Component of ART given to the mother in the prevention of mother to child transmission -
Ans- D Tenofovir, efavirenz and lamivudine Ref 1 - The current WHO guidelines of June 2013 recommends two options for PPTCT: (i) provision of lifelong ART to all the pregnant and breast feeding women living with HIV regardless of CD4 count or clinical stage (earlier called Option B+) or (ii) provision of ART during pregnancy and breast feeding and thereafter providing ART as indicated.8 Having gone through 30 years of the global AIDS epidemic, it is now felt that, despite hindrance, PPTCT of HIV can be considered as a realistic public health goal. Government of India is committed to working towards achievement of the global target of "elimination of new HIV infections among children" by 2015 and has decided to adopt the first option i.e lifelong ART (triple drug regime) irrespective of CD4 count or WHO clinical staging.9 This, in turn, is expected to help maximise the coverage to those needing treatment, avoiding the need for starting ART in future pregnancies, provide protection against parent-to-child transmission in future pregnancies and avoid drug resistance. These guidelines have been implemented across the country from 1st January 2014. The aim is to ensure integrated PPTCT services within the existing Reproductive and Child Health (RCH) programme.5 The recommended first-line regimen for HIV infected pregnant women is Tenofovir (TDF) (300 mg) + Lamivudine (3TC) (300 mg) + Efavirenz (EFV) (600 mg) at any gestational age. Further, as part of PPTCT, the infant also needs to be exposed to NVP for at least 06 weeks, but increased to 12 weeks in case the mother was started on ART late in her pregnancy. However, the last word has not been said and warnings about the use of Option/Plan B + are also being published.10 Triple drug therapy decreases the viral load substantially, thus paving the way for normal delivery and breast feeding. The exclusive breast feeding is recommended by NACO to avoid chances of gastrointestinal infection and malnutrition. Vertical transmission of HIV from mother to the newborn generally occurs during contact of the foetus with vaginal secretion after rupture of amniotic membrane. Therefore elective caesarean section was considered an option for prevention of mother-to-child transmission. With decrease in viral load in vaginal secretions due to antenatal use of triple drug therapy, vaginal delivery is now considered safe and the caesarean section is recommended only for obstetric indications. Ref 2 - A comprehensive approach to PMTCT Effective PMTCT programmes require women and their infants to have access to - and to take up - a cascade of interventions including antenatal services and HIV testing during pregnancy; use of ART by pregnant women living with HIV; safe childbirth practices and appropriate infant feeding; uptake of infant HIV testing and other post-natal healthcare services.4 The World Health Organization (WHO) promotes a comprehensive approach to PMTCT programmes which includes: preventing new HIV infections among women of childbearing age preventing unintended pregnancies among women living with HIV preventing HIV transmission from a woman living with HIV to her baby providing appropriate treatment, care and support to mothers living with HIV and their children and families.5 World Health Organization PMTCT guidelines Guidelines for pregnant and breastfeeding women living with HIV WHO's 2013 guidelines recommended that a woman living with HIV only continue on ART after breastfeeding if it would benefit her own health.6 However, in September 2015 the WHO released new guidelines recommending that all pregnant women living with HIV be immediately provided with lifelong treatment, regardless of CD4 count (which indicates the level of HIV in the body). This approach is called Option B+.7 By 2015, the implementation of Option B+ had resulted in 91% of the 1.1 million women receiving ARVs as part of PMTCT services being offered lifelong ART.8 In resource-poor settings, when formula feeding is not a viable option, the WHO advises women living with HIV to exclusively breastfeed (rather than mixed feeding), providing that they are on ART. This is because, while formula feeding offers the safest option for postnatal HIV prevention, in resource poor settings it is not always easy for families to afford formula or access things such as clean water which are needed for it use.9 Guidelines for HIV-exposed infants If an HIV-exposed infant is given ART within the first 12 weeks of life, they are 75% less likely to die from an AIDS related illness.10 This is one of the reasons that WHO recommends that infants born to mothers living with HIV are tested between four and six weeks old. This is often referred to as 'early infant diagnosis'.11 The WHO further recommends that another HIV test is carried out at 18 months and/or when breastfeeding ends to provide the final infant diagnosis.12 According to WHO guidelines, all infants who test positive for HIV should be immediately initiated on treatment. The treatment should be linked to the mother's course of ARVs and would vary according to the infant feeding method as follows: breastfeeding - the infant should receive once-daily nevirapine from birth for six weeks replacement feeding - the infant should receive once-daily nevirapine (or twice-daily zidovudine) from birth for four to six weeks.13 Global PMTCT targets In 2011, a Global Plan was launched to reduce the number of new HIV infections via mother-to-child transmission by 90% by 2015.14 The WHO identified 22 priority countries, with the top 10 (Angola, Botswana, Burundi, Cameroon, Chad, Cote d'Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana and India) accounting for 75% of the global PMTCT service need. It was estimated that the effective scaling up of interventions in these countries would prevent over 250,000 new infections annually.15
Lamivudine and Efavirenz
Nevirapine and Lamivudine
Tenofovir, efavirenz and Stavudine
Tenofovir, efavirenz and lamivudine