Prevention of Mother-to-Child Transmission of HIV. (PMTCT) National Guidelines, May 2007 - United Republic of Tanzania
(2007; 177 pages)

Abstract

PMTCT services provided in Tanzania’s PMTCT programme include routine HIV testing and counselling, antiretroviral (ARV) treatment and prophylaxis for mothers and children, safer delivery practices, counselling and support for safer infant feeding practices, longterm follow-up care for mother and child and family planning.

All women of reproductive age should receive HIV counselling and testing as a routine procedure in reproductive and child health (RCH) services. Pregnant women should receive pretest HIV information at their first antenatal visit—or as soon as possible thereafter.

Nationally, the diagnosis of HIV infection in adults is established by detecting HIV antibodies using simple rapid tests according to the national HIV rapid testing algorithm. Routine, provider-initiated HIV testing is the recommended strategy for HIV testing in Tanzanian RCH services. With this approach, women of unknown status should receive information about HIV as a part of normal care and should be given the opportunity to ask questions about this information. HIV testing should then be performed unless the woman refuses.

All clients who are tested for HIV should receive post-test counselling regardless of their HIV status. The HIV test result should always be given in person.

Antenatal care (ANC) for women infected with HIV includes the same basic services provided for all pregnant women. However, obstetric and medical care should be expanded to address the specific needs of women infected with HIV.

Pregnant women who are HIV infected and eligible for ARV treatment for their own health should be offered combination ARV treatment in accordance with national guidelines.

ARV treatment is recommended for HIV-infected women in the following situations:

  • World Health Organisation (WHO) Stage IV disease, regardless of CD4 count
  • WHO Stage III disease AND CD4 count less than 350 cells/mm3
  • All clients whose CD4 cell count is less than 200 cells/mm3

ARV treatment can start at any point during a woman’s pregnancy. Treatment should start as soon as possible, even if she is in the first trimester. The first-line ARV treatment for pregnant women is zidovudine (AZT) 300 mg twice daily (BD) + lamivudine (3TC) 150 mg BD + nevirapine (NVP) 200 mg.

Pregnant women who do not need ARV treatment for their own health should be given combination ARV prophylaxis starting in ANC. Combination ARV prophylaxis regimens for the mother and child, which include the ARV medications NVP, AZT and 3TC, should be delivered by PMTCT programmes at sites that also initiate ARV treatment. PMTCT programmes at sites that do not have the capacity to deliver ARV treatment or do not have the ARV medications available should provide the minimum regimen of single-dose NVP (sdNVP) to mother and child.

The recommended combination ARV prophylaxis regimen for women who present in ANC is AZT 300 mg BD from 28 weeks or anytime thereafter. Single-dose NVP 200 mg, AZT 300 mg and 3TC 150 mg is given at the onset of labour. AZT is continued every 3 hours and 3TC every 12 hours until delivery. During the postpartum period, AZT 300 mg BD and 3TC 150 mg BD is continued for 7 days. All infants receive sdNVP 2 mg/kg as soon as possible after delivery and AZT syrup 4 mg/kg BD for 4 weeks or 1 week (7 days) if a mother received at least 4 weeks of AZT during ANC.

The minimum ARV prophylaxis regimen for women who present in ANC is sdNVP 200 mg at the onset of labour for the mother and sdNVP 2 mg/kg for the infant as soon as possible after delivery but within 72 hours.

There are variations of these regimens available for women presenting during labour who test HIV positive and for those who test HIV positive after delivery.

In addition to providing ARV prophylaxis, healthcare facilities should also practice safer obstetric practices that reduce the risk of MTCT. These include practicing Standard Precautions during all patient care, minimising vaginal examinations, avoiding prolonged labour, avoiding artificial rupture of membranes, avoiding unnecessary trauma during delivery, minimising the risk of postpartum haemorrhage and using safe transfusion practices.

The infant feeding recommendation for HIV-infected women is exclusive breastfeeding for the first 6 months of life. Exclusive replacement feeding for the first 6 months of life with commercial infant formula or home-modified animal milk is recommended only when it is acceptable, feasible, affordable, sustainable and safe.

Whenever possible, HIV-exposed infants and children should receive viral testing at 8 weeks postdelivery to determine their HIV status. When viral testing is not available, symptomatic children & 18 months of age should receive antibody testing to confirm HIV exposure. Healthcare workers can make a presumptive diagnosis of HIV infection based on a positive antibody test, the child’s clinical symptoms and, if available, the child’s CD4 percentage.

For children older than 18 months, an antibody test should be used to confirm HIV infection.

If the infant or child is breastfeeding, HIV testing should be repeated 6 weeks after the complete cessation of breastfeeding, regardless of the testing methodology that is used. Every infant born to an HIV-infected mother should receive cotrimoxazole preventive therapy (CPT) to prevent Pneumocystis pneumonia (PCP), beginning at 4 weeks of age or as soon as possible thereafter.

 
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