Infant Survival:Meeting the Challenges of Maternal-Child HIV
Doug Watson MD (Robb Sheneberger MD)University of Maryland, School of Medicine
Institute of Human VirologyMonday August 11
Sixth Annual Tract I Meeting
AIDSRelief Tanzania Challenges
• Only 56% of women who were first seen in either ANC (99% tested) or L&D (28% tested) received HIV CT (but 60% of women were first seen in L&D)
• Only 47% of known positives received any ARV, and 95% of those getting any ARV prophylaxis received only sd-NVP
Age Range of Children on ART
Age Range(years)
N= %
< 5 186 34.70%
5 – 7 104 19.40%
7 – 12 236 44.03%
>12 10 1.87%
536 total charts reviewed. Overall median age for population was 6.5 years
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Detectable
Suppressed
Proportion of Patients VL <200c/mm3
85.4% On Treatment 74.2% ITT (missing=failure)
N=466 N=536
Same country adult suppression on treatment 94.6%
Regimen Choice and Suppression
ARV RegimenN=466
Detectable Suppressed
1st line regimen containing NNRTI
17.87%(n=62)
82.13%(n=285)
1st line regimen containing LPV/r
5.04%(n=6)
94.96%(n=113)
p<.001Children on a Lop/r containing 1st regimen were 11.69 times (Pearson Chi2 = 11.6954) more likely to be suppressed at review than patients on 1st regimen that did not contain Lop/r
NVP and Suppression
ARV RegimenN=466
Detectable Suppressed
1st line regimen not containing NVP( EFV or LPV/r)
9.09%(n=26)
90.91%(n=260)
1st regimen containing NVP
23.33%(n=42)
76.67%(n=138)
p<.0001Children on a NVP containing 1st regimen were 17.98 times (Pearson Chi2 = 17.9804) more likely to have viral failure at review than patients on 1st regimen that did not contain NVP
Common Problems with Care of Infected Children
• Where are they? Average age at ART initiation is 6.5 years meaning most die before diagnosis and treatment
• Delay in infant diagnosis• Unavailability or tardiness of DNA PCR• Lack of understanding of clinical diagnosis-
developmental milestones and growth curves
• ART guidelines that do not recommend treatment of children at high risk of progression (initiating treatment at much too advanced disease in children)
Common Problems with Care of Infected Children
• Use of NVP-based regimen in children exposed to NVP
• Dosing errors (under dosing)• Need for child-specific approach to care &
adherence• Not recognizing treatment failure• Limited options after prolonged initial
thymidine based regimen failure
Problem: Opportunities to reduce morbidity and mortality in HIV-infected and –affected children are being missed.
Response: University of Maryland/IHV AIDSRelief integrated Maternal-Child HIV care strategy
• Establish community-based identification of infected pregnant women
• Engage pregnant women into comprehensive HIV care system• A maternal-child focused approach within a
comprehensive HIV care system rather than a vertically-integrated “PMTCT” program
• Earlier and more aggressive ART for pregnant women
• ARV prophylaxis to protect breastfeeding infants• Data on maternal HAART more mature at this
point than ARV prophylaxis to infant
Minimize transmission from mother to child
Provide a package of support for HIV-exposed infants
• Enroll infected pregnant women and exposed infants in AR program and provide package of care until 2 years of age
• Infant nutrition counseling• Starting in antenatal period and continuing
through infancy• More evidence-based: Base counseling on risk of
HIV infection or death from substitute feeding for the individual infant
• Facilitate general availability of robust early infant virologic diagnosis• Emphasize clinical diagnosis in interim
Rapidly diagnose infants and children
• Facilitate general availability of robust early infant virologic diagnosis
• Training on importance of early diagnosis of infants and children
• Broad testing of children: every child should have his HIV-exposure or HIV-infection status determined• Multiple entry points: Children and siblings of
patients, child health center attendees, in-patients, orphanages, community-based testing, etc.
Ensure long-term health of infected children
• Evidence-based, non-discriminatory identification of children who require ART• Many current guidelines do not treat children at
much higher risk of progression than adult guidelines allow
• Selection of regimens that maximize prospect for long-term viral suppression with minimal toxicity• NVP based regimens with high viral loads and
after sd-NVP exposure inadequate• Failure of current standard thymidine regimens
leaves few options
• Child-focused clinical services
Engage mothers and families in HIV care
• Testing of children & partners of infected women
• The best OVC strategy is to prevent Vulnerable Children from becoming Orphans• Family-based tracking• Family clinic: parents and children seen at same
time• Engagement of parents in care, particularly
fathers
Measure meaningful outcomes applied across the community
• Use ANC seroprevalence and census data to estimate proportion of infected pregnant women who engage in care in communities served by AR
• Monitoring maternal-child care “cascade” on site-specific basis to identify system gaps• Link mothers and children
• Determine final infection status• Determine infant survival (12 months) and at
18 & 24 months• Pediatric targeted evaluation of viral
suppression• Use outcomes data to advance program