Module 2 Overview of HIV Prevention in Mothers

Malawi PMTCT Participant Manual

Module 2 Overview of HIV Prevention in Mothers, Infants and Young Children

After completing the module, the participant will be able to:  Discuss the epidemiology of MTCT in Malawi.  Discuss biological, social and cultural factors explaining women’s vulnerability to HIV infection.  Define mother-to-child transmission of HV infection (MTCT).  Explain the factors that influence the transmission of HIV from mother to child.  Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children.  Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children.

Module 2 Overview of HIV Prevention in Mothers, Infants and Young Children 2-1 Malawi PMTCT Participant Manual

UNIT 1 HIV in Malawi

After completing the unit, the participant will be able to:  Discuss the epidemiology of MTCT in Malawi.  Discuss biological, social and cultural factors explaining women’s vulnerability to HIV infection.

MTCT epidemiology in Malawi Review of national HIV, AIDS and MTCT facts and figures The implications of the epidemic are serious:  According to UNICEF, there are over 800,000 orphans in Malawi. The cumulative number of orphans in this country is directly related to the AIDS epidemic is approximately 400,000. This figure is expected to increase by more than 60,000 per year.  The death rate for adults aged 15-49 has tripled since 1990.  The number of tuberculosis cases is triple what it would have been without the HIV epidemic.

The need for expanded services is large:  Approximately 185,000 people were in need of antiretroviral treatment as of 2005.  An even larger number need testing and counselling services to learn their HIV status.  About 500,000 pregnant women who need comprehensive antenatal care, including HIV testing and counselling.  About 80,000 of these women will be HIV-infected and will need PMTCT services to prevent passing HIV to their children.

Exercise 2.1 Epidemiology of HIV: interactive discussion Purpose To involve the participants in a discussion about the local epidemiology of HIV. Duration 10 minutes Instructions The trainer will ask that participants :  Share their perspective on the data about HIV infection in Malawi provided in this module and Module 1.  Share their thoughts on factors that are fuelling the epidemic.

Gender and HIV  Both men and women are vulnerable to HIV infection; however, unlike women in other regions in the world, African women are at least 1.3 times more likely to be infected with HIV than men. The gender difference is most pronounced among young people aged 15–24 years. In Malawi, women between the ages of 15 and 24 are 2.2 times more likely to be HIV-infected than their male counterparts in the same age group. In sub-Saharan Africa, women in this age group are 3 times as likely to be HIV-infected as their male counterparts (UNAIDS, Women and AIDS Fact Sheet, Malawi; AIDS Epidemic Update, UNAIDS, December 2004). The female

2-2 Malawi PMTCT Participant Manual

vulnerability to HIV infection has been attributed to many factors: biological, social and cultural.

Socio-cultural factors that make women vulnerable to HIV infection:  Less formal education  Inability of women and young girls to negotiate for safer sex  Vulnerability to, pressure from, and infidelity of male counterparts  Trauma and bleeding caused by sexual intercourse at an early age, and at a time of physical immaturity, increases exposure to HIV infection.  When a woman marries at a young age, she is exposed to older men who may be HIV-infected.  Forced sex due to rape or sexual abuse increases a woman’s risk of infection.  Economic pressures and lack of job opportunities force women to exchange sex for the necessities of survival – food, shelter and safety  Lack of access to appropriate information on HIV and other sexually transmitted infections (STIs).

Biological factors that make women vulnerable to HIV infection:  The cells in the cervix; “the Langerhans” cells, may provide a portal of entry for HIV. It is suggested that some HIV serotypes are attracted to these cells and that they are therefore more efficient for heterosexual transmission of HIV.  Vulva and vaginal inflammation or ulceration may facilitate entry of the virus.  Silent chlamydial and other STI infections (including pelvic inflammatory disease (PID)) may facilitate acquisition of HIV. It has been reported (in Zimbabwe) that women with genital ulceration are 6 times more likely to be HIV positive than women without genital ulcerations.  STIs in women are frequently undiagnosed because:  Asymptomatic infection (symptoms are either not present or observable only on internal examination)  Unable to recognize symptoms  Lack of access to care and treatment services  Changes in the vaginal flora characterized by bacterial vaginosis facilitate transmission of HIV.  Presence of cervical ectopy is a risk factor for HIV transmission.  Sexual intercourse during menstruation increases the risk of HIV transmission.

Socio-cultural factors that influence the sexual behaviour of men. Common risk factors for HIV infection in men include:  Failure to seek proper care for HIV and other STIs due to lack of knowledge, lack of comfort with being in healthcare settings, and/or stigma  Culturally-accepted practice of having multiple sex partners both in and out of wedlock  Ego-driven behaviours to display manhood, including alcohol abuse that may lead to high-risk sexual practices  Peer pressure from other young men to conform to unsafe sex practices without regard for consequences

Youth of both genders are more vulnerable to HIV infection because of the following factors:  Lack of information on sexuality and their own physical development

 Lack of skills to negotiate delaying sexual debut, reducing the number of partners, using condoms correctly and every time they have sex, substance use or abuse  Limited access to health services, including testing and counselling, risk reduction with condom use, and testing and treatment of STIs.

Exercise 2.2 Local HIV-related terminology: interactive discussion Purpose To determine local language used in HIV prevention, care, and treatment programmes. Duration 20 minutes Instructions  A volunteer from the group will discuss the risks of HIV transmission from a mother to her baby during pregnancy, labour and delivery, and when breastfeeding, just as he or she would explain these concepts to a patient.  The trainer will lead a discussion on the words and concepts used (especially those in local languages) that are useful and clear when working with pregnant women. Common words should be offered for important concepts such as window period, condom, HIV, virus, ARVs, replacement feeding, stigma, and disclosure.

UNIT 2 Mother-to-Child Transmission of HIV Infection

After completing the unit, the participant will be able to:  Define mother-to-child transmission of HV infection (MTCT).  Explain the factors that influence the transmission of HIV from mother to child.

Definition: Mother-to-child transmission Mother-to-child transmission (MTCT) is the transmission of HIV from an HIV-infected mother to her baby during pregnancy, labour, delivery and breastfeeding. Mother-to- child transmission (MTCT) is also referred to as vertical transmission or perinatal transmission. The term “MTCT” is used because the direct source of infection is the mother. (Source WHO 2000). However, “MTCT” attaches no blame or stigma to the woman who gives birth to a child who is HIV-infected or becomes infected during breastfeeding. It does not suggest deliberate transmission by the mother, who is often unaware of her own infection status and unfamiliar with how HIV is passed from mother- to-child.

Rates and timing of MTCT The overall MTCT rate is approximately 25%-50% without intervention. Most transmission occurs during labour and delivery, but depending on breastfeeding practices and duration, there is also a substantial risk of HIV transmission during breastfeeding. Figure 2.1 shows that without intervention, up to 50% of infants born to mothers infected with HIV who breastfeed can become HIV-infected.

Figure 2.2: HIV outcomes of infants born to women infected with HIV

100 infants born to HIV-infected women who 50 to 75 infants breastfeed, without any interventions will not be HIV-infected

10-20 10-20 5–10 infants infants infants infected infected infected during during during labour breast- pregnancy and feeding delivery

25 to 50 infants will be HIV-infected

Timing of infection during pregnancy  Infection in utero can occur as early as 8 weeks gestation period.  Some infants get sick very early in life whilst others have prognosis similar to adults, suggesting that those with rapid progression may have acquired infection in utero.

HIV infection during pregnancy or while breastfeeding  A woman who becomes infected with HIV during pregnancy or while breastfeeding, has higher levels of the virus in her blood, and is more likely therefore to infect her infant. See Appendix 2-B for additional information on the timing and diagnosis of HIV infection.

Risk factors for transmission  Risk of transmission to the infant is greatest when:  A mother’s viral load is high and she has advanced AIDS.  A mother’s viral load is high and she has a new HIV infection.  A mother’s viral load is high for any reason.  HIV transmission during labour and delivery occurs when the baby comes in contact with, ingests, or inhales maternal blood or vaginal secretions that contain HIV.  Other viral, maternal, obstetrical, foetal, and infant factors, alone or in combination, influence MTCT of HIV infection. These are outlined in Table 2.1.  Early identification and treatment of STIs in pregnant women can minimize the risk of associated infections that increase MTCT of HIV infection.  PMTCT interventions are designed to address these risk factors.

Table 2.1 Maternal factors that may increase the risk of HIV transmission Pregnancy Labour and Delivery Breastfeeding  High maternal  High maternal viral load (new  High maternal viral load (new infection or advanced AIDS) viral load (new infection or advanced  Placental separation, which tends to infection or AIDS) occur in cases of antepartum and advanced AIDS)  Viral, bacterial, intrapartum haemorrhage  Duration of or parasitic placental  Rupture of membranes for more than breastfeeding infections e.g., 4 hours  Mixed feeding malaria  Invasive delivery procedures that (e.g., food or fluids  Sexually increase contact with mother's infected in addition to transmitted infections blood or body fluids (e.g., episiotomy, breastmilk) (STIs) artificial rupture of membranes, vacuum  Breast  Maternal and forceps deliveries) abscesses, nipple malnutrition,  Vacuum extraction fissures, mastitis especially  Chorioamnionitis (from untreated  Maternal micronutrient STI or other infection) malnutrition deficiency such as  Premature delivery due to fragility of  Oral disease in selenium and vitamin infant skin and immature immune system the baby (e.g., A  Low birth weight of the infant thrush or sores)  Anaemia  Breaks in the skin or mucous membranes  First infant in multiple birth

Table 2.2 Summary of PMTCT Interventions

Primary Preventions Core MTCT Interventions Continuum of Care  Behaviour change  Testing and counselling  Family planning communication  Optimal antenatal care services including the including community  Improved infant feeding provision of mobilization, education counselling and practices contraceptives and involvement of  Optimal obstetric care  Post natal care for partners and families, HIV positive mothers and  Avoidance of invasive Life skills and other infants including routine procedures programmes targeting treatment and palliative the youth  Birth canal cleansing care for AIDS related  Promotion and  Safe delivery practices conditions, including provision of condoms  Avoid invasive procedures HIV-related conditions  Prevention and for resuscitation of new born  Infant feeding options treatment of STIs  ARV therapy or prophylaxis  Social support for  Testing and  Reproductive health and HIV positive mothers and counselling family planning counselling orphans affected by HIV/AIDS  Primary prevention measures

HIV and pregnancy Effect of pregnancy on HIV infection  In pregnancy, the immune function is suppressed in both HIV-infected women and those who are not infected.  Studies have shown that pregnancy appears to have little effect on the progression of HIV infection in asymptomatic HIV-infected women.  African women, however, with late stage disease have been found to have more complications during pregnancy, labour and delivery and the postpartum period.

Effect of HIV on pregnancy Pregnancy-related complications for women with HIV include:  Increased risk of spontaneous abortions  Double the rate of pre-term deliveries  Increased risk of having a low birth weight (LBW) infant  Increased risk of stillbirths  Increased risk of bacterial pneumonia, urinary tract and other postnatal infections, and other illnesses

UNIT 3 Comprehensive Approach to Prevention of HIV Infection in Infants and Young Children

After completing the unit, the participant will be able to:  Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children.

The comprehensive approach to PMTCT To significantly reduce PMTCT and achieve national targets, PMTCT must be viewed as a comprehensive public health approach, focusing not only on women with HIV, but also their partners and, equally as importantly, focusing on parents-to-be who do not know their HIV status or who know they are HIV-negative. A comprehensive approach includes four elements, as listed in the box below:

Four Elements in a Comprehensive Approach to PMTCT  Element 1: Primary prevention of HIV infection  Element 2: Prevention of unintended pregnancies among women infected with HIV  Element 3: Prevention of HIV transmission from women infected with HIV to their infants  Element 4: Provision of treatment, care and support to women infected with HIV, their infants, and their families.

Because of limitations in coverage in service, use of services, and drug efficacy, using the third element alone will only reduce HIV in infants by between 2% and 12%. The most effective way to reduce the proportion of infants infected by HIV is by preventing primary HIV infection in women (element 1), and by preventing unintended pregnancies among women infected with HIV (element 2). These two measures can decrease the proportion of infants infected by HIV by 35% to 45%. Each of the four elements is discussed in turn in this unit.

Element 1 Primary prevention of HIV infection Strategies for primary prevention of MTCT  Behaviour change intervention  Prevention and treatment of STIs  Testing and counselling  Promotion and provision of condoms  Prevention of HIV in young people

Behaviour change intervention Behaviour change intervention (BCI) is the backbone of the primary prevention of mother-to-child transmission of HIV and refers to an approach used to support an individual’s ability to adopt and maintain new behaviours. Three main strategies are used: communication for behaviour change, social mobilization and advocacy, as follows:

 Communication for behaviour change seeks to alter knowledge, beliefs, attitudes and practices. Communication strategies therefore need to be based on existing knowledge, attitudes and practices among the target group. Healthcare workers (HCWs) should explore the factors that could hinder the adoption of these behaviours and at the same time look for factors that could motivate a person to adopt these behaviours. Some of the behaviours that HCWs should promote include the following:  Abstinence and avoidance of pre-marital sex among the youth. This should include programmes for life-skills and dealing with peer influence.  Testing and counselling (TC) services before a woman becomes pregnant. Issues to be discussed include the benefits of utilising TC services.  Participation of male partners and spouses in PMTCT services.  Couple counselling and shared confidentiality  Use of condoms as a dual method to prevent unintended pregnancies, STIs and HIV. Condoms may be used alone or in combination with another family planning method such as the contraceptive pill.  Early recognition and treatment of STIs. The discussion should include the relationship between STIs and HIV as well as the need for partner notification.  Attendance for antenatal care and delivery in a healthcare setting. Issues to be discussed include early antenatal care (first trimester), danger signs during pregnancy, and the importance of good nutrition.

 Social mobilization seeks to promote wider participation of the community and uses social networks to encourage community support and action. This includes disseminating messages, creating social or religious support groups, strengthening links and referrals between community members, HCWs, and health centres. Messages may include:  HIV awareness and stigma reduction  Support for optimal infant feeding choices  Changes in harmful traditional and cultural practices  Improvements in linkages between communities and the health units that offer services

 Advocacy seeks to increase political and civic commitment and social will, and to provide the resources needed to engage in BCI activities, by ensuring that appropriate policies and laws are in place. HCWs will work with political and civic leaders to identify some of the barriers that could be addressed by changes in policy or regulations. Some examples include:  Low use of PMTCT services as a result of user fees  Increased availability of ARVs and support services for HIV-infected women  Youth-friendly reproductive health services  Improving access to safe infant feeding options for HIV-infected women  Discrimination based on stigma

Prevention and early treatment of STIs There is a close relationship between the other sexually transmitted infections and HIV. The presence of STIs in general, increases the risk of HIV infection. Likewise, the presence of HIV infection tends to worsen the severity of the STI and renders it less

Module 2 Overview of HIV Prevention in Mothers, Infants and Young Children 2-9 Malawi PMTCT Participant Manual responsive to conventional treatment. Prevention and early, effective treatment of STIs is a strategy that should be promoted as part of the primary prevention of MTCT.

Importance of testing and counselling Testing and counselling (TC) is the hub as well as the entry point (or “gateway”) into HIV-related prevention and care services. Knowledge of one’s sero-status is critical when counselling and supporting a client around risk reduction. If the client is HIV- infected, TC can act as the gateway to HIV-related care, treatment and support services including PMTCT services and family planning.

Promotion and provision of condoms Both male and female condoms, used correctly and consistently, can provide protection against STIs, reduce the risk of HIV transmission, and also prevent unintended pregnancies. At the community level, the primary message for the adolescents and youth should be abstinence and avoidance of pre-marital sex. However, for those who after counselling decide to have sex, then using condoms should be strongly advocated. Condom education should include a demonstration of proper use and disposal of condoms. Tips for correct use of male and female condoms can be found in Appendix 2-C.

Prevention of HIV in young people In addition to providing young people with information about HIV and AIDS, it is important to enable them to put what they have learned into practice. Teaching young people “life skills”—the social and interpersonal skills necessary to communicate effectively, make informed decisions, and develop coping and self-management mechanisms—enables them to postpone sexual activity, limit the number of sex partners and practice safer sex.

Exercise 2.3 Supporting condom use: discussion and demonstration Purpose To examine strategies to promote the consistent and correct use of condoms. Duration 30 minutes Instructions  Refer to Appendix 2-C for instructions on male and female condom use.  After a trainer-led discussion on access to condoms and a demonstration on the correct use of both male and female condoms, the group will be divided into four groups. Two groups will be practising with male condoms and two with female condoms. A trainer will be there to assist and answer questions.  Groups will be rotated so that each person will have the opportunity to practise with both male and female condoms.  When finished, the large group will reassemble and participate in a discussion on condom use.

Exercise 2.4 The handshake game: interactive game Purpose To explore the concept of HIV and STI transmission—both with and without the use of protection—when individuals are sexually active with multiple partners. Duration 20 minutes Instructions  Take a piece of paper from the basket and do not look at it.  Approach three other people in the group and shake hands with them. It is important to remember with whom you shook hand.  After shaking hands with three people, participants will return to their seats and open the sheet of paper.  The trainer will give specific directions about standing up or sitting down based on what is written on the piece of paper and the people with whom a handshake took place.  This process may be repeated if requested by the facilitator.  After the game, the trainer will lead a discussion on HIV and STI transmission and ways to prevent transmission.

Element 2 Prevention of unintended pregnancies among women who are HIV-infected Family Planning (FP) is part of a comprehensive public health strategy to prevent MTCT. With appropriate support, women who know they are HIV-infected can avoid unintended pregnancies and therefore reduce the number of infants at risk for MTCT. For many reasons, the rapid spread of HIV has made access to effective contraception and family planning services even more important throughout the world. Women attending any reproductive health service who are unaware of their HIV status can be referred for testing. Those who know their status should be referred for family planning services. Access to family planning counselling and referral for women known or suspected to be HIV-infected and their partners is critical for preventing unintended pregnancies. Family-planning services, when integrated into existing health services, also may minimize the stigma associated with HIV and provide either directly or by referral:  Access to contraceptives  Continued health promotion and risk reduction advice and counselling including information and skills to practise safer sex. Sex education must include information about condoms, emphasizing that they provide dual protection against both pregnancy and STIs, including HIV.  Early diagnosis and treatment of STIs including HIV  Referrals for care, treatment and support services  Individual and couples HIV counselling

Contraceptive methods FP methods should be discussed with women before becoming pregnant, during pregnancy and soon after delivery. Women should be provided access to their chosen method of contraception within 6 weeks after delivery to avoid unintended pregnancy and/or risk of STI infection including re-infection with a different subtype of HIV.

Common Contraceptive Options Method Examples Barrier methods  Male condoms  Female condoms Must be readily available Must be used consistently and correctly Hormonal methods  Combination oral contraceptive pills, taken daily  Injectable contraceptives o Medroxyprogesterone Acetate (administered once every three months)  Contraceptive implants (subdermal, contain progestin only) o Norplant® — 5-7 years’ duration  Emergency contraception Intrauterine  Copper T IUD (Paragard® or Nova T or Flexi T 300) — contraceptive device 10 years (IUCD)  Progesterone-releasing IUD (Mirena® or Progestasert) — 1-5 years Voluntary surgical  Tubal ligation – female contraception  Vasectomy – male (permanent)

Each of the above contraceptive options should be explored within the context of the individual’s health, medical history, partner relationship(s), social circumstances and availability.

Element 3 Prevention of HIV transmission from women to their infants PMTCT usually refers to specific services that identify pregnant women infected with HIV and provide them with effective interventions to reduce MTCT. Specific or core interventions to reduce HIV transmission from an infected woman to her child include:  HIV testing and counselling  Antiretroviral prophylaxis or ARV therapy, if the woman is eligible  Safer delivery practices  Safe infant-feeding practices

How these interventions work  Identify women infected with HIV.  Reduce maternal viral load.  Reduce infant exposure to the virus during labour and delivery.  Reduce infant exposure to the virus through safer feeding options.

In industrialized countries where women infected with HIV receive triple-drug ARV therapy and do not breastfeed—and where elective caesarean sections are safe, feasible, and commonly performed—the rate of MTCT has been reduced to about 2%. The reason

2-12 Malawi PMTCT Participant Manual women with HIV do not breastfeed in industrialized countries is because access to replacement feedings is acceptable, feasible, affordable, sustainable and safe In resource-constrained settings, ARV prophylaxis can reduce MTCT by 40–70%. The impact is highest (closer to 70%) when women do not breastfeed. Studies are ongoing to determine whether ARV prophylaxis for mother and/or child during breastfeeding can help reduce the risk of HIV transmission during that period.

Partner involvement in PMTCT PMTCT efforts should be as comprehensive as possible and acknowledge that both mothers and fathers have an impact on transmission of HIV to the infant:  Both partners need to be responsible for safer sex during and after pregnancy.  Both partners should be tested and counselled for HIV.  Both partners should be responsible for child feeding.

ARV prophylaxis and therapy for the mother When an ARV drug is given to the mother and infant to prevent MTCT, it is referred to as ARV prophylaxis. ARV prophylaxis given to a pregnant woman who is HIV-infected does not provide long-term benefits to the woman. Pregnant women with advanced HIV infection require clinical staging according to WHO guidelines and, if eligible, referral for ARV therapy to reduce the risk of AIDS-related illnesses. As treatment becomes more available, there should be integration between prophylaxis and treatment services.

Element 4 Provision of treatment, care and support to women infected with HIV, their infants and their families Services for the prevention of HIV in infants and young children will identify larger numbers of women infected with HIV who will need special attention. While not all HIV positive women will experience medical issues during pregnancy and/or postpartum, medical care and social support are essential for women living with HIV/AIDS to address concerns about their own health and the health and future of their children and families. If a woman is assured that she will receive adequate treatment and care for herself, her children and her partner, she is more likely to accept HIV testing and counselling and, if HIV-positive, to accept interventions to reduce MTCT. To promote long-term care of women who are HIV-infected and their families, it is important for PMTCT services to develop and reinforce linkages with care, treatment and support services.

Treatment, care and support services for women Treatment, care and support services for women with HIV may include:  Prevention and treatment of opportunistic infections  ARV therapy (at ARV clinics)  Treatment of symptoms  Nutritional support  Reproductive health care, including family planning services  Psychosocial and community support  Palliative care

Care and support of the infant and child who are HIV-exposed Children whose mothers are infected with HIV are at higher risk than other children for illness and malnutrition for multiple reasons:  They may be infected with HIV and become sick—even when adequate health care and nutrition are provided.  Infants who receive replacement feeding lack the protective benefits of breastfeeding against gastroenteritis, respiratory infections and other serious infections.  If mothers are sick, they may have difficulty caring for their children.  If the infant or child is sick, he or she may have a reduced appetite or other symptoms and conditions that make eating difficult, e.g. oral candidiasis.  Families may be economically vulnerable due to AIDS-related illnesses and deaths among adult relatives.

Nutritional support for the infant or child who is HIV-exposed  Support the mother’s infant-feeding choice.  Provide education on the importance of hydration and early reporting of diarrhoea.  Monitor for growth and development.  Monitor for signs of infection that may alter feeding patterns.

Infants and children who are HIV-exposed require regular follow-up care—especially during the first 2 years of life—including cotrimoxazole preventive therapy; screening, diagnosis and treatment of tuberculosis; as well as immunizations, HIV testing and ongoing monitoring of feeding, nutritional status, growth and development (See Module 7: Comprehensive Care and Support for Mothers and Families with HIV Infection).

UNIT 4 Role of Maternal and Child Health Services and Reproductive Health Services for the Prevention of HIV Infection in Infants and Young Children

After completing the unit, the participant will be able to:  Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children.

Maternal and child health (MCH) services HIV infection is one of the most critical health problems for pregnant women and newborns in many developing countries. Access to comprehensive MCH services (i.e., antenatal, postpartum and child health services) is central to efforts to reduce HIV infection in infants and young children. MCH care encompasses a broad range of educational and clinical services that help mothers, their children, and their families lead healthy lives.

Antenatal care, a central component of MCH services, is the most common entry point into PMTCT services.

MCH services facilitate PMTCT by providing:  Essential antenatal care (ANC)  ARV prophylaxis and therapy  Cotrimoxazole preventive therapy (CPT)  Safe delivery practices  Counselling and support for the woman's infant-feeding choice  Follow-up for a period of 18 months  Referral to paediatric services for those testing HIV-positive

The Reproductive Health Unit (RHU) facilitates PMTCT by providing services addressing:  Sexually transmitted infections (STIs)  Cancers of the reproductive system  Family planning  Infertility counselling

The HIV/AIDS Unit facilitates PMTCT by providing services addressing:  Testing and counselling  Antiretroviral therapy (ART)  Management of HIV- and AIDS related conditions

Effective integration of PMTCT into ANC, maternity and postpartum care, as well as into the continuum of care that meets other identified health needs, will strengthen maternal care, infant care and family care.

Comprehensive PMTCT services  Group pre-test HIV-related education  Individual counselling; client provides consent for testing  Partner involvement  Community mobilization  Routine offering of HIV testing  Counselling on and provision of family planning services to HIV-infected women and their partners  Post-test counselling, including infant feeding counselling and support  ARV prophylaxis for mother and infant  Nutrition counselling and supplements for all HIV-infected pregnant and lactating women  Clinical staging  Referral to ART clinics, if eligible  Follow up care for all HIV-infected women, their children, and their families

Module 2: Key Points  Approximately 80,000 women per year in Malawi need PMTCT services to prevent passing HIV to their infants.  Young women in Malawi are 2.2 times more likely to be HIV-infected than young men. This is due to biological, social and cultural factors.  The overall MTCT of HIV rate is approximately 40% without intervention.  Effective PMTCT services provide access to interventions that can significantly reduce the rate of MTCT.  Because ARV prophylaxis alone does not treat the mother’s infection, ongoing care and ARV therapy (if eligible) is needed.  The four elements of a comprehensive PMTCT programme effectively reduce MTCT of HIV:  Primary prevention of HIV infection  Prevention of unintended pregnancies in women infected with HIV  Prevention of HIV transmission from women infected with HIV to their infants  Provision of treatment, care and support to women infected with HIV, their infants, and their families  MCH, especially ANC services are an entry point to the range of services that provide treatment, care and support to the woman who is HIV-infected and her family.  Linkages to community services can enhance treatment, care and support.

APPENDIX 2-A Glion Call to Action on Family Planning and HIV/AIDS in Women and Children Consensus Report from the International Conference on Population and Development, 3-5 May 2004

Preamble In order to achieve internationally agreed development goals, it is vital that the linkages between reproductive health and HIV/AIDS prevention and care be addressed. To date, the benefits of the linkages have not been fully realized. United Nations agencies have initiated consultations with a wide range of stakeholders to identify opportunities for strengthening potential synergies between reproductive health and HIV/AIDS efforts.

This Glion Call to Action reflects the consensus of one such consultation, which focused on the linkage between family planning (a key component of reproductive health) and prevention of mother-to-child HIV transmission (PMTCT) (a key component of HIV/AIDS programmes).

The focus of the Glion Call to Action on preventing HIV among women and children is fully consistent with the parallel need for increased commitment to the health and wellbeing of women themselves. Therefore, the Glion Call to Action rests on the consensus achieved at the International Conference on Population and Development (ICPD) in Cairo and acknowledges the rights of women to decide freely on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence, and the need to improve access to services so that couples and individuals can decide freely the number, spacing and timing of their children. In order to ensure that these rights are respected, policies, programmes and interventions must promote gender equality, and give priority to the poor and underserved populations.

Although the prevention of MTCT is often restricted to the provision of antiretrovirals (ARV) to pregnant women who are infected with HIV, safe delivery practices and infant- feeding counselling and support, a broader approach has been defined by the United Nations and includes the following four elements: 1. Preventing primary HIV infection in women; 2. Preventing unintended pregnancies in women with HIV infection; 3. Preventing transmission of HIV from infected pregnant women to their infants; and 4. Providing care, treatment and support for HIV-infected women identified through PMTCT or Testing and counselling programmes and their families.

All four elements are essential if the UN goal for reducing the proportion of infants infected with HIV by 20% by 2005 and by 50% by 2010 is to be attained. Current estimates1 show that, because of limitations in coverage, use of services and drug efficacy, using the third element alone will only reduce HIV in infants by between 2% and 12% in many countries.

APPENDIX 2-A Glion Call to Action on Family Planning and HIV/AIDS in Women and Children Consensus Report from the International Conference on Population and Development, 3-5 May 2004 (continued)

The most effective way to reduce the proportion of infants infected by HIV is by preventing primary HIV infection in women (element 1), and by preventing unintended pregnancy among women infected by HIV (element 2). These two measures have intrinsic benefits to women and can decrease the proportion of infants infected by HIV by 35% to 45% in some countries with a significant contribution coming from the provision of family planning information, services and counselling.

Recommendations for Action We, the undersigned, call upon governments, parliamentarians, UN agencies, donors, civil society, including Non-Governmental and community-based organizations, to:

1. Policy and Advocacy a. Increase awareness, understanding and commitment to the four elements of PMTCT.

b. Commit to developing and implementing policies that strengthen the linkage between family planning and PMTCT.

c. Formulate legislation and policies that support the rights of all women, including HIV-infected women, to make informed choices about their reproductive lives.

2. Programme Development a. Strengthen commitment to achieving universal access to reproductive health services, including family planning, and recognize and support the contribution of these services to HIV/AIDS prevention efforts.

b. Ensure access for all women to family planning information and services, within both PMTCT and testing and counselling services.

c. Ensure that psychosocial counselling and support services are available to women seeking to be tested for HIV and for women infected with HIV.

d. Operationalize the linkage between family planning and PMTCT (through training; ensuring the supply of antiretroviral drugs, contraceptives, HIV testing kits, pregnancy testing kits, male and female condoms, and establishing referral systems and tracking mechanisms).

APPENDIX 2-A Glion Call to Action on Family Planning and HIV/AIDS in Women and Children Consensus Report from the International Conference on Population and Development, 3-5 May 2004 (continued)

e. Promote the concept of dual protection against transmission of HIV and other sexually transmitted infections as well as unintended pregnancy by the use of condoms alone or in combination with other methods of contraception.

f. Ensure that condoms are available and distributed at family planning, PMTCT and HIV Testing and Counselling (HTC, formerly referred to as “VCT”) settings, together with the information and counselling necessary for their correct and consistent use.

g. Promote and facilitate the participation of men, both as individuals and as a partner in a relationship, in PMTCT services.

h. Ensure the participation of young people in the design of programmes addressing their special needs in PMTCT.

3. Resource Mobilization a. Allocate the necessary funds for the implementation of all four elements of PMTCT, including family planning.

b. Improve cooperation and coordination among donors to support and strengthen the linkage.

c. Rectify the severe funding shortfall for the provision of reproductive health supplies, including contraceptives and condoms, and invest in the logistics systems in countries to improve their ability to procure, forecast and deliver those supplies.

4. Monitoring and Evaluation and Research a. Build on existing data to develop and improve monitoring and evaluation mechanisms for programmes linking family planning to PMTCT services, including measurement of the reduction in numbers of women and infants infected with HIV.

b. Continue innovative operations research to identify the most effective and efficient strategies and technologies to support linkages between PMTCT and family planning programmes.

APPENDIX 2-B Timing of MTCT Transmission and Diagnosis

Risk of transmission without interventions Most transmission occurs during labour and delivery but, depending on breastfeeding practices and duration, there is also a substantial risk of HIV transmission during breastfeeding.

MTCT can occur During pregnancy (in utero across placenta 5-10%, average 7%). Factors affecting transmission:  Advanced maternal HIV disease (AIDS)  Presence of other infections like sexually transmitted infections (STIs) and malaria  Maternal malnutrition, especially micronutrient deficiency such as selenium and vitamin A deficiency

During labour and delivery (through blood and secretions 10-20%, average 15%). Factors affecting transmission:  Placental separation, which tends to occur in cases of antepartum and intrapartum haemorrhage  Prolonged rupture of membranes (more than 4 hours)  Invasive procedures like artificial rupture of membranes, episiotomy, vacuum and forceps deliveries  Premature birth

After birth and during breastfeeding (during breastfeeding 10-20%, average 15%). Factors affecting transmission:  Mixed feeding  Prolonged breastfeeding (longer than six months);  Breast conditions like mastitis, breast abscess, cracked nipples  Oral sores in the infant like candidiasis

Infection during pregnancy  Infection during pregnancy can occur as early as 8 weeks’ gestation.  HIV-1 and viral antigens have been detected in foetal specimens and placental tissue.  Virus has been isolated from some infected infants at birth, which implies the infection occurred before birth  Some infants get sick very early in life whilst others have a prognosis similar to adults, suggesting that rapid progression indicates infection during pregnancy.

Laboratory confirmation of infection during pregnancy  A positive polymerase chain reaction (PCR) test within 48 hours of birth confirms infection that occurred during pregnancy. Whereas the infant who tests HIV-negative (by PCR) within the first 48 hours after birth but HIV-positive (by PCR) 7-90 days after birth is assumed to have been infected during labour or delivery.

APPENDIX 2-B Timing of MTCT Transmission and Diagnosis (continued)

Post natal infection during breastfeeding  Exclusive breastfeeding for up to 6 months leads to an approximately 1-5% of MTCT.  Women who acquire HIV infection during the lactation period are more likely to pass the virus to their infants through breastfeeding (29-30% versus 10-20%)

Laboratory confirmation of infection that occurred during breastfeeding  If a breastfeeding baby who was HIV-negative between 7-90 days after birth tests HIV-positive after 90 days or later, then transmission most likely occurred during breastfeeding.

APPENDIX 2-C Male and Female Condoms

Correct and consistent condom use prevents transmission of STIs, including HIV and unintended pregnancies.

Male condoms Instructions  Examine the condom package for tears or damage.  Check the expiration date on the package.  Carefully open the package so that the condom inside is not mistakenly torn.  Remove the condom and squeeze the tip of the unrolled condom (about ½ inch) in order to leave an airless pocket to collect semen.  Make sure there is no air in the tip to avoid breakage.  After erection and before any sexual contact, place the condom on the tip of the penis.  If needed, use only water based lubricants (such as KY jelly or other lubricants designed for use with condoms); never use oil based lubricants (such as Vaseline, mineral oil, baby oil or cooking oils) as they can weaken the latex, causing breakage.  Roll the condom down the shaft of the penis.  After intercourse, while the penis is still erect, grip the rim of the condom and carefully withdraw.  Hold the condom in place at the base of the penis to avoid it slipping off.  Do not flush male condoms in the toilet – wrap in tissue and safely discard.

Other tips:  If you feel the condom break during intercourse, stop immediately, withdraw and put on a new condom.  Never reuse a male condom.  Avoid long-term storage of condom in wallet or in hot, sunny places.

APPENDIX 2-C Male and Female Condoms (continued)

Female condoms Characteristics of female condoms: Safe and pre-lubricated  If extra lubricant is necessary, water- or oil-based lubricant may be used  No special storage conditions are required: the female condom is made of a strong, soft plastic (polyurethane), which is not affected by differences in temperature or humidity  Reliable, and provide sensitive sexual pleasure for the couple  Have a flexible ring at each end to prevent shifting  One size fits all: the inner ring is inserted in the vagina and the outer ring covers the outside of her genitals  Can be inserted up to eight hours before sex or just before sex  Intended for single use only  Act as an effective barrier against all STIs, including HIV/AIDS and pregnancy  Empower women to actively apply primary prevention strategies  More costly than male condoms Instructions  Examine the condom package for tears or damage.  Check the expiration date on the package.  Examine the condom: Most models have an inner ring and an outer ring. The inner ring is used for insertion. The open end covers the outer area of the vagina.

 Fold or squeeze the inner ring together and insert the condom as far as it will go. When in place, it should not be uncomfortable – you should not even feel it.  The outer ring should be outside the vagina and the inside sheath not twisted.  A few drops of water-based lubricant can be used inside the sheath or applied to the penis.  Remove the condom before standing up by squeezing and twisting the outer ring and gently pulling it out.  Do not flush female condoms in the toilet. Wrap in tissue and safely discard.

Other tips:  Always remove and use a new condom if the condom tears or the outer ring is pushed inside.  Female condoms are more costly than male condoms  It is always better to use a new condom each time you have sex

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