Table of contents
Preface
Message
Executive summary
Abbreviations
Chapter 1: Overview of Prevention of Parent to Child Transmission
of HIV/AIDS (PPTCT)
Chapter 2: Voluntary, confidential, counseling and testing (VCCT)
Chapter 3: Antenatal care for HIV positive pregnant mothers – ARV
treatment and prophylaxis
Chapter 4: Management of HIV in Labour and Delivery
Chapter 5: Postpartum management
Chapter 6: Treatment, Care and Support for HIV positive mothers,
their infants and families
Chapter 7: HIV and Infant Feeding
Chapter 8: Stigma and discrimination
Chapter 9: Safety and Care at the Work Place
Chapter 10: Monitoring and Evaluation
Annexes
1. Procurement and Supply Management of ARVs and HIV related Supplies
2. Nutritional care and support of pregnant and lactating women
3. WHO clinical staging of HIV for infants and children with established HIV infection
4. Questionnaire for HIV risk screening during ANC
References
Executive summary
Parent to child transmission of HIV/AIDS is the most significant mode of transmission of HIV in children. It can transmit during pregnancy, delivery and breastfeeding, and without any form of intervention the transmission rate vary between 25 – 40 %. However, despite the fact that few and relatively basic interventions can reduce the rate of transmission from parent to child to less than 2 %, more than half a million children were infected with HIV/AIDS globally in 2006[1].
In Bangladesh the first case of HIV was discovered in 1989, but the country is still a HIV low prevalence country with 1495 reported cased as of December 2008[2]. However, many factors (behavioral, geographical and socio-cultural) suggest that the epidemic could increase rapidly at any point in the near future. Based on reports from self help organizations it is apparent that vertical transmission is happening, and the number of HIV positive children under the age of 10 is increasing.
Prevention of Parent To Child Transmission of HIV (PPTCT) in Bangladesh is still in its early phases. However, the initiative of supporting and counseling HIV positive women who are pregnant was already put forth by the National Policy on HIV/AIDS and STD Related Issues developed in 1996. Since then this has become a focus area of the National Strategic Plan for HIVAIDS 2004 – 2010 where the Government of Bangladesh has committed itself to strengthening PPTCT programmes through capacity building, care and support.
These national priorities are in line with the 2001 UNGASS declaration which also underlines the importance of reducing HIV infection among infants and children, and improving health care and treatment for HIV positive women and children[3]. Likewise, they are fundamental for the achievement of the 6th Millennium development Goal of halting and beginning to reverse the spread of HIV/AIDS.
Global evidence points out that women are at increased risk of contracting HIV due to their relative low socio-economic status as well as limited decision making power in matters related with sexuality, and in Bangladesh women are often at increased risk of contracting HIV, merely due to their position as spouses. Thus it is of vital importance that PPTCT programmes are established and focus not only on preventing transmission from HIV positive pregnant women to their infants, but also address prevention ofprimary HIV infection in mothers to be.
At the same time it is imperative that the PPTCT services also recognizes the need to address and reach men, as male involvement in the programme is essential, regardless of their HIV status. By involving husbands and partners from the very beginning in the Voluntary, Confidential Counseling and Testing (VCCT) they not only become aware of their HIV status, but their support may also be evoked, which eases the difficult choices and necessary activities to be undertaken by the HIV positive pregnant women regarding ART adherence, infant feeding practices and the necessary post natal care and support.
As a result of this recognition – the significance and role of both parents in the process of vertical transmission – the term parent to child transmission of HIV has been adopted as the term used in Bangladesh, and is thus applied throughout this Guideline.
This first version of the National PPTCT Guideline is primarily designed to guide health workers at the implementing facilities. However, it also targets national-level programme planners and managers involved in ANC and responsible for designing services for PPTCT. Additionally it is a useful reference and orientation resource for front line health care workers involved in care and treatment of infants and children in programmes such as IMCI.
It goes through all the aspects of a comprehensive PPTCT programme, starting from the VCCT provided through ANC to ARV treatment, care and support throughout pregnancy, safe delivery and post partum follow up.
Thus it provides comprehensive guidance on complex issues such as infant feeding, it offers an understanding of HIV related stigma and discrimination and explains the procedures necessary in order to maintain safety at the workplace within the context of working with HIV.
In this way the PPTCT Guideline is a wide-ranging document, which will provide the users with the correct technical information, and assist the development of PPTCT interventions in clinical settings.
The Guideline has been developed based on existing regional PPTCT guidelines and publications and adapted to the Bangladeshi context through a consultative process, involving a wide range of technical experts within the field of HIV. It is meant to exist as a dynamic and live document which should be updated regularly incorporating the newest and most up to date information and evidence within the field of HIV/AIDS and PPTCT.
At the same time it is to be supplemented with the existing relevant manuals and guidelines which provide more specific guidance on technical issues, such as the National Guideline for Antiretroviral Therapy for HIV/AIDS in Bangladesh and the WHO/UNICEF publication Management of HIV infection and Antiretroviral Therapy in infants and Children, documents which are all referred to throughout.
Abbreviations
3TCLamivudine
AIDS Acquired Immunodeficiency Syndrome
ANC Antenatal Care
ART Antiretroviral Therapy
ARV Antiretroviral
BHUBasic Health Unit
d4T Stavudine
EFV Efavirenz
HAARTHighly Active Antiretroviral Therapy
HIV Human Immunodeficiency Virus
IDUInjecting drug user
IECInformation, education and communication
IUDIntra-Uterus Device
MCHMaternal and Child Health
MTCTMother to child transmission
NVP Nevirapine
PI Protease inhibitor
PCP Pneumocystis jiroveci Pneumonia
PNCPostnatal Care
PLWHAPeople living with HIV/AIDS
PMTCT Prevention of Mother to Child Transmission of HIV
PPTCTPrevention of Parent to Child Transmission of HIV
PTCTParent-to-child transmission of HIV
TBTuberculosis
VCCTVoluntary Confidential Counseling and Testing
ZDV Zidovudine
Globally an estimated 420 000 children became infected with HIV in 2007[4]. The overwhelming majority of the infected children acquire the infection through Parent to Child Transmission of HIV (PTCT), which can occur during pregnancy, delivery and the breast feeding period.As of December 2007 33.2 million people were living with HIV. Out of them 15.4 were women and 2.5 million were children[5].
Heterosexual transmission is the primary mode of HIV transmission among girls and women. Girls and young women are 2-6 times more vulnerable to HIV infection then their male counterparts[6]. Throughout the developing world the proportion of women infected with HIV continues to grow, as women are often at increased risk of contracting HIV, due to gender inequality which also leads to gender based violence and discrimination. Women have limited decision making power in matters related with sexuality, and have little say in whether their partner engages in extra-marital and risky sexual relations. As women are often dependent on their male partners, both culturally, socially and economically, their negotiation power regarding the practice of safe sex is substantially reduced.
HIV infection in pregnancy is associated with significant maternal morbidity and mortality. Without interventions infected children die early and uninfected children are left without parents. Apart from the human tragedy, society has to bear the loss of working people and the expense of looking after the orphans.
- More than 90% of the children living with HIV/AIDS were infected through PTCT.
- Without interventions, rates of transmission are 25-40% in the developing country and 15 -25% in the developed countries.
- The combination of early diagnosis of infection, ART, safer obstetric practice and infant feeding counseling and support can reduce the risk to less than 2%.
1.1 Timing of HIV Transmission
Without any interventions, the risk of transmission differs at various stages:
- During Pregnancy 5 – 10%
- Intra-partum 10 - 20 %
- Postpartum period 5 – 20%
1.1.2 Factors that will increase the risk for HIV transmission
Pregnancy / Labour & Delivery / Breast feedingHigh maternal viral load (newly acquired HIV infection or advanced AIDS)
Viral, bacterial, or parasitic placental infection (e.g. malaria)
Untreated Sexually transmitted infections (STIs)
Maternal malnutrition (indirect cause) / High maternal viral load (newly acquired HIV infection or advanced AIDS)
Prolonged labour (Rupture of membranes more than 4 hours before labour begins)
Invasive delivery procedures that increase contact with the mother's infected blood or body fluids (e.g., episiotomy, fetal scalp monitoring)
First infant in multiple birth
Chorioamnionitis (from untreated STI or other infection) / High maternal viral load (newly acquired HIV infection or advanced AIDS)
Duration of breastfeeding (the longer the duration, the greater the risk)
Early mixed feeding of infant (e.g., food or fluids in addition to breast milk)
Breast abscess, mastitis and cracked or bleeding nipples
Maternal malnutrition (indirect cause)
Oral disease in the baby (e.g., thrush or sores)
1.2.1Situation of HIV in Bangladesh
The first case of HIV was detected in Bangladesh in 1989, and since then a total of 1495 cumulative cases of HIV have been confirmed and reported by the end of December 2008[7]. Out of them 476 people have developed AIDS, and 165 have already died. However, it is estimated that the number of unknown cases of HIV could be at least around 7,500. Due to limited access to and acceptability of voluntary counseling and testing services less than 5 % of the HIV positive people are aware of their HIV status. As these numbers indicate Bangladesh is still considered a HIV low prevalence country, but as demonstrated in the 6thround serological surveillance study the HIV prevalence among IDUs in central Bangladesh was 7 % and thus approaching a concentrated epidemic[8]. Moreover, many factors (behavioral, geographical and socio-cultural) suggest that the epidemic could explode, just as figures indicate that vertical transmission is happening. Although there is still no reporting system for PPTCT in Bangladesh, different NGOs and self support groups addressing issues of care and support to HIV positive people reportthat 32 HIV positive children have been found among the total number of 1495 reported HIV positive cases.
As in many other developing countries, women in Bangladesh are also at increased risk of contracting HIV. Women are expected to be ignorant of sexuality issues and their access to HIV prevention information and protective measures are limited. Gender inequality, gender based violence and general social subordination means that women lack access to land, education, employment opportunities and inheritance, while their health and nutrition needs are often not adequately met. As a natural result their negotiation powers in relation with sexual matters are substantially reduced, and men hold overwhelming power in decisions on sexual matters, including whether to use condoms.
The health care system is not at all accustomed to working with HIV positive people, and they are many times rejected from the hospitals. The fear of stigma and discrimination makes it difficult for people to expose their status, and poses a very important challenge for the success of the implementation of PPTCT. Hence one of the most important tasks for the implementation process is to build capacity along with improving the knowledge and attitudes of health care providers.
Bangladesh has taken important steps to ensure safe blood supplies by adopting a Safe Blood Legislation (2002) and by scaling up laboratory facilities in selected blood banks. However, the private sector supplies one third of the blood transfusions and is not regulated. It may be assumed that the risk of transmission through blood transfusion is higher for women who often receive transfusions more frequently than men due to anaemia or complications related to childbirth. However, there is no data available to support this assumption as the recording of blood transfusion is not disaggregated by sex.
1.2.2Awareness and knowledge of HIV
In Bangladesh a culture of silence exists around what is considered sensitive issues such as reproductive health and sexuality. As a natural result awareness of HIV among the general public is still low,although it has increased in recent years. According to the Demographic and Health Survey carried out by MoHFW in 2004, around 60 % of women and 82 % of men have heard about AIDS, but more detailed and in-depth knowledge is absent. Less than one fifth of women know that condoms can prevention the transmission of HIV, and similarly less than one third of men can name just one way to avoid HIV infection[9].
Among high risk behavior groups knowledge of AIDS is substantially higher. 95% of Intravenous Drug Users (IDUs) have heard of HIV/AIDS and are well aware of the risks of transmission, but still 65 % report sharing needles when injecting. Likewise Female Sex Workers (FSW) also have substantial knowledge of HIV. But again the practice of safe behaviors is limited and only 2-4 % of FSW practice consistent condom use with their clients – the lowest rate in Asia[10].
1.3National Policy for PPTCT
In Bangladesh the issue of parent to child transmission of HIV was first brought to the forefront back in 1996, when it was stated in the National Policy on HIV/AIDS and STD Related Issues that support and counseling should be given to HIV positive women who are pregnant. This was followed up in the National Strategic Plan for HIV/AIDS 2004 – 2010 where the Government of Bangladesh has committed itself to strengthening PPTCT programmes through involvement of male, capacity building of service providers and providing follow up care and support to families and children affected by HIV. An allocation has been kept in the revised Health, Nutrition and Population Sector Programme (HNPSP) for PPTCT activities and in addition provision has been made for procurement of ARVs.
The Joint Forum meeting for incorporating the consultation on integrating Prevention of STI/RTI/HIV into MCH and family Planning held inKuala Lumpurin December 2006 recommended incorporating PPTCT into maternal and child health services, thereby effectively linking issues of maternal health, sexual and reproductive health and HIV prevention. Based on the global recommendation, the Government of Bangladesh has also decided that the locus of the PPTCT services will be through thematernal health program of the DGHS.
1.4Aim of PPTCT
The aim of PPTCT interventions is to maintain the current low HIV epidemic status in Bangladesh by preventing new HIV infections among women of reproductive age and their children through integrating PPTCT into MCH/FP/RH/ANC settings. This guideline will contribute to the planning and implementation of a comprehensive package of PPTCT interventions taking into account Bangladesh’s low HIV prevalence and incidence, established HIV infection among high risk behavior groups and the financial, human resources and capacities of the current health care system to respond.
1.4.1Objectives of PPTCT
- Reduce the number of children born with HIV
- Reduce the number of women of childbearing age becoming infected with HIV
- Reduce the number of unintended pregnancies among HIV positive women
- Among HIV positive children Increase the number who live longer and healthier lives through early diagnosis and supportive therapy
- Among HIV positive mothers Increase the number who live longer and healthier lives and are better able to nurture and care for their children through early diagnosis and supportive therapy
1.5Four prong approach
The comprehensive PPTCT approach consists of a combination of interventions offered to prevent HIV infection at different stages of the life cycle: among pre-marital, young married couples, women of reproductive age and their husbands/partners, and pregnant women. It also ensures that there is adequate and appropriate follow-up care, treatment and support for women and children after delivery. The approach extends primary prevention initiatives across the spectrum of health systems and services, linking with safe motherhood (maternal health), interventions of ante-natal care (ANC), family planning services for couples, sexual and reproductive health services (STI prevention and management), safe delivery and post-natal care (PNC), where efforts should be exerted for pregnant women and their partners to remain negative.
This approach which is referred to as the “Four Prong Approach” and contains the following activities:
Primary prevention of HIV in parents to be / Prevention of unintended pregnancies among HIV- positive women / Prevention of transmission from an HIV- positive woman to her infant / Care and Support for HIV-positive women, their infants and their husband/partnersPromotion of safer sexual behavior by :
- Behavior change communication/counseling to ensure adoption of protective behaviors
- Promotion and provision of condoms
- Prevention, diagnosis and treatment of sexually transmitted diseases
- Offering VCCT to couples of reproductive age
VCCT services / Offer comprehensive PPTCT services including:
- VCCT services
- Provide ART for prophylaxis and treatment
- Counseling and support for safe infant feeding
- Optimal obstetric practices
- Family planning
Counseling on infant feeding
Post partum care for mothers and infants
Nutritional advise and support
Palliative care
Home based care
Refer families to support groups
1.6Strategies