HIV Services at Mae Tao Clinic

Preventing Maternal to Child

Transmission of HIV
(PMTCT)

-- Dec 2010
 Objectives for this Training

 Explain basic HIV/AIDS information.

 Present information about HIV transmission and

prevention.

 Describe benefits and risks of HIV screening for

pregnant women

 Describe the stages of the PMTCT program

PMTCT Counseling
Knowledge Quiz
 List the Ways in Which HIV Infection
Is Transmitted

 Unprotected sex with an infected person.

 From an infected mother to her infant before birth,
during birth, or during breastfeeding.
 Blood transfusion in areas where blood is not
screened.
 Blood-to-blood transmission.
 Injection drug use.
 Accidental exposure to needles or sharps.
 What Body Fluids Contain High
Concentrations of HIV?

 Blood
 Semen
 Vaginal secretions
 Breast milk
 What Specific Part of the Human Body
Does HIV Attack and What Is the
Result?

 HIV infects the immune system,

specifically the CD4 cells.
 Over time, the weakened immune system
has a progressively more difficult time
fighting infections.
If 100 Women Who Were HIV Infected
Gave Birth to 100 Babies and They All
Breastfed Their Babies and None of
Them Received Any Treatment, How
Many Babies on Average Would
Become Infected With HIV at 1 Year of
Age?
 Mother to Child Transmission

100 infants born to HIV-infected women who breastfeed, 60 to 75 infants

Without any interventions will not be HIV
infected

About 15 5-15
5-10 infants infants infants
infected infected infected
during during during
pregnancy labour and breastfeed
delivery ing

25 to 40 infants will be HIV infected

 Name at Least 4 Interventions That Are
Universal Precautions.

 Wash hands after any direct contact with patients.

 Do not recap needles.
 Dispose of needles and sharps safely in puncture-
proof containers.
 Wear gloves
 Promptly and carefully clean up spills of blood and
other body fluids.
 2 Reasons Why an HIV Positive Woman
May Choose to Breastfeed

 To avoid stigma
 To maintain denial of her HIV status
 To comfort the infant in an easy way
 To save money if she cannot afford milk
powder and cannot get it another way.
 To accommodate family pressure
What Is Specifically Measured in an
HIV Screening Test?

 Antibodies
 What Does “Window Period” Mean?

 This is the period between initial infection

and the time when the HIV test can detect
the antibodies.
 People infected with HIV usually develop
antibodies 4 to 6 weeks after infection but it
may take as long as 3 months.
 What 2 Factors Increase the Risk of
Transmitting Infection to the Baby
During Pregnancy

 New HIV infection during pregnancy

 Malaria or any other infection that goes to
the placenta
 STI
 Maternal malnutrition
 Advanced or late-stage AIDS
 Name 1 Symptom Associated With
HIV Infection in the Infant or Child.

 Low weight and failure to gain weight

 Pneumonia
 Lymphadenopathy
 Diarrhea
 TB
HIV and AIDS Overview
 HIV and AIDS

Human Immunodeficiency Virus

H = Human
I = Immunodeficiency
V = Virus
 HIV and AIDS

Acquired ImmunoDeficiency Syndrome

A = not inherited

I = immune system

D = deficiency – inability to protect against illness

syndrome, a group of symptoms or illnesses
S =
that occur as a result of HIV infection
 T Cells (CD4 Cells) =
Part of body’s immune system
CD4
The average person has between 800 & 1500
CD4 cells per cubic millimetre of blood

The immune system helps fight diseases

CD4 Disease Disease

IMMUNE ATTACKS DISEASE KILLS DISEASE

SYSTEM
 Transmission of HIV

HIV is transmitted by
 Direct contact with infected blood
 Sexual contact: oral, anal or vaginal
 Direct contact with semen or vaginal and
cervical secretions
 Mothers infected with HIV to infants during
pregnancy, delivery and breastfeeding
 Transmission of HIV

HIV cannot be transmitted by:

 Coughing, sneezing  Toilets

 Insect bites  Handshakes

 Work or school contact
 Touching, hugging
 Telephones
 Water, food
 Cups, glasses,
 Kissing plates, or other utensils
 Public baths/pools
 Are Some People
More Susceptible to HIV?

Women are 3 times more easily infected

than males!
The vagina is more susceptible to lesions
allowing the virus to pass into the
body, and semen can remain in the
body for up to three days.

Worldwide 75% of HIV is transmitted sexually.

¾ of infections are through heterosexual sex and ¼
are homosexual sex.
 Are Some People
More Susceptible to HIV?

People with STIs are up to 10 times more

at risk as many of the STI will result in
cuts and open sores giving the HIV
more chance to enter the body.
HIV Animation
 Natural History of HIV Infection

 Severity of illness is
determined by amount of
virus in the body
(increasing viral load)
and the degree of
immune suppression
(decreasing CD4 count).
 Higher the viral load, the
sooner immune
suppression occurs.
 When does HIV become AIDS?

1500 to 800 CD4 - Average healthy person

CD4 Below 500 CD4 - HIV+ person at risk from

COUNT Opportunistic Infections

200 CD4 Person is considered to have AIDS

In many developing countries they are unable to conduct the

! difficult CD4 count tests. In these countries AIDS is
diagnosed by looking at the symptoms that the person has.
 HIV-Related Opportunistic
Infections
_______________Head__________________
Toxoplasmosis (Toxo)
Draft
Cryptococcal meningitis

_______________Eyes__________________
Cytomegalovirus (CMV)

___________Mouth and Throat__________

Candidiasis (Yeast)

________________Lungs________________
Pneumocystis carinii pneumonia (PCP)
Tuberculosis (TB)
Histoplasmosis

_________________Gut_________________
Cytomegalovirus (CMV)
Cryptosporidiosis
Mycobacterium avium complex (MAC)

________________Skin_________________
Herpes simplex
Shingles

_______________Genitals______________
Genital herpes
Human papillomavirus (HPV)
Vaginal candidiasis (Yeast)

PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV Module 1

26
PMTCT Program
 PMTCT Strategies

 Prevention of primary HIV infection

 Prevention of unintended pregnancies among
women infected with HIV
 Prevention of mother to child transmission
 Providing treatment, care and support to
women who are HIV infected, their infants,
and their families
 HIV Prevalence at Mae Tao Clinic

Percent of ANC clients testing

positive

2.50 Insert
2.00
1.50
1.00
0.50
0.00
1999 2000 2001 2002 2003 2004 2005 2006 2007
 Outcomes for ANC Screening in 2007

Pregnant Women
4,545 seen in ANC in 2007

3,421 (75.3%) tested for HIV in 2007

1,124 (24.7%) not tested

Assume 1.55% 3368 (98.45%)

17.42 (1.55%) 53 (1.55%) tested positive
HIV rate 1106.58 tested negative
hypothetical HIV for HIV
(98.45%) not
positive
hypothetically 52.20 (1.55%) 3315.80
HIV positive +1 patients diagnosed elsewhere
5.38 (30.9%) 12.04 (69.1%) Hypothetical (98.45%)
Hypothetical Hypothetical 17.15 (1.55%) 1089.43 HIV Positive Hypothetical
HIV infected Non HIV Hypothetical (98.45%) (seroconversion HIV
infants infected infants HIV Positive Hypothetical during pregnancy) Negative
54 patients enrolled in PMTCT in 2007
(seroconversion HIV Negative 1 ( 1.85%)
during pregnancy) patient given
5.30 (30.9%) 12.09 (69.1%) wrong result and
Hypothetical Hypothetical thus not enrolled
HIV Positive HIV Negative in program until
2 (3.70%) after delivery
Infants Infants 27 (50%) received AZT received 11 (20.37%) 13 (24.07%) lost to follow-up
antepartum NVP at pending
delivery, no delivery at
23 (85.2%) 4 (14.8%) 4.02 (30.9%) 8.98 (69.1%)
AZT < 28 weeks
delivered as pending Hypothetical Hypothetical
antepartum as of 1/18/2008
of 1/18/2008 delivery as of HIV Positive HIV Negative
1/18/2008 infants infected infant
 Antenatal Care for PMTCT

 Extensive post-test counseling

 Includes partner, STI, GBV, TB screening, VDRL,
Hepatitis B, discrimination, work)
 Home-based care and/or other Support Networks
 World Vision, METRO
 Mae Sot hospital
 Ultrasound, repeat HIV testing with ELISA)
 Start daily dose of AZT at 28 weeks gestation
 Labour and Delivery

 Delivery at Mae Sot Hospital

 Before rupture of membranes
 Normal (vaginal) or Cesarean
 Post partum tubal ligation available
 Intrapartum Medicine
 Nevirapine, Lamivudine, AZT
 Post-Partum

 Continue medication and personal care

 Family Planning
 Baby to start 1-3 drug therapy
 Baby HIV test at 12 months of age is
important
 Infant Feeding choice
 Types of Infant Feeding

1. Breastfeed exclusively
 Except for medicine and vitamins
2. Replacement feeding – milk formula
3. Mixed feeding
 Both breast milk and formula
 Mixed feeding should be avoided - it
increases the risk of HIV infection, diarrhea
and other infections
 Formula Feeding Is OK
When It Is:

 Acceptable
– no stigma
 Feasible
– mother can correctly prepare it
 Affordable
– can pay for cost (incl. travel)
 Sustainable
 Will not switch back to breast milk
 Safe
 Clean water, cups, bottles
 Breast Feeding

 Give breast milk for first few months only

then switch to other foods
 About 6 months
 No Breast milk if mother has
 new HIV infection
 AIDS or Opportunistic Infections
 Explain what a positive HIV test means to a
client.

 Explain what a negative HIV test means.

 Case 1

 20 year old G1 P0 at 3 months gestation.

 No previous ANC.
 She comes by herself.
 Complains of diarrhea for 2 weeks and
weight loss, weakness.
 Exam shows bruises on her face, chest and
legs.
 Case 1

 She tells you her husband beats her and told

her to get an abortion when he found out she
was pregnant.
 Her HIV test is reactive.

 How do you counsel her?

 What services should she receive?
 Case 2

 22 year old G1 P0 admitted to RH IPD for septic

induced abortion at 2½ months gestation.
 She is not married.
 She has worked in a brothel for 3 months and
plans to continue there.
 Her HIV test is reactive.
How do you counsel her?
What services should she receive?
 Case 3

 34 yr old G4 P1+2 at 6 months gestation comes for

her first ANC visit.
 Her husband is working in Bangkok. He is not the
father of this baby. He does not know she is
pregnant and sends her money every month.
 Her HIV test is reactive.

How do you counsel her?

 PMTCT Goals for 2008:
Goal 1

 90 percent or more of all ANC clients will be

screened for HIV (and Hepatitis B and VDRL).

 Women will be tested at the first ANC visit

 Repeat testing will be done in the third trimester for
women at high risk for infection
 New STI
 Partner positive
 Other risk factors
 PMTCT Goals for 2008:
Goal 2

 All HIV infected ANC clients will have a peer

counselor to meet with throughout pregnancy and
afterwards either through Home-based Care or at
RH OPD.

 Each session will include education about HIV

transmission, ARV’s, infant feeding, and risk
reduction practices.
 PMTCT Goals for 2008:
Goals 3 & 4

 All HIV infected clients will be referred to

Mae Sot Hospital for CD4 count and if
eligible full ARV therapy through the
migrant ARV program.

 All data forms on ANC HIV infected clients

will be complete, accurate, and prompt.