Circular Minute on Prevention of Mother-To-Child Transmission of HIV

16 April 2002

In view of the Constitutional Court's interim order regarding the provision of Nevirapine for the prevention of mother-to-child transmission of HIV (PMTCT) in government health services where there is currently no PMTCT programme, this circular guides the provision of Nevirapine in terms of the order.

This circular is valid until judgment is given on the case that is scheduled to be heard in the Constitutional Court on 2nd and 3rd May 2002.

The court order reads as follows:

"The first to ninth respondents are ordered to make Nevirapine available to pregnant women with HIV who give birth in the public sector and to their babies, in the public health facilities to which the respondents' present programme for the prevention of mother-to-child transmission of HIV has not yet been extended, where in the opinion of the attending medical practitioner, acting consultation with the medical superintendent of the facility concerned, this is medically indicated, which shall at least include that the woman concerned has been appropriately tested and counselled."

The Constitutional Court explains the order to mean:

"This order does not require the wholesale extension of the prescription of Nevirapine outside the pilot sites established by the government. It requires only that government make Nevirapine available in public facilities where, in the opinion of the attending medical practitioner in consultation with the medical superintendent of the clinic or hospital, it is medically indicated and the preconditions for its prescription already exist."

It is important to note that the Court order is designed to cater for individual cases only: this is to cater for what the High Court referred to as "missed opportunities". Each request shall be dealt with on a case-by-case basis.

This means that the attending medical practitioner must, in relation to a specific pregnant woman, who has been appropriately counselled and tested, determine (in consultation with the medical superintendent of the facility concerned) that it is medically indicated to prescribe Nevirapine for the woman and her baby.

To ensure the highest quality of care and to comply with nationally endorsed minimum standards on PMTCT, all medical superintendents are requested to ensure that the provision of Nevirapine is consistent with the three attachments to this circular which require that:

• HIV positive pregnant women would receive all relevant information during counselling (Attachment 1)
• Attending medical practitioners should administer Nevirapine according to an established regimen (Attachment 2)
• All necessary documentation must be properly complied and records kept as recommended (Attachment 3)

Where the necessary preconditions for prescribing Nevirapine exist (as described in the order) the medical superintendent shall in writing request the Head of Health in the province to provide Nevirapine. This request should specify.

• The name of the facility
• The name of the attending medical practitioner(s)
• The quantity of Nevirapine required.

Kindly inform all relevant personnel of the contents of the circular. Your co-operation in this regard will be highly appreciated.

If you require any guidelines, training manuals or other documents relevant to PMTCT please feel free to contact

Nono Simelela at 012-312-0121

or

Sesupo Makakole-Nene at 012-312-0131

at the National Aids Programme Office.

The Minister in consultation with the MECs for Health has established a PMTCT Task Team. Among other things members of this team will advise on implementation of this circular where requested.

ATTACHMENT 1

FLOW CHART OF COUNSELLING PROCESS

Pre-test individual counselling session on:

• HIV transmission, contraception and termination of pregnancy (if applicable)
• MTCT of HIV and possible interventions
• Testing process
• Implications of negative results
• Implications of positive results
• Risk assessment
• Re-emphasize confidentiality
• Explain forms that need to be signed and obtain signature

Post-test and ongoing counselling on:

HIV-positive:

• Information about therapy, including the availability of Nevirapine
• Counselling about feeding options
• Stigma
• Information of future fertility
• Information on partner testing
• Information on safer sex during pregnancy
• Referral to support services

HIV-negative

• Prevention of future infections
• High risk of MTCT if infected during pregnancy
• Information on partner testing

Counselling for special circumstances

When an HIV-positive women presents in advanced labour, without having taking Nevirapine, counselling should be deferred until after delivery. Then the woman must be counselled appropriately and her consent sought for administration of Nevirapine to her baby.

ATTACHMENT 2

NEVIRAPINE REGIMEN AND ADMINISTRATION

The Medical Superintendent is responsible for the administration of correct doses of Nevirapine to women and infants according to the guidelines below.

Doses

Maternal NVP regimen: one tablet of NVP (200 mg)

Neonatal NVP regimen: if less 2,5 kg: 0,2 ml per kg

if more 2,5kg: 0,6ml

Administration:

• Women should receive Nevirapine (prescription) only at or after 28 weeks of gestation with the appropriate instructions for self-administration
• If woman takes NVP correctly: Infant NVP 6-72 hrs post delivery
• If woman takes NVP less than 2hrs before birth: Infant NVP immediately No later than 72 hrs
• If women not taken NVP: Infant NVP immediately No later than 72 hrs
• Woman in prolonged or false labour - Do not receive repeat dose: Infant NVP immediately No later than 72 hrs

ATTACHMENT 3

RECORD TO BE KEPT FOR PMTCT INTERVENTIONS

Records that are kept should at least include the following:

• The name of the prescribing clinician
• The hospital file number of the patient
• The relevant signed consent forms

During all stages of maternity and follow-up care the utmost attention must be given to respecting the woman's right to confidentiality of her HIV-status, particularly with regard to patient-held records.