Module 7
Comprehensive Care and
Support for Mothers and
Families with HIV Infection
Module Objectives
 Describe the components of postpartum care for
women with HIV.
 Discuss the prevention of HIV-related
conditions.
 Discuss treatment of HIV-related conditions.
 Discuss management of common STIs.
 Explain the interrelationships between STIs and
HIV
Malawi PMTCT Training Package
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Module Objectives
(continued)
 Discuss STI prevention.
 Describe eligibility criteria for referral to ARV
clinic.
 Describe the staging of HIV/AIDS.
 Describe ways in which a healthcare worker
(HCW) is able to support antiretroviral (ARV)
therapy adherence.
 Describe ongoing care of HIV-exposed infants
and children.
Malawi PMTCT Training Package
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Unit 1
Treatment, Care and Support of
the Mother with HIV Infection
Malawi PMTCT Training Package
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Unit 1 Objective
 Describe the components of postpartum
care for women with HIV.
Malawi PMTCT Training Package
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Postpartum Care & Support Needs
Women & Families with HIV
Improving uptake of postpartum care:
 During ANC, stress importance of postpartum
care and follow-up.
 HCWs should provide mother with referral
information for follow-up care including time,
location and contact information.
 Educate women to give birth in health facility
 Advise women who give birth at home to report
to maternity department for infant’s
antiretroviral (ARV) dose within 72 hours.
Malawi PMTCT Training Package
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Postpartum Care & Support Needs
Women & Families with HIV (continued)
 Optimum timeframe for postpartum appointments is at
one week and six weeks after birth.
 Women who gave birth in healthcare facility should
receive postpartum appointments upon discharge.
 Postpartum appointments for women who gave birth at
home.
 HCWs need community support to facilitate follow-up care.




Traditional birth attendants (TBAs)
Local chiefs
Health Surveillance Assistants
Community Based Organizations
Malawi PMTCT Training Package
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Postpartum Care & Support Needs
Women & Families with HIV (continued)
Assessment of healing during postpartum visits
 Check healing of repaired genital/perineal lacerations
 Monitor uterine involution
 Confirm cessation of postpartum bleeding
 Review optimal nutritional requirements
Infant-feeding support
 Assess progress of infant feeding
 Assist mother to implement chosen feeding option
 Assess family support for the infant-feeding option
 Work with mother to address challenges
Malawi PMTCT Training Package
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Postpartum Care & Support Needs
Women & Families with HIV (continued)
Family planning counselling
 Advise client to initiate family planning within 6 weeks
of delivery.
 Inform client about available family planning methods
 Offer information in accurate, unbiased, sensitive
manner.
 Involve partners in family planning counselling
Clients have:
 Right to decide whether or not to practise family
planning
 Freedom to choose which method to use
 Right to privacy and confidentiality
 Right to refuse any type of examination
Malawi PMTCT Training Package
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Postpartum Care & Support Needs
Women & Families with HIV (continued)
 Counselling plays major role in promotion
of safe and effective family planning
 Counsel woman on risk of becoming
pregnant if she is HIV-infected and
importance of practising safer sex
Malawi PMTCT Training Package
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Postpartum Care & Support Needs
Women & Families with HIV (continued)
Sexual and reproductive care
 Discuss condom use as dual protection against
HIV, other STIs, and for family planning
 Discuss importance of safer sex to prevent
spread of HIV and other STIs
 Support mother's choice of contraceptive
method
 Provide advice on early STI treatment, symptom
recognition, and locations for STI assessment /
treatment
 Answer questions about safer sex
Malawi PMTCT Training Package
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Nutritional Counselling,
Care, & Support
Lactation is requires an additional 600-700 kcal
every 24 hours. The energy requirements during
EBF is equivalent to an extra meal per day.
 Lactating women meet these requirements by:




Increasing nutritional intake
The body improving its metabolic efficiency
The body using energy stored during pregnancy
Decreasing level of physical activity
Malawi PMTCT Training Package
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Effects of Malnutrition on the
Mother & Infant
Mother
 When the nutritional intake is inadequate, the body uses
its nutritional stores to maintain breast-milk production
 Poorly nourished women do not have sufficient energy
resources, so milk production declines
Infant
Inadequate intake of essential micronutrients by
breastfeeding mother, especially with advanced disease,
may result in:
 Early onset of infant growth stunting
 Early cessation of breastfeeding
 Babies who are stunted, or cease breastfeeding too early,
have higher likelihood of malnutrition and death.
Malawi PMTCT Training Package
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Nutritional Counselling & Support
Nutritional counselling and support should ensure:
 All mothers are supplemented with single dose
of vitamin A (200,000 IU) within 2 months of
delivery.
 Supplementation of food to malnourished
mothers
 HIV-infected women who take ARVs may
require nutrition and diet counselling at every
visit to manage side effects and avoid nutritionrelated complication
 Women also require infant-feeding counselling
and support in ANC and postpartum periods
Malawi PMTCT Training Package
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Nutritional Counselling & Support
(continued)
Food hygiene
 People living with HIV are especially
vulnerable to bacterial infections because
of weakened immune systems.
 Emphasize importance of cleanliness
during food preparation and storage.
Malawi PMTCT Training Package
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Exercise 7.1
Postpartum Care: Case Study
Malawi PMTCT Training Package
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Unit 2
Prevention and Treatment of
HIV-Related Conditions
Malawi PMTCT Training Package
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Unit 2 Objectives
 Discuss the prevention of HIV-related
conditions.
 Discuss treatment of HIV-related
conditions.
Malawi PMTCT Training Package
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HIV-Related Conditions
Definition:
An HIV-related condition is a disease or other physical
condition that is a result of HIV or is exacerbated by HIV
causing illness in a person with HIV, particularly as a result
of a weakened immune system. Examples include:
Tuberculosis (TB)
Pneumocystis pneumonia (PCP)
Candidiasis
Herpes zoster
Kaposi’s sarcoma
Cryptococcosis
Malawi PMTCT Training Package
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HIV-Related Conditions (continued)
 HCWs should be able to recognize early signs
and symptoms of these diseases and infections
 Early diagnosis and prompt treatment can lead
to significant improvement in quality of life
 HIV-related conditions should be treated
according to treatment guidelines and within the
context of available resources
 When services not available, refer clients to the
ARV Clinic
Malawi PMTCT Training Package
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Prevention of HIV-Related
Conditions
Encourage clients to:
 Take prophylaxis medication as prescribed
 Example: Cotrimoxazole Preventive Therapy (CPT)
prevents PCP, some bacterial pneumonias,
salmonella sepsis, toxoplasmosis
 Maintain bodily hygiene to avoid skin infections
 Ensure adequate nutrition with supplemental
multivitamins, folic acid and ferrous sulphate to prevent
anaemia
 Prioritize oral and dental health care and hygiene
 Ensure prompt rehydration in case of diarrhoea
 Get adequate rest
 Use condoms, which can help prevent spread of STIs
Malawi PMTCT Training Package
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Tuberculosis (TB)
(continued)
 A HIV-infected person is 10 times more
likely to develop TB than one who is HIVnegative.
 Tuberculosis is the most common HIVrelated condition in Malawi and Africa.
Malawi PMTCT Training Package
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Tuberculosis (TB)
 Women with symptoms
suggestive of TB should
have
 Clinical evaluation
 Sputum examination
 And, if negative, a chest
X-ray
 Pulmonary disease
occurs more often than
classical cavity disease
 A TB diagnosis should
be considered in women
presenting with :
 Cough lasting longer than 3
weeks
 Sputum production
 Weight loss
 Fever and night sweats
 Coughing up blood
 Chest pain
 Shortness of breath
Malawi PMTCT Training Package
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Challenges to Management of TB
Among challenges to the management of
TB/HIV in Malawi are:
 Compliance to long-term medication
regimens with side effects
 Drug interactions with first-line ARVs
 Difficulty ruling out active TB
 Follow-up with long term regimens
 Cost associated with long-term regimens
and care
Malawi PMTCT Training Package
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Treatment of HIV-Infected Clients
with Tuberculosis
 All HIV-infected clients with TB potentially eligible for
ARV therapy, since they are categorized as WHO clinical
Stage III or IV.
 ARV therapy not given during initial phase of anti-TB
treatment, because of interaction between rifampicin and
nevirapine.
 The initial phase refers to the first two months of TB
treatment which rapidly kills actively growing TB
bacteria. The continuation phase follows the initial phase
and can last from 4 to 6 months.
 Client eligible for ARV therapy after completion of initial
treatment phase and started on continuation phase.
Malawi PMTCT Training Package
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ARV Therapy with AntiTuberculosis Treatment
Phase of Anti-TB Treatment
Initial Phase (2 months):
rifampicin, isoniazid,
pyrazinamide and ethambutol
[RHZ(E)]
Continuation Phase (4-6 months):
ethambutol and isoniazid (EH)
ARV Therapy
No ARV therapy
Continuation Phase (4-6 months):
rifampicin and isoniazid (RH)
Start ARV therapy immediately after
initial phase
Start ARV therapy 2 weeks after
initial phase to allow rifampicin
levels to decrease
Malawi PMTCT Training Package
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Malaria
 Malaria episodes more frequent / severe during
pregnancy – especially first or second pregnancy
 Malaria increases the chance of maternal anaemia,
preterm birth and intrauterine growth retardation.
 The infants are more likely to be low birth weight and
die during infancy.
 IPT is essential for pregnant women who are not taking
CPT
 Definitive malaria diagnosis only made by microscopy
 Clinical features of malaria include: fever, myalgia, joint
pains, chills, enlarged spleen, mental confusion,
abdominal pain and diarrhoea, nausea and vomiting and
loss of appetite.
Malawi PMTCT Training Package
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Malaria Prevention Measures
Malaria prevention measures include:
 Intermittent presumptive treatment for malaria
(IPT) with sulphadoxine-pyrimethamine
(Fansidar®)
 Use of insecticide-treated bednets
 Other preventive measures, e.g., use of ferrous
sulphate and folic acid to prevent anaemia.
 Regular screening for malaria
 Eliminating mosquito breeding places in and
around the home
Malawi PMTCT Training Package
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Cotrimoxazole Preventive Therapy
(CPT)
 CPT prevents PCP, some bacterial pneumonias,
forms of salmonella sepsis, malaria,
toxoplasmosis and certain causes of diarrhoea.
 CPT reduces frequency of opportunistic
illnesses, decreases clinic visits and
hospitalizations
 In sub-Saharan Africa, CPT associated with
25%-46% reduction in mortality
 CPT has direct maternal health benefits and may
have indirect benefits for neonatal and infant
health
Malawi PMTCT Training Package
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Eligibility
CPT should be offered to the following HIVinfected adults:
 All persons with symptomatic HIV disease
(Stage II, III and IV)
 All persons with CD4-lymphocyte count of 500/
mm3 or less, regardless of symptoms
 Pregnant women after first trimester who are
symptomatic or have a CD4-lymphocyte count
< 500/ mm3
 If a woman with HIV is receiving CPT and
resides in a malaria endemic zone, IPT is not
necessary
Malawi PMTCT Training Package
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Adult Drug Regimen
 One single-strength tablet of
cotrimoxazole (480mg) twice a day
(morning and evening).
 CPT is lifelong
 Should NOT be administered to clients
with allergies to sulfa-containing drugs.
 HCWs should monitor clients receiving
CPT for side effects
Malawi PMTCT Training Package
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Treatment of Symptoms &
Palliative Care
 Healthcare interventions focused on managing
symptoms and relieving discomfort can improve
quality of life.
 Common HIV symptoms: nausea, vomiting, fatigue
and skin problems
 Assessment and management of complex issues
such as pain, weight and muscle loss resulting
from disease progression can improve comfort,
function and emotional well-being.
Malawi PMTCT Training Package
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Palliative Care
 Palliative Care is a set of supportive interventions that
improves quality of life for clients and their families
who face problems associated with chronic disease or
life-threatening illness.




Pain relief
Integrate psychological and spiritual aspects of care
Enhance quality of life
Offer support system to help clients live actively and family
cope with illness
 Affirm life (and regard dying as normal process)
 Neither hastening nor postponing death
Can be provided at hospital or clinic or in home.
Malawi PMTCT Training Package
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Exercise 7.2
HIV-Related Conditions in
Adults: Case Studies
Malawi PMTCT Training Package
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Social & Psychosocial Support
Regular monitoring of mental health is critical at all stages
of HIV infection.
 Support in accepting diagnosis.
 Psychosocial support for parents of HIV-exposed infants
and children whose HIV status is uncertain or HIVinfected.
 Community support, including referrals to communitybased and faith-based programmes.
 Peer group counselling and support from health agencies
or NGOs.
 Support and counselling to assist women who are HIVinfected and their partners with disclosure issues.
Malawi PMTCT Training Package
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Faith-Based Support
 The involvement of faith-based
organizations (FBOs) provides HIVinfected mothers with spiritual and
psychosocial support.
 May provide them with an important
sense of belonging to a larger community
that offers compassionate care.
Malawi PMTCT Training Package
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Home-Based Care
Advantages of home-based care:
 Care provided in familiar environment that allows for
continued participation in family matters
 Medical expenses are reduced
 Family is involved
 Reduced burden on healthcare system
Disadvantages of home-based care:
 Shifts cost of health care provision from government to
family members
 Adds extra burden on women
 Takes away time from child care and income-generating
activities
Malawi PMTCT Training Package
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Unit 3
Identification & Management of
Sexually Transmitted
Infections (STIs)
Malawi PMTCT Training Package
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Unit 3 Objectives
 Discuss management of common STIs.
 Explain the interrelationships between
STIs and HIV
 Discuss STI prevention.
Malawi PMTCT Training Package
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Sexually Transmitted Infections
(STI)
 Presence of STIs in an individual
associated with increased risk of HIV
transmission (both ulcerative and nonulcerative conditions)
 Definition of sexually transmitted
infections: a group of infections that are
spread as a result of unprotected sexual
contact with an infected sexual partner.
Malawi PMTCT Training Package
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Sexually Transmitted Infections
(STI)
(continued)
Comprehensive STI management includes:
 Proper syndromic diagnosis
 Effective antibiotic treatment
 Preventive efforts beginning with client education
on risk reduction
 Condom promotion
 Partner notification, follow up and treatment
 HIV Testing and Counselling
 Referrals
Malawi PMTCT Training Package
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Common STI Syndromes




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

Genital Ulcer Disease (GUD)
Urethral Discharge (UD)
Persistent/Recurrent Urethral Discharge
Abnormal Vaginal Discharge (AVD)
Lower Abdominal Pain (LAP)
Inguinal Bubo (BU)
Neonatal Conjunctivitis
Other common STIs not included in syndromic
management approach include: genital warts,
congenital syphilis, secondary syphilis, latent
syphilis and tertiary syphilis.
Malawi PMTCT Training Package
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Predisposing Factors
 Negative cultural/traditional practices
 Unsafe sex
 Gender disparities/low status of women making
them unable to negotiate for sex
 Urbanization and migration/mobility
 Poverty/social economic status resulting in
women selling sex
 Non-responsive health care system in relation to
STI management and treatment
 Young age
Malawi PMTCT Training Package
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STI Complications & Implications
In adults:
 Increased morbidity
 Drain on resources at facility level
 Increased vulnerability to HIV infection
 Pregnancy complications
 Pelvic sepsis leading to abscess formation,
chronic and recurrent pelvic inflammatory
disease, ectopic pregnancy, infertility and
chronic pelvic pain
 Chronic genital tract infection, infertility in men
 Increased chances of cervical cancer
Malawi PMTCT Training Package
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STI Complications & Implications
(continued)
In neonates, infants and children:
 Congenital syphilis
 Ophthalmia neonatorum
 Blindness
 Pneumonia (chlamydia)
 Prematurity
 Low birth weight
 Stillbirth
Malawi PMTCT Training Package
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STI Complications & Implications
(continued)
Complications of STIs relating to MTCT
During pregnancy, changes in cervical and vaginal micro
flora associated with bacterial vaginitis contributes to:
 Premature rupture of membranes
 Low birth weight
 Premature labour
 Chorioamnionitis
Genital herpes simplex virus
 High risk of infection in newborn
Chancroid
 Increased risk of premature rupture of membranes and
premature onset of labour
Malawi PMTCT Training Package
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HIV & STIs
Interrelationships between HIV & STIs:
 Primary mode of transmission of HIV and other STIs is
sexual intercourse
 Measures for preventing both HIV & STIs are the same
 Increased risk of HIV transmission in the presence of
other STIs
 HIV can affect natural history and response to therapy of
STIs, including chancroid, syphilis, genital herpes and
genital warts
 Possible acceleration in progression of HIV disease in
the presence of other STIs
 Treating STIs significantly reduces transmission of HIV
Malawi PMTCT Training Package
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Prevention of STIs
Objectives of STI prevention and care:
 Reduce prevalence by interrupting
transmission
 Reduce duration of infection
 Prevention of complications in those
infected
Malawi PMTCT Training Package
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Prevention of STIs
(continued)
Primary prevention
 Health education to create awareness
 Promotion of safer sex and risk reduction
 Education on the association between HIV and
other STIs
 Promotion of correct and consistent condom use
Secondary prevention
 Treatment
 Promote early health care seeking behaviour
 Provide health education and counselling
 Provision of accessible, effective care
Malawi PMTCT Training Package
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Effective Client Case Management
of STIs




Ensure correct diagnosis and treatment
Take complete and accurate client history
Provide through examination
Education and counselling on:






Mechanism of transmission
Treatment compliance
Risk of acquiring HIV
Correct and consistent condom use
Partner treatment
Avoidance of sex during treatment
Malawi PMTCT Training Package
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Effective Client Case Management
of STIs
(continued)
 Equip client with negotiation skills
 Provide support or referrals for economic
empowerment to prevent reliance on sex
work to generate income
 Positive attitude of HCWs including
respect for clients
 Ensure confidentiality
Malawi PMTCT Training Package
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Unit 4
Adult HIV Staging and ARV
Therapy
Malawi PMTCT Training Package
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Unit 4 Objectives
 Describe eligibility criteria for referral to
ARV clinic.
 Describe the staging of HIV/AIDS.
 Describe ways in which a healthcare
worker (HCW) is able to support
antiretroviral (ARV) therapy adherence.
Malawi PMTCT Training Package
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Eligibility for ARV therapy
HIV-infected asymptomatic clients generally NOT eligible
for ARV therapy
 Lack of evidence that early ARV therapy benefits client
 Adult clients should be referred to the ARV Clinic if:




They are HIV-positive, AND
They are assessed as being in WHO Clinical Stage 3 or 4, OR
They have a CD4 lymphocyte below 250/ mm3, OR
They are assessed as being in WHO Clinical Stage 2 with a total
lymphocyte count less than 1200/ mm3
Malawi PMTCT Training Package
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Eligibility for ARV therapy
(continued)
 Client MUST understand that ARV
therapy requires adherence to prescribed
drugs and is a life long commitment.
Malawi PMTCT Training Package
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Pregnant Women & ARV Therapy
 Eligibility for ARV therapy determined by
clinical staging or CD4-count.
 Clinical staging is most accessible way of
assessing client eligibility for referral to
ARV Clinic.
 Wherever available, all HIV-infected
pregnant women should have a CD4 count
performed to determine eligibility for
ARV therapy
Malawi PMTCT Training Package
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ARV Clinic Referral & Screening
Referral sites: Out-patients; Wards: PMTCT: Health centres
HIV testing and counselling
HIV-positive
HIV-positive and
asymptomatic
HIV-positive and symptomatic
Screened for eligibility for ART:
e.g. WHO stage III or IV,
Low CD4-lymphocyte count or Low CD4%
200/mm
HIV-positive eligible for ART
Opportunistic infections stabilised
Group counselling for ART
Individual counselling for ART
Patient understands implications of ART
START ART
Linkage to support services, home based care
Malawi PMTCT Training Package
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Staging Systems for HIV
Staging systems for HIV can:
 Guide care of individuals who are HIV-infected
 Provide framework for follow-up and
management
 Help assess treatment outcomes
 Help define prognosis and guide counselling
 Assist in evaluating new treatments
 Provide criteria for diagnosing HIV/AIDS in the
absence of laboratory testing
Malawi PMTCT Training Package
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Stages of HIV Infection: Adults
Medical history and physical exam should be used
together to stage clients. Use the following
criteria.
Primary HIV Infection
 Asymptomatic
 Acute retroviral syndrome
WHO Clinical Stage I
 Asymptomatic
 Persistent generalized lymphadenopathy (PGL)
Malawi PMTCT Training Package
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WHO Clinical Stage II
 Moderate unexplained weight loss (< 10% of
presumed or measured body weight)
 Recurrent respiratory tract infections (sinusitis,
tonsillitis, bronchitis, otitis media, pharyngitis)
 Herpes zoster
 Angular cheilitis
 Recurrent oral ulceration
 Papular itchy dermatitis
 Seborrhoeic dermatitis
 Fungal nail infections
Malawi PMTCT Training Package
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WHO Clinical Stage III
 Unexplained severe weight loss
 Unexplained chronic diarrhoea for longer than one
month
 Unexplained persistent fever for longer than one month
 Persistent oral candida
 Oral hairy leukoplakia
 Pulmonary tuberculosis
 Severe presumed bacterial infections (e.g., pneumonia,
empyema, pyomyositis, bone/joint infections,
meningitis, sepsis)
 Acute necrotising ulcerative stomatitis, gingivitis or
periodontitis
 Unexplained anaemia (<8g/dl), neutropoenia
(<500/mm3) or thrombocytopenia (<50,000/ mm3)
Malawi PMTCT Training Package
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WHO Clinical Stage IV
 HIV wasting syndrome
 Pneumocystis jiroveci pneumonia [PCP]
 Recurrent severe or radiological presumed bacterial
pneumonia
 Recurrent bacteraemia or sepsis
 Toxoplasmosis of the brain
 Cryptosporidiosis
 Isosporiasis
 Cryptococcosis, extrapulmonary
 Cytomegalovirus of an organ other than liver, spleen or
lymph node
Malawi PMTCT Training Package
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WHO Clinical Stage IV (continued)
 Herpes simplex infection, mucocutaneous for > 1 month
or visceral
 Progressive multifocal leucoencephalopathy
 Any disseminated endemic mycosis
 Candidiasis of oesophagus, trachea and bronchus
 Atypical mycobacteriosis, disseminated or lungs
 Extrapulmonary tuberculosis
 Lymphoma (cerebral or B cell non-Hodgkin)
 Invasive cervical carcinoma
 Kaposi’s sarcoma
 HIV encephalopathy
 Visceral leishmaniasis
Malawi PMTCT Training Package
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Exercise 7.3
WHO Clinical Staging:
Group Discussion
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ARV Therapy
 ARV therapy is increasingly available in Malawi
 Combining ARV medications to reduce viral load is
standard of care for HIV treatment.
 Combination of 3 or more ARV medications slows HIV
replication
 Referred to as ARV therapy or highly active
antiretroviral therapy (HAART)
Advantages of combination ARV therapy:
 Improved health status of client
 Decreased MTCT rates
 Reduced HIV-related illness (morbidity) and
hospitalizations
 Reduction in number of deaths from AIDS (mortality)
Malawi PMTCT Training Package
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Role of ANC & MCH HCWs in
Supporting ARV Therapy
The HCW in ANC should have:
 Background and knowledge to assess eligibility
for ARV therapy for pregnant women
 Understand when to refer
 Comfort exploring issues related to ARV
therapy, e.g., managing side effects
 Understand importance of adherence to ARV
therapy
Malawi PMTCT Training Package
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Basic Facts about ARV Therapy
ARV therapy does not cure HIV
 ARV medications cannot cure HIV-infection
 ARVs stop HIV from replicating (reduce viral load); if
ARVs are stopped, HIV disease progresses
Always use 3 different ARV medications for treatment
 Use regimens effective enough to drastically reduce
viral replication, prevent viral resistance, and avoid
therapy failure.
 National first line regimen (d4T/3TC/NVP as one tablet
taken in the morning and another in the evening)
contains three ARV medications.
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Basic Facts about ARV Therapy
(continued)
ARV medications must be taken every day otherwise
they will not work
 Important to keep effective concentration of ARVs in
client’s bloodstream
 Low drug concentrations in the blood allow HIV to
mutate
 These changes (mutations) can make the virus resistant
to ARV medications so they do not work as well
 Missing even one or two doses, taking medication late,
or taking medication with certain foods can lower
concentrations of ARVs in the blood
 ARV therapy should not be initiated or continued
without consistent adherence assessment, counselling,
and support
Malawi PMTCT Training Package
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Basic Facts about ARV Therapy
(continued)
Selection of ARV medications should be done by an
experienced clinician.
 Selection guided by national ARV guidelines.
 Certain ARV medications are safe in pregnancy while
others are not.
Other medications will interact with ARVs
 Clients should avoid use of other medications that could
reduce concentration of ARVs in the blood.
 HCWs should closely monitor all traditional and nontraditional medication taken by clients for possible
interactions.
Malawi PMTCT Training Package
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Increase Adherence to ARV
Therapy
Educate Clients
 Make sure client knows ARV therapy not a cure and
requires long-term commitment
 Review each medication in ARV regimen with client
 Assist client in planning a dosage schedule
 Remind clients of food and beverage restrictions
Assess and give client tips on how to take their
medication
 Ask clients to bring medications to appointments
 Provide information on when to take medications
 Encourage clients to disclose to at least one person who
can support adherence
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Increase Adherence to ARV
Therapy
(continued)
Help clients understand and manage side effects
 Discuss how to manage side effects
 Differentiate between short-term side effects &
emergency symptoms that need medical attention
Work with other organizations/care and treatment
clinics
 Help client understand they must attend ARV clinics on
regular basis
 Establish communication between PMTCT and ARV
clinics
 Encourage clients to join HIV support groups
 Keep appointment records for clients; follow-up if a
client misses an appointment
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Treatment of HIV Symptoms &
Side Effects of ARV Therapy
 HCWs can help clients adhere to ARV therapy
by helping them to manage the signs and
symptoms of HIV disease and the side effects of
ARV medications
 Management of common problems, such as
nausea, vomiting, fatigue and skin problems can
ease discomfort
 Assessment and management of issues such as
pain, weight and muscle loss can improve
comfort, function and emotional well-being
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Unit 5
Treatment, Care, and Support of
the Infant and Young Child
Exposed to HIV
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Unit 5 Objectives
 Describe ongoing care of HIV-exposed
infants and children.
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Care of Newborn & Infant
Care of the Newborn
 Should receive recommended package of care
that includes immunization, and other
micronutrient supplementation as well as the
regular under-five services.
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Care of Newborn & Infant
Follow-up care of infant
 Assessment of infant or young child growth and
development
 Assessment and support of infant or young child feeding
 Assessment of mother’s coping
 Assessment of signs and symptoms of HIV-related
conditions and clinical features of AIDS
 Routine immunizations
 Counselling (for mother) according to identified needs
 Referrals for mother and child
 HIV testing (PCR testing at six weeks of age, if
available, or HIV antibody testing at 18 months)
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Timing of Follow-Up Visits
 Close monitoring and regular visits are
important.
 Newborn should be seen in healthcare facility or
at home within two weeks of delivery or sooner.
 For all infants/children, schedule subsequent
visits to coincide with immunization schedule:
 At birth (for infants delivered at home)
 At 6, 10 and 14 weeks
 Once a month from 14 weeks to 1 year, then
quarterly to 2 years
 At 18 months for HIV diagnosis (where PCR testing
not available)
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Guidance on Infant Feeding
 Discussions about infant feeding especially important in
early months of life and during special high-risk periods:
 Child is sick
 Mother returns to work
 Mother decides to change feeding methods
Mother knows she is feeding baby adequately when:
 Baby gains weight
 Baby urinates 6 to 8 times in 24-hour period
 Baby had at least 2 to 5 bowel movements in a 24-hour
period
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Vitamin A Supplementation
Age
Less than 12 months
of age
12-59 months
Dose
100,000 IU capsule once every six
months
200,000 IU capsule once every six
months
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Vitamin A Supplementation
(continued)
 Children with persistent diarrhoea, measles,
severe malnutrition and xerophthalmia should
receive treatment dose of vitamin A even if they
received vitamin A supplement within the past 6
months.
 Ensure that all children age 0-59 months receive
Vitamin A supplements according to schedule
even if they had treatment dose less than 6
months ago.
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Promote Health through Follow-Up
Each visit with HCW should include:
 Assess and manage for common illnesses
 Identify non-specific symptoms / conditions
related to HIV infection
 Provide HIV testing
 Provide micronutrient supplementation,
nutrition education and support including
information on food hygiene and fortified foods
 Provide CPT
 Assess patient’s stage of HIV disease using the
WHO Clinical Staging system.
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Promote Health through Follow-Up
(continued)
Promote health and prevention of illness
 Assess and support the mother's infant-feeding
choice.
 Infants who fail to grow require special attention.
 Underlying infections should be diagnosed and
treated promptly.
 Monitor growth and assess causes of growth failure,
if observed
 Immunize according to the guidelines
 Screen for TB and treat if indicated.
 Recommend the use of ITN as appropriate; offer
malaria treatment and prophylaxis
 Treat anaemia as indicated
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Growth Monitoring
 Growth-monitoring programmes focus on foetal growth and
child growth in first five years of life.
 Conditions related to weight loss are underlying infection,
acute diarrhoea and HIV-related growth failure.
Growth indicators
 Weight for age is useful for detecting the sum total of
nutritional experiences the child has had.
 Weight for height is a useful measure of acute malnutrition.
 Height for age is useful for detecting chronic malnutrition
and helps identify stunted growth in children.
 Head circumference is useful during the first two years and is
a measure of brain growth.
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Isoniazid Preventive Therapy
 Babies born to mothers with smear-positive PTB
should be given isoniazid.
 5mg/kg daily for 6 months
 After 6 months child is vaccinated with BCG.
 Breast feeding is safe
 If child develops symptoms while on isoniazid
preventive therapy, must investigate for TB.
 If TB is diagnosed, isoniazid is stopped and
anti-TB treatment instituted.
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Cotrimoxazole Preventive Therapy
(CPT)
 Every infant born to HIV-infected mother
should receive cotrimoxazole preventive
therapy (CPT) to prevent PCP and other
HIV-related conditions.
 CPT should be offered to children in the
following circumstances:
 Any child, 6 weeks or more, born to an HIVinfected woman irrespective of whether the
woman received ARV therapy in pregnancy
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Cotrimoxazole Preventive Therapy
(CPT)
(continued)
Paediatric Drug Regimen for Cotrimoxazole starting from 6 weeks of age
Clients are provided with a 3 month supply of drugs.
Children aged 5-14 years
Children aged 6 months to 4 years
Children aged 6 weeks to 5 months
One tablet (480mg) once a day
Half a tablet (240mg) once a day
Quarter of a tablet (125mg) once a day
Contra-indications
 If client has known allergy, CPT should not be started.
 Should be discontinued in the event of severe cutaneous
reactions, renal or hepatic toxicity or severe
haematological toxicity.
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Cotrimoxazole Preventive Therapy
(CPT)
(continued)
Duration of therapy
 HIV-exposed infants should take CPT until HIV
infection can be excluded.
 At 18 months of age child should have an HIV test
 Provided child has stopped breast-feeding
 If child continues to breast feed after 18 months, CPT
continued until 3 months after breast-feeding cessation
 Child is then tested for HIV
 In both situations, if HIV test is positive, child continues
on CPT indefinitely.
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Signs & Symptoms of HIV
Infection in HIV-Exposed Children
Specificity for HIV
Infection
Signs and conditions
Common in children who
are HIV-infected; also seen
in ill, uninfected children
Common in children who
are HIV-infected;
uncommon in uninfected
children













Chronic, recurrent otitis media with discharge
Persistent or recurrent diarrhoea
Failure to thrive
Tuberculosis
Severe bacterial infections, particularly if recurrent
Persistent or recurrent oral thrush
Chronic parotitis (often painless)
Generalized persistent non-inguinal
lymphadenopathy in two or more sites
Hepatosplenomegaly
Persistent or recurrent fever
Neurologic dysfunction
Herpes zoster (shingles), single dermatome
Persistent generalized dermatitis unresponsive to
treatment




Pneumocystis pneumonia (PCP)
Oesophageal candidiasis
Lymphoid interstitial pneumonitis (LIP)
Herpes zoster (shingles) with multidermatomal
involvement
Kaposi's
sarcoma
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Training
Package
Specific to HIV infection
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Diagnostic Testing of HIV-Exposed
Infants & Young Children
HIV antibody testing
 Since maternal antibodies cross the placenta, all
infants born to mothers infected with HIV will
test antibody positive, irrespective of their own
infection status
 Because maternal antibodies persist, antibody
testing prior to 18 months is not reliable
 Antibody testing will provide a reliable
diagnosis of the non-breastfeeding infant’s
infection status from 18 months of age or older
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Diagnostic Testing of HIV-Exposed
Infants & Young Children
(continued)
For children not breastfeeding or cessation of
breastfeeding occurred at least 6 weeks prior:
 Negative HIV antibody test result for child 18 months or
older indicates the child is not HIV-positive.
 Confirmed positive HIV antibody test at 18 months or
older indicates child is infected with HIV.
For children who are breastfeeding:
 If test is negative at 18 months of age or older and infant
breastfed within the last 6 weeks, antibody test repeated
6 weeks after complete cessation of breastfeeding
 Confirmed positive HIV antibody test result at 18
months indicates the child is HIV-infected
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Diagnostic Testing of HIV-Exposed
Infants & Young Children
(continued)
Viral Assays
 Viral assays detect the actual virus
 Using a viral test, infants may be tested as
early as one week of age
 To ensure reliable result, PCR testing
(where available) is done at or after 6
weeks of age
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Exercise 7.4
HIV Diagnosis of Infants &
Young Children:
Case Study
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Stages of HIV Infection: Children
WHO Paediatric Clinical Stage I
 Asymptomatic
 Persistent generalized lymphadenopathy
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Stages of HIV Infection: Children
(continued)
WHO Paediatric Clinical Stage II
 Unexplained persistent hepatomegaly and splenomegaly
 Papular itchy skin eruptions
 Extensive skin warts (human papilloma virus infection)
 Extensive molluscum contagiosum
 Recurrent oral ulcerations
 Unexplained persistent parotid gland enlargement
 Lineal gingival erythema
 Herpes zoster
 Recurrent or chronic respiratory tract infections
(sinusitis, otorrhoea, tonsillitis, otitis media)
 Fungal nail infections
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Stages of HIV Infection: Children
(continued)
WHO Paediatric Clinical Stage III
 Moderate unexplained malnutrition not responding to standard therapy a
 Unexplained persistent diarrhoea for longer than 14 days
 Unexplained persistent fever above 37.5 (intermittent or constant for longer
than one month)
 Persistent oral candida (outside the first 6-8 weeks of life)
 Oral hairy leukoplakia
 Acute necrotising ulcerative gingivitis or periodontitis
 TB lymphadenopathy
 Pulmonary tuberculosis
 Severe recurrent presumed bacterial pneumonia
 Symptomatic lymphoid interstitial pneumonitis
 Chronic HIV-associated lung disease, including bronchiectasis
 Unexplained anaemia (<8g/dl), neutropaenia (<500/mm3) or
thrombocytopaenia (<50,000/ mm3)
 HIV-associated cardiomyopathy or HIV-associated nephropathy
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Stages of HIV Infection: Children
(continued)
WHO Paediatric Clinical Stage IV
 Chronic herpes simplex infection
 Unexplained severe wasting,
(orolabial or cutaneous for > 1
stunting, or severe malnutrition
month) or visceral at any site
not responding to standard
therapy
 Progressive multifocal
leucoencephalopathy
 Pneumocystis carinii (jiroveci)
pneumonia
 Any disseminated endemic
mycosis
 Recurrent severe presumed
bacterial infections (eg,
 Candidiasis of oesophagus,
empyema, pyomyositis, bone or
trachea and bronchus
joint infections, meningitis,
 Atypical mycobacteriosis,
sepsis, but excluding pneumonia)
disseminated or lungs
 Toxoplasmosis of the brain
 Extrapulmonary tuberculosis,
 Cryptosporidiosis with diarrhoea
excluding TB lymphadenopathy
> 1 month
 Lymphoma (cerebral or B cell
 Isosporiasis with diarrhoea > 1
non-Hodgkin)
month
 Acquired HIV associated rectal
 Cryptococcosis, extrapulmonary
fistula
 Cytomegalovirus of an organ
 Kaposi’s sarcoma
other than liver, spleen or lymph
 HIV encephalopathy
node
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Care of Infant with HIV Infection
Eligibility for ARV Therapy
 Asymptomatic children who are HIV-infected not
eligible for ARV therapy because no evidence that early
ARV therapy benefits the patient.
General Principles:
 Parents/caregivers must understand implications of ARV
therapy and eligibility criteria
 Children who are acutely unwell should be stabilised
before being considered for ARV therapy.
 Doses of prophylactic or treatment medications should
be adjusted for growth, compliance and tolerability of
ARV regime (assessed at every visit).
 Medication plans need to be discussed intensively with
parents or guardians.
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Exercise 7.5
Clinical Presentation of HIV in
Infants & Children:
Small Group Discussion
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Module 7: Key Points
 Comprehensive PMTCT programmes involve strategies
to provide treatment, care and support of women
infected with HIV, their infants and their families.
 Adequate nutritional intake for mother and child is
required to reduce risk of growth stunting (for the child),
malnutrition and even death.
 Early diagnosis and prompt, effective treatment of HIVrelated conditions lead to significant improvement in the
quality of life. Co-infection with TB and malaria may
increase HIV-related morbidity and mortality;
prevention, diagnosis and treatment of these conditions
are important.
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Module 7: Key Points (continued)
 All adult clients eligible for ARV therapy are also
eligible for CPT. Every attempt should be made to place
clients on CPT either before or at the same time as
starting ART. CPT should be offered to any child, aged
6 weeks or above, born to an HIV-infected woman.
 STIs must be identified and treated promptly; if left
untreated can have negative outcomes on both the
mother and her infant. Pregnant women who are
eligible for ARV therapy should be referred to the ARV
Clinic for management and monitoring.
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Module 7: Key Points (continued)
 The Treatment of AIDS, Guidelines for the Use
of Antiretroviral Therapy in Malawi include
eligibility criteria for commencing ARV therapy
and recommended ARV regimens.
 The care of infants and young children exposed
to HIV should be integrated into the routine care
of the under 5s. Routine follow-up care will
include not only growth and developmental
monitoring, infant feeding support and
immunizations but also HIV testing, HIV
staging and referrals for specialized care.
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