EMTCT Cascade

  • Family Planning
  • Antenatal Care
  • Voluntary Counselling and Testing
  • Maternal ARV uptake and syphilis treatment
  • Infant ARV uptake and evaluation of susceptible VDRL exposed infant
  • Infant feeding
  • Infant and maternal follow up
  • Partner notification and testing

Antenatal Management

Every pregnant woman should present in the first trimester to access antenatal care. Education and counselling should begin and cover the following topics: signs and symptoms of pregnancy, HIV and STI education, safe sex, importance of clinic attendance, nutrition and healthy lifestyle in pregnancy, labour and delivery, infant feeding, avoidance of medication  not prescribed by your physician, birth registration, care of the infant and parenting.

Every pregnant woman should be tested for HIV, Syphilis, Haemaglobin, Sickle, Group and Rhesus, Hepatitis B and C. These results should be obtained as soon as possible and the mother informed of the results. She should also have a detailed history and physical examination aimed at determining if she can continue routine care or if there are indications for High Risk care.

If HIV and Syphilis tests are negative, routine antenatal care continues. The mother receives post test counselling, safe sex messages in pregnancy and breastfeeding should be emphasized and the tests are repeated in the third trimester.

Partner involvement in antenatal care should be encouraged.

Syphilis positive

If the Syphilis screening test (SD Bioline Syphilis) is positive, VDRL or TRUST should be done to obtain a titre. A detailed history and physical examination should be done to determine the stage of Syphilis. She is treated for the stage of Syphilis.

Contact investigation is also done to ensure all her sexual partners are treated. Following treatment, the same test should be repeated whether VDRL or TRUST to determine if there has been a fourfold fall in titre (an indication of treatment success). The mother should be advised to avoid sexual activity until treatment is complete for both her and her partner(s).

CONDITION

TREATMENT

1°, 2° and early latent syphilis<1 year

BPG 2.4 MU IM; 2 doses; 1 week apart

Late latent syphilis

BPG 2.4MU IM; 3-4 doses; 1 week apart

Penicillin allergy

Erythromycin 500mg po qid. Infant must be treated at birth.

The Serofast Woman

  • The serofast patient is one with documented evidence of adequate treatment but with a persistent low titre.
  • Two schools of thought
    • She should receive a stat treatment of Benzathine Penicillin G (BPG) with each new pregnancy
    • Do follow-up tests monthly; treat only if fourfold increase in titre.

The Unbooked Patient

An unbooked patient with a positive SD Bioline Syphilis test without documented evidence of previous complete management for Syphilis should receive a stat treatment of Benzathine Penicillin G (BPG) prior to delivery. She should subsequently have further follow up post delivery to ensure adequate treatment for herself and her partner(s).

HIV Positive

If the HIV rapid test is positive, the mother should be informed of the result and counselled. She should subsequently referred for further management at the nearest High Risk Clinic (Hyperlink to list of High Risk Antenatal sites). Her CD4 panel must be done. She should have a detailed history and physical examination to determine her clinical stage.

New Diagnosis of HIV

If the CD4 is < 350 cells/mm3 or if history and examination reveals AIDS defining conditions, the mother requires HAART for her own health and this should be commenced as soon as this assessment is made. She should remain on HAART post delivery and be linked to treatment and care.

If the CD4 is> 350 cells/mm3 and the mother has no AIDS defining conditions, she requires HAART for prevention of vertical transmission of HIV and this should be commenced at 12 weeks (start of the second trimester). HAART should be discontinued post delivery and the mother should be linked to treatment and care.

 Mothers Previously Diagnosed as HIV positive

If a mother was diagnosed as HIV positive prior to pregnancy but was not on HAART prior to pregnancy, she should be evaluated and placed on HAART as per the same recommendations stated above for the Newly Diagnosed HIV positive mother.

If a mother was diagnosed as HIV positive prior to pregnancy and was receiving HAART, she should continue the same medications but have CD4 panel and a Viral load to assess if her regime has been effective. If her CD4 is low and/or her viral load is elevated, consult an HIV specialist at an HIV Treatment Site (hyperlink to list of HIV Treatment Sites)(preferably the patient’s usual Treatment Site) to consider changing to a more effective regime. Adherence Issues should be addressed and the mother should be counselled.

The Unbooked Patient

An unbooked patient with a positive HIV Rapid Test should receive a stat treatment of Zidovudine 300mg, Lamivudine 150 mg and Lopinavir/ ritonavir 400/100 mg prior to delivery. She should subsequently have further follow up post delivery to ensure that she is linked to care and receives treatment for herself and her partner(s).

All HIV positive Mothers

  • Should receive ongoing counselling and support. Many will find this diagnosis devastating. Many may have concerns about the health of the unborn child or the impact of this diagnosis on their families. Some may also have difficulties re taking medications.
  • Should have a viral load test at 36 weeks. Consider the benefits of Elective Caesarean Section for preventing Mother to Child Transmission of HIV for mothers whose Viral load exceeds 1000 copies/ml.
  • Should continue their ARVs throughout Labour and Delivery.
  • Should have contact investigation so that partner(s) can also be evaluated.
  • Should be linked to treatment and care post delivery

The Syphilis Exposed Infant

The Syphilis Exposed Infant is an infant born to a mother who had syphilis in pregnancy. The infant is assessed as Congenital Syphilis if:

  • Symptomatic
  • Non treponemal tests of infant show a four fold rise compared to maternal titres of the same non treponemal test
  • Darkfield microscopy of exudates from lesions reveal spirochetes
  • CSF VDRL, cells or protein positive

Guide for interpretation of Syphilis serologic test results

Nontreponemal Test Result (VDRL, RPR, ART)

Treponemal Test Result (TP-PA, FTA-ABS)

 

MOTHER

INFANT

MOTHER

INFANT

INTERPRETATION

-

-

-

-

No syphilis or incubating syphilis in mother or infant

+

+

-

-

No syphilis in mother or infant (false positive – passive transfer of antibody to infant)

+

+ or -

+

+

Maternal syphilis with possible infant infection

+

+

+

+

Recent or previous syphilis in mother; possible infant infection

-

-

+

+

Mother successfully treated before or early in pregnancy; infant syphilis unlikely

 History and Examination

  • Antenatal History
  • Maternal tests done: dates, results, treatment, repeat testing, Re- exposure, partner treatment
  • Examination
  • Detailed examination: signs of syphilis

Investigations as indicated by clinical presentation:

  • Non treponemal test same as mother and compare titres
  • Lumbar puncture: CSF VDRL, cells, protein
  • CBC and platelet count
  • CXR, LFT’s, Ultrasonography
  • Ophthalmologic examination
  • Auditory brainstem response test
  • Specific fluorescent antitreponemal antibody staining – body fluid
  • Pathologic examination of placenta of umbilical cord

Treatment

Treatment of Congenital Syphilis as per the Algorithm below

Follow up

Follow-up

Schedule

Endpoint

Clinical evaluations

1, 2, 4, 6, 12 months of age

Normal examination

Serologic nontreponemal tests *

2-4, 6, 12 months after conclusion of treatment

Nonreactive test

Or

Titer decreased fourfold

Congenital neurosyphilis

CSF examination at 6 month intervals

Normal CSF findings (nonreactive VDRL; no WBCs)

*should by 3 months and nonreactive by 6 months

The HIV Exposed Infant

The HIV Exposed Infant is usually an infant born to an HIV infected mother. Identification of the HIV exposed infant begins with finding HIV positive woman in pregnancy.

Antenatal Management (hyperlink)

Management of the HIV Exposed Infant

  • Clean infant (soap and water)
  • Medication
    • Nevirapine 2mg/kg po stat
    • Commence Zidovudine 4 mg/kg/ dose po q12h x 28 days extend to 42 days if <4/52 maternal HAART
    • For premature infants GA< 34/40 2mg/kg x2/52 then 3 mg/kg x4/52
    • Commence cotrimoxazole 5mg TMP/kg po od at 6/52. Discontinue when 2 PCR tests are negative
  • Nutrition
    • No breastfeeding
    • Full formula replacement (Formula given x 1 year)
  • Continue well infant care
    • Monitor growth: plot on appropriate chart
    • Monitor development
    • Abnormal growth & development are early warning signs of an HIV positive infant
    • Immunisation as per government schedule
      • Substitute IPV for OPV
  • History
    • Current complaints
    • Past acute illnesses
    • AIDS defining conditions
  • Examination
    • Detailed examination to determine HIV category
    • Temperature
    • weight, height, head circumference,
    • skin eruptions, ENT infections, abdominal organs enlargement, development
    • febrile illnesses, chest infections
  • Testing: all infants
    • HIV DNA PCR testing at 6/52 & 4/12
    • HIV antibody testing at 18/12
    • If breastfed: HIV DNA PCR 6/52 post last breastfeeding episode
    • If infants are symptomatic do HIV DNA PCR eg. Failure to thrive, developmental delay, hepatosplenomegaly, generalised lymphadenopathy, spasticity, severe infections

Breastfeeding

Reinforce information on the advantages and disadvantages of breastfeeding and Breast Milk Substitutes including the respective risks. Advise the client that avoidance of all breastfeeding is recommended if replacement feeding is feasible, affordable, sustainable and safe.

Advise the client about the inappropriateness and high risks of HIV transmission associated with mixed feeding.

If she chooses to breast feed, demonstrate to the client good breastfeeding techniques to help prevent and treat breast problems that can increase the risk of HIV transmission (e.g. cracked nipples, mastitis).