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

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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)

EMTCT in Pregnancy and Women of child-bearing age

Description HIV-Negative Female of child-bearing age HIV-Positive Female of child-bearing age
1st Trimester Screen for Hep-B, Syphilis; if +ve treat client +ve partner Counsel and continue/Initiate ART
Counsel and Initiate PrEP if eligible Screen for Hep-B, Syphilis and OIs; if +ve treat client + partner
• At ANC1, for known +ves on ART, check if VL was done: if >3 months retest, if >3 months repeat, 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, Syphilis
If +ve treat client + partner		 Counsel and continue/Initiate ART
Counsel and Initiate PrEP if eligible Screen for Hep B, Syphilis and OIs, if +ve treat client + 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 +ves 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, Syphilis
If +ve treat client + partner		 Counsel and continue/Initiate ART
Counsel and Initiate PrEP if eligible Screen for Hep B, Syphilis and OIs, if +ve treat client + 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		 • Check if VL was done/do if not done and if >3 months repeat
• Repeat viral load 1- 4 weeks before delivery
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

Management of HIV-exposed infants

  1. 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

  1. 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.
  2. 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.