G2. PROVIDE KEY INFORMATION ON HIV
What is HIV (human immunodeficiency virus) and how is HIV transmitted?
HIV is a virus that destroys parts of the body's immune system. A person infected with HIV may not feel sick at first, but slowly the body's immune system is destroyed. The person becomes ill and unable to fight infection. Once a person is infected with HIV, she or he can give the virus to others.
HIV can be transmitted through:
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Exchange of HIV-infected body fluids such as semen, vaginal fluid or blood during unprotected sexual intercourse.
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HIV-infected blood transfusions or contaminated needles.
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From an infected mother to her child (MTCT) during:
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pregnancy
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labour and delivery
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postpartum through breastfeeding.
Almost four out of 20 babies born to HIV infected women may be infected without any intervention.
HIV cannot be transmitted through hugging or mosquito bites.
A blood test is done to find out if the person is infected with HIV.
All pregnant women are offered this test. They can refuse the test.
Advantage of knowing the HIV status in pregnancy
Knowing the HIV status during pregnancy is important so that:
the woman knows her HIV status
can protect her baby
can share information with her partner
encourage her partner to be tested
If the woman is HIV-infected she can:
get appropriate medical care to treat her HIV infection and/or prevent HIV-associated illnesses.
reduce the risk of transmission of infection to the baby:
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by taking antiretroviral drugs in pregnancy, during labour and after delivery and during breastfeeding G6, G9
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by practicing safer infant feeding options G9
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by adapting birth and emergency plan and delivery practices G4.
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Can breastfeed her baby if taking antiretroviral medicines regularly
protect herself, her sexual partner(s) and her infant from infection or reinfection.
make a choice about future pregnancies.
If the woman is HIV- negative she can:
Counsel on safer sex including use of condoms
SAFER SEX IS ANY SEXUAL PRACTICE THAT REDUCES THE RISK OF TRANSMITTING HIV AND SEXUALLY TRANSMITTED INFECTIONS (STIS) FROM ONE PERSON TO ANOTHER
THE BEST PROTECTION IS OBTAINED BY:
Correct and consistent use of condoms during every sexual act.
Choosing sexual activities that do not allow semen, fluid from the vagina, or blood to enter the mouth, anus or vagina of the partner.
Reducing the number of partners.
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If the woman is HIV-negative explain to her that she is at risk of HIV infection and that it is important to remain negative during pregnancy, breastfeeding and later. The risk of infecting the baby is higher if the mother is newly infected.
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If the woman is HIV-infected explain to her that condom use during every sexual act during pregnancy and breast feeding will protect her and her baby from sexually transmitted infections, or
reinfection with another HIV strain and will prevent the transmission of HIV infection to her partner.
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Make sure the woman knows how to use condoms and where to get them.
G3. HIV TESTING AND COUNSELLING
HIV testing and Counselling services
Explain about HIV testing:
HIV test is used to determine if the woman is infected with HIV.
It includes blood testing and counselling.
Result is available on the same day.
The test is offered routinely to every woman at every pregnancy to help protect her and her baby's health. She may decline the test.
If HIV testing is not available in your setting, inform the woman about:
Where to go.
How the test is performed.
How confidentiality is maintained ( see below).
When and how results are given.
When she should come back to the clinic with the test result
Costs involved.
Provide the address of HIV testing in your area's nearest site :
Discuss confidentiality of HIV infection
Assure the woman that her test result is confidential and will be shared only with herself and any person chosen by her.
Ensure confidentiality when discussing HIV results, status, treatment and care related to HIV, opportunistic infections, additional visits and infant feeding options
A2.Ensure all records are confidential and kept locked away and only health care workers taking care of her have access to the records.
DO NOT label records as HIV-infected.
Counsel on implications of the HIV test result
Discuss the HIV results when the woman is alone or with the person of her choice.
State test results in a neutral tone.
Give the woman time to express any emotions.
IF TEST RESULT IS NEGATIVE:
IF TEST RESULT IS POSITIVE:
Explain to the woman that a positive test result means that she is carrying the infection, is ill and has the possibility of transmitting the infection to her unborn child, or by breastfeeding the baby without any intervention.
Let her talk about her feelings. Respond to her immediate concerns.
Inform her that she will need further assessment to determine the severity of the infection, appropriate care and treatment needed for herself and her baby. Treatment will slow down the progression of her HIV infection and will reduce the risk of infection to the baby.
Inform her about the cost of treatment.
Provide information on how to prevent HIV re-infection.
Inform her that support and counselling is available if needed, to cope on living with HIV infection.
Discuss disclosure and partner testing.
Ask the woman if she has any concerns.
Benefits of disclosure (involving) and testing the male partner(s)
Encourage the women to disclose the HIV results to her partner or another person she trusts. By disclosing her HIV status to her partner and family, the woman may be in a better position to:
Encourage partner to be tested for HIV.
Prevent the transmission of HIV to her partner(s).
Prevent transmission of HIV to her baby.
Protect herself from HIV reinfection.
Access HIV treatment, care and support services.
Receive support from her partner(s) and family when accessing antenatal care and HIV treatment, care and support services.
Help to decrease the risk of suspicion and violence.
G4. CARE AND COUNSELLING FOR THE HIV-INFECTED WOMAN
Additional care for the HIV-infected woman
Determine how much the woman has told her partner, labour companion and family, then respect this confidentiality.
Be sensitive to her special concerns and fears. Give her additional support
G5.Advise on the importance of good nutrition
C13
D26.Use standard precautions as for all women
A4.Advise her that she is more prone to infections and should seek medical help as soon as possible if she has:
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fever
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persistent diarrhoea
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cold and cough – respiratory infections
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burning urination
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vaginal itching/foul-smelling discharge
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no weight gain
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skin infections
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foul-smelling lochia.
DURING PREGNANCY:
Revise the birth plan
C2
C13.- →
Strongly advise her to deliver in a facility.
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Advise her to go to a facility as soon as her membranes rupture or labour starts.
Discuss the infant feeding options
G8-G9.Modify preventive treatment for malaria, according to national strategy
F4.
DURING CHILDBIRTH:
Give ART as prescribed in her treatment plan
G6
G9, G12.Adhere to standard practice for labour and delivery.
Respect confidentiality when giving ART to the mother and baby.
Record all ART given on labour record, postpartum record and on referral record, if woman is referred.
DURING THE POSTPARTUM PERIOD:
Tell her that lochia can cause infection in other people and therefore she should dispose of blood stained sanitary pads safely (list local options).
Counsel her on family planning
G4.
If not breastfeeding, advise her on breast care
K8.Tell her to visit HIV services with her baby 2 weeks after delivery for further assessment.
Counsel the HIV-infected woman on family planning
The family planning counsellor will provide more information.
G5. SUPPORT TO THE HIV-INFECTED WOMAN
Pregnant women who are HIV- infected benefit greatly from the following support after the first impact of the test result has been overcome.
Provide emotional support to the woman
Empathize with her concerns and fears.
Use good counselling skills
A2.Help her to assess her situation and decide which is the best option for her, her (unborn) child and her sexual partner. Support her choice.
Connect her with other existing support services including support groups, income-generating activities, religious support groups, orphan care, home care.
Help her to find ways to involve her partner and/or extended family members in sharing responsibility, to identify a figure from the community who will support and care for her.
Discuss how to provide for the other children and help her identify a figure from the extended family or community who will support her children.
Confirm and support information given during HIV testing and counselling, the possibility of ARV treatment, safe sex, infant feeding and family planning advice (help her to absorb the information and apply it in her own case).
If the woman has signs of AIDS and/or of other illness, refer her to appropriate services.
How to provide support
Conduct peer support groups for women who have HIV-infection and couples affected by HIV/AIDS:
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Led by a social worker and/or woman who has come to terms with her own HIV infection.
Establish and maintain constant linkages with other health, social and community workers support services:
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To exchange information for the coordination of interventions
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To make a plan for each family involved.
Refer individuals or couples for counselling by community counsellors.
G6. GIVE ANTIRETROVIRAL DRUGS (ART) TO TREAT HIV INFECTION
Use these charts when starting ARV drug(s) and to support adherence to ART
Support the initiation of ART
If the woman is already on ART continue the treatment during pregnancy, as prescribed
G9, G12.If the woman is not on ART treatment and is tested HIV-infected, start ART
G9, G12.Write the treatment plan in the Home Based Maternal Record.
Give written instructions to the woman on how to take the medicines.
Refer her to HIV services for further assessment and modify ART and other treatments accordingly.
Modify preventive treatment for malaria according to national guidelines
F4.
Explore local perceptions about ART
Explain to the woman and family that:
ART will improve the woman's health and will greatly reduce the risk of infection to her baby. The treatment will not cure the disease.
The choice of regimen depends on the stage of the disease C19.
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If she is in early stage of HIV infection, she will need to take medicines during pregnancy, childbirth and during breastfeeding to prevent transmission of HIV to her child (PMTCT). Progress of disease will be monitored to determine if she needs additional treatment.
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If she has advanced HIV disease she will need to continue the treatment even after childbirth and postpartum period, for life.
Her baby will need prophylaxis for 6 weeks after brith.
She may have some side effects but not all women have them. Common side effects like nausea, diarrhoea, headache or fever often occur in the beginning but they usually disappear within 2–3 weeks. Other side effects like yellow eyes, pallor, severe abdominal pain, shortness of breath, skin rash, painful feet, legs or hands may appear at any time. If these signs persist, she should come to the clinic.
Give her enough ART tablets for 2 weeks for herself (and her baby) or till her next visit.
Ask the woman if she has any concerns. Discuss any incorrect perceptions.
Support adherence to ART
For ART to be effective:
Advise woman on:
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which tablets she needs to take during pregnancy, when labour begins (painful abdominal contractions and/or membranes rupture) and after childbirth.
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taking the medicine regularly, every day, at the right time. If she chooses to stop taking medicines during pregnancy, her HIV disease could get worse and she may pass the infection to her child.
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if she forgets to take a dose, she should not double the next dose.
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continue the treatment during and after the childbirth (if prescribed), even if she is breastfeeding.
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taking the medicine(s) with meals in order to minimize side effects.
For newborn:
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Give the first dose of medicine to the newborn preferably 6-12 hours after birth G12.
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Teach the mother when and how to give treatment to the newborn K13.
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Tell the mother that she and her baby must complete the full course of treatment as prescribed.
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Tell her that they will need regular visits after delivery and throughout infancy.
Explain to her when and where to go for the HIV-infection related visit.
Record all treatment given. If the mother or baby is referred, write the treatment given and the regimen prescribed on the referral card.
DO NOT label records as HIV-infected
DO NOT share drugs with family or friends.
G7. COUNSEL ON INFANT FEEDING OPTIONS
These recommendations assume that the national authorities have decided that the maternal and child health programmes will principally support breastfeeding and antiretroviral treatment as the way to ensure infants born to HIV-infected mothers the greatest chance of HIV-free survival.
Explain the risks of HIV transmission through breastfeeding and not breastfeeding
Four out of 20 babies born to known HIV-infected mothers will be infected during pregnancy and delivery without ART. Three more may be infected by breastfeeding.
The risk to the infant is very reduced if the mother is receiving ART in pregnancy, during childbirth and during breastfeeding.
The risk may be reduced if the baby is breastfed exclusively using good technique, so that the breasts stay healthy.
Mastitis and nipple fissures increase the risk that the baby will be infected.
The risk of not breastfeeding may be much higher because replacement feeding carries risks too:
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diarrhoea because of contamination from unclean water, unclean utensils or because the milk is left out too long.
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malnutrition because of insufficient quantity given to the baby, the milk is too watery, or because of recurrent episodes of diarrhoea.
Mixed feeding increases the risk of diarrhoea. It may also increase the risk of HIV transmission.
If a woman does not know her HIV status
Counsel on the importance of exclusive breastfeeding
K2.Encourage exclusive breastfeeding.
Counsel on the need to know the HIV status and where to go for HIV testing and counselling
G3.Explain to her the risks of HIV transmission:
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even in areas where many women have HIV, most women are negative
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the risk of infecting the baby is higher if the mother is newly infected
explain that it is very important to avoid infection during pregnancy and the breastfeeding period.
If a woman knows that she is HIV-infected
Inform the mother about the most appropriate infant feeding options.
Counsel the mother on importance of exclusive breastfeeding for her infant.
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The best for her baby is exclusive breastfeeding for 6 months.
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At six months baby should begin receiving complementary foods and continue breastfeeding until 12 months old. (Use national guidelines for details.)
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Tell her that she will be taking ART while breastfeeding.
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Explain her that she should only stop breastfeeding once a nutritionally adequate and safe diet without breast milk is available.
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If mother chooses breastfeeding, give her special counselling G7.
Counsel the mother on replacement feeding.
Tell her to only give her baby commercial infant formula.
Assess the conditions needed to safely formula feed:
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Are safe water and sanitation assured at home and in the community?
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Is the family able to provide sufficient infant formula milk for baby's needs? K6.
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Can mother and family members prepare the formula cleanly and frequently enough so that it is safe for the baby?
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Is family supportive of formula feeding?
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Does family have access to child health services?
If the mother chooses replacement feeding teach her to prepare infant formula.
All babies receiving replacement feeding need regular follow-up, and their mothers need support to provide correct replacement feeding.
Give special counselling to the mother who is HIV-infected and chooses breastfeeding
Support the mother in her choice of breastfeeding.
Ensure good attachment and suckling to prevent mastitis and nipple damage
K3.Advise the mother to return immediately if:
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she has any breast symptoms or signs
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the baby has any difficulty feeding.
Ensure a visit in the first week to assess attachment and positioning and the condition of the mother's breasts.
Give psychosocial support
G5.Tell her that if she decides to stop breastfeeding at any time, she must stop gradually within one month. During this time she continues taking ART. Depending to her ART regimen she will either continue taking ART (for life) or will stop ART one week after breastfeeding is fully stopped.
In some situations an additional possibility is heat-treated expressed breast milk as an interim feeding option if:
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the baby is born small or ill after birth and temporarily unable to breastfeed;
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mother is unwell and temporarily unable to breastfeed or has mastitis;
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antiretrovial drugs are temporarily not available.
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Teach the mother heat-treating expressed breast milk K5.
G8. TEACH THE MOTHERS SAFE REPLACEMENT FEEDING
If the mother chooses replacement feeding, teach her replacement feeding
Baby should be fed commercial infant formula only if this is safe for the baby
G7Teach the HIV-infected mother safe replacement feeding.
Ask the mother what kind of replacement feeding she chose.
For the first few feeds after delivery, prepare the formula for the mother, then teach her how to
prepare the formula and feed the baby by cup
K9:
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Wash hands with water and soap
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Boil the water for few minutes
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Clean the cup thoroughly with water, soap and, if possible, boil or pour boiled water in it
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Decide how much formula the baby needs from the instructions
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Measure the formula and water and mix them
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Teach the mother how to feed the baby by cup
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Let the mother feed the baby 8 times a day (in the first month). Teach her to be flexible and respond to the baby's demands
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If the baby does not finish the feed within 1 hour of preparation, give it to an older child or add to cooking. DO NOT give the milk to the baby for the next feed
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Wash the utensils with water and soap soon after feeding the baby
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Make a new feed every time.
Give her written instructions on safe preparation of formula.
Explain the risks of replacement feeding and how to avoid them.
Advise when to seek care.
Advise about the follow-up visit.
Explain the risks of replacement feeding
Follow-up for replacement feeding
Ensure regular follow-up visits for growth monitoring.
Ensure the support to provide safe replacement feeding.
Advise the mother to return if:
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the baby is feeding less than 6 times, or is taking smaller quantities K6
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the baby has diarrhoea
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there are other danger signs.
G9. ANTIRETROVIRAL MEDICINES (ART) FOR HIV-INFECTED WOMAN AND HER NEWBORN
This table provides information on the WHO first-line ART treatment options for the HIV-infected woman for her own health or for preventing HIV infection of her infant. See page G12 for details on ARV medicines for the mother and the infant. Use national guidelines for local protocols. Record ART given at the facility.
ART REGIMENS FOR THE HIV-INFECTED WOMAN AND HER NEWBORN INFANT
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| Woman | | Newborn infant |
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Pregnancy | Labour, delivery | Postpartum | Breastfeeding | Replacement feeding |
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ART initiated before pregnancy | Continue ART for life | Once -daily NVP for 6 weeks | NVP once-daily or AZT every 12 hours for 4-6 weeks |
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Tested HIV-infected in pregnancy (Option B+) | Triple ARV (TDF+3TC or FTC+EFV) starting as soon as diagnosed, continued for life |
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Tested HIV-infected in pregnancy (Option B) | Triple ARV (TDF+3TC or FTC+FV) starting as soon as diagnosed. Sent for further assessment to HIV services for the eligibility for the lifetime ART |
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Eligible for treatment for her own health | ART continues for life |
Not eligible for treatment (prophylaxis) | Triple ARV stops after delivery - 1 week after the cessation of breastfeeding |
G10. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS
Use this chart to manage the woman who has a problem while taking ARV medicines. These problems may be side effects of ARV medicines or of an underlying disease. Rule out serious pregnancy-related diseases before assuming that these are side effects of the drugs. Follow up in 2 weeks or earlier if condition worsens. In no improvement, refer the woman to hospital for further management.
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IF WOMAN HAS ANY PROBLEM | SIGNS | ADVISE AND TREAT |
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| Headache |
Measure blood pressure and manage as in C2 and E3. If DBP≤ 90 mm give paracetamol for headache F4.
|
Nausea or vomiting |
Measure blood pressure and manage as in C2 and C3.Advise to take medicines with food. If in the first 3 months of pregnancy, reassure that the morning nausea and vomiting will disappear after a few weeks. Refer to hospital if not passing urine.
|
Fever |
Measure temperature. Manage according to C7-C8, C10-C11 if during pregnancy, and E6-E8 if in postpartum period.
|
Diarrhoea |
Advise to drink one cup of fluid after every stool. Refer to hospital if blood in stool, not passing urine or fever >38ºC.
|
Rash or blisters/ulcers |
If rash is limited to skin, follow up in 2 weeks. If severe rash, blisters and ulcers on skin, and mouth and fever >38ºC refer to hospital for further assessment and treatment.
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Yellow eyes or mucus membrane |
|
G11. PREVENT HIV INFECTION IN HEALTH-CARE WORKERS AFTER ACCIDENTAL EXPOSURE WITH BODY FLUIDS (POST EXPOSURE PROPHYLAXIS)
If you are accidentally exposed to blood or body fluids by cuts or pricks or splashes on face/eyes do the following steps
If blood or bloody fluid splashes on intact skin, immediately wash the area with soap and water.
If the glove is damaged, wash the area with soap and water and change the glove.
If splashed in the face (eye, nose, mouth) wash with water only.
If a finger prick or a cut occurred during procedures such as suturing, allow the wound to bleed for a few seconds, do not squeeze out the blood. Wash with soap and water. Use regular wound care. Topical antiseptics may be used.
Check records for the HIV status of the pregnant woman.
1If woman is HIV-negative no further action is required.
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If woman is HIV-infected take ART based on the country's first line ART regimen for HIV as soon as possible, within 72 hours after exposure to reduce the likelihood of HIV infection and continue for 28 days.
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If the HIV status of the pregnant woman is unknown:
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Start the ART as above.
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Explain to the woman what has happened and seek her consent for rapid HIV test. DO NOT test the woman without her consent. Maintain confidentiality A2.
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Perform the HIV test L6.
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If the woman's HIV test is negative, discontinue the ARV medicines.
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If the woman's HIV test is positive, manage the woman as in C2 and E3. The health worker (yourself) should complete the ARV treatment and be tested after 6 weeks.
Inform the supervisor of the exposure type and the action taken for the health-care worker (yourself).
G12. GIVE ANTIRETROVIRAL DRUGS (ART) TO THE HIV-INFECTED WOMAN AND HER BABY
Give antiretroviral drugs (ART) to the HIV-infected woman and her baby
Give antiretroviral drugs (ART) to the woman
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| Give once daily |
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Give first-line fixed dose combination of TDF + 3TC (or FTC) + EFV | 1 tablet | |
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OR |
TDF | (tenofovir disoproxil fumarate) | 1 tablet | (300 mg) |
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3TC | (lamivudine) | 1 tablet | (300 mg) |
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OR |
FTC | (emtricitabine) | 1 Capsule | (200 mg) |
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EFV | (efavirenz) | 1 tablet | (600 mg) |
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Give antiretroviral drug(s) (ART) to the infant of HIV-infected mother (first 6 weeks of life)
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| Nevirapine (NVP) | Zidovudine (AZT) |
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Oral liquid 5 ml=50 mg | Oral liquid 5 ml=50 mg |
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Give once daily | Give every 12 hours |
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Birth weight | mg | ml | mg | ml |
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=>2.5 kg | 15 mg | 1.5 ml | 15 mg | 1.5 ml |
2.0 - 2.4 kg | 10 mg | 1 ml | 10 mg | 1 ml |
<2.0 kg | | Give once daily |
| |
Dose = 2 mg/kg | Dose = 2 mg/kg |
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1.5 - 1.9 kg | 3.5 mg | 0.35 ml | 3.5 mg | 0.35 ml |
1.0 - 1.4 kg | 2.5 mg | 0.25 ml | 2.5 mg | 0.25 ml |
Use a 2 ml syringe for a baby with birth weight =>2 kg and a 1 ml syringe for a smaller baby. Wash the syringe after each treatment and keep it in the clean and dry place.
Teach the mother measuring the medicine, giving it to the baby and cleaning and storing the syringe.
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If the health-care worker (yourself) is HIV-infected no PEP is required. DO NOT test the woman.