pmtct: guidelines for pregnant women · pdf filepmtct: guidelines for pregnant women 2015 ......
Post on 25-Mar-2018
219 Views
Preview:
TRANSCRIPT
PMTCT: GUIDELINES FOR PREGNANT WOMEN 2015
ROUTINE MONITORING OF MOTHER
Test Purpose and responseFIRST ANC VISIT: PATIENTS WHOSE HIV STATUS IS UNKNOWN/UNCONFIRMED
HIV Rapid Test and CD4, if HIV-positive To establish/confirm HIV status CD4 < 200: initiate co-trimoxazole prophylaxis (CPT)CD4 < 100: do CrAg or CLATCD4 > 250: do NOT use NVP
WHO Clinical Staging, if HIV-positive To assess risk
Hb or FBC To detect anaemia and/or neutropaenia
Creatinine* To assess renal function (and eligibility for TDF)
ALT, if requiring NVP To exclude liver dysfunction
FIRST ANC VISIT: ALL PATIENTS (ALREADY ON ART AND NEWLY-DIAGNOSED)
Screen for chronic diseases To identify high-risk pregnancy
Nutritional assessment To detect deficiency and provide necessary nutritional support. All pregnant women should get calcium, folate and iron supplementation
Family planning Provide counselling on safer sex, post-natal contraception, partner testing and cervical cancer screen
TB screening To identify TB suspects and assess IPT/INH eligibility. If TB is suspected in patients not yet on ART, do not start ART and refer for urgent diagnosis/exclusion of TB:TB diagnosed: start ART 2 – 8 weeks after starting TB treatmentTB excluded: start ART
STI and syphilis screening (RPR) To identify and treat STIs
CrAg (cryptococcal antigen), if CD4 < 100 To treat/provide prophylaxis for cryptococcal meningitis
Hb or FBC To detect anaemia and/or neutropaenia
PATIENTS ON ART
CD4 count At initiation, at 12 months, then yearly, if clinically indicated
Viral LoadBe sure to check results and respond quickly!
To detect treatment failure Repeat VL on confirmation of pregnancy if on ART > 3 months, then after 3, 6, 12, 18 and 24 months throughout pregnancy and breastfeeding
ALT, if on NVP, and symptomatic (rash, hepatitis) To identify NVP toxicity
FBC, if on AZT Month 3, 6, then yearly. To identify AZT toxicity
Creatinine*, if on TDF Month 3, 6, 12, then yearly. To identify TDF toxicity
*Please note that calculated eGFR is not accurate during pregnancy. Serum creatinine and not the eGFR should be used
Give adherence counselling at every clinic visit
MOM AT BOOKING OF PREGNANCY
Not on ART
Unknown HIV status HIV-positive Do VLAdherence counsellingReview within 2 weeks
Perform HCT Start ART, regardless of CD4 count
VL > 1000Comprehensive adherence
counsellingRepreat VL in ONE month
VL < 1000Repeat VL after 3, 6, 12,
18 and 24 months throughout pregnancy
and breastfeeding
HIV-negative HIV-positive
VL unchanged OR VL < 1 log drop
OR increased
3-monthly HCT throughout
pregnancy and breastfeeding.
Repeat at labour/delivery
Review results ONE week later
CD4 count
CPT CrAg or CLAT
CD4 < 200 CD4 < 100
Serum Creatinine
Stop FDC. Start AZT if Hb > 7 g/dL.
Urgent referral
Continue ART lifelong
> 85 μmol/L < 85 μmol/L
On ART
VL LDL or > 1 log drop in VL
Switch to second line. If failing on second line, consult expert
Continue on ARVs
Based on the National Consolidated Guidelines for the Prevention of Mother-to-Child Transmission of HIV (PMTCT) and the Management of HIV in Children, Adolescents and Adults. National Department of Health, South Africa. April 2015.
This service is brought to you as a result of the generous support of the American people through USAID/PEPFAR. The contents are the responsibility of UCT and do not necessarily reflect the views of USAID or the US Government
ART FOR MOTHERFIRST ANC VISIT
All pregnant and breastfeeding women not on ART
FDC is given immediately, regardless of trimester of pregnancy. If TB is suspected, delay initiation of ARVs until TB is excluded or the patient is established on TB treatment
TDF + 3TC (or FTC) + EFVgiven as FDC
Pregnant women already on ART
Continue on ARTCheck VL as soon as pregnancy is diagnosed, regardless of when it was last done
Patients on TDF + 3TC + EFV:Change to FDC(if weight > 40 kg)Patients on other first line regimens: If VL LDL and no contraindications, change to FDC
Contraindications to EFV (active psychiatric illness) or TDF (history of renal disease)
Initiate AZT if Hb > 7g/dL Review CD4 result a week later to choose alternate ART regimen
SECOND ANC VISIT (1 WEEK LATER)
Creatinine > 85 µmol/L*TDF is contraindicated
Stop FDCInitiate AZT if Hb > 7g/dL
Refer urgently for alternate triple therapy (within 2 weeks) and renal investigation. Dose adjust according to renal function Suggested regimen:ABC + 3TC + EFV
Active psychiatric illnessEFV is contraindicated
Continue AZT until initiated on triple therapy
TDF + 3TC + NVP or LPV/r CD4 < 250: NVPCD4 > 250: LPV/r
SECOND LINE REGIMENS
Pregnant women failing first line on AZT/d4T + 3TC + EFV/NVP
Check Cr*:Cr < 85 µmol/L
TDF + 3TC + LPV/r
Pregnant women failing first line on TDF + 3TC + EFV/NVP
Check Hb:Hb > 7 g/dL
AZT + 3TC + LPV/r If hepatitis B +ve (HBV co-infected):AZT + TDF + 3TC + LPV/r
Pregnant women currently on second line
Check VL VL LDL: Continue on current ART Raised VL: follow VL guidelines
Dyslipidaemia or diarrhoea associated with LPV/r
Switch LPV/r to ATV/r
UNBOOKED/PRESENTS IN LABOUR
Women not on ART, who test HIV-positive in labour
Check creatinine* and CD4. Review results at 3-6 day visit and adapt ART accordingly
sdNVP + sdTruvada (TDF+FTC) + AZT 3-hourly in labour Start FDC next day
Emergency caesarean section in an unbooked woman not on ART
sdNVP + sdTruvada (TDF+FTC) prior to caesarean sectionStart FDC next day
DIAGNOSED WITHIN 1 YEAR POST-PARTUM
Women diagnosed within 1 year post-partum or still breastfeeding beyond 1 year
ART is given lifelong, regardless of CD4
TDF + 3TC (or FTC) + EFV as FDC. If contraindications (renal, psych), follow guidelines
*Please note that calculated eGFR is not accurate during pregnancy. Serum creatinine and not the eGFR should be used
BREASTFEEDING ADVICE• All breastfeeding, HIV-positive women
should be on ART, regardless of CD4 count• Initiate breastfeeding immediately after
delivery, preferably within one hour• Intensive counselling should be given on the
benefits of exclusive feeding, the dangers of mixed feeding and the importance of adherence to ART
• Exclusive breastfeeding for the first six months
• Complementary (mixed) feeding from 6 months onwards only
• Encourage breastfeeding: – If infant HIV-negative: breastfeed until
12 months old – If infant HIV-positive: breastfeed until at
least 2 years old• Mothers with confirmed second or third line
ART failure should NOT breastfeed unless exclusive formula feeding will be unsafe for that infant e.g. no facilities to sterilise bottles. These women should be managed at a tertiary referral site
VIRAL LOAD MONITORINGViral load (VL) Response
< 1 000 copies/mL Assess adherence, continue ART and provide step-up adherence counselling if VL > 400. Continue VL testing as specified: after 3, 6, 12, 18 and 24 months throughout pregnancy and breastfeeding
> 1 000 copies/mL Adherence counsellingRepeat VL in ONE MONTH:If suppressed or > 1 log (10-fold) reduction; continue on current ART. If unchanged or not a 1 log reduction; switch to second line with ++ adherence. If failing on second line, consult expert
WHAT DOES EXCLUSIVE BREASTFEEDING MEAN?
For the first six months of life, the baby only gets mother’s milk and medication. This means NO water, formula, other foods or fluids.
NEED HELP?Contact the TOLL-FREE National HIV & TB
Health Care Worker Hotline
0800 212 506 / 021 - 406 6782Alternatively send an SMS or “Please Call Me”
to 071 840 1572www.mic.uct.ac.za
top related