PMTCT Continuum of Care Services
Safe motherhood means ensuring that women receive the care they need to be healthy through pregnancy and childbirth. To achieve this goal and to reduce the risk of mother-to-child HIV transmission, an interconnected array of services is critically important. The PMTCT Continuum of Care represents a comprehensive range of prevention, treatment, and care services for pregnant women and their infants during pregnancy, labor, delivery, and beyond.
Queue Reports and Publications (PMTCT) NewNoteworthy
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The first ANC visit is the primary entry point for PMTCT, offering women an opportunity to learn their HIV status and, if HIV-infected, engage PMTCT continuum of care services. Improving access to ANC allows more pregnant women to use PMTCT services. |
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With provider-initiated testing and counseling (PITC), the health care provider initiates the test. This approach is also known as “opt-out” testing and counseling because the client can refuse the test. PITC is advantageous because it can lead to higher numbers of clients receiving rapid testing. Studies associate rapid testing with a higher proportion of clients seeking results. |
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Highly active antiretroviral therapy (HAART) combines at least three antiretroviral drugs that prevent the virus from entering blood cells. The best method to determine when to start treatment is through CD4 count testing, which measures the strength of the immune system. The latest WHO guidelines (2009) recommend earlier treatment for all patients, including HIV-infected pregnant women, when their CD4 count falls to 350 cells/mm3 or less, regardless of symptoms. All HIV-infected pregnant women with a CD4 count over 350 cells/mm³ receive prophylaxis from the 14th week of pregnancy. |
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All HIV-infected pregnant women who do not meet the eligibility criteria for ARV treatment for their own health require an effective ARV prophylaxis strategy to prevent HIV transmission to the infant. ARV prophylaxis should be started from as early as 14 weeks gestation (second trimester) or as soon as possible when women present late in pregnancy, in labor, or at delivery. |
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For infants of mothers who are medically ineligible for antiretroviral therapy (ART) for their own health, emerging evidence suggests that ART given to the mother during the period of breastfeeding or to the infant as prophylaxis while breastfeeding can reduce transmission. Breastfeeding is therefore a safer option for infants of mothers living with HIV. Mothers known to be HIV-infected (and whose infants are not infected or whose status is unknown) should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breast¬feeding until the infant is at least a year old. If infants are known to be HIV-infected, mothers are encouraged to exclusively breastfeed for the first six months and continue breastfeeding as per the recommendations for the general population (up to two years). |
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The “window period” is the time between original infection with HIV and the appearance of detectable antibodies to the virus, normally a period of about 14 to 21 days. For this reason, subsequent retesting for those who initially test negative is recommended. |
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Preventing unintended pregnancies in women living with HIV improves maternal health and reduces HIV-infected births and, by extension, the number of children needing HIV-related services. Adding family planning and reproductive health to PMTCT services in high HIV-prevalence countries could halve the number of infant HIV infections when compared to PMTCT alone. |
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Strategies to encourage women to deliver in a health facility include removing or subsidizing delivery fees; offering incentives such as soap, blanket wrap, mosquito nets, and nutrition supplements; offering transportation subsidies; building maternity waiting homes; coordinating services with safe motherhood programs; and linking traditional birth attendants to health facilities and midwives. |
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A significant number of infants born to women living with HIV become infected during labor and delivery. Adherence to standard practices for delivery and procedures that reduce fetal exposure to maternal blood and secretions can reduce the risk of mother-to-child transmission. |
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Offering 24-hour rapid provider-initiated testing and counseling (PITC) for HIV in labor and delivery is critical to identify HIV-infected women who have not had an HIV test before or during pregnancy, as well as women who may have seroconverted after receiving a negative HIV test during pregnancy. |
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Delivery staff must be appropriately trained and authorized to select and administer ARVs for treatment or prophylaxis. ARV drugs need to be available continuously in labor and maternity wards. Giving ARVs to a traditional birth attendant to administer is being discussed as a way to improve access to intrapartum prophylaxis for women who deliver at home. |
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For infants of mothers who are medically ineligible for antiretroviral therapy (ART) for their own health, emerging evidence suggests that ART given to the mother during the period of breastfeeding or to the infant as prophylaxis during the period of breastfeeding can reduce transmission. Breastfeeding is therefore a safer option for infants of mothers living with HIV. Mothers known to be HIV-infected (and whose infants are not infected or whose status is unknown) should exclusively breastfeed their infants for the first six months of life, introducing appropriate complementary foods thereafter, and continue breast¬feeding until the infant is at least a year old. If infants are known to be HIV-infected, mothers are encouraged to exclusively breastfeed for the first six months and continue breastfeeding as per the recommendations for the general population (up to two years). |
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Preventing unintended pregnancies in women living with HIV improves maternal health and reduces HIV-infected births and, by extension, the number of children needing HIV-related services. Adding family planning and reproductive health to PMTCT services in high HIV-prevalence countries could halve the number of infant HIV infections when compared to PMTCT alone. |
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In 2009, new WHO guidelines recommended starting lifelong antiretroviral therapy (ART) for all HIV-infected pregnant women with advanced clinical disease, or with a CD4 count at or below 350 cells/mm3, regardless of symptoms. All HIV-infected pregnant women with a CD4 count over 350 cells/mm³ receive prophylaxis from the 14th week of pregnancy and, depending on the prophylaxis option, until one week postpartum or one week after breastfeeding has finished. |
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With provider-initiated testing and counseling (PITC), the health care provider initiates the test. This approach is also known as “opt-out” testing and counseling because the client can refuse the test. PITC is advantageous because it can lead to higher numbers of clients receiving rapid testing. Studies associate rapid testing with a higher proportion of clients seeking results. |
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Cotrimoxazole (CTX) is a safe, inexpensive, and highly effective antibiotic that can reduce morbidity and mortality among HIV-infected infants, especially in the first weeks of life. In resource-limited settings with 1) a high prevalence of HIV and high infant mortality due to infectious diseases and 2) limited health infrastructure, CTX is universally indicated for HIV-exposed infants starting at four to six weeks of age, and should be maintained until cessation of risk of HIV transmission and exclusion of HIV infection. |
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WHO now recommends that the HIV exposure status of infants be determined at the first contact with the health system, ideally before six weeks of age. All sites providing PMTCT and follow-up services for HIV-exposed infants must be able to draw blood for polymerase chain reaction (PCR) testing, recognizing that the test will likely be processed elsewhere. In many countries, diagnosis of HIV-infected infants often occurs too late to allow early initiation of ART. One of the most effective strategies for increasing uptake of EID is the use of dried blood spot (DBS) tests, which enables health care staff to reach children unable to travel to health facilities. |
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Depending on national policy, health care staff should ensure that the postpartum mother either breastfeeds and receives ARV interventions or avoids all breastfeeding. Health care staff need to support the mother, provide training, observe proper infant feeding technique before discharge, and involve the partner or other family caregivers whenever possible. Continued support is needed for adherence to an exclusive method of infant feeding, safer sex, contraception, family planning, and disclosure. |
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Many women are lost to follow-up after their infection is identified but before they are referred to ongoing care and treatment. Recommendations to address this challenge include making services more patient-centered, providing ANC within the ART clinic to streamline services, and introducing electronic registration systems starting at ANC to allow earlier identification and follow-up of women. |
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Preventing unintended pregnancies in women living with HIV improves maternal health and reduces HIV-positive births and, by extension, the number of children needing HIV-related services. Adding family planning and reproductive health to PMTCT services in high HIV-prevalence countries could halve the number of infant HIV infections when compared to PMTCT alone. |
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Community awareness, acceptance, and involvement are essential to support the continuum of care through the various levels of the health system. Dialogue, careful planning, strong coordination, and solid linkages between the formal health system and the community are necessary to create a successful community integration strategy. Community leaders and members, including women, male partners, organizations, and providers, must have input into the strategy. Mobilizing the community around assessment, advocacy, and health education aids the planning process. |
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