![](media/image1.png){width="1.0263888888888888in"
height="1.5798611111111112in"}

Module 3 Specific Interventions to Prevent MTCT

**SESSION 1** Antiretroviral Treatment and Prophylaxis for the
Prevention of MTCT

**SESSION 2** Antenatal Management of Women who are HIV-Infected and
Women with Unknown HIV Status

**SESSION 3** Management of Labour and Delivery of Women Infected with
HIV and Women with Unknown HIV Status

**SESSION 4** Immediate Postpartum Care of Women who are HIV-Infected
and Women with Unknown HIV Status

**SESSION 5** Immediate Newborn Care of Infants who are HIV-Exposed and
Infants with Unknown HIV Status

After completing the module, the participant will be able to:

-   Name specific interventions for preventing mother-to-child
    transmission (PMTCT).

-   List locally available and recommended antiretroviral (ARV)
    regimens.

-   Discuss the antenatal management of women infected with HIV and
    women whose HIV status is unknown.

-   Explain the management of labour and delivery in women infected with
    HIV and women whose HIV status is unknown.

-   Explain postpartum care of women infected with HIV and women whose
    HIV status is unknown.

-   Explain immediate newborn care of infants born to mothers who are
    HIV-infected and mothers whose HIV status is unknown.

+-----------------------------------------------------------------------+
| > **Relevant Policies for Inclusion in National Curriculum**          |
+-----------------------------------------------------------------------+
| Session 1                                                             |
|                                                                       |
| -   National policy/guidelines on antiretroviral treatment and        |
|     prophylaxis for the prevention of MTCT (PMTCT)                    |
|                                                                       |
| Session 2                                                             |
|                                                                       |
| -   National guidelines on antental care (ANC) for women infected     |
|     with HIV                                                          |
|                                                                       |
| -   ANC and/or PMTCT confidentiality policy, policy on recording HIV  |
|     status in patient's medical record (if not included in national   |
|     guidelines)                                                       |
|                                                                       |
| Session 3                                                             |
|                                                                       |
| -   National policy on management of labour and delivery for women    |
|     infected with HIV and women with unknown HIV status               |
|                                                                       |
| -   National policy on testing and counselling during labour          |
|                                                                       |
| Session 4                                                             |
|                                                                       |
| -   National guidelines on immediate postpartum care of women         |
|     infected with HIV and women with unknown HIV status               |
|                                                                       |
| Session 5                                                             |
|                                                                       |
| -   National guidelines on immediate newborn care of infants who are  |
|     HIV-exposed and infants with unknown HIV status                   |
+-----------------------------------------------------------------------+

  ---------------------------------------------------- -----------------------------------------------------------
  ![](media/image2.png){width="0.7597222222222222in"   The Pocket Guide contains a summary of each session in this
  height="0.6263888888888889in"}                       module.

  ---------------------------------------------------- -----------------------------------------------------------

SESSION 1 Antiretroviral Treatment and Prophylaxis for the Prevention of
MTCT

> **ARV treatment:** Long-term use of antiretroviral drugs to *treat*
> maternal HIV/AIDS and prevent PMTCT
>
> **ARV prophylaxis:** Short-term use of antiretroviral drugs to *reduce
> HIV* *transmission* from mother to infant

ARV treatment

ARV drugs are effective for both treating maternal HIV infection and
preventing MTCT. Several antiretroviral regimens reduce the risk of MTCT
in both breastfeeding and non-breastfeeding women. The mechanisms by
which these regimens prevent or reduce mother-to-child HIV transmission
include decreasing viral replication in the mother, leading to a
decrease in viral load in the infant and/or prophylaxis during and after
exposure to the virus.

Pregnant women who are HIV-infected need ARV treatment for their own
health should receive it, according to the treatment guidelines
recommended by WHO. ARV treatment during pregnancy, when indicated, will
improve the health of the woman and decrease the risk of transmission of
HIV to the infant.

ARV treatment is recommended in the following situations: For detailed
information, please refer to Appendix 1-A.

*If CD4 testing is available*, it is recommended that baseline CD4
counts be documented and ARV treatment offered to patients with:

-   **WHO Stage IV disease, irrespective of CD4 cell count**

-   **WHO Stage III disease** (including but not restricted to HIV
    wasting, chronic diarrhoea of unknown aetiology, prolonged fever of
    unknown aetiology, pulmonary TB, recurrent invasive bacterial
    infections, or recurrent or persistent mucosal candidiasis); **with
    consideration of using CD4 cell counts of less than 350/mm^3^ to
    assist with decision-making**[^1]

-   **WHO Stage I or II disease with CD4 cell counts of 200/mm^3^ or
    lower**[^2]

*If CD4 testing is unavailable*, it is recommended that ARV treatment be
offered to patients with:

-   **WHO Stage IV disease, irrespective of total lymphocyte count**

-   **WHO Stage III disease** (including but not restricted to wasting,
    chronic diarrhoea of unknown aetiology, prolonged fever of unknown
    aetiology, pulmonary TB, recurrent invasive bacterial infections, or
    recurrent/ persistent mucosal candidiasis), **irrespective of total
    lymphocyte count**[^3]

-   **WHO Stage II disease, with a total lymphocyte count of less than
    or equal to 1,200/mm^3^**[^4]

ARV treatment during pregnancy

For women diagnosed with HIV during pregnancy and eligible for treatment
with ARVs, treatment should be initiated as soon as possible. The start
of treatment may be delayed until after the first trimester. However,
when the woman is severely ill, the benefits of treatment outweigh any
potential risk to the foetus. Efavirenz (EFV), an antiretroviral drug
that is considered potentially teratogenic is not recommended until
after the first trimester of pregnancy and should be avoided in women of
childbearing age unless effective contraception can be ensured. Module 3
Appendix 3-B provides guidance for the use of antiretroviral drugs in
pregnant women and women of childbearing age.

> Pregnant women receiving ARV therapy
>
> Pregnant women receiving ARV therapy require ongoing care and
> monitoring within the local HIV/AIDS programme. When co-infection with
> TB exists, additional drug therapy and clinical management are
> required to minimise side effects that may occur when ARV drugs are
> coadministered with TB therapy.

ARV prophylaxis

Women who do not need treatment (ie, women who are not "eligible" for
treatment based on the criteria above), or do not have access to
treatment, should be offered prophylaxis to prevent MTCT using one of a
number of ARV regimens known to be effective. ARV prophylaxis regimens
vary and are selected based on efficacy, safety, drug resistance,
feasibility, and acceptability. Please refer to Appendix 3-A for a
complete listing of ARV prophylaxis regimens.

The first choice prophylaxis regimen for PMTCT

> Zidovudine (ZDV) starting at 28 weeks of gestation, or as soon as
> possible thereafter and intrapartum every 3 hours until delivery plus
> single-dose nevirapine (NVP) at the onset of labour for the mother,
> and single-dose NVP plus one week of ZDV for the infant.

Drug information

Zidovudine (ZDV, AZT)

-   Absorbed rapidly and completely after oral administration

-   Prenatal and neonatal exposure to ZDV is generally well tolerated

-   Mild anaemia may occur but usually resolves when treatment ends

-   May be taken with or without food

Nevirapine (NVP)

-   Absorbed rapidly and completely after oral administration and
    crosses the placenta quickly

-   Long half-life that benefits the infant

-   May be taken with or without food

Lamivudine (3TC)

-   Absorbed rapidly and completely after oral administration

-   May safely be taken with other medications that treat HIV-related
    symptoms

-   May be taken with or without food

> **WHO recommendations on longer prophylaxis regimens**
>
> Until recently, the emphasis of PMTCT guidelines has been on
> short-course prophylaxis (eg short-course zidovudine or short-course
> nevirapine in resource-constrained settings). New recommendations from
> WHO (2004) emphasise longer, combination prophylaxis regimens, where
> feasible, while recognising the need for short-course prophylaxis
> where longer regimens have not been provided or are not feasible.

SESSION 2 Antenatal Management of Women who are HIV-Infected and Women
with Unknown HIV Status

Antenatal care

Antenatal care improves the general health and well being of mothers and
their families. Given the rapid spread of HIV infection worldwide, all
pregnant women may be considered at risk for acquiring HIV infection.

The ANC setting is a main source of health care for women of
childbearing age. By integrating PMTCT services into essential ANC
services, healthcare programmes can improve care---and pregnancy
outcomes---for all their clients.

This session addresses integrating PMTCT services for and antenatal
management of women infected with HIV and women of unknown HIV status
within the context of ANC programmes.

[]{.mark}

Antenatal interventions can reduce the risk of MTCT. Good maternal
health care helps women with HIV infection stay healthy longer and care
for their children better. When mothers die prematurely, their children
face higher rates of illness and death.

For the successful implementation of PMTCT programmes, the following
elements need to be included as part of ANC:

-   Health information and education

-   Education about safer sex practices and HIV

-   HIV testing and counselling

-   Partner HIV testing and counselling

-   Interventions to reduce the risk of MTCT

-   Infant-feeding counselling and support for

-   Safe Motherhood including malaria and TB treatment

-   Diagnosis and treatment of sexually transmitted infections (STIs)

Antenatal care of women infected with HIV

ANC for women infected with HIV includes the basic services recommended
for all pregnant women. However, obstetric and medical care should be
expanded to address the specific needs of women infected with HIV. (See
Table 3.1.)

HIV infection in women of childbearing age presents a great challenge in
resource-limited settings. Determining a woman's HIV status is the first
step in providing appropriate treatment, care and support services,
including access to antiretroviral prophylaxis when indicated.
Availability of rapid testing allows women to be tested and receive
their HIV test results at the first prenatal visit. When HIV status is
known, mothers can be evaluated for ARV eligibility and offered the ARV
treatment and prophylaxis indicated, if available.

In some situations, because of the lack of accessible testing services
or because a woman refuses to be tested, her HIV status may remain
unknown. In such circumstances, the woman should be considered at risk
for MTCT, and she should be counselled accordingly during ANC. Women of
unknown HIV status should be made aware that testing is available at
later ANC visits and be reminded of the benefits of knowing their HIV
status.

Preventing opportunistic infections

Preventing opportunistic infections (OIs) can reduce rates of illness
and death among pregnant women who are HIV-infected. It also can reduce
the risk of adverse pregnancy outcomes, such as preterm labour and
delivery, which can increase the risk of MTCT.

**Prevention, screening, and treatment for TB, a leading cause of
mortality among persons who are HIV-infected, is particularly
important.\
Module 7, Appendix 7-A contains information on tuberculosis.**

Healthcare workers should pay special attention to signs and symptoms of
possible opportunistic infections and follow protocols for prophylaxis
of common problems. In Module 7, Appendix 7-C provides information about
*pneumocystis carinii* pneumonia (PCP) prophylaxis.

Assessment and management of HIV-related illnesses

HIV-related illnesses can increase the risk of MTCT. Women should be
monitored for signs or symptoms of progressive HIV/AIDS.

Recurrent or chronic infection

Women infected with HIV are susceptible to other infections that can be
treated in keeping with local protocols. Examples include the following:

-   TB

-   Urinary tract infections

-   Respiratory infections

-   Recurrent vaginal candidiasis

-   Malaria

Psychosocial and community support

Pregnancy is a time of unique stress, and healthcare workers may
consider assessing the amount of support a woman is receiving from
family and friends. Women with HIV usually have additional concerns
related to their own health, their child's health, confidentiality, and
the possibility that their HIV status might be disclosed to other
people. Referrals to AIDS support organisations and clubs should be
made.

  -----------------------------------------------------------------------
  Table 3.1 Essential Package of Integrated Antenatal Care Services

  Client history: Obtain routine data including medical, obstetric, and
  psychosocial history. Determine drug history, known allergies, and use
  of alternative medicines such as herbal products.

  Physical exam and vital signs: Include visual and hands-on exam and
  assess for current signs or symptoms of illness including AIDS,
  tuberculosis (TB), malaria and sexually transmitted infections (STIs).

  Abdominal exam: Include speculum and bimanual exams, where acceptable
  and feasible.

  Lab diagnostics: Perform routine serology for syphilis including
  testing for anaemia. Perform HIV testing as per country protocol based
  on availability and informed consent. When woman is HIV-positive,
  obtain CD4 count and RNA polymerase chain reaction (PCR) (measures
  viral load, response to ARV treatment), when available.

  **Tetanus toxoid immunisations:** Administer when appropriate.

  Nutritional assessment and counselling: Include iron and folate
  supplementation, monitor for anaemia, adequate caloric and nutrient
  intake, and recommend realistic diet adjustments based on local
  resources.

  STI screening: Include risk assessment for STIs. Diagnose and treat
  early according to protocols. Counsel about STIs, signs and symptoms
  and increased risk of HIV transmission. Educate to avoid transmission
  or re-infection.

  Opportunistic Infection (OI) Prophylaxis: Provide prophylaxis based on
  country protocols.

  Screening and care for other infections: Screen and treat any locally
  prevalent parasitic, bacterial, or fungal infections, including
  helminth infections. Treat herpes, candidiasis, PCP, and any other
  AIDS-related OIs.

  Tuberculosis (TB): Co-infection with tuberculosis is the leading cause
  of HIV mortality. All women presenting for ANC services with a cough of
  more than 2 weeks' duration should be screened for TB, regardless of
  HIV status. Specific treatment protocols are recommended for women
  infected with HIV, pregnant women, and women already receiving
  antiretroviral therapy.

  Antimalarials: Malaria is a major cause of high maternal and infant
  morbidity and mortality and is linked to increased MTCT (via placental
  infection). Malaria prophylaxis is needed in endemic areas; identify
  acute cases and treat aggressively and promptly. Use insecticide on bed
  nets where possible.

  ARV prophylaxis during pregnancy: Provide in accordance with country
  PMTCT protocol.

  ARV treatment during pregnancy: Refer for treatment when indicated
  according to country protocols.

  Counselling on infant feeding: All women require infant-feeding
  counselling and support. When women do not know their HIV status,
  exclusive breastfeeding should be promoted and supported. Women
  infected with HIV should consider replacement feeding when it is
  feasible, acceptable, affordable, accessible, and safe; otherwise,
  exclusive breastfeeding with early cessation is recommended.

  **Counselling on pregnancy danger signs:** Provide women with
  information and instructions on seeking early care for pregnancy
  complications such as bleeding, fever and pre-eclampsia.

  Counselling on HIV/AIDS danger signs: Provide women with information
  and instructions on seeking health care for symptoms of HIV disease
  progression, such as opportunistic infections, chronic persistent
  diarrhoea, candidiasis*,* fever or wasting. Refer women to AIDS
  treatment programmes when indicated and available.

  **Partners and family:** HIV-related stress and lack of support have
  been linked to progression of HIV infection. Refer women, partners, and
  families to community-based support clubs or organisations when
  possible.

  Effective contraception plan: Counsel about consistent use of condoms
  during pregnancy, as well as throughout postpartum and breastfeeding
  periods to avoid new infection, re-infection and further transmission.
  Include long-term family planning with partner involvement when
  possible.
  -----------------------------------------------------------------------

+-----------------+----------------------------------------------------+
| ### Exercise 3. |                                                    |
| 1 Antenatal car |                                                    |
| e: case studies |                                                    |
+-----------------+----------------------------------------------------+
| **Purpose**     | To review national or local policies on ANC and    |
|                 | PMTCT                                              |
|                 |                                                    |
|                 | To review antenatal management practices for women |
|                 | infected with HIV                                  |
+-----------------+----------------------------------------------------+
| **Duration**    | 25 minutes                                         |
+-----------------+----------------------------------------------------+
| *               | ### Part 1                                         |
| *Instructions** |                                                    |
|                 | -   Take a few minutes to become familiar with the |
|                 |     national or local policies on ANC and PMTCT.   |
|                 |                                                    |
|                 | -   Review the key points of the policies that the |
|                 |     facilitator has written on the flipchart.      |
|                 |                                                    |
|                 | -   Share your perceptions of how these policies   |
|                 |     are/are not applied in your clinical setting.  |
|                 |                                                    |
|                 | ### Part 2                                         |
|                 |                                                    |
|                 | -   Review copies of the two antenatal case        |
|                 |     studies, Exercise 3.1, and think about your    |
|                 |     responses to the questions posed.              |
|                 |                                                    |
|                 | -   Share your perceptions on the similarities and |
|                 |     differences in these case studies and the      |
|                 |     situations you encounter in your work setting. |
|                 |                                                    |
|                 | -   Describe HIV/PMTCT-related experiences that    |
|                 |     you have found challenging in the ANC setting. |
+-----------------+----------------------------------------------------+

Case study 1

Selma, a 22-year-old single woman, tested HIV-positive at her first
antenatal visit at 24 weeks gestation. At that time, she received
post-test counselling and was encouraged to bring her partner in for
testing. She is now 28 weeks pregnant with her first child.

*What are the ANC management steps that should be taken?*

Case study 2

You are an antenatal clinic midwife. Louisa, your patient, is 30 weeks
pregnant. When you ask her about her delivery plans, she says that she
wants to have the baby at home. She informs you that this is her third
child and even though she is HIV-infected, this pregnancy (like her
previous two) has been a healthy pregnancy. You can see that she is
determined to have a home delivery.

*What do you tell Louisa?*

*Consider how you would approach meeting ANC and PMTCT care needs in the
context of home delivery. What would your next steps be?*

> SESSION 3 Management of Labour and Delivery of Women Infected with HIV
> and Women with Unknown HIV Status
>
> **A significant number of infants, who are born to women who are\
> HIV-infected, become infected during labour and delivery. Adhering to
> standard practices for delivery and to procedures that reduce foetal
> exposure to maternal blood and secretions can reduce the risk of
> MTCT.**

Interventions that can reduce MTCT include the following:

Administer ARV treatment and prophylaxis during labour in accordance
with national protocols.

-   Continue ARV treatment/prophylaxis or implement ARV prophylaxis at
    labour\
    to reduce maternal viral load and provide protection to the infant.

Use good infection prevention practices for all patient care.

-   Use universal precautions, which include use of protective gear,
    safe use and disposal of sharps, sterilisation of equipment, and
    safe disposal of contaminated materials.

    (For additional information, see *Module 8: Safety and Supportive
    Care in the Work Environment.**)***

Minimise cervical examinations.

-   Perform cervical examination only when absolutely necessary and with
    appropriate clean technique.

Avoid prolonged labour.

-   Consider using oxytocin to shorten labour when appropriate.

-   Use noninvasive foetal monitoring to assess need for early
    intervention.

Avoid routine rupture of membranes.

-   Use a partogram to measure the progress of labour.

-   Avoid artificial rupture of membranes, unless necessary.

Avoid unnecessary trauma during delivery.

-   Avoid invasive procedures, including scalp electrodes or scalp
    sampling.

-   Avoid routine episiotomy.

-   Minimise the use of forceps or vacuum extractors.

Minimise the risk of postpartum haemorrhage.

-   Actively manage the third stage of labour.

-   Give oxytocin immediately after delivery.

-   Use controlled cord traction.

-   Perform uterine massage.

-   Repair genital tract lacerations.

-   Carefully remove all products of conception.

Use safe transfusion practices.

-   Minimise the use of blood transfusions.

-   Use only blood screened for HIV and when available syphilis,
    malaria, and hepatitis B and C.

Considerations regarding mode of delivery

Caesarean section, when performed before the onset of labour or membrane
rupture, has been associated with reduced MTCT.

Consider the benefits and risks of vaginal delivery versus elective
caesarean section, including the safety of the blood supply and the risk
of complications.

Strategies to reduce MTCT risk in women with unknown HIV status

In some cases, a woman presents to the health service at the time of
labour without knowing her HIV status. She may not have received ANC or
been offered HIV testing and counselling, she may have refused HIV
testing, or may not have received her test result. In order to prevent
MTCT in women with unknown HIV status the following steps may be taken:

[]{.mark}

Testing and counselling during labour

If *rapid testing* is available (See *Module 6: HIV Testing and
Counselling for PMTCT):*

-   Offer rapid HIV testing with right to refuse.

-   Mention benefits of the HIV test:

    -   If positive, ARVs can be administered for PMTCT and referral for
        treatment and care can be made.

        Describe the testing process.

        Provide post-test counselling.

It may be difficult to offer counselling or obtain informed consent
during labour. The healthcare worker should remain sensitive and
supportive to the woman. Rapid testing can be done in labour with
post-test counselling provided after delivery.

Providing ARVs at labour and delivery

ARV prophylaxis can be provided to the mother who is HIV-infected and
the infant to prevent MTCT. (See Appendix 3-A for the complete listing
of recommended regimens.)

Providing ARV prophylaxis without testing

-   Consider only as a last resort in high prevalence areas when no
    rapid testing is available.

-   Use single dose nevirapine as the prophylactic regimen.

-   Provide testing, counselling, and related PMTCT services postpartum.

+-----------------+----------------------------------------------------+
| ### Ex          |                                                    |
| ercise 3.2 Labo |                                                    |
| ur and delivery |                                                    |
|  ARV prophylaxi |                                                    |
| s: case studies |                                                    |
+-----------------+----------------------------------------------------+
| **Purpose**     | To review national policies on testing and         |
|                 | counselling during labour and on ARV prophylaxis.  |
|                 |                                                    |
|                 | To discuss administering ARV prophylaxis during    |
|                 | labour and delivery.                               |
+-----------------+----------------------------------------------------+
| **Duration**    | 25 minutes                                         |
+-----------------+----------------------------------------------------+
| *               | ### Part 1                                         |
| *Instructions** |                                                    |
|                 | -   Take a few minutes to become familiar with the |
|                 |     national policies on testing and counselling   |
|                 |     in labour and on ARV prophylaxis.              |
|                 |                                                    |
|                 | -   Review the key points written on the           |
|                 |     flipchart.                                     |
|                 |                                                    |
|                 | -   Comment on how these policies are applied in   |
|                 |     your clinical setting and share the challenges |
|                 |     and obstacles you face when applying these     |
|                 |     policies in your practice.                     |
|                 |                                                    |
|                 | ### Part 2                                         |
|                 |                                                    |
|                 | -   Review the 2 case studies below.               |
|                 |                                                    |
|                 | -   Think about the questions posed in the case    |
|                 |     studies and participate in the group           |
|                 |     discussion to answer the questions.            |
|                 |                                                    |
|                 | -   Review the key points written on the           |
|                 |     flipchart.                                     |
|                 |                                                    |
|                 | -   Share your perspective on the similarities and |
|                 |     differences in these case studies and the      |
|                 |     situations you encounter in your clinical      |
|                 |     setting.                                       |
|                 |                                                    |
|                 | -   Describe challenging HIV/PMTCT experiences in  |
|                 |     the labour and delivery care setting.          |
+-----------------+----------------------------------------------------+

Case study 1

Consuelo arrives at the labour and delivery unit. This is her first
baby. She hands you her ANC card, which indicates that she was tested
during pregnancy and is infected with HIV. Her water broke 4 hours ago
and her contractions are now less than 3 minutes apart. Consuelo earlier
received a NVP tablet to take at home. When you examine her, you find
that she is 5 centimetres dilated.

*After providing general support during labour, what is your first
priority?*

*If you discover that she has not taken her NVP tablet, what do you do?*

Case study 2

Deborah arrives to deliver. This is her fourth child and she tells you
that she has had a good pregnancy. Deborah has received no antenatal
care and was never tested for HIV. At this time, her contractions are
regular and about 2 minutes apart. During your examination, you find
that she is 7 centimetres dilated.

*Considering your national policy on testing and counselling during
labour and delivery, what are your next steps?*

SESSION 4 Immediate Postpartum Care of Women who are HIV-Infected and
Women with Unknown HIV Status

Postpartum care of women infected with HIV

When providing postpartum care to women infected with HIV, healthcare
workers may follow routine protocols, but several areas require
additional attention:

Continuing care

Encourage and make plans for continued health care in the following
areas:

-   Routine gynaecologic care, including pap smears, if available.

-   Ongoing treatment, care and support for HIV/AIDS and opportunistic
    infections along with nutritional support.

-   Treatment and monitoring of TB and malaria.

-   Referral for antiretroviral treatment (or treatment eligibility)

-   Referral for prophylaxis and treatment of OIs.

    *(For additional information,* see *Module 7, Linkages to Treatment,
    Care and Support for Mothers and Families with HIV Infection.)*

Newborn feeding

-   Ensure that the mother chooses feeding options before she leaves the
    facility or hospital after delivery.

-   Support the mother's choice of feeding option. *(*See *Module 4,
    Infant Feeding in the Context of HIV Infection,* for additional
    information*).*

-   Provide training and observe proper feeding technique prior to
    discharge.

Signs and symptoms of postnatal infection

Review the following symptoms of infection before the new mother leaves
the clinic or hospital and provide her with information on where to seek
treatment for:

-   Burning with urination

-   Fever

-   Foul smelling lochia

-   Cough, sputum, shortness of breath

-   Redness, pain, pus, or drainage from incision or episiotomy

-   Severe lower abdominal tenderness

**Education**:

-   Instruct the mother on perineal and breast care

-   Ensure that the mother knows how to dispose of potentially
    infectious materials such as lochia and blood-stained sanitary pads

Family planning

Contraception and child spacing should be discussed with every woman
during antenatal care and again in the immediate postpartum period. The
main family planning goals for the woman who is HIV-infected are:

-   Preventing unintended pregnancy

-   Appropriate child spacing, which can help reduce maternal and infant
    morbidity and mortality

*(*See *Module 2,* *Overview of HIV Prevention in Mothers, Infants and
Young Children* for additional information.)

Postpartum care of women with unknown HIV status

Women whose HIV status is unknown should receive the same postpartum
care as women with HIV infection (outlined above). They should be
encouraged to be tested for HIV and to follow national recommendations
for feeding their infants.

HIV testing after delivery can assist women infected with HIV to:

-   Initiate post-exposure ARV prophylaxis for the infant

-   Choose safer infant-feeding options

+-----------------+----------------------------------------------------+
| ### Exercis     |                                                    |
| e 3.3 Immediate |                                                    |
|  postpartum car |                                                    |
| e of women who  |                                                    |
| are HIV-infecte |                                                    |
| d: Case studies |                                                    |
+-----------------+----------------------------------------------------+
| **Purpose**     | To review postnatal management of the woman with   |
|                 | HIV infection.                                     |
+-----------------+----------------------------------------------------+
| **Duration**    | 25 minutes                                         |
+-----------------+----------------------------------------------------+
| *               | -   Take a few minutes to become familiar with the |
| *Instructions** |     national policies on postpartum care.          |
|                 |                                                    |
|                 | -   Review the case studies below on immediate     |
|                 |     postpartum care of women infected with HIV and |
|                 |     women with unknown HIV status.                 |
|                 |                                                    |
|                 | -   Think about the questions posed in the case    |
|                 |     studies and participate in the group           |
|                 |     discussion to answer the questions.            |
|                 |                                                    |
|                 | -   Review the key points written on the           |
|                 |     flipchart.                                     |
|                 |                                                    |
|                 | ```{=html}                                         |
|                 | <!-- -->                                           |
|                 | ```                                                |
|                 | -   Share your perspective on the similarities and |
|                 |     differences in these case studies and the      |
|                 |     situations you encounter in your clinical      |
|                 |     setting.                                       |
|                 |                                                    |
|                 | -   Describe experiences that you have found       |
|                 |     challenging in the postnatal care setting.     |
+-----------------+----------------------------------------------------+

Case study 1

Deborah presented to the labour and delivery ward without having had an
HIV test during her pregnancy. The result of the rapid HIV test
performed during labour was positive. When told of the test result,
Deborah became upset but agreed to take the NVP tablet. Subsequently,
she had an uneventful labour and delivered a 2.4 kg healthy boy she
named William. Although breastmilk substitute is available at the
clinic, Deborah is determined to breastfeed her baby. It is now two
hours after her delivery and she is resting. Her mother and husband are
staying with her.

*What postpartum care does she require?*

*What HIV-specific services does she need?*

*What can you accomplish before she leaves the facility in 24 hours?*

Case study 2

Consuelo, who is HIV-positive, has been following the ZDV and NVP
regimen for herself and her child. After a short labour, she delivered a
2 kg girl named Samantha. Consuelo has chosen to use breastmilk
substitute; she will be discharged in 48 hours.

*What postpartum care does she require?*

*What HIV-specific services does she need?*

*What can you do to support her infant-feeding choice?*

*What services can you provide to her before she leaves in 24 hours?*

*What continuing support do you anticipate providing to her?*

SESSION 5 Immediate Newborn Care of Infants who are HIV-Exposed and
Infants with Unknown HIV Status

The immediate care of the newborn exposed to HIV follows standard
practice. Regardless of the mother's HIV status, all infants are kept
warm after birth and are handled with gloves until maternal blood and
secretions have been washed off.

Immediate newborn care

-   Maintain universal precautions throughout care and treatment. Wear
    gloves when giving injections, and clean all injection sites with
    surgical spirits. Dispose of all needles according to facility
    policy.

-   Clamp cord immediately after birth, and avoid milking the cord.
    Cover the cord with gloved hand or gauze before cutting.

-   Wipe infant's mouth and nostrils with gauze when the head is
    delivered.

-   Use suction only when meconium-stained liquid is present. Use either
    mechanical suction at less than 100 mm Hg pressure or bulb suction,
    rather than mouth-operated suction.

-   Wipe the infant dry with a towel.

-   Determine the mother's feeding choice. If she is using breastmilk
    substitute, place the infant on her body for skin-to-skin contact
    and provide help with the first feeding. If she is breastfeeding,
    place the infant on the mother's breast.

-   Administer vitamin K, silver nitrate eye ointment, and Bacille
    Calmette Guérin (BCG) according to national guidelines.

ARV prophylaxis

ARV prophylaxis should be administered to the newborn according to
country protocol. (See Appendix 3-A).

Follow-up newborn care

Care of the newborn baby should follow standard practices. Care for
babies exposed to HIV should follow the approach described in *Module*
*7, Linkages to Treatment, Care and Social Support for Mothers and
Families with HIV Infection.*

Infants born to mothers with unknown HIV status

In the immediate postpartum period, the goal is to reduce MTCT by
minimising newborn exposure to maternal blood and body fluids and by
providing ARV prophylaxis to the newborn. When HIV testing is
unavailable or the mother's HIV status is unknown, newborn care should
follow national or local policy.

-   Newborns of mothers with unknown HIV status should be tested as soon
    as possible after birth, if the mother consents.

-   In some high-prevalence settings, national policy could recommend
    that all babies be given a single oral dose of nevirapine 2 mg/kg
    liquid suspension as soon as possible after birth, if the mother
    consents, whether or not the mother has been tested for HIV.

-   The mother should receive counselling about feeding her infant, as
    described in *Module 4, Infant Feeding in the Context of HIV
    Infection.*

+-----------------+----------------------------------------------------+
| ### Exerc       |                                                    |
| ise 3.4 Immedia |                                                    |
| te newborn care |                                                    |
|  of infants who |                                                    |
|  are HIV-expose |                                                    |
| d: case studies |                                                    |
+-----------------+----------------------------------------------------+
| **Purpose**     | To review ARV prophylaxis for and newborn care of  |
|                 | infants exposed to HIV.                            |
+-----------------+----------------------------------------------------+
| **Duration**    | 25 minutes                                         |
+-----------------+----------------------------------------------------+
| *               | -   Take a few minutes to become familiar with the |
| *Instructions** |     national policies on newborn care of infants   |
|                 |     exposed to HIV.                                |
|                 |                                                    |
|                 | -   Read the 2 case studies below on immediate     |
|                 |     newborn care of infants exposed to HIV.        |
|                 |                                                    |
|                 | -   Discuss your responses with other participants |
|                 |     in the large group discussion.                 |
+-----------------+----------------------------------------------------+

Case study 1

Deborah has just delivered her son, William. She tested HIV-positive
during labour.

*What HIV-specific infant interventions are required after the birth?*

*What are the components of follow-up care for William?*

*How can you help Deborah manage ongoing HIV-related care for herself
and her infant?*

Case study 2

Samantha, the newborn daughter of Consuelo (who is HIV-positive), is
irritable and cries often. Consuelo's mother-in-law, who is visiting her
at the facility and will be helping care for the infant after discharge,
is worried. You overhear her repeatedly telling Consuelo that the baby
needs breastmilk and that the breastmilk substitute is not satisfying
the baby.

*What can you do to help Consuelo at this stressful time?*

*What support will Consuelo need from the PMTCT programme to continue
using breastmilk substitute after discharge?*

Home birth case study

Louisa was diagnosed as HIV-positive during her one ANC visit prior to
delivery at home. She has returned to the health centre 6 days after the
birth of Teresa, her daughter. The baby appears to be happy, well
hydrated, and thriving. Louisa remains convinced she is not infected
with HIV and that the baby is not at risk. In fact, she did not give the
NVP syrup to Teresa because the baby "didn't need it" and Teresa is
breastfeeding.

*Is this a typical response in your setting?*

*What services would you offer this mother?*

*What follow-up and referrals are necessary for this mother and her
infant?*

*How will you deal with her denial of her diagnosis and risk for her
infant?*

Module 3: Key Points

-   Integrating PMTCT services into the essential package of ANC
    services promotes improved care for all pregnant women and provides
    the best opportunity for a successful PMTCT programme.

-   Specific interventions to reduce MTCT include ARV treatment and
    prophylaxis, safer delivery procedures, and counselling and support
    for safe infant feeding.

-   Using antiretroviral drugs for treatment and prophylaxis reduces the
    risk of MTCT. Longer-course combination regimens are more effective,
    but short-course prophylaxis regimens may be more feasible in some
    resource-constrained settings.

-   PCP prophylaxis and the prevention and treatment of TB and malaria
    are part of comprehensive care for mothers infected with HIV and
    their infants.

-   Safer delivery procedures include avoiding unnecessary invasive
    obstetrical procedures and offering the option of elective caesarean
    section when safe and feasible.

-   Infant-feeding options to minimise the risk of MTCT require support
    and guidance throughout ANC, labour and delivery and postpartum.

APPENDIX 3-A Antiretroviral prophylaxis regimens to prevent MTCT

HIV-related treatment, care and support must be provided during the
antenatal and postpartum periods. All HIV-exposed infants should be
followed-up for diagnosis of HIV, prophylaxis of opportunistic
infection, and treatment, care and support.

**All regimens are administered by mouth. Paediatric formulations are
needed for all infant regimens. Efforts must be made to monitor for side
effects and support maternal infant adherence.**

+----------+----------------+-------------+----------+----------------+
| > **     | >              | > **In      | > **Post | >              |
| Course** |  **Antenatal** | trapartum** | partum** |  **Postnatal** |
+==========+================+=============+==========+================+
| > **Zi   | **Mother:**    | *           | None     | > **Infant:**  |
| dovudine |                | *Mother:**\ |          |                |
| > (ZDV)  | ZDV 300 mg     | ZDV 300 mg  |          | NVP 2mg/kg     |
| > and    | twice a day    | at onset of |          | oral           |
| > ne     | starting at 28 | labour and  |          | suspension     |
| virapine | weeks or as    | every 3     |          | immediately    |
| >        | soon as        | hours until |          | after birth    |
|  (NVP)** | possible       | delivery    |          | and ZDV 4      |
|          | thereafter     | and         |          | mg/kg twice a  |
|          |                | single-dose |          | day for 7 days |
|          |                | NVP 200 mg  |          |                |
|          |                | at onset of |          |                |
|          |                | labour      |          |                |
+----------+----------------+-------------+----------+----------------+
|          |                | OR          |          | OR             |
|          |                |             |          |                |
|          |                | ZDV 600 mg  |          | > NVP 2 mg/kg  |
|          |                | at onset of |          | > oral         |
|          |                | labour      |          | > suspension   |
|          |                |             |          | > immed-iately |
|          |                |             |          | > after birth  |
+----------+----------------+-------------+----------+----------------+
| >        | > **Mother:**  | >           | None     | > **Infant:**  |
|  **ZDV** | >              | **Mother:** |          |                |
|          | > ZDV 300 mg   |             |          | ZDV 4 mg/kg    |
|          | > twice a day  | ZDV 600 mg  |          | twice a day    |
|          | > starting at  | at onset of |          | for 7 days     |
|          | > 28 weeks or  | labour      |          |                |
|          | > as soon as   |             |          | OR             |
|          | > possible     | OR          |          |                |
|          | > thereafter   |             |          | ZDV 2 mg/kg 4  |
|          |                | ZDV 300 mg  |          | times\         |
|          |                | at onset of |          | a day for 7    |
|          |                | labour and  |          | days           |
|          |                | every 3     |          |                |
|          |                | hours until |          |                |
|          |                | delivery    |          |                |
+----------+----------------+-------------+----------+----------------+
| > **ZDV  | > None         | > None      | > None   | > **Infant:**  |
| > and    |                |             |          |                |
| > NVP    |                |             |          | NVP 2 mg/kg    |
| > for    |                |             |          | oral\          |
| >        |                |             |          | suspension     |
| infant** |                |             |          | immediately    |
| >        |                |             |          | after birth    |
| > (when  |                |             |          | and ZDV\       |
| > mother |                |             |          | 4 mg/kg twice  |
| > has    |                |             |          | a day for 7    |
| >        |                |             |          | days. When ZDV |
| received |                |             |          | oral           |
| > no ARV |                |             |          | suspension not |
| > prop   |                |             |          | available NVP  |
| hylaxis) |                |             |          | 2 mg/kg as     |
|          |                |             |          | soon as        |
|          |                |             |          | possible after |
|          |                |             |          | delivery and a |
|          |                |             |          | dose of NVP 72 |
|          |                |             |          | hours after    |
|          |                |             |          | birth          |
+----------+----------------+-------------+----------+----------------+
| >        | > None         | **Mother:** | > None   | > **Infant:**  |
|  **NVP** |                |             |          |                |
|          |                | Single-dose |          | NVP 2 mg/kg    |
|          |                | NVP 200 mg  |          | oral           |
|          |                | at onset of |          | suspension     |
|          |                | labour      |          | immediately    |
|          |                |             |          | after birth    |
+----------+----------------+-------------+----------+----------------+
| > **ZDV  | **Mother:**    | >           | **M      | > **Infant:**  |
| > and    |                | **Mother:** | other:** |                |
| > la     | ZDV 300 mg and |             |          | ZDV 4 mg/kg    |
| mivudine | 3TC 150 mg     | ZDV 300 mg  | ZDV 300  | and 3TC 2      |
| >        | twice a day    | every 3     | mg and   | mg/kg twice a  |
|  (3TC)** | starting at 28 | hours until | 3TC 150  | day for 7 days |
|          | weeks or as    | delivery    | mg twice |                |
|          | soon as        | and 3TC 150 | a day    |                |
|          | possible       | mg every 12 | for 7    |                |
|          | thereafter     | hours until | days     |                |
|          |                | delivery    |          |                |
+----------+----------------+-------------+----------+----------------+

= First choice regimen

APPENDIX 3-A Antiretroviral prophylaxis regimens to prevent MTCT
*(continued)*

+----------+----------------+------------+-----------+----------------+
| ######## | >              | > **Int    | > **Pos   | >              |
| # Course |  **Antenatal** | rapartum** | tpartum** |  **Postnatal** |
+----------+----------------+------------+-----------+----------------+
| > **ZDV  | None           | > *        | > **      | > **Infant:**  |
| > and    |                | *Mother:** | Mother:** |                |
| > 3TC**  |                |            |           | ZDV 4 mg/kg    |
|          |                | ZDV 600 mg | ZDV 300   | and 3TC 2      |
|          |                | and 3TC    | mg and    | mg/kg twice a  |
|          |                | 150 mg at  | 3TC 150   | day for 7 days |
|          |                | onset of   | mg twice  |                |
|          |                | labour     | a day     |                |
|          |                | followed   | for\      |                |
|          |                | by ZDV 300 | 7 days    |                |
|          |                | mg every 3 |           |                |
|          |                | hours and  |           |                |
|          |                | 3TC 150 mg |           |                |
|          |                | every\     |           |                |
|          |                | 12 hours   |           |                |
|          |                | until      |           |                |
|          |                | delivery   |           |                |
+----------+----------------+------------+-----------+----------------+
| >        | > **Mother:**  | > *        | None      | > **Infant:**  |
|  **ZDV + |                | *Mother:** |           |                |
| > 3TC +  | ZDV 300 mg,    |            |           | NVP 2 mg/kg    |
| > sa     | 3TC 150 mg and | Continue   |           | oral           |
| quinavir | SQV/r 1000     | antenatal  |           | suspension     |
| >        | mg/100 mg      | dosing     |           | immediately    |
|  (SQV/r) | twice a day    | schedule   |           | after birth    |
| > \***   | starting at 36 |            |           |                |
| >        | weeks or as    |            |           | OR             |
| > (Co    | soon as        |            |           |                |
| nsidered | possible       |            |           | ZDV 4 mg/kg    |
| > for    | thereafter     |            |           | twice\         |
| > MTCT   |                |            |           | a day for 7    |
| > pro    |                |            |           | days           |
| phylaxis |                |            |           |                |
| > in     |                |            |           | OR             |
| > women  |                |            |           |                |
| > not    |                |            |           | > NVP 2 mg/kg  |
| >        |                |            |           | > oral         |
|  needing |                |            |           | > suspension   |
| > ARV    |                |            |           | > immediately  |
| >        |                |            |           | > after birth  |
| therapy) |                |            |           | > and ZDV\     |
|          |                |            |           | > 4 mg/kg      |
|          |                |            |           | > twice a day  |
|          |                |            |           | > for 7 days   |
+----------+----------------+------------+-----------+----------------+
| > **ZDV  | > **Mother:**  | > *        | None      | > **Infant:**  |
| > or     | >              | *Mother:** |           |                |
| > s      | > ZDV 300 mg   | >          |           | NVP 2 mg/kg    |
| tavudine | > and 3TC 150  | > Continue |           | oral           |
| > (d4T)  | > mg and NVP\  | >          |           | suspension     |
| > +**    | > 200 mg twice |  antenatal |           | immediately    |
| >        | > a day        | > dosing   |           | after birth    |
| >        | >              | > schedule |           |                |
|  **3TC + | > OR           |            |           | OR             |
| >        | >              |            |           |                |
| NVP**^+^ | > d4T 40 mg,   |            |           | ZDV 4 mg/kg    |
| >        | > 3TC 150 mg   |            |           | twice\         |
| > (When  | > and NVP 200  |            |           | a day for 7    |
| > used   | > mg twice a   |            |           | days           |
| > for    | > day starting |            |           |                |
| > t      | > at 36 weeks  |            |           | OR             |
| reatment | > or as soon   |            |           |                |
| > in     | > as possible  |            |           | NVP 2 mg/kg    |
| >        | > thereafter   |            |           | suspension     |
| pregnant |                |            |           | immediately    |
| > women, |                |            |           | after birth    |
| > this   |                |            |           | and ZDV\       |
| >        |                |            |           | 4 mg/kg twice  |
|  regimen |                |            |           | a day for 7    |
| > also   |                |            |           | days           |
| >        |                |            |           |                |
| provides |                |            |           |                |
| > MTCT   |                |            |           |                |
| > proph  |                |            |           |                |
| ylaxis.) |                |            |           |                |
+----------+----------------+------------+-----------+----------------+

**\*** In women who do not require ARV, alternative triple-combination
regimens for MTCT prophylaxis may be considered. If the woman is in the
third trimester of pregnancy, these regimens may include ZDV + 3TC +
nelfinavir (NFV) or ZDV + 3TC + efavirenz (EFV).

^+^ In women who require ART, this is the recommended first-line
regimen. However, in the third trimester of pregnancy, a regimen
consisting of ZDV (or d4T) + 3TC + EFV may be considered.

APPENDIX 3-B Clinical situations and recommendations for the use of
antiretroviral drugs in pregnant women and women of child-bearing
potential in resource-constrained settings

+---------------------+------------------------------------------------+
| **Clinical          | **Recommendation**                             |
| Situation**         |                                                |
+=====================+================================================+
| **A:** HIV-infected | ######## First-lin                             |
| women with          | e regimens: ZDV + 3TC + NVP or d4T + 3TC + NVP |
| indications for     |                                                |
| initiating ARV      | Efavirenz (EFV) should be avoided in women of  |
| treatment^1^ who    | childbearing age, unless effective             |
| may become pregnant | contraception can be assured. Exclude          |
|                     | pregnancy before starting treatment with EFV.  |
+---------------------+------------------------------------------------+
| **B:** HIV-infected | **Women**                                      |
| women receiving ARV |                                                |
| treatment who       | -   Continue the current ARV regimen^2^ unless |
| become pregnant     |     it contains EFV. If it does, substitution  |
|                     |     with NVP or a PI should be considered if   |
|                     |     in the 1^st^ trimester.                    |
|                     |                                                |
|                     | -   Continue the same ARV regimen during the   |
|                     |     intrapartum period and after delivery.     |
|                     |                                                |
|                     | **Infants**                                    |
|                     |                                                |
|                     | -   If born to women receiving either 1^st^ or |
|                     |     2^nd^-line ARV regimens: 1-week ZDV OR     |
|                     |     single-dose NVP OR 1-week ZDV and single   |
|                     |     dose NVP.                                  |
+---------------------+------------------------------------------------+
| **C:** HIV-infected | **Women**                                      |
| pregnant women with |                                                |
| indications for ARV | -   Follow the treatment guidelines as for     |
| treatment^1^        |     non-pregnant adults except that EFV should |
|                     |     not be given in the 1st trimester.         |
|                     |                                                |
|                     | -   First line regimens: ZDV + 3TC + NVP or    |
|                     |     d4T + 3TC + NVP                            |
|                     |                                                |
|                     | -   Consider delaying therapy until after the  |
|                     |     1st trimester, although in severely ill    |
|                     |     women the benefits of early therapy        |
|                     |     clearly outweigh the potential risks.      |
|                     |                                                |
|                     | **Infants**                                    |
|                     |                                                |
|                     | -   1-week ZDV OR single-dose NVP OR 1-week    |
|                     |     ZDV and single-dose NVP.                   |
+---------------------+------------------------------------------------+

APPENDIX 3-B Clinical situations and recommendations for the use of
antiretroviral drugs in pregnant women and women of child-bearing
potential in resource-constrained settings *(continued)*

+--------------------+-------------------------------------------------+
| **Clinical         | **Recommendation**                              |
| Situation**        |                                                 |
+--------------------+-------------------------------------------------+
| **D:**             | ##### First-choice regimen: ZDV and NVP         |
| HIV-infected       |                                                 |
| pregnant women     | # Women                                         |
| without            |                                                 |
| indications for    | -   ZDV starting at 28 weeks or as soon as      |
| ARV treatment^1^   |     possible thereafter. Continue ZDV at the    |
|                    |     same dose in labour. In addition, women     |
|                    |     should receive single-dose NVP at the onset |
|                    |     of labour.                                  |
|                    |                                                 |
|                    | # Infants                                       |
|                    |                                                 |
|                    | -   Single-dose NVP and 1-week ZDV^3^           |
|                    |                                                 |
|                    | ##### Alternative regimen: NVP only             |
|                    |                                                 |
|                    | **Women**                                       |
|                    |                                                 |
|                    | -   Single-dose NVP                             |
|                    |                                                 |
|                    | **Infants**                                     |
|                    |                                                 |
|                    | -   Single-dose NVP                             |
|                    |                                                 |
|                    | ##### Alternative regimen: ZDV only             |
|                    |                                                 |
|                    | # Women                                         |
|                    |                                                 |
|                    | -   ZDV starting at 28 weeks or as soon as      |
|                    |     possible thereafter. Continue in labour.    |
|                    |                                                 |
|                    | **Infants**                                     |
|                    |                                                 |
|                    | -   1-week ZDV^3^                               |
|                    |                                                 |
|                    | ##### Alternative regimen: ZDV + 3TC            |
|                    |                                                 |
|                    | # Women                                         |
|                    |                                                 |
|                    | -   ZDV + 3TC starting at 36 weeks or as soon   |
|                    |     as possible thereafter. Continue in labour  |
|                    |     and for 1 week postpartum.                  |
|                    |                                                 |
|                    | **Infants**                                     |
|                    |                                                 |
|                    | -   1-week ZDV + 3TC                            |
+--------------------+-------------------------------------------------+
| **E:**             | Follow the recommendations in Situation D, but  |
| HIV-infected       | preferably use the most efficacious regimen     |
| pregnant women     | that is available and feasible.                 |
| with indications   |                                                 |
| for starting ARV   |                                                 |
| treatment^1^ but   |                                                 |
| treatment is not   |                                                 |
| yet available      |                                                 |
+--------------------+-------------------------------------------------+
| **F:**             | If ARV treatment is initiated, consider^4^:     |
| HIV-infected       | (ZDV or d4T) + 3TC + SQV/r.                     |
| pregnant women     |                                                 |
| with active        | If treatment is initiated in the third          |
| tuberculosis       | trimester (ZDV or d4T) + 3TC +EFV can be        |
|                    | considered.                                     |
|                    |                                                 |
|                    | If ARV treatment is not initiated, follow the   |
|                    | recommendations in Situation D.                 |
+--------------------+-------------------------------------------------+

APPENDIX 3-B Clinical situations and recommendations for the use of
antiretroviral drugs in pregnant women and women of child-bearing
potential in resource-constrained settings *(continued)*

+---------------------+------------------------------------------------+
| **Clinical          | **Recommendation**                             |
| Situation**         |                                                |
+---------------------+------------------------------------------------+
| **G:** Pregnant     | If there is time, offer HIV testing and        |
| women of unknown    | counselling to women of unknown status and if  |
| HIV status at the   | positive, initiate intrapartum ARV             |
| time of labour or   | prophylaxis.                                   |
| women in labour     |                                                |
| known to be         | Women                                          |
| HIV-infected who    |                                                |
| have not received   | -   Single-dose NVP. If in advanced labour do  |
| ARV drugs before    |     not give the dose but follow the           |
| labour              |     recommendations in Situation H.            |
|                     |                                                |
|                     | #### Infants                                   |
|                     |                                                |
|                     | -   Single-dose NVP                            |
|                     |                                                |
|                     | **Women**                                      |
|                     |                                                |
|                     | -   ZDV + 3TC in labour and 1-week ZDV + 3TC   |
|                     |     postpartum                                 |
|                     |                                                |
|                     | #### Infants                                   |
|                     |                                                |
|                     | -   1-week ZDV+3TC                             |
|                     |                                                |
|                     | If there is insufficient time for HIV testing  |
|                     | and counselling during labour, then offer      |
|                     | testing and counselling as soon as possible    |
|                     | postpartum. Follow the recommendations in      |
|                     | Situation H for women testing positive         |
|                     | postpartum.                                    |
+---------------------+------------------------------------------------+
| **H:** Infants born | Infants                                        |
| to HIV-infected     |                                                |
| women who have not  | -   Single-dose NVP as soon as possible after  |
| received any ARV    |     birth and 1-week ZDV                       |
| drugs               |                                                |
|                     | If the regimen is started more than 2 days     |
|                     | after birth, it is unlikely to be effective.   |
+---------------------+------------------------------------------------+

^1^ WHO recommendations for initiating ARV treatment in HIV-infected
adolescents and adults. If CD4 testing is available it is recommended to
offer ARV treatment to patients with: WHO Stage IV disease irrespective
of CD4 cell count, WHO Stage III disease with consideration of using CD4
cell counts less than 350 10^6^ cells/L to assist decision-making and
WHO Stage I and II disease in the presence of a CD4 cell count less than
200 10^6^ cells/L. If CD4 testing is unavailable, it is recommended to
offer ARV treatment to patients with WHO Stage III and IV disease
irrespective of total lymphocyte count or WHO Stage II disease with a
total lymphocyte count less than 1200 10^6^ cells/L.

^2^ Conduct clinical and laboratory monitoring as outlined in the 2003
revised WHO treatment guidelines.

^3^ Continuing the infant on ZDV for four to six weeks can be considered
if the woman received antepartum ARV drugs for less than four weeks.

^4^ ABC can be used in place of SQV/r; however, experience with ABC
during pregnancy is limited. In the rifampicin-free continuation phase
of tuberculosis treatment, an NVP-containing ARV regimen can be
initiated.

*Source:* WHO*. 2004. Antiretroviral drugs for treating pregnant women
and preventing HIV infection in infants: guidelines on care, treatment
and support for women living with HIV/AIDS and their children in
resource-constrained settings*. pp 39--41.

[^1]: CD4 count advisable to assist with determining need for immediate
    therapy. For example, pulmonary TB can occur at any CD4 level, and
    other conditions can be mimicked by non-HIV aetiologies (eg, chronic
    diarrhoea, prolonged fever).

[^2]: The precise CD4 count above 200/mm^3^ at which ARV treatment
    should be initiated has not been established.

[^3]: The recommendation to start ARV treatment in all patients with
    stage III disease, without reference to total lymphocyte counts
    reflects a consensus of experts. The discussion took into account
    the need for a practical recommendation that allows clinical
    services and TB programmes in severely constrained settings to offer
    access to ARVs to their patients. As some adults and adolescents
    with stage III disease will be presenting with CD4 counts above
    200/mm^3^, some of them will receive antiretroviral treatment before
    the CD4 less than 200/mm^3^ threshold is reached. However, if CD4
    counts cannot be determined, the experts did not consider starting
    ARVs earlier in these patients to be problematic.

[^4]: A total lymphocyte count of less than or equal to 1200/mm^3^ can
    be substituted for the CD4 count when the latter is unavailable and
    HIV-related symptoms exist. It is not useful in the asymptomatic
    patient. Thus, in the absence of CD4 cell testing, asymptomatic
    HIV-infected patients (WHO Stage I) should not be treated because
    there is currently no other reliable marker in severely
    resource-constrained settings.