. NEVER apply cord traction (pull) without applying counter-traction to the uterus
(push upwards on the uterus above the pubic bone with the other hand).
Massage the uterus after delivery of the placenta: After the placenta is out, check if the
uterus is well contracted and there is no heavy bleeding. Respond to poor contraction and
bleeding by massaging the uterus, giving oxytocin 10 IU IM, starting an IV line with 20 IU
oxytocin per litre (infuse at 60 drops per minute), calling for help, and emptying the
bladder.Gently examine for and quickly repair genital tract lacerations. Examine the placenta
for completeness and, if necessary, carefully remove all retained products of conception. If
blood loss is severe, the woman may need a blood transfusion, exposing her to potentially
infected blood.
15.4.2 Interventions in the immediate post partum period:

ARV prophylaxis for HEI. This should be given as soon as possible after birth.It is best to give
the first ARV prophylaxis dose before the new-born leaves the delivery room. Speed is
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especially important if the mother did not receive ARV prophylaxis or ART during the
antenatal period.
A warm surface for the baby and skin-to-skin contact with the mother.
Someone to stay with the woman and new-born. Should not be alone.
Monitoring the mothers temperature, blood pressure and pulse as well as bleeding, pallor
and painetc.
.Assessment of the babys temperature,bleeding umbilical cord, movements, asymmetry or

lack of movement of part of the body, or any abnormal movements, malformations, muscle
tone etc.
Counselling on infant feeding
15.4.3 Interventions at discharge

At discharge the mother should receive or have received the following:
Tetanus toxoid if due.
Mebendazole if not taken in the last 6 months.
Three months supply of iron.
Advice on use of insecticide-treated bed net.
Family planning counselling and services.
Nutrition education.
Advise on postpartum care and hygiene.
How to dispose of cloths or perineal pads soiled with lochia (especially if HIV
positive).
Advice on the need for rest and sleep during the postnatal period.
Advice on when to resume sexual activity after childbirth and use of condoms when
lochia is still present.
Advice on safer sex practices, the risk of new HIV infection and MTCT while
breastfeeding.
When to return for the first postnatal visit and the importance of continuing health
care visits.
Need for the mother to return with her partner and/or a family member.
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Instruction on danger signs. These include:
vaginal bleeding (2-3 pads soaked in 20-30 minutes after delivery or if bleeding
increases after delivery rather than decreasing), convulsions, breathing difficulty,
fever and difficulty getting out of bed, severe abdominal pain, painful, swollen, or red
breasts, or sore nipples, urine dripping or painful urination, pain in the perineum or
draining pus, foul smelling lochia, feels ill.
Discussion on how to prepare for an emergency after childbirth (woman or the

newborn).
The need to have someone near for at least 24 hours after delivery to respond to any
change in condition.
Discussion with the woman and her partner/family about emergency related issues:
where to go if she has danger signs, how to reach the hospital, costs involved, as well
as family and community support needed.
Available community support.
Prophylaxis for opportunistic infections (OIs) for women living with HIV.
Family planning services.
Advice on infant feeding
Record of services provided, return date etc. in the mother and child card and facility
based registers.
Recording PMTCT and child birth data: (to be added after revision of the data tools is
complete)
15.5 PMTCT services for breastfeeding mothers

Traditionally the postnatal period is up to 6 weeks after birth. Women should be encouraged
to return with their babies for routine postnatal follow-up visits on the 3 rd day and at 6
weeks. Women need to understand the advantages of continued care. Women, who give
birth at home, should be encouraged to go/return to the health facility as soon as possible
after childbirth. PMTCT services for breastfeeding women include postnatal services
recommended for all postnatal women, PLUS special interventions for breastfeeding women
living with HIV. Women who did not test for HIV during pregnancy should be offered PITC
and managed accordingly. Women who tested during ANC should have the data on the
maternal card transferred to the baby card.
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Table 10: Interventions at the postnatal visit for all women
Triage Asess for emmergency signs. Check for the following and manage or refer.
Airway and breathing
Circulation (shock)
Vaginal bleeding
Severe abdominal pain
Dangerous fever
Other danger signs or symptoms
Group This covers pre-test counselling for HIV and other topics such as:-
information
Eat and rest more during postnatal period
and
counselling Personal hygiene to avoid infections
Know danger signs
Exclusive and complementary feeding
Family planning
HIV acquisition and transmission during breastfeeding
Interventions for WASH
Laboratory ALL WOMEN
This includes routine tests and any other test depending on illness. Routine
tests include:-
Blood for HIV (if not tested before), haemoglobin concentration, syphilis,
hepatitis etc. (when required).
WOMEN WITH HIV
CD4 testing (when required)
Hepatitis surface antigen (when required)
Creatinine clearance (if necessary)
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Assessment ALL WOMEN (especially for postnatal care)
(look, listen
Measure BP, pulse, temperature, look for pallor
and feel) and
management Respond to observed signs and volunteered problems especially bleeding,
discharge, pain, fever etc.
Examine the breasts, uterus, vulva and perineum
Provide Iron / folic acid, vitamin A, Albendazole/Mebendazole as required.
One-on-one discussions&counselling on HIV (post test), family planning,

male partner engagement, possible complications including and postnatal
depression.
Immunise baby
WOMEN WITH HIV
WHO clinical staging
Screening for TB with ITP if no TB disease
Septrin prophylaxis
Start ART
Adherence counselling & infant feeding counselling
Linkage with peer supporters
Services for HEI
Records
15.6 Breastfeeding women living with HIV
14.6..1Woman not on ART:

If a breastfeeding woman is not ART, probably because she has just tested or tested before
but never started, then she should start on ART after receiving the pre-ART package. The
HIV-exposed infants should be examined clinically for HIV, and at that point get a DBS taken
off. Infants without clinical features of HIV should receive NVP prophylaxis for 6 weeks.
15.6.2. Woman is on ART:

If the breastfeeding woman is already on ART, she should continue with the regimen she is
on and receive the package of care for PLWHIV on ART.Of particular importance is
counselling and psychosocial support for adherence to care and ART. Postnatal women are
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particularly more likely to be lost to follow-up. So it is important to ensure they receive
counselling and support to stay in care and adhere to ART. An HIV-positive postnatal woman
might need additional support if she is experiencing postnatal depression, and is anxious
about the HIV status of her baby and issues surrounding infant feeding. She should be
encouraged to disclose her HIV status to a family member or, her partner, or friends o that
she can continue to receive support at home. She should also be encouraged to join peer
support groups at health facilities. She also needs counselling and support for infant feeding
choice, and advice on HEI follow-up.
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CHAPTER 16 STANDARD PRECAUTIONS FOR INFECTION CONTROL IN
HEALTH CARE SETTINGS
16.1. Introduction
Standard precautions are infection prevention and control measures that reduce the risks of
transmission of HIV and other pathogens in health care settings. Standard precautions
should be observed with every client, regardless of whether or not the service provider
thinks the client might be infected with HIV, hepatitis, or any other pathogen. Standard
precautions are particularly important to HCWs offering PMTCT services especially during
labour and childbirth due to the high potential for blood and bodily fluid exposure.
Following standard precautions with every client is important because:
Until laboratory tests are conducted it is not possible to tell who is infected such as with HIV
or hepatitis virus.
Some infections for example, HIV have a window period following exposure, when
laboratory test results are negative even though the person is infected
Health care settings have high risk of acquired infection
Infected individuals themselves may not be aware of their status.
All providers should observe standard precautions in health care settings, including
volunteers, all staff who handle patients or health facility wastes, clinical and laboratory
service providers, etc. Good infection prevention and control practices help to:
Prevent transmission of HIV by reducing contact with maternal secretions and blood
Prevent transmission of infections in health care settings: from patient-to-patient, patient-to-

provider, and provider-to-patient.
16.2.1 Proper hand hygiene

Hand hygiene is essential before touching a patient or a clean/aseptic procedure and after
body fluid exposure, removing gloves or touching a patient or his/her surroundings.
16.2.2. Use safe injection techniques

Do not recap needles unless absolutely necessary. Especially do not recap needles using
both hands. When recapping is necessary, use the one-handed scoop technique.
Figure 7: Safe injection needles technique.
118
Step 1: Scoop up the cap from a flat Step 2: Push cap down firmly.
surface.
16.2.3.
Handle and clean instruments safely

Use needles or scalpel blades on one patient only.
Always warn clients when they are about to get injection.
Safely handle and dispose of needles (hypodermic and suture) and sharps (scalpel blades,
lancets, razors, and scissors) in puncture- and leak-proof safety boxes.
Pass all sharp instruments from one person to another by placing them in a sterile kidney
basin (or other receiver) or in a designated safe zone rather than passing them hand-to-
hand.
Apply proper surgical practice to use needle holders to avoid using fingers for needle
placement.
When episiotomy is necessary, use an appropriate-size needle (21 gauge,

4 cm, curved) and needle holder during the repair.
Properly process instruments, devices, and equipment used during invasive procedures
decontaminate, clean, and high-level disinfect or sterilize all devices and equipment.
16.3. Handle and dispose sharps safely

Always point the shart end away from yourself and others.
To pass any sharp instrument from one person to another; place it in a kidney dish (or
receiver) or in a designated safe zone rather than passing them from hand.
Do not bend, break, manipulate, remove, or recap needles before disposing of syringes. Pick
up sharps one at a time.
Do not pick up handfuls of sharp instruments or needles.
16.3.1 Use sharps disposal containers

Using sharps disposal containers helps prevent injuries. Sharps
containers should be fitted with a cover, and should be
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puncture-proof, leak-proof, and tamper-proof (i.e. difficult to open or break). If plastic or
metal containers are unavailable or too costly, use containers made of dense cardboard
(cardboard safety boxes) that meet WHO specifications. If cardboard safety boxes are
unavailable, many easily available objects can substitute as sharps containers (tin with a lid,
thick plastic bottle, heavy-duty plastic box or heavy-duty cardboard box.)
Recommendations for safe use of sharps containers
All sharps containers should be clearly marked SHARPS and/or have pictorial instructions
for the use and disposal of the container. Mark the containers clearly so that people will not
unknowingly use them as garbage bins.
Place sharps containers away from crowded areas and as close as possible to where the
sharps will be used.
The placement of the container should be practical (ideally within arms reach) but
unobtrusive.
Do not place containers near switcheswhere people go often.
Seal and close containers when full. Do not fill safety box beyond full.Never reuse or
recycle sharps containers. Avoid shaking a container to settle its contents to make room for
more sharps.
Position the containers at a convenient height so staff can use and replace them easily.
16.5.1 Use personal protective materials

11.5.1Gloves:
Gloves should be used in:
In all invasive procedures.
If the procedure brings you in direct contact with patient's mucous membranes, blood, body
fluids, moist body substances, non-intact skin.
When handling potentially infectious materials, contaminated linen, or waste.
For performing venepuncture.
If the integrity of the skin of the health care worker's hand is compromised.
When handling and cleaning instruments.
When cleaning blood and body fluid spills.
Different gloves for different procedures:
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Surgical gloves: These should be used for all procedures where the provider will be in
contact with the tissue under the skin or with the blood stream (e.g. surgical procedures,
episiotomy repair, etc.). Sterile surgical gloves are preferable for such procedures; however,
high level disinfected (HLD) surgical gloves can be used when sterilized gloves are not
available.
Examination gloves: These should be worn for procedures where there will be contact with
intact mucous membrane (e.g. IUD insertion or pelvic exam) or where the primary purpose
of wearing gloves is to reduce the risks of exposure to blood or other body fluids (e.g. during
manual vacuum aspiration)
Utility or heavy duty household gloves: These thick rubber gloves should be worn when
handling contaminated instruments and other items, for handling waste linens, for cleaning
contaminated surfaces, and for performing housekeeping activities.
Long, cuffed sterile gloves: These gloves extend up to the providers elbow and are used
during procedures such as manual removal of a placenta.
While wearing gloves, continue to exercise caution in handling needles, scalpels, etc. Gloves
do not provide protection from needle sticks or other puncture wounds caused by sharp
objects.
After taking off gloves of any type, wash hands. The gloves might have tiny holes or tears
that leave the potential for exposure to contaminated blood and other body fluids.
Do not wear gloves away from the bedside, delivery couch or procedure site, e.g. at nursing
stations to handle phones or charts, to handle clean linen, to clean equipment or patient
care supplies, or in hallways or elevators.
Tips for effective glove use
Wear gloves that are the correct size for you.
Use water-soluble hand lotions and moisturisers often to prevent hands from drying,
cracking, and chapping.
Avoid oil-based hand lotions or creams because they will damage latex rubber
surgical and examination gloves.
Do not wear rings because they may serve as a breeding ground for bacteria, yeast,
and other disease-causing microorganisms, and they may rip the gloves.
Keep fingernails short (less than 3 mm (1/8 inch) beyond the fingertip). Long nails
may provide a breeding ground for bacteria, yeast, and other disease-causing
microorganisms.
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Long fingernails are also more likely to puncture gloves.
Store gloves where they are protected from extreme temperature, which can damage
them.
16.5.2 Aprons, gowns, masks and eye protection

Use masks, eye protection, and gowns (or plastic aprons) when blood or other body fluids
could splash e.g. while attending second and third stages of labour.
When possible, wear eye shield during caesarean section and episiotomy suturing.
Wear a clean, non-sterile, and impermeable plastic apron while attending delivery: to
protect skin and to prevent soiling of clothing.
If the gown has long sleeves, gloves should be placed over the gown sleeves to avoid
contaminating the gloves.
Ensure gloved hands are held high above the level of the waist and do not come into contact
with the gown.
Change gown: daily or between patients if it becomes moist or visibly soiled.
After use, remove soiled gown quickly; perform hand hygiene to avoid transfer of
microorganisms to other patients or environment; dry hands with towel and use it to turn
off tap and discard towel in waste receptacles.
Do not wear gown outside of the area for which it is intended.
16.6 Prevent and clean up splashes and spills

Wear appropriate protective goggles, gloves, and gown during delivery.
Prevent splashes from blood or amniotic fluid by following these guidelines.
Avoid snapping the gloves when removing, as this may cause contaminants to splash into
the eyes, mouth, or onto the skin yours or other peoples.
To avoid splashing, place items gently into the decontamination bucket, and hold
instruments and other items under the surface of the water while scrubbing and cleaning.
Avoid rupturing membranes during uterine contraction.
If unavoidable, stand to the side to avoid splashes from amniotic fluid.
Cut the cord using sterile scissors under the cover of a gauze swab to prevent blood spatter.
Clean up spills of potentially infectious fluids immediately. While cleaning, always wear
gloves.
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If the spill is small, wipe it up with a cloth that has been saturated with a disinfectant
solution (0.5% chlorine).If the spill is large, cover (flood) the area with a disinfectant (0.5%
chlorine) solution, mop up the solution, and then clean the area with a disinfectant cleaning
solution.
Do not simply place a cloth over the spill for cleaning up later; someone could easily slip and
fall on it and get injured.
16.7 Handle and dispose of waste safely

Use systems for safe waste collection and disposal. Collect wastes by type: general waste,
medical waste, and hazardous chemical waste. Guidelines when handling waste are as
follows:-
Wastes should be deposited in leak-proof materials.
Wear heavy-duty gloves.
Use covered containers to transport solid contaminated waste to disposal site.
Burn or bury contaminated solid waste.
Carefully pour liquid waste down a drain or flushable toilet.
Wash hands, gloves, and containers after disposal of infectious waste.
16.8 Manage needle sticks or other workplace exposures to HIV

When needle stick or other potential exposure to HIV occurs:-
Stop what you are doing (hand over to your colleagues) and attend to the injury.
If blood or body fluids splash on intact skin, wash the area immediately with water and soap.
If splashed in the face (eye, nose, and mouth) wash with clean water only.
If finger prick or cut occurred, allow the wound to bleed for a few second, do not squeeze
out blood. Wash with soap and water.
Dry and apply water proof dressing, as necessary.
Use regular wound care.
Topical antiseptics may be used.
If your glove is damaged, wash the area with soap and water and change the glove.
Re-check records for the HIV status of the woman.
Follow the post-exposure prophylaxis (PEP) protocol.
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Report incidents of occupational exposure.
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CHAPTER 17 : PMTCT PROGRAM MANAGEMENT AND COORDINATION
17.1. Introduction
A strong governance ,leadership and management of the National PEMTCT programme is a
critical ingredient of the heath systems requirements for efficient and effective
management of the program and project interventions to achieve a nation free from
HIV/AIDS .This section describes the leadership and management requirements for a robust
national program for elimination of mother to child transmission of HIV at all levels of the
national health care system in south with their roles and responsibilities ,coordination
,communication and reporting relationships .
17.2 Rationale for effective Program Management system

A sound PMTCT program stewardship helps:
To ensure a unified policy ,legal and regulatory frameworks for implementation .

To guide strategic and operational planning for program interventions
To ensure efficient results based allocation and utilization of program resources
To coordinate implementation ,supervision and reporting on program performance
To manage stakeholder expectations and account for use of resources invested in
the national PMTCT program
To monitor ,evaluate and report on program performance
17.3 The Organizational Structure For PMCT Program Management

The South Sudan AIDS commission and MOH the National MoH Directorate of health
promotion and prevention services has overall leadership and management responsibility
for the National PMCT program .The department of STIs/HIV/AIDS services in the ministry of
health assisted by the National PMTCT Coordinator/Manager (at the RCH) who heads the
PMTCT program and the assisted by the state and county Reproductive and Child health
coordinators (RRCHCO and CRCHCO) are responsible in assisting the state and county health
Officers in coordinating the implementation of the PMTCT programme at the decentralized
levels .
The organization and management of PMTCT program has to be strengthened at all the four
levels of the national health care system :
National level
State Level responsible for policy and strategy as well as program oversight .
County Level
Health Facility level
Community levels
17.4 .Roles and responsibilities of Program management Structures

17.4.1. National level PMTCT program Management Teams
The key functions of the national level PMTCT program section in the department of
STI/HIV/AIDS are to :
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Review ,update and develop National policy guidelines
Review ,update and develop national strategic and investment plan for PMTCT
Review ,update and develop National PMTCT program implementation Guidelines
Develop standards operating procedure for PMTCT service delivery at all levels of the
national health care system
To mobilize, allocate and leverage resources for implementation of PMTCT program
and project priority interventions
To coordinate implementation of upstream policy and strategic activities
To support and supervise state level PMTCT program implementation for quality
assurance purposes
To control ,monitor and evaluate program performance
To manage strategic partnerships ,alliances and donor relationships
To coordinate research and innovative solutions
17.4.2 State Level PMTCT program management functions

State PMTCT program management roles and responsibilities include :
National PMTCT policy and program implementation

Developing state level strategic and annual work plans and budgets
Enforcing national standards operating procedure for PMTCT service delivery at all
levels of the national health care system
To mobilize, allocate and leverage local resources for implementation of PMTCT
program and project priority interventions
To manage health infrastructure, supplies ,human and financial resources allocated
for HIV/AIDS and PMTCT and ensure efficient use and value for money .
To coordinate implementation of state level program activities and services
To support and supervise county level HIV/AIDS and PMTCT program implementation
To monitor and evaluate state HIV/AIDS and PMTCT program performance
To manage state level partnerships ,alliances and donor relationships
To coordinate research and development activities at the state level in collaboration
with national Ministry of Health .
17.4.3 Roles of the County Health department and Management Team
The roles and responsibilies of the county health department is to :
Lead ,manage and coordinate the county level health sector HIV/AIDs and PMTCT
response efforts in collaboration with other departments and the county AIDS
commission .
Planning and budget for decentralized HIV/AIDS prevention ,treatment and care for
women ,children and their families .
To mobilize local resource and manage physical ,material,human and financial
resources allocated and transferred to the country to deliver the basic package of
health ,nutrition and HIV/AIDS services in the county hospital ,primary health care
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centres ,primary health care units and community and family based health and
HIV/AIDS services .
To coordinate the implementation of decentralized Health and HIV prevention
,treatment and care services .
To supervise and monitor performance of the PHCCs , PHCUs ,BHT ,CHWs and HHPs
in their counties .
To monitor ,evaluate and report on performance of the country health ,nutrition and
HIV/AIDS programs and services .
17.4.5 The Roles of Health facility level Management Team
A successful PMTCT programme requires the support and cooperation of the entire health
facility team that includes ,doctors, clinical officers, nurses ,midwives ,nutritionist ,laboratory
personnel, Pharmacists and dispensers, Records personnel, Administrative staff, Social
workers ,community extension health workers , where available.
The health facility management team comprises the Facility In-charge, Antenatal Care In-
charge, Labor Ward In-charge, Laboratory In-charge, Pharmacy In-charge, Records In-charge
and Community Contact Persons. The roles and responsibilities of the health facility
management team are:
Planning for facility based services

Allocation of resources for (space ,equipment ,staff ,materials ) for PMTCT service
delivery
Ordering of supplies, testing kits, and ARVs from the main store;
Coordinating and integrating of prevention ,treatment and care services
On-site supervision and monitoring of service delivery
Promotion of the Baby Friendly Hospital Initiative;
Collection of data, preparation, analysis and discussion of monthly PMTCT reports;
Submission of PMTCT reports to the District Medical Officers (DMO) office;
Facilitation of community-based activities;
Collaboration and partnership with other actors in PMTCT and HIV
17.4.6 Roles of Community based PMCT program management team
Community EMTCT is the provision of EMTCT services by formal (trained health personnel)
or informal care providers such as BHTs, HHP, Linkage facilitators, Peer Educators, PHLIV
networks, family members and other stakeholders outside the health facility settings usually
within communities. The roles of the community based service providers include :
o Periodic assessment of the community situation of HIV/AIDS and EMTCT services
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o Develop CB e MTCT action plans
o Mobilize community resources for HIV/AIDS service delivery
o Conduct community mobilization and education on HIV/AIDS prevention
o Distribute RH/STI/HIV/AIDS products /commodities (condoms ,contraceptives ,birth
kits etc)
o Mobilize communities for community based HCT services
o Refer positive clients for enrolment on treatment and care
o Provide community based support for positive living package for mothers and
exposed babies
o Conduct home visits to provide HBC for PHAs (MBP)
o Provide psychosocial support services
o Support infant and young child feeding counseling
o Monitor community based adherence counseling
o Provide support for Mother support groups
o Support Direct observation of treatment for CB-DOTS for TB/HIV clients
o Prepare and report on CB EMTCT services
o Participate in review and planning meetings
o Document good practices and share experience with other BHTs
o Participate in exchange and learning visits to other villages and Bomas
Coordination between national, state ,county ,facility and community levels is very
important within this decentralized approach to health ,nutrition and HIV/AIDS service
delivery model .
17.5 Coordination of PMTCT Program interventions
Coordinating the efforts of the various partners contributiton to the agenda for veritual
elimination of MTCT of HIV at all levels of the national health care system is very critical .
The MOH is strongly committed to decentralized health care that include Reproductive
healt ,HIV/AIDS and PMTCT services at the state and county levels, although its current
capacity is not adequate both to provide health care and to strengthen leadership,
management, and coordination throughout the country. Consensus among PMTCT
stakeholders suggests that the county administrative unit is the appropriate locus for
strengthened coordination efforts for effective service delivery. County Health Management
Teams (CHMT) would coordinate decentralized health, HIV/AIDS and PMTCT program
planning and management, and, under the guidance and supervision of the MOH, NGOs and
FBOs would help provide and co-manage health services in counties where such
organizations have a strong presence.
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17.5.1 The Rationale for strengthened coordination mechanisms
The objectives of strengthening coordination of efforts for EMTCT are to avoid duplication of
effort, ensure harmonized planning and efficient resource use, strengthen linkages between
actors, and share lessons learned and best practices.
17.5.2 Strategies to improve EMTCT program coordination

To succeed, coordination usually depends on mechanisms that are the centerpiece of a
coordination strategy and involve regular meetings, regular and frequent communication,
effective leadership, follow-up on action items, and participatory, consensus-based decision
making. The starting point for effective coordination of EMCTC program interventions is an
agreed-upon national ,state ,county and community PMTCT scale up plan and budget that
should be developed in consultation with stakeholders. With support from partners ,the
SSAC and MOH will ensure the coordination of training and capacity-building efforts to
produce maximum impact, along with CHD-to-CHD learning exchanges to share learning
across the project.
17.5.2.1 Conduct a PMTCT stakeholder mapping at both national ,state, county and lower
level PHC levels. During implementation, the MOH and partners will conduct stakeholder
mapping at the state and county levels in order to identify all health system stakeholders,
their roles and interests, available resources, unserved geographic areas, and each countys
program coordination needs. Stakeholders include NGOs, FBOs, CBOs, private health
practitioners, persons infected and affected by HIV/AIDS and organizations focused on
humanitarian issues. The mapping exercise itself will enhance county commitment to
coordination.
17.5.2.2. Develop a decentralized HIV/AIDS coordination strategy.
Drawing on the results of stakeholder mapping, the SACC and MOH will help states and
counties, respectively, organize consultative meetings for the purpose of agreeing to a
coordination strategy and its mechanisms. The strategy will define the coordination
objectives, the coordination mechanisms that best meet the challenges of each county, and
how best to operationalize the mechanisms.
17.5.2.3 Form and institutionalize stakeholder networks/groups.
Based on the terms of the agreement on the coordination strategy, the SSAC and MOH will
assist states and county health departments in establishing networks/groups of different
types of stakeholders operating within their respective jurisdictions. The purpose of the
networks will be to increase information sharing, expand the reach of state and county
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coordination efforts, and ensure a comprehensive inventory of contributors to the health
sector and HIV/AIDS program efforts .
In addition, MOH will help state and counties reach consensus on the following: rationale for
establishing a common voice, terms of reference, and guiding principles for network
operations and leadership selection.
MOH will recommend the formation of networks that reflect partnerships already
established at the national level, including the NGO forum, the FBO network, and the private
sector network. MOH will provide the networks, once established, with capacity-building
support to ensure their transformation into institutional arrangements that are an integral
part of the state coordination mechanism.
17.5.2.4 Develop the capacity of SMOH, CHDs and community level structures to manage
coordination mechanisms.
With support from partners , the SSAC and national MOH will support SMOH and the CHDs
in establishing state and county health and PMTCT coordination committees. The state
committees will comprise representatives of each CHD and the respective stakeholder
network. The county committees will comprise representatives of each Payam
administration, FBOs, NGOs, and the private sector. MOH will then develop the capacity of
SMOH and the CHDs to manage their formalized coordination mechanisms. The skills
developed by SMOH and the CHDs, which are expected to lead the coordinating bodies,
include agenda setting, the conduct of effective meetings, communication, consensus
decision making, and follow-up on action items. The HIV/AIDS and EMTCT program will help
both state and local committees launch their activities.
Coordination mechanisms are in essence temporary organizations and cannot be expected

to function without organizational development assistance. Accordingly, the PMTCT program
will conduct start-up meetings for each mechanism in order to secure agreement on roles
and responsibilities, operating procedures, an action plan, and norms for working together;
MOH will also assist the operation of the coordination committees, especially in the first
year. The project will periodically monitor the effectiveness of the committees and revise
them as necessary (quarterly in the first year and semiannually thereafter). MOH will attend
the meetings and provide feedback to the organizers.
17.5.2.5 Develop simple tools and guidelines.
The SSAC and MOH will support development of simple tools that will aid the functioning of
the coordinating committee, including guidelines for effective coordination and simple tips
and tools on how to run effective meetings. In addition, MOH will facilitate the
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establishment of technical working groups to harmonize existing tools, curricula for VHC
capacity-building efforts, and coordination guidelines. TRG has developed similar tools for
use in the harmonization process.
17.5.2.6. Set up decentralized support for coordination points to serve a limited

geographic area. Restricted movements attributable to long rainy seasons, limited CHD
capacity, and unpredicted civil unrest pose challenges to coordination in the health system.
Therefore, MOH will establish decentralized backup points in locations where coordination
efforts are likely to be limited. The project will identify a Payam administration or an NGO
whose capacity may be developed to serve as a time-limited resource for the CHD in the
event that a particular CHD is not yet ready to manage the coordination process.
Indicative activities to be initiated during program scale up
Convene consultative stakeholder meetings at county and state levels

Develop coordination strategy
Form and institutionalize stakeholder networks/groups (NGOs, FBOs, private sector,
populations of concern)
Conduct orientation seminar for the networks
Reproduce/develop guidelines and TOR for stakeholder groups and coordination
meetings
Indicative activities for medium and term program development
Develop state and CHD coordination mechanisms

Develop BHC leadership and management capacity
Institutionalize stakeholder networks
Establish technical working groups to coordinate curricula
Review and harmonize existing tools, curricula, and guidelines
Chapter 18 : Managing Human Resource EMTCT
18.1 Introduction
The most crucial health systems support requirement in the scale up of PMTCT option B+ services is
the availability of adequate numbers and quality of well motivated facility and community based
health care workers to plan ,management ,provide quality services, supervise ,monitor ,report and
learn from the performance of the program and services .Human resources for EMTCT refers to the
health workforce necessary for the delivery of the defined package of EMTCT services at the various
levels of the national health care system . The provision of HIV prevention, care and treatment
services requires a multidisciplinary team of health care providers at the different levels of service
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delivery. This section describe the need for the right numbers and skills mix of health workforce for
EMTCT,the principles underpinning their management ,approaches to attached ,development and
motivate the health workforce for quality and sustained EMTCT and MCH service delivery ,especially
at the primary health care levels .
18.2 Why invest in HRH for EMTCT?

Public health programs including PMTCT cannot succeed without the appropriate health
personnel that must be trained ,recruited ,oriented ,developed ,assigned jobs and motivated
to provide quality HIV/AIDS prevention ,treatment ,care and support services including
EMTCT/MCH services .
18.3 Basic principles underpinning HRH management

A good human resources for health management system to scale up EMTCT services
requires :
o Job analysis and projection of the staffing needs for PMTCT /MCH service provision at
all levels of the health care system based on the national staffing norms .
o Planning for recruitment ,placement and redeployment of the health workforce to
ensure equitable distribution of the available staff with focus on hard to reach and
live in areas .
o The existence of a pool of resource persons to scale up training and development of
health care workers for PMTCT
o In service training (continuous professional development ) of the staff at post to keep
them up to date with the latest knowledge and skills in EMTCT
o A good human resources performance planning and management system in place .
18.4 The HRH requirements for EMTCT at the facility level

A successful PMTCT programme requires the support and cooperation of the entire health
team in the facility. Team members include doctors, Clinical officer/medical assistant
,Midwives ,Nurses,Laboratory personnel,Pharmacists,Records personnel,Administrative staff,
Social workers and nutritionists where available,and community based volunteer
,including mother support groups and network of persons living with HIV/AIDS .The major
roles of each team member are described in the table below;
Table 11-2: Summary of the roles and responsibilities of staff in ART/PMTCT sites
Cadre Roles and responsibilities

Medical Officers Clinical supervision and facility / district management
Management of HIV patients in all aspects

Clinical officer Clinical assessment , case management ,supervision of nursing
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staff ,program management ,reporting on program
performance .
Nurses/midwives Nursing care
Triage of patients
Continuation of clinical care of stable patients
Adherence counseling supervision and training of community

workers
Post pharmacy counseling

Nutritionists Nutritional assessment and counseling
Laboratory Phlebotomy
technologists
/technicians Lab services provision
Lab commodity management
Counselors Counseling for HIV testing

Patient education
Adherence counseling
Community health Community and home treatment support including defaulter

workers tracing
Health records Patient records management
information
officers / data clerks
Pharmacist/ pharmacy Adherence counseling, rational drug use, ARVs dispensing,

effective
technicians commodity/inventory management
Store keeper Commodity management (with lab and pharmacy staff)
Social worker and /or Adhere support
community health Defaulter tracing
worker
Mother support groups Community linkage
PLHA Health education
18.5 Planning and managing HRH requirements for EMTCT
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To ensure the right numbers and skills mix of health care workers are available to scale up
EMTCT service country wide ,with focus on high burden states, the ministry of health and
partners shall undertake the following :
o Conduct training needs assessment for scale up of EMTCT services

o Develop appropriate PMTCT /EMTCT capacity building training and development
plan .
o Review and develop job descriptions for the various cadre of health care workers
involved in MCH/PMTCT service delivery .
o Develop training manuals and materials for the facility and community based health
care workers .
o Train a pool of trainers to cascade the training of health care workers in EMTCT and
option B+.
o Collaborate with the health facility managers and county health officers to ensure
selection of the right caliber of staff for PMTCT trainings .
o Conduct training workshops for various cadre of health care workers on the
recommended package of training programs .
o Conduct post training follow up ,supervision ,coaching and mentorship sessions for
the trained health care workers to ensure application of knowledge and skills
acquired into clinical practice.
o Providing opportunities for staff learning exchange visits to share experiences .
o Due to challenges in staffing (both in numbers of staff and skills), task shifting (of
responsibilities) will be adopted in order to support services delivery especially at the lower
health facility levels.
o This will include greater involvement of community based organizations and PLHIV. Task
shifting will be supplemented by mentorship, ongoing support supervision, and continuous
quality improvement.
18.6 Recommended PMTCT training packages

To ensure quality PMTCT services delivery, all staff is expected to have undergone basic
training in provision of HIV services prevention, care and treatment. Guidelines, job
aides, and SOPs should be provided to support consistent service quality.The following
are the recommended training packages in basic ,intermediate and comprehensive
provision of PMTCT services integrated with ART and MCH :
o 10-14 days comprehensive training in the WHO IMAI/IMPAC package .

o 6-7 days basic PMTCT/EMTCT training for facility
o 5 days training for community based health care workers on EMTCT/PMTCT
o 3 days orientation workshop for other staff on PMTCT /EMTCT
o Conducting follow up refresher training based on emergency of new knowledge and
evidence .
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o Continuous professional development sessions on the job in various aspects of
EMTCT
o Incorporation of the PMTCT training package in the pre services curriculum for
national health training institutes .
o On line training programs and materials
18.7 Team Management at the health facility level
The facility management team comprises the Facility In-charge, Antenatal Care In-charge,
Labour Ward In-charge, Laboratory In-charge, Pharmacy In-charge, Records In-charge and
Community Contact Person. The facility team responsibilities are:
o Conducting a site situation analysis and needs assessment

o Developing a site work plan and budget for start up of EMTCT services
o Designating and organizing appropriate clinic space and equipment for MCH/EMTCT
services
o Selecting of staff and ensuring training on MCH/HIV/AIDS and PMTCT
o Ordering of supplies, testing kits, and ARVs from the main store;
o Providing static and outreach MCH/EMTCT services
o On-site supervision, monitoring ,coaching and mentoring of supervisees
o Facilitation of community-based activities
o Collaboration and partnership with other actors in PMTCT and HIV
o Collection of data, preparation, analysis and discussion of monthly PMTCT reports;
o Submission of PMTCT reports to the District Medical Officers (DMO) office;
18.8 Monitoring and reporting on health workforce performance
To ensure continuous quality improvement in delivery of PMTCT services, it is recommended

that the ministry of health and partners shall adopt staff performance planning
,management and evaluation at the beginning ,middle and end of year ,linked to results
based compensation mechanisms .
It is also recommended that the ministry of health and partners establish a database of
human resources for health trained and developed across the country to inform policy
,planning and practice .
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CHAPTER 19.PMTCT OPTION B+ SUPPLIES AND LOGISTICS CHAIN
MANAGEMENT SYSTEMS
19.1 Introduction
This section describes the supply chain management components that support the scale-up
of HIV prevention, care and treatment services for South Sudanto attain the 90-90-90 goal.
The uninterrupted supply of PMTCT Diagnostic and pharmaceutical products is a key health
systems requirement for successful scale up of services for virtual elimination of HIV in south
sudan .They are selected with regard to public health relevance, evidence on efficacy and
safety, and comparative cost-effectiveness.
19.2 Purpose of PMTCT supplies chain management system

The purpose of a functional PMTCT commodities management system is to ensure
uninterrupted supply of adequate amounts program diagnostics and pharmaceutical
products, in the appropriate dosage forms, with assured quality and adequate information,
and at a price the individual ,the community, government and partners can afford. The
implementation of the concept of essential medicines is intended to be flexible and
adaptable to many different situations.
The objectives of the PMTCT procurement and logistics system is :
To improve access to and rational use of high quality and affordable PMTCT
medicines and supplies for sustainable program scale up .
To improve demand for and rational use of essential PMTCT medicines ,laboratory
diagnostic products and health supplies for EMTCT services .
To strengthen capacity of managers and providers to plan ,implement and report on
the PMTCT supplies and logistics management system.
Enhanced capacity of managers and health care workers to plan and manage
pharmaceutical products and supplies.
19.3. Principles of a sound PEMTCT Supplies and logistics system.

The basic principles underpinning a sound procurement and supplies chain management for
EMTCT and option B+ plus are :
Evidence based procurement planning that takes into account the burden of MTCT
and expected number of mothers ,babies and family members expected to be
enrolled on HIV/AIDS prevention ,treatment and care programs.
The procurement system is aligned to the HIV/AIDS strategic plan ,the option B plus
scale up plan and the 90 -90-90 targets .
The procurement plan is backed by sufficient budgetary allocation .
It should be an integral part of the national pharmaceutical management system .
136
Backed by a sound procurement and logistics management information system .
19.4. The PEMTCT Supplies and Logistics Cycle

A sound procurement systems starts with good planning and forecasting of need based on the
burden of disease ,expected number of clients to be served and efficiency and effectiveness of the
procurement system to select ,quantify ,order ,receive, pay for ,distribute and ensure rational use ,in
line with the procurement cycle .
19.4.1. Selection Of Health Products At The Facility

In general, all health facilities should select antiretroviral drugs and related commodities
for both existing and new patients in line with these treatment guidelines (ART 2016).
It is recommended that the overall selection of HIV-related commodities and regimens
be minimizedto optimize treatment and product sourcing. Only health facilities
designated by MOH to provide third-line treatment should select third line ARVs.
HIV-related commodities include; (ARVs, Isoniazid, Cotrimoxazole, Dapsone, HIV test kits,
Fluconazole and other laboratory diagnostics)
19.4.2 Quantification And Forecasting

All facilities are required to estimate the amounts of HIV commodities required for all
existing and anticipated new patients. Patient numbers and consumption information should
be analyzed and used for decision making.
19.4.3. Ordering Of Supplies And Medicines

Ordering and reporting of medicines at health facilities is a multi-disciplinary task
that should involve Pharmacists, dispensers, clinicians, Laboratory Officer, M&E
officer, and store managers.
Ordering process should be coordinated and led by a pharmacist or a dispenser or a
person designated to manage supplies of medicines in the facility.
137
Facilities should order for medicines on a bi-monthly basis following schedules
provided by their central warehouse.
Health facilities will use the ARV order and report form for ARVs, Fluconazole
Cotrimoxazole, and Dapsone
Isoniazid for prevention of TB in HIV-positive patients should be ordered using the TB
order form
HIV test kits should be ordered using the HIV test kit order form
Other laboratory commodities should be ordered using the general laboratory
commodities form
The Ministry of health has revised all Laboratory Management Information System
(LMIS) tools to accommodate changes in the 2016 treatment guidelines. Health
facilities should obtain copies of updated LMIS from the warehouses.
19.4.4 Sources Of ARVs Medicines And Health Supplies
Following the rationalization guidelines in 2012, the MOH allocated every ART and PMTCT
accredited health facility to one central warehouse. The central warehouses include
National Medical Stores, Joint Medical Stores, and Medical Access South. Newly accredited
facilities should refer to the accreditation letter for information on warehouse allocation.
19.4.5 Preparing Bi-Monthly Orders And Reports

When making bi-monthly orders and reports, health facilities should prepare and use the
following information:
Consumption data obtained from dispensing logs or electronic ordering tools

Stock on hand of commodities from the stock cards/ stock books.
M&E officers should analyze facility patient data and provide the following information
o The number of existing patients on treatment aggregated by age and treatment
regimens at the beginning of the reporting period
o The number of new patients enrolled in the reporting period. New patients including
ART nave patients initiated on first-line treatment and those switched to second or
third line regimens
Further information to consider when ordering is;
The amount of stock currently available

The minimum and maximum stock levels
The required delivery date for new orders
Any anticipated risk of expiry
19.4.6 Submitting The Bi-Monthly Order
Health facilities should submit all HIV commodity orders and reports to the appropriate
warehouse in line with their delivery schedules. Orders can be submitted electronically
through the DHIS2 Web Based ordering system (WAOS) at the facility or through the
district.
Where it is not possible to submit an electronic order, facilities should submit paper-
based orders through the district.
138
19.5. Stock Redistribution.
When there is a risk of expiries or medicines stock out, health facilities should establish
contacts with neighbouring facilities / implementing partners and regional central
warehouse focal contact sites to facilitate thestock transfer. The stock should be
redistributed in line with the MOH commodity redistribution strategy.It is important to note
that all HIV commodities are free of charge and transfer to another facility does not lead to
financial loss.
19.6 Rational Medicines Use.

Rational medicines use ensures patients receive medications appropriate to their clinical
needs, in doses that meet their individual requirements for an adequate period, and at the
lowest cost to them and their community
19.6.1 Principles Of Rational Medicines Use
19.6.2. Rational Prescribing

Health- care workers should prescribe medicines according to the following principles;
Prescribe medicines according to the treatment guidelines.

Use the correct combination of drugs
Prescribe medicines for the correct treatment duration
Counsel the patients on how to take the medicines
Counsel patient substituting or switching treatment regimens
Counsel patients on safety and use of medicines
19.6.3. Rational Dispensing

Health care workers should dispense medicines according to the following principles;
Dispense the correct quantity, dose and dosage formulation to the correct patient.
Fixed Dose Combinations are preferred.
Provide explanation how patients should take their medicines.
Appropriately label the medicine packs to include the patients name and dose.
Medicines for distribution under the community drug delivery points should be
packaged and labeled for each patient
Offer further explanation/counseling to patients on multiple medicines because of
other co-morbidities. Communicate possible drug interactions and adverse effects
New formulations should be introduced to patients effectively while taking into
consideration medication branding.
Counsel patient to adhere to medicine
19.7 Distribution Of Medicines To Patients

Health care workers should do the following while distributing ARV medicines
Ensure medicine shelf life are long enough

Issue 3 month of stock to stable patients.
Supply medicine to new patients for a duration determined by the clinician.
Appropriately record all medicines issued
139
19.8 Guidance For Stock Management At Health Facility
Medicines and medical supplies should be received at the facility store according to the
recommended receipt procedure by MoH
The person receiving the supplies should enter them into the facility stock books and
stock cards, and store them under recommended storage conditions
Stock books and cards should be updated whenever stock is issued from the health
facility main store
Monthly stock check and physical counts should be done
19.9 Pharmacovigilance
It is important for patients to report any adverse drug effects to the health facility staff
The data needs to be captured and relayed to NDA and central warehouses for
investigation and follow-up
19.10 PMTCT Supplies and Logistics information management

A sound logistics information management system is required to ensure evidence based
planning ,purchase ,use and timely replenishment of PMTCT commodities to meet the needs
of the expected clientele to be served over the timespan of the strategic and business plan
at all levels of the health .
CHAPTER 20: PMTCT PROGRAM MONITORING AND EVALUATION

MECHANISM
20.1 Introduction
Chapter Eight describes the integrated monitoring and evaluation plan to track progress and
measure the impact of the National guidelines for scale up PMTCT option B+ against the
planned results and strategic objectives of the scale up plan and national strategic plan . It
starts with the purpose of monitoring and evaluation, key indicators to track progress and
measures of success. It concludes with the strategic information management systems
necessary to generate information for management decision making.
A comprehensive and well-functioning monitoring and evaluation (M&E) framework is
essential to ensure that South Sudan s program to prevent and treat HIV in pregnant and
lactating mothers and their HIV exposed babies using ART is effective and efficient. The
purpose of this chapter is to guide how to monitor implementation of the revised guidelines,
program performance and to provide a framework for assessing the impact of the
guidelines. This chapter is aligned to the guidance contained in the National HIV and AIDS
Strategic Plan 20132017 and National HIV and AIDS Monitoring and Evaluation Plan
2015/20162019/2020.
140
20.2 The purpose of the Monitoring and Evaluation mechanism
Monitoring is the routine tracking of the key elements of a planned project, programme or
organizational performance, up to the output level, through record-keeping, regular
reporting and surveillance systems. Monitoring helps projects, programmes or unit
managers determine which areas require greater effort and identify areas that might
contribute to an improved business performance.
Evaluation, on the other hand ,is the periodic assessment of the change in planned results
that can be attributed to the project, programme or organizational efforts. In other words,
evaluation attempts to link a particular output or outcome directly to an intervention after
a period of time has passed. Evaluation helps programme or project managers determine
the value or worth of a specific programme or project. Linkage with financial data permits
cost-effectiveness and cost-benefit analysis, which are useful in determining the added
value of a particular programme or project to the MOH portfolio of businesses and
projects therein .
20.3 Program Monitoring and evaluation Indicators

The performance of the implementation guidelines will be monitored and evaluated in line
with globally agreed, national and MOH HIV/AIDS and PMTCT specific monitoring and
evaluation frameworks .Key performance indicators have been identified to track progress
and measure short, medium and long term impact of program and project interventions.
The PEMTCT indicators include but are not limited to:
Percentage of pregnant women who know their HIV sero status
Percentage of HIV-infected pregnant women who receive ARVs to reduce risk of MTCT
Percentage of HIV-exposed infants receiving any HIV test by age of 18 months
Percentage of HIV-exposed infants who received ARV prophylaxis
Percentage of HIV-exposed infants receiving Cotrimoxazole by 2 months of age
Percentage of HIV-exposed children tested with DNA PCR by four to six weeks of age
Percentage of HIV-infected women receiving infant feeding

Percentage of postpartum HIV-infected women who receive family planning
services
Percentage of male partners of pregnant women who know their HIV status.
141
A baseline survey shall be conducted to establish bench marks against which progress shall
be measured.
20.4 PMTCT Program Data Management

19.4.1 Indicators For Routine Monitoring
Indicators for routine monitoring have been updated and can be found in the National HIV
and AIDS Monitoring and Evaluation Plan 20132017.
20.4.2 Data collection

Standardized data collection tools shall be used for daily data collection .These tools are
aligned to the existing SSAC and MOH specific strategic information management tools
(DHIS) . These include :
o Antenatal cards
o ANC Registers
o HTC registers
o Laboratory Registers
o Dispensing and Daily consumption Logging tools
o Delivery and Maternity registers
o Post Natal/Family planning Registers
o Pre-ART and ART registers
o Monthly DHIS reporting tools
PMTCT programme monitoring data should be collected daily and recorded accurately
and consistently in a way that protects clients confidentiality.
For the purpose of confidentiality clients should not be identified by name but by
their unique numbers.
Registers should be kept in locations away from public viewing.
Registers should be accessible only to healthcare workers who need to work with
them.
20.4.3 PMTCT Data analysis and Reporting

The data collected is collated ,validated and entered in the DHIS system for analysis and
reporting .Health facilities should submit timely reports of aggregated patient data on a
weekly, monthly and quarterly basis. The monthly and quarterly reports shall be
consolidated and entered into DHIS-2.Table 9 below shows the different reports and
frequency of submission
Table 9: Routine Reports and their frequency
142
Report Description Source Documents Frequency Recipient
Reports the quarterly Pre-ART Register,

HMIS 106A: Health
attendance figures for ART Register, PEP
Unit Quarterly Quarterly DHIS-2
HIV care/ART, nutrition, Register, EID
Report
and TB services Register, TB Register
Reports the monthly

attendance figures for
HCT Register, EID
OPD, OPD diagnoses,
HMIS 105: Health Register, Safe Male
MCH, HIV/AIDS service
Unit Outpatient Circumcision Monthly DHIS-2
data, laboratory data,
Monthly Report Register, Laboratory
stock-out of essential
Tests Daily Summary
drugs and supplies and
financial data
HMIS 102: Report

Form for HIV-
DHIS-2
Exposed Infant at
24 months
HMIS 033B: Health Health

Report cases of
Unit Weekly HIV Laboratory Tests sub-
notifiable diseases
Epidemiological Log and eMTCT Weekly district
after the first few cases
Surveillance Drug Dispensing Log HQ and
have been notified.
Report DHO
eMTCT SMS
Weekly
reports
eMTCT Early
Retention Monthly
Monitoring Report
HIV Drug
Annual
Resistance Report
Facility ARV stock and orders shall be monitored via the Web-Based ARV Ordering System
(WAOS).
20.4.4 Data Flow

below shows data flow from the points of collection up to international level.
143
Figure 7: HIV data and report flow
20.5 Strategic Information Dissemination and use.

The information generated by the M&E system shall be shared with key stakeholders, both
internally and externally depending on their information needs. Periodic review meetings
shall be convened with key stakeholders to take stock of the business performance. These
will include quarterly, mid-year and annual performance review meetings.
20.6 Special studies and surveys

Where need be MOH shall commission special studies, surveys, assessments and action
oriented operations research projects to generate extra information for policy and practice
decision making on alcohol, drug abuse and gambling situation in Uganda.
20.7 Other Data Sources

The following sources complement the data generated from DHIS:
Surveillance data from AIDS Indicator Survey, HIV/AIDS Sero-behavioral Survey, ANC
sentinel surveillance,HIV case-based surveillance
Longitudinal and evaluation studies
HIV estimates from modeling
20.8 New Considerations For Routine Monitoring

The Indicators from the following programmatic areas identified in the revised guidelines
should incorporate into the M&Eframework and monitoring and reporting tools.
Differentiated service delivery models- especially the community models.

Viral load monitoring
Pre-Exposure Prophylaxis
And Mental health
144
20.9. HIV Drug Resistance Monitoring
HIV drug resistance has been previous been monitored using early warning indicators mainly
through surveys. We now recommend that these indicators should be integratedinto the
routine data collection and quarterly reports for program monitoring.
20.10 Routine Supervision And Data Auditing

All program areas should institutionalize M&E support, supervision, and routine data quality
assessments (RDQAs). This is to ensure adherence standards and data quality.
20.11 RESEARCH AND EVALUATION

The program will continue to conduct the following research studies to inform the disease
burden and evaluate the impact of programs;
AIDS Indicator Survey and HIV/AIDS Sero-behavioral Survey

ANC sentinel surveillance
HIV case-based surveillance
Modes of transmission study.
We also recommend programs and academia to conduct especially implementation science

research especially in thearea of differentiated service delivery and other relevant areas. The
research should be conductedin line with the National HIV and AIDS Monitoring and
Evaluation Plan 2015/20162019/2020.
20.12 DATA USE

The information generated from the M&E system shall be disseminated promptly and shall
guide decision making.
21. ANNEXES
ANNEX 1.Map of South Sudan Health facilities 2016.
Annex 2: Map of South sudan Showing PMTCT program coverage (2016)
Annex 3: Staffing Norms for Health care workers in South Sudan (2016)
Annex 4: List of health workers trained in PMTCT and Option B+ Dec 2016.
Annex 5: Essential Medicines and Health supplies for PMTCT _MOH RSS
Annex 6: Recommended ART prophylaxis and treatment regimen 2016
Annex 7: National PMTCT program Financing Status and Trends 2016 .
Annex 8: Demographic and Health statistics for PMTCT 2016/2017
Annex 9: National PMTCT program Targets by state, county and Facility
Annex10: National PMTCT program performance status and trends analysis (2016)
145
Annex 11: PMTCT Stakeholder Analysis
Annex 12: National PMTCT program Risk Analysis and Contingency plan
146

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MINISTRY OF HEALTH

GOVERNMENT OF SOUTH SUDAN

Revised Guidelines for the Prevention of Mother-

1.2. Background and contexts

1.3 Rationale For The Guidelines

These guidelines are intended:

1.5 The Guideline Review Process

1.6 The scope and structure of the guidelines

Chapter 14 provides guidance on measures to create an enabling environment for prevention

1.7 The intended users of the guidelines

Clinicians and other health service providers

CHAPTER TWO : OVERVIEW OF HIV/AIDS AND MTCT IN SOUTH SUDAN

2.2.The HIV/AIDS Epidemic in South Sudan

Population group Percentage (%) Numbers

Total population 100% 11,425,377

Women of child bearing age (15-49) 22% 2,500,000

Expected pregnant women 5% 585,0000

Expected HIV positive pregnant women 3% 17,500

Expected HIV+ deliveries/exposed infants 4.4% 14,000

2.4 Risk of transmission without intervention

100 infants born to HIV-infected women who breastfeed, 5580 infants

2045 infants will be HIV-infected

2.5 Factors that determine HIV transmission

Table 1: Factors increasing risk of mother-to-child transmission of HIV

External cephalic version

During labour and childbirth

Prolonged rupture of membranes (>4 hours)

Instrumental delivery (forceps or vacuum

First infant in multiple birth

Mixed feeding (non-exclusive breastfeeding or non-

Long duration of breastfeeding

Mastitis, cracked nipples, breast abscess

2.6 Bottleneck to current PMTCT program interventions.

There is no Early Infant Diagnosis mechanism in place to facilitate better follow-up of

CHAPTER THREE : STRATEGIC FRAMEWORK FOR ELIMINATION OF

3.2. Program Goal and objectives

3.2.2. Strategic objectives

1. To create an enabling policy and practice environment for elimination of HIV/AIDS in

7. To strengthen logistics management system and commodity security;

3.3 Comprehensive Approach To PMTCT.

Table 2: Elements of comprehensive PMTCT

Element Target population Additional information

Element 3: Women living This element focuses on:

Safer delivery practices to decrease the risk of

Infant feeding information, counselling and

This also includes community outreach and efforts

*ABC refers to Abstinence, Be faithful Condom use

3.4 EMTCT Program Component Expected Results

3.4.1 Planned Program component Level Results

By 2021 , the following program results should have been achieved :

Prong 3 MTCT 90% reduction in estimated number of new infant

infections and a MTCT rate of less than 5%

3.4.2 Intermediate (Output) Results

ARVs for PMTCT option B+ provided according to recommended guidelines to 90% of

ARVs for PMTCT option B+ provided according to recommended guidelines provided

90% of all pregnant and lactating mothers provided IYCF counselling

Co-trimoxazole prophylaxis provided to 90% of HIV exposed infants from 6 weeks of

DNA PCR test provided to 90% of all HIV exposed infants

50% reduction in HIV incidence among women 15-24 years

1. Primary prevention of HIV infection among women of childbearing age;

2. Preventing unintended pregnancies among women living with HIV;

3.6 . Program Implementation Approaches

National policy and implementation guidelines for EMTC