Module II: Feeding and HIV Testing for Exposed Infants

1. Module II: Feeding and HIV Testing for Exposed Infants This module, we will discuss: Unit 1: Infant Feeding Guidelines Unit 2: HIV Testing and Treatment for Infants

2. Feeding and HIV Testing for Exposed Infants • Who is the counselling for? • Mothers and caregivers of infants under 18 mo • Goals: • Discuss ongoing HIV risk from breastfeeding and the implications on test results • Support the mother as she makes choices about feeding for the infant • Ensure that the mother understands the testing procedure for infants under 18 months • If positive, discuss need to start ART immediately

3. Multiple Counselling Sessions May Be Needed • There will likely be multiple counselling sessions from birth to 18 months– at every visit counselling should be given • Just after giving birth, the mother should be counselled on: • HIV testing for herself: if she did not test in antenatal, she should be tested soon after delivery • Infant feeding practices • HIV testing for the infant: at 6 weeks, the infant can be tested

4. Module II: Feeding and HIV Testing for Exposed InfantsUnit 1: Infant Feeding Guidelines By the end of this unit, participants should be able to: Discuss the benefits and risks of infant feeding options Explain reasons for exclusive breastfeeding Explain which job aids can help you counsel according to the MoHrecommendations for exclusive breastfeeding

5. Counselling on Infant Feeding Options for HIV Infected Mothers is Important • Nearly 40% of MTCT occurs during breastfeeding • Yet, breastfeeding is the main source of nutrition for infants in Uganda • Counsellors should consider most appropriate option determined by mother’s individual circumstances

6. Risks/Benefits of Breastfeeding • What are the risks of breastfeeding feeding? • What are the benefits of breastfeeding?

7. Overview of Infant Feeding Guidelines for Exposed Infants • HIV+ mothers should exclusively breastfeed infants for first 6 months • Complementary feeds from 6 months • Continue to breastfeed for 12 months • During breastfeeding, infant should receive daily NVP until 1 week after stopping breastfeeding • Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided • When an infected mother decides to stop breastfeeding at any time, they should do so over the course of 1 month

8. Uganda Infant Feeding Algorithm

9. Case Studies: Using the Infant Feeding Algorithm • Form groups of 3—each group should review all 3 case studies • Look in your participant manual for the scenarios • When you are finished, we will discuss your answers

10. Supporting Choices • REMEMBER: The ultimate choice as to the feeding method is the mother’s • Counsellor’s role is to support the mother’s choice and ensure that risk is reduced within that choice

12. Infant Feeding Guidelines What are 2 benefits and 2 risks of an HIV positive mother breastfeeding her baby? Why does breastfeeding need to be EXCLUSIVE for the first 6 months? Which job aids can help you counsel caregivers about reducing risk through breastfeeding?

13. Module II: Feeding and HIV Testing for Exposed InfantsUnit 2: Infant HIV Testing & Treatment By the end of this unit, participants should be able to: Discuss the steps in counselling for infant HIV testing Identify when to start an HIV positive infant on ART Identify the tools that can help a health worker interpret the test results

14. Review the Child’s Situation • Confirm relationship with caretaker (biological parent, aunt, other) • What are the reasons for testing the child? • If parent, have you ever had an HIV test? • If yes, what were the results? • Positive: confirmation needed • Negative: what are the reasons for testing the child? • If no, determine reasons for testing the child as well as encourage the parent to also be tested.

15. Discuss HIV Risk Issues and Concerns ASSESS • Ask about the child’s health • Ask about the health of the parents • If mother is known to have HIV infection or the mother’s status is unknown, ask: • What were the circumstances during the biological mother’s pregnancy? During delivery? • Is/was the child breastfed? For how long? • Is/was mixed feeding done?

17. Discussion: Testing in the Child’s Best Interest In what situations would an HIV test not be in an infant’s best interest?

18. Testing for HIV-Exposed Infants • Antibody Testing • All exposed infants will test antibody positive during the first 18 months of life • A positive antibody test does not mean that the child is HIV infected, only that the child is exposed • DNA PCR Testing • With DNA PCR, if result is positive, the child is positive • With DNA PCR, if the test is negative, and the child continues to breastfeed, exposure is ongoing • With ongoing exposure, final testing should be done 6 weeks after breastfeeding stops

20. Case Studies: Using the Testing Algorithm • An HIV infected mother of a 13 month old baby attends the clinic. Although she tried to wean the baby at one year, she has been breastfeeding on and off for the last month. Six weeks ago, the baby’s DNA PCR test was negative. How would you interpret the baby’s test result and what do you do? • A caregiver of a 9 month old baby comes to your clinic with a 6 month old baby, but the mother’s status is unknown. The rapid test was negative. How would you interpret the baby’s test result?

21. What are the Key Counselling Messages for Infant Testing? ADVISE • During the pre-test counselling session for the first DNA PCR, explain to the caregiver that: • If the test is positive, the child will start on ARVs right away. • At the time of starting ARVs, the child will also be given a 2nd DNA PCR to double-check HIV status • If the 2nd test is discordant, then a 3rd DNA PCR will need to be done– discordant test results are rare, but they do sometimes occur.

22. Preparation and Consent for HIV Testing ADVISE • Explain benefits of HIV testing for the infant • Early diagnosis=early treatment =better outcomes AGREE • A parent or legal guardian must consent for an infant’s HIV test • Explain the test and the testing process • Establish a time for the parent to return to receive the test results

23. Closing of Pre-Test ASSIST • Explore support for infant feeding choice • Discuss who will be told of the infant’s test result and support disclosure, if needed ARRANGE • Referrals • When /how the client will pick up test results • Document the counselling session in patient’s file

27. Infants Between 18 and 24 Months • By 18 months, infants have lost maternal antibodies– at this age, an HIV antibody test is accurate to determine the child’s status. • Other elements of counselling are the same: • Ask about breastfeeding practices and other ongoing risk • For those still breastfeeding after 18 months, they need to be re-tested (with antibody test) 6 weeks after breastfeeding has stopped • After 12 months, HIV positive mothers should be advised to stop breastfeeding if the baby is not infected

28. Closing: ASSIST and ARRANGE ASSIST • Identify how counsellor can support risk reduction and positive living plans • Discuss how counsellor can support disclosure of the infant’s status to others ARRANGE • Referrals, follow-up visits • Document the session in the patient’s file

30. Reviewing the Process • Review the Counselling Observation Tool– Feeding and HIV Testing for Exposed Infants

31. COUNSELLING ON FEEDING AND HIV TESTING FOR EXPOSED INFANTS: DEMONSTRATION

32. Using the Tools: Explaining Results • What key messages do you give to an HIV+ mother who is still breastfeeding and the infant’s first PCR is negative? • Is one positive PCR test enough to start a child on ART? How do you explain this to the caregiver? • What do you say to an HIV positive mother with her 3 month old infant who is breastfeeding?

33. Infant HIV Testing & Treatment What are the steps in counselling and testing an HIV-exposed infant? When do you start an HIV-positive infant on ART? Which tools can you use to interpret the results of a DNA PCR?

34. Key Messages for this Module • When counselling mothers on infant feeding choice, exclusive breastfeeding is recommended for the first 6 months. • Infants are tested using the DNA PCR, which differs from the HIV antibody test used with older children and adults. • During the pre-test counselling, caregivers should be advised that multiple tests may be needed to determine the infant’s status.

35. Key Messages (2) • Infants under 2 years with a positive HIV test start ART right away– early start of ART reduces mortality. • The Testing Algorithm can assist the health worker interpret results and the Paediatric Counselling Flipchart can help the health worker counsel the caregiver.