Elimination of Mother-to-Child Transmission of HIV (EMTCT)

Overview

Elimination of Mother-to-Child Transmission of HIV (EMTCT) is a global public health strategy aimed at ending vertical HIV transmission from mothers to infants during pregnancy, childbirth, or breastfeeding. The goal is to ensure that no child is born with HIV, while maintaining the health and well-being of mothers living with HIV.

The Four Prongs of EMTCT

1. Primary Prevention of HIV among Women of Childbearing Age:

   • Preventing new HIV infections in women before and during pregnancy.

   • Promoting safe sex practices, HIV education, and use of preventive tools like condoms and Pre-Exposure Prophylaxis (PrEP).

2. Prevention of Unintended Pregnancies among Women Living with HIV:

   • Ensuring access to family planning and contraceptive services.

   • Supporting women to make informed reproductive choices.

3. Prevention of HIV Transmission from Mother to Infant:

   • Ensuring universal HIV testing for pregnant and breastfeeding women.

   • Immediate initiation of combination antiretroviral therapy (cART).

   • Monitoring of viral load and adherence during pregnancy and breastfeeding.

4. Provision of Treatment, Care, and Support for Women, Children, and Families Affected by HIV:

   • Ensuring lifelong ART, cotrimoxazole prophylaxis, nutritional support, and psychosocial care.

   • Involving partners and families in treatment and adherence support.

Prevention of Mother-to-Child Transmission (PMTCT)

Key Principles

• Early initiation of ART leads to better maternal and neonatal outcomes.

• All pregnant and breastfeeding women who test HIV-positive should start cART immediately within Maternal, Newborn, and Child Health (MNCH) services.

• ART initiation can be done by trained nurses or midwives within MNCH settings.

• Where cART cannot be initiated in MNCH, the woman should be fast-tracked to the ART clinic.

• Cotrimoxazole prophylaxis must begin for all HIV-infected pregnant women, irrespective of CD4 count or WHO clinical stage.

• Viral load (VL) should be checked within four weeks before delivery to assess transmission risk.

• At six weeks postnatal, reassess CD4 count — if >350 cells/μL on two results, cotrimoxazole can be discontinued.

Combination Antiretroviral Therapy (cART) for EMTCT

First-Line Regimen

For ART-naïve women or those with confirmed tail coverage:

• Preferred: TDF + XTC (3TC or FTC) + DTG

• Alternative options:

  • TDF + XTC + EFV400

  • TDF + XTC + ATV-r (or LPV-r)

  • ABC + 3TC + ATV-r (or LPV-r)

  • ABC + 3TC + DTG

For women with previous Nevirapine (NVP) exposure or uncertain tail coverage:

• Preferred: TDF + XTC + DTG

• Alternative: TDF + XTC + ATV-r (or LPV-r) or ABC + 3TC + ATV-r (or LPV-r)

Second-Line Regimen

• If DTG- or NNRTI-based first-line regimen fails, switch to AZT + 3TC + LPV-r (or ATV-r).

Clinical Approach Across Reproductive Stages

1. Pre-Pregnancy and Adolescence

• Provide family planning counselling and encourage dual protection (condoms + hormonal or IUD methods).

• Screen for hepatitis B and syphilis; treat both the woman and her partner if positive.

• Counsel on HIV prevention, including PrEP for HIV-negative women at risk.

• For HIV-positive women, initiate or continue ART and provide adherence and Positive Health, Dignity, and Prevention (PHDP) counselling.

• Retest HIV-negative women every three months.

2. Pregnancy (All Trimesters)

First Trimester

• Screen for hepatitis B and syphilis; treat if positive.

• For HIV-positive women:

  • Initiate or continue ART immediately.

  • Conduct viral load testing; if >3 months since last test, repeat.

  • Provide adherence counselling and partner testing.

• For HIV-negative women:

  • Counsel on HIV prevention and PrEP eligibility.

  • Retest every three months during pregnancy.

Second Trimester

• Repeat screening for hepatitis B, syphilis, and opportunistic infections.

• For HIV-positive women:

  • Continue ART and adherence counselling.

  • Repeat viral load if >3 months since last test.

• For HIV-negative women:

  • Continue PrEP if at risk and reinforce combination prevention measures.

Third Trimester

• Screen again for hepatitis B and syphilis; treat both woman and partner if positive.

• Repeat viral load testing 1–4 weeks before delivery.

• Ensure adherence and evaluate ART efficacy.

• Retest HIV-negative women every three months.

3. Labour and Delivery

• Conduct HIV testing if last result was done more than six weeks ago.

• For HIV-positive women:

  • Continue ART and ensure adherence during labour.

  • Provide intrapartum prophylaxis as per national protocol.

4. Postnatal and Infant Follow-up

At Birth

• For HIV-exposed infants:

  • Send dried blood spot (DBS) or fresh blood for Nucleic Acid Testing (NAT).

  • Test for syphilis (RPR) and treat if positive.

  • Provide scheduled immunizations.

  • Start ART or prophylaxis based on results.

  • Begin AZT + 3TC + NVP regimen for 14 days, then transition to ABC + 3TC + LPV-r if positive.

  • Provide infant feeding counselling and maternal adherence support.

At 6 Weeks

• Repeat HIV test for mother if due.

• For HIV-exposed infants:

  • Continue ART or prophylaxis.

  • Begin cotrimoxazole prophylaxis regardless of feeding status.

  • Continue adherence counselling, immunizations, and viral load monitoring for mothers.

At 10 Weeks

• Repeat HIV and syphilis screening as indicated.

• Continue ART, cotrimoxazole, and infant feeding support.

• Perform maternal viral load testing.

At 14 Weeks

• Review maternal viral suppression status:

  • If virally suppressed: continue ART, discontinue AZT + 3TC + NVP prophylaxis for infant.

  • If not suppressed: continue AZT + 3TC + NVP and reinforce maternal adherence.

• Continue cotrimoxazole and immunizations for the infant.

Infant Feeding and Maternal Care

• Promote exclusive breastfeeding for the first six months if the mother is on ART and virally suppressed.

• Mixed feeding should be avoided.

• Continue ART for the mother and monitor viral load regularly.

• Ensure cotrimoxazole for the infant from 6 weeks until HIV infection is ruled out.

Key Messages

• Test early, treat immediately, and monitor continuously.

• Partner involvement in testing and adherence support improves outcomes.

• Retention in care and viral load suppression are the cornerstones of EMTCT success.

• Comprehensive counselling (PrEP, contraception, feeding, adherence) must accompany all clinical interventions.