Antenatal Clinic

Antenatal Clinic

Testing for HIV

Treatment for HIV

VL Monitoring and Management

Screening for TB and other OI's

Prevention of transmission of Syphilis, HBV and other infections

Other care

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Antenatal Clinic

• Recognise the pregnant client that requires urgent attention as outlined in BANC Plus and manage/refer as appropriate
• Identify the pregnant client who needs secondary level antenatal care as outlined in BANC Plus and manage/refer as appropriate
• Provide routine antenatal care to the woman not requiring urgent referral.

Testing for HIV

 

HIV Testing: Provider Initiated Counselling and Testing (PICT) should be provided to all women with unknown or HIV-negative status:

• Offer an HIV test at ANC first/booking visit.
  • If she tests negative, HIV testing should be repeated at scheduled antenatal visits, at approximately 4-weekly intervals, e.g., for BANC+ clients, this could be at 20, 26, 30, 34, and 38 weeks gestation
  • During her labour/delivery admission
• Syphilis testing should be aligned with the HIV testing schedule (See “Syphilis”).
  • If a woman tests positive for HIV, but tests negative for syphilis, repeat syphilis testing should continue at the intervals described above.
  • If a woman tests positive for syphilis but tests negative for HIV, repeat HIV testing should continue at recommended intervals
• Offer couple/partner testing to promote prevention, access to HIV care and treatment, and/or manage serodifferent results (when one partner has HIV and the other partner does not).
• If the woman and/or her partner test HIV-negative, provide HIV prevention information (Go to “Prevention of HIV”).
• Women who choose not to be tested should be offered ‘post-refusal’ counselling and offered a re-test at every subsequent visit.
• If a woman tests HIV-positive at any stage, encourage testing of her other children, and linkage to HIV care and treatment as necessary.
• For the HIV testing algorithm, including the management of discrepant HIV test results, refer to the HTS Guideline.

Treatment for HIV

• All pregnant women newly diagnosed with HIV are eligible for lifelong ART regardless of gestation, CD4 count, or clinical stage.
• Creatinine and CD4 count should still be done to determine her renal function and the need for prophylaxis for pneumocystis jerovecii pneumonia (PJP) and cryptococcal meningitis (CM).
• TDF, 3TC, and DTG (as the fixed-dose combination TLD) is the preferred regimen for women who are newly initiating, or re-initiating, ART. ART should be initiated on the same day as HIV diagnosis10, and after contra-indications to ART have been excluded (Go to “ART Initiation Algorithm”).
• Pregnant women who are already on TLD at entry into antenatal care, should continue their current TLD regimen.
• Pregnant women who are already on ART at entry into antenatal care but not yet on DTG, should be transitioned to a DTG- containing regimen as a matter of urgency (see also “Switching Existing Clients to DTG-containing Regimens”)
  • Pregnant women on efavirenz-containing ART, or women on AZT, 3TC and DTG (as a second-line regimen), should be switched to TLD at their first antenatal visit. The result of their 1st VL (to be done at entry into antenatal care as outlined below) will not influence the decision to switch, and outstanding VL results should therefore not delay her switch to TLD. If her VL is ≥ 50 c/mL, manage her as per the “VL Non-Suppression Algorithm”).
  • Pregnant women on a LPV/r-containing regimen should await the results of their 1st VL to be done at entry into antenatal care, and be managed as per the Switching Existing Clients to DTG-containing Regimens table on page 14 of the ART Clinical Guideline.
  • If a woman who is already on ART at entry into antenatal care will now collect her ART from the antenatal service point, ensure that she is documented as a transfer-out from her former ART clinic, and not classified as lost-to-follow-up.
• Known HIV-positive women, who are not currently on ART, but are ART-experienced (e.g. previous VTP, or previous LTFU on ART) should re-initiate TLD*.
• Appropriate ART literacy education should be given to the woman before she leaves the facility. (Go to Key Adherence Messages)
• All women living with HIV should be referred to a CHW to support adherence, breastfeeding and retention in care pre- and post delivery.

* Unless previously already on a 3rd line regimen or unsuppressed on a PI-based regimen for over 2 years before interrupting treatment. These clients should be discussed with an expert before re-initiating.

VL Monitoring and Management

Go to “Viral Load Monitoring Schedule”

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Remember to put the VTP code: C#PMTCT in the EGK code field of the laboratory form for each VL done to ensure the electronic gatekeeping rules (EGK) do not lead to sample rejection

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Pregnant adolescents are at a higher risk for poor adherence and poor viral suppression and require more intense support. Go to “Care of the Pregnant Adolescent Living with HIV”

Remember to insert the laboratory barcode sticker and record all VL, TB, and syphilis results in the Maternity Case Record/ANC Card, and the ART Clinical Stationery (if available in that facility)

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Early referral to community-based services improves adherence to ART, exclusive breastfeeding and retention in care

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Newly diagnosed and initiated ART for the first time:

• Do 1st VL at 3 months on ART.
• If VL < 50 c/ml, repeat VL at delivery.

Known HIV-positive women already on ART:

• VL at first/booking visit in ANC,
• If VL < 50 c/ml, repeat VL at delivery.

Known HIV-positive women, who are not currently on ART, but are ART exposed (e.g. previous PMTCT, or ART LTFU) and who are initiating a DTG-containing regimen:

• Do 1st VL at 3 months on ART.
• If VL < 50 c/ml, repeat VL at delivery.

If the VL is ≥50 c/ml in any of the above scenarios, go to the VL Non-suppression Algorithm.

Screening for TB and Other OI’s

Screen for TB at every visit regardless of HIV status and consider TPT if eligible. Ensure any woman diagnosed with TB is adherent to TB treatment and that she is aware that her newborn may require TB prophylaxis (Go to “TB Screening and TPT during Pregnancy, Labour, and the Breastfeeding Period”).

Initiate Cotrimoxazole Prophylaxis (CPT) if CD4 count ≤ 200 cells/μL, or WHO clinical stage 2, 3, or 4.

If CD4 ≤100 cells/uL the laboratory will automatically perform a Cryptococcal Antigen test (CrAg). CrAg-positive clients who are pregnant should be offered an LP (regardless of symptoms) and discussed with an expert before a decision is made regarding management.

Prevention of Transmission of Syphilis, HBV and Other Infections

Syphilis: All pregnant women need to be screened and tested for syphilis

• At her 1st/booking visit in antenatal care.
• If she tests negative, syphilis testing should be repeated:
  • At scheduled antenatal visits, at approximately 4-weekly intervals, e.g., for BANC+ clients, this could be at 20, 26, 30, 34, and 38 weeks gestation
  • During her labour/delivery admission
  • At the time of diagnosis of an intrauterine death
  • At any time, if the mother has clinical symptoms or signs suggestive of syphilis

The frequency of syphilis testing should be aligned with the HIV testing schedule.

• If a woman tests positive for HIV, but tests negative for syphilis, repeat syphilis testing should continue at the intervals described above.
• If a woman tests positive for syphilis but tests negative for HIV, repeat HIV testing should continue at recommended intervals

Rapid syphilis tests are available as a single rapid diagnostic test (RDT) that tests only for syphilis, and a dual RDT which tests for both syphilis and HIV using the same drop of blood. Dual syphilis-HIV rapid tests should only be used in clients:

• Whose HIV status is negative or unknown AND
• Who have not had a previous syphilis infection

For more detail on the types of syphilis tests available, their interpretation and the clinical management of syphilis, go to “Syphilis”

HBV: All women living with HIV will automatically be treated for HBV when they start routine ART containing TDF and 3TC /FTC. Any woman who is HIV/HBV coinfected and cannot use TDF due to renal dysfunction should be discussed with an expert. If an HIV-negative pregnant woman is known to have HBV infection, she should be referred to a high-risk clinic for further tests to determine eligibility for treatment. Mothers who are Hepatitis B infected should deliver at a facility where both hepatitis vaccine and anti-Hep B Immunoglobulin can be given to the baby on the day of birth.

Malaria: Although vertical transmission is rare, malaria in pregnancy poses serious risks for both the mother and the baby. Malaria presents as a febrile illness and is often unrecognized or misdiagnosed with severe consequences. The most important aspect of making a diagnosis of malaria is having a high index of suspicion. If a woman presents with a fever during pregnancy, always ask about her travel history. Refer any woman with signs of severe illness or danger signs as outlined in PC101. Comprehensive information on Malaria in Pregnancy is available in the Guideline for Maternity Care in South Africa, and the National Guideline for the Treatment of Malaria SA.

Other Care

• Routine antenatal care according to the BANC Plus guideline.
• If indicated, a Pap smear can be done during antenatal care at the first visit if the woman is < 20 weeks gestation. If an abnormality is detected, there should be prompt referral for a colposcopy. A Pap smear can be done at 6 weeks post-delivery, if indicated.
• Encourage male partner involvement throughout antenatal care. (Go to “Involving Fathers* in Antenatal and Postpartum Care”)
• Nutritional screening for mother. Refer any woman with a MUAC of less than 23cm to a dietician
• Counselling on infant feeding. See the Infant and Young Child Feeding Policy
• Mental health screen for mother
• Assist the mother to register on MomConnect

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TB and other nonpregnancy related infections remain an important cause of maternal and neonatal mortality

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Click here for the pdf.

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South African National Department of Health, Guideline for Vertical Transmission Prevention of Communicable Infections, Version 2_August 2023