guideline for the prevention of mother to child ... · for care provided by the community health...

Guideline for the Prevention of Mother to Child Transmission

of Communicable Infections

South African National Department of Health20

19November 2019

Published: November 2019 v2

iiGuideline for the Prevention of Mother to Child Transmission of Communicable Infections (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB) 2019

iiiGuideline for the Prevention of Mother to Child Transmission of Communicable Infections (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB) 2019

FOREWORD

Acknowledgement

I am grateful to all the internal and external stakeholders (listed in the ‘Acknowledgements’) who actively contributed to the development of these guidelines despite their demanding schedules. Your efforts are contributing toward attaining A LONG AND HEALTHY LIFE FOR ALL CITIZENS.

It is my pleasure to present the Guidelines for the Prevention of Transmission of Communicable infections from mother to child (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB).

While the WHO calls for dual elimination of HIV and syphilis, South Africa aspires to eliminate all infections that are transmittable from mother to child by promoting the prevention of such infections, early diagnosis and proper management in order to reduce maternal, neonatal and child morbidity and mortality.

In 2015 Option B+ (lifelong ART irrespective of CD4 count or WHO staging) and birth PCR testing were implemented. The birth PCR test provides an opportunity for early identification of babies who acquired HIV in utero and linking them to HIV care and treatment as early as possible. Monitoring of the infant PCR test positive around 10 weeks rate indicated a reduction in the MTCT rate from 1.3% in the FY 2016/17 to 0.9% in the FY 2017/18.

As we are approaching the milestones to elimination of MTCT for HIV, we are now being challenged by the rising of other transmittable diseases from mother to child. It is therefore important that in this guideline other infections such as Hepatitis, Malaria, Syphilis and TB, in addition to HIV, be given due attention. In the period 2014 – 2016, TB was responsible for 9% of all maternal deaths, hepatitis contributed 1.1% and malaria 1.7%. In 2017, the STI sentinel sites survey reported an increase in syphilis amongst pregnant woman to 2% and the recent outbreak of Listeriosis resulted in fatalities in neonates. The integrated approach will allow clinicians to comprehensively screen all pregnant women and their newborn babies and promptly manage those who are diagnosed with these infections.

The challenge that PMTCT is currently facing is an increasing number of babies who acquire HIV infection during the postnatal period. To address this challenge, the guidelines provide guidance on the following:

• Strengthening antenatal and postnatal care for both HIV negative and positive mothers.

• The introduction of a dolutegravir-based ART regimen which is more efficacious in reducing the risks of transmission of HIV.

• Promoting integrated management of the mother-baby pair by aligning PMTCT interventions with BANC visits during antenatal period and EPI visits during postnatal period.

These guidelines provide a framework for a service benefits package steering us towards the implementation of NHI. Therefore, we urge all clinicians, working in both public and private health facilities, to use these guidelines to offer quality, comprehensive services to the public.

Ms MP MatsosoDirector –General: Health

ivGuideline for the Prevention of Mother to Child Transmission of Communicable Infections (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB) 2019

Nov 2019 version 2

Based on decisions taken by the National EML Committee in February 2020, the following two updates have been made to the guideline:

1. The CD4 count threshold for TPT eligibility in pregnancy has been amended from 100 cells/μL to 350 cells/μL.

• Supported by a recent local study by Kalk et al.17, 18

• This change affects pages 18 and 26.

2. Nevirapine is no longer recommended as part of a triple therapy ART regimen, and specifically in pregnant women living with HIV.

• Toxicity associated with nevirapine is a concern

• This change affects page 19

What’s new in this version?

vGuideline for the Prevention of Mother to Child Transmission of Communicable Infections (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB) 2019

Part 1 Introduction ...............................................................................................................................................2Background ....................................................................................................................................................2Overall Guideline Objective...........................................................................................................................2Overview of Transmittable Infections during Pregnancy and the Breastfeeding Period ......................3Populations to whom this guideline applies ...............................................................................................5Summary of What’s New in the 2019 PMTCT Guideline .............................................................................6

Part 2 Prevention .................................................................................................................................................7Universal Measures to Prevent Infections during Pregnancy ...................................................................7Prevention of HIV ...........................................................................................................................................8Prevention of Unintended Pregnancies and Safe Conception in Women ...............................................9

Part 3 Charts per Service Delivery Area ............................................................................................................10Antenatal Clinic ..............................................................................................................................................10Labour and Delivery .......................................................................................................................................12Care of the Mother after Birth .......................................................................................................................14Care of the HIV-Exposed Infant after Birth ...................................................................................................15The Community Health Worker .....................................................................................................................16

1

Abbreviations .................................................................................................................................................viOverview of the Structure of this Guideline ................................................................................................1

Data Management ................................................................................................................................................33Documentation in the Client Record ............................................................................................................33Using NHLS reports for Quality Improvement AND Client Tracking .........................................................33

2

3

Part 4 Algorithms and Decision Tools ...............................................................................................................17Dolutegravir (DTG) in Pregnancy..................................................................................................................17ART Initiation Algorithm ................................................................................................................................18Key Adherence Messages .............................................................................................................................19Viral Load Monitoring Schedule ...................................................................................................................20Viral Load Non-Suppression Algorithm .......................................................................................................21Care of the Pregnant Adolescent Living with HIV .......................................................................................22Prophylaxis for the HIV-exposed Infant .......................................................................................................23Management of a High Maternal Viral Load after Delivery .........................................................................24Management of Indeterminate PCR Results in Infants ...............................................................................25The Abandoned Infant ...................................................................................................................................25TB Screening and TB Preventative Therapy during Pregnancy, Labour, and the Breastfeeding Period ....................................................................................................................................26Management of the TB-Exposed Neonate ...................................................................................................27The WHO Ten Steps to Successful Breastfeeding ......................................................................................28Breastfeeding Plus .........................................................................................................................................29Stopping Breastfeeding .................................................................................................................................30Care of the HIV-exposed but Uninfected Infant ...........................................................................................30Syphilis ...........................................................................................................................................................31

4

Annexure 1 Post Natal Club (PNC) Model ....................................................................................................34Acknowledgements........................................................................................................................................35References .....................................................................................................................................................36

CONTENT

viGuideline for the Prevention of Mother to Child Transmission of Communicable Infections (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB) 2019

3TC LamivudineANC Antenatal CareART Antiretroviral TherapyARVs AntiretroviralsAZT ZidovudineBANC Basic Antenatal CareBANC Plus Basic Antenatal Care Plusbd Twice DailyCBP Child Bearing PotentialCHW Community Health WorkerCM Cryptococcal MeningitisCPT Cotrimoxazole Prophylaxis TherapyCrAg Cryptococcal AntigenCTX CotrimoxazoleDHIS District Health Information SystemDST Drug Sensitivity TestingDTG DolutegravirEFV EfavirenzEGK Electronic Gate KeepingEML Essential Medicines ListEMTCT Elimination of Mother to Child Transmission of HIVEPI Expanded Programme on Immunization FGR Foetal Growth RestrictionFTC EmtricitabineGXP Gene Expert TB TestHb HaemoglobinHCW Health Care WorkerHEI HIV-exposed InfantHEU HIV-exposed but uninfectedHIV Human Immunodeficiency VirusHTS HIV Testing ServicesIM IntramuscularINH IsoniazidIPT Isoniazid Preventative TherapyIRIS Immune Reconstitution Inflammatory SyndromeIUCD Intrauterine Contraceptive DeviceIV IntravenousLAM LipoarabinomannanLP Lumbar PunctureLPA Line Probe AssayLPV/r Lopinavir/ritonavirLTBI Latent TB InfectionMCR Maternity Case RecordMDO Missed Diagnostic OpportunityMIP Mother-infant Pair

MNCWH&N Maternal Neonatal Child Women’s Health and Nutrition

MTCT Mother to Child Transmission of HIVNHLS National Health Laboratory SystemNVP NevirapineNSA Non-suppression AlgorithmNTD Neural Tube DefectOD Once DailyOI Opportunistic InfectionPCP Pneumocystis jirovecii PneumoniaPCR Polymerase Chain ReactionPEP Post Exposure ProphylaxisPHC Primary Health CarePICT Provider Initiated Counselling and TestingPMTCT Prevention of Mother to Child Transmission of HIVPNC Postnatal ClubPO Per os (per mouth)PrEP Pre-Exposure ProphylaxisRfA Results for Action NHLS ReportsRPR Rapid Plasma ReaginRTHB Road to Health BookletRx TreatmentSA South AfricaSRH Sexual and Reproductive HealthSTI Sexually Transmitted Infectionssd Single doseTB TuberculosisTDF TenofovirTEE ART Regimen containing Tenofovir, Emtricitabine,

and EfavirenzTLD ART Regimen containing Tenofovir, Lamivudine,

and DolutegravirTPHA Treponema pallidum haemagglutination assayTPT TB Preventative TherapyTST Tuberculin Skin TestUTI Urinary Tract InfectionVMMC Voluntary Medical Male CircumcisionVL Viral LoadVLS Viral Load SuppressionWASH Water, Sanitation and HygieneWLHIV Woman Living with HIVWHO World Health Organization

ABBREVIATIONS

1Guideline for the Prevention of Mother to Child Transmission of Communicable Infections (HIV, Hepatitis, Listeriosis, Malaria, Syphilis and TB) 2019

OVERVIEW OF THE STRUCTURE OF THIS GUIDELINE

The guideline is divided into four parts:

Part One: Introduction provides an introduction and background to this guideline

Part Two: Prevention gives guidance around the universal measures to prevent transmission of infections during pregnancy and breastfeeding, prevent HIV, prevent unintended pregnancies, as well as safe conception.

Part Three: Charts per Service Delivery Area is structured by service delivery point across the continuum of care. It deals with the care and treatment of the woman living with HIV, her partner and children, and preventing mother-to-child-transmission (MTCT) to her exposed infant.

Part Four: Algorithms and Decision Tools provides algorithms and decision tools that may apply to any service point, e.g. how to manage an elevated VL, how to screen for TB and initiate TPT, important adherence messages, etc.

For each service delivery point in the facility the following components of care are outlined: 1. HIV testing, 2. Antiretroviral therapy (ART) as treatment or prophylaxis, 3. Viral load (VL) monitoring and management, 4. Tuberculosis (TB) screening, TB Preventative Therapy (TPT), and opportunistic infection (OI) prophylaxis, 5. Prevention of mother to child transmission of syphilis, hepatitis B virus (HBV) and other infections, and 6. Other care required, e.g. basic antenatal care (BANC) services, immunization services (EPI), growth monitoring and nutrition.

For care provided by the community health worker (CHW) at home the following components of care are outlined:7. Care of the non-pregnant woman of child bearing potential (CBP) at home, 8. Home-based care during the antenatal period, and 9. Home-based care after delivery for the mother and infant

Where additional information is needed you will be redirected to the relevant sections in Part Four.

START BY SELECTING THE SERVICE POINT AT WHICH SERVICES ARE PROVIDED

Antenatal Care Labour and Delivery

Primary Health Care (PHC)

services providing Postpartum Care to

the Mother

PHC services providing Care to the HIV-exposed

infant

Services offered by the Community

Health Worker

12

3

4


PART 1 – INTRODUCTION1BACKGROUNDInfections during pregnancy are a major contributing factor to perinatal morbidity and mortality. In utero infections may directly affect the foetus and can lead to intra uterine deaths and still births. The foetus may also be affected indirectly as a consequence of maternal infection leading to premature birth or foetal growth restriction (FGR). Infections that are asymptomatic at birth may present later in life, often within the first five years. In general, primary infections during pregnancy are substantially more damaging than re-infections or reactivations of infection. Likewise, infections acquired at an earlier gestational age tend to lead to more serious infections.1 HIV, syphilis, TB, HBV, malaria, and more recently, listeriosis, are all infections with significant impact on maternal and child health outcomes in SA. Although all these infections are important, this guideline will focus mainly on preventing mother to child transmission of HIV, syphilis and TB.

OVERALL GUIDELINE OBJECTIVEThis guideline aims to outline the minimum standards for routine care for women of child bearing age and their families relating to:

• the prevention of new HIV cases, TB cases, syphilis cases, and other infections • the prevention of unintended pregnancies• the prevention of mother-to-child transmission of HIV, syphilis, and other infections, and • the care and treatment of the women living with, and their children exposed to HIV, syphilis and other infections

PILLAR 1

Primary prevention of transmittable diseases,

especially among women of childbearing age

PILLAR 2

Preventing unintended pregnancies among women diagnosed with transmittable

infections

PILLAR 3

Preventing disease transmission from a woman living with a transmittable

disease to her infant

PILLAR 4

Providing appropriate treatment, care, and support

to women, their children, partners and families

Figure 1 The Four Pillars for Prevention of Transmittable Infections from Mother to Child


OVERVIEW OF TRANSMITTABLE INFECTIONS DURING PREGNANCY AND THE BREASTFEEDING PERIOD

OVERVIEW OF PMTCT OF HIVSouth Africa (SA) is committed to achieving the elimination targets outlined in the Last Mile Plan. Whilst significant progress has been made in preventing HIV infections in children, HIV remains the third leading cause of maternal mortality2, and a significant contributor to under-five deaths in SA. Therefore, managing the health of women living with HIV and preventing mother-to-child transmission of HIV remains a critical intervention for ensuring that women and children survive and thrive in South Africa. PMTCT Option B Plus entailed initiating ART for life in all pregnant and breastfeeding women regardless of CD4 count or clinical stage and was launched in SA in January 2015. Now, three years down the line, it is necessary to reflect on new evidence, both scientific and operational, to ensure that SA’s HIV PMTCT program remains relevant, practical, and evidence based. The PMTCT program outlines four pillars by which to achieve the targets of zero HIV transmission from mothers to their infants and an HIV-free generation. They are outlined in Figure 2 below.

PILLAR 1

Primary prevention of HIV, especially among women of

childbearing potential

PILLAR 2

Preventing unintended pregnancies among women

living with HIV

PILLAR 3

Preventing HIV transmission from a woman living with HIV

to her infant

PILLAR 4


to women living with HIV, their children, partners and

families

Figure 2 The Four Pillars of PMTCT for HIV

SYPHILIS IN PREGNANCYSyphilis remains a significant cause of preventable perinatal death in SA.3 The 2015 provincial level syphilis prevalence estimates for women attending ANC ranged form 1.1% (95% CI: 0.8%-1.5%) to 4.6% (95% CI: 3.8%-5.6%). With only an estimated 72% of woman receiving screening for syphilis, many woman may remain undetected and untreated. Adverse pregnancy outcomes occur in up to 80% of syphilis seropositive, untreated pregnant women. South Africa has committed to dual elimination of both HIV and syphilis, and greater emphasis is therefore needed on the process of screening and effectively treating mothers, their partners, and their infants affected by syphilis.

PILLAR 1

Primary prevention of syphilis, especially among women of


PILLAR 2


diagnosed with syphilis

PILLAR 3

Preventing disease transmission from a woman

diagnosed with syphilis to her infant

PILLAR 4


to women, their children, partners, and families

Figure 3 The Four Pillars of Preventing Mother to Child Transmission of Syphilis


TUBERCULOSIS IN PREGNANCYNon pregnancy related infections remains the leading cause of maternal mortality in South Africa and in all provinces. Within this category, respiratory infection remains the most common causes of death, and TB the most common underlying disease. Yet, deaths from TB are likely to be unrecognized, with many deaths due to pulmonary or disseminated TB being attributed to other causes.4 Furthermore, maternal TB may result in premature birth, low birth weight, and congenital or neonatal TB infection or disease.5 Preventing, diagnosing and treating women for TB must receive greater emphasis if maternal and child outcomes are to be improved in SA.

PILLAR 1

Primary prevention of TB, especially among women of


PILLAR 2


living with TB

PILLAR 3

Preventing TB transmission from a woman living with TB

to her infant

PILLAR 4


to women living with TB, their children, partners and

families

Figure 4 The Four Pillars of Preventing Mother to Child Transmission of Tuberculosis

OTHER INFECTIONSMALARIA IN PREGNANCYPregnant women, particularly in the second and third trimesters of pregnancy, are more likely to develop severe malaria and have a higher malaria-related mortality rate than other adults. Malaria in pregnancy is more frequently associated with complications such as cerebral malaria, hypoglycaemia, and pulmonary oedema/adult respiratory distress syndrome. In addition, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery, low birth weight (a leading cause of child mortality) and rarely, congenital malaria. Foetal distress may occur peripartum. The risk of severe malaria extends into the early postpartum period. Pregnant and breastfeeding women living in malaria-endemic areas should therefore be a focal group for malaria prevention interventions. It is important to follow up pregnant women treated for malaria, and their infants, more closely to promptly diagnose and adequately manage any complications of malaria in pregnancy.6

HEPATITIS IN PREGNANCYWorsening of liver disease in HBV-infected pregnant women is uncommon, but case reports have suggested that HBV reactivation, hepatic exacerbations and fulminant liver failure may occur. Furthermore, maternal HBV infection may result in higher rates of preterm births, lower APGAR scores, gestational diabetes and antepartum hepatitis. Whilst horizontal transmission during childhood remains the primary mode of HBV transmission, vertical transmission from mother to child remains an important mechanism of infection in countries with high HBV prevalence.7 In SA, a large proportion of HBV infected women are also living with HIV and will receive ART during pregnancy. The ART drugs tenofovir and lamivudine treat both HIV and HBV and reduce the risk of mother to child transmission by decreasing the viral load of both HIV and Hepatitis B. Health care workers need to be aware of the required management of a HBV-infected mother and her infant as outlined in the National Guidelines for the Management of Viral Hepatitis.

LISTERIOSIS, ZIKA AND OTHER INFECTIONSListeriosis is a disease caused by ingesting food contaminated with the bacterium Listeria monocytogenes. Pregnant women, newborn infants and those with weakened immune systems are particularly at risk and the infection may result in sepsis or meningitis with high mortality. Vertical transmission may result in stillbirth, premature delivery or severe infection in the newborn.1

Zika virus in transmitted by mosquitos, sexual contact, and contaminated blood products. While the majority of Zika infections are asymptomatic, infected persons may present with a short-lived febrile illness. There is no evidence that pregnant women are more susceptible to Zika virus, or that they are more likely to develop complications of the disease. However, maternal Zika infection may result in congenital brain abnormalities including microcephaly in the infant.8

While Zika virus infections may not be an imminent threat in the South African context, the recent outbreak of Listeriosis highlights the importance of universal measures to prevent infections during pregnancy and the breastfeeding period to prevent any form of infection and their consequences during this vulnerable time.


POPULATIONS TO WHOM THIS GUIDELINE APPLIESThis guideline covers all settings where routine sexual and reproductive health (SRH) services and HIV care and treatment services are offered to HIV-uninfected and HIV-infected women, their partners and their families. It is to be used in all South African health care facilities, and by doctors, nurses and allied health workers at primary, secondary and tertiary care levels where clients may require uncomplicated PMTCT care. This guideline does not cover clients with complex care issues who may require individualised client care approaches.


SUMMARY OF WHAT’S NEW IN THE 2019 PMTCT GUIDELINE

Table 1 Summary of changes in the PMTCT Guideline

CONTENTS 2015 CONSOLIDATED GUIDELINE 2019 PMTCT GUIDELINE

Overall approach • Focus on practicality for the end user• Focus on integration of services, including use of CHWs in the community

Prevention • Guidance on universal infection precautions, and for preventing HIV in HIV-negative women and serodiscordant couples

Preventing unplanned pregnancies and promoting safe conception

• Guidance for contraception in women living with HIV, as well as safe conception

HIV testing for mother

• At first visit and every three months • At first visit and at each routine BANC plus visit (eight visits in all)

ART initiation • Guidance on adherence messages• Guidance on considerations for adolescents• Guidance for use of dolutegravir (DTG) in women of childbearing potential

VL monitoring for Mother

• Guidelines for newly diagnosed mothers, and known positives on ART

• Additional guidance for mothers with previous ART exposure, and who book late for antenatal care

• Do a VL at delivery and at six months postpartum for all women on ART, and six-monthly during breastfeeding

ART for the mother presenting in labour

• Stat dose nevirapine (NVP) and Truvada, and zidovudine (AZT) three-hourly during labour

• Once DTG is available, replace previous regimen with a stat dose of tenofovir (TDF), lamivudine (3TC), and dolutegravir in a fixed dose combination tablet (TLD) and a stat single dose of nevirapine (NVP). Start lifelong ART on the following day after appropriate counseling to understand her fertility intentions and contraceptive needs

Infant HIV testing • HIV-PCR testing at birth, and 10-weeks

• 18-week PCR for high risk infants who received extended NVP for 12 weeks

• Age appropriate HIV testing six-weeks post cessation of breastfeeding

• 18-month HIV rapid testing for HIV-exposed infants, with a second rapid used for confirmation of HIV diagnosis

• Birth HIV-PCR testing and 10-week HIV-PCR testing remain unchanged• No 18-week PCR for high risk infants• Do a six-month HIV-PCR for all HIV-exposed infants • Do an age appropriate HIV test at six-weeks post cessation of breastfeeding, even if

breastfeeding continues for longer than 18 months• Universal HIV testing at 18 months (HIV rapid test for ALL infants regardless of HIV

exposure, except in those who previously tested HIV positive and are on ART)• HIV-PCR should be used as the confirmatory test for any HIV positive test result up to

two years of age

Definition of a “high risk” infant at birth

• Maternal VL ≥ 1000c/ml• Maternal ART < 4 weeks prior to

delivery

• Mother with a VL of ≥ 1000 c/ml at delivery (or most recent VL taken during the last 12 weeks of antenatal care), or

• a mother with no VL result in the last 12 weeks of antenatal care. Infant post exposure prophylaxis

• High risk infants: AZT for six weeks and NVP prophylaxis for 12 weeks

• High risk infants at birth: AZT for six weeks and NVP prophylaxis for a minimum of 12 weeks. Stop NVP after 12 weeks only if mother’s VL is less than 1000 copies/ml. If the maternal VL is not less than 1000 c/ml by 12 weeks, continue NVP until mother’s VL is less than 1000 c/ml, or until four weeks after she is no longer breastfeeding.

• Guidance for management of the infant of a newly diagnosed mother during breastfeeding

• Guidance on the breastfeeding mother who was previously less than 1000 c/ml and is now found to have a VL ≥ 1000 c/ml

Breastfeeding • Breastfeeding recommended for 12 months

• Breastfeeding in the context of ART recommended for 24 months or longer, in line with recommendations for general population

• Guidance on stopping breastfeeding and indications for formula feedingTB screening and TPT for pregnant women, mothers, and their infants

• TB Gene Expert (GXP) only if TB symptom screen positive

• TST to determine duration of IPT

• Isoniazid Preventative Therapy (IPT) to become known as TB Preventive Therapy (TPT) for Treatment of Latent TB Infection (LTBI)

• TB GXP for all newly diagnosed women living with HIV, or known positive women with a new pregnancy diagnosis

• No tuberculin skin test (TST) required• If CD4 > 350, defer TPT for pregnant women until 6 weeks postpartum • If CD4 ≤ 350 during pregnancy, initiate TPT for 12 months

Syphilis, HBV, Malaria

• Not featured • Guidance for screening and treatment of syphilis, HBV, and malaria


PART 2 – PREVENTION2UNIVERSAL MEASURES TO PREVENT INFECTIONS DURING PREGNANCYTable 2 below summarizes the universal preventative measures that all pregnant woman should observe to prevent transmission of infections to her infant during pregnancy or breastfeeding.

Table 2 Universal Measures to Prevent Infections during Pregnancy

The Health care provider should advise the pregnant or breastfeeding client about the following practices that may increase or decrease the risks for contracting infections

Contact with Adults with Respiratory or Flu-Like Symptoms

• Avoid close or intimate contact with adults with communicable respiratory diseases, acute or recent fever or flu like symptoms. To prevent respiratory infections, avoid:

- Kissing - Sharing food utensils, drinking from the same container

• Wash hands frequently and, if available, use alcohol gel after shaking hands and before eating

Sexual Contact • Use male latex condoms consistently and correctly. - Carefully handle the condom to avoid damaging. - Put the condom on after the penis is erect and before any genital, oral, or anal contact with the partner - To prevent the condom from slipping off, hold the condom firmly against the base of the penis during

withdrawal, and withdraw while the penis is still erect. - Do not use the condom more than once

• Use female condoms correctly• Avoid receptive oral sex with a partner with oral herpes or intercourse during the third trimester with men who

have genital herpes.• Ensure that all sexual contacts of individuals treated for STIs are linked to care and receive STI treatment.

Blood Contact • Consider the risks if you are thinking about getting a tattoo or body piercing. Infected tools can transmit hepatitis B or other infections

• Do not share personal care items that might have blood on them (razors, toothbrushes).• Avoid using drugs. Do not share needles or other equipment related to drug use.

Contact with Children with Respiratory, Flu-Like Symptoms or Skin Rash

• Careful hand washing with soap and running water and, if available at home, use alcohol gel rub after - exposure to a child’s bodily fluids and diaper changes, - bathing the child or handling dirty laundry, - touching the child’s toys and other objects

• Avoid close or intimate contact with the child such as - kissing on the mouth or cheek (kiss them on the head or give them a hug) - sleeping together, - sharing towels and washcloths,

• Avoid contact with baby’s saliva while feeding - sharing or tasting foods with the same utensils (spoons, forks) - drinking from the same container

Consuming, Handling, and Processing of Food

• Avoid eating raw or undercooked lamb, pork, beef or poultry. Cook all meat until it is no longer pink, and the juices run clear. Reheat any processed meat until steaming

• Do not eat food that has passed its expiry date • Do not eat unpasteurized dairy products (including all soft cheeses), • Peel or wash raw fruit and vegetables thoroughly. • Wash hands, knives, and cutting boards after handling uncooked foods or fluids from their packages. • Wash hands thoroughly after handling raw meat

Protection from Insects • Always use Insecticide-treated bed nets if you live in a malaria endemic area.

Table adapted from ‘Perinatal Infections transmitted by the Mother to her Infant’, March of Dimes Foundation, Latin American Center for Perinatology / Women and Reproductive Health - Pan American Health Organization / World Health Organization1


WHERE should HIV prevention services be offered?

All persons of reproductive age need access to comprehensive information, as well as non-judgmental, confidential, and (as necessary), youth friendly SRH services.

WHO should be offered HIV prevention

services?

All HIV negative women, including adolecent girls, young women, and sex

workers

HIV negative partners and other

men

HIV positive persons

WHAT HIV prevention options

should be offered?HTS services

Couples Counselling and partner testingScreen and treat STI’sSafe sex education

Post Exposure Prophylaxis (PEP)Pre-Exposure Prophylaxis (PrEP) as

applicable & available #

+Voluntary Medical Male Circumcision

(VMMC) and communication for

men

HTS, couples counselling

and partner testing, Linkage to Care,

ART and VL suppression

BASIC PREVENTION PACKAGE BASIC PREVENTION

PACKAGE

TREATMENT AS PREVENTION

Remember, condoms are recommended for all couples regardless of HIV status

Safe Sex Education:Counsel the women to avoid the following sexual practices that could put her at risk for contracting HIV and other STI’s:

• The woman or her regular partner having new or multiple sexual partners

• Unreliable use of condoms• Alcohol abuse

# PrEP is routinely available foradolescent girls and young women, as well as for sex workers. For PrEP in other populations consult the current PrEP guideline.

Ways to prevent HIV transmission within a discordant couple

PREVENTION OF HIVFamily Planning (FP) and

HIV testing services (HTS) should always be provided together. At every

FP visit, offer HTS. At every HTS visit, offer FP

At all contact points with the health system, including PHC, SRH services, MNCWH&N services, Chronic and Acute Care services (including hospitals)

Community based services, including mobile/outreach services for sex workers and other working persons

School based prevention (in the context of comprehensive sexuality education)


Ideally, engage the women living with HIV and her current partner in a couples-based approach, as the health and co-operation of both partners is important for safe contraception or conception

Regularly discuss issues of childbearing and contraception to understand current fertility desires and health care needs

A. Currently wanting to conceive

!Classify client

Recommend, discuss, and agree on steps before conception

Optimise HIV treatment in the partner living with HIV (serodiscordant couple), or in both partners living with HIV (sero-concordant couple).

• Continue to use condoms• Document HIV status of both partners• Identify and manage co-morbidities, including

syphilis and other STIs• Initiate ART and support good adherence• Maintain an undetectable VL, ideally for 4-6

months before conception• Start folate supplementation and do an Hb if

clinically pale• Consider PrEP for the uninfected partner

Once viral load suppression is achieved in the HIV positive partner(s), the following additional options are available to make conception safer

• timed, limited, peri-ovulatory, sex without a condom

• intravaginal insemination • male circumcision • intra-uterine insemination • sperm washing• surrogate sperm donation

Initiating Dolutegravir (DTG) in women wanting to conceive now or in the future may carry risks. Counsel the mother on use of DTG in pregnancy and allow her to make an informed choice. See Dolutegravir in Pregnancy on page 17

!

Not readily available in the public sector

If pregnancy confirmed, counsel the mother to book at ANC before 14 weeks and to continue using condoms consistently during pregnancy and the breastfeeding period

B. Not currently desiring a child, but may do so in the future

C. No desire for a child now or in the future

Counsel about options for contraception including long-acting

reversible contraceptives (IUCD and implants), and barrier methods

Counsel about options for contraception including permanent

methods (male and female voluntary sterilisation), long-acting reversible contraceptives (IUCD and implants) and barrier methods. If permanent

methods are not appropriate, proceed to an alternative dual method as

outlined below

Dual method is always recommended:

A hormonal method (including implants) or intra-uterine contraceptive device to prevent pregnancy

A barrier method (male/female condoms) to augment the hormonal method, and prevent STIs and HIV

Discuss the different contraceptive options available for use in the women living with HIV (See PC101, and the National Contraceptive Clinical Guideline, 2018) Available options include:

All hormonal methods including implants (e.g. Implanon NXT®) and the long acting injectables (e.g. Depo Provera®) are effective when used with Dolutegravir. Women should be counseled about the possibility of reduced efficacy when using progestin subdermal implants (e.g. Implanon NXT®) with enzyme inducing drugs such as Efavirenz, Rifampicin, and certain epilepsy drugs. Women who are already using an implant should consider an alternative non-hormonal method for contraception e.g. the IUCD, and should continue to use condoms correctly and consistently.

+

• Injectable progestins• Combined oral contraceptive pills.• Intra-uterine contraceptive device• Emergency contraception

PREVENTION OF UNINTENDED PREGNANCIES AND SAFE CONCEPTION IN WOMEN

Family planning should be an integral

part of ARTservices!


ANTENATAL CLINICWhen caring for a pregnant woman, always be sure to:

• Recognise the pregnant client that requires urgent attention as outlined in BANC Plus and manage/refer as appropriate

• Identify the pregnant client who needs secondary level antenatal care as outlined in BANC Plus and manage/refer as appropriate

• Provide routine antenatal care to the woman not requiring urgent referral.

TESTING for HIV

HIV Testing: Provider Initiated Counselling and Testing (PICT) should be provided to all women with unknown or HIV-negative status:

• Offer an HIV test at ANC first/booking visit.• Retest the HIV-negative mother at every routine BANC Plus visit.• Offer couple/partner testing to promote prevention, access to HIV care and

treatment, and/or manage discordant results (when one partner is HIV-positive and the other partner HIV-negative).

• If the woman and/or her partner test HIV-negative, provide HIV prevention information (Go to HIV Prevention on page 8).

• Women who choose not to be tested should be offered ‘post-refusal’ counselling and offered a re-test at every subsequent visit.

• If a woman tests HIV-positive at any stage, encourage testing of her other children, and linkage to HIV care and treatment as necessary.

• For the HIV testing algorithm, including the management of discrepant HIV test results, refer to the HTS Guideline.

TREATMENT for HIV

• Pregnant women already on ART should continue their current ART regimen pending their 1st VL result (see below). If she will now collect her ART at ANC, ensure that she is documented as a transfer-out from her former clinic, and not classified as lost-to-follow-up.

• All newly diagnosed HIV-positive pregnant women are eligible for lifelong ART regardless of gestation, CD4 count, or clinical stage.

• Creatinine and CD4 count should still be done to determine renal function and the need for prophylaxis (TB, PCP and CM).

• TDF, 3TC, and DTG (as a fixed dose combination) is the preferred regimen for women who are newly initiating ART. However, each mother should understand the risks and benefits of DTG and EFV-based regimens, and be enabled to make an informed choice. ART should be initiated on the same day as HIV diagnosis10, and after contra-indications to ART have been excluded (Go to ART Initiation Algorithm on Page 18).

• Pregnant women already on ART should continue their current ART regimen pending the result of their 1st VL (to be done at entry into antenatal care as outlined below). Only if her VL is <50 c/ml, and she is no longer in the 1st six weeks, offer her the option of switching to DTG (If her VL is ≥ 50 c/ml, manage her as per the VL Non-suppression algorithm on page 21). A switch to DTG needs to be preceded by appropriate counseling on the risk for NTDs for subsequent pregnancies, postpartum contraception, and the new side-effects that may be experienced when switching to a new drug (see DTG in pregnancy on page 17). If she will now collect her ART at ANC, ensure that she is documented as a transfer-out from her former clinic, and not classified as lost-to-follow-up.

• Known HIV positive women, who are not currently on ART, but are ART-exposed (e.g. previous PMTCT, or previous LTFU on ART) should initiate a DTG-containing regimen. If she has a documented VL that was suppressed while she was previously on ART, start TLD. If no VL result is available, or her VL was not suppressed, start AZT, 3TC, and DTG.

• Appropriate ART literacy education should be given to the woman before she leaves the facility. (Go to Key Adherence Messages on page 19)

• All women living with HIV should be referred to a CHW to support adherence, breastfeeding and retention in care pre- and post-delivery.

PRIMARY OBJECTIVES

Identify HIV infection and achieve viral suppression

Identify and treat syphilis and other infections

1

2

Initiating Dolutegravir in pregnant women in the 1st 6 weeks may carry risks. Counsel the mother on use of DTG in pregnancy and allow her to make an informed choice.

!

PART 3 – CHARTS PER SERVICE DELIVERY AREA3


VL MONITORING and Management

(Go to VL Monitoring Schedule

on page 20)

Newly diagnosed and initiated ART for the first time:

• Do 1st VL at 3 months on ART. • If VL < 50 c/ml, repeat VL at delivery.

Known HIV-positive women already on ART: • VL at first/booking visit in ANC, • If VL < 50 c/ml, repeat VL at delivery.

Known HIV-positive women, who are not currently on ART, but are ART exposed (e.g. previous PMTCT, or ART LTFU) and who are initiating a DTG-containing regimen:

• Do 1st VL at 3 months on ART.• If VL < 50 c/ml, repeat VL at delivery.

If the VL is ≥50 c/ml in any of the above scenarios, go to the VL Non-suppression Algorithm on page 21.

SCREENING for TB and other OI’s

Screen for TB at every visit regardless of HIV status and consider TPT if eligible. Ensure any woman diagnosed with TB is adherent to TB treatment and that she is aware that her newborn may require TB prophylaxis (Go to TB screening and TPT on page 27). Initiate Cotrimoxazole Prophylaxis (CPT) if CD4 count ≤ 200 cells/μL, or WHO clinical stage 2, 3, or 4.

If CD4 ≤100 cells/uL the lab will automatically perform a Cryptococcal Antigen test (CrAg). CrAg-positive clients who are pregnant should be offered an LP (regardless of symptoms) and discussed with an expert before a decision is made regarding management.

PREVENTION of transmission of

Syphilis, HBV and other

infections

Syphilis: Test all women for syphilis and screen for other STI’s, e.g. gonorrhoea, at their first ANC visit. (Go to Syphilis on Page 31)

• If the first test is performed before 20 weeks gestation and is negative, a second test should be done at 32 to 34 weeks.

• Treat all women with a positive syphilis screening test, irrespective of titer (MCG, PC101).

HBV: All woman living with HIV will automatically be treated for HBV when they start routine 1st line ART containing TDF and 3TC/FTC. If she should need to switch to 2nd line ART, HBsAg should be checked. If HBsAg is positive, TDF should be retained as a fourth drug in her new regimen. If a HIV negative pregnant woman is known to have HBV infection, she should be referred for further tests to determine eligibility for treatment. All babies should receive hepatitis B vaccinations in accordance with the EPI schedule.

Malaria: Although MTCT is rare, malaria in pregnancy poses serious risks for both the mother and the baby. Malaria presents as a febrile illness and is often unrecognised or misdiagnosed with severe consequences. The most important aspect of making a diagnosis of malaria is having a high index of suspicion. If a woman presents with fever in pregnancy, always ask about her travel history. Refer any woman with signs of severe illness or danger signs as outlined in PC101. Comprehensive information on Malaria in Pregnancy is available in the Guideline for Maternity Care in South Africa, and the National Guideline for the Treatment of Malaria SA.

Other Care • Routine antenatal care according to the BANC Plus guideline. Encourage male partner involvement throughout antenatal care.

• Nutritional screening for mother. Refer any woman with a BMI of less than 23 to a dietician

• Counselling on infant feeding. See the Infant and Young Child Feeding Policy.• Mental health screen for mother• Assist the mother to register on Mom-Connect

Pregnant adolescents are at a higher risk for poor adherence and poor viral suppression and require more intense support.Go to “The Pregnant Adolescent” on Page 22

!

Remember to insert the laboratory barcode sticker and record all VL, TB, and syphilis results in the Maternity Case Record/ANC Card, and the ART Clinical Stationery (if available in that facility)

!

Early referral to community-based services improves adherence to ART, exclusive breastfeeding and retention in care

TB and other non-pregnancy related infections remain an important cause of maternal and neonatal mortality

!

Remember to put the PMTCT code: C#PMTCT in the

EGK code field of the lab form for each VL done to ensure the electronic gatekeeping

rules (EGK) do not lead to sample rejection


LABOUR AND DELIVERY

TESTING for HIV

PICT should be provided to all women presenting in labour ward who are not known to be HIV-positive (including born-before-arrivals [BBAs]):

• Offer couples counselling and partner testing. For the management of the discordant couple, go to the HIV Prevention section on page 8.

• Women who choose not to be tested should be offered ‘post-refusal’ counselling and offered a re-test at every subsequent visit.

• If a woman tests positive at any stage, encourage testing of her other children, and linkage to HIV care and treatment as necessary.

• If a woman has indeterminate or discrepant HIV test results, treat the baby as a high-risk HIV-exposed infant until mother’s HIV status can be confirmed. Communicate clearly to the mother and document the results and plan of action in the maternal record and RTHB.

Antiretrovirals Pregnant women already on ART should continue their current ART regimen at usual dosing times during labour.

Newly diagnosed, or known HIV positive women not on ART: • Give a stat single fixed dose combination tablet of TDF, 3TC and DTG (TLD) and a

stat single dose of NVP.• Lifelong ART should be initiated the following day after contra-indications to ART

have been excluded (Go to ART Initiation Algorithm on ). TLD is the preferred regimen, provided the mother has been provided with all necessary information on DTG and EFV-based regimens including the risk of NTDs. A contraceptive method is recommended. Provide her with a choice of contraceptive options as desired.

• Appropriate ART literacy education should be given to the women before she leaves the facility. (Go to Key Adherence Messages on Page 19).

• Mothers must understand and anticipate the adherence challenges that may be experienced in the postpartum period.


Check if the mother has had a VL result in the last 12 weeks and categorize the risk for the infant:

• VL < 1000c/ml = Low risk• VL ≥ 1000 c/ml = High risk • No VL result in the last 12 weeks = High risk

All women must have a VL test done at the time of delivery. Although this VL result will mostly still be unknown when infant prophylaxis is initiated, remember to insert the laboratory barcode sticker into the postnatal discharge form andthe RTHB. The results of the delivery VL must be checked at the 3-6-day postnatal visit, and the management of the mother-infant pair adjusted accordingly.

SCREENING for TB and other OI’s • Screen all women for TB at entry to the labour ward, and initiate TPT for women

living with HIV before discharge, if eligible (Go to TB Screening and TPT on page 26).

• Initiate Cotrimoxazole Prophylaxis before discharge if CD4 count ≤ 200 cells/uL, or WHO clinical stage 2, 3, or 4.

PRIMARY OBJECTIVES

Safe delivery for mother and infant

Prevent MTCT during labour

1

2

An elevated viral load atdelivery increases therisk for poor maternaloutcomes and MTCTduring labour andthrough breastfeeding.

!

Remember to put the correct PMTCT code in the EGK code field of the lab form for each VL done to ensure the electronic gatekeeping rules (EGK) do not lead to sample rejection. Use the code C#Delivery for all VLs done at the time of delivery.


Other Care for the Mother living with

HIV at delivery

Provide routine labour and delivery management according to the Maternity Guidelines of SA, including safe delivery techniques for the HIV positive mother:

• Avoid episiotomy & assisted delivery unless essential. Avoid prolonged rupture of membranes. Avoid unnecessary suctioning of the infant.

• If C/section required: Provide prophylactic antibiotics for all HIV-positive women according to the Maternity Care Guidelines 2016.

Within 1 hour of delivery• Encourage skin-to-skin contact with baby and initiate exclusive breastfeeding. Hospitals and labour wards can support

mothers to breastfeed by following the WHO 10 Steps to Successful Breastfeeding on Page 28. In addition, counsel mother on Breastfeeding Plus on page 29.

At discharge• Ensure contraception has been administered after appropriate counselling (go to Contraception and Safe Conception

Page 9).• Provide the mother with two-months’ supply of ART and six-weeks supply of infant prophylaxis.• Communicate follow-up appointment dates for the six-day post-natal visit at a named facility. Provide necessary referral

letters. Provide an ART transfer-out letter, if she will receive her ART at a different facility. However, it is recommended that the mother-baby pair continue to receive integrated care within the maternal and child health stream until the baby is two years old or no longer breastfeeding.

Care of the HIV-exposed

Infant at Delivery

All HIV-exposed Infants should receive a birth HIV-PCR to identify HIV transmission that occurred in-utero.All HIV-exposed Infants should receive a minimum of six weeks post exposure prophylaxis with NVP.

Identify the high-risk infants for whom additional prophylaxis must be provided: • Mother with a VL of ≥ 1000 c/ml at delivery (or most recent VL taken during the last 12 weeks of antenatal care), or• Mother with no VL result in the last 12 weeks. • These infants should be provided with high-risk prophylaxis until the result of the delivery-VL can be checked at the

3-6-day postnatal visit. When the delivery-VL result is known, the infant can be re-classified as high/ low-risk and prophylaxis adjusted accordingly.

All high-risk infants who are breastfed should receive additional AZT for the first six weeks of life and should receive NVP for a minimum of 12 weeks. NVP should only be stopped when the breastfeeding mother has a VL of less than 1000 c/ml, or until four weeks after she has stopped breastfeeding. All high risk infants who are exclusively formula fed should receive AZT for 6 weeks and NVP for 6 weeks. (Go to HEI Prophylaxis Infographic and the NVP and AZT dosing chart on Page 23)

Provide oral polio vaccine, BCG and other routine neonatal care as per the Maternity Care and Neonatal Care Guidelines.Do not give BCG if baby is TB-exposed, and will be receiving TB prophylaxis (Go to Management of the TB-Exposed Infant on Page 27).

PREVENTION of transmission of

Syphilis, HBV and other infections

Syphilis: Examine and treat the newborn of the RPR positive mother (go to Syphilis on page 31): Well (asymptomatic) baby: Treat baby with benzathine penicillin 50 000u/kg IM stat only if:

• Mother was not treated, or• If the mother has received < 3 doses of benzathine benzylpenicillin, or• If the mother delivers within 4 weeks of commencing treatment.

Symptomatic baby (hepatosplenomegaly, pseudoparesis, snuffles, oedema, jaundice, anaemia, purpura, desquamative rash -especially involving palms and soles): Refer all symptomatic babies for treatment of congenital syphilis: procaine penicillin 50 000 u/kg IM daily for 10 days, or benzyl penicillin (penicillin G) 50 000 u/kg/dose 12-hourly IV for 10 days.

HBV: All babies should receive hepatitis B vaccinations in accordance with the EPI schedule.


CARE OF THE MOTHER AFTER BIRTH

6 DAYS 6 WEEKS 10 WEEKS 6 MONTHS 18 MONTHS

TESTING for HIVRetest the HIV-negative mother if she was not retested in labour

Retest every HIV-negative mother at the 10-week visit (~ three months postpartum), the six-month visit, and every three months whilst breastfeedingRemember to offer partner testing. If no longer breastfeeding, ensure that the mother receives an HIV test at least every year

Antiretrovirals Mother to continue ART during the postpartum period and for life.If she is newly diagnosed during the breastfeeding period, initiate ART after contra-indications to ART have been excluded (Go to ART Initiation Algorithm on Page 18). Provide appropriate counselling on available ART options. TDF, 3TC, and DTG (TLD) is the preferred regimen, provided the mother has been given all necessary information on DTG and EFV-based regimens including the risk of NTDs. This is a high-risk period for poor adherence. Ensure that the mother understands the importance of continued viral suppression for her own health and that of her baby. She must also understand and anticipate the adherence challenges that may be experienced in the postpartum period. Link the mother to mom-connect, a CHW, a mentor mother, or a support group/club if available (See Post-natal Clubs on Page 34). Whether continued ART care is provided at MNCWH services (preferred) or at PHC/Wellness services, ensure that mother is retained in care, adherent to ART, and maintains a suppressed viral load.


Check ART adherenceFollow-up on result of delivery-VL. (If not yet available, follow-up again in 1 week. If VL not done at delivery, do VL at this visit)

If VL ≥ 50 c/ml: manage mother as per VL Non-suppression Algorithm on Page 21. If VL ≥ 1000 c/ml:manage infant as a high-risk infant i.e. add AZT for six weeks, and extend NVP until mother’s VL is <1000 c/ml.

Check ART adherence

Repeat VL if delivery-VL was ≥ 1000 c/ml.

Check mother’s ART supply and confirm where she will be receiving her ongoing ART care

Check ART adherence

Check, record and act on any earlier VL tests

Check mother’s ART supply and confirm where she will be receiving her ongoing ART care

Check ART adherence at every visit. Check, record and act on results of any earlier VL tests Do a VL for all HIV-positive mothers on ART at six months.Continue VL monitoring every six months (at 12,18, and 24months) whilst breastfeeding.Ensure that the results of any VL test are checked within 1week. If VL ≥ 50c/ml:• Recall the mother-infant pair to

the facility• Manage mother as per VL Non-

suppression Algorithm on Page 21

If VL ≥ 1000 c/ml:• Restart/extend infant prophylaxis if

mother is still breastfeeding. Go to Management of a High Maternal VL after Delivery on Page 25.

SCREENING for TB and other

OI’s

• Routine postpartum care as per the Maternity Care Guideline

• TB screening, TPT, and CTMX according to guidelines

• Mental Health: Screen for postpartum depression

• Contraception and STI screening• Infant feeding counselling and support

according to the Infant and Young Child Feeding Policy

• Counselling on safe use of water, sanitation and hygiene (WASH)

• A papsmear can be done from six weeks onwards

• TB screening, TPT, and CTMX according to guidelines• Mental Health: Screen for postpartum depression• Contraception and STI screening• Infant feeding counselling and support according to the

Infant and Young Child Feeding Policy• Counselling on safe use of water, sanitation and

hygiene (WASH)• Papsmear (if indicated)

PRIMARY OBJECTIVES

Prevent MTCT through Breastfeeding

Retain Mother in Care

1

2

Viral Load suppression is critical for the health of the mother, her baby, her subsequent pregnancies, and her partner!

!

Achieve and Maintain Viral Suppression

3


HIV Testing and Early

Infant Diagnosis

CARE OF THE HIV-EXPOSED INFANT AFTER BIRTH

3-6 DAYS 6 WEEKS 10 WEEKS 6 MONTHS 18 MONTHSOTHER TESTS

(at any time)Follow-up results of

birth PCR and manage accordingly. Any HIV

positive neonate should be discussed/referred to a clinician experienced in managing an HIV-

positive neonate. ART should be initiated even

if the infants weighs less than 2,5 kg.

Ensure that birth PCR and mother’s VL results were checked, recorded and acted

upon correctly.

HIV-PCR for all HIV-exposed

infants who previously tested

HIV-PCR negative.

Known HIV-exposed infants:• Do HIV-PCR test at

6 months in all HIV-exposed infants, except in those who previously tested positive and are on ART.

Universal HIV testing at 18 months (HIV rapid test for ALL

infants regardless of HIV exposure, except

in those who previously tested HIV positive and

are on ART)

Do an age-appropriate HIV

test 6 weeks post cessation of

breastfeeding, even if breastfeeding

continues beyond 18 months of age. Test a symptomatic child at any age according to

IMCI guideline.

Infants not known to be HIV-exposed: • At six months of age, establish the HIV status of all

infants not already known to be HIV-exposed• Offer an HIV test to the mother. If she tests HIV

negative, no infant test is required• If the mother is not available, or refuses an HIV

test, get consent and do an HIV rapid test on the infant

• All positive infant rapid tests need to be confirmed with an HIV-PCR.

Confirmatory test for HIV Any child under two years with a positive HIV-PCR or a positive HIV rapid test should have

their HIV status confirmed with a HIV-PCR test on a new sample. At the clinician’s discretion, the HIV-PCR may be replaced by a viral load test which has the advantage of both confirming the HIV diagnosis and providing a baseline VL for monitoring the child’s response to ART. Any child who tests HIV positive should initiate ART according to the Paediatric ART guideline as a matter of urgency. Do not wait for the confirmatory result before initiating ART but ensure that this result is checked. For the Management of Indeterminate HIV PCR results, go to page 25.

AGE OF CHILD HIV SCREENING TEST

HIV CONFIRMATORY

TEST

Less than 18 months PCR PCR

18 months to 2 years Rapid PCR

More than 2 years Rapid Rapid

Infant Prophylaxis

Check adherence/ tolerance to NVP (and AZT, if applicable). Ask the mother to explain how she administers

the infant’s medication. Check result of

mother’s delivery-VL.

If necessary re-classify infant as high/ low-risk and adjust prophylaxis

accordingly.

See the Infant Prophylaxis

Infographic and the NVP and AZT dosing chart on Page 23.

All HEI’s: Start cotrimoxazole

prophylaxis therapy (CPT), even if birth PCR was negative.

Go to Cotrimoxazole Dosing Chart on

Page 23

Low-risk infant: Stop NVP if mother’s

VL at delivery was <1000 c/ml.

High-risk infants: • stop AZT, • continue NVP

for a minimum of 12 weeks, or until four weeks after all breastfeeding has stopped

High-risk infants:Continue NVP prophylaxis.

Ask mother to return at 12 weeks

to evaluate VL result and stop/extend NVP as

necessary

At every visit, check results of mother’s most recent VL. An elevated VLmay require high-risk infant prophylaxis (6 weeks AZT twice daily and 12

weeks NVP daily) to be restarted or existing NVP prophylaxis to be extended. Go to Management of a High Maternal VL after Delivery

on Page 25.

Remember to adjust NVP dosages according to weight!Stop NVP after 12 weeks only if mother’s VL is < 1000 c/ml. If the maternal VL is not suppressed

by 12 weeks, continued NVP until mother’s VL is <1000 c/ml, or until four weeks after all breastfeeding has stopped.

Continue cotrimoxazole prophylaxis until infant is confirmed HIV negative six weeks post cessation of breastfeeding. For formula fed infants, CPT may be stopped if the infant is

confirmed to be HIV negative at the 10-weeks PCR test, provided that no breastfeeding has occurred in the six weeks prior to the 10-week PCR test.

If a child tests HIV positive at any stage, stop NVP prophylaxis, initiate ART, do a confirmatory HIV PCR, and continue cotrimoxazole prophylaxis according to guidelines.

If mother diagnosed with HIV after delivery or during the breastfeeding period go to

Management of a High Maternal VL (due to HIV Diagnosis) after Delivery on Page 24

Other Routine

Care

Routine growth monitoring, immunisations, nutritional support. Provide advice to support breastfeeding. Go to Breastfeeding Plus on

Page 29

Routine growth monitoring, immunisations, vit A, deworming and nutritional support. Provide advice to support breastfeeding. Go to Breastfeeding Plus on Page 29

Use the NHLS Results for Action (RfA) Reports to follow up on lab results (See page 33). Any child with a positive, indeterminate, or not-resulted PCR should be traced to come back to the clinic urgently. A clinical audit can provide insight into reasons for the failed PMTCT

!

! For any child that tests HIV-positive ensure that: • Confirmatory testing has been done and the child is tracked and linked to care,• The mother and other significant caregivers are counselled appropriately, • CHWs are involved,• The child is registered on Tier.net & retained in care.

The HIV-exposed but uninfected (HEU) child is at higher risk for poor outcomes and requires careful follow-up. Go to “Care of the HEU Infant” on page 30

!


Promote safety during pregnancy and delivery

• Educate her and her family on danger signs in pregnancy.• Educate her on the signs of labour.• Encourage the mother to deliver in a clinic or hospital.• Encourage her to plan her mode of transport to the delivery site.

THE COMMUNITY HEALTH WORKER

Postnatal care for mother and baby

• Check mother for bleeding, infections, mastitis, and depression. Screen the mother for TB.

• Refer mother or baby at any stage if ill, including the jaundiced (yellow-skinned) baby.

• Educate mother on universal infection control practices if either mom or baby are ill (Go to Universal Measures to Prevent Infections during Pregnancy on page 7).

• Provide support for exclusive breastfeeding and advise on latching and positioning of baby whilst feeding.

• Educate on hygienic cord care and keeping the baby warm (thermal care).

• Continue to support good adherence to ART, cotrimoxazole (if indicated), and other treatment.

• Make sure that the mother is giving infant NVP (and AZT) correctly (NVP once daily and AZT twice daily).

• Make sure mother and baby attend all postnatal check-ups and immunisation appointments.

• Check that baby is growing well.• Educate mother on contents of RTHB, including infant nutrition and

danger signs in infants and children.

Counsel all pregnant women on good nutrition and following a healthy lifestyle

• Discuss infant feeding.• Follow a healthy diet.

• Avoid tobacco, alcohol, drugs and traditional remedies.

• Wash your hands after using the toilet, before and after preparing food, or after changing a baby’s diaper/nappy.

• Practice safe sex and continue to use condoms.

Prevent mother to child transmission of HIV, syphilis and TB

• Provide education on STI’s, HIV, ART and the importance of viral load suppression.

• Encourage adherence to ART and all other treatment provided by the clinic.

• Counsel on the importance of exclusive breastfeeding

• Screen all woman for TB and STI’s

Care of the non-pregnant woman of child bearing potential (CBP) at home

• Ask if she is using reliable family planning, and if not, refer to the clinic. Discuss the advantages of planned parenthood.

• Screen all woman of child bearing potential (CBP) for pregnancy. If she is not on reliable contraception or her period is late, provide/refer her for a pregnancy test.

• Encourage all girls, boys, women, and men to test for HIV if they are sexually active. Offer an HIV test to the woman and her partner if they have not tested in the last year.

• Discuss healthy nutrition with the family.

Early referral to community-based services improves

adherence to ART, exclusive breastfeeding and retention

in care

Encourage pregnant women to attend at the antenatal clinic

• Identify pregnant woman early. • Encourage booking at the antenatal clinic before 14

weeks.• Encourage attendance of all 8 antenatal

appointments.• Track and trace any woman who missed their clinic

appointments.

Identify the pregnant woman living with HIV

• Check that she has been offered an HIV test during this pregnancy.

• Encourage partner testing.• Encourage testing of any other children living in the

household if she tests positive for HIV.


1 For adolescent girls who weigh less than 35 kg, replace tenofovir with abacavir (ABC)

2 Women wanting to conceive should be started on folate and should be counselled to defer attempts to conceive until they are virally suppressed. See also “Contraception and Safe Conception” on page 9 of the PMTCT guideline.

3 Women should be provided a choice of contraceptive options (which includes condoms, oral contraceptives, implants, injectables, and IUCDs)

4 Women who choose to use TEE around the time of conception can be offered a switch to TLD if their VL is suppressed at 3-months on ART.

5 Documentation that the woman has been counselled and consents to receive DTG must be included in the patient’s chart/file.

6 If a woman’s fertility intentions change and she is concerned about the risk of NTDs, she can be offered a switch from TLD to TEE, provided that she has a suppressed VL in the last 6 months

DOLUTEGRAVIR (DTG) IN PREGNANCY

Dolutegravir with TDFand 3TC/FTC as a

fixed dose combination(TLD) is now the preferred first line regimen in South

Africa for all persons except women who

actively want to conceive, and women in the first 6

weeks of pregnancyStandard dose:

50 mg dailyDTG requires boosting with TB treatment to

50 mg twice daily. This will require one standard fixed dose combination

tablet of TLD to be taken at the normal time, and an additional single tablet of DTG 50 mg to be taken

12 hours later.

Risk of Neural Tube DefectsThere are some concerns regarding the risk of neural tube defects (NTD) if a woman should fall pregnant on DTG. Therefore:• Women should be counseled about the potential risk of NTDs when

DTG is taken around the time of conception and be allowed to make an informed choice.

• Any non-pregnant woman taking or starting DTG should be advised to use contraception and folic acid supplements.

• Once a non-pregnant woman is taking DTG, fertility intentions should be discussed at every visit. Should she desire a pregnancy, and she is concerned about the risk of NTDs, she can be offered a switch from TLD to TEE, provided that she has a suppressed VL in the last 6 months.

• Woman who fall pregnant on DTG should be entered into the antiretroviral pregnancy register (http://www.APRegistry.com/)

• Pregnant women already on an EFV containing ART regimen may switch to DTG containing regimen provided that: - Her most recent VL in the last 6 months is < 50 c/ml*. - She has been counseled on the risk for NTDs for subsequent pregnancies,

and the need for postpartum contraception. - She is aware of the side-effects that may be experienced when switching to

DTG (insomnia, headache, GIT disturbances). These are usually mild and self-limiting. If she does not feel well, encourage her not to stop her ART, but rather to report to the clinic.

- She is aware that whilst her previous TEE regimen was taken at night, TLD may be taken in the morning or at night. However, should she experience insomnia, it is recommended that TLD be taken in the morning.

BENEFITS OF DOLUTEGRAVIR16

Superior Efficacy

Side-effects are mild and uncommon

High genetic barrier to resistance

Cost effective

Small tablet

No interaction with hormonal contraceptives

Can be used with TB treatment if boosted

POTENTIAL RISKS OF USING DTG AROUND THE TIME OF CONCEPTION¹²DTG may increase the risk of neural tube defects (NTDs). The absolute risk is very low and translates into a risk difference of 2 additional NTDs

per 1000 periconception exposures to DTG (0.3% risk), compared to EFV ART at conception (0.1% risk). DTG should be avoided

periconception and in the first 6 weeks of pregnancy. The neural tube closes by the end of the sixth week of pregnancy (fourth week post-

conception). DTG appears to be safe if started after the neural tube has closed. Thus, there is no risk of NTDs with TLD use after this period.

Effective contraceptionAll women of child bearing potential should be screened for pregnancy before initiating DTG. It is recommended that any non-pregnant woman

taking or starting DTG should be provided a choice of contraceptive options, which includes condoms, oral contraceptives, implants,

injectables, and intra-uterine contraceptive devices (IUCDs). Dual methods are recommended. DTG does not have any known drug interactions with

long acting hormonal contraceptives.

!

PART 4 – ALGORITHMS AND DECISION TOOLS4

Calcium supplements decrease DTG concentrations if taken together on an

empty stomach. To prevent this, DTG and calcium supplements can be taken at the same time after food intake. Magnesium/aluminium containing antacids decrease

DTG concentrations regardless of food intake and should be taken a minimum of 2 hours after or 6

hours before DTG. Iron and calcium supplements should be taken at least 4 hours apart.

!

* For adolescent girls who weigh less than 35 kg, replace tenofovir with abacavir (ABC)17

#Never switch only one drug in a failing regimen. Ensure that her VL is < 50 c/ml before switching

from EFV to DTG, or from DTG back to EFV should she desire to become pregnant!

Adult Women and Adolescent Girls ≥ 35 kg1 and ≥ 10 years of Age

YES

TEE 1, 4 TLD 1, 5, 6

NO

Determine current pregnancy status and fertility intentions

Pregnant, up to 6 completed weeks of gestation, or actively wanting to conceive in the near future 2

All other WOCP, including:Pregnant, from 7 weeks gestation onwards

Not pregnant, and not currently desiring to become pregnant

Provide all necessary information on DTG and EFV-based regimens including the risk of NTDs for this and

subsequent pregnanciesDiscuss postpartum contraceptive options3

Provide all necessary information on DTG and EFV-based regimens including the risk of NTDs and

recommend contraception. Provide her with a choice of contraceptive options as desired 3

TEE recommended TLD recommended

Client makes an informed choice after understanding risks and benefits

Women or Adolescent Girls of Childbearing Potential?


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in W

OCP

on pa

ge 17

)If T

DF co

ntrain

dicate

d due

to hi

story

of/su

spec

ted re

nal d

iseas

e rep

lace T

DF w

ith A

BC.

Revie

w re

sults

in 3-

7 day

sEn

sure

a th

orou

gh ev

aluat

ion

for T

B

CrAG

po

sCr

AG

negCD

4 ≤

100

Do C

rAG

TB G

XP ne

gativ

e (or

un

able

to pr

oduc

e sp

utum)

, AND

no T

B sy

mptom

s

Cont

inue

ART

: TD

F, 3T

C/FT

C, D

TG

Histo

ry of

rena

l dise

ase

Any p

regn

ant o

r bre

astfe

edin

g wo

men

with

a ne

w HI

V di

agno

sis, o

ran

y kno

wn p

ositi

ve w

oman

(not

curre

ntly

on A

RT) w

ith a

new

preg

nanc

y diag

nosis

Take

a hi

stor

y and

do

a clin

ical e

xam

inat

ion:

Ex

clude

contr

a-ind

icatio

ns to

star

ting A

RT on

the s

ame d

ay. A

sk ab

out T

B sy

mptom

s,

a hist

ory o

f ren

al dis

ease

, or c

urre

nt ps

ychia

tric sy

mptom

s. De

termi

ne th

e clie

nt’s

WHO

Clin

ical S

tage.

Star

t cotr

imox

azole

(CPT

) if el

igible

. D

o the

follo

wing

tests

on A

LL H

IV po

sitive

preg

nant

wome

n, re

gard

less o

f sym

ptoms

or hi

story:

CD4

coun

t, s-

Crea

tinin

e, sp

utum

for T

B Ge

ne E

xper

t (GX

P), a

nd u

rine d

ipst

ix

Timing

of A

RT

initia

tion i

n pre

gnan

cy

is cri

tical.

Eve

ry we

ek

a moth

er is

on A

RT

furthe

r dec

reas

es he

r ris

k of M

TCT10

!

Kno

wn H

IV po

sitive

wom

en, w

ho ar

e not

curre

ntly

on A

RT, b

ut ar

e ART

-exp

osed

(e.g.

prev

ious P

MTCT

, or

prev

ious L

TFU

on A

RT) s

hould

initia

te a D

TG-

conta

ining

regim

en. If

she h

as a

docu

mente

d VL t

hat

was s

uppr

esse

d whil

e she

was

prev

iously

on A

RT,

start

TLD.

If no

VL r

esult

is av

ailab

le, or

her V

L was

no

t sup

pres

sed,

start A

ZT, 3

TC, a

nd D

TG

TB S

ympto

mswi

thout

dang

er si

gns

If no a

bnor

mal h

istor

y

$ Only

switc

h an e

xistin

g, sta

ble cl

ient fr

om E

FV to

DT

G if h

er V

L is <

50c/m

l and

she i

s no l

onge

r in

the fir

st 6 w

eeks

of pr

egna

ncy.

A sw

itch t

o DTG

ne

eds t

o be p

rece

ded b

y app

ropr

iate c

ouns

eling

on

the r

isk fo

r NTD

s for

subs

eque

nt pr

egna

ncies

, po

stpar

tum co

ntrac

eptio

n, an

d the

new

side-

effec

ts tha

t may

be ex

perie

nced

whe

n swi

tching

to

a new

drug

. See

DTG

in pr

egna

ncy o

n pag

e 17.

Refer

Ur

gentl

y for

LP

If CD4

< 35

0 and

the c

lient

is tol

erati

ng A

RT,

initi

ate T

PT fo

r 12 m

onth

s.15, 1

7, 18

Ensu

re th

at ac

tive T

B ha

s bee

n exc

luded

, an

d che

ck fo

r othe

r con

tra-in

dicati

ons

to TP

T. No

TST

nece

ssar

y. (G

o to

TB

Scre

enin

g an

d TP

T alg

orith

m on

page

26)

No ab

norm

al re

sults

and C

D4

more

than

100

Cont

inue

ART

If CD

4 ≥ 35

0, de

fer

TPT

until

6 we

eks

afte

r deli

very

TB G

XP

posit

ive

TB D

iagno

sis co

nfirm

edIn

itiat

e TB

Rx

ART INITIATION ALGORITHMFor a Summary of

1st line ART Regimens go to page 19

TB S

ympt

oms w

ith d

ange

r sig

ns:

If the

wom

an ap

pear

s ver

y ill w

ith an

y of th

e foll

owing

sign

s, di

scus

s with

a do

ctor

or r

efer

for f

urth

er as

sess

men

t. Do

not

star

t ART

unt

il TB

is ex

clude

d/di

agno

sed

as

thes

e wom

en m

ay b

e at a

hig

her r

isk o

f dev

elopi

ng

IRIS

: weig

ht los

s > 5%

, diffi

culty

brea

thing

, res

pirato

ry ra

te >3

0/min,

temp

eratu

re >

38°C

, puls

e > 10

0min,

BP

< 90

/60,

coug

hing u

p bloo

d, co

nfusio

n, ag

itatio

n, or

unab

le to

walk

unaid

ed. TB

GXP

nega

tive,

but s

till T

B sy

mptom

s

Inves

tigate

with

CXR

, 2nd

sp

utum

for cu

lture

/line p

robe

as

say (

LPA)

+/-

antib

iotics

as

per N

ation

al TB

Guid

eline

s. If

CD4 <

100,

do a

urine

LAM.

Crea

tinine

> 85

umol/

L

Conti

nue/a

djust

ART

to AB

C,

3TC

and D

TG.

Adjus

t dos

e of 3

TC (a

nd

any o

ther d

rugs

) as n

eede

d. Di

scus

s with

an ex

pert/

HIV-

hotlin

e re f

urthe

r inve

stiga

tions

an

d man

agem

ent.

Revie

w in

2 wee

ks. If

stab

le an

d tole

ratin

g TB

Rx, in

itiate

ART

(if no

t alre

ady i

nitiat

ed).

DTG

requ

ires b

oosti

ng w

ith T

B tre

atmen

t to 50

mg

twice

daily

. If T

B sy

mptom

s wor

sen a

fter A

RT

initia

tion,

cons

ider T

B IR

IS an

d refe

r/disc

uss w

ith

the H

IV ho

tline.

If TB

menin

gitis,

defer

ART

for 4

to

6 wee

ks.


KEY

ADHE

RENC

E ME

SSAG

ES

(NAT

IONA

L AD

HERE

NCE

GUID

ELIN

E, 2

015)

11

KEY ADHERENCE MESSAGES (NATIONAL ADHERENCE GUIDELINE, 2015), AND SUMMARY OF 1ST LINE ART REGIMENS

Step

1 Ed

ucati

on ab

out H

IV•

Wha

t doe

s HIV

do to

your

body

?•

How

taking

ART

can h

elp yo

u?•

The i

mpor

tance

of V

L sup

pres

sions

for m

other

and b

aby.

• Ri

sks o

f poo

r adh

eren

ce.

• Si

de-e

ffects

of A

RT.

Step

2 Ide

ntify

Life G

oals

• W

hat a

re th

e thin

gs th

at ma

ke yo

u wan

t to st

ay he

althy

and a

live?

Step

3 Ide

ntify

Supp

ort S

ystem

s•

Who

could

supp

ort y

ou in

takin

g you

r tre

atmen

t?•

Wou

ld yo

u agr

ee to

have

a CH

W vi

sit yo

u at h

ome?

Step

4 Co

ming

to yo

ur ap

point

ments

• W

hat w

ill yo

u do i

f som

ething

prev

ents

you f

rom

comi

ng to

your

appo

intme

nt (su

ch as

no

mone

y for

tran

spor

t, rain

ing w

hen y

ou us

ually

walk

, taxi

strike

or a

sick c

hild,

or an

y othe

r re

ason

)?•

Go to

the c

linic

as so

on as

poss

ible i

f you

do m

iss an

appo

intme

nt or

run o

ut of

ART

• Al

ways

take

your

med

icatio

n with

you t

o you

r clin

ic ap

point

ments

to en

able

the H

CW to

bette

r as

sist y

ou

Step

5 As

sess

read

iness

to st

art A

RT•

Do yo

u fee

l read

y to s

tart tr

eatm

ent a

s soo

n as p

ossib

le?If

not,

stay s

uppo

rtive

. Inv

ite cl

ient t

o ex

pres

s the

ir be

liefs

or

conc

erns

.Cor

rect

misc

once

ption

s (av

oiding

judg

men

ts).

Step

6 Me

dicati

on sc

hedu

le•

Acco

rding

to yo

ur sc

hedu

le, w

hat w

ould

be th

e bes

t time

for y

ou to

take

your

trea

tmen

t?

Step

7 Re

mind

ers

• W

hat c

ould

you u

se to

remi

nd yo

u to t

ake y

our m

edica

tion?

(e.g.

alar

m, so

meon

e to r

emind

the

m, w

hen “

Gene

ratio

ns” is

star

ting o

n TV,

etc.)

Step

8 Mi

ssed

Dos

es•

Wha

t will

you d

o if y

ou m

iss a

dose

?Ad

vise

them

to ta

ke th

e tre

atm

ent a

s soo

n as

they

rem

embe

r. St

ep 9

Stor

ing yo

ur m

edica

tion a

nd ex

tra do

ses

• Do

you w

orry

abou

t peo

ple se

eing o

r stea

ling y

our t

reatm

ent?

• W

hich s

afe pl

ace c

ould

you i

denti

fy to

store

your

trea

tmen

t? Ch

eck t

hat it

is ou

tside

the r

each

of

child

ren.

• In

case

you d

on’t h

ave a

cces

s to y

our t

reatm

ent a

t the t

ime y

ou ar

e sup

pose

d to t

ake i

t, how

ca

n you

alwa

ys ca

rry 1

or 2

dose

s with

you?

Step

10 M

anag

ing S

ide-e

ffects

• Si

de-e

ffects

such

as di

zzine

ss, n

ause

a, he

adac

he or

diar

rhea

can h

appe

n whe

n star

ting

treatm

ent. M

ost s

ide-e

ffects

go aw

ay af

ter a

few w

eeks

. If yo

u vom

it up t

o one

hour

after

tak

ing th

e med

icatio

n, tak

e you

r tre

atmen

t aga

in. S

ever

e side

-effe

cts ar

e rar

e. If y

ou do

n’t

feel w

ell, it

is im

porta

nt yo

u don

’t stop

your

trea

tmen

t and

come

to th

e clin

ic.

SUMM

ARY

OF 1

ST L

INE

ART

REGI

MENS

FOR

ADO

LESC

ENTS

GI

RLS

(10

– 19

YEA

RS) A

ND A

DULT

WOM

AN

Any W

OCP

with

norm

al re

nal

functi

on,

with

or w

ithou

t TB,

and w

ho

choo

ses t

o use

DTG

after

un

derst

andin

g the

risk a

nd

bene

fits

Weig

ht ≥

35 kg

TDF

300 m

g, 3T

C 30

0 mg,

DTG

50 m

g (TL

D) as

a sin

gle fix

ed

dose

comb

inatio

n tab

let ta

ken o

nce d

aily

Weig

ht <

35 kg

Repla

ce T

DF w

ith A

baca

vir 30

0mg b

d (or

600m

g onc

e dail

y)

DTG

requ

ires b

oosti

ng w

ith T

B tre

atmen

t to 50

mg t

wice

daily

. This

will

requ

ire on

e stan

dard

fix

ed do

se co

mbina

tion t

ablet

of T

LD to

be ta

ken a

t the n

orma

l time

, and

an ad

dition

al sin

gle

tablet

of D

TG 50

mg t

o be t

aken

12 ho

urs l

ater.

Clien

ts wh

o cur

rentl

y wish

to

conc

eive a

nd ar

e con

cern

ed

abou

t the r

isk fo

r NTD

s on

DTG

Weig

ht ≥

40 kg

TDF

300 m

g, FT

C 20

0 mg,

EFV

600 m

g (TE

E) as

a sin

gle

fixed

dose

comb

inatio

n tab

let ta

ken o

nce d

aily i

n the

even

ing

Weig

ht <

40 kg

TDF

300 m

g dail

y, 3T

C 30

0 mg d

aily,

Efav

irenz

400 m

g dail

y

Abno

rmal

rena

l func

tion

Teno

fovir (

TDF)

is

contr

aindic

ated

Repla

ce T

DF w

ith A

baca

vir 30

0mg b

d (or

600m

g onc

e dail

y),

or do

se-a

djuste

d AZT

Activ

e psy

chiat

ric ill

ness

Efav

irenz

(EFV

) is

contr

aindic

ated

Repla

ce E

FV w

ith D

TG. If

DTG

not s

uitab

le, gi

ve LP

V/r o

r AT

Z/r.

Know

n HIV

posit

ive w

omen

, wh

o are

not c

urre

ntly o

n ART

, bu

t are

ART

-exp

osed

(e.g.

prev

ious P

MTCT

, or

prev

ious L

TFU

on A

RT)

VL <

50 c/

ml w

hile

prev

iously

on A

RTTD

F 30

0 mg,

3TC

300 m

g, DT

G 50

mg (

TLD)

as a

single

fixed

do

se co

mbina

tion t

ablet

take

n onc

e dail

y

Unsu

ppre

ssed

VL,

or no

do

cume

nted V

L whil

e pr

eviou

sly on

ART

AZT

300 m

g twi

ce da

ily, 3

TC 15

0 mg t

wice

daily

(or 3

00 m

g on

ce da

ily),

and D

TG 50

mg d

aily

For f

urthe

r infor

matio

n see

the 2

019 C

onso

lidat

ed A

RT G

uide

line

MON

ITOR

ING

BLOO

DS O

N AR

T Tim

e on A

RTCr

eatin

ine

(only

if on

TDF

)CD

4FB

C

(only

if on

AZT

)

At A

RT In

itiatio

n

Only

if clie

nt de

velop

s ras

h or

symp

toms o

f hep

atitis

Month

3

Month

6

At 1

year

Annu

ally

If c

linica

lly in

dicate

d

Do H

B an

d HBs

Ag if

switc

hing f

rom

1st to

2nd l

ine A

RT

Thes

e mo

nitor

ing bl

oods

ar

e in a

dditio

n to t

he V

L m

onito

ring

sche

dule

on P

age 2

0

Do no

t turn

away

an

ART

clien

t who

re

ports

to ha

ve ru

n ou

t of tr

eatm

ent a

nd

pres

ents

witho

ut a

trans

fer le

tter!

!

ALT

(o

nly if

on N

VP)


Mont

hs o

n ART

in

ANC/

Post

partu

mNe

wly i

nitia

ting A

RT o

r re-

initi

atin

g ART

on

a DT

G-ba

sed

regi

men

* (be

fore

28 w

eeks

ges

tatio

n)Al

read

y on A

RT at

Pre

gnan

cy D

iagno

sisLa

te p

rese

nter

in A

NC af

ter 2

8 wee

ks, o

r at d

ellive

ry

Antenatal VL Monitoring

Base

line

1 mon

ths

2 mon

ths

3 mon

ths

(4 m

onths

)

(5 m

onths

)

Deliv

ery

Postnatal VL Monitoring

10-1

2 we

eks P

P

4 mon

ths

PP

5 mon

ths

PP

6 mon

ths

PP

6-mo

nthly

VIRAL LOAD MONITORING SCHEDULE

NSAVL≥50

VL<50

VL<50 VL<50

VL 6

month

ly du

ring b

reas

tfeed

ing

STAR

T HE

RE

refer

s to t

he V

L No

n-Su

ppre

ssio

n Alg

orith

m

on th

e nex

t pag

eNS

A

Selec

t a ca

tegor

y for

the w

oman

star

ting A

RT fr

om th

e pink

bloc

ks be

low:

1st VL a

t 3 m

onths

on A

RT

ART

initia

ted at

1st ANC

visit

VL≥50

NSA

NSAVL≥50

* If a

wom

en w

ho is

prev

iously

ART

expo

sed c

hoos

es to

re-in

itiate

EFV

rathe

r tha

n DTG

, do a

VL b

efore

re-st

artin

g ART

. Rep

eat th

e VL i

n one

mon

th. If

more

than

one l

og dr

op in

VL i

s ach

ieved

, con

tinue

cu

rrent

regim

en an

d rep

eat V

L in t

wo m

onths

. If V

L < 50

c/ml

, rep

eat V

L at d

elive

ry. If

the re

peat

VL is

≥ 50

c/ml

, man

age a

ccor

ding t

o the

VL

non-

supp

ress

ion

algor

ithm

on pa

ge 21

Reme

mber,

an el

evate

d VL i

n a

preg

nant

or br

eastf

eedin

g moth

er

is a M

EDIC

AL E

MERG

ENCY

!Ev

ery w

eek s

he co

ntinu

es w

ith an

ele

vated

VL i

ncre

ases

her r

isk fo

r MT

CT!

!VL<50

VL≥50

NSA

All w

omen

get a

VL a

t deli

very

(resu

lts m

ust b

e che

cked

at po

stnata

l visi

t befo

re 6

days

)

VL at

6 mo

nths p

ostpa

rtum

Ensu

re th

at the

resu

lts of

any V

L tes

t are

chec

ked

withi

n 1 w

eek.

If VL ≥

50c/m

l: -

Reca

ll the

moth

er-in

fant p

air to

the f

acilit

y. -

If the

VL i

s ≥ 10

00 c/

ml,

resta

rt / e

xtend

infan

t pro

phyla

xis if

mothe

r is st

ill br

eastf

eedin

g. Go

to M

anag

emen

t of a

Hig

h Ma

tern

al VL

afte

r Deli

very

on P

age 2

5. If i

n dou

bt ab

out w

hen t

o tak

e, or

how

to int

erpr

et, a

VL

resu

lt, ca

ll the

HIV

hotlin

e 080

0 212

506

!

ART

initia

ted af

ter 28

wee

ks or

at de

liver

y

VL at

10-1

2 wee

ks on

ART

VL at

ANC

1st visit

1st VL a

t deli

very

Reme

mber

to pu

t the c

orre

ct PM

TCT

code

in th

e EGK

code

fie

ld of

the la

b for

m for

each

VL d

one t

o ens

ure t

he el

ectro

nic

gatek

eepin

g rule

s (EG

K) do

not le

ad to

samp

le re

jectio

n. Us

e the

code

C#P

MTCT

for a

ll VLs

done

durin

g ANC

or th

e br

eastf

eedin

g per

iod.

Use t

he co

de C

#Deli

very

for a

ll VLs

done

at th

e tim

e of d

elive

ry.


Repe

at as

per

VL M

onito

ring

sche

dule

on

page

20

Deter

mine

if the

clien

t sho

uld sw

itch

to 2n

d line

, takin

g into

acco

unt h

er

curre

nt re

gimen

and h

ow lo

ng sh

e ha

s bee

n on A

RT. R

efer t

o the

2019

Co

nsoli

dated

ART

Guid

eline

for

furthe

r man

agem

ent.

A th

orou

gh as

sess

men

t is e

ssen

tial f

or an

y cli

ent w

ith a

viral

load

mea

surin

g ≥

50 c/

ml

AAd

here

nce

Is ad

here

nce t

o med

icatio

n poo

r?

Ask a

bout

factor

s tha

t may

influ

ence

ad

here

nce e

.g.•

Medic

ation

side

-effe

cts,

• De

pres

sion,

• Al

coho

l or s

ubsta

nce a

buse

,•

Poor

socia

l sup

port

or•

Non-

disclo

sure

.

Preg

nant

wome

n may

expe

rienc

e nau

sea,

hear

tburn

, and

cons

tipati

on. A

sses

s the

ne

ed fo

r sym

ptoma

tic tr

eatm

ent w

ith an

an

ti-eme

tic, a

nti-d

iarrh

ea ag

ent, o

r fibe

r su

pplem

ent.

Tips

Ask o

pen e

nded

ques

tions

e.g.

“Wha

t mak

es it

diffic

ult fo

r you

to

take y

our t

reatm

ent?”

, and

“H

ow m

any d

oses

have

you

miss

ed th

is we

ek?”

Be no

n-jud

geme

ntal. S

tatem

ents

like “

we al

l miss

a do

se no

w an

d the

n” ca

n enc

oura

ge a

clien

t to be

mo

re op

en.

B Bugs

(In

fect

ions

)

Chec

k for

symp

toms a

nd si

gns o

f infec

tion.

Do a

TB an

d STI

scre

en.

Reme

mber

that

immu

ne

comp

romi

sed a

nd pr

egna

nt cli

ents

may n

ot ex

hibit o

vert

symp

toms o

f TB

. If in

doub

t, do a

TB

GXP.

CCo

rrect

Dos

e

Is the

clien

t on t

he co

rrect

dose

for h

er w

eight?

This

is es

pecia

lly ap

plica

ble to

youn

g or m

alnou

rishe

d girls

who

may

have

rece

ntly

gaine

d weig

ht, or

clien

ts wi

th pr

eviou

s ren

al im

pairm

ent.

D Drug

Inte

ract

ions

Are t

here

any p

otenti

al dr

ug in

terac

tions

? Co

nside

r:•

Othe

r pre

scrib

ed tr

eatm

ent e

.g.

rifamp

icin,

anti-e

pilep

sy dr

ugs

• Ov

er th

e cou

nter t

reatm

ent e

.g. an

tacids

• Su

pplem

ents

and h

erba

l/trad

itiona

l me

dicati

ons e

.g. S

t Joh

n’s w

ort

If in a

ny do

ubt, c

all th

e

HIV

Hotli

ne

0800

212 5

06

ERE

-sist

ance

Cons

ider H

IV dr

ug re

sistan

ce if

other

caus

es

of vir

ologic

al fai

lure h

ave b

een e

xclud

ed an

d the

clien

t is ad

here

nt to

their m

edica

tion.

The n

eed f

or 2n

d-lin

e ART

is de

termi

ned b

y he

r cur

rent

regim

en an

d how

long

she h

as

been

on A

RT.

Refer

to th

e 201

9 Con

solid

ated

ART

Guide

line f

or fu

rther

ma

nage

ment

Mont

hs o

n ART

in

ANC/

Post

partu

mNe

wly i

nitia

ting A

RT o

r re-

initi

atin

g ART

on

a DT

G-ba

sed

regi

men

* (be

fore

28 w

eeks

ges

tatio

n)Al

read

y on A

RT at

Pre

gnan

cy D

iagno

sisLa

te p

rese

nter

in A

NC af

ter 2

8 wee

ks, o

r at d

ellive

ry

Antenatal VL Monitoring

Base

line

1 mon

ths

2 mon

ths

3 mon

ths

(4 m

onths

)

(5 m

onths

)

Deliv

ery

Postnatal VL Monitoring

10-1

2 we

eks P

P

4 mon

ths

PP

5 mon

ths

PP

6 mon

ths

PP

6-mo

nthly

VIRAL LOAD NON-SUPPRESSION ALGORITHM

Wom

en w

ho fa

il to s

uppr

ess d

espit

e swi

tching

to se

cond

line,

or w

ho ar

e fail

ing 2n

d or

3rd l

ine sh

ould

be di

scus

sed w

ith an

expe

rt/HI

V ho

tline o

r refe

rred.

Thes

e wom

en

may b

e ex

perie

ncing

com

plex

clinic

al an

d/or p

sych

osoc

ial ch

allen

ges b

eyon

d the

sc

ope o

f this

prim

ary c

are g

uideli

ne, a

nd m

ay re

quire

a tai

lored

appr

oach

to m

atern

al ma

nage

ment,

infan

t pro

phyla

xis an

d rec

omme

ndati

ons f

or br

eastf

eedin

g.

Non-

Supp

ress

ed V

iral L

oad

(VL ≥

50 c/

ml)

Do a

thoro

ugh a

sses

smen

t of th

e cau

se of

an el

evate

d VL

VL 50

- 99

9 c/m

l +VL

< 50

c/ml

VL 50

- 99

9 c/m

lVL

≥ 10

00 c/

ml

Star

t, re-

start,

or ex

tend i

nfant

hig

h-ris

k pro

phyla

xis.

Repe

at VL

in 4-

6 wee

ks*

VL dr

oppe

d by

> 1 l

ogVL

≥ 10

00 c/

mlRe

peat

VL in

8 -1

0 wee

ks#

* The

shor

ter 4-

week

inter

val b

etwee

n the

first

VL ab

ove 1

000 a

nd th

e rep

eat V

L is p

refer

red w

here

ver p

ossib

le.

Howe

ver, i

f the fi

rst el

evate

d VL i

s the

deli

very

-VL,

the n

ext v

isit m

ay on

ly oc

cur a

t the 6

-wee

ks po

st-na

tal vi

sit. A

HB

VsAg

and H

B ca

n also

be do

ne at

the s

ame t

ime t

o info

rm th

e swi

tch to

2nd l

ine if

this b

ecom

es ne

cess

ary.

# The

shor

ter 8-

week

inter

val b

etwee

n the

first

VL of

50 -

999 c

/ml a

nd th

e rep

eat V

L is p

refer

red w

here

ver

poss

ible.

Howe

ver, i

f the fi

rst el

evate

d VL i

s the

deli

very

-VL,

and t

he m

other

opts

to re

main

in the

mate

rnal

and

child

stre

am fo

r foll

ow-u

p ART

care

, the c

loses

t coin

ciding

visit

will

occu

r at th

e 10-

week

EPI

visit

.

Brea

stfe

edin

g wi

th an

Elev

ated

VL

It is

reco

mmen

ded t

hat w

omen

with

a VL

≥ 10

00 c/

ml on

1st li

ne A

RT co

ntinu

e to b

reas

tfeed

. Infan

t pr

ophy

laxis

shou

ld be

exten

ded /

resta

rted w

hile a

conc

erted

effor

t is m

ade t

o re-

supp

ress

the m

other

’s VL

(se

e Man

agem

ent o

f a H

igh

Mate

rnal

Vira

l Loa

d af

ter D

elive

ry on

page

24).

Brea

stfee

ding i

n wom

en w

ho

are f

ailing

2nd a

nd 3r

d line

ART

is no

t rec

omme

nded

. The

se w

omen

shou

ld be

refer

red o

r disc

usse

d with

a t

eam

of ex

perts

as ou

tlined

in th

e ora

nge b

ox to

the r

ight. S

ee al

so S

topp

ing

Brea

stfe

edin

g an

d

Indi

catio

ns fo

r For

mul

a Fee

ding

on pa

ge 30

Reme

mber,

an el

evate

d VL i

n a

preg

nant

or br

eastf

eedin

g moth

er

is a M

EDIC

AL E

MERG

ENCY

!Ev

ery w

eek s

he co

ntinu

es w

ith an

ele

vated

VL i

ncre

ases

her r

isk fo

r MT

CT!

!VI

RAL

LOAD

NO

N-SU

PPRE

SSIO

N AL

GO

RITH

M (N

SA)

+ Wom

en on

an E

FV-co

ntaini

ng re

gimen

who

have

a se

cond

VL r

esult

of be

twee

n 50 a

nd 99

9 c/m

l may

be

cons

idere

d for

a sw

itch t

o a D

TG-co

ntaini

ng re

gimen

, pro

vided

she h

as be

en th

orou

ghly

asse

ssed

for h

er

eleva

ted V

L, an

d has

been

appr

opria

tely c

ouns

eled a

s outl

ined o

n pag

e 17.


Psyc

ho-

socia

l stre

ssor

s for

the p

regn

ant

and p

ostpa

rtum

adole

scen

t

Medic

al ris

ks

for th

e moth

er

and b

aby

Finan

cial s

tress

ors

poten

tially

resu

lting i

n tra

nsac

tiona

l sex

ual

relat

ionsh

ips Unab

le to

finish

the

ir edu

catio

n

Child

care

re

spon

sibilit

ies

Risk

of ab

use o

r no

n-co

nsen

sual

sex

Urina

ry Tr

act In

fectio

ns

(UTI

s), S

TIs,

Anae

mia,

Pre-

eclam

psia,

Ecla

mpsia

Pr

eterm

labo

ur Depr

essio

n, su

bopti

mal

anten

atal c

are

Poor

adhe

renc

e to

ART,

at ris

k for

ele

vated

VL

Decre

ased

birth

weig

ht,

not b

reas

t fed,

highe

r ris

k of d

eath

CARE OF THE PREGNANT ADOLESCENT LIVING WITH HIV

A de

termi

natio

n of

wheth

er or

not th

e pr

egna

ncy

was

inten

ded/u

ninten

ded?

wa

nted/u

nwan

ted?

Prov

ide co

unse

lling

abou

t opti

ons i

n ter

ms

of pr

ocee

ding/n

ot pr

ocee

ding w

ith th

e pr

egna

ncy.

High

qua

lity b

asic

ante

nata

l car

e, co

nside

ring t

he

addit

ional

medic

al ris

ks

in an

adole

scen

t.

Inte

nsive

ART

ad

here

nce s

uppo

rt du

ring A

NC,

brea

stfee

ding a

nd

there

-afte

r. If a

vaila

ble,

she s

hould

atten

d a

peer

-led s

uppo

rt gr

oup.

Educ

ation

and

inten

sive s

uppo

rt for

br

east

feed

ing

and

PMTC

T. A

doles

cent

are m

ore l

ikely

not to

br

eastf

eed.

Coun

sellin

g on

cont

race

ptive

s, ST

Is as

well

as re

-ent

erin

g th

e edu

catio

n sy

stem

.Lo

ng-a

cting

reve

rsible

co

ntrac

eptiv

e meth

ods

are p

refer

red.

An ex

plora

tion o

f the

poss

ibilit

y of a

buse

or

non-

cons

ensu

al se

x to

ensu

re th

at sh

e is i

n a s

afe en

viron

ment.

If no

t, the

invo

lveme

nt of

the po

lice a

nd so

cial

servi

ces s

hould

be

facilit

ated.

The p

regn

ant a

doles

cent

requ

ires n

on-ju

dgm

enta

l, con

fiden

tial, a

nd q

ualit

y you

th fr

iendl

y SRH

serv

ices t

hat a

re

sens

itive

to th

e cha

lleng

es an

d st

ress

ors e

xper

ience

d by

adol

esce

nts.

This

care

shou

ld in

clude

:

Preg

nant

adol

esce

nts a

re a

vuln

erab

le gr

oup

that

hav

e psy

cho-

socia

l stre

ssor

s and

med

ical r

isks t

hat m

ay re

sult

poor

hea

lth o

utco

mes

14

For a

Sum

mar

y of 1

st lin

e ART

Re

gim

ens a

pplic

able

to ad

olesc

ents

go to

page

19


Risk

Pro

fileAn

tenata

lLa

bour

and D

elive

ry

Postn

atal P

eriod

Low-

Risk

Mo

mMo

m bo

oked

early

in A

NC,

and i

s adh

eren

t to tr

eatm

ent

Deliv

ery

VL <

1000

c/m

l

Low-

Risk

In

fant

Keep

ing th

e mom

’s VL

su

ppre

ssed

is th

e bes

t way

to

prote

ct he

r infan

t

Infan

t gets

Bi

rth P

CR

High

Risk

Mom

Mothe

r with

a VL

of ≥

1000

c/m

l (mos

t rec

ent V

L tak

en

durin

g the

last

12 w

eeks

of

anten

atal c

are)

, or a

moth

er

with

no V

L res

ult in

the l

ast

12 w

eeks

.

De

liver

y VL ≥

1000

c/m

l

High

Risk

In

fant

Any s

ituati

on th

at ca

uses

mo

m to

have

an el

evate

d VL

puts

her in

fant a

t risk

for H

IV

infec

tion

Infa

nt g

ets B

irth

PCR.

If at d

ischa

rge n

o VL r

esult

is

avail

able

(deli

very-

VL or

a V

L in t

he la

st 12

wee

ks),

initia

te the

baby

on hi

gh ris

k pr

ophy

laxis

until

resu

lt can

be

chec

ked a

t 3-6

-day

postn

atal

visit

PROPHYLAXIS FOR THE HIV-EXPOSED INFANT

STOP

NVP

6 wee

ks

PP12

wee

ks

PP

Conti

nue t

he V

L mon

itorin

g and

man

agem

ent s

ched

ule on

page

20Mo

m’s

VL

Star

t cotr

imox

azole

from

6 we

eks o

nwar

ds

STOP AZT

STOP

NVP

The b

reas

tfed b

aby g

ets N

VP fo

r a m

inimu

m of

12 w

eeks

, and

if ne

eded

, on

going

until

mothe

rs VL

is <

1000

c/ml

, or u

ntil 4

wee

ks af

ter ce

ssati

on of

all

brea

stfee

ding.

The e

xclus

ive fo

rmula

-fed b

aby w

ill re

ceive

NVP

for 6

wee

ks.

NVP

Once

daily

Baby

gets

AZT

for 6

week

s only

, whe

ther

brea

stfed

or fo

rmula

fed

AZT

Twice

daily

Star

t cotr

imox

azole

from

6 we

eks o

nwar

ds

Nevir

apin

e (NV

P)

Age

Curre

nt w

eight

Once

dail

y dos

e

Birth

to 6

week

s2,0

- 2,4

9 kg

1 ml (1

0 mg)

daily

> 2,5

kg1,5

ml (1

5 mg)

daily

> 6 w

eeks

to 6

month

s2 m

l (20 m

g) da

ily>

6 to 9

mon

ths3 m

l (30 m

g) da

ily9 m

onths

until

4 wee

ks af

ter al

l br

eastf

eedin

g has

stop

ped

4 ml (4

0 mg)

daily

Prophylactic doses

Zido

vudi

ne (A

ZT)

Age

Curre

nt w

eight

Twice

dail

y dos

e

Birth

to

6 wee

ks

< 2 k

g, >

35 w

eeks

gesta

tion

4 mg/k

g/dos

e twi

ce da

ily2,0

to 2,

49 kg

1 ml (1

0 mg)

twice

daily

> 2,5

kg1,5

ml (1

5 mg)

twice

daily

> 6 w

eeks

(dos

es

acco

rding

to

ART

Drug

Do

sing C

hart

for C

hildr

en)

< 3 k

g4 m

g/kg/d

ose 1

2 hou

rly

(0.4

ml/kg

/dose

12 ho

urly)

3,0 to

5,9 k

g6 m

l (60 m

g) tw

ice da

ily6 t

o 7,9

kg9 m

l twice

daily

8 kg t

o 13,9

kg12

ml tw

ice da

ily

Cotri

mox

azol

e syr

up (2

00/40

mg

per 5

ml)

Weig

htOn

ce d

aily d

osag

e2,5

to <

5 kg

2,5 m

l5 t

o < 14

kg5 m

l St

op co

trimox

azole

whe

n PCR

is ne

gativ

e ≥

6 wee

ks af

ter fu

ll ces

satio

n of b

reas

tfeed

ing

AND

infan

t is cl

inica

lly H

IV ne

gativ

eST

OP

Cer

tain b

abies

are a

t high

er

risk o

f dev

elopin

g ana

emia

on A

ZT e.

g. pr

ematu

re an

d ma

lnour

ished

infan

ts. C

loser

mo

nitor

ing is

reco

mmen

ded.

If in d

oubt,

disc

uss w

ith an

expe

rt an

d refe

r as n

eede

d.

!

Prem

atur

e inf

ants

< 35

wee

ks g

esta

tiona

l age

shou

ld be

dos

ed u

sing

expe

rt gu

idanc

e.•

For i

nfan

ts we

ighing

< 2

000

g, th

e su

gges

ted

NVP

dose

is 2

mg/

kg/d

ose

(0.2

ml/k

g/do

se) o

nce

daily

from

birt

h –

2 we

eks o

f age

fo

llowe

d by

4 m

g/kg

/dos

e (0

.4 m

l/kg/

dose

) onc

e da

ily fr

om 2

– 6

wee

ks o

f age

.•

If th

e inf

ant s

till w

eighs

< 2

kg a

t 6 w

eeks

of a

ge, c

ontin

ue w

ith d

osag

e of

4 m

g/kg

/dos

e (0

.4 m

l/kg/

dose

) onc

e da

ily u

ntil r

each

es 2

kg.

Mom’

s VL <

1000

c/ml

Baby

gets

NVP

for

6 we

eks o

nlyNV

POn

ce da

ily

Get th

e mom

’s VL

supp

ress

ed as

a ma

tter o

f urg

ency

! Eve

n tho

ugh N

VP

prop

hylax

is to

the in

fant c

an be

stop

ped i

f her

VL i

s < 10

00 c/

ml, a

ny de

tectab

le VL

≥ 50

c/ml

mea

ns th

e viru

s is r

eplic

ating

and p

uts he

r at r

isk fo

r dev

elopin

g re

sistan

ce m

utatio

ns. F

ollow

the V

L No

n-su

ppre

ssio

n alg

orith

m on

page

21

Mom’

s VL

Sum

mar

y of I

nfan

t Pro

phyla

xis R

egim

ens

Risk

Pro

file

NVP

AZT

Low

risk,

wheth

er br

eastf

ed or

form

ula fe

d6 w

eeks

no A

ZTHi

gh R

isk, a

nd br

eastf

edmi

nimum

of 12

wee

ks6 w

eeks

High

risk,

and e

xclus

ively

formu

la fed

6 wee

ks6 w

eeks

The P

MTCT

guide

line u

ses t

wo V

L thr

esho

lds. If

an

y clie

nt on

ART

, inclu

ding m

other

s, su

rpas

ses

the fir

st VL

thre

shold

of 50

c/ml

, acti

on is

re

quire

d to t

imeo

usly

asse

ss fo

r pos

sible

caus

es

that m

ay le

ad to

confi

rmed

viro

logica

l failu

re.

Once

the m

atern

al VL

exce

eds 1

000 c

/ml, t

he

risk f

or M

TCT

warra

nts th

e use

of hi

gh-ri

sk

prop

hylax

is.


Imme

diate

Infan

t HIV

-PCR

A Mo

ther

may

hav

e a h

igh

VL af

ter d

elive

ry d

ue to

:or

MANAGEMENT OF A HIGH MATERNAL VIRAL LOAD AFTER DELIVERY

Wom

en w

ho fa

il to s

uppr

ess

desp

ite sw

itchin

g to s

econ

d lin

e, or

who

are f

ailing

2nd o

r 3r

d line

shou

ld be

disc

usse

d wi

th an

expe

rt/HI

V ho

tline o

r re

ferre

d. Th

ese w

omen

may

be

exp

erien

cing

comp

lex

clinic

al an

d/or p

sych

osoc

ial

chall

enge

s bey

ond t

he

scop

e of th

is pr

imar

y car

e gu

idelin

e, an

d may

requ

ire

a tail

ored

appr

oach

to

mater

nal m

anag

emen

t, inf

ant p

roph

ylaxis

(inclu

ding

LPV/

r) an

d rec

omme

ndati

ons

for po

ssibl

e stop

ping o

f br

eastf

eedin

g and

the

pres

cripti

on of

infan

t for

mula

to be

supp

lied b

y the

DoH

(see

“Sto

ppin

g Br

east

feed

ing”

om pa

ge 30

.

For a

ny ch

ild th

at tes

ts HI

V-po

sitive

ensu

re th

at:

• A

confi

rmato

ry HI

V tes

t wa

s don

e•

The c

hild i

s tra

cked

and

linke

d to c

are

• Th

e moth

er an

d othe

r sig

nifica

nt ca

regiv

ers a

re

coun

selle

d app

ropr

iately

, •

CHW

s are

invo

lved

• Th

e chil

d is r

egist

ered

on

Tier

.net &

retai

ned

in ca

re

!Enqu

ire as

to w

hy

brea

stfee

ding w

as st

oppe

d or

neve

r star

ted. E

nsur

e tha

t the

moth

er un

derst

ands

the

risks

of no

t bre

astfe

eding

, an

d tha

t she

has m

ade

an in

forme

d cho

ice as

to

wheth

er sh

e will

conti

nue

brea

stfee

ding o

r not.

See

als

o the

Infan

t and

Youn

g Ch

ild F

eedin

g Poli

cy.

Get m

other

’s VL

re

-supp

ress

ed as

a ma

tter o

f ur

genc

y! Fo

llow

the V

L No

n-su

ppre

ssio

n alg

orith

m

on pa

ge 21

Confi

rm po

sitive

resu

lt with

a 2nd

PCR

on a

new

samp

le. S

top an

y NVP

prop

hylax

is.

Initia

te AR

T. St

art c

otrim

oxaz

ole (C

PT) if

not a

lread

y star

ted.

Infan

t cur

rentl

y bre

astfe

eding

, or

has b

reas

tfed i

n the

last

week

Brea

stfee

ding n

ever

star

ted or

stop

ped

more

than

1 we

ek ag

o.

Imme

diate

Infan

t HIV

-PCR

Prov

ide H

igh-ri

sk In

fant P

roph

ylaxis

:AZ

T tw

ice da

ily fo

r 6 w

eeks

, and

NVP

for a

mi

nimum

of 12

wee

ks re

gard

less o

f infan

t’s ag

e.

Clea

rly do

cume

nt the

prop

hylax

is

start

date.

If infa

nt >

6 wee

ks ol

d pro

vide C

PT

Infan

t HIV

-PCR

nega

tive

Comp

lete 6

wee

ks of

AZT

and a

mi

nimum

of 12

wee

ks of

NVP

.If n

eede

d, co

ntinu

e NVP

for lo

nger

until

mothe

rs VL

< 10

00 c/

ml.

Do al

l routi

ne H

IV te

sts ac

cord

ing to

the a

ge an

d sch

edule

for H

IV ex

pose

d Infa

nts:

• HI

V-PC

R at

age 1

0 wee

ks•

HIV-

PCR

at ag

e 6 m

onths

• HI

V-PC

R 6 w

eeks

post

cess

ation

of br

eastf

eedin

g•

HIV

Rapid

test

at ag

e 18 m

onths

• Te

st an

ytime

baby

is un

well

Do H

IV-P

CR 6

week

s aft

er st

oppin

g NVP

No pr

ophy

laxis

need

ed as

baby

is no

long

er be

ing ex

pose

d to H

IV

Infan

t HIV

-PCR

nega

tive

A ne

w HI

V dia

gnos

is aft

er de

liver

yAn

elev

ated V

L of ≥

1000

c/ml

after

pr

eviou

sly be

ing su

ppre

ssed

on A

RT.

Follo

w AR

T In

itiat

ion

Algo

rithm

for m

other

on

page

18, a

nd th

e VL

Moni

torin

g sc

hedu

le on

pa

ge 20

See N

VP, a

nd C

PT d

osin

g ch

arts

on pa

ge 23

.

If Infa

nt tes

ts HI

V-PC

R po

sitive

at an

y stag

e.


THE

ABAN

DONE

D IN

FANT

MAN

AGEM

ENT

OF

INDE

TERM

INAT

E PC

R

RESU

LTS

IN IN

FANT

S

Inde

term

inat

e HIV

-PCR

resu

lt(T

his r

esul

t is n

ot p

ositi

ve, b

ut n

ot n

egat

ive ei

ther

)

Chec

k for

prio

r HIV

-PCR

and

VL re

sults

Trea

t infan

t as H

IV in

fected

Ini

tiate

ART

HIV-

PCR

is po

sitive

or in

deter

mina

tean

d/or

HIV

VL is

de

tectab

le

HIV-

PCR

is ne

gativ

ean

d HI

V VL

is

unde

tectab

le #

Furth

er H

IV te

sting

as

per P

MTCT

gu

idelin

es

# Fina

l HIV

statu

s can

not b

e dete

rmine

d un

til the

infan

t has

stop

ped a

ll anti

retro

viral

prop

hylax

is an

d is a

t leas

t 6 w

eeks

post-

cess

ation

of br

eastf

eedin

g. In

case

s whe

re

clien

ts ha

ve be

en in

itiated

on A

RT an

d dia

gnos

is re

mains

unce

rtain,

clien

ts sh

ould

be re

ferre

d for

furth

er m

anag

emen

t by a

sp

ecial

ist cl

inica

l and

labo

rator

y tea

m. A

RT

shou

ld ne

ver b

e stop

ped w

ithou

t spe

cialis

t su

pervi

sion. PC

R, po

lymer

ase c

hain

reac

tion;

VL, v

iral lo

ad; A

RT, a

ntire

trovir

al the

rapy

If in d

oubt,

disc

uss w

ith a

virolo

gist, o

r co

ntact

the N

ICD

at HI

V@nic

d.ac.z

a Do

cume

nt all

test

barco

des i

n the

RT

HB an

d refe

rral le

tters

!

Prior

HIV

-PCR

is po

sitive

or

indete

rmina

te An

d/or

Prior

HIV

VL i

s dete

ctable

Prior

HIV

-PCR

or V

L is n

egati

ve

or un

detec

table,

orNo

prior

HIV

-PCR

or V

L don

e

Repe

at HI

V-PC

R an

d HIV

VL

urge

ntly

$ A po

sitive

HIV

rapid

test

will c

onfirm

HIV

expo

sure

and a

ssist

clini

cal m

anag

emen

t. Ho

weve

r, a n

egati

ve H

IV ra

pid te

st ma

y be f

alsely

nega

tive.

Due t

o the

unav

ailab

ility

of the

moth

er, th

e HI

V-ex

posu

re s

tatus

of a

n inf

ant w

ith a

neg

ative

rapid

test

can

there

fore

not b

e de

finitiv

ely e

stabli

shed

. For

this

reas

on, a

ll ab

ando

ned

infan

ts sh

ould

have

an

HIV-

PCR

test p

erfor

med

and

be m

anag

ed a

s a

high-

risk

HIV-

expo

sed

infan

t. An H

IV ra

pid te

st the

refor

e ad

ds va

lue if

it is p

ositiv

e but

does

not

chan

ge th

e man

agem

ent o

f the i

nfant

if it s

hould

be ne

gativ

e.

Perfo

rm an

HIV

-PCR

and

HIV

rapi

d te

st$ .

Prov

ide h

igh-

risk i

nfan

t pro

phyla

xis.

Star

t NVP

once

daily

for 6

wee

ks an

d AZT

twice

daily

for 6

wee

ks

HIV-

PCR

is ne

gativ

e HI

V-PC

R is

posit

ive

Do H

IV-P

CR at

10 w

eeks

of ag

e or

4 we

eks a

fter s

toppin

g NVP

Stop

NVP

(and

AZT

)

HIV-

PCR

is

nega

tive

HIV-

PCR

is po

sitive

Go to

Ma

nage

men

t of

HEU

infa

nt

on pa

ge 30

Aban

done

d in

fant

with

unk

nown

HIV

expo

sure

Tr

eat i

nfan

t as a

hig

h-ris

k, H

IV-e

xpos

ed in

fant

MANAGEMENT OF INDETERMINATE PCR RESULTS AND THE ABANDONED INFANT

Initia

te AR

T as

per g

uideli

nes

and c

onfirm

with

a se

cond

HI

V-PC

R or

VL.


All p

regn

ant o

r bre

astfe

eding

wom

en w

ith a

new

HIV

diagn

osis,

orAl

l kno

wn H

IV po

sitive

wom

an w

ith ne

w pr

egna

ncy d

iagno

sis (w

hethe

r on

ART

or no

t on A

RT)

All H

IV po

sitive

wom

en fr

om 12

wee

ks

after

birth

who

had I

PT de

ferre

d in

preg

nanc

y (CD

4 cou

nt ab

ove 1

00 du

ring

anten

atal c

are)

HIV

posit

ive w

oman

cur

rentl

y on T

PT

ALL

wom

en sh

ould

be s

cree

ned

for T

B at

ever

y visi

t

At 1st

/ Boo

king

visit

in A

NCAt

Fol

low-

up vi

sits

TPT

dosa

ge: I

soni

azid

(INH

) 300

mg

daily

PO,

and

Pyrid

oxin

e 25 m

g OD

PO

x 12 m

onth

s

The A

PPRI

SE ra

ndom

ised c

ontro

l trial

foun

d a hi

gher

incid

ence

of ad

verse

preg

nanc

y ou

tcome

s in m

other

s who

used

TPT

in pr

egna

ncy 15

, 17,

18

$ DTG

requ

ires b

oosti

ng w

ith T

B tre

atmen

t. Se

e DTG

in p

regn

ancy

on pa

ge 17

All p

regn

ant w

omen

with

a ne

w HI

V dia

gnos

is, or

All k

nown

HIV

posit

ive w

oman

with

new

preg

nanc

y diag

nosis

(w

hethe

r on A

RT or

not o

n ART

)

Asse

ss T

B sy

mpt

oms a

nd cl

inica

l con

ditio

n:If T

B sy

mptom

s with

out d

ange

r sign

s, or

no T

B sy

mptom

s pr

esen

t, ini

tiate

ART

.If t

he w

oman

appe

ars v

ery i

ll with

any o

f the f

ollow

ing si

gns,

di

scus

s with

a do

ctor

or r

efer

for f

urth

er as

sess

men

t.

Do n

ot st

art A

RT u

ntil T

B is

exclu

ded/

diag

nose

d as

thes

e wo

men

may

be a

t a h

ighe

r risk

of d

evelo

ping

IRIS

:

weigh

t loss

> 5%

, diffi

culty

brea

thing

, res

pirato

ry ra

te >3

0/min,

tem

pera

ture >

38°C

, puls

e > 10

0min,

BP

< 90

/60, c

ough

ing up

blo

od, c

onfus

ion or

agita

tion,

or un

able

to wa

lk un

aided

.

GXP

neg,

but T

B sy

mptom

s still

pr

esen

t

GXP

posit

iveTB

GXP

nega

tive

(or u

nable

to pr

oduc

e sp

utum)

AND

no

TB

symp

toms

Addit

ional

inves

tigati

ons a

s pe

r Nati

onal

TB G

uideli

nes

If CD4

≤ 10

0,

do a

urine

LAM

Initia

te/co

ntinu

e ART

CD4 m

ore

than 3

50CD

4 350

or

less

Defer

TPT

un

til 6

week

s afte

r de

liver

yIni

tiate

TPT

after

co

ntra-

indica

tions

ha

ve be

en

exclu

ded

TB di

agno

sis

confi

rmed

Initia

te T

B Rx

Revie

w in

2 wee

ks: If

stab

le an

d tole

ratin

g TB

Rx,

conti

nue T

B Rx

and i

nitiat

e/con

tinue

ART

:TD

F, 3T

C/FT

C, E

FV/D

TG$

If TB

menin

gitis,

defer

ART

for 4

to 6

week

s

HIV

posit

ive w

oman

curre

ntly o

n TPT

All H

IV po

sitive

wom

en fr

om 6

week

s afte

r bir

th wh

o had

TPT

defer

red i

n pre

gnan

cy

(CD4

coun

t abo

ve 35

0 dur

ing an

tenata

l ca

re)

Chec

k:1.

Adhe

renc

e to T

PT, A

RT an

d CPT

2. Si

de-e

ffects

of T

PT3.

TB sy

mptom

s

TB sy

mptom

scre

en

1 or m

ore

TB sy

mptom

s pr

esen

t

No T

B sy

mptom

s pr

esen

t

Inves

tigate

as pe

r Na

tiona

l TB

Guide

line

Conti

nue T

PT

for a

total

of

12 m

onths

If TB

diagn

osed

, stop

TPT

, ini

tiate

full T

B Rx

and

send

a s

putum

samp

le for

LPA,

or

cultu

re an

d dru

g sen

sitivi

ty tes

t (DS

T)

No

TB

symp

toms

pres

ent

1 or m

ore T

B sy

mptom

s pr

esen

t

Initia

te TP

T for

12

mon

ths (a

fter

exclu

ding o

ther

contr

a-ind

icatio

ns

to TP

T )

Reco

rd st

art d

ate

of TP

T

Inves

tigate

as

per N

atio

nal T

B Gu

ideli

ne (2

014)

pa

ge 28

Cont

ra-in

dica

tions

to T

PT

• Po

sitive

TB

symp

tom sc

reen

• Al

coho

l abu

se•

Liver

dise

ase

• Kn

own h

yper

sens

itivity

to IN

H

TB SCREENING AND TPT DURING PREGNANCY, LABOUR, AND THE BREASTFEEDING PERIOD

IPT

is no

w kn

own

as T

PT (T

B Pr

even

tive

Ther

apy)

TP

T tre

ats La

tent T

B Inf

ectio

n (LT

BI)

Do a

TB G

XP fo

r all w

omen

at 1s

t visi

t in A

NC, d

ue to

the l

ower

se

nsitiv

ity of

the s

ympto

m sc

reen

in pr

egna

nt wo

men.


Refer

/disc

uss a

ny m

other

diag

nose

d with

dru

g re

sista

nt T

B wi

th an

expe

rt or

call t

he H

IV H

otline

08

00 21

2 506

MANAGEMENT OF THE TB-EXPOSED NEONATE

INH

Dosin

g Ch

art

Isoni

azid

(INH

), or

al,10

mg/

kg d

aily f

or 6

mon

ths.

Maxim

um d

ose 3

00 m

g da

ily

Weig

ht (k

g)Da

ily IN

H(1

00m

g ta

blet

)

>2-3

,4 kg

¼ tab

let

>3,5-

6,9 kg

½ tab

let

>7-9

,9 kg

1 tab

let

>10-

14,9

kg1 ½

table

ts

>15-

19,9

kg2 t

ablet

s

>20-

24,9

kg2 ½

table

ts

>25 k

g3 t

ablet

s

*If A

RT is

delay

ed du

e to o

ther c

linica

l co

mplic

ation

s, dis

cuss

with

an ex

pert

or th

e HIV

Ho

tline t

o dete

rmine

the b

est c

ourse

of ac

tion

rega

rding

BCG

vacc

inatio

n

Symp

tomati

c (Re

sp ra

te >

60/m

in, di

fficult

y bre

athing

, fee

ding p

roble

ms, p

oor w

eight

gain,

abdo

mina

l dist

entio

n, en

large

d live

r/sple

en, ja

undic

e)

Preg

nant

Mot

her w

ith T

B (d

iagno

sed i

n las

t 2 m

onths

of pr

egna

ncy/N

o res

pons

e to T

B Rx

/Still

AFB

pos)

Infan

t bor

n to a

moth

er w

ith T

B

Do a

thor

ough

clini

cal e

xami

natio

n

Asym

ptoma

tic

Star

t TPT

(INH

10 m

g/kg/d

ay fo

r 6

month

s)Do

not g

ive B

CGEn

sure

that

HIV

testin

g and

pr

ophy

laxis

(or A

RT tr

eatm

ent)

has

been

prov

ided a

s rele

vant

No T

BOt

her c

ause

foun

dRe

fer to

hosp

ital:

Evalu

ate fo

r TB

TB

disea

seSt

art T

B Rx

regim

en 3

acco

rding

to w

eight

(in ho

spita

l)Te

st an

d tre

at for

HIV

as re

levan

t

Follo

w up

at ev

ery c

ontac

t ses

sion:

Clini

cal s

tatus

Adhe

renc

e to T

PTTe

st an

d tre

at for

HIV

as re

levan

t

Infan

t HIV

nega

tive a

t the

end o

f TPT

Give

BCG

(a

t 2 w

eeks

after

co

mplet

ion of

INH)

Infan

t HIV

nega

tive a

t en

d of T

B Rx

(Sus

pecte

d) H

IV po

sitive

at the

end o

f TPT

Give

BCG

(a

t 2 w

eeks

after

co

mplet

ion of

INH)

Co

ntinu

e ART

*

HIV

posit

ive at

the

end o

f TB

Rx


Not promoting infant formula, bottles or teats

Making breastfeeding care standard practice and

other items under the scope of regulation R991

Monitoring policy implementation


Breastfeeding Plus

Infant Feeding AdviceFor all women, exclusive breastfeeding (EBF) is recommended for the 1st six months of life. Thereafter, breastfeeding should continue for two years or longer, with the introduction of nutritionally adequate, appropriate and safe complementary feeding. Women living with HIV

should be fully supported for ART adherence during the breastfeeding period and thereafter

HIV NEGATIVE WOMEN1. HIV Risk Reduction

• Number of sexual partners• Condom use• Partner testing• Partner ART and viral suppression• PrEP (as available and applicable)

2. Regular HIV Testing3. Infant Feeding advice and support

WOMEN LIVING WITH HIV1. ART and VL suppression2. Infant prophylaxis3. Infant testing4. HIV Risk reduction (re-infection and risk to partner)

• Number of sexual partners• Condom use• Partner testing• Partner ART and viral suppression

5. Infant Feeding advice and support

WHO Practice Statements for Women Living with HIV • Any mother that is mixed feeding in the first 6 months should be encouraged to return to exclusive breastfeeding.• However, mothers living with HIV and health-care workers can be reassured that ART reduces the risk of postnatal HIV transmission in the context of

mixed feeding. Although exclusive breastfeeding is recommended, practicing mixed feeding with formula milk is not a reason to stop breastfeeding in the presence of ARV drugs.

• Mothers living with HIV and health-care workers can be reassured that shorter durations of breastfeeding of less than 12 months are better than never initiating breastfeeding at all.

HIV-exposed InfantHIV Un-exposed Infant

HIV VL suppression in mother is essential to prevent MTCT through breastfeeding!!

Whether a woman is living with HIV or HIV-uninfected,

recommendations for Infant feeding remain the same

Introducing solids before 6 months is strongly discouraged! The younger the infant, the higher the risk to the infant’s health. !

Counselling on the benefits of breastfeeding should start during the

antenatal period

Early initiation of BF within 1 hour

after birth. EBF for 1st

6 months of life

Antenatal 6 months

Continue breastfeeding until 2 years of age or longer

12 months 18 months 2 years

BREASTFEEDING PLUS

Start introducing age appropriate solid foods from 6 months onwards as outlined in the RTHB

Breastfeeding

Bonding

ART & VL

BF+Infant feeding in the context of HIV:

Integration of nutrition, nurture & medical intervention.

HIV Risk reduction

Breastfeeding

Bonding


Ongoing Care for the Mother and her Family

• Remember to provide appropriate ongoing care to the women living with HIV and her family.• If a breastfeeding mother is sick or hospitalised, consider appropriate ways she can continue breastfeeding. If not, ensure that baby

receives appropriate care whilst mother is hospitalised.• Screen partner and other children for HIV and other infectious disease as indicated (e.g. TB)

Additional Management for the HEU Infant

HEU infants may experience poorer outcomes despite being HIV uninfected, and may require more regular follow-up.Identify high-risk HEU infants who may require closer monitoring, including those with:

• Poor birth outcomes• Symptoms of anaemia• Impaired growth and/or neurodevelopment• History of hospitalisation• Maternal illness or death

Routine Child Health Management

• Manage and treat acute problems according to the IMCI guidelines

• Provide feeding counselling and support• Monitor growth and development• Provide routine immunizations, Vit A, and

deworming• Screen for TB symptoms and TB index cases and

manage accordingly• Ask about mother’s health, ART adherence, and

family planning needs• Provide social support and counselling for age-

appropriate parental disclosure

Routine Management for the HIV-Exposed Infant

• Ongoing interventions to prevent vertical transmission through breastfeeding

• All routine HIV tests as indicated in this guideline for HIV-exposed infants

CARE OF THE HIV-EXPOSED BUT UNINFECTED INFANTMore than 25% of the total infant population in SA are HIV-exposed and more than 98% of these infants are HIV negative. Yet, having escaped HIV infection, they may still suffer the consequences of being born to a woman living with HIV. HIV-exposed but Uninfected (HEU) children still require:

Indications for Formula Feeding to be provided by the Dept of Health Supplementation Scheme

1. Infants of mothers who are failing second or third-line ARV treatment (VL ≥1000 copies/ml) should be advised not to breastfeed.

2. The mother has died, or the infant has been abandoned.3. Other individual circumstances deemed necessary by a multidisciplinary team including certain metabolic

conditions in the infant, medical conditions in the mother, or certain maternal medications as outlined in the PHC EML.

Stopping BreastfeedingMothers living with HIV who decide to stop breastfeeding should do so gradually over a period of a month.

Abrupt cessation of breastfeeding is not recommended and may increase the VL in breastmilk. If subsequent intermittent breastfeeding should occur, the infant is at increased risk of becoming HIV infected.

Infants who have been receiving ART prophylaxis should continue prophylaxis for four weeks after all breastfeeding has stopped.

Children must receive an adequate diet following cessation of breastfeeding as outlined in the Infant and Young Child Feeding Policy.

STOPPING BREASTFEEDING


Testing for Syphilis First test Confirmatory

test

Use of RPR RPR(rapid or laboratory)

TPHA(laboratory)

If rapid syphilis testing used (dual and standalone)

TPHA (HIV-syphilis combination

or standalone syphilis test)

RPR(rapid or

laboratory)

Syphilis is a sexually transmitted infection that can have multiple different presentations but also be asymptomatic. The signs of secondary syphilis occur six to eight weeks after the primary ulcer (chancre) and include a generalized rash (including palms and soles), flu-like symptoms, flat wart-like genital lesions (condylomata lata), mouth ulcers and patchy hair loss. Tertiary syphilis occurs many years later and affects skin, bone, heart and nervous system.

The stages of disease progression of syphilis are illustrated in the figure below, together with the typical clinical presentation in each stage, and the level of the RPR titer (blue graph). Note that a genital ulcer caused by syphilis will resolve spontaneously within four to six weeks without treatment; however, the syphilis infection persists, and the ulcer resolving does not represent cure.

Testing for SyphilisIt is important to know what type of test is being used to test for syphilis. Older syphilis tests are of the RPR type (non-treponemal test). False positive RPR’s can occur. It is therefore good practice to confirm any positive RPR with a TPHA/FTA test (treponemal test). TPHA remains positive for life, but an RPR changes in titer in response to treatment or disease progression. Consider re-infection if the RPR titer increases by four times or more. Conversely, if a TPHA is used as the first test (as what is used in the HIV-syphilis combination or standalone syphilis rapid test), the positive result should be confirmed using an RPR. The RPR will determine if the positive TPHA result indicates a current active infection or an earlier infection.

Treating the Newborn InfantExamine and treat the newborn of the mother with syphilis: Well (asymptomatic) baby: Treat baby with Benzathine penicillin 50 000 u/kg intramuscularly (IM) stat only if:

• Mother was not treated, or• If the mother has received less than three doses of benzathine benzylpenicillin, or• If the mother delivers within four weeks of commencing treatment.

Symptomatic baby: • Refer all symptomatic babies for treatment of congenital syphilis: • Procaine penicillin 50 000 u/kg IM daily for 10 days, or benzyl penicillin (penicillin

G) 50 000 u/kg/dose 12-hourly intravenously (IV) for 10 days• Erythromycin does not reliably cure syphilis in either the mother or the baby

Congenital SyphilisVertical transmission occurs in 40% of mothers with untreated syphilis, and can result in miscarriage, still birth, non-immune hydrops fetalis and congenital syphilis of the newborn. Signs of congenital syphilis are desquamative rash (red/blue spots or bruising especially on soles and palms), jaundice, pallor, distended abdomen due to enlarged liver or spleen, low birthweight, respiratory distress, large, pale placenta, and hypoglycaemia.

SYPHILIS

Painless ulcer/chancre and condylomata lata on genitals Rash involving palms and soles

EARLY SYPHILIS - Infectious! LATE SYPHILIS - Non-infectious

Primary Syphilis Secondary Syphilis Early Latent Phase Late Latent Phase Tertiary Syphilis

Skin Lesions e.g. Condylomata Lata

Asymptomatic RPR negativeTPHA positive

Asymptomatic RPR positive

Other systems affected e.g. CNS,

CVS

2 years2 yearsWindow period may

result in a false negative RPR

Incubation 17-28 days 1

wk

• Painless• May be

multiple• May be

undetected if on cervix

• • PainlessPainless• • BilateralBilateral• • If on cervix, then If on cervix, then

no inguinal lymph no inguinal lymph nodesnodes

Chancre Lymph nodes

1:8 and higher95% of RPR’s will be negative 2 years after

infection1:4RPR titre

Once positive the TPHA test remains positive for life, regardless of whether infection was treated or not


SYPHILIS IN PREGNANCY

Y Y

Use appropriate flowchart, manage appropriately

Treat pregnant woman with:Use appropriate

flowchart, manage appropriately

Y N

Post test counselling, same day TB screen, HIV education, CD4

count, creatinine, clinical staging,

support, and same day ART start

Repeat HIV testing monthly at every

full BANC Plus visit throughout pregnancy,

at labour/delivery, at 10-week EPI visit, and every

3 months throughout breastfeeding

• Refer all symptomatic babies Notify: Notification of medical conditions, form GW17/5

Symptomatic newborns of mothers with positive syphilis test during pregnancy:

• Benzathine penicillin (depot formulation), IM, 50,000 units/kg as a single dose into lateral thigh*

* Benzathine penicillin (depot formulation) must never be given IV

Treat asymptomatic newborns of mothers with positive syphilis test if mother was not treated, OR if mother received < 3 doses of Benzathine penicillin, OR if mother delivers

within 4 weeks of commencing treatment, with:

Follow up at 3 months after the last injection to confirm a fourfold (i.e. 2 dilution) reduction in RPR litres, provided the initial

litre was > 1:8. If the initial litre was < 1:8, further reduction may not occur.

All pregnant women: • Educate, ensure compliance and counsel; promote couple-counselling if applicable• Explain the risk of vertical transmission• Promote consistent condom use particularly during pregnancy, demonstrate

condom use, provide condoms• Stress the importance of partner treatment, issue one notification slip for each

sexual partner• Promote HIV counselling and testing of partner

Any STI syndrome or illness? Syphilis positive? HIV test positive?

Do a syphilis test, an HIV test, and any other tests according to the BANC Plus protocol

• Benzathine penicillin 2.4MU imi once weekly for 3 weeks. Reconstitute with 6mL of lidocaine 1% without epinephrine (adrenaline)

OR In case of penicilin allergy: • Refer for penicillin desensitisation

Source: Sexually Transmitted Infections Management Guidelines 2015, Adapted from: Standard Treatment Guidelines and Essential Drugs List PHC

All pregnant women at first visit and repeat testing at 32-34 weeks for women testing negative in the first trimester

Take history and examine, explain needs for syphilis screening, do pre-test counselling for HIV


DOCUMENTATION IN THE CLIENT RECORDDocument all clinical findings, results and decisions clearly, and insert the barcode stickers of any blood tests taken in the following client records as applicable:1. The Maternity Case Record 2. The Adult Clinical Record (ART Stationery) for HIV positive women, if available in that facility3. The Road to Health Booklet for the HIV-exposed infant

DATA MANAGEMENT

These reports are compiled from NHLS HIV laboratory data and are e-mailed in different formats depending on the user’s requirements. The purpose of these reports is to assist with monitoring of the HIV PMTCT program, identify HIV-infected pregnant women with high viral loads and link HIV-infected infants to care.

REPORT NAME REPORT NO. DESCRIPTION USEFUL FOR

HIV PCR Facility Report RPT01001 • Provincial level data disaggregated per facility• Number of PCR tests and results at each facility per age range • Reported per month with comparison to previous year• Can be used to check accuracy of DHIS stats• Total MDOs per facility reported

HIV National Report (Birth Testing) RPT01008 • National monthly report• Number of PCR tests done within 7 days of birth with results and

MDOs• Reports intra-uterine infection case rates

HIV PCR RfA Report RPT01002 W/D • All verified PCR results (with client identifiers) since the previous weekly (W)/daily (D) report

• To assist with tracing HIV-exposed infants and linkage to care• All previous HIV PCR results per client are also reported (within

limitations of demographic linking)

HIV VL RfA Report (all ages) RPT00001 W/D • All VL ≥ 1000 c/ml (with client identifiers) since previous weekly (W)/ daily (D) report

• Previous consecutive VL ≥ 1000 c/ml per client are also reported (within limitations of demographic inking)

HIV PCR MDO Report RPT01004/5/6/7 (monthly) • Facilities with the highest number of MDOs are listed at either National, Provincial, District or Facility level

• The 10 facilities with the most MDOs in a region receive a detailed report of their MDOs (e.g. rejection type, rejection reason and test result text)

• A laboratory report is also available for laboratorians• To improve the quality of specimen collection and processing

RfA, Results for Action; MDOs, Missed Diagnostic Opportunities = registered HIV PCR tests that are neither positive or negative (includes rejections, invalid and indeterminate results); DHIS, District Health Information System

DESCRIPTION DESCRIPTIONNational/ Provincial/ District ManagerFacility ManagerClinical Healthcare WorkerLaboratorian

Registering on the self-service portal and requesting reports STEP 1: Go to www.nicd.ac.za

→ Click on the “M&E Dashboards” and “HIV” → Select “Guest User” → Click on “Self Service Registration” → Self-Service Portal Landing Page

STEP 2: Select “New User Registration” → Complete the registration form, and follow further instructions

Please direct any queries to [email protected]

USING NHLS REPORTS FOR QUALITY IMPROVEMENT AND CLIENT TRACKING


PNC Timeline

PNCs were developed in the Western Cape Province due to the need for reducing MTCT during the postnatal period and for retaining mother-infant pairs (MIP) in care. It is a holistic client-centred model of care that:

• addresses both the medical needs of a mother living with HIV and her HIV-exposed infant.

• provides peer support, psychosocial support and early childhood development support.

WHO CAN BE RECRUITED FOR A PNC The mother living with HIV is given the option of joining PNC when she first presents to the clinic (usually around six-weeks post natally). She is then given a date and time for the first session of the PNC. The recruitment is usually done either by the m2m mentor or by the nurse seeing the mother-infant pair. Babies are grouped per same month of age and PNCs start around ten weeks post natally.

THE KEY COMPONENTS OF A CLUB SESSION

Early Childhood Development Activities

45-min group session

Clinical CareOne-Stop Shop

• Peer support• Adherence

counselling• HIV and non-HIV

topics

• Mental health screening every 6 months

• Breastfeeding support

• Clinical visit at every session

• Pre-packed medicine

• Experienced nurses (ART, MCH)

• Mother: Viral load, family planning, pap smear

• Infant: HIV testing, growth monitoring, feeding suport, immunisations, IMCI

Adult ART Club model

Early Childhood Develeopment

Integration of maternal and child health

Integration of HIV and non-HIV Care

PNCs aim to provide high quality care to both mother and infant and have been shown to:

• Improve retention in care, • Improve maternal viral load

suppression rates, and• Increase the uptake of infant

HIV tests and vaccinations.

In the first six months, babies are seen monthly because of their higher mortality and morbidity risk in this period. After six months of age, clubs are held three-monthly until 18 months of age (following the “Road to Health” card clinical appointments). At 18 months, children go back to the standard of care and mothers are encouraged to join an adult ART club (facility or community based).

Mother has active TB(they pose an infection risk to other mothers and babies)

Mother refuses to have her ART care in the same clinic as the baby (making integrated care impossible)

Baby is HIV-positive(they require different care than what is offered in PNC)

Mothers who are stable on ARV treatment

“High-risk” mothers who have a high viral load or other characteristics

INCLUSION CRITERIA

Mothers with HIV and their HIV-exposed infants

EXCLUSION CRITERIA

We include both

WHAT HAPPENS AT EACH CLUB?As in the adult club model, PNC starts with a peer support session, which is led by peer-educators, following a session guide. Early childhood development (ECD) activities and promoting the “First 1000 Days” campaign are included. Mother-infant pairs (MIPs) will have an integrated clinical session provided by the nurse. Each visit’s interventions will depend on the age of the baby. The mother’s clinical care schedule is adapted around the baby’s visits. More info on the PNC model including stationery, the club register and monitoring and evaluation go to www.bit.ly/PNCtoolkit

ANNEXURE 1 – POST NATAL CLUB (PNC) MODELFor more info on the

PNC model including stationery, the club register and monitoring and evaluation go to www.bit.ly/

PNCtoolkitVL = Viral loadFP = Family planning ART = Antiretrovaral theraphyIMCI = Integrated management of childhood illnessMCH = Maternal and child health

RecruitSession 1Session 2Session 3Session 4Session 5

Session 6

Session 7

Session 8

Session 9

6 weeks10-12 weeks14-16 weeks18-20 weeks22-24 weeks6 months

9 months

12 months

15 months

18 months

Mothers transition to standard club care


VL = Viral loadFP = Family planning ART = Antiretrovaral theraphyIMCI = Integrated management of childhood illnessMCH = Maternal and child health

UP/MRC Research Centre for Maternal, Fetal, Newborn and Child Health Care StrategiesProf. Ute Feucht Dr Jeannette WesselsProf. Bob Pattinson

National Department of HealthDr Manala MakuaDr Lesley BamfordMathilda NtloanaTabisa Silere MaqetsebaEllence MokabaNtombi MazibukoJoyce MahuntsiThembi ZuluDimpho ChweneyagaeVuyiswa LebeseDineo TshikediKeshika Sivnanaan- Narainsamy Lillian Diseko.Tebogo MaomelaDr Riona GovenderDr MvusiAnne BehrZandile Kubeka

Use of MaterialsUNICEFWHOAIDSinfoFreepikELMAZoe-LifeMSF

PMTCT Technical Working Group MembersProf. Ameena GogaProf. Gayle ShermanDr Natasha DaviesDr Shuaib KauchaliDr Carol Marshall Dr Mary MogashoaDr Kondwani N’gomaDr Busisiwe-Msimanga RadebeKerry-Lee WolfaardtMantsi TeffoManjekana DyeshanaDr. Sithembile Dlamini-NqeketoDr Mariame Sylla

Subject ExpertsDr H RabieDr M ArcheryDr M KroonDr Lee FairlieProf. M CottonDr J NuttallDr Leon LevinDr A SlogroveDr Lesley RoseDr N SipamboDr A Haeri-MazanderaniDr Karl TechnauProf. N IsmaelDr Michelle Moorhouse

Graphic DesignTharina du Preez

Disclaimer: The information presented in these guidelines conforms to the current medical, nursing and pharmaceutical practice.

Contributors and editors cannot be held responsible for errors, individual responses to medicines, and other consequences.

ACKNOWLEDGEMENTS

The honorouble Dr Aaron Motsoaledi, Minister of Health, is grateful to all the internal and external stakeholders (listed below) who actively contributed to the development of these guidelines despite their demanding schedules. Their efforts are contributing toward attaining A LONG AND HEALTHY LIFE FOR ALL CITIZENS.


REFERENCES

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isoniazid preventive therapy during or after pregnancy (APRISE); Presented at: Conference on Retroviruses and Opportunistic Infections; March 4-7, 2018; Boston, MA. Abstract 142LB

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