National PMTCT Guidelines National PMTCT Guidelines Table of Contents TABLE OF CONTENTS ........................................................................................................ 1 ABBREVIATIONS AND ACRONYMS ................................................................................... 8 ACKNOWLEDGEMENTS ................................................................................................... 10 FOREWORD ...................................................................................................................... 11 EXECUTIVE SUMMARY .................................................................................................... 13 CHAPTER 1: INTRODUCTION .......................................................................................... 15 1.1 DEVELOPMENT AND USE OF THE NATIONAL PMTCT GUIDELINES ................................................ 15 1.2 GLOBAL AND NATIONAL OVERVIEW OF THE HIV AND AIDS EPIDEMIC .......................................... 15 1.3 GENDER AND HIV .................................................................................................................... 17 CHAPTER 2: OVERVIEW OF HIV PREVENTION IN MOTHERS AND FAMILIES ............ 18 2.1 BASIC FACTS ABOUT MOTHER-TO-CHILD TRANSMISSION OF HIV ................................................. 18 2.2 GOAL OF TANZANIA’S PMTCT PROGRAMME ............................................................................. 19 2.3 FOUR ELEMENTS OF A COMPREHENSIVE APPROACH TO PMTCT ................................................ 20 Primary prevention of HIV among women and their partners .............................................. 20 Prevention of unintended pregnancies among women infected with HIV ............................ 21 CHAPTER 3: STIGMA AND DISCRIMINATION ASSOCIATED WITH HIV AND AIDS ...... 23 3.1 HIV-RELATED STIGMA AND DISCRIMINATION .............................................................................. 23 Stigma, gender and PMTCT programmes ............................................................................ 23 3.2 ACTIONS TO REDUCE STIGMA IN PMTCT PROGRAMMES ............................................................ 24 Role of health care workers in reducing stigma .................................................................... 24 CHAPTER 4: TESTING AND COUNSELLING ................................................................... 26 4.1 INTRODUCTION ........................................................................................................................ 26 Benefits and risks of HIV testing for women and their partners ........................................... 26 When does testing and counselling occur? .......................................................................... 26 4.2 GUIDING PRINCIPLES OF TESTING AND COUNSELLING ................................................................. 27 Confidentiality ....................................................................................................................... 27 Pre-test information and Informed consent .......................................................................... 27 When testing is declined ....................................................................................................... 27 Post-test counselling ............................................................................................................. 28 4.3 HIV TESTING AND COUNSELLING STRATEGY .............................................................................. 28 Provider-initiated HIV testing ................................................................................................ 28 4.4 PRE-TEST HIV INFORMATION ................................................................................................... 29 Group pre-test information sessions in ANC ........................................................................ 29 When clients opt-out of HIV testing ...................................................................................... 30 4.5 POST-TEST COUNSELLING AND SUPPORT .................................................................................. 31 Post-test activities for all clients ............................................................................................ 31 When the client is HIV negative ............................................................................................ 31 When the client is HIV-positive ............................................................................................. 32 ARV adherence counselling for clients who are HIV-positive .............................................. 32 4.6 COUNSELLING COUPLES........................................................................................................... 32 Considerations in counselling couples.................................................................................. 33 Consenting Couples ............................................................................................................. 33 Provider-Assisted Mutual Disclosure .................................................................................... 34 Follow-up Services for Couples ............................................................................................ 34 4.7 PRE-TEST INFORMATION AND POST-TEST COUNSELLING FOR INFANTS AND CHILDREN .................. 35 Pre-test information............................................................................................................... 35 Post-test counselling ............................................................................................................. 36 4.8 REFERRALS ............................................................................................................................. 36 4.9 COUNSELLING PREGNANT WOMEN WITH SPECIAL NEEDS ............................................................ 37 Table of Contents 1 National PMTCT Guidelines 4.10 TESTING AND COUNSELLING FOR WOMEN OF UNKNOWN HIV STATUS AT THE TIME OF LABOUR AND DELIVERY ......................................................................................................................... 37 4.11 OVERVIEW OF HIV TESTING ..................................................................................................... 38 Antibody-detecting tests ....................................................................................................... 38 Antigen and virological tests ................................................................................................. 38 4.12 NATIONAL RECOMMENDATIONS FOR HIV TESTING IN PMTCT PROGRAMMES .............................. 39 HIV testing procedures ......................................................................................................... 39 Serial testing ......................................................................................................................... 39 National algorithm for serial HIV testing ............................................................................... 39 4.13 LABORATORY DIAGNOSIS OF HIV INFECTION IN CHILDREN .......................................................... 40 Types and Use of HIV tests for infants and children ............................................................ 41 Assessing HIV exposure and infection in infants and children ............................................. 41 4.14 COLLECTION, STORAGE, TRANSPORTATION AND RETURNING RESULTS OF DRIED BLOOD SPOTS FOR DNA-PCR ....................................................................................................................... 45 DBS Collection ...................................................................................................................... 45 Transportation of specimens to the laboratory ..................................................................... 46 4.15 QUALITY ASSURANCE AND CONTROL IN HIV TESTING ............................................................... 48 Ensuring quality .................................................................................................................... 48 Quality assurance ................................................................................................................. 48 Quality control ....................................................................................................................... 48 Quality assurance measures at testing sites: HIV rapid test assays .................................... 48 Quality assurance measures at laboratory: HIV DNA-PCR assays ..................................... 49 General procedure for HIV testing ........................................................................................ 49 CHAPTER 5: SPECIFIC INTERVENTIONS TO PREVENT MTCT ..................................... 50 5.1 PMTCT SERVICES DURING ANC .............................................................................................. 50 5.2 ESSENTIAL ANC FOR WOMEN WITH HIV INFECTION ................................................................... 50 HIV testing ............................................................................................................................ 53 Prevention and treatment of OIs and other infections during ANC ...................................... 54 Evaluation for ART eligibility ................................................................................................. 54 Nutritional assessment, counselling and support ................................................................