ABSTRACT
Introduction
Mother to child transmission (MTCT) of HIV is a preventable
route of HIV transmission in Nigeria. The federal government
of Nigeria introduced the prevention of mother to child
transmission (PMTCT) of HIV programme in NAUTH Nnewi in
2002. This study was carried out to assess the effects of the
PMTCT services on the health of mothers and children who
accessed these services in NAUTH Nnewi, SE Nigeria.
Methods
This is a cross-sectional descriptive study. 288 mother-child
pairs who had accessed the PMTCT services and attending the
paediatric follow-up clinic were recruited into the study by a
systematic sampling method using the daily clinic register of
exposed babies. Data was collected using a structured
interviewer-administered questionnaire and analyzed using
SPSS version 16. A p-value <0.05 was considered significant.
viii
Results
The mean age of all the respondents was 30+4.86 years. Most
(89.2%) were married, 10.1% had less than secondary
education while 4.2% had no formal education. 55.2% were
traders while 18.4% were unemployed. Median parity was 2.
Partner notification was 87.2%. 99% of the pregnancies was
carried to term while mean birth weight was 3.02+0.49kg.
Mother to child HIV transmission rate was 1%. Majority of the
mothers had good knowledge of routes of HIV transmission.
99% of mothers identified MTCT as main mode of
transmission. 93.4% did not perceive risk of transmission in
homosexuals and bisexuals. 75.8% used contraceptive
methods. 94.7% did not breastfeed while breastfeeding was
associated with MTCT of HIV (X 2=9.16; p<0.02). Infant
formula was associated with impaired baby’s current health
status. Majority of mothers reported excellent health status.
Conclusion
The PMTCT programme has resulted in good knowledge of
routes of HIV transmission and modes of prevention of MTCT
ix
of HIV, low MTCT rate, high rate of contraceptive use and
excellent health status among participating mothers and
children.
x
TABLE OF CONTENTS
Page
Title page
Declaration ii
Approval iii
Dedication iv
Acknowledgement v
Abstract vii
Table of content x
List of tables xi
List of acronyms xiii
Chapter one
Introduction 1
Chapter two
Literature review 34
Chapter three
Methodology 45
Chapter four
Results 52
Chapter five
Discussion 78
Conclusion 87
Recommendations 89
References 91
Appendix 1 – Informed consent form 110
Appendix 2 – Questionnaire 112
Appendix 3 – ethical Review Board Approval 126
xi
LIST OF TABLES
Page
Table 1: Socio-demographic characteristics of
all the respondents 39
Table 2: PMTCT ante-natal clinic activities outcome 41
Table 3: PMTCT programme outcome for infants 42
Table 4: Knowledge of route of transmission, PMTCT
programs & condom use 43
Table 5: Perception of HIV risk by participants 45
Table 6: Degree of perception concerning HIV
transmission 46
Table 7: Relationship between infant’s current
health status & some selected variables 47
Table 8: Correlation of receipt of replacement feed
with baby’s current health status 48
Table 9: Relationship between infant’s result of HIV
test and some selected variables 49
Table 10: Effect of breastfeeding infant any time on
result of baby’s HIV test 50
xii
Table 11: Breastfeeding infant any time versus
result of baby’s HIV test (further confirmed) 51
Table 12: Relationship between duration of breastfeeding
and result of baby’s HIV test (further confirmed) 52
Table 13: Mother’s current health status according
to ART intake 53
Table 14: Mother’s use of family planning method 54
Table 15: Mother’s current health status by
contraceptive use 55
Table 16: Mother’s current health status according to
type of contraception 56
Table 17: Mother’s current health status according to
participation in social support group 57
Table 18: Mother’s current health status according to
what is done to remain healthy/prevent infection 58
Table 19: Cross tabulation of comments on PMTCT
program with how treated at the clinic 59
Table 20: How treated at the hospital versus feeling
about HIV status confidentiality in the facility 60
xiii
ACRONYMS
3TC Lamivudine
AIDS Acquired Immuno-deficiency Syndrome
ARM Artificial Rupture of Membrane
ART Antiretroviral Treatment
ARV Antiretroviral
C/S Caesarean Section
CD4 Cluster Differentiation 4
DBS Dried Blood Spot
E & U Electrolyte & Urea
ECV External Cephalic Version
EFZ Efavirenz
ELISA Enzyme-Linked Immuno-sorbent Assay
ERB Ethical Review Board
ESR Erythrocyte Sedimentation Rate
FBC Full Blood Count
FBS Fasting Blood Sugar
FMOH Federal Ministry of Health
HAART Highly Active Antiretroviral Treatment
HIV Human Immunodeficiency Virus
IHVN Institute for Human Virology Nigeria
xiv
IUCD Intra-uterine Contraceptive Device
IUD Intra-uterine Death
KABP Knowledge, Attitude, Beliefs, Practices
LAM Lactational Amenorrhoea
LFT Liver Function Test
MTCT Mother to Child Transmission
NAUTH Nnamdi Azikiwe University Teaching Hospital
NVP Nevirapine
PCR Polymerase Chain Reaction
PEPFAR President’s Emergency Plan for AIDS Relief
PI Principal Investigator
PLWHA People Living With HIV/AIDS
PMTCT Prevention of Mother to Child Transmission
RA Research Assistant
STI Sexually Transmitted Infections
TB Tuberculosis
TFR Total Fertility Rate
UNGASS United Nations General Assembly
WHO World Health Organisation
ZDV Zidovudine
xv
1
CHAPTER ONE
INTRODUCTION
Acquired immuno-deficiency syndrome (AIDS) is a disease
condition caused by infection of the human body by a
retrovirus called the human immunodeficiency virus (HIV) 1.
On entry into the body, the virus invades the Cluster
differentiation 4 (CD4) cells in which it replicates. Its
successful multiplication leads to the destruction of the CD4
cells. Thus, the CD4 cells count reduces as the viral load
increases.
The CD4 cells are responsible for the protection of the human
body against numerous pathogenic organisms with which it
comes into contact in day to day living. Depletion of the CD4
cells leads to immune deficiency state and an increased
likelihood of the body being invaded by opportunistic
organisms. These organisms, which are ordinarily harmless to
the human body, then become pathogenic and cause what is
known as opportunistic infections 2. It is the opportunistic
infections that persistently reduce the quality of life of the
2
individual and eventually result in death if treatment is not
promptly and adequately provided. Highly Active Antiretroviral
Therapy (HAART), when promptly and adequately
provided and taken, reduces HIV morbidity and mortality 3, 4.
Magnitude of the Problem of HIV/AIDS
The HIV and AIDS pandemic is one of the most serious health
crises in the world today. By the end of 2008, AIDS and AIDSrelated
illnesses had killed more than 25 million people (2
million in 2008 alone including 280,000 children under 15
years) and an estimated 35.8million people were living with
HIV, out of which 15.7 and 2.1million were women and
children under 15 years respectively5. Sub-Saharan Africa has
continued to bear the greatest burden of the HIV and AIDS
epidemic, with approximately 67% of the total number of
people living with HIV, 68% of the new infections and 72% of
AIDS-related deaths in 2008. Over the decades, the epidemic,
once dominated by infected males has become progressively
feminized and in sub-Saharan Africa approximately 60% of
adults living with the HIV are women6,7,8.
3
Over 90% of infection in children is acquired through motherto-
child transmission (MTCT) and as more women contract the
virus, the number of children infected also increases9.
Estimate of the Global HIV pandemic demonstrated that in
sub-Saharan Africa, more than 1200 children become infected
with HIV each day5. In 2008 alone an estimated 2.1 million
children were living with HIV and up to 430,000 were newly
infected worldwide, with sub-Saharan Africa accounting for
about 90% of both of these figures5.
Nigeria, with a population of 140 million10, is the most
populous country in Africa and was ranked 2nd worst affected
by HIV/AIDS in the world in 2008 after South Africa5. Since
the first case of HIV/AIDS in Nigeria was reported in 1986
involving a 13 year old girl who died of the disease11, there
has been progressive increase in the total number of people
living with HIV/AIDS (PLWHA). The national prevalence rose
from 1.8% in 1991 to 5.8% in 2001 but declined to 5% in
2003 and 4.4% in 2005 before rising again to 4.6% in 2008
with prevalence in Anambra State determined to be 5.6%12.
4
The HIV prevalence rate is higher in the urban (5.4%) than
rural areas (3.4%). Among young persons, the highest
prevalence rate of 5.6% is in the age group 25 to 29 years13.
The average number of adults living with HIV was 3,500,000
in 2005 at a time when number of women (15-49 years old)
living with HIV was 1,900,000, giving a female: male ratio of
1.2:1. Heterosexual transmission accounts for nearly 80% to
95% of all infections14. About 10% of HIV infections are
transmitted by MTCT, while another 10% is transmitted by the
use of unsterilized needles and surgical implements, infected
blood and blood products15.
Mother-to-Child Transmission of HIV
Over 90% of HIV infections in children less than 15 years are
due to MTCT. In the absence of interventions, between 15%
and 45% of infants born to HIV-infected mothers acquire the
infection during pregnancy, delivery or through breastfeeding16.
The burden of MTCT of HIV is higher in sub-
Saharan Africa than the rest of the world, because of higher
5
levels of hetero-sexual transmission, high female to male
ratio, high total fertility rate (TFR) and high rate of breastfeeding17,18.
Transmission of HIV in children has become a
critical health problem undermining the positive impact of
child survival strategies in the African continent19,20.
Estimated magnitude of MTCT in Nigeria
Population 140 million
Birth rate per annum 42/ 1000
Birth per annum 5,900,000
HIV prevalence in ANC women 4.4%
Total number of infants born to
HIV infected women exposed to the
risk of MTCT assuming no multiple
pregnancy
260,000
Number of HIV positive infants per
annum
65,000 to 117,500
Source: FMOH. National Guidelines on Prevention of Motherto-
Child Transmission of HIV, July 2007.
6
Risk Factors for MTCT of HIV
Factors associated with increased risk of MTCT of HIV
Factors strongly associated with MTCT of HIV include viral
characteristics and high viral load; maternal advanced disease,
immune deficiency and HIV infection acquired during
pregnancy or breastfeeding21,22, obstetric practices like vaginal
delivery23, rupture of membranes for more than 4 hours
before delivery24; prematurity of the infant; and feeding
factors like prolonged breastfeeding, mixed feeding and breast
diseases like abscess, mastitis and cracked nipples during
breastfeeding25.
Other factors associated with MTCT of HIV but with limited
evidence include viral resistance; maternal vitamin A
deficiency, anaemia, Chorioamnionitis, sexually transmitted
diseases, frequent unprotected sex, multiple sexual partners,
smoking and intravenous drug abuse; obstetric practices like
invasive or traumatic procedures, instrumental deliveries,
amniocentesis, episiotomy, external cephalic version and intrapartum
haemorrhage; and foetal or infant lesions of the skin
or mucous membranes and genetic factors.
7
Prevention of Mother-to-Child Transmission of HIV
One of the goals of the June 2001 Declaration of Commitment
of the United Nations General Assembly Special Session on
HIV/AIDS (UNGASS)26 is to reduce the proportion of infants
infected with HIV by 20% by 2005 and 50% by 2010. The
Nigeria national goal for PMTCT as contained in the 2003
AIDS Policy is to reduce the transmission of the HIV through
MTCT by 50% by the year 2010 and to increase access to
quality voluntary confidential counseling and testing services
by 50% by the same year. To achieve this goal, a
comprehensive strategy to prevent HIV infection among
infants and young children has been developed, which
promotes implementation in an integrated manner within the
health care delivery system.
The NAUTH PMTCT programme started in 2003 as a national
programme implemented by the Federal Government of
Nigeria with NAUTH as one of the pilot sites. The NAUTH
programme was taken over by the Institute of Human
Virology Nigeria (IHVN) in 2005. NAUTH has 7 satellite sites,
8
including 3 private hospitals, for the PMTCT programme which
is implemented according to the National Guidelines on
Prevention of Mother-to-Child Transmission of HIV15.
The PMTCT interventions consist of four strategic approaches
which include:
1. Primary prevention of HIV infection in women of
reproductive age group and their partners
This involves provision of early diagnosis and treatment
of STIs, making HIV testing and counseling widely
available and provision of suitable counseling for
women who are HIV negative.
2. Prevention of unintended pregnancies among
HIV positive women
The responsibility of the government and health services is to
provide HIV positive women and their partners with
comprehensive information and education about the risks
associated with child bearing as part of routine public
9
information about HIV and AIDS, to ensure that HIV positive
women and their partners have real choices of action, and to
respect and support the decisions they reach15. This means:
providing good quality, user-friendly, and easily accessible
family planning services so that HIV positive women can avoid
pregnancy if they choose, promoting condom use, either alone
or combined with a more effective method of contraception
(dual method) for dual protection from HIV and other STIs
and from unplanned pregnancies as an effective strategy to
prevent HIV transmission, integrating dual protection
messages into family planning counseling services and
offering contraception to replace the birth spacing effect of
exclusive breastfeeding in women who chose replacement
feeding because of their HIV status.
3. Antenatal Care for HIV Positive Women
Specific Modification of Obstetric Care for HIV Positive
Women
Health workers in the antenatal clinic are able to identify
women who have tested positive in order to treat them
10
appropriately. This is done in a way that respects the privacy
and rights of the HIV positive woman. As part of the initial
counseling, women are told why it is important that health
workers know their HIV status. NAUTH has a way of making
this available in the notes, without making it accessible to the
public, visitors or others. When a woman is known to be HIV
positive or is diagnosed as HIV positive during pregnancy, her
obstetric and medical care are strengthened and modified.
Post test counseling for HIV positive pregnant women is
conducted appropriately.
All HIV positive women are given optimal health care to
ensure their safe delivery. Additional visits are not required for
obstetric reasons, although she may need to attend for further
counseling sessions. To minimize the likelihood of MTCT of
HIV, care is taken to avoid invasive procedures such as
chronic villous sampling, amniocentesis or cordocentesis and
external cephalic version (ECV) which may carry a risk of HIV
transmission to the foetus. Care is individualized in special
circumstances such as premature rupture of membrane
11
(preterm and term) and ante-partum haemorrhage. Proper
and consistent use of the partograph in monitoring progress
of labour improves the management of labour and also
reduces the risk of prolonged labour in all women. Because
rupture of membranes of more than four (4) hours duration is
associated with an increased risk of HIV transmission, ARM is
reserved for those with foetal distress or abnormal progress
and is only done if cervical dilatation is 7 cm or more. Forceps
and vacuum delivery is avoided as they have been shown to
be associated with increased risk of MTCT. Vaginal cleansing
with chlorhexidine (0.25% solution) helps to reduce the risk of
puerperal and neonatal sepsis including HIV transmission
where membranes are ruptured for more than 4 hours. After
every vaginal examination, the birth canal is wiped with gauze
or cotton wool, soaked in chlorhexidine solution and the
number of vaginal examinations is kept to a minimum.
Episiotomies are used only for specific obstetric indications.
12
4. Prevention of HIV transmission from HIV
infected mothers to their unborn babies and
infants.
The Use of Antiretroviral Drugs in PMTCT of HIV
In addition to the normal criteria for initiation of antiretroviral
therapy (ART) in adults infected with HIV, pregnancy
constitutes another indication for ART or prophylaxis.
Treatment is indicated as per the WHO clinical staging and
eligibility criteria. When the HIV-positive mother does not
meet the criteria for treatment then prophylaxis is offered.
In HIV infected adult population, ART is initiated based on any
of the following criteria if CD4 cell count is available:
1. WHO Stage IV disease irrespective of CD4 cell count
2. WHO Stage III disease with CD4 cell count < 350
cells/mm3
3. WHO Stage I or II disease with CD4 cell count ≤ 200
cells/mm3
However, pregnancy in the HIV-seropositive woman is an
indication for prophylactic ART irrespective of CD4 count, viral
load or clinical stage of the disease. The time of
13
commencement and choice of ART in HIV-seropositive
pregnant woman depends on the clinical setting. Where
necessary, ART is provided in consultation with an
experienced physician.
Pre-treatment evaluation:
This includes complete history and physical examination,
checking laboratory parameters (FBC/ESR, FBS, LFT, E&U,
Serum lipids and CD4 count), WHO clinical and immunological
staging of the client, ensuring availability of supportive
measures (nutritional and psychosocial) and developing
patient-specific adherence strategy.
For ARV prophylaxis
All patients placed on ART are monitored clinically,
biochemically and immunologically. The regimens stated
below in different clinical settings are based on the 2007
National Guidelines on Prevention of Mother-to-Child
Transmission of HIV15 which was still in use during this study.
14
ART prophylaxis in different clinical settings
Clinical Setting I
For pregnant woman who is HAART eligible, but not
currently on ART, initiation of ART is delayed until after the
first trimester, unless benefits outweigh risks. ZDV is included
in the regimen unless the haemoglobin level is less than
8g/dL. ZDV, 3TC and NVP are given if CD4 count is less than
250 cells/mm3. If CD4 count is more than 250 cells/mm3, NVP
is avoided or if used, hepatotoxicity is monitored closely. NVP
is stopped for women commenced on HAART – (ZVD, 3TC and
NVP) before they became pregnant and found to react to NVP
in first trimester pregnancy but EFV + ZDV + 3TC can be
given in the second and third trimesters.
Infant
Single-dose NVP is given as soon as possible after birth
preferably within 72 hours because NVP given to the HIVexposed
infant has been shown to prevent perinatal HIV
transmission to the infant27. ZDV is also given for 6 weeks.
ZDV is avoided if haemoglobin is less than 8g/dl for the adult
and less than 10 g/dl for the infant.
15
Clinical Setting II
Pregnant HIV-seropositive women who do not meet the
criteria for ART are given ZDV ante-partum from week 2828 or
ZDV+ 3TC from week 34-3629.
Intra-partum: Single-dose NVP (sdNVP) + ZDV + 3TC is
given at onset of labour
Post-partum: ZDV + 3TC are given for 7 days. ZDV is
avoided if haemoglobin is less than 8g/dl.
For the exposed Infant, prophylaxis is as in Clinical Setting I.
Clinical Setting III
Mother receiving HAART at the time of current
pregnancy
HIV infected women receiving HAART in whom pregnancy is
identified are allowed to continue therapy. Zidovudine is
always a component of the regimen unless haemoglobin is
less than 8 g/dl. Efavirenz is avoided in the first trimester.
Infant
For the exposed Infant, prophylaxis is as in Clinical Setting I.
16
Clinical Setting IV
For HIV sero-positive women who are diagnosed or
seen for the first time in labour sdNVP + ZDV + 3TC is
given at onset of labour then ZDV + 3TC is given post-partum
for 7 days. Thereafter the women are referred to the Adult
ARV Unit for evaluation for their and follow-up.
For the exposed Infant, prophylaxis is as in Clinical Setting I.
Clinical Setting V
HIV-seropositive mother who presents after delivery is
assessed for eligibility for HAART for her disease, following the
2007 Guideline. For the exposed Infant, prophylaxis is as in
Clinical Setting I but if more than 72 hours after birth, NVP is
withheld and is given ZDV for 6 weeks.
Clinical Setting VI
For pregnant HIV-seropositive patients who are co-infected
with tuberculosis and have active tuberculosis, TB is treated
first while ARV is delayed till second trimester if possible when
she is started on EFV + ZDV + 3TC and Rifampin is changed
17
to low dose Rifabutin. ZDV is avoided if haemoglobin is less
than 8 g/dl. For the exposed Infant, prophylaxis is as in
Clinical Setting I.
Intra-partum care:
The HIV positive women are not isolated or treated differently
from other women in labour. The health care providers take
supportive measures and show empathy and caring attitudes
necessary to boost the morale of the clients. Universal safety
precautions are observed by the health workers on all women
in labour irrespective of their HIV status.
Rapid HIV testing and counseling in Labour
The HIV statuses of all women who are admitted to the labour
ward are verified by checking on the Mother’s records and/or
by asking the mother whether she has been tested for HIV
infection. Those who are unaware of their HIV status and are
in labour are offered rapid counseling and testing for HIV in
the labour ward.
18
Specific Management of HIV Positive Pregnant Women
in labour
Prophylactic antiretroviral therapy is offered all HIV positive
pregnant women accessing the NAUTH PMTCT services.
Mode of delivery
Vaginal delivery
This is offered to HIV positive women where there is no
contraindication and especially those who have assessed ARV
therapy in the antenatal period and whose maternal viral load
may be considered to be low.
(a) Management of labour
Labour management follows normal obstetric guidelines30. HIV
positive women are not isolated, but staff use universal safety
precautions with all patients. Analgesia is given in labour if
required.
(b) Support during labour
Emotional support during labour is important for all women,
and may be even more necessary for an HIV-infected woman
19
who is concerned about her condition and the risk of
transmission to the child. This may be made worse by her fear
of stigmatization and discrimination by medical staff, or
because she has not disclosed her status to her partner or
family members. Whenever possible, during labour, HIV
positive women are given the option to have a companion of
their choice who knows their HIV status and can provide
supportive companionship. Where this is not possible labour
ward staff should be sensitive to the fears and concerns of the
HIV positive mother about her infection, and how much she
had told any of her companions.
(c) Induction of labour
As prolonged rupture of membranes is associated with
increased risk of MTCT, careful assessment of the need for,
and the desirability of, caesarean section (C/S) rather than
induction is made. Labour may be induced by one or a
combination of the following: artificial rupture of membrane
(ARM), oxytocin therapy, and prostaglandins. Where induction
of labour is chosen, membranes are left intact for as long as
possible. Oxytocin is not used with intact membranes.
20
(d) Conduct of Delivery
Delivery is conducted using standard practice and aseptic
technique while avoiding unnecessary trauma or prolongation
of the second stage.
Interventions for safe vaginal delivery
The steps include: performing vaginal cleansing with warm
0.25% chlorhexidine to prevent genital infections; avoiding
frequent vaginal examinations, episiotomies unless absolutely
necessary, instrumental delivery unless absolutely necessary;
clamping the cord immediately after baby is delivered and
avoid milking the cord; and cutting cord under cover of a
lightly wrapped gauze swab to avoid blood spurting.
Care of the baby at delivery:
The measures taken include wiping the baby’s mouth and
nostrils with gauze at delivery of the head, handling all babies
with surgical gloves regardless of HIV status of mother until
maternal blood and secretions are washed off, keeping all
babies warm after delivery irrespective of their HIV status,
baby is washed with warm chlorhexidine solution and wiped
21
dry with a towel or surgical cloth to remove maternal body
fluids immediately after birth. Where suctioning is indicated,
mechanical suction unit (at a pressure below 100mmHg) or
bulb suction is used. Mouth operated suction is avoided.
Determining mother’s infant feeding choice
If the mother has decided to breastfeed, she is helped to
attach and position the baby to her breast and if the mother
has decided not to breastfeed, the baby is placed on the
mother’s body for skin-to-skin contact.
Caesarean Section (C/S)
HIV infection on its own is not an absolute indication for a
caesarean section. Available evidence shows that elective C/S
on women on HAART with low viral load (< 1000 copies/ml)
has no added advantage over vaginal delivery. Elective
caesarean section is offered to HIV positive women before the
onset of labour or rupture of membranes. Where C/S is
performed (elective or emergency) in HIV positive women,
they receive prophylactic antibiotics. If C/S is performed after
22
prolonged labour or prolonged rupture of membranes, longer
courses of antibiotics are given.
Activities for optimal obstetric practices
All concerned health workers have been trained in safe
delivery techniques and life-saving skills for mothers and
infants and provisions have been made for safe delivery kits
and essential obstetric drugs, safe delivery infrastructure with
a water source, good drainage, electricity, delivery beds
covered with waterproof materials, antiseptics, gloves, and
other materials required for a hygienic delivery environment.
Safe blood supply is assured and education about the
importance of antenatal care and deliveries is regularly carried
out.
Post-Partum Care
Immediate Post-Partum care
The post-partum period in the health facility offers an
opportunity to educate all patients about HIV, to provide
counseling and testing if this was not carried out previously,
and to reinforce the education provided during the antenatal
23
period. This is done in a private place so that the discussion
can be confidential. Both HIV infected and uninfected mothers
receive this education and counseling before discharge.
Emphasis is also made on the importance of routine
immunization and the need for good hygiene to prevent
infection.
For HIV-negative mothers, breastfeeding is reinforced and
supported, sexual activity in the postpartum period and
protection against HIV infection are discussed, couple or
partner testing and Counseling is done. Appropriate family
planning methods where appropriate are offered, education
on, and reinforcement of infant care is carried out, mother
care sessions on education and counseling, delivery and
postnatal exam are completed and post-natal visit is
scheduled.
For HIV-positive mothers, infant feeding choices are
reviewed and supported, discussions are carried out on couple
or partner testing and Counseling, sexual activity in the
24
postpartum period and protection of partners against HIV
infection. Appropriate family planning methods are offered
where appropriate, infant antiretroviral drugs are provided,
infant care is taught and reinforced, adherence counseling is
provided for women that need to continue on ARV while ARV
is discontinued according to the guideline. Infection
prevention and prompt medical attention are discussed.
Mother-care sessions, education and counseling, delivery and
postnatal examination are completed. The importance of early
infant diagnosis is discussed while post-natal visit is
scheduled.
For mothers whose HIV status is unknown, counseling
and testing is provided in labour or as soon as possible after
birth, instructions for immediate post exposure prophylaxis
with an appropriate ARV regimen for infants of mothers who
are HIV positive are followed while education and counseling
as for HIV-positive mothers are completed before discharge.
25
In the immediate Post partum period routine physical
examination is performed with particular emphasis on the vital
signs, detection of anaemia, breast examination, abdominal
examination and perineal and lochia examination. HIVinfected
women are more prone to post-natal infections
including urinary tract infections, chest infections (e.g.
pneumonia), infected episiotomy, post-partum sepsis and
caesarean section wound sepsis. Health workers are aware of
this and they observe for signs of infection.
For HIV positive mothers the following are also
essential:
Breast care
A woman who is not breastfeeding should use a firm brassier
to limit milk production and support the breast. Bromocriptine
therapy to limit milk production is given when necessary in
some cases especially for mothers who chose not to
breastfeed.
For a breast feeding woman, cracked nipples, mastitis and
breast abscess increase the risk of breast milk transmission of
26
HIV17. Cracked nipples are often caused by poor attachment
of the baby’s mouth on the breast, candida infection, frequent
washing of the nipples, and application of abrasive creams
and lotions.
Measures for prevention of cracked nipples include making
sure that there is good breastfeeding technique with the baby
latching on the areola and the nipple, prompt treatment of
vaginal thrush or infant oral thrush, the mother washing her
breast once a day and avoid use of creams and lotions on the
nipples. The mothers are shown how to put a finger on the
baby’s mouth to remove a baby from the breast without
traumatizing their nipples. A mother is instructed to smear her
nipples with breast milk after feeds and air-dry her breasts.
Women are encouraged to seek health care promptly if they
have nipple discomfort when they are breastfeeding. They are
reminded that babies should not be fed on a breast with
mastitis or breast abscess.
For care of the perineum, measures include emphasis on
good perineal hygiene and proper handling of body fluids,
27
avoiding contaminating the baby with body fluids or bedding
soiled with lochia, discouraging bed sharing in hospital and
Sitz bath: In the past sitz baths were encouraged for the
management of episiotomies30. Local experience is that it is
difficult to keep the basins clean and they become a source of
contamination. The mothers are taught to clean with a clean
cloth soaked in warm saline.
Family planning
Appropriate family planning methods are discussed during
antenatal period and again before discharge home. In our
area where prolonged exclusive breastfeeding is the norm,
some women may rely on lactational amenorrhoea (LAM) as a
contraceptive method, and this will be lost with changes in
infant feeding. Some women may have a period of abstinence
after the birth of the child, and may not wish to start
contraceptive use before this. They are given information
about how and where to obtain contraception when they wish
it.
28
Some artificial family planning methods are:
1. Hormonal
The options include combined oral contraceptive pills,
progestogen-only pills, injectable progestogen (DMPA or
noristerate/NET-EN) and progestogen implants (such as
Implanon or Uniplant/Norplant) but it should be borne in mind
that these do not protect against HIV and AIDS.
2. Barrier methods
The methods include female condoms, male condoms,
diaphragms, used with spermicides. These can provide
contraception and protect against HIV and AIDS
3. Intra-uterine contraceptive devices (IUCD or
IUD)
4. Sterilisation:
This is suitable for HIV positive women and their partners who
do not wish to have more children.
29
5. Emergency contraception
This is especially important where barrier methods are being
used as the primary contraceptive method and women should
be told about the possibility of using emergency contraception
if the condom breaks or slips.
Cervical Screening
HIV-positive women have a higher risk of cervical dysplasia
and malignancy31. Therefore, they should have a cervical
smear, if possible at a postnatal check-up and at least once
annually. In women with CD4 counts below 200cells/μl or who
have symptoms of AIDS, a six-monthly smear is advised.
Follow up
The follow up schedule for mother- infant pair is at 2, 4 and 6
weeks after delivery. Post natal follow-up is provided as a
comprehensive package by the child welfare provider,
paediatrician, adult HIV physician and family planning
provider. The postnatal period is the beginning of the ongoing
30
care and support for women with HIV infection, especially
where the diagnosis was first made during pregnancy. Dried
blood spot (DBS) polymerase chain reaction (PCR) provides a
feasible method to assess PMTCT programs and identify HIVinfected
children and this is done at 6 weeks post-partum
visit32. Advice on the need for prophylactic treatment for
Pneumocystis Jerovecii pneumonia (PJP) and tuberculosis is
given if indicated by the clinical stage of the disease. The
woman is linked to a community based support group for
ongoing counseling and other support services.
Referral after postnatal care
All HIV infected women are referred to the adult ART Clinic
after postnatal visit.
Post Abortion Care
HIV positive women are more likely to have spontaneous
abortions. In some cases, the HIV status of the woman is not
known. Health workers are aware of the possibility of HIV and
look for clinical signs and symptoms related to HIV. Where the
31
woman is known to be HIV-positive, prophylactic antibiotics
are given after uterine evacuation and ensure that there is
family planning counseling available and the provision of a
method as required, as well as access to HIV counseling. They
are counseled about possible problems, such as infection or
bleeding, which may occur after the procedure.
32
Rationale for the study
The overall purpose of the assessment is to inform future
programming in order to build on the programme’s successes
and remedy its failures. Understanding the effectiveness of
the PMTCT programme is crucial for sustenance and scale-up.
The success of a PMTCT programme in reducing seroconversion
among exposed newborn infants is determined by
many factors, including the administration of ARVs (Nevirapine
or Zidovudine [AZT], or HAART) to both HIV-positive mothers
and their newborns; infant feeding practices; access to and
use of well-baby care; and the health system’s ability to
provide care, including counseling and support to both the
HIV-positive mother and her exposed newborn. Prior to the
assessment, very little is known about the impact of PMTCT
interventions in NAUTH, Nnewi, Anambra State, Nigeria.
33
General Objective:
To assess the effects of prevention of mother to child
transmission of HIV (PMTCT) programme on maternal and
child health at Nnamdi Azikiwe University Teaching Hospital
(NAUTH) Nnewi
Specific Objectives:
1. To assess the knowledge, attitude, beliefs and
practices of HIV-positive women on the PMTCT
programme/Services.
2. To determine the effect of infant feeding choices
and
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