IV. Provision of Care and Support to Women Infected With HIV, Their Infants, and Their Families

The comprehensive care of all people living with HIV/AIDS, including HIV-positive women and their exposed or HIV-positive infants and children with her spouse is the fourth prong of PMTCT.

a) HIV Testing and Counselling in the Context of PMTCT

Women are particularly vulnerable to HIV infection and face multiple challenges in making decisions concerning their reproductive lives. Through counselling, women can be empowered to make informed choices concerning their sexual and reproductive health (RH). Specific PMTCT interventions depend on upon women's knowledge of their HIV status. Therefore, you should note the following important points during HCT services:

Play a vital role in identifying women who are HIV-positive to provide appropriate services for themselves and their family.
Help women who are HIV-negative and empower them to remain negative.
Serve as an entry point to comprehensive HIV/AIDS treatment, care, and support to the mother and whole family.
Help women identify their status and take steps to reduce behaviours that increase the risk of HIV infection or transmission.
Be available to all women in reproductive age, particularly, to pregnant, parturient and lactating women.
Need to be available to male partners as well.

All women of childbearing age presenting to Maternal, Newborn and Child Health (MNCH) should receive information through group education on the following issue:

Prevention and treatment of HIV/AIDS including STIs.
Family planning.
Prevention of HIV in infants and young children including interventions for PMTCT (ART during pregnancy, ARV prophylaxis for infants born to HIV-infected women).
Safer sex practices and risk reduction.
The benefit of HIV testing at every pregnancy and partner testing.
Pre-test information, HIV testing, post-test counselling and follow-up services.

b) Advantages of Testing and Counselling in the Context of PMTCT

For HIV-negative women:

Helps them remain uninfected.
Helps them to have HIV-free babies.
Help them receive the FP methods of their choice.
Help them receive information on the importance of delivery by a skilled birth attendant.

For HIV-positive women:

The following points should be raised when counselling HIV-positive mother.

Effect of pregnancy on HIV and effect of HIV on pregnancy outcomes.
The risk of transmission of HIV to the infant.
Treatment options and intervention methods.
Infant feeding options.
Disclosure of the result to the partner.
Follow up of the mother and infant.
Further fertility and contraceptive option.

Here, let the woman make informed decisions about FP and receive appropriate and timely interventions to reduce MTCT including ARV treatment to reduce MTCT, infant feeding counselling and support and information and counselling on FP. Also, advise her to:

Receive information on the importance of giving birth in a setting where standard precautions for infection prevention and safer obstetric practices are implemented.
Secure early access to HIV treatment, care, and support services.
Receive information and counselling on the prevention of HIV transmission to others.
Receive follow-up and ongoing health care for themselves and their HIV-exposed infants.
Disclose their results to partners and family members.

c) Integrated Approaches to HIV Testing in MNCH Settings

There are two methods to HIV testing in the MNCH setting. Each approach provides information to the client about HIV, the benefits and risks of testing.

Opt-in: after the woman has received information about HIV and testing and individual counselling, she is given the choice of refusing or consenting to an HIV test. This option is presented in a neutral, supportive manner. Women who "opt in" explicitly request to be tested, and their informed consent (written or oral)is clearly established. The opt-in approach requires an active step by the individual woman to agree to be tested.
iOpt-out: HIV testing is offered as a routine part of a standard package of care. Women are given the opportunity to decline the test should they choose to do so. The opt-out approach emphasises that HIV testing is a routine component of MNCH services. However, testing is still voluntary under the opt-out approach; women have a right to refuse testing. Issues that are preventing a woman from accepting testing should be explored. Opt-out testing is also sometimes referred to as "provider-initiated testing and counselling" (PITC) because the provider routinely initiates offering HIV testing and counselling as part of care.

Opt-out testing is the BEST approach for testing because it:

Normalises HIV testing by integrating it into ANC services, offering HIV testing at each pregnancy.
Increases the number of women who receive testing and PMTCT interventions.
Improves access to HIV/AIDS services, increasing ART coverage.
Reduces stigma when integrated in the ANC set-up.

Pre-Test Information (Counselling):

Pre-test information sessions can be given for clients in groups or individually.

The purposes of a pre-test information session are to:

Provide basic information about HIV/AIDS and MTCT of HIV, including prevention.
Describe the benefits of testing.
Explain the testing process.
Discuss the importance of partner testing and discordance.
Counsel on risk reduction.
Introduce MNCH/PMTCT care and support services (ART for the HIV+ mother and ARV prophylaxis for the infant).
Encourage clients to share such information with other community members.

Use different teaching aids for better understanding (refer your health education module) and follow the steps to implement them.

a) Informed consent: informed consent is the process by which each woman receives clear and accurate information about HIV testing to ensure the client has the right and the opportunity to decline or continue with testing. In the context of PMTCT, oral consent is enough as far as the woman understands the risk and the benefit of the testing.

b) HIV testing process: HIV testing detects antibodies, antigens or viral particles (testing for HIV PCR, which is less commonly available) associated with HIV in whole blood, saliva, or urine. Blood is the most commonly used sample. A person who performs or handles the HIV test process must be trained so that the accuracy of testing is preserved and should follow the basic steps of HIV Rapid Test Algorithm for Ethiopia (refer your CDC module).

c) Confidentiality: maintaining confidentiality is an important responsibility of all health care providers and is essential in establishing women's trust. Information that is shared between health care providers and women must be kept private. It is essential that a private venue (room) be used for all discussions of HIV-related matters, particularly HIV diagnosis. Women should be informed that personal and medical information, including HIV test results, might be disclosed to other healthcare providers only for those directly involved in her care.

Post-Test Counselling:

The result of HIV testing should always be offered in person in a confidential setting. Along with the result, appropriate post-test information, counselling, or referral should also be offered.

i. Post-test counselling HIV-negative:

Say, thank you for waiting.
Your HIV test result is now ready.
Your result is negative, meaning that the test did not detect HIV in your blood.
The test result indicates the status you had before three months. This type of test usually does not pick recent infections that are in the window period (in the past three months).
So, I recommend you to have another test after three months to confirm your status if you think that you had any exposure (risk in the past three months). To stay HIV free, it is important to protect yourself from other STIs including HIV which can be harmful to your baby as well. You may need always to use a condom and seek early treatment if you observe any signs or symptoms of an infection.

ii. Partner notification:

Knowing your own sero-status does not indicate the status of your partner, although rare, there is a possibility of being couples with a discordant result. If your partner is HIV-negative, the two of you will need to be faithful to each other. If your partner is HIV-positive or you do not know his status, or if you have sex with more than one partner, you can protect yourself from HIV. I would like to make you aware that if you get HIV infection while pregnant or breastfeeding, the chances of transmitting HIV to your child is much higher than any other time.

As you probably know, the fact that you are HIV-negative doesn't necessarily mean that your partner is HIV-negative. Thus, you are strongly advised to ask your partner get tested.

You are encouraged to bring your partner to this clinic for HIV test or just refer him so that providers can offer and do HIV testing for him. If you need any information or referral slip for your partner, here is some information about where to get HIV testing service and how you can protect yourself from getting HIV.At last, thank you for getting tested and I would like to advise you that next time you come, make sure your partner will have been tested for HIV.

iii. Post-test counselling session: HIV-positive

a) Inform the test result is positive and provide support. What do you say first?: Say, thank you for waiting. Your test result is available and your HIV test result is positive. This means you are infected with HIV. Allow a moment for the patient to absorb the meaning of the result.I know how difficult it can be receiving this result. It is normal to feel upset and overwhelmed at first. You need time to adjust to this, but I am confident that in time you will be able to adjust and cope. Now the services are good, there is a treatment for HIV, people are living a healthy life with medication.

b) Provide HIV clinical care recommendations: being HIV-infected and a pregnant woman means you are in high need of treatment. This helps you to feel better and live longer and prevents you from the risk of MTCT even though you have HIV infection.The medicine you take treatment of HIV infection is antiretroviral therapy (ART).For your information, our facility provides ARV treatment to all HIV-positive pregnant women.

Hence, if you are pregnant and HIV-infected, you can automatically start ART, a treatment for life. ARV will protect your baby from HIV infection (MTCT) and help you live longer It will be best for you to deliver at a health facility where you will be attended by skilled professionals who will assist you reduce the risk of MTCT and provide ARV prophylaxis for the newborn immediately after birth. The baby will take the medicine until the age of 6 weeks.

c) Counselling on breastfeeding options:

Exclusive breastfeeding for the first six months: This is beneficial in that it is nutritious, easily accessible and has a disease-protective effect and promotes bonding. If you follow the treatment and the advice given, you can reduce the chance of passing the virus to the baby significantly. This is the preferred infant feeding choice in Ethiopia (figure 12.1). By the way, when choosing EBF, it means starting BF immediately (including the colostrum) with no addition of even fluid water for the first six months of life. Mixing is the worst practice that predisposes the infant for HIV infection and frequent illnesses.

Fig 12.1 Early initiations and exclusive breastfeeding.

Commercial infant formula (alternative option): If you are using this option, there is no risk of virus transmission through breastfeeding, but unless it is given in a safe way, it has a higher risk of infection and death in Ethiopia. Formula feeding shall be prepared clean and at the right constituency. From these feeding options, you can choose whichever is applicable for your infant feeding practice. However, there may be situations that prevent you from continuously practising your feeding method of choice. Thus, any alternatives you use shall also fulfil the above-given conditions.

d) Address risk issues and provide referrals: the best way to assure that your partner does not get HIV or any other STIs is not to have sex. If you do have sex, you need to use a condom every time. Condoms will not only protect you from HIV but also from other STIs. We have condoms available in the clinic and you are welcome to take some.

Prevention and early treatment of other STIs (including HIV) will reduce the chance of spreading them to your partner or your baby. Thank you, (patient's name) for coming today.