POLICIES AND

GUIDELINES RELATED
TO HIV / AIDS
Presented by sandhya sahoo
 INTRODUCTION

• The threat of HIV to the Indian working population is

evident from the fact that nearly 90% of the reported HIV
infections are from the most productive age group of 15-49
years.

• Expanding HIV/AIDS policy and programmes in the world

of work is a key component under the mainstreaming
strategy in the National AIDS Control Programme phase-
III (2007-2012).
 AIMS
i. Prevent transmission of HIV infection amongst workers
and their families.
ii. Protect rights of those who are infected and provide access
to available care, support and treatment.
iii. Protect workers from stigma and discrimination related
to HIV/AIDS by assuring them equity and dignity at the
workplace.
iv. Ensure safe migration and mobility with access to
information services on HIV/AIDS.
 GUIDING PRINCIPLES
THE POLICY ADOPTS THE KEY PRINCIPLES OF THE ILO
CODE OF PRACTICE ON HIV/AIDS

1. HIV/AIDS, a workplace issue

2. Non-discrimination
3. Gender equality
4. Healthy work environment
5. Social dialogue
6. No Screening for purpose of Employment
7. Confidentiality
8. Continuation of Employment relationship
9. Prevention
10. Care and support
 KEY STRATEGIES
Prevention of HIV transmission.

Provide education and training at all levels in

workplaces.

Set up interventions for unorganized/informal sector

workers and migrant workers, based on vulnerability
studies and risk assessment.

Enhance access to condoms, treatment of STIs,

universal precaution and Post Exposure Prophylaxis
(PEP).
 CONT…

Widen scope of social security coverage to include

HIV in employee and family assistance programmes,
health insurance etc.
Undertake vulnerable studies/epidemiological
surveillance at the workplace to gather
data/information for taking informed policy and
programmatic decisions.
1. Creating and ensuring an enabling environment to
discourage stigma and discrimination towards
people infected and affected by HIV/AIDS
2. Provision of counselling facilities and care and
support services
3. Strengthening Public-Private Partnerships in
HIV/AIDS Prevention and care.
4. Strengthen partnership of private sector with the
SACS/ILO/other expert agencies to offer technical
assistance for setting up workplace policy and
programmes
 IMPLIMENTATION AND
MONITORING
1. At the national and state levels
a) National AIDS Control Organisation proposes to form
a Steering Committee on HIV/AIDS and the World of
Work comprising of employers and workers
organizations, development agencies, NACO,
MOL&E and PLHIV to oversee/facilitate
implementation of broad policy guidelines and take
strategic decisions related to HIV/AIDS programmes
in the world of work in India.
b) MOL&E and NACO will also take up issues
necessary for action at the level of National Council
on AIDS, chaired by the Prime Minister.
c) State Council on AIDS are proposed to be set up at
the state levels by SACS under the NACP-III.
2. At the workplace
I. Every workplace – organization, institution,
businesses, company etc. – should establish an
HIV/AIDS Committee to coordinate and
implement the HIV/AIDS workplace policy and
programme.
II. The scope and content of the policy and
programme will depend on the
organization’s/company’s size, needs and
resources.
III. A checklist for planning and implementing a
workplace policy on HIV/AIDS

IV. Periodic reviewing and monitoring of the policy will

allow the organization or the company to keep up with
and adjust to a constantly changing internal and external
situation.
V. Regular review of the workplace programme will
ensure that it is managed efficiently, producing the
expected results and meeting the needs of the employees.
3. Budgetary and Financial Provisions
All the stakeholders viz. Central/State
Governments Ministries/Departments,
employers/workers organizations, public and
private sector enterprises, key national
organizations and civil societies etc.
 GUIDELINE FOR PPTCT IN INDIA
There are an estimated 2.1 million (2011) People
Living with HIV (PLHIV) in India, with National
adult HIV prevalence of 0.27% (2011).
Of these, women constitute 39% of all PLHIV while
children less than 15 years of age constitute 7% of all
infections
Mother-to-child-transmission of HIV is a major
route of HIV infection in children.
in india (2017) 2.1million living with hiv. 0.2%
adult hiv prevalence (age 15- 49, 88000 new hiv
infections. 69,000 aids related deaths, 56% are in
antiretroviral treatment. Source( UNAIDS DATA
2018)
 CONT…
India has the third largest HIV epidemic in world. In
2017, hiv prevalence among adult ( aged 15-45) was
estimated 0,2%. india’s huge population (1.3 billion)
this equates to 2.1 million people living with HIV
Overall, India’s HIV epidemics is slowing down
between 2010 AND 2107 new infections declined
by27% and AIDS related deaths more than halved,
falling by 56%.
 However, in 2017 new infections increased to 88,000
from 80,000 and AIDS related death increased to
69,000 from 62,000. USAIDS(2017)
 PPTCT AND ART IN PREGNANT
WOMEN

•Parent-to-child transmission of HIV is a major route of new HIV

infections in children. Children born to women living with HIV
acquire HIV infection from their mother, either during
pregnancy, labour/delivery or through breast feeding
•which is largely preventable with appropriate intervention, by
providing Anti-retroviral therapy (ART) to mothers and Anti-
Retroviral (ARV) prophylaxis to infants.
•these HIV infected pregnant women have to be detected and
provided with timely ART in order to reduce mother to child
transmission and ultimately to eliminate paediatric HIV.
PPTCT SERVICES
 CONT..

•Currently, the major activities focused under

PPTCT services have been Prong- 3 and 4.
However, Prong 1 and prong 2 are also
emphasized, to achieve the overall results of the
PPTCT Programme.
 GOAL AND OBJECTIVES OF
PPTCT SERVICES IN INDIA

Vision:
Women and children, alive and free from HIV
Goal:
To work towards elimination of paediatric HIV and
improve maternal, newborn and child health and
survival in the context of HIV infection
 OBJECTIVES:
To detect more than 90 % HIV infected pregnant women in
India
To provide access to comprehensive PPTCT services to more
than 90 % of the detected pregnant women
To provide access to early infant diagnosis to more than 90 %
HIV exposed infants
To ensure access to anti-retroviral drug (ARVs) prophylaxis or
Anti-Retroviral Therapy (ART) to 100 % HIV exposed infants
To ensure more than 95 % adherence with ART in HIV infected
pregnant women and ARV/ ART in exposed children
 RISK OF HIV TRANSMISSION FROM
MOTHER TO CHILD WITH ARV
INTERVENTIONS

• ARV Intervention Risk of HIV Transmission from

Mother to child
• No ARV; breastfeeding 30-45%

• No ARV; No breastfeeding 20-25%

• Short course with one ARV; breastfeeding 15-25%

• Short course with one ARV; No breastfeeding 5-15%

• Short course with two ARVs; breastfeeding 5%

• 3 ARVs (ART) with breastfeeding 2%

• 3 ARVs (ART) with No breastfeeding 1%

ESSENTIAL PACKAGE OF PPTCT
SERVICES IN INDIA INCLUDES
 PREGNANT WOMEN AND STI/
RTI SERVICES

•All pregnant women should be screened for syphilis.

Syphilis is one of the easily treatable Sexually
Transmitted Infection (STI/RTI) caused by Treponema
pallidum, which can be transmitted to sexual partners
as well as from infected pregnant woman to her new
born child.
•The rapid plasma regain test or veneral disease
laboratoryTest (VDRL Test) are the most commonly
used screening tests to detect syphilis.
 PROCESS OF SCREENING ANC
WOMEN

ANM at the village/subcentre level will do screening test

for HIV and Syphilis using whole blood finger prick test.
If the HIV test is reactive then the pregnant woman will be
referred to stand alone ICTC for confirmation of HIV by
rapid tests. The patient then undergoes pre-test counselling at
the ICTC by the ICTC counsellor.
The ICTC collects 5 ml blood for HIV rapid tests and RPR
test.
After HIV and RPR testing, the patient returns to the ICTC
counsellor for post test counselling.
 CONTINUM CARE UNDER
PPTCT
•With the revision of PPTCT guidelines that
recommend use of the more efficacious Multi Drug
ART regimen.
•it is important to consider Prong-3 of National PPTCT
programme as a continuum of interventions rather
than a one-time activity.
•This requires close coordination between various
implementing components for PPTCT-ART linkage,
Early Infant Diagnosis (EID), Paediatric ART services
etc.
 THE CONTINUUM OF CARE INVOLVES THE
FOLLOWING STEPS
1. Increasing uptake of PPTCT services by pregnant women.
2. Counselling and Testing of pregnant women as an integral
part of ANC Comprehensive Services package.
3. Detection of HIV infected pregnant women.
4. Linking HIV infected pregnant women to Care, Support and
Treatment services.
5. Initiating ART for all HIV infected pregnant women
regardless of CD4 count
6. Obtain blood sample for cd4 count.
7. counselling on birth-planning and institutional deliveries
8. emergency labour-room care services
9. Provision of Syrup Nevirapine for the new born infant from birth
till 6 weeks of age (minimum).
10. CPT initiated and that link with EID.
11. If the infant is detected positive in EID programme then ensure
initiation of Pediatric ART
12. Follow-up until breastfeeding period is over.
13. At six weeks of age of baby, do DBS test and confirm with
WBS test.
14. If the age of baby is more than 6 months, then do antibody
(rapid) test first, if found positive then only DBS sample should be
sent.
• Confirmation of diagnosis of child using 3 anti-body tests (Rapid)
at ICTCs at 18 months of age.
 CRITERIA FOR ART INITIATION

• In HIV infected pregnant women the dictum should

be “do not delay ART initiation”.

• ART eligibility in pregnant women:

• Initiate lifelong ART in all pregnant women with
confirmed HIV infection regardless of WHO clinical stage
or CD4 cell count. TDF + 3TC + EFV is recommended as
first-line ART in pregnant and breastfeeding women,
(including pregnant women in the first trimester of
pregnancy and women of childbearing age)
• ART shall be initiated only at ART centre.
 CO-TRIMOXAZOLE IN PREGNANCY
 

• The indications for co-trimozaxole initiation in pregnant

women are same as those for other adults (CD4≤250
cells/cmm). Co-trimoxazole prophylaxis is helpful in reducing
morbidity and mortality as it prevents Opportunistic Infections
(OIs) such as Pneumocystis jiroveci pneumonia (PCP),
toxoplasmosis, diarrhoea as well as other bacterial infections.
Starting Co-trimoxazole in pregnancy
• Co-trimoxazole should be started if CD4 count is ≤ 250
cells/mm3 and continued through pregnancy
• Ensure that pregnant women take their folate supplements
regularly.
 ART FOR HIV INFECTED
PREGNANT WOMEN
The recommended first-line regimen for HIV infected
Pregnant Women is
•Tenofovir (TDF) (300 mg) + Lamuvidine (3TC) (300
mg) + Efavirenz (EFV)(600 mg) (if there is no prior
exposure to NNRTIs (NVP/EFV) at any gestational
Age
 THE ALTERNATE REGIMEN IF THE
PREGNANT WOMEN ARE UNABLE TO
TOLERATE PREFERRED FIRST-LINE
REGIMEN ARE AS BELOW:

First line ART for Preferred Alternate

First-line Regimen

First-line Regimen

HIV positive TDF + 3TC+ EFV AZT+ 3TC+EFV

AZT+3TC+NVP
pregnant women TDF+ 3TC+NVP
 ARV FOR PREGNANT WOMEN AND
EXPOSED INFANT

 All HIV positive pregnant women including those presenting

in labour and breast feeding should be initiated on a triple drug
ART regardless of CD4 count and clinical stage (Test and
Treat), for preventing Mother-to-Child Transmission and
continue lifelong ART.

`The duration of Nevirapine prophylaxis to HIV exposed

infant should be minimum of 6 weeks. However, this duration
of Nevirapine prophylaxis should be extended to 12 weeks, if
the duration of ART in pregnant mother falls short 4 weeks
during pregnancy and before delivery or reporting at the time
labour or after delivery, if not already on ART
 CLINICAL AND LABORATORY
MONITORING OF HIV
•Look for clinically significant anaemia among HIV-
infected pregnant women
•WHO clinical staging will help in monitoring the
patient clinically, potential disease progression or
treatment failure.
•Weight loss is one of the indicators used to determine
deteriorating clinical stage, but this can be difficult to
assess during pregnancy.
•Assessments of haemoglobin or Liver Function Tests
(LFT), Renal Function Tests (RFT) should be
performed when warranted by clinical signs &
symptoms.
 ART REGIMENS IN PREGNANT AND
BREASTFEEDING WITH HIV

Target Population Drug Regimen Remark

 
Pregnant and breastfeeding TDF + 3TC + EFV FDC of TDF (300 mg) + 3TC (300
women with HIV (ART Naïve / mg) + EFV (600 mg)- To be given 2
hours after low-fat or fat-free dinner
“Not-already” receiving ART)
 
 

Pregnant and breastfeeding The same ART regimen must E.g. If they are already on AZT
women with HIV already be continued +3TC +NVP/ EFV, continue the
  same regimen
receiving ART
 
 

ART regimen for pregnant TDF + 3TC and LPV/r FDC of TDF (300 mg) + 3TC (300
women having prior exposure to mg) -- 1-tab OD and
NNRTI for PPTCT FDC of LPV (200 mg)/r (50 mg) -
  2-tab BD
 
 CARE AND ASSESSMENT FOR
WOMEN PRESENTING
DIRECTLY-IN-LABOUR
•Labour room nurse will offer bed side counselling
and HIV screening test
• If the woman consents, screen using the “Whole
Blood Finger Prick test” in delivery room or labour
ward
• If detected HIV positive, the medical Officer i/c
will initiate TDF + 3TC + EFV and ensure
immediate linkage to ART centre Labour room
nurse informs the ICTC counsellor and lab
technician for further confirmation of HIV test as
per guidelines
  
PREGNANT WOMEN
PRESENTING IN ACTIVE
LABOUR:
Maternal Status Intra-partum Post-partum
 

Presenting in Initiate TDF (300 Continue TDF

active labour, no mg) + 3TC (300 mg) + 3TC
prior ART (300 mg) + EFV (300
  (600 mg) mg) + EFV (600
  mg)
 
 SAFE DELIVERY TECHNIQUE
• Standard/Universal Work Precautions (UWP)
• Do NOT rupture membranes artificially (keep
membranes intact for as long as possible).
• Minimize vaginal examination and use aseptic
techniques.
• Avoid invasive procedures like foetal blood sampling,
foetal scalp electrodes.
• Avoid instrumental delivery as much as possible.
•Avoid routine episiotomy as far as possible.
• Suctioning the newborn with a nasogastric tube
should be avoided unless there is meconium staining
of the liquor.
FALSE LABOUR
•In the case of false labour or mistaken ruptured
membranes, for women taking ART should continue
with normal dosing schedule of the combination
regimen
•Caesarean section is not recommended for prevention
of mother-to-child-transmission and only if there is an
Obstetric indication for the same.
 SAFER SURGICAL TECHNIQUES
• Use of ‘dry’ haemostatic techniques to minimize bleeding
• During Caesarean section, wherever possible, the membranes are
left intact until the head is delivered through the surgical incision.
The cord should be clamped as early as possible after delivery;
• Use of round-tip blunt needles for Caesarean section
• Do not use fingers to hold the needle;
• Use forceps to receive and hold the needle
• Observe good practice when transferring sharps to surgical
assistant eg. holding container for sharps.
• For disposal of tissues, placenta and other medical/infectious waste
material from the delivery of HIV-infected deliveries Standard
waste disposal management guidelines should be followed.
 ARV PROPHYLAXIS FOR
INFANT

• Duration of daily infant NVP prophylaxis will depend on

“how long the mother was on lifelong ART [for a minimum
of 4 weeks or not]”
• 6 week-Nevirapine prophylaxis should be increased to 12
weeks, if ART to the mother has been started in late pregnancy,
during or after delivery
• • The recommendation on extended Nevirapine duration (12
weeks) applies to infants of breast-feeding women only and not
to those on exclusive replacement feeding
• Infants of women with prior exposure to NVP should get syrup
Zidovudine (AZT) in place of syrup Nevirapine
 RECOMMENDED ARV PROPHYLAXIS FOR HIV
EXPOSED INFANTS
Infants Birth Weight NVP daily dose NVP daily dose (in ml) Duration
  (in mg) (10 mg Nevirapine in 1  
ml suspension)
   
 
Infants with birth 2 mg/kg once 0.2 ml/kg once daily Up to minimum of 6 weeks of
weight < 2000 g daily age
  regardless of whether
exclusively
Birth weight 2000 10 mg once 1 ml once daily breast fed or exclusively
– 2500 g daily   replacement fed
      Extended to 12 weeks, if the
Birth weight > 15 mg once 1.5 ml once daily duration of ART received by
2500 g daily   the
  mother is less than 24 weeks
and
she is breast feeding
 PREGNANT WOMEN CO-
INFECTION
PREGNANT WOMEN WITH ACTIVE TB
• A recent study in India 2 found that maternal TB increases the risk
of HIV transmission from mother-to-child by 2.5 times.
• Intensified Case Finding (ICF) as per national TB-HIV protocols
must be instituted for all HIV infected pregnant women.
• HIV-infected pregnant women with active tuberculosis should start
ART, irrespective of CD4 cell count.
• EFV is the preferred NNRTI for Pregnant women which can be
used in those with concurrent TB treatment also.
• For those HIV-TB co-infected women not able to tolerate EFV, a
NVP-based or a boosted PI regimen can be considered after expert
clinical consultation.
• With the use of a boosted PI regimen, Rifampicin should be
substituted with Rifabutin.
•For Women Co-infected with HIV and HBV
• If treatment is required for HBV infection3, ART
should be started irrespective of the CD4 cell count or
the WHO clinical stage:
• The regimen preferred is TDF + 3TC + EFV.
•There is increase the risk of hepatotoxicity with
certain antiretroviral drugs, specifically NVP and
protease inhibitors.
•Should be counselled about signs and symptoms of
liver toxicity.
 SAFER INFANT FEEDING

• A – Affordable F – Feasible A – Acceptable S – Sustainable S –

Safe
• Mothers living with HIV should breastfeed for at least 12
months and may continue breastfeeding for up to 24 months or
beyond .
• ARVs require ongoing care and monitoring and reduce risk of
PTCT in the following ways:-
Reduce viral replication and viral load
Treat maternal infection
Protect the HIV-exposed infant
Improve overall health of mother
 THE POST-PARTUM PERIOD
WITHIN AN HOUR OF DELIVERY
• Infants born to HIV-infected mothers should receive NVP
prophylaxis immediately after birth.
• Infants after delivery should be put on the mother’s
• initiation of breast milk within 1 hour of birth.
• Infants should be given exclusive breastfeeds for the first six months
preferably.
• Exclusive replacement feeding may be done only if the mother has
died or has a terminal illness or decides not to breastfeed despite
adequate counselling.
• Counsel and support parent to give infant NVP prophylaxis using the
syringe/dropper provided.
• Emphasize on washing the equipment with clean boiled water after
every use.
 POST-PARTUM FOLLOW-UP AND CARE
EXTENDS BEYOND THE SIX-WEEK
POSTPARTUM PERIOD AND INCLUDES:
• Assessment of maternal healing after delivery and evaluation for
post-partum infectious Complications.
• Continued counselling and information on fertility choices and
effective post-partum
• Contraceptive methods as well as condom promotion and
ensuring Cu-T IUD adoption and
• Continued motivation for NSV for males at 18 months
specifically, in HIV infected pregnant
• Women, there should be linking of the baby to the Early Infant
Diagnosis (EID) programme And ART programme for
mother/child as indicated.
 COUNSEL AND FOLLOW-UP MOTHER-
BABY (M-B) PAIRS AFTER DISCHARGE

1.Counselling on Issues Related to the

Mother:
2.Counselling for Issues of Infant to the
Parents/ Caregivers
SUMMERY
CONCLUSION