Mother-to-Child Transmission (Dr. Laura Guay)

8/7/2019 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









HIV Disease Course



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



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





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



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



If W ith HIV d t t k HIV d



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



Timing of HIV transmission to the infant

During pregnancy Around labour/delivery During Breastfeeding



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



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



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



• 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



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



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



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



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



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



Negotiating the PMTCT Activities

?

Negotiating the PMTCT Activities cont



Negotiating the PMTCT Activities cont.

The way forward



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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Mother-to-Child Transmission (Dr. Laura Guay)