guidelines for prevention of mother to child transmission ... for... · 107 guidelines for...
TRANSCRIPT
1
07
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
1
1
G
uid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
M
INIS
TRY
OF
HEA
LTH
Rep
ublic
of K
enya
Gui
delin
es fo
r
Pre
vent
ion
of M
othe
r to
Chi
ld
Tr
ansm
issi
on (P
MTC
T) o
f HIV
/AID
S
in K
enya
N
ATI
ON
AL
AID
S &
STI
CO
NTR
OL
PRO
GR
AM
ME
P.O
. BO
X 19
361-
002
00
NA
IRO
BI
Third
Edi
tion,
200
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
106
1
05
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
2
Enq
uiri
es r
egar
ding
thes
e PM
TCT
Gui
delin
es s
houl
d be
add
ress
ed to
:
D
irect
or
Nat
iona
l AID
S an
d ST
I Con
trol
Pro
gram
me
(NA
SCO
P)
Min
istr
y of
Hea
lth
P.O
. Box
193
61 -
0020
0 N
airo
bi, K
enya
Te
leph
one:
+25
4 20
272
9502
/272
9549
Fa
x: +
254
20 2
71 0
518
or 2
72 9
502
Emai
l: he
adna
scop
@ic
onne
ct.c
o.ke
W
ebsi
te: w
ww
.aid
sken
ya.o
rg
Th
ird e
ditio
n
Cop
yrig
ht ©
200
9, M
inis
try o
f Hea
lth, G
over
nmen
t of K
enya
3
G
uid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Li
st o
f Con
trib
utor
s
Dr.
Ayi
si, R
ober
t K.
Dep
uty
Hea
d, N
ASC
OP/
PMTC
T Pr
grm
Mng
r,
M
OH
-NA
SCO
P
Dr.
Abd
alla
h, S
aade
H
IV T
rain
er, J
HPI
EG
O
Ms.
Ake
lola
, Rut
h
Nut
ritio
n &
HIV
Man
ager
, MO
H-N
ASC
OP
Mr.
Dey
a, J
osph
at
PMTC
T Pr
ogra
m O
ffice
r, M
OH
-NA
SCO
P
Dr.
Die
lem
ans,
Pau
l M
ater
nal N
eona
tal H
ealth
(MN
H) A
dvis
or, E
HS/
DR
H
Ms.
Gitu
to, A
nnie
W.
Prog
ram
Offi
cer,
MO
H-D
RH
Dr.
Inw
ani,
Iren
e Pa
edia
tric
ian
I/C A
RT,
KN
H
Mr.
Isav
wa,
Ant
hony
D
ata
Prog
ram
Man
ager
, CD
C K
enya
Dr.
Kar
anja
, Dom
inic
PM
TCT
Prog
ram
Man
ager
, PA
THFI
ND
ER
Inte
rnat
iona
l
Dr.
Kia
rie,
Jam
es N
. PM
TCT
Prog
ram
Man
ager
, KN
H/U
ON
Dr.
Kig
en, B
atile
l Pr
ogra
m M
anag
er, M
OH
-DR
H
Ms.
Koe
ch, R
osel
ine
Pr
ogra
m O
ffice
r, M
OH
-DR
H
Dr.
Mac
hari
a, S
heila
R
H S
ervi
ces
Spec
ialis
t, U
SAID
/K
Dr.
Mat
u, L
ucy
PM
TCT
Prog
ram
Man
ager
, USA
ID/K
Ms.
Mau
a, J
udith
Pr
ogra
m O
ffice
r, D
RH
-MO
H
Prof
. Mbo
ri-N
gach
a, D
. Se
nior
Tec
hnic
al A
dvis
or, A
ssoc
iate
Pro
fess
or
of
Pae
diat
rics
, CD
C K
enya
/UoN
Dr.
Mud
any,
Mild
red
Te
chni
cal A
dvis
or, C
DC
Ken
ya
Ms.
Muh
enje
, Ody
lia
Beh
avio
ral S
cien
tist,
CD
C K
enya
Ms.
Mut
sots
o, W
infr
ed
PMTC
T Te
chni
cal A
dvis
or/P
rogr
am M
anag
er, C
DC
Ken
ya
Ms.
Mut
uku,
Ter
esia
H
IV T
rain
er, J
HPI
EG
O
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
104
App
endi
x V
III
1
03
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
App
endi
x V
II
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
4
Ms.
Mw
anga
ngi,
Alic
e
Prog
ram
Offi
cer,
DR
H-M
OH
Ms.
Mw
angi
, Nan
cy
PMTC
T A
dmin
istr
ativ
e A
ssis
tant
, CD
C K
enya
Mr.
Ndw
iga,
Fra
ncis
Pr
ogra
m O
ffice
r, M
OH
-NA
SCO
P
Prof
. Ndu
ati,
Rut
h
Ass
ocia
te P
rofe
ssor
of P
aedi
atri
cs, U
oN
Dr.
Nju
guna
, Cha
rles
Pr
ogra
m A
ssoc
iate
, MSH
/RPM
Plu
s
Mr.
Nya
beri
, Dav
id
Prog
ram
Offi
cer,
MO
H-D
RH
Mr.
Ode
ra, J
. W.
Prog
ram
Coo
rdin
ator
, GTZ
Ms.
Olu
och,
Pat
rici
a
Tech
nica
l Adv
isor
, CD
C K
enya
Mr.
Olu
och,
Tom
Te
chni
cal A
dvis
or, C
DC
Ken
ya
Dr.
On’
gech
, Joh
n
Prog
ram
Coo
rdin
ator
, KN
H
Dr.
Otie
no-N
yuny
a, B
. Se
nior
Lec
ture
r/H
ead
of D
epar
tmen
t, PM
TCT
Dir
ecto
r,
Moi
Uni
vers
ity/A
MPA
TH
Dr.
Oum
a, C
hris
PM
TCT
Prog
ram
Offi
cer,
UN
ICE
F
Dr.
Saw
e, F
redr
ick
K.
Dep
uty
Dir
ecto
r, W
RP
Mr.
Soo
, Leo
nard
Pr
ogra
m M
anag
er, W
RP
Dr.
Vak
il, S
obha
N.
Tech
nica
l Adv
isor
AR
T Pr
ogra
m, N
ASC
OP
Ms.
Way
ua, R
uth
Prog
ram
Offi
cer,
MO
H-D
RH
Dr.
Yon
ga, I
sabe
lla
PMTC
T Te
chni
cal A
dvis
or, E
GPA
F
5
G
uid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e of
Con
tent
s Li
st o
f con
trib
utor
s 3
Tabl
e of
con
tent
s 5
Ack
now
ledg
emen
ts
10
Fore
wor
d
11
Abb
revi
atio
ns a
nd A
cron
yms
12
Exe
cutiv
e Su
mm
ary
16
Cha
pter
1:
Bac
kgro
und
20
1.1T
he G
loba
l Pan
dem
ic
20
1.2
Mag
nitu
de o
f HIV
in P
regn
ancy
in
22
1.3
Ris
ks o
f Tra
nsm
issi
on o
f MTC
T at
Diff
eren
t Tim
e Pe
riod
s 23
1.4
Ris
k Fa
ctor
s of
MTC
T of
HIV
24
1.5
Ben
efits
of P
MTC
T of
HIV
25
1.6
Ben
efits
of H
IV C
ouns
ellin
g &
Tes
ting
25
1.7
The
Four
-pro
nged
App
roac
h to
PM
TCT
26
1.8
Ove
rvie
w o
f the
New
PM
TCT
Gui
delin
es
28
1.9
Obj
ectiv
es &
Org
anis
atio
n of
the
Gui
delin
es
28
1.10
U
sing
the
Gui
delin
es
29
Cha
pter
2: A
nten
atal
Car
e an
d Pr
even
tion
of M
TCT
of H
IV
32
2.1
Intr
oduc
tion
32
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
102
4. B
acte
riolo
gica
l con
firm
atio
n
App
ropr
iate
clin
ical
sam
ples
incl
ude
sput
um,
gast
ric
aspi
rate
s an
d ce
rtai
n ot
her
mat
eria
ls.
Sin
ce m
ost
TB
in c
hild
ren
is in
infa
nts
and
youn
g ch
ildre
n, s
putu
m
indu
ctio
n m
ay b
e do
ne f
irst
or g
astr
ic a
spira
tions
and
exp
ecto
ratio
ns
a. S
putu
m In
duct
ion
Spu
tum
indu
ctio
n is
saf
e an
d ef
fect
ive
in c
hild
ren
of a
ll ag
es a
nd t
he b
acte
rial
yi
elds
a]r
e as
goo
d or
bet
ter
that
for
gas
tric
asp
irate
s.
b. G
astr
ic a
spira
tion
Thi
s is
per
form
ed in
you
ng c
hild
ren
who
are
una
ble
or u
nwill
ing
to
expe
ctor
ate
sput
um
A g
astr
ic a
spir
ate
shou
ld b
e ob
tain
ed o
n ea
ch o
f th
e th
ree
cons
ecut
ive
m
orni
ngs
c. E
xpec
tora
tions
S
putu
m s
houl
d al
way
s be
obt
aine
d in
adu
lts a
nd o
lder
chi
ldre
n >1
0 ye
ars
of
age
susp
ecte
d of
hav
ing
pulm
onar
y T
B
Bac
teri
al y
ield
s ar
e hi
gher
in o
lder
chi
ldre
n
Thr
ee s
putu
m s
peci
men
s sh
ould
be
obta
ined
: an
on-
the
–spo
t sp
ecim
en (
at t
he
first
eva
luat
ion)
, an
ear
ly m
orni
ng s
peci
men
and
a s
econ
d on
-the
-spo
t sp
ecim
en.
Spu
tum
indu
ctio
n is
saf
e an
d ef
fect
ive
in c
hild
ren
of a
ll ag
es a
nd t
he b
acte
rial
yi
elds
are
as
good
or
bett
er t
han
for
gast
ric a
spira
tes
1
01
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
NO
TES:
1. H
isto
ry
• A
sk f
or s
ympt
oms
cons
iste
nt w
ith T
B in
clud
ing
chro
nic
coug
h> 2
wee
ks,
feve
r- b
ody
tem
pera
ture
of
38 o C
for
14 d
ays
afte
r co
mm
on c
ause
s su
ch a
s m
alar
ia a
nd p
neum
onia
hav
e be
en e
xclu
ded,
wei
ght
loss
or
failu
re t
o th
rive
(
also
look
at
the
grow
th c
hart
), a
nd o
r ni
ght
swea
ts.
Enq
uire
whe
ther
the
pat
ient
has
bee
n in
clo
se c
onta
ct w
ith s
mea
r-po
sitiv
e pu
l-m
onar
y T
B (
usua
lly a
par
ent
or o
ther
mem
ber
of th
e fa
mily
) 2.
Clin
ical
exa
min
atio
n a.
Phy
sica
l sig
ns h
ighl
y su
gges
tive
of e
xtra
pul
mon
ary
TB
:
• O
ften
the
mai
n cl
inic
al f
indi
ng is
just
fai
lure
to
thriv
e
• G
ibus
, es
peci
ally
of
rece
nt o
nset
(re
sulti
ng f
rom
ver
tebr
al T
B)
• N
on-p
ainf
ul e
nlar
ged
cerv
ical
lym
phad
enop
athy
with
fis
tula
for
mat
ion
b. P
hysi
cal s
igns
req
uiri
ng in
vest
igat
ions
to
excl
ude
extr
a pu
lmon
ary
TB
.
• M
enin
gitis
not
res
pond
ing
to a
ntib
iotic
s tr
eatm
ent
• P
leur
al e
ffus
ion
• P
eric
ardi
al e
ffus
ion
• D
iste
nded
abd
omen
with
asc
itis
• N
on-p
ainf
ul e
nlar
ged
lym
ph n
odes
with
out
fistu
la f
orm
atio
n
• N
on-p
ainf
ul e
nlar
ged
join
t
Sig
ns o
f tu
berc
ulin
hyp
erse
nsiti
vity
3.
Man
toux
test
A
man
toux
tes
t sh
ould
be
rega
rded
pos
itive
as
follo
ws:
• In
hig
h-ris
k ch
ildre
n (i
nclu
des
HIV
-inf
ecte
d ch
ildre
n an
d se
vere
ly m
al-
nour
ishe
d ch
ildre
n ):
>5m
m d
iam
eter
of
indu
ratio
n
• In
all
othe
r ch
ildre
n( w
heth
er t
hey
have
rec
eive
d B
CG
or
not)
:>1
0mm
di-
amet
er o
f ind
urat
ion
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
6
2.2
Ope
ratio
nal G
uide
lines
32
2.3
Job
Aid
s
34
2.4
App
endi
ces
13
Cha
pter
3: I
ntra
part
um C
are
38
3.1
Intr
oduc
tion
38
3.2
Ope
ratio
nal G
uide
lines
38
Cha
pter
4:
Use
of A
RVs
in P
regn
ancy
for T
reat
men
t & P
MTC
T of
HIV
infe
ctio
n 4
2
4.1
Intr
oduc
tion
42
4.2
Ope
ratio
nal G
uide
lines
43
Cha
pter
5: I
mm
edia
te P
ostn
atal
and
Neo
nata
l Car
e
51
5.1
Intr
oduc
tion
51
5.2
Ope
ratio
nal G
uide
lines
51
Cha
pter
6: L
ate
Post
nata
l Car
e an
d Fa
mily
Pla
nnin
g
54
6.1
Intr
oduc
tion
54
6.2
Ope
ratio
nal G
uide
lines
54
Cha
pter
7: H
IV D
iagn
osis
in C
hild
ren
58
7.1
Intr
oduc
tion
58
7.2
O
pera
tiona
l Gui
delin
es
59
7.2.
0
Gui
delin
es fo
r H
IV D
iagn
osis
in C
hild
ren
59
7
G
uid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
7.2.
1
HIV
Neg
ativ
e In
fant
at 6
wee
ks o
r Fi
rst C
onta
ct
59
7.2.
2
HIV
Pos
itive
Infa
nt b
y D
NA
PC
R
60
7.2.
3
Com
preh
ensi
ve C
are
for
HIV
-exp
osed
Infa
nt
61
Cha
pter
8:
Feed
ing
Infa
nts
and
Youn
g C
hild
ren
Bor
n to
HIV
infe
cted
mot
hers
62
8.1
Intr
oduc
tion
62
8.2
Ope
ratio
nal G
uide
lines
on
Infa
nt F
eedi
ng (0
-6 m
onth
s)
63
8.3
Ope
ratio
nal G
uide
lines
on
Feed
ing
Chi
ldre
n 6
mon
ths
and
olde
r 64
8.4
Nut
ritio
nal C
are
and
Supp
ort o
f HIV
infe
cted
Chi
ldre
n
64
8.5
Ext
ract
s fr
om R
esea
rch
on In
fant
Fee
ding
and
HIV
/AID
S 65
Cha
pter
9:
Car
e an
d Fo
llow
up
of C
hild
ren
of H
IV-in
fect
ed m
othe
rs 7
3
9.1
Intr
oduc
tion
73
9.2
Ope
ratio
nal G
uide
lines
74
Cha
pter
10:
Mon
itorin
g an
d Ev
alua
tion
of P
MTC
T se
rvic
es
83
10.1
In
trod
uctio
n
83
10.2
O
pera
tiona
l Gui
delin
es
85
Bib
liogr
aphy
91
Job
Aid
s/R
efer
ence
s
91
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
100
App
endi
x V
I D
IAG
NO
STIC
ALG
OR
ITH
M F
OR P
ULM
ON
AR
Y T
B IN
CH
ILD
REN
9
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
App
endi
x V
CO
MM
ON
AD
VER
SE E
FFEC
TS O
F A
RV
USE
DU
RIN
G P
REG
NA
NC
Y
Cla
ss
Adv
erse
effe
cts
Cou
nsel
ing
and
Follo
w-u
p Ti
ps
Zido
vudi
ne(A
ZT)
Lam
ivid
ine
(3TC
) St
avud
ine
(d4T
) A
baca
vir(
AB
C)
Teno
fovi
r(TF
V/TD
F)
Emitr
icita
bine
(FTC
)
Nau
seau
D
iarh
oea
Hyp
erse
nsiti
vity
(AB
C)
Ana
emia
(AZT
)
May
not
be
wel
l-tol
erat
ed in
ear
l pr
egna
ncy
whe
n
mor
ning
sic
knes
s is
com
mon
M
ay in
crea
se ri
sk o
f non
-ad
here
nce
May
hav
e in
adeq
uate
blo
od le
vels
A
ll A
RVs
sho
uld
be d
isco
ntin
ued
and
rest
arte
d w
hen
N&
V is
gon
e or
effe
ctiv
ely
trea
ted
Fo
llow
-up
labs
: CB
C, L
FTs,
Non
- Nuc
leos
ide
Rev
erse
Tra
nscr
ipta
se In
hibi
tors
(NN
RTI
s)
Nev
irapi
ne(N
VP)
Del
avird
in
Efav
irenz
(EFV
)
Ras
h
Elev
ated
live
r enz
ymes
(c
omm
on w
ith N
VP in
hig
h C
D4
coun
t) EF
V: C
NS
effe
cts(
seda
tion,
in-
som
nia,
viv
id d
ream
s, d
izzi
ness
, co
nfus
ion,
feel
ing
of
‘dis
enga
gem
ent’
Tera
toge
nici
ty
If ra
sh in
1st
2 w
ks d
o no
t inc
reas
e N
VP d
ose
and
cont
act c
linic
ian
Mild
rash
may
be
man
aged
with
an
tihis
tam
ines
A
void
cor
ticos
tero
ids
durin
g N
VP
dose
esc
alat
ion
EFV
shou
ld b
e ta
ken
initi
ally
at
bed
time
Avo
id E
FV in
wom
en o
f hig
h ch
ild-b
earin
g po
tent
ial
Do
not o
pera
te h
eavy
mac
hine
ry
Pro
teas
e In
hibi
tors
(PIs
)
Saqu
inav
ir(SQ
V)
Indi
navi
r(ID
V)
Rito
navi
r(R
TV)
Nel
finav
ir(N
LF)
Lopi
navi
r/rito
navi
r(LP
V/r)
A
taza
navi
r(A
TV)
Fose
mpr
enav
ir Ti
pana
vir(
TPV)
D
arun
avir(
DR
V)
GI i
ntol
eran
ce
Hep
atot
oxic
ity
Lipo
dyst
roph
y D
yslip
idem
ias
Insu
lin re
sist
ance
H
yper
glyc
aem
ia
Lact
ic a
cido
sis
and
hepa
tic s
tea-
tosi
s
Mon
itor g
luco
se le
vels
A
sk re
gula
rly fo
r sym
ptom
s of
hy
perg
lyca
emia
M
onito
r hep
atic
tran
sam
inas
es
(ALT
and
AST
) par
ticul
arly
dur
ing
the
first
18
wee
ks o
f the
rapy
, w
hen
this
toxi
city
is m
ost l
ikel
y Ta
ke w
ith fo
od
Ant
iem
etic
s A
ntim
otili
ty
Nuc
leos
ide/
Nuc
leot
ide
Rev
erse
Tra
nscr
ipta
se In
hibi
tors
( NR
TIs)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
8
App
endi
ces
92
App
endi
x I:
W
HO
Clin
ical
Sta
ging
of H
IV/A
IDS
for
Adu
lts a
nd
A
dole
scen
ts w
ith C
onfir
med
HIV
infe
ctio
n
92
App
endi
x II
: C
ontr
acep
tive
Opt
ions
for
Peop
le L
ivin
g w
ith H
IV
95
App
endi
x II
I: U
se o
f AR
Vs
for
Trea
tmen
t and
PM
TCT
of H
IV in
AN
C
97
App
endi
x IV
: Use
Of A
RV
s fo
r PM
TCT
of H
IV in
Lab
our
And
Del
iver
y U
nit
98
App
endi
x V
: Com
mon
Adv
erse
Effe
cts
of A
RV
Use
Dur
ing
Preg
nanc
y 99
App
endi
x V
I: D
iagn
ostic
alg
orith
m fo
r pu
lmon
ary
TB in
Chi
ldre
n 10
0
App
endi
x V
II: I
nteg
rate
d M
onito
ring
and
Eval
uatio
n Re
port
For
m, M
OH
726
10
3
App
endi
x V
III:
Rep
rodu
ctiv
e H
ealth
, HIV
/AID
S R
epor
t For
m, M
OH
711
10
4
Lis
t of T
able
s
Tabl
e 1.
1 A
dult
HIV
-pre
vale
nce
Est
imat
e by
Pro
vinc
e in
200
6 21
Tabl
e 1.
2 E
stim
ated
Mag
nitu
de o
f MTC
T in
Ken
ya, 2
007
22
Tabl
e 1.
3 Tr
ansm
ission
Pat
tern
s in
Brea
stfee
ding
and
Non
bre
astfe
edin
g Pop
ulat
ions
23
Tabl
e 1.
4 R
isk
Fact
ors
for
MTC
T of
HIV
24
Tabl
e 1.
5 Th
e Fo
ur-p
rong
ed A
ppro
ach
App
lied
to th
e PM
TCT
Gui
delin
es
30
Tabl
e 2.
1 E
ssen
tial P
acka
ge o
f Int
egra
ted
Ant
enat
al C
are
Serv
ices
33
Tabl
e 4.
1 R
ecom
men
datio
ns fo
r In
itiat
ing
AR
V T
reat
men
t in
Preg
nant
Wom
en B
ased
on
Clin
ical
Sta
ge a
nd A
vaila
bilit
y of
CD
4 co
unt
44
Tabl
e 4.
2 R
ecom
men
ded
Firs
t Lin
e A
RT
Reg
imen
for
Trea
ting
Preg
nant
Wom
en a
nd P
roph
ylac
tic R
egim
en fo
r In
fant
s 45
Tabl
e 4.
3a R
ecom
men
ded
Firs
t Lin
e A
RV
Pro
phyl
axis
to P
reve
nt H
IV
46
In
fect
ion
in In
fant
s A
mon
g pr
egna
nt W
omen
Pre
sent
ing
Bef
ore
38 W
eeks
Tabl
e 4.
3b A
ltern
ativ
e A
RV
Pro
phyl
axis
to P
reve
nt H
IV In
fect
ion
in In
fant
s 4
6
Am
ong
Preg
nant
Wom
en P
rese
ntin
g B
efor
e 38
Wee
ks
9
G
uid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e 4.
4 A
RV
Pro
phyl
axis
for
PMTC
T am
ong
Preg
nant
Wom
en w
ho h
ave
47
not r
ecei
ved
Ant
enat
al A
RT
or P
roph
ylax
is
Tabl
e 4.
5 C
hoic
e of
HA
AR
T fo
r Pr
egna
nt W
omen
bas
ed o
n C
D4
coun
t 47
Tabl
e 4.
6
AR
V P
roph
ylac
tic R
egim
ens
for
Infa
nts
Bor
n to
HIV
-pos
itive
49
Wom
en w
ho h
ave
not r
ecei
ved
Intr
apar
tum
AR
T or
AR
V P
roph
ylax
is
Tabl
e 9.
1
Dos
e of
Co-
trim
oxaz
ole
for
PCP
prop
hyla
xis
76
Tabl
e 9.
2
WH
O R
ecom
men
datio
ns fo
r Fo
llow
-up
of a
n H
IV-e
xpos
ed C
hild
79
Tabl
e 10
.1 C
ontr
acep
tive
Met
hods
for
Use
in C
oupl
es a
nd W
omen
Liv
ing
96
with
HIV
Infe
ctio
n
List
of F
igur
es
Figu
re 2
.1 R
apid
HIV
Ser
ial T
estin
g A
lgor
ithm
35
Figu
re 8
.1 G
uide
lines
for
Cou
nsel
ling
on H
IV a
nd In
fant
feed
ing
66
Job
Aid
s an
d IE
C M
ater
ials
on
Infa
nt a
nd Y
oung
Chi
ld F
eedi
ng
67
Figu
re 1
0.1
Mon
itori
ng a
nd E
valu
atio
n D
ata
Flow
in K
enya
84
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
98
September 08
USE OF ARVs FOR PMTCT OF HIV IN LABOUR AND DELIVERY UNITSALL MOTHERS
1. History2. Examination3. Establish mother’s HIV status4. Offer HIV counseling and testing for motherwith unknown HIV status5. Provide standard obstetrical management andcare
HIV NEGATIVECounsel on risk reduction
HIV POSITIVE
Establish Mother’s use of ARVs in pregnancy and give appropriate ARVs as shown in boxes below
Regardless of Duration received HAART
Action:
i.Give mother ARV dose as per regimen
ii.Post partum Infant: Give Infant sdNevirapine 2mg/kg within 72 hours of birth PLUS 3TC 4mg/kg BD for 1 week and AZT syrup 4 mg/kg BD for 6 weeks.
iii.Post partum mother: Continue with ARVsas per regimen.
MOTHER RECEIVED HAART IN PREGNANCY
FOR MORE INFORMATION CONTACT THE NATIONAL AIDS/STD CONTROL PROGRAMME (NASCOP)P.O. BOX 19361-00202 NAIROBI TEL: 0202729502 FAX 020 2710518
MINISTRY OF HEALTH
•Give mother sdNevirapine 200mg , AZT 600mg and 3TC 150 mg stat
•Post partum Infant: Give Infant sdNevirapine 2mg/kg within 72 hours of birth PLUS
3TC syrup 4mg/kg BD for 1 week and AZT syrup 4 mg/kg BD for 6 weeks.
•Post partum mother: Give mother AZT 300mg & 3TC 150 mg BID for 7days.
MOTHER RECEIVED AZT IN PREGNANCYORNO ARVsTAKEN IN PREGNANCY
App
endi
x IV
9
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
September 2008
USE OF ARVs FOR TREATMENT AND PMTCT OF HIV IN ANCALL MOTHERS
1. History2. Health Information3. Examination4. Investigations (with informed consent for HIV test)
HIV NEGATIVE1.Provide post-test HIV preventive
interventions defined in national HTC guidelines
2.Refer for other post-test HIV preventive interventions not available in the clinic but available within the facility
HIV POSITIVE1. Counsel on risk reduction2. Perform WHO clinical staging for HIV disease 3. Determine CD4 level (if testing facilities available)4. Determine Gestation age and HB level5. Give ARV’sas shown below6.Provide or refer for other post-test HIV interventions defined in national HTC
guidelines
1.WHO clinical stage I or II with CD4 cell count >350/mm3 OR2.WHO clinical stage I or II no CD4 cell count done3.HB =8g/dl OR no clinical features of anaemia
•Initiate AZT 300mg BD daily at 28 weeks gestation or any time period immediately thereafter
•Monitor for clinical features of anemia and treat•Dispense ANC Nevirapine 200mg PLUS AZT 600mg + 3TC 150mg for
mother to take at onset of labour•Dispense NVP syrup to give infant at birth
•At onset of labouroAdminister Nevirapine 200mg, AZT 600mg, 3TC 150 mg
stat to mother.•Post partum
oGive Infant sdNevirapine 2mg/kg within 72 hours of birth PLUS 3TC 4mg BD for 1 week and AZT syrup 4 mg/kg BD for 6 weeks.
oGive mother AZT300 mg / 3TC 150 BID for 7 days
1.WHO clinical stage I or II with CD4 cell count >350/ mm3 OR2.WHO clinical stage I or II with no CD4 cell count done
•Dispense ANC Nevirapine 200mg PLUS AZT 600mg + 3TC 150mg for mother to take at onset of labour
•Dispense NVP syrup to give infant at birth•At Onset of labour
oAdminister sdNevirapine, AZT 600 mg and 3TC 150mg stat.
•Post PartumoGive Infant sdNevirapine 2mg/kg within 72
hours of birth PLUS 3TC 4mg/kg BD for 1 week and AZT syrup 4mg/kg BD for 6 weeks.
oGive mother AZT300 mg / 3TC 150 mg BID for 7 days
1.Any gestational age2.WHO clinical stage III or IV of HIV disease regardless of CD4 cell count OR3.WHO clinical stages I or II of HIV disease withCD4 cell count =350/mm3(*)
•Refer to Clinician for Evaluation and initiation of NNRTI based ART as per national ART guidelines
•At Onset of LabouroGive mother ARV dose as per regimen
•Post partumoGive Infant sdNevirapine 2mg/kg within 72 hours of birth PLUS
3TC 4mg/kg and AZT syrup 4 mg/kg BD for 6 weeks.oGive mother ARVsas per regimen
4.If no HAART available , manage the woman as indicated in box no.2 and refer to ART site appropriately.
FOR MORE INFORMATION CONTACT THE NATIONAL AIDS/STD CONTROL PROGRAMME (NASCOP)P.O. BOX 19361-00202 NAIROBI TEL: 0202729502 FAX 020 2710518
MINISTRY OF HEALTH
ELIGIBLE FOR TREATMENT
NOT ELIGIBLE FOR TREATMET AND PRESENTING BELOW 38 WEEKS GESTATIONNOT ELIGIBLE FOR TREATMENT AND PRESENTING > 38 WEEKS
GESTATION
*Please note:•Pregnant women with WHO clinical stage I or II plus CD4 cell count >250/mm3and =350/ mm3can be initiated on ART where a PI based HAART regimen is available. NVP hypersensitivity has been previously reported among women in this group initiated on NNRTI based
ART regimens. Where PI based ART regimen is not available, refer the patient to a site where the regimen is available or continue to manage the woman as is indicated in box No 2. •The grading of anaemiain pregnancy is > 8-10 Mild anemia: > 6-8 Moderate anemia: < 6 Severe anemia•Treatment ifcommon pathologies ruled out: Mild anaemia,haematinicsirrespective of gestation; Moderate anaemiatransfusion ifclose to term >36 weeks otherwise give haematinics; Severe anaemiatransfusion irrespective of gestation.Do not stop AZT if Hbdrops but
would manage it as above and only stop if continues to fall orfails to respond despite transfusion.
App
endi
x II
I
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
10
A
ckno
wle
dgem
ents
Th
e th
ird
editi
on o
f G
uide
lines
for
Pre
vent
ion
of M
othe
r-to
-Chi
ld T
rans
mis
sion
of
HIV
/ AID
S in
Ken
ya is
a r
esul
t of e
ffort
s of
man
y in
divi
dual
s an
d or
gani
zatio
ns in
the
coun
try.
The
Tec
hnic
al W
orki
ng G
roup
on
PMTC
T le
d th
ese
effo
rts.
Mem
bers
of t
he
team
rev
iew
ed a
ll th
e m
odul
es, r
evis
ed a
nd in
som
e ca
ses
re-w
rote
the
mod
ules
bas
ed
on th
e se
cond
edi
tion
to m
ake
them
up
to d
ate
and
in li
ne w
ith c
urre
nt s
cien
tific
evi
-de
nce
and
expe
rien
ce. W
e ac
know
ledg
e th
e co
ntri
buto
rs a
nd r
evie
wer
s of
the
cur
rent
an
d pr
evio
us e
ditio
ns. O
f sp
ecia
l m
entio
n ar
e th
e fo
llow
ing:
Ken
ya O
bste
tric
al a
nd
Gyn
aeco
logi
cal S
ocie
ty (K
OG
S), t
he U
nive
rsity
of N
airo
bi a
nd M
oi U
nive
rsity
.
We
wou
ld l
ike
to t
hank
the
fol
low
ing
inst
itutio
ns f
or t
echn
ical
as
wel
l as
fin
anci
al
supp
ort,
duri
ng t
he r
evis
ion
of t
he g
uide
lines
: N
atio
nal A
IDS
and
STD
Con
trol
Pro
-gr
amm
e (N
ASC
OP)
, the
Div
isio
n of
Rep
rodu
ctiv
e H
ealth
, Cen
ters
for
Dis
ease
Con
trol
an
d Pr
even
tion
(CD
C).
It is
not
pos
sibl
e to
men
tion
all i
ndiv
idua
ls a
nd o
rgan
izat
ions
th
at p
artic
ipat
ed in
this
impo
rtan
t exe
rcis
e. T
o al
l of y
ou, A
sant
e Sa
na!
Min
istr
y of
Hea
lth
1
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Fore
wor
d Th
e M
inis
try
of H
ealth
(M
oH)
is c
omm
itted
to
deve
lopm
ent
of e
ffect
ive
PMTC
T pr
o-gr
amm
es. G
uide
lines
are
an
impo
rtan
t pa
rt o
f the
Gov
ernm
ent
stra
tegy
to
redu
ce M
TCT
and
is i
n lin
e w
ith t
he N
atio
nal
Hea
lth S
ecto
r St
rate
gic
Plan
II
(NH
SSPI
I) a
nd K
enya
N
atio
nal A
IDS
Stra
tegi
c Pl
an (K
NA
SP) 2
000-
2010
whi
ch fo
cuse
s on
pri
ority
are
as o
f pre
-ve
ntio
n of
new
infe
ctio
ns, i
mpr
ovin
g qu
ality
of l
ife o
f tho
se in
fect
ed a
nd a
ffect
ed, a
nd m
iti-
gatio
n of
soc
ial a
nd e
cono
mic
impa
ct o
f the
infe
ctio
n.
MTC
T is
the
pre
dom
inan
t m
ode
of t
rans
mis
sion
of
HIV
in
infa
nts
and
youn
g ch
ildre
n.
This
tra
nsm
issi
on o
ccur
s du
ring
pre
gnan
cy,
labo
ur a
nd d
eliv
ery
and,
am
ong
brea
stfe
d ba
bies
, in
the
post
-par
tum
per
iod.
Mem
bers
of t
he T
echn
ical
Wor
king
Gro
up (T
WG
) on
PMTC
T re
view
ed t
he m
odul
es o
f the
se
cond
edi
tion,
rev
ised
and
in s
ome
case
s re
-wro
te th
e m
odul
es b
ased
on
up to
dat
e kn
owl-
edge
and
in
line
with
cur
rent
sci
entif
ic e
vide
nce
and
expe
rien
ce. T
he T
WG
con
sist
s of
a
grou
p of
pro
fess
iona
ls d
raw
n fr
om v
ario
us d
isci
plin
es t
hat
are
impl
emen
ting
and/
or m
an-
agin
g PM
TCT.
The
gro
up a
dopt
ed a
nd a
dapt
ed th
e la
test
rec
omm
enda
tions
of t
he W
HO
on
PMTC
T as
wel
l as
vari
ous
natio
nal g
uide
lines
on
HIV
pre
vent
ion,
trea
tmen
t and
car
e.
A f
our-
pron
ged
appr
oach
thr
ough
the
var
ious
rep
rodu
ctiv
e lif
e cy
cles
as
prop
osed
by
the
Inte
r-A
genc
y Ta
sk T
eam
(IA
TT)
on c
hild
ren
and
HIV
and
AID
S w
as a
dopt
ed i
n th
ese
guid
elin
es w
ith e
mph
asis
bei
ng p
lace
on
all t
he fo
ur p
rong
s.
For
any
of t
he P
MTC
T in
terv
entio
ns t
o be
suc
cess
fully
impl
emen
ted
coun
selin
g an
d te
st-
ing
(CT)
mus
t fir
st b
e do
ne. R
outin
e H
IV te
stin
g w
ith o
pt-o
ut o
ptio
n is
rec
omm
ende
d. T
his
is fo
llow
ed b
y ap
prop
riat
e m
edic
al, s
urgi
cal i
nter
vent
ions
incl
udin
g an
tiret
rovi
ral p
roph
y-la
xis,
saf
er o
bste
tric
pra
ctic
es a
s w
ell a
s in
fant
feed
ing
coun
selin
g an
d pr
ovis
ion
of a
ppro
-pr
iate
infa
nt fe
edin
g. H
IV-p
ositi
ve w
omen
are
ass
esse
d cl
inic
ally
usi
ng W
HO
sta
ging
and
w
here
fea
sibl
e im
mun
olog
ical
ass
essm
ent
usin
g C
D4
cell
coun
t. H
IV e
xpos
ed in
fant
s ar
e te
sted
thro
ugh
earl
y in
fant
dia
gnos
is (E
ID).
In th
ese
guid
elin
es m
ore
effic
acio
us r
egim
ens
are
intr
oduc
ed fo
r th
e fir
st ti
me
whi
le in
for-
mat
ion
and
coun
selin
g on
inf
ant
feed
ing
follo
ws
the
AFA
SS (
Ava
ilabl
e, f
easi
ble,
acc
ept-
able
, saf
e an
d su
stai
nabl
e) c
rite
ria.
The
mod
ule
on m
onito
ring
and
eva
luat
ion
addr
esse
s is
sues
of d
ata
colle
ctio
n, c
olla
tion
and
repo
rtin
g as
wel
l as
use
of d
ata
for
deci
sion
-mak
ing
at th
e fa
cilit
y-le
vel.
We
hope
that
app
ropr
iate
impl
emen
tatio
n in
stru
men
ts w
ill b
e us
ed to
ope
ratio
naliz
e th
ese
guid
elin
es.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
96
Tabl
e 11
.1:
Con
trac
eptiv
e M
etho
ds fo
r Use
in
Cou
ples
and
Wom
en L
ivin
g w
ith H
IV In
fect
ion
*DM
PA =
Dep
ot M
edro
xypr
oges
tero
ne A
ceta
te (D
epo-
Prov
era)
MET
HO
D
CO
MM
ENTS
U
SE
IN H
IV P
OSI
TIV
E P
ATI
EN
TS
Con
dom
s •
Mal
e &
fem
ale
cond
oms
avai
labl
e
• P
rovi
de d
ual p
rote
ctio
n ag
ains
t STI
s/H
IV
& p
regn
ancy
. •
Req
uire
atte
ntio
n &
care
fo
r cor
rect
use
eac
h tim
e.
• M
ay re
quire
co-
oper
atio
n of
par
tner
• C
an a
nd s
houl
d be
use
d at
all
stag
es o
f HIV
in
fect
ion
•
Can
and
sho
uld
be u
sed
by p
atie
nts
on A
RT
• C
orre
ct a
nd c
onsi
sten
t use
by
HIV
infe
cted
pat
ient
s is
re
com
men
ded
rega
rdle
ss o
f the
use
of o
ther
met
hods
of
con
trace
ptio
n (d
ual c
ontra
cept
ion)
.
Hor
mon
al
Met
hods
•
Ver
y ef
fect
ive
and
easy
to u
se
• S
uita
ble
for s
hort-
or l
ong-
term
use
•
Rev
ersi
ble
• A
ssoc
iate
d w
ith n
on-
cont
race
ptiv
e he
alth
ben
efits
•
Ser
ious
com
plic
atio
ns
extre
mel
y ra
re
• C
an b
e us
ed w
ithou
t res
trict
ion
in H
IV+
wom
en n
ot o
n AR
T •
Can
be
used
with
out r
estri
ctio
n in
all
HIV
+ w
omen
for
emer
genc
y co
ntra
cept
ion
• S
ome
AR
V dr
ugs
may
redu
ce m
etho
d
effe
ctiv
enes
s.
• D
MP
A*/
Impl
ants
can
how
ever
be
used
with
AR
T; re
-in
ject
ion
of D
MP
A s
houl
d be
don
e at
10-
12 w
eeks
•
If ho
rmon
al m
etho
d is
cho
sen,
con
dom
s sh
ould
stil
l be
used
cor
rect
ly a
nd c
onsi
sten
tly
Intra
uter
ine
C
ontra
cept
ive
Dev
ice
• H
ighl
y ef
fect
ive,
long
-term
, re
vers
ible
met
hod
•
Rem
ains
in p
lace
up
to 1
2 ye
ars
•
Alm
ost 1
00 p
erce
nt
effe
ctiv
e
• H
as n
o ef
fect
on
ferti
lity
whe
n us
ed b
y nu
llipar
ous
wom
en
• S
houl
d no
t be
prov
ided
to
wom
en w
ith h
igh
risk
sexu
al li
fest
yle
• B
acte
rial S
TIs
shou
ld b
e sc
reen
ed fo
r and
/or
treat
ed a
s a
prec
autio
n pr
ior t
o in
serti
on o
f IU
CD
• A
ttrac
tive
met
hod
for w
omen
with
HIV
who
des
ire v
ery
relia
ble
preg
nanc
y pr
otec
tion
• C
an b
e in
serte
d in
HIV
+ w
omen
who
do
not h
ave
WH
O
Sta
ge 4
dis
ease
/AID
S d
efin
ing
illne
ss
• Fo
r wom
en w
ith s
tage
4 d
isea
se IU
D c
an b
e in
serte
d on
ce th
ey a
re o
n AR
T an
d ha
ve c
ontro
lled
sym
ptom
s of
sev
ere
illne
ss
Ste
riliz
atio
n •
Goo
d, v
ery
effe
ctiv
e fo
r co
uple
s or
indi
vidu
als
who
w
ant n
o m
ore
child
ren
• S
afe,
sim
ple
surg
ical
pr
oced
ure.
Con
side
red
perm
anen
t
• N
o m
edic
al re
ason
s to
den
y st
eriliz
atio
n to
clie
nts
w
ith H
IV
• P
roce
dure
may
be
dela
yed
in e
vent
of a
cute
HIV
-rel
ated
in
fect
ion
or s
tage
4 d
isea
se p
endi
ng im
mun
e re
cons
titut
ion
•
Enc
oura
ge c
ondo
m u
se a
s w
ell
9
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
App
endi
x II
C
ON
TRA
CEP
TIV
E O
PTIO
NS
FOR P
EOPL
E LI
VIN
G W
ITH
HIV
It
has
bee
n sh
own
in a
num
ber
of s
tudi
es o
f coh
orts
of H
IV p
ositi
ve w
omen
tha
t so
me
choo
se t
o co
ntin
ue s
exua
l act
ivity
des
pite
kno
wle
dge
of t
heir
sta
tus.
Evi
denc
e of
con
-ce
ptio
n ha
s de
mon
stra
ted
that
fert
ility
in H
IV p
ositi
ve w
omen
for
the
mos
t pa
rt is
un-
affe
cted
. H
owev
er, c
erta
in c
ondi
tions
may
affe
ct fe
rtili
ty s
uch
as lo
w b
ody
mas
s in
dex,
A
IDS
and
inte
rcur
rent
illn
ess,
esp
ecia
lly t
uber
culo
sis.
Put
ting
wom
en w
ho a
re H
IV
infe
cted
on
cont
race
ptiv
es is
one
of t
he m
eans
of p
reve
ntin
g m
othe
r to
chi
ld t
rans
mis
-si
on o
f HIV
(PM
TCT)
.
It is
the
rig
ht o
f HIV
infe
cted
wom
en t
o m
ake
thei
r ow
n de
cisi
ons
rega
rdin
g re
prod
uc-
tion.
The
y m
ay w
ish
to h
ave
mor
e ba
bies
, lim
it th
eir
fam
ilies
or
avoi
d pr
egna
ncy
alto
-ge
ther
. The
hea
lth c
are
prov
ider
s th
ey c
onsu
lt sh
ould
ena
ble
them
to
mak
e in
form
ed
choi
ces
by th
emse
lves
.
The
follo
win
g co
ntra
cept
ive
met
hods
are
ava
ilabl
e in
Ken
ya: -
pro
gest
eron
e on
ly p
ills,
lo
w d
ose
com
bine
d or
al c
ontr
acep
tives
, de
pot
med
roxy
prog
este
rone
ace
tate
(D
MPA
-
depo
), le
vono
rges
trel
and
eto
noge
stre
l im
plan
ts. E
mer
genc
y co
ntra
cept
ive
pills
, cop
per
intr
aute
rine
con
trac
eptiv
e de
vice
s, b
arri
er m
etho
ds, f
emal
e an
d m
ale
ster
ilisa
tion
are
also
ava
ilabl
e.
Som
e dr
ugs
inte
ract
with
hor
mon
al c
ontr
acep
tives
. A
nd c
oncu
rren
t us
e sh
ould
be
avoi
ded
. The
se d
rugs
incl
ude:
• P
rote
ase
inhi
bito
rs –
Rito
navi
r, N
elfin
avir,
Lop
inav
ir w
ith R
itona
vir
• N
on-n
ucle
otid
e re
vers
e tr
ansc
ript
ase
inhi
bito
rs (
NN
RT
Is)
– N
evir
apin
e
• E
favi
renz
• A
nti-T
B d
rugs
– R
ifam
pici
n an
d R
ifabu
tin
• O
ther
dru
gs –
Gris
eofu
lvin
, P
heno
barb
itone
, C
arba
maz
epin
e, P
heny
toin
All
the
abov
e do
not
app
ly i
n th
e fa
ce o
f ot
her
med
ical
con
ditio
ns t
hat
are
cont
ra-
indi
catio
ns f
or t
he v
ario
us m
etho
ds e
.g. k
now
n ca
rdio
vasc
ular
dis
ease
, hep
atic
con
di-
tions
, sm
okin
g, h
igh
bloo
d pr
essu
re a
nd th
rom
boem
bolic
dis
orde
rs.
The
follo
win
g ta
ble
sum
mar
ises
maj
or is
sues
reg
ardi
ng u
se o
f diff
eren
t co
ntra
cept
ives
by
HIV
-pos
itive
wom
en.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
12
Abb
revi
atio
ns a
nd A
cron
yms
A
FASS
A
ccep
tabl
e, F
easi
ble,
Affo
rdab
le, S
usta
inab
le a
nd S
afe
A
b A
nti-b
ody
A
IDS
Acq
uire
d Im
mun
e D
efic
ienc
y Sy
ndro
me
A
LT
Ala
nine
Tra
nsfe
rase
A
NC
A
nten
atal
Car
e
A
RM
A
rtifi
cial
Rup
ture
of M
embr
anes
A
RT
Ant
iret
rovi
ral T
hera
py
A
RV
A
ntir
etro
vira
l
A
ZT
Azi
doth
ymid
ine
(Zid
ovud
ine
or Z
DV
)
A
ZT/3
TC
Com
bivi
r
3T
C
Lam
ivud
ine
B
CC
B
ehav
iour
Cha
nge
Com
mun
icat
ion
B
CG
B
acill
e C
alm
ette
Gue
rine
vac
cine
B
FHI
Bab
y Fr
iend
ly H
ospi
tal I
nitia
tive
B
ID/B
D
“T
wic
e a
day”
C
DC
(K)
Cen
tres
for
Dis
ease
Con
trol
and
Pre
vent
ion,
Ken
ya
C
NS
Cen
tral
Ner
vous
Sys
tem
C
S C
aesa
rean
Sec
tion
C
T C
ouns
ellin
g an
d Te
stin
g
C
TX/C
TZ
Cot
rim
oxaz
ole
d4
T
St
avud
ine
D
ASC
O
Dis
tric
t AID
S/ST
I Coo
rdin
ator
1
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
D
BS
Dri
ed B
lood
Spo
t spe
cim
en
D
NA
D
eoxy
ribo
nucl
eic
Aci
d
D
RH
D
ivis
ion
of R
epro
duct
ive
Hea
lth
E
CV
E
xter
nal C
epha
lic V
ersi
on
E
FV
Efa
vire
nz
E
ID
Ear
ly In
fant
Dia
gnos
is
E
LISA
E
nzym
e Li
nked
Imm
unos
orbe
nt A
ssay
FB
C
Full
Blo
od C
ount
G
TZ
Ger
man
Tec
hnic
al C
oope
ratio
n
H
AA
RT
Hig
hly
Act
ive
Ant
iret
rovi
ral T
hera
py
H
b
H
aem
oglo
bin
H
IV
Hum
an Im
mun
odef
icie
ncy
Viru
s
IA
TT
Inte
r-A
genc
y Ta
sk T
eam
IM
CI
Inte
grat
ed M
anag
emen
t of C
hild
hood
Illn
ess
IP
PT
Inte
rmitt
ent P
resu
mpt
ive
Trea
tmen
t for
Mal
aria
IT
Ns
Inse
ctic
ides
Tre
ated
Net
s
IU
CD
In
tra
Ute
rine
Con
trac
eptiv
e D
evic
e
K
DH
S K
enya
Dem
ogra
phic
and
Hea
lth S
urve
y
K
EPI
K
enya
Exp
ande
d Pr
ogra
mm
e on
Imm
uniz
atio
n
K
OG
S K
enya
Obs
tetr
ical
and
Gyn
aeco
logi
cal S
ocie
ty
K
NH
K
enya
tta
Nat
iona
l Hos
pita
l
LA
M
Lact
atio
nal A
men
orrh
oea
Met
hod
M
&E
M
onito
ring
and
Eva
luat
ion
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
94
8.
Cyt
omeg
alov
irus
infe
ctio
n (r
etin
itis
or in
fect
ion
of o
ther
org
ans)
9.
Cen
tral
ner
vous
sys
tem
tox
opla
smos
is
10.
HIV
enc
epha
lopa
thy
11.
Ext
rapu
lmon
ary
cryp
toco
ccos
is in
clud
ing
men
ingi
tis
12.
Dis
sem
inat
ed n
on-t
uber
culo
us m
ycob
acte
rial
infe
ctio
n
13.
Pro
gres
sive
mul
tifoc
al le
ukoe
ncep
halo
path
y
14.
Chr
onic
cry
ptos
pori
dios
is
15.
Chr
onic
isos
poria
sis
16.
Dis
sem
inat
ed m
ycos
is (
extr
apul
mon
ary
hist
opla
smos
is
or c
occi
diom
ycos
is)
17.
Rec
urre
nt s
eptic
aem
ia (
incl
udin
g no
n-ty
phoi
dal S
alm
onel
la)
18.
Lym
phom
a (c
ereb
ral o
r B
-cel
l non
-Hod
gkin
s)
19.
Inv
asiv
e ce
rvic
al c
arci
nom
a
20.
Aty
pica
l dis
sem
inat
ed le
ishm
ania
sis
21.
Sym
ptom
atic
HIV
-ass
ocia
ted
neph
ropa
thy
or s
ympt
omat
ic H
IV-
asso
ciat
ed
22.
Car
diom
yopa
thy
*Ple
ase
note
: S
igns
and s
ympto
ms
of
HIV
was
ting s
yndro
me
incl
ude:
Unex
pla
ined
invo
lunta
ry w
eight
loss
(>
10%
base
line
body
wei
ght)
with o
bvi
ous
was
ting o
f body
mas
s in
dex
<18.5
PLU
S
unex
pla
ined
chro
nic
dia
rrhoea
(lo
ose
or
wat
ery
stools
thre
e or
more
tim
es d
aily
) re
port
ed
for
longer
than
one
month
OR r
eport
s of
feve
r or
nig
ht
swea
ts f
or
more
than
one
month
w
ithout
oth
er c
ause
and lack
of
resp
onse
to a
ntibio
tics
or
antim
ala
rial ag
ents
. M
ala
ria
must
be
excl
uded
in m
ala
ria
pro
ne
area
s.
*Fo
r th
e purp
ose
of
the
WH
O s
tagin
g s
yste
m,
adole
sents
and a
dults
are
def
ined
as
adults
aged
≥15 y
ears
.
9
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
CLI
NIC
AL
STA
GE
3 1.
U
nexp
lain
ed s
ever
e w
eigh
t lo
ss (
>10%
of
pres
umed
or
mea
sure
d
body
wei
ght)
2.
Une
xpla
ined
chr
onic
dia
rrho
ea f
or lo
nger
tha
n on
e m
onth
3.
Une
xpla
ined
per
sist
ent
feve
r (a
bove
.37.
5°C
inte
rmitt
ent
or c
onst
ant
for
long
er t
han
one
mon
th)
4.
Per
sist
ent
oral
can
didi
asis
5.
Ora
l hai
ry le
ukop
laki
a
6.
Pul
mon
ary
tube
rcul
osis
7.
Tub
ercu
lous
Lym
phad
enop
athy
8.
Sev
ere
bact
eria
l inf
ectio
ns (
such
as
pneu
mon
ia,
empy
ema,
pyo
myo
sitis
, bo
ne o
r jo
int
infe
ctio
n, m
enin
gitis
or
bact
erae
mia
)
9.
Acu
te n
ecro
tizin
g ul
cera
tive
stom
atiti
s, g
ingi
vitis
or
perio
dont
itis
10.
Une
xpla
ined
ana
emia
(<8
g/dl
), n
eutr
opae
nia
(<0.
5 ×1
09 pe
rlitr
e) a
nd/o
r ch
roni
c th
rom
bocy
topa
enia
(<5
0×10
9 per
litr
e).
CLI
NIC
AL
STA
GE
4 1.
H
IV w
astin
g sy
ndro
me*
2.
Pne
umoc
ystis
pne
umon
ia
3.
Rec
urre
nt s
ever
e ba
cter
ial p
neum
onia
4.
Chr
onic
her
pes
sim
plex
infe
ctio
n (o
rola
bial
, ge
nita
l or
anor
ecta
l of
mor
e th
an o
ne
mon
th’s
dur
atio
n or
vis
cera
l at
any
site
)
5.
Oes
opha
geal
can
didi
asis
(or
can
didi
asis
of
trac
hea,
bro
nchi
or
lung
s)
6.
Ext
rapu
lmon
ary
tube
rcul
osis
exc
ept
Tub
ercu
lous
Lym
ph a
deno
path
y
7.
Kap
osi’s
sar
com
a
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
14
M
CH
M
ater
nal a
nd C
hild
Hea
lth
M
oH
Min
istr
y of
Hea
lth
M
SF
Med
icin
s Sa
ns F
ront
iers
M
TCT
Mot
her-
To-C
hild
Tra
nsm
issi
on
N
ASC
OP
Nat
iona
l AID
S an
d ST
D C
ontr
ol P
rogr
amm
e
N
VP
Nev
irap
ine
O
D
“Onc
e a
Day
”
O
I O
ppor
tuni
stic
Infe
ctio
n
O
PV
Ora
l Pol
io V
acci
ne
PA
SCO
Pr
ovin
cial
AID
S/ST
I Coo
rdin
ator
PC
P Pn
eum
ocys
tis ji
rove
cii p
neum
onia
PC
R
Poly
mer
ase
Cha
in R
eact
ion
PI
Pr
otea
se In
hibi
tor
PL
WH
A
Pers
ons/
Peop
le L
ivin
g W
ith H
IV/A
IDS
PM
TCT
Prev
entio
n of
Mot
her
To C
hild
Tra
nsm
issi
on
R
DA
R
ecom
men
ded
Dai
ly A
llow
ance
R
H
Rep
rodu
ctiv
e H
ealth
R
NA
R
ibon
ucle
ic A
cid
Sd
NV
P
Si
ngle
dos
e N
evir
apin
e
SR
H
Sexu
al a
nd R
epro
duct
ive
Hea
lth
ST
D
Sexu
ally
Tra
nsm
itted
Dis
ease
ST
I Se
xual
ly T
rans
mitt
ed In
fect
ion
TB
Tu
berc
ulos
is
1
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
TB
As
Trad
ition
al B
irth
Att
enda
nts
TL
C
Tota
l Lym
phoc
yte
Cou
nt
TT
Te
tanu
s To
xoid
vac
cine
U
NIC
EF
Uni
ted
Nat
ions
Chi
ldre
n’s
Fund
U
NG
ASS
U
nite
d N
atio
ns G
ener
al A
ssem
bly
Spec
ial S
essi
on o
n
HIV
/AID
S
U
oN
Uni
vers
ity o
f Nai
robi
V
CT
Vol
unta
ry C
ouns
ellin
g an
d Te
stin
g
V
IA
Vis
ual I
nspe
ctio
n us
ing
Ace
tone
V
DR
L
Ven
erea
l Dis
ease
Res
earc
h La
bora
tory
(tes
t for
syp
hilis
)
W
HO
W
orld
Hea
lth O
rgan
isat
ion
W
RP
Wal
ter
Ree
d Pr
ogra
m
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
92
App
endi
x I
WH
O C
LIN
ICA
L ST
AG
ING
OF
HIV
/AID
S FO
R A
DU
LTS
AN
D A
DO
LES-
CEN
TS W
ITH
CO
NFI
RM
ED H
IV IN
FEC
TIO
N
CLI
NIC
AL
STA
GE
1
• A
sym
ptom
atic
• P
ersi
sten
t ge
nera
lized
lym
phad
enop
athy
CLI
NIC
AL
STA
GE
2 1.
U
nexp
lain
ed m
oder
ate
wei
ght
loss
(<1
0% o
f pr
esum
ed o
r m
easu
red
body
wei
ght)
2.
Rec
urre
nt u
pper
res
pira
tory
tra
ct in
fect
ions
(si
nusi
tis,
tons
illiti
s,
otiti
s m
edia
and
pha
ryng
itis)
3.
Her
pes
Zos
ter
4.
Ang
ular
Che
ilitis
5.
Rec
urre
nt o
ral u
lcer
atio
n
6.
Pap
ular
pru
ritic
eru
ptio
ns
7.
Seb
orrh
oeic
der
mat
itis
8.
Fun
gal n
ail i
nfec
tions
9
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Bib
liog
raph
y 1.
Offic
e of
the
Pres
iden
t, N
ational
AID
S C
ontr
ol Counci
l: K
enya
Nat
ional H
IV/A
IDS
Str
ate
gic
pla
n 2
005/6
-2009/1
0.
2.
Rep
ublic
of
Ken
ya,
Nat
ional AID
S C
ontr
ol C
ounci
l: N
atio
nal H
IV/A
IDS M
onitori
ng
and E
valu
atio
n F
ram
ework
.
3.
Rep
ublic
of
Ken
ya,
Nat
ional AID
S C
ontr
ol C
ounci
l: N
atio
nal H
IV/A
IDS M
onitori
ng
and E
valu
atio
n I
mple
men
tation M
anual.
Job
Aid
s/R
efer
ence
s 1.
M
oH
AN
C R
egis
ters
. 2.
M
oH
Mat
ernity
Reg
iste
rs.
3.
M
oH
Post
-nata
l Reg
iste
rs.
4.
M
ater
nal
and C
hild
Wel
fare
Han
dbook.
5.
Rep
roduct
ive
Hea
lth S
ervi
ces
month
ly r
eport
.
6.
M
oH
Form
726.
(Appen
dix
IV).
7.
M
oH
Form
727.
8.
M
OH
Form
711
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
16
Ex
ecut
ive
Sum
mar
y Th
e R
evis
ed G
uide
lines
(3rd e
ditio
n) fo
r Pr
even
tion
of M
othe
r to
Chi
ld T
rans
mis
sion
(P
MTC
T) o
f H
IV a
nd A
IDS
addr
esse
s th
e ri
sks
of m
othe
r-to
-chi
ld t
rans
mis
sion
(M
TCT)
of
HIV
and
AID
S us
ing
mor
e ef
ficac
ious
inte
rven
tions
tha
n in
the
pre
viou
s ed
ition
s. T
he G
uide
lines
are
in
line
with
Ken
ya’s
Nat
iona
l H
ealth
Sec
tor
Stra
tegi
c Pl
an I
I (N
HSS
P II
) an
d ar
e an
chor
ed o
n th
e K
enya
Nat
iona
l A
IDS
Stra
tegi
c Pl
an
(KN
ASP
) 20
00-2
010
whi
ch f
ocus
es o
n th
e pr
iori
ty a
reas
of
prev
entio
n of
new
inf
ec-
tions
, im
prov
ing
the
qual
ity o
f life
of p
eopl
e in
fect
ed a
nd a
ffect
ed b
y H
IV a
nd A
IDS,
an
d m
itiga
tion
of t
he s
ocia
l and
eco
nom
ic im
pact
of t
he in
fect
ion.
One
of t
he p
rior
ity
area
s of
NH
SSP
II i
s ad
here
nce
to s
et c
linic
al a
nd p
ublic
hea
lth s
tand
ards
. Th
e G
uide
lines
wer
e de
velo
ped
thro
ugh
a pa
rtic
ipat
ory
and
cons
ulta
tive
proc
ess
that
dr
ew p
artic
ipan
ts f
rom
pub
lic h
ealth
ins
titut
ions
, N
GO
s, F
BO
s, a
cade
mic
and
re-
sear
ch i
nstit
utio
ns a
nd d
evel
opm
ent
part
ners
. Th
e pr
oces
s w
as c
o-or
dina
ted
by
NA
SCO
P w
ith te
chni
cal a
nd fi
nanc
ial s
uppo
rt fr
om C
DC
(K).
HIV
infe
ctio
n ha
s re
vers
ed g
ains
rea
lised
in c
hild
hea
lth a
nd s
urvi
val i
n th
e la
st d
ec-
ade
in K
enya
. The
infe
ctio
n ha
s al
so c
ontr
ibut
ed s
igni
fican
tly t
o th
e co
mm
on c
ompl
i-ca
tions
of
preg
nanc
y in
man
y co
untr
ies.
Glo
bally
, mor
e th
an 6
30,0
00 c
hild
ren
wer
e in
fect
ed w
ith H
IV t
hrou
gh M
TCT
in 2
003.
In
2007
, K
enya
had
a p
opul
atio
n es
ti-m
ated
at
34 m
illio
n, t
he n
umbe
r of
bir
ths
per
annu
m w
as 1
.73
mill
ion,
the
HIV
pr
eval
ence
am
ong
preg
nant
mot
hers
was
6.7
per
cen
t an
d th
e to
tal n
umbe
r of
bir
ths
to H
IV-in
fect
ed m
othe
rs e
xpos
ed t
o M
TCT
was
163
,800
. A
ssum
ing
a tr
ansm
issi
on
rate
of 4
0 pe
r ce
nt, a
nd in
the
abs
ence
of a
ny in
terv
entio
n, t
he n
umbe
r of
HIV
pos
i-tiv
e in
fant
s pe
r an
num
wou
ld b
e 65
,520
. Ken
ya A
IDS
Indi
cato
r su
rvey
(KA
IS) 2
007
HIV
ser
opre
vale
nce
amon
g ad
ults
age
d 15
-49
year
s is
7.8
%.
Var
ious
inte
rven
tions
hav
e be
en p
ut in
pla
ce t
o re
spon
d to
the
em
ergi
ng c
halle
nges
an
d co
nstr
aint
s to
MTC
T ac
ross
the
cou
ntry
. Ana
lysi
s of
effe
ctiv
enes
s of
the
var
ious
ap
proa
ches
nee
ded
to m
anag
e ri
sks
of M
TCT
prov
ides
val
uabl
e in
sigh
ts th
at n
eces
si-
tate
the
ado
ptio
n of
mor
e ef
ficac
ious
car
e an
d tr
eatm
ent
regi
men
s. T
hese
ins
ight
s ha
ve in
form
ed t
he d
evel
opm
ent
of n
ew G
uide
lines
. The
Gui
delin
es in
corp
orat
e th
ese
chan
ges
and
are
reco
mm
ende
d fo
r us
e by
hea
lth p
rofe
ssio
nals
and
hea
lth in
stitu
tions
at
all
leve
ls o
f car
e. T
he G
uide
lines
will
enh
ance
the
capa
city
of h
ealth
car
e pr
ovid
ers
to g
ive
mor
e ef
ficie
nt a
nd e
ffect
ive
serv
ices
to
HIV
pos
itive
exp
ecta
nt m
othe
rs a
nd
new
born
s.
The
Gui
delin
es h
ave
ten
chap
ters
and
cov
er th
e fo
llow
ing:
just
ifyin
g th
e ne
ed fo
r sp
e-ci
fic m
anag
emen
t of
HIV
pos
itive
wom
en; c
are
befo
re, d
urin
g an
d af
ter
preg
nanc
y;
use
of a
ntir
etro
vira
l the
rapy
in p
regn
ancy
; pos
tnat
al c
are;
fam
ily p
lann
ing;
ear
ly in
-fa
nt d
iagn
osis
; fe
edin
g, c
are
and
follo
w-u
p of
HIV
-infe
cted
inf
ants
; an
d m
onito
ring
an
d ev
alua
tion.
Add
ition
al i
nfor
mat
ion
on W
HO
sta
ging
, co
ntra
cept
ive
optio
ns f
or
PLW
As
and
a su
mm
ary
of A
RV
use
in P
MTC
T is
giv
en in
the
appe
ndic
es.
1
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
The
Gui
delin
es h
ave
also
inc
orpo
rate
d ba
sic
info
rmat
ion
that
pro
gram
man
ager
s ne
ed in
ord
er to
mak
e th
eir
inst
itutio
ns P
MTC
T-fr
iend
ly. T
his
info
rmat
ion
is fo
und
in
the
boxe
s an
d ap
pend
ices
. Sum
mar
ies
of t
he i
nfor
mat
ion
cont
aine
d in
the
tex
t ar
e fo
und
in th
e ta
bles
.
The
Gui
delin
es p
rovi
de a
bac
kgro
und
to t
he P
MTC
T pr
oble
m in
the
wor
ld, i
n A
fric
a an
d in
Ken
ya. T
hey
also
giv
e de
tails
on
HIV
in p
regn
ancy
, the
tran
smis
sion
pat
tern
s of
MTC
T an
d de
scri
be t
he b
enef
its o
f pr
even
ting
mot
her-
to-c
hild
tra
nsm
issi
on
(PM
TCT)
. The
y al
so p
rovi
de in
form
atio
n on
inte
rven
tions
nec
essa
ry t
o re
duce
MTC
T th
at in
clud
e co
unse
lling
and
test
ing,
labo
rato
ry in
vest
igat
ions
, obs
tetr
ic in
terv
entio
ns
and
trea
tmen
t/pro
phyl
axis
.
The
ante
nata
l man
agem
ent
for
HIV
pos
itive
wom
en, i
nclu
ding
pol
icy
guid
e, jo
b ai
ds
with
sum
mar
ised
ess
entia
l pac
kage
of i
nteg
rate
d an
tena
tal c
are
serv
ices
are
det
aile
d in
Cha
pter
2.
Cha
pter
3 p
rovi
des
info
rmat
ion
on i
ntra
part
um c
are.
Thi
s is
the
man
agem
ent
of
wom
en fr
om th
e on
set o
f lab
our
to d
eliv
ery.
At t
his
stag
e, it
is im
port
ant t
o es
tabl
ish
the
HIV
sta
tus
of w
omen
pri
or to
del
iver
y or
dur
ing
labo
ur. G
uide
lines
sho
uld
be fo
l-lo
wed
for
all w
omen
adm
itted
to la
bour
and
del
iver
y. T
o co
nduc
t vag
inal
del
iver
ies
for
HIV
pos
itive
wom
en,
mod
ified
rou
tine
care
is
give
n. T
he g
uide
lines
pro
vide
a r
e-m
inde
r on
the
activ
ities
ess
entia
l to
carr
y ou
t for
saf
e va
gina
l del
iver
y fo
r al
l wom
en,
not
just
for
thos
e in
fect
ed w
ith H
IV. I
t is
rec
omm
ende
d th
at t
here
sho
uld
be n
o di
s-cr
imin
atio
n or
isol
atio
n of
HIV
pos
itive
wom
en d
urin
g la
bour
and
del
iver
y. D
eliv
ery
thro
ugh
elec
tive
caes
area
n se
ctio
n re
duce
s th
e ri
sk o
f H
IV M
TCT
as c
ompa
red
to
vagi
nal d
eliv
ery
amon
g H
IV p
ositi
ve w
omen
. Whe
re C
S is
per
form
ed a
s an
em
erge
ncy
or e
lect
ivel
y, a
ntib
iotic
s sh
ould
be
give
n.
Ant
iret
rovi
ral (
AR
V) t
hera
py is
dis
cuss
ed in
det
ail i
n C
hapt
er 4
. Thi
s in
clud
es t
her-
apy
for
the
mot
her
befo
re la
bour
, dur
ing
labo
ur a
nd a
fter
del
iver
y, a
nd fo
r th
e in
fant
af
ter
deliv
ery.
Cur
rent
ly,
Nev
irap
ine
is t
he r
ecom
men
ded
regi
men
. How
ever
, sh
ort
cour
se e
ffica
ciou
s A
RV
dru
g re
gim
ens
can
be i
mpl
emen
ted
in r
esou
rce
limite
d se
t-tin
gs. A
RV
s ar
e us
ed b
oth
for
trea
tmen
t an
d fo
r PM
TCT
in H
IV i
nfec
ted
preg
nant
w
omen
and
thei
r ne
onat
es.
Gui
delin
es f
or t
he p
ostp
artu
m c
are
of t
he m
othe
r an
d ca
re f
or H
IV e
xpos
ed in
fant
s ar
e de
taile
d in
Cha
pter
5. I
n C
hapt
er 6
, the
Gui
de p
rovi
des
deta
iled
info
rmat
ion
on
late
pos
tnat
al c
are
and
fam
ily p
lann
ing.
HIV
pos
itive
wom
en c
an u
se a
ll ty
pes
of fa
m-
ily p
lann
ing
base
d on
sta
ndar
d el
igib
ility
cri
teri
a as
exp
licitl
y ou
tline
d in
the
text
.
Gui
delin
es fo
r in
fant
dia
gnos
is, c
are
and
trea
tmen
t ar
e di
scus
sed
in C
hapt
er 7
. Cur
-re
ntly
the
re is
no
test
to
diffe
rent
iate
bet
wee
n an
tibod
ies
from
the
mot
her
and
thos
e pr
oduc
ed b
y th
e ba
by. T
o id
entif
y H
IV in
fect
ed in
fant
s le
ss t
han
18 m
onth
s, D
NA
or
RN
A –
PC
R te
st is
cur
rent
ly r
ecom
men
ded.
HIV
exp
osed
infa
nts
at 6
wee
ks a
nd s
ick
infa
nts
at 1
2 m
onth
s sh
ould
hav
e ac
cess
to
DB
S fo
r D
NA
PC
R. H
IV e
xpos
ed in
fant
s sh
ould
be
star
ted
on c
otri
mox
azol
e fr
om 6
wee
ks. A
ll m
othe
rs w
ith 6
wee
k ol
d in
fant
s
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
90
E U
ptak
e of
cou
nsel
ling
and
test
ing
in M
ater
nity
clin
ic: R
atio
of
m
ater
nity
clie
nts
with
unk
now
n H
IV s
tatu
s w
ho a
re c
ouns
elle
d an
d
test
ed fo
r HIV
in m
ater
nity
.
Num
erat
or:
Num
ber o
f pre
gnan
t wom
en a
dmitt
ed in
to m
ater
nity
with
un
know
n H
IV s
tatu
s th
at a
re c
ouns
elle
d an
d te
sted
for H
IV
durin
g la
bour
or a
fter d
eliv
ery.
Den
omin
ator
: N
umbe
r of p
regn
ant w
omen
adm
itted
into
mat
erni
ty
with
unk
now
n H
IV s
tatu
s.
F M
ater
nity
mot
her A
RV
prop
hyla
xis
upta
ke:
R
atio
of H
IV in
fect
ed m
othe
rs in
mat
erni
ty c
linic
rece
ivin
g pr
even
tive
A
RV
pro
phyl
axis
.
Num
erat
or:
Num
ber o
f HIV
-infe
cted
mot
hers
adm
itted
in m
ater
nity
tak-
ing
or re
porte
d to
hav
e ta
ken
the
mot
her d
ose(
s) o
f pre
ven-
tive
AR
V p
roph
ylax
is.
Den
omin
ator
Num
ber o
f pre
gnan
t wom
en a
dmitt
ed in
to m
ater
nity
who
ar
e H
IV-in
fect
ed.
G
Infa
nt A
RV
prop
hyla
xis
upta
ke:
R
atio
of i
nfan
ts b
orn
to H
IV-in
fect
ed m
othe
rs in
mat
erni
ty c
linic
rece
ivin
g pr
even
tive
AR
V p
roph
ylax
is.
Num
erat
or:
Num
ber o
f inf
ants
bor
n to
HIV
-infe
cted
mot
hers
who
rece
ive
prev
entiv
e
Den
omin
ator
Num
ber o
f inf
ants
bor
n to
HIV
-infe
cted
mot
hers
. N
umbe
r of p
regn
ant w
omen
adm
itted
into
mat
erni
ty w
ho a
re
HIV
-infe
cted
is u
sed
to a
ppro
xim
ate
this
num
ber.
8
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
With
the
mea
sure
men
ts li
sted
abo
ve, t
he fo
llow
ing
perf
orm
ance
indi
cato
rs
for m
onito
ring
PMTC
T ac
tiviti
es a
re c
alcu
late
d:
A
Upt
ake
of c
ouns
ellin
g an
d te
stin
g in
Ant
enat
al c
linic
:
R
atio
of a
nten
atal
clie
nts
who
wer
e co
unse
lled
and
test
ed fo
r HIV
.
Num
erat
or:
This
is n
umbe
r of p
regn
ant w
omen
atte
ndin
g th
eir f
irst
ante
nata
l clin
ic v
isit
who
are
test
ed fo
r HIV
.
Den
omin
ator
: N
umbe
r of n
ew v
isits
to th
e an
tena
tal c
linic
.
B
Ant
enat
al H
IV s
erop
reva
lenc
e:
R
atio
of A
nten
atal
pre
gnan
t wom
en te
sted
for H
IV th
at a
re H
IV in
fect
ed.
Num
erat
or:
Num
ber o
f clie
nts
who
test
HIV
pos
itive
Den
omin
ator
: To
tal n
umbe
r of p
regn
ant w
omen
test
ed fo
r HIV
in a
nten
a-ta
l clin
ic
C
Ant
enat
al m
othe
r AR
V pr
ophy
laxi
s up
take
:
Rat
io o
f kno
wn
HIV
infe
cted
pre
gnan
t wom
en in
ant
enat
al c
linic
rece
ivin
g A
RV
pre
vent
ive
prop
hyla
xis.
Num
erat
or:
Tota
l num
ber o
f HIV
-infe
cted
pre
gnan
t wom
en in
ant
enat
al
clin
ic re
ceiv
ing
mot
her p
reve
ntiv
e A
RV
pro
phyl
axis
.
Den
omin
ator
: To
tal n
umbe
r of p
regn
ant w
omen
who
are
HIV
-infe
cted
in
the
ante
nata
l clin
ic.
D
Ant
enat
al in
fant
AR
V pr
ophy
laxi
s up
take
:
Rat
io o
f kno
wn
HIV
-infe
cted
pre
gnan
t wom
en in
ant
enat
al c
linic
who
rece
ive
infa
nt d
ose(
s) o
f pre
vent
ive
AR
V p
roph
ylax
is.
Num
erat
or:
Tota
l num
ber o
f HIV
infe
cted
pre
gnan
t wom
en in
an
tena
tal c
linic
rece
ivin
g in
fant
dos
e(s)
pre
vent
ive
A
RV
pro
phyl
axis
.
Den
omin
ator
: To
tal n
umbe
r of p
regn
ant w
omen
who
are
HIV
-infe
cted
in
the
ante
nata
l clin
ic.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
18
shou
ld h
ave
rout
ine
HIV
ant
ibod
y te
st.
Gui
delin
es f
or f
eedi
ng in
fant
s an
d yo
ung
child
ren
born
to
HIV
infe
cted
mot
hers
are
di
scus
sed
in C
hapt
er 8
. The
Min
istr
y of
Hea
lth r
ecom
men
ds p
rom
otio
n of
exc
lusi
ve
brea
st fe
edin
g fo
r th
e fir
st 6
mon
ths
of li
fe. W
here
rep
lace
men
t fee
ding
is a
ccep
tabl
e,
feas
ible
, af
ford
able
, su
stai
nabl
e an
d sa
fe (
AFA
SS),
avoi
danc
e of
bre
astf
eedi
ng b
y H
IV-in
fect
ed w
omen
is
reco
mm
ende
d (W
HO
200
6). D
iscu
ssio
n on
diff
eren
t ty
pes
of
feed
ing
alte
rnat
ives
to
brea
stfe
edin
g is
cap
ture
d in
the
tex
t. Th
ese
optio
ns e
xist
for
th
e m
othe
r to
cho
ose
with
the
aid
of
coun
selli
ng. I
deal
ly, c
oupl
e de
cisi
on-m
akin
g is
en
cour
aged
for
the
HIV
pos
itive
mot
her.
For
the
HIV
neg
ativ
e m
othe
r, e
xclu
sive
br
east
feed
ing
is r
ecom
men
ded
for
6 m
onth
s or
less
follo
wed
by
wea
ning
.
Car
e an
d fo
llow
-up
of c
hild
ren
of H
IV-in
fect
ed m
othe
rs is
dis
cuss
ed in
det
ail i
n C
hap-
ter
9. A
ll ch
ildre
n bo
rn t
o H
IV i
nfec
ted
mot
hers
sho
uld
be f
ollo
wed
up
clos
ely
from
bi
rth
thro
ugh
2 ye
ars.
Tab
le 9
.2 p
rovi
des
the
WH
O r
ecom
men
ded
follo
w u
p de
tails
. Si
mila
rly,
the
mot
hers
sho
uld
be s
uppo
rted
to
prov
ide
optim
al in
fant
feed
ing
and
to
avoi
d m
ixed
feed
ing
with
in 6
mon
ths.
In C
hapt
er 1
0, t
he G
uide
lines
exp
lain
the
ben
efits
of
mon
itori
ng a
nd e
valu
atio
n of
PM
TCT
prog
ram
s. M
&E
pro
vide
s an
opp
ortu
nity
to
mea
sure
and
app
rais
e pe
rfor
m-
ance
with
in d
efin
ed ti
me
fram
e to
ens
ure
acco
mpl
ishm
ent o
f set
goa
ls a
nd o
bjec
tives
. PM
TCT
serv
ices
mus
t be
gui
ded
by t
imel
y an
d ac
cura
te d
ata
repo
rted
fro
m t
he
heal
th f
acili
ties,
thr
ough
the
dis
tric
t an
d pr
ovin
cial
lev
els,
to
the
natio
nal
leve
l at
N
ASC
OP.
1
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
88
(xiii
) H
IV in
fect
ed in
mat
erni
ty w
ard:
Num
ber
of p
regn
ant
wom
en a
dmitt
ed in
to
mat
erni
ty c
linic
who
are
HIV
infe
cted
. I
nclu
des
both
tho
se w
ho w
ere
adm
itted
al
read
y kn
owin
g th
ey a
re H
IV-i
nfec
ted
and
thos
e w
ho w
ere
test
ed a
nd r
ecei
ved
thei
r re
sults
in m
ater
nity
clin
ic. T
his
is o
btai
ned
from
the
mat
erni
ty r
egis
ter.
(xiv
) P
reve
ntiv
e A
RV
pro
phyl
axis
in m
ater
nity
war
d (m
othe
r do
se):
Num
ber
of
preg
nant
wom
en a
dmitt
ed in
mat
erni
ty t
akin
g or
rep
orte
d to
hav
e ta
ken
the
mot
her
dose
(s)
of p
reve
ntiv
e A
RV
pro
phyl
axis
. T
his
is o
btai
ned
from
the
m
ater
nity
reg
iste
r.
(xv)
Inf
ant
prev
entiv
e A
RV
pro
phyl
axis
in m
ater
nity
clin
ic/
war
d : N
umbe
r of
in-
fant
s bo
rn in
mat
erni
ty r
ecei
ving
the
infa
nt p
reve
ntiv
e A
RV
pro
phyl
axis
in t
he
mat
erni
ty c
linic
. T
his
is o
btai
ned
from
the
mat
erni
ty r
egis
ter.
(xvi
) D
eliv
erie
s: T
otal
num
ber
of p
regn
ant
wom
en d
eliv
erin
g at
the
hea
lth f
acili
ty.
(xvi
i) C
ouns
ellin
g on
infa
nt f
eedi
ng o
ptio
ns:
Num
ber
of m
othe
rs d
eliv
erin
g at
the
he
alth
fac
ility
cou
nsel
led
on in
fant
fee
ding
opt
ions
. T
his
is o
btai
ned
from
the
m
ater
nity
reg
iste
r.
(xvi
ii) I
nfan
t te
stin
g at
6 w
eeks
:
• N
umbe
r of
infa
nts
test
ed f
or H
IV a
t 6
wee
ks o
ld
• N
umbe
r of
infa
nts
test
ing
HIV
-pos
itive
. T
his
is o
btai
ned
from
labo
rato
ry
regi
ster
(xix
) R
efer
red
for
care
and
tre
atm
ent:
• N
umbe
r of
HIV
infe
cted
wom
en a
ttend
ing
ante
nata
l clin
ic t
hat
is r
efer
red
for
HIV
car
e an
d tr
eatm
ent
• N
umbe
r of
HIV
infe
cted
wom
en in
mat
erni
ty t
hat
is r
efer
red
for
HIV
car
e an
d tr
eatm
ent
• N
umbe
r H
IV in
fect
ed in
fant
s re
ferr
ed f
or H
IV c
are
and
trea
tmen
t. T
his
is
obta
ined
fro
m a
nten
atal
and
mat
erni
ty r
egis
ters
(xx)
Ini
tiate
d on
Cot
rim
oxaz
ole:
Num
ber
of H
IV in
fect
ed p
regn
ant
wom
en a
ttend
ing
ante
nata
l clin
ic th
at h
as
been
initi
ated
on
Cot
rimox
azol
e. T
his
is o
btai
ned
from
the
ant
enat
al r
egis
ter.
8
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
The
data
is p
rese
nted
usi
ng d
efin
ed p
erfo
rman
ce in
dica
tors
that
incl
ude
the
follo
win
g:
(i)
New
clie
nts/
first
ant
enat
al c
linic
vis
its: N
umbe
r of
pre
gnan
t w
omen
atte
ndin
g th
eir
first
ant
enat
al v
isit
for
the
curr
ent
preg
nanc
y at
the
hea
lth f
acili
ty.
Thi
s is
ob
tain
ed f
rom
the
ant
enat
al r
egis
ter.
(ii)
Ret
urn
visi
ts/r
evis
its:
Num
ber
of r
etur
n an
tena
tal c
linic
vis
its/r
evis
its
atte
nded
by
the
preg
nant
wom
en a
t th
e fa
cilit
y. T
his
is o
btai
ned
from
the
an
tena
tal r
egis
ter.
(iii)
C
ouns
ellin
g an
d te
stin
g fo
r H
IV in
ant
enat
al c
linic
: Tot
al n
umbe
r of
pre
gnan
t w
omen
cou
nsel
led
and
test
ed f
or H
IV a
t th
e an
tena
tal c
linic
, w
heth
er t
his
is d
one
on t
he f
irst
ante
nata
l vis
it or
a la
ter
visi
t. T
his
is o
btai
ned
from
the
an
tena
tal r
egis
ter.
(iv)
H
IV c
ouns
ellin
g an
d te
stin
g at
fir
st a
nten
atal
clin
ic v
isit :
Num
ber
of p
regn
ant
wom
en a
tten
ding
the
ir fir
st a
nten
atal
clin
ic v
isit
for
curr
ent
preg
nanc
y w
ho a
re
test
ed f
or H
IV.
Thi
s is
obt
aine
d fr
om t
he a
nten
atal
reg
iste
r.
(v)
Lear
ning
HIV
sta
tus
in a
nten
atal
clin
ic:
Num
ber
of a
nten
atal
clin
ic p
regn
ant
wom
en t
este
d fo
r H
IV w
ho r
ecei
ve t
heir
HIV
res
ults
, w
heth
er t
his
is d
one
on t
he
first
ant
enat
al c
linic
vis
it or
at
a la
ter
visi
t. T
his
is o
btai
ned
from
the
ant
enat
al
regi
ster
.
(vi)
HIV
infe
cted
in a
nten
atal
clin
ic:
Num
ber
of a
nten
atal
clin
ic p
regn
ant
wom
en
who
are
HIV
-inf
ecte
d on
the
late
st t
est
durin
g th
e pr
egna
ncy.
Thi
s is
obt
aine
d fr
om t
he a
nten
atal
reg
iste
r.
(vii)
Pre
vent
ive
AR
V p
roph
ylax
is in
ant
enat
al c
linic
(m
othe
r do
se):
Num
ber
of
preg
nant
wom
en in
the
ant
enat
al c
linic
rec
eivi
ng t
he m
othe
r do
se(s
) of
pre
ven-
tive
AR
V p
roph
ylax
is.
Thi
s is
obt
aine
d fr
om t
he a
nten
atal
reg
iste
r.
(viii
) P
reve
ntiv
e A
RV
pro
phyl
axis
in a
nten
atal
clin
ic (
infa
nt d
ose)
: N
umbe
r of
pr
egna
nt w
omen
in t
he A
nten
atal
clin
ic is
sued
with
the
infa
nt d
ose(
s) o
f pr
even
-tiv
e A
RV
pro
phyl
axis
. T
his
is o
btai
ned
from
the
ant
enat
al r
egis
ter.
(ix)
New
clie
nts
in m
ater
nity
clin
ic:
Num
ber
of p
regn
ant
wom
en a
tten
ding
the
Ma-
tern
ity c
linic
for
the
firs
t tim
e. T
his
is o
btai
ned
from
the
mat
erni
ty r
egis
ter.
(x)
Unk
now
n H
IV s
tatu
s at
mat
erni
ty:
Num
ber
of p
regn
ant
wom
en a
dmitt
ed in
to
the
mat
erni
ty w
ith u
nkno
wn
HIV
sta
tus.
Thi
s is
obt
aine
d fr
om t
he m
ater
nity
reg
is-
ter.
(xi)
Cou
nsel
ling
and
test
ing
for
HIV
in m
ater
nity
war
d :T
otal
num
ber
of p
regn
ant
wom
en a
dmitt
ed in
to m
ater
nity
with
unk
now
n st
atus
tha
t ar
e co
unse
lled
and
test
ed fo
r H
IV d
urin
g la
bour
or
afte
r de
liver
y. T
his
is o
btai
ned
from
the
mat
erni
ty
regi
ster
.
(xii)
Lea
rnin
g H
IV s
tatu
s in
mat
erni
ty w
ard :
Num
ber
of p
regn
ant
wom
en a
dmitt
ed
into
mat
erni
ty a
nd t
este
d fo
r H
IV w
ho r
ecei
ved
thei
r H
IV r
esul
ts.
Thi
s is
obt
aine
d fr
om t
he m
ater
nity
reg
iste
r.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
20
Cha
pter
1
Bac
kgro
und
1.1
THE
GLO
BA
L PA
ND
EMIC
O
ver
38 m
illio
n pe
ople
are
livi
ng w
ith H
IV/A
IDS
wor
ldw
ide,
and
abo
ut tw
o-th
irds
or
25
mill
ion
of P
LWH
A l
ive
in s
ub-S
ahar
an A
fric
a1.
HIV
/AID
S m
ainl
y af
fect
s pe
ople
of
repr
oduc
tive
age
and
incr
easi
ngly
affe
cts
wom
en,
who
now
acc
ount
for
57%
of
new
in
fect
ions
in s
ub-S
ahar
an A
fric
a, w
here
wom
en a
re 3
0% m
ore
likel
y to
be
livin
g w
ith
HIV
/AID
S th
an m
en, a
nd y
oung
wom
en a
ged
15-2
4 ar
e ne
arly
four
tim
es m
ore
likel
y to
be
inf
ecte
d th
an t
heir
mal
e co
unte
rpar
ts2.
Youn
g, m
arri
ed w
omen
, w
ho a
re o
ften
m
onog
amou
s, h
ave
beco
me
one
of t
he g
roup
s m
ost
vuln
erab
le t
o H
IV i
n th
e re
gion
. Th
is r
equi
res
new
and
rap
id r
espo
nses
that
bro
aden
the
focu
s be
yond
trad
ition
al “h
igh
risk
” gro
ups
like
com
mer
cial
sex
wor
kers
, tru
ck d
rive
rs, a
nd d
rug
user
s.
To r
each
you
ng m
arri
ed w
omen
, w
ho m
ay n
ot b
e aw
are
of t
heir
vul
nera
bilit
y, H
IV/
AID
S pr
even
tion,
ca
re
and
supp
ort
activ
ities
m
ust
be
inte
grat
ed
into
al
read
y es
tabl
ishe
d he
alth
ser
vice
s th
at a
re u
sed
by t
he g
ener
al p
opul
atio
n. A
n es
timat
ed
630,
000
child
ren
wor
ld-w
ide
beca
me
infe
cted
with
HIV
in
2003
— m
ost
thro
ugh
MTC
T3.
The
risk
of
an H
IV-in
fect
ed m
othe
r pa
ssin
g th
e vi
rus
to h
er i
nfan
t du
ring
pr
egna
ncy,
labo
ur a
nd d
eliv
ery
or in
the
post
nata
l per
iod
is 1
in 3
if n
othi
ng is
don
e to
re
duce
this
ris
k. I
n ot
her
wor
ds, o
ut o
f 100
infa
nts
born
to w
omen
with
HIV
/AID
S an
d w
ithou
t in
terv
entio
n, 6
0-75
of t
hem
will
not
be
infe
cted
. Of t
he o
ne-t
hird
who
bec
ome
infe
cted
, abo
ut 5
-10
babi
es w
ill b
e in
fect
ed d
urin
g pr
egna
ncy,
15
will
be
infe
cted
dur
ing
labo
ur a
nd d
eliv
ery
whi
le 5
-15
will
be
infe
cted
dur
ing
brea
stfe
edin
g, l
arge
ly b
eing
de
pend
ent
on b
reas
tfee
ding
pra
ctic
es a
nd o
n th
e du
ratio
n of
bre
astfe
edin
g4. I
n 20
03,
near
ly 5
00,0
00 c
hild
ren
died
of A
IDS-
rela
ted
caus
es. M
ost
child
ren
born
with
HIV
die
be
fore
they
rea
ch th
eir
fifth
bir
thda
y, w
ith m
ost n
ot s
urvi
ving
bey
ond
two
year
s5 .
The
high
rat
es o
f M
TCT
in d
evel
opin
g co
untr
ies,
com
pare
d to
muc
h lo
wer
rat
es i
n ri
cher
cou
ntri
es,
illus
trat
e gr
owin
g in
equa
litie
s in
glo
bal
heal
th.
In t
he w
ealth
y co
untr
ies,
the
rat
e of
MTC
T is
les
s th
an 2
% b
ecau
se o
f w
ides
prea
d ac
cess
to
anti-
retr
ovir
al th
erap
y (A
RT)
, pla
nned
cae
sare
an s
ectio
ns (C
S), t
he m
eans
to s
afel
y fo
rmul
a fe
ed, a
nd a
cces
s to
qua
lity
med
ical
ser
vice
s. I
n po
orer
cou
ntri
es li
ke K
enya
, the
re is
a
30-4
0% c
hanc
e th
at a
n H
IV-p
ositi
ve b
reas
tfee
ding
mot
her
will
pas
s H
IV to
her
chi
ld in
th
e ab
senc
e of
the
se s
ervi
ces.
In
such
set
tings
, it
is c
ritic
al t
hat
prev
entio
n pr
oced
ures
be
int
egra
ted
into
exi
stin
g se
xual
and
rep
rodu
ctiv
e he
alth
(SR
H)
and
mat
erna
l an
d ch
ild h
ealth
(M
CH
) se
rvic
es,
reac
hing
as
man
y w
omen
as
poss
ible
and
low
erin
g tr
ansm
issi
on r
ates
. Alth
ough
pha
rmac
eutic
al c
ompa
ny d
onat
ions
, don
or s
uppo
rt, a
nd
othe
r go
vern
men
t in
itiat
ives
hav
e he
lped
exp
and
acce
ss t
o H
IV t
estin
g fo
r pr
egna
nt
wom
en a
nd u
se o
f ant
iret
rovi
ral d
rugs
like
Nev
irap
ine,
whi
ch r
educ
e th
e ch
ance
of H
IV
tran
smis
sion
, stil
l onl
y 10
% o
f pre
gnan
t wom
en g
loba
lly h
ave
acce
ss to
thes
e dr
ugs6 .
2
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
HIV
/AID
S tr
ansm
issi
on fr
om m
othe
r to
chi
ld in
Ken
ya is
one
of t
he b
igge
st h
ealth
and
de
velo
pmen
t cha
lleng
es in
Ken
ya. A
ccor
ding
to th
e 20
03 D
emog
raph
ic a
nd H
ealth
Sur
-ve
y7, 6
.7%
or
over
1.2
mill
ion
Ken
yan
adul
ts w
ere
livin
g w
ith H
IV/A
IDS
in 2
003.
The
re
has
been
a s
tead
y de
clin
e in
HIV
ser
opre
vale
nce
in K
enya
. In
2005
, the
pre
vale
nce
rate
w
as e
stim
ated
at 5
.9%
and
as
per
the
2006
sta
tistic
s th
e pr
eval
ence
rat
e am
ong
adul
ts
had
drop
ped
to 5
.1%
8. A
ccor
ding
to
2007
Ken
ya A
IDS
Indi
cato
r Su
rvey
(K
AIS
)8a t
he
HIV
ser
opre
vale
nce
in K
enya
is c
urre
ntly
7.8
% a
mon
g ad
ults
age
d 15
-49
year
s, b
eing
hi
gher
in
wom
en (
8.7%
) th
an i
n m
en (
5.6%
), Y
oung
wom
en a
re m
ore
vuln
erab
le i
n K
enya
tha
n m
en, a
s ev
iden
ced
by a
nea
rly
9% p
reva
lenc
e ra
te a
mon
g w
omen
and
un-
der
5% a
mon
g m
en9 .
Ther
e ar
e w
ide
vari
atio
ns b
etw
een
urba
n an
d ru
ral
area
s, b
etw
een
regi
ons,
bet
wee
n ad
ults
and
you
ng p
eopl
e an
d be
twee
n m
en a
nd w
omen
. The
re h
as b
een
a no
tabl
e dr
op
in t
he n
umbe
r of
new
inf
ectio
ns,
with
an
estim
ated
60,
000
new
inf
ectio
ns i
n 20
05,
drop
ping
to 5
5,00
0 in
200
6. In
fant
s an
d yo
ung
child
ren
unde
r 15
yea
rs a
ccou
nt fo
r 16
%
of a
ll ne
w H
IV in
fect
ions
mai
nly
as a
res
ult o
f MTC
T. M
ost o
f the
new
infe
ctio
ns o
ccur
am
ong
youn
g pe
ople
, in
who
m t
he m
ain
mod
e of
tra
nsm
issi
on is
thr
ough
sex
ual i
nter
-co
urse
.
Tabl
e 1.
1: A
dult
HIV
-Pre
vale
nce
Estim
ate
by P
rovi
nce
in 2
006
Prov
ince
N
umbe
r of H
IV +
Prev
alen
ce (%
)
Tota
l M
ale
Fe
mal
e
Mal
e/Fe
mal
e R
atio
Nai
robi
19
7,00
0 10
.1
8.0
12.3
1.
5
Cen
tral
96,
000
4.1
1.7
6.5
3.
8
Coa
st
93,
000
5.9
5.0
6.9
1.
4
Eas
tern
7
2,00
0 2.
8 1.
1 4
.4
4.0
N. E
aste
rn
9
,000
1.
4 0.
9 1
.8
2.0
Nya
nza
183,
000
7.8
6.1
9.6
1.
6
Rift
Val
ley
171,
000
3.8
2.6
4.9
1.
9
Wes
tern
11
2,00
0 5.
3 4.
2 6
.4
1.5
Tota
l 1.
1 m
illion
5
.1
3.5
6.7
1.
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
86
all t
he d
ata
from
the
prov
ince
s (a
nd r
efer
ral h
ospi
tals
). Th
e ag
greg
ated
dat
a is
di
ssem
inat
ed t
o th
e H
ealth
Man
agem
ent
Info
rmat
ion
Syst
em, N
atio
nal A
IDS
Con
trol
Cou
ncil’
s (N
AC
C)
natio
nal
data
ban
k an
d re
sour
ce c
entr
e. T
he f
ocal
pe
rson
s he
re a
re t
he d
irec
tor,
NA
CC
and
the
M&
E m
anag
er. D
ata
is d
isse
mi-
nate
d ba
ck to
the
prov
ince
s an
d re
ferr
al h
ospi
tals
for
use
in d
ecis
ion-
mak
ing.
7.
D
ata
flow
fro
m f
acili
ty l
evel
to
natio
nal
leve
l: A
t th
e he
alth
fac
ility
, PM
TCT
indi
vidu
al
leve
l dat
a re
cord
ed in
the
MoH
sta
ndar
dise
d re
gist
ers
(AN
C, M
a-te
rnity
and
Pos
tnat
al)
is s
umm
aris
ed/
aggr
egat
ed o
n a
mon
thly
bas
is o
nto
MoH
For
m 7
26.
For
m 7
26 i
s th
en f
orw
arde
d up
war
ds t
o th
e di
stri
ct L
evel
(D
ASC
O’s
Offi
ce) f
or a
ggre
gatio
n of
the
Dis
tric
t lev
el d
ata
onto
For
m 7
27. C
op-
ies
of F
orm
726
and
For
m 7
27 a
re fo
rwar
ded
to th
e N
atio
nal O
ffice
(NAS
CO
P)
with
ano
ther
copy
of F
orm
727
bei
ng s
ent t
o th
e Pr
ovin
cial
Offi
ce (P
ASC
O).
8.
Dat
a di
ssem
inat
ion:
Thi
s is
car
ried
out
at
all
leve
ls s
tart
ing
from
fac
ility
to
natio
nal l
evel
. It i
s th
e re
spon
sibi
lity
of N
AC
C to
coo
rdin
ate
the
diss
emin
atio
n an
d us
e of
all
HIV
/AID
S da
ta a
nd in
form
atio
n fo
r na
tiona
l res
pons
e. J
APR
, a
join
t pro
gram
me
of a
ll st
akeh
olde
rs in
HIV
/AID
S re
ceiv
es a
nd u
ses
the
data
to
disc
uss
the
chal
leng
es, a
chie
vem
ents
and
les
sons
lea
rnt
from
HIV
/AID
S an
d gi
ves
feed
back
for n
atio
nal r
espo
nse.
9.
PMTC
T in
dica
tors
and
thei
r so
urce
s: H
ealth
car
e fa
cilit
ies
colle
ct th
e fo
llow
ing
data
as
a m
inim
um t
o be
use
d in
the
mon
itori
ng o
f PM
TCT
prog
ram
s. T
he
data
is
to b
e ag
greg
ated
on
a m
onth
ly b
asis
ont
o th
e M
inis
try
of H
ealth
, In
tegr
ated
Mon
itori
ng a
nd E
valu
atio
n R
epor
t For
m M
oH 7
26 u
sing
dat
a fr
om
the
Min
istr
y of
Hea
lth,
Ken
ya A
nten
atal
and
Mat
erni
ty R
egis
ters
(D
eliv
ery
Reg
iste
r), M
oH 4
05 a
nd M
oH 3
33 r
espe
ctiv
ely.
8
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
10.2
O
PER
ATI
ON
AL
GU
IDEL
INES
The
follo
win
g gu
idel
ines
sho
uld
be fo
llow
ed in
the
mon
itorin
g an
d ev
alua
-tio
n of
PM
TCT
serv
ices
: 1.
W
ithin
PM
TCT
prog
ram
s, d
ata
is c
olle
cted
and
rep
orte
d at
the
fol
low
ing
le
vels
: Ind
ivid
ual,
faci
lity,
dis
tric
t, pr
ovin
cial
and
nat
iona
l.
2.
Indi
vidu
al l
evel
: The
com
bine
d m
othe
r an
d ch
ild h
ealth
boo
klet
pro
vide
s de
-ta
iled
info
rmat
ion
on t
he w
oman
and
chi
ld i
nclu
ding
the
HIV
sta
tus,
oth
er
HIV
car
e se
rvic
es, d
rugs
, del
iver
y in
form
atio
n, im
mun
isat
ion,
gro
wth
mon
itor-
ing
and
othe
r par
amet
ers.
3.
Faci
lity
leve
l da
ta c
aptu
re t
ools
: The
MoH
has
sta
ndar
dise
d re
gist
ers
for
re-
cord
ing
data
at
faci
litie
s. T
hese
inc
lude
the
Rev
ised
AN
C R
egis
ter,
Rev
ised
M
ater
nity
Reg
iste
r an
d Po
st N
atal
Reg
iste
r an
d W
orkl
oad,
MO
H 7
17. O
ther
re
gist
ers
incl
ude
Chi
ld H
ealth
and
Nut
ritio
n In
form
atio
n Sy
stem
and
In-
patie
nt M
orbi
dity
and
Mor
talit
y. F
orm
711
and
the
Rep
rodu
ctiv
e H
ealth
Ser
-vi
ces
mon
thly
rep
orts
are
use
d fo
r m
akin
g fa
cilit
y le
vel s
umm
arie
s on
PM
TCT
and
repr
oduc
tive
heal
th s
ervi
ces.
3. F
acili
ty le
vel d
ata
capt
ure
tool
s: T
he M
oH
has
stan
dard
ized
reg
iste
rs f
or r
ecor
ding
dat
a at
fac
ilitie
s. T
hese
inc
lude
the
R
evis
ed A
NC
Reg
iste
r, R
evis
ed M
ater
nity
Reg
iste
r an
d Po
st N
atal
Reg
iste
r an
d w
orkl
oad
MO
H 7
17. O
ther
reg
iste
rs in
clud
e C
hild
Hea
lth a
nd N
utri
tion
Info
rmat
ion
Syst
em a
nd I
n-pa
tient
mor
bidi
ty a
nd m
orta
lity.
Fo
rm 7
26 a
nd
the
Rep
rodu
ctiv
e he
alth
ser
vice
s m
onth
ly r
epor
ts a
re u
sed
for
mak
ing
faci
lity
leve
l sum
mar
ies
on P
MTC
T an
d re
prod
uctiv
e he
alth
ser
vice
s.
4.
Dis
tric
t le
vel
data
: For
m 7
27 i
s us
ed t
o su
mm
aris
e an
d re
port
dis
tric
t le
vel
data
. Oth
er s
umm
ary/
repo
rtin
g to
ols
are
also
use
d to
rep
ort
dist
rict
leve
l in-
form
atio
n. A
t th
e di
stri
ct le
vel,
the
DAS
CO
’s of
fice
aggr
egat
es d
ata
from
sev
-er
al h
ealth
faci
lity
spec
ific
Form
726
ont
o Fo
rm 7
27 th
at is
use
d to
sum
mar
ise
and
repo
rt d
istr
ict l
evel
dat
a.
5.
Prov
inci
al l
evel
dat
a: A
t th
e pr
ovin
cial
lev
el, t
he P
ASC
O r
ecei
ves
Form
727
da
ta f
rom
the
res
pect
ive
DA
SCO
’s of
fices
in
the
prov
ince
for
the
ir o
wn
data
us
e an
d re
cord
s. A
cop
y of
the
sam
e is
sen
t to
the
Nat
iona
l Offi
ce (N
ASC
OP)
by
the
DA
SCO
’s of
fice.
At
the
prov
inci
al le
vel,
the
dist
rict
leve
l dat
a is
agg
re-
gate
d to
giv
e th
e pr
ovin
cial
leve
l dat
a.
6. N
atio
nal
leve
l da
ta:
At
the
natio
nal
leve
l, th
e M
&E
Man
ager
rec
eive
s da
ta
from
the
PASC
Os
for
each
of t
he p
rovi
nces
. Dat
a is
als
o re
ceiv
ed fr
om th
e R
e-fe
rral
hos
pita
ls a
nd o
ther
fac
ilitie
s at
the
ref
erra
l ho
spita
l or
ter
tiary
lev
el.
The
data
rec
eive
d at
the
nat
iona
l lev
el is
als
o co
pied
to
the
Hea
d of
NA
SCO
P an
d PM
TCT
prog
ram
me
man
ager
. The
M&
E m
anag
er a
t NA
SCO
P ag
greg
ates
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
22
1.2
MA
GN
ITU
DE
OF
HIV
IN P
REG
NA
NC
Y IN
KEN
YA
Ken
ya N
atio
nal
AID
S/ST
I C
ontr
ol P
rogr
amm
e (N
ASC
OP)
est
imat
es t
hat
ther
e w
ere
1.2
mill
ion
babi
es b
orn
in 2
006
in K
enya
and
that
as
man
y as
9%
of p
regn
ant w
omen
in
Ken
ya w
ere
livin
g w
ith H
IV/A
IDS.
10
At
leas
t 50
,000
to
60,0
00 i
nfan
ts i
n K
enya
wer
e th
ough
t to
hav
e be
en i
nfec
ted
with
H
IV a
s a
resu
lt of
MTC
T th
at y
ear.
With
an
estim
ated
pop
ulat
ion
of 3
7.2
mill
ion
in th
e ye
ar 2
007,
the
num
ber
of b
irth
s in
200
7 w
as 1
.73
mill
ion.
With
an
HIV
pre
vale
nce
of 6
.7%
, the
num
ber
of H
IV -
expo
sed
babi
es is
114
,101
and
at
leas
t 45,
640
HIV
-pos
itive
bab
ies
are
born
, ass
umin
g a
40 %
tran
smis
sion
(Tab
le 1
.2).
Tabl
e 1.
2: E
stim
ated
mag
nitu
de o
f MTC
T in
Ken
ya, 2
007
Popu
latio
n (E
stim
ates
200
7)
37.2
mill
ion
Birt
hs p
er a
nnum
1.
73 m
illio
n
HIV
pre
vale
nce
in m
othe
rs
6.7%
Tota
l num
ber o
f birt
hs to
HIV
-infe
cted
mot
hers
exp
osed
to
MTC
T as
sum
ing
no m
ultip
le p
regn
ancy
14
1,10
1
Num
ber o
f HIV
pos
itive
infa
nts
per a
nnum
in K
enya
as
sum
ing
40%
tran
smis
sion
45
,640
2
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
1.3
RIS
KS
OF
TRA
NSM
ISSI
ON
OF
MTC
T A
T D
IFFE
REN
T
T I
ME
PER
IOD
S In
Ken
ya, a
n es
timat
ed 4
0,00
0 to
50,
000
infa
nts
are
infe
cted
with
HIV
ann
ually
due
to
mot
her-
to-c
hild
tra
nsm
issi
on.
This
can
occ
ur in
ute
ro, d
urin
g la
bour
and
del
iver
y an
d th
roug
h br
east
feed
ing.
Dur
ing
preg
nanc
y, a
bout
5 t
o 8
perc
ent
of H
IV-e
xpos
ed b
abie
s be
com
e in
fect
ed t
hrou
gh t
rans
mis
sion
acr
oss
the
plac
enta
. Lab
our
and
deliv
ery
pose
s th
e gr
eate
st r
isk
for
tran
smis
sion
with
10
to 2
0 pe
rcen
t of
exp
osed
inf
ants
bec
omin
g in
fect
ed a
t thi
s tim
e.
Bre
astf
eedi
ng a
lso
expo
ses
infa
nts
to H
IV.
Whe
n m
othe
rs b
reas
tfee
d fo
r 18
to
24
mon
ths
anot
her
10 to
15
perc
ent o
f inf
ants
bec
ome
infe
cted
. Thu
s, in
non
-bre
astf
eedi
ng
popu
latio
ns, w
ithou
t an
tiret
rovi
ral t
reat
men
t, ap
prox
imat
ely
15 t
o 30
per
cent
infa
nts
will
bec
ome
infe
cted
; w
ith p
rolo
nged
bre
astf
eedi
ng,
25 t
o 45
per
cent
inf
ants
will
be
com
e in
fect
ed.
Tabl
e 1.
3: T
rans
mis
sion
pat
tern
s in
bre
astfe
edin
g
and
non
brea
stfe
edin
g po
pula
tions
S
ourc
e: D
e C
ock
K.M
(200
2)
Tim
ing
No
B
reas
tfeed
ing
Bre
astfe
edin
g th
roug
h
6 m
onth
s
Bre
astfe
edin
g th
roug
h
18 to
24
mon
ths
Dur
ing
preg
nanc
y 05
to 1
0 05
to 1
0 05
to 1
0
Dur
ing
labo
ur
10 to
20
10 to
20
10 to
20
Thro
ugh
brea
stfe
edin
g 10
to 2
0 05
to 1
0 05
to 1
0
Ear
ly (f
irst 2
mon
ths)
10
to 2
0 05
to 1
0 05
to 1
0
Late
(afte
r 2 m
onth
s)
10 to
20
01 to
05
05 to
10
Ove
rall
15 to
30
25 to
35
30 to
45
Tran
smis
sion
rate
in %
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
84
Form
MoH
711
has
bee
n re
com
men
ded
to r
epla
ce F
orm
MoH
726
HIV
M&
E d
ata
flow
pip
elin
e fr
om t
he i
ndiv
idua
l he
alth
fac
ilitie
s, t
o th
e di
stri
ct a
nd
prov
inci
al le
vels
up
to th
e ce
ntra
l or
natio
nal l
evel
s at
NA
SCO
P an
d N
AC
C is
sum
ma-
rise
d in
Fig
ure.
10.
1.
Figu
re 1
0.1:
HIV
Mon
itorin
g an
d Ev
alua
tion
data
flow
pip
elin
e in
Ken
ya
HM
IS
NA
SC
OP
H
ead
M/E
Man
ager
P
rogr
amm
e M
anag
er
Ref
erra
l Hos
pita
ls,
CE
Os,
Spe
cial
ists
The
Prov
ince
P
MO
P
AS
CO
P
AR
TO
PH
RIO
P
CO
The
Dis
trict
D
MO
D
AS
CO
, Dat
a en
try
cler
k D
AR
TO
DH
RIO
Hea
lth F
acilit
y P
ublic
Sec
tor
FBO
etc
NAC
C
Nat
iona
l Dat
a B
ank
&
Res
ourc
e C
entre
Th
e D
irect
or
M/E
Man
ager
8
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Cha
pter
10
Mon
itorin
g an
d Ev
alua
tion
of P
MTC
T Se
rvic
es
10.1
IN
TRO
DU
CTI
ON
PM
TCT
prog
ram
mon
itori
ng a
nd e
valu
atio
n ac
tiviti
es p
rovi
de th
e op
port
unity
to m
eas-
ure
and
appr
aise
per
form
ance
with
in d
efin
ed p
aram
eter
s th
at e
nsur
e ac
com
plis
hmen
t of
goa
ls a
nd o
bjec
tives
.
In l
ine
with
thi
s, t
he c
ount
ry h
as d
evel
oped
the
Nat
iona
l H
IV/A
IDS
Mon
itori
ng a
nd
Eva
luat
ion
Fram
ewor
k th
at p
rovi
des
stak
ehol
ders
with
a t
ool
for
wel
l co
ordi
nate
d,
inte
rlin
ked
and
func
tiona
l HIV
/AID
S M
&E
sys
tem
tha
t al
low
s fo
r ef
ficie
nt m
onito
ring
of
int
erve
ntio
ns i
n ac
hiev
ing
the
natio
nal
prog
ram
mat
ic g
oals
usi
ng d
efin
ed t
arge
ts.
This
pro
vide
s th
e fr
amew
ork
for M
&E
act
iviti
es w
ithin
PM
TCT
prog
ram
s.
Nat
iona
l PM
TCT
data
is
repo
rted
usi
ng M
oH I
nteg
rate
d M
onito
ring
and
Eva
luat
ion
Rep
ortin
g Fo
rms,
For
m M
oH 7
11 o
r Fo
rm M
oH 7
27* .
Ind
ivid
ual P
MTC
T da
ta is
col
-le
cted
at
the
heal
th f
acili
ties
offe
ring
PM
TCT
serv
ices
usi
ng s
tand
ard
MoH
reg
iste
rs
(AN
C, M
ater
nity
and
Pos
tnat
al R
egis
ters
).
On
mon
thly
bas
is, t
he h
ealth
faci
litie
s w
ill a
ggre
gate
the
dat
a fr
om t
he r
egis
ters
on
to
Form
MoH
711
or
MO
H 7
26 w
hich
is th
en fo
rwar
ded
upw
ards
to th
e D
ASC
O’s
offic
e. A
co
py i
s le
ft a
t th
e he
alth
fac
ility
for
the
ir o
wn
data
use
. A
t th
e di
stri
ct l
evel
, th
e D
ASC
O’s
offic
e ag
greg
ates
dat
a fr
om s
ever
al h
ealth
fac
ility
spe
cific
For
m 7
26 o
nto
Form
MoH
727
(or
Form
711
) tha
t is
use
d to
sum
mar
ise
and
repo
rt d
istr
ict
leve
l dat
a.
Bot
h Fo
rm 7
26 a
nd F
orm
MoH
727
are
then
sen
t to
NA
SCO
P. A
cop
y of
the
Form
727
or
For
m 7
11 is
sen
t to
the
PASC
O a
nd a
noth
er to
the
heal
th fa
cilit
ies
in th
e di
stri
ct fo
r th
eir
own
data
use
.
Ken
ya is
com
mitt
ed to
the
“Thr
ee-o
nes”
pri
ncip
les
whi
ch a
re:
• O
ne a
gree
d A
IDS
Act
ion
Fra
mew
ork
that
pro
vide
s th
e ba
sis
for
coor
dina
ting
the
wor
k pl
an o
f al
l par
tner
s.
• O
ne N
atio
nal A
IDS
Coo
rdin
atin
g A
utho
rity
with
a b
road
-bas
ed
mul
tisec
tora
l man
date
.
• O
ne a
gree
d co
untr
y-le
vel M
onito
ring
and
Eva
luat
ion
(M
&E
) sy
stem
.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
24
1.4
RIS
K F
AC
TOR
S FO
R M
TCT
OF
HIV
M
any
fact
ors
are
know
n or
sus
pect
ed t
o in
crea
se t
he r
isk
of a
n H
IV in
fect
ed m
othe
r tr
ansm
ittin
g th
e vi
rus
to h
er i
nfan
t. Th
ese
fact
ors
incl
ude
the
HIV
vir
al l
oad
in t
he
mot
her,
as
wel
l as
othe
r m
ater
nal,
obst
etri
cal,
vira
l and
infa
nt fa
ctor
s (T
able
1.4
).
The
mos
t sig
nific
ant r
isk
fact
or a
ppea
rs to
be
the
HIV
vir
al lo
ad in
the
mot
her,
thou
gh
the
othe
r fa
ctor
s m
ay a
lso
cont
ribu
te t
o in
crea
sing
an
infa
nt’s
expo
sure
or
susc
eptib
il-ity
to
acqu
irin
g H
IV. S
ome
fact
ors
may
cau
se a
bre
akdo
wn
in t
he p
rote
ctio
n of
fere
d to
th
e fo
etus
by
the
plac
enta
, whi
ch in
nor
mal
cir
cum
stan
ces
wou
ld n
ot a
llow
HIV
to c
ross
th
e pl
acen
ta fr
om m
othe
r to
foet
us.
Tran
smis
sion
dur
ing
labo
ur a
nd d
eliv
ery
occu
rs w
hen
the
infa
nt s
ucks
, im
bibe
s or
as-
pira
tes
mat
erna
l bl
ood
or c
ervi
cal
secr
etio
ns t
hat
cont
ain
HIV
, or
whe
n it
has
othe
r m
ucou
s m
embr
ane
expo
sure
.Tab
le 1
.4:
Ris
k fa
ctor
s fo
r M
TCT
of H
IV
St
rong
evi
denc
e Li
mite
d ev
iden
ce
VIR
AL
Hig
h vi
ral l
oad
Vira
l res
ista
nce
(theo
retic
al p
ossi
bilit
y)
Vira
l gen
otyp
e an
d ph
enot
ype
MA
TER
NA
L Im
mun
e de
ficie
ncy
(low
C
D4
coun
t), H
IV in
fect
ion
acqu
ired
durin
g pr
egna
ncy
or
brea
stfe
edin
g pe
riod
Vita
min
A d
efic
ienc
y, a
naem
ia, s
exua
lly
trans
mitt
ed d
isea
ses,
ch
orio
amni
oniti
s, fr
eque
nt u
npro
tect
ed
sexu
al in
terc
ours
e, m
ultip
le s
exua
l pa
rtner
s, s
mok
ing,
inje
ctin
g dr
ug a
buse
OB
STE
TRIC
AL
Vagi
nal d
eliv
ery
(com
pare
d to
ele
ctiv
e ca
esar
ean
sect
ion)
, ru
ptur
e of
the
mem
bran
es
for m
ore
than
4 h
ours
Inva
sive
or t
raum
atic
pro
cedu
res:
in
stru
men
tal d
eliv
erie
s, a
mni
ocen
tesi
s,
epis
ioto
my,
ext
erna
l cep
halic
ver
sion
(E
CV
), et
c., i
ntra
partu
m h
aem
orrh
age
FETA
L/IN
FAN
T Pr
emat
urity
Le
sion
s of
ski
n an
d/or
muc
ous
m
embr
anes
BR
EA
ST-
FEE
DIN
G
Dur
atio
n of
bre
astfe
edin
g,
mix
ed fe
edin
g, b
reas
t di
seas
e (m
astit
is/c
rack
ed
nipp
les)
Ora
l thr
ush
(bab
y)
2
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
1.5
BEN
EFIT
S O
F PR
EVEN
TIN
G M
OTH
ER-T
O-C
HIL
D
T R
AN
SMIS
SIO
N O
F H
IV
AID
S re
late
d de
aths
are
rev
ersi
ng g
ains
mad
e in
chi
ld h
ealth
and
sur
viva
l in
Ken
ya.
Car
ing
for
HIV
-infe
cted
chi
ldre
n ha
s m
ajor
eco
nom
ic a
nd s
ocia
l im
pact
s on
fam
ilies
an
d he
alth
sys
tem
s. T
hus
at t
he n
atio
nal l
evel
, pre
vent
ing
MTC
T ha
s th
e po
tent
ial t
o in
crea
se th
e un
ders
tand
ing
and
acce
ptan
ce o
f the
HIV
/AID
S ep
idem
ic a
nd th
ose
livin
g w
ith H
IV/A
IDS.
Cou
nsel
ling,
tes
ting
and
com
mun
ity s
ensi
tisat
ion
can
cont
ribu
te t
o re
duci
ng s
tigm
a.
1.6
BEN
EFIT
S O
F H
IV C
OU
NSE
LLIN
G A
ND T
ESTI
NG
(CT)
(a
) It p
rom
otes
beh
avio
ur c
hang
e by
: •
Red
ucin
g hi
gh r
isk
beha
viou
r fo
r H
IV
• Id
entif
ying
HIV
dis
cord
ant
coup
les
• In
crea
sing
the
use
of
dual
met
hods
of f
amily
pla
nnin
g an
d S
TI
prev
entio
n
• Im
prov
ing
ante
nata
l car
e
• G
uidi
ng in
fant
feed
ing
(b
) It e
nabl
es p
reve
ntiv
e th
erap
y fo
r:
• M
alar
ia
• O
ppor
tuni
stic
infe
ctio
ns (
e.g.
Pne
umoc
ystis
jiro
veci
i pn
eum
onia
)
• T
B
Red
uctio
n of
MTC
T of
HIV
:
• D
ecre
ases
num
bers
of
HIV
infe
cted
chi
ldre
n
• In
crea
ses
child
hea
lth a
nd s
urvi
val
• D
ecre
ases
the
load
on
the
heal
th s
yste
m
• G
ives
an
oppo
rtun
ity t
o im
prov
e an
d ex
pand
hea
lth s
ervi
ces
as
wel
l as
to s
tren
gthe
n th
e ex
istin
g he
alth
infr
astr
uctu
re
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
82
Foo
tnot
es
9
Use
oth
er o
ptions
for
child
ren o
ver
9 k
ilogra
ms
10
Use
reg
ula
r or
double
-str
ength
tab
lets
for
child
ren o
ver
16 k
ilogra
ms
8
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
The
fram
ewor
k be
low
illu
stra
tes
poin
ts o
f int
egra
tion
of c
ompr
ehen
sive
HIV
ca
re p
acka
ge in
to e
xist
ing
child
hea
lth s
ervi
ces
Fro
m P
edia
tric
HIV
Pre
ven
tio
n to
Car
e: A
C
on
cep
tual
Fra
mew
ork
\im
mun
izat
ion/
GM
Fou
rtee
n w
eeks
New
bo
rn/I
nfa
nt
NO
T A
PP
LIC
AB
LE
Wo
ma
n
Pre
gn
an
cy
•F
ocus
ed A
NC
incl
udin
g:
STI/
syph
ilis
Mal
aria
trea
tmen
t & p
reve
ntio
n
incl
udin
g IP
T &
ITN
s
Lab
ou
ran
d D
eliv
ery
•D
eliv
ery
care
•E
OC
-Em
erge
ncy
obst
etri
c ca
re
•R
efer
ral s
yste
m
New
born
Ca
re
•B
CG
•P
olio
0
•Is
sue
child
hea
th c
ard
•Ent
er b
irth
wei
ght,
HIV
an
d A
RV
Exp
osur
e st
atus
on
chi
ld h
ealth
car
d
Post
Na
tal
Ca
re
•B
reas
t hea
lth
•Se
xual
hea
lth
•F
amil
y pl
anni
ng
Tw
o w
eeks
Infa
nt fe
edin
g co
unse
ling
Infa
nt fe
edin
g co
unse
ling
Dia
gnos
is (
antib
ody)
if
expo
sure
unk
now
n
DN
A P
CR
if e
xpos
ed
CT
Z p
roph
ylax
is, I
FC-
infa
nt f
eedi
ng c
ouns
elin
g
CT
for
unt
este
d m
othe
rs;
CT
for
par
tner
Six
wee
ks
Imm
uniz
atio
n/gr
owth
mon
itori
ng
Ten
wee
ks
Imm
uniz
atio
n/gr
owth
mon
itori
ng
Dia
gnos
is (
antib
ody
test
), C
T f
or n
egat
ive
wom
en a
nd p
artn
ers
IFC
, Wea
ning
, B/f
eedi
ng
cess
atio
n s
uppo
rtSi
x m
onth
s
Com
plem
enta
ry fe
eds
Vita
min
A S
uppl
emen
tatio
n
9 m
onth
s
imm
uniz
atio
n/G
M
Dia
gnos
is (
antib
ody
test
)
Uni
vers
al p
reca
utio
ns
CT
for
unt
este
d m
othe
rs in
clud
ing
part
ner
AR
V p
roph
ylax
is
(mot
her
and
infa
nt)
/AR
T C
TZ
pro
phyl
axis
Exc
lusi
ve b
reas
t fe
edin
g or
rep
lace
men
t fe
edin
g
12 &
18
mon
ths
HIV
edu
catio
n
prev
entio
n, C
T
AR
V p
roph
ylax
is, s
tagi
ng
CT
Z p
roph
ylax
is/A
RT
CD
4 w
here
ava
ilabl
e
Infa
nt f
eedi
ng c
ouns
elin
g (I
FC)
•Bre
ast e
xam
•Psp
, sm
ear,
DB
S re
sult,
IF
C
Fram
ewor
k for
integ
ratio
n
•Pap
sm
ear
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
26
(c
) It p
rom
otes
acc
ess
to e
arly
med
ical
car
e:
• O
bste
tric
al c
are
• T
B th
erap
y
• M
alar
ia t
reat
men
t
• S
TI t
reat
men
t
• A
RV
the
rapy
for
mot
her
and
fam
ily
(d) I
t hel
ps to
pla
n fo
r the
futu
re
• In
fant
fee
ding
sup
port
sys
tem
s
• F
amily
pla
nnin
g
• P
erso
nal a
nd f
inan
cial
dec
isio
ns
(e) I
t ena
bles
pre
vent
ive
ther
apy
of m
alar
ia a
nd
othe
r opp
ortu
nist
ic in
fect
ions
suc
h a
PCP
(f) It
giv
es ti
me
to p
lan
for t
he fu
ture
e.g
. inf
ant
feed
ing
supp
ort s
yste
ms
1.7
THE
FOU
R-P
RO
NG
ED A
PPR
OA
CH
TO
PM
TCT
The
Inte
r A
genc
y Ta
sk T
eam
on
Prev
entio
n of
HIV
Tra
nsm
issi
on in
pre
gnan
t w
omen
, m
othe
rs a
nd t
heir
chi
ldre
n (I
ATT
) ha
s pr
opos
ed a
fou
r-pr
onge
d ap
proa
ch f
or t
he p
re-
vent
ion
of H
IV t
rans
mis
sion
tha
t ta
rget
s no
n-pr
egna
nt a
nd p
regn
ant
wom
en, m
othe
rs
and
thei
r ch
ildre
n.
2
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Ove
rall,
the
cov
erag
e of
PM
TCT
prog
ram
mes
and
the
upt
ake
of s
ervi
ces
prov
ided
th
roug
h th
ese
prog
ram
mes
in
clud
ing
HIV
te
stin
g an
d co
unse
lling
an
d A
RV
pr
ophy
laxi
s ar
e st
ill v
ery
low
. In
2006
, wor
ldw
ide,
less
tha
n 10
% o
f pr
egna
nt w
omen
te
stin
g H
IV-p
ositi
ve r
ecei
ved
AR
V d
rugs
for
PMTC
T11 .
In K
enya
, acc
ordi
ng to
the
2007
Ken
ya A
IDS
Indi
cato
r Su
rvey
(KA
IS) 7
, the
re h
as b
een
a sm
all i
ncre
ase
in H
IV te
stin
g am
ong
wom
en a
nd m
en c
ompa
red
to th
e 20
03 K
DH
S
KA
IS s
how
s th
at t
houg
h a
vast
maj
ority
(83
%)
of H
IV-in
fect
ed w
omen
and
men
in
Ken
ya d
o no
t kn
ow t
heir
HIV
sta
tus,
the
re h
as b
een
a cl
ear
and
dram
atic
incr
ease
in
cove
rage
of H
IV-t
estin
g am
ong
AN
C c
linic
att
ende
es.
PMTC
T se
rvic
es a
re t
here
fore
im
port
ant
entr
y po
ints
for
HIV
pre
vent
ion
and
trea
t-m
ent.
Ove
rall
AR
V c
over
age
for
HIV
infe
cted
peo
ple
who
nee
d tr
eatm
ent
in K
enya
is
only
35%
The
four
pro
ngs
are:
1. P
rimar
y pr
even
tion
of H
IV in
fect
ion
in w
omen
2. P
reve
ntio
n of
uni
nten
ded
preg
nanc
y am
ong
HIV
-inf
ecte
d w
omen
3. I
nter
vent
ions
to
redu
ce t
rans
mis
sion
fro
m H
IV-i
nfec
ted
preg
nant
and
la
ctat
ing
wom
en t
o th
eir
child
ren
4. C
are
and
supp
ort
of w
omen
, ch
ildre
n an
d fa
mili
es in
fect
ed a
nd
affe
cted
by
HIV
and
AID
S (
The
PM
TC
T-p
lus)
• 90
% o
f Ken
yan
wom
en w
ho d
eliv
ered
in th
e la
st 4
yea
rs a
tten
d A
NC
• 57
% o
f th
ose
atte
ndin
g A
NC
tes
ted
for
HIV
• A
mon
g H
IV in
fect
ed w
omen
with
rec
ent
birt
hs,
47%
wer
e te
sted
in
AN
C
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
80
(8)
HIV
dis
ease
sta
ging
in H
IV-in
fect
ed c
hild
ren:
D
isea
se s
tagi
ng, w
ith o
r w
ithou
t la
bora
tory
sup
port
, fol
low
s H
IV d
iag-
nosi
s. S
tagi
ng H
IV d
isea
se p
rovi
des
a gu
ide
to th
e pr
ogno
sis
and
inte
r-ve
ntio
ns n
eede
d at
the
diffe
rent
sta
ges.
(Ref
er to
Cha
pter
5 a
nd 8
)
(9)
AR
V th
erap
y:
C
hild
ren
who
are
elig
ible
for
AR
T sh
ould
be
linke
d w
ith t
he A
RT
pro-
gram
and
pro
vide
d w
ith tr
eatm
ent a
ccor
ding
to N
atio
nal G
uide
lines
as
soon
as
an H
IV d
iagn
osis
is
mad
e. E
arly
tre
atm
ent
sign
ifica
ntly
re-
duce
s m
orta
lity
in H
IV in
fect
ed c
hild
ren.
(10)
C
omm
unic
atio
n:
Com
mun
icat
ing
with
car
e-pr
ovid
ers
and
prov
idin
g ps
ycho
soci
al s
up-
port
for
the
child
, mot
her/
care
give
r an
d fa
mily
are
a c
ruci
al c
ompo
nent
of
car
e.
Pa
rent
s/ca
regi
vers
and
/or
the
child
nee
d to
par
ticip
ate
in m
akin
g de
ci-
sion
s an
d pl
anni
ng a
ppro
pria
te c
are
for
the
child
, inc
ludi
ng d
ecis
ions
ab
out t
hera
py a
nd w
here
the
child
sho
uld
rece
ive
care
. In
this
res
pect
, he
alth
wor
kers
mus
t en
sure
tha
t th
e fa
mily
con
side
rs t
he s
ocia
l nee
ds
of H
IV in
fect
ed a
nd a
ffect
ed c
hild
ren.
H
ealth
car
e w
orke
rs s
houl
d en
sure
that
they
pro
vide
ade
quat
e tim
e fo
r ca
regi
vers
to a
sk q
uest
ions
so
that
they
can
fully
und
erst
and
the
impl
i-ca
tions
of H
IV a
nd H
IV t
estin
g, fo
r th
emse
lves
and
for
thei
r ch
ildre
n.
Hea
lth c
are
wor
kers
sho
uld
coun
sel c
areg
iver
s on
dis
clos
ure,
incl
udin
g di
sclo
sure
to th
e ch
ild.
(11)
R
efer
rals
:
Ref
erra
ls a
re a
n im
port
ant p
art o
f man
agin
g an
HIV
exp
osed
or
infe
cted
chi
ld.
Thes
e in
clud
e re
ferr
als
to:
• H
ighe
r le
vels
of s
peci
alis
ed c
are
for
furt
her
inve
stig
atio
ns a
nd
trea
tmen
t
• S
ocia
l sup
port
pro
gram
mes
• C
omm
unity
-bas
ed c
are
prog
ram
mes
• P
ITC
site
s fo
r pa
rent
s an
d si
blin
gs
7
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e 9.
2: W
HO
Rec
omm
enda
tions
for
Follo
w-u
p of
an
HIV
-Exp
osed
Chi
ld
From
M
onito
r
6 w
eeks
–12
mon
ths
Mon
thly
12 –
24 m
onth
s Ev
ery
3 m
onth
s
24 m
onth
s an
d on
war
ds
Yea
rly, i
f not
sym
ptom
atic
If
sym
ptom
atic
, fol
low
up
as n
eede
d
For t
he H
IV-in
fect
ed, f
ollo
w th
ese
guid
elin
es
• A
t birt
h (f
or in
fant
s de
liver
ed a
t ho
me)
• A
t age
1 t
o 2
wee
ks (
mai
nly
for
infa
nt f
eedi
ng c
ouns
elin
g)
• A
t ag
e 6,
10,
and
14
wee
ks (
for
imm
uniz
atio
n an
d in
fant
fee
ding
co
unse
ling)
• A
fter
age
14
wee
ks,
mon
thly
thr
ough
age
12
mon
ths
• A
fter
age
12 m
onth
s, e
very
3 m
onth
s th
roug
h 24
mon
ths
• A
t 18
mon
ths,
do
conf
irm
ator
y H
IV la
bora
tory
tes
t (if
the
re a
re n
o re
sour
ces
for
an e
arlie
r an
tigen
-bas
ed t
est)
• A
fter
2 ye
ars,
a m
inim
um o
f ye
arly
vis
its
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
28
1.8
OV
ERV
IEW
OF
THE
NEW
PM
TCT
GU
IDEL
INES
K
enya
’s M
inis
try
of H
ealth
(M
OH
), th
roug
h N
ASC
OP,
has
tak
en s
ever
al a
ctio
ns t
o ex
pand
and
str
engt
hen
PMTC
T in
terv
entio
ns i
n th
e co
untr
y. I
n 20
00,
a N
atio
nal
Tech
nica
l W
orki
ng G
roup
(TW
G)
on P
MTC
T w
as f
orm
ed.
The
TWG
, co
-cha
ired
by
NA
SCO
P an
d th
e D
ivis
ion
of R
epro
duct
ive
Hea
lth,
coor
dina
tes
impl
emen
tatio
n an
d pr
ovid
es t
echn
ical
sup
port
to
the
Nat
iona
l PM
TCT
Prog
ram
. Th
e TW
G s
erve
s as
a
foru
m t
o up
date
sta
keho
lder
s an
d di
scus
s ch
alle
nges
and
upc
omin
g ac
tiviti
es.
The
TWG
is
also
res
pons
ible
for
upd
atin
g na
tiona
l gu
idel
ines
for
PM
TCT.
The
nat
iona
l PM
TCT
prog
ram
was
offi
cial
ly l
aunc
hed
in 2
002.
NA
SCO
P al
so e
stab
lishe
d se
vera
l pi
lot P
MTC
T si
tes
thro
ugho
ut th
e co
untr
y an
d pr
epar
ed n
atio
nal P
MTC
T gu
idel
ines
.
The
goal
of t
he n
atio
nal P
MTC
T pr
ogra
m is
in li
ne w
ith th
e go
al, s
et o
ut a
t the
Uni
ted
Nat
ions
Gen
eral
Ass
embl
y Sp
ecia
l Ses
sion
on
HIV
/AID
S (U
NG
ASS
) in
2001
, to
redu
ce
the
prop
ortio
n of
infa
nts
infe
cted
with
HIV
by
20%
by
the
year
200
5 an
d 50
% b
y 20
10.
In K
enya
, the
nat
iona
l PM
TCT
prog
ram
pla
nned
to
exte
nd it
s se
rvic
es t
o at
leas
t 80
%
of a
ll he
alth
fac
ilitie
s by
200
712.
Acc
ordi
ng t
o th
e 20
03 P
MTC
T se
rvic
e st
atis
tics,
ap
prox
imat
ely
9% o
f al
l pr
egna
nt w
omen
rec
eive
d PM
TCT
serv
ices
in
that
yea
r.
Cur
rent
ly m
ore
than
50%
of
all
preg
nant
wom
en i
n K
enya
rec
eive
PM
TCT
serv
ices
. Th
ese
guid
elin
es a
re b
ased
on
a pu
blic
hea
lth a
ppro
ach
to c
are,
tak
ing
into
con
side
ra-
tion
issu
es o
f fe
asib
ility
and
acc
epta
bilit
y, i
n ad
ditio
n to
effi
cacy
and
cos
t-be
nefit
in
di
ffere
nt s
ettin
gs.
The
guid
elin
es a
re e
xpec
ted
to i
mpr
ove
the
upta
ke,
qual
ity a
nd
effe
ctiv
enes
s of
PM
TCT
serv
ices
in th
e co
untr
y.
1.9
OB
JEC
TIV
ES A
ND O
RG
AN
ISA
TIO
N O
F TH
E G
UID
ELIN
ES
The
PMTC
T gu
idel
ines
are
par
t of
the
impl
emen
tatio
n in
stru
men
ts t
owar
ds u
nive
rsal
ac
cess
to
PMTC
T se
rvic
es, a
nd a
res
pons
e to
the
cal
l to
actio
n to
war
ds H
IV-fr
ee a
nd
AID
S-fr
ee g
ener
atio
n. T
oget
her
with
two
othe
r gu
idel
ines
(AR
V Th
erap
y in
Adu
lts a
nd
Adol
esce
nts
and
ARV
Ther
apy
in I
nfan
ts a
nd Y
oung
Chi
ldre
n),
they
for
m a
tri
logy
ai
med
at
cont
extu
alis
ing
and
mai
nstr
eam
ing
the
WH
O t
rilo
gy o
f gu
idel
ines
on
H
IV/A
IDS
prev
entio
n an
d tr
eatm
ent.
The
cont
ext,
reso
urce
s an
d de
man
ds o
f PM
TCT
prog
ram
mes
diff
er g
reat
ly a
cros
s co
un-
trie
s an
d ev
en a
cros
s pr
ogra
mm
es w
ithin
the
sam
e co
untr
y. C
onsi
deri
ng t
his
vari
abil-
ity, t
hese
gui
delin
es in
clud
e th
e cu
rren
t con
sens
us o
n be
st p
ract
ices
as
wel
l as
alte
rna-
tives
whi
ch m
ight
be
mor
e ap
prop
riat
e in
par
ticul
ar s
ettin
gs. E
xper
ts a
gree
tha
t th
e “s
tate
of
the
art”
in
PMTC
T is
cha
ngin
g ra
pidl
y an
d th
at r
ecom
men
datio
ns w
ill c
er-
tain
ly a
lter
with
adv
ance
s in
med
ical
sci
ence
and
as
mor
e pr
ogra
mm
e ex
peri
ence
is
docu
men
ted
and
diss
emin
ated
. The
are
as o
f A
RV
pro
phyl
axis
and
inf
ant
feed
ing
are
part
icul
arly
sub
ject
to r
apid
cha
nge.
In 2
005,
the
WH
O is
sued
pro
pose
d re
visi
ons
to it
s re
com
men
datio
ns o
n th
e us
e of
ant
i-re
trov
iral
dru
gs f
or P
MTC
T. T
he r
ecom
men
datio
ns w
ere
the
prod
uct
of e
xper
ts w
ho
2
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
conv
ened
to
disc
uss
impo
rtan
t ne
w i
nfor
mat
ion
conc
erni
ng t
he d
evel
opm
ent
of r
esis
-ta
nce
in w
omen
and
chi
ldre
n us
ing
sing
le d
ose
nevi
rapi
ne (S
dNV
P) fo
r PM
TCT
as w
ell
as n
ew c
linic
al fi
ndin
gs o
n st
rate
gies
that
mig
ht r
educ
e th
e de
velo
pmen
t of r
esis
tanc
e.
Bas
ed o
n th
e ne
w W
HO
gui
delin
es, K
enya
’s TW
G h
as d
evel
oped
sim
ple,
pra
ctic
al a
nd
evid
ence
-bas
ed r
ecom
men
datio
ns o
n PM
TCT
that
wou
ld w
ork
in a
var
iety
of r
esou
rce-
limite
d en
viro
nmen
ts a
nd c
linic
al s
ituat
ions
that
con
fron
t hea
lthca
re w
orke
rs, n
ot o
nly
in K
enya
but
als
o in
oth
er d
evel
opin
g co
untr
ies.
1.10
U
SIN
G T
HE
GU
IDEL
INES
Th
ese
guid
elin
es a
re in
tend
ed p
rimar
ily fo
r use
by
PMTC
T pr
ovid
ers.
Thes
e in
clude
nur
ses,
mid
wiv
es, c
linica
l offi
cers
, doc
tors
, cou
nsel
lors
, nut
ritio
nist
s an
d ot
her
heal
thca
re p
rofe
s-si
onal
s. T
hey
will
als
o be
use
ful a
s a re
fere
nce
for p
rogr
amm
e m
anag
ers a
t fac
ility
, dis
trict
, pr
ovin
cial
and
nat
iona
l lev
els
thro
ugho
ut th
e he
alth
sec
tor.
The
guid
elin
es a
re d
ivid
ed in
to
ten
chap
ters
as o
utlin
ed in
Tab
le 1
.5.
The
spec
ific
obje
ctiv
es o
f the
new
PM
TCT
guid
elin
es a
re to
:
• O
utlin
e th
e po
licy
issu
es in
pro
vidi
ng P
MT
CT
ser
vice
s
• R
ecom
men
d op
erat
iona
l gui
delin
es t
o be
fol
low
ed b
y he
alth
car
e pr
ovid
ers
of P
MT
CT
ser
vice
s
• E
nabl
e pr
ovid
ers
of P
MT
CT
to s
elec
t an
d pr
escr
ibe
AR
Vs
for
prop
hyla
xis
agai
nst
MT
CT
and
for
tre
atm
ent
of p
regn
ant
wom
en,
infa
nts
and
youn
g ch
ildre
n
• S
tand
ardi
se t
he c
are
and
coun
selli
ng g
iven
by
PM
TC
T s
ervi
ce
prov
ider
s re
gard
ing
risk
of
MT
CT
and
on
PM
TC
T
• Im
prov
e P
MT
CT
ser
vice
s us
ing
easy
-to-
use
job
aids
and
a
stan
dard
ised
M&
E s
yste
m
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
78
(6)
Tre
atm
ent o
f acu
te in
fect
ions
and
oth
er H
IV-r
elat
ed c
ondi
tions
:
H
IV-e
xpos
ed c
hild
ren
are
susc
eptib
le to
com
mon
infe
ctio
ns a
s w
ell a
s O
Is fo
r th
e H
IV in
fect
ed, a
nd H
IV m
ay a
lter
the
inci
denc
e, p
rese
n-ta
tion
and
resp
onse
to
conv
entio
nal
ther
apy.
In
som
e ca
ses,
mor
e ag
gres
sive
and
long
er t
reat
men
t co
urse
s m
ay b
e ne
cess
ary,
as
trea
t-m
ent f
ailu
res
are
mor
e fr
eque
nt.
(7)
Reg
ular
follo
w-u
p ca
re &
ref
erra
ls:
R
egul
ar fo
llow
-up
is th
e ba
ckbo
ne to
car
ing
for
the
HIV
exp
osed
chi
l-dr
en a
nd e
nsur
es o
ptim
al h
ealth
care
and
psy
chos
ocia
l sup
port
to th
e fa
mily
. WH
O h
as m
ade
reco
mm
enda
tions
on
freq
uenc
y of
follo
w-u
p,
as s
how
n in
Tab
le 9
.2. T
his
is t
he m
inim
um a
nd m
ore
freq
uent
con
-ta
ct w
ith t
he h
ealth
car
e sy
stem
may
be
indi
cate
d fo
r H
IV in
fect
ed
child
ren
and
espe
cial
ly if
they
are
on
anti-
retr
ovir
al tr
eatm
ent.
Prev
entin
g TB
: Fo
r chi
ldre
n ex
pose
d to
sm
ear p
ositi
ve tu
berc
ulos
is:
• E
xclu
de a
ctiv
e T
B th
roug
h ca
refu
l his
tory
, ph
ysic
al e
xam
and
in
vest
igat
ions
•
If t
here
is n
o ev
iden
ce o
f ac
tive
TB
, st
art
on I
NH
for
pro
phyl
axis
for
6
mon
ths
(IP
T)
• If
TB
is p
rese
nt,
star
t on
TB
tre
atm
ent
as p
er N
atio
nal T
B g
uide
lines
If
a ch
ild is
bor
n to
a m
othe
r with
act
ive
TB:
• S
tart
on
INH
pro
phyl
axis
(IP
T)
and
give
for
3 m
onth
s •
Afte
r 3
mon
ths
do a
man
toux
•
If m
anto
ux is
neg
ativ
e, s
top
INH
and
giv
e B
CG
•
If m
anto
ux is
pos
itive
at
3 m
onth
s, c
ontin
ue f
or a
fur
ther
3 m
onth
s •
At t
he e
nd o
f pr
ophy
laxi
s re
-val
uate
for
act
ive
TB
If no
evi
denc
e of
act
ive
TB, d
o no
t tre
at fo
r TB
If th
ere
is e
vide
nce
of a
ctiv
e TB
, tre
at fo
r TB
as p
er N
atio
nal
TB g
uide
lines
7
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Pro
phyl
axis
aga
inst
Pne
umoc
ysti
s ji
rove
cii
Pne
umon
ia (
PC
P)
in c
hild
ren
whe
re C
otri
mox
azol
e is
con
trai
ndic
ated
Alte
rnat
ive
drug
s to
use
if C
TX is
con
train
dica
ted
are
give
n be
low
:
A s
econ
d ch
oice
wou
ld b
e ei
ther
dap
sone
or
atov
aqui
ne
Dap
sone
• C
hild
ren
> 1
mon
th:
2 m
g/kg
/24
hour
s or
ally
onc
e da
ily.
• If
both
CT
X a
nd D
apso
ne a
re c
ontr
aind
icat
ed (
e.g.
, in
chi
l-dr
en w
ith G
6PD
def
icie
ncy
who
get
hae
mol
ysis
with
CT
X a
nd
Dap
sone
), t
hen
use
eith
er:
Ato
vaqu
one
•
30m
g/kg
/day
for
age
1-3
mon
ths
• H
ighe
r do
se 4
5mg/
kg/d
ay f
or a
ge 4
-24
mon
ths
OR
Aer
osol
ized
Pen
tam
idin
e
• 30
0 m
g in
6 m
l wat
er v
ia in
hala
tion
nebu
lizer
onc
e m
onth
ly
• ch
ildre
n >
5 ye
ars
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
30
Tabl
e 1.
5: T
he F
our-
Pron
ged
App
roac
h
App
lied
to th
e PM
TCT
Gui
delin
e
Cha
pter
Pr
ong
1 Pr
imar
y
prev
entio
n of
HIV
in
fect
ion
in w
omen
Pron
g 2
Prev
entio
n of
un
inte
nded
pr
egna
ncy
amon
g H
IV in
fect
ed w
omen
Pron
g 3
Inte
rven
tions
to
redu
ce
tran
smis
sion
from
H
IV in
fect
ed
preg
nant
and
la
ctat
ing
wom
en to
th
eir c
hild
ren
Pron
g 4
Car
e an
d su
ppor
t of
wom
en, c
hild
ren
and
fam
ilies
in
fect
ed a
nd
affe
cted
by
HIV
/A
IDS
CH
AP
TER
1:
Bac
kgro
und
CH
AP
TER
2:
Ant
enat
al C
are
and
Pre
vent
ion
of M
TCT
of H
IV
◙
CH
AP
TER
3:
Intra
partu
m C
are
◙ ◙
CH
AP
TER
4:
Use
of A
ntire
trovi
ral
Dru
gs in
Pre
gnan
cy
for T
reat
men
t and
P
reve
ntio
n of
Mot
her
to C
hild
Tr
ansm
issi
on o
f HIV
In
fect
ion
◙ ◙
CH
AP
TER
5:
Imm
edia
te P
ostn
atal
an
d N
eona
tal C
are
◙ ◙
CH
AP
TER
6:
Late
Pos
tnat
al C
are
and
Fam
ily P
lann
ing
◙
◙ ◙
CH
AP
TER
7:
HIV
Dia
gnos
is in
C
hild
ren
◙
CH
AP
TER
8:
Feed
ing
Infa
nts
and
Youn
g C
hild
ren
born
to
HIV
infe
cted
m
othe
rs
◙ ◙
CH
AP
TER
9:
Car
e an
d Fo
llow
-up
of C
hild
ren
of H
IV
infe
cted
mot
hers
◙
CH
AP
TER
10:
M
onito
ring
and
Eva
luat
ion
of P
MTC
T
serv
ices
◙
◙ ◙
◙
3
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
For
each
of t
hese
cha
pter
s (e
xcep
t ch
apte
r on
e on
bac
kgro
und)
, the
gui
delin
es g
ive
an
intr
oduc
tion
follo
wed
by
polic
y st
atem
ents
, the
n op
erat
iona
l gui
delin
es o
f wha
t pro
vid-
ers
shou
ld d
o to
red
uce
mot
her-
to-c
hild
tra
nsm
issi
on o
f H
IV a
nd/o
r to
im
prov
e th
eir
perf
orm
ance
and
the
effe
ctiv
enes
s of
thei
r ser
vice
s.
A li
st o
f job
aid
s fo
r us
e by
the
hea
lthca
re p
rovi
der
follo
ws
the
oper
atio
nal g
uide
lines
an
d, w
here
nec
essa
ry, a
list
of
appe
ndic
es a
nd a
dditi
onal
doc
umen
ts t
hat
may
be
re-
ferr
ed t
o bu
t ar
e co
nsid
ered
too
big
or
deta
iled
to b
e in
clud
ed w
ithin
the
mai
n bo
dy o
f th
e gu
idel
ines
.
Foo
tnot
es
1.
UN
AID
S (
2004).
Rep
ort
on t
he
Glo
bal AID
S E
pid
emic
. Ava
ilable
at
ww
w.u
nai
ds.
org
2.
Ibid
. 2004.
3.
It is
import
ant
to r
ecognis
e th
at t
he
use
of
the
phra
se M
TC
T in n
o w
ay is
inte
nded
to
pla
ce b
lam
e on t
he
moth
er,
who m
ay o
r m
ay n
ot
know
her
HIV
sta
tus,
who t
ransm
its
the
viru
s to
her
child
. Pat
hfinder
ack
now
ledges
that
man
y tim
es p
regnant
wom
en
may
hav
e bee
n infe
cted
by
thei
r m
ale
par
tner
, and d
o n
ot
hav
e th
e ab
ility
to n
egoti-
ate
safe
r se
x, o
r to
see
k M
TC
T s
ervi
ces
for
fear
of
viole
nce
, st
igm
a, o
r ab
andonm
ent
if t
hei
r st
atu
s is
rev
eale
d.
Path
finder
uphold
s th
e re
pro
duct
ive
rights
of
all w
om
en t
o
choose
if
and w
hen
to h
ave
child
ren,
regar
dle
ss o
f H
IV-s
tatu
s.
4.
WH
O,
CD
C,
Dep
artm
ent
of
Hea
lth a
nd H
um
an S
ervi
ces.
(2004).
Pre
vention o
f M
oth
er-t
o-C
hild
Tra
nsm
issi
on o
f H
IV:
Gen
eric
Tra
inin
g P
acka
ge.
Gen
eva,
Sw
itze
r-la
nd:
WH
O.
5.
UN
AID
S (
2004).
Rep
ort
on t
he
Glo
bal AID
S E
pid
emic
. Ava
ilable
at
ww
w.u
nai
ds.
org
6.
Polic
y Pro
ject
(2004).
Cove
rage
of
sele
cted
ser
vice
s fo
r H
IV/A
IDS p
reve
ntion a
nd
care
in low
and m
iddle
-inco
me
countr
ies
in 2
003.
Ava
ilable
at
ww
w.p
olia
/pro
ject
.com
. 7.
Cen
tral Bure
au o
f Sta
tist
ics
(CBS)
[Ken
ya],
Min
istr
y of
Hea
lth (
MO
H)
[Ken
ya],
and
ORC M
acro
(2004).
Ken
ya D
emogra
phic
and H
ealth S
urv
ey 2
003.
Cal
vert
on,
Mar
y-la
nd:
CBS,M
OH
, an
d O
RC M
acr
o.
8.
Nat
ional AID
S C
ontr
ol Counci
l, 2
007.
8a
Ken
ya A
IDS I
ndic
ato
r Surv
ey 2
007
9
Ibid
, 2004.
10
NASCO
P (
2002).
Surv
eilla
nce
data
, as
cite
d in N
ASCO
P/M
OH
. (2
003).
Nat
ional
PM
CT
Str
ate
gic
Managem
ent
Pla
n 2
003-2
007.
11,1
2 A
IDS in K
enya
: Tre
nds,
Inte
rven
tions
and I
mpact
, 7th
editio
n.
(2005).
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
76
C
linic
ians
sho
uld
clea
rly
info
rm H
IV i
nfec
ted
mot
hers
at
deliv
ery
that
the
ir c
hild
ren
need
pro
phyl
axis
aga
inst
PC
P st
artin
g at
6 w
eeks
of a
ge u
ntil
it is
est
ablis
hed
that
the
child
is
not
HIV
inf
ecte
d. A
pra
ctic
al w
ay t
o en
sure
tha
t m
othe
rs a
nd o
ther
hea
lth
wor
kers
are
inf
orm
ed i
s to
mak
e a
note
on
the
child
’s im
mun
izat
ion
card
at
birt
h st
atin
g “P
leas
e gi
ve c
o-tr
imox
azol
e (5
mg/
kg/d
ay o
rally
dai
ly) f
rom
6 w
eeks
of a
ge.”
Tabl
e 9.
1: D
ose
of C
otrim
oxaz
ole
for P
CP
Prop
hyla
xis
In
rar
e ca
ses,
as
in c
hild
ren
with
G6P
D d
efic
ienc
y, C
TX m
ay b
e co
ntra
indi
cate
d.
• A
ll in
fant
s bo
rn t
o H
IV-i
nfec
ted
mot
hers
, irr
espe
ctiv
e of
any
ant
iret
rovi
ral
ther
apy
duri
ng p
regn
ancy
and
labo
ur.
Pro
phyl
axis
con
tinue
s un
til t
he
infa
nt is
12
mon
ths
or is
PC
R n
egat
ive
or a
ntib
ody
nega
tive,
whi
chev
er
com
es e
arlie
r
• A
ll in
fant
s id
entif
ied
as H
IV-i
nfec
ted
duri
ng th
e fir
st y
ear
of li
fe b
y a
PC
R
test
or
by a
clin
ical
dia
gnos
is o
f H
IV in
fect
ion
and
a po
sitiv
e
antib
ody
test
.
• C
hild
ren
olde
r th
an 1
2 m
onth
s, w
ith s
ympt
omat
ic H
IV d
isea
se o
r an
A
IDS
-def
inin
g ill
ness
(W
HO
sta
ge I
I an
d III
; se
e ch
apte
r 5)
or
with
CD
4 <
15%
or
TLC
150
0/m
m3
• A
ny c
hild
with
a h
isto
ry o
f P
CP
sho
uld
cont
inue
with
sec
onda
ry
prop
hyla
xis
(dai
ly C
T)
for
life
Who
Nee
ds P
CP
Prop
hyla
xis?
Wei
ght o
f C
hild
(kg)
C
T ta
blet
s
20 m
g TM
P/1
00
mg
SM
X p
edia
tric
stre
ngth
(120
mg)
Cot
rimox
azol
e
susp
ensi
on 4
0 m
g TM
P/2
00m
g S
MX
/ 5m
l (24
0 m
g)
CT
tabl
ets
80 m
g TM
P/4
00 m
g S
MX
re
gula
r stre
ngth
(4
80 m
g)
CT
Tabl
ets
160
mg
TMP
/800
mg
SM
X
Dou
ble
stre
ngth
(9
60 m
g)
1–4
1 ta
b 2.
5 m
l ¼
tab
-
5–8
2 ta
bs
5
ml
½ ta
b ¼
tab
9–16
10
ml
1 ta
b ½
tab
17–5
0
2
tabs
1
tab
> 50
2
tabs
1
tab
7
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
(3)
Mon
itor
the
child
’s g
row
th a
nd d
evel
opm
ent
as a
mea
ns o
f id
entif
ying
the
ch
ild w
ho is
faili
ng to
thriv
e an
d al
so a
s a
tool
for m
onito
ring
the
effe
ct o
f int
er-
vent
ions
(4)
Ens
ure
that
im
mun
isat
ions
are
sta
rted
and
com
plet
ed
acco
rdin
g to
the
re
com
men
datio
ns o
f the
nat
iona
l im
mun
isat
ion
sche
dule
A
dditi
onal
con
side
ratio
ns a
re a
s fo
llow
s:
• W
hen
cons
ider
ing
BCG
vac
cina
tion
at a
late
r age
(r
e-va
ccin
atio
n fo
r no
scar
or m
isse
d ea
rlier
vac
cina
tion)
, ex
clud
e sy
mpt
omat
ic H
IV in
fect
ion
• D
o no
t giv
e ye
llow
feve
r vac
cine
to s
ympt
omat
ic H
IV-in
fect
ed c
hil-
dren
. How
ever
, asy
mpt
omat
ic c
hild
ren
in e
ndem
ic a
reas
sho
uld
re-
ceiv
e th
e ye
llow
feve
r vac
cine
at 9
mon
ths
of a
ge
• M
easl
es v
acci
ne s
houl
d be
giv
en to
HIV
infe
cted
chi
ldre
n at
6 a
nd 9
m
onth
s si
nce
HIV
infe
cted
chi
ldre
n ex
perie
nce
muc
h m
ore
seve
re
dise
ase
with
wild
mea
sles
viru
s, w
hich
out
wei
ghs
the
risk
of a
mild
er
illnes
s fro
m th
e va
ccin
e
(5)
Pro
vide
pro
phyl
axis
for o
ppor
tuni
stic
infe
ctio
ns:
P
roph
ylax
is a
gain
st P
neum
ocys
tis ji
rove
cii P
neum
onia
• P
neum
ocys
tis ji
rove
cii (
form
erly
Pne
umoc
ystis
car
inii)
pne
umon
ia (P
CP
), is
a s
igni
fican
t cau
se o
f mor
bidi
ty a
nd m
orta
lity
amon
g yo
ung
infa
nts
in
Afri
ca. C
o-tri
mox
azol
e (C
TX) p
roph
ylax
is s
igni
fican
tly re
duce
s th
e in
ci-
denc
e an
d se
verit
y of
PC
P. A
dditi
onal
ben
efits
of c
o-tri
mox
azol
e in
clud
e pr
otec
tion
agai
nst c
omm
on b
acte
rial i
nfec
tions
, tox
opla
smos
is, a
nd m
a-la
ria. A
ll ch
ildre
n bo
rn to
HIV
infe
cted
mot
hers
sho
uld
rece
ive
prop
hy-
laxi
s ag
ains
t PC
P, a
t lea
st d
urin
g th
e fir
st y
ear o
f life
, or u
ntil
they
are
pr
oven
to b
e un
infe
cted
(see
box
bel
ow)
• C
TX is
cle
arly
the
drug
of c
hoic
e fo
r pro
phyl
axis
bec
ause
of i
ts h
igh
ef
ficac
y, re
lativ
e sa
fety
, low
cos
t and
bro
ad a
ntim
icro
bial
spe
ctru
m.
In c
ase
of C
TX h
yper
sens
itivi
ty d
esen
sitiz
atio
n is
reco
mm
ende
d
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
32
CH
AP
TE
R 2
Ant
enat
al C
are
and
Prev
entio
n of
MTC
T of
HIV
2.
1
INTR
OD
UC
TIO
N
HIV
inf
ectio
n ha
s em
erge
d in
Ken
ya a
s th
e m
ost
impo
rtan
t he
alth
ris
k fa
ctor
for
m
othe
rs a
nd t
heir
chi
ldre
n an
d ha
s a
grea
t im
pact
on
the
long
ter
m o
utco
me
of
preg
nanc
y an
d ch
ild s
urvi
val.
All
preg
nant
wom
en s
houl
d be
enc
oura
ged
to le
arn
thei
r H
IV in
fect
ion
stat
us, a
s w
ell a
s th
at o
f the
ir s
exua
l par
tner
s.
Onl
y by
kno
win
g on
e’s
HIV
sta
tus
can
the
heal
th w
orke
rs m
ake
appr
opri
ate
heal
th c
are
man
agem
ent
reco
mm
enda
tions
and
the
cou
ple
mak
e ap
prop
riat
e de
cisi
ons
abou
t m
aint
aini
ng t
heir
he
alth
and
tha
t of
the
ir u
nbor
n ba
by.
Pre-
conc
eptio
n ca
re i
s en
cour
aged
whe
re a
n op
port
unity
ari
ses
and
a bi
rth
plan
is d
iscu
ssed
with
the
preg
nant
wom
an.
In m
ost
case
s, t
he p
regn
ant
wom
an w
ill n
ot h
ave
HIV
infe
ctio
n. P
regn
ancy
offe
rs a
n op
port
une
time
to d
iscu
ss p
reve
ntio
n of
HIV
inf
ectio
n as
man
y w
omen
com
e in
to
cont
act
with
hea
lth s
ervi
ces
for
the
first
(an
d in
som
e ca
ses
the
only
) tim
e du
ring
pr
egna
ncy.
In
Ken
ya,
50%
of
mar
ried
HIV
pos
itive
per
sons
hav
e an
HIV
neg
ativ
e sp
ouse
.1 Th
eref
ore,
kno
win
g th
e H
IV i
nfec
tion
stat
us o
f on
e’s p
artn
er i
s cr
itica
l. A
dditi
onal
ly,
this
for
ms
an i
mpo
rtan
t en
try
poin
t fo
r es
tabl
ishi
ng p
reve
ntio
n w
ith
posi
tive
(PW
P) p
rogr
ams
amon
g co
uple
s as
wel
l as
prov
idin
g ac
cess
to H
IV p
reve
ntio
n,
care
and
trea
tmen
t ser
vice
s fo
r th
e w
hole
fam
ily.
PMTC
T pr
ovid
es a
n op
port
unity
for
prev
entin
g ne
w p
aedi
atri
c H
IV in
fect
ions
as
wel
l as
for
reac
hing
the
10 to
20%
of H
IV p
ositi
ve p
regn
ant w
omen
who
mee
t WH
O e
ligib
il-ity
cri
teri
a fo
r in
itiat
ing
AR
T fo
r th
eir
own
heal
th. N
ew in
fect
ions
and
hig
h vi
ral l
oads
du
ring
pre
gnan
cy p
ose
the
grea
test
ris
k of
MTC
T to
the
unb
orn
baby
, thu
s pr
imar
y pr
even
tion,
AR
V p
roph
ylax
is a
s w
ell a
s tr
eatm
ent a
t thi
s tim
e is
cri
tical
. Giv
en th
at 2
5 pe
rcen
t of w
omen
in K
enya
hav
e an
unw
ante
d pr
egna
ncy;
str
engt
heni
ng th
e lin
k to
FP
serv
ices
and
con
dom
acc
ess
for
dual
pro
tect
ion
offe
rs a
cha
nce
to f
urth
er p
reve
nt
MTC
T2.
2.2
OPE
RA
TIO
NA
L G
UID
ELIN
ES
Ant
enat
al c
are
and
prev
entio
n of
MTC
T du
ring
thi
s pe
riod
can
be
sum
mar
ised
usi
ng
an e
ssen
tial
pack
age
of i
nteg
rate
d an
tena
tal
care
ser
vice
s as
sho
wn
in T
able
2.1
. Th
is
outli
nes
the
pack
age
of
care
to
be
pr
ovid
ed
to
ever
y w
oman
at
tend
ing
A
NC
ser
vice
s.
3
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e 2.
1 Es
sent
ial P
acka
ge o
f Int
egra
ted
Ant
enat
al C
are
Serv
ices
Sourc
e: K
enya
Nat
ional PM
TC
T T
rain
ing C
urr
iculu
m,
2005
Gro
up e
duca
tion:
Incl
ude
info
rmat
ion
on fo
ur A
NC
vis
its, b
reas
tfeed
ing,
mat
erna
l and
infa
nt n
utrit
ion,
per
sona
l hyg
iene
, birt
h pr
epar
edne
ss, d
ange
r sig
ns, p
reve
ntio
n of
com
plic
atio
ns, s
kille
d bi
rth a
ttend
ance
, fam
ily p
lann
ing,
imm
uniz
atio
n sc
hedu
le,
post
-nat
al c
are
and
HIV
and
AID
S m
anag
emen
t.
Clie
nt h
isto
ry: O
btai
n ro
utin
e da
ta in
clud
ing
med
ical
, obs
tetri
c, a
nd p
sych
osoc
ial h
isto
ry. D
eter
min
e dr
ug h
isto
ry, k
now
n al
lerg
ies,
and
use
of a
ltern
ativ
e m
edic
ines
suc
h as
her
bal p
rodu
cts.
Phy
sica
l exa
min
atio
n: In
clud
e vi
tal s
igns
, ins
pect
ion,
aus
culta
tion
and
palp
atio
n.
Abd
omin
al a
nd g
enita
l exa
min
atio
n: In
clud
e in
spec
tion,
pal
patio
n, fo
etal
aus
culta
tion,
spe
culu
m a
nd b
iman
ual e
xam
inat
ions
, w
here
indi
cate
d.
AN
C P
rofil
e: R
outin
e te
sts
for s
yphi
lis, H
b, b
lood
gro
up a
nd R
hesu
s fa
ctor
, urin
alys
is a
nd p
rovi
de ra
pid
HIV
test
ing
to th
e pr
egna
nt w
oman
and
her
par
tner
if a
ccom
pany
ing
her.
If in
dica
ted
chec
k sp
utum
for A
AFB
and
CD
4 co
unt.
Cou
nsel
ing
on b
irth
prep
ared
ness
: Sup
port
the
preg
nant
wom
an a
nd h
er p
artn
er to
dev
elop
an
indi
vidu
al b
irth
plan
that
in
clud
es p
lace
of d
eliv
ery
with
ski
lled
birth
atte
ndan
ce, e
mer
genc
y tra
nspo
rt, b
irth
com
pani
onsh
ip a
nd re
adin
ess
for i
nfan
t ca
re.
Cou
nsel
ing
on p
regn
ancy
dan
ger s
igns
: Pro
vide
wom
en w
ith in
form
atio
n an
d in
stru
ctio
ns o
n se
ekin
g ea
rly c
are
for p
reg-
nanc
y co
mpl
icat
ions
suc
h as
ble
edin
g, fe
ver,
seve
re h
eada
che,
sw
olle
n fe
et, f
its o
r con
vuls
ions
.
Cou
nsel
ing
on in
fant
feed
ing:
All
wom
en re
quire
infa
nt-fe
edin
g co
unse
ling
and
supp
ort.
Exc
lusi
ve b
reas
tfeed
ing
for s
ix
mon
ths
shou
ld b
e pr
omot
ed a
s th
e no
rm fo
r all
wom
en re
gard
less
of H
IV s
tatu
s. W
omen
infe
cted
with
HIV
nee
d to
be
guid
ed in
the
sele
ctio
n of
saf
er in
fant
-feed
ing
optio
ns (r
efer
to W
HO
gui
delin
es a
nd M
OH
circ
ular
on
infa
nt a
nd y
oung
chi
ld
feed
ing)
.
Nut
ritio
nal a
sses
smen
t, co
unse
ling
and
educ
atio
n: In
clud
e iro
n, m
ultiv
itam
in a
nd fo
late
sup
plem
enta
tion,
mon
itor f
or a
nae-
mia
, ade
quat
e ca
loric
and
nut
rient
inta
ke, a
nd re
com
men
d re
alis
tic d
iet a
djus
tmen
ts b
ased
on
loca
l res
ourc
es a
nd n
eeds
of
HIV
+ pr
egna
nt w
omen
(at l
east
10%
mor
e of
the
RD
A).
Cou
nsel
ing
on H
IV a
nd A
IDS
: Pro
vide
wom
en w
ith in
form
atio
n an
d in
stru
ctio
ns o
n se
ekin
g he
alth
car
e fo
r sy
mpt
oms
of H
IV d
isea
se p
rogr
essi
on, s
uch
as fr
eque
nt a
nd re
curre
nt il
lnes
ses,
chr
onic
per
sist
ent d
iarr
hoea
, can
didi
asis
, fe
ver,
was
ting
or s
igns
of a
ny o
ppor
tuni
stic
infe
ctio
n. L
ink
wom
en to
AID
S tr
eatm
ent a
nd o
ther
sup
port
prog
ram
mes
whe
re
avai
labl
e.
Cou
nsel
ing
the
HIV
neg
ativ
e w
oman
and
her
par
tner
: Pro
vide
info
rmat
ion
on re
peat
test
ing,
risk
redu
ctio
n an
d pa
rtner
test
ing.
RTI
scr
eeni
ng: A
ll w
omen
with
hig
h ris
k se
xual
his
tory
or p
rese
ntin
g w
ith s
igns
of R
TI s
uch
as a
bnor
mal
gen
ital d
isch
arge
, ge
nita
l ulc
ers
and
pelv
ic in
flam
mat
ory
dise
ase
shou
ld b
e sc
reen
ed a
nd m
anag
ed a
ccor
ding
to K
enya
pro
toco
ls.
Tube
rcul
osis
(TB
): A
ll w
omen
pre
sent
ing
for A
NC
ser
vice
s w
ith a
cou
gh o
f mor
e th
an 2
wee
ks’ d
urat
ion
shou
ld b
e sc
reen
ed
for T
B re
gard
less
of H
IV s
tatu
s. F
ollo
w K
enya
pro
toco
ls fo
r scr
eeni
ng, p
roph
ylax
is a
nd tr
eatm
ent.
Teta
nus
toxo
id im
mun
isat
ions
: Adm
inis
ter a
ccor
ding
to c
urre
nt K
EP
I TT
Imm
uniz
atio
n S
ched
ule.
Dew
orm
ing:
All
preg
nant
wom
en s
houl
d re
ceiv
e an
ti-he
lmin
thes
afte
r firs
t trim
este
r as
per t
he g
uide
lines
on
m
ater
nal n
utrit
ion.
Ant
imal
aria
ls, I
TNs:
All
preg
nant
wom
en in
mal
aria
end
emic
are
as s
houl
d sl
eep
unde
r an
ITN
and
rece
ive
SP
inte
rmitt
ent
pres
umpt
ive
treat
men
t acc
ordi
ng to
the
Nat
iona
l Mal
aria
gui
delin
es
AR
V a
nd O
ppor
tuni
stic
Infe
ctio
ns p
roph
ylax
is (d
urin
g pr
egna
ncy)
: Pro
vide
AR
V, C
TX, a
nd o
ther
pro
phyl
actic
m
edic
atio
ns a
ccor
ding
to th
e K
enya
AR
T pr
otoc
ol o
n O
I pro
phyl
axis
and
use
of A
RV
s in
pre
gnan
cy.
AR
V tr
eatm
ent d
urin
g pr
egna
ncy:
Pro
vide
HA
AR
T w
ithin
the
MC
H s
ettin
g ac
cord
ing
to th
e K
enya
pro
toco
l on
use
of A
RV
s.
Est
ablis
h cl
ear r
efer
ral n
etw
orks
with
sen
ior c
linic
ians
.
Pre
vent
ion
with
Pos
itive
s: E
ncou
rage
pos
itive
livi
ng, d
iscl
osur
e, c
orre
ct a
nd c
onsi
sten
t con
dom
use
, and
pro
vide
psy
chos
o-ci
al s
uppo
rt to
the
affe
cted
fam
ilies.
For
the
HIV
-infe
cted
and
affe
cted
fam
ilies,
est
ablis
h an
d/or
stre
ngth
en li
nkag
es to
car
e,
treat
men
t and
sup
port
serv
ices
incl
udin
g po
st-p
artu
m fo
llow
up.
Effe
ctiv
e co
ntra
cept
ion
plan
: Cou
nsel
abo
ut o
ther
fam
ily p
lann
ing
met
hods
em
phas
izin
g on
par
tner
invo
lvem
ent
and
dual
pro
tect
ion
met
hods
to a
void
unw
ante
d pr
egna
ncy,
new
infe
ctio
n, re
-infe
ctio
n an
d fu
rther
tran
smis
sion
.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
74
9.2
OPE
RA
TIO
NA
L G
UID
ELIN
ES
Hea
lth w
orke
rs s
houl
d pr
ovid
e th
e fo
llow
ing
pack
age
of c
are
as a
min
imum
to
thes
e ch
ildre
n:
(1)
Con
firm
HIV
sta
tus
as e
arly
as
poss
ible
. (R
efer
to C
hapt
er 7
)
(2)
Mot
hers
sho
uld
be s
uppo
rted
to p
rovi
de o
ptim
al in
fant
feed
ing
and
parti
cula
rly to
av
oid
mix
ed fe
edin
g in
the
first
6 m
onth
s of
life
. It i
s im
porta
nt th
at in
fant
feed
ing
choi
ces
at in
itiat
ion
of fe
edin
g, fo
llow
ing
early
infa
nt d
iagn
osis
, at w
eani
ng a
nd a
t th
e tim
e of
intro
duct
ion
of c
ompl
emen
tary
feed
s ar
e gu
ided
by
the
AFA
SS
crit
eria
. (R
efer
to C
hapt
er 8
)
The
follo
win
g gu
idel
ines
sho
uld
be fo
llow
ed in
the
care
and
fo
llow
-up
of c
hild
ren
of H
IV-in
fect
ed m
othe
rs:
• A
ll ch
ildre
n bo
rn t
o H
IV in
fect
ed m
othe
rs s
houl
d be
see
n in
the
he
alth
car
e fa
cilit
y w
ithin
tw
o w
eeks
of
deliv
ery
• F
or a
ll H
IV e
xpos
ed in
fant
s, m
onth
ly f
ollo
w u
p vi
sits
are
re
com
men
ded
begi
nnin
g at
six
wee
ks t
hrou
gh 2
yea
rs
• W
here
pos
sibl
e, v
isits
sho
uld
be li
nked
to
the
imm
unis
atio
n an
d gr
owth
mon
itori
ng v
isits
• A
ll H
IV e
xpos
ed in
fant
s sh
ould
be
star
ted
on C
otri
mox
azol
e
prop
hyla
xis
from
6 w
eeks
of
age
• F
or in
fant
s w
ho te
st H
IV p
ositi
ve b
y D
NA
PC
R b
efor
e 18
mon
ths
or
by a
ntib
ody
test
aft
er 1
8 m
onth
s of
age
, co
-trim
oxaz
ole
shou
ld b
e gi
ven
daily
for
life
• F
or in
fant
s w
ho te
st H
IV n
egat
ive:
If
they
hav
e st
oppe
d br
east
feed
ing
for 2
mon
ths
or m
ore,
sto
p
Cot
rimox
azol
e
If
still
brea
stfe
edin
g, c
ontin
ue C
otrim
oxaz
ole
until
two
mon
ths
afte
r co
mpl
ete
cess
atio
n of
bre
astfe
edin
g
• C
ompr
ehen
sive
car
e fo
r th
e H
IV e
xpos
ed o
r in
fect
ed in
fant
s sh
ould
be
pro
vide
d in
the
bro
ader
con
text
of
othe
r ch
ild h
ealth
car
e
stra
tegi
es
7
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Cha
pter
9
Car
e an
d Fo
llow
-up
of C
hild
ren
of H
IV-in
fect
ed M
othe
rs
9.1
IN
TRO
DU
CTI
ON
PM
TCT
inte
rven
tions
redu
ce b
ut d
o no
t elim
inat
e th
e ri
sk o
f HIV
tran
smis
sion
from
mot
h-er
s to
thei
r inf
ants
and
you
ng ch
ildre
n. B
oth
HIV
-infe
cted
and
uni
nfec
ted
expo
sed
child
ren
have
incr
ease
d ri
sks
of in
fect
ion
and
deat
h fr
om c
omm
on c
hild
hood
infe
ctio
ns. T
he s
ur-
viva
l of
HIV
-exp
osed
chi
ldre
n, w
heth
er o
r no
t th
ey a
re i
nfec
ted,
is
clos
ely
linke
d to
the
he
alth
and
sur
viva
l of t
heir
mot
hers
. The
refo
re, l
ong-
term
ben
efits
of P
MTC
T pr
ogra
ms
will
onl
y be
sus
tain
ed if
the
re is
ong
oing
com
preh
ensi
ve c
are
for
the
child
ren
and
thei
r m
othe
rs a
nd/o
r car
e gi
vers
.
HIV
exp
osed
chi
ldre
n ar
e vu
lner
able
to
the
com
mon
illn
esse
s af
fect
ing
othe
r ch
ildre
n.
Thes
e in
fect
ions
incl
ude
neon
atal
infe
ctio
ns, m
alar
ia, p
neum
onia
, dia
rrho
ea, m
easl
es a
nd
othe
r vac
cine
pre
vent
able
dis
ease
s. H
IV in
fect
ed ch
ildre
n ar
e lik
ely
to s
uffe
r mor
e se
vere
ly
and
have
a h
ighe
r lik
elih
ood
of d
ying
from
com
mon
chi
ldho
od il
lnes
ses
than
non
-infe
cted
ch
ildre
n. W
here
as m
alnu
triti
on c
ause
s 53
% o
f all
child
hood
dea
ths,
HIV
exp
osed
chi
ldre
n ar
e m
ore
vuln
erab
le to
it th
an n
on-in
fect
ed c
hild
ren.
Thi
s is
bec
ause
HIV
exp
osed
child
ren
have
hig
her
calo
ric
requ
irem
ents
as
a re
sult
of th
eir
HIV
infe
ctio
n, th
e pr
esen
ce o
f opp
or-
tuni
stic
infe
ctio
ns a
nd o
ther
com
plic
atio
ns re
late
d to
AID
S.
Regu
lar
follo
w u
p ca
re is
cri
tical
for
an in
fant
bor
n to
a m
othe
r w
ith H
IV/A
IDS.
The
com
-pr
ehen
sive
car
e of
HIV
exp
osed
chi
ldre
n in
clud
ing
nutr
ition
, im
mun
isat
ion,
mon
itori
ng o
f gr
owth
and
dev
elop
men
t, pr
even
tion
and
trea
tmen
t of
opp
ortu
nist
ic in
fect
ions
and
ear
ly
infa
nt d
iagn
osis
of
HIV
is f
easi
ble
in r
esou
rce-
cons
trai
ned
sett
ings
and
sig
nific
antly
im-
prov
es th
e su
rviv
al o
f the
se ch
ildre
n.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
34
2.3
JO
B A
IDS
Prov
ider
s ar
e en
cour
aged
to re
fer t
o th
e ap
prop
riate
job
aid(
s) w
hen
deal
ing
with
spe
cific
issu
es:
• P
MT
CT
test
ing
and
coun
selli
ng t
ools
• C
oupl
e co
unse
lling
too
ls
• A
NC
alg
orith
ms
for
AR
V p
roph
ylax
is a
nd in
fant
fee
ding
gui
delin
es
as a
dapt
ed f
rom
WH
O g
uide
lines
• P
reve
ntio
n w
ith p
ositi
ves
tool
kit
on d
iscl
osur
e
• F
ocus
ed a
nte-
nata
l car
e
• M
alar
ia in
pre
gnan
cy
• T
B in
pre
gnan
cy
• K
EP
I S
ched
ule
3
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
A ra
pid
HIV
test
ing
algo
rithm
for s
eria
l tes
ting
is il
lust
rate
d be
low
Pre-Test Education and or Counselling
First HIV Rapid Test –DETERMINE
Negative Test Result
Counsel for Negative Result
Positive Test Result
Second HIV Rapid Test –BIOLINE
Positive Test ResultCounsel for
Positive Result
Negative Test Result
Third HIV Rapid Test –UNIGOLD
Positive Test ResultCounsel for
Positive Result
Negative Test ResultCounsel for
Negative Result
Figure 3.2 Rapid HIV testing algorithm: Serialtesting
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
72
7
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
36
Mot
her a
nd C
hild
Hea
lth B
ookl
et
3
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Cha
pter
ref
eren
ces
Rep
ublic
of
Ken
ya M
inis
try
of
Hea
lth,
Div
isio
n o
f Rep
roduct
ive
Hea
lth:
National G
uid
e-lin
es f
or
Qual
ity
Obst
etri
cs a
nd P
erin
atal Car
e, (
2004).
W
HO
, U
NFP
A,
UN
ICEF,
World B
ank:
Manag
ing C
om
plic
atio
ns
in P
regnan
cy a
nd C
hild
birth
. A g
uid
e fo
r m
idw
ives
and d
oct
ors
(2003).
W
HO
, Sta
ndar
ds
for
Mat
ernal
and N
eonat
al C
are
(2006).
W
HO
, Antire
trovi
ral dru
gs
for
trea
ting p
regnan
t w
om
en a
nd p
reve
nting H
IV infe
ctio
ns
in
infa
nts
in r
esourc
e lim
ited
set
tings:
Tow
ard
s U
niv
ersa
l Acc
ess,
Rec
om
men
dations
for
a public
hea
lth a
ppro
ach (
2006).
M
inis
try
of
Hea
lth,
Nat
ional AID
S &
STD
Contr
ol Pro
gra
mm
e (N
ASCO
P)
Guid
elin
es f
or
Antire
trovi
ral dru
g t
her
apy
in K
enya
(2005).
M
inis
try
of
Hea
lth,
Ken
ya N
atio
nal
Rep
roduct
ive
Hea
lth I
nst
ruct
ional M
anual
for
Ser
vice
Pro
vider
s (M
arch
2005)
Nat
ional AID
S &
STD
Contr
ol Pro
gra
mm
e, K
enya
AID
S I
ndic
ator
Syr
vey
Foo
tnot
es
1,
2Ken
ya D
emogra
phic
and H
ealth S
urv
ey (
KD
HS),
2003
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
70
6
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
38
CH
AP
TE
R 3
Intr
apar
tum
Car
e 3.
1 IN
TRO
DU
CTI
ON
In
trap
artu
m c
are
is t
he m
anag
emen
t of
wom
en f
rom
the
ons
et o
f la
bour
to
deliv
ery.
Thi
s pe
riod
pos
es th
e gr
eate
st r
isk
for
tran
smis
sion
of H
IV fr
om th
e m
othe
r to
the
child
(MTC
T)
with
10
to 2
0 pe
rcen
t of e
xpos
ed in
fant
s be
com
ing
infe
cted
at t
his
time i
n th
e ab
senc
e of
any
in
terv
entio
n.1
In t
he c
onte
xt o
f H
IV/A
IDS,
it is
, the
refo
re, i
mpo
rtan
t to
est
ablis
h th
e H
IV
stat
us o
f wom
en p
rior
to, o
r du
ring
labo
ur a
nd d
eliv
ery
and
prov
ide
inte
rven
tions
aim
ed a
t re
duci
ng th
e ri
sk o
f tra
nsm
issi
on. W
ith a
ppro
pria
te in
terv
entio
ns, t
he r
isk
of M
TCT
can
be
redu
ced
sign
ifica
ntly
.
3.2
O
PER
ATI
ON
AL
GU
IDEL
INES
a) O
ptim
al In
trap
artu
m C
are
The
follo
win
g gu
idel
ines
sho
uld
be fo
llow
ed fo
r all
wom
en a
dmitt
ed
to la
bour
and
del
iver
y un
its 2,
3
1. M
inim
ise
vagi
nal e
xam
inat
ions
2. U
se a
sept
ic t
echn
ique
s in
con
duct
ing
deliv
ery
3. A
void
rou
tine
artif
icia
l rup
ture
of m
embr
anes
(A
RM
)
4. A
void
pro
long
ed la
bour
5. A
void
unn
eces
sary
tra
uma
duri
ng d
eliv
ery
6. M
inim
ise
the
risk
of p
ostp
artu
m h
aem
orrh
age
7. U
se s
afe
bloo
d tr
ansf
usio
n pr
actic
es
3
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
b) S
peci
fic M
anag
emen
t of H
IV P
ositi
ve P
regn
ant W
omen
P
roph
ylac
tic
Ant
iret
rovi
ral t
hera
pies
4
The
AR
V p
roph
ylac
tic r
egim
en d
epen
ds o
n w
heth
er th
e m
othe
r ha
d A
RV
s du
ring
pre
g-na
ncy
or n
ot. T
hus,
the
heal
th c
are
wor
ker s
houl
d es
tabl
ish
the
regi
men
use
d du
ring
th
e A
NC
, whe
ther
the
wom
an h
ad ta
ken
the
SdN
VP
and
AZT
at t
he o
nset
of l
abou
r an
d de
term
ine
the
appr
opri
ate
intr
a-pa
rtum
AR
V c
are
as p
er th
e al
gori
thm
s on
pag
e 80
(App
endi
x II
I), p
age
81 (A
ppen
dix
IV) a
nd a
s su
mm
aris
ed b
elow
.
Mod
e of
del
iver
y E
lect
ive
caes
area
n se
ctio
n (C
S) r
educ
es t
he r
isk
of H
IV M
TCT
as c
ompa
red
to v
agin
al
deliv
ery,
but
will
not
be
avai
labl
e in
man
y se
ttin
gs in
our
cou
ntry
. Whe
re C
S is
per
-fo
rmed
(ele
ctiv
e or
em
erge
ncy)
in H
IV p
ositi
ve w
omen
, the
y sh
ould
rec
eive
pro
phyl
actic
an
tibio
tics.
If
the
CS
is p
erfo
rmed
aft
er p
rolo
nged
lab
our
or r
uptu
re o
f m
embr
anes
, lo
nger
cour
ses
of a
ntib
iotic
s sh
ould
be
cons
ider
ed.
No
AR
Vs t
aken
in p
regn
ancy
Mot
her i
n ea
rly la
bour
(up
to 4
cm c
ervi
cal d
ilata
tion)
•
Intr
apar
tum
per
iod:
Giv
e m
othe
r S
dNV
P 2
00m
g, A
ZT
600
mg
and
3T
C 1
50m
g st
at
• P
ostp
artu
m m
othe
r: G
ive
mot
her
AZ
T 3
00m
g an
d 3T
C 1
50m
g B
D
for
7 da
ys
• P
ostp
artu
m p
erio
d: G
ive
infa
nt S
d N
evir
apin
e 2
mg/
kg w
ithin
72
hour
s of
birt
h P
LUS
3T
C 4
mg/
kg B
D f
or 1
wee
k an
d A
ZT
syr
up 4
mg/
kg
BD
for
6 w
eeks
Mot
her r
ecei
ved
AZT
300
mg
BD
in P
regn
ancy
• P
ostp
artu
m:
Giv
e in
fant
Sd
Nev
irap
ine
2mg/
kg w
ithin
72
hour
s of
birt
h,
PLU
S 3
TC
4m
g/kg
BD
for
1 w
eek
and
AZ
T s
yrup
4 m
g/kg
BD
for
6 w
eeks
Mot
her r
ecei
ved
HA
AR
T in
Pre
gnan
cy
Reg
ardl
ess
of d
urat
ion
rece
ived
HA
AR
T •
Giv
e m
othe
r A
RV
dos
e as
per
reg
imen
• P
ostp
artu
m:
Giv
e In
fant
Sd
Nev
irap
ine
2mg/
kg w
ithin
72
hour
s of
bir
th,
PLU
S 3
TC
4m
g/kg
BD
for
1 w
eek
and
AZ
T s
yrup
4 m
g/kg
BD
for
6 w
eeks
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
68
6
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
40
Supp
ort d
urin
g la
bour
E
mot
iona
l su
ppor
t du
ring
lab
our
is i
mpo
rtan
t fo
r al
l w
omen
, and
may
be
even
mor
e ne
cess
ary
for
an H
IV p
ositi
ve w
oman
who
is c
once
rned
abo
ut h
er c
ondi
tion
and
risk
of
HIV
tran
smis
sion
to c
hild
. Whe
neve
r po
ssib
le, d
urin
g la
bour
, war
d st
aff m
ust b
e se
nsi-
tive
to t
he fe
ars
and
conc
erns
of t
he H
IV p
ositi
ve m
othe
r ab
out
her
infe
ctio
n, a
nd h
ow
muc
h sh
e ha
d to
ld h
er p
artn
er.
Indu
ctio
n of
labo
ur
Indu
ctio
n of
labo
ur m
ay b
e as
soci
ated
with
incr
ease
d ri
sk o
f H
IV M
TCT.
Car
eful
as-
sess
men
t of
the
nee
d fo
r an
d de
sira
bilit
y of
ind
uctio
n ra
ther
tha
n C
S is
nec
essa
ry.
Whe
n in
duct
ion
of la
bour
is c
hose
n, m
embr
anes
sho
uld
be le
ft in
tact
for
as lo
ng a
s po
s-si
ble.
Syn
toci
non
shou
ld n
ot b
e us
ed w
ith in
tact
mem
bran
es.
Indi
catio
ns fo
r ele
ctiv
e C
S A
lthou
gh e
lect
ive
CS
will
not
be
avai
labl
e in
mos
t hea
lth fa
cilit
ies
as a
rou
tine
for
HIV
po
sitiv
e w
omen
, the
re m
ay b
e so
me
case
s th
at m
erit
cons
ider
atio
n fo
r C
S. T
hese
in-
clud
e pr
egna
ncie
s w
here
lab
our
is e
xpec
ted
to b
e pr
olon
ged
or w
here
oth
er o
bste
tric
co
mpl
icat
ions
may
be
asso
ciat
ed w
ith in
crea
sed
risk
of t
rans
mis
sion
(e.g
. abr
uptio
pla
-ce
ntae
, pl
acen
ta p
raev
ia,
pre-
term
rup
ture
of
mem
bran
es,
prev
ious
CS
and
bree
ch
pres
enta
tion)
.
Man
agem
ent o
f lab
our a
nd d
eliv
ery
Labo
ur a
nd d
eliv
ery
man
agem
ent
shou
ld fo
llow
opt
imal
obs
tetr
ic m
anag
emen
t gu
ide-
lines
. (R
efer
to
Opt
imal
Int
rapa
rtum
car
e ab
ove
and
Nat
iona
l G
uide
lines
for
Qua
lity
Obs
tetr
ics
and
IMPA
C C
are
Man
ual).
RO
LE O
F TH
E C
OM
MU
NIT
Y
A la
rge
prop
ortio
n (6
0%) o
f wom
en in
Ken
ya is
del
iver
ed o
utsid
e th
e he
alth
sys
tem
s by
fam
ily
mem
bers
, nei
ghbo
urs a
nd T
BAs.
• T
here
is n
eed
to e
duca
te th
e co
mm
unity
on
the
risk
of M
TC
T an
d w
ays
of
prev
entio
n
• T
hose
ass
istin
g th
e de
liver
ies
need
to u
nder
stan
d th
eir
own
risk
of in
fect
ion
and
how
to p
rote
ct th
emse
lves
• T
he c
omm
unity
sho
uld
be e
ncou
rage
d to
faci
litat
e m
othe
rs to
del
iver
in
heal
th fa
cilit
ies
• T
he c
omm
unity
sho
uld
be e
ncou
rage
d to
ref
er to
hea
lth fa
cilit
ies
all c
hild
ren
born
at h
ome
4
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Cha
pter
ref
eren
ces
1.R
epublic
of
Ken
ya,
Min
istr
y of
Hea
lth,
Ess
ential
Obst
etric
Car
e M
anual
for
Hea
lth
Ser
vice
Pro
vider
s in
Ken
ya (
3rd
Editio
n J
an 2
006).
Foo
tnot
es
1 D
e Cock
K.M
. 2002.
2 K
enya
National
Rep
roduct
ive
Hea
lth I
nst
ruct
ion M
anual
for
Ser
vice
Pro
vider
s (2
006).
3 D
ivis
ion o
f Rep
roduct
ive
Hea
lth:
Guid
elin
es f
or
Qual
ity
Obst
etri
cs a
nd P
erin
ata
l Car
e (2
004).
4 W
HO
: Antire
tovi
ral dru
gs
for
trea
ting p
regnan
t w
om
en a
nd p
reve
nting H
IV infe
ctio
n in
infa
nts
: to
ward
s univ
ersa
l acc
ess
(2006).
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
66
Figu
re 8
.1: G
uide
lines
for C
ouns
ellin
g on
HIV
and
Infa
nt fe
edin
gJob
Aid
s an
d IE
C M
ater
ials
on
Infa
nt a
nd Y
oung
Chi
ld F
eedi
ng
6
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
8.5
EXTR
AC
TS F
RO
M R
ESEA
RC
H O
N IN
FAN
T FE
EDIN
G
A
ND H
IV/A
IDS
Evid
ence
ava
ilabl
e fr
om c
urre
nt re
sear
ch d
ata
show
s th
at:
• In
crea
sed
risk
of m
orta
lity
with
rep
lace
men
t fe
edin
g is
sig
nific
ant
• H
IV f
ree
surv
ival
rat
e at
18
mon
ths
of a
ge d
oes
not
sign
ifica
ntly
var
y be
twee
n a
brea
stfe
d an
d re
plac
emen
t fed
chi
ld
• M
odifi
ed a
nim
al’s
milk
doe
s no
t pr
ovid
e ad
equa
te n
utrit
ion
for
child
ren
less
tha
n 6
mon
ths
henc
e m
icro
nutr
ient
s sh
ould
be
give
n un
der
thes
e ci
rcum
stan
ces
• A
brup
t ce
ssat
ion
of b
reas
tfee
ding
is n
o lo
nger
rec
omm
ende
d
• E
xclu
sive
bre
astf
eedi
ng u
p to
6 m
onth
s is
rec
omm
ende
d un
less
re
plac
emen
t fee
ding
can
mee
t AF
AS
S c
rite
ria
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
42
Cha
pter
4
Use
of A
ntire
trov
iral D
rugs
in P
regn
ancy
for T
reat
men
t and
for
Prev
entio
n of
Mot
her-
to-C
hild
Tra
nsm
issi
on o
f HIV
Infe
ctio
n 4.
1 IN
TRO
DU
CTI
ON
W
ithou
t an
y in
terv
entio
n, u
p to
40
perc
ent
of H
IV p
ositi
ve w
omen
will
tra
nsm
it th
e in
fect
ion
to t
heir
chi
ldre
n du
ring
pre
gnan
cy, l
abou
r an
d br
east
feed
ing.
Use
of a
ntir
et-
rovi
ral d
rugs
(AR
Vs)
, obs
tetr
ic in
terv
entio
ns a
nd a
void
ance
of a
ll br
east
feed
ing
for
pre-
vent
ion
of m
othe
r to
chi
ld tr
ansm
issi
on o
f HIV
infe
ctio
n (P
MTC
T) h
as r
educ
ed th
e ri
sk
of m
othe
r to
chi
ld tr
ansm
issi
on o
f HIV
infe
ctio
n (M
TCT)
to le
ss th
an 2
per
cent
in d
evel
-op
ed c
ount
ries
.
Shor
t cou
rse
effic
acio
us A
RV
dru
g re
gim
ens
can
redu
ce th
e ri
sk o
f MTC
T to
2-4
per
cent
an
d ca
n be
im
plem
ente
d in
res
ourc
e-lim
ited
sett
ings
on
a po
pula
tion-
base
d pu
blic
he
alth
sca
le. A
RV
s ar
e us
ed b
oth
for
the
trea
tmen
t of
HIV
dis
ease
and
for
PMTC
T in
H
IV-in
fect
ed p
regn
ant
wom
en a
nd t
heir
neo
nate
s. A
ntir
etro
vira
l tre
atm
ent
(AR
T) fo
r w
omen
, who
qua
lify
for
it, p
rolo
ngs
and
impr
oves
the
qua
lity
of t
heir
liv
es. T
he s
ur-
viva
l of
the
chi
ld i
s cl
osel
y in
terl
inke
d w
ith t
he h
ealth
and
sur
viva
l of
the
mot
her.
W
omen
elig
ible
for
AR
T sh
ould
be
star
ted
on tr
eatm
ent a
s so
on a
s po
ssib
le. P
regn
ancy
is
not
a r
easo
n to
del
ay A
RT.
Wom
en w
ho a
re a
lrea
dy o
n A
RT
befo
re b
ecom
ing
preg
-na
nt s
houl
d co
ntin
ue w
ith th
eir
trea
tmen
t. In
cer
tain
situ
atio
ns, m
odifi
catio
ns m
ay b
e ne
eded
to m
ake
trea
tmen
t saf
er fo
r th
e m
othe
r an
d th
e un
born
bab
y.
The
bene
fits
of u
sing
AR
Vs
to t
reat
HIV
-infe
cted
pre
gnan
t w
omen
and
/or
PMTC
T ou
t-w
eigh
the
ris
ks. H
owev
er, w
hen
AR
T or
oth
er s
hort
cou
rse
AR
V r
egim
ens
are
used
, ba
selin
e ev
alua
tion
and
mon
itori
ng is
enc
oura
ged
to e
nsur
e th
e sa
fety
of t
he m
othe
rs
and
thei
r ne
wbo
rns.
Lin
kage
s of
HIV
-infe
cted
pre
gnan
t w
omen
and
the
ir c
hild
ren
to
othe
r ca
re a
nd s
uppo
rt p
rogr
ams
at h
ealth
fac
ility
and
com
mun
ity l
evel
s sh
ould
be
ensu
red.
4
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
4.2
O
PER
ATI
ON
AL
GU
IDEL
INES
A
ll H
IV-in
fect
ed p
regn
ant
wom
en s
houl
d be
cou
nsel
led
on c
ompr
ehen
sive
HIV
car
e in
clud
ing
use
of A
RV
s fo
r th
eir
own
heal
th a
nd fo
r PM
TCT.
The
wom
en s
houl
d al
so b
e sc
reen
ed a
nd tr
eate
d fo
r op
port
unis
tic in
fect
ions
(OIs
) inc
ludi
ng
Tube
rcul
osis
(TB)
.
All
HIV
-infe
cted
pre
gnan
t wom
en s
houl
d ha
ve b
asel
ine
labo
rato
ry a
nd o
ther
nec
essa
ry
diag
nost
ic e
valu
atio
ns.
All
HIV
-infe
cted
pre
gnan
t wom
en s
houl
d ha
ve th
eir H
IV d
isea
se
stag
ed u
sing
:
• W
HO
clin
ical
sta
ging
(se
e A
ppen
dix
1) a
nd
• Im
mun
olog
ical
sta
ging
(C
D4
coun
t) (
see
tabl
e 1)
Thes
e di
agno
stic
s sh
ould
incl
ude:
• R
outin
e an
tena
tal c
are
labo
rato
ry in
vest
igat
ions
that
are
nor
mal
ly
done
for
all
preg
nant
wom
en:
haem
oglo
bin
(Hb)
, rh
esus
blo
od
grou
p an
d A
BO
typ
ing,
VD
RL,
uri
ne a
naly
sis
and
scre
enin
g
for
ST
I
• A
LT a
nd c
reat
inin
e le
vels
for
wom
en e
ligib
le f
or H
AA
RT
Pr
ophy
laxi
s &
mic
ronu
trie
nt s
uppl
emen
tatio
n:
• C
otrim
oxaz
ole
(CTX
) one
dou
ble
stre
ngth
or t
wo
sing
le s
treng
th ta
blet
s on
ce d
aily
• M
ultiv
itam
ins
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
64
8.3
OPE
RA
TIO
NA
L G
UID
ELIN
ES O
N F
EED
ING
CH
ILD
REN
6 M
ON
THS
A
ND O
LDER
8.4
NU
TRIT
ION
AL
CA
RE
AN
D S
UPP
OR
T O
F H
IV
IN
FEC
TED C
HIL
DR
EN
The
follo
win
g sh
ould
gui
de fe
edin
g fo
r chi
ldre
n 6
mon
ths
and
olde
r:
• A
t 6
mon
ths,
oth
er f
orm
s of
milk
alo
ne a
re n
ot a
dequ
ate
to m
eet
the
baby
’s n
utrit
iona
l req
uire
men
ts
• C
ompl
emen
tary
foo
ds s
houl
d be
intr
oduc
ed w
ith c
ontin
ued
brea
stfe
edin
g or
with
rep
lace
men
t fe
edin
g un
til a
nut
ritio
nally
ad
equa
te d
iet
can
be s
usta
ined
with
out
milk
• A
brup
t ces
satio
n of
bre
astf
eedi
ng s
houl
d be
dis
cour
aged
to
avoi
d tr
aum
a fo
r bo
th t
he m
othe
r an
d th
e ba
by
• M
ilk s
houl
d co
ntin
ue a
s an
impo
rtan
t co
mpo
nent
of
the
diet
• C
ompl
emen
tary
foo
ds s
houl
d be
enr
iche
d fr
om lo
cally
ava
ilabl
e fa
mily
foo
ds
• E
nerg
y ne
eds
for
asym
ptom
atic
HIV
infe
cted
chi
ldre
n in
crea
se b
y 10
pe
rcen
t to
mai
ntai
n gr
owth
as
com
pare
d to
the
non-
infe
cted
chi
ldre
n
• T
here
is n
o ev
iden
ce o
f in
crea
sed
prot
ein
requ
irem
ents
. The
re
quir
emen
ts s
houl
d be
bas
ed o
n in
divi
dual
sym
ptom
s an
d ne
eds
• M
icro
nutr
ient
req
uire
men
ts d
o no
t ch
ange
. W
HO
rec
omm
ends
not
m
ore
than
one
RD
A.
(For
fur
ther
det
ails
, re
fer
to K
enya
n G
uide
lines
on
nutr
ition
and
HIV
/A
IDS
)
6
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
8.2
OPE
RA
TIO
NA
L G
UID
ELIN
ES O
N IN
FAN
T FE
EDIN
G (0
-6 M
ON
THS)
The
follo
win
g sh
ould
gui
de in
fant
feed
ing
for t
he fi
rst 6
mon
ths:
• A
ll w
omen
and
men
irre
spec
tive
of th
eir
HIV
sta
tus
shou
ld r
ecei
ve
coun
selin
g an
d de
mon
stra
tions
on
how
to
safe
ly f
eed
thei
r ba
bies
du
ring
the
ant
enat
al a
nd p
ostn
atal
fol
low
up
• T
he m
ost
appr
opria
te in
fant
fee
ding
opt
ion
for
an H
IV in
fect
ed
mot
her
shou
ld c
ontin
ue t
o de
pend
on
indi
vidu
al c
ircu
mst
ance
s an
d th
e
avai
labl
e su
ppor
t
• E
very
HIV
infe
cted
wom
an s
houl
d be
eva
luat
ed a
t ev
ery
visi
t to
ch
eck
whe
ther
her
soc
ial,
econ
omic
and
hea
lth s
tatu
s ha
s ch
ange
d su
ffic
ient
ly e
noug
h to
aff
ect
her
infa
nt f
eedi
ng o
ptio
n
• E
xclu
sive
bre
astf
eedi
ng fo
r H
IV in
fect
ed w
omen
for
the
firs
t 6
mon
ths
of t
he in
fant
’s li
fe is
adv
isab
le,
unle
ss r
epla
cem
ent f
eedi
ng is
ac
cept
able
, fea
sibl
e, a
ffor
dabl
e, s
usta
inab
le a
nd s
afe
for
them
and
th
eir
infa
nts
befo
re t
hat t
ime
• W
hen
repl
acem
ent
feed
ing
is a
ccep
tabl
e, f
easi
ble,
aff
orda
ble,
su
stai
nabl
e an
d sa
fe,
avoi
danc
e of
exc
lusi
ve b
reas
tfee
ding
by
HIV
in
fect
ed w
omen
is r
ecom
men
ded
• If
the
con
ditio
ns f
or r
epla
cem
ent
feed
ing
are
still
not
met
for
6
mon
ths
then
, co
ntin
uatio
n of
bre
astf
eedi
ng w
ith a
dditi
onal
co
mpl
emen
tary
fee
ding
is r
ecom
men
ded,
giv
ing
prio
rity
to t
he lo
cally
av
aila
ble
food
s
• In
fant
fee
ding
dec
isio
ns f
or a
ll H
IV e
xpos
ed in
fant
s sh
ould
be
base
d on
the
AF
AS
S c
riter
ia e
ven
whe
re e
arly
infa
nt d
iagn
osis
(E
ID)
is
avai
labl
e
• B
reas
tfeed
ing
mot
hers
of
infa
nts
and
youn
g ch
ildre
n w
ho a
re k
now
n to
be
HIV
infe
cted
sho
uld
be s
tron
gly
enco
urag
ed t
o co
ntin
ue b
reas
t fe
edin
g. H
owev
er,
brea
stfe
edin
g H
IV in
fect
ed m
othe
rs s
houl
d be
gi
ven
nutr
ition
sup
port
(nu
triti
onal
cou
nsel
ing,
edu
catio
n, f
ood
and
nutr
ition
al s
uppl
emen
ts)
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
44
Sulp
hur-
base
d in
term
itten
t pr
esum
ptiv
e m
alar
ia t
reat
men
t (I
PT) s
houl
d no
t be
giv
en
to w
omen
who
are
on
CTX
pro
phyl
axis
.
Tabl
e 4.
1: R
ecom
men
datio
ns fo
r ini
tiatin
g A
RV
trea
tmen
t in
preg
nant
w
omen
bas
ed o
n cl
inic
al s
tage
and
ava
ilabi
lity
of C
D4
Cou
nt
Sourc
e: A
dopte
d f
rom
WH
O,
Anti-r
etro
vira
l dru
gs
for
trea
ting p
regnant
wom
en a
nd p
re-
venting H
IV infe
ctio
ns
WH
O
Clin
ical
Sta
ge
CD
4 te
stin
g
not a
vaila
ble
CD
4 te
stin
g
avai
labl
e
1 D
o no
t Tre
at
Trea
t if C
D4≤
350
cells
/mm
3
2 D
o no
t Tre
at
Trea
t if C
D4 ≤
350
cells
/mm
3
3 Tr
eat
Trea
t irre
spec
tive
of C
D4
coun
t (c
onsi
der C
D4
valu
es fo
r bet
ter
man
agem
ent)
4 Tr
eat
Trea
t irre
spec
tive
of C
D4
cell
coun
t
AR
V us
e:
• A
RV
s ar
e us
ed fo
r tr
eatin
g H
IV-i
nfec
ted
elig
ible
wom
en a
nd/o
r fo
r pr
even
tion
of m
othe
r-to
-chi
ld tr
ansm
issi
on
• H
IV-i
nfec
ted
preg
nant
wom
en e
ligib
le f
or A
RT
sho
uld
initi
ate
AR
T
as s
oon
as p
ossi
ble
as s
how
n in
Tab
le 4
.1
• H
IV-i
nfec
ted
preg
nant
wom
en a
lread
y on
AR
T b
efor
e be
com
ing
pr
egna
nt s
houl
d co
ntin
ue A
RT
. T
he b
aby
shou
ld b
e gi
ven
AR
V
prop
hyla
xis
soon
aft
er b
irth
as s
how
n in
Tab
le 4
.2
4
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e 4.
2: R
ecom
men
ded
first
-line
AR
T re
gim
en fo
r tre
atin
g
preg
nant
wom
en a
nd p
roph
ylac
tic re
gim
en fo
r inf
ants
Infa
nt D
osag
es:
NV
P
2mg/
kg s
tat w
ithin
72
hour
s
AZT
4m
g/kg
BID
X 6
wee
ks
3TC
4m
g/kg
BID
X 1
wee
k
Mat
erna
l dos
ages
:
A
ZT 3
00 m
g B
ID
N
VP
200
mg
OD
for t
wo
wee
ks, t
here
afte
r 200
mg
BID
3T
C 1
50 m
g BI
D
Ant
epar
tum
AZ
T +
3TC
+ N
VP D
aily
Intra
partu
m
AZT
+ 3T
C +
NVP
Dai
ly
Pos
tpar
tum
AZ
T +
3TC
+ N
VP D
aily
Infa
nt p
roph
ylax
is
Sd
NV
P 2
mg/
kg s
tat w
ithin
72
hour
s 3T
C X
1 w
eek
(4
mg/
kg B
ID)
AZT
X 6
wee
ks (
4mg/
kg B
ID)
Mot
her
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
62
Cha
pter
8
Feed
ing
Infa
nts
and
Youn
g C
hild
ren
Bor
n to
HIV
Infe
cted
Mot
hers
8.
1 IN
TRO
DU
CTI
ON: T
RA
NSM
ISSI
ON O
F H
IV T
HR
OU
GH
B
REA
STFE
EDIN
G
In A
fric
a, 3
to 4
out
of e
very
10
infa
nts
born
to H
IV in
fect
ed w
omen
acq
uire
HIV
infe
c-tio
n. T
here
is, t
here
fore
, a 5
– 2
0 pe
rcen
t ri
sk o
f inf
ants
bor
n to
HIV
pos
itive
mot
hers
ac
quir
ing
infe
ctio
n th
roug
h br
east
-fe
edin
g if
ther
e ar
e no
inte
rven
tions
in
pla
ce.
For
wom
en w
ho a
re i
n-fe
cted
with
HIV
for
the
first
tim
e or
w
ho a
re r
e-in
fect
ed w
ith a
diff
eren
t st
rain
of H
IV d
urin
g th
e br
east
feed
-in
g ph
ase,
the
ris
k in
crea
ses
up t
o 29
per
cen
t. H
alf (
1/2)
of H
IV b
reas
t m
ilk t
rans
mis
sion
tak
es p
lace
by
6 w
eeks
and
thre
e qu
arte
rs (
3/4)
by
6 m
onth
s. M
ixed
feed
ing
incr
ease
s th
e ri
sk o
f br
east
milk
tra
nsm
issi
on o
f H
IV.
6
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
7.2.
3 C
OM
PREH
ENSI
VE
CA
RE
FOR H
IV-E
XPO
SED C
HIL
DR
EN
Bot
h H
IV-in
fect
ed a
nd u
ninf
ecte
d ch
ildre
n re
quir
e co
mpr
ehen
sive
car
e (R
efer
to C
hap-
ter
8 an
d 9)
.
ALGO
RITH
M FO
R EA
RLY
INFA
NT D
IAGN
OSIS
FOR
HIV
EXPO
SED
CHILD
REN*
WEL
L CHI
LDSI
CK C
HILD
(Man
age
pres
entin
g ill
ness
and
stab
ilize
)
STAR
T CO
TRIM
OXAZ
OLE
PROP
HYLA
XIS
FOR M
ORE I
NFOR
MATIO
N CON
TACT
THE N
ATIO
NAL A
IDS/ST
D CO
NTRO
L PRO
GRAM
ME (N
ASCO
P)P.O
. BOX
1936
1-002
02 N
AIROB
I TEL
: 020
2729
502 F
AX 02
0 271
0518
MINI
STRY
OF H
EAL
TH
*Exp
osur
e sta
tus s
houl
d be
det
erm
ined
for a
ll in
fants
of u
nkno
wnst
atus
at t
he6
week
visi
t or f
irst c
onta
ct
**Co
unse
l on
infan
t fee
ding
as p
er n
atio
nal g
uide
linesConf
irma
tory
AB t
est
at 1
8 M
onth
s
Eval
uate
for
ART
star
t on
ARV
if el
igibl
e
If HI
V+ a
t 12
Mont
hs
Evalu
ate f
or A
RTSta
rt o
n AR
V if
eligi
ble6 Wee
ks D
BS (P
CR)
**HIV
+
If HI
V-sto
p CT
X, if
not
B/
F fo
r at l
east
2 Mo
nths
**HI
V-
Antib
ody
test
ing
12 M
onth
s
Conf
irmat
ory
AB te
st at
18 M
onth
s
Conf
irmat
ory A
B te
st
at 18
Mon
ths
Eval
uate
for A
RT
star
t on
ARV
if el
igible
If HIV
+ at
12
Mon
ths
Eval
uate
for A
RTSt
art o
n AR
V if
elig
ible
If <1
2 Mon
ths D
BS (P
CR)
If >
12m
o An
tibod
y te
st
**HIV
+
If HIV-
stop
CTX
, if n
ot
B/F
for a
t lea
st 2
Mont
hs
**HI
V-
Antib
ody
testi
ng
12 M
onth
s
Conf
irma
tory
AB
test
at
18
Mont
hs
*Exp
osur
e sta
tus s
hould
be de
term
ined
for a
ll in
fant
s of u
nkno
wnsta
tus a
t the
6 wee
k vis
it or
firs
t con
tact
**
Coun
sel o
n in
fant
feed
ing
as p
er n
atio
nal g
uideli
nes
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
46
For
prop
hyla
xis
the
reco
mm
enda
tions
are
ran
ked
and
will
dep
end
on t
ime
of fi
rst
con-
tact
with
the
wom
an. H
IV-in
fect
ed p
regn
ant w
omen
who
are
not
elig
ible
for
AR
T or
in
who
m it
is n
ot p
ossi
ble
to s
tart
AR
T im
med
iate
ly a
nd th
e m
othe
r is
bei
ng s
een
betw
een
28 a
nd 3
8 w
eeks
of
preg
nanc
y, s
houl
d be
sta
rted
on
reco
mm
ende
d m
ore
effic
acio
us
shor
t co
urse
pro
phyl
actic
AR
V r
egim
ens
as s
how
n in
Tab
le 4
.3a.
The
bab
y sh
ould
als
o be
giv
en A
RV
pro
phyl
axis
soo
n af
ter
birt
h as
sho
wn
in th
e sa
me
tabl
e. T
he r
egim
ens
as
outli
ned
belo
w a
re fo
r pr
ophy
laxi
s an
d no
t for
trea
tmen
t.
Tabl
e 4.
3a: R
ecom
men
ded
Firs
t Lin
e A
RV
prop
hyla
xis
to
pre
vent
HIV
infe
ctio
n in
infa
nts
Am
ong
Preg
nant
Wom
en
Pres
entin
g B
efor
e 38
Wee
ks
Tabl
e 4.
3b b
elow
sho
ws
alte
rnat
ive
prop
hyla
ctic
regi
men
s fo
r w
omen
pre
sent
ing
befo
re 3
8 w
eeks
of p
regn
ancy
HIV
-infe
cted
pre
gnan
t w
omen
who
are
see
n fo
r th
e fir
st t
ime
afte
r 38
wee
ks o
f pr
eg-
nanc
y or
in la
bour
sho
uld
be g
iven
AR
V p
roph
ylac
tic r
egim
ens
as s
how
n in
Tab
le 4
.4.
The
baby
sho
uld
also
be
give
n A
RV
pro
phyl
axis
soo
n af
ter
birt
h as
sho
wn
in t
he s
ame
tabl
e. R
anki
ng
Tim
e of
Adm
inis
trat
ion
P
regn
ancy
La
bour
P
ostp
artu
m
M
ater
nal
Infa
nt
Rec
omm
ende
d
AZT(
28-3
8 w
eeks
ge
stat
ion)
sd
NV
P
+
AZT+
3TC
AZT+
3TC
X
7 d
ays
sdN
VP
PL
US
3TC
X1
wee
k +
AZT
X
6 w
eeks
Ran
king
Ti
me
of A
dmin
istr
atio
n
P
regn
ancy
La
bour
P
ostp
artu
m
Infa
nt
Alte
rnat
ive
AZT(
28-3
8 w
eeks
) sd
NV
P
+
AZT(
600m
gs
stat
)
sd
NV
P
+ 3T
C X
7
days
+ A
ZT
X 6
wee
ks
Min
imum
sdN
VP
+ A
ZT+3
TC
AZT+
3TC
X
7 d
ays
sdN
VP
+
3TC
day
s +
AZT
X
6 w
eeks
4
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e 4.
4: A
RV
prop
hyla
xis
for P
MTC
T am
ong
preg
nant
wom
en w
ho
have
not
rece
ived
ant
enat
al A
RT
or p
roph
ylax
is
Tabl
e 4.
5: R
ecom
men
ded
HA
AR
T fo
r Pre
gnan
t Wom
en
base
d on
CD
4 C
ount
and
Sta
ge o
f Pre
gnan
cy
Ran
king
La
bour
P
ostp
artu
m
Mat
erna
l In
fant
Rec
omm
ende
d
sdN
VP
+
AZ
T+3T
C
AZT+
3TC
X
7 d
ays
SdN
VP
P
LUS
3TC
X 1
wee
k +
AZT
X 6
wee
ks
Min
imum
sd
NV
P
-
SdN
VP
P
LUS
3TC
X1
wee
k +
AZ
T X
6 w
eeks
Tim
e of
Adm
inis
trat
ion
CD
4 C
ount
C
ells
/mm
3 H
AA
RT/
Trim
este
r
1st
Trim
este
r 2nd
Trim
este
r 3rd
Trim
este
r
<250
A
ZT*+
3TC
+NV
P**
AZ
T+3T
C+N
VP
AZT+
3TC
+NVP
250-
350
AZT
+3TC
+LPV
/r O
R
AB
C+3
TC+L
PV/r
AZT
+3TC
+LPV
/r O
R
AB
C+3
TC+L
PV/r
AZT
+3TC
+LPV
/r O
R
AB
C+3
TC+L
PV/r
> 35
0***
A
ZT+3
TC+L
PV/r
OR
A
BC
+3TC
+LPV
/r
AZT
+3TC
+LPV
/r O
R
AB
C+3
TC+L
PV/r
AZT
+3TC
+LPV
/r O
R
AB
C+3
TC+L
PV/r
M
othe
r B
aby
NV
P
200
mg
stat
2m
g/kg
sta
t with
in 7
2 ho
urs
3TC
15
0 m
g BI
D
4mg/
kg B
ID X
1 w
eek
AZT
30
0 m
g BI
D
4mg/
kg B
ID X
6 w
eeks
Dos
ages
:
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
60
7.2.
2 H
IV P
OSI
TIV
E IN
FAN
T B
Y D
NA
PC
R
• A
ll H
IV p
ositi
ve in
fant
s sh
ould
be
eval
uate
d fo
r el
igib
ility
for
ant
i-re
trov
iral
trea
tmen
t an
d lin
ked
to c
are
and
trea
tmen
t as
app
ropr
iate
• W
HO
clin
ical
sta
ging
sho
uld
be d
one
for
all H
IV p
ositi
ve in
fant
s.
Chi
ldre
n w
ho a
re a
t W
HO
Clin
ical
sta
ge 3
or
4 ar
e el
igib
le f
or
antir
etro
vira
l tre
atm
ent.
• A
ll H
IV p
ositi
ve in
fant
s sh
ould
be
asse
ssed
for
CD
4 co
unt
whe
re
poss
ible
and
ava
ilabl
e. R
efer
to
AR
T g
uide
lines
for
CD
4 co
unts
tha
t de
term
ine
elig
ibili
ty f
or A
RT
for
chi
ldre
n of
diff
eren
t ag
e br
acke
ts
• A
ll H
IV-p
ositi
ve in
fant
s sh
ould
hav
e a
visi
ble
guar
dian
or
care
-tak
er
befo
re t
hey
can
be s
tart
ed o
n A
RT
• A
ll H
IV-p
ositi
ve in
fant
s sh
ould
be
star
ted
on C
otri
mox
azol
e fr
om 6
w
eeks
or
on f
irst
cont
act t
here
afte
r
• A
ll H
IV-p
ositi
ve in
fant
s sh
ould
be
star
ted
on A
RT
if e
ligib
le
• B
reas
tfeed
ing
shou
ld b
e en
cour
aged
for
all
HIV
-pos
itive
infa
nts
for
a
min
imum
of t
wo
year
s. (
Ref
er t
o C
hapt
er 8
)
• F
or a
ll H
IV-p
ositi
ve in
fant
s, p
erfo
rm a
ntib
ody
test
ing
at 9
mon
ths,
12
mon
ths
and
conf
irm
at
18 m
onth
s
5
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
7.2
OPE
RA
TIO
NA
L G
UID
ELIN
ES
7.2.
0 G
UID
ELIN
ES F
OR H
IV D
IAG
NO
SIS
IN C
HIL
DR
EN
7.2.
1 H
IV N
EGA
TIV
E IN
FAN
T A
T A
GE
6 W
EEK
S O
R F
IRST
CO
NTA
CT
• P
erfo
rm r
outin
e ra
pid
HIV
ant
ibod
y te
sts
for
all m
othe
rs o
f 6
wee
k ol
d in
fant
s pr
esen
ting
with
unk
now
n st
atus
• P
erfo
rm r
outin
e dr
y bl
ood
spot
s (D
BS
) fo
r D
NA
PC
R f
or a
ll in
fant
s kn
own
to b
e H
IV-e
xpos
ed a
t 6
wee
ks
• P
erfo
rm r
outin
e an
tibod
y te
stin
g fo
r al
l sic
k in
fant
s in
out
patie
nt a
nd
paed
iatr
ic w
ards
to
esta
blis
h H
IV e
xpos
ure/
infe
ctio
n st
atus
• P
erfo
rm D
BS
for
all
HIV
-exp
osed
sic
k in
fant
s un
der
12 m
onth
s
• A
ll H
IV-e
xpos
ed in
fant
s sh
ould
be
star
ted
on C
otri
mox
azol
e fr
om 6
w
eeks
of
age
or o
n fir
st c
onta
ct th
erea
fter
• R
efer
to
chap
ter
on c
are
and
follo
w u
p of
the
HIV
-exp
osed
/infe
cted
in
fant
.
Perf
orm
ant
ibod
y te
stin
g at
9 m
onth
s an
d 12
mon
ths
of a
ge
• If
HIV
neg
ativ
e at
12
mon
ths
and
still
bre
astf
eedi
ng,
cont
inue
Cot
rim
oxaz
ole.
• If
not b
reas
tfee
ding
for
at
leas
t 2
mon
ths,
sto
p C
otri
mox
azol
e
• P
erfo
rm c
onfir
mat
ory
antib
ody
test
ing
at 1
8 m
onth
s.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
48
Not
es: I
mpo
rtan
t con
side
ratio
ns th
at m
odify
cho
ice
of A
RV
s du
ring
pre
gnan
cy in
clud
e C
D4
coun
t, m
ater
nal a
naem
ia a
nd
stag
e of
pre
gnan
cy
•
2 N
RT
Is (
AZ
T a
nd 3
TC
) ac
ting
as a
“tr
eatm
ent
back
bone
”, w
ith a
dditi
on o
f an
N
NR
TI (
NV
P)
rem
ains
the
pre
ferr
ed fi
rst-
line
AR
V t
hera
py in
res
ourc
e-po
or
sett
ings
• P
rote
ase
inhi
bito
rs b
ased
reg
imen
s ar
e pr
efer
able
whe
n C
D4
coun
t is
high
er
than
250
• *R
epla
ce A
ZT
with
d4T
if H
b< 8
gm
/dL
• **
EF
V m
ay b
e us
ed in
stea
d of
NV
P a
fter
first
trim
este
r
• **
* U
sual
ly A
RV
sho
uld
be w
ithhe
ld if
CD
4 co
unt
is n
ot a
vaila
ble
or n
ot d
one.
A
RV
is h
owev
er u
sed
for
PM
TC
T a
nd/o
r in
adv
ance
d H
IV d
isea
se (
WH
O
Sta
ge 3
or
4) ir
resp
ectiv
e of
CD
4 co
unt.
Bab
ies
who
se
mot
hers
di
d no
t re
ceiv
e an
tepa
rtum
or
in
trap
artu
m
AR
V
prop
hyla
xis
shou
ld b
e gi
ven
AR
V p
roph
ylax
is a
s sh
own
in T
able
4.6
.
Mat
erna
l dos
ages
AZT*
30
0 m
g B
ID
3TC
15
0 m
g BI
D
NVP
**
200
mg
OD
for t
wo
wee
ks, t
here
afte
r 200
mg
BID
AB
C
300m
g B
ID
LPV
/r (4
00/1
00)
2 ta
blet
s B
ID
EFV
60
0mg
QID
4
9
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Tabl
e 4.
6: A
RV
prop
hyla
ctic
regi
men
s fo
r inf
ants
bor
n to
H
IV-p
ositi
ve w
omen
who
hav
e no
t rec
eive
d an
tepa
rtum
or
intr
apar
tum
AR
T or
AR
V pr
ophy
laxi
s
Plea
se n
ote:
A
t fir
st c
onta
ct, a
ll H
IV i
nfec
ted
preg
nant
wom
en s
houl
d be
giv
en s
dNV
P ta
blet
s to
ta
ke h
ome
with
the
m. T
hey
shou
ld b
e in
stru
cted
to
take
the
tab
lets
at
the
onse
t of
la-
bour
, if l
abou
r oc
curs
out
side
hea
lth fa
cilit
y se
ttin
gs. T
hey
shou
ld a
lso
be g
iven
NV
P,
3TC
and
AZT
syr
up fo
r th
eir
babi
es to
be
adm
inis
tere
d so
on a
fter
bir
th.
Som
e w
omen
with
a C
D4
coun
t gr
eate
r th
an 2
50 c
ells
/ µl
on
Nev
irap
ine
(NV
P)-b
ased
A
RT
may
dev
elop
NV
P hy
pers
ensi
tive
reac
tions
tha
t ca
n be
life
thr
eate
ning
. In
thes
e gu
idel
ines
it is
rec
omm
ende
d th
at fo
r pr
egna
nt w
omen
with
CD
4 m
ore
than
250
, NV
P-ba
sed
reg
imen
may
stil
l be
use
d bu
t w
ith c
lose
mon
itori
ng.
Oth
erw
ise
the
reco
m-
men
ded
regi
men
to u
se w
ith C
D4
coun
t abo
ve 2
50 is
a P
I-ba
sed
HA
AR
T re
gim
en.
Whe
n si
ngle
dos
e N
VP
(sdN
VP)
is u
sed
in P
MTC
T, s
ome
wom
en a
nd c
hild
ren
may
de-
velo
p re
sist
ance
to
NV
P th
at m
ay l
imit
futu
re u
se o
f N
on-N
ucle
osid
e R
ever
se T
ran-
scri
ptas
e In
hibi
tors
(NN
RTI
s) t
o tr
eat
them
. Th
e ri
sk o
f NN
RTI
res
ista
nce
is p
artic
u-la
rly
high
if
two
dose
s of
sdN
VP
are
give
n. T
here
fore
SdN
VP
shou
ld n
ever
be
used
m
ore
than
onc
e in
any
one
pre
gnan
cy. W
here
pos
sibl
e, A
ZT /3
TC s
houl
d be
giv
en fo
r 7
days
to
cove
r th
e N
VP
tail
both
in t
he m
othe
r an
d th
e ba
by.
The
baby
is t
hen
cont
in-
ued
on A
ZT fo
r a
tota
l of 6
wee
ks fo
r pr
ophy
laxi
s ag
ains
t MTC
T.
HIV
-infe
cted
pre
gnan
t w
omen
sta
rtin
g zi
dovu
dine
(A
ZT)
cont
aini
ng r
egim
ens
shou
ld
have
hae
mog
lobi
n (H
b) le
vels
abo
ve 8
gm
/dl.
The
Hb
leve
l sho
uld
be c
heck
ed m
onth
ly
for
the
first
thr
ee m
onth
s. W
here
pos
sibl
e, A
ZT s
houl
d be
use
d in
stea
d of
sta
vudi
ne
(d4T
).
Clin
ical
judg
emen
t can
be
used
to e
stim
ate
Hb
leve
ls a
nd in
itiat
e AR
V pr
ophy
laxi
s if l
abo-
rato
ry t
ests
are
una
vaila
ble.
Efa
vire
nz (
EFV
) m
ay b
e te
rato
geni
c if
used
in t
he f
irst
tri
mes
ter.
If t
he p
atie
nt is
on
Ran
king
*T
ime
of a
dmin
istr
atio
n an
d In
fant
dos
age
Rec
omm
ende
d
sdN
VP (2
mg/
kg s
tat)
PLU
S 3T
C (4
mg/
kg B
ID) X
1 w
eek
+ AZ
T (4
mg/
kg
BID
) X 6
wee
ks
Min
imum
sd
NVP
(2 m
g/kg
sta
t)
*sdN
VP
is g
iven
to th
e in
fant
with
in 7
2 ho
urs
of b
irth
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
58
Cha
pter
7
HIV
Dia
gnos
is in
Chi
ldre
n 7.
1
INTR
OD
UC
TIO
N
In g
ener
al,
a ch
ild m
ay b
e te
sted
und
er a
num
ber
of c
ircu
mst
ance
s. T
hese
inc
lude
: sh
ortly
aft
er b
irth
for
earl
y di
agno
sis
of H
IV; f
or th
e pu
rpos
es o
f ind
ivid
ual d
iagn
osis
in
a ch
ild w
ho is
ill (
e.g.
tho
se p
rese
ntin
g w
ith a
n H
IV r
elat
ed il
lnes
s); i
n ca
ses
whe
re a
ch
ild h
as e
ither
bee
n ex
pose
d or
is p
oten
tially
exp
osed
to
HIV
e.g
. thr
ough
mot
her-
to-
child
tra
nsm
issi
on,
sexu
al a
buse
, se
xual
act
ivity
, w
ithin
a h
ealth
care
set
ting
(e.g
. th
roug
h co
ntam
inat
ed n
eedl
es o
r re
ceip
t of
pot
entia
lly in
fect
ious
blo
od),
thro
ugh
othe
r m
eans
, and
in o
rpha
ns.
Ear
ly i
nfan
t di
agno
sis
(EID
) re
fers
to
the
mak
ing
of H
IV d
iagn
osis
in
infa
nts
and
youn
g ch
ildre
n be
fore
18
mon
ths
of a
ge. E
ID g
ives
an
oppo
rtun
ity fo
r ea
rly
iden
tific
a-tio
n of
HIV
infe
cted
infa
nts
(des
pite
PM
TCT)
and
ear
ly li
nkag
e to
car
e an
d tr
eatm
ent.
Dis
ease
pro
gres
sion
in H
IV in
fect
ed in
fant
s is
fast
, with
a h
igh
mor
talit
y ra
te (>
50%
) by
2 y
ears
of a
ge. T
he m
edia
n ag
e of
dea
th in
the
first
two
year
s is
6 m
onth
s. H
IV a
nti-
body
tes
ting
amon
g ch
ildre
n ag
ed 1
8 m
onth
s or
mor
e is
abl
e to
det
erm
ine
whe
ther
a
child
is in
fect
ed o
r no
t.
Dur
ing
preg
nanc
y, m
othe
rs g
ive
thei
r ba
bies
ant
ibod
ies
to in
fect
ions
the
y ha
ve e
xper
i-en
ced
and
thes
e an
tibod
ies
wan
e w
ith ti
me.
Ant
ibod
y te
stin
g in
chi
ldre
n ag
ed le
ss th
an
18 m
onth
s id
entif
ies
child
ren
who
hav
e be
en e
xpos
ed to
thei
r m
othe
rs’ H
IV in
fect
ion
or
who
may
be
trul
y in
fect
ed a
nd a
re m
akin
g H
IV a
ntib
odie
s. C
urre
ntly
, the
re is
no
test
to
diff
eren
tiate
the
mot
her’s
ant
ibod
ies
from
tho
se p
rodu
ced
by t
he b
aby.
In
orde
r to
id
entif
y th
e H
IV-in
fect
ed c
hild
age
d le
ss t
han
18 m
onth
s, a
sec
ond
test
is r
equi
red
for
all b
abie
s te
stin
g po
sitiv
e on
ant
ibod
y te
stin
g or
kno
wn
to b
e H
IV-e
xpos
ed (m
othe
r is
H
IV-p
ositi
ve).
Infa
nt D
NA
(or
RN
A) P
CR
tes
ting
is t
he c
urre
nt r
ecom
men
ded
met
hod
for
EID
.
Sinc
e m
ost b
abie
s lo
se m
ater
nal a
ntib
odie
s (A
b) b
y 12
mon
ths,
a n
egat
ive
antib
ody
test
w
ill i
dent
ify u
ninf
ecte
d ba
bies
as
long
as
they
are
not
stil
l br
east
feed
ing.
A p
ositi
ve
antib
ody
test
at
12 m
onth
s, a
lthou
gh h
ighl
y lik
ely
to b
e di
agno
stic
, may
stil
l be
due
to
pass
ivel
y ca
rrie
d m
ater
nal a
ntib
odie
s. S
uch
test
s ne
ed t
o be
con
firm
ed b
y PC
R t
estin
g or
rep
eat a
ntib
ody
test
at 1
8 m
onth
s.
5
7
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
CARE
, SU
PPO
RT A
ND
TREA
TMEN
T FO
R H
IV P
OSI
TIVE
MO
THER
AN
D CH
ILD
Cha
pter
ref
eren
ces
1.
Rep
ublic
of
Ken
ya M
inis
try
of
Hea
lth,
Div
isio
n o
f Rep
roduct
ive
Hea
lth:
Pla
nnin
g
G
uid
elin
es f
or
serv
ice
pro
vider
s.
Rev
ised
in M
arch
2006.
Foo
tnot
es
1
Pre
ble
and P
iwoz,
2001
2
WH
O:
Contr
ace
ptive
Elig
ibili
ty C
rite
ria
Guid
e
HIV
-pos
itive
mot
hers
requ
ire c
are
and
supp
ort w
hich
incl
udes
: •
Cou
nsel
ing
• P
roph
ylax
is a
nd t
reat
men
t
• Li
nk t
o su
ppor
t gr
oups
and
ass
essm
ent
of t
he n
eed
for
AR
T
• E
arly
infa
nt d
iagn
osis
sho
uld
be p
rovi
ded
at s
ix w
eeks
usi
ng D
NA
-P
CR
tes
ting
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
50
EFV
bef
ore
beco
min
g pr
egna
nt, i
t sho
uld
be s
ubsi
tute
d w
ith N
VP
in th
e 1s
t tri
mes
ter.
In c
ase
of s
ever
e hy
pere
mes
is g
ravi
daru
m, A
RT
may
nee
d to
be
brie
fly in
terr
upte
d.
On
aver
age
mot
her-
to-c
hild
tra
nsm
issi
on r
ates
are
15%
for
sdN
VP,
6.5
% fo
r m
ore
effi-
caci
ous
dual
reg
imen
s an
d 2.
4% fo
r 3-
drug
AR
V c
ombi
natio
n
Futu
re P
ersp
ectiv
es:
Ext
ende
d pr
ophy
laxi
s w
ith 3
AR
V d
rug
com
bina
tions
sta
rtin
g du
ring
pre
gnan
cy a
nd
cont
inui
ng a
fter
del
iver
y fo
r a
peri
od o
f up
to
6 m
onth
s, a
mon
g H
IV-in
fect
ed b
reas
t-fe
edin
g m
othe
rs, h
as b
een
show
n in
a f
ew r
ecen
t an
d is
olat
ed s
tudi
es a
nd p
ilot
pro-
gram
me,
to le
ad to
low
er b
reas
tfee
ding
-rel
ated
pos
tnat
al M
TCT.
Thi
s ap
proa
ch m
ay b
e co
nsid
ered
whe
re th
is is
feas
ible
, acc
epta
ble,
saf
e an
d w
here
adh
eren
ce c
an b
e as
sure
d.
Mor
e st
udie
s on
this
issu
e ar
e ex
pect
ed.
Thre
e A
RV
dru
g co
mbi
natio
ns g
iven
to
HIV
pos
itive
pre
gnan
t w
omen
who
are
not
yet
el
igib
le fo
r in
itiat
ion
of A
RTs
for
thei
r ow
n he
alth
als
o le
ad to
low
er M
TCT
and
may
be
cons
ider
ed in
pro
gram
mes
with
the
capa
city
to in
itiat
e th
e re
gim
en a
nd fo
llow
up
such
w
omen
. Suc
h in
terv
entio
n is
initi
ated
at
arou
nd 2
8 w
eeks
, or
soon
aft
er a
nd s
topp
ed
afte
r bi
rth
if C
D4
coun
t is
still
abo
ve 3
50 c
ells
/mm
3 .
App
endi
ces
Appen
dix
I:
W
HO
Clin
ical
Sta
gin
g o
f H
IV/A
IDS f
or
Adults
and A
dole
scen
ts
w
ith c
onfirm
ed H
IV infe
ctio
n.
Appen
dix
II:
Contr
acep
tive
Options
for
Peo
ple
Liv
ing w
ith H
IV.
Appen
dix
III
:
Sum
mar
y of
ARV D
rug U
se f
or
PMTCT o
f H
IV.
Appen
dix
IV:
In
tegra
ted M
onitori
ng a
nd E
valu
ation R
eport
Form
MO
H 7
26.
Cha
pter
ref
eren
ces
1
Sum
mar
y of
ARV D
rugs
Adve
rse
Effec
ts a
nd M
anag
emen
t: T
able
6-1
0,
pages
101-1
12 o
f G
uid
elin
es f
or
Antire
trovi
ral D
rug T
her
apy
in K
enya
, 3rd
Editio
n,
De-
cem
ber
2005.
2
Dru
g I
nte
ract
ions:
Tab
le 7
-10,
pag
es 1
12-1
22 o
f G
uid
elin
es f
or
Antire
trovi
ral
Dru
g T
her
apy
in K
enya
, 3rd
editio
n,
Dec
. 2005.
5
1
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Cha
pter
5
Imm
edia
te P
ostn
atal
and
Neo
nata
l Car
e 5.
1
INTR
OD
UC
TIO
N
Imm
edia
te p
ostn
atal
and
neo
nata
l car
e re
fers
to th
e pa
ckag
e of
ser
vice
s pr
ovid
ed to
the
mot
her
and
infa
nt b
efor
e th
ey le
ave
the
heal
th fa
cilit
y (u
p to
48
hour
s) a
fter
del
iver
y.
The
peri
od p
rovi
des
an o
ppor
tuni
ty to
edu
cate
all
mot
hers
abo
ut H
IV, t
o pr
ovid
e co
un-
selli
ng a
nd t
estin
g if
it w
as n
ot d
one
prev
ious
ly, a
nd t
o re
info
rce
the
educ
atio
n pr
o-vi
ded
duri
ng t
he a
nten
atal
per
iod.
Bot
h H
IV i
nfec
ted
and
HIV
uni
nfec
ted
mot
hers
sh
ould
rec
eive
this
edu
catio
n an
d co
unse
lling
bef
ore
disc
harg
e.
5.2
OPE
RA
TIO
NA
L G
UID
ELIN
ES
The
follo
win
g gu
idel
ines
sho
uld
be fo
llow
ed fo
r all
wom
en a
nd
infa
nts
in th
e im
med
iate
pos
t par
tum
per
iod:
a)
Opt
imal
pos
tpar
tum
car
e
• R
outin
e ca
re in
clud
ing
brea
st e
xam
inat
ion,
exa
min
atio
n of
the
ute
rus,
ex
amin
atio
n of
the
per
ineu
m a
nd lo
chia
, pa
ssag
e of
uri
ne r
egul
arly
, pr
oper
hyg
iene
to
prev
ent
infe
ctio
n, c
heck
ing
for
sign
s of
ana
emia
, fe
ver
and
tach
ycar
dia
• D
iscu
ss m
ater
nal n
utri
tion
• E
stab
lish
the
HIV
sta
tus
of t
he m
othe
rs in
clud
ing
thos
e gi
ving
birt
h
outs
ide
the
heal
th in
stitu
tion
setti
ng
• P
rovi
de H
IV C
T f
or m
othe
rs w
ith u
nkno
wn
HIV
sta
tus
• E
ncou
rage
HIV
res
ults
dis
clos
ure
and
part
ner
test
ing
• F
ollo
w t
he s
tand
ard
guid
elin
es o
n th
e ca
re o
f a n
ewbo
rn (
IMP
AC
C
are
Man
ual)
• A
ll ba
bies
sho
uld
rece
ive
thei
r ro
utin
e im
mun
izat
ion
(OP
V a
nd B
CG
) in
th
eir
first
hou
rs o
f lif
e1 .
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
56
Con
trac
eptio
n A
ll m
othe
rs, r
egar
dles
s of
the
ir H
IV s
tatu
s, h
ave
a ri
ght
to r
ecei
ve a
dequ
ate
info
rma-
tion
on a
vaila
ble
met
hods
of f
amily
pla
nnin
g an
d to
mak
e an
info
rmed
cho
ice
on w
hat
is b
est
for
them
. H
IV-in
fect
ed w
omen
who
are
not
bre
astf
eedi
ng s
houl
d in
itiat
e a
re
liabl
e co
ntra
cept
ive
met
hod
by 2
-4 w
eeks
pos
tpar
tum
. Th
is i
s in
add
ition
to
the
prop
er a
nd c
onsi
sten
t us
e of
the
con
dom
as
a fo
rm o
f du
al p
rote
ctio
n. A
ll m
etho
ds o
f co
ntra
cept
ion
can
be u
sed
by H
IV p
ositi
ve w
omen
bas
ed o
n st
anda
rd m
edic
al e
ligib
ility
cr
iteri
a in
clud
ing
taki
ng c
are
of d
rug
inte
ract
ions
as
outli
ned
belo
w2 .
• La
ctat
iona
l Am
enor
rhoe
a M
etho
d (L
AM
): S
uita
ble
for
excl
usiv
ely
brea
stfe
edin
g H
IV in
fect
ed w
omen
who
hav
e no
t re
sum
ed m
ense
s.
• H
orm
onal
con
trac
eptio
n: A
ll ho
rmon
al c
ontr
acep
tives
can
be
used
in
HIV
pos
itive
wom
en in
clud
ing
thos
e on
HA
AR
T.
Com
bine
d or
al
cont
race
ptiv
es a
re c
ontr
aind
icat
ed f
or u
se w
ith d
rugs
that
indu
ce
hepa
tic m
icro
-enz
yme
that
may
red
uce
the
effe
ctiv
enes
s of
hor
mon
al
cont
race
ptiv
es:
Som
e an
ti-T
Bs,
ant
iret
rovi
rals
, an
tifun
gals
and
ant
i-ep
ilept
ics,
and
in c
ondi
tions
tha
t ca
use
mal
abso
rptio
n8 .
• In
tra-
uter
ine
cont
race
ptiv
e de
vice
s (I
UC
Ds)
: IU
CD
s ar
e no
t co
ntra
indi
cate
d in
HIV
pos
itive
wom
en.
In s
ever
ely
imm
uno
supp
rese
d w
omen
, use
sho
uld
not
be d
isco
ntin
ued
but
new
inse
rtio
n is
dis
cour
aged
as
it m
ay b
e as
soci
ated
with
incr
ease
d ri
sk o
f in
fect
ion
duri
ng t
he in
sert
ion
proc
ess.
• S
urgi
cal m
etho
ds: S
urgi
cal c
ontr
acep
tion
shou
ld b
e of
fere
d to
HIV
po
sitiv
e w
omen
and
the
ir pa
rtne
rs.
• B
arri
er m
etho
ds:
Fem
ale
and
mal
e co
ndom
s pr
ovid
e pr
otec
tion
agai
nst
ST
Ds
and
redu
ce t
he r
isk
of H
IV t
rans
mis
sion
and
sho
uld
be
enco
urag
ed a
lone
or
toge
ther
with
oth
er c
ontr
acep
tive
met
hods
.
• S
perm
icid
es:
Use
d in
con
junc
tion
with
bar
rier
met
hods
, spe
rmic
ides
w
ill p
rovi
de a
dditi
onal
con
trac
eptiv
e pr
otec
tion.
How
ever
, sp
erm
icid
es s
houl
d no
t be
use
d al
one
as t
hey
can
incr
ease
the
ris
k of
HIV
acq
uisi
tion.
• E
mer
genc
y co
ntra
cept
ion:
HIV
pos
itive
wom
en s
houl
d be
info
rmed
ab
out
emer
genc
y co
ntra
cept
ion,
whe
re it
is a
vaila
ble
and
how
to
obta
in a
nd u
se it
.
5
5
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
Opt
imal
pos
tpar
tum
car
e fo
r HIV
pos
itive
wom
en
Loch
ia
• P
ut e
mph
asis
on
good
per
inea
l hyg
iene
and
pro
per
hand
ling
of b
ody
fluid
s
• A
void
con
tam
inat
ing
the
baby
with
bod
y flu
ids
or w
ith b
eddi
ng s
oile
d
with
loch
ia
• S
hari
ng o
f be
ds b
y m
othe
rs in
the
hos
pita
l sho
uld
be d
isco
urag
ed
Cae
sare
an S
ectio
n
B
road
spe
ctru
m a
ntib
iotic
s sh
ould
be
used
rou
tinel
y af
ter
CS
Esse
ntia
l mat
erna
l edu
catio
n an
d fo
llow
-up
• M
onito
r fo
r br
east
and
pel
vic
infe
ctio
n at
all
post
nat
al c
linic
vis
its
• E
duca
te o
n pr
ompt
hea
lth s
eeki
ng b
ehav
iour
• H
ealth
edu
catio
n on
hyg
iene
, lo
chia
and
bre
ast
care
• A
void
sex
ual i
nter
cour
se f
or a
t lea
st 2
wee
ks a
fter
birt
h or
unt
il th
ere
is
no lo
nger
any
loch
ia r
ubra
or
sero
sa
• D
o pa
p sm
ear
or V
IA a
t 4-
6 w
eeks
• F
or e
very
sex
ual a
ctiv
ity,
the
coup
le s
houl
d us
e co
ndom
s
• D
iscu
ss f
amily
pla
nnin
g at
eve
ry o
ppor
tuni
ty a
nd p
rovi
de t
he
Bre
ast c
are
in b
reas
tfeed
ing
mot
hers
• E
ncou
rage
dai
ly c
lean
ing
of t
he b
reas
ts a
nd a
void
ing
the
appl
icat
ion
of
lotio
ns
• T
reat
mat
erna
l vag
inal
can
didi
asis
and
infa
nt o
ral c
andi
dias
is
• E
duca
te m
othe
r on
opt
imal
bre
astf
eedi
ng te
chni
que
incl
udin
g la
tchi
ng
on t
echn
ique
, ex
lusi
ve b
reas
tfee
ding
and
rem
ovin
g ba
by f
rom
bre
ast
• E
duca
te th
e m
othe
r on
bre
ast c
are
to p
reve
nt c
ompl
icat
ions
(cr
acki
ng
and
engo
rgem
ent)
• E
xpre
ss a
nd h
eat
trea
t th
e m
ilk if
bre
ast
has
mas
titis
or
absc
ess
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
52
Supp
ort
infa
nt fe
edin
g op
tions
. For
all
HIV
neg
ativ
e w
omen
, wom
en o
f unk
now
n H
IV
stat
us a
nd H
IV p
ositi
ve m
othe
rs o
ptin
g fo
r ex
clus
ive
brea
stfe
edin
g, in
itiat
e br
east
feed
-in
g w
ithin
hal
f hou
r of
bir
th a
nd fo
llow
oth
er g
uide
lines
as
per
Bab
y Fr
iend
ly H
ospi
tal
Initi
ativ
e2 (B
FHI)
.
(b) S
peci
fic p
ostp
artu
m c
are
for H
IV p
ositi
ve w
omen
(c)
Spec
ific
care
for H
IV e
xpos
ed in
fant
s
• G
ive
info
rmat
ion
on fa
mily
pla
nnin
g an
d du
al p
rote
ctio
n
• C
ouns
el o
n H
IV r
isk
redu
ctio
n
• S
ched
ule
post
nata
l clin
ic v
isits
at
2 w
eeks
and
at
4-6
wee
ks a
nd
com
plet
e m
othe
r-ch
ild b
ookl
et (
refe
r to
DR
H m
anua
l)
• S
uppo
rt e
xclu
sive
bre
astf
eedi
ng u
nles
s m
othe
r ha
s ap
prop
riat
ely
opte
d fo
r an
d be
en c
ouns
elle
d on
rep
lace
men
t fe
edin
g an
tena
tally
• In
itiat
e or
con
tinue
co-
trim
oxaz
ole
prop
hyla
xis
-1 d
oubl
e st
reng
th t
ab-
let
daily
• F
or H
IV p
ositi
ve m
othe
rs t
hat
rece
ived
sd
nevi
rapi
ne in
trap
artu
m,
initi
-at
e A
ZT
300
mg
and
3TC
150
mg
BD
for
1 w
eek
• F
or n
ewly
dia
gnos
ed m
othe
rs,
do H
IV s
tagi
ng,
CD
4 co
unt
and
refe
r ap
prop
riat
ely
for
cont
inue
d ca
re
• F
or H
IV e
xpos
ed in
fant
s, a
dmin
iste
r sd
NV
P 2
mg/
kg s
tat
with
in 7
2 ho
urs.
Giv
e A
ZT
4 m
g/kg
BID
for
6 w
eeks
and
3T
C 4
mg/
kg B
ID f
or 1
w
eek.
Ref
er t
o C
hapt
er 4
• R
efer
to
Cha
pter
8 f
or d
etai
ls o
n in
fant
fee
ding
opt
ions
5
3
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
C
hapt
er r
efer
ence
s 1.
Rep
ublic
of
Ken
ya M
inis
try
of
Hea
lth,
Div
isio
n o
f Rep
roduct
ive
Hea
lth:
Nat
ional
Guid
elin
es f
or
Qual
ity
Obst
etri
cs a
nd P
erin
ata
l Car
e (2
004).
2.
2. R
epublic
of
Ken
ya M
inis
try
of
Hea
lth,
Ess
ential
Obst
etri
c C
are
Man
ual
for
Hea
lth
Ser
vice
Pro
vider
s in
Ken
ya 3
rd E
ditio
n (
Jan 2
006).
Foo
tnot
es
1
WH
O r
ecom
men
ds
that
all
vacc
ines
should
be
giv
en t
o H
IV-s
ero-n
egat
ive
child
ren
and t
o a
sym
pto
mat
ic s
ero-p
osi
tive
s.
The
only
vac
cines
to b
e w
ithhel
d f
rom
child
ren w
ith s
ympto
mat
ic A
IDS a
re B
CG
and
Yel
low
fev
er v
acc
ines
. 2
The
“Ten
Ste
ps”
of
BFH
I: R
ecom
men
ded
Pra
ctic
es f
or
Mat
ernity
Ser
vice
s ad
apte
d f
or
W
HO
/UN
ICEF
1989.
Guid
elin
es for
Prev
ention o
f M
oth
er t
o C
hild
Tra
nsm
issi
on (
PM
TCT)
of H
IV/A
IDS in K
enya
(3rd
Editio
n)
54
Cha
pter
6
Late
Pos
tnat
al C
are
and
Fam
ily P
lann
ing
6.1
IN
TRO
DU
CTI
ON
La
te p
ostn
atal
car
e is
pro
vide
d to
the
mot
her
and
the
child
48
hour
s to
6 w
eeks
aft
er
deliv
ery.
Dur
ing
this
per
iod,
the
heal
th o
f the
mot
her
and
child
is a
sses
sed
and
clos
ely
mon
itore
d.
The
risk
of M
TCT
duri
ng th
e po
stpa
rtum
per
iod
can
be r
educ
ed b
y pr
ovid
ing
HIV
cou
n-se
lling
and
test
ing,
pos
t-ex
posu
re p
roph
ylax
is fo
r ex
pose
d ba
bies
, cou
nsel
ling
on a
ppro
-pr
iate
infa
nt fe
edin
g op
tions
and
bre
ast c
are.
Pos
tpar
tum
car
e fo
r H
IV p
ositi
ve w
omen
sh
ould
incl
ude
clin
ical
sta
ging
, CD
4 co
unt a
nd A
RT
for
thos
e w
ho q
ualif
y.
Fam
ily p
lann
ing
serv
ices
are
am
ong
the
core
inte
rven
tions
of P
MTC
T pr
ovid
ed to
hel
p w
omen
det
erm
ine
futu
re c
hild
bear
ing
patt
erns
inc
ludi
ng t
he p
reve
ntio
n of
HIV
-in
fect
ed b
irth
s.
Rep
rodu
ctiv
e he
alth
cou
nsel
ling
can
help
a w
oman
pra
ctis
e sa
fer
sex
and
dete
rmin
e he
r fu
ture
ch
ildbe
arin
g pa
tter
ns
on
a m
ore
resp
onsi
ble
and
in
form
ed b
asis
1. 6.
2
OPE
RA
TIO
NA
L G
UID
ELIN
ES
Opt
imal
pos
tpar
tum
car
e fo
r all
wom
en
This
ent
ails
rou
tine
care
inc
ludi
ng b
reas
t ex
amin
atio
n, e
xam
inat
ion
of t
he u
teru
s,
exam
inat
ion
of t
he p
erin
eum
and
loch
ia, p
assa
ge o
f uri
ne r
egul
arly
, pro
per
hygi
ene
to
prev
ent
infe
ctio
n, c
heck
ing
for
sign
s of
ane
mia
, fe
ver
and
tach
ycar
dia
and
doin
g pe
rine
al e
xerc
ises
.
Add
ition
al c
are
incl
udes
:
• C
ouns
ellin
g an
d te
stin
g fo
r m
othe
rs o
f un
know
n H
IV s
tatu
s •
Pro
visi
on o
f co
ndom
s an
d ris
k re
duct
ion
coun
selli
ng
• C
ouns
ellin
g on
con
trac
eptiv
e op
tions
, in
clud
ing
dual
met
hod
use
• D
iscu
ssin
g m
ater
nal n
utrit
ion
• M
alar
ia p
reve
ntio
n •
Scr
eeni
ng f
or S
TI a
nd c
ervi
cal c
ance
r