Tearfund Good Practice Guidelines
Focus Area One
Prevention of Parent to child transmission of HIV (PMTCT)
1 DEFINITION AND DESCRIPTION
1.1In 2008, nearly 430,000 babies became infected with HIV as a result of transmission of the virus
from HIV infected mothers to their infants during pregnancy, labour or breastfeeding. Without
treatment, 50% of these HIV infected children die before their second birthday, suffering a series of
severe, distressing infections before they eventually succumb. Several factors increase the risk of HIV
transmission from mother to child - the amount of virus in the mother (viral load), the immunity of
the mother (her CD4 cell count), the severity (clinical WHO stage) of her own HIV related illness,
opportunistic infection (such as TB), prolonged and difficult labour, poor obstetric care and pelvic
infection. Without treatment, the chance of transmitting HIV from a mother to a baby is somewhere
between 20 and 45% in resource limited settings. In well resourced environments, HIV transmission
can be reduced to less than 2%.
1.2 However this requires early diagnosis, anti-retroviral (ARV) prophylaxis (prevention) and ARV
treatment to the mother and baby, good obstetric care and treatment including elective caesarean
section and avoidance of breast feeding. These are not widely available in resource limited
environments and so outcome for a HIV+ve woman depends on what resources she can access. A
particular dilemma she faces is how to feed her child. HIV is transmitted in breast milk. While avoiding
breast feeding reduces the risk of post natal infection, this puts the infant at increased risk of death
from infection as a result of not receiving the immune protective factors in breast milk; these are life
saving in poor environments.
1.3 Screening for HIV in antenatal clinics and providing HIV +ve mothers and their infants with
prophylactic courses of ARVs is vital. In addition, some mothers (can be up to 20% of HIV +ve
mothers) have severe HIV disease and/or low CD4 counts (<350). They need treatment with ARVs
for themselves and to reduce transmission as such mothers are at particularly high risk of transmitting
HIV to their babies. A key additional point is that Exclusive Breast Feeding (EBF) - as opposed to the
more traditional mixed feeding – reduces postnatal transmission and mothers need encouragement
and support to breast feed exclusively.
1.4 The term PMTCT is used to describe Prevention of Mother to Child Transmission. The term PPTCT
is used if the father is also involved in prevention of HIV infection to infants as the father is frequently
the source of the HIV infection. Both partners need to know their HIV status and about the particular
times in pregnancy and the post natal period when fathers are most likely to transmit HIV to their
partner and infant.
2. POLICY FRAMEWORKS FOR PMTCT
There are several policy frameworks within which PPTCT programmes play a vital role:-2.1 UN Millennium Development Goals (MDGs)
PMTCT directly affects the achievement of three MDGs (to be met by 2015):
- 4th MDG: Reduce by two thirds the mortality rate among children under five
- 5th MDG: Reduce by three quarters the maternal mortality ratio
- 6th MDG: Halt and begin to reverse the spread of HIV/AIDS
2.2 Universal Access of Prevention, Treatment and Care
The G8 nations at the Gleneagles Summit in July 2005 called for the development and
implementation of "a package for HIV prevention, treatment and care, with the aim of as close as
possible to universal access to treatment for all those who need it by 2010."
2.3 Abuja Call to Action
In 2005, representatives of governments, multilateral agencies, development partners,
research institutions, civil society and people living with HIV assembled at the PMTCT
1
High Level Global Partners Forum in Abuja, Nigeria which resulted in a 'Call to Action'
for the elimination of HIV infection in infants and children and an HIV- and an AIDS-free generation.
2.4 UNGASS
The Declaration of Commitment of UNGASS in June 2001 set the goal of reducing
the proportion of infants infected with HIV by 20% by the year 2005 and by 50% by the year 2010, by
means of:
2.4.1 - Ensuring that 80% of pregnant women access antenatal care and receive
information, counseling and other HIV-prevention services
2.4.2 - Increasing the availability of and providing access for HIV-infected women and
babies to effective treatment to reduce MTCT, as well as to voluntary and
confidential counseling and testing
2.5 United Nations Comprehensive Approach
The UN four-pronged strategy for PMTCT addresses a broad range of HIV-related
prevention, care, treatment and support tackles the needs of pregnant women, mothers, their
children and families. This comprehensive approach includes the following four elements:
2.5.1 The primary prevention of HIV infection among women, especially young
women. Avoiding infection in parents-to-be will help to prevent HIV transmission to infants and young
children, as well as help towards other prevention goals. HIV prevention needs to be directed at a
broad range of women at risk and their partners. As primary HIV infection during pregnancy and
breastfeeding poses an increased threat
of MTCT, HIV prevention efforts should address the needs of pregnant and lactating
women, especially in high prevalence areas. In addition, special effort should be
made to prevent future infection among women diagnosed HIV-negative especially in
antenatal care settings.
2.5.2 The prevention of unintended pregnancies among HIV-infected women.
Reproductive health (including family planning) services need to be strengthened so
that all women, including those who are infected, can make informed decisions about
their future reproductive life, including when to seek appropriate support and services
to prevent unintended pregnancies. Most HIV-infected women in the developing
world do not know their HIV status.
2.5.3 Provision of specific interventions to reduce HIV transmission from HIV infected
women to their infants. For HIV-positive women who do become
pregnant, WHO has identified a package of interventions for the PMTCT. It includes
antiretroviral drug regimens for HIV-infected pregnant women and their newborn,
safe obstetric practices and counseling and support for HIV-infected pregnant
women on infant feeding options.
2.5.4 Provision of treatment, care and support for HIV-infected mothers, their infants
and family. Care and support must be fully integrated into ongoing efforts to
improve maternal and child health services, and be tailored to the needs of women
for safe and effective antenatal, obstetric and reproductive health services. This also
includes sexual and reproductive health interventions for HIV-infected women and
other care for HIV-infected women and for children born to HIV-infected mothers.
3 PREVENTION OF MOTHER TO CHILD TRANSMISSION AND PREVENTION OF UNWANTED
PREGNANCY WILL ALMOST ELIMINATE HIV INFECTION IN CHILDREN
The Prevention of MTCT requires several, linked activities:3.1 The primary prevention of HIV among youth and adults of both sexes – this involves behaviour
change which is tackled in the Good Practice Guidelines on Behaviour.
3.2 The prevention of unintended pregnancies among HIV +ve women- this involves careful cultural
considerations. There may be pressures on a woman to have more children than she wishes. There
may be lack of family planning supplies to enable her to implement her decisions. There may be
considerable problems that a woman faces in getting to know and sharing her HIV status; this limits
her ability to make informed choices as to when to become pregnant.
2
3.3 Provision of services and style of services has changed considerably in recent years. For instance,
most countries have moved from the “classic” one to one consultation before testing towards group
counselling and “opt out” testing for all in antenatal clinics. In this procedure all women are
counselled before testing in a group and all women have a blood test taken. Women are then given
the choice of listening to their result in a “one to one” interview. In practice this has increased uptake
of HIV testing such that nearly 100% of most antenatal clinics now record testing and receiving the
result of an HIV test. More and more clinics now provide CD4 testing facilities and ARVs in treatment
doses when indicated. And yet there are many women who do not avail themselves of the testing and
treatment. The reasons include geographical distance from clinics, the expense of travel, and fear of
disclosure to their partner and stigma from family and friends.
3.4 Prophylactic ARV regimes for mothers and infants are changing all the time in the light of new
knowledge from research. These are described in the WHO website . A key factor at present is the
move away from single dose nevirapine given to mothers in labour and to their infant within 72hrs of
birth towards more intensive treatment with AZT to mothers from 28 gestational weeks and to infants
for a week or a month postnatally. Modern ARV prophylaxis regimes make it even more important
than ever for a mother to deliver her baby in a health facility rather than at home. This raises
challenges for those in rural areas who live far from such facilities.
3.5 The contribution of the father to HIV transmission. There are several factors which need to be
tackled. Firstly a father may become HIV+ve and infect his partner during her pregnancy; she may
have been HIV –ve at the first antenatal clinic booking and subsequently becomes HIV+ve. Secondly a
father may introduce another strain of HIV into the mother/baby through sex during pregnancy if he
has acquired another infection from another sexual partner. Thirdly the reproductive tract is very
vulnerable during pregnancy and postpartum and an HIV +ve father may more easily transmit HIV at
these times; for this reason, fathers need advice to use condoms/abstinence at these times especially.
4. ANTI-RETROVIRAL THERAPY
WHO provides technical guidance on the best form of prevention and treatment of HIV transmission
from mothers to children in the light of recent research.
4.1 WHO first issued recommendations for the use of ARV drugs for PMTCT in 2000.
4.2 A comprehensive approach to PMTCT (outlined by four elements) was promoted by the UN after a
consultative meeting in 2002.
4.3 Use of ARV drugs was revised in 2004 with the adoption of a simplified and
standardized regimens.
4.4 Following a Technical Consultation in 2005, the guidelines on the use of ARV drugs for treating
pregnant women and preventing HIV infection in infants were updated
4.5 In 2006, the guidelines were updated in detail and these provide the most authoritative
recommendations currently.
4.6 In November 2008 there was a further consultation on the use of ARVs in the prevention of
mother to child transmission. It is anticipated that there will be a further annual updates as new
knowledge becomes available.
4.7 Key points of the current guidelines
4.7.1 All women of reproductive age should know their HIV status, preferably before they become
pregnant. “ Opt out testing” is advised as this increases the number of women who get to know their
HIV status.
4.7.2 All HIV +ve women should receive prophylactic ARV regimes –this includes maternal AZT (from
28 weeks of pregnancy or as soon as possible thereafter) plus single-dose nevirapine at delivery
followed by a 7-day course of AZT and 3TC. The infant should receive a single dose of nevirapine and a
7 day course of AZT. This replaces the previous advice on giving a single dose of nevirapine to the
mother during delivery and a single dose of nevirapine to the infant within 72 hours of delivery.
4.7.3 All HIV +ve women should be assessed for their needs for ARV treatment for their own health
and to reduce the risk of HIV transmission to their infant. This is done on the basis of CD4 count
testing and clinical assessment using the WHO AIDS staging classification. If the CD4 is < 350
treatment with AV is started. If CD4 counts are not available – then women in WHO Stage 3 and 4
should start ART. The regime should include (a) During pregnancy - AZT + 3TC + nevirapine twice daily,
3
(b) During delivery- single dose nevirapine +AZT/3TC and (c) after delivery AZT + 3TC + nevirapine
twice daily. The Infant requires AZT for 7 days.
4.8 The implication of these new regimes is that:4.8.1 Use of single dose therapy using Nevirapine to Mother and Infant has been replaced by modern
regimes
4.8.2 All HIV +ve mothers should receive a CD4 count and access to treatment with ARVs if they need
them
4.8.3 This puts additional burdens on families, communities and professional staff. Each country has
they own National HIV/AIDS Policies which should be followed at all times. Availability of ARVs and
the regimen recommended will vary between countries and are regularly updated. Tearfund partners
should only implement PMTCT programmes in consultation with, and subject to approval from, the
appropriate National HIV and AIDS Programme and local medical advisers.
5.1 INFANT FEEDING
5.1.There are three key facts
5.1.1 Breastfeeding can transmit HIV.
5.1.2 Breastfeeding up to the age of six months provides newborn babies and infants with life saving,
protective factors against diarrhoea and respiratory infection and is widely acceptable
5.1.3 Exclusive breastfeeding is associated with a lower risk of transmission of HIV infection compared
with mixed feeding (providing breast milk along with juices, porridge, infant formula or other foods
which increases the uptake of HIV into the infants body).
5.2 So, most HIV +ve mothers face a dilemma. If she is well off, (well educated, clean water always
available, good sanitation, always able to afford infant formula and the fuel to prepare it hygienically
and is encouraged by family and friends) – she is best advised to formula feed. If however she is not
able to provide these constantly she should exclusively breast feed for as long as possible, preferably
up to 6 months.
5.3 HIV +ve mothers need careful, informed advice and support in their choice of Infant Feeding
Method. An assessment of their domestic situation uses an AFASS review (Acceptable, Feasible,
Affordable, Safe and Sustainable). This needs to be provided for each HIV+ve mother. An AFASS
assessment needs to involve key people in the family and community who influence the choice of
Infant Feeding as well as the mother herself.
5.4 The socio-economic and cultural factors involved in the choice of infant feeding will vary between
countries and even between communities in the same country. It is important for Tearfund partners
to discuss infant feeding and the recommended regimens with their National HIV and AIDS
Programme and local medical advisers.
6 CARE OF HIV EXPOSED CHILDREN
6.1 HIV infected children have decreased immunity like their mothers and are more likely to develop
severe infections including diarrhoea and respiratory infections. A daily dose of co-trimoxazole (an
antibiotic) reduces this risk. The daily dose should be continued for 18 months if only ELISA (antibody
tests) for HIV are available or for less time if PCR (detection of the virus itself) are available. HIV
antibodies from an HIV +ve mother cross the placenta into her infant and continue to circulate in the
infant for up to 18 months. So it is not possible until that time to know if a +ve ELISA test is due to a
true HIV infection in the infant or just due to circulating maternal antibodies. The more accurate PCR
test for HIV s increasingly available and is performed on infants of HIV +ve mothers at 6 weeks. If
negative -the Cotrimoxazole prophylaxis can be stopped. ARVs for infants and children are
increasingly available and infants who are truly HIV+ ve should start receiving ART as soon as possible.
4
7 INVOLVEMENT OF FATHERS
Fathers have 5 key roles in preventing HIV infection in their infant:7.1 Ensuring that they do not become infected themselves
7.2 Ensuring that they know their HIV status – men are often reticent to attend clinics, especially
antenatal clinics - for HIV testing. Innovative ways of encouraging attendance include “fast track”
access to services if a mother attends with the father, special clinics for fathers and texting special
invitations for fathers to attend special clinics
7.3 Ensuring that fathers know that infection with a new strain of HIV is more easily transmitted
during pregnancy
7.4 Ensuring that fathers know that HIV is more easily transmitted after delivery because of damage
to the reproductive tract; this requires the use of condoms
7.5 Ensuring that fathers know the importance of choosing a method of infant feeding that is
appropriate to the domestic circumstances and ensuring that the father supports the mother in
feeding their child appropriately
8 NGO CODE OF GOOD PRACTICE IN HIV
10
The Code calls for NGOs to provide, or advocate for access to, PMTCT services. PMTCT includes the
specific interventions of ARVs and counselling on infant feeding. There needs to be comprehensive
networking between different sectors to ensure that pregnant women and their partners can access
these. It is also stated that PMTCT needs to extend to contraception, prevention of HIV, prevention
and treatment of other sexually transmitted diseases, and antenatal care. These should therefore
always be integrated into a PMTCT programme.
9 WHAT DO THESE GUIDELINES MEAN FOR THE PERSON LIVING WITH HIV?
9.1 Pregnant women and their partners need to have the opportunity for counselling and testing for
HIV. If they are found to be HIV +ve they need to receive advice about the most appropriate
treatment available to reduce the risk of transmission to their unborn child and to protect their own
health. They need to receive counselling related to infant feeding options and support following their
decision. If the mother is found to be HIV –ve the couple will be informed of the risk of acquiring HIV
during pregnancy or breastfeeding and the importance of protecting themselves from infection,
including the need for condom use.
9.2 Children of an HIV positive mother need to receive early prophylaxis with Cotrimoxazole, ELISA
testing for HIV at 18 months of age or PCR testing at 6 weeks. If HIV +ve they need to be referred for
ARV treatment.
9.3 Women need to be provided with advice and supplies for contraception.
10 WHAT SHOULD TEARFUND-SUPPORTED PROJECTS IMPLEMENTED BY PARTNERS ENSURE?
10.1 Link with national government AIDS programme and receive regular updated advice about
national guidelines and good practice.
10.2 Support local and national efforts to improve access to, and quality of, existing obstetric care.
10.3 Provide education about PMTCT to professionally trained midwives, traditional birth attendants
and other women in the community who are active in women’s health care, and to link up PMTCT
work with work on maternal and child health (e.g. clinics for children under the age of five, family
planning clinics, antenatal clinics)
10.4 Involve community members in PMTCT, such as men, church leaders, lay volunteers.
10.5 Provide confidential and voluntary HIV testing and counselling to all couples and single women.
This should include:
10.5.1 Pre-test counselling for groups or individuals. There should be discussion about risk factors and
education to reduce risk and ensure that the woman and her partner understand the test and
implications of a positive result.
5
10.5.2 Post-test counselling when both partners are HIV positive. Ensure that the woman and her
partner understand the test result, and are provided with emotional support and follow up which
includes referral to ARV/PMTCT services.
10.5.3 Post-test counselling when one or both of the couple are HIV negative. This should advise the
woman and her partner that the woman is at increased risk of acquiring HIV infection when pregnant
or breastfeeding, and, if newly infected, is at greater chance of transmitting the virus to their unborn
or breastfeeding child.
11 HOW CAN PEOPLE LIVING WITH HIV BE INVOLVED?
HIV positive women who have themselves had a child and taken treatment for PMTCT are a strong
resource for counselling pregnant women for VCT, providing education before ARV, encouraging long
term adherence to ARVs and for counselling on infant feeding and stigma reduction. As part of a
homecare network they are able to participate in the full range of homecare services, with the added
strength of speaking from direct experience. Greater involvement of people living with HIV and AIDS
should be encouraged at all levels of the organisation and programmes with the aim being to obtain
representation in each of the following categories: target audience; contributors; speakers;
implementers; experts and decision makers. It is crucial that women are actively encouraged to
participate. The level and extent of PLHA involvement in the organisation will depend on access to
treatment, other responsibilities such as family and income generation, and on the climate of
discrimination.
12 TACKLING GENDER BASED VIOLENCE
12.1 It is important that the potential risks to women of disclosure of positive HIV status to sexual
partners and family are recognised.
12.2 If an HIV positive woman is at risk of domestic violence, sexual abuse or being thrown out of the
home, she will need considerable support in taking her ARVs, especially where she fears the
consequence of disclosure. .
12.4 Ill treatment of the mother will compromise the survival of her children and needs to be tackled
as part of a church/community based programme against Gender Based Violence (GBV).
12.5 An HIV +ve mother needs a lot of support if she chooses to formula feed in a community where
breastfeeding is expected and stigma is common.
12.6. Where disclosure is leads to partner violence, sheltered care may need to be made available.
Involvement of human rights organisations and legal advocacy may be required.
13 RELATIONSHIP TO HOME CARERS
Through their network of community contacts and knowledge about HIV transmission and treatment
services, home based care givers should support all aspects of PMTCT, in particular:13.1 Encourage pregnant women to access antenatal care and HIV testing.
13.2 Provide support for the HIV pregnant woman in her family and community, in particular with
issues relating to disclosure of HIV status, delivery at a health facility and adherence to medication.
13.4 Respond with referral to appropriate agencies in the event of abusive situations.
13.5 Provide support in the chosen infant feeding method.
13.6 Encourage health clinic attendance of mother, father and child for follow-up after birth.
14 RELATIONSHIP WITH CHURCHES
Church leaders are becoming increasingly confident about speaking about HIV to their congregations.
However there are special skills and experience they need to acquire:- _
14.1 Gain information about PPTCT activities. Taking church leaders to an antenatal clinic that is well
run and “father-friendly” will be useful so that they understand the different components of PPTCT.
Seminars for church leaders in the different components of PPTCT will enable leaders to become
envisioned about what they can speak about in church services and meetings.
6
14.2 See that PPTCT is something which all church members need to know about. Youth of sexes,
adults, middle aged and older people all play specific and complementary roles in family support for
PPTCT.
14.3 Ensure that church based teaching sessions on PPTCT have a strong focus on the responsibilities
of men.
14.4 Develop skills in compassionate counselling – especially in the support for
discordant couples.
14.5 Ensure that supplies (e.g. of HIV testing kits) are regularly provided by government or donor
before they start a PPTCT programme.
14.6 Become aware of what PPTCT activities are already being run in their community. If they are not,
then church leaders need to know who to contact for advocacy purposes.
14.7 Become informed on how other church based programmes are tackling PPTCT and be proactive
in sharing their experiences.
14.8 Develop male peer educators who support fathers in their decision to become active in PPTCT.
14.9 Develop skills and experience in writing applications, along with other members of appropriate
consortia, for funds from sources such as the Country Coordinating Mechanism of the Global Fund.
14.10 Ensure a clear linkage between the church based and government services, especially those for
testing (CD4 and PCR) and treatment (ARVs) supporting wherever possible a high coverage rate for
CD4 counts among HIV +ve pregnant women.
14.11 Ensure that the issues around Infant Feeding are understood by all ages and sexes and that
individual’s roles in support of mothers’ choice is clearly defined.
15 KEY PROGRAMMES MONITORING AND EVALUATION INDICATORS
Baseline assessment is part of project planning and should be included in the initial proposal
submitted to Tearfund. This may be carried out by the partner organisation themselves or they can
use relevant information gathered by other agencies within the target community. Examples of useful
indicators include:15.1 % of HIV positive pregnant women receiving a complete course of AZT , from at least 28 weeks
of pregnancy
15.2 % of pregnant mothers receiving an HIV test
15.2 % of HIV infected mothers receiving a CD4 test
15.4 % of HIV infected mothers receiving ART (because of low CD4 count or WHO staging)
15.5 % of HIV +ve mothers receiving comprehensive counselling re breastfeeding options, according
to WHO guidelines
15.6 Among HIV positive mothers - % using exclusive breastfed until they are six months old and %
using replacement feeds (formula or animal milks)
15.7 % of Mothers whose partners (father of the child) receive an HIV test13.8 % of Fathers tested for
HIV who are HIV +ve.
7
REFERENCE LIST
1. Veneman A. Achieving Millennium Development Goal 4. Comment. Lancet; 368:1044-1046;
statistic quoted from http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp
2. HIV & AIDS Treatment in Practice Newsletter. HIV treatment for mothers and children in
th
Botswana: lessons from a dynamic program. #76 October 20 2006 hatp@nam.org.uk
3. Focused Church based action for PMTCT: case studies of Tearfund partner PMTCT
programmes. Draft document. Lead Author: Dr. Rena Downing. October 2006. Document
available on request from Tearfund UK.
4. Making a difference. Tearfund’s strategic response to the AIDS pandemic. July 2006
5. Chronic HIV Care with ARV therapy and prevention. Integrated management of adolescent
and adult illness; Integrated management of childhood illness. Interim guidelines for health
workers at health centre of district hospital outpatient clinic. World Health Organisation. July
2006. Available online.
th
6. Handbook of HIV Medicine. Oxford University Press, Southern Africa. 5 Edition 2005.
Chapter 34 (Infant Feeding), Chapter 41 (Prevention of mother to child transmission of HIV).
7. HIV Management Course: University of the Witwatersrand, South Africa. November 2005
8. Coovadia HM, Rollins NC, Bland RM, e t al. Mother to child transmission of HIV-1 infection
during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.
Lancet 2007;369:1107-16
9. WHO and HIV and infant feeding technical consultation. October 2006. Consensus
Statement. http://www.who.int/hiv/mediacentre/Infantfeedingconsensusstatement.pf.pdf
10. Renewing our voice: Code of good practice for NGOs responding to HIV/AIDS 2004. Julia
Cabassi, David Wilson. Distributed by Oxfam GB. www.oxfam.org.uk/publications
11. UNAIDS Global Epidemic Report 2008
12. WHO ARVs for treating pregnant women and preventing HIV infection in infants; towards
universal access 2006. www.who.int/hiv/pub/guidelines/pmtct/en/index.html
13. HIV infected pregnant women receivingARV for PMTCT.
www.who.int.whosis/indicators/compendium/2008/2pmf/en/
14. UNAIDS Report 2009 – www.unaids.org
8