Elimination of Mother-to-Child Transmission of HIV (EMTCT) 5.7.4

The four prongs of EMTCT:

Prong 1 – Primary prevention of HIV among women of childbearing age
Prong 2 – Prevention of unintended pregnancies among women living with HIV
Prong 3 – Prevention of HIV from mother to her infant
Prong 4 – Provision of appropriate treatment, care and support to women and children living with HIV and their families.

Prevention of Mother-to-Child Transmission

There are better clinical and laboratory outcomes if HIV treatment is initiated early.
Initiate cART immediately among all pregnant or breastfeeding women who test positive within Maternal Newborn Child Health (MNCH) services.
Treatment preparation and adherence counselling should be accelerated so that it is completed on the same day where feasible.
Initiation may be done by ART trained nurses/midwives within MNCH.
Where there is no capacity within MNCH to initiate cART the pregnant woman should be fast-tracked through the ART clinic.
Start Cotrimoxazole among all HIV infected pregnant women regardless of gestational age, CD4 count or WHO clinical staging.
Viral load should be performed within 4 weeks before labour and delivery to estimate the risk of transmission for all pregnant women on cART.
At 6 weeks postnatal, check CD4 count and if >350cells/ul on two results, Cotrimoxazole may be discontinued.

Combination antiretroviral therapy (cART) for eMTCT

First-line cART

For ARV naïve or sure of tail coverage 1st line cART is TDF + XTC + DTG - alternative regimen is TDF + XTC + or EFV₄₀₀ or TDF + XTC + ATV-_r (or LPV-_r) or ABC +3TC +ATV-_r (or LPV-_r) or ABC + 3TC + DTG
For previous single dose Niverapine (sdNVP) exposure; or Niverapine (NVP) monotherapy exposure, or unsure of tail coverage 1st line cART is TDF + XTC + DTG
Alternative regimen is TDF + XTC + ATV-_r (or LPV-_r) or ABC + 3TC + ATV-_r (or LPV-_r).

Second- line cART

DTG and NNRTI –based first-line regimens can be substituted by AZT +3TC + LPV-_r (or ATV-_r)

Table 146:Combination antiretroviral therapy (cART) for eMTCT

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)
	HIV Prevention	Counsel and Initiate PrEP if eligible	Provide condoms or information on where to access condoms, including female condoms

Elimination of Mother-to-Child Transmission of HIV (EMTCT)

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	Screen for Hep B, Syphilis and OIs If positive treat client plus partner
		Counsel and Initiate PrEP if eligible	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

Specific Population	Description	Child-bearing Female with Negative HIV Test Result*	Child-bearing Female with Positive HIV Test Result*
	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
		Counsel and Initiate PrEP if eligible	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
	Labor and Delivery	Do HIV test if done >6 weeks	Counsel and continue/Initiate ART

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) Scheduled immunization

Adherence Counselling and continue/Initiate ART

Infant Feeding Counselling

Specific Population	Description	Child-bearing Female with Negative HIV Test Result	Child-bearing Female with Positive HIV Test Result
			Positive NAT	Negative NAT
			Send fresh DBS or blood for confirmatory NAT Initiate treatment AZT+3TC+NVP for 14 days and thereafter change to the ABC+3TC+LPV-r If RPR is positive treat congenital syphilis	Initiate AZT+3TC+NVP prophylaxis for 12 weeks If RPR is positive treat for congenital syphilis
	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 initiate on ABC+3TC+LPV-r 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
	10 weeks		Continue Co- trimoxazole. Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+LPV-r	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	Negative NAT	If mother virally suppressed continue same regimen Mother not virally take action to ensure mother is on more efficacious regimen

Specific

Population

Description

Child-bearing Female with Negative HIV Test Result

Child-bearing Female with Positive HIV Test Result

Continue Co- trimoxazole. Continue ART Continue adherence counselling Scheduled immunization Initiate any newly diagnosed to ABC+3TC+LPV-r

If mother virally suppressed stop AZT+3TC+NVP

Mother not virally suppressed continue AZT+3TC+NVP

Scheduled immunization

Management of HIV-exposed infants

High-risk HIV exposed infants
1. Born to women with established HIV infection and has received less than 12 weeks of cART at the time of delivery or
2. Born to women with established HIV infection with viral load >1000 copies/ml within the four weeks before delivery:

Management

Start or continue cART immediately for the mother and all exposed infants to be put on AZT/3TC+NVP for 12 weeks.

Note: The use of NVP is only for prophylaxis in infants and treatment for up to 2 weeks of age in absence of Raltegravir.

b. High risk exposed infants
1. Born to women with established HIV infection not on cART;
2. Born to known HIV positive woman who refuses cART.

Management

Start or continue cART immediately/continue counselling for the need to start therapy. Suggest to start cART with the possibility of stopping after delivery (Option B) while counselling continues toward the mother accepting lifelong cART (Option B+).
Prophylactic ART (AZT/3TC+NVP) until confirmed final outcome HIV negative after complete cessation of breastfeeding.

Low-risk HIV exposed infants

Known HIV positive women on cART for more than 12 weeks, continue cART for the mother and all exposed infants to be put on AZT/3TC +NVP for 6 weeks.
HIV negative mother with a known positive partner does a nucleic acid test (NAT), if negative, continue pre-exposure prophylaxis (PrEP) and provide HIV testing services every 3 months. If NAT on mother is positive do NAT on the baby.

Zambia

Elimination of Mother-to-Child Transmission of HIV (EMTCT) 5.7.4