Prevention of Mother to Child HIV Transmission

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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, 2009
• Cape 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,
  rapid tests, western blot)
• HIV antibodies from an HIV infected women cross
  the placenta and enter the babys 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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WHOs 4-Component Strategy for MTCT Prevention
Prevention of unintended pregnancies in
HIV-infected women
Prevention of transmission from an HIV infected
woman to her infant
Prevention of HIV in women, especially young women
Support for HIV infected women, their infant, and
family
Component 1
Component 2
Component 3
Component 4
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Access to Mother-to-Child Prevention
WHO, UNAIDS, UNICEF - Towards Universal Access
Progress Report 2008
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Benefits of global expansion of PMTCT programs

• Provides opportunity for primary prevention for
  large number of HIV uninfected women identified
• Provides opportunity for prevention of HIV
  infection in children
• Provides opportunity as an entry point into HIV
  Care for large number of HIV infected women and
  their infected infants
• However, this is often a missed opportunity as
  ongoing HIV care and treatment is not available

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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
their mothers
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Revised WHO Guidelines for infant feeding for HIV
infected women in resource-limited settings

• Balances risk of HIV transmission through BF with
  increased illness and death associated with not
  BF
• The best option depends on a womans health
  status/the local situation should take greater
  consideration of the counseling/support she can
  receive
• Exclusive BF is recommended for the first 6
  months of life unless replacement feeding is
  acceptable, feasible, affordable, sustainable and
  safe (AFASS) before that time
• When replacement feeding is AFASS, avoidance of
  all BF is recommended
• At 6 months if replacement feeding is still not
  AFASS, continuation of BF with additional foods
  is recommended. All BF should stop once a
  nutritionally adequate and safe diet without
  breast milk can be provided.

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Infant HIV diagnosis

• Early diagnosis of HIV infection in children born
  to HIV infected women is critical
• -Allows early identification of children who will
  benefit from antiretroviral 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., then standard antibody tests are accurate
• Early infant diagnosis using dried blood spots
  has made services available even in remote areas

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Infant Survival by HIV Infection Status-HIVNET
012 cohort
Proportion alive
HIV neg
92.1
HIV pos
43.2
---- HIV Negative ---- HIV Positive
Age (years)
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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
  restore the 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

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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, early
  intervention/support

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WHO Indications for Initiation of ARV Therapy in
Children lt 1 Year

• Initially WHO guidelines for ART in children
  (2006) recommended starting therapy according to
  clinical and/or immunologic criteria
• Recent data from a study in South Africa where
  infants were put into one group that started
  therapy immediately or a second group where
  therapy started when WHO criteria were met showed
  75 decrease in death when ART was started
  immediately
• Therefore, WHO revised recommendations in April
  2008 such that ALL infants diagnosed with HIV
  infection in the first year of life should
  receive ART immediately

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Negotiating the PMTCT Activities
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Negotiating the PMTCT Activities cont.
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The way forward

• Challenges
• High initial implementation costs
• Community sensitization/mobilization lacking
• Integration of PMTCT within ANC difficult
• Access to women who dont 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 progress
  worldwide, but we all need to keep pushing
• forward.

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