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National Centre for AIDS
and STD Control
Module 2
Overview of HIV Prevention in
Mothers, Infants and Young
Children

and STD Control
Session 1
Introduction to Mother-to-Child
Transmission of HIV

and STD Control
Session 1 Objectives
? Provide an overview of mother-to-child
transmission of HIV (MTCT)
? Identify factors that increase the risk of MTCT

and STD Control
MTCT
? Mother-to-child transmission of HIV (MTCT)
is the transmission of HIV from an infected
mother to her baby during pregnancy, labour
and delivery and breastfeeding
? Also known as ��vertical transmission�� or
��perinatal transmission��
? Most children with HIV acquired the virus
through MTCT

and STD Control
PMTCT: Prevention of MTCT
? PMTCT services include:
�C HIV testing and counselling during ANC, labour
and delivery and postpartum
�C Provision of ARV drugs to mother and infant
�C Safer delivery practices
�C Infant feeding information, counselling and
support
�C Referrals to comprehensive treatment, care and
social support for mothers and families with HIV
infection

and STD Control
Universal Access
The idea that
The idea that everyone
everyone has a right to the prevention,
has a right to the prevention,
treatment, care & support related to HIV and
treatment, care & support related to HIV and
AIDS
AIDS

and STD Control
ANC service coverage
? MMR = 258 / 100,000 live birth (Nepal Demographic profile,
2016)
? NMR = 23 / 1000 live birth (MICS 2014) (Multiple Indicator
Cluster Survey) (NDHS 33 %, 2011)
? Deliveries by Skill Birth Attendant (SBA)=55.6%(MICS 2014),
? ANC 1st
visit = 96% (DOHS annual report 71/72) and 4th
ANC visit
= 54 (DOHS annual report 71/72)
? FCHV are playing important role for creating service demand and
community mobilization

and STD Control
Attend 1st
ANC clinic
695,845
Counseled & tested for
HIV 167,395
HIV exposed baby who received
Prophylaxis for HIV 74
724,839
Total pregnant women in
Nepal 2014/15
Yes
PMTCT
Babies born to HIV+ pregnant
women 77
HIV + Pregnant women in ANC
and LR 105
HIV + pregnant who received ART
101
PMTCT Services in July 2016

and STD Control
PMTCT service challenges (35 % coverage of positive
pregnant women)
? Inadequate PMTCT sites leading to low coverage and HIV testing of pregnant
women
? Health centers beyond birthing centers do not have HIV testing facilities
? Private health facilities has not been reporting the HIV +ve cases; hence leading
to low coverage
? Poor Integration of HIV related activity with FHD
? Poor awareness of reporting requirement of HIV testing to all ANC among
health care providers
? HIV related stigma and discrimination
? shortages of PMTCT staff
? interruptions in treatment and supplies of medical equipment
? shortfall in counselling services
? Men usually makes decision on HIV testing

and STD Control
PMTCT service challenges (EID 17 % Coverage)
? Inadequate DBS collection sites
? Lack of trained lab personnel to collect DBS even in the existing facility sites.
? HIV +ve mothers do not come for postpartum services
? Zonal, Sub-Regional and Regional hospitals have very low linkages with ��Care and
Support Program��
? Lack of proper counselling on importance of EID and need to do it at 6 weeks of age.
? Poor human resource to follow up client on time
? Difficult to follow up through phone number provided, so could not do EID on time
? Failure to identify an infant as HIV exposed
? Limited number of laboratories with PCR facility
? Low testing acceptance rate
? Long waiting time to receive test results
? Insufficient/inadequate sample
? Lack of urgency in responding to positive results

and STD Control
Barriers to Universal Access to
PMTCT
? Weak healthcare
systems, inadequate
ANC
? Limited access to pre-
test counselling
? Lack of effective
coordination
? Inadequate community
engagement
? Stigma and
discrimination
? Lack of awareness that
HIV can be passed from
mother-to-child
? Inadequate access to
ARV therapy or
prophylaxis

and STD Control
MTCT: Overview
? The term ��MTCT�� attaches no blame or stigma
to a woman who gives birth to a child who is
HIV-infected
? Does not suggest deliberate transmission by
mother, who is often unaware of her own
infection status and unfamiliar with how HIV is
passed from mother-to-child

and STD Control
MTCT: Overview (Continued)
? The term should not hide this fact: either the
woman or her sexual partner may introduce
HIV into a family��and both
both of them share
responsibility for preventing transmission to
the infant

and STD Control
MTCT Overview (Continued)
? MTCT can occur during
�C Pregnancy
�C Labour and delivery
�C Breastfeeding
Without intervention, the overall MTCT rate is 20-45%

and STD Control
MTCT Overview (Continued)
? Risk of transmission during breastfeeding
depends on:
�CUse of safer breastfeeding
practices (e.g., avoidance of
mixed feeding)
�CDuration of breastfeeding

and STD Control
100 infants born to HIV-infected
women who breastfeed,
without any interventions
55�C80 infants will
not be HIV-
infected
5-10
infants
infected
during
pregnancy
10-15
infants
infected
during
labour
and
delivery
5-20
infants
infected
during
breast-
feeding
20-45 infants will be HIV-infected
HIV-Exposed Infant Outcomes
Here BF is mixed
feeding up to
24 months

and STD Control
Reducing MTCT
? In industrialized countries the rate of MTCT
has been reduced to 2%
MTCT can be reduced by 20-45% through
core PMTCT interventions

and STD Control
Transmission Risk Factors
What are the risk factors for MTCT?

and STD Control
? High viral load increases risk of passing HIV during
pregnancy, delivery and breastfeeding.
? Mother��s viral load is highest during:
�C Recent HIV infection
�C Advanced AIDS
The most important risk factor for MTCT is the
amount of HIV in the mother's blood. This is
known as the viral load.

and STD Control
During Pregnancy:
1. Viral, bacterial, or parasitic placental
infections, such as malaria
2. Sexually transmitted infections (STIs)
(Other than Viral Load)

and STD Control
During Labour and Delivery:
1. Rupture of membranes for more than 4 hours
2. Invasive delivery procedures that increase contact with
mother's infected blood or body fluid
3. Infections in the uterus (Chorioamnionitis)
4. Preterm delivery
5. Low birthweight

and STD Control
During Breastfeeding:
1. Longer duration of breastfeeding
2. Mixed feeding (giving water, other liquids, or solid
foods in addition to breastfeeding)
3. Breast abscesses, nipple fissures, mastitis
4. Mouth disease in the baby (e.g. thrush or sores)

and STD Control
HIV and Pregnancy
Effect of pregnancy on HIV infection:
�CStudies have shown that pregnancy does
not effect progression of HIV

and STD Control
Effect of HIV on Pregnancy
? HIV causes increased risk of:
�C Spontaneous abortions and still birth
�C Stillbirth
�C Pre-term deliveries
�C Low birth weight infants
�C Bacterial pneumonia, UTI and other illnesses
�C Postnatal infections
? It is critical that pregnant women with HIV get the best
possible ANC and postpartum care

and STD Control
Key Points
? Risk of MTCT without intervention is 20�C45%
? Effective PMTCT programmes provide access to interventions
that can significantly reduce the rate of MTCT
? There are multiple factors that increase the risk of MTCT
during pregnancy, delivery and breastfeeding
? Risk of transmission to the infant is highest when the
mother��s viral load is high. Two times when a mother has the
highest viral load are: recent HIV infection and advanced AIDS

and STD Control

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