Prevention of Parent to Child transmission of HIV

1
Prevention of Parent to Child transmission of HIV

• M. Prasanna Kumar MD
• Dy. Director of Health Services
• Kerala State AIDS Control Society
• Thiruvananthapuram

2
Magnitude of the problem

• Roughly 10 of HIV infected are children
• Mother to child transmission (MTCT) is the most
  important route of infection in children under 15
  years

3
Mother to Child Transmission in the U.S. Over
Time
Decline due to - Enhanced prenatal HIV testing
- Increase in use of
HAART by HIVwomen
- Increase in elective C/S by HIV women.
4
Timing of MTCT with Breastfeeding and No ARV
Early Antenatal (lt36 wks)
Late Postpartum (6-24 months)
Early Postpartum (0-6 months)
Labor and Delivery
Late Antenatal (36 wks to labor)
5-10
10-20
10-20
Adapted from N Shaffer, CDC
5
Factors Contributing to Prenatal and Intrapartum
MTCT

• Behavioral Factors
• Number of sexual partners during pregnancy

• Biological Factors
• Maternal viral factors
• Membrane rupture
• Chorioamnionitis
• Preterm birth/ low birth weight
• STDs

6
Risk Factors for Postnatal Transmission

• Mother
• Immune status
• Plasma viral load
• Breast milk virus
• Breast infection (mastitis, abscess, bleeding
  nipples)
• New HIV infection
• Viral Characteristics

• Infant
• Breastfeeding duration
• Non-exclusive BF
• Age (first months)
• Lesions in mouth, intestine
• Prematurity
• Infant immune response

WHO, 1998 Bulterys et al, 2002 Newell et al,
2002
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How Does HIV Transmission During Breastfeeding
Occur?

• Exact mechanisms unknown
• HIV virus in blood passes to breast milk
• cell-free, cell-associated virus observed
• virus shed intermittently (undetectable 25-35)
• levels vary between breasts in samples taken at
  same time (Willumsen, 2001)
• Infant consumes HIV
• enters/infects through permeable mucosal
  surfaces, lymphoid tissues, lesions in mouth,
  intestine
• Although BF infant may consume gt500,000 virions,
  gt25,000 infected cells per day, majority dont
  become infected (Lewis, 2001)
• immune factors in BM may play a role (Sabba et
  al, 2002)

8
Elements To Reduce MTCT
ARV Prophylaxis
Early cessation
Interventions
Use of breastfeeding alternatives/ Exclusive
breastfeeding (?)
HIV Testing/ Counseling Prevention of Infection
9
WHOs 4 pronged prevention approach

• Primary prevention of HIV infection
• Preventing unintended pregnancies among positive
  women
• Preventing transmission to children from infected
  mothers
• Providing care for infected mothers and their
  infants

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1. Preventing HIV infection in women especially
young women

• Awareness programs
• PPTCT/ VCTCs
• Prevention of HIV infection in men
• Prevention of HIV infection in high risk groups

11
2. Preventing unintended pregnancy among infected
women

• Strengthening family planning services
• MTP/ contraception etc

12
3. Prevention of HIV transmission from infected
mothers to infants

• Anti retroviral use
• Safe delivery practices- Caesarian section.
• Avoidance of invasive procedures such as, ARM,
  fetal scalp monitoring, episiotomy etc
• Infant feeding counseling and support

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4. Care for HIV infected mothers and their
children

• Care and support of mother protects the health of
  the child
• Care for mothers increases uptake of all services
  to prevent transmission
• Care needed for exposed and infected children
• Anti-retroviral therapy reduces viral load and
  thus reduces transmission

14
Completed Trials Focused on Prevention AP/IP
Transmission
IP
AP
PP (baby, mother or both)
3d to 1 wk
36 wks
14 wks
6 wks
28 wks
076
NonBF
NonBF
Thai (Harvard)
NonBF
Thai (Harvard)
NonBF
Thai (Harvard), BMS
IvC (ANRS), PETRA, Thai (Harvard)
BF/NonBF
Thai (CDC), IvC (CDC)
NonBF/BF
PETRA, 012, SAINT
BF
PETRA
BF

PP Minimal duration? Is it needed?
AP Minimum duration? Is it needed?
IP Work alone?
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Current ARV regimens

• Tab Nevirapine 200mgs- to mother in labour and
  2mg/Kg B.wt to infant within 72 hours of birth
• Tab. Zidovudine 300mgs BD last 4 weeks of
  pregnancy and Q 3 hours during labour
• Shift towards combination regimes

16
Mother to Child Transmission in the U.S. Over
Time
Decline due to - Enhanced prenatal HIV testing
- Increase in use of
HAART by HIVwomen
- Increase in elective C/S by HIV women.
17
More Potent Antiretroviral Regimens Are
Associated with Lower Perinatal Transmission
Women Infants Transmission Study,
1990-1999Cooper E et al. JAIDS 200229484-94
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MODE OF DELIVERY
19
WHO Recommendations on Infant Feeding for HIV
Women
When replacement feeding is acceptable,
feasible, affordable, sustainable and safe,
avoidance of all breastfeeding by HIV-infected
mothers is recommended. Otherwise, exclusive
breastfeeding is recommended during the first
months of life. To minimize HIV transmission
risk, breastfeeding should be discontinued as
soon as feasible, taking into account local
circumstances, the individual womans situation
and the risks of replacement feeding (including
infections other than HIV and malnutrition). New
Data on the Prevention of Mother-to-Child
Transmission of HIV and their Policy
Implications Conclusions and Recommendations
(WHO 2001)
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SUMMARY

• Antenatal ART
• Elective LSCS
• Artificial feeds
• Infant AZT prophylaxis
• Transmission is reduced to 2

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TRAINING -TEAM

• PROF HEAD, DEPT. OF OBS GYN. (TEAM LEADER)
• PROF HEAD, DEPT. OF PAEDIATRICS
• PROF HEAD, DEPT. OF MICROBIOLOGY
• HEALTH EDUCATOR/PSYCHIATRIST
• SENIOR STAFF NURSE OF OBS GYN

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IMPLEMENTING STRATEGY

• THE PMTCT TEAM OF MEDICAL COLLEGES WILL TRAIN
  DISTRICT PMTCT TEAM

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DISTRICT TEAM

• SENIOR OBS GYN
• SENIOR PAEDIATRICIAN
• SENIOR PATHOLOGIST/MCROBIOLOGIST
• HEALTH EDUCATOR/MSW/COUNSELLOR
• SENIOR STAFF NURSE OF OBS GYN.

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PMTCT-MCH-MANPOWER

• ONE COUNSELLOR
• ONE LAB TECHNICIAN
• (ON CONTRACT BASIS)

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• Thank You