HIV in Children: Preventing Mother-to-Child Transmission (Dr. Laura Guay)

8/7/2019 HIV in Children: Preventing Mother-to-Child Transmission (Dr. Laura Guay)

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Dr. Laura Guay

Vice President for Research

Elizabeth Glaser Pediatric AIDS Foundation

J2J Global Media Training on HIV/AIDS

July 14, 2010

Vienna, Austria

HIV in Children:

Preventing Mother-to-Child

Transmission


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Elizabeth Glaser


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Ariel and Jake Glaser


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The Elizabeth Glaser Pediatric AIDS

Foundation


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HIV Disease Course


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HIV antibody tests

When exposed to HIV (or any infection) the bodymakes antibodies to fight the infection

Standard HIV tests measure these antibodies

(EIA, rapid tests, western blot) HIV antibodies from an HIV-infected woman 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 veryyoung baby

Diagnosis of HIV


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WHOs 4-Component Strategy for MTCT

Prevention

Prevention

of HIV in

women, especially young

women

Prevention of

unintended

pregnanciesin HIV-

infected

women

Prevention of

transmission

from an HIV-infected

woman to her

infant

Support for

HIV-infected

women, theirinfants, and

families

Component

1

Component

2

Component

3

Component

4


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Year

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

0

400 000

500 000

600 000

200 000

300 000

100 000

This bar indicates the range

New infections among children, 19902007


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10%

15%

24%

34%

45%

6%

12%

18%20%

32%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

2004 2005 2006 2007 2008

Pregnant women living with HIV receiving ARVs

Infants born to pregnant women living with HIV receiving ARVs

Provision of Antiretroviral Drugs

WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2009

55% of pregnant womennot receiving PMTCT drugs

68% of HIV-exposed infants

not receiving PMTCT drugs


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Benefits of global expansion of PMTCT

programs Provides opportunity for primary prevention for

large number of identified HIV-uninfected

women

Provides opportunity for prevention of HIV

infection in children

Provides opportunity as an entry point into HIVCare 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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- about 30 out of 100 babies born to these

women will get HIV.

If women with HIV do not take any HIV drugs

during pregnancy and they breastfeed -


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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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United Nations

SCN News

May 1991

Use my picture

if it will help,

I dont want

other people to

make the same

mistake.

Breast Feeding vs Bottle Feeding


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2009 Revised WHO guidelines


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Key Changes in 2009 Revised

WHO guidelines

Begin ART at CD4 cell count of 350 rather than 200

Start ARV prophylaxis earlier in pregnancy

Provide ARV prophylaxis during breastfeedingProvide single drug Nevirapine daily to infants OR

Provide three drug ARV prophylaxis to the mother

National authorities should decide whether MCH

services will recommend HIV-infected mothers to:Breastfeed and receive ARV interventions OR

Avoid all breastfeeding

(Taking into account socioeconomics, health

services, and local infant mortality and under-


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Infant HIV diagnosis

Early diagnosis of HIV infection in children bornto HIV-infected women is critical Allows early identification of children who will

benefit from antiretroviral treatment, appropriateinfant feeding choices, prophylaxis, and close

medical follow-up Decreases the psychological stress of uncertainty for

the parents

HIV detection tests must be used in first 12-18

mos., then standard antibody tests are accurate

Early infant diagnosis using dried blood spotshas made services available even in remoteareas


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Infant Survival by HIV Infection Status -

HIVNET 012 cohort

Proportion

alive

Age (years)


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Goals of an HIV Care Program

Prevention of opportunistic infections

Early identification of complications and theirappropriate management

Use of antiretroviral therapy to maintain andrestore the immune system

Provision of support for HIV-infectedpersons, including psychosocial

Engage patients/families in HIV care andprevention through education, support andoutreach

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 (safewater, bednets)

Management of Diarrhea

Growth Monitoring & Nutrition Education

- Early intervention/support


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WHO Indications for Initiation ofARV

Therapy in Children < 2 Years

Initial WHO guidelines for ART in infants andchildren (2006) recommended starting therapyaccording to clinical/immunologic criteria

Studies in infants showed that there was a~75% decrease in death when ART was startedimmediately rather than waiting

WHO revised recommendations in April 2008

such that ALL infants < 1 yr diagnosed with HIVinfection should receive ART immediately

Recent revised WHO guidelines increased this

to all infants < 2 yrs of age


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Negotiating the PMTCT Activities

?


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Negotiating the PMTCT Activities

(PMTCT = MCH)


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The Way Forward

Challenges: High initial implementation costs

Community sensitization/mobilization lacking

Integration of PMTCT within antenatal clinic can bedifficult

Access to women who dont deliver in health facility

Very low numbers of partners involved

Inadequate infant feeding education

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 allneed to keep pushing forward


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Documents

HIV in Children: Preventing Mother-to-Child Transmission (Dr. Laura Guay)