mother-to-child transmission (dr. laura guay)
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Prevention of Mother to Child
HIV Transmission
Dr. Laura Guay
Vice President for Research
Elizabeth Glaser Pediatric AIDS Foundation
July 15, 2009Cape Town, South Africa
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HIV Disease Course
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Diagnosis of HIV
• HIV antibody tests
– When exposed to HIV (or any infection) the body makes
antibodies to fight the infection
– Standard HIV tests measure these antibodies (EIA, rapidtests, western blot)
– HIV antibodies from an HIV infected women cross theplacenta and enter the baby’s blood
• HIV detection tests
– These tests measure the actual parts of the HIV virus itself (PCR, p24 antigen, viral culture)
– These tests can identify HIV infection in a very young baby
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Prevention of HIV
in women,
especially young
women
Prevention of
unintended
pregnancies in
HIV-infected
women
Prevention of
transmission
from an HIV
infected woman
to her infant
Support for HIV
infected women,
their infant, and
family
Component
1
Component
2
Component
3
Component
4
WHO’s 4-Component Strategy for
MTCT Prevention
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New infections among children, 1990–2007
Year
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20070
400 000
500 000
600 000
200 000
300 000
100 000
This bar indicates the range
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Access to Mother-to-Child Prevention
WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2008
67% of pregnant women
not receiving PMTCT drugs
80% of HIV-exposed infants
not receiving PMTCT drugs
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If W ith HIV d t t k HIV d
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If Women with HIV do not take any HIV drugs
during pregnancy and they breastfeed-
about 30 out of 100 babies born to these women will
get HIV
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Timing of HIV transmission to the infant
During pregnancy Around labour/delivery During Breastfeeding
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If women and newborns take 1 dose of the drug
nevirapine around the time the baby is born-
only ~16 out of 100 babies will get HIV from their mothers
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If women and newborns take a combination of HIV
drugs during pregnancy and after delivery-
As few as 4-6 out of 100 babies will get HIV from theirmothers
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United Nations
SCN News
May 1991
“Use my picture
if it will help,
“I don’t want
other people to
make the same
mistake”.
Revised WHO Guidelines for infant feeding for HIV
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• Balances risk of HIV transmission through BF with increased illness
and death associated with not BF• The best option depends on a woman’s health status/the local situation;
should take greater consideration of the counseling/support she canreceive
• Exclusive BF is recommended for the first 6 months of life unlessreplacement feeding is acceptable, feasible, affordable, sustainable andsafe (AFASS) before that time
• When replacement feeding is AFASS, avoidance of all BF isrecommended
• At 6 months if replacement feeding is still not AFASS, continuation of BF with additional foods is recommended. All BF should stop once anutritionally adequate and safe diet without breast milk can beprovided.
Revised WHO Guidelines for infant feeding for HIV
infected women in resource-limited settings
I f t HIV di i
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Infant HIV diagnosis
• Early diagnosis of HIV infection in children born to HIVinfected women is critical
-Allows early identification of children who will benefit fromantiretroviral treatment, appropriate infant feeding choices,prophylaxis, and close medical follow-up
-Decreases the psychological stress of uncertainty for the parents,
-Early endpoint in implementation program evaluation and HIV
clinical trials
• HIV detection tests must be used in first 12-18 mos., thenstandard antibody tests are accurate
• Early infant diagnosis using dried blood spots has madeservices available even in remote areas
Infant Survival by HIV Infection Status
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Infant Survival by HIV Infection Status-
HIVNET 012 cohort
Pro
po
rtion
aliv
e
---- HIV Negative
---- HIV Positive
Age (years)
92.1 %
43.2 %
HIV neg
HIV pos
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Goals of an HIV Care Program
• Prevention of opportunistic infections
• Early identification of complications and their appropriate management
• Use of antiretroviral therapy to maintain and restorethe immune system
• Provision of support for HIV-infected persons,including psychosocial
• Engage patients/families in HIV care and prevention
through education, support and outreach• Establish strong links to community resources
Basic Medical Care
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Basic Medical Care
• Close follow-up and health monitoring
- Prompt treatment of acute illnesses
• Childhood Immunization
• Vitamin A Supplementation
• General Health Education (Safe water, bednets)
• Management of Diarrhea
• Growth Monitoring; Nutrition Education, earlyintervention/support
WHO Indications for Initiation of ARV
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WHO Indications for Initiation of ARV
Therapy in Children < 1 Year
• Initially WHO guidelines for ART in children (2006)
recommended starting therapy according to clinicaland/or immunologic criteria
• Recent data from a study in South Africa where infants
were put into one group that started therapy immediatelyor a second group where therapy started when WHOcriteria were met showed ~75% decrease in death whenART was started immediately
• Therefore, WHO revised recommendations in April 2008such that ALL infants diagnosed with HIV infection in thefirst year of life should receive ART immediately
Negotiating the PMTCT Activities
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Negotiating the PMTCT Activities
?
Negotiating the PMTCT Activities cont
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Negotiating the PMTCT Activities cont.
The way forward
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The way forwardChallenges:• High initial implementation costs
• Community sensitization/mobilization lacking• Integration of PMTCT within ANC difficult• Access to women who don’t deliver in health facility• Very low numbers of partners involved
• Changing infant feeding education/practices• Poor postnatal follow-up
Successes:• Despite the challenges, we know this can be done,
we have done it. We are making great progressworldwide, but we all need to keep pushing
forward.
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