Malawi PMTCT Trainer Manual

Module 2Overview of HIV Prevention in Mothers,Infants and Young Children

/ Total Unit Time: 185 minutes

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

  • Discuss the epidemiology of MTCT in Malawi.
  • Discuss biological, social and cultural factors explaining women’s vulnerability to HIV infection.
  • Define mother-to-child transmission of HV infection (MTCT).
  • Explain the factors that influence the transmission of HIV from mother to child.
  • Discuss the four elements of a comprehensive approach to prevention of HIV infection in infants and young children.
  • Describe the role of maternal and child health (MCH) and reproductive health (RH) services in the prevention of HIV infection in infants and young children.

Have the following additional materials available, whenever possible:

  • Flipchart for exercise 2.2
  • Supply of male condoms and, if available, female condoms for exercise 2.3
  • Male anatomical models for demonstration of condom use, if available, for exercise 2.3.
  • Paper strips (one for each participant) measuring about 5 x 8 cm for exercise 2.4.
  • A basket, bowl or paper bag to hold paper strips for exercise 2.4

Unit 1HIV in Malawi

Activity/Method / Time
Interactive lecture / 15 minutes
Exercise 2.1 Epidemiology of HIV: interactive discussion / 10 minutes
Exercise 2.2 Local HIV-related terminology: interactive discussion / 20 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 55 Minutes

Unit 2Mother-to-Child Transmission of HIV Infection

Activity/Method / Time
Interactive lecture / 30 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 40 minutes

Unit 3Comprehensive Approach to Prevention of HIV Infection in Infants and Young Children

Activity/Method / Time
Interactive lecture / 20 minutes
Exercise 2.3 Supporting condom use: discussion and demonstration / 30 minutes
Exercise 2.4 The handshake game: interactive game and discussion / 20 minutes
Questions and answers / 5 minutes
TOTAL UNIT TIME / 75 minutes

Unit 4Role of Maternal and Child Health Services and Reproductive Health Services for the Prevention of HIV Infection in Infants and Young Children

Activity/Method / Time
Interactive lecture / 10 minutes
Questions and answers / 5 minutes
TOTAL UNIT TIME / 15 minutes
/ Trainer Instructions
Slides 1-3

Begin by introducing the module, and reviewing the module objectives listed above.

UNIT 1 HIV in Malawi

/ Advance Preparation
The trainer should become familiar with the local and national epidemiology of HIV so that you feel comfortable presenting the HIV and MTCT information in this unit.
In preparation for Exercise 2.2, the trainer may wish to ask colleagues working in the HIV prevention and care field or any related field to name the local terms and phrases used to discuss sex, STIs, HIV disease and/or condoms.
/ 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:

  • Discuss the epidemiology of MTCT in Malawi.
  • Discuss biological, social and cultural factors explaining women’s vulnerability to HIV infection.

/ Trainer Instructions
Slides 6-8

Briefly review the national data on HIV and MTCT epidemiology below.

/ Make These Points
  • Discuss local rates of HIV infection particularly among women, and the impact on PMTCT services.
  • Emphasize that HIV can spread very rapidly. Many countries in Africa that had very low rates of HIV infection among pregnant women a decade ago now have high infection rates. For example, HIV prevalence in Swaziland among pregnant women soared to 43% in 2004, up from 34% in 2000 and 4% in 1992.
  • In Malawi, the epidemic has not exhausted its potential for growth.

MTCT epidemiology in Malawi

Review of national HIV, AIDS and MTCT facts and figures

The implications of the epidemic are serious:

  • According to UNICEF, there are over 800,000 orphans in Malawi. The cumulative number of orphans in this country is directly related to the AIDS epidemic is approximately 400,000. This figure is expected to increase by more than 60,000 per year.
  • The death rate for adults aged 15-49 has tripled since 1990.
  • The number of tuberculosis cases is triple what it would have been without the HIV epidemic.

The need for expanded services is large:

  • Approximately 185,000 people were in need of antiretroviral treatment as of 2005.
  • An even larger number need testing and counselling services to learn their HIV status.
  • About 500,000 pregnant women who need comprehensive antenatal care, including HIV testing and counselling.
  • About 80,000 of these women will be HIV-infected and will need PMTCT services to prevent passing HIV to their children.

/ Trainer Instructions

Lead participants through a discussion of the local epidemiology of HIV.

Exercise 2.1 Epidemiology of HIV: interactive discussion
Purpose / To involve the participants in a discussion about the local epidemiology of HIV.
Duration / 10 minutes
Introduction / Ask participants their perspective on the data about HIV infection in Malawi provided in this module and Module 1.
Activities /
  • Ask participants to tell you what factors they — as individual and as healthcare workers — think are fuelling the epidemic.
  • Ask participants to consider and discuss whether these factors could create a rapid increase in HIV prevalence as experienced by other countries, such as Mozambique.
  • Write their responses on the flipchart or board in the front of the room.

Debriefing / Summarize the exercise by noting that HIV and MTCT are fuelled by a number of individual behaviours, which may be shaped by a range of personal, social, cultural, political and legal factors.
/ Trainer Instructions
Slides 9-13

Introduce the concept of gender and HIV. Tell participants that in Malawi young women (between the ages of 15-24) are more than twice as likely to be HIV-infected then men of the same age. Why do they think this is so? When presenting the material below, focus on points not mentioned by participants.

/ Make These Points
  • There are many biological, social and cultural factors to explain why women are more vulnerable to HIV infection than men. Awareness of these factors is the first step in addressing the issue of gender and HIV at an individual and community level.

Gender and HIV

  • Both men and women are vulnerable to HIV infection; however, unlike women in other regions in the world, African women are at least 1.3 times more likely to be infected with HIV than men. The gender difference is most pronounced among young people aged 15–24 years. In Malawi, women between the ages of 15 and 24 are 2.2 times more likely to be HIV-infected than their male counterparts in the same age group. In sub-Saharan Africa, women in this age group are 3 times as likely to be HIV-infected as their male counterparts (UNAIDS, Women and AIDS Fact Sheet, Malawi; AIDS Epidemic Update, UNAIDS, December 2004). The female vulnerability to HIV infection has been attributed to many factors: biological, social and cultural.

Socio-cultural factors that make women vulnerable to HIV infection:

  • Less formal education
  • Inability of women and young girls to negotiate for safer sex
  • Vulnerability to, pressure from, and infidelity of male counterparts
  • Trauma and bleeding caused by sexual intercourse at an early age, and at a time of physical immaturity, increases exposure to HIV infection.
  • When a woman marries at a young age, she is exposed to older men who may be HIV-infected.
  • Forced sex due to rape or sexual abuse increases a woman’s risk of infection.
  • Economic pressures and lack of job opportunities force women to exchange sex for the necessities of survival – food, shelter and safety
  • Lack of access to appropriate information on HIV and other sexually transmitted infections (STIs).

Biological factors that make women vulnerable to HIV infection:

  • The cells in the cervix; “the Langerhans” cells, may provide a portal of entry for HIV. It is suggested that some HIV serotypes are attracted to these cells and that they are therefore more efficient for heterosexual transmission of HIV.
  • Vulva and vaginal inflammation or ulceration may facilitate entry of the virus.
  • Silent chlamydial and other STI infections (including pelvic inflammatory disease (PID)) may facilitate acquisition of HIV. It has been reported (in Zimbabwe) that women with genital ulceration are 6 times more likely to be HIV positive than women without genital ulcerations.
  • STIs in women are frequently undiagnosed because:
  • Asymptomatic infection (symptoms are either not present or observable only on internal examination)
  • Unable to recognize symptoms
  • Lack of access to care and treatment services
  • Changes in the vaginal flora characterized by bacterial vaginosis facilitate transmission of HIV.
  • Presence of cervical ectopy is a risk factor for HIV transmission.
  • Sexual intercourse during menstruation increases the risk of HIV transmission.

Socio-cultural factors that influence the sexual behaviour of men. Common risk factors for HIV infection in men include:

  • Failure to seek proper care for HIV and other STIs due to lack of knowledge, lack of comfort with being in healthcare settings, and/or stigma
  • Culturally-accepted practice of having multiple sex partners both in and out of wedlock
  • Ego-driven behaviours to display manhood, including alcohol abuse that may lead to high-risk sexual practices
  • Peer pressure from other young men to conform to unsafe sex practices without regard for consequences

Youth of both genders are more vulnerable to HIV infection because of the following factors:

  • Lack of information on sexuality and their own physical development
  • Lack of skills to negotiate delaying sexual debut, reducing the number of partners, using condoms correctly and every time they have sex, substance use or abuse
  • Limited access to health services, including testing and counselling, risk reduction with condom use, and testing and treatment of STIs.

/ Trainer Instructions
Slide14

End this unit and transition to the next one, which begins the discussion of mother-to-child transmission of HIV, by emphasizing that PMTCT services function within region-specific, cultural, and social contexts. PMTCT services in this country will look much different than in Russia, for example. Healthcare workers, clients and policy makers often use local terminology when discussing HIV, AIDS and related topics. Use the interactive discussion below to define some of the terms used in Malawi.

Exercise 2.2 Local HIV-related terminology: interactive discussion
Purpose / To determine local language used in HIV prevention, care and treatment programmes.
Duration / 20 minutes
Introduction / HIV disease has fostered the development of words in every language to describe the disease, how it is transmitted, how it is prevented, and those infected and at risk. Although these terms are at times stigmatizing, it is important that as healthcare workers we are familiar with the language used by and about our patients. Additionally, it is important that providers are consistent with their use of words for new concepts.
Activities /
  • In a local language, have the healthcare worker briefly discuss the risks of HIV transmission from a mother to her baby during pregnancy, during labour and delivery, and when breastfeeding—as he or she would explain these concepts to a patient.
  • Ask the group to identify the words and concepts used locally that are the most useful and clear when working with pregnant women. Concepts where consensus might be important include: window period, condom, HIV, virus, ARVs, replacement feeding, stigma and disclosure.
  • Ask the group to list the words used to describe HIV disease and people who are HIV-infected.
  • Write these words on the flipchart; chose the most appropriate words to describe each concept, and agree to use this language to avoid misinformation or stigmatizing language.

Debriefing / These concepts can be communicated to pregnant women, even if they have not existed previously in the local language.

UNIT 2Mother-to-Child Transmission of HIV Infection

/ Advance Preparation
The trainer should become familiar with Appendix 2-A, the Glion Call to Action on Family Planning and HIV/AIDS in Women and Children, as one method of presenting the United Nations (UN) approach to PMTCT.
/ Total Time: 40 minutes
/ Trainer Instructions
Slides 15-16

Introduce the unit and review objectives.

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

  • Define mother-to-child transmission of HV infection (MTCT).
  • Explain the factors that influence the transmission of HIV from mother to child.

/ Make These Points
  • Clarify the definition of MTCT and emphasize that access to comprehensive services is essential for effective prevention of MTCT.

Definition: Mother-to-child transmission

Mother-to-child transmission (MTCT) is the transmission of HIV from an HIV-infected mother to her baby during pregnancy, labour, delivery and breastfeeding. Mother-to- child transmission (MTCT) is also referred to as vertical transmission or perinatal transmission. The term “MTCT” is used because the direct source of infection is the mother. (Source WHO 2000). However, “MTCT” attaches no blame or stigma to the woman who gives birth to a child who is HIV-infected or becomes infected during breastfeeding. It does not suggest deliberate transmission by the mother, who is often unaware of her own infection status and unfamiliar with how HIV is passed from mother-to-child.

/ Trainer Instructions
Slides 17-20

Review rates of transmission, that is, the likelihood that HIV will be passed from mother to baby, as well as when transmission is most likely to occur. Refer participants to Appendix 2B for more information.

/ Make These Points
  • Emphasize that there are 3 stages when a mother can pass HIV to her child—while she is pregnant, during labour and delivery and during breastfeeding. Tell participants that future modules will discuss more about how to prevent transmission during these 3 stages.
  • Discuss timing and factors associated with HIV transmission.

Rates and timing of MTCT

The overall MTCT rate is approximately 25%-50% without intervention. Most transmission occurs during labour and delivery, but depending on breastfeeding practices and duration, there is also a substantial risk of HIV transmission during breastfeeding. Figure 2.1 shows that without intervention, up to 50% of infants born to mothers infected with HIV who breastfeed can become HIV-infected.

Figure 2.2: HIV outcomes of infants born to women infected with HIV

Timing of infection during pregnancy

  • Infection in utero can occur as early as 8 weeks gestation period.
  • Some infants get sick very early in life whilst others have prognosis similar to adults, suggesting that those with rapid progression may have acquired infection in utero.

HIV infection during pregnancy or while breastfeeding

  • A woman who becomes infected with HIV during pregnancy or while breastfeeding, has higher levels of the virus in her blood, and is more likely therefore to infect her infant. See Appendix 2-B for additional information on the timing and diagnosis of HIV infection.

/ Trainer Instructions
Slides 21-22

First review the factors that increase the risk of HIV transmission during pregnancy, labour and delivery, and breastfeeding; then review the factors that decrease the risk.

/ Make This Point
  • Much is known about specific factors that may put a woman at higher risk of HIV transmission, as outlined in the following text and Table 2.1.

Risk factors for transmission

  • Risk of transmission to the infant is greatest when:
  • A mother’s viral load is high and she has advanced AIDS.
  • A mother’s viral load is high and she has a new HIV infection.
  • A mother’s viral load is high for any reason.
  • HIV transmission during labour and delivery occurs when the baby comes in contact with, ingests, or inhales maternal blood or vaginal secretions that contain HIV.
  • Other viral, maternal, obstetrical, foetal, and infant factors, alone or in combination, influence MTCT of HIV infection. These are outlined in Table 2.1.
  • Early identification and treatment of STIs in pregnant women can minimize the risk of associated infections that increase MTCT of HIV infection.
  • PMTCT interventions are designed to address these risk factors.

Table 2.1 Maternal factors that may increase the risk of HIV transmission
Pregnancy /

Labour and Delivery

/ Breastfeeding
  • High maternal viral load (new infection or advanced AIDS)
  • Viral, bacterial, or parasitic placental infections e.g., malaria
  • Sexually transmitted infections (STIs)
  • Maternal malnutrition, especially micronutrient deficiency such as selenium and vitamin A
  • Anaemia
/
  • High maternal viral load (new infection or advanced AIDS)
  • Placental separation, which tends to occur in cases of antepartum and intrapartum haemorrhage
  • Rupture of membranes for more than 4 hours
  • Invasive delivery procedures that increase contact with mother's infected blood or body fluids (e.g., episiotomy, artificial rupture of membranes, vacuum and forceps deliveries)
  • Vacuum extraction
  • Chorioamnionitis (from untreated STI or other infection)
  • Premature delivery due to fragility of infant skin and immature immune system
  • Low birth weight of the infant
  • Breaks in the skin or mucous membranes
  • First infant in multiple birth
/
  • High maternal viral load (new infection or advanced AIDS)
  • Duration of breastfeeding
  • Mixed feeding (e.g., food or fluids in addition to breastmilk)
  • Breast abscesses, nipple fissures, mastitis
  • Maternal malnutrition
  • Oral disease in the baby (e.g., thrush or sores)

Table 2.2 Summary of PMTCT Interventions
Primary Preventions / Core MTCT Interventions / Continuum of Care
  • Behaviour change communication including community mobilization, education and involvement of partners and families, Life skills and other programmes targeting the youth
  • Promotion and provision of condoms
  • Prevention and treatment of STIs
  • Testing and counselling
/
  • Testing and counselling
  • Optimal antenatal care
  • Improved infant feeding counselling and practices
  • Optimal obstetric care
  • Avoidance of invasive routine procedures
  • Birth canal cleansing
  • Safe delivery practices
  • Avoid invasive procedures for resuscitation of new born
  • ARV therapy or prophylaxis
  • Reproductive health and family planning counselling
/
  • Family planning services including the provision of contraceptives
  • Post natal care for HIV positive mothers and infants including treatment and palliative care for AIDS related conditions, including HIV-related conditions
  • Infant feeding options
  • Social support for HIV positive mothers and orphans affected by HIV/AIDS
  • Primary prevention measures

/ Trainer Instructions
Slide 23-24

Explain the effect of pregnancy on HIV and vice versa as described below