International Guidelines

As part of the global effort to eliminate mother-to-child transmission of HIV (MTCT), the World Health Organization (WHO) periodically issues guidelines related to the prevention of mother-to-child transmission (PMTCT) using evidence-based interventions and strategies to develop international principles and recommendations. In this section of the Toolkit you will find the most current WHO guidelines addressing PMTCT and other relevant issues, including infant feeding, antiretroviral therapy, nutrition,and counseling and testing. Related resources included throughout this section summarize the key recommendations and rationale supporting these recommendations.

Recently, important new evidence emerged on the use of antiretroviral (ARV) prophylaxis to prevent MTCT, including during breastfeeding, on the optimal time to initiate antiretroviral therapy (ART) in individuals who need treatment, and on safe feeding practices for HIV-exposed infants. This evidence forms the basis for the new recommendations contained in WHO’s 2010 revised guidelines. The 2010 guidelines were developed to provide international standards, primarily for low- and middle income settings, in support of the global scale-up of more effective interventions aimed at preventing MTCT in resource-limited settings. The 2010 revised PMTCT recommendations are based on two key approaches:

1. Lifelong ART for HIV-infected women in need of treatment for their own health, which is also safe and effective in reducing MTCT.

2. ARV prophylaxis to prevent MTCT during pregnancy, delivery and breastfeeding for HIV-infected women not in need of treatment.

These revised recommendations emphasize the need to have a unified approach to preventing MTCT throughout pregnancy, labor and delivery, postpartum, and the breastfeeding period.

Infant Feeding (2 resources)

The optimal infant feeding decision for HIV-infected mothers living in resource-constrained settings remains a major challenge in preventing mother-to-child transmission of HIV. HIV-infected mothers who breastfeed their babies risk transmitting the virus to their babies through breastmilk. However, replacement feeding (with infant formula) often poses risks of illness and death from malnutrition, pneumonia, and diarrheal diseases due to contaminated water. The 2010 WHO guidelines emphasize that breastfeeding is a strategy for maximizing infant HIV-free survival. The updated guidelines are an effort to balance the risks of mother-to-child transmission with the risks of increased morbidity and mortality associated with non-breastfeeding.

    Antiretroviral Therapy (4 resources)

    The recently revised 2010 WHO guidelines for the prevention of mother-to-child transmission recommend that all women eligible for ARTs (based on CD4 ≤ 350 cells/mm3 or those in WHO clinical stages 3 or 4) begin lifelong treatment with ART for their own health. ART should be initiated as early as possible, regardless of whether one is pregnant and if pregnant, regardless of gestational age. Infants should also receive ARV prophylaxis during the first six weeks of life. Women who are pregnant but not eligible for lifelong ART should be started on prophylactic ARVs for preventing mother-to-child transmission of HIV. Prophylactic ARVs should be initiated at 14 weeks gestation or as soon as possible thereafter.

      Nutrition (2 resources)

      The relationship between nutrition and HIV/AIDS is complex and not fully understood, though evidence does demonstrate that HIV infection negatively affects nutritional status. Women living in resource-limited settings are at increased risk of poor nutrition during pregnancy and lactation. HIV-infected women may be at even greater risk, because of the effects of HIV on dietary intake, the absorption and use of nutrients, and related metabolic processes. Pregnant women require enhanced follow-up and support so that they can achieve adequate nutrition during antenatal and postnatal care. Guidelines recommend an assessment of a woman’s nutritional status, diet, and social and other conditions. Proper nutritional counseling should address: • Ways of achieving adequate weight gain during pregnancy • The prevention of anemia • The importance of an adequate diet to support lactation and prevent the nutritional depletion associated with childbearing

        Counseling and Testing (3 resources)

        Providers should determine the HIV status of women of reproductive age. Women who are negative need counseling on prevention messages to help them reduce their risk of infection. For HIV-positive women, prevention of mother-to-child transmission (PMTCT) efforts should focus on preventing unintended pregnancies and linking clients with appropriate services, such as antiretroviral (ARV) treatment or prophylaxis, family planning, and counseling on appropriate infant feeding. Global guidance recommends provider-initiated counseling and testing (PICT) in health facilities, including antenatal clinics and other reproductive health settings. HIV counseling and testing should be a routine component of antenatal care. HIV-negative women should be tested as early as possible in each new pregnancy. Repeat testing late in pregnancy is also recommended for HIV-negative women in areas where HIV is epidemic.