Integrated HIV Training for Healthcare Workers

Session 12: ART in Pregnant and Breastfeeding Women

Overview

In this section we will explain what PMTCT is, how it has been rolled out in Zimbabwe, and the current focus on dual elimination of mother-to-child transmission (EMTCT) of HIV and syphilis. We will then discuss the counselling issues related to PMTCT. We will also cover how to involve male partners in PMTCT.

Learning Objectives

By the end of this section, you will be able to:

  • Describe PMTCT.
  • Describe the Zimbabwe PMTCT programme.
  • Define EMTCT.
  • Discuss the principles of HIV testing and counselling in the context of pregnant and breastfeeding women.
  • List the steps in involving male partners in PMTCT services.
  • Discuss the criteria for initiating HIV positive partners of HIV infected pregnant and breastfeeding women.

Learning Activities

  • Quiz (5 min)

    We have already touched on PMTCT in some of the earlier sessions. Let’s test your knowledge on what you have already covered. Please refer back to earlier sessions if you need a refresher.

    1Sekai is 22 years old and comes in for her first ANC visit. She is four months pregnant and has agreed to get tested for HIV. Her test result is positive. You conduct post-test counselling with Sekai. Select all the statements you will say to her in your counselling session.

    2When should we test pregnant and lactating women for HIV? Select all that apply.

    3If pregnant woman tests HIV-positive, you should do all of the following except:

    We will cover more details about the clinical tests and care for pregnant women in this session.

  • Introduction (10 min)

    HIV-positive pregnant and breastfeeding women have specific clinical needs that we need to learn. As you learned in previous sessions, there are many things that need to be considered when treating PLHIV. For pregnant and breastfeeding women, there are additional concerns. Before we get into the specifics of treatment, let’s first review the basics of PMTCT.

    With ART and other interventions, transmission can be reduced to less than 5% in developing countries and to less than 2% in developed countries. Both globally and nationally there is a four-pillar comprehensive approach to eliminating mother to children transmission that has been widely accepted. Tap on each of the pillars to learn more:

    Pillar 1: Prevent HIV infection amongst women of child bearing age

    Focuses on keeping women and men HIV negative through:

    • Provision of health information and education
    • Discussion of behavior change communications to avoid high risk behaviours
    • Delay of onset of sexual activity, and targeting the youth
    • HIV testing and counselling – regular re-testing for those at risk (for PMTCT this would be during pregnancy, delivery, and postpartum)
    • Couples counselling and partner testing
    • Safer sex practices, including dual protection (condom promotion)
    • PrEP
    Pillar 2: Prevention of unintended pregnancy

    Focuses on reproductive health choices and family planning for people living with HIV:

    • Family Planning (FP) counselling and services to ensure women can make informed decision about their reproductive health
    • HIV testing and counselling in Reproductive Health (RH) and FP services
    • Safer sex practices, including dual protection (condom promotion)
    • Interaction between some contraceptives and ART
    Pillar 3: Prevent HIV transmission to HIV-exposed infants

    Addresses care for women during pregnancy, labour, and delivery and thereafter including their infants:

    • Antiretroviral treatment and prophylaxis
    • Safer delivery practices
    • Safer infant and young child feeding practices
    Pillar 4: Support HIV-infected families to remain adherent on effective ART

    Provide support to women living with HIV to ensure that they remain adherent to ART and retain health care throughout pregnancy, breastfeeding, and for life. Specific avenues of support include:

    • ART for all HIV-positive pregnant women for their own health
    • Care and support for HIV-exposed infants
    • Nutritional support for HIV-exposed infants
    • Treatment, care, and support services for women and their families

    You should integrate HIV care services into routine ante partum care within maternal, neonatal, and child health (MNCH) settings. When you have a pregnant woman who is HIV positive and already on ART, mothers are transferred from the general OI/ ART clinic for continued HIV care/ART in the MNCH up to 24 months after delivery.

    What Are the Key Justifications for Treating All Pregnant and Breastfeeding Women?

    Take a moment to reflect on what are some key justifications for treating all pregnant and breastfeeding women. In the box below, list 2-3 justifications. Then tap the compare answer button for feedback.

    Evolution of PMTCT Programme in Zimbabwe

    map
    rectangle circle triangle arrow triangle arrow
    1999

    3 site PMTCT pilot

    2002

    Roll-out in 2002

    2010

    PMTCT services in 1560 ANC sites (95% coverage)

    2006

    Transition from SD NVP Option A

    2013

    Launch of IATT supported B+ transition plan Nov 2013

    2014

    Option B+ roll-out completely

    As you can see in the graphic above, Zimbabwe began providing PMTCT in 1999 in a few pilot sites. The programme was rolled out in 2002 and has evolved over the years with Option B+ being rolled out nationally in 2014. Treatment of all pregnant and breastfeeding women with triple ARV therapy was rolled out in 2013.

  • EMTCT (5 min)

    Recently, there has been a shift in focus from prevention of mother to child transmission to elimination of mother to child transmission (EMTCT).

    In line with the WHO global guidance towards eliminating mother-to-child transmission of HIV and syphilis, Zimbabwe has developed a dual elimination strategy plan for HIV and syphilis 2018-2020. Its goal is to have the programme validated on the Path to Elimination. The plan sets the target for gold tier (having an HIV case rate of ‹250/ 100,000 and a syphilis case rate of ‹50/100,000).

    Tap on the following boxes to see the targets in the Zimbabwe five-year EMTCT plan for HIV and syphilis elimination 2018-2020:

    HIV
    Impact criteria Process criteria
    • MTCT ‹5% in breastfeeding populations
    • Gold tier
    • HIV Case rate ‹250/100,000 live births
    • ANC coverage ≥ 95%
    • Testing coverage ≥ 95%
    • ART coverage ≥95%
    Syphilis
    Impact criteria Process criteria
    • Case rate ≤ 50 per 100,000 live births
    • ANC coverage ≥ 95%
    • Testing coverage ≥ 95%
    • Treatment coverage >95%

    The process criteria should be achieved and maintained at least for two consecutive years before the country applies for validation of its EMTCT program and the impact criteria should be achieved for at least a year before validation can occur. Validation of EMTCT is not an event and countries that had achieved validation can regress if they slacken PMTCT interventions.

  • Check Your Knowledge (5 min)

    1Which of the following are components of the third prong of the PMTCT strategy? Select all that apply.

    2Why do we want to treat all pregnant and breastfeeding women? Select all that apply.

    3In what year did Zimbabwe roll out treatment for all HIV positive pregnant and breastfeeding women?

    4What is the WHO process criteria for EMTCT?

  • Counselling Issues (5 min)

    You should be offering HIV testing and counselling to pregnant women as part of essential care during pregnancy. HIV testing should be coordinated with other tests done during pregnancy (e.g., testing for syphilis); this will minimise repeated invasive procedures.

    Think about some of the feelings that a pregnant client might be having when she is considering whether or not to test for HIV. There are a number of very important factors that you need to consider when offering HIV testing to a pregnant woman.

    Tap on each of the tabs below to learn more about some of the common feelings pregnant women face when deciding to take an HIV test:

    Apprehension

    Apprehension during pregnancy related to the HIV diagnosis may be worse if the woman is not sure how she feels about being pregnant, or if she is worried about how she is going to manage caring for a child, etc. In addition to having to deal with her own HIV diagnosis, a pregnant woman may worry about transmitting the virus to her baby. Pre-counselling should include information about the medication that she will take if she is positive that will protect her baby and keep her healthy.

    Concern that the drugs might harm the baby

    Concern that the drugs might harm the baby may make a pregnant woman hesitant to take ARVs. Assure the woman that there is little likelihood of harm to the unborn or breastfeeding baby from the ARV drugs.

    Stigma and discrimination

    Stigma and discrimination attached to becoming pregnant and having a known HIV-positive status might cause her to feel guilty about the risk of transmitting HIV to the baby. This feeling of guilt may in turn affect her ability to adhere to treatment. It will be important to address these concerns and provide psychosocial support.

    Fear of revealing her HIV status

    Fear of revealing her HIV status may make a pregnant woman feel reluctant to take ARVs. Assure her of shared confidentiality in your facility, and support her in disclosing her status to her partner, family, and/or friends in whom she has confidence.

  • Principles of HIV Testing & Counselling (10 min)

    You should adhere to the guiding principles of provider-initiated counselling and testing for HIV during pregnancy and with particular attention to the special needs of a woman in labour.

    All forms of HIV testing should adhere to the WHO 5 Cs: Consent, Confidentiality, Counselling, Correct test results, and Connection (linkage to prevention, treatment, and care services).

    Tap on the tab below to learn more about each of the 5 Cs:

    Consent

    You must get informed consent for HIV testing at any time, including during labour: your client must receive clear and accurate information about HIV testing, and you as the tester must respect the client’s right to decide whether to be tested.

    Confidentiality

    HIV testing and counselling services are confidential, meaning that what you and the client discuss will not be disclosed to anyone else without the expressed consent of the person being tested. Although confidentiality should be respected, it should not be allowed to reinforce secrecy, stigma, or shame. You should raise, among other issues, whom else the person may wish to inform and how they would like this to be done. It’s often very beneficial to the client to share confidentiality with a partner, family members, or trusted friends, and with health care providers.

    In the busy and complex delivery ward, maintaining confidentiality requires staff members to be both knowledgeable and attentive to client’s needs. Here are practical tips to help protect the confidentiality of women who receive HIV testing during labour:

    • Offer HIV testing and counselling when the client is alone and feels safe to answer openly. Spouses, partners, and other family members may not know her sexual, reproductive, or HIV testing history; this information should not be disclosed to them without her consent.
    • Ask the client in labour ahead of time whom, if anyone, she would like present when she receives the results of the HIV test. Give test results in the presence of that person, if that is what she has chosen.
    • If the test result is positive, ensure confidentiality when discussing ART.
    • If possible provide an interpreter if needed, rather than asking family members to translate.
    • Develop and implement procedures to ensure the confidentiality of HIV test results received in the delivery units. Document the results in the chart or in the register and when transferring information to the post-delivery and newborn care units. The system should both maintain confidentiality and ensure that results are communicated promptly to clinical staff who are providing care to the woman and the newborn.
    Counselling

    Pre-test information can be provided in a group setting, but all people should have the opportunity to ask questions in a private setting if they request it. All HIV testing must be accompanied by appropriate and high-quality post-test counselling, based on the specific HIV test result and HIV status reported. Quality assurance (QA) mechanisms as well as supportive supervision and mentoring systems should be in place to ensure the provision of high-quality counselling.

    Pre-test information for women who are pregnant, in labour, or are postpartum should also include:

    • The potential risk of transmitting HIV to the infant
    • Measures that can be taken to reduce mother-to-child transmission, including the provision of ART to benefit the mother and prevent HIV transmission to the infant
    • Counselling on infant feeding practices to reduce the risk of HIV transmission
    • The benefits of early HIV diagnosis for mothers and infants
    • Encouragement for partner testing

    Post-test counselling, support, and services: The HIV test result should always be given in person to the woman.

    Correct

    You should strive to provide high-quality testing services and QA mechanisms should ensure that people receive a correct diagnosis. QA may include internal and external measures and should receive support from the national reference laboratory. All people who receive a positive HIV diagnosis should be retested to verify their diagnosis before initiation of HIV care or treatment.

    Connection

    Along with the result, you should provide referral linkages with HIV care services. Linkage to prevention, treatment, and care services should include effective and appropriate follow-up, including long-term prevention and treatment support.

    The Sixth C

    For a woman in labour, there is an additional C (for comfort).

    You should assess the client’s stage of labour, comfort level, and need for analgesics. Show empathy while presenting information about HIV testing and counselling. The content should be short, to the point, and explained based on the comfort level of the woman (i.e., between contractions). You should ask the woman to signal for a pause when a contraction is starting. The client’s language and culture deserve consideration. Terminology should suit her level of understanding. You should check after each point to make sure that the client understands the information.

    Be sure to tailor all messages to the client’s level of understanding, but all clients benefit when information is simple and clear. Women who opt out of an HIV test need to have the barriers to HIV testing and counselling addressed and be given information about how to reduce HIV transmission.

  • Male Involvement (5 min)

    Take a moment to think about the benefits of male partner involvement in PMTCT. In the space below type in at least two benefits and then tap the compare answer button.

    Your efforts at PMTCT of HIV should be as comprehensive as possible, recognising and supporting the involvement of partners in PMTCT services. Partners need to be aware of the importance of safer sex practices (i.e., correct and consistent use of condoms throughout the pregnancy and breastfeeding period).

    Important steps in involving male partners are:

    • Informing men and women about the risks of MTCT of HIV and services available to reduce these risks
    • Recommending HIV testing and counselling for the partner as well as the client
    • Encouraging and supporting disclosure and, where possible, encouraging couple counselling
    • Sensitization on existence of male mobilizers, their scope of work, and how to strengthen male engagement through their utilization

    ART in the Male Partner

    All HIV-positive partners of pregnant and breastfeeding women are eligible for ART. You should start this within MNCH settings on the day of diagnosis, or as soon as possible thereafter.

  • Chiedza (15 min)

    Chiedza is 19 years old and comes to the clinic for her first ANC visit. She tells you she is almost six months pregnant and has no other children. When asked why she waited to come in she tells you that her mother and grandmother had her checked by the local traditional birth attendant in her village. Because she was doing well and feeling fine, she didn’t think it was necessary to come to the clinic.

    Chiedza is here today because she wants to make sure her baby is okay. She didn’t tell her family she was coming to clinic.

    Her past medical history includes treatment for an STI, which cleared up. She told her boyfriend about her infection, and he said he went to a clinic and was treated. She also tells you she had an HIV test last year and it was negative. Her boyfriend told her he was negative.

    Chiedza appears nervous. When you ask her about her boyfriend and his feelings about the pregnancy, she tells you he isn’t happy that she’s pregnant. He drives a truck and his work takes him away from her for several days every week. That’s why he’s not with her today. He’s not sure if he can support her and the baby, but she’s planning on finding another job since she is only working part-time.

    You complete a physical exam and discuss taking an HIV test. She tells you she doesn’t understand why she needs another HIV test since the last one she took was negative.

    1What will you tell Chiedza is the reason for HIV testing at today’s visit? Select all that apply.

    Chiedza agrees to take the HIV test. You conduct pre-test counselling with Chiedza before giving her the HIV test.

    2Select all the statements you will say to Chiedza about the HIV test during your pre-test counselling.

    3It’s OK to say all the following statements to Chiedza about disclosing her status except

    4Select all the statements you will say to Chiedza about risk reduction.

    5Select all the statements you will say to Chiedza if the test is positive.

    Chiedza’s HIV test result comes back positive. She begins crying and telling you that the results are wrong. She feels perfectly fine and is not sick. She tells you that the counsellor last year told her that if she felt sick, she should get another test done, but she never felt sick! The only problem she had was a rash under her arm and on her chest about a year ago. The medicine that the traditional healer gave her worked and it went away.

    6You conduct post-test counselling with Chiedza. Select all the statements you will say to her in your counselling session.

    7Select all the statements you will say to Chiedza about talking to her boyfriend.

  • Key Points (5 min)
    • Lifelong ART is provided to HIV-positive pregnant or lactating women regardless of their CD4 count or clinical stage.
    • The PMTCT programme in Zimbabwe began in 1999 and has evolved over the years to the current focus of elimination of mother-to-child transmission of HIV and syphilis.
    • The guiding principles of PITC for HIV should be adhered to when providing HTS for pregnant and breastfeeding women.
    • The sixth C should be used when providing HTS during labour and delivery, ensuring comfort for the client.
    • Provision of ART for the male partner should be provided for in MNCH services.