Prevention of Mother-To-Child- Transmission (PMTCT) of HIV Flashcards
The transmission of HIV from an HIV-positive mother to her child during __________ , __________, __________ or __________ is called mother-to-child transmission (MTCT).
pregnancy
labour
delivery
breastfeeding
In the absence of any interventions, the risk of transmission is _____% in non-breastfeeding populations and ________% if breastfeeding occurs.
Therefore, Breastfeeding by an infected mother adds an additional ______% risk
15−30%
15-45%
5-20% risk
Overall, _________ accounts for 40% of all MTCT transmission in the absence of any interventions.
This rate can be reduced to levels below 5% with effective interventions in breastfeeding population and to less than 2 % in __________ infants.
breastfeeding
formula-fed infants.
The development of _________________ for the diagnosis of HIV in 1989 made it easier to distinguish between babies infected before or during birth and those infected during infancy.
This assisted in the more accurate estimates of the risk of transmission through breastfeeding, which was still unknown but was initially believed to be (low or high?).
Polymerase Chain Reaction (PCR)
low.
88% of HIV infections in children are as a result of _____________
mother-to- child transmission (MTCT)
Without ARV drugs during pregnancy, risk of transmission from mother to infant is 1 in 4
Pediatric AIDS Clinical Trials Group (PACTG) 076 found that by giving ___________ to the pregnant woman during pregnancy, labor, and delivery, and to her newborn, transmission could be reduced to 8%
zidovudine (ZDV)
Currently, the risk of perinatal transmission can be less than 2%
(1 in 50) with:
_________
_________ as appropriate
_________
Highly effective ARV therapy (HAART) Elective Cesarean section
Formula feeding
Timing of Perinatal HIV Transmission: Non-Breastfeeding Women
Intrauterine (before 36 weeks) ~______% of cases
● Virologic detection of HIV in newborn at ______days of life
Peripartum ~_____% of cases
●Onset of ______________
●Mother-to-fetus ______________
●Labor and ______________
Most transmission occurs close to or during labour and delivery (L&D)
20% ; 1–2
80; placental separation
microtransfusions
rupture of membranes
Factors that enhance HIV transmission
Obstetric Factors
Mode of delivery: _______ delivery (if Viral load >_______ copes/ml)
Intra-partum ___________
Obstetric procedures like:
early rupture of membranes,
routine ___________,
________ delivery or ________ delivery, invasive foetal monitoring during delivery
Vaginal ; 1,000
haemorrhage; episiotomies,
vacuum ; forceps
Factors that enhance HIV transmission
Infant factors
_________
_________ for gestation age
_________ or ________ pregnancy
______ feeding
Mixed feeding (breast milk with water, formula, other liquids or solids)
Oral _________ e.g. oral thrush, mouth ulcers, gastritis
Pre-maturity
Small
Twin or multiple
Breast
Oral lesions
Twin or multiple pregnancy
______ twin - increased risk compared to ______ twin
Individual genetic susceptibility
First
second
Factors that enhance HIV transmission
Postnatal Factors
About 10-18% additional risk of transmission from ____________
Risk highest in __________ but continues throughout ___________
breastfeeding
early infancy
breastfeeding
Timing of HIV transmission postnatally
Transmission can occur anytime during breastfeeding – from the ________ after delivery through colostrum/early milk and later months through mature milk until __________________________ ends.
The rate of post natal transmission of HIV is estimated to be constant at 0.8% per month throughout the period of breastfeeding.
first days
all breast milk exposure ends.
Timing of HIV transmission postnatally
Currently, it is not possible to distinguish in a breastfed child whether an infection that is not detectable by PCR at birth but becomes detectable by PCR around 4-6 weeks was acquired during the intrapartum period or whether it was acquired through colostrum or early breastfeeding .
Why???
Due to persistence of maternal antibodies and the presence of a “window period” during which infection is undetectable using currently available technology.
Comprehensive approach to prevention of MTCT
The prevention of mother-to-child transmission of HIV involves all persons of reproductive age group. It is based on the WHO four-pronged approach, which are:
________ prevention of HIV infection in women of _____________________
Prevention of ____________ among HIV positive women
Prevention of ______________ from infected mothers to their infants
Provision of _______________, care and support to HIV-infected mothers, their infants and family
Primary ; reproductive age and their partners
unintended pregnancies
HIV transmission
appropriate treatment
HIV-infected CD4 cells have a greater capacity to replicate in (breast milk or blood?) than in (breast milk or blood?).
breast milk
blood
A protein called ________ or ________ in breast milk was recently shown to have the capacity to neutralizes HIV and may protect babies from acquiring HIV from their infected mothers
Tenascin-C
TNC
Primary Prevention of HIV
Primary prevention of HIV infection in women of reproductive age and their partners include the:
Use of the “ABC” approach to enhance safer and responsible sexual behaviour and practices. This includes the following:
A = ____________
B = ____________
C = ________ use
Abstinence
Be faithful
Condom use
Elimination of Mother-to-Child-Transmission (EMTCT) of HIV
This initiative has become one of the greatest public health achievements possible when _______, in June 2015 became the first country in the world to be certified by WHO to have successfully eliminated transmission of HIV from mother to child.
Since then, more countries in the word have succeeded in eliminating HIV transmission from mother to child.
Cuba
Factors that enhance HIV transmission:
Viral Factors:
Virulence of the transmitted strain
•HIV-____ is more aggressive and more easily transmitted than HIV-___
•Subtype-____ is more aggressive and more easily transmitted than other sub types
HIV-1
HIV-2
Subtype-C
Factors that enhance HIV transmission:
Maternal Factors
High Viral Load
_________ infection
________ stage of ________
Low ________ counts
Nutrient deficiencies : ________ , ________
Other co-infections
______, _______, bacterial vaginosis, ______
Placental problems: ________, ________
Acute infection ; Advanced stage ; AIDS
CD4 ; Vitamin A ; anaemia
STIs ; malaria ; TB
abruption ; chorioamnionitis
Minimum of Package of care - Antenatal care
Provision of quality antenatal care
At least _____ antenatal visits
Vitamin & micronutrient supplementation
Screening and treatment of STI’s
Screening and treatment for anemia (iron and folate supplementation) + routine de-worming
Intermittent presumptive treatment for malaria x 3 starting from ______ trimester
Provision of routine HIV counseling and testing services.
Commence all HIV positive women on ________-Option _____
Infant feeding counseling to guide informed choice
4
2nd
HAART
Option B+
ARV-prophylaxis options recommended for HIV-infected pregnant women
Mother
Antepartum _____-daily AZT starting from as early as _____weeks of gestation and continued during pregnancy. At onset of labour, _______ and initiation of twice daily ______ + ______ for ____ days postpartum.
(Note: If maternal AZT was provided for more than 4 weeks antenatally, omission of the sd-NVP and AZT + 3TC tail can be considered; in this case, continue maternal AZT during labour and stop at delivery)
twice ; 14 weeks
sd-NVP ; AZT ; 3TC
7 days
ARV-prophylaxis options recommended for HIV-infected pregnant women
Infant
Irrespective of mode of infant feeding
Daily ______ or twice daily _______ from ______ until ______________of age.
NVP
AZT
birth
4 to 6 weeks
P-3 Intrapartum Care
Delivery in a health facility* Safe delivery
Avoid prolonged _____________ and avoid routine ____________________ unless medically indicated
Minimize use of invasive procedures-________ , ___________ , ___________ or aggressive ___________
Cleanse vagina with 0.25% ___________ solution with every vaginal examination
rupture of membranes
artificial rupture of membranes
episiotomy ; vacuum delivery
forceps delivery ; neonatal suction
chlorhexidine
NB: Chlorhexidine vaginal douches have been shown to reduce the incidence of _______________________ , but not of _______________ unless ????????
some neonatal and maternal infections,
HIV transmission
The membranes are ruptured for longer than four ho
P-3 Elective Caesarian section
Elective Caesarian section (before the onset of labour or the rupture of membranes) significantly __________ mother-to-child transmission of HIV
This intervention is not routinely offered because of
____________ to support this intervention on a wide scale
Risk of post-operative ______________ in the woman.
High __________ rates and _____________ in low resource settings
reduces
Lack of resources
morbidity and mortality
High fertility rates ; HIV seroprevalence
For women on ART, caesarean section is probably only indicated in women with a ________________________________\ at time of delivery.
detectable viral load (Viral load >1,000copies/ml)
HIV Transmission and Cesarean Delivery
● Cesarean section recommended:
● For women with HIV RNA levels >_______ near time of delivery
● For women with ____________ HIV RNA levels
● Schedule at ____ weeks
> 1,000 ; unknown
38 weeks
● Benefits of Cesarean is unclear after _______ or ___________ : base decision on clinical factors
● Benefits of Cesarean unclear for women with HIV RNA levels ________ on combination ARVs
ROM ; onset of labor:
<1,000
Management of Membrane Rupture
● Risk of transmission with rupture of membranes (ROM) increases with ______
● If labor is progressing and membranes are intact, avoid ____________ and ________________
time
artificial ROM ; invasive monitoring
Women scheduled for Cesarean who present with premature rupture of membranes (PROM):
individualize management
● Duration of rupture, progress of labor
● HIV RNA level, current ARV regimen
….
ARV prophylaxis for the HIV exposed
Infant.
When NVP is not available and AZT has to be used, _____ should be monitored closely for early detection of ________
HB
Anaemia
NVP-??
Nevirapine
Special situations for extended ARV
prophylaxis for HIV exposed Infants at High Risk of MTCT
Breastfed infants who are at high risk of acquiring HIV should continue infant prophylaxis for an additional _________ (total of ___________ of infant prophylaxis) using AZT (______ daily) and NVP (_______ daily).
6 weeks
12 weeks
twice daily
once daily
High-risk infants are defined as those:
Born to women with established HIV infection who have received ___________________________ at the time of delivery
OR
Born to women with established HIV infection with __________________________________ before delivery, if viral load measurement available;
OR
Born to women with ___________________________ during pregnancy or breastfeeding;
OR
Identified for the first time during the ____________ period, with or without a ____________________________.
less than four weeks of ART
viral load >1000 copies/mL in the four weeks
incident HIV infection
postpartum period, with or without a negative HIV test prenatally.
___________________ prophylaxis is recommended for HIV-exposed infants from 6 weeks of age and should be continued until HIV infection has been excluded by an age-appropriate HIV test 12 weeks after complete cessation of breastfeeding.
Cotrimoxazole
Complementary feeding- the ______________________________________________________________________________________ when breast milk/formula becomes insufficient to satisfy all the nutritional requirements of the infant. This usually occurs around _________ of age.
addition of any food, whether manufactured or locally prepared, to breast milk or formula
6 months
Early cessation of breastfeeding- the mother _________________ including __________ before she would have otherwise done. This can occur as early as the ___________ of life and anytime before ____________ of age.
stops all breastfeeding
suckling
first weeks
12 months
Exclusive breastfeeding (EBF)-infant receives _______________ and no other liquids or solids including _______________________ , except prescribed medications such as ________ , _______ supplements or ___________ .
only breast milk
water, tea, and commercial formula,
vitamins ; mineral supplements ; medicine.
Formula feeding (FF)- use of _____________________ feeding which is formulated industrially in accordance with applicable __________
commercial infant feeding
Codex
HIV-free survival- child is _______ and does ____________ HIV infection.
Home-modified animal milk- a ______________ prepared at _____ from _______________________ by ________ and _____________ and ____________
alive ; does NOT acquire
breast milk substitute ; home
fresh or processed animal milk
diluting with water
adding sugar
micronutrients.
Mixed feeding or partial breastfeeding- feeding _________________________________ prior to six months of age.
Postnatal transmission (PNT) – mother-to-child-transmission of HIV occurring _______ delivery through ______________.
breast milk and other liquids and or solids
after ; breastfeeding.
Replacement feedings- feeding infants with ________________ or __________________ instead of _____________ until the child is fully fed on family food.
commercial infant formula
home modified animal milk
breastfeeding
Weaning-period when the child is transitioned from ________ to a diet ___________________________.
breastfeeding
completely devoid of any breast milk.
Feeding guidelines for HIV-positive infants
If an infant is discovered to be HIV positive, mothers are encouraged to ______________________ for the first _________ and _______________ for up to ______________ while _________ feeding is being introduced.
exclusively breastfeed
6 months
continue breastfeeding
2 years
Studies have shown that early cessation of breastfeeding for HIV positive infants can ______rease mortality compared with an extended breastfeeding period.
Increase
Advice for HIV-positive mothers in high-income countries
National health agencies and the WHO 2013 guidelines recommend that HIV-positive mothers in high-income countries:
avoid ___________: risk of HIV transmission is far greater than the risk of _____________ feeding
breastfeeding
replacement feeding
_______________ feed: the only infant feeding method that does not expose an infant to HIV
replacement
Replacement feeding means giving a _________________________ (prepared from powder and boiling water) or ____________________________ (boiled with added water, sugar and micronutrients) instead of breast milk.
In regions of the world where clean water and facilities are available; it is usually promoted as the only option.
baby commercial infant formula
home- modified animal milk
The risk of transmitting HIV to her infant during breastfeeding is higher in certain conditions such as:
•When the woman is __________
•When she has _________ , a breast _________, or other similar conditions
•When the child has _________ in the mouth
•When breastfeeding is _________
more ill
mastitis ; abscess
ulcers ; prolonged
Breast milk substitute provides protection against infection
T/F
F
Unlike breastfeeding, it does not provide protection against infections.
Early Infant Diagnosis (EID)
All HIV–exposed infants should have initial DNA PCR testing at _________ of age (or earliest opportunity thereafter) and __________ after ____________________________________.
12 weeks
6 weeks
complete cessation of breastfeeding.
Children with advanced and symptomatic HIV infection (CD4 < 200 or < 14%, or Stage 3 or 4 disease), (should or should not?) be given live vaccines (______,_______,________,_________, and __________ vaccine).
Should not
BCG, varicella-zoster, OPV, measles and yellow fever
________ polio vaccine may cause disease in HIV infected children. Symptomatic HIV infected children should therefore be given the _________ polio vaccine (intramuscular).
Oral
Inactivated
HIV EXPOSED INFANTS
what do you do??
Breastfeeding :
Replacement feeding:
Daily NVP for 6 weeks then EID at 6-8th week
6weeks of NVP or twice daily AZT
