(PPTCT) of HIV Using Multi Drug Anti-Retroviral Regimen in India

Updated Guidelines for Prevention of Parent to Child Transmission (PPTCT) of HIV using Multi Drug Anti-retroviral Regimen in India

December, 2013

Government of India Ministry of Health & Family Welfare Department of AIDS Control Basic Services Division Chandralok Building, Janpath New Delhi - 110001

Updated Guidelines for Prevention of Parent to Child Transmission (PPTCT) of HIV using Multi Drug Anti-retroviral Regimen in India

December, 2013

Government of India Ministry of Health & Family Welfare Department of AIDS Control Basic Services Division Chandralok Building, Janpath New Delhi - 110001

Acknowledgement We acknowledge the valuable contributions made by technical experts from the Department of AIDS Control/ GoI, WHO, UNICEF, Clinton Health Access Initiative and CDC India.

Writing Group: 1. Dr Geetanjali Kumari, (ex) National Programme Officer/ PPTCT, DAC 2. Dr Avinash Kanchar, (ex) Programme Officer/ HIV-TB, DAC 3. Dr Raghuram Rao, National Programme Officer/ ICTC, DAC 4. Dr B B Rewari, WHO National Consultant & NPO/ ART, DAC 5. Dr M. Naina Rani, National Consultant/ PPTCT, WHO, India 6. Dr Srilatha Sivalenka, Scientific Affairs Specialist, CDC, India

Guidance Group: 1. Dr Suresh Mohammed, (ex) National Programme Officer/ ICTC, DAC 2. Dr Po-Lin Chan, (ex) Medical Officer, WHO/ SEARO 3. Dr Vimlesh Purohit, (ex) National Consultant/ PPTCT, WHO, India 4. Dr Ivonne Cameroni, (ex) Country Director, UNICEF, India 5. Ms Ameeta Chebbi, (ex) Country Director, CHAI, New Delhi 6. Dr Pauline Harvey, Director, CDC DGHA, India 7. Dr K Sudhakar, National Advisor, CDC, India 8. Dr Malalay Ahmadzai, Health Specialist, UNICEF, India 9. Dr Sudha Balakrishnan, Health Specialist, UNICEF, India 10. Dr Sandhya Kabra, (ex) Asstt. DG/ Lab Services, DAC 11. Dr Laxman Bharathi, Programme Officer/ ART, DAC 12. Dr Padmini Srikantiah, Consultant, CDC, India 13. Dr Subhashree Raghavan, Executive Director, SAATHII, India 14. Dr Reshu Agarwal, Programme Officer/ CST, DAC 15. Dr Debashish Dutta, (ex) Maternal & Child Health Specialist, UNICEF, India 16. Dr Amaya Maw Naing, Regional Advisor, HIV/AIDS, WHO/ SEARO 17. Dr Razia Pendse Narayanan, WHO/ SEARO 18. Dr Melita Vaz, (ex) Programme Officer/ Counseling, DAC We also sincerely acknowledge the technical support extended by Members of the Technical Resource Groups (TRGs) of PPTCT, ART, Paediatric & Laboratory Services; Project Directors & BSD Officers at all SACS, Regional Coordinators/ CST, DAC, PPTCT Consultants and all others concerned with PPTCT.

Mentors: 1. Dr Ashok Kumar, Dy. DG/ BSD, DAC 2. Dr R S Gupta, (ex) Dy. DG/ BSD, DAC 3. Dr Mohd Shaukat, (ex) Dy. DG/ CST, DAC 4. Dr R S Rathore, Dy. DG/ CST, DAC 5. Dr S Venkatesh, Dy. DG/ M&E, DAC 6. Dr S Khaparde, Dy. DG/ STI, DAC 7. Dr Neeraj Dhingra, Dy. DG/ TI, DAC 8. Dr Naresh Goel, Dy. DG/ Lab Services, DAC The assistance provided in preparing this document by Mr Stefen Tonsing (Technical Officer/ PPTCT, DAC), Mr Rohit Mehta (M & E Officer, DAC), Ms Divya Taneja (Technical Officer/ Training, DAC), Mr Reneej K B (Technical Officer/ ICTC, DAC), Ms Manali Jain (Office Assistant/ BSD, DAC) and Mr Vikas Gaur (Office Assistant/ BSD, DAC), is appreciated The technical support provided by WHO India Office in developing this document, as well as to UNAIDS India and CDC India for facilitating its printing are acknowledged with thanks.

Contents

Chapter 1 Introduction 11 Chapter 2 PPTCT Policy, Essential Package and Guiding Principles 14 2.1 The Overall Goals of the PPTCT Programme 15 2.2 The Essential Package of Services under the PPTCT Programme 16 2.3 General Principles 18 2.3.1 Sexually Transmitted Infections and Reproductive Tract Infections 20 2.3.2 HIV–TB Collaborative Activities 22 2.4 Guiding Principles for Use of ARV Drugs (ART) in PPTCT 24 Chapter 3 PPTCT Services Under NACP 26 3.1 Existing Facilities 27 3.2. Continuum of Care under PPTCT 28 Chapter 4 Care and Assessment of HIV Infected Pregnant Women 30 4.1 Care during the Antenatal Period 31 4.2 Initial Assessment 32 4.3 Criteria for ART Initiation 34 4.4 Indications for Co-trimozaxole Prophylactic Therapy (CPT) in Pregnancy 34 Chapter 5 HIV Infected Pregnant Women Requiring ART for her own Health 35 5.1 HIV Infected Pregnant Women being Newly Initiated on ART 36 5.2 Principles of Management 36 5.2.1 For HIV-infected Pregnant Women who Require ART for their Own Health 36 5.2.2 Choice of ART Regimen for HIV-infected Pregnant Women 36 5.2.2 Safety of Efavirenz (EFV) in Pregnant Women 38 5.3 ART Regimen for Pregnant Women having Prior Exposure to 38 NNRTI for PPTCT Figure 2: Components of PPTCT Programme 5.4 Pregnant Women Already Receiving ART 38 5.5 Clinical and Laboratory Monitoring of Pregnant Women Receiving ART 39 5.6 OfferARV ofProphylaxis HIV Counselling for Infants and Born Testing to Mothers Services Receiving to all Lifelong Pregnant ART Women 41 Chapter 6 Interventions for Women Diagnosed with HIV Infection in 40 Labour and Postpartum 6.1 ART for Women Presenting in Active Labour 43 HIV Negative HIV Infected Pregnant Women 6.2 ARV Prophylaxis for Infants Born to Women Presenting in Active Labour 44 Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l 6.3Safe sex ARV Prophylaxis for Infantsprophylaxis Born to at Women ART Centers. who did not Receive any ART 44 Chaptercounselling. 7 Special Considerations 46 l Counselling on choices of continuation or medical termination of l Couple 7.1 Pregnant Women with Activepregnancy TB (MTP)–to undertake within the first 3 months47 of counselling. 7.2 Pregnant Women with HIV-2pregnancy Infection only. 47 l Linkages to family 7.3planning Pregnantservices. Women withl HepatitisScreening B for or TBHepatitis and other C Virus OIs. Co-infection 48 Chapterl Free 8condoms.Labour and Delivery lin Screeningthe HIV Infected and treatment Pregnant for STIs.Women 50 l Behaviour change l WHO clinical staging and CD4 testing. 8.1 Intra Partum Management 51 communication l Counselling on positive living, safe delivery, birth-planning and 8.2(BCC) forIntra high Partumrisk Anti Retroviral Treatment (ART) 51 infant feeding options. 8.3women andSpecial her Circumstances: Caesarean Section 51 l Couple and safe sex counselling and HIV testing of spouse and 8.4partner. False Labour 51 l Repeat HIV other living children. 8.5 Safer Delivery Techniques 52 testing, l Referral to ART Center. Chapterconsidering 9 Care During the Postnatal Period 53 l Provide ART or ARV prophylactic regimen based on CD4 count 9.1window, Theperiod Postpartum if Period and/or clinical staging. 54 9.2spouse isScreening positive for Postpartum Depression 56 or s/he have high l Nutrition counselling and linkages to Government/other 9.3risk behaviourCounsel. and Follow-up ofNutrition Mother-baby programmes. (m-b) Pairs after Discharge 57 Chapterl Infant 10 feedingInfant and Feeding Practicel Postpartum ARV prophylaxis for mother. 59 10.1nutrition Principles of Infant Feedingl Family for PlanningHIV Infected Services. Pregnant Women 60 counselling. Chapter 11 Care and Follow-up ofl HIVEBF Exposedreinforcement/Infant Infants feeding support through home visits.66 11.1 During the First Post-deliveryl Psycho Visit-social at 6suppor Weeks/t through First Immunization follow-up counselling, Visit home 67 11.2 Confirmation of HIV Statusvisits in and HIV suppor Exposedt groups. Infants should be done at 18 69 Months, Regardless of Earlier Diagnosis Chapter 12 Essential Gynaecologic Care for HIV Infected Pregnant Women 70 HIV12.1 ExposedCervical Infant Cancer(HEI) Screening 71 l12.2ExclusiveFamily breastfeeds Planning upto and 6 monthsBirth-spacing (preferred Option-I WHO/NACO Guidelines 2010-'11) 71 and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for Chapter 13 Monitoring and Evaluation 74 EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. Chapter 14 PPTCT Programme: Roles and Responsibilities of Staff 93 l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Annexures 08

Annex 1 : Guidelinesomen W forregnant P Rolling-outall to NACPvices Ser and NRHMesting T and ConvergenceCounselling PlanHIV inof the StatesOffer 100

Annex 2 : Dosing Schedules ART for Pregnant Women 111

Annex 3 : ART for Pregnant Womenomen PresentingW regnant P in ActiveInfected LabourHIV with no Prior ART Negative 111HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Annex 4 : Infant NVP Prophylaxis Dosing 111 Centers. T AR at prophylaxis sex Safe l counselling. Annex of 5 :termination WHO medical Clinical or Stagingcontinuation forof Adultschoices andon AdolescentsCounselling l 111 Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy Grading of Selected Clinical and Laboratory Toxicities counselling. Annex 6 : . only pregnancy 113 (Reference: WHO 2010 Guidelines for ART in Adults and Adolescents) family to Linkages l OIs. other and TB for Screening l vices. ser planning Annex 7 : Postpartum DepressionSTIs. for Screeningtreatment Tool–theand EdinburghScreening l Scale condoms. ree F 116l testing. CD4 and staging clinical WHO l change Behaviour l

Annex 8and : Comparingth-planning bir , y Effectivenessdeliver safe living, of Familypositive on Planning MethodsCounselling l communication 119 (BCC) for high risk risk high for (BCC) options. feeding infant Flowchart on Counselling Mothers and their Families on Infant Feedingher and women Annex 9 : 120 and spouse of Options testing 0-6HIV Monthsand of Agecounselling sex safe and Couple l . tner par . children living other HIV epeat R l Annex 10 : Testing Algorithm for HIV-1 Exposed Infants and Children <6 Months 121 . Center T AR to eferral R l testing, considering considering Annex 11count CD4 :on Testingbased Algorithmregimen for HIV-1prophylactic ExposedARV or T InfantsAR androvide P Childrenl >6 Months 122 staging. staging. clinical and/or if period , window spouse is positive positive is spouse Annex 12 : ICTC-ARTGovernment/other to Centrelinkages Referral and Form counselling Nutrition l high have s/he or 123 programmes. Nutrition . behaviour risk Annex 13 : OM for Laboratory Investigations 124 . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition Annex 14 : List of Items that can be Procured under Universal Work Precautions 126 visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

Annex 15 home : CF-consentcounselling, Formfollow-up for Patientsthrough t Registeringsuppor -social intosycho HIVP l Care & Starting ART 127 groups. t suppor and visits Annex 16 : Transfer Out Form (Form for Transfer of PLHIV to Other ART Centre) 128

OM Regarding Provision of ART/ARV Prophylactic Drugs at ART Centre to Annex 17 : 129 HIV Infected Pregnant Women (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l List of Reference Doctors for Advice on PPTCT Services Including Care of Annex 18for year :1 upto months 6 ter af feeds complement to addition in breastfeeds continued and 130 HIV Exposed Child . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Annex 19 : National Coordination Committee forweeks. PPTCT-NRHM6 for infant for Integrationprophylaxis ActivitiesARV tum ostpar P 131l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l OM from DDG (BSD) for Roll-out of PPTCT Multi-Drug Regimen in India Annex 20 : breastfeeds. of cessation ter af 133 from 1st January 2014 age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 9 care. infant routine and Immunizations l

months months 6 from feeds y complementar of introduction and months 6 ter af weaning Gradual l of of development & growth adequate for year 1 atleast for BF of continuation with along onwards child. the

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Abbreviations

ANC Antenatal Care IUCD Intra-uterine contraceptive device AIDS Acquired Immune Deficiency Syndrome LPV/r Lopinavir/ritonavir ALT Alanine Aminotransferase 3TC Lamivudine ART Antiretroviral Therapy MTCT Mother-to-Child Transmission of HIV ARV Antiretroviral NACO National AIDS Control Organisation ARSH Adolescent Reproductive & Sexual Health NNRTI Non-Nucleoside Reverse Transcriptase AZT Zidovudine Inhibitor BCC Behaviour Change Communication NRTI Nucleoside Reverse Transcriptase CPT Cotrimoxazole Prophylactic Therapy Inhibitor CDC Centers for Disease Control and NRHM National Rural Health Mission Prevention NVP Nevirapine DBS Dried Blood Spot OIs Opportunistic Infections DIL Direct-in-Labour PEP Post-Exposure Prophylaxis DNA Deoxyribonucleic Acid PCP Pneumocystis Jiroveci Pneumonia d4t Stavudine PCR Polymerase Chain Reaction EBF Exclusive Breast Feeding PPTCT Prevention-of-Parent-to-Child- EID Early Infant Diagnosis Transmission of HIV e-MTCT Elimination of Mother–to-Child RCH Reproductive & Child Health Transmission RPR Rapid Plasma Reagin ERF Exclusive Replacement Feeding NVP Single-Dose Nevirapine EFV Efavirenz SRH Sexual and Reproductive Health EPI Expanded Programme of Immunization TB Tuberculosis HBV Hepatitis B Virus TDF Tenofovir Disoproxil Fumarate HCT HIV Counselling and Testing ULN Upper limit of normal HCV Hepatitis C Virus UNAIDS United Nations Programme on HIV/AIDS HEI HIV Exposed Infant UNICEF United Nation International Childrens HIV Human Immunodeficiency Virus Emergency Fund ICF Intensified case finding of TB VCT Voluntary Counselling and Testing ICTC Integrated counselling and Testing Centre WBS Whole Blood Specimen IMNCI Integrated Management of Childhood WHO World Health Organisation and Neonatal Illness WBFPT Whole Blood Finger Prick Test 11

Introduction There are an estimated 2.1 millionFigure (2011) 2: Components People Living of PPTCT with Programme HIV (PLHIV) in India, with National adult HIV prevalence of 0.27% (2011). Of these, women constitute 39% of all PLHIV while children less than 15 years of ageOffer constitute of HIV 7%Counselling of all infections. and Testing As on SerMarchvices 2013, to all 0.1 Pregnant million HIVWomen positive children had been registered under the antiretroviral therapy (ART) programme and 38,579 are receiving free ART. There has been a significant scale-up of HIV counselling & testing, Prevention of Parent-to-Child Transmission (PPTCT) and ART services across the country over last five years. Between 2004 and 2013, the number of pregnant women tested annually under the Prevention of Parent-To-Child -Transmission HIV Negative HIV Infected Pregnant Women (PPTCT) programme increased from 0.8 million to 8.83 million and reach of the services has expanded Pregnant Women to the rural areas to a large extent. Concurrently,l Antenatal Carethere (ensure has also at-least been 4a visits)–Monthlysignificant decentralisation ART/ARV and l Safe sex scale-up of the ART services, with 7.34prophylaxis Lakhs PLHIV at ARreceivingT Centers. free ART across the country through 409 counselling. ART centres and 860 Link-ART centresl Counselling (LAC). on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. Mother-to-child-transmission of HIV ispregnancy a major only route. of HIV infection in children. However, out of an estimatedl Linkages 27 to millionfamily pregnancies in a year, only about 52.7% attend health services for skilled l Screening for TB and other OIs. care duringplanning child ser vices.birth in India. Of those who availed health services, 8.83 million ANCs received HIVl counsellingFree condoms. and testing (March l2013)Screening out of and which treatment 12,551 for pregnant STIs. women were detected to be HIVl positive.Behaviour To enhancechange this coverage,l WHO a joint clinical directive staging from and CD4the National testing. AIDS Control Programme communication (NACP) and the National Rural Healthl CounsellingMission (NRHM) on positive regarding living, convergence safe delivery ,of bir theth-planning two programme and (BCC) for high risk components was issued in July 2010, explicitlyinfant feeding stating options. that universal HIV screening should be included women and her as an integral component of routine ANC check-up. The objective was to ensure that pregnant women partner. l Couple and safe sex counselling and HIV testing of spouse and who are diagnosed with HIV would be linked to HIV services for their own health as well as to ensure l Repeat HIV other living children. prevention of HIV transmission to newborn babies under the PPTCT programme. testing, l Referral to ART Center. considering In the absence of any intervention,l Parovide substantial ART or ARVproportion prophylactic of children regimen born based to on women CD4 count living with HIwindowV, acquire, period HIV ifinfection from theirand/or mothers clinical eitherstaging. during pregnancy, labour/delivery or during breastfeeding.spouse is Without positive any intervention, the risk of transmission of HIV from infected pregnant or s/he have high l Nutrition counselling and linkages to Government/other women to her children is estimated Nutritionto be around programmes. 20-45%. Use of ART and sd NVP/Sy NVP to mother-babyrisk behaviour pairs has. shown to be quite effective in reducing this transmission as l o w a s 10 per l Infant feeding and l Postpartum ARV prophylaxis for mother. cent. Use of single dose Nevirapine (sd-NVP) at the onset of labour significantly reduces pre-partum nutrition l Family Planning Services. HIV transmission. However, it is less effective than other available ARV prophylaxis and it does not cover counselling. the risk of HIV transmission during thel EBFantenatal reinforcement/Infant or breastfeeding feeding periods. suppor Further,t through it also home adds visits. to the risk of acquiring drug resistance to nevirapinel Psycho (NVP)-social as suppor well ast throughcross resistance follow-up to counselling,Efavirenz (NNRTIs). home WHO in 2010 had recommended two more efficaciousvisits and regimen, suppor toption groups. A & option B, to further reduce the chances of HIV transmission from mother-to-child. Further in 2013, consolidated ART guideline, WHO has recommended moving away from the previous termsHIV “Options Exposed A, InfantB and (HEI)B+”. Instead, the WHO new guidelines (June 2013) 1 recommend two options: l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 1. Providing lifelong ART to all the pregnant and breastfeeding women living with HIV regardless of CD4 and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for count or clinical stage OR EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

2. Providingl Postpar ARTtum ARV (ARV prophylaxis drugs) for for pregnant infant for and 6 weeks. breastfeeding women with HIV during the mother- to-child transmission risk period and then continuing life-long ART for those women eligible for l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks treatmentafter cessation for their of own breastfeeds. health.

1Worldl HealthCo-trimoxazole Organization, prophylaxis Consolidated fromguidelines 6 weeks on the of use age. of Antiretroviral drugs for treating and preventing HIV infection, Recommendations for a public health approach, June 2013. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 12 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Government of India is committed to workProgramme towardsPPTCT of achievementComponents 2: of theFigure global target of “elimination of new HIV infections among children” by 2015. Based on the new guidelines from WHO (June 2013), Department of AIDSomen ControlW hasregnant P decidedall to to providevices Ser life-longesting T ARTand (triple drugCounselling regimen)HIV of forOffer all pregnant and breast feeding women living with HIV, in which all pregnant women living with HIV receive a triple- drug ART regimen regardless of CD4 count or WHO clinical stage, both for their own health and to prevent vertical HIV transmission from mother-to-child. This would also help in maximising coverage for those needing treatment for keeping them aliveomen W and forregnant P their ownInfected health,HIV avoiding stopping and Negative starting HIV drugs with repeatT/ARV AR pregnancies, providevisits)–Monthly 4 earlyat-least protection(ensure Care against Antenatal mother-to-childl transmissionomen W in futureregnant P pregnancies and avoiding drug resistance. Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l These recommendations have the potential to reduce the risk of mother-to-child-transmission toCouple lessl of of months 3 first the within e tak under (MTP)–to pregnancy than 5 per cent in breastfeeding populations. These guidelines shall be implemented across the countrycounselling. . . only pregnancy from 1st January 2014. family to Linkages l OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

HIV Exposed Infant (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 13 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

PPTCT-Policy, Essential Package and Guiding Principles 2.1 The Goals of the PPTCTProgramme ProgrammePPTCT of Components 2: Figure

In line with WHO standardsomen W forregnant P a comprehensiveall to vices Ser strategy,esting T theand National PPTCTCounselling programmeHIV of Offer recognises the four elements integral to preventing HIV transmission among women and children. These are:

Prong 1: Primary prevention of HIV, especially among women of child bearing age.

Prong 2: Preventing unintended pregnanciesomen W among womenregnant P livingInfected withHIV HIV. Negative HIV omen W regnant P Prong 3: PreventT/ARV AR HIV transmissionvisits)–Monthly 4 from pregnantat-least (ensure womenCare infectedAntenatal withl HIV to their child. Centers. T AR at prophylaxis sex Safe l Prong 4: Provide care, support and treatment to women living with HIV, her children and familycounselling. in of of termination medical or continuation of choices on Counselling l Couple Couple l of of womenmonths 3 in first child the bearingwithin e age.tak under (MTP)–to pregnancy counselling. counselling. . . only pregnancy 4 prongs for PPTCT family to Linkages l OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l l change Behaviour l testing. CD4 and staging clinical WHO Prong 4: Prong 2: Prong 1: Care, Prevent Prong 3: communication and th-planning bir , y Primardeliver y safe living, positive on Counselling l support unintended Prevention prevention and pregnancies of MTCT risk high for (BCC) of HIV options. feeding infant treatment women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par . children living other HIV epeat R l . Center T AR to eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l HIV +ve HIV +ve HIV +ve Mother high have s/he or HIV Negative i.e. Not Pregnant & programmes. P regnant Nutrition & Child general Family Planning . behaviour risk population, counselling in e.g.. ARSH mother for ICTC but more prophylaxis ARV tum ostpar P l and feeding Infant l importantly at ART centresvices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling. The National PPTCT programme adopts a public health approach to provide these services to pregnant home counselling, follow-up through t suppor -social sycho P l women and their children. This approach seeks to ensure equitable access to high-quality PPTCT groups. t suppor and visits services at the grass-root level while taking into account what is feasible on a large-scale within available health infrastructure, human and financialresources.

Goals of National PPTCT Programme in India are: (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l 1. Primary prevention of HIV, especially among women in child-bearing age. ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and 2. Integration . T AR of aediatric PPTCTP interventionsreceive o wh babies with generalpositive EID healthfor servicesyears 2 upto suchand as basicbabies Ante-natalnegative EID Care

(ANC), Natal and Post –Natal Services, Sexualweeks. Reproductive6 for infant for Health andprophylaxis FamilyARV Planning,tum ostpar P EID,l

weeks Paediatricweeks 6 & ARTmonths and12 Adolescentmonths, 6 at Reproductivetesting repeat and age; Sexual of Healthweeks 6 at (ARSH),(EID) TB anddiagnosis STI/RTIinfant services.Early l breastfeeds. of cessation ter af 3. Strengthening post-natal care of the HIV-infected mother and her exposed infant. age. of weeks 6 from prophylaxis -trimoxazole Co l

4. Provide theEID. essentialthrough packagepositive ofHIV PPTCTas servicesdiagnosed (seechildren Figureand 1 oninfants nextfor T page).AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 15 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

2.2 The Essential PackageFigure 2: Componentsof Services of PPTCT under Programme the PPTCT Programme The PPTCT services provide access to all pregnant women for HIV diagnostic, prevention, care and Offer of HIV Counselling and Testing Services to all Pregnant Women treatment services. As such, the key goal is to ensure the integrated PPTCT services delivery within existing Reproductive & Child Health (RCH) programme.

The Essential Package of PPTCT Services includes: HIV Negative HIV Infected Pregnant Women

•P regnantRoutine W offeromen of HIV counsellingl (Group/IndividualAntenatal Care (ensure counselling) at-least and 4 visits)–Monthlytesting to all pregnant ART/ARV women l attendingSafe sex ante-natal care, with ‘optprophylaxis out’ option. at ART Centers. counselling. • Ensure involvement of spousel & Counsellingother family on members choices ofand continuation move from or anmedical “ANC termination centric” to ofa l Couple pregnancy (MTP)–to undertake within the first 3 months of “Familycounselling. centric” approach. pregnancy only. l Linkages to family • Provide ART to all HIV infected pregnant women regardless of WHO staging and CD4 count planning services. l Screening for TB and other OIs. results. Preferred regimen is TDF+3TC+ EFV. l Free condoms. l Screening and treatment for STIs. • l PromoteBehaviour institutional change delivery lfor WHOall HIV clinical infected staging pregnant and CD4 women testing. (ANMs/ASHAs, Community communication workers to accompany to institutions;l Counselling reduction on positive of stigma living, and safe discrimination delivery, birth-planning amongst health and (BCC) for high risk care providers through sensitisationinfant and feeding capacity options. building). women and her l Couple and safe sex counselling and HIV testing of spouse and • Provisionpartner. of care for associated conditions (STI/RTI, TB & other Opportunistic Infections (OIs). l Repeat HIV other living children. • Providetesting, nutrition counselling l andReferral psychosocial to ART Center support. for HIV infected pregnant women considering (Linkages with ANM, ASHAs, lCommunityProvide AR outreachT or ARV workers, prophylactic DLNs regimen to advise based them on on CD4 the count right foodswindow to, takeperiod and if to go to Anganwadiand/or Centresclinical staging.for nutritional support and to the district level networkspouse isof positivePositive People for peer counselling and psycho-social support). or s/he have high l Nutrition counselling and linkages to Government/other Nutrition programmes. • Providerisk behaviour counselling. and support for initiation of exclusive breastfeeds within an hour of delivery l Postpartum ARV prophylaxis for mother. l asInfant the feedingpreferred and Option and continue for 6 months. After 6 months, complementary feeding shouldnutrition be given along with breastfeeds.l Family APlanning small number Services. of babies born to HIV infected mothers counselling. who have serious illness or havel diedEBF andreinforcement/Infant a few reluctant mothers feeding (whosuppor att theirthrough own home risk despitevisits. counselling) may decide not tol breastfeedPsycho-social but adopt suppor exclusivet through replacement follow-up counselling, feeding (ERF). home visits and support groups. • Provide antiretroviral prophylaxis to infants from birth up to a minimum period of 6 weeks.

• Integrate follow-up of HIV-exposed infants (HEIs) into routine healthcare services including HIVimmunization. Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) • Ensure initiation of Co-trimoxazole Prophylactic Therapy (CPT) and Early Infant Diagnosis (EID) usingand continuedHIV DNA PCR breastfeeds at 6 weeks in addition of age onwards to complement as per the feeds EID af guidelines.ter 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

• l StrengthenPostpartum follow- ARV prophylaxisup and outreach for infant through for 6 weeks. ANMs, ASHAs and District level networks and other outreach workers to support HIV infected pregnant women and their family. l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxisFigure from 1: Essential 6 weeks Packageof age. of PPTCT Services

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 16 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Offer of HIV Counselling andProgramme TestingPPTCT of ServicesComponents to2: all PregnantFigure Women

omen W regnant P all to vices Ser esting T and Counselling HIV of Offer HIV Negative HIV Infected Pregnant Women Pregnant Women • Ante-natal Care (ensure at least 4 visits) • Safe sex counselling • Counselling on choices of continuation or medical termination of omen W regnant P Infected HIV Negative HIV • Couple counselling. pregnancy (MTP)–to undertake with in the first 3 months of pregnancy T/ARV AR only.visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P • Linkages to family • Screening for TBCenters. T (40AR at Gene-Xpert testingprophylaxis sites is being launched sex shortly)Safe l planning services. counselling. of of termination medical or and othercontinuation of OIs. choices on Counselling l Couple Couple l • Freeof condoms.months 3 first the • within Screening e tak andunder treatment(MTP)–to for STIs.pregnancy counselling. counselling. • Behaviour change • WHO clinical staging . andonly CD4 testing.pregnancy family family to Linkages l communication • CounsellingOIs. other on positiveand TB for living, safeScreening l delivery, birth-planning vices. ser and infantplanning (BCC) for high risk feedingSTIs. options.for treatment and Screening l women and her condoms. ree F l partner. • Coupletesting. CD4 and and safe sexstaging counsellingclinical WHO andl HIV testing of spousechange and otherBehaviour l living children. communication • Repeatand HIV testing,th-planning bir , y deliver safe living, positive on Counselling l (BCC) for high risk risk high for (BCC) considering window • Linkage to ART services.options. feeding infant period if spouse is • Provide ART regardless of clinical stage and CD4 counther and women and spouse of testing HIV and counselling sex safe and Couple l positive or s/he have . tner par • Nutrition counselling. children andliving linkagesother to Government/other nutrition high risk behaviour. programmes. HIV epeat R l . Center T AR to eferral R l testing, • Infant feeding • Family Planning Services. considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l and nutrition • EBF reinforcement/Infant feeding support through home visits. counselling. staging. clinical and/or if period , window • Psycho-social support through follow-up counselling, homepositive is visitsspouse and Government/other Government/other to linkages and counselling Nutrition l support groups. high have s/he or programmes. Nutrition . behaviour risk HIV Exposed Infant (HEI). mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition • Exclusive breastfeeds up to 6 months (preferred Option-I WHO/NACO Guidelines 2010-11) and counselling. continuedvisits. home breastfeedsthrough t in additionsuppor feeding to complementary feedsreinforcement/Infant EBF afterl 6 months up to 1 year for EID negativehome babies andcounselling, up to 2 yearsfollow-up forthrough EIDt positivesuppor babies-social sycho whoP l receive Paediatric ART. • Postpartum ARV prophylaxis for infant forgroups. minimumt suppor 6and weeks.visits • Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds. • Co-trimoxazole prophylaxis from 6 weeks of age. (HEI) Infant Exposed HIV • HIV care and2010-'11) PediatricGuidelines ARTO for infantsWHO/NAC and Option-I children diagnosed(preferred months as6 HIVupto positive throughbreastfeeds EID.Exclusive l • Growth for andyear 1 nutritionupto monitoring.months 6 ter af feeds complement to addition in breastfeeds continued and • Immunizations . T AR andaediatric P routinereceive o infantwh care.babies positive EID for years 2 upto and babies negative EID

• Gradual weaning after 6 months and introductionweeks. 6 for of complementaryinfant for feedsprophylaxis ARV fromtum 6 monthsostpar P l onwards along with continuation of BF for at least 1 year for adequate growth & development of weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l the child.. breastfeeds. of cessation ter af • Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests. age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through Figurepositive 2: ComponentsHIV as diagnosed of PPTCTchildren Programmeand infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 17 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

The first and foremost importantFigure step for 2: Componentsall pregnant of PPTCTwomen Programme attending health services is to know their HIV status as part of the routine ante natal screening blood tests. This has been clearly stated a directive jointly issued byOffer both of NRHM HIV Counselling and NACO1 (Annexureand Testing 1). Services to all Pregnant Women Four typical scenarios where pregnant women may attend the counselling and testing services include: • Women attending ante natal clinics. HIV• PregnantNegative spouse of HIV-positiveHIV men, Infected or those Pregnant with Whighomen risk behaviour.

P•regnant Pregnant Women women screened al t theAntenatal Sub centre Care (ensure level byat-least ANM/Nurse 4 visits)–Monthly (whole blood ART/ARV finger prick l Safetest) sex & Confirmation at ICTC. prophylaxis at ART Centers. counselling. • Women presenting directly-in-labourl Counselling (un-booked on choices cases, of continuation require a HIVor medical screening termination test before of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling.delivery). pregnancy only. l Linkages to family 2.3 planningGeneral services. Principles l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. • Informed consent as per guidelines to be taken for all ANCs. l Behaviour change l WHO clinical staging and CD4 testing.

• communicationCounselling to inform all pregnantl Counselling women about on positive the ante living, natal routinesafe deliver screeningy, birth-planning tests haemoglobin and (BCC) for high risk (Hb %), Urine albumin/sugar, VDRL/RPR,infant feeding blood options. grouping & typing and the benefits of testing for womenHIV. and her partner. l Couple and safe sex counselling and HIV testing of spouse and • Nurse/Counsellors to provide information on the ante natal screening comprehensive package l Repeat HIV other living children. including HIV testing through both individual counselling and group counselling information testing,sessions. l Referral to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count • Pregnant Women who opt-out of HIV testing should be offered repeat counselling to explore window, period if and/or clinical staging. spousethe reasons is positive for opting out, address any misunderstandings and encourage her to reconsider her ordecision. s/he have These high women shouldl beNutrition offered routinecounselling HIV testingand atlinkages each subsequent to Government/other clinic visit. Nutrition programmes. • riskPost-test behaviour counselling. for all pregnant women is very important so as to educate those with l Postpartum ARV prophylaxis for mother. l Infantnegative feeding tests and to remain un-infected; while for those with confirmed HIV positive tests-further nutritioncounselling, support and referralsl Family to care Planning & treatment Services. services. counselling. • Pregnant women who have lbeenEBF referred reinforcement/Infant by ANMs after feeding whole suppor bloodt through screening home tests visits. must undergo pre-test counselling landP sychofollow-social the usual suppor HIVt throughtesting protocolfollow-up similar counselling, to the homeregular ante natal cases at the stand-alone ICTCsvisits andfor confirmatory support groups. tests. • Disclosure of HIV status is to be done only at stand-alone ICTCs after appropriate confirmatory testing as per laboratory guidelines (post-test counselling) and only by trained health staff (MO, Nurse or Counsellor). HIV Exposed Infant (HEI) •l ExclusiveAll pregnant breastfeeds women uptoreferred 6 months to other (preferred HIV services Option-I including WHO/NAC ART OCentre, Guidelines should 2010-'11) be tracked to ensure that they actually reach the services, and have been registered at the respective centres. and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for • EIDPartner/Spouse negative babies and andfamily upto (other 2 years children) for EID testing positive for babiesHIV to whbe odone receive as per Paediatric ICTC guidelines. ART.

•l PPartnerostpartum (Husband) ARV prophylaxis involvement for infant during for the 6 weeks.pregnancy and thereafter. PPTCT interventions and FP

l Earlymethods infant to diagnosis be encouraged (EID) ate.g., 6 weeks couple of counsellingage; repeat fortesting mutual at 6 psycho-social months, 12 months support, & 6mother weeks to afARTter cessationand baby of to breastfeeds. ARV, Family planning counselling etc.

1Guidelinesl Co -trimoxazole for rolling out prophylaxis NACP and from NRHM 6 weeks Convergence of age. plan in the state. No X-19020/17/2009-NACP(IEC), 10 August 2010 l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 18 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

5.2 Flow of HIV Infected Pregnant Women Detected during Ante-natal Care and PPTCT Services

Figure-3 summarizes the ﬂ ow of pregnant women presenting in antenatal care and PPTCT services. Figure 3: Services to Pregnant Women during Antenatal Period Programme PPTCT of Components 2: Figure Pregnant women visiting Sub center

omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

ANC Registration by Sub center ANM/MPHW (F)

A omen W regnant P Infected HIV Negative HIV

T/ARV AR Sub center: Routinevisits)–Monthly 4 ANC &at-least PNC (ensure SubCare center: ScreenAntenatal l pregnant women omen W regnant P Services for HIV, Syphilis and TB Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy Screening Test for HIV: Screening test for Syphilis: Screening for Tuberculosis: counselling. Does Finger prick Whole blood test . foronly Syphilis pregnancy -Provide Screening for Tuberculosis: Referfamily to Pregnant Linkages l screening. Ask pregnant women for -more than women to designated microscopic center at Group/Individual OIs. other and TB for Screening l vices. ser planning counselling session one syndrome or condition, check for PHC if there is persistent cough of any Vaginal/CervicalSTIs. Discharge,for Genitaltreatment or and Screening duration,l usually with expectoration. It may Offer HIV test condoms. ree F l - ano-rectal ulcer/blisters, Lower Abdominal Pain be accompanied by one or more of the or tenderness,testing. Ano-rectalCD4 and Discharge,staging Inguinal clinical WHO followingl symptoms such as weightchange loss, Behaviour l Bubo, Genital or anal warts, Individuals with chest pain, tiredness, shortness of breath, and th-planning bir , y deliver safe living, positive on Counselling l communication anal or genitalwarts, Genital scabies, Genital fever,particularly with riserisk of temperaturehigh for in (BCC) Pediculosis, Genital lesions over genitaliaoptions. feeding infant the evening, in some cases there willbe blood in the sputum, loss of appetiteher and and women and spouse of testing HIV and counselling sex safe and Couple nightl sweats . tner par . children living other HIV epeat R l -Refer to PHC with Designated Agree for test Opt out/Refuse . Center T AR to eferral R l Microscopic center (DMC) if a testing, If Syphilis reactive refer to PHC/STI Collection of test woman hasany of the above considering Clinic for symptomatic treatmentandl count count bloodCD4 sampleon based regimen prophylactic ARV or T AR rovide P symptoms RPR testing for confirmation if period , window and does staging. clinical and/or Finger Prick positive is spouse Government/other Wholeblood Government/other to Repeat Counselinglinkages and counselling Nutrition l high have s/he or test for HIV programmes. RPRNutrition Positive . behaviour risk . Offermother HIVfor test at each prophylaxis ARV tum ostpar P l Start Antiand Tuberculosisfeeding Infant l subsequent visit Continue treatment, vices. Ser Planning amily F l treatment after confirmation nutrition advise condom use and partner HIVNegative of TB at DMC visits. home HIVthrough t suppor feeding treatmentreinforcement/Infant EBF l counselling. Reactive home counselling, follow-up through t suppor -social sycho P l groups. t ICTC collectssuppor 5 and ml bloodvisits for HIV rapid test and RPR test RPR Positive Post-test Counseling Refer to ICTC for (if RPR is not done earlier) information, support confirmation of HIV

Start treatment If HIV IfHIV Negative (HEI) immediately,Infant adviseExposed HIV provide post -test Positive condom use and l O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I counseling (preferred months 6 upto breastfeeds partner treat Exclusive ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID -Refer HIV infected Pregnant mother to ART center for CD4 test, TB screening and clinical staging ** Ensure allreferred pregnant women actually reach theweeks. ART6 for center andinfant arefor started on ARTwithoutprophylaxis ARV delaytum or ostpar P l weeks weeks 6 & waitingmonths for 12 CD 4 and othermonths, 6 laboratoryat reports**testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af Figure 3: Services to Pregnant Womenage. of duringweeks 6 Antenatalfrom Periodprophylaxis -trimoxazole Co l EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l National Strategic Plan Multi-Drug ARV for Prevention of Parent to Child Transmission of HIV 27 monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 19 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

2.3.1 Sexually Transmitted InfectionsFigure and2: Components Reproductive of PPTCT Tract Programme Infections

Sexually transmitted infections and reproductive tract infections (STIs/RTIs) are important public health problems in India.Offer Studies of HIV suggestCounselling that around and T esting6 per centServices of the to adult all P populationregnant W inomen India is infected with one or more STIs/RTIs. Individuals with STIs/RTIs have a significantly higher chance of acquiring and transmitting HIV. Moreover, STIs/RTIs are also known to cause infertility and reproductive morbidity. Controlling STIs/RTIs helps decrease HIV infection rates and provides a window of opportunity for HIV Negative HIV Infected Pregnant Women counselling about HIV prevention and reproductive health. Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV Thel implementationSafe sex framework of Nationalprophylaxis Rural atHealth ART Centers.Mission (NRHM) provides the directions for counselling. synergizing the strategies for prevention,l Counselling control and on management choices of continuation for STI/ RTI or services medical under termination Phase IIof of l Couple Reproductive and Child Health Programmepregnancy (RCH II)(MTP)–to and Phase under III oftak Nationale within AIDSthe firstControl 3 months Programme of counselling. (NACP III). While the RCH programmepregnancy advocates only a strong. reference “to include STI/RTI and HIV/AIDS l Linkages to family preventions, screening and management in maternal and child health services”, the NACP includes planning services. l Screening for TB and other OIs. services for management of STIs and ART as a major programme strategy for prevention of HIV. l Free condoms. l Screening and treatment for STIs. Syndromicl Behaviour Case Managementchange (SCM)l is WHOthe cornerstone clinical staging of STI/RTI and CD4 management, testing. being a comprehensive communication approach for STI/RTI control endorsedl byCounselling the World onHealth positive Organization living, safe (WHO). deliver yThis, bir th-planningapproach classifies and (BCC) for high risk infant feeding options. STI/RTIwomen into syndromes, and her which are easily identifiable group of symptoms and signs and provides treatment for thepar mosttner common. organisms causingl Couple the syndrome.and safe sex Treatment counselling has and been HIV standardizedtesting of spouse as givenand in Tablel 1.R epeatSCM achievesHIV high cure rates becauseother living it provides children .immediate treatment on the first visit at little or no laboratorytesting, cost. However, it goesl hand-in-handReferral to AR Twith Center other. important components like counselling, considering partner treatment, condom promotionl andProvide referral AR Tfor or HIV ARV testing. prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive Table 1: Syndromic Management of STI/ RTIs or s/he have high l Nutrition counselling and linkages to Government/other Syndrome Nutrition Treatmentprogrammes. Colour-coded Kits for STI Treatment Urethralrisk Discharge behaviour (UD),. Tab. Azithromycin 1 G (1) and Grey Cervicitisl Infant (CD) feedingAno-rectal and discharge Tab.l CefiximePostpar tum400 ARVmg (1) prophylaxis for mother. (ARD)Painfulnutrition Scrotal Swelling (PSS) l Family Planning Services. Presumptive Treatment (PT) counselling. l EBF reinforcement/Infant feeding support through home visits. Vaginitis (VD) Tab. Secnidazole 2 g (1) and Green Tab.l FluconazolePsycho-social 150 suppormg (1) t through follow-up counselling, home Genital Ulcer Disease- Non Herpetic Inj. Benzathinevisits and penicillin suppor t2.4 groups. MU (1) and White (GUD-NH) Tab. Azithromycin 1 G (1) and Disposable syringe 10 ml with 21 gauge needle (1) and Sterile water 10 ml (1) HIV Exposed Infant (HEI) Genital Ulcer Disease- Non Herpetic Tab. Doxycycline 100 mg (30) and Blue (GUD-NH)–forl Exclusive patients breastfeeds allergic to upto 6Tab. months Azithromycin (preferred 1 G (1) Option-I WHO/NACO Guidelines 2010-'11) penicillin.and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for Genital EIDUlcer negative Disease- Herpeticbabies and uptoTab. 2 Acycloviryears for 400 EID mg positive (21) babies whoRed receive Paediatric ART. (GUD-H) Lowerl AbdominalPostpartum Pain ARV (LAP/PID) prophylaxis Tab.for infant Cefixime for 6400 weeks. mg (1) and Yellow l Early infant diagnosis (EID) atTab. 6 weeksMetronidazole of age; 400 repeat mg (28) testing and at 6 months, 12 months & 6 weeks after cessation of breastfeeds.Cap. Doxycycline 100 mg (28) Inguinal Bubo (IB) Tab. Doxycycline 100 mg (42) and Black l Co-trimoxazole prophylaxis fromTab. 6Azithromycin weeks of age.1 G l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 20 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

STI/ RTI Service Package Programme PPTCT of Components 2: Figure

The syndromic approach is the foundation of STI/RTI services at all facilities. Laboratory tests can be used wherever available.omen W The minimumregnant P all to packagevices Ser of STI/RTIesting T servicesand (Table 2)Counselling to beHIV of provided Offer at different facilities are tabulated below: Table 2: Level of Care Service Provider Modalities Package of Services

Level of Care Service Provider omen W Modalitiesregnant P Infected HIV Package of Services Negative HIV Village T/ARV AR ASHA/Linkvisits)–Monthly 4 worker/at-least Through(ensure theirCare Antenatal • l Information omen W regnant P Health worker outreachCenters. T AR at prophylaxis • Condom provision and promotionsex Safe l (M/F) meetings and • Screening for STI/RTI counselling. of of termination medical or continuation of choices on Counselling l observance of village • Referral for treatment Couple l of of months 3 first the within e tak under (MTP)–to pregnancy health and counselling. . . only pregnancy nutrition days family to Linkages l Sub-centre ANM/Health workerOIs. other Throughand TB ANCfor Screening Inl addition to above,vices. ser planning STIs. for clinics,treatment groupand Screening • l Provide counselling condoms. ree F l meetings and • Referral to ICTC testing. CD4 and staging clinical WHO l change Behaviour l household communication and th-planning bir , y deliver safe living, contactspositive on Counselling l (BCC) for high risk risk high for (BCC) options. feeding infant PHC/Mobile Medical Medical Officer/ Routine OPDs, In addition to above, her and women Unit/Dispensary/CHC/and spouse of Stafftesting HIV Nurse/ and ANCcounselling sex Clinics/safe and Couple • l STI/RTI treatment through. tner par Urban Health post/ LHV/Laboratory Camps syndromic approach and partner . children living other Rural Hospital/Sub Technician management HIV epeat R l divisional . Center T AR to eferral R • l Simple diagnostic tests (includingtesting, considering considering Hospital count CD4 on based regimen prophylactic ARV or T AR rovide P l Syphilis screening) staging. staging. clinical and/or • ARSH services if period , window • Referral to ICTC positive is spouse Government/other Government/other to linkages and counselling Nutrition l • Reporting to districthigh have RCH Officers/he or programmes. Nutrition District hospital, Medical Officer STI/RTI clinic • Syndromic case . managementbehaviour risk of Medical College Staff. nursemother for Gynaecology/prophylaxis ARV tum ostpar P l STI/ RTI (provisionand offeeding directly Infant l hospitals, select Rural Counsellor, Obstetricsvices. Ser clinicsPlanning amily F l observed treatment for singlenutrition Hospital/Sub divisional Laboratory ANC Clinics dose regimen) visits. home through t suppor feeding reinforcement/Infant EBF l counselling. Hospital). Technician General OPD • Minimal laboratory testing “SURAKSHA home CLINIC” counselling, follow-up through t suppor -social sycho P • l Counselling groups. t suppor and visits • Condom Promotion • Partner treatment • Syphilis screening • Referral to ICTC • Linkage with(HEI) otherInfant servicesExposed HIV Pregnant Women2010-'11) and STI/ Guidelines RTI O ServicesWHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and All pregn . antT AR women aediatric shouldP bereceive o screenedwh babies for syphilis.positive EID Syphilis for isyears 2 one ofupto theand easilybabies treatablenegative SexuallyEID

Transmitted Infection (STI/RTI) caused by Treponemaweeks. pallidum,6 for infant whichfor can beprophylaxis transmittedARV tum toostpar P sexuall partners weeks as6 & well asmonths from12 infectedmonths, 6 pregnantat testing womanrepeat age; to of her newweeks 6 bornat child.(EID) Untreateddiagnosis infant syphilisEarly l is responsible for multisystem complications and other sickness among infected patientsbreastfeeds. of andcessation mayter af cause miscarriages, low birth weight and premature delivery age. in of the pregnantweeks 6 from woman. Manyprophylaxis patients of-trimoxazole syphilisCo l EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 21 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

are asymptomatic and do not manifestFigure 2:any Components symptoms of PPTCTof the Programmedisease. The National STI/RTI prevention and control programme mandates a screening test to detect hidden syphilis among all pregnant women attending AntenatalOffer ofClinics. HIV CounsellingThe Rapid Plasma and T Reaginesting testSer vices(RPR toTest) all orP regnantVenereal WDiseasesomen Laboratory Test (VDRL Test) are the most commonly used screening tests to detect syphilis. The programme recommends treatment of all RPR reactive patients.

ProcessHIV Negativeof Screening ANC Women HIV Infected Pregnant Women Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV ANMl atSafe the sex village/subcentre level will prophylaxisdo screening at testART forCenters. HIV and Syphilis using whole blood finger counselling. prick test. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of If the Syphiliscounselling. test is reactive then the pregnant woman would be referred to designated STI/RTI clinics pregnancy only. or PHCl Linkages with RPR to testing family availability for Syphilis confirmation. planning services. l Screening for TB and other OIs. If thel HIVFree test condoms. is reactive then the pregnantl Screening woman and will treatment be referred for STIs.to stand alone ICTC for confirmation of HIVl Behaviourby rapid tests. change The patient thenl undergoesWHO clinical pre-test staging counselling and CD4 attesting. the ICTC by the ICTC counsellor. communication The ICTC collects 5 ml blood for HIVl rapidCounselling tests and on RPR positive test. living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. After HIVwomen and andRPR her testing, the patient returns to the ICTC counsellor for post test counselling. During partner. l Couple and safe sex counselling and HIV testing of spouse and post-test counselling the ICTC counsellor provides the HIV and syphilis test report and counsels the l Repeat HIV other living children. patient to go to the STI/RTI clinic for further follow-up and advice from the STI/RTI counsellor and testing, l Referral to ART Center. Medicalconsidering officer for treatment if required. l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. 2.3.2 HIV-TBspouse isCollaborative positive Activities or s/he have high l Nutrition counselling and linkages to Government/other Nutrition programmes. Tuberculosisrisk behaviour (TB) is responsible. for about 25% of all deaths among HIV infected individuals. The risk of l Postpartum ARV prophylaxis for mother. activel TBInfant is approximately feeding and 10 times higher in HIV-infected pregnant women compared to HIV uninfected nutrition l Family Planning Services. women. Active TB in HIV-infected pregnant women can contribute to increased risk of maternal mortality, counselling. l EBF reinforcement/Infant feeding support through home visits. and is also associated with prematurity, low birth weight, and perinatal tuberculosis among infants. A l Psycho-social support through follow-up counselling, home recent study in India found that maternal TB increases the risk of HIV transmission from mother -to child visits and support groups. by 2.5 times. The key TB prevention interventions recommended by World Health Organization at HIV care settings include airborne infection control at HIV care settings and Isoniazid Preventive Therapy (IPT). NACP is currently implementing airborne infection control measures like fast tracking of cough HIV Exposed Infant (HEI) symptomatic patients, promotion of cough hygiene etc. at ART centres. Further, the National Technical l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) Working Group (NTWG) on TB-HIV collaboration, at NACO endorsed IPT as a strategy and recommended and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for its implementation at all ART centres in the country. This activity is planned for roll-out in 2014-15. EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. Alongl withPostpar TBtum prevention, ARV prophylaxis early detection for infant andfor 6 treatmentweeks. of HIV-TB are also important for reducing mortality.l Early The infant NACP diagnosis and Revised (EID) National at 6 weeks TB of Control age; repeat Programme testing (RNTCP) at 6 months, implement 12 months various & 6 activities weeks jointly toaf terensure cessation early ofdetection breastfeeds. and treatment. These include: l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 22 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Activities for Early Detection of HIV AssociatedProgramme TBPPTCT of Components 2: Figure

• HIV testing of presumptive TB cases omen W regnant P all to vices Ser esting T and Counselling HIV of Offer • HIV testing of diagnosed TB patients

• Intensified TB case finding (ICF) at ICTC omen W regnant P Infected HIV Negative HIV • ICF at ART centres T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Activities to Ensure Early Treatment of HIV Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l • Linkage of HIV-TB cases to ART Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. . . only pregnancy • Initiation of HIV-TB cases on ART family to Linkages l OIs. other and TB for Screening l vices. ser planning HIV testing of presumptive TB cases: Detection of HIV by offering HIV tests to diagnosed TB patients is STIs. for treatment and Screening l condoms. ree F l being implemented by NACP and RNTCPtesting. CD4 jointlyand sincestaging clinical WHO l change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication 2007-08. NACP and RNTCP decided to offer HIV test upstream during evaluation risk ofhigh patientsfor (BCC) for TB options. feeding infant when they present with TB symptoms. This activity is expected to expedite detection her ofand HIV bywomen 2-4 and spouse of testing HIV and counselling sex safe and Couple l weeks, leading to early linkage to treatment and hence reduction in mortality. . tner par . children living other HIV epeat R l Intensified TB case finding at ART centres:. ICF atCenter T ARTAR to centres eferral isR implementedl since 2010 and ittesting, is now considering considering implemented count CD4 at allon ARTbased centres,regimen Link ART centresprophylactic ARV and or T LinkAR ART rovide plusP l centres. Gene-Xpert testing is being staging. staging. clinical and/or if period , window proposed by the TB programme in 40 sites soon for early screening and testing for TB. positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or Process of Screening ANC Women programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l Women registered for ANC care would be screenedvices. Ser for TBPlanning alongamily F withl HIV and Syphilis by ANMs nutrition at sub centre level.visits. home through t suppor feeding reinforcement/Infant EBF l counselling. ANM checkshome for TB symptomscounselling, (Referfollow-up Pregnantthrough t womensuppor to -social designatedsycho P l microscopic centre (DMC) at PHC groups. t suppor and visits if there is a persistent cough of any duration. It may be accompanied by one or more of the following symptoms such as weight loss, chest pain, tiredness, shortness of breath, fever, particularly rise of temperature in the evening, in some cases there can be blood in the sputum, loss of appetite and night HIV Exposed Infant (HEI) Infant Exposed HIV sweats). O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l Refer all HIVfor positiveyear 1 upto pregnant months women6 ter af to RNTCPfeeds for TBcomplement diagnosisto andaddition in treatment atbreastfeeds the earliest.continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 23 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Stand Alone ICTC Stand Alone ICTC Sub-centre level Whole Blood Finger Offer of HIV Counselling and Testing Services to all PregnantPrick Test W (WBFPTomen centre)

• Three Rapid test for Screening of Ante-natal cases Screening of Ante-natal Confirmation of HIV for HIV and syphilis/STI/TB cases for HIV using WBFPT, Screening women for Syphilis HIV• SyphilisNegative confirmation using HIV Infected Pregnant Women using WBFPT/STI and Screen RPR test and women for TB by history taking Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV • TB screening l Safe sex • Referral linkage with prophylaxisStand-alone at ICTCART forCenters. counselling. confirmation of HIV status. • Provides confirmation of l Counselling on choices of continuation• orReferral medical linkage termination with of l Couple HIV status for Women pregnancy (MTP)–to undertake withinStand-alone the first ICTC3 months for of counselling. • Refer to STI clinic/PHC/ screened positive with pregnancyICTC with only RPR. testing confirmation of HIV status l LinkagesWhole Blood to Fingerfamily Prick facility for confirmation of • Refer to STI clinic/PHC/ Test (WBFPT) l ScreeningSyphilis for TB and other OIs. planning services. ICTC with RPR testing l• FreeProvides condoms. confirmation of l •Screening Refer to andDMC treatment for TB for STIs. facility for confirmation of Syphilis status for women confirmation Syphilis l Behaviourscreened reactive change with l WHO clinical staging and CD4 testing. • Refer to DMC for TB communicationWBFPT l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk confirmation infant feeding options. women and her Referral Linkage with ART Tracking referral of infected l Couple and safe sex counselling and HIV testing of spouse and centrepartner. pregnant women to ART centre other living children. Tracking referral of infected l Repeat HIV pregnant women to ART centre Coordinationtesting, for institutional l Referral to ART Center. Through MO-PHC delivery,considering EID, provision of ART for “direct-in-labor” cases etc. l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. Liaisonspouse with isoutreach positive workers, Liaison with outreach workers, Follow-up visits to infected l Nutrition counselling and linkages to Government/other ANMor etc.s/he for have follow-up high of HIV ANM etc. for follow-up of HIV women for EID, visits to ART infectedrisk behaviourWomen . infectedNutrition women programmes. centre, regular treatment l Infant feeding and l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services. Figure 4: PPTCT Services for Pregnant Women at Different Levels counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home 2.4 Guiding Principles for Usevisits andof supporART int groups. PPTCT The guiding principles for the use of ART to prevent HIV transmission from mother-to-child are: • HIV infected pregnant women, in need of ART for their own health should receive life-long A R T. HIV Exposed Infant (HEI) •l ExclusivePostpartum breastfeeds ART initiation upto 6to months mother (preferredand ARV ProphylaxisOption-I WHO/NAC to childO are Guidelines aimed at 2010-'11) improving HIV- andfree continuedchild survival breastfeeds by reducing in addition HIV transmission to complement through feeds breastfeeding. after 6 months upto 1 year for • EIDHIV negativeexposed infantsbabies andshould upto be 2 followed-up years for EID and positive managed babies as per wh theo receive National Paediatric Guidelines AR Ton. “Care l Pofostpar HIV exposedtum ARV infants prophylaxis and children for infant”. for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks In India, the PPTCT programme has been in place for many years, and recommended ARV prophylaxis after cessation of breastfeeds. was sd of Tab Nevirapine (200mg) to mother during labour and single dose of Sy Nevirapine to the l Co-trimoxazole prophylaxis from 6 weeks of age. infant at birth. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 24 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

However, with evolving evidence, the NationalProgramme PPTCT technicalof guidelinesComponents 2: Figure have been revised and, it is recommended that: 1. All HIV infectedomen W pregnantregnant P womenall to shouldvices Ser be initiatedesting T onand life-long ARTCounselling (onHIV tripleof ART)Offer regardless of WHO clinical stage or CD4 cell count. 2. HIV infected pregnant women should preferably be initiated on ART at ART centre and should not be delayed for want of CD4 cell count report. omen W regnant P Infected HIV Negative HIV The summary of the technical guidelines Multi Drug Anti-retroviral Regimen for PPTCT is provided in T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Figure 5. Centers. T AR at prophylaxis sex Safe l counselling. Care of for the HIV-infectedtermination medical pregnantor womencontinuation of beginschoices onon the first Counselling contactl with health services during the Couple Couple l ante of natal period.months 3 Establishingfirst the within a e relationshiptak under or a rapport(MTP)–to withpregnancy the HIV infected pregnant woman is counselling. counselling. fundamental in providing a continuum of care involving . only prevention,pregnancy care, support, and treatment for family family to Linkages l the mother and child. This requires the involvement of the clinical and para-medical team at the health OIs. other and TB for Screening l vices. ser planning facility – the Obstetricians, Paediatricians, Physicians, Medical Officers, Nurses, ANMs, ASHAs, Lab STIs. for treatment and Screening l condoms. ree F l Technicians, Counsellors and Outreach Workers. District Level Positive Networks, Local Community testing. CD4 and staging clinical WHO l change Behaviour l Based Organizations and Self-Help Groups (SHGs) should help support the HIV infected mother and and th-planning bir , y deliver safe living, positive on Counselling l communication her family. risk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and Establish HIVcounselling statussex ofsafe Pregnantand WomenCouple l . tner par . children living other HIV epeat R l . Center T AR to eferral R l testing,

considering considering Antenatal count Knowncount HIV CD4 infected on casebased and alreadyregimen receiving ARTprophylactic ARV Newly or T detectedAR HIVrovide P infectionl HIV test Negative staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l From ICTC Collect the blood high have s/he or programmes. Nutrition Repeat HIV test (as per Continue ART sample for CD4 and send it to guidelines for window . period & behaviour risk (as per guidelines) ART centre and refer women to . mother for prophylaxis ARV tum ostpar P l H/o risk factor) ART centre and feeding Infant l vices. Ser Planning amily F l nutrition counselling. visits. home through t ARTsuppor Centre: feeding Initiate ART to HIV positivereinforcement/Infant pregnantEBF l mother regardless of WHO clinical stage and CD 4 count results home counselling, follow-up through t suppor -social sycho P l Preferred regimen:groups. t TDF+3TC+EFVsuppor and visits

ART centre will collect sample for baseline and other Labour & Delivery investigations

Mother: Continue ART during Labour, (HEI) Infant Exposed HIV Delivery and thereafter lifelong O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and Mother: Continue ART life long . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Infant: Daily NVP from birth until minimum 6 weeks of age, then stop (irrespective of choiceweeks. 6 offor infant feeding)infant for prophylaxis ARV tum ostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l

Exclusive Breastfeeds or Exclusive Replacement Feed Postpartum breastfeeds. of cessation ter af Figure 5: The Summary of the Technicalage. of Guidelines weeks 6 andfrom Options forprophylaxis the -trimoxazole Co l EID. through Morepositive HIV Efficaciousas diagnosed PPTCT children Regimenand infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 25 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

PPTCT Services under NACP 3.1 Existing Facilities Programme PPTCT of Components 2: Figure

Under the Nationalomen AIDSW Controlregnant P Programme,all to vices variousSer HIVesting T relatedand services areCounselling providedHIV of throughOffer public and private health care providers depending on the programme need and the availability of health infrastructure, human resource and their expertise. The PPTCT services are provided through the Integrated Counselling and Testing Centres (ICTCs) which are of the following types: omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P 1. Stand-Alone ICTCs: These are HIV counselling and testing facilities supported by NACP in the Centers. T AR at prophylaxis sex Safe l form of staff (Counsellor & Lab Tech) and necessary logistic support. These centres performcounselling. of of confirmatorytermination testsmedical or for HIV. continuation Typicallyof choices theseon centresCounselling l are located in Medical Colleges, District Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy Hospitals, Taluk Hospitals and Community Health Centres. counselling. . . only pregnancy 2. Facility-Integrated ICTCs (F-ICTCs): These are facilities where the staff – (Stafffamily to Nurses andLinkages Labl OIs. other and TB for Screening l vices. ser planning Technicians) from existing health facilities are trained in counselling and testing, and service STIs. for treatment and Screening l condoms. ree F l delivery is ensured with provision of HIV test kits from the NACP. though it would be best to be testing. CD4 and staging clinical WHO l change Behaviour l purchased from NRHM budget. The centres perform only screening tests for HIV using Whole communication communication Bloodand Fingerth-planning Prickbir , y test kitsdeliver andsafe anyliving, client foundpositive on positive onCounselling screeningl is referred to a stand-alone (BCC) for high risk risk high for (BCC) options. feeding infant ICTC for confirmation. Typically, these centres are located at PHCs. The private/NGOher and facilitieswomen alsoand functionspouse of undertesting thisHIV model.and counselling sex safe and Couple l . tner par 3. Screening Centres: These are health facilities. children whereliving the other Auxillary Nurse Midwives HIV (ANMs;epeat R nowl called Jr. Health Assistant (F)) at existing. healthCenter T AR facilitiesto eferral areR l trained in counselling and screeningtesting, considering considering count forcount HIVCD4 byon wholebased blood fingerregimen prick test.prophylactic TheseARV or T centresAR performrovide P l only screening test for HIV through , period if if period , window whole blood finger prick test (WBFPT) andstaging. any clientclinical foundand/or reactive through this screening test spouse is positive positive is spouse is referred to Stand-Alone ICTCs for confirmation. Typically,l these centres are located at PHCs Government/other Government/other to linkages and counselling Nutrition high have s/he or and Sub Centres. programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l The 5 tier structure of public health system and HIV related services at different levelsand is detailedfeeding Infant belowl vices. Ser Planning amily F l nutrition in the Table 3: visits. home through t suppor feeding reinforcement/Infant EBF l counselling. Table 3: HIV Services at Different Level of Health Facilities home counselling, follow-up through t suppor -social sycho P l Level of Health Infrastructure Availablegroups. t HIV Facilitiessuppor and visits Available HIV Services Medical College Stand -Alone ICTC, ART Centre ICTC, PPTCT, HIV-TB, ART Centre of Excellence (CoE) in HIV care including Paediatric Centre of Excellence (pCoE) Paed. ART, OI, STI, EID District Hospital Stand- Alone ICTC, ART Centre ICTC, PPTCT,(HEI) HIV-TB,Infant ART, OI,Exposed STI,HIV O Guidelines 2010-'11) 2010-'11) Guidelines O Link ARTWHO/NAC Centre, BloodOption-I Bank (preferred months 6 EID services,upto Linkagesbreastfeeds to DLNs/Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in DIC for psycho-socialbreastfeeds supportcontinued and and services . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Sub-district/Community Health Stand- Alone ICTC, Facility-ICTC ART/ ICTC / HIV Screening, PPTCT, HIV- Centre Link -ART Centre Blood weeks. storage 6 for centreinfant for TB, ART, OI,prophylaxis STI,ARV DIC,tum EID Servicesostpar P l

Primary weeks Health 6 & Centres/months 12 Stand-Alonemonths, 6 at ICTCstesting repeat age; of weeks 6 at HIV Screening,(EID) PPTCT,diagnosis infant HIV-TB, Early STIl 24x7 PHCs Facility integrated ICTCs breastfeeds. of cessation ter af Sub-Centres Screening Centre (Whole Blood Finger HIV Screening Test age. of weeks 6 from prophylaxis -trimoxazole Co l Prick Test) EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 27 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

3.2. Continuum of careFigure under 2: Components PPTCT of PPTCT Programme With the revision of PPTCT guidelines that recommend use of the more efficacious Multi Drug ART regimen, Offer of HIV Counselling and Testing Services to all Pregnant Women it is important to consider Prong-3 of National PPTCT programme as a continuum of interventions rather than a one-time activity (Fig 6). This requires close coordination between various implementing components for PPTCT-ART linkage, Early Infant Diagnosis (EID), Paediatric ART services etc.

TheHIV continuum Negative of care involves the HIVfollowing Infected steps: Pregnant Women Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV 1. Increasing uptake of PPTCT services by pregnant women. l Safe sex prophylaxis at ART Centers. counselling. 2. Counselling and Testing of pregnantl Counselling women on as choices an integral of continuation part of ANC or Comprehensivemedical termination Services of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling.package. pregnancy only. l3. LinkagesDetection to of family HIV infected pregnant women. planning services. l Screening for TB and other OIs. l4. FLinkingree condoms. HIV infected pregnantl womenScreening to Care, and treatment Support andfor STIs. Treatment services. l Behaviour change l WHO clinical staging and CD4 testing. 5. Initiating ART for all HIV infected pregnant women regardless of CD4 count, starting it as soon as communication l Counselling on positive living, safe delivery, birth-planning and (BCC)diagnosed for high and risk continued for life. However, make sure to obtain samples for CD4 cell count and infant feeding options. womenbaseline and tests her at the time of initiating ART or soon after initiating ART. partner. l Couple and safe sex counselling and HIV testing of spouse and 6. Counselling on birth-planning and institutional deliveries of identified HIV infected pregnant l Repeat HIV other living children. women. testing, l Referral to ART Center. considering 7. Screening emergency labour lroomProvide deliveries ART (un-bookedor ARV prophylactic cases) for regimen HIV. If HIVbased positive, on CD4 providing count windowART and, period obtaining if sample for CD4and/or cell clinical count staging.as soon as possible. spouse is positive 8. orLinking s/he have of HIV high infected pregnantl Nutrition women identifiedcounselling through and emergencylinkages labour-roomto Government/other care services Nutrition programmes. riskto Care,behaviour Support. and Treatment services. l Infant feeding and l Postpartum ARV prophylaxis for mother. 9. Provision of Syrup Nevirapine for the new born infant from birth till 6 weeks of age (minimum). nutrition l Family Planning Services. At the end of 6 weeks, CPT should be initiated and baby to be linked to the EID programme. counselling. l EBF reinforcement/Infant feeding support through home visits. CPT continued to baby from 6 weeks up to 18 months or until the confirmatory test of the baby l Psycho-social support through follow-up counselling, home is done using all three Rapid Antibody Tests. If baby is confirmed positive, then CPT will be continued. visits and support groups.

10. If the infant is detected positive in EID programme (DBS+WBS tests are positive), then ensure initiation of Pediatric ART for the baby through ART centre as per ART guidelines as soon as HIV Exposed Infant (HEI) possible. l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 11.and Follow-up continued of HIV breastfeeds infected motherin addition and tobaby complement until breastfeeding feeds after period 6 months is over. upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. 12. At six weeks of age of baby, do DBS test and confirm with WBS test. If the age of baby is more l Pthanostpar 6 tummonths, ARV prophylaxisthen do antibody for infant (rapid) for 6 test weeks. first, if found positive then only DBS sample should l Earlybe sent. infant If diagnosisDBS comes (EID) positive at 6 weeks then do of age;a WBS repeat test testing If WBS at is 6 positive,months, 12start months Paediatric & 6 weeksART as afsoonter cessation as possible. of breastfeeds. l Co-trimoxazole prophylaxis from 6 weeks of age. 13. Confirmation of diagnosis of child using 3 anti-body tests (Rapid) at ICTCs at 18 months of age. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 28 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure

Ante-natal PPTCT omen W regnant P all to Intra natalvices Ser PPTCT esting T and Counselling PostHIV natalof PPTCTOffer services: services: services: Initiate–ART Continue–ART Continue– ART life long

omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Centers. T AR at prophylaxis sex Safe l Counselling and testing in all phases; encourage institutional deliveries counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. . . only pregnancy family family to Linkages l OIs. other and TB for Screening l vices. ser planning Link with ART services and CD4 Link with ART services and CD4 Link with ART services, CD4 testing, STIs. for treatment and Screening l testing testing EID & paediatric ART Initiationcondoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l

and Figureth-planning 6:bir , PRONGy deliver 3: Continuumsafe living, of Carepositive on for HIV InfectedCounselling l Pregnant Women communication (BCC) for high risk risk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par . children living other HIV epeat R l . Center T AR to eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 29 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Care and Assessment of HIV Infected Pregnant Women 4.1 Care during the Antenatal Programme PeriodPPTCT of Components 2: Figure

HIV infected pregnantomen W women regnant mayP all presentto vices to ICTCsSer andesting T ARTand centres at variousCounselling HIV stagesof Offer of pregnancy (Refer to Table 4).

• Pregnant Women who are detected to be HIV infected during ante natal care should be initiated on ART (TDF+3TC+EFV) regardless of clinical stage or CD4 count. However, it is important to obtain sample of blood for CD4 countomen W and forregnant baselineP testsInfected HIV before initiating ART. The initiationNegative HIV omen W regnant P of ARTT/ARV shouldAR not be delayedvisits)–Monthly 4 for wantat-least of CD4(ensure testCare results.Antenatal l Centers. T AR at prophylaxis sex Safe l • Pregnant women who are detected to be HIV infected by screening test (by one test kit) counselling. during of of termination medical or continuation of choices on Counselling l Couple Couple l of of activemonths labour3 first should the be initiatedwithin e tak onunder ART but should(MTP)–to be referredpregnancy for confirmation of HIV status at counselling. counselling. the earliest and linked to ART centre, if confirmed . only positive.pregnancy family family to Linkages l • The table below (Table 4) providesOIs. summaryother and ofTB maternalfor ARTScreening (lifel long) and infantvices. ARVser prophylaxisplanning for different clinical scenarios.STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l Table 4: Summary of Maternal ART (Life Long) and Infant ARV Prophylaxis for communication and th-planning bir , y deliver safe Differentliving, Clinicalpositive on ScenariosCounselling l (BCC) for high risk risk high for (BCC) options. feeding infant Scenarios Different Clinical Scenarios Maternal ART Infant ARV Durationher and of women and spouse of testing HIV and counselling sex safe and prophylaxisCouple l Infant ARV prophylaxis. tner par Scenario 1 Mother diagnosed with HIV Initiate. maternalchildren ART living NVP other 6 weeks HIV epeat R l during pregnancy . Center T AR to eferral R l testing, Scenario 2 Mother diagnosed with HIV Initiate maternal ART NVP Extending NVP prophylaxis to 12considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l during labour or immediately weeks staging. staging. clinical and/or if period , window postpartum and plans to positive is spouse breastfeed l Government/other Government/other to linkages and counselling Nutrition high have s/he or Scenario 3 Mother diagnosed with HIV Refer mother for HIVprogrammes. NVP Nutrition 6 weeks . behaviour risk during labour or immediately care and evaluation . mother for prophylaxis ARV tum ostpar P l postpartum and plans for treatment and feeding Infant l Exclusive Replacement vices. Ser Planning amily F l nutrition visits. feeding(ERF)home through t suppor feeding reinforcement/Infant EBF l counselling. Scenario 4 Infant identified as HIV Initiate maternal ART NVP Perform infant DNA/PCR test if child home counselling, follow-up through t suppor -social sycho P l exposed after birth (through is 6 weeks old or older Immediately infant (at 6 weeks or after) or groups. t suppor and visits initiate 6 weeks or longer of NVP– maternal HIV antibody testing)) strongly consider extending this to 12 and is breastfeeding weeks Scenario 5 Infant identified as HIV Refer mother to ART No NVP Do HIV DNA/PCR test in accordance exposed after birth (through Centre after CD4 tests (No drugs) with national(HEI) recommendationsInfant Exposed onHIV O Guidelines 2010-'11) infant2010-'11) or maternal Guidelines HIV O andWHO/NAC baselineOption-I test and (preferred months 6 earlyupto infant diagnosis;breastfeeds no infantExclusive ARVl ter 6 months upto 1 year for for antibodyyear 1 testing)upto andmonths is6 not ter af treatmentfeeds complement to addition in prophylaxis; breastfeeds initiate treatmentcontinued ifand the breastfeeding infant is infected . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Scenario 6 Mother receiving ART but Determine an NVP Until 6 weeks after maternal ART interrupts ART regimen alternative ART weeks. 6 for infant for is restartedprophylaxis or untilARV 1 tum week afterostpar P l while breastfeeding (such as regimen or solution; breastfeeding has ended weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l toxicity, stock-outs or refusal to counsel regarding continue) continuing ART breastfeeds. of cessation ter af without interruptionage. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 31 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

HIV infected pregnant women requireFigure 2: joint Components management of PPTCT from Programme both the HIV care team (for her HIV condition) and the Obstetric team (for successful outcomes of pregnancy). HIV infected pregnant women requireOffer all components of HIV Counselling of good antenatal and Testing care, Serincludingvices toiron-folate all Pregnant supplementation, Women anaemia management, baseline CD4 count, screening of TB, prevention and management of OIs, STI treatment, special Obstetric practices especially during labour and delivery, ART initiation and its continuation, counselling for infant feeding options, post natal care, follow-up, family planning and contraception. PostpartumHIV Negative care and follow-up for theHIV well- Infected being Pofregnant mother W andomen infant, as well as adherence to ART and

otherPregnant care, to Wpreventomen HIV transmissionl Antenatalduring breastfeeding Care (ensure is at-least important. 4 visits)–Monthly ART/ARV l Safe sex Good antenatal careprophylaxis ensures at that AR Tpregnancy Centers. and delivery: counselling. l Counselling on choices of continuation or medical termination of l Couple • Is a safe experiencepregnancy for the(MTP)–to mother. undertake within the first 3 months of counselling. Box 1 pregnancy only. l Linkages to family• Builds the foundation for the delivery of a healthy baby (minimal risk of HIV l Screening for TB and other OIs. planning services. transmission to the baby) l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

communication l Counselling on positive living, safe delivery, birth-planning and 4.2 (BCC)Initial for highassessment risk infant feeding options. women and her All HIV infected pregnant women should have routine ante natal care for the well-being of her baby partner. l Couple and safe sex counselling and HIV testing of spouse and including: l Repeat HIV other living children. • testing,At least 4 ANC check-ups duringl R pregnancyeferral to AR (registrationT Center. and 1st check-up within 12 weeks, 2nd considering between 14-26 weeks, 3rd betweenl Provide 28-32 ART weeksor ARV and prophylactic 4th between regimen 36-40 based weeks) on CD4as per count RCH/ windowNACP ,guidelines. period if and/or clinical staging. spouse is positive • orHistory, s/he have physical high and abdominall Nutrition examination. counselling and linkages to Government/other risk behaviour. Nutrition programmes. • Antenatal routine blood screening: l Infant feeding and l Postpartum ARV prophylaxis for mother. nutritiono Hb, blood group & Rh typing,l Family urine Planning routine atSer 1stvices. visit; including tests for syphilis, Hepatitis counselling.‘B’ and HIV. l EBF reinforcement/Infant feeding support through home visits. o Urine routine to be donel atP allsycho visits,-social and suppor Hb% tto through be re-checked follow-up at counselling, the 3rd visit home at 28-32 weeks gestation. visits and support groups. • 2 Doses of Tetanus Toxoid (TT) to prevent maternal and newborn tetanus:

HIVo Exposed First dose: Infant at (HEI) ANC registration. l Exclusiveo Second breastfeeds dose: 4-6 upto weeks 6 aftermonths the (preferredfirst dose, Option-I preferably WHO/NAC at least Oone Guidelines month before 2010-'11) the expected and continueddate of delivery breastfeeds (EDD). in addition to complement feeds after 6 months upto 1 year for • AntenatalEID negative drug supplementation: babies and upto 2 years for EID positive babies who receive Paediatric ART. l Postpartum ARV prophylaxis for infant for 6 weeks. o IFA tablet (100mg iron + 0.5 mg folic acid) daily for 100 days, after 1st trimester to prevent l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after anaemia.cessation of breastfeeds. l Coo -trimoxazoleDouble the prophylaxis dose if anaemia from 6 persists. weeks of age. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 32 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Counselling on nutrition, rest, warning signs,Programme ARTPPTCT of linkages-CD4Components 2: testingFigure if HIV positive and ART, birth planning, institutional delivery, exclusive breastfeeding within an hour of delivery, safe sex, HIV-specific advice and contraception.omen W regnant P all to vices Ser esting T and Counselling HIV of Offer From the HIV care aspect for pregnant women, the initial assessment follows standard adult ART guidelines including: • WHO clinical staging. omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P • Clinical screening for TB and STI symptoms: Screen for TB at each visit: Intensified Case Finding Centers. T AR at prophylaxis sex Safe l (ICF) as per TB-HIV guidelines for screening TB in all HIV-infected individuals. counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of o Clinicalmonths 3 screening–askfirst the within e for tak coughunder (of any duration),(MTP)–to coughpregnancy with blood in sputum, unexplained counselling. counselling. fever or weight loss, fatigue, night sweats, . lossonly of appetite,pregnancy pleuritic chest pain; glands/nodes in neck, armpits/axilla or groin. family to Linkages l OIs. other and TB for Screening l vices. ser planning o The normal weight gain inSTIs. afor normal pregnancytreatment and is aroundScreening l 11 kg. Most of it occurscondoms. ree F in l the second and third trimestertesting. (approximatelyCD4 and staging 5 kgclinical in eachWHO l trimester), while thechange first trimesterBehaviour l

and is usuallyth-planning 1-2bir , y kg. Thedeliver weightsafe gainliving, patternspositive on should beCounselling co-relatedl clinically and other factorscommunication (BCC) for high risk risk high for (BCC) like twin pregnancy, hyperemesis gravidarumoptions. duringfeeding infant the first trimester etc. A failure to gain weight should arouse the suspicion for further evaluation. Weight loss her duringand pregnancywomen and spouse of testing HIV and counselling sex safe and Couple l requires detailed assessment, because it can be a sign of underlying Opportunistic. tner Infectionspar (OIs) in HIV infected individuals. . children living other HIV epeat R l . Center T AR to eferral R l testing, • Screen and treat any STIs: any concurrent STIs may increase the risk of HIV transmission considering from count count CD4 on based regimen prophylactic ARV or T AR rovide P l mother-to-child, and may adversely affect staging. the pregnancy.clinical and/or Treat STIs according if period to , the nationalwindow guidelines. Baseline laboratory investigations as per national adult guidelines. positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or • CD4 cell count (baseline): programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l o Women who do not return for results should be actively traced back and and broughtfeeding Infant to l the vices. Ser Planning amily F l nutrition continuum of care through the help of grass-root level health functionaries – ANMs/ASHAs/ counselling. visits. Communityhome healththrough t workers.suppor feeding reinforcement/Infant EBF l home counselling, follow-up through t suppor -social sycho P l • Initiate adherence counselling (antiretroviral treatment for mother and ARV prophylaxis for infant) groups. t suppor and visits and it is re-emphasized that the initiation of ART for the pregnant women should not be withheld for want of the above laboratory investigations and clinical staging. Initiate Co-trimozaxole Prophylactic Therapy (CPT) if CD4 ≤ 250 cells/mm3. HIV Exposed Infant (HEI) Infant Exposed HIV • Nutritional counselling for the mother: good food, rest and exercise. O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l • Adherencefor year 1 to upto iron-folate months 6 and ter vitamin/mineralaf feeds supplements.complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID • Counsel for regular ante natal check-up and institutional delivery. weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks • Counselweeks 6 & for exclusivemonths 12 breastfeedingmonths, 6 at withintesting anrepeat hourage; of of delivery.weeks 6 at (EID) diagnosis infant Early l • No MIXED FEEDING (No breast feeding and other milk feeds during thebreastfeeds. firstof 6 months)cessation ter af under any circumstances. age. of weeks 6 from prophylaxis -trimoxazole Co l EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 33 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

4.3 Criteria for ART InitiationFigure 2: Components of PPTCT Programme Initiation of ART in pregnant women needs to be done at the earliest and after adequate treatment Offer of HIV Counselling and Testing Services to all Pregnant Women preparedness for adherence to maintain her own health and also to prevent HIV virus transmission to the unborn baby.

In HIV infected pregnant women the dictum should be “do not delay ART initiation”. The eligibility criteriaHIV forNegative initiating ART in HIV positiveHIV Infected pregnant P regnantwomen Wareomen as below: Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex ART eligibility inprophylaxis pregnant women: at ART Centers. counselling. • Initiate lifelongl Counselling ART in all on pregnant choices of women continuation with confirmedor medical terminationHIV infection of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. regardless of WHO clinical stage or CD4 cell count. TDF + 3TC + EFV pregnancy only. l LinkagesBox to2 family is recommended as first-line ART in pregnant and breastfeeding women, planning services. (including lpregnantScreening women for TB in and the other first OIs. trimester of pregnancy and women l Free condoms. of childbearingl Screening age) and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing. • ART shall be initiated only at ART centre communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. women and her 4.4 parIndicationstner. for Co-trimozaxolel Couple and safeProphylactic sex counselling Therapyand HIV testing (CPT) of spouse in and l RPregnancyepeat HIV other living children. testing, l Referral to ART Center. considering The indications for co-trimozaxole initiationl Provide in AR pregnantT or ARV women prophylactic are same regimen as thosebased foron CD4 other count adults (CD4≤250window cells/cmm)., period if Co-trimoxazoleand/or prophylaxis clinical is staging. helpful in reducing morbidity and mortality as it preventsspouse Opportunistic is positive Infections (OIs) such as Pneumocystis jiroveci pneumonia (PCP), toxoplasmosis, or s/he have high l Nutrition counselling and linkages to Government/other diarrhoea as well as other bacterial infections. risk behaviour. Nutrition programmes. l Postpartum ARV prophylaxis for mother. l Infant feeding andStarting Co-trimoxazole in pregnancy nutrition l Family Planning Services.

counselling. • Co-trimoxazolel EBF should reinforcement/Infant be started if CD4 feeding count suppor is ≤t through250 cells/mm3 home visits. and continued through pregnancy, delivery and breastfeeding as per national l Psycho-social support through follow-up counselling, home Box 3 guidelines (Dose:visits Double and suppor strengtht groups. tablet – 1 tab daily). • Ensure that pregnant women take their folate supplements regularly.

HIV Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 34 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

ART for HIV Infected Pregnant Women All HIV infected pregnant women Figure(irrespective 2: Components of CD4 of count/Clinical PPTCT Programme stage) should receive lifelong ART.

This treatment serves two key purposes: Offer of HIV Counselling and Testing Services to all Pregnant Women 1. Improves health and prolongs survival of the mother.

2. Reduces the risk of HIV transmission from mother-to-child during pregnancy, labour, delivery, and throughout the breastfeeding period. HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV 5.1l SafeHIV sex Infected Pregnant prophylaxis Women at being ART Centers. Newly Initiated on ART counselling. HIV-infected pregnant women who arel Counsellinginitiated on onART choices should of continuationbe referred for or medicalroutine baselinetermination clinical of l Couple pregnancy (MTP)–to undertake within the first 3 months of and laboratorycounselling. evaluation as per national guidelines for adults and adolescents. The absence or delay of pregnancy only. laboratoryl Linkages investigations to family should not prevent the initiation of ART. planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing. All HIV infected pregnant women should be seen on a priority in the ART communicationBox 4 l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk Centre. infant feeding options. women and her partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. testing, l Referral to ART Center. considering 5.2 Principles of managementl Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. 5.2.1 spouseAll HIV-infected is positive Pregnant Women should Start ART or s/he have high l Nutrition counselling and linkages to Government/other • riskStart behaviour ART as. soon as possible andNutrition continue programmes. ART throughout pregnancy, delivery, breast feeding l Infantperiod feeding and thereafter and lifelong.l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services. • Even if the pregnant women presents very late in pregnancy (including those who present after counselling. l EBF reinforcement/Infant feeding support through home visits. 36 weeks of gestation), ART should be initiated promptly. l Psycho-social support through follow-up counselling, home visits and support groups. 5.2.2 Choice of ART Regimen for HIV-infected Pregnant Women

There are several regimens recommended for use as first-line ART regimen for adults in India. However,HIV Exposed in case ofInfant HIV infected(HEI) pregnant women requiring ART, the recommended first-line regimen is Tenofovir (TDF) (300 mgs) + Lamuvidine (3TC) (300 mg) + Efavirenz (EFV) (600 mg). l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for EID negative babiesThe recommendedand upto 2 years first-line for EID positiveregimen babies for wh HIVo receive infected Paediatric Pregnant ART. Women is l PostparBox tum5 ARVTenofovir prophylaxis (TDF) for infant(300 mg)for 6 +weeks. Lamuvidine (3TC) (300 mg) + Efavirenz (EFV) l Early infant diagnosis(600 mg) (EID) (if atthere 6 weeks is no priorof age; exposure repeat testing to NNRTIs at 6 (NVP/EFV)months, 12 at months any gestational & 6 weeks after cessation ofage breastfeeds. l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 36 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure First line ART for pregnant and breastfeeding women and ARV drugs for their infants omen W regnant P all to vices Ser esting T and Counselling HIV of Offer • A once-daily fixed-dose combination of TDF + 3TC + EFV is recommended as first-line ART in pregnant and breastfeeding women, including pregnant women in the first trimester of pregnancy and women of childbearing age.

• Infants of mothers who are receivingomen ARTW andregnant areP exclusivelyInfected HIV breastfeeding or doing exclusiveNegative HIV replacementT/ARV AR feeding should visits)–Monthly receive4 atleastat-least six(ensure weeksCare of infantAntenatal prophylaxisl with daily Sypomen W Nevirapine.regnant P Infant prophylaxis should begin at birth orCenters. T whenAR at HIV exposureprophylaxis is known. sex Safe l counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. The recommended first-line regimen for pregnant . only and breastfeedingpregnancy women, is available as afixed family family to Linkages l dose combination (FDC), is safe for bothOIs. pregnantother and TB and for breastfeedingScreening l women and theirvices. ser infants, isplanning well tolerated, has low monitoring requirements,STIs. for is compatibletreatment and with otherScreening l drugs used in clinical care,condoms. ree F andl is harmonised with the new recommendationstesting. CD4 and for non-pregnantstaging clinical womenWHO l as well as for men.change The algorithmBehaviour l communication communication for ART and for pregnantth-planning womenbir , y anddeliver theirsafe infantsliving, is describedpositive on in FigureCounselling l 7 below (BCC) for high risk risk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par PREGNANT AND BREASTFEEDING HIV – EXPOSED INFANTS WOMEN WITH HIV . children living other HIV epeat R l . Center T AR to eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l MTCT RISK PERIOD MTCT Exclusive Breastfeeding high have s/he or programmes. for first 6Nutrition months. Daily Exclusive. Replacementbehaviour risk NVP for minimum feeding for first 6 months . mother for prophylaxis ARV tum ostpar P l 6 weeks (or maximum and feeding Infant l Initiate lifelong ART: vices. Ser Planning if maternalamily F l ART 6 weeks of NVPnutrition started late) visits. home TDF +through 3TCt + EFVsuppor feeding reinforcement/Infant EBF l counselling.

home (Assess CD4 baselinecounselling, butfollow-up do not through t suppor -social sycho P l withhold ART while waiting for results) groups. t suppor Earlyand infantvisits diagnosis (EID) at 6 weeks, 6 months; 12 (ART Initiation to be done only at ART centre) months (or after 6 weeks of stopping breast-feeds completely)

HIV Exposed Infant (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l Final infant diagnosis at 18 months (3 rapid tests) ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and CESSATION OF MTCT RISK OF MTCT CESSATION . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID LINKAGE TO ART TREATMENT AND CAREweeks. 6 FORfor BOTHinfant for WOMAN ANDprophylaxis INFANTARV tum ostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l Figure 7: Algorithms for the 2013 Recommendations for Pregnant and Breastfeedingbreastfeeds. of Womencessation ter af Lifelong ART for all Pregnant and Breastfeeding Women with HIV age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 37 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

The alternate regimen if the pregnantFigure women 2: Components are unable of PPTCT to tolerateProgramme preferred first-line regimen are as below:

First-LineOffer ART of forHIV Counselling Preferred and Testing First-line Ser Regimenvices to all PregnantAlternate First-lineWomen Regimens HIV positive pregnant women TDF + 3TC+ EFV AZT+ 3TC+EFV AZT+3TC+NVP TDF+ 3TC+NVP HIV Negative HIV Infected Pregnant Women 5.2.3 Safety of Efavirenz (EFV) in Pregnant Women Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. Safety counselling.is a critical issue for pregnant and breastfeeding women and infants as well as women who might l Counselling on choices of continuation or medical termination of becomel Couple pregnant. Although data on EFV and TDF use in pregnant women remain limited, more data have pregnancy (MTP)–to undertake within the first 3 months of counselling. become available since 2010 and providepregnancy increased only .assurance for recommending TDF+3TC+EFV as the lfirst-lineLinkages ART to regimen family for pregnant and breastfeeding women (Ford. Net. al, 2011, Ekouevi DK et.al planning services. l Screening for TB and other OIs. 2011, Use of Efavirenz during pregnancy: a public health perspective, Technical update on treatment l Free condoms. l Screening and treatment for STIs. optimisation,l Behaviour Geneva, change World Health lOrganization,WHO clinical 2012). staging Based and CD4 on testing.evidence available, EFV has been

recommendedcommunication for use in pregnant womenl Counselling in all trimesters on positive of pregnancy living, safe including delivery, birfirstth-planning trimester. and (BCC) for high risk infant feeding options. women and her 5.3 parARTtner .Regimen for Pregnantl Couple Womenand safe sex having counselling Prior and HIV Exposure testing of spouse to and l RNNRTIsepeat HIV for PPTCT other living children. testing, l Referral to ART Center. considering HIV infected pregnant women who havel P hadrovide previous ART or exposure ARV prophylactic to Sd NVP regimen(or EFV) basedfor PPTCT on CD4 prophylaxis count in priorwindow pregnancies,, period an if NNRTI-based ARTand/or regimen clinical such staging. as TDF+3TC+EFV may not be fully effective spouse is positive due to orpersistence s/he have ofhigh archived mutationl Nutrition to NNRTIs. counselling Thus, these and women linkages will require to Government/othera protease-inhibitor based riskART behaviourregimen viz:. Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. TDF +nutrition 3TC + LPV/r (Lopinavir/ritonavir)l Family Planning Services. counselling. The dose will be TDF+3TC (1tabletdaily)+l EBF reinforcement/InfantLPV (200mg)/r (50mg) feeding (2 tablets suppor BD)t through home visits. l Psycho-social support through follow-up counselling, home 5.4 Pregnant Women Alreadyvisits andReceiving support groups. ART

Pregnant women who are already receiving ART for their own health, should continue to receive the sameHIV regimen Exposed throughout Infant (HEI) pregnancy, labour, breast-feeding period and thereafter life-long. If a woman is onl anExclusive EFV based breastfeeds regimen, upto there 6 months is no need(preferred to substitute Option-I withWHO/NAC nevirapineO Guidelines (this was 2010-'11) done as per and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for earlier guidelines). She must continue on whatever regimen she is stabilized on and is responding to EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. adequately. l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 38 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

5.5 Clinical and Laboratory MonitoringProgramme PPTCT of of Components Pregnant 2: Figure Women Receiving ART omen W regnant P all to vices Ser esting T and Counselling HIV of Offer Clinical and laboratory monitoring of HIV infected pregnant women on ART should be done as per national ART guidelines for adults and adolescents.

Key points to be noted in pregnant women omen inW monitoringregnant P ART inInfected pregnantHIV women are: Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P • Look for clinically significant anaemia among HIV-infected pregnant women, since anaemia Centers. T AR at prophylaxis sex Safe l during pregnancy is common (usually developing around 28-34 weeks of gestation). counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of •of WHOmonths clinical 3 first stagingthe willwithin helpe tak in monitoringunder the(MTP)–to patient clinically,pregnancy potential disease progression counselling. counselling. . . only pregnancy or treatment failure. family to Linkages l OIs. other and TB for Screening l vices. ser planning • Weight loss is one of the indicators used to determine deteriorating clinical stage, but this can be STIs. for treatment and Screening l condoms. ree F l difficult to assess during pregnancy.testing. CD4 and When staging definingclinical the WHO clinicall stage of a pregnantchange woman,Behaviour l it is

necessaryand toth-planning takebir , y into considerationdeliver safe living, her expectedpositive on weight gainCounselling l in relation to the gestational communication age of (BCC) for high risk risk high for (BCC) the pregnancy and her potential weight lossoptions. from HIVfeeding (seeinfant section 5.1). women and her her and women and spouse of testing HIV and counselling sex safe and Couple l • ART-related side-effects may overlap with that of common pregnancy conditions eg.. nauseatner par and . children living other vomiting. Minor symptoms should be controlled symptomatically with medicines. HIV Consultepeat R l the . Center T AR to eferral R l testing, Obstetrician for drugs that are safe for use in pregnancy. considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l , period if if period , window • Due to pregnancy-related haemo-dilution, absolutestaging. clinical CD4 and/or cell count decreases during pregnancy. spouse is positive positive is spouse Government/other After delivery,Government/other body to fluid changeslinkages and normalise tocounselling the non-pregnantNutrition l state, and high CD4 levelshave s/he mayor rise programmes. Nutrition by 50-100 cells/ul. Therefore, a decrease in absolute CD4 count in a pregnant . womanbehaviour receivingrisk . mother for prophylaxis ARV tum ostpar P l ART in comparison to CD4 values prior to pregnancy may not necessarily indicateand feeding immunologic Infant l vices. Ser Planning amily F l nutrition decline and should be interpreted with caution (ref to SACEP in case of any doubt). visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

The recommendedhome clinicalcounselling, and laboratoryfollow-up through t follow-upsuppor schedule-social sycho forP l pregnant women is similar to that recommended for non-pregnant adults, and is detailedgroups. t insuppor Tableand 5.visits Additional assessments of hemoglobin or Liver Function Tests (LFT), Renal Function Tests (RFT) should be performed when warranted by clinical signs & symptoms. HIV Exposed Infant (HEI) Infant Exposed HIV HIV care and follow-up of pregnant women should be scheduled to coincide with their antenatal visits, O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l as far as possible. Document all investigation results in the RCH/MCH card (Antenatal & Child) also, so ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and that the Obstetric. T AR teamaediatric P is awarereceive o of testwh results.babies Informpositive patientEID for to years ensure 2 upto that and other healthbabies carenegative providersEID in the team eg. Obstetricians & their support staff are updated on the progress of their HIV care. weeks. 6 for infant for prophylaxis ARV tum ostpar P l After 6 monthsweeks 6 & of pregnancy,months 12 in casemonths, 6 aat pregnanttesting womanrepeat isage; unableof weeks to 6 goat to the(EID) ART centre,diagnosis theinfant ARTEarly drugsl breastfeeds. of cessation ter af can be given to an authorised member of her family. The drug dispensing to an authorised member can age. of weeks 6 from prophylaxis -trimoxazole Co l continue for 2 more months after delivery. ( Refer Annexure-17) EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 39 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Table 5: Recommended ClinicalFigure and 2: LaboratoryComponents Follow-upof PPTCT Programme of Pregnant Women Receiving ART

Assessment Baseline 2 Weeks 4 Weeks 8 Weeks 12 Weeks Every 6 Comment Offer of HIV Counselling and Testing Services to all PMonthsregnant Women Clinical evaluation √ √ √ √ √ √ Every month Adherence counselling √ √ √ √ √ √ Every month Weight √ √ √ √ √ √ Every month *HaemoglobinHIV Negative √ HIV√ Infected√ Pregnant√ Women√ √ Re-check at 28-32 weeks Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV √ √ X X X √ As and when required l Safe sex ALT (LFT) prophylaxis at ART Centers. clinically counselling. Urinalysis* √ l Counselling on choices of continuation√** or medical**Specifically termination for of l Couple pregnancy (MTP)–to undertake within the TDF-basedfirst 3 months regimen. of counselling. pregnancy only. Urinalysis dipsticks is l Linkages to family routinely done in planning services. l Screening for TB and other OIs. follow-up CD 4 count √ Thereafter every 6 months as per guidelines l Free condoms. l Screening and treatment for STIs. Blood Urea / Sr. Creatinine √ √ l Behaviour change l WHO clinical staging and CD4 testing. Blood Grouping and Typing √ communication l Counselling on positive living, safe delivery, birth-planning and HBV, HCV(BCC) for high risk √ Screening should infant feeding options. screeningwomen and her be performed in l Couple and safe sex counselling and HIV testingStates of spouse where ANCs and partner. are being tested l Repeat HIV other living children. routinely or based on testing, l Referral to ART Center. the risk profile (e.g. considering IDUs, through blood l Provide ART or ARV prophylactic regimen basedtransfusion) on CD4 count window, period if and/or clinical staging. RPR/ VDRL*spouse is positive √ Blood Sugar*or s/he have high √ l Nutrition counselling and linkages to RepeatGovernment/other every 6 months Lipid profilerisk behaviour. √ Nutrition programmes. if started on LPV/r based regimen l Infant feeding and l Postpartum ARV prophylaxis for mother. * Normally part of standard ante-natal routine screening. nutrition l Family Planning Services. A baseline Blood urea and serum creatinine should be undertaken before starting Tenofovir based regimen, wherever available counselling. l EBF reinforcement/Infant feeding support through home visits. (ART should not be withheld in pregnant women for want of these baseline investigations that could be carried out over time, as soon as possible). l Psycho-social support through follow-up counselling, home Lipid profile and Blood Sugar at baseline, 6 monthsvisits and onesuppor year, tif groups. started on LPV/r based regimen.

Table 6: Dosage Schedule and Common Side-Effects with ART Drugs

Name of ARV Dose Major side-effects HIV Exposed Infant (HEI) 1 Tenofovir Disoproxil Fumarate (TDF) 300mg Once Daily Nephrotoxicity, Hypophosphaetemia l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 2 Lamivudine (3TC) 300mg Once Daily Very few side effects: Hypersensitivity, and continued breastfeeds in addition to complement feeds afterrarely 6 months Pancreatitis upto 1 year for 3 EIDEfavirenz negative (EFV) babies and upto 2 600years mg for Once EID Daily positive babies whNeuro-psychiatrico receive Paediatric symptoms AR likeT. hallucinations, suicidal ideations, l Postpartum ARV prophylaxis for infant for 6 weeks. nightmares, vivid dreams etc l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks 4 Lopinavir/Ritonavir (LPV/r) 400/100 mg Twice Daily Gastro-intestinal disturbances, glucose after cessation of breastfeeds. (Dose of FDC tablet of LPV(200mg)/r intolerance, Lipo-dystrophy and l Co-trimoxazole prophylaxis from 6(50mg) weeks – 2of tabs age. BD) hyperlipidemia

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 40 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

5.6 ARV Prophylaxis for InfantsProgramme BornPPTCT of to MothersComponents 2: ReceivingFigure Life-long ART

Infant ARV prophylaxisomen W is requiredregnant P forall to all infantsvices Ser born toesting T HIV and infected womenCounselling receivingHIV of ARTOffer to further reduce pre-partum and postpartum HIV transmission, in addition to the protection received from the mother’s ART regimen. Infant ARV prophylaxis provides added protection from early postpartum transmission, particularly in situations where women started ART late in pregnancy, have less than optimal adherence to ART and have not achievedomen W fullregnant HIVP viral suppression.Infected HIV Negative HIV omen W regnant P The infant ARVT/ARV prophylaxisAR wherevisits)–Monthly 4 mothersat-least are receiving(ensure Care ART is: Antenatal Dailyl NVP for 6 weeks (i.e. till the first Safe sex sex Safe l immunization visit for the infant), regardless Centers. of T whetherAR at the infantprophylaxis is exclusively breastfed or receives counselling. exclusive of replacementtermination feeding.medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. Dose and duration of infant daily NVP prophylaxis . is givenonly belowpregnancy in Table 7. family family to Linkages l Table 7: Dose andOIs. Durationother and ofTB Infantfor Daily Screening NVPl Prophylaxis vices. ser planning STIs. for treatment and Screening l (based on WHOcondoms. Guidelines)ree F l testing. CD4 and staging clinical WHO l change Behaviour l Birth Weight NVP daily dose (in mg) NVP daily dose (in ml)* Duration and th-planning bir , y deliver safe living, positive on Counselling l communication Birth to 6 weeks: risk high for (BCC) options. feeding infant Infants with birth weight < 2000 gm 2 mg/kg once daily. 0.2 ml./kg. once daily Up toher 6 weeksand women and spouse of testing HIV and In consultationcounselling withsex a safe and Couple l irrespective . of whethertner par paediatrician trained in HIV exclusively breast fed or . children living other HIV epeat R l care. exclusively replacement . Center T AR to eferral R l testing, Birth weight 2000 – 2500 gm 10 mg. once daily 1 ml. once a day fed. (may be extended to 12 weeks, if motherconsidering count count CD4 on based regimen prophylactic ARV or T AR rovide P l has not received ART for staging. staging. clinical and/or if period , window spouse is positive adequatepositive durationis spouse Birth weight more than 2500 gm 15 mg. once daily 1.5 ml. once a day Government/other Government/other to linkages and counselling Nutrition l i.e atleasthigh 24have weekss/he or *Considering the content of 10 mg Nevirapine in 1ml suspension programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 41 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Interventions for Women Diagnosed with HIV Infection in Labour and Postpartum There is a significant percentage of Programme pregnantPPTCT of women withComponents 2: unknownFigure HIV status presenting directly- in-labour for delivery (un-booked cases). Any pregnant woman who presents in active labour with unknown HIV statusomen W should regnant beP offeredall to thevices routineSer screeningesting T and of HIV, withCounselling opt-outHIV of optionOffer as per National Guidelines. Screening using Whole Blood Finger Prick Test in the delivery/labour ward should be undertaken.

omen W regnant P Infected HIV Negative HIV

6.1 PregnantT/ARV AR Women visits)–Monthly in4 Labourat-least Who(ensure Care are FoundAntenatal l Positive in omen W regnant P HIV-screening Test should be:Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l 1. Initiated on ART (TDF+3TC+EFV) immediately. Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. 2. The next day the Counsellor should visit the . post-natalonly wardpregnancy offer pre-test Counselling, counsel family family to Linkages l and advise for exclusive breast feedingOIs. other forand firstTB for 6months, ifScreening shel has already startedvices. ser breast feeds;planning if not she must be counselled onSTIs. optionfor for breasttreatment and vs replacementScreening l feeding but must adherecondoms. toree F eitherl exclusive breast feeding or exclusivetesting. CD4 and replacement staging feedingclinical WHO thel first six months. Thereafter,change theBehaviour l Lab and th-planning bir , y deliver safe living, positive on Counselling l communication tech will confirm the HIV status by 3 rapid anti-body tests. Blood sample forrisk CD4high testingfor shall(BCC) be options. feeding infant drawn of all HIV confirmed cases by Lab tech and S/he will personally carry her the and sample women to CD4 and spouse of testing HIV and counselling sex safe and Couple l lab and bring the report along with a month’s supply of ART taking her spouse or. buddytner par along . children living other with her/him under extreme circumstances when the post-partum mother is unableHIV toepeat R reachl . Center T AR to eferral R l testing, the ART Centre within the next 2 days for Pre-ART Registration and Adherence Counselling.considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l However, she should be motivated and followed- up for ensuring she reports to the ART Centre staging. staging. clinical and/or if period , window within 30 days. The ICTC Counsellor and Lab Technician after confirming herpositive statusis thespouse next Government/other Government/other to linkages and counselling Nutrition l day will ensure no interruption in the continuation ART once the first dose high was givenhave tos/he theor HIV programmes. Nutrition . behaviour risk positive pregnant women in the labour-room and the next day in the post-natal ward. . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition The broad principle is “as far as possible direct-in-labour women must be seen by ART Medical Officer” visits. home through t suppor feeding reinforcement/Infant EBF l counselling. at the earliest opportunity but this should not lead to delaying in ART initiation. All efforts should be home counselling, follow-up through t suppor -social sycho P l made that at least she is seen by the facility Medical Officer. groups. t suppor and visits

Women who are screened and found HIV Infected during(HEI) labourInfant or just Exposed after HIV O Guidelines 2010-'11) Box 62010-'11) deliveryGuidelines O should beWHO/NAC given aOption-I Top Priority(preferred for months Clinical 6 upto Managementbreastfeeds and CD4Exclusive l ter 6 months upto 1 year for for year 1 upto Assessment months 6 inter theaf ARTfeeds Centre. complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 43 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme Protocol for Women Presenting Directly-in-Labour (Unbooked Cases) Offer of HIV Counselling and Testing Services to all Pregnant Women

Pregnant women coming directly-in-labour

HIV Negative HIV Infected Pregnant Women

PregnantFound W HIVomen positive using Whole Bloodl Antenatal Finger Prick Care testing (ensure in labour at-least room/ 4 delivery visits)–Monthly ward ART/ARV l Safe sex

prophylaxis at ART Centers. Intrapartum counselling. l Counselling on choices of continuation or medical termination of l Couple Collect blood sample for CD4 and send the sample next day to ART centre pregnancy (MTP)–to undertake within the first 3 months of counselling. Initiate maternal ART (TDF+3TC+EFV) pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. Next morning: l FreeCounselling condoms. and confirmation of l HIVScreening status and andblood treatment sample collection for STIs. for CD4 testing l Behaviour change l WHO clinical staging and CD4 testing. Mother: Continue ART after delivery communication l

Counselling on positive living, safe delivery, birth-planning and Postpartum (BCC) for high risk infant feeding options. women and her partner. l Couple and safe sex counselling and HIV testing of spouse and lInfant:Repeat Daily HIV Sy. Nevirapine from other living childrenMother:. Link with ART centre to birth until 6 weeks (minimum) continue ART as soon as possible. testing, l Referral to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouseFigure is positive 8: Protocol for Women Presenting Directly-in-Labour (Unbooked Cases) or s/he have high l Nutrition counselling and linkages to Government/other Nutrition programmes. 6.2 riskARV behaviour Prophylaxis. for Infants Born to Women Presenting in l Infant feeding and l Postpartum ARV prophylaxis for mother. nutritionActive Labour l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits. All infants born to women who present directly-in-labour and receiving intra partum ART and regularly l Psycho-social support through follow-up counselling, home thereafter, should be started on daily NVP prophylaxis at birth and continued for a minimum of 6 weeks. visits and support groups. These needs to be extended to 12 weeks as mother has not received adequate duration of ART to suppress viral replication. However, EID should be carried out at 6 weeks as per guidelines. HIV Exposed Infant (HEI) 6.3l ExclusiveARV Prophylaxis breastfeeds upto for6 months Infants (preferred Born Option-I to Women WHO/NAC Owho Guidelines did not2010-'11) andReceive continued Any breastfeeds ART in(Home addition toDelivery) complement feeds after 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

In casel P ofostpar infantstum who ARV are prophylaxis born to HIV for infectedinfant for mothers 6 weeks. who did not receive any antenatal or pre-partum

ART,l orEarly in cases infant where diagnosis maternal (EID) HIV at 6infection weeks of is age; detected repeat after testing the atbirth 6 months, of the infant 12 months (home & delivery): 6 weeks after cessation of breastfeeds. • Infants should be started on daily Sy NVP prophylaxis at their first contact with health services. l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 44 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

• Daily infant NVP prophylaxis can beProgramme startedPPTCT of even if moreComponents 2: than 72Figure hours have passed since birth.

• Daily infant NVP prophylaxis should continue for atleast 12 weeks, by which time the mother should be linkedomen W to appropriateregnant P all to ART services.vices Ser esting T and Counselling HIV of Offer

The duration of daily infant NVP prophylaxis will depend on whether the mother is to be initiated on life-long ART and infant feeding practices (see Chapter 12). omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P 5 Do’s for infants at 6 weeks Centers. T AR at prophylaxis sex Safe l counselling. of of termination It ismedical importantor to docontinuation of the followingchoices on for infantsCounselling atl 6 weeks: Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy • Do re-inforcement for Exclusive Breastfeeding for the first 6 months counselling. . . only pregnancy (Continuation of breastfeeds with introduction of complementary family to feeds Linkages l OIs. other and TB for Screening l Box 7 thereafter) vices. ser planning STIs. for treatment and Screening l condoms. ree F l • Do EID testingtesting. CD4 and staging clinical WHO l change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication • Do Immunization risk high for (BCC) options. feeding infant women and her her and women • Do CPT initiation and continue until baby is 18 months old and spouse of testing HIV and counselling sex safe and Couple l . tner par or longer if baby is confirmed positive . children living other HIV epeat R l • Do stop NVP Prophylaxis. Center T for AR babyto at 6eferral R weeksl (maternal ART is not of testing, considering considering count count CD4 on based adequateregimen duration)prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 45 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Special Considerations 7.1 Pregnant Women with ActiveProgramme PPTCT of TB Components 2: Figure

The risk of active omen TBW is approximatelyregnant P all to 10 vices timesSer higheresting T in and HIV-infected pregnantCounselling HIV of womenOffer compared to HIV uninfected women. Active TB in HIV-infected pregnant women can contribute to increased risk of maternal mortality, and is also associated with prematurity, low birth weight, and perinatal 2 tuberculosis. A recent study in India found that maternal TB increases the risk of HIV transmission from mother-to-child by 2.5 times. omen W regnant P Infected HIV Negative HIV • IntensifiedT/ARV AR Case Findingvisits)–Monthly (ICF)4 as perat-least national(ensure Care TB-HIV protocolsAntenatal l must be institutedomen W for allregnant P HIV infected pregnant women. Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l • All HIV-infected pregnant women presenting with a cough, fever, night sweats and weightCouple lossl of of months 3 first the within e tak under (MTP)–to pregnancy should be evaluated for TB and started on TB treatment when indicated. counselling. . . only pregnancy family family to Linkages l • HIV-infected pregnant women withOIs. activeother and tuberculosisTB for shouldScreening l start ART, irrespectivevices. ser of CD4planning cell count. STIs. for treatment and Screening l condoms. ree F l l change Behaviour l • The tuberculosis treatmenttesting. shouldCD4 and be startedstaging first,clinical andWHO followed by ART as soon as feasible communication communication (usuallyand afterth-planning bir 2 , y weeks)deliver safe living, positive on Counselling l (BCC) for high risk risk high for (BCC) options. feeding infant • Drug interactions between Rifampicin and some of the antiretroviral drugs, her includingand women NVP, and spouse of testing HIV and counselling sex safe and Couple l complicate simultaneous treatment of the two diseases. EFV is the preferred. NNRTItner par for . children living other pregnant women which can be used in those with concurrent TB treatment also. HIV epeat R l . Center T AR to eferral R l testing, considering considering count • Forcount thoseCD4 on HIV-TBbased co-infectedregimen womenprophylactic notARV ableor T toAR toleraterovide P l EFV, a NVP-based or a boosted PI regimen can be considered after expert staging. clinical clinical consultation.and/or With the if use ofperiod , a boostedwindow PI regimen, Rifampicin should be substituted with Rifabutin. positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk 7.2 Pregnant Women. mother withfor HIV-2prophylaxis InfectionARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition Although the great majority of HIV infections in India are due to HIV-1, there are small foci of HIV-2 visits. home through t suppor feeding reinforcement/Infant EBF l counselling. infection as well, primarily in western India. HIV-2 will also progress to AIDS, although progression is home counselling, follow-up through t suppor -social sycho P l generally much slower. HIV-2 has the same modes of transmission as HIV-1 but has been shown to be groups. t suppor and visits much less transmissible from mother-to-child (transmission risk 0-4%).

DETECTION OF HIV-2 INFECTION SHOULD BE DONE ACCORDING TO NACO’S TESTING GUIDELINES for HIV-2

NNRTI drugs, such as NVP and EFV, are not effective against HIV-2 infection. Therefore,(HEI) Infant for womenExposed whoHIV are infected with2010-'11) HIV-2 aloneGuidelines should:O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and • Follow . T AR standardaediatric P adult guidelinesreceive o wh forbabies HIV-2 treatmentpositive EID for whichyears 2 consistsupto and of 2NRTIsbabies + LPV/r.negative EID • Prophylaxis NVP with AZT (instead of Syp NVP)weeks. 6 tofor be giveninfant for to babies inprophylaxis mothersARV tum withostpar HIVP l -2 weeks (Dosageweeks 6 & detailsmonths are12 given months, in6 Table-8)at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af 2Maternal Tuberculosis: A Risk Factor for Mother-to-Child-Transmission of Human Immunodeficiency virus. Gupta A, Bhosale R, Kinikar A, et al for the Six age. of weeks 6 from prophylaxis -trimoxazole Co l Week Extended-Dose EID. Nevirapine through (SWEN)positive IndiaHIV Studyas Team. JIDdiagnosed 2011:203children (1and February)infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 47 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Table 8: DoseFigure of AZT 2: Componentsfor Infants of PPTCTMother Programme with HIV-2 Infection

Birth Weight AZT Daily Dosage in mg. AZT Daily Dosage in ml. Duration Infant with birth Offerweight ofof HIV Counselling and Testing Services to all Pregnant Women < 2000 gms 5mg/dose twice daily 0.5 ml twice daily 6 weeks <2500 gms 10mg/dose twice daily 1 ml twice daily 6 weeks 2500 gms and > 15 mgs/dose twice daily 1.5 ml twice daily 6 weeks Source:HIV WHO Negative Guidelines HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple If a pregnant womanpregnancy is detected (MTP)–to to have under BOTHtak HIV-1e within and theHIV-2 first infections, 3 months she of counselling.Box 8 should receive standardpregnancy first only ART. Regimen (TDF+3TC+EFV) recommended l Linkages to family for women with HIV-1 infection planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. 7.3 womenPregnant and her Women with Hepatitis B or Hepatitis C Virus parCo-infectiontner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. The HIVtesting, epidemic in India is driven lby Rinjectingeferral to drug ART Centeruse in. some regions of the Country. Hepatitis B considering and Hepatitis C may be a concern inl theseProvide areas. ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive For Women Co-infected with HIV and HBV or s/he have high l Nutrition counselling and linkages to Government/other Nutrition programmes. • riskIf treatment behaviour .is required for HBV infection3, ART should be started irrespective of the CD4 cell l Postpartum ARV prophylaxis for mother. l Infantcount feeding or the WHOand clinical stage: nutrition l Family Planning Services.

• counselling.The regimen preferred is TDFl +EBF 3TC reinforcement/Infant + EFV. feeding support through home visits. • An elevation in liver enzymesl followingPsycho-social the initiation support throughof ART may follow-up occur counselling, in HIV-HBV homeco-infected women because of an immune-mediatedvisits and supporflarein tHBV groups. disease secondary to immune reconstitution (IRIS) with therapy, particularly in women with low CD4 cell counts.

• HBV infection may also increase the risk of hepatotoxicity with certain antiretroviral drugs, HIV Exposed Infant (HEI) specifically NVPand protease inhibitors. l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) • andPregnant continued women breastfeeds with HIV-HBV in addition co-infection to complement should befeeds counselled after 6 months about signsupto 1 and year symptoms for EIDof liver negative toxicity. babies and upto 2 years for EID positive babies who receive Paediatric ART.

l Postpartum ARV prophylaxis for infant for 6 weeks. • For women who do not require HBV treatment, ART general recommendations for HIV-infected l Earlypregnant infant women diagnosis should (EID) be at followed.6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds. 3(Anti-HBVl Co-trimoxazole therapy should prophylaxis be considered from for all 6 weekswomen ofco age.infected with HIV and Hepatitis B virus with evidence of severe liver disease) l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 48 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

For Women Co-infected with HIV and HCV Programme PPTCT of Components 2: Figure

• No specific changes intreatment are recommended in the adult ART treatment guidelines. omen W regnant P all to vices Ser esting T and Counselling HIV of Offer • Pregnant women co-infected with HIV and HCV should receive ART according to the general recommendations for HIV-infected pregnant women.

• Those women on ART require careful clinical and laboratory monitoring. omen W regnant P Infected HIV Negative HIV Co-infection withT/ARV AR HIV and HBV visits)–Monthly or4 HCV isat-least common(ensure amongCare InjectingAntenatal l Drug Users (IDUs).omen W Hence,regnant P all women living with HIV who are recognized toCenters. beT AR IDUs at should routinelyprophylaxis be offered testing forsex HepatitisSafe l counselling. B and of Hepatitis termination C infectionsmedical or and monitored.continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. . . only pregnancy family family to Linkages l OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l Box 9 Provision of treatment for Hepatitis B & C for HIV co-infected pregnant women testing. CD4 and staging clinical WHO l change Behaviour l (with Hepatitis B or C) will be the responsibility of the general health systems and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par . children living other HIV epeat R l . Center T AR to eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 49 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Labour and Delivery in the HIV Infected Pregnant Women 8.1 Intra-partum Management Programme PPTCT of Components 2: Figure

The women’s sero-statusomen W shouldregnant P beall to recorded vices Ser in the RCH/MCHesting T and Card (AntenatalCounselling HIV card)of andOffer maternity register. Health care workers should check the woman’s HIV status and details of the ART drugs during pregnancy. If her HIV status is unknown and she is in the first stage of labour, offer HIV counselling and testing using Whole Blood Finger Prick Testing. If found positive, she should be administered the first dose of ART and advised for confirmation of tests throughomen W ICTC Counsellorregnant P andInfected Lab HIV technician the following day. SheNegative shouldHIV be counselled on Exclusive Breast Feeds (EPF) to the baby for the first six months and the baby should be given Sy T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Niverapine for a minimum of 6 weeks and another 6Centers. weeksT AR at continuation prophylaxis if need be. sex Safe l counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy 8.2 Intra-partum Anti Retroviral Therapy counselling. . . only pregnancy family family to Linkages l Women on life-long ART should continue to receive ART as per the usual schedule including during OIs. other and TB for Screening l vices. ser planning labour and delivery. STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l communication communication 8.3 and Special th-planning Circumstances:bir , y deliver safe living, Caesareanpositive on SectionCounselling l (BCC) for high risk risk high for (BCC) options. feeding infant Caesarean section is not recommended for prevention of mother-to-child-transmission her andand only ifwomen there and spouse of testing HIV and counselling sex safe and Couple l is an Obstetric indication for the same. . tner par . children living other HIV epeat R l Use of ARV drugs during Caesarean Sections. Center T AR to eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l • For planned (elective) Caesarean sections, staging. ART shouldclinical beand/or given prior to the if operation.period , window spouse is positive positive is spouse Government/other • Women on life-longGovernment/other to ART shouldlinkages continueand theircounselling standard ARTNutrition l regimen. high have s/he or programmes. Nutrition . behaviour risk • In case of an emergency Caesarean section in pregnant women who are not on ART, ensure that . mother for prophylaxis ARV tum ostpar P l and feeding Infant l the women receive ART prior to the procedurevices. Ser andPlanning continuesamily F l thereafter. nutrition counselling. All HIV-infectedvisits. home womenthrough t who undergosuppor feeding Caesarean section reinforcement/Infant shouldEBF l receive the standard prophylactic antibiotics. Complicationshome counselling, of Caesareanfollow-up sectionthrough t aresuppor higher-social in womensycho P l with HIV, with the most frequently reported complication being post-partum fever. groups. t suppor and visits

Box 10 Caesarean sections in HIV positive pregnant women should(HEI) be Infant performed Exposed forHIV O Guidelines 2010-'11) 2010-'11) ObstetricGuidelines O indicationsWHO/NAC only. Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID

weeks. 6 for infant for prophylaxis ARV tum ostpar P l 8.4 Falseweeks 6 & Labourmonths 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af In the case of false labour or mistaken ruptured membranes, for women taking ART should continue age. of weeks 6 from prophylaxis -trimoxazole Co l with normal dosing schedule of the combination regimen. EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 51 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

8.5 Safer Delivery TechniquesFigure 2: Components of PPTCT Programme Mother-to-child -transmission risk is increased by the prolonged rupture of membranes, repeated P/V Offer of HIV Counselling and Testing Services to all Pregnant Women examinations, assisted instrumental delivery (vacuum or forceps), invasive foetal monitoring procedures (scalp/foetal blood monitoring), episiotomy and prematurity. Thus, when delivering HIV-infected women, observe:

HIV• StNegativeandard/Universal Work PrecautionsHIV Infected (UWP) Pregnant Women P•regnant Do NOT W omenrupture membranesl artificiallyAntenatal(keep Care membranes (ensure at-least intact 4 visits)–Monthly for as long as possible). ART/ARV l Safe sex prophylaxis at ART Centers. counselling.o The membranes should be left intact as long as possible and artificial rupture of membrane l Counselling on choices of continuation or medical termination of l Couplereserved for cases of foetal distress or delay in progress of labour. pregnancy (MTP)–to undertake within the first 3 months of counselling. • Minimize vaginal examination andpregnancy use aseptic only. techniques. l Linkages to family • planningAvoid invasive services. procedures likel foetalScreening blood for sampling, TB and other foetal OIs. scalp electrodes. l Free condoms. l Screening and treatment for STIs. • Avoid instrumental delivery as much as possible. l Behaviour change l WHO clinical staging and CD4 testing.

communicationo Unless required in cases lof foetalCounselling distress on or positive significant living, safematernal deliver fatiguey, bir th-planningto shorten labour and or (BCC) for high risk the duration of ruptured membranes.infant feeding options. women and her paro tner If indicated,. low-cavity outletl Couple forceps and is safe preferable sex counselling to ventouse, and HIV as testingit is generally of spouse associated and l Repeatwith HIV lower rates of foetal traumaother living than childrenventouse.. testing, • Avoid routine episiotomy as farl asReferral possible. to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count • windowSuctioning, period the ifnewborn with a and/ornasogastric clinical tube staging. should be avoided unless there is meconium spousestaining is ofpositive the liquo r. or s/he have high l Nutrition counselling and linkages to Government/other Safer surgicalrisk behaviour techniques. are useful inNutrition conducting programmes. any operative procedures such as the Caesarean section, repairing wounds/lacerations etc. l Infant feeding and l Postpartum ARV prophylaxis for mother. Use of ‘dry’nutrition haemostatic techniques l to minimizeFamily Planning bleeding; Ser i.e.vices. good observation and following of surgical fascial counselling.planes during dissection, judiciousl EBF use reinforcement/Infant of electro-cautery feeding during supporCaesareant through section home etc. visits.

l Psycho-social support through follow-up counselling, home During Caesarean section, wherever possible, the membranes are left intact until the head is delivered through the surgical incision. The cord visitsshould and be suppor clampedt groups. as early as possible after delivery; • Use of round-tip blunt needles for Caesarean section

•HIV Do Exposed not use Infant fingers (HEI) to hold the needle; •l ExclusiveUse forceps breastfeeds to receive upto and 6hold months the needle(preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for • Observe good practice when transferring sharps to surgical assistant eg. holding container for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. sharps. l Postpartum ARV prophylaxis for infant for 6 weeks.

For ldisposalEarly infantof tissues, diagnosis placent (EID)a atand 6 weeks other ofmedical/infectious age; repeat testing waste at 6 months, material 12 frommonths the & delivery 6 weeks of HIV-infectedafter cessation deliveries of Standard breastfeeds. waste disposal management guidelines should be followed. l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 52 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Care during the Postnatal Period 9.1 The Post-partum FigurePeriod 2: Components of PPTCT Programme

• WithinOffer an Hour of HIVof Delivery Counselling and Testing Services to all Pregnant Women o Infants born to HIV-infected mothers should receive NVP prophylaxis immediately after birth.

HIV oNegative Infant s after delivery shouldHIV Infected be put P regnant on the Wmomenother’s abdomen for skin contact to be Pregnante sWtaomenblished which helpsl inAntenatal bonding andCare m (ensureainten at-leastance of 4b avisits)–Monthlyby’s body temperature ART/ARV as well l Safe assex helps initiation of breast prophylaxis milk within at1 hourART Centers.of birth. counselling. Infants should be given lexclusiveCounselling breastfeeds on choices for ofthe continuation first six months or medical preferably. termination Exclusive of l Coupleo pregnancy (MTP)–to undertake within the first 3 months of counselling.replacement feeding may be done only if the mother has died or has a terminal illness pregnancy only. l Linkagesor decides to family not to breastfeed despite adequate counselling. (See chapter 11 for updated planningguidelines services. on infant feeding).l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. • If the mother has not made a decision about feeding yet, she should be counselled to give exclusive l Behaviour change l WHO clinical staging and CD4 testing. breastfeeds for the first 6 months which is the preferred option, followed by complementary feeds communication l Counselling on positive living, safe delivery, birth-planning and (BCC)after 6for months. high risk No abrupt weaning to be done after 6 months. The follow up guidance for babies infant feeding options. womenon exclusive and her breast feeding and exclusive replacement feeding is given in (Table 9). partner. l Couple and safe sex counselling and HIV testing of spouse and • Counsel and support parent to give infant NVP prophylaxis using the syringe/dropper provided. l Repeat HIV other living children. • testing,Emphasize on washing the equipmentl Referral with to AR cleanT Center boiled. water after every use. considering During the post-delivery period, it l is P importantrovide AR toT or continue ARV prophylactic follow-up regimen and support based onthe CD4 postpartum count window, period if and/or clinical staging. mother,spouse considering is positive the fact that this is a stressful period and she has to assume multiple roles and responisbilitiesor s/he haveas mother, high wife and HIVl Nutrition infected person.counselling Wherever and possible,linkages includeto Government/other family counselling (of husband,risk behaviour in-laws,. direct family members)Nutrition toprogrammes. support care of the HIV infected mother and HIV exposedl Infant infant. feeding Postpartum and depressionl Postpar & psychosistum ARV is commonprophylaxis in HIVfor mother infected. women. nutrition l Family Planning Services. • Involvement of men (husband/close male family members) is important so that the family counselling. l EBF reinforcement/Infant feeding support through home visits. support to the HIV-infected mother and infant is optimal. Husband’s support to the mother- l Psycho-social support through follow-up counselling, home baby pair (m-b pair) should be encouraged so as to: visits and support groups. o To remind the HIV positive mother to take ART regularly

o Support administration of daily infant NVP prophylaxis medications for 6 weeks to the baby. HIV Exposed Infant (HEI) o Be involved in care and follow-up of the infant including clinic visits and immunization l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) follow-up; EID and CPT initiation and continuation up to 18 months at least. and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for EIDo negativeBe involved babies in care and of upto mother 2 years for ART for centreEID positive visits babies who receive Paediatric ART. l Poostpar Supporttum ARV exclusive prophylaxis breastfeeding for infant for for 6 aweeks. minimum period of 6 months and continuation of l Earlybreastfeeds infant diagnosis for 1 (EID)year inat EID6 weeks negative of age; babies, repeat and testing up to at 2 6 years months, in EID 12 positivemonths babies& 6 weeks with after initiationcessation of of Paediatric breastfeeds. ART. Weaning foods should be introduced from 6 months onwards in l Co-trimoxazoleall babies whetherprophylaxis breast from fed 6 weeksor replacement of age. feeds fed. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 54 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

o Insertion of Cu-T (temporary contraceptiveProgramme PPTCT of method)Components for2: HIV Figure infected mother at 6 weeks if a post-partum IUD (PP-IUD) has already not been inserted within 48 hours in addition to the useomen ofW condomsregnant P willall preventto vices unwantedSer esting T pregnancies and (dualCounselling protection)HIV of Offer o Encourage male sterilization in father (No Scalpel Vasectomy (NSV) between 18 months to 2 years when baby’s survival has been ensured). Table 9: Points to beomen FollowedW regnant forP BabiesInfected on HIV EBF OR ERF Negative HIV

Babies ReceivingT/ARV AR Exclusive Breastfeedsvisits)–Monthly 4 (EBF)at-least (ensure BabiesCare ReceivingAntenatal l Exclusive Replacement omen FeedsW (ERF)regnant forP for the First 6 Months Centers. T AR at prophylaxis the First 6 Months sex Safe l counselling. of of termination Mothermedical or continuation of choices on Counselling l Mother Couple Couple l Life-long of ART months initiated 3 first as soonthe as possiblewithin e tak includingunder entire (MTP)–to Life-long ART pregnancy initiated as soon as possible even though the counselling. counselling. breast feeding period . babyonly is gettingpregnancy exclusive replacement feeding family family to Linkages l Infants Infants OIs. other and TB for Screening l vices. ser planning i) At Birth: Start Sy. NVP Prophylaxis immediately and give I) At Birth: Start Sy. NVP Prophylaxis from birth until 6 STIs. for treatment and Screening l until 6 weeks (or more indicated) weeks condoms. ree F l ii) At 6 weeks: testing. CD4 and staging ii) At 6clinical weeks:WHO l change Behaviour l a. Start CPT and continue until baby is 18 months of age a. Start CPT and continue until baby is 18 months of age and th-planning bir , y deliver safe living, positive on Counselling l communication b. Immunization: Start 1st dose of DPT/OPV/Hep-B vaccine (and may be thereafter, if babies risk statushigh isfor positive(BCC) in the nd options. feeding infant (2 dose) confirmatory test) her and women c. Earlyand Infant Diagnosis(EID):spouse of testing DoHIV DBSand at 6 weeks forcounselling sex safe b. and Immunization: Couple l Start 1st dose of DPT/OPV/Hep-B all babies; if positive do WBS. If WBS positive, start vaccine (2nd dose) . tner par Paediatric ART irrespective of CD4% for babies less. than children c. Earlyliving Infantother Diagnosis(EID): Do DBS HIV at 6 weeksepeat R l for 2 years. . Center T AR to all babies;eferral R ifl positive do WBS. If WBS positive,testing, start d. NO MIXED FEEDING is to be done during the first 6 Paediatric ART irrespective of CD4% for babiesconsidering less count count CD4 on based regimen prophylactic ARV or T AR rovide P l months i.e.(not to give along with Breastfeeds any other than 2 years. if period , window milk (tinned formula food or cow’s milk or dairy milk)staging. d. NOclinical MIXEDand/or FEEDING is to be done during the first 6 liquid, juices or even water months i.e.(not to give Breastfeeds+any positive is otherspouse milk Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. (tinned formulaNutrition food or cow’s milk or dairy milk) liquid, juices or even water. No breast . feed to be givenbehaviour risk within . mother for prophylaxis ARV tum first sixostpar P monthsl and feeding Infant l vices. Ser Planning amily F l nutrition Post-partum Follow-up and Care Extends Beyond the Six-weeks Postpartum Period and Includes: visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

• Assessmenthome of maternalcounselling, healingfollow-up afterthrough t deliverysuppor -social and evaluationsycho P l for post partum infectious complications. groups. t suppor and visits • Continued counselling and information on fertility choices and effective post partum Contraceptive methods as well as condom promotion and ensuring Cu-T IUD adoption and continued motivation for NSV for males at 18 months Specifically, in(HEI) HIV infectedInfant pregnantExposed HIV O Guidelines 2010-'11) women, 2010-'11) there shouldGuidelines O be linkingWHO/NAC of the Option-I baby to the(preferred Earlymonths Infant6 upto Diagnosis (EID)breastfeeds programmeExclusive l ter 6 months upto 1 year for andfor ARTyear 1 programmeupto months for 6 mother/childter af feeds as indicated.complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID

weeks. 6 for infant for prophylaxis ARV tum ostpar P l weeks Boxweeks 6 & 11 months Condom12 shouldmonths, 6 at be consistentlytesting repeat age; usedof byweeks 6 all at HIV (EID) infected diagnosis malesinfant despiteEarly l following any other Family Planning Method (Dual Protection)breastfeeds. of cessation ter af age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 55 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

9.2 Screening for Post-PartumFigure 2: Components Depression of PPTCT Programme

Postnatal bluesOffer occur of in HIV almost Counselling 80 per cent and of women,Testing Sermostvices commonly to all Pinregnant the first post Women natal week, and improves afterwards. The “post natal or baby blues” refers to a range of feelings between the third and tenth day after delivery:

HIV• TheNegative feelings include being HIV tearful, Infected irritable, Pregnant mood W omen changes, fatigue, anxiety and feelings of Pregnantsadness Women or loneliness. l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. • counselling.These feelings are thought to be caused by a number of factors, including sudden changes l Counselling on choices of continuation or medical termination of l Couple in hormone levels after childbirth,pregnancy unexpected (MTP)–to discomfort under takfrome withinbreast the engorgement first 3 months and birthof counselling. pregnancy only. l Linkagespain, adjustment to family to parenthood and sleep deprivation. planning services. l Screening for TB and other OIs. l• FTheseree condoms. feelings should disappearl Screening a f t e r and a few treatment days and for STIs.no specific treatment is required, l Behaviourapart from change recognition, empathyl WHO and clinicalsupport staging from family and CD4 and testing. friends.

communication l Counselling on positive living, safe delivery, birth-planning and However,(BCC) in afor group high riskof post partum women, these feelings may persist and become post partum infant feeding options. women and her depression. Two prospective studies on pregnant women, in the states of Goa and rural South India, partner. l Couple and safe sex counselling and HIV testing of spouse and detectedl Repeat depressive HIV disorder in 23 perother cent living and children16 per .cent respectively, with depression persisting 6 six monthstesting, after child birth in 11-14l perReferral cent toof AR womenT Center. In. HIV infected women, this may be higher. considering l Provide ART or ARV prophylactic regimen based on CD4 count Post partumwindow depression, period if may begin at delivery,and/or clinical or a month staging. later; in some women, it may begin during spouse is positive the firstpost-natal menstrual period or weaning: or s/he have high l Nutrition counselling and linkages to Government/other Nutrition programmes. • riskThe behaviour symptoms. include crying, irritability, sleep problems (insomnia or sleeping all day), eating l Infant feeding and l Postpartum ARV prophylaxis for mother. problems (no appetite or eating all day), persistent feelings of sadness, lack of desire or nutrition l Family Planning Services.

counselling.inability to care for self or baby,l EBFexaggerated reinforcement/Infant concerns about feeding the suppor baby, tand through memory home loss. visits.

l Psycho-social support through follow-up counselling, home • Some women may feel extremely anxious or fearful, sometimes experiencing panic attacks visits and support groups. including palpitations, chest pain, dizziness, cold flushes and shaking.

Post partum depression should be detected early so that counselling support and other interventions mayHIV be provided.Exposed InfantPostpartum (HEI) depression can interfere with mother-infant bonding, cause problems l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) with spouse and family or other children; and may affect health of the mother. More importantly, and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for postpartumEID negative depression babies may and reduce upto the 2 years adherence for EID to positive ART especially babies whtheo receiveinfant NVP Paediatric prophylaxis ART. for the

firstl6 weeksPostpar oftum life. ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks Screening for postpartum depression should be done before the mother goes home after delivery and after cessation of breastfeeds. during follow-up visits. See Annex 7 for the screening tool. l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 56 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

9.3 Counsel and Follow-up Programme Mother-babyPPTCT of Components (m-b)2: Figure Pairs after Discharge omen W regnant P all to vices Ser esting T and Counselling HIV of Offer Counselling on Issues Related to the Mother: • Counsel mothers taking ART for her own health for good adherence to life-long ART. • The ART drugs will reduce the risk omen ofW HIV transmissionregnant P throughInfected HIV breastmilk during breastfeedingNegative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P • Counsel mother who came directly-in-labour about the importance of ART. Centers. T AR at prophylaxis sex Safe l • Counsel mother to have adequate rest, nutrition and to take iron-folate during the lactationcounselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of period,months 3 ensure first enoughthe proteinswithin e tak andunder fluids in (MTP)–to the diet. pregnancy counselling. counselling. . . only pregnancy • Family support: involve husband and family members to help out with baby carefamily to so that sheLinkages canl rest and recuperate, and to remindOIs. other her and of herTB ARTfor and infantScreening l ARV prophylaxis. vices. ser planning STIs. for treatment and Screening l condoms. ree F l • Counsel mother for her post-natal checkup at 6 weeks to coincide with the infant’s first testing. CD4 and staging clinical WHO l change Behaviour l immunization visit. and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) • Discuss and ensure contraception Copper-T(Cu-T)options. feeding insertioninfant and condom use as dual protection at subsequent visits.4 her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par • Arrange for the mother on ART to be followed. withchildren theliving ARTother Centre. HIV epeat R l . Center T AR to eferral R l testing, • ANMs/ASHAs/Counsellors/ORWs will follow-up the mother and baby within a week of dischargeconsidering count forcount mother’sCD4 on progress,based supportregimen infant feedingprophylactic ARV practice,or T AR ensurerovide P adherencel to infant NVP prophylaxis staging. staging. clinical and/or if period , window at home, general counselling advice and infant follow-up. positive is spouse Government/other Government/other to linkages and counselling Nutrition l Refer to Annex 9: Counselling the HIV infected mother/family for infant feeding options:high have 0–6 s/he months. or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l Counselling for Issues of Infant to the Parents/ Caregivers: vices. Ser Planning amily F l nutrition

• Counselvisits. home and reinforcethrough t decisionsuppor feeding on infant feeding practicereinforcement/Infant EBF whetherl exclusive breastfeedingcounselling. for

first home 6 months (preferably)counselling, follow-up or exclusivethrough t replacementsuppor -social feedingsycho P l (for first six months if not willing to breast-feed and resistant to doing so).groups. t suppor and visits • All infants (irrespective of maternal ART in mother) must receive a minimum of 6 weeks of infant NVP prophylaxis daily until the first visit forimmunization at 6 weeks of age.

o If exclusive replacement feeding is being done, then infant NVP prophylaxis(HEI) Infant may be Exposed stopped HIV O Guidelines 2010-'11) at 6 2010-'11) weeks of age.Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and • Infants . T AR who areaediatric P diagnosedreceive o DNA/wh PCRbabies negative.positive EID for years 2 upto and babies negative EID o Should continue breastfeeding and be re-evaluatedweeks. 6 for asinfant perfor EID protocol.prophylaxis ARV tum ostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l o Stop NVP prophylaxis at 6 weeks for babies given exclusive replacementbreastfeeds. of feeding.cessation ter af

4Postpartum psychiatric care in India: the need for integration andage. of innovation.weeks 6 Prabhafrom S Chandra.prophylaxis World Psychiatry.-trimoxazole Co 2004l June; 3(2): 99–100. EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 57 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

• Infants who are diagnosedFigure DBS 2: positive, Components are of to PPTCT be referred Programme to the ART Centre for Whole Blood Specimen (WBS) collection. If WBS is also positive, then the infant will be initiated on Paediatric ART, irrespectiveOffer of HIV of CD4 Counselling %. and Testing Services to all Pregnant Women • Final confirmation of the HIV status in the baby should be done at 18 months in ICTC by doing all 3 Rapid Tests even if the firstrapid antibody test comes negative.

HIV Negative HIV Infected Pregnant Women

Pregnant Women 5 Do’s for infantsl Antenatal at 6 weeks Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex For infants at 6 weeks,prophylaxis it is importantat ART Centers. to do the following: counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. Do re-inforcement for Exclusive Do EID testing Breastfeeds for pregnancy the first only 6 . months l Linkages to family planningBox 12services.for (Continuationl Screening of breastfeeds for TB and otherDo OIs. Immunization with introductionl Screening of complementary and treatment for STIs. l Free condoms. Do CPT initiation and continue until l Behaviour changefeeds thereafter)l WHO clinical staging andbaby CD4 istesting. 18 months/continue if baby communication l Counselling on positive living,is tested safe positive delivery , birth-planning and (BCC) for high risk infant feeding options. women and her Do stop NVP Prophylaxis for b a b y partner. l Couple and safe sex counselling and HIV testing of spouse and after 6 weeks (may need extension l Repeat HIV other living children. to 12 weeks if mother has been testing, l Referral to ART Center. considering initiated late on ART) l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 58 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

1010

Infant Feeding Practice Refer to National Guidelines for NutritionFigure 2: Components of HIV affected of PPTCT and Programme infected infants and children, 2011.

More than 50 per cent of children under 5 years of age in India have malnutrition. NFHS-3 (2005-06) dataOffer show of thatHIV overall, Counselling 57 per and cent T ofesting women Ser ofvices childbearing to all P regnantage in India Women (urban and rural) have anaemia with 30 per cent of infants being born underweight. Growth retardation in young children starts during pregnancy and is irreversible by age of two years if not corrected. But especially in rural areas, where women often go back to the fields a few days after giving birth, babies’ diets are often HIV Negative HIV Infected Pregnant Women supplemented with cow’s milk and water, which exposes them to infection. Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV Thel infantSafe feedingsex guidelines for HIV-exposedprophylaxis and at infected ART Centers. infants age 0 to 6 months has been up counselling. dated in 2011. After 6 months of age,l Counselling complementary on choices foods of should continuation be introduced or medical just termination like for other of l Couple infants of this age. pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family l Screening for TB and other OIs. planning services.Recommendations for infant feeding in HIV exposed and infected infants < 6 l Screening and treatment for STIs. l Free condoms. months of age l Behaviour change l WHO clinical staging and CD4 testing.

communicationThe 2011 Nationall Counselling Guidelines on on positive Feeding living, for HIV-exposed safe delivery ,and birth-planning infected infants and (BCC) for high risk < 6 months old recommends:infant feeding options. women and her parBoxtner. 13 • Exclusive breastfeedingl Couple and for safe at sexleast counselling 6 months and HIV testing of spouse and l Repeat HIV other living children. • Only in situations where breastfeeding cannot be done (maternal death, testing, l Referral to ART Center. considering severe maternal illness) or individual mother’s choice (at her own risk), then l Provide ART or ARV prophylactic regimen based on CD4 count exclusive replacement feeding may be considered window, period if and/or clinical staging. spouse is positive l Nutrition counselling and linkages to Government/other Exclusiveor s/he breastfeeding have high is the preferred feeding option for HIV-exposed infants <6 months of age. risk behaviour. Nutrition programmes. However, it is recognized that for some women, breastfeeding may not be possible – for example in l Infant feeding and l Postpartum ARV prophylaxis for mother. situations of maternal death and severe maternal illness in which case Exclusive Replacement Feeding nutrition l Family Planning Services. should be done only when AFASS criteria is fulfilled: counselling. l EBF reinforcement/Infant feeding support through home visits.

A – Affordable F – Feasible A – Acceptablel Psycho S –-social Sustainable suppor St through– Safe follow-up counselling, home visits and support groups. 10.1 Principles of Infant Feeding for HIV Infected Pregnant Women The 10 principles of infant feeding options for HIV infected pregnant women and their infants are: HIV Exposed Infant (HEI) 1.l ExclusiveAll HIV infected breastfeeds pregnant upto women6 months should (preferred have PPTCTOption-I interventions WHO/NACO provided Guidelines early 2010-'11) in pregnancy andas farcontinued as possible. breastfeeds in addition to complement feeds after 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. 2. Exclusive breastfeeding is the recommended infant feeding choice in the first 6 months, irrespective l Postpartum ARV prophylaxis for infant for 6 weeks. of the fact that mother is on ART early or infant is provided with ARV prophylaxis for 6 weeks. l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks 3. afMIXEDter cessation FEEDING of breastfeeds. SHOULD NOT BE DONE AT ANY COST WITHIN THE FIRST 6 MONTHS

l Co(Feeding-trimoxazole breast-feeds prophylaxis and fromreplacement 6 weeks feedsof age. simultaneously in the first 6 months).

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 60 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure

omen W AFASS criteriaregnant P all for to Exclusive vices ReplacementSer esting T and Feeding Counselling HIV of Offer

Mothers known to be HIV-infected, if insist on opting for exclusive replacement feeding which is contrary to the WHO/NACO’s guidelines of giving exclusive breastfeeds for first omen 6 W months,regnant P are doingInfected HIV so at their own risk. TheyNegative shouldHIV be

T/ARV AR counselled notvisits)–Monthly 4 to give anyat-least breast (ensure feeds Care during the firstAntenatal l six months. MIXED FEEDINGomen W shouldregnant P NOT be done during the Centers. first T AR 6months. at (Feedingprophylaxis a baby with both breast sex feedsSafe l and replacement feeds in the first 6 months is known as mixed feeding whichcounselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first leadsthe to mucosalwithin e tak abrasionsunder in the(MTP)–to gut of thepregnancy baby facilitating HIV virus entry counselling. counselling. through these abrasions) . only pregnancy Box 14 family to Linkages l When opting for ExclusiveOIs. other Replacementand TB for Feeding,Screening l they should fulfilthe vices. ser AFASS criteriaplanning given below: STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l 1. Safe water and sanitation are assured at the household level and in the and th-planning bir , y deliver safe living, positive on Counselling l communication community, and can prepare clean feeds risk high for (BCC) options. feeding infant women and her her and women and spouse of testing 2. HIV The and mother or counselling other sex caregiversafe and canCouple reliablyl afford to provide. sufficienttner par replacement feeding. (milk),children to living supportother normal growth and developmentHIV epeat R l of the infant, . and canCenter T sustainAR to it un-interruptedlyeferral R l for first 6 monthstesting, at considering considering count count CD4 on based least.regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window 3. The mother or caregiver can prepare it frequently enough in a positive clean is mannerspouse Government/other Government/other to linkages and counselling Nutrition l so that it is safe and carries a low risk of diarrhoea and high malnutrition. have s/he or programmes. Nutrition . behaviour risk 4. The mother or caregiver can, in the l first six months exclusively give . mother for prophylaxis ARV tum ostpar P and feeding Infant l replacement feeding,vices. Ser and is feasible.Planning amily F l nutrition counselling. visits. home through t 5. Thesuppor family feeding is supportive of thisreinforcement/Infant practice,EBF l and accepts it without forcing home counselling, her tofollow-up breastfeedthrough t duringsuppor the -social first sycho 6months. P l groups. t suppor and visits

4. Only in situations where breastfeeding cannot be done or on individual parents’ informed decision, then replacement feeding may be considered only if AFASS Criteria for exclusive replacement HIV Exposed Infant (HEI) Infant Exposed HIV feeding is fulfilled(Figure 8). O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l 5. Exclusivefor year 1 breastfeedingupto months should6 ter af be donefeeds for at leastcomplement 6to months,addition afterin which complementarybreastfeeds continued feedingand should . T AR be introducedaediatric P gradually,receive o wh irrespectivebabies positive of whetherEID for theyears 2 infantupto is and diagnosed babies HIV negative EID or positive by EID. weeks. 6 for infant for prophylaxis ARV tum ostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l 6. Mother should be receiving ART during the whole duration of breastfeedingbreastfeeds. of (remembercessation ter af it is

lifelong ART for the mother). age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 61 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

7. For breastfeeding infants Figurediagnosed 2: Components HIV negative, of PPTCT breastfeeding Programme should be continued until 12 months of age ensuring the mother is on ART as soon as possible. Offer of HIV Counselling and Testing Services to all Pregnant Women 8. The EID is repeated for the 3rd time (when previous 2 EIDs have been negative) after 6 weeks of stopping breast feeds, repeat EID i.e., Rapid test followed by DBS (if Rapid Test turns positive) send DBS test. If DBS is positive, do a WBS test. If WBS test is positive, Paediatric ART should HIV beNegative initiated in ART centre. HoweveHIV Infectedr, confirmation Pregnant test Women forHIV has to be done at 18 months using

Pregnant3 Rapid Women Tests for all babies lirrespectiveAntenatal of Care the (ensure earlier at-leastEID status 4 visits)–Monthly or the fact that AR PaediatricT/ARV ART l Safehas sexalready been initiated. prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l9. Couple For breastfeeding infants who have been diagnosed HIV positive, paediatric ART should be pregnancy (MTP)–to undertake within the first 3 months of counselling.started and breastfeeding to be continued ideally until the baby is 2 years old. pregnancy only. l Linkages to family 10.planning Breastfeeding services. should stop oncel Screening a nutritionally for TB adequate and other OIs.and safe diet without breast milk can l Fberee provided.condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing. 11. Breast-feeding should NOT be stopped ABRUPTLY. communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk Refer to Annex 9 for flowchartinfant on feeding counselling options. mothers and families for infant feeding 0-6 women and her parmonthstner. of age. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. The summary charts given in the next few pages, gives the various action points in the continuum testing, l Referral to ART Center. consideringof the PPTCT activities according to infant feeding practices. Most HIV infected women should l Provide ART or ARV prophylactic regimen based on CD4 count breastfeed their infants, unless there are special situations described previously. window, period if and/or clinical staging. spouse is positive orTo s/he use have the summaryhigh charts, lstartNutrition from the counselling left side of theand chart linkages and continue to Government/other towards the right riskside. behaviour Advice .to the mother/childNutrition for ART and programmes. for ARV prophylaxis, when to stop or continue infant l Postpartum ARV prophylaxis for mother. l InfantNVP prophylaxis,feeding and when to continue or stop breastfeeding etc. is described on the headings of the nutritioncharts. l Family Planning Services. counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups. All babies detected positive <2years of age are given Paediatric ART Box 15 irrespective of CD4 % HIV Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 62 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Chart 1: Exclusive Breastfeeding (EBF)

Infant feeding summaryomen W charts:regnant P Continuumall to vices of Ser Prevention esting T ofand HIV TransmissionCounselling HIV fromof Parent-to-ChildOffer (PPTCT) through ante natal, labour/delivery, post partum and infant feeding options

omen W regnant P Infected HIV Negative HIV Mother antiretroviral drug regimen T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Safe sex sex Safe l ART Centers. T AR at prophylaxis Infant Feeding counselling. of of termination Eligibilitymedical or continuation of choices on Counselling l Choice Couple Couple l Antenatal During of of months 3 first the within e tak under (MTP)–to pregnancy Postpartum Mother (AN) Labour and counselling. . . only pregnancy (PP) Delivery family to Linkages l OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l Initiate mother on lifelong ART, irrespective condoms. ree F l HIV Positive ART testing. regimen CD4 forand ofstaging pregnancyclinical gestationWHO l and Continue ART change Behaviour l HIV positive pregnant woman Pregnant mother’s own health throughout AN, labour/delivery, PP throughout EBF and th-planning bir , y deliver safe living, positive on Counselling l communication women TDF+3TC+EFV breastfeeding period and thereafter life-longrisk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par Infant NVP: Give first . children living other HIV epeat R l dose of NVP within EID*results at Stop BF at . Center T AR to eferral R l testing, 6 to 12 hours of 6 weeks EBF till (Maximum Remarksconsidering delivery count and continueCD4 on based regimen prophylactic ARV or T AR rovide P Timel daily NVP for *** staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk Stopping . mother for prophylaxis ARV tum ostpar P l and feeding Infant l breastfeeds should EID negative 6 monthsvices. Ser Planning 12amily F monthsl nutrition

usual be done gradually 6 weeks minimum status (considervisits. anotherhome through t suppor feeding reinforcement/Infant EBF l within 1 monthcounselling. 6 weeks when mother home counselling, follow-up through t suppor -social sycho P l has been initiated on ART later in pregnancy groups. t suppor and visits Infants diagnosed or post partum) EID positive should be on ART as per EID positive 6 months 24 months national paediatric HIV Exposed Infant (HEI) Infant guidelinesExposed HIV Introduce complementary feeding at 6 months of age as Confirmation of HIV status by 3 antibody tests at 18 O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto months of age, irrespective the results earlier EID breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and *EID means DNA /PCR screening at ICTC, and if detected positive, confirmation by Whole Blood Specimen (WBS) at the ART centre. . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID **Wherever written “HIV positive pregnant women”, kindly read it as “HIV infected pregnant women”. weeks. 6 for infant for prophylaxis ARV tum ostpar P l ***6 weeks after cessation of breastfeeds the baby’s 3rd EID should be done if earlier EID tests were negative(Rapid Test positive, doweeks DBS;6 & if DBS months positive; 12 do WBS;months, 6 ifat WBS positive,testing startrepeat Paediatricage; of ART,weeks 6 irrespectiveat (EID) of baby’sdiagnosis CD4 %.infant Early l + Follow up as usual at ART centre for routine ART monitoring. breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 63 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme Chart 2: Exclusive Replacement Feeding (ERF) 4.

Note: HIV infectedOffer women of HIV who Counselling become pregnant and Testing while Seron vicesART should to all alsoPregnant follow Wtheomen charts below

Infant feeding summary charts: Continuum of Prevention of HIV Transmission from Parent-to-Child (PPTCT) through ante natal, labour/delivery, postpartum and infant feeding options HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxisMother at AR T Centers.Antenatal (AN) Postpartum counselling. Infant feeding ART eligibility Motherl Counsellingantiretroviral on choices During of continuation labour or (PP)medical termination of l Couple choice pregnancydrug (MTP)–toregimen underand deliverytake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change ART regimenl WHOfor clinicalInitiate staging mother andon life-long CD4 testing. ART, irrespective of HIV positive communication mother’s own health pregnancy gestation and continue ART throughout pregnant l Counselling on positive living, safe delivery, birth-planningERF and TDF+3TC+EFV AN, labour/delivery, PP and thereafter life- long HIV positive Pregnant Woman HIV positive Pregnant (BCC) for high risk women infant feeding options. women and her partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. Infanttesting, NVP: Give first EID* results atl ReferralEBF tillto ART Center. Remarks dose ofconsidering NVP within 6 to 6 weeks l Provide ART or ARV prophylactic regimen based on CD4 count 12 hourswindow of delivery, period and if continue daily and/or clinical staging. spouseNVP for.... is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits. EID negative 6 months l Psycho-social support through follow-up counselling, home

6 weeks minimum done earlier Infants diagnosed EID (consider another 6 weeks visits and support groups. positive should be initiated

when mother has been usual and continue BF on ART as per national initiated late in pregnancy paediatric guidelines or post-partum)

HIV Exposed Infant (HEI)EID positive 6 months l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) Introduce complementary feeding at 6 months of age as months of age, irrespective the results EID tests and continued breastfeeds in addition to complement feeds afterConfirmation of HIV status by 3 antibody tests at 18 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. * EID means DNA/ PCR screening at ICTC, and if detected positive, confirmation by Whole Blood Specimen (WBS) at the ART lcentre.Postpartum ARV prophylaxis for infant for 6 weeks.

± Followl Early up as infant usual at diagnosis ART centre (EID) for routine at 6 weeksART monitoring. of age; repeat testing at 6 months, 12 months & 6 weeks * If pregnantafter woman cessation is detected of breastfeeds. HIV positive do not delay initiation of ART as per National Guidelines. § If mother is detected as HIV positive AFTER DELIVERY, her infant should receive infant NVP prophylaxis for minimum of 6 weeks.andl Co she-trimoxazole should be linked prophylaxis to the closest from ART6 weeks Centre of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 64 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Chart 3: Antiretroviral Treatment for Women Presenting Directly-In-Labour, Immediately Postpartum and prophylaxis for their Infants, Including Infant Feeding Options omen W regnant P all to vices Ser esting T and Counselling HIV of Offer ART Mother antiretroviral drug regimen Infant feeding eligibility choice Mother Antenatal During labour Postpartum (PP) (AN) and delivery omen W regnant P Infected HIV Negative HIV

l omen EBFW (6 months,regnant P T/ARV AR Women visits)–Monthly in4 direct at-least (ensure Care Antenatal if already started labour who are sex Safe l Unknown Centers. T AR at prophylaxis on breast feeds)

screening detected HIV counselling. CD4 at none TDF+3TC+EFVl TDF+3TC+EFV otherwise of of termination medical or positive using continuation of choices on Counselling baseline ERF (6monthsCouple l of of months 3 first the whole bloodwithin e fingertak under (MTP)–to pregnancy counselling. if alternate counselling. feeds prick testing . only pregnancy Women with unknown status Women family to already started)Linkages l post-delivery and undergoes HIV l presenting in labour or immediately OIs. other and TB for Screening vices. ser planning STIs. for treatment and Screening l Postpartum ART to be initiated as soon as condoms. ree F l possible (sample for CD4 testing collectedtesting. by CD4 and Infantstaging NVP:clinical WHO l change Behaviour l Lab Technician the following day during HIV Give first dose of NVP within and th-planning bir , y deliver safe living, positive on Counselling l communication confirmation and reached to ART Centre and 6 to 12 hours of delivery and risk EID resultshigh for (BCC) CD4 report handed over to Mother before continueoptions. for minimumfeeding ofinfant 6 discharge if mother is not likely to go to ART weeks her and women and spouse of testing HIV and counselling sex safe and Couple l centre within the next 2 days) . tner par . children living other HIV epeat R l After initial 6 weeks, continue EID positive . infant Center NVP T untilAR to mothereferral hasR l testing, considering considering count Mothercount needsCD4 on ART for based her own health*regimen completedprophylactic ARV or atT leastAR 6 weeksrovide P ofl maternal ART. Thereafter, infant staging. staging. clinical and/or if EID negativeperiod , window NVP can be stopped positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 65 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

1111

Care and Follow-up of HIV Exposed Infants Table 10: A checklist for the care and followProgramme up PPTCT activitiesof for Components all 2: HIV exposedFigure infants. Any intervention or ARV prophylaxis given to the HIV exposed newborn should be documented in the child health card beforeomen W discharge.regnant P all The to followingvices Ser shouldesting T be notedand in the card:Counselling HIV of Offer • Whether the infant had received ARV prophylaxis and the duration received/advice • What feeding choice the mother has made? Whether EBF or ERF? • Date of next follow-up. omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Centers. T AR at prophylaxis sex Safe l 11.1 During the First Post-delivery Visit at 6 Weeks/ First counselling. of of termination medical or continuation of choices on Counselling l Immunization Visit Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. All HIV exposed infants must be checked for the following . only at thepregnancy first immunization visit to ICTC health family family to Linkages l facility: OIs. other and TB for Screening l vices. ser planning • Co-trimoxazole Prophylactic TherapySTIs. for (CPT)treatment initiatedand at 6 Screening weeksl of age (decision on condoms. extendingree F l Syp NVP to 12 weeks). testing. CD4 and staging clinical WHO l change Behaviour l communication communication • Adherenceand ofth-planning inbir f, ay nt NVPdeliver prophylaxissafe living, for thepositive paston 6 weeksCounselling . l (BCC) for high risk risk high for (BCC) options. feeding infant • EID (DNA/PCR) as per National Guidelines. her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par • Decision made whether to stop infant NVP prophylaxis or continue as per guidelines (see below) . children living other HIV epeat R l • For exclusively breastfed infants whose. mothersCenter T AR areto not eferral takingR l ART: testing, considering considering count ocount TheCD4 patternon based of feediregimen n g, attachmentprophylactic andARV or T positioningAR rovide P & l mother’s breast condition must be staging. staging. clinical and/or if period , window enquired. positive is spouse Government/other Government/other to linkages and counselling Nutrition l o Any infant with problems must have a medical assessment. high have s/he or programmes. Nutrition . behaviour risk o Provide 6 weeks. supplymother offor infant syrupprophylaxis NVPARV prophylaxistum ostpar P l at ICTCs for alland HIV exposedfeeding bInfant abl ies (3 bottles of Sy NVP:25 ml) vices. Ser Planning amily F l nutrition counselling. o visits. Arrangehome for monthlythrough t follow-upsuppor feeding of the infants. reinforcement/Infant EBF l home counselling, follow-up through t suppor -social sycho P l o Such mothers have to be on life-long ART groups. t suppor and visits • For infants on exclusive replacement feeding, check with the parents and family if any problems faced so far:

o Emphasise good hygiene, use of clean boiled water, hand-washing.(HEI) Infant Exposed HIV • Any infan2010-'11) t with problemsGuidelines O must WHO/NAC have a medicalOption-I ass(preferred essmenmonths t.6 NVPupto infant prophylaxisbreastfeeds isExclusive tol be ter 6 months upto 1 year for stoppedfor year 1 at 6 weeksupto : months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID o How and what are being given as exclusive replacement feeds? weeks. 6 for infant for prophylaxis ARV tum ostpar P l o When has the mother been started on life-long ART to know the duration (atleast 24 weeks weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l of ART) breastfeeds. of cessation ter af

o All infants with HIV DNA/ PCR positive resultsage. of to be referredweeks 6 from urgently toprophylaxis the ART centre-trimoxazole Co as l per guidelines. EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 67 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

o Confirmation with WholeFigure Blood 2: Components Specimen of (WBS) PPTCT test Programme will be done at the ART centre. o All infants/children less than 2 years of age with a confirmed Whole Blood Specimen(WBS) positiveOffer statusof HIV atCounselling ART centre shouldand Testing be initiated Services on Paediatric to all Pregnant ART, irrespective Women of CD4 % at the earliest.

o All HIV-exposed infants should be followed-up monthly, in the first year of life and every 3 months thereafter, regardless of the infant feeding practice being adopted. HIV Negative HIV Infected Pregnant Women

Pregnanto Any W infantomen clinically suspectedl Antenatal of having Care HIV (ensure should at-least be tested 4 visits)–Monthly for HIV, regardless ART/ARV of their age. l Safe sex All HIV exposed infants irrespectiveprophylaxis of priorat AR Tstatus, Centers. should have the final confirmatory HIV counselling.o tests at l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. o 18 months in any ICTC usingpregnancy 3 Rapid onlyAnti-body. tests, even if the firstrapid test is negative. l Linkages to family planningo No DBS/WBS services. (DNA/PCR) ltestingScreening to be fordone TB atand or other after OIs. 18 months. l Screening and treatment for STIs. Activitiesl Free that condoms. need to be conducted at each visit are shown below: l Behaviour change l WHO clinical staging and CD4 testing. Table 10: Activities at Each Follow-up Visit for HIV Exposed Infants and Children < 18 Months communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk Visit Birth 6 wks 10 wksinfant14 feedingwks options.6 mths 9 mths §12 mths 18 mths women and her Co-trimoxazole l Start CPT from 6 weeks (or firstimmunization visit) for all HIV-exposed infants and children partner. l Couple and safe sex counselling and HIV testing of spouse and prophylactic l Continue CPT for all babies up to 18 months irrespective of EID status and thereafter if l Repeat HIV other living children. therapy (CPT) confirms positive testing, l Referral to ART Center. Counsellingconsidering for Exclusive √ √ √ BF+complementary √ If EID is –ve √ Infant feeding breast l Provide ART or ARVfeeds prophylactic regimen basedstop BF. on CD4 count window, periodfeeds for if and/or clinical staging. Continue spouse is positivefirst six BF if EID is or s/he havemonths high l Nutrition counselling and linkages to +veGovernment/other after risk behaviour. Nutrition programmes. 12 months up to 2 yrs l Infant feeding and l Postpartum ARV prophylaxis for mother. Growth √ √ √ √ √ √ √ √ nutrition l Family Planning Services. monitoring counselling. Developmental √ √ √l EBF√ reinforcement/Infant√ feeding√ support through√ home√ visits. assessment l Psycho-social support through follow-up counselling, home Immunization BCG OPV 1 OPV 2visitsOPV and 3 support groups. Measles OPV DPT & Vitamin A HBV0* DPT 1 DPT 2 DPT 3 + Vit. A and Measles supplements OPV0 HBV 1* HBV 2 HBV 3 (Booster doses) Vit.A ClinicalHIV Exposed√ Infant (HEI)√ √ √ √ √ √ √ assessment l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) HIV testing √ √ +/- (12 √ (√-if required)and continued breastfeeds(DNA/ in addition to complement(Rapid feedsTest after 6 months uptomonths) 1 yearAll for 3 Rapid EID negative babies andPCR) upto 2 years for EID positive+ DNA/PCR) babies who receive P√aediatric Rapid Test ARTests(NoT. + DNA/PCR) DNA/PCR) l Postpartum ARV prophylaxis for infant for 6 weeks. *HBV vaccines as per state approved schedules Note:l 18Early months infant – OPV diagnosis and DPT booster(EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks For any illnessafter cessation– educate parents/caregiver of breastfeeds. to bring infant/child back to ICTC at the earliest. § 6 weeks after cessation of breastfeeds, HIV testing to be done (Rapid and DNA/PCR, if former is positive). l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 68 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

11.2 Confirmation of HIV StatusProgramme PPTCT of in HIV Components Exposed2: Figure Infants should be done at 18 Months, Regardless of Earlier Diagnosis omen W regnant P all to vices Ser esting T and Counselling HIV of Offer • All HIV exposed infants and children regardless of HIV status will be followed-up until 18 months of age for care, monitoring and the final confirmatory HIV test at 18 months using 3 HIV Rapid tests (even if HIV-1 rapid test is negative). omen W regnant P Infected HIV Negative HIV • If any HIV exposed infant or child develops clinical signs and symptoms suggestive of HIV infection, T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P the Medical Officer at the health care facility should start immediate treatment for the acute Centers. T AR at prophylaxis sex Safe l illness, stabilise and refer urgently to ART Centre. HIV testing according to the national testingcounselling. of of termination medical or continuation of choices on Counselling l algorithm for infants and children <18 months also has to be done. Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. • Follow-up of HIV infected infants and children . only started onpregnancy ART shall be done by ART centres in family family to Linkages l collaboration with the PaediatricianOIs. other at theand institutionTB for whereScreening l ART Centre is located.vices. ser Infantsplanning and children on ART must undergoSTIs. thefor confirmatortreatment yand three antibodyScreening l tests at 18-months ofcondoms. ageree F in l the nearest ICTC, irrespective oftesting. the CD4 results and of thestaging first rapidclinical antibodyWHO l test. change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication • No DBS & WBS (DNA/PCR) testing to be done at or after 18 months. risk high for (BCC) options. feeding infant • In case there is discordance with DNA/PCR tests (DBS and WBS) and subsequent her and 18 monthwomen and spouse of testing HIV and counselling sex safe and Couple l . tner par anti-body test, such cases should be referred to NPO (ART) electronically for further guidance . children living other HIV epeat R l but to be on or continued paed. ART. (this guidance shall be finalised over the next six months . Center T AR to eferral R l testing, and intimated accordingly) considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 69 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

1212

Essential Gynaecologic Care for HIV Infected Pregnant Women During the long term follow-up of HIV infectedProgramme pregnantPPTCT of women,Components 2: apartFigure from ART and pre-ART care, key areas which must be discussed, are: • Cervical screeningomen W regnant P all to vices Ser esting T and Counselling HIV of Offer • Family planning and birth-spacing

• Contraception omen W regnant P Infected HIV Negative HIV omen W regnant P 12.1 CervicalT/ARV AR Screeningvisits)–Monthly 4 at-least (ensure Care Antenatal l Centers. T AR at prophylaxis sex Safe l counselling. Women of infected termination with HIVmedical areor at higher riskcontinuation of developingchoices on cervical dysplasiaCounselling l leading to cervical cancer. The Couple Couple l Human of Papillomamonths 3 virusfirst (HPV)the infectionwithin e tak is moreunder common(MTP)–to in HIV infectedpregnancy pregnant women, particularly Geno counselling. counselling. types 16, 18 and others incriminated to be carcinogenic . only being IARCpregnancy (WHO) 31,33,35,39,45,51,52,56, family family to Linkages l 58,59 & 68 more incriminated to cause cervical cancer. In the National ART Guidelines for adults and OIs. other and TB for Screening l vices. ser planning adolescents, cervical screening eg. Pap smear or trichloro-acetic acid screening of the cervix should be STIs. for treatment and Screening l condoms. ree F l done annually for all HIV infected pregnant women. testing. CD4 and staging clinical WHO l change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) 12.2 Family Planning and Birth-spacingoptions. feeding infant women and her her and women With ARTand and PPTCTspouse of beingtesting HIV increasingly and available,counselling sex safe HIV and infected Couple pregnantl women and men. tner arepar now living longer and healthier lives and desiring to. have children.children living Accordingly,other reproductive plansHIV includingepeat R l pre- conception counselling, and counselling. regardingCenter T AR to reversible eferral R methodsl of contraception shouldtesting, be discussed with HIV infected pregnant women of child bearing age. considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window Pre-conception counselling–HIV infected pregnant women are similar to non-HIV infectedpositive is pregnantspouse women. The goals areGovernment/other toto improve thelinkages healthand of the womancounselling beforeNutrition conceptionl and to high identify have risks/he factorsor for adverse maternal and foetal outcomes. These include:programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l • Safe sex practice and feeding Infant l vices. Ser Planning amily F l nutrition • Prevent test and treat STI. visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

• Reproductivehome historycounselling, includingfollow-up numbersthrough t of pregnanciessuppor -social andsycho P outcomesl of pregnancies. • Length of relationship with current partner,groups. t HIVsuppor statusand ofvisits partner and couple’s sexual history including condom use and sexual decision-making or control of reproductive choices. • Patient’s and partners reproductive desires and discussion of options. HIV Exposed Infant (HEI) Infant Exposed HIV • Reduce/avoid risky behaviour eg. smoking, substance abuse. O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l • Takefor folicyear 1 acidupto before conceptionmonths 6 ter af . feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Family planning counselling5 information includes: weeks. 6 for infant for prophylaxis ARV tum ostpar P l weeks • Informationweeks 6 & aboutmonths 12 effectivemonths, 6 contraceptiveat testing methodsrepeat age; of to preventweeks 6 at pregnancy,(EID) dualdiagnosis protection;infant Early l the effects of progression of HIV disease on the woman’s health; breastfeeds. of cessation ter af 5Sexual and reproductive health of women living with HIV/AIDS Guiage. delinesof onweeks care,6 treatmentfrom and supportprophylaxis for women-trimoxazole Co livingl with HIV/AIDS and theirEID. children through in resource-constrainedpositive HIV as settings.diagnosed WHO/UNFPchildren Aand 2006. infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 71 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

• The importance of family Figureplanning 2: Components and birth planning;of PPTCT Programme

• The risk of HIV transmission to an uninfected partner while having unprotected intercourse (for instance,Offer when of HIVtrying Counselling to become pregnant); and Testing Services to all Pregnant Women

• The risk of transmission of HIV to the infant and the risks and benefits of Antiretroviral prophylaxis in reducing transmission; and HIV Negative HIV Infected Pregnant Women • Information on the interactions between HIV and pregnancy, including a possible increase in Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV certain adverse pregnancy outcomes. l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of Contraceptivel Couple Methods pregnancy (MTP)–to undertake within the first 3 months of counselling. Most women with asymptomatic HIV andpregnancy those who only .are on ART can safely use the available forms of l Linkages to family contraception for preventing unintended pregnancies. However, prevention of cross-infection of HIV planning services. l Screening for TB and other OIs. virus to the partner as well as STIs is important and hence dual protection with consistent condom use l Free condoms. l Screening and treatment for STIs. is important. Dual protection refers to simultaneous protection against both unplanned pregnancy and l Behaviour change l WHO clinical staging and CD4 testing. STIs and HIV by using: communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. • womenCondoms and togetherher with another effective method of contraception, including emergency parcontraceptiontner. . l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. Available forms of contraception for HIV infected pregnant women include: Hormonal contraception: is testing, l Referral to ART Center. safe in women living with HIV. These may be either: considering l Provide ART or ARV prophylactic regimen based on CD4 count • windowOral contraceptives, period if and/or clinical staging. spouse is positive l Nutrition counselling and linkages to Government/other • orDepot s/he havemedroxyprogesterone high acetate (DMPA) risk behaviour. Nutrition programmes. DMPAl Infantis safe feeding to use and in women livingl Pwithostpar HIVtum as ARV well prophylaxis as those on for ARTmother. There. is no hormone-drug interactionnutrition with several ARV drugs commonlyl Family usedPlanning such Ser asvices. NVP, EFV and Nelfinavir.

counselling. l 3 In women living with HIV (whose CD4 isEBF > 350reinforcement/Infant cells/mm ), hormonal feeding contraception support through is safe. home Adherence visits. to oral contraception needs to be counselled.l Psycho Dual-social protection support throughwith consistent follow-up condom counselling, use is home important. visits and support groups. In women taking ART for their own health, they should be assessed for oral contraception use according to the WHO Medical Eligibility Criteria for Contraceptive Use guidelines6. There may be hormone-drug interactions which need dosing to be adjusted or an alternative contraception to be used HIV Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) Ritonavir and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for • EIDCombined negative oral babies contraception and upto 2pills years are for generally EID positive not recommended babies who receive for women Paediatric taking AR ritonavir-T.

l Pboostedostpartum PIs, ARV due prophylaxis to the potentially for infant decreased for 6 weeks. efficacy ofthe contraception

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

7Medicall Co Eligibility-trimoxazole Criteria forprophylaxis Contraceptive from Use. 6 weeks4th edition. of age. WHO 2009. http://www.who.int/reproductivehealth/publica- tions/family_planning/en/index.html l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 72 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

• Nevirapine Programme PPTCT of Components 2: Figure

o NVP reduces the levels of combined oral contraception (ethinyl estradiol and norethindrone) but at present,omen W no dosageregnant P all mto odificationvices Ser are beingesting T suggestedand Counselling HIV of Offer

• Efavirenz:

o Women taking EFV may be able to take combined oral contraception without loss of omen W regnant P Infected HIV Negative HIV contraceptive efficacy T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P • NRTI such as AZT and TDF: Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l o Women taking AZT and TDF may take combined oral contraception without loss of c ontracCouple eptl ive of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. efficacy . only pregnancy family family to Linkages l Lactational Amenorrhoea Method (LAM)OIs. doesother notand protectTB for against Screening STIs,l pregnancy andvices. HIser V. Correctplanning and consistent condom use should be adoptedSTIs. for at everytreatment sexualand encounteScreening l r. condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l Male sterilization (NSV): Males should be motivated at every mother-baby pair follow-up visit to undergo and th-planning bir , y deliver safe living, positive on Counselling l communication sterilization. No Scalpel Vasectomy (NSV) when the baby attains 18 months/2 risk yearshigh offor age (at(BCC) 18 options. feeding infant months confirmatory test, irrespective of the baby’s HIV status). However, after NSVher operation,and women male should continueand spouse toof use a testing condom HIV and at every sexualcounselling sex encountersafe and .7 Couple l . tner par . children living other HIV epeat R l . Center T AR to eferral R l testing, Intra-Uterine Contraceptive Device (IUCD) is a good contraceptive method for considering HIV count count CD4 on infectedbased pregnantregimen women.prophylactic IUCDARV or 8T CopperAR T rovide 380AP l is recommended by MoHFW as Box 16 staging. clinical and/or if period , window a long term reversible method of contraception up to 10 years. PPpositive is IUD (Cu-’T’spouse Government/other Government/other to linkages and counselling Nutrition l A-380) to be inserted within 48 hrs of delivery. high have s/he or programmes. Nutrition . behaviour risk PP IUD. - Postpartummother for IUDprophylaxis requiresARV tum specialisedostpar P l training before and the healthcarefeeding Infant l personnel undertake thevices. same.Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l 8 IUCD Reference manualEID. for Medicalthrough Officerspositive 2007.HIV as Family Planningdiagnosed Division.children and MoHFW. infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 73 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

1313

Monitoring and Evaluation Tools Monitoring and evaluation facilitates the assessmentProgramme PPTCT of of the performanceComponents 2: Figure of an individual as well as the performance of the programme, which forms the basis of decision making, policy planning and resource allocation and mid-termomen W corrections,regnant P all if to required vices . Ser esting T and Counselling HIV of Offer

Client Monitoring

Monitoring of HIV infected pregnant women is an essential component of quality patient care in PPTCT omen W regnant P Infected HIV Negative HIV programme. It involves documenting all client encounters by maintaining regular and accurate records of T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P key aspects of the services provided to the PPTCT beneficiaries and herbab y. Centers. T AR at prophylaxis sex Safe l counselling. A set of of M&E toolstermination have beenmedical or devised tocontinuation ensureof thatchoices on continuum Counselling of l care from detection of HIV infection Couple Couple l among of pregnantmonths 3 womenfirst the to theirwithin linkagee tak tounder ART centre(MTP)–to and for EIDpregnancy after delivery is well maintained. In counselling. counselling. addition to regular CMIS format of monthly reporting . only a PPTCT beneficiarypregnancy Line-list has been designed, family family to Linkages l which shall be updated on an event basisOIs. byother ICTCsand TB andfor ART centresScreening l to ensure delivery vices. ofser the completeplanning package of PPTCT services to all pregnantSTIs. for womentreatment viz Anti-Retroviraland Screening l Therapy, Delivery; Feedingcondoms. ree history;F l Early Infant Diagnosis along with finaltesting. confirmationCD4 and staging at 18clinical monthsWHO . l change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) 13.1 Guidance on Data Flow of PPTCToptions. Beneficiariesfeeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l 1. A line-list has been devised for the PPTCT beneficiaries and is labeled as Tool 1. . Thistner line-listpar is meant for all PPTCT beneficiaries (Pregnant. children Womenliving in other antenatal care, Direct-in-labour HIV epeat R & Post-l delivery; breastfeeding mothers). This. line-Center T listAR to will originateeferral R l at the concerned ICTC wheretesting, a considering considering count pregnantcount CD4 on womanbased is detectedregimen to be positive.prophylactic ARV or This T AR will berovide P an l electronic format and shall NOT be staging. staging. clinical and/or if period , window printed in a register form at present. positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or 2. The ICTC generating this line-list will fill up the column numbers 1 to 17 d; 29 to 37c and 42 & programmes. Nutrition . behaviour risk 43 (Colour coded in yellow). . mother for prophylaxis ARV tum ostpar P l and feeding Infant l 3. When this line-list is shared by the vices. ICTCSer with thePlanning ARTamily F centre,l where the positive pregnantnutrition counselling. womanvisits. ishome registered,through t thesuppor concernedfeeding ART centre will fillreinforcement/Infant upEBF thel column numbers 18 to 28; 38a to 38d; home 39 to 41; 44acounselling, to 47 follow-up (Colour codedthrough t insuppor green).-social sycho P l groups. t suppor and visits 4. Columns 23, 24 and 25 can be filled up by ICTC counsellor if and when applicable.

5. The line-lists should be generated at ICTC on the first visit of a new HIV positive pregnant case presenting either during pregnancy, direct-in-labour or after delivery. One(HEI) row shouldInfant be assignedExposed HIV O Guidelines 2010-'11) for each 2010-'11) client. MostGuidelines O often, the WHO/NAC first visitOption-I is at the(preferred ICTC months when 6 a upto women in ante-natalbreastfeeds Exclusive carel is ter 6 months upto 1 year for detectedfor year 1 to haveupto HIV infection.months 6 ter af Hence,feeds line-lists complement will to be generatedaddition in there andbreastfeeds details sharedcontinued and with the . T ARTAR Centreaediatric P for entryreceive o of wh relevant babies information.positive EID Sometimesfor years 2 anupto HIVand infectedbabies pregnantnegative womanEID may have her first visit at the ART Centre, rather than ICTC eg. a positive female client already weeks. 6 for infant for prophylaxis ARV tum ostpar P l enrolled at ART centre, gets pregnant or has a second pregnancy after previously being detected. weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l In such cases, the line-list will be generated at the ART Centre and afterbreastfeeds. of the relevantcessation ter columnsaf have been filled up, the line-list will be shared by the ART centre with the ICTC forfurther age. of weeks 6 from prophylaxis -trimoxazole Co l follow-up. EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 75 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

6. This line-list should be updatedFigure 2: at Components each activity of PPTCT in the Programme continuum of PPTCT care services eg. ANC/ICTC visits, CD4 test, ART initiation, delivery, Syp. NVP initiation, CPT initiation, EID visits, immunizationOffer of etc.HIV and Counselling shared on and a weekly Testing basis Ser vices between to all ICTC Pregnant and ART W omen centre counsellors and staff. If it is not possible to share information weekly then the information about all newly detected HIV positive cases at ICTCs must be given to the ART Centre by the District Supervisor/ DAPCU officer where client wants to get enrolled for the early registration and initiation of ART. HIV PrintNegative outs of this electronicallyHIV shared Infected line-lists Pregnant on a Wmonthlyomen basis after updating them should be

Pregnantkept in W aomen ring- binder file bothl Antenatalat the ICTCs Care and (ensure ART Centres.at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. 7. counselling.The updated line-lists should be shared between ICTCs and ART Centres on a monthly basis at l Counselling on choices of continuation or medical termination of l CoupleDAPCU/District level monthly co-ordination meetings (which are held by the 5th of every month). pregnancy (MTP)–to undertake within the first 3 months of counselling.List of LFUs should be generated during DAPCU/Monthly co-ordination meetings at District and pregnancy only. l Linkagesshared with to familyrespective ICTCs/ANMs/ ASHAs /Outreach workers/District Level Networks for follow- l Screening for TB and other OIs. planningup. District services. Nodal persons should take responsibility of linkages of all the newly detected HIV l Fcasesree condoms. with ANMs/ASHAs /Communityl Screening Out-reach and treatment Workers/District for STIs. Networks of Positive People l Behaviouras well as change tracking of LFU cases.l WHO Accompanied clinical staging referral and by CD4 them testing. should be ensured so that the communication pregnant woman reaches thel ARTCounselling Centre as on soon positive as possible. living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. 8. womenIn case and the expectedher place of delivery is in another district, it is the responsibility of ICTC counsellor l Couple and safe sex counselling and HIV testing of spouse and parof tnerthe .centre where her original registration was done, to inform the ICTC counsellor of expected other living children. l Rplaceepeat ofHIV delivery with copy to DAPCU/District Supervisor and other concerned officials at SACS. testing, This is to ensure that this womanl Referral is not to lost AR -toT Center -follow-up. and is not registered again at another considering ICTC where she delivers. Thisl willProvide ensure AR Tthat or ARVthere prophylactic is no double regimen counting based of cases.on CD4 The count ICTC window, period if and/or clinical staging. spouseCounsellor is positive at second ICTC will be responsible for updating the line- list of this woman, linking this orpatient s/he have to EID high and ART services.l NutritionOnce this womancounselling comes and back linkages to the original to Government/other (previous) ICTC, the Nutrition programmes. riskdata behaviour in the line-list. should also be transferred to this ICTC and ART Centre. l Infant feeding and l Postpartum ARV prophylaxis for mother. 9. nutritionAt district level, the updatedl line-listsFamily Planningfrom all ICTCs Services. should be compiled into one Consolidated list and updated on a monthly basis by DAPCU/ Nodal Person for HIV in the district. The compiled counselling. l EBF reinforcement/Infant feeding support through home visits. district level line-list should be cross checked and validated by the nodal person in district and l Psycho-social support through follow-up counselling, home then sent to M&E officerat SACS with copy to JD (BSD) and PPTCT focal person in SACs by 10th of visits and support groups. every month. The responsibility of compilation of District level, PPTCT beneficiaries line–lists lies with District Supervisor (in DAPCU Districts) and ICTC Counsellor/s (preferably located in Gynae OPD) of District headquarters. HIV Exposed Infant (HEI) 10.l Exclusive The M&E breastfeedsofficer at SACS upto will 6 monthsthen compile (preferred these Option-I district WHO/NAC level line-listsO Guidelines into one 2010-'11)State level line- andlist. continued This State breastfeeds level line-list in ofaddition PPTCT tobeneficiaries complement should feeds afbeter sent 6 months by JD (BSD) upto 1at yearSACS for to BSD EIDDivision negative and babiesCST Division and upto at NACO 2 years with for copy EID topositive RCs by babies 15th whof everyo receive month. Paediatric ART. 11.l P Theostpar generationtum ARV prophylaxis and compilation for infant of for line-lists 6 weeks. at District/State/NACO level is primarily the l Earlyresponsibility infant diagnosis of BSD (EID) division. at 6 weeksOnly the of age;ART repeatcomponent testing of at the 6 months, line- list 12 shall months be filled& 6 weeks in and afupdatedter cessation by ART of breastfeeds.Centres and shared with ICTCs after each activity is accomplished electronically l Co&/or-trimoxazole in the monthly prophylaxis meetings. from 6 weeks of age. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 76 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

12. The M&E officerat BSD Division, NACOProgramme shallPPTCT of compile andComponents 2: analyse Figure these reports every month and give feedback to the concerned person at BSD and CST at NACO on gaps in the cascade of service delivery to PPTCTomen W beneficiariesregnant P all to so thatvices Ser measures esting T to fill and in these gaps Counselling can beHIV of instituted. Offer 13. Another tool shall be used by ART centre for reporting on PPTCT and EID indicators. This is presently being sent as a separate tool (Tool-2) but ultimately will be part of monthly reporting format from ART centres (once new form page format is rolled -out across the country.) omen W regnant P Infected HIV Negative HIV

T/ARV AR 15.2 Toolvisits)–Monthly 4 1: PPTCTat-least Beneficiary(ensure Care Line-ListAntenatal (ICTC-ART)l omen W regnant P Safe sex sex Safe l Name of the State: Updated for Centers. the T month:AR at prophylaxis counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy Year: counselling. . . only pregnancy family family to Linkages l OIs. other and TB for Screening l vices. ser planning District: Name of MO I/c of ICTC: STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l Contact No. of MO: and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) options. feeding infant women and her her and women Name of ICTC: e-mail id: and spouse of testing HIV and counselling sex safe and Couple l . tner par . children living other HIV epeat R l (where generated) Name of . SMO/MOCenter T of ARTAR to Centre:eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window Contact No. of SMO/MO positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition Name of ART: e-mail id: . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition (with whom shared) Name of DAPCUO/Nodal Officer I/c of HIV Programme: visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l Designation ofgroups. I/ct Officersuppor and visits

Contact No.: HIV Exposed Infant (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O e-mailWHO/NAC id: Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and Pertains to. T ICTCAR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID weeks. 6 for infant for prophylaxis ARV tum ostpar P l

Pertains toweeks ART6 & centre months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l 15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd.... EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 77 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme 11 (EDD) Offer of HIV Counselling and Testing Services to all Pregnant Women of Delivery Expected Date 10 weeks) HIVAge (in Negative HIV Infected Pregnant Women Gestational Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers.

counselling. 9 l Counselling on choices of continuation or medical termination of l Couple mother in -Labour/ ANC/ Direct- Post-delivery Post-delivery

Type of Client Type pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family l Screening for TB and other OIs.

planning services. 8

l Freetested condoms. l Screening and treatment for STIs. ICTC where ICTC Name of the

l Behaviour change l WHO clinical staging and CD4 testing. 15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd....

communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant7 feeding options.

womenNumber and her ICTC PID ICTC partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. testing, l Referral to ART Center. 6 test)

Date of considering HIV Test HIV Test l Provide ART or ARV prophylactic regimen based on CD4 count window(Confirmatory , period if and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. 5 Nutrition programmes. Village/ number District/ Address Pin Code Door no./ (including Landmark, State) with l

and contact Postpartum ARV prophylaxis for mother. l Infant and Parental feeding and Block/ Taluka/ Father’s name Father’s nutrition l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits. 4

Village/ l Current number District/ Address Psycho-social support through follow-up counselling, home Pin Code Door no./ (including name and Husband’s Landmark, State) with and contact Block/ Taluka/ Block/ Taluka/ visits and support groups.

3 Age

HIV(in years) Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for 2

EID negativemother babies and upto 2 years for EID positive babies who receive Paediatric ART. Pregnant Pregnant in labour/ Women in Women Name of the ANC/ Direct- l Postpartum delivery Post- ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks i ii 1 iv after cessation of breastfeeds. iii

l Co-trimoxazole prophylaxis from 6 weeks of age. (Expandable) Clients Sl. No. ...15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 78 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure 21 WHO Stage Clinical omen W regnant P all to vices Ser esting T and Counselling HIV of Offer 20 Date of CD4 Baseline count and CD4 Count

omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P 19 No. sex Safe l at ART Date of

Pre-ART Pre-ART Centers. T AR at prophylaxis Centre and Registration Registration Registration counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. 18 . only pregnancy at ART Already l

Registered Registered family to Linkages New Case/ OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l 17d

at 18 l testing. CD4 and staging clinical WHO l change Behaviour 15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd.... months

and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) options. feeding infant women and her her and women 17c at 12 l and spouse months of testing HIV and counselling sex safe and Couple . tner par . children living other HIV epeat R l . Center T AR to eferral R l testing, at 6 17b considering

count count CD4 months on based regimen prophylactic ARV or T AR rovide P l

17. Infant feeding practice staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or 17a programmes. Nutrition . behaviour risk at 6 weeks . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition 16

after counselling.

Dead) l weeks visits. home (Alive/ through t suppor feeding reinforcement/Infant EBF Mother up to 6 delivery Status of home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits 15 MTP/ Abortion) Pregnancy Pregnancy Still Birth/ (Live Birth/ Outcome of

HIV Exposed Infant (HEI) Infant Exposed HIV 14 O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l (refer to Place of Delivery guidance) ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID 13 l

Date of weeks. 6 for infant for prophylaxis ARV tum ostpar P Delivery weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

12 age. of weeks 6 from prophylaxis -trimoxazole Co l Place of Delivery Expected

...15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd. EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 79 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme 31 Syp Offer of HIV Counselling and Testing Services to all Pregnant Women 6 weeks, reason If stopped before for stopping NVP

HIV Negative 30 HIV Infected Pregnant Women Date of Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV completing 6 weeks of NVP Syp dd/mm/yy l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of

l Couple 29

Date of pregnancy (MTP)–to undertake within the first 3 months of

counselling.dd/mm/yy Syp at birth starting NVP pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Screening and treatment for STIs. l Free condoms.28 ART * Stopping 15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd.... l for Reason Behaviour change l WHO clinical staging and CD4 testing.

communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. women and her 27

Date of l Couple and safe sex counselling and HIV testing of spouse and

pardd/mm/yy tner. stopping ART l Repeat HIV other living children.

testing, l Referral to ART Center.

considering26 l Provide ART or ARV prophylactic regimen based on CD4 count initiation

windowdd/mm/yy , period if

Date of ART and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. Nutrition programmes. 25 l no. Infant feeding and l Postpartum ARV prophylaxis for mother. dd/mm/yy nutrition l Family Planning Services. ART Registration ART Registration counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home

24 visits and support groups. DOTS) Date of (dd/mm/yy) (DOTS/ Non- Completing ATT Completing ATT

HIV Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 23

and continuedDOTS) breastfeeds in addition to complement feeds after 6 months upto 1 year for (DOTS/Non- (dd/mm/yy) If Column 22 is “Yes”, date is “Yes”, EID of starting ATT negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks

after cessation22 of breastfeeds. (Yes/No) Whether having TB

l diagnosed as Co-trimoxazole prophylaxis from 6 weeks of age. ...15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 80 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure 38d with Date of Referral Referral negative If infant is

omen W 2nd WBS, regnant P all to vices Ser esting T and Counselling HIV of Offer (dd/mm/yy) back to ICTC back to ICTC 38c DBS & Negative Result of Result 1st WBS 2nd WBS (in case of Positive or Positive

discordance) omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Centers. T AR at prophylaxis sex Safe l WB 38b counselling. Result for Result Specimen

or Negative l 38. DNA/ PCR: WBS tests

of of termination test Positive medical or continuation of choices on Counselling Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. . . only pregnancy family family to Linkages l WB 38a OIs. other and TB for Screening l mm/yy) date (dd/ specimen collection vices. ser planning STIs. for treatment and Screening l condoms. ree F l

l testing. CD4 and staging clinical WHO l change Behaviour 15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd....

37c communication and after th-planning bir , y deliver safe living, positive on Counselling l at 6 weeks stopping of

breastfeeds risk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par

. children living other l 37 b HIV epeat R negative) (positive or at 6 months . Center T AR to eferral R l testing, considering considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l 37. DNA /PCR: DBS tests staging. clinical and/or if period , window

37a positive is spouse

Government/other negative) Government/other to linkages and counselling Nutrition l at 6 weeks (positive or high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l 36 vices. Ser Planning amily F l nutrition infant code Unique DNA visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l 35

infant groups. t suppor and visits ICTC ID of ICTC

34 (HEI) Infant Exposed HIV Infant Name of O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID 33 what (Dual is being addition followed to use of condoms

(Copper-T (Copper-T l temporary or OCP) in weeks. 6 for infant for prophylaxis ARV tum ostpar P Protection) FP method At 6 weeks, weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af 32

Date of age. of weeks 6 from prophylaxis -trimoxazole Co l dd/mm/yy initiation of CPT in baby

...15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd. EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 81 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme 47 Offer of HIV Counselling and Testing Services to all Pregnant Women Remarks*** 46b (Y/N) months dose at 18 HIV Negative booster First HIV Infected Pregnant Women

Pregnantcompleted Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV 46a

l Safe sex (Y/N)

Primary prophylaxis at ART Centers. including Vitamin A measles and

46. Whether immunization counselling. her baby

l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Client’s current location with date Information on authorized attendant to months 6 dispensed(from be can ART whom of pregnancy upto 2 months post delivery) Any other importantrelated or information on to client Linkages to family 45b l planning services.Date and Screening for TB and other OIs. ***Relevant information to be captured, eg: ***Relevant 1. 2. 3. reason for ART l Free condoms. discontinuation** l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing. communicationOutcome (Child) l45a Counselling on positive living, safe delivery, birth-planning and 45. ART/ ARV prophylaxis Treatment (BCC) for high riskAlive & On infant feeding options. women and her partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. 44b testing, l Referral to ART Center.

considering (code) for ART Date and reason l

/discontinuation** Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive l Nutrition counselling and linkages to Government/other

or s/he have high 44a

44. ART Outcome (Mother) Nutrition programmes. Treatment risk behaviour. Alive & On l Infant feeding and l Postpartum ARV prophylaxis for mother.

l B – Stopped on Medical advice, out, C – Transfer D – Lost to follow up.(LFU) E – opted out of the programme

nutrition 43 Family Planning Services. **A – Maternal death, mm/yy Date of CPT dd/ counselling.stopping l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home 42 yy) visits and support groups. positive Antibody Confirmed & result of 18 months negative or - Confirmed conducted at Tests (Rapid) Tests Date (dd/mm/

HIV Exposed Infant (HEI) 41 Date of Paed ART Paed (dd/mm/yy) l Exclusive breastfeedsInitiation of upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for or

EID negative babies and upto 40 2 years for EID positive babies who receive Paediatric ART. CD4 % Baseline

l Postpartum ARV prophylaxisCD4 count for infant for 6 weeks. HIV +ve infant l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds. After one week of stopping breastfeeding Death of baby Death of mother decision Parent/Guardian Medical Reason 39

l Co-trimoxazole prophylaxis from 6 weeks of age. 2. 3. 4. 5. yy) and Pre yy) and Pre *1. Registration Registration ART Number Date (dd/mm/ ...15.2 Tool 1: PPTCT Beneficiary Line-List (ICTC-ART) Contd. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 82 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

15.3 Definition of Tool 1 Variables in PPTCTProgramme BeneficiaryPPTCT of Line-listComponents 2: Figure

omen W Tool 1: Definitionregnant P all ofto Differentvices VariablesSer esting inT PPTCTand Beneficiary LineCounselling ListHIV of Offer Sl. No. Variable Description 1 Sl. No. It is a number provided to the each client coming to avail the PPTCT package of service on her first visit. omen W regnant P Infected HIV Negative HIV 2 Name of the Pregnant Women/ Direct-in- labour ANC/Post- Write the complete name of the Client here in deliveryT/ARV motherAR visits)–Monthly 4 at-least (ensure Care blockAntenatal letters.l omen W regnant P Safe sex sex Safe l 3 Age (In Years) Centers. T AR at Writeprophylaxis the age of the Client in years. counselling. of 4of Husband’stermination name andmedical or Current Addresscontinuation (includingof Doorchoices on No./ WriteCounselling thel address of the client where currently Couple Couple l of of Village/Block/months 3 first Taluka/ the District/State)within e tak with under Landmark, Pin(MTP)–to Code residing:pregnancy Husband’s name, along with Door No./ counselling. counselling. and contact number . only Village/Block/Taluka/District/Statepregnancy with landmark and Pin code and Contact Numbersfamily to Linkages l OIs. other and TB for Screening l 5 Father’s name and Parental Address (including Door no./ Write the name and address vices. of fatherser of theplanning Village/Block/ Taluka//District/State)STIs. withfor Landmark,treatment Pinand Code clientScreening alongl with Father’s name/Door condoms. No./Village/ ree F l and contact number testing. CD4 and staging clinical Block/Taluka/District/StateWHO l withchange landmark andBehaviour l Pin code and Contact Numbers and th-planning bir , y deliver safe living, positive on Counselling l communication 6 Date of HIV Test Mention the Date (dd/mm/yy) risk whenhigh for HIV Test(BCC) of options. feeding infant the client conducted. This shouldher and be a test women at ICTC (and not the screening test) and spouse of testing HIV and counselling sex safe and Couple l . tner par 7 ICTC PID Number Mention the PID number provided to client from . children living other HIV epeat R l the ICTC, where she got tested for HIV . Center T AR to eferral R l testing, 8 Name of ICTC where tested Write the Name of the ICTC where the clientconsidering got count count CD4 on based regimen prophylactic ARV or T AR testedrovide P forl HIV staging. staging. clinical and/or if period , window 9 Type of Client ANC/ Direct-in- Labour/ Post-delivery mother Mention whether the Client is ANCpositive is case or spouse Direct-in-l Labour Case or a post-delivery case Government/other Government/other to linkages and counselling Nutrition high have s/he or programmes. (whoNutrition have been diagnosed/ registered post delivery) . behaviour risk . mother for prophylaxis ARV tum ostpar P l 10 Gestational Age (in Weeks) If the client is ANC case writeand her Gestationalfeeding Infant l vices. Ser Planning Ageamily F in l weeks. nutrition 11 Expectedvisits. home Date of Deliverythrough t (EDD)suppor feeding reinforcement/Infant ForEBF ANCl case, write the date (dd/mm/yy) oncounselling. which she is expected to deliver. home counselling, follow-up through t suppor -social sycho P l 12 Expected Place of Delivery groups. t suppor and For visits ANC Case, Write the name of the place (Health Facility) where she opts for delivery. 13 Date of Delivery Write the date (dd/mm/yy) when she has delivered. 14 Place of Delivery (refer to guidance) Write the name of the(HEI) place (HealthInfant Facility,Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred Home deliverymonths 6 etc)upto where she breastfeeds has delivered.Exclusive Inl this case data needs to be transferred to ICTC at ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to place ofaddition delivery.in Refer tobreastfeeds point 7 in datacontinued flowand for . . T AR aediatric P receive o wh babies positive EID for descriptionyears 2 ofupto thisand indicator.babies negative EID

15 Outcome of Pregnancy (Live Birth/ Still Birth/ MTP/ Abortion)weeks. 6 for Writeinfant herefor the outcomeprophylaxis of theARV Pregnancytum ostpar P l whether it is a Live Birth, Still Birth, Medical weeks weeks 6 & months 12 months, 6 at testing repeat age; of Terminationweeks 6 at of Pregnancy(EID) or diagnosis an Abortion.infant Early l breastfeeds. of cessation ter af 16 Status of Mother after delivery up to 6 weeks (Alive/ Dead) Mention here the status of client after delivery age. of andweeks 6 up tofrom 6 weeks (whetherprophylaxis alive or dead)-trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 83 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme Tool 1: Definition of Different Variables in PPTCT Beneficiary Line List

Sl. No. Variable Description Offer of HIV Counselling and Testing Services to all Pregnant Women 17 Infant feeding practice at: Please ask the mother at each of the 4 visits: (a) 6weeks: regarding infant feeding practice. 1. Exclusive Breast Feeding (a) At 6 weeks, whether the baby is receiving Exclusive Breast 2. Exclusive Replacement Feeding feeds only or Exclusive Replacement feeds or if any Mixed 3. Mixed feeding* feeding has occurred (Baby is receiving both breast feeds and HIV Negative(b) 6months: HIV Infected Pregnantreplacement Women feeds within first 6 months). Pregnant1. W omenContinued Breast Feedingl +Antenatal (b)Care At (ensure6 months, at-least enquire 4whether visits)–Monthly baby which isAR continuedT/ARV on Complimentary feeds & semi solids breast feeds has also been started on complementary feeds l Safe sex prophylaxis at ART Centers. counselling.2. Continued Replacement feeding + and semisolids or whether the baby was getting exclusive semi solids l Counselling onreplacement choices of feeds continuation for the first or6 medicalmonths and termination now has been of l Couple 3. Whether mixed feeding occurredpregnancy (MTP)–tostarted on semi-under solids.take Enquirewithin alsothe whether first 3 any months mixed of counselling. between 6 weeks to 6 monthspregnancy onlyfeeding. happened any time from 6 weeks up to 6 months. l Linkages (Yes/No)to family (c) At 12 months, enquire from the mother whether breast feeds planning(c) 12 months: services. l Screening for hasTB beenand otherstopped. OIs. If yes, indicate date (dd/mm/yy) 1. Continued Breast Feeding (d) At 18 months, enquire whether 1. Breast feeding is being l Screening and treatment for STIs. l Free condoms.2. Breast Feeds stopped (dd/mm/yy) continued or 2. Breast- feeding has been stopped. If stopped, l Behaviour(d) 18 months: change l WHO clinicalindicate staging date and of CD4 stopping testing. (dd/mm/yy). 1. Continued Breast Feeding communication l Counselling on positive living, safe delivery, birth-planning and (BCC)2. for Stoppedhigh risk Breast Feeding (dd/mm/yy) infant feeding options. 18 womenNew Case/ and Alreadyher Registered at ART Mention whether the client availing the service is a fresh case or partner. l Couple andhas safe already sex counsellingbeen registered and at ARTHIV with testing Pre ARTof spouse number. and Write “New Case” for fresh case and “Already Registered at ART” for l Repeat HIV other living children. client registered at ART. testing, l Referral to ART Center. 19 consideringDate of Registration at ART Centre and Pre- Mention the Date (dd/mm/yy) of registration of the client under ART Registration No. l Provide ARHIVT or (Pre-ART) ARV prophylactic care at ART Centre. regimen based on CD4 count window, period if and/or clinical staging. 20 spouseDate ofis CD4positive count and Baseline CD4 Count Mention the date (dd/mm/yy) of assessment of CD4 count of the client. Mention the baseline CD4 count of the client. or s/he have high l Nutrition counselling and linkages to Government/other 21 riskWHO behaviour Clinical. Stage Nutrition programmes.Write the WHO Clinical stage (whether I,II,III or IV) of the client here. l Infant feeding and l Postpartum ARV prophylaxis for mother. 22 Whether Diagnosed as having TB (Yes/No) If the client have been diagnosed as having TB write YES, if not nutrition l Family Planningwrite NO Services. counselling. l EBF reinforcement/Infant feeding support through home visits. 23 If Column 22 is “Yes”, date of starting ATT If yes, date of starting of TB treatment (ATT) (DOTS/Non-DOTS) (dd/mm/yy) l Psycho-social support through follow-up counselling, home 24 Date of completing ATT (dd/mm/yy) visits and supporWrite thet groups.exact date when TB treatment (ATT) was completed 25 ART Reg no. When initiated on ART, write the ART registration number allotted to the client. 26 Date of ART initiation Write the date (dd/mm/yy) of initiation of ART to the client. HIV Exposed Infant (HEI) 27 Date of stopping of ART If ART stopped, write the date l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) (dd/mm/yy) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for 28 Reason for Stopping ART* *Mention the Reason for stopping of ART EID1. negative babies and upto 2 years for EIDhere, positive The reason babies could be:who receive Paediatric ART. 2. 1. After one week of stopping breastfeeding l Postpartum ARV prophylaxis for infant for 6 weeks. 3. 2. Death of Baby l Early4. infant diagnosis (EID) at 6 weeks of age;3. repeatDeath of testing Mother at 6 months, 12 months & 6 weeks after5. cessation of breastfeeds. 4. Patient/Guardian’s decision 5. Medical Reason l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 84 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Tool 1: Definition of Different Variables in PPTCT Beneficiary Line List

Sl. No. Variable Description omen W regnant P all to vices Ser esting T and Counselling HIV of Offer 29 Date of starting NVP Syp at birth dd/mm/yy Mention the date (dd/mm/yy) when NVP syrup was initiated after birth 30 Date of completing 6 weeks of NVP Syp dd/mm/yy Mention the date (dd/mm/yy) when NVP syrup (6 weeks) to baby has been completed omen W regnant P Infected andHIV stopped. Negative HIV

31 If stoppedT/ARV AR before 6 weeks, reasonvisits)–Monthly 4 for stoppingat-least NVP(ensure SypCare Antenatal Tryl to find out the reason omen as toW why Sypregnant P NVP Centers. T AR at prophylaxis was stopped sex Safe l 32 Date of initiation of CPT in baby dd/mm/yy At 6 weeks, find out from the mother counselling. the of of termination medical or continuation of choices on Counselling l date (dd/mm/yy) when baby was initiatedCouple l on of of months 3 first the within e tak under (MTP)–to pregnancy Co- trimoxazole prophylactic therapy (CPT)counselling. . . only pregnancy 33 At 6 weeks, what temporary FP method is being followed (Copper-T At 6 weeks visit, enquirefamily fromto the motherLinkages l or OCP) in addition to condoms (dualOIs. protection)other and TB for Screening asl to whether she has hadvices. ser a Copper-Tplanning inserted or is taking Oral Contraceptive pills STIs. for treatment and Screening l condoms. ree F l in addition to her spouse or she using a testing. CD4 and staging clinical WHO condoml as(dual protection)change Behaviour l communication communication 34 and Name of Infantth-planning bir , y deliver safe living, positive on Counselling Writel the name of the baby. (BCC) for high risk risk high for (BCC) options. feeding infant 35 ICTC ID of infant Write the ID given to infanther byand the ICTC.women 36 and Unique DNAspouse of infant testing code HIV and counselling sex safe and Couple Writel the unique DNA infant code. tner for par all babies registering for DNA PCR testing . children living other HIV epeat R l 37 DNA PCR: (1) DBS tests: The DNA PCR DBS test when done at . Center T AR to eferral R l testing, a) At 6 weeks: Positive/Negative 6 weeks is negative; repeat it again atconsidering 6 count count b) AtCD4 6months:on Positive/Negativebased regimen prophylactic ARV or T AR rovide P months.l If negative again, it should be c) At 6 weeks after stopping breast-feeds: Positive/Negativestaging. clinical and/or repeated 6 weeks afterif breastfeedsperiod , haswindow been stopped. positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or 38 DNAPCR: a) WB specimen collection date (dd/mm/yy)programmes. for Nutrition Write the date (dd/mm/yy) when whole WBS tests DBS test 37a or 37b or 37c Blood Specimen of infant . is collected.behaviour risk . mother for prophylaxis ARV tum ostpar P l b) WB Specimen Result for DBS test 38 (38a or Write the result of theand Whole Bloodfeeding Infant l 38b )-Positive or Negativevices. Ser Planning amily F Specimenl of the infant. In case there isnutrition a c) Result of 2nd WBS(in case of DBS & 1st WBS visits. home through t suppor feeding reinforcement/Infant EBF discrepancyl in DBS and first WBS, writecounselling. the discordance)Positive or Negative result of 1st and 2nd WBS in columns 38c home d) counselling, If infant is negativefollow-up withthrough t 2nd WBS,suppor Date-social of sycho P & l 38c Referral back to ICTC groups. t suppor and visits If infant is negative, write the date (dd/mm/yy) of referral back of infant to ICTC. 39 HIV +ve Registration Date (dd/mm/yy) and Pre ART Number If infant is positive, write the Pre ART infant registration number allotted to infant. HIV Exposed Infant (HEI) Infant Exposed HIV 40 Baseline CD4 count or CD4 % Write the baseline CD4 count or CD4 % of O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l the infant. ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and 41 Date of Initiation of Paed. ART (dd/mm/yy) Write the date (dd/mm/yy) of registration of . . T AR aediatric P receive o wh babies positive EID for years infant2 atupto ARTand Centre.babies negative EID 42 Date (dd/mm/yy) & result of Antibody Testsweeks. 6 (Rapid)for infant Writefor the date (dd/m/yy)prophylaxis ARV of antibodytum ostpar (Rapid)P l conducted at 18 months - Confirmed negative or tests conducted for the infant at the age of weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l Confirmed positive 18 months for confirmation. Write the result whetherbreastfeeds. of the babycessation ister af age. of weeks 6 confirmedfrom as HIV prophylaxis positive or negative-trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 85 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme Tool 1: Definition of Different Variables in PPTCT Beneficiary Line List

Sl. No. Variable Description Offer of HIV Counselling and Testing Services to all Pregnant Women 43 Date of stopping CPT dd/mm/yy Write the date when CPT for infant has been stopped. It is advised that CPT be continued for 18 months in children even if the EID results are negative at 6 weeks or 6 months or after 6 weeks of stopping HIV Negative HIV Infected Pregnant Women breastfeeds, as it reduces infant mortality due to inter- Pregnant Women l Antenatal Carecurrent (ensure infections, at-least like 4 diarrhoeavisits)–Monthly and ART/ARV l Safe sex prophylaxis atrespiratory ART Centers. infections or other OIs. counselling. 44 ART** a) Alive & On Treatmentl Counselling onTick choices this cell of if continuation the client is alive or medicaland on ART termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling.Outcome b) Date and reason (code) for **Put the appropriate Code in this Cell with date (Mother) ART discontinuationpregnancy only. A – Death, l Linkages to family planning services. l Screening for TBB and – Stopped other OIs.on Medical advice, C – Transfer-out, l Free condoms. l Screening and treatment for STIs. D – Lost-to-follow-up (LFU) l Behaviour change l WHO clinical staging and CD4 testing. E – opted out of the programme communication l Counselling on positive living, safe delivery, birth-planning and 45 (BCC)Antiretroviral for high riska) Alive & On Treatment Tick this cell if the client is alive and on ART infant feeding options. womentreatment and her a) Date and reason for ART/ ARVs **Put the appropriate Code in this Cell with date l Couple and safe sex counselling and HIV testing of spouse and parOutcometner. discontinuation A – Death l Repeat(Child)** HIV other living childrenB – Stopped. on Medical advice testing, l Referral to ART CenterC – Transfer-out,. considering l Provide ART or ARVD – Lost-to-follow-up prophylactic regimen(LFU) based on CD4 count window, period if and/or clinical staging.E – Opted out of the programme on her own spouse is positive 46 or s/he have highWhether immunizationl Nutrition counselling(a) Write “Yes” and if all linkagesprimary immunization to Government/other has been risk behaviour. completed: Nutrition programmes.completed or “No” if any immunization, including (a) Primary immunization, measles and Vitamin A have not been received (the baby l Infant feeding and l Postpartum ARV prophylaxis for mother. including measles and should be sent for completion of immunization schedule nutrition l Family Planning Services. Vitamin A (Y/N) within a week) counselling. l EBF reinforcement/Infant feeding support through home visits. (b) Whether 1st booster dose at Write “Yes” if DPT/ OPV have been received at 18 months or l Psycho-social support through follow-up counselling, home 18 months received “No” if baby has not yet received (ensure baby receives the (Yes/No) visits and supporsamet groups. within a week) 47 Remarks*** This column is common for both ICTC and ART centres ***Relevant information to be captured, eg: HIV Exposed Infant (HEI) 1. Client’s current location with date l Exclusive breastfeeds upto 6 months (preferred2. Option-IInformation WHO/NAC of authorizedO Guidelines attendant to 2010-'11)whom ART can and continued breastfeeds in addition to complementbe dispensed(from feeds after 6 monthsmonths of upto two 1 yearmonths for post delivery)(refer letter of ADG, CST, NACO, dated 28 EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. August 2012) l Postpartum ARV prophylaxis for infant for 6 weeks. 3. Any other important information related to client or her l Early infant diagnosis (EID) at 6 weeks of age; repeatbaby testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 86 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

15.4 Tool 2: Reporting on PPTCT and EIDProgramme from PPTCT ARTof CentresComponents 2: Figure

3 a. PPTCT omen W regnant P all to vices Ser esting T and Counselling HIV of Offer 3.1a Cumulative number of Pregnant women ever registered/ reported in HIV care 0 till the end of this month (Out of 2.5) 3.2a Cumulative number of pregnant women ever initiated on ART till the end of 0 this month (out of 3.1a) 3.3a Cumulative number of pregnant women initiatedomen W on PPTCTregnant P ARV prophylaxisInfected HIV Negative HIV from 1st Sept 2012T/ARV AR till the end of Decembervisits)–Monthly 4 2013at-least (Out of 3.1(ensure a)(applicableCare forAntenatal AP,l omen W regnant 0P Karnataka, Tamil Nadu) Centers. T AR at prophylaxis sex Safe l 3.4a Total number of pregnant women ever initiated on ART/ ARV prophylaxis 0 0 counselling. 0 (3.2a+3.3a) of (applicabletermination for AP,medical or Karnataka, Tamilcontinuation of Nadu) choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy 3.5a Number of pregnant women currently on ART counselling. 0 . . only pregnancy 3.5a.1 Number of women currently on PPTCT ARV prophylaxis (dynamic figure, family to Linkages l as and when pregnancy/ lactation completed andOIs. ARVother prophylaxisand TB for stopped reduceScreening l vices. vices. ser planning 0 from this section9 (applicable for AP, Karnataka, Tamil Nadu for breast feeding STIs. for treatment and Screening l condoms. ree F l mothers: max period applicable is Dec 2014) testing. CD4 and staging clinical WHO l change Behaviour l EID and th-planning bir , y deliver safe living, positive on Counselling l communication 3.6a Cumulative number of children registered at ART centre with DBS reactive for risk high for (BCC) options. feeding infant 0 DNA/PCR her and women 3.7a Out and of 3.6a spouse cumulative of testing numberHIV ofand children whocounselling underwentsex safe WBSand testingCouple atl . tner par 0 the ART centre . children living other HIV epeat R l 3.8a Out of 3.7a cumulative number of children who are WBS reactive for DNA/ . Center T AR to eferral R l testing, 0 PCR considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l 3.9a Out of 3.8a cumulative number of children initiated on ART 0 staging. staging. clinical and/or if period , window 3.10a Out of 3.9a cumulative number of children initiated on LPV/r based regimen positive is spouse 0 Government/other Government/other to linkages and counselling Nutrition l 3.11a Out of 3.8a cumulative number of children found HIV+ve by 3 antibody tests high have s/he or programmes. Nutrition 0 at 18 months of age . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l ART Centres Reporting vices. Ser Planning amily F l nutrition visits. home through t suppor feeding reinforcement/Infant EBF l counselling. (Section 3a of CMIS – PPTCT) home counselling, follow-up through t suppor -social sycho P l (Refer to the remarks column of the HIV columngroups. t 6 and suppor 23 ofand “Previsits ART’ register, column no. 16 of ART enrolment register, any separate register maintained for pregnant women, if required from individual white card or from the PPTCT line-list) 3.1a Cumulative number of Pregnant women ever registered/ reported in HIV care(HEI) tillInfant the end Exposed of thisHIV O Guidelines 2010-'11) month (Out2010-'11) of 2.5) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and Number of HIV positive pregnant women ever registered at your ART centre since the beginning. These can . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID be new registrations or those already registered at the ART centre and then later on become pregnant. weeks. 6 for infant for prophylaxis ARV tum ostpar P l Generation of this figure will be a onetime exercise and can be done from column no. 16 and 23 of weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l the HIV Care register, column no. 16 of ART enrolment register, any separate breastfeeds. registerof maintainedcessation ter af for

pregnant women or if required from individual white cards.age. of Onceweeks 6 this from is firmed up,prophylaxis new registrations-trimoxazole Co l to

be added to this figureEID. every through month,positive fromHIV as next monthdiagnosed onwards.children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 87 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

3.2a Cumulative number of pregnantFigure women2: Components ever initiated of PPTCT on Programme ART till the end of this month (out of 3.1a) Total no. of pregnantOffer of women HIV Counselling ever initiated and on ART Testing (who Serare viceseligible to for all ART Pregnant, for their W ownomen health) at this centre from the beginning of this centre. 3.3a Cumulative number of pregnant women initiated on PPTCT ARV prophylaxis from 1st Sept 2012 till the end of December 2013 (Out of 3.1 a) (Applicable for AP, Karnataka and Tamil Nadu) HIV Negative HIV Infected Pregnant Women

TotalP regnantno of pregnant Women women initiatedl onAntenatal PPTCT ARV Care prophylaxis (ensure at-least treatment 4 visits)–Monthly for PPTCT (not AR T/ARVfor their own health)l Safe from sex 1st Sept 2012 onwards. prophylaxisThis only includes at ART thoseCenters. women who have been given triple drug ARV prophylaxiscounselling. for PPTCT. Applicable only for AP; Karnataka & Tamil Nadu States which rolled out l Counselling on choices of continuation or medical termination of l Couple triple drug ARV Prophylaxis. (This doespregnancy not include (MTP)–to sd NVP underprophylaxistake within). the first 3 months of counselling. 3.4a Total number of pregnant womenpregnancy ever initiated only .on ART/ ARV prophylaxis (AP, Karnataka and TN) l Linkages to family planning(3.2a+3.3a services.) l Screening for TB and other OIs. Totall noFree of womencondoms. ever initiated on ART/l Screening ARV prophylaxis, and treatment sum of for 3.2a STIs. and 3.3a l Behaviour change l WHO clinical staging and CD4 testing. 3.5a Number of pregnant women currently on ART communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk Total no.of pregnant women currently oninfant ART feeding at this options.centre. Remember to reduce the numbers as and when pregnancywomen and is hercompleted and then this particular women becomes like other women on ART (non partner. l Couple and safe sex counselling and HIV testing of spouse and pregnant) already being reflected in column no.3.10 of monthly ART centre report. l Repeat HIV other living children. 3.5a.1testing, Numb er of women currentlyl onR eferralPPTCT to ARV ART prophylaxisCenter. (dynamic figure, as and when considering pregnancy/ lactation completel dP rovideand ARV AR prophylaxisT or ARV prophylactic stopped reduce regimen from based this section)on CD4 count window, period if and/or clinical staging. Total no.spouse of pregnant is positive women currently on PPTCT ARV prophylaxis at this centre. Remember to reduce the numbersor s/heas and have when high pregnancy/lactation l Nutrition completed counselling and ARV andprophylaxis linkages has tobeen Government/other stopped. risk behaviour. Nutrition programmes. EIDl Infant feeding and l Postpartum ARV prophylaxis for mother. (Refer nutritionto EID register and for 3.10a landFamily 3.10b, Planning patient Ser whitevices. card) counselling. l EBF reinforcement/Infant feeding support through home visits. 3.6a Cumulative number of children registered at ART centre with DBS reactive for DNA /PCR l Psycho-social support through follow-up counselling, home Cumulative no. of children entered in thevisits EID and register support groups. 3.7a Out of 3.6a cumulative number of children who underwent WBS testing at the ART centre Out of the total children detected DBS positive, cumulative no. of children who have undergone Whole BloodHIV Specimen Exposed (WBS) Infant testing(HEI) (column no. 10 of EID register) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 3.8a Out of 3.7a cumulative number of children who are WBS reactive for DNA /PCR and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for Out of theEID totalnegative children babies who and underwent upto 2 years WBS for testing, EID positive cumulative babies no. wh ofo children receive whoPaediatric have hadART .positive results (column no. 11 of EID register) l Postpartum ARV prophylaxis for infant for 6 weeks.

3.9al EarlyOut of infant 3.8a diagnosis cumulative (EID) number at 6 weeks of children of age; initiated repeat testingon Paedtric at 6 months, ART 12 months & 6 weeks after cessation of breastfeeds. Out of the total children who had positive WBS results (column no. 11 of EID register) how many were l Co-trimoxazole prophylaxis from 6 weeks of age. initiated on Paediatric ART (column no. 16 of EID register) l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 88 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

3.10a Out of 3.9a cumulative number ofProgramme childrenPPTCT of initiated onComponents 2: LPV/r Figure based regimen due to previous exposure to sd NVP.

Out of the total childrenomen W who initiatedregnant P all onto Paedvices ARTSer underesting T the EIDand programme,Counselling cumulativeHIV of no.Offer of children who have been started on LPV/r based regimen due to previous exposure to sd NVP

3.11a Out of 3.8a cumulative number of children found HIV+ve by antibody tests at 18 months of age: omen W regnant P Infected HIV Negative HIV Of all the patients with WBS positive, how many children had HIV +ve status at 18th month of age. T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P 3.12 a. Out of the total no. of live births 18 monthsCenters. T ago,AR at no. of childrenprophylaxis reported to be living: sex Safe l counselling. of of termination medical or continuation of choices on Counselling l b. No. of children born to HIV positive pregnant women born 18 months ago, reported to be dead Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. c. No. of children born to HIV positive pregnant women . only born 18 monthspregnancy ago tested for confirmation of status family family to Linkages l at 18 months: OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l 15.5 SIMS Monthly Progress Reporttesting. forCD4 PPTCTand staging clinical WHO l change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication Monthly Input Formats for Integrated Counselling and Testing Centres (ICTC) risk high for (BCC) options. feeding infant NRHM-NACO Convergence Action Section D: Progress during the month (only for Pregnant Women ) her and women and spouse of testing HIV and counselling sex safe and Couple l i. Pregnancy, delivery and breastfeeding . tner par S. No. Indicators . children living other During ANC Directly-in-labour HIV epeat R Totall testing, testing, . Center T AR to Duringeferral R l this Month During this Month considering considering count 1 count NumberCD4 on of New based ANC Registrationsregimen prophylactic ARV or T AR rovide P l 0 staging. staging. clinical and/or if period , window 2 Number of pregnant women provided with pre-test positive is spouse 0 Government/other counselling outGovernment/other of to all registeredlinkages and counselling Nutrition l high have s/he or 3 Number of pregnant women tested for HIV programmes. Nutrition . behaviour risk 0 4 Total number Among. thosemother detectedfor infected,prophylaxis numberARV intum ostpar P l and feeding Infant l of pregnant first trimester vices. Ser Planning amily F l nutrition women Among those detected infected, number in visits. home through t suppor feeding reinforcement/Infant EBF l counselling. detected HIV second trimester Infectedhome counselling, follow-up through t suppor -social sycho P l Among those detected infected, number in third trimester groups. t suppor and visits 5 Number of pregnant women who received post-test 0 counselling and given test results 6 Number of pregnant women referred by the F- ICTC (HEI) Infant Exposed 0HIV Govt(Fixed/Mobile) after HIV screening test O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l 6.1 Out of the above, Number of pregnant women diagnosed HIV 0 ter 6 months upto 1 year for for infected year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and 7 . T NumberAR of pregnantaediatric P womenreceive o referredwh by thebabies PPP ICTCpositive (Fixed/EID for years 2 upto and babies negative EID 0 Mobile) after HIV screening test weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks 7.1 weeks Out6 & of the abovemonths 12 Number ofmonths, pregnant6 at womentesting diagnosedrepeat age; HIVof weeks 6 at (EID) diagnosis infant Early 0l infected breastfeeds. of cessation ter af 8 Number of pregnant women referred by the PHC/Sub Centre/ 0 age. of weeks 6 from prophylaxis -trimoxazole Co l ANM after HIV screening test EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 89 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

8.1 Out of the above, Number of Figurepregnant 2: womenComponents diagnosed of PPTCT HIV Programme 0 infected 9.a. NumberOffer of spouses/partners of HIV Counselling of HIV infected and pregnantTesting women Services to all Pregnant Women 0 tested 9.b. Number of spouses/partners of HIV infected pregnant women 0 found HIV infected 10 Number of HIV infected pregnant women who underwent 0 HIV NegativeMTP during the month HIV Infected Pregnant Women 11PregnantNumber Women of HIV infected pregnantl womenAntenatal expected Care to (ensuredeliver at-least 4 visits)–Monthly ART/ARV 0 l Safeduring sex this month prophylaxis at ART Centers. counselling. Monthly Input Formats for Integrated Counsellingl Counselling and Testing onCentres choices (ICTC) of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of NRHM-NACOcounselling. Convergence Action Section D: Progress during the month (only for Pregnant Women ) pregnancy only. i. Pregnancy,l Linkages delivery to andfamily breastfeeding S. No.planning services. Indicatorsl Screening for TB and other OIs. During ANC Directly-in Total l Free condoms. l Screening and treatment for STIs. -labor l Behaviour change l WHO clinical staging and CD4 testing.During this During this Month Month communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk 12 Total number a. In same Facilityinfant feeding options. 0 of HIV infected women and her b. In other Govt hospitals 0 pardeliveriestner. this l Couple and safe sex counselling and HIV testing of spouse and month: c. Pvt Hospitasl/ any other facilities 0 l Repeat HIV other living children. d. Home Deliveries 0 testing, l Referral to ART Center. 13.a.consideringTotal number of normal (vaginal) deliveries of HIV infected pregnant women 0 l Provide ART or ARV prophylactic regimen based on CD4 count during this month window, period if and/or clinical staging. 13.b.spouseTotal isnumber positive of deliveries by Caesarean section of HIV infected pregnant 0 or s/hewomen have during high this month l Nutrition counselling and linkages to Government/other Nutrition programmes. 14 riskOutcome behaviour of HIV. a. Number live male child 0 l Postpartum ARV prophylaxis for mother. l Infantinfected feeding deliveries and b. Number live female child 0 this month nutrition l Family Planning Services. c. Still births 0 counselling. d. Deaths l EBF reinforcement/Infant feeding support through home visits.0 15 Total number of mother-baby pairsl Pwhosycho received-social Nevirapine suppor t(single through dose) follow-up counselling, home 0 (whenever new guidelines not rolledvisits out) and support groups. 16 Number of HIV infected pregnant women (only) received Nevirapine (single 0 dose) during the month (whenever new guidelines not rolled out)

17HIV ExposedNumber of Infant babies(only) (HEI) of HIV infected mothers received Sy. Nevirapine x 0 6 weeks during month l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 22 Number of HIV infected pregnant mother opting for exclusive breast feeding 0 andfor continued first 6 months breastfeeds in addition to complement feeds after 6 months upto 1 year for 23 EIDNumber negative of HIV babies infected and pregnant upto 2mother years opting for EID for exclusivepositive Replacement babies wh o receive Paediatric ART. 0 l Postparfeedingtum for firstARV 6prophylaxis months for infant for 6 weeks.

24l EarlyNumber infant HIV diagnosis infected pregnant (EID) at women 6 weeks registered of age; at ARTrepeat centre testing at 6 months, 12 months & 6 weeks0 25 afterNumber cessation of HIV of infected breastfeeds. pregnant women whose CD4 count is < 350 0

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 90 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Monthly Input Formats for Integrated Counselling and Testing Centres (ICTC) ii. Age-wise distribution omen W regnant P all to vices Ser esting T and Counselling HIV of Offer Agewise Distribution Number of pregnant Number of pregnant women women tested for HIV detected infected

1. 15-19 years 2. 20-24 years omen W regnant P Infected HIV Negative HIV 3. 25-34 years T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Centers. T AR at prophylaxis sex Safe l 4. >35 Years counselling. of of termination medical or continuation of choices on Counselling l Total Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. iii. Follow -up . only pregnancy family family to Linkages l Description OIs. other and TB for Screening Thisl month vices. ser planning A. Visit for DBS and WBS Test STIs. for Firsttreatment Visitand Screening l Second Visit Thirdcondoms. ree VisitF l l change Behaviour l testing. CD4 6 and weeks – staging 6 monthsclinical – WHO 6 months – 12 months 12 months – and th-planning bir , y deliver safe living, 6 monthspositive on 18 months Counselling 12l months – 18 months 18 monthscommunication (BCC) for high risk risk high for (BCC) options. feeding infant 1. Number of infants/children visited her and women 2. Numberand of infants/childrenspouse of testing testedHIV and for HIV counselling sex safe and Couple l . tner par using DBS-DNA PCR/Antibody test . children living other HIV epeat R l 3. No of infants/children who were found . Center T AR to eferral R l testing, positive considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l , period if if period , window 4. Number of infants on exclusive breast staging. clinical and/or feeding (EBF) positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or 5. Number of infants on exclusive replacement programmes. Nutrition . behaviour risk feeding (ERF) . mother for prophylaxis ARV tum ostpar P l and feeding Infant l 6. Number of infants on CPT –initiated at 6 vices. Ser Planning amily F l nutrition weeks and continuing visits. home through t suppor feeding reinforcement/Infant EBF l counselling. 7. No. of infants registered at ART centre home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits C. Details at 18 months:

1. Number of infants who came for follow- up at 18 months (HEI) Infant Exposed HIV 2. Number of infants2010-'11) who wereGuidelines testedO (using WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l 3 antibody for year tests) 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and 3. Number . T ofAR infants HIVaediatric P infected receive o wh babies positive EID for years 2 upto and babies negative EID 4. No. of infants registered at ART centre weeks. 6 for infant for prophylaxis ARV tum ostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 91 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

iv. Outreach Linkages for HIV Positive PregnantFigure 2: Women Components of PPTCT Programme Number (By Out Reach Worker) 1. Number of Offeroutreach of workers HIV Counselling(ORWs) (IL &FS)/ and ANMs/ Testing Services to all Pregnant Women ASHAs/DLNs 2. Number of HIV infected pregnant women visited at home by the outreach worker during the month (specify who visited) 3. HIVNumber Negative of HIV infected pregnant womenHIV who Infected were Pregnant Women Pexpectedregnant to W deliveromen this month, visited lby theAntenatal outreach Care (ensure at-least 4 visits)–Monthly ART/ARV worker (specify) l Safe sex prophylaxis at ART Centers. 4. Numbercounselling. of HIV infected women visited post delivery by ORWs/ANMs/ASHAs/DLNs l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of i. Beforecounselling. 6 weeks pregnancy only. ii. 6l weeksLinkages to 6 months to family l Screening for TB and other OIs. iii. 6 monthsplanning to 12 ser monthsvices. l Screening and treatment for STIs. iv. 12l monthsFree condoms. to 18 months l Behaviour change l WHO clinical staging and CD4 testing. v. 18 months until the time baby is breastfed communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. women and her partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. testing, l Referral to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 92 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

1414

Roles and Responsibilities of Staff at Different Levels Roles and Responsibilities of programmeFigure 2: managersComponents and of PPTCT staff inProgramme PPTCT services is shown in (Table:11)

PPTCT program is to be implemented through the ICTC and ART centres and also needs to be an integrated responseOffer ofwith HIV general Counselling health system.and Testing Following Services table todetails all P regnantterms of Wreferenceomen of staff at different level regarding their roles and responsibilities in implementation of PPTCT programme: Table 11: Roles and Responsibilities of Programme Managers and Staff in PPTCT Programme

Sl.HIV No. NegativeDesignation of Official/staff HIV Infected PregnantRole W omenin PPTCT Implementation Pregnant Women l 1.Antenatal Facilitate Caredevelopment (ensure of at-leaststate micro-plan 4 visits)–Monthly for implementation ART/ARV of PPTCT l Safe sex prophylaxisprogramme at ART Centers. counselling. 2. Facilitate establishment of Joint State PPTCT programme implementation l Counsellingcommittee on choices of continuation or medical termination of l Couple 3.pregnancy Facilitate regular (MTP)–to meetings under of thetak implementatione within the committee first 3 monthsfor of counselling. pregnancyprogramme only review. and policy decisions l Linkages to family 4. Advocacy with Principal Secretary, Health & Family Welfare and MD- planning services. l ScreeningNRHM to forensure TB andownership other of OIs. PPTCT programme by Director, Health & Family Welfare Services, state RCH officer l Screening and treatment for STIs. l Free condoms. 5. Facilitate formation of the Joint District PPTCT implementation committee l Project Director State AIDS l and Case Management Team in all districts of the state 1 Behaviour change WHO clinical staging and CD4 testing. Control Society (SACS) 6. Facilitate measures to ensure ownership of the programme at district level communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk by District Health & Family Welfare Officer, CMHO, Civil Surgeon, District infantRCH feedingofficer etc. options. women and her 7. Advocacy with Secretary Medical Education to ensure adherence to partner. l CoupleNational and programme safe sex guidelinescounselling so as and to minimizeHIV testing linkage of spouse loss in medical and college hospitals l Repeat HIV other living children. 8. Facilitate joint review meetings of NACP-NRHM and Medical Education testing, l Referralprogramme to AR managersT Center at. regular intervals considering 9. Facilitate involvement of professional organizations like FOGSI, IAP, IMA l Provide ART or ARV prophylactic regimen based on CD4 count to ensure systematic involvement of private sector window, period if and/or clinical staging. spouse is positive 10. Overall leadership of programme with regular monitoring of progress or s/he have high l 1.Nutrition Ensure close counselling coordination betweenand linkages the Basic Servicesto Government/other division and Care risk behaviour. Nutritionand Support programmes. & Treatment division at state and district level 2. Establish close liaison with State RCH officers and other key stakeholders l Postpartum ARV prophylaxis for mother. l Infant feeding and in NRHM nutrition l 3.F amilyEstablish Planning close liaison Services. with state level office bearers of professional counselling. organizations like FOGSI for systematic involvement of private nursing l EBFhomes reinforcement/Infant feeding support through home visits. l 4.P sychoFacilitate-social formation suppor of thet through Joint District follow-up PPTCT counselling, implementation home committee and Case Management Team in all districts of the state 5.visits Ensure and regular suppor meetingt groups. of Joint District PPTCT implementation committee through supportive supervision and monitoring 6. Establish mechanisms for monitoring progress in linking up of HIV Nodal Officer for PPTCT in 2 infected pregnant women to PPTCT services e.g. use of google doc. for the SACS HIV Exposed Infant (HEI) tracking and monitoring at state level 7. Establish Stand-alone ICTCs at all CHC level health facilities l Exclusive breastfeeds upto 6 months8. Ensure (preferred availability Option-I of HIV screening WHO/NAC facilitiesO Guidelines at all high deliver 2010-'11)y points and continued breastfeeds in additionbelow to CHCs complement in the form feedsof F-ICTCs after and 6 sub-centremonths upto level screening1 year for using WBFPT EID negative babies and upto 29. years Ensure for availability EID positive of PPTCT babies services who at receive all high deliveryPaediatric points AR T. l Postpartum ARV prophylaxis for10. infant Ensure for mechanisms6 weeks. for quick linkage of screened positive pregnant women to SA-ICTCs for confirmation, to ART Centre for life-long ART and l Early infant diagnosis (EID) at 6 weeksEID services of age; for repeat HIV exposed testing babies at 6 months, 12 months & 6 weeks after cessation of breastfeeds. 11. Monitoring of compliance of infected pregnant women with PPTCT guidelines through regular follow-up visits of NACP outreach workers and l Co-trimoxazole prophylaxis from 6 weeksother health of age. system human resources l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 94 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Sl. No. Designation of Official/staff Role in PPTCT Implementation 1. Facilitate ownership of the PPTCT programme by the District Health & omen W regnant P all to Famil;yvices WelfareSer Officersesting T and (CMHO, Civil surgeon)Counselling HIV of Offer 2. Facilitate ownership of PPTCT activities by PHC medical officers and the field staff 3. Facilitate provision of support for confirmation of HIV status of pregnant women, travel to ART centre for enrolment and drug collection along with facilities for institutional delivery 4. Facilitateomen W establishmentregnant P of Infected HIV screeningHIV facilities at all high deliveryNegative HIV 3 State RCH Officer points in the form of F-ICTCs and sub-centre level screening using WBFPT T/ARV AR visits)–Monthly 4 5. Ensureat-least availability(ensure Care of PPTCT Antenatal servicesl at all high delivery pointsomen W regnant P 6. FacilitateCenters. T regularAR at meeting of theprophylaxis Joint District PPTCT implementation sex Safe l committee counselling. of of termination medical or 7. continuation Facilitateof involvementchoices on of PHCCounselling medicall officers and concerned ANM and Couple Couple l of of months 3 first the within e tak otherunder health system(MTP)–to functionariespregnancy in the Case Management Team 8. Ensure involvement of medical officers at PHCs and ANMs in monitoringcounselling. of linkages . to ICTCs,only ART centrespregnancy and compliance of HIV infected family family to Linkages l pregnant women to PPTCT regimen OIs. other and TB for Screening l vices. ser planning 1. Ensure formation of the Joint District PPTCT implementation committee STIs. for treatment and Screening l and Case Management Team in all districts of the state condoms. ree F l testing. 2. CD4 Ensureand regularstaging meetingclinical of JointWHO Districtl PPTCT implementationchange committeeBehaviour l 3. Establish Stand-alone ICTC at all CHC level health facilities communication and th-planning bir , y deliver safe 4. Ensureliving, availabilitypositive on of HIV screeningCounselling l facilities at all high delivery points (BCC) for high risk risk high for (BCC) below CHCsoptions. in the formfeeding of F-ICTCsinfant and sub-centre level screening using WBFPT her and women and spouse of testing HIV and 5. Ensurecounselling availabilitysex safe ofand PPTCT Couple servicesl at all high delivery points. tner par 6. Ensure mechanisms for quick linkage of screened positive pregnant women. to SA-ICTCchildren forliving confirmation,other to ART Centre for initiationHIV ofepeat lifeR l -long. ART Center andT EIDAR to serviceseferral forR HIVl exposed babies testing, 7. Monitoring of compliance of infected pregnant women with PPTCT District HIV programme considering count 4 count CD4 on based regimen guidelinesprophylactic ARV throughor T AR regular follow-uprovide P l visits of NACP outreach workers and Manager – DAPCU / DNO other healthstaging. system clinical human resourcesand/or if period , window 8. Training load assessment positive is spouse Government/other Government/other to linkages 9. and Establish close counselling liaison with DistrictNutrition l Health & Family Welfarehigh have Officerss/he or (CMHO/ Dy. CMHOs/programmes. RCH Officers)Nutrition 10. Overall planning and implementation of programme . at the districtbehaviour levelrisk . mother for 11. Ensure upprophylaxis –to-ARV datetum recordingostpar P atl all facilities and timelyand reportingfeeding to Infant statel level vices. Ser Planning amily F l nutrition 12. Supervisory visit to ART centres, ICTCs and other HIV screening centres visits. home through t suppor 13.feeding Close liaison with professionalreinforcement/Infant EBF associationl like FOGSI, IAP, IMA to counselling. facilitate involvement of private nursing homes & institutions home counselling, follow-up 14. Advocacy,through t Communicationsuppor -social sycho andP sociall mobilization activities for effective implementationgroups. t ofsuppor PPTCTand servicesvisits 1. Advocacy with District Health & Family Welfare Officers (CMHOs Civil surgeons) for ownership of PPTCT programme 2. Ensure ownership of PPTCT activities by PHC medical officers and the field staff 3. Ensure provision of support for confirmation of(HEI) HIV statusInfant of pregnantExposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC women, travelOption-I to ART (preferred centre for months enrolment 6 upto and drug collectionbreastfeeds alongExclusive withl facilities for institutional delivery ter 6 months upto 1 year for for year 1 upto months 6 ter af 4. Facilitatefeeds establishmentcomplement to of HIV screeningaddition in facilitiesbreastfeeds at all high deliverycontinued and 5 District RCH Officer . . T AR aediatric P receive o wh pointsbabies in thepositive formEID of F-ICTCfor years and 2 sub-centreupto and level screeningbabies usingnegative WBFPTEID 5. Ensure availability of PPTCT services at all high delivery points 6. Ensure regular meetingweeks. 6 for of Jointinfant Districtfor PPTCT implementationprophylaxis ARV tum committeeostpar P l 7. Ensure involvement of PHC medical officer, concerned ANM and other weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l health system functionaries in Case Management Team so as to ensure linkage to screened positive pregnant women tobreastfeeds. ICTCsof for confirmation,cessation ter af to ART centre for enrolment and to monitor compliance with PPTCT age. of weeks 6 from prophylaxis -trimoxazole Co l programme guidelines EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 95 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Sl. No. Designation of Official/staffFigure 2: Components of PPTCTRole inProgramme PPTCT Implementation Monitoring and evaluation 1. Maintenance of consolidated PPTCT line-lists assistant at DAPCU /ICTC 2. Updating PPTCT line-lists with all events, compilation, analysis and 6 Offer of HIV Counselling and Testing Services to all Pregnant Women counsellor at the district interpretation etc. headquarter 3. Timely reporting of PPTCT line-lists to SACS 1. Supervisory visit ART centres, ICTCs and other HIV screening centres (TB and STI) HIV Negative HIV2. InfectedSupportive P supervisionregnant W ofomen ICTC 3. Facilitate co-ordination between ICTC/ART centre staff with general health Pregnant Women l Antenatalstaff (RCH Care / NRHM) (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex 4.prophylaxis Ensure preparedness at ART Centers. for conducting HIV positive deliveries at delivery 7 counselling.District ICTC supervisor points l 5.Counselling Ensure linkage on ofchoices HIV exposed of continuation infants (HEIs) or to medical Early Infant termination diagnosis of l Couple pregnancysites ICTCs (MTP)–towhere DBC isunder beingtak donee within the first 3 months of counselling. 6.pregnancy Ensure follow-up only. visits to HIV infected pregnant women by health staff / l Linkages to family outreach workers/District Level Networks planning services. l 7.Screening Facilitate reportingfor TB and of all other key eventsOIs. to district M and E assistants for updating line-lists l Free condoms. l Screening and treatment for STIs. 1. Measures to ensure 100% screening of all pregnant women enrolled into l Behaviour change l WHO clinical staging and CD4 testing. Ante-Natal Care communication l 2.Counselling Measure to ensureon positive HIV, STI, living, TB screening safe deliver earlyy , birth-planning and (BCC) for high risk 3.infant Ensure feeding uninterrupted options. availability of test-kits, drugs, referral forms and women and her registers partner. l 4.Couple Ensure and prompt safe referral sex counselling and linkage ofand HIV HIV infected testing pregnant of spouse women and to otherART living centres children . l RepeatIn-charge HIV medical officer at 5. Ensure safe institutional deliveries 8 testing,ICTC l 6.R eferralEnsure toprovision ART Center of ARV. prophylaxis for the baby for 6 weeks – Sy.NVP for considering 6 weeks (3 bottles each) 25ml l Provide ART or ARV prophylactic regimen based on CD4 count window, period if 7. Ensure linkage of the baby to EID services 8.and/or Clinical clinical assessment staging. and care of patients while on ART spouse is positive 9. Monitoring adherence to ART or s/he have high l Nutrition counselling and linkages to Government/other 10.Nutrition Ensure home programmes. visits to the infected pregnant women at prescribed risk behaviour. frequency l 11. Ensure timely follow-up visits of infected pregnant women to ART centres l Infant feeding and Postpartum ARV prophylaxis for mother. nutrition l 1.F amilyProvision Planning of preventive Services. health education to all Ante-natal care women and counselling. explain about screening of women for HIV, Syphilis and TB l 2.EBF Ensure reinforcement/Infant coverage of all registered feeding ANCs suppor in the areat through of jurisdiction home visits.with HIV l Psychocounselling-social testing suppor Provisiont through of psychosocial follow-up support counselling, to all infected home women 3. Ensure prompt referral of infected ANCs with ART centres 4.visits Coordination and suppor witht ARTgroups. / LAC Plus / LAC for confirmation of linkages and follow- up Counsellor stand-alone ICTC 5. Track evaluation at ART centre, initiation of ART and referral back for care 9 / F-ICTC 6. Maintaining record of referral, its outcomes, planned place for delivery, HIV Exposed Infant (HEI) planned follow -up dates, person responsible for follow-up etc. 7. Ensure hospital delivery l Exclusive breastfeeds upto 6 months8. Ensure (preferred provision Option-I of ARV to WHO/NACbaby as prescribedO Guidelines 2010-'11) and continued breastfeeds in addition9. Ensure to provisioncomplement of ART feedsto all direct-in- after 6 labourmonths cases upto 1 year for 10. Maintain up- to-date recording of all events and communication of the EID negative babies and upto 2 yearssame for to DistrictEID positive M&E Assistants babies who receive Paediatric ART. l Postpartum ARV prophylaxis for11. infant Ensure for linkage6 weeks. of HIV exposed infants (HEIs) to EID

l Early infant diagnosis (EID) at 61. weeks Nurse of at age; F-ICTCs repeat –all activitiestesting atmentioned 6 months, for counsellors 12 months & 6 weeks 2. Administration of ART (TDF+3TC+EFV) to pregnant women presenting 10 after Nursecessation of breastfeeds. directly- in- labour and initiation of Sy. Nevirapine for 6 weeks to HIV l Co-trimoxazole prophylaxis from 6 weeksexposed of babies age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 96 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Sl. No. Designation of Official/staff Role in PPTCT Implementation 1. Screening test for HIV and Syphilis using WBFPT for all ANCs registered. omen W regnant P all to If reactive,vices Ser refer toesting ART,T STIand and Gene-xpertCounselling testing/DMCHIV of forOffer TB screening 2. Screening the pregnant women for Syphilis using WBFPT, if reactive then refer to STI clinic/PHC for RPR confirmation 3. Screening the pregnant women for TB if symptomatic refer to a health facility where Gene-xpert testing is done or PHC with DMC 4. Ensureomen W confirmationregnant P of HIVInfected statusHIV among screened positive ANCs Negative HIV 11. ANM 5. Establishing linkage of HIV infected pregnant women to ART CENTRE T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P 6. Facilitate institutional deliveries Safe sex sex Safe l 7. Follow-upCenters. T withAR at the mother afterprophylaxis delivery to monitor compliance in ART counselling. of of termination medical or continuation consumptionof choices on Counselling l Couple Couple l of of months 3 first the within e tak 8. Facilitateunder linkages(MTP)–to of HIV exposedpregnancy babies to EID counselling. counselling. 9. Provide reminders . only to mother pregnancy on ART regarding visit to ART centre, CD4 test, etc. family to Linkages l OIs. other and TB for Screening l vices. ser planning 1. Conduct HIV testing as per guidelines and provide feedback to referring STIs. for treatment and Screening l PHC MO regarding status with concurrence of patient condoms. ree F l testing. 2. CD4 Liaisonand with staging F-ICTCs clinical and Sub-centreWHO l screening facility staffchange for early Behaviour l information on screening positive women and track their arrival for and th-planning bir , y deliver safe living, positive on Counselling l communication confirmation collection and dispatch of blood specimenrisk high for for CD4 testing(BCC) options. feeding infant 12 ICTC Lab technician 3. Collection and dispatch of blood specimen for CD4 testingher and women and spouse of testing HIV and 4. Maintainingcounselling sex stocksafe ofand WBFPTCouple for l F-ICTCs and sub-centre screening. tner par facilities 5. Ensure. uninterruptedchildren supplyliving other of test kits to Screening facility HIV in the epeat R l jurisdiction. Center withT AR coldto -chaineferral R maintenancel testing, 6. Record maintenance and timely reporting to district and state level considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l , period if if period , window 1. Mobilize pregnantstaging. womenclinical screenedand/or positive with WBFPT to visit ICTC for spouse is positive positive is spouse confirmation Government/other Government/other to linkages and counselling Nutrition l high have s/he or 2. Facilitate Linkageprogrammes. of HIV infectedNutrition pregnant women to ART centre or STI clinic or Gene-xpert testing site/DMC for TB . behaviour risk Outreach worker (ILFS/ . mother for 3. Facilitateprophylaxis institutionalARV tum deliveryostpar P l and feeding Infant l 13 Link-workers, CSC outreach 4. Facilitate visit of the HIV Exposed Infants(HEIs) to ICTC for EID worker, etc.) vices. Ser Planning amily F l nutrition 5. Facilitate regular follow-up visits to ART centre for ART, CD4 testing counselling. etc. visits. home through t suppor 6. feeding Home visit to monitor adherencereinforcement/Infant EBF l to ART medication home counselling, follow-up 7. Liaisonthrough t withsuppor ANMs/ASHAs/Community-social sycho P l Outreach Workers/DLNs for follow- up withgroups. thet infectedsuppor Pregnantand visits women 1. Ensure safe delivery practices, availability of safe delivery KITs 2. Ensure continuation of ART during labour and delivery 3. Provide ART (TDF+3TC+EFV) for direct- in- labour positive pregnant Medical Officer of facility women and Nevirapine suspension for 6 weeks(HEI) to HIV Infant exposed newExposed bornsHIV 14 O Guidelines 2010-'11) conducting2010-'11) positive deliveryGuidelines O 4. WHO/NAC Ensure confirmationOption-I of(preferred HIV statusmonths 6 of direct-in-upto labour casesbreastfeeds at earliestExclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af 5. Counselfeeds the infectedcomplement to pregnant womenaddition in regarding importancebreastfeeds ofcontinued enrolling and ART centre and receiving life-long ART . . T AR aediatric P receive o wh 6. Counselbabies infectedpositive EID pregnant for womenyears 2 regardingupto and importancebabies of EIDnegative EID weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 97 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Sl. No. Designation of Official/staffFigure 2: Components of PPTCTRole inProgramme PPTCT Implementation 1. Prompt evaluation of HIV infected pregnant women at ART centre Offer of HIV Counselling2. Promptand T initiationesting Serof life-longvices ARTto all(TDF+3TC+EFV) Pregnant W toomen every infected pregnant women regardless of CD4 levels or clinical stage 3. Ensure feedback to referring ICTC regarding receipt of case at ART centre, outcome of evaluation and prescribed drug regimen for the patients 4. Formulation of Case Management Team comprising ICTC counsellor, 15 ART centre SMO/MO concerned ANM, concerned out-reach worker HIV Negative HIV5. InfectedDraw plan P forregnant follow-up W omenvisits including linkage to LAC in consultation Pregnant Women l Antenatalwith the infected Care (ensure pregnant at-least women 4for visits)–Monthly assessment and drug AR T/ARVcollection l Safe sex 6.prophylaxis Ensure uninterrupted at ART Centers. supply of drugs and logistics to LAC-Plus, LAC counselling. 7. Ensure provision of information on all events to the districts M&E assistant l Counsellingfor updating on in PPTCTchoices line-lists of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. 1. Prioritisation of HIV infected pregnant women for ART preparedness and pregnancyadherence onlycounselling. l Linkages to family 2. Counselling on important components of PPTCT programme like role of l Screening for TB and other OIs. planning services. ART, duration, safe hospital delivery, EID, breastfeeding etc. ART centre counsellor/ staff l 3.Screening Up-to-date and record treatment keeping andfor STIs.documentation of follow- up and ensure l16 Free condoms. nurse tracking of missed cases l Behaviour change l WHO clinical staging and CD4 testing. 4. Liaison with referring ICTC counsellor, outreach workers to track communication l Counsellingcompliance onand positive adherence living, to schedule safe deliver of follow-upy, bir visitth-planning to ART centre and (BCC) for high risk 5.infant Liaison feeding with referring options. ICTC counsellor for whole blood specimen testing of women and her DBS positive babies at ART Centres partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. testing, l Referral to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 98 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annexures (1-20) Annex 1: Guidelines forFigure Rollling 2: Components out NACPof PPTCT Programmeand NRHM Convergence Plan in No X-19020/17/2009-NACP (IEC), 10 August 2010 Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. women and her partner. l Couple and safe sex counselling and HIV testing of spouse and l Repeat HIV other living children. testing, l Referral to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other risk behaviour. Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. nutrition l Family Planning Services.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 100 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 1: Guidelines for rolling out NACP Programme and NRHMPPTCT of convergenceComponents 2: planFigure in the states. No. X-19020/17/2009-NACP(IEC), 10 August 2010 omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Centers. T AR at prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. . . only pregnancy family family to Linkages l OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 101 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 102 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure

omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 103 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 104 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure

omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 105 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 106 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure

omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 107 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 108 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure

omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 109 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 110 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 2: Dosing Schedules forProgramme ARTPPTCT of for PregnantComponents 2: Figure Women

Clinical Scenario omen W ARV Prophylaxisregnant P all andto vices Ser Antepartumesting T and IntrapartumCounselling HIV of PostpartumOffer dosing

Pregnant women TDF 300mg once daily Start ART as soon as Continue ART Continue ART life-long requiring ART 3TC 300 mg once daily possible EFV 600mg once daily (first trimester) omen W regnant P Infected HIV Negative HIV omen W regnant P Annex 3: T/ARV ARTAR for Pregnantvisits)–Monthly 4 Womenat-least (ensure PresentingCare Antenatal l in Active Labour with Centers. T AR at prophylaxis sex Safe l No. Prior ART counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy Maternal Status Intrapartum Postpartum counselling. . . only pregnancy family family to Linkages l Presenting in active labour, TDFOIs. 300mgother onceand dailyTB for Screening l TDF 300mg once daily No Prior ARV prophylaxis 3TC 300 mg once daily 3TC 300 vices. mg ser once dailyplanning EFVSTIs. 600mgfor once treatment daily and Screening l EFV 600mg once dailycondoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication Annex 4: Infant NVP Prophylaxis dosing risk high for (BCC) options. feeding infant women and her her and women Birth Weight NVP daily dose (in mg) NVP daily dose (in ml)** Duration and spouse of testing HIV and counselling sex safe and Couple l . tner par Birth to 6 weeks: * . children living other HIV epeat R l testing, testing, Infants with birth weight 2 mg/kg once daily.. Center T AR 0.2to ml/kg eferral onceR l daily Up to 6 weeks irrespective of considering considering < 2000 count gm CD4 on based Inregimen consultation withprophylactic a ARV or T AR rovide P l whether exclusively breastfed pediatrician trained in HIVstaging. clinical and/or or exclusiveif period replacement, window fed. care. positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or Birth weight 2000 – 2500 gm 10 mg once daily 1 ml once a day programmes. Nutrition . behaviour risk Birth weight more than 2500 gm. 15 mgmother for once daily prophylaxis ARV 1.5tum ml onceostpar P a dayl and feeding Infant l * * considering the content of 10 mg Nevirapine in 1ml.vices. suspensionSer basedPlanning onamily F WHOl Guidelines. nutrition * Infants withvisits. birthhome weight

CLINICAL STAGE 1 (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l Asymptomatic Persistent for generalized year 1 lymphadenopathyupto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID CLINICAL STAGE 2 weeks. 6 for infant for prophylaxis ARV tum ostpar P l Moderate unexplaineda weight loss (under 10% presumed or measured body weight)b Recurrent respiratory tract infection weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l (sinusitis, tonsillitis, otitis media, pharyngitis) Herpes zoster Angular cheilitis Recurrent oral ulceration breastfeeds. of cessation ter af age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 111 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme Papular pruitic eruptions Seborrhoeic dermatitis Fungal nail infections

CLINICAL STAGE 3 Offer of HIV Counselling and Testing Services to all Pregnant Women Unexplaineda severe weight loss (over 10% of presumed or measured body weight)b Unexplaineda chronic diarrhoea for longer than one month Unexplaineda persistent fever (intermittent or constant for longer than one month) Persistent oral candidiasis Oral hairy leukoplakia HIV Negative HIV Infected Pregnant Women Pulmonary tuberculosis SeverePregnant bacterial W infectionsomen (e.g. pneumonia,l empyema,Antenatal pyomyositis, Care (ensure bone orat-least joint infection, 4 visits)–Monthly meningitis, bacteraemia) ART/ARV Acute necrotizingl Safe ulcerative sex stomatitis, gingivitis or periodontitisprophylaxis at ART Centers. Unexplainedacounselling. anaemia (below 8 g/dl ), neutropenia (below 0.5 x 100/1) and/or chronic thrombocytopenia l Counselling on choices of continuation or medical termination of l Couple (below 50 x 100 /1) pregnancy (MTP)–to undertake within the first 3 months of counselling. CLINICAL STAGE 4C pregnancy only. l Linkages to family l Screening for TB and other OIs. HIV wastingplanning syndrome services. Pneumocystisl Free condoms. jeroveci pneumonia (PCP) l Screening and treatment for STIs. Recurrentl Behaviour severe bacterial change pneumonia l WHO clinical staging and CD4 testing. Chronic herpes simplex infection (orolabial, genital or anorectal of more than one month’s duration or visceral at any site) communication l Counselling on positive living, safe delivery, birth-planning and Oesophageal(BCC) candidiasis for high risk(or candidiasis of trachea, bronchi or lungs) infant feeding options. Extrapulmonarywomen tuberculosisand her Kaposi parsarcomatner. l Couple and safe sex counselling and HIV testing of spouse and Cytomegalovirusl Repeat HIV infection (retinitis or infection otherof other living organs) children Central. nervous system toxoplasmosis HIV encephalopathy testing, l Referral to ART Center. Extrapulmonaryconsidering cryptococcosis including meningitis Disseminated non-tuberculous mycobacteria infection Progressive l Provide ART or ARV prophylactic regimen based on CD4 count multifocal leukoencephalopthy window, period if and/or clinical staging. Chronicspouse cryptosporidiosis is positive Chronicor isosporiasis s/he have high l Nutrition counselling and linkages to Government/other Disseminatedrisk behaviour mycosis (extrapulmonary. histoplasmosis,Nutrition coccidiomycosis) programmes. Recurrent septicaemia (including non-typhoidal Salmonella) l l Infant feeding and Postpartum ARV prophylaxis for mother. Lymphoma (cerebral or B cell non-Hodgkin) Invasive cervical carcinoma nutrition l Family Planning Services. Atypical disseminated leishmaniasis counselling. l EBF reinforcement/Infant feeding support through home visits. Symptomatic HIV-associated nephropathy or HIV-associated cardiomyopathy l Psycho-social support through follow-up counselling, home a Unexplained refers to where the condition is not explained by other conditions. b Assessment of body weight among pregnant womenvisits and needs suppor to considert groups. the expected weight gain of pregnancy. c Some additional specific conditions can also be included in regional classifications, such as the reactivation of American trypanosomiasis (meningoencephalitis and/or myocarditis) in the WHO Region of the Americas and penicilliosis in Asia. Source: Revised WHO clinical staging and immunological classification of HIV for surveillance. 2006 (in press). HIV Exposed Infant (HEI) l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 112 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 6: Grading of Selected Programme ClinicalPPTCT of and LaboratoryComponents 2: Figure Toxicities (Reference: WHO 2010 Guidelines for ART in Adults and Adolescents)omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

Mild Moderate Severe Potentially life- Grade 1 Grade 2 Grade 3 threatening Grade 4 Estimating severity grade omen W regnant P Infected HIV Negative HIV

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Clinical adverse Symptoms causing no Symptoms causing Symptoms causing Symptoms causing event Not identified or minimal interference greaterCenters. T thanAR minimalat inabilityprophylaxis to perform inability tosex performSafe l elsewhere in the with usual social and interference with usual usual social and basic self–care counselling. or of of termination medical or continuation of choices on Counselling l table functional activities social and functional functional activities medical or operativeCouple l of of months 3 first the within e tak under (MTP)–to pregnancy activities intervention indicatedcounselling. . . only pregnancy to prevent permanent family family to Linkages l impairment, OIs. other and TB for Screening l vices. persistentvices. ser disabilityplanning or STIs. for treatment and Screening l death condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l Haemoglobin 8.0–9.4 g/dl OR 7.0–7.9 g/dl OR 6.5–6.9 g/dl OR < 6.5 g/dl OR and th-planning 80–94bir , y g/l ORdeliver safe living, 70–79 g/lpositive ORon 65–69Counselling l g/l OR < 65 g/l OR communication (BCC) for high risk risk high for (BCC) 4.93–5.83 mmol/l 4.31–4.92options. mmol/l feeding 4.03–4.30infant mm0l/l < 4.03 mmol/l women and her her and women 3 3 3 3 Absolute and neutrophil spouse of 1000–1500/mmtesting HIV and 750–999/mmcounselling sex safe ORand 500–749/mmCouple l OR <500/mm. tner ORpar count or 1.0–1.5/g/I* 0.75–0.99/g/I* 0.5 -0.749/g/I* <0.5/g/I* . children living other HIV epeat R l 3 3 3 3 Platelets 75000-99000/mm 50000–74999/mm. Center T AR to eferral 20000–49999/mmR l <20000/mm ORtesting, OR 75-99/g/I* OR 50–74.9/g/I* OR 20–49.9/g/I* <20/g/I* considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l Chemistries staging. clinical and/or if period , window spouse is positive positive is spouse Hyperbilirubinaemia >1.0–1.5Government/other to x ULN linkages and >1.5–2.5 x ULNcounselling >2.5–5Nutrition l x ULN high >5 x ULNhave s/he or programmes. Nutrition Glucose (fasting) 110–125 mg/dl 126–250 mg/dl 251–500 mg/dl . > 500 mg/dlbehaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l Hypoglycaemia 55–64 mg/dl OR 40–54vices. mg/dlSer OR Planning 30–39amily F l mg/dl OR <30 mg/dl OR nutrition 3.01–3.55 mmol/l 2.19–3.00 mmol/l 1.67–2.18 mmol/l <1.67 mmol/l visits. home through t suppor feeding reinforcement/Infant EBF l counselling. Hyperglycaemia 116–160 mg/dl OR 161–250 mg/dl OR 251–500 mg/dl OR >500 mg/dl OR home counselling, follow-up through t suppor -social sycho P l (nonfasting and no 6.44–8.90 mmol/l 8.91–13.88 mmol/l 13.89–27.76 mmol/l >27.76 mmol/l prior diabetes) groups. t suppor and visits

Triglycerides - 400–750 mg/dl OR 751–1200 mg/dl or >1200 mg/dl or 4.52–8.47 mmol/l 8.48–13.55 mmol/l >13.55 mmol/l

Creatinine >1.0–1.5 x ULN >1.5–3.0 x ULN >3.0-6.0 x ULN (HEI) >6.0Infant X ULNExposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l AST (SGOT) 1.25–2.5 x ULN >2.5–5.0 x ULN >5.0–10.0 x ULN >10.0 x ULN ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and ALT (SGPT) . T AR 1.25–2.5aediatric P x ULNreceive o wh >2.5–5.0babies positive x ULNEID for >5.0-10.0years 2 upto x ULNand babies >10.0 x ULNnegative EID GGT 1.25–2.5 x ULN >2.5–5.0 x ULNweeks. 6 for >5.0–10.0infant for x ULN prophylaxis >10.0ARV tum x ULNostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l Alkaline 1.25–2.5 x ULN >2.5–5.0 x ULN >5.0–10.0 x ULN >10.0 x ULN phosphatase breastfeeds. of cessation ter af age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 113 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Mild Figure 2: ComponentsModerate of PPTCT ProgrammeSevere Potentially life- Grade 1 Grade 2 Grade 3 threatening Grade 4 Chemistries Offer of HIV Counselling and Testing Services to all Pregnant Women Bilirubin 1.1–1.5 x ULN 1.6–2.5 x ULN 2.6–5.0 x ULN > 5 x ULN

Amylase >1.0–1.5 x ULN >1.5–2.0 x ULN >2.0–5.0 x ULN > 5.0 x ULN

PancreaticHIV Negative amylase >1.0–1.5 x ULN HIV Infected>1.5–2.0 Pregnant x ULN Women>2.0–5.0 x ULN > 5.0 x ULN Pregnant Women Lipase >1.0–1.5 x ULN l Antenatal>1.5–2.0 Care x ULN (ensure at-least>2.0–5.0 4 visits)–Monthly x ULN > AR5.0T/ARV x ULN l Safe sex prophylaxis at ART Centers. Lactatecounselling. <2.0 x ULN without >2.0 x ULN without Increased lactate with Increased acidosis l Counsellingacidosis on choices of pHcontinuation <7.3 without or medicallactate termination with pH of l Couple pregnancy (MTP)–to underlife-tak threateninge within the first<7.3 3 withoutmonths of counselling. pregnancy only. consequences life- threatening l Linkages to family consequences planning services. l Screening for TB and other OIs. Gastrointestinal l Free condoms. l Screening and treatment for STIs. Nauseal Behaviour changeMild OR transient; l WHOModerate clinical discomfort staging and SevereCD4 testing. discomfort OR Hospitalisation reasonable intake OR intake decreased minimal intake for³ 3 required communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for highmaintained risk for <3 days days infant feeding options. Vomitingwomen and herMild OR transient; 2-3 Moderate OR Severe vomiting of Hypotensive shock partner. episodes per day ORl Couplepersistent; and safe sex counsellingall foods/fluids and HIV in testing24 OR of spousehospitalisation and l Repeat HIV mild vomiting <1 weekother4-5 living episodes children per day. hours OR orthostatic for intravenous testing, OR hypotension OR treatment required l Referralvomiting to AR lastingT Center ³1 . intravenous treatment considering l Provideweek ART or ARV prophylacticrequired regimen based on CD4 count window, period if and/or clinical staging. spouse is positiveMild OR transient; Moderate OR Bloody diarrhoea OR Hypotensive shock Diarrhoeaor s/he have high3-4 loose stools perl Nutritionpersistent; counselling andorthostatic linkages hypotension to Government/otherOR day OR mild diarrhoea Nutrition5-7 loose programmes. stools per OR ³ 7 loose stools/ hospitalisation risk behaviour.lasting<1 week day OR diarrhoea day OR intravenous Rx required l Infant feeding and l Postparlastingtum ³1 ARVweek prophylaxisrequired for mother. nutrition l Family Planning Services. Respiratory counselling. l EBF reinforcement/Infant feeding support through home visits. Dyspnoea Dyspnoea on exertion Dyspnoea with normal Dyspnoea at rest Dyspnoea requiring l Psycho-social support through follow-up counselling, home activity O2 visits and support groups. therapy

Urinalysis

Proteinuria HIV Exposed Infant (HEI) Spot urine 1+ 2+ or 3+ 4+ Nephrotic syndrome l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 24-hourand urine continued200 breastfeeds mg to 1 g loss/dayin addition1 gto to complement2 g loss/day OR feeds2 g afto ter3.5 6 g monthsloss/day uptoNephrotic 1 year syndrome for EID negative babiesOR <0.3% and OR upto <3 g/l2 years0.3% for toEID 1.0% positive OR 3 g babiesOR > wh 1.0%o receive OR >10 P aediatricOR ART. to 10 g/l g/l >3.5 g loss/day l Postpartum ARV prophylaxis for infant for 6 weeks. Gross haematuria Microscopic only Gross, no clots Gross plus clots Obstructive l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 114 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Mild Moderate Severe Potentially life- Grade 1 Grade 2 Grade 3 threatening Grade 4 Miscellaneous omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

Fever 37.7-38.50C OR 38.6-39.50C OR 39.6- 40.50C OR > 40.50C OR (Oral, >12 hours) 100.0 -101.50F 101.6 -102.90F 103 -1050F > 1050F for ³ 12 continuous hours

Headache Mild; no treatment omen ModerateW ORregnant non-P Infected SevereHIV OR responds Intractable Negative HIV T/ARV AR required visits)–Monthly 4 at-least narcotic (ensure analgesia Care Rx toAntenatal initiall narcotic omen W regnant P treatment Centers. T AR at prophylaxis sex Safe l counselling. Allergic of reaction termination Pruritusmedical or without rash continuation of Localizedchoices urticariaon GeneralizedCounselling l urticaria, Anaphylaxis Couple Couple l of of months 3 first the within e tak under (MTP)–to angioedemapregnancy counselling. counselling. Rash hypersensitivity Erythema, pruritus Diffuse maculopapular . only Vesiculationpregnancy OR moist ANY ONE OF: family family to Linkages l rash OR dry desquamation OR mucous membrane OIs. other and TB for Screening l desquamation ulceration vices. involvement,ser planning STIs. for treatment and Screening l suspectedcondoms. ree F l testing. CD4 and staging clinical WHO l Stevens-change JohnsonBehaviour l communication (TEN), erythemacommunication and th-planning bir , y deliver safe living, positive on Counselling l multiforme, (BCC) for high risk risk high for (BCC) options. feeding infant exfoliative dermatitis women and her her and women Fatigue and spouse of Normaltesting activityHIV and reduced Normalcounselling sex activitysafe and NormalCouple l activity Unable. to caretner par for by < 25% reduced by 25-50% reduced by > 50%; self . children living other HIV epeat R l cannot work . Center T AR to eferral R l testing, Source: Division of AIDS, National Institute of Allergy and Infectious Diseases, version 1.0 December 2004, clarificationconsidering August 2009count CD4 on based regimen prophylactic ARV or T AR rovide P l , period if if period , window NOTE: This clarification includes the addition of Grade 5 toxicitystaging. , whichclinical is death.and/or For abnormalities not found elsewhere in the toxicity table, use the information on estimating severitypositive gradeis in thespouse first Government/other Government/other to linkages and counselling Nutrition l column. high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 115 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Annex 7: Postpartum DepressionFigure 2: Components Screening of PPTCT Programme Tool—The Edinburgh Scale

Offer of HIV EdinburghCounselling Postnatal and Testing Depression Services Scale to1 (EPDS)all Pregnant Women Name: ______Address: ______

Your Date of Birth: ______HIV Negative HIV Infected Pregnant Women Baby’s Date of Birth: ______Phone: ______Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV As youl Safe are sexpregnant or have recently hadprophylaxis a baby, atwe AR wouldT Centers. like to know how you are feeling. Please counselling. check the answer that comes closestl toCounselling how you have on choices felt IN ofTHE continuation PAST 7 DAYS, or medical not just termination how you offeel l Couple today. pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. Herel isLinkages and example, to family already completed. l Screening for TB and other OIs. I have planningfelt happy: services. l Free condoms. l Screening and treatment for STIs. -- Yes, all the time l Behaviour change l WHO clinical staging and CD4 testing. þ Yes, most of the time communication l ThisCounselling would mean: on positive “I have living, felt happy safe deliver mosty ,of bir theth-planning time” during and the (BCC) for high risk -- No, not very often pastinfant week. feeding Please options. complete the other questions in the same women and her -- No, not at all way. partner. l Couple and safe sex counselling and HIV testing of spouse and In thel Rpastepeat 7 days:HIV other living children. 1. testing,I have been able to laugh landReferral see theto AR T Center4. .I have been anxious or worried for no good considering funny side of the things l Provide ART or ARV prophylacticreason regimen based on CD4 count window, period if As much as I always could and/or clinical staging. spouse-- is positive -- No, Not at all or-- s/he Not havequite high so much now l Nutrition counselling-- Hardlyand linkages ever to Government/other Nutrition programmes. risk-- Definitely behaviour .not so much now -- Yes, sometimes l Infant feeding and l Postpartum ARV prophylaxis for mother. -- Not at all -- Yes, very often nutrition l Family Planning Services.

2. counselling.I have looked forward with lenjoymentEBF reinforcement/Infant to *5. I have feeding felt supporscaredt throughor panicky home for visits. no very things good reason l Psycho-social support through follow-up counselling, home -- As much as I ever did visits and support groups.-- Yes, quite a lot -- Rather less than I used to -- Yes, sometimes -- Definitely less than I usedto -- No, not much HIV-- Exposed Hardly atInfant all (HEI) -- No, not at all *3.l Exclusive I have blamed breastfeeds myself upto unnecessarily 6 months (preferredwhen Option-I*6. Things WHO/NAC have beenO Guidelines getting on 2010-'11) top of me andthings continued went wrong breastfeeds in addition to complement --feeds Yes, af mostter 6 of months the time upto I haven’t 1 year been for able to cope at all EID-- Yes, negative most babiesof the time and upto 2 years for EID positive babies who receive Paediatric ART. l Postpartum ARV prophylaxis for infant for 6 weeks. -- Yes, sometimes I haven’t been coping as -- Yes, some of the time l Early infant diagnosis (EID) at 6 weeks of age; repeat testingwell at as 6 usualmonths, 12 months & 6 weeks -- Not very often after cessation of breastfeeds. -- No, most of the time I copied quite well -- No, never l Co-trimoxazole prophylaxis from 6 weeks of age. -- No, I have been coping as well as ever l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 116 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

*7. I have been so unhappy that I haveProgramme hadPPTCT of *9. I Components have 2: beenFigure so unhappy that I have been difficultly sleeping crying -- Yes, mostomen ofW the timeregnant P all to vices Ser esting T --and Yes, most of Counselling the timeHIV of Offer -- Yes, sometimes -- Yes, quite often -- Not very often -- Only occasionally -- No, not at all omen W regnant P -- No,Infected neverHIV Negative HIV

*8. I have T/ARV feltAR sad or miserablevisits)–Monthly 4 at-least (ensure Care *10. TheAntenatal l thought of harmingomen W myself regnant hasP -- Yes, most of the time Centers. T AR at occurredprophylaxis to me sex Safe l counselling. of of -- Yes, quitetermination oftenmedical or continuation of choices on --Counselling Yes,l quite often Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy -- Not very often -- sometimes counselling. . only pregnancy -- No, not at all -- Hardly ever family to Linkages l OIs. other and TB for Screening l vices. ser planning -- Never STIs. for treatment and Screening l condoms. ree F l Administered/Reviewed by______testing. CD4 and staging clinical Date______WHO l change Behaviour l and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) options. feeding infant 1Source: Cox, J.L. Holden, J.M. and Sagovsky, R.1987. Detection of postnatal depression: Development her and of the 10-itemwomen and spouse of testing HIV and counselling sex safe and Couple l Edinburgh Postnatal . tner par Depression Scale. British Jormal of Psychiatry 150:782-786.. children living other HIV epeat R l 2Source: K.L. Wisner, B.L. Parry, C.M. Piontek, Postpartum Depression N Engl J Med Vol. 347, No 3, July 18, 2002, 194-199 . Center T AR to eferral R l testing, Users may reproduce the scale without further permission providing they respect copyright by quoting the namesconsidering of the authors, thecount titleCD4 andon the sourcebased of theregimen paper in all reproducedprophylactic ARV or copies.T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 117 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

EdinburghFigure Postnatal2: Components Depression of PPTCT ScaleProgramme1 (EPDS)

Postpartum depression is the most common complication of child bearing.2 The 10-question Edinburgh Postnatal DepressionOffer of ScaleHIV Counselling (EPDS) is a and valuable Testing and Ser efficientvices to wayall Pofregnant identifying Women patients at risk for “perinatal” depression. The EPDS is easy to administer and has proven to be an effective screening tool.

Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDSHIV score Negative should not override clinicalHIV judgment. Infected P Aregnant careful Wclinicalomen assessment should be carried out to

confirmPregnant the diagnosis.Women The scale indicatesl Antenatal how the Care mother (ensure has at-least feltduring 4 visits)–Monthly the previous week ART/ARV. In doubtful casesl itSafe may sex be useful to repeat the toolprophylaxis after 2 weeks. at AR TThe Centers. scale will not detect mothers with anxiety counselling. neuroses, phobias or personality disorders.l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of Womencounselling. with postpartum depression need not feel alone. They may find useful information on the web pregnancy only. sitesl ofLinkages the National to family Women’s Health information Centre and from groups l Screening for TB and other OIs. such asplanning Postpartum services. Support International and Depression after l Screening and treatment for STIs. Deliveryl Free l Behaviour change l WHO clinical staging and CD4 testing.

Questionscommunication 1, 2, & 4 (without an *) Scoringl Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk infant feeding options. Are scoredwomen 0, and1, 2 heror 3 with top box scored as 0 and the bottom box scored as 3. l Couple and safe sex counselling and HIV testing of spouse and Questionspartner 3,. 5-10 (marked with an *) l Repeat HIV other living children. Are reverse scored, with top box scored as 3 and the bottom box scored as 3. testing, l Referral to ART Center. considering Maximum score: 30 l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. Possiblespouse Depression: is positive 10 or greater l Nutrition counselling and linkages to Government/other Alwaysor look s/he at have item high 10 (suicidal thoughts) risk behaviour. Nutrition programmes. Users may reproduce the scale without further permission, providing they respect copyright by l Infant feeding and l Postpartum ARV prophylaxis for mother. quotingnutrition the names of the authors, thel Ftitle,amily and Planning the source Services. of the paper in all reproduced copies.

counselling. l EBF reinforcement/Infant feeding support through home visits. Instructions for using the Edinburgh Postnatal Depression Scale: l Psycho-social support through follow-up counselling, home 1. The mother is asked to check thevisits response and suppor thatt groups.comes closest to how she has been feeling in the previous 7 days. 2. All the items must be completed. HIV Exposed Infant (HEI) 3. Care should be taken to avoid the possibility of the mother discussing her answers with others. l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) (Answers come from the mother or pregnant woman.) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for 4. EIDThe negative mother shouldbabies andcomplete upto 2the years scale for herself, EID positive unless babies she has wh limitedo receive English Paediatric or has AR difficultlyT.

l Pwithostpar reading.tum ARV prophylaxis for infant for 6 weeks.

1Source:l Early Cox; J.L.infant Holden, diagnosis J.M. and (EID) Sagovsky, at 6 weeks R. 1987. of age; Detection repeat of testingpostnatal at depression:6 months, Development 12 months of & the6 weeks 10-item Edinburghaf terPostnatal cessation Depression of breastfeeds. Scale. British Journal of Psychiatry 150:782-786. 2Source: K.L. Wisner, B.L. Parry, C. M. Piontek, Postpartum Depression N Engl J Med vol 347, No 3, July 18, 2002, 194-199 l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 118 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 8: Comparing effectiveness of family planning methods Annex 8: Comparing Effectiveness Programme PPTCT ofof FamilyComponents 2: Planning Figure Methods

omen W Comregnant P Comparingpall aringto vices EEffectivenessffectivSer eesting T ness of Methodsand of MethoCounselling dsHIV of Offer

More Effective How to make your Less than 1 pregnancy per 100 women in one year method most omen W regnant P Infected HIV effective Negative HIV T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P Centers. T AR at prophylaxis After procedure, little or nothingsex Safe l to do or remember counselling. of of termination medical or continuation of choices on Counselling l Couple l of of months 3 first the within e tak under (MTP)–to pregnancy Vasectomy: Use another counselling. . only pregnancy method foor first 3 months Implants Vasectomy Female IUD family to Linkages l Implants VasectomyOIs. other Sterilizationand TB for IUDScreening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l Injections: Get repeat injections testing. CD4 and staging clinical WHO l change Behaviour l on time

and th-planning bir , y deliver safe living, positive on Counselling l communication LAM (for 6 months risk ): high for (BCC) options. feeding infant Breastfeed often, dayher andand women and spouse of testing HIV and counselling sex safe and Couple l night . tner par Injectables LAM Pills . children living other Pills: Take a pill each dayHIV epeat R l testing, testing, . Center T AR to eferral R l considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l Condoms, diaphragm: Use if period , window staging. clinical and/or correctly every time you have sex positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or Fertility-awareness based programmes. Nutrition . behaviour risk methods: Abstain or use . mother for prophylaxis ARV tum ostpar P l and feeding Infant l condoms when fertile. vices. Ser Planning amily F l nutrition Male Female Diaphragm Fertility-Awareness Newest methods (Standard Days visits. Condomshome through t Condomssuppor feeding Based Methodsreinforcement/Infant EBF l Method and Two Day Method) counselling. may be easier to use. home counselling, follow-up through t suppor -social sycho P l

groups. t suppor and visits Withdrawal, Spermicide: Use correctly every time you have sex

(HEI) Infant Exposed HIV Withdrawal Spermicide O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Less effective About 30 pregnancies per weeks. 6 for infant for prophylaxis ARV tum ostpar P l weeks 100weeks wom6 & en in onemonths ye12 ar months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

Reference: Reproductive Choices and Family Planning for People Living with HIVage. of Counsellin weeks g Too6 l from prophylaxis -trimoxazole Co l (http://www.who.int/hiv/pub/toolkits/rhr/en/index.html ) EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 119 care. infant routine and Immunizations l

months months 6 from feeds y complementar of introduction and months 6 ter af weaning Gradual l of of development & growth adequate for year National1 Guideatleast linesfor forBF Preventiof on of Parent-to-Ccontinuation hild Transmissiowith along n of HIV onwards 116 child. the

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme e s e or age age month of any for ART encourag for at 6 NVP NVP

Offer of HIV Counselling and Testing Services to breastfeeding all Pregnant Women ART; ART; that offers that of infant on at 6 months 2011. to breast to breast care one month t or mothers on status: back and NACO NACO and malnutrition feeding over initiated depression) t National GuidelinesNational EID the number health baby is encourage mother to continu and advise y plementary feeding ctice, es wn ntary uate and safe d see llness tum nfan s ut ldren, ing. ing. P; b very visi phylaxis p ss e e i i i i a i a i r r r c r c e T e e T e o o q q s m s m p p e e a a r V d ro us of ch p co NV p AR at do ade acce NOT cut requir servi care p ostpa this daily daily signs signs is DO baby or mothe complem spacing of for can for the baby of

HIV Negative HIV Infected PregnantART Women mother and continue regimen regimen health refill of or infants and check birth gradually with look nutritionally cotrimoxazole feeding status

Pregnant Women is l and health: child

infant NVP daily Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV PPTCT completely, caregiver prophylaxis consistent condom comfort pre-ART monthly or coping on infected infected health, supportive 2 2 age of years infant abruptly: breastfeeding own complementary feeding. to & l is for NVP

Safe sex or stop breastfeeding is or doctor's feeding till <2 years old: check that b check old: years <2 ART still still and for age prophylaxis at ART Centers. her nutritional d s about f for changes oo d changes (screen reinforce k baby's adherence to family mily or other, rehensive gress ording is stopped e as appropriate ntary ence and ontraception ants feeding opping ce to ce infant cte action c tinue immunization: months. months. should Infants start p conunselling p conunselling and support ntinue and ines T gress on ldren r growth r r r t d d f f t counselling. c e c o g p m e n e & s n m o o o n fa u u r R R ro c ac p o n A l12 ch aff p Counselling on choices of continuation or medical termination of reas cent to adhe b com The The B: till guidel still l day Couple further growth HIV adhere if mother mother ART l l complem planning/ mother's restfeedin

pregnancy (MTP)–to undertakefor within the first 3 months of for to b condoms an whether how for about baby's option about the about baby's status and infants mother on mother counselling.Baby: not stop a breastfeeding in breastfeeding prophylaxis Ask ASk Ask Discu and Ask Ask Give Ask For For sessions a Ensure Once sucking Asscess pregnancyFamily only. Refer Do Check Reinforce Providefollow- Counselling s for in months months of age age of About l l l l l For HIV-infected Chi breastfeeding to co For PPTCT breastfeeding Follow IMNCI About l l l l l l l 8. l l l l l l 7. l Linkages to family nutrition l Screening for TB and other OIs. exclusively of

planning 0-6 services. enough are met: are met: and ths ths for tly h, nd void ns the the risk on g) s lk ing ing ths: ently i c a a n s h n i o y

l A e er e n d n

Screening and treatmentn for STIs. l Free condoms. w n m wit for lo an doe the the mo easi frequ stoma feedi and and it 6 mo and no six into freque to preparat finished thrush

l conditi l empty.

Behaviour changewater

WHO clinical staging and CD4 testing.baby it formula milk expressed if option is hygiene prevention demonstrat and p ositio oral feed first or making formula to get even feeds as it ma

communication oral feed (if prevention prevention breast and hand hygienic the l soap one breastfeeding breast

the infant's the infant's Counselling on positive living, safe delivery, birth-planning and according r milk and 6 months: nipple nipples: in breast of following prepare animal (ie. and for and with with only

(BCC) for high risk leftover after baby has scoop the can can, can, the the Discuss and breast lining : r infant feeding options. r is safe and carries a carries and is safe of in mastitis: mastitis: breastfeed milk with or solids, not not or solids, cracked oral ulcers and medicines it feeds) - giving feeding mother, and r y of the the women and her until of of of cuss cuss cuss cuss and cuss All water utensils surface and away leftover washing eplacement Feeding Feeding eplacement for n ns eding uids inflammation od nipple for east trate the amount to be fed inish hat feeding, feeding, her to prepare astfeeding ed" egive nutrition, the chosen feeding ngorgement. ions egive the nt nt nt n d are enough fo ate Feeding optio virus attachment to attachment iscuss to food poisoning t ot re-use a r n w o r t t t f R s t t d q l t l s s s s s t b t r r e ed r r e e x e e x e e e e g e e e e e e o e fe p p d d l n r t br

li Couple and safe sex counselling and HIV testing of spouse and fe b ca ca so irri me ove mo

partner. HIV "mi ma not lea Han Clea Pre wh Boil Thro Do D baby infan } } } } } } can EBF other excepti NO giving causin the baby's Breast correct of Di treatm some rub treatm and breast Di treatm in Di hygien baby Di demon Tell Di instruc Explain feeds: and

l other living children. only Exculve 6. Repeat HIV l l l l l l l Exclusive l l l of manner Infan replacemen mother, or mother, testing, l or mother,

Referral to ART Center. infants clean clean diarrhoea give give The The 6 be In l for l considering their or ART l Provide ARmay T or ARV prophylactic regimen based on CD4 count to 0-6 months if ART as ilies on en (eg. good window: , period if n elop abies se the riteria riteria lain: d this must be Rupees y of ding ns and infections) months of rotect the the rotect PTCT ups, using ups, using s o m e v b u c e k k p b 0 0 e e o o and/or clinical staging. P p c m 4 de fe mil opti regi 100

spouse is positive b eca fulfill first rovid of may which p to the 6 to healthy Fa

l of new feeding Nutritionlow counselling and linkages to Government/other or the the are adherence to respiratory option PPTCT up

or s/he have high in very child well and schedules, ex schedules, and earinfecti

Nutrition is programmes. new Sterilize the the as a feeding replacement antibodies according risk behaviour. afford through breast grow -reinforce the scale keep (diarrhoea, (about 8,000 to 10,00 time: HIV give growth not

l done (ERF) Postpartum ARV prophylaxis for mother. to criterla for RF l of feeding Infant feeding and the breast milk respiratory feeding will in reliably contained each safely k regimen drug regimen feeds 12-15 feeds 12-15 times il ent P during P gs, gs, less than 5 babies out and their ission eeding eeding irus eding choice assured at the household mother-to-child ansmission ant T ll y portant child should should prescribed normal

hoea, l f the 6 ired expensive be baby ns t not receiving receiving not t problems can u u m e

Family Planning Services.m e r

nutrition r a v n i a v nd i r r r r e V e F V F s s f f C C t t u e u e d d s s m m m m t h m m m m a i dr of ar for can req HIV erso fro is sd-N -diar and it p but is healt trans of counselling. l ARV ERF food drugs drugs a necessa EBF reinforcement/Infant feedingof support through home visits. infecte otherwis life, if replace food caregiver other of declde on f other risk ART infant, , , to suppor taking of by HIV- preparation done infections is preparation or mother/infan l the Psycho-social support through follow-up counselling, community, home the feeding. parent-to-child complete of small transmission taking taking or ART PPT risks of given complete of take stillare using (milk) t baby to be ART ART is risk 6 months HIV to the the transmission is a RF correctly Criteria for for Criteria on of infetions-unless freshand hygienic is not a visits and support groups. Excluslve Replacement Replacement Excluslve risks first can be reduce the numbers HIV with there is a there milk not not risk known Six Six sanitation and water and in the practices milk cannot cannot breastfeed only and of and from the the the regimen. replacement water : will is or other mother, r mother or mother ula al has more 's life el uestions d e fe elling Mother d d her family forin s e ths) r or baby itions itions ful the the r to velopmen ough milks in ing ers ricts which which ricts nced mother and family points 2-4 again, ugh antages: n fficient iscuss explain: nes), infected w isk must be CT tages: nutrition is recommended because breast y e important y t ing r y t ies r i q v e q v e e e h m e h m g e g t m t m n n l l a h a h l l r § r a h § a h a e e a e e d d o v p o v p h s F F h F F s u u o o T n n n D D le s d S T is al oil dis Car thr ER mo Bab b b ab Tha dru wh HIV PP T Dur fee EBF b ab ER ma Alt b due No Ani For It 3. mot bel Hel Expl Box Box Mot l l 5. Advan l l Disad l l l malnut l 4 If moth l l l If moth the guldel l l l l Clarify Go

HIVCoun Exposed Infant (HEI) to on ART the the PPTCT & or go health and is l Exclusive breastfeeds upto 6 in months (preferred Option-I WHO/NACO Guidelines 2010-'11) or d during day have benefits taking home water facility ART as it as it ear infections d feeding r hart ore s? onths e re or get out of transmission of us, d ded le she s per lth e else? to(need ia, t nfected mothers a ually against infections infections against mende i i y u

and continuedt breastfeeds in addition to complement feeds after 6 months upto 1 year for a a v c e s r m e a e n i n m V n o us ab b he 6 th HI sta b stat p rep has howe for if the the with neumo HIV HIV HIV 0-6 Months of Age Counselling the HIV infected mothers and her family for infant feeding options: 0-6 months

EID negative babieshelp and upto 2 years for EID positive babies who receive Paediatric ART. protects in is recom do not p as cost for infa recomme prevent to baby Flow count and i of feed virus, her of HIV/ART of life, is milk for the recommend of drugs, drugs, no need to

l CD4 free HIV deliver Postpartum ARV husband/family prophylaxis for infant for 6 weeks. baby's life know willing g Type her husband's is per month of to diarrhoea, breast mother breastfeeding ART to other to ICTCs) l in breastfeeding and regimen? breastfeeding breastfeeding and like nutrition plan significantly know the family l Early infant diagnosis (EID)used at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks r for contains contains 6 months months 6 available, the decision the decision with income on during will convenient, situation is her latest latest is her Breastfeeding utensils eg. to up utensils 12-15 tim she her she water and mother to parent's house somewhe t referral 4 months she prepare each she prepare feeds at night? first milk t about PPTCT d at night s her ha t ost oes oes oes ntibodies abies lways xclusive omplete an an unsellin roblems e amily s ack lan aby dvantages: port astfeeding are? lean nnex 9: 9: nnex tatus? upportive mily irs

after cessation of breastfeeds. antages: ounsel he sk or virus men men lain: king ne/toile Safer Convenient. Convenient. Affordable, Affordable, Feasible E D E a D B M B M D D s I s c c f W b p t b A p b D D s I s c F Source C c f C W b p t b C A p A b a F C C C A a e e i i i i a p a p v v o o n p p A C A C f Su Br l l l l A C 1. l l l l dri n latr l l l l 2. l Ex Ad l l l l l Dis Bre reg HIV A l Co-trimoxazole prophylaxis from 6 weeks of age. Annex 9: Flowchart on Counselling Mothers and their Families on Infant Feeding Options on Infant Feeding Annex 9: Flowchart on Counselling Mothers and their Families l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID. National Guidelines for Prevention of Parent-to-Child Transmission of HIV 117 l Growth and nutrition monitoring. 120 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure -1 ﬁrst

omen W regnant P all to vices Ser esting T and -1 Counselling HIV of Offer HIV Infant is uninfected before test to breast the 6 weeks A <6 months Not breastfed in - 1 DNA detected void putting baby A Stop cotrimoxazole HIV y 3

- 1 DNA not detected omen W regnant P Infected HIV Negative HIV -1 DNA/PCR test HIV test l omen W regnant P apid antibody test not

T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal weeks and above is the recommended DNA PCR not recommended optimal age for a routine HIV Safe sex If baby is < 6 weeks- HIV sex Safe l l lR l6

Centers. T 6 weeks before AR at prophylaxis Breastfed in the t ollow Advisor

F counselling. of of termination medical or continuation of choices on Counselling l l

-1 Couple of of months 3 first the within e tak under (MTP)–to pregnancy -1 DNA not detected owchar counselling. y 1 in ollow all steps . . only HIV pregnancy F

from Guidance 1 family to Linkages l OIs. other and TB for Screening l vices. ser planning y 2 months of age at <6 months of age, repeat HIV DNA PCR by DBS In asymptiomatic child, repeat HIV DNA PCR at 6 If child develops signs and symptoms of HIV infection STIs. for treatment and Screening l condoms. by HIV ree F l diagnosis 3 antibody l l tests (rapid) - 1 DNA detected ollow Advisor l at 18 months, l testing. CD4 and F staging clinical WHO change Behaviour -1 Establish deﬁnitive DNA PCR test using HIV Whole Blood specimen communication l HIV and th-planning bir , y deliver safe living, positive Conﬁrm with repeat HIV on Counselling infected Infant is y 3 -1 DNA detected risk high for (BCC) options. feeding infant HIV Continue Advisor

C) her and women

and spouse of - 1 DNA testing HIV and counselling sex safe and Couple l . tner par HIV not detected . children living other l

ollow Advisor HIV epeat R F . Center T AR to eferral R l testing,

ASS considering count count CD4 on based regimen prophylactic ARV or T AR rovide P l , period if if period , window

-1 DNA PCR (At ICT staging. clinical and/or

ter last breast positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or for HIV programmes. Nutrition . behaviour risk T centre if result is ten a good time to discuss . mother for - 1 DNA detected prophylaxis ARV tum ostpar P l -1 DNA PCR by DBS test at and feeding Infant l HIV vices. Ser Planning amily F l nutrition discordant and rely on the from AR y 3 ﬁnal whole blood test result Guidance 1-Lab will request for fresh whole blood sample visits. home through t suppor feeding reinforcement/Infant EBF l counselling. epeat HIV risk 6 months, weeks af milk feeding or if the child develops symptoms of HIV infection negative local guidelines and ensure AF criteria are met before weaning. 6 months is of possibility of weaning Infant is probably not infected, but at Continue cotrimoxazole until deﬁnitely Discourage weaning too early - use l

home counselling, follow-up through t suppor Advisor l -social lR sycho P l l Less than 6 months old and born to HIV positive mother y 2 [email protected]

groups. t suppor and visits ter follow the algorithms to determine infection status -1 Collect & send Dried Blood Spot (DBS) of babies between 6 weeks to <6 months age HIV -1 DNA not infected Infant is detected by whole Blood T HIV ollow Advisor F HIV Exposed Infant (HEI) Infant Exposed HIV y 1 aed AR . y 2 void mixied O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds -exposed; thereaf Exclusive l t P T Centre Mange OI, if any Star ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to cotrimoxazole. addition in breastfeeds continued and therapy as per national protocol If breast feed, continue breast feeding for 2 yrs. A feeding , contact NACO at labser Advisor l Continue l l . . T AR aediatric P y 1 receive o wh babies positive EID for years 2 upto and babies negative EID -1 DNA PCR ollow Advisor efer to AR F

R l T Centre) weeks. 6 for infant for prophylaxis ARV tum ostpar P

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l ollow Advisor ( At AR - 1 DNA detected y 1 F t ted ted breastfeeds. of cessation ter af form rapid test for HIV antibodies. If negative, label child as uninfected, if positive follow algorithm - 1 DNA detected HIV cotrimoxazole if not already star encourage breast feeding if replacement feeding not star Assess and Star age. of weeks 6 from prophylaxis -trimoxazole Co or more information l In children (< 18 months) with signs and symptoms of HIV whose exposure status is unknown per A or B, depending on age of child. Attempt to determine the HIV infection status parents determine if the child is HIV in the child. F Collect and send whole Blood specimen for HIV HIV l l Advisor EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l Annex 10: Testing Algorithm for HIV-1 Exposed Infants and Children <18 Months Algorithm for HIV-1 Annex 10: Testing

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 121 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme if T,

Offer of HIV Counselling and Testing Services -1 to all Pregnant Women months C ) £ -1 DNA PCR A6 cotrimoxazole uninfected ted B>6 months Infant is HIV void putting baby star to breast Discontinue AR A Stop l l HIV Negative HIV Infected Pregnant Women l Not breastfed in the 6 weeks before test Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. Establish deﬁnitive diagnosis at 18 months, by HIV antibody test t from counselling.-1 DNA PCR (Level ICT

l Counselling on choices of continuationter last or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of

counselling. ow char pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. Rapid test negative - does not need HIV l Free condoms. l Screening and treatment for STIs. Breastfeed in the 6 weeks before test l Behaviour change l WHO clinical staging and CD4 testing.

communication l Counselling on positive living, safe delivery, birth-planning and

(BCC) for high risk form rapid test for HIV

infant feeding options. epeat rapid HIV test 6 weeks af breast milk feeding or if the child develops symptoms of HIV infection step onwards. If negative repeat rapid test at 12 months negative Infant is probably not infected, but at risk If rapid test positive, follow Continue cotrimoxazole until deﬁnitely women and her , per l lR partner. l Couple and safe sex counselling and HIV l testing of spouse and

l other living children.

Repeat HIV ter follow the algorithms to determine testing, l Referral to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count window, period if -1 DNA PCR and/or clinical staging. spouse is positive or s/he have high l Nutrition counselling and linkages to Government/other-exposed; thereaf risk behaviour. Nutrition programmes.

l Infant feeding and l Postpartum ARV prophylaxis- 1 DNA not detected for mother. - 1 DNA not detected

l HIV

nutritionChild of 6-18 months age born to HIV positive mother Family Planning Services. HIV counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home Lab will request for fresh whole blood sample [email protected] y 1 Rapid test positive visits and suppor- 1 DNA not detected t groups. HIV -1 DNA PCR T centre if result is discordant and rely on the y 1. - 1 DNA detected HIV CO at labser Send Dried Blood Spot (DBS) of child for HIV from AR ﬁnal whole blood test result Guidance 1 - ollow Advisor F Collect blood and test for HIV antibodies using rapid test. Also prepare a Dried Blood Spot (DBS) HIV Exposed Infant (HEI) - 1 DNA detected

l Exclusive breastfeeds upto 6HIV months (preferred Option-I WHO/NACO Guidelines 2010-'11) ollow Advisor and continued breastfeeds in additionF Collect and send whole Blood tospecimen for HIV complement feeds after 6 months upto 1 year for ted -1

EID negative babies and upto 2 years for EID positive babiesHIV who receive Paediatric ART. infected infant is T Centre l Postpartum ARV prophylaxis for infant for 6 weeks. y 2 ted - 1 DNA detected - 1 DNA not detected contrimoxazole t ARV therapy as per national protocol e information contact NA t

l Early infanty 1 diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks HIV HIV Continue cotrimoxazole. Manage OI, if any star efer to AR mor R antibodies. If negative, label child as uninfected, if positive follow algorithm A or B, depending on age of child. Attempt to determine the HIV infection status of parents to determine if child is In children (< 18 months) with signs and symptoms of HIV whose exposure status is unknown infection status in the child. Advisor l l l if not already star breast feeding if replacement feeding not star Star after cessationAssess and encourage of breastfeeds. Advisor l l Co-trimoxazolel prophylaxis from 6 weeks of age.

Annex 11: Testing Algorithm for HIV-1 Exposed Infants and Children <18 Months Algorithm for HIV-1 Annex 11: Testing l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 122 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Figure 2: Components of PPTCT Programme Programme PPTCT of Components 2: Figure Annex 12: ICTC- ART CentreAnnex 12: Referral ICTC- ART cent formre referral form

State AIDS omen ControlW Society regnant P all to Statevices AIDSSer Control Sesting ocietyT and StateCounselling AIDSHIV Controlof SocietyOffer Referral Form Referral Form Referral Form

Name & Address of Name & Address of Name & Address of ICTC: ICTC: ICTC: omen W regnant P Infected HIV Negative HIV Copy-1 (to be retained at the ICTC) Copy-2 (to be carried by the client to the Copy-3 (to be sent to ART centre through T/ARV AR visits)–Monthly 4 ART centreat-least and retained(ensure Care at ART centre)Antenatal l e-mail or post)omen W regnant P Safe sex sex Safe l Part-1 to be filled by the ICTC Part-1 Centers. t o T be filledAR at by the ICTC prophylaxis Part-1 to be filled by the ICTC Counsellor/Staff Nurse Counsellor/Staff Nurse Counsellor/Staff Nurse counselling. of of termination medical or continuation of choices on Counselling l Couple Couple l of of Name & signatmonths u3 re of Counsellofirst the r /Staff nurse:within e Nametak & signatunder ure of Counsell(MTP)–to or/Staff nurse:pregnancy Name & signature of Counsellor/Staff nurse: counselling. counselling. . . only pregnancy family family to Linkages l PID No. Date of OIs. PID No. other and TB Datefor of Screening l PID No. Datevices. ofser planning referral referral referral STIs. for treatment and Screening l condoms. ree F l Name of the client (optional): Name of the client (optional): Name of the client (optional): testing. CD4 and staging clinical WHO l change Behaviour l

Age:and th-planning Sex:bir , y deliver safe Age: living, positive on Sex: Counselling l Age: Sex: communication (BCC) for high risk risk high for (BCC) options. feeding infant Ph. No.: Ph. No.: Ph. No.: her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par Category of the client (Tick Mark): Category. of the clientchildren (Tick Mark):living other Category of the client (Tick Mark): ANC/General/Exposed infant ANC/General/Exposed infant ANC/General/Expose d infantHIV epeat R l . Center T AR to eferral R l testing, Name and address of the ART centre Name and address of the ART centre Name and address of the AR T centre considering count referredcount to CD4 on based regimen referred to prophylactic ARV or T AR rovide P l referred to staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l Counsellor's signature: Counsellor's signature: Counsellor's signature: high have s/he or programmes. Nutrition . behaviour risk Part-2 to be filled by the ICTC. staff aftermother for Part-2 to be filledprophylaxis by theARV ARTtum centre staffostpar P l Part-2 to be filled and by the ART feeding centre Infant l feedback from ARTcentre staff@ vices. Ser Planning amily F l nutrition Has the patient reached ART centre: Yes/No Has the patient reached ART centre: Yes/No Has the patient reached ART centre: Yes/No visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

If Yes home counselling, follow-up If Yes through t suppor -social sycho P l If Yes groups. t suppor and visits Pre ART Baseline ART Initiated (Yes/No) Pre ART Baseline ART Initiated Pre ART Baseline ART Initiated Regn No. CD4 Regn No. CD4 (Yes/No) Regn No. CD4 (Yes/No) Count Count Count

HIV Exposed Infant (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l If ARTfor not year 1 upto months 6 ter af If ART notfeeds complement to addition Ifin ART not breastfeeds continued and initiate initiated initiated reason . T AR aediatric P receive o wh reasonbabies positive EID for years 2 reasonupto and babies negative EID

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks ART weeks Counsello 6 & r Name months & Sig12 nature months, 6 ARTat Counselltesting or Namerepeat & Sigage; n atureof weeks 6 ARTat Counsell(EID) or Name & Sigdiagnosis natureinfant Early l

To be filled for all patients detected positivebreastfeeds. at ICTCof and sent to ART centre/LACcessation ter plus.af

@ Copy 3age. to bof e sent back toweeks the6 referringfrom ICTC by ART centre/LACprophylaxis plus through email/post/patient-trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 123 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Annex 13: OM for LaboratoryFigure 2: Components Investigations of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women T-11020/36/2005-NACO (ART) Department of AIDS Control Goverment of India National AIDS Control Organisation HIV Negative (Care,HIV InfectedSupport &P regnantTreatment W omenDivison)

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV th l Safe sex prophylaxis at ART Centers. 6 Floor, Chanderlok Building counselling. l Counselling on choices of continuation36 Janpath, or medical New D terminationelhi- 110001 of l Couple pregnancy (MTP)–to undertake within theDate-January, first 3 months 2012 of counselling. pregnancy only. l Linkages to family OFFICE MEMORANDUM planning services. l Screening for TB and other OIs. Subject:l Free Revis condoms.ed Technical Guidelinesl onScreening Laboratory and Monitoring treatment for for STIs. patients at ART centres/LAC/LAC plus centres l Behaviour change l WHO clinical staging and CD4 testing. communication 1. Essential/Mandatory Tests for all lPatientsCounselling Registering on positive in HIV living, Care safeat Art deliver Centrey, bir/ LACth-planning Plus and (BCC) for high risk infant feeding options. • womenHaemogram/CBC, and her Urine for routine and microscopic examination, fasting blood sugar, blood parurea,tner .ALT (SGPT), VDRL, CD4l count,Couple Gene-xpertand safe sex in counselling institutions and where HIV testing located of X-rayspouse Chest and PA l Rview.epeat Pregnancy HIV test if required.other living children. testing, l Referral to ART Center. • Symptoms and signs directed investigations for ruling out Ols. considering l Provide ART or ARV prophylactic regimen based on CD4 count 2. Additionalwindow ,Tests period for ifall Patients to beand/or Started clinical on ART staging. spouse is positive • orOther s/he investigationhave high like USG labdomen,Nutrition sputum counselling for AFB , andCSF analysislinkages etc. to as Government/otherper the physician ’s riskdecision behaviour depending. on clinical presentation.Nutrition programmes. Efforts to be made to fast track these investigations l Infantso that feeding ART initiation and is not dlelaPyostpared. tum ARV prophylaxis for mother. nutrition l Family Planning Services. • Serum creatinine is essential when considering TDF. counselling. l EBF reinforcement/Infant feeding support through home visits. • PAP smear, fundus examination also to be done but ART initiation not to be delayed for these l Psycho-social support through follow-up counselling, home tests. visits and support groups. 3. Tests for Special Situation • HBs Ag-for all patients if facility is available but mandatorily for those with history of IDU, multiple HIVblood Exposed & blood Infant products (HEI) transfusion, ALT > 2 times of ULN, on strong clinical suspicion. But l ExclusiveART not to breastfeeds be withheld upto if HBsAg 6 months testing (preferred is not a vOption-Iailable. WHO/NACO Guidelines 2010-'11) • andAnti-HCV continued antibody breastfeeds only for thosein addition with history to complement of IDU, multiple feeds af bloodter 6 & months blood p uptorodu c1t syear tran forsfu sion, EIDALT >negative 2 times babies of ULN, and on upto strong 2 years clinical for EIDsus ppositiveicion. babies who receive Paediatric ART. l Postpartum ARV prophylaxis for infant for 6 weeks. • For patients with Hepatitis B or C co-infection, further tests may be required to assess for chronic l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks active hepatitis. after cessation of breastfeeds.

•l CoFor-trimoxazole patients to prophylaxisbe switched from to a 6 Pl weeks based of regimen,age. Blood Sugar, LFT and Lipid profileto be done at baseline. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 124 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

4. Tests for Monitoring Purpose Programme PPTCT of Components 2: Figure

• Essential - CD4,Hb, TLC, DLC, ALT(SGPT)/creatinine clearance (if on TDF), every 6 months or earlier if required.omen W For patientsregnant P all startedto vices on Ser AZT Basedesting T regimen,and Hb at Counselling 15 days,HIV of then Offer every, month for initial 3 months, 6 months and then every 6 months/as & when indicated. For patients started on EFV based regimen, lipid profileshould also done yearly. For patients started on ATV, LFT to be done at 15 days, 1 month, 3 months, 6 months and then every 6 months. Blood sugar and Lipid omen W regnant P Infected HIV Negative HIV profile every 6 months for patients on Pl based regimen. All the above tests can be done earlier T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P based on clinicians assessment/discretion. Centers. T AR at prophylaxis sex Safe l counselling. of •of Other investigationstermination medical or during follow-continuation of up as perchoices ron e quirementCounselling /avl ailability. Couple Couple l of of months 3 first the within e tak under (MTP)–to pregnancy All above investigations other than CD4 and viral load estimations (when required), shall be done counselling. from . . only pregnancy the health facility where the centre is located with support from State Health Depar tment.family to Linkages l OIs. other and TB for Screening l vices. ser planning STIs. for treatment and Screening l condoms. ree F l testing. CD4 and staging clinical WHO l change Yours faithfullyBehaviour l

and th-planning bir , y deliver safe living, positive on Counselling l communication (BCC) for high risk risk high for (BCC) options. feeding infant women and her her and women and spouse of testing HIV and counselling sex safe and Couple l . tner par . children living other HIV epeat R l . Center T AR to eferral R l (Dr. Mohammad Shaukat)testing, considering ADGconsidering (CST) count count CD4 on based regimen prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or Copy to: programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l 1. Project Director, All State AIDS control Society and feeding Infant l vices. Ser Planning amily F l nutrition 2. Nodal Officers of allART centres visits. home through t suppor feeding reinforcement/Infant EBF l counselling. 3. ADG (Labhome Services), NACOcounselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 125 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Annex 14: List of ItemsFigure that 2: canComponents be Procured of PPTCT Programme under Universal Work Precautions Offer of HIV Counselling and Testing Services to all Pregnant Women 1) Disposable latex Gloves–2 Boxes (100 per Box) 2) Disposable Laboratory gowns–As per Number of positive deliveries in years.

3)HIV DisposableNegative Plastic aprons–24HIV Number Infected Pregnant Women

4)Pregnant Disposable Women Face Mask–2 Boxesl Antenatal(100 per CareBox) (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. 5) counselling.Disposable Caps–4 Boxes (25 per box) l Counselling on choices of continuation or medical termination of l Couple 6) Shoe covers–2 Boxes (25 pairs pregnancyper box) (MTP)–to undertake within the first 3 months of counselling. pregnancy only. 7)l LinkagesRubber boots–2to family pairs planning services. l Screening for TB and other OIs. 8) Hand rubs/disinfectant solution for hand wash- 6 bottles. l Free condoms. l Screening and treatment for STIs. 9)l BehaviourNeedle destroyer–1 change Number l WHO clinical staging and CD4 testing.

communication l Counselling on positive living, safe delivery, birth-planning and 10)(BCC) Sharp for disposal high risk containers–2 Numbers infant feeding options. 11)women 1% Sodium and her hypochlorit e–24 cans per year (5 litres canister of 4–5%) partner. l Couple and safe sex counselling and HIV testing of spouse and 12)l R 10%epeat Sodium HIV hypochlorite–1canother per yearliving (5 children litres canister. of 40% solution) testing, 13) Spirit/70% alcohol–6 bottlesl (500Referral ml/bottle) to ART Center. considering l Provide ART or ARV prophylactic regimen based on CD4 count 14)window Cotton-6, period Bundles if (large 500 gm/pack)and/or clinical staging. spouse is positive 15)or Tissue s/he havepaper high rolls–24 Numbersl Nutrition counselling and linkages to Government/other Nutrition programmes. 16)risk Cloth behaviour Aprons/Laboratory. coats–4 Numbers l Infant feeding and l Postpartum ARV prophylaxis for mother. 17)nutrition Colour coded waste disposal lbags–4Family Dozen Planning Services. counselling. 18) Colour coded waste disposal lbins–8EBF reinforcement/InfantNumbers feeding support through home visits. l Psycho-social support through follow-up counselling, home 19) Biohazard labels–2 Dozen visits and support groups. 20) Bandaids –100 Numbers 21) Needles/Syringes–3 Boxes (100 per box) HIV Exposed Infant (HEI) 22) Rubber gloves for dirty washing and waste handling-8 Numbers l Exclusive breastfeeds upto 6 months (preferred Option-I WHO/NACO Guidelines 2010-'11) 23) and Measuring continued cylinder breastfeeds glass 1 in litre addition –2 Number to complement feeds after 6 months upto 1 year for EID negative babies and upto 2 years for EID positive babies who receive Paediatric ART. 24) Covered discard jars/discard buckets with lid–4 Number l Postpartum ARV prophylaxis for infant for 6 weeks.

25)l Early Hepatitis infant B diagnosis vaccination (EID) and at antibody 6 weeks titresof age; for repeat staff employedtesting at 6under months, NACO–4 12 months vials of & 6 weeks af6ter doses cessation each of breastfeeds. 26)l Co Any-trimoxazole other item prophylaxis with prior approval from 6 weeks of NA ofCO age. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 126 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 15: CF- Consent form Programme for PatientsPPTCT of RegisteringComponents 2: Figure into HIV Care & Starting ART omen W regnant P all to vices Ser esting T and Counselling HIV of Offer I, (name)………………...... , (address)…………………………...... CONSENT to share all information pertaining to my health and HIV/AIDS status with the service providers who will be part of the management of my condition. omen W regnant P Infected HIV Negative HIV And T/ARV AR visits)–Monthly 4 at-least (ensure Care Antenatal l omen W regnant P I AGREE to receive Antiretroviral Therapy providedCenters. T AR under at the Nationalprophylaxis programme. sex Safe l counselling. of of termination medical or continuation of choices on Counselling l I fully understand the information that has been provided by the health care staff in the following: Couple l of of months 3 first the within e tak under (MTP)–to pregnancy counselling. counselling. • That the ART is not an emergency and thus . willonly be startedpregnancy as per the decision of the doctor. I family family to Linkages l shall attend the ART centre as perOIs. appointmentother and TB for for timely Screening initiationl of ART and vices. regularser follow-planning up. STIs. for treatment and Screening l condoms. ree F l • That receiving ART involves shared confidentiality with other service providers such as CBO/ testing. CD4 and staging clinical WHO l change Behaviour l NGO/CCC/positive network who may support my treatment and other welfare measures through and th-planning bir , y deliver safe living, positive on Counselling l communication outreach and home-based care activities at home. risk high for (BCC) options. feeding infant women and her her and women • That ART requires 100% adherence to drugs and I shall abide by the same. and spouse of testing HIV and counselling sex safe and Couple l . tner par • That I understand the side effects of ART.. children living other HIV epeat R l . Center T AR to eferral R l testing, • That I shall not stop the drugs on my own and will return to the centre if there is any problem.considering In count count CD4 on based regimen prophylactic ARV or T AR rovide P l case I stop the drugs on my own accord/do staging. not adhereclinical to and/or the regimen, I shall if not period hold , the window health care staff of the ART Centre responsible for any complication arising out of the same.positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or • In case, I am on ART from outside on a differentprogrammes. regimen,Nutrition I agree to receive . the drugs/regimenbehaviour risk provided under the. nationalmother programme.for prophylaxis ARV tum ostpar P l and feeding Infant l vices. Ser Planning amily F l nutrition • In case, I want to take ART from other centre or to go other city for livelihood or other reasons, I visits. home through t suppor feeding reinforcement/Infant EBF l counselling. will inform my ART Centre and get a “transfer out” letter before leaving. home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

......

Signature of patient with date (HEI) Infant Exposed HIV O Guidelines 2010-'11) 2010-'11) Guidelines O WHO/NAC Option-I (preferred months 6 upto breastfeeds Exclusive l ...... ter 6 months upto 1 year for for year 1 upto months 6 ter af feeds complement to addition in breastfeeds continued and Signature . T of AR witness aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID (Doctor/nurse/counsellor) weeks. 6 for infant for prophylaxis ARV tum ostpar P l weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l (This should be translated in local language &/or explained to patient before takingbreastfeeds. of patientscessation signaturter af e)

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 127 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Annex 16: Transfer outFigure form 2: Components(Form for of PPTCT Transfer Programme of PLHIV to Other ART Centre) Offer of HIV Counselling and Testing Services to all Pregnant Women Name and address of the transferring ART Centre ______

Name and address of ART Centre where patient is being transferred ______

NameHIV of Negative Patient: ______HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV HIV Care (Pre-ART) Registration No. ______l Safe sex prophylaxis at ART Centers. counselling. Address and contact details: ______l Counselling on choices of continuation or medical termination of l Couple _ pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. Reasonl Linkages for transfer to family(Specify) 1. Patient Choice 2. Provision of second line ART/ Alt First line planning services. l Screening for TB and other OIs. Datel ofF reetransfer condoms.:______l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing. ART regimen (pls. specify): ______communication l Counselling on positive living, safe delivery, birth-planning and (BCC) for high risk Date of starting ART:______/______infant feeding/ options.(Date/Month/Year); Latest CD4______women and her Next datepartner for .dispensing drug is ______l Couple and/______safe sex counselling/ and HIV testing of spouse and l Repeat HIV other living children. Please find the following originaldocuments handed over to the patient: testing, l Referral to ART Center. considering 1. Patient Treatment Record (White Card)l Provide ART or ARV prophylactic regimen based on CD4 count window, period if and/or clinical staging. 2. Patientspouse Booklet is positive (Green Booklet) or s/he have high l Nutrition counselling and linkages to Government/other 3. Others,risk ifbehaviour any (Mention). Nutrition programmes. l Infant feeding and l Postpartum ARV prophylaxis for mother. Name and Signature of SMO/MO Phone no. and e-mail of SMO/MO: nutrition l Family Planning Services.

(To be counselling.filled by the receiving ART Centrel EBF and reinforcement/Infant sent to the transferring feeding ART suppor Centret throughby post/email) home visits.

l Psycho-social support through follow-up counselling, home (Name of Patient), referred by you on date ______/_____/______has reported and been visits and support groups. registered with us on______/______/______along with the documents sent by you. Her/ His HIV Care (Pre- ART) registration no. is ______and ART registration no. (if applicable)

is ______HIV Exposed Infant (HEI) Namel andExclusive Signature breastfeeds of SMO/MO upto 6Phone months no (preferredwith e-mail Option-I of SMO/MO WHO/NACO Guidelines 2010-'11) and continued breastfeeds in addition to complement feeds after 6 months upto 1 year for AddressEID of thenegative ART Centre,babies andtransferring upto 2 yearsout the for patient:EID positive ______babies who receive Paediatric ART.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 128 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 17: OM Regarding ProvisionProgramme PPTCT of of ART/Components ARV2: Figure Prophylactic Drugs at ART Centre to HIV Infected Pregnant Women omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

Government of India Ministry of Health and Family Welfare Departmentomen W of AIDS regnant ControlP NationalInfected HIV Negative HIV

T/ARV AR visits)–Monthly 4 AIDSat-least Control(ensure OrganizationCare Antenatal l omen W regnant P (Care, SupportCenters. T & AR Treatment at Divison)prophylaxis sex Safe l counselling. of of termination medical or continuation of choices on Counselling l th Couple l of of months 3 first the within e tak under (MTP)–to pregnancy 6 Floor, Chanderlok Building counselling. counselling. . . only pregnancy 36 Janpath, New Delhi-110001 family family to Linkages l OIs. other and TB for Screening l Date - 28thvices. ser August,planning 2012 STIs. for treatment and Screening l OFFICE MEMORANDUM condoms. ree F l testing. CD4 and staging clinical WHO l change Behaviour l

and th-planning bir Subject: , y deliver ART/ARVsafe Proyhylaxisliving, positive foron pregnant Counselling positivel women communication (BCC) for high risk risk high for (BCC) options. feeding infant It has been decided that ART/ARV prophylaxis for pregnant positive women will beher initiatedand onlywomen at the ART and centres.spouse of After 6testing monthsHIV and of pregnancy,counselling sex in casesafe and the pregnantCouple l woman is not able. totner comepar to ART centre, the ARV drugs may be given to . an authorizedchildren living memberother of her family. This drugHIV supplyepeat R l to authorized member can continue till 2 months. afterCenter T delivery.AR to Aftereferral R l that drugs will be dispensed testing, to the considering considering women onlycount onCD4 heron attendingbased theregimen “ART centre”.prophylactic ARV or T AR rovide P l staging. staging. clinical and/or if period , window spouse is positive positive is spouse Government/other Government/other to linkages and counselling Nutrition l high have s/he or programmes. Nutrition . behaviour risk . mother for prophylaxis ARV tum ostpar P l and feeding Infant l (Dr. Mohammed Shaukat) vices. Ser Planning amily F l nutrition ADG (CST) visits. home through t suppor feeding reinforcement/Infant EBF l counselling. Ph: 011- 23731805 home counselling, follow-up through t suppor -social sycho P l To, groups. t suppor and visits

1. Project Director, State AIDS Control Society, Andhra Pradesh & Karnataka 2. Regional Coordinator (CST), Andhra Pradesh & Karnataka HIV Exposed Infant (HEI) Infant Exposed HIV 3. Programme2010-'11) Director,Guidelines CoE,O GandhiWHO/NAC Hospital,Option-I Secunderabad(preferred months & Bowring6 upto Hospital,breastfeeds BangaloreExclusive l 4. Nodalfor year Officer, 1 upto All ART Centresmonths 6 ter af in Andhrafeeds Pradesh complement & Karnatakato addition (Toin be coordinatedbreastfeeds by SACS)continued and . . T AR aediatric P receive o wh babies positive EID for years 2 upto and babies negative EID Copy to, weeks. 6 for infant for prophylaxis ARV tum ostpar P l 1. DDG (BSD), NACO weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l 2. NPD (ICTC), NACO breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 129 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Annex 18: List of ReferenceFigure 2: DoctorsComponents offor PPTCT Advice Programme on PPTCT Services Including Care of HIV Exposed Child Offer of HIV Counselling and Testing Services to all Pregnant Women S. No. Name of Centre Contact Person E-mail Mobile Other Contact No.

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds.

l Co-trimoxazole prophylaxis from 6 weeks of age.

l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 130 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 19: National Coordination Programme PPTCT Committee of Components 2: for PPTCT-NRHMFigure Integration Activities omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 131 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Figure 2: Components of PPTCT Programme

Offer of HIV Counselling and Testing Services to all Pregnant Women

HIV Negative HIV Infected Pregnant Women

Pregnant Women l Antenatal Care (ensure at-least 4 visits)–Monthly ART/ARV l Safe sex prophylaxis at ART Centers. counselling. l Counselling on choices of continuation or medical termination of l Couple pregnancy (MTP)–to undertake within the first 3 months of counselling. pregnancy only. l Linkages to family planning services. l Screening for TB and other OIs. l Free condoms. l Screening and treatment for STIs. l Behaviour change l WHO clinical staging and CD4 testing.

counselling. l EBF reinforcement/Infant feeding support through home visits.

l Psycho-social support through follow-up counselling, home visits and support groups.

l Postpartum ARV prophylaxis for infant for 6 weeks.

l Early infant diagnosis (EID) at 6 weeks of age; repeat testing at 6 months, 12 months & 6 weeks after cessation of breastfeeds. l Co-trimoxazole prophylaxis from 6 weeks of age. l HIV care and Ped ART for infants and children diagnosed as HIV positive through EID.

l Growth and nutrition monitoring. 132 National Guidelines for Prevention of Parent-to-Child Transmission of HIV l Immunizations and routine infant care.

l Gradual weaning after 6 months and introduction of complementary feeds from 6 months onwards along with continuation of BF for atleast 1 year for adequate growth & development of the child.

l Confirmation of HIV status of all babies at 18 months using all 3 Antibody (Rapid) Tests.

8 National Guidelines for Prevention of Parent-to-Child Transmission of HIV

Annex 20: OM from DDG(BSD) Programme forPPTCT of Roll-outComponents of2: PPTCTFigure Multi-Drug Regimen in India from 1st January 2014 omen W regnant P all to vices Ser esting T and Counselling HIV of Offer

omen W regnant P Infected HIV Negative HIV

visits. home through t suppor feeding reinforcement/Infant EBF l counselling.

home counselling, follow-up through t suppor -social sycho P l groups. t suppor and visits

weeks. 6 for infant for prophylaxis ARV tum ostpar P l

weeks weeks 6 & months 12 months, 6 at testing repeat age; of weeks 6 at (EID) diagnosis infant Early l breastfeeds. of cessation ter af

age. of weeks 6 from prophylaxis -trimoxazole Co l

EID. through positive HIV as diagnosed children and infants for T AR ed P and care HIV l

monitoring. nutrition and Growth l National Guidelines for Prevention of Parent-to-Child Transmission of HIV 133 care. infant routine and Immunizations l

ests. T apid) (R Antibody 3 all using months 18 at babies all of status HIV of Confirmation l

ion of HIV HIV of ion Transmiss Parent-to-Child of Prevention for Guidelines National 8

Back Inner

State / UT wise Number of HIV Counseling and Tesng Centers (ICTCs) In India (December, 2013)

SA –ICTC / F- ICTC/ PPP-ICTC 15539

State / UT wise Number of HIV / AIDS Treatment Centers In India (December, 2013)

ART/ LAC 1278

The HIV Counseling & Tesng and Treatment Faclies are being rapidly further scaled up during NACP- IV (2012-17) Updated Guidelines for Prevention of Parent to Child Transmission (PPTCT) of HIV using Multi Drug Anti-retroviral Regimen in India

December, 2013

Government of India Ministry of Health & Family Welfare Department of AIDS Control Basic Services Division Chandralok Building, Janpath New Delhi - 110001