Malawi PMTCT Trainer Manual

Module 7Comprehensive Care and Support for Mothers and Families with HIV Infection

/ Total Time: 325 minutes

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

  • Describe the components of postpartum care for women with HIV.
  • Discuss the prevention of HIV-related conditions.
  • Discuss treatment of HIV-related conditions.
  • Discuss management of common STIs.
  • Explain the interrelationships between STIs and HIV
  • Discuss STI prevention.
  • Describe eligibility criteria for referral to ARV clinic.
  • Describe the staging of HIV/AIDS.
  • Describe 5 ways in which a healthcare worker (HCW) is able to support antiretroviral (ARV) therapy adherence.
  • Describe ongoing care of HIV-exposed infants and children.

Have the following additional materials available, whenever possible:

  • Treatment of AIDS, Guidelines for the Use of Antiretroviral Therapy in Malawi

Unit 1Treatment, Care and Support of the Mother with HIV Infection

Activity/Method / Time
Interactive lecture / 30 minutes
Exercise 7.1 Postpartum care: case study / 40 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 80 minutes

UNIT 2Prevention and Treatment of HIV-Related Conditions

Activity/Method / Time
Interactive lecture / 40 minutes
Exercise 7.2 HIV-related conditions in adults: case studies / 25 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 75 minutes

Unit 3Identification and Management of Sexually Transmitted Infections (STIs)

Activity/Method / Time
Interactive lecture / 20 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 30 minutes

UNIT 4Adult HIV Staging and ARV Therapy

Activity/Method / Time
Interactive lecture / 20 minutes
Exercise 7.3 WHO Clinical Staging: group discussion / 20 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 50 minutes

UNIT 5Treatment, Care and Support of the Infant and Young Child Exposed to HIV

Activity/Method / Time
Interactive lecture / 30 minutes
Exercise 7.4 HIV diagnosis of infants and young children: case study / 25 minutes
Exercise 7.5 Clinical presentation of HIV in infants and children: small group discussion / 25 minutes
Questions and answers / 10 minutes
TOTAL UNIT TIME / 90 minutes
/ Trainer Instructions
Slides 1-3

Begin by reviewing the module objectives listed above.

UNIT 1Treatment, Care and Support of the Mother with HIV Infection

/ Advance Preparation
The trainer should review the appendices so that the content can be integrated into the presentation.
/ Total Unit Time: 80 minutes
/ Trainer Instructions
Slides 4-5

Introduce the unit and review objectives.

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

  • Describe the components of postpartum care for women with HIV.

/ Trainer Instructions
Slides 6-8

Explain to participants that Module 7 will address the ongoing treatment, care and support of families infected and affected by HIV. The referral process will be further discussed in Module 8.

Introduce the discussion of postpartum care using the content below.

/ Make These Points
  • Postpartum care includes physical assessment and treatment, infant-feeding support, family planning, and referral for ARV therapy.
  • After clinical staging, women who are eligible should be referred to the ARV clinic.
  • HIV-infected women and their infants should return for postpartum follow-up at one week and at six weeks, or anytime she is worried about her health or the health of her infant.
  • The mother’s chosen feeding option may not always reflect national guidelines.
  • Psychosocial support is very important in the postpartum period, because mothers will have concerns about their infant’s infection status and may be coping with their own recent HIV diagnosis.
  • Home-based care and assistance for appropriate referrals are important.

Postpartum care and support needs of women and families with HIV

Improving the uptake of postpartum care

During ANC, HCWs should advise women who are infected with HIV of the importance of postpartum care and follow-up. They should also consider the opportunities to strengthen the linkages between postpartum services and ANC as well as labour and delivery wards.

To improve uptake of postpartum services, it is important for HCWs to provide the mother with referral information for follow-up care including time, location and contact information. Educate women to plan to give birth in a health facility; advise women who do give birth at home to report to the maternity department for the infant’s antiretroviral (ARV) dose within 72 hours.

The optimum timeframe for postpartum appointments is at one week and six weeks after birth.

Appropriate linkage and referrals to services helps to identify and resolve potential problems and provides support for safer, effective infant-feeding practices.

Women who have given birth in a healthcare facility should receive postpartum appointments upon discharge. Procedures should be established to ensure women actually attend for their postpartum appointment.

It is especially difficult to coordinate postpartum appointments for women who have given birth at home. HCWs (e.g., community health nurses) will need community-based support to facilitate this important follow-up care. A system of community linkages designed to help implement postpartum care for women in rural areas requires the creative and dedicated efforts of community members that may include traditional birth attendants (TBAs), local chiefs involved in registration of home deliveries, Health Surveillance Assistants (HSAs) and community based organizations (CBOs).

Assessment of healing during postpartum visits

  • Check healing of any repaired genital/perineal lacerations.
  • Monitor uterine involution.
  • Confirm cessation of postpartum bleeding.
  • Review optimal nutritional requirements including fluids.

Infant-feeding support

  • Assess progress of infant feeding.
  • Assist the mother to safely implement her chosen feeding option.
  • Assess family support for the infant-feeding option.
  • Work with the mother to develop a plan to address challenges.

(Additional information about infant feeding may be found in Module 4; additional information about the care and support needs of women infected with HIV can be found in Module 8.)

/ Trainer Instructions
Slides 9-11

Continue to review the list of areas to address in the postpartum visit focusing next on family planning counselling, sexual and reproductive care.

/ Make These Points
  • Emphasize that if used consistently and correctly, condoms protect against STIs/HIV as well as prevent unintended pregnancies (referred to as “dual protection). For HIV-infected individuals, condoms prevent re-infection with other HIV strains.
  • Contraceptive counselling and advice should be tailored to each individual client to support her in choosing the option that is most sustainable for her situation.

Family planning counselling

All clients should be counselled to initiate familyplanning within 6 weeks of delivery. The client should be informed about the family planning methods available, relating them to the client’s particular situation and needs. The information should be offered in an accurate, unbiased, sensitive manner. Partners should be involved in family planning counselling whenever possible. (Refer to Module 2 for details on family planning methods).

It is important to remember that clients have the:

  • Right to decide whether or not to practise family planning
  • Freedom to choose which method to use
  • Right to privacy and confidentiality
  • Right to refuse any type of examination

Counselling plays a major role in the promotion of safe and effective family planning. Women should receive information and counselling about family planning, including the use of condoms as dual protection during both the antenatal and postnatal periods. Women should be counselled on all available family planning methods so that she can make an informed choice. The woman should also be counselled on the risk of becoming pregnant if she is HIV-infected and the importance of practising safer sex. An important way to prevent mother-to-child transmission of HIV is by counselling and supporting women with HIV to avoid a subsequent pregnancy. The counsellor should highlight the importance of dual protection through correct and consistent use of condoms.

Sexual and reproductive care

  • Discuss condom use as dual protection against STIs, including HIV, and for family planning.
  • Discuss the importance of safer sex to prevent the spread of HIV and other STIs.
  • Support the mother's choice of contraceptive method.
  • Provide advice regarding early STI treatment, including symptom recognition and where to go for STI assessment and treatment.
  • Answer any questions the woman may have about safer sex behaviours.

/ Trainer Instructions
Slides 12-15

Module 4 addressed the increased nutritional demands of the breastfeeding mother and special challenges of the mother infected with HIV. Discuss the impact of nutrition during the postpartum period emphasizing the consequences of poor nutrition for both mother and baby.

Remind participants to review Appendix 7-A, Suggestions to maximize food intake for People Living with HIV for suggestions to improve the nutrition of HIV-infected women.

/ Make These Points
  • Women who breastfeed exclusively have increased nutritional demands.
  • Ill or poorly nourished mothers may not be able to care for their infants.
  • Women and their families require nutritional monitoring to ensure good health, especially if they are receiving ARV therapy.
  • HIV-exposed infants are susceptible to diarrhoea and require careful preparation and storage of their foods.
  • Provide Vitamin A supplementation according to Malawi guidelines.

Nutritional counselling, care and support

Lactation is a metabolically expensive process requiring an additional 600-700 kcal every 24 hours. The energy requirements are highest during exclusive breastfeeding when milk production is maximal. This energy amount is equivalent to an extra meal per day.

Lactating women meet these requirements by:

  • Increasing their nutritional intake
  • The body improving the efficiency of its metabolism
  • The body using the energy it has stored during pregnancy
  • Decreasing their level of physical activity

Effects of malnutrition on the mother: Well-nourished women lose 0.4 to 0.8 kg in weight per month for the first six months after delivery, and then lose more slowly. When the nutritional intake is inadequate, the body uses its nutritional stores to maintain breast-milk production. Poorly nourished women do not have the energy resources as a safety mechanism, and as a result their milk production declines.

Effects of malnutrition on the infant: Inadequate nutritional intake of essential micronutrients by the breastfeeding mother, especially if she has advanced disease, may result in:

  • Early onset of infant growth stunting
  • Early cessation of breastfeeding

Babies who are stunted, or cease breastfeeding too early, have a higher likelihood of malnutrition and death.

Nutritional counselling and support should ensure:

  • All mothers are supplemented with a single dose of vitamin A (200,000 IU) within 2 months of delivery.
  • Supplementation of food to malnourished mothers is maintained.

In addition, HIV-infected women who takeARVsmay require counselling at every visit on specific dietary practices and nutritional needs to successfully manage side effects and avoid nutrition-related complications. Appendix 7-A contains suggestions to maximize food intake for women living with HIV.

Nutritional counselling and support should be complemented by safer infant-feeding counselling and support in both the ANC and postpartum periods to help ensure adequate nutrition and the proper growth and development of the child.

Food hygiene

People living with HIV are especially vulnerable to bacterial infections because their immune systems may be weakened. HCWs should emphasize to people with HIV infection the importance of cleanliness during food preparation and storage.

/ Trainer Instructions
Slide16

Exercise 7.1 addresses many of the issues facing the HIV-infected mother and family postpartum. Suggested responses appear after the case study.

Exercise 7.1 Postpartum care: case study
Purpose / To prepare participants to address problems with which mothers may present during postpartum visits
Duration / 40 minutes
Introduction / Refer participants to the postpartum case study in their manuals.
Explain that the case study will help them evaluate and make recommendations for addressing problems that may arise at postpartum checkups.
Activity /
  • Divide participants into three groups.
  • Instruct them to read through the case study.
  • Ask each group to assign one person (the group recorder) to write down key issues in the case study.
  • Ask the groups to list each issue that the HCW needs to address.
  • Tell participants that the groups have 15 minutes to discuss and develop strategies to resolve the issues on their lists.
  • Ask the group recorder to list key issues on a flip chart in a column on the left. Leave the right side of the paper for recording strategies discussed.
  • Ask group: did they feel that this case study was appropriate for discussing a postpartum visit?
  • What other issues typically come up?

Debriefing

/
  • Women who are HIV-infected often require special consideration for both treatment and emotional support.
  • HCWs should ensure that eligible clients are referred to the ARV clinic.

Case study

Patricia is a 24-year-old woman who was diagnosed as HIV-infected during her recent pregnancy. She is presently not on ARV therapy, but she and her infant received ARV prophylaxis for PMTCT, as recommended. Patricia has returned for her 6-week follow-up visit.

Patricia has chosen to exclusively breastfeed. She feels, however, that the baby is always hungry and is wondering if her breastmilk is enough; she has also been giving him supplemental vitamins. Patricia and her husband, who is also HIV-infected, expect to eventually resume sexual relations. She has been told by her friends that she will not need to use contraception because breastfeeding eliminates her chances of getting pregnant.

Upon examination, Patricia appears to be doing well. She has a 0.3 cm fissure (crack) at the base of her right nipple. There is no heat or observable sign of infection at the fissure site. Patricia reports that she has been feeling more tired than usual and has about half her normal energy, but does not have any other physical complaints. She wants to know whether starting HIV medicine may help her feel better.

Patricia’s husband has been sitting in the waiting room. He is currently unemployed. While Patricia is getting dressed, he says, "I have always taken good care of my family, but now, without money coming in, I don't see how we are going to make it. I feel like God is punishing me, somehow, for infecting my wife with HIV."

  • What are the important issues for Patricia and her husband?

Exercise 7.1 Postpartum care: case study, case study answers
In reviewing responses to the case study, be certain that the group addresses the following issues:
1)Patricia will require support to continue exclusive breastfeeding:
a)Review nutritional benefits of breastfeeding and check the supplemental vitamins she is giving to her infant. Infants that are exclusively breastfeed may be given vitamins or medicines but only as prescribed by a HCW.
b)Find out why she feels that the baby is always hungry. What signals is he giving her? Is he gaining weight? How often is the baby feeding? Remind her that weight gain and adequate output—6 or 8 wet nappies, and at least two to five bowel movements every 24 hours for the first several months—are signs of adequate feeding.
c)Review her breastfeeding technique and remind her of the importance of proper latching on and alternating positions.Assure her that using good feeding techniques can help avoid problems such as cracked nipples, engorgement and mastitis.However, today she has an actual fissure. Patricia should be taught how to express milk from this breast, to release pressure, and to discard the milk. She should breastfeed the baby on the other breast to permit the fissure to heal and to prevent transmitting the HIV virus through breastfeeding.
d)She should feed her baby only from the healthy breast.
e)Assure her that nearly all women do have sufficient breastmilk.
2)While breastfeeding does promote lactational amenorrhoea (not having menses), protection against further infection with HIV or STIs is recommended. It is also important to let her know that breastfeeding is not a reliable form of contraception. If she does not want to become pregnant and wants to be protected against further infection she needs to use an additional method of contraception. Discuss how she can protect herself and her husband by correctly and consistently using condoms as a barrier method. Also, use this opportunity to discuss long-term family planning.
3)Patricia’s energy level appears to be of concern to her. Remind Patricia of the need for increased nutritional intake to meet the metabolic demands of breastfeeding. Explain that she will need to take in the equivalent of a small “extra meal”, about 600-700 kcal per day to support her breastmilk production and maintain her energy level. Review the types of foods in her diet to ensure that the food she is taking will provide nutritional balance. Advise her to avoid “empty calories”—foods that may fill her up but have little or no nutritive value. Also ask about her ability to buy or obtain additional food, since her husband is currently unemployed and is worried about taking care of his family. Lack of money may be a major barrier to good nutrition for many clients. Consider referring Patricia to community based organizations (CBOs) that can offer financial or nutritional assistance e.g., income generating activities, HIV support groups or nutritionalsupplementation.
Also, assess her workload in a given day and help her plan for rest periods. Encourage the involvement of her partner.
Patricia’s fatigue may be related to her postpartum status, but could also be an indication that her disease is progressing. Ask Patricia how many hours/night she is sleeping and how often her sleep is broken (particularly with night feeds). Remind Patricia that Malawi has established eligibility criteria for initiating ARV therapy. Reinforce the need for continued follow-up for herself and her HIV-exposed infant, to assess if she now meets the criteria for ARV therapy. Take this opportunity to review immunization schedules, the need for monthly follow-up visits and HIV testing of her infant when the time comes.
4)Patricia’s husband may benefit from counselling referral. The guilt he expresses for having infected his wife is commonly experienced in partners. Assure him that his involvement in the care of his wife and baby are signs that he truly cares for them and show the importance of his role in the family. Explain that he may benefit from joining an HIV support group and provide him with referrals for counselling and other family assistance through faith-based organizations (FBOs) or CBOs offering supportive services. Reinforce the importance of family planning with Patricia’s husband.

UNIT 2Prevention and Treatment of HIV-related Conditions