Prevention of mother- to -child transmission (PMTCT) of HIV

Question 1

What are the transmission risks of HIV from mother-to-child without PMTCT intervention?

Answer 1

HIV may be transmitted during pregnancy (5%), labor and delivery (15%), and breastfeeding (15%).

Question 2

When does the transmission risk of HIV peak during labor and delivery?

Answer 2

The transmission risk of HIV peaks during the eight to 12 hours of labor and delivery.

Question 3

What is the primary determinant of HIV transmission from mother-to-child?

Answer 3

High maternal viral load is the primary determinant of transmission at all stages.

Question 4

How can women on antiretroviral therapy (ART) prevent HIV transmission to their infants?

Answer 4

Women on ART with suppressed viral loads are unlikely to transmit HIV to their infants through pregnancy or extended breastfeeding.

Question 5

What is critical to optimizing HIV-free survival in infants?

Answer 5

Optimizing maternal ART and supporting breastfeeding are critical to optimizing HIV-free survival.

Question 6

What is the goal of Universal Test and Treat (UTT) policy?

Answer 6

The goal of UTT is to identify 90% of people with HIV, treat 90% of them, and achieve a 90% rate of viral suppression (90-90-90 WHO).

Question 7

What are the consequences for infants infected with HIV in utero?

Answer 7

Infants infected in utero experience rapid disease progression and high morbidity and mortality unless treated promptly.

Question 8

How has PMTCT impacted child and maternal mortality in the last decade?

Answer 8

PMTCT has significantly reduced child and maternal mortality in the last 10 years, with transmission rates reduced to less than 1%.

Question 9

What does South African PMTCT policy require regarding antenatal HIV testing?

Answer 9

South African PMTCT policy requires repeated antenatal HIV testing, including poorly implemented partner testing.

Question 10

What is the first-line ART regimen for newly diagnosed and known HIV positive women in South Africa?

Answer 10

Newly diagnosed and known HIV positive women are initiated on ART, typically a fixed-dose combination of Tenofovir, Emtricitabine, and Efavirenz.

Question 11

What is recommended for women with virological failure after 12 weeks of ART during pregnancy and breastfeeding?

Answer 11

Women with virological failure after 12 weeks of ART during pregnancy and breastfeeding require intensified adherence support and may need to be switched to 2nd-line ART if still failing despite good compliance.

Question 12

What is crucial for PMTCT and maternal health?

Answer 12

Viral suppression is crucial for PMTCT and maternal health.

Question 13

How does South African PMTCT policy reduce transmission risk during labor for women with no pre-labor ART?

Answer 13

Intrapartum rescue ARV regimens, followed by enhanced infant post-exposure prophylaxis, are used to reduce transmission risk during labor for women with no pre-labor ART.

Question 14

What shows promise for women with poor viral control in PMTCT, although not yet policy for prevention?

Answer 14

Strand integrase inhibitors, such as Dolutegravir, show promise for women with poor viral control in PMTCT, although they are not yet policy for prevention.

Question 15

How is infant management categorized in PMTCT?

Answer 15

Infant management is categorized by risk category.

Question 16

What factors increase the risk of in utero transmission of HIV?

Answer 16

In utero transmission risk is increased if the disease is advanced, there is new infection during pregnancy, or ART was started less than 12 weeks before delivery.

Question 17

What increases the risk of intrapartum transmission of HIV?

Answer 17

Intrapartum transmission risk is increased if maternal viral load is greater than 1000 copies/ml at the time of delivery.

Question 18

What increases the risk of postpartum transmission of HIV?

Answer 18

Postpartum transmission risk is increased if maternal viral load is unsuppressed or there is viral rebound during breastfeeding.

Question 19

What is the transmission risk for infants when mothers are on ART with suppressed viral loads through pregnancy?

Answer 19

Infants whose mothers are on ART with suppressed viral loads through pregnancy have a low risk for transmission.

Question 20

How are infant testing and prophylaxis regimens adjusted based on risk?

Answer 20

Infant testing and prophylaxis regimens are boosted when the risk is not low.

Question 21

Why is nucleic acid amplification testing (NAAT or PCR) necessary for HIV testing in infants?

Answer 21

NAAT or PCR testing is necessary because trans-placental transfer of maternal antibodies can invalidate antibody testing in infants.

Question 22

How is in utero transmission of HIV detected in infants?

Answer 22

In utero transmission is detected by routine testing of all HIV-exposed infants at birth.

Question 23

How is intrapartum transmission of HIV detected in infants?

Answer 23

Intrapartum transmission is detected by repeat testing at ten weeks and, in high-risk exposures, again after 18 weeks.

Question 24

How is breastfeeding transmission of HIV detected in infants?

Answer 24

Breastfeeding transmission is detected by age-appropriate testing six weeks after the final breastfeed.

Question 25

When should malnourished, acutely unwell, or growth faltering HIV-exposed infants be tested?

Answer 25

Malnourished, acutely unwell, or growth faltering HIV-exposed infants should be tested by age-appropriate tests.

Question 26

When is antibody testing recommended for HIV testing in infants?

Answer 26

After 18 months, antibody testing is recommended as almost all infants will have cleared maternal antibodies.

Question 27

How does infant post-exposure prophylaxis impact HIV transmission?

Answer 27

Infant post-exposure prophylaxis from soon after birth reduces the frequency of intrapartum transmissions but cannot reduce in utero transmission.

Question 28

What reduces breastfeeding transmission of HIV to very low rates?

Answer 28

Maternal ART or extended infant ARV prophylaxis reduces breastfeeding transmission to very low rates.

Question 29

What is the reported impact of combination ARV infant post-exposure prophylaxis when there has been no pre-labor ART?

Answer 29

Combination ARV infant post-exposure prophylaxis has been reported to halve the frequency of intrapartum transmission compared with a single agent when there has been no pre-labor ART.

Question 30

What prophylactic regimen is recommended for infants of mothers who are virally suppressed on ART close to delivery?

Answer 30

Infants whose mothers are virally suppressed on ART close to delivery are given daily prophylactic Nevirapine syrup only until six weeks of age. Thereafter, maternal ART makes breastfeeding safe.

Question 31

What prophylactic regimen is recommended for infants of mothers who are virally unsuppressed close to delivery?

Answer 31

Infants whose mothers are virally unsuppressed close to delivery are given combination prophylaxis for 6 weeks to reduce intrapartum transmission. Infant combination prophylaxis is currently Zidovudine and Nevirapine.

Question 32

When do formula-fed infants stop ARV prophylaxis?

Answer 32

Formula-fed infants stop ARV prophylaxis at six weeks.

Question 33

How long should breastfed infants continue with Nevirapine monotherapy for prophylaxis?

Answer 33

Breastfed infants should continue with Nevirapine monotherapy for a minimum of twelve weeks until the maternal viral load is suppressed.

Question 34

What prophylactic treatment should all HIV-exposed infants receive from 6 weeks?

Answer 34

All HIV-exposed infants should be started on prophylactic co-trimoxazole from 6 weeks until HIV infection has been excluded.

Question 35

What should be done regarding routine immunizations for HIV-exposed infants?

Answer 35

HIV-exposed infants, whether infected or not, should receive routine immunizations.

Question 36

Should BCG be administered to infants known to be HIV-infected?

Answer 36

No, BCG should not be given to infants known to be HIV-infected.

Question 37

What is the mortality risk associated with never breastfeeding in low-resource settings?

Answer 37

Never breastfeeding incurs a significant mortality risk, including malnutrition, pneumonia, and gastroenteritis, which is greater than the risk of HIV transmission.

Question 38

What is the current default feeding policy in South Africa?

Answer 38

The current default feeding policy in South Africa is exclusive breastfeeding for the first 6 months of life, followed by the addition of complementary food while continuing to breastfeed to 2 years or more (previously only 12 months).

Question 39

What should mothers be taught regarding breastfeeding techniques?

Answer 39

Mothers should be taught correct latching and breastfeeding techniques to prevent cracked nipples and mastitis.

Question 40

What did the 2017 feeding policy update recommend regarding infant feeding in the context of HIV?

Answer 40

The 2017 feeding policy update normalizes infant feeding in the HIV context and recommends that ART and breastfeeding be supported systemically.

Question 41

What does the 2017 feeding policy update recommend regarding exclusive breastfeeding?

Answer 41

The 2017 feeding policy update promotes exclusive breastfeeding for six months but discourages stopping breastfeeding if it is not exclusive or only possible for a shorter duration.

Question 42

What alternatives to breastfeeding are mentioned in the update, especially for neonatal units?

Answer 42

Pasteurized own mother’s milk or donor milk can be used, especially in neonatal units.

Question 43

Under what circumstances should formula feeding be considered according to the update?

Answer 43

Formula feeding should only be considered if safety criteria are met or if the mother is failing 2nd or 3rd line ART.

Question 44

Why is feeding support especially necessary for some mothers, according to the update?

Answer 44

Feeding support is especially necessary for mothers whose home circumstances are not safe for replacement feeding.