Elimination of mother to child transmission of HIV (EMTCT)

Globally mother to child transmission of HIV is a significant contributor (9%) of paediatric HIV infections. In Africa more than 95% of paediatric HIV infections are due to mother to child transmission of HIV. The goal is to eliminate MTCT of HIV, Syphilis and HBV (Triple EMTCT).

The implementation of this triple elimination of HIV, Syphilis and Hepatitis B is outlined in the following Tables.

Pre-Pregnancy and Adolescents

Pre-Pregnancy and Adolescents

Specific Population	Description	Child-bearing Female with Negative HIV Test Result	Child-bearing Female with Positive HIV Test Result
Pre-Pregnancy/ Adolescents	Family Planning/ Contraception	Counsel on family planning and offer dual method of contraception with either of the following: Progestogen-only contraceptive methods without restriction Copper-bearing Intrauterine Devices (Cu-IUDs) and LNG-IUDs without restriction Combined hormonal contraceptive methods without restriction	Counsel on family planning and offer dual method of contraception with either of the following: Progestogen-only contraceptive methods without restriction Copper-bearing Intrauterine Devices (Cu-IUDs) and LNG-IUDs without restriction Combined hormonal contraceptive methods without restriction
	Co-morbidity	Screen for Hep B and Syphilis: If positive treat client plus partner	Screen for Hep B, Syphilis and OIs, if positive treat client plus partner
	HIV Prevention	Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention Retest for HIV every 3 months	Counsel and continue/Initiate ART Positive Health Dignity and Prevention (PHDP)
		Counsel and Initiate PrEP if eligible	Provide condoms or information on where to access condoms, including female condoms

Pregnancy

Pregnancy

Specific Population	Description	Child-bearing Female with Negative HIV Test Result*	Child-bearing Female with Positive HIV Test Result*
Pregnancy	1st Trimester	Screen for Hep B and Syphilis. If positive treat client plus partner	Counsel and continue/Initiate ART
		Counsel and Initiate PrEP if eligible (see for eligibility criteria)	Screen for Hep B, Syphilis and OIs If positive treat client plus partner
			At ANC1, for known positives on ART, check if VL was done: if > 3 months retest, and thereafter every 3 months For those who initiate ART in ANC do VL at 3 months, thereafter, retest every 3 months
		Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention Retest for HIV every 3 months	Provide condoms or information on where to access condoms, including female condoms
	2nd Trimester	Screen for Hep B and Syphilis. If positive treat client plus partner	Counsel and continue/Initiate ART
		Counsel and initiate PrEP if eligible	Screen for Hep B, Syphilis and OIs, if positive treat client plus partner
		Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention Retest for HIV every 3 months	At ANC1, for known positives on ART, check if VL was done: if > 3 months retest, and thereafter every 3 months For those who initiate ART in ANC do VL at 3 months, thereafter, retest every 3 months
			Provide condoms or information on where to access condoms, including female condoms
	3rd Trimester	Screen for Hep B and Syphilis. If positive treat client plus partner	Counsel and continue/Initiate ART
		Counsel and Initiate PrEP if eligible	Screen for Hep B, Syphilis and OIs, if positive treat client plus partner
			Check if VL was done/do if not done and if > 3 months repeat Repeat viral load 1-4 weeks before delivery
		Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention Retest for HIV every 3 months	Provide condoms or information on where to access condoms, including female condoms
	Labour and delivery	Do HIV test if done > 6 weeks	Counsel and continue /Initiate ART

ANC1 = First antenatal visit; OIs = Opportunistic Infections

*Duo HIV/Syphilis Test kits should be used to test for both HIV and Syphilis in pregnant women and their sexual partners.

Infants and Children

Infants and Children

Specific Population	Description	Child-bearing Female with Negative HIV Test Result	Child-bearing Female with Positive HIV Test Result
Children	Birth	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention	HIV Exposed Infant/Child		Mother
			Send DBS or fresh blood for NAT Send blood for Syphilis (RPR) where indicated Scheduled immunization		Adherence Counselling and continue/ Initiate ART Infant Feeding Counselling
			Positive NAT	Negative NAT
			Term infants; Initiate treatment AZT+3TC+NVP until 4 weeks old and weight ≥ 3kg. Thereafter change to the ABC+3TC+DTG Preterm infants; Initiate treatment AZT+3TC+NVP until 40+4weeks old and weight ≥ 3kg. Thereafter change to the ABC+3TC+DTG Send fresh DBS or blood for confirmatory NAT Treat for congenital Syphilis as in Negative NAT infants	Initiate AZT+3TC+NVP prophylaxis for 12 weeks. Treat for congenital Syphilis if Infant has clinical symptoms of congenital Syphilis Infant has tested positive for Syphilis Mother has Syphilis but was not treated, or inadequately treated (< 30 days before delivery), or treated with non- penicillin drugs during pregnancy
	6 weeks	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	Positive NAT	Negative NAT	Adherence Counselling and continue/Initiate ART Infant Feeding Counselling
			Start Co-trimoxazole Continue ART Scheduled immunization Newly diagnosed and weight ≥ 3kg initiate on ABC+3TC+DTG Continue adherence counselling	Start Co-trimoxazole Send DBS or fresh blood for NAT Continue AZT+3TC+NVP prophylaxis BUT if never breastfed, stop the AZT+3TC+NVP prophylaxis Scheduled immunization
	10 weeks	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	Positive NAT	Negative NAT	Viral Load Testing in the mother Adherence Counselling and continue/Initiate ART Infant Feeding Counselling
			Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Continue Co- trimoxazole Continue AZT+3TC+NVP Scheduled immunization
	14 weeks	Do HIV test if done > 6 weeks Counsel and initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	Positive NAT Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Negative NAT If mother virally suppressed stop AZT+3TC+NVP Mother not virally suppressed continue AZT+3TC+NVP Scheduled immunization	If mother virally suppressed continue same regimen If mother not virally suppressed, take action to ensure she is on more efficacious regimen

	6 months	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	Positive NAT	Positive NAT	Viral load Adherence counselling Continue ART Review in 2-4 weeks with results of viral load [within or at time of next child visit]
			Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG
	9 months	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	Positive NAT	Negative NAT	Viral load Adherence counselling Continue ART Review in 2-4 weeks with results of viral load [within or at time of next child visit]
			Continue Co- trimoxazole. Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Send DBS or fresh blood for NAT At next child visit, Stop AZT+3TC+NVP prophylaxis if mother suppressed Continue AZT+3TC+NVP if mother not suppressed If NAT positive start ABC+3TC+DTG Scheduled immunization
	12 months	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	Positive NAT	Negative NAT	Viral load Adherence counselling Continue ART Review in 2-4 weeks with results of viral load. [within or at time of next child visit]
			Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Do serology test if positive send DBS or fresh blood for NAT At next child visit, Stop AZT+3TC+NVP prophylaxis if mother suppressed Continue AZT+3TC+NVP if mother not suppressed If NAT positive start ABC+3TC+DTG Scheduled immunization
	18 months	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	HIV Positive (Serology then NAT)	HIV Negative	Viral load Adherence counselling Continue ART Review in 2-4 weeks with results of viral load. [within or at time of next child visit]
			Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Do serology test if positive send DBS or fresh blood for NAT At next child visit, Stop AZT+3TC+NVP prophylaxis if mother suppressed. Continue AZT+3TC+NVP if mother not suppressed If NAT positive start ABC+3TC+DTG Scheduled immunization
	24 months	Do HIV test if done > 6 weeks Counsel and Initiate PrEP if eligible Counsel client and partner on HIV combination prevention Provide condoms or information on where to access condoms, including female condoms Refer to youth friendly services for more comprehensive sexual information, including HIV prevention	HIV Positive (Serology then NAT)	HIV Negative	Viral load Adherence counselling Continue ART Review in 2-4 weeks with results of viral load. [within or at time of next child visit]
			Continue Co- trimoxazole Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+DTG	Do serology test if positive send DBS or fresh blood for NAT At next child visit, Stop AZT+3TC+NVP prophylaxis if mother suppressed Continue AZT+3TC+NVP if mother not suppressed If NAT positive start ABC+3TC+DTG Scheduled immunization

Infant Prophylaxis Dosing

Infant Prophylaxis Dosing

Treatment

Management of an HIV-Exposed Infant (HEI) and Extended Prophylaxis

All HEI should receive prophylaxis for at least 12 weeks with AZT + 3TC plus NVP to be stopped when there is a documented suppressed Viral Load in the mother at 3 months postnatally. See Tables X and X for the weight-based dosing.

In a situation where the Viral Load of the mother is unsuppressed (or the mother not on ART), the prophylaxis should be documented while closely monitoring for side effects in the baby. This prophylaxis should be extended until the mother is suppressed or one-week post-breast-feeding cessation.

Where the mother refuses to be on treatment, continued counselling should be done, and ART initiated as soon as possible while the baby is on extended prophylaxis

Simplified Infant Prophylaxis Dosing

Weight Band	NVP 10mg/ mL	AZT/3TC 60/30mg tablet dissolved in 6mL of water (10mg/5mg/mL)
Birth weight < 2kg	0.8mL OD	0.8mL BD
Birth weight 2 – 2.499kg	1mL OD	1mL BD
Birth weight > 2.5kg	1.5mL OD	1.5mL BD
6 weeks to < 6 months old	2mL OD	Use treatment dose based on infant’s weight
6 months to 9 months old	3mL OD	Use treatment dose based on infant’s weight (Table xx)
9 months old to 1 week after cessation of breast-feeding	4mL OD	Use treatment dose based on infant’s weight (Table xx)

Simplified Dosing Chart for AZT/3TC Prophylaxis

Weight Band	Strength of AZT/3TC Tablet	AZT/3TC Dosage for Prophylaxis
3 – 5.9kg	60/30mg	1 tablet BD
6 – 9.9kg	60/30mg	1.5 tablets BD
10 – 13.9kg	60/30mg	2 tablets BD
14 – 19.9kg	60/30mg	2.5 tablets BD

NOTE: AZT/3TC is a dispersible tablet containing AZT = 60mg and 3TC = 30mg:

Dissolve one dispersible tablet into 6mL of water; 1mL of the suspension will contain 10mg of AZT and 5mg of 3TC
Take NOTE that the suspension made should be kept in a cool place! Daily reconstitution is recommended to assure stability of the suspension
Shake the suspension before use
Care givers should be educated by the pharmacists and clinicians on how to reconstitute the AZT/3TC dispersible Care givers should demonstrate to the pharmacists on how they are reconstituting these formulations.
Care givers should demonstrate to the pharmacist on how they are reconstituting these formulations
Infants weighing < 2kg should receive 2mg/kg NVP once daily and 2mg/kg once daily calculated based on the AZT in the AZT/3TC
For complicated cases e.g., severe AZT induced anaemia, consult a medical officer with appropriate training or call 7040

Zambia

Elimination of mother to child transmission of HIV (EMTCT)

Pre-Pregnancy and Adolescents

Pregnancy

Infants and Children

Infant Prophylaxis Dosing