HIV AND PREGNANCY
HIV (Human Immunodeficiency Virus) is a virus that attacks the body\’s immune system, specifically the CD4 cells (T cells), which are important for immune defence.
If untreated, HIV can lead to AIDS (Acquired Immunodeficiency Syndrome), a condition where the immune system is severely weakened.
HIV is a lenti-virus (slow and long acting) and belongs to the Retroviruses group. HIV invades the helper T cells to replicate itself thereby limiting the body’s ability to fight infection . HIV is the virus that causes AIDS, and it has no cure
Types of HIV
- HIV-1: This is the most common and widespread type of HIV, accounting for the vast majority of HIV infections globally. It is highly infectious and has several subtypes (or clades), labelled A through K. HIV-1 is the primary cause of the global HIV pandemic and is more aggressive in its progression to AIDS compared to HIV-2.
- HIV-2: This type is less common and primarily found in West Africa. It is less transmissible and generally progresses more slowly to AIDS than HIV-1. There are fewer subtypes of HIV-2, labelled A through H.
Modes of HIV Transmission
1. Sexual Contact:
- Unprotected Vaginal Sex: HIV can be transmitted through vaginal fluids and semen during unprotected vaginal intercourse..
2. Blood-to-Blood Contact:
- Sharing Needles: Using contaminated needles or syringes, common among intravenous drug users, can transmit HIV.
- Blood Transfusions: Although rare in countries with stringent blood screening, HIV can be transmitted through infected blood transfusions.
- Exposure to Contaminated Blood: Health care workers can be at risk through needle stick injuries or contact with open wounds.
3. Mother-to-Child Transmission:
- During Pregnancy: HIV can cross the placenta from mother to baby.
- During Childbirth: The baby can be exposed to HIV in the mother\’s blood and vaginal fluids during delivery.
- Breastfeeding: HIV can be transmitted through breast milk from an infected mother to her child.
4. Other Modes:
- Contaminated Medical Equipment: Use of non-sterile instruments during medical or dental procedures can transmit HIV.
- Organ and Tissue Transplants: Transplantation of infected organs or tissues, though rare due to screening practices, can transmit HIV.
5. Less Common Modes:
- Tattooing and Piercing: If non-sterile needles are used, there is a risk of HIV transmission.
- Contact Sports: Although extremely rare, transmission can occur if both participants have open wounds.
Factors That Facilitate Mother-to-Child Transmission of HIV
Maternal Factors:
1. Viral Load and Immune Status:
- High Viral Load: Higher levels of HIV in the mother’s blood increase the risk of transmission to the baby.
- Low CD4 Count: A weakened immune system due to low CD4 counts enhances transmission risk.
- Maternal Acquisition of HIV: New HIV infections during pregnancy or lactation significantly increase transmission risk.
2. Infections and Inflammation:
- Vaginal Infections: Infections such as bacterial vaginosis can elevate the risk of HIV transmission.
- Chorioamnionitis: Inflammation of the foetal membranes due to infection can facilitate HIV transmission.
3. Access to Antiretroviral Therapy (ART):
- Lack of ART: Mothers who do not receive ART are more likely to transmit HIV.
- Poor Adherence to ART: Inconsistent use of ART reduces its effectiveness in preventing transmission.
- Timing of ART Initiation: Starting ART late in pregnancy or not at all reduces its preventive benefits.
4. Socioeconomic Factors:
- Lack of Healthcare Access: Limited access to prenatal care and HIV testing can lead to missed opportunities for prevention.
- Education and Awareness: Lack of knowledge about HIV transmission and prevention strategies among pregnant women.
5. Nutritional Status:
- Poor Maternal Nutrition: Malnutrition can weaken the mother’s immune system, increasing the risk of transmission.
Labour and Delivery Factors:
6. Delivery Method:
- Vaginal Delivery: Higher risk of transmission compared to elective caesarean section, especially if the mother has a high viral load.
- Prolonged/Difficult Labour: Increased exposure to maternal fluids during extended or complicated labour can raise the risk.
7. Prematurity:
- Premature Birth: Prematurity can increase the risk of transmission due to underdeveloped immune systems in infants.
8. Membrane Rupture:
- Prolonged Rupture of Membranes (PROM): Rupture lasting more than 4 hours before delivery increases the risk of HIV transmission.
9. Invasive Monitoring and Procedures:
- Use of invasive monitoring or procedures during labour can increase the risk of HIV transmission.
Postnatal Feeding Factors:
10. Breastfeeding Practices:
- Prolonged Breastfeeding: Longer duration of breastfeeding increases the risk of HIV transmission.
- Breast Health: Conditions like sore nipples, abscesses, or mastitis can increase the risk.
- Mixed Feeding: Combining breastfeeding with other foods or fluids increases transmission risk. Exclusive breastfeeding for the first 3-6 months does not show excess transmission compared to formula feeding alone.
11. Exclusive Breastfeeding:
- Exclusive breastfeeding means providing breast milk only, without additional fluids, water, food, teats, or pacifiers, and involves on-demand feeding.
12. Oral Health in Infants:
- Oral Thrush: Presence of oral thrush in breastfed infants can increase the risk of HIV transmission.
Phases of HIV Entry into Host Cells
- Binding: The HIV virus first attaches to the CD4 receptors on the surface of the host cell, typically a type of immune cell called a CD4+ T lymphocyte. HIV\’s envelope protein, gp120, specifically binds to the CD4 receptor. This interaction triggers a conformational change in gp120 that allows it to also interact with a co-receptor, usually CCR5 or CXCR4, on the host cell surface. This dual receptor binding is essential for the virus to proceed to the next step.
- Fusion: After binding, the HIV viral envelope fuses with the host cell membrane, allowing the viral contents to enter the host cell. The conformational change in gp120 caused by CD4 and co-receptor binding exposes another viral protein, gp41. gp41 facilitates the merging of the viral envelope with the host cell membrane, creating a fusion pore through which the viral capsid containing the viral RNA and enzymes can enter the host cell cytoplasm.
- Reverse Transcription: Once inside the host cell, the viral RNA genome is reverse transcribed into DNA. The enzyme reverse transcriptase, carried within the viral capsid, converts the single-stranded viral RNA into double-stranded DNA. This process is error-prone, leading to a high mutation rate which contributes to the virus’s ability to evade the immune system and develop drug resistance.
- Integration: The newly synthesized viral DNA is integrated into the host cell’s genome. The viral DNA is transported into the host cell nucleus, where the enzyme integrase integrates it into the host cell’s DNA. This integrated viral DNA is known as a provirus and can remain dormant for a period before becoming active.
- Replication: Once integrated, the viral DNA can be transcribed and translated to produce new viral RNA and proteins. The host cell’s machinery reads the integrated viral DNA and begins to produce viral RNA. Some of this RNA will serve as genomes for new viral particles, while others will be used to produce viral proteins through the process of translation.
- Assembly: New viral particles are assembled within the host cell. The newly made viral RNA and proteins are transported to the host cell’s surface, where they assemble into new immature viral particles. This assembly process involves the gathering of viral components into a budding virion.
- Budding: The new viral particles bud off from the host cell, acquiring an envelope from the host cell membrane in the process. The immature viral particles bud off from the host cell, during which they incorporate a portion of the host cell’s membrane as their envelope. The viral enzyme protease then cleaves certain viral precursor proteins into their mature forms, resulting in a fully mature and infectious virus ready to infect other cells.
Clinical Manifestations of HIV/AIDS
The World Health Organization (WHO) has established a staging system to classify HIV infection and disease progression:
Clinical Stage I:
- Asymptomatic: No symptoms of HIV-related illness.
- Persistent Generalized Lymphadenopathy: Enlargement of lymph nodes lasting more than three months.
- Performance Scale 1: Asymptomatic with normal activity level.
Clinical Stage II:
- Moderate Weight Loss: Less than 10% of presumed or measured body weight lost.
- Minor Muco-cutaneous Manifestations: Skin conditions like seborrheic dermatitis, prurigo, or fungal nail infections.
- Herpes Zoster: History of shingles within the last five years.
- Recurrent Upper Respiratory Tract Infections: Such as bacterial sinusitis, tonsillitis, or otitis media.
- Performance Scale 2: Symptomatic but normal activity level.
Clinical Stage III:
- Severe Weight Loss: More than 10% of presumed or measured body weight lost.
- Unexplained Chronic Diarrhoea: Lasting more than one month.
- Unexplained Prolonged Fever: Constant or intermittent, lasting more than one month.
- Oral Candidiasis: Oral thrush, a fungal infection.
- Oral Hairy Leukoplakia: White patches on the tongue or mouth.
- Pulmonary Tuberculosis: Active TB infection.
- Severe Bacterial Infections: Such as pneumonia, pyomyositis, or bacteremia.
- Acute Necrotizing Ulcerative Gingivitis: Severe gum disease.
- Unexplained Anaemia, Neutropenia, or Thrombocytopenia: Abnormal blood counts.
- Performance Scale 3: Bedridden for less than 50% of the day during the last month.
Clinical Stage IV:
- HIV Wasting Syndrome: Weight loss of more than 10% with chronic diarrhoea or prolonged fever.
- Pneumocystis Pneumonia (PCP): A severe fungal lung infection.
- Toxoplasmosis of the Brain: Brain infection caused by the Toxoplasma parasite.
- Cryptosporidiosis: Parasitic infection causing prolonged diarrhea.
- Cytomegalovirus Infection: A viral infection affecting various organs.
- Progressive Multifocal Leukoencephalopathy (PML): Brain infection causing neurological symptoms.
- Lymphoma: Cancer of the lymphatic system.
- Kaposi’s Sarcoma: Cancerous skin lesions caused by a herpesvirus.
- HIV Encephalopathy: Cognitive and/or motor dysfunction due to HIV infection.
- Atypical Disseminated Leishmaniasis: Parasitic infection affecting multiple organs.
- Symptomatic HIV-Associated Nephropathy or Cardiomyopathy: Kidney or heart disease associated with HIV.
- Performance Scale 4: Bedridden for more than 50% of the day during the last month.
Diagnostic Measures for HIV/AIDS
Pre and Post-Counselling and Consent: Essential for all diagnostic procedures unless in specific circumstances:
- Testing of very sick, unconscious, symptomatic, or mentally ill individuals by healthcare teams for better patient management.
- Routine testing for individuals likely to pose a risk of HIV infection to others, such as pregnant and breastfeeding mothers, sexual offenders and survivors, and blood or organ donors. These individuals must still be given the opportunity to know their status.
Criteria for Diagnosis: Diagnosis based on:
- Clinical Staging Criteria.
- Positive HIV Blood Test: Confirmation of HIV infection through serological (antibody) testing.
Testing Protocol: Testing for Adults and Children >18 Months:
- Serological (Antibody) Testing: Most common method. Due to the window period between infection and antibody production, negative individuals should be re-tested after three months if exposed.
- Reactive Rapid Test: Requires confirmation before diagnosis.
Diagnostic Tests
Screening Tests:
- ELISA (Enzyme-Linked Immunosorbent Assay) AglAb Tests: Commonly used to screen blood donations to exclude those in the window period.
Molecular Tests:
- PCR (Polymerase Chain Reaction) Tests: Nucleic-Acid Amplification Testing (NAT) detects genetic material of HIV itself, not antibodies or antigens.
Considerations: Testing should consider:
- Clinical status, medical history, and risk factors of the individual being tested.
- Use of tests in conjunction with patient assessment for accurate diagnosis and appropriate care.
Immediate Connection to HIV Care
- If positive, immediate referral to HIV care services for management and treatment initiation.
HIV Testing Provision Protocol
Step 1: Pre-Test Information and Counseling
- Provide information on HIV transmission, prevention measures, and testing benefits.
- Discuss potential test results, available services, and ensure consent and confidentiality.
- Conduct individual risk assessment and complete necessary documentation.
Step 2: HIV Testing
Perform blood-based testing.
- For infants below 18 months: Use DNA PCR testing.
- For individuals above 18 months: Conduct antibody testing as per testing algorithms.
Step 3: Post-Test Counseling (Individual/Couple)
- Assess readiness to receive results and deliver them simply.
- Address concerns, provide guidance on disclosure, partner testing, and risk reduction.
- Offer information on basic HIV care, ART, and complete documentation.
Step 4: Linkage to Other Services
- Provide information on available services and assist in completing referral forms.
- Upon enrollment in services, record pre-ART enrollment numbers and transfer relevant information to ART registers.
Principles of HIV Testing Services (HTS)
- Confidentiality: Ensure privacy and confidentiality of test results.
- Consent: Obtain informed consent from individuals before testing.
- Counselling: Offer supportive counselling before and after testing.
- Correct Test Result: Ensure accuracy of test results through proper testing procedures.
- Connection to Other Services: Facilitate access to appropriate services for individuals testing positive.
Linkage from HIV Testing to Prevention, Care, and Treatment
Linkage is the process of connecting individuals who test positive for HIV to the necessary services.
Successful linkage to care ensures that patients receive the services they need. For HIV-positive clients, linkage should occur promptly, within seven days if within the same facility, and within 30 days for referrals between facilities or from the community. Lay providers are recommended as linkage facilitators.
Types of Linkages:
- Internal Facility Linkage: Connecting patients within the same facility.
- Inter-Facility Linkage: Connecting patients to another facility.
- Community-Facility Linkage: Connecting clients from the community to a health facility.
Internal Facility Linkage Steps:
- Post-Test Counselling: Provide accurate results and information about available care.
- Next Steps Discussion: Describe the care and treatment process, emphasizing early treatment benefits.
- Address Barriers: Identify and overcome any obstacles to linkage.
- Involvement: Involve the patient and family in decision-making.
- Documentation: Complete client and referral forms.
- Escort to Clinic: A linkage facilitator escorts the client to the ART clinic.
- Enrollment: Register the patient, open an ART file, and provide preparatory counselling.
- Initiation: Start ART if ready, and continue with counselling support.
- Integrated Care: Coordinate other services if needed.
- Follow-Up: Ensure the patient attends appointments.
Inter-Facility and Community-Facility Linkages:
- Inter-Facility Linkage: Refers to connecting patients to another facility. The referring facility should track referred patients and ensure enrollment within 30 days.
- Community-Facility Linkage: Connects clients from the community to a health facility. Utilize community health systems and mobilize peer leaders for outreach and follow-up. Linkage should occur within 30 days after diagnosis.
Treatment Modalities of HIV/AIDS
Treatment Modality |
Description |
Antiretroviral Therapy (ART) |
Suppresses viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV. |
Treatment of Acute Bacterial Infections |
Addresses immediate bacterial infections. |
Prophylaxis and Treatment of Opportunistic Infections |
Prevents and manages opportunistic infections. |
Maintenance of Good Nutrition |
Ensures adequate nutrition to support overall health. |
Immunization |
Administers vaccines to prevent opportunistic infections. |
Management of AIDS-Defining Illnesses |
Addresses specific illnesses associated with advanced HIV infection. |
Psychological Support for the Family |
Provides emotional support and guidance for affected families. |
Palliative Care for the Terminally Ill |
Offers comfort and support for patients nearing the end of life. |
Antiretroviral Drug Treatment
Goal of ART: Suppress viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.
When to Initiate ARV:
- All HIV-infected children below 12 months.
- Clinical AIDS
- Mild to moderate symptoms and immunosuppression.
Process of Starting ART:
- Assess for opportunistic infections, defer ART if TB or cryptococcal meningitis present.
- Offer ART on the same day through an opt-out approach.
- If not ready for same-day initiation, agree on a timely ART preparation plan.
Available ARVs in Uganda
Drug Class |
Examples |
Nucleoside Reverse Transcriptase Inhibitors (NRTIs): Incorporate into the DNA of the virus, thereby stopping the building process. |
Tenofovir (TDF), Zidovudine (AZT), Lamivudine (3TC), Abacavir (ABC) |
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stop HIV production by binding directly onto the reverse transcriptase enzyme, and prevent the conversion of RNA to DNA. |
Efavirenz (EFV), Nevirapine (NVP), Etravirine (ETV) |
Integrase Inhibitors: interfere with the HIV DNA’s ability to insert itself into the host DNA and copy itself. |
Dolutegravir (DTG), Raltegravir (RAL) |
Protease Inhibitors (PIs): prevent HIV from being successfully assembled and released from the infected CD4 cell. |
Atazanavir (ATV), Lopinavir (LPV), Darunavir (DRV) |
Entry Inhibitors: prevent the HIV virus particle from infecting the CD4 cell. |
Enfuvirtide (T-20), Maraviroc |
Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children
HIV management guidelines are constantly being updated according to evidence and public policy decisions. Always refer to the latest official guidelines.
The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an integrase inhibitor as the anchor ARV in the preferred first and second-line treatment regimens for all HIV infected clients; children, adolescents, men, women (including pregnant women, breastfeeding women, adolescent girls and women of child bearing potential).
Patient Category |
Preferred Regimens |
Alternative Regimens |
Adults and Adolescents |
||
Adults (including pregnant women, breastfeeding mothers, and adolescents ≥30Kg) |
TDF + 3TC + DTG |
– If DTG is contraindicated: TDF + 3TC + EFV400 – If TDF is contraindicated: TAF + FTC + DTG – If TDF or TAF is contraindicated: ABC + 3TC + DTG – If TDF or TAF and DTG are contraindicated: ABC + 3TC + EFV400 – If EFV and DTG are contraindicated: TDF + 3TC + ATV/r or ABC + 3TC + ATV/r |
Children |
||
Children ≥20Kg – <30Kg |
ABC + 3TC + DTG |
– If DTG is contraindicated: ABC + 3TC + LPV/r (tablets) – If ABC is contraindicated: TAF + FTC + DTG (for children >6 years and >25Kg) – If ABC and TAF are contraindicated: AZT + 3TC + DTG |
Children <20Kg |
ABC + 3TC + DTG |
– If intolerant or appropriate DTG formulations are not available: ABC + 3TC + LPV/r granules – If intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10Kg) – If ABC is contraindicated: AZT + 3TC + DTG or LPV/r |
Notes:
- Contraindications for DTG include known diabetics, patients on anticonvulsants (carbamazepine, phenytoin, phenobarbital) – use the DTG screening tool prior to DTG initiation.
- Contraindications for TDF and TAF include renal disease and/or GFR <60ml/min, weight <30Kg.
- TAF can be used in subpopulations with bone density anomalies.
- Children will be assessed individually for their ability to correctly take the different formulations of LPV.
Notes from Ministry of Health
- For clients on an ABC-3TC-DTG based regimen weighing >25 kg, use the fixed-dose combination of Abacavir/Lamivudine/Dolutegravir 600/300/50 mg instead of the separate pills of Abacavir/Lamivudine 600/300 mg plus Dolutegravir 50 mg.
- Use Abacavir/Lamivudine 600/300 mg for patients on the following regimens: ABC-3TC-ATV/r, ABC-3TC-LPV/r, and ABC-3TC-DRV/r.
- Use the single pill of Dolutegravir 50 mg for patients on AZT-3TC-DTG based regimens.
- For eligible patients on ATV/r and LPV/r, optimize to Dolutegravir.
- For PrEP, while the guidelines provide options for the use of either TDF/3TC 300/300 mg or TDF/FTC 300/200 mg, use TDF/FTC 300/200 mg for PrEP in terms of programmatic implementation.
Monitoring of ARV Treatment
The monitoring of patients on antiretroviral therapy (ART) serves several purposes:
- Assess Response to ART and Diagnose Treatment Failure
- Ensure Safety of Medicines: Identify Side Effects and Toxicity
- Evaluate Adherence to ART
Methods of Monitoring ARV Treatment
1. Clinical Monitoring: Involves medical history and physical examination.
2. Laboratory Monitoring: Includes various laboratory tests.
- Viral Load Monitoring: Preferred for assessing response to ART and diagnosing treatment failure.
- CD4 Monitoring: Recommended in specific scenarios.
- Other Minor Laboratory Tests: Includes tests for specific indications.
Viral Load Monitoring
- Preferred method for monitoring ART response. A patient who has been on ART for more than 6 months and is responding to ART should have viral suppression (VL <1000 copies/ml) irrespective of the sample type (either DBS or plasma).
- Provides an early and more accurate indication of treatment failure and the need to switch from first line to second-line drugs, hence reducing the accumulation of drug resistance mutations and improving clinical outcomes.
- Early and accurate indication of treatment failure.
- Differentiates between treatment failure and non-adherence.
- Recommended frequency: Every six months for children and adolescents under 19 years.
CD4 Monitoring
- Baseline CD4 count is essential for assessing opportunistic infection risk.
- Recommended for patients with high viral load or advanced clinical disease.
Other Laboratory Tests
Tests |
Indication |
CrAg |
Screen for cryptococcal infection |
Complete Blood Count (CBC) |
Assess anaemia risk |
TB Tests |
Suspected tuberculosis |
Serum Creatinine |
Assess kidney function |
ALT, AST |
Evaluate liver function |
Lipid Profile, Blood Glucose |
Assess metabolic health |
HIV AND PREGNANCY
In 2004, the WHO reported that 40 million people were infected with HIV/AIDS, including 17.6 million women, 2.7 million children, and 13 million orphans worldwide. In 2005, 700,000 children became infected with HIV, with approximately 95% arising from mother-to-child transmission of HIV (MTCT). Ninety percent of new infections in children occur in Africa due to the near non-existence of PMTCT interventions.
Mother-to-child transmission (MTCT) is the vertical transmission of HIV from mother to child that occurs during pregnancy, childbirth, and breastfeeding. The most probable point of transmission occurs in the late third trimester and even more so during the intrapartum period. In some areas of the world, MTCT has been virtually eliminated thanks to the availability of specific interventions to reduce the risk of transmission. These interventions include:
- Effective voluntary and confidential testing and counselling.
- Access to Antiretroviral Therapy (ART).
- Safe delivery practices.
- Availability and safe use of breast milk substitutes.
Factors Affecting Perinatal Transmission
HIV-related Factors:
- Viral load: The higher the viral load, the greater the risk of transmission.
- Strain variation (genotype): HIV1 or 2.
- Biological growth characteristics.
- CD4 cell count: Lower CD4 count or decreased CD4
ratio is associated with increased risk of transmission.
Maternal and Obstetric Factors:
- Clinical stage: Primary infection with greater viremia is associated with increased risk.
- STDs: Increased HIV shedding in genital tract epithelial disruption is associated with an increased risk of transmission.
- Sexual behavior: Unprotected sex with multiple partners is associated with increased risk.
- Placental abruption: Disruption of fetal-placental barriers increases exposure to the fetus.
- Duration of membrane rupture: The transmission rate is directly proportional to the increased duration of rupture of membranes, with a 2% increase for each hour increment.
- Gestational age at delivery: Prematurity is associated with increased risk.
- Invasive procedures in labor such as episiotomy, vacuum delivery, artificial rupture of membranes.
- Modes of delivery: A study in developed countries shows that elective cesarean section done prior to rupture of membranes and labor significantly reduces the risk of perinatal transmission. Planned cesarean section surgery must be considered in the context of the woman’s life and availability of local resources.
- Knowledge of HIV status combined with accessibility to and acceptance of ART decreases transmission.
- Substance abuse: Substance use during pregnancy is associated with increased risk.
Maternal and Neonatal Factors:
- Immature immune system (especially in preterm babies).
- Genetic susceptibility.
Breastfeeding:
- Without ART, the risk of transmission through breastfeeding by an infected mother may increase the risk to a total of 20-45%.
- Where breastfeeding is common and prolonged, transmission through breastfeeding may account for up to half of HIV infections in infants and young children.
- Early findings show a low rate of transmission through breastfeeding in the first 3 months in infants receiving prophylaxis with either Lamivudine or Nevirapine.
- The risk can be reduced to under 2% by a combination of antiretroviral prophylaxis during pregnancy and delivery, and to the neonate, with elective cesarean section and avoidance of breastfeeding.
- Availability of safe breast milk substitutes must be considered, including a safe water supply, when educating and counseling women to avoid breastfeeding.
Strategies for Prevention of Mother-to-Child Transmission (PMTCT):
- Primary prevention of HIV among prospective parents.
- Prevention of unwanted pregnancy among HIV-infected women.
- Prevention of MTCT among HIV-infected mothers through:
- Provision of voluntary confidential counseling and testing.
- Antiretroviral agents.
- Safe delivery practices.
- Safe infant feeding practices.
- Support for the affected family and the community at large. Education and counseling services may help the woman’s family understand the issues and thus support the woman in her choice to prevent transmission of HIV to her baby.
Components of a Comprehensive HIV Prevention Program:
- Health education, provision of information, and counseling on HIV prevention and care, including MTCT.
- Voluntary confidential counseling and testing services that are acceptable and accessible.
- Quality and focused antenatal care.
- Safe delivery practices.
- Support and counseling on infant feeding practices.
- Family planning services.
- Community mobilization and education to decrease stigma and discrimination against, as well as to increase support for, HIV-positive clients.