For general information on HIV, including clinical diagnosis, management and psychosocial support, see p251
15.2.1 Additional care for HIV +ve women
Ensure the following additional care is provided during pregnancy, labour, delivery and postpartum period to all HIV +ve women:
• Find out what she has told her partner, labour companion and family and respect this confidentiality
• Use universal precautions as for all HIV patients
- see Appendix 2, p445
• Revise the birth plan
- advise her to deliver in a health facility
- advise her to go there as soon as membranes rupture or labour starts
• Counsel on ARV treatment as appropriate
• Discuss infant feeding choice, see 15.2.2 below
• Modify preventive treatment as appropriate using ARVs if available
• Be sensitive to special concerns and fears
- give psychosocial support, see p254
• Advise on the importance of good nutrition
- talk to family members to encourage the woman to eat enough and help them avoid hard physical work
• Advise her that she is more liable to infections and to seek medical help as soon as possible for:
- fever
- persistent diarrhoea
- respiratory infectons, eg. cough & cold
- burning urination
- vaginal itching or foul-smelling discharge
- severe weight loss
- skin infections
- foul-smelling lochia
During postpartum period:
• Advise on the infectiousness of lochia and blood-stained sanitary pads and how to dispose of these safely according to local facilities
• If not breastfeeding exclusively, advise her to use a family planning method immediately (see p425)
• Breast care: If not breastfeeding, advise as follows:
- breasts may be uncomfortable for a while
- avoid stimulating the breasts
- support breasts with firm well-fitting bra or cloth
- express just enough milk to make breasts comfortable
- advise to seek care if breasts become painful, swollen, red, if she feels ill or has fever
15.2.2 Counselling on Infant Feeding Choice
Note: Special training is needed to counsel an HIV +ve mother about this issue and to support the chosen method. Such mothers should be referred to a suitably trained counsellor. However, if one is not available, or the woman will not seek such help, counsel her as follows:
a) Explain the risks of HIV transmission by breastfeeding & other risks by not breastfeeding
• 25% (5/20) of babies born to HIV +ve mothers will be infected during pregnancy and delivery without ARV treatment
• Another 15% (3/20) may be infected by breastfeeding
• If baby breastfed exclusively the risk may be reduced by good technique keeping the breasts healthy - mastitis & cracked nipples raise HIV infection risk
• The risk of not breastfeeding may be much higher because alternative feeding has its own risks:
- diarrhoea: from use of unclean water, utensils or stale milk
- malnutrition: from insufficient quantity, milk too dilute, or from recurrent diarrhoea
• Mixed feeding may also increase risk of HIV transmission and diarrhoea
b) If a woman has unknown or HIV -ve status:
• Counsel on importance of exclusive breastfeeding and encourage this
• Counsel on need to know HIV status and where to go for VCT
• Explain risks of HIV transmission:
- even in areas where many women have HIV, up to 70% of babies may be born HIV -ve
c) If a woman knows & accepts that she is HIV +ve:
• Tell her about options for feeding, advantages & risks:
- exclusive breastfeeding, then + complementary feeding after 4-6 months old
- exclusive breastfeeding stopping at 3-6 months old if replacement feeding possible after this
If replacement feeding introduced early: mother must stop breastfeeding
- replacement feeding with home-prepared formula or commercial fomula and then family foods (provided this is acceptable, feasible, safe and sustainable/ affordable)
• In some situations other possibilities are:
- expressing and heat-treating her breast milk
- wet nursing by an HIV -ve woman
• Help her to assess choices, decide on the best option and then support her choice
If she chooses breastfeeding: give her special advice (see e) below)
If she chooses replacement feeding: ensure she understands it includes enriched complementary feeding for up to 2 years. If this cannot be ensured, an alternative is exclusive breastfeeding, stopping early when replacement feeding becomes feasible
• All babies on replacement feeding need regular follow up and all their mothers need support to ensure correct use of this method
d) If mother chooses replacement feeding:
• Ask her which kind of replacement feeding she chose
• For the first few feeds after delivery, prepare the formula for her then teach the mother how to do this and how to cup feed the baby:
- wash hands with soap & water
- boil the water for milk preparation for 5-10 minutes
- clean cup carefully with soap & water and if possible boil or pour hot boiled water in it
- decide how much milk and water is needed from the instructions
- measure these amounts and mix well together
- allow the liquid to cool down
- teach mother how to feed baby by cup (8 times daily in the 1st month) and to be flexible and respond to baby’s demands
- if baby does not finish the feed within 1 hour of preparation give it to an older child or add to cooking. Do not use for the next feed!
- wash utensils with soapy and water soon after feeding
- make a new feed each time
• Give her written instructions on safe preparation of formula feeds
• Explain replacement feeding risks & how to avoid them (see section a) above)
• Ensure regular follow-up visits for growth monitoring
• Ensure necessary support for safe replacement feeding
• Advise mother to return if:
- baby feeding <6 times/day or taking smaller amounts
- diarrhoea
- other danger signs
e) If mother HIV +ve and chooses breastfeeding:
• Give special counselling
• Support her in her choice
• Advise mother to breastfeed exclusively (ie. not to give any other drinks or food) for the first 3-6 months
- breast milk is enough and best for young infants
- once the mother decides to stop breastfeeding, this should be stopped abruptly and completely and suitable replacement foods started (see p406+)
• Ensure good attachment and suckling to prevent mastitis and nipple damage (p418)
• Advise her to return immediately if:
- any breast problems
- any baby feeding problems
• Ensure a visit in 1st week to assess the above
• Arrange for further counselling to prepare for possible early stopping of breastfeeding
• Encourage correct condom use to prevent new HIV infection
• Give psychosocial support (p254)
