Malawi PMTCT Trainer Manual

Module 3 Specific Interventions to Prevent Mother- to-Child Transmission of HIV (PMTCT)

/ Total Time: 265 minutes

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

  • Describe all essential components of antenatal care (ANC) for a woman who is
    HIV-infected.
  • Explain the role of antiretroviral drugs (ARVs) in preventing mother-to-child transmission of HIV (PMTCT).
  • Describe strategies for reducing the risks of MTCT during labour and delivery.
  • Discuss the management of women during labour and delivery who are of unknown HIV status.
  • Describe immediate postpartum care of women with HIV infection.
  • Explain the need to integrate family planning into community services.
  • Describe guidelines for immediate newborn care.

Unit 1Implementation of Comprehensive ANC Services

Activity/Method / Time
Interactive lecture / 20 minutes
Exercise 3.1 Antenatal care: case studies / 25 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 55 minutes

Unit 2Antiretroviral Prophylaxis and Therapy for PMTCT

Activity/Method / Time
Interactive lecture / 20 minutes
Exercise 3.2 Nevirapine prophylaxis for PMTCT: case studies / 30 minutes
Questions and answers / 5 minutes
TOTAL UNIT TIME / 55 minutes

Unit 3Optimal Management of Women During Labour and Delivery

Activity/Method / Time
Interactive lecture / 20 minutes
Exercise 3.3 Obstetric practices and HIV: group discussion / 25 minutes
Exercise 3.4 HIV testing and ARV prophylaxis during labour and delivery: case studies / 35 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 90 minutes

Unit 4Postpartum Management of Women and Infants

Activity/Method / Time
Interactive lecture / 30 minutes
Exercise 3.5 Supporting postpartum follow-up: group discussion / 25 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 65 minutes
/ Trainer Instructions
Slides 1-3

Begin by reviewing the module objectives listed above.

UNIT 1Implementation of Comprehensive ANC Services

/ Advance Preparation
The trainer should become familiar with the appendices and be prepared to integrate the content into the presentation. .
Review Exercise 3.1. If necessary, adapt the cases and the names to reflect typical scenarios at the clinics where participants work. The trainer should consider speaking with clinic staff to adapt the cases.
/ Total Time: 55 minutes
/ Trainer Instructions
Slides 4-5

Introduce the unit and review objectives.

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

  • Describe all essential components of antenatal care (ANC) for a woman who is HIV-infected.

/ Trainer Instructions
Slides 6-7

Beginthe discussion of quality reproductive health services and the importance of integrating PMTCT services into antenatal care, using the information below.

/ Make These Points
  • Confidential HIV testing services must be made available to all women.
  • Testing and counselling serve as the gateway to PMTCT interventions.
  • Women who refuse HIV testing should be offered counselling to address their concerns and reservations. If they continue to decline testing, this decision must be respected. They should be informed that if they change their mind, or want to discuss this further, testing and counselling will be available throughout their pregnancy.

Antenatal care

Antenatal care (ANC) is an essential part of quality reproductive health services and improves the general health and well-being of mothers and their families. Given the rapidspread of HIV infection worldwide, all pregnant women should be considered at risk for acquiring HIV infection.

The ANC setting is an important 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 unit addresses the integration of PMTCT services into ANC for all women, as well as the management of pregnant HIV-infected women and women of unknown HIV status in ANC programmes.

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.

Components of quality ANC and reproductive health relevant to PMTCT

Determining a woman’s HIV status is the first step in providing appropriate treatment, care and support services. Availability of rapid testing allows women to be tested and receive their HIV test results at the first prenatal visit. In the context of PMTCT, components of quality ANC and reproductive health services include (see also Module 2, Unit 4: Role of Maternal and Child Health Services and Reproductive Health Services for the Prevention of HIV Infection in Infants and Young Child):

  • Comprehensive antenatal services
  • Routine HIV testing and counselling
  • Counselling on the use of antiretroviral drugs for PMTCT prophylaxis. If the woman meets eligibility criteria for initiating ARV therapy, she should receive counselling about that as well.
  • Safer infant feeding counselling and support
  • Quality intrapartum care that avoids unnecessary invasive procedures and adheres to infection-prevention practices.
  • Quality postpartum care that includes:
  • Safer infant feeding counselling and support
  • Family planning services
  • Comprehensive follow up care for both the HIV-infected mother and her HIV-exposed baby

The woman who refuses HIV testing during ANC should be counselled so she has an opportunity to have her reservations about testing addressed. Where available and appropriate, she should also be offered couples counselling. Women of unknown HIV status should be made aware that testing is available at any ANC visit and reminded of the benefits of knowing their HIV status. If they continue to decline testing, this decision must be respected. They should be informed that if they change their mind, or want to discuss this further, testing and counselling will continue to be available throughout their pregnancy.

/ Trainer Instructions
Slides 8-10

Discuss routine ANC and ANC for women who are HIV-infected using the following information.

/ Make These Points
  • A comprehensive approach to the care of the woman who is HIV-infected is important for a successful PMTCT services.
  • Screening for, and treatment of, HIV-related conditions and common illnesses can greatly improve the quality of life for pregnant women living with HIV infection.
  • Male involvement in birth preparedness is important, especially for women with HIV, as it provides an opportunity for the male partners to hear about PMTCT and its benefits from the healthcare worker.

Integrated essential package for ANC services

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.

Table 3.1: Integrated essential package for ANC services

Integrated essential package for ANC services
Schedule of ANC visits
  • First visit
/ Within the first 16 weeks
  • Second visit
/ Between 20 and 24 weeks
  • Third visit
/ Between 28 and 32 weeks
  • Fourth visit
/ From 36 weeks
Every pregnant woman should have at least 4 ANC visits. There is no need to increase the number of antenatal visits for HIV-infected women, unless there are complications. However additional counselling time may be required.
Client history / Determine the following:
  • History of puerperal sepsis, postpartum haemorrhage, infected caesarean section wound, pre-term labour and delivery, and/or history of abortions
  • Past infant-feeding practices; growth and development of the previous child, history of still birth
  • History of HIV Testing and Counselling (HTC, formerly referred to as “VCT”) and ARV therapy
  • History of chronic cough or tuberculosis
  • Drug history, known allergies, and use of traditional medicines such as herbal products.

History of present pregnancy / Determine the following:
  • History and treatment of STIs for woman and partner
  • History of significant weight loss
  • History of recurrent fever, diarrhoea, and/or cough

Social history / Enquire about:
  • Death of children in previous two years and cause of death
  • Death of partner and cause of death
  • Nature of relationship with partner, e.g., monogamous, polygamous, casual relationship

Physical exam and vital signs / Perform full physical exam to assess for current signs or symptoms of illness, targeting common symptoms of TB, malaria, anaemia, and sexually transmitted infections (STIs). Assess for/perform the following:
  • General appearance
  • Height and weight
  • Nutritional status (skin fold measurement)
  • Anaemia (check sclera and nails, auscultate heart)
  • Lymphadenopathy
  • Full breast exam
  • Full gynaecological exam, speculum and bimanual (inspecting for evidence of STIs)
  • Abdominal exam (checking size of uterus, spleen and liver)
  • Intra uterine growth retardation
  • Lung sounds (evidence of TB or other respiratory infections)
Avoid any unnecessary assessment that would potentially rupture a woman’s membranes.
Lab tests /
  • Request the following lab tests:
  • Haemoglobin to test for anaemia
  • Whole blood rapid test for syphilis
  • HIV testing if patient did not decline testing
  • Urinalysis
  • Others according to history and physical exam findings

STI screening /
  • Diagnose and treat early according to national protocols, refer if necessary
  • Include risk assessment for STIs.
  • Counsel about STIs, their signs and symptoms and how STIs increase the risk of HIV transmission.
  • Educate about how to avoid transmission or re-infection.

HIV-related conditions /
  • Treat according to national guidelines or refer
  • Provide prophylaxis based on national protocol.

  • Tuberculosis
/ Co-infection with TB is the leading cause of HIV mortality.
  • Prevention and screening
  • If pulmonary TB is suspected, refer for registration in national programme and for sputum collection

  • Antimalarials
/ Malaria is a major cause of maternal and infant morbidity and mortality rates and is linked to increased MTCT (via placental infection).
  • Administer malaria prophylaxis according to national protocol.

Immunizations /
  • Immunize according to national guidelines

ARV prophylaxis and/or therapy: /
  • Determine stage and eligibility for therapy at ARV Clinic
  • Refer to ARV Clinic if eligible according to national guidelines
  • If woman is not eligible for ARV therapy, counsel and educate her about use and benefits of ARV prophylaxis

Nutritional assessment, counselling, and support /
  • Include iron and folate supplementation according to national guidelines
  • Monitor for anaemia, adequate caloric, and nutrient intake.
  • Counsel about proper diet based on local resources.
  • Consider providing supplements of protein and energy rich food to high risk mothers (primigravida, multiple gestation, grandmultipara, women with anaemia, and those who are malnourished)
  • De-worm according to national guidelines.

Health Education /
  • Provide ongoing education about HIV.
  • Encourage mother to deliver at a health facility

Counselling on infant feeding /
  • Provide infant-feeding counselling and support.

Key support needs of mothers infected with HIV

Living Positively
“Living Positively with HIV” refers to living with HIV disease healthily and productively. That is, maintaining physical, psychological and emotional health. Having dependable sources of counselling and support to health in an effort to lead a happier, more fulfilling life. HIV/AIDS is a major medical condition that must be taken seriously, but it is not necessarily a death sentence.

Pregnancy is a time of unique stress, and healthcare workers should consider assessing the amount of support a woman is receiving from family and friends. Both mothers who are HIV-infected and those who are not HIV-infected need support. However, women with HIV infection usually have additional concerns related to their own health, their child’s health, and the possibility that their HIV status may be disclosed to other people. Providing support to mothers who are infected with HIV will lead to more hope and acceptance, essential elements for “living positively” (see box). Referrals for clients with HIV and their families may include the following:

  • Food along with nutritional counselling and supplementation
  • Practical necessities such as clothing and housing
  • Social and psychological support, including counselling as well as peer support such as groups for people living with HIV and groups for mothers.
  • Home care, including referrals to community-based health care (CBHC) and community based distribution (CBD) agents
  • Traditional/herbal healers
  • Orphan care and support
  • Care of children with HIV/AIDS, including growth monitoring

Additional information about linkages and referrals can be found in Module 8.

/ Trainer Instructions
Slides 11-12

Discuss the prevention of HIV-related conditions as well as other recurrent or chronic infections.

Introduce the basic principles of maternal nutrition and the prevention of MTCT.

Preventing HIV-related conditions

Preventing HIV-related conditions 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.

All women who are infected with HIV and have HIV-related conditions should be treated according to the treatment guidelines and within the context of the available resources in Malawi. In situations where such services are not available, a woman should be referred for appropriate management of the infections to other centres that have the capability.

Women infected with HIV are more susceptible to common infections. Healthcare workers should pay special attention to signs and symptoms of possible HIV-related conditions, and follow guidelines for treatment and prophylaxis of common problems (see Module 7 for additional information). Examples of common conditions that affect HIV-infected women are

  • TB
  • Urinary tract infections
  • Respiratory tract infections
  • Recurrent vaginal candidiasis
  • Malaria
  • Breast conditions
  • Unhealed episiotomies and/or delayed healing of caesarean section wounds
  • Herpes zoster
  • Puerperal sepsis

Maternal nutrition and mother-to-child transmission

Maternal nutrition during pregnancy and lactation is of considerable importance in preventing mother-to-child transmission of HIV. A well-nourished woman is likely to be in good health. However, nutritional deficiencies, such as iron and Vitamin A deficiency, are associated with an increased risk of mother-to-child transmission of HIV. Maternal malnutrition is also associated with preterm delivery, a factor that significantly increases the risk of HIV infection in the infant.

Weight gain during pregnancy is an indicator of the mother’s nutritional status. See Table 3.2 below for recommendations on weight gain in pregnancy.

Table 3.2 Recommended weight gain during pregnancy

Women’s pre-pregnancy weight / Recommended weight gain (kg)
Normal / 11.5- 18.0
Underweight / 12.5-18.0
Overweight / 7.0-11.5

See Appendix 3-A for additional information about maternal nutrition in the context of HIV.

/ Trainer Instructions
Slide13

Facilitate Exercise 3.1 to explore community and individual-level challenges to the provision of integrated ANC services in Malawi. Please note that the first case study is used to review all the services required in ANC. Responses listed to case study questions are for illustration and are not the only “correct” answers. Do not provide or read the answers to participants. However, they can be used as prompts to help participants respond to the questions.

Exercise 3.1 Antenatal care: case studies
Purpose / To review ANC management in the context of HIV.
Duration / 25 minutes
Introduction / The purpose of this exercise is to review ANC management in the context of HIV.
Activities / Using information in this unit, ask participants—who will remain in the large group for this exercise—to comment on whether these services (i.e. PMTCT services and the services described in “Table 3.1: Integrated essential package for ANC services) are being provided in their clinical settings.
  • Ask participants about any challenges or obstacles they may have experienced in their ANC settings related to providing these services.
  • The Participant Manual includes copies of the ANC case studies.
  • Ask a volunteer to read the narrative section of the first case study.
  • Ask participants for answers to the questions posed in the case study.
  • Repeat these steps for the second case study.
  • Determine whether any participants disagree with the answers offered.
  • Ask whether this case study is similar to cases the participants may have encountered when providing ANC.
  • Write exceptions (i.e., ways in which the participants’ experiences differ from the case studies) on the flipchart.
  • Ask participants to describe a particular case that has challenged them in the ANC clinical setting, and how they resolved the case.

Debriefing /
  • Summarize how the local policies are reflected in local practice.
  • Remind participants that the policies serve as practice guidelines.
  • Mention that each case is as unique as the person or circumstances involved.