Prevention of Vertical Transmission: The role of families

Elaine J. Abrams, MDHarlem Hospital and the International Center for AIDS Care and Treatment Programs Columbia University

Prevention of vertical transmission: Spectrum of care for mother & child

The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post PartumNon-pregnant:

Family planning (FP) counselingPreconception CarePartner HIV testing

Antepartum:PITC in ANCCD4 TestingART treatment or prophylaxisAdherence supportInfant feeding (IF) counselingSafe Motherhood Birth Preparedness

Intrapartum:PITC in L&D CD4 testingARV prophylaxis Safe DeliveryIF counselingFP counselingAdherence support

1-8 Weeks Post Partum:

Maternal postpartum follow-up Enrollment into HIV careART treatment or prophylaxis during BFFP counselingIF counselingAdherence support

2-6 Months Post Partum:

Repeat CD4 (6 months pp)ART treatment or BF prophylaxisFP counselingIF counselingAdherence support

6-9 Months Post Partum:

ART treatment or BF prophylaxis

FP counseling IF counseling Adherence support

9-12 Months Post Partum:

ART treatment or BF prophylaxis FP counseling IF counseling Adherence support

12-18 Months Post Partum:

ART treatment FP counseling Adherence support Repeat CD4

Effective ‘PMTCT’ is a long term intervention for women

Effective PMTCT includes a series of biomedical and psychosocial interventions administered throughout the reproductive live of the

woman living with HIV

Birth:ART prophylaxis FU appt at 6 weeks

1-8 Weeks :Infant prophylaxis during BFPCR testing at 4-6weeksGrowth & developmental monitoringCTX initiation at 6 weeks

2-6 Months:Infant prophylaxis during BF Growth & developmental monitoring CTX continuation

HIV infected infants: HAART initiationCD4 testing

6-9 Months:Infant prophylaxis during BF Growth & developmental monitoring CTX continuationRepeat HIV test 6weeks post BF cessationIF supportHIV infected infants: HAART initiationCD4 testing

9-12 Months : Infant prophylaxis during BF Growth & developmental monitoring CTX continuation Repeat HIV test 6weeks post BF cessationIF support

HIV infected infants: HAART initiationCD4 testing

12-18 Months:IF supportDetermine final infection status: antibody testing at >12-18mosChild discharged from PMTCT program

HIV infected infants: HAART initiationCD4 testing

The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

Effective ‘PMTCT’ is a long term intervention for infants & children

Illustrations by Petra Rohr-Rouendaal, 2010

Birth:ART prophylaxis FU appt at 6 weeks

1-8 Weeks :Infant prophylaxis during BFPCR testing at 4-6weeksGrowth & developmental monitoringCTX initiation at 6 weeks

2-6 Months:Infant prophylaxis during BF Growth & developmental monitoring CTX continuation

HIV infected infants: HAART initiationCD4 testing

6-9 Months:Infant prophylaxis during BF Growth & developmental monitoring CTX continuationRepeat HIV test 6weeks post BF cessationIF support

HIV infected infants: HAART initiationCD4 testing

9-12 Months : Infant prophylaxis during BF Growth & developmental monitoring CTX continuation Repeat HIV test 6weeks post BF cessationIF support

HIV infected infants: HAART initiationCD4 testing

12-18 Months:IF supportDetermine final infection status: antibody testing at >12-18mosChild discharged from PMTCT program

HIV infected infants: HAART initiationCD4 testing

The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum

Discharged from PMTCT

Program Engaged in

family-focused HIV care services

Happy Healthy Family

PMTCT Spectrum of Care

Non-pregnant:Family planning (FP) counselingPreconception CarePartner HIV testing

Antepartum:PITC in ANCCD4 TestingART treatment or prophylaxisAdherence supportInfant feeding (IF) counselingSafe Motherhood Birth Preparedness

Intrapartum:PITC in L&D CD4 testingARV prophylaxis Safe DeliveryIF counselingFP counselingAdherence support

1-8 Weeks Post Partum:

Maternal postpartum follow-up Enrollment into HIV careART treatment or prophylaxis during BFFP counselingIF counselingAdherence support

2-6 Months Post Partum:

Repeat CD4 (6 months pp)ART treatment or BF prophylaxisFP counselingIF counselingAdherence support

6-9 Months Post Partum:

ART treatment or BF prophylaxis

FP counseling IF counseling Adherence support

9-12 Months Post Partum:

ART treatment or BF prophylaxis FP counseling IF counseling Adherence support

12-18 Months Post Partum:

ART treatment FP counseling Adherence support Repeat CD4

Prevention of vertical transmission is a family-centered intervention

• Addresses the health of the maternal-child dyad• Provides an unparalleled opportunity to engage other

family members in HIV and other health and social services– Partner, husband, children, extended family members– HIV services include testing, prevention, care and treatment

• Offers a platform to initiate other health services– TB screening, diagnosis, treatment– Early infant interventions

• Effective PMTCT prevents orphanhood

Family involvement enhances prevention of vertical transmission

• Partner testing in PMTCT programs has been associated with – greater use of antiretrovirals for prophylaxis– higher acceptance of post-test counseling – increased spousal communication about HIV and sexual risk

• Using PMTCT services as an entry point into HIV care and treatment for women, partners and family members has been associated with high rates of retention and ART adherence

• Family-focused home based HIV testing, care and treatment services can improve health outcomes for HIV positive and negative family members

• Disclosure of HIV status has been associated with better pediatric outcomes

The MTCT-Plus Initiative

• A multi-country HIV care and treatment program (2003-2010)– PMTCT entry point for pregnant & postpartum women to

engage in HIV care and treatment– PMTCT as an entry point to identify HIV-infected partners, children

and family members and engage in HIV care and treatment• Reframes PMTCT in the context of the reproductive lives of

women living with HIV– Recognizes that pregnancy is a normal and expected aspect of a

woman’s life and aims to support and maximize the health of the woman, her child and her family

• Model for Family-Focused HIV services

The MTCT-Plus InitiativeFactors shaping the MTCT-Plus

model of care• HIV is a multi-generational family

disease: multiple family members living with HIV

• All family members are affected when any individual within the family has HIV

• Most HIV care occurs within households and families

• Women and children have multiple needs that may impact on adherence to care & treatment

• Families can be important sources of support for successful treatment

• Cultural and community factors impact access and adherence

MTCT-Plus approach to HIV care & treatment

• Comprehensive HIV primary care inclusive of antiretroviral therapy to all family members

• Family-centered care– Inclusive of infants and children

• Attention to psychosocial, behavioral, structural, and environmental issues

• Care provided by multidisciplinary teams of health providers

• Involvement of person living with HIV and outreach to community resources

• HIV care and treatment for staff living with HIV

MTCT-Plus approach to HIV care & treatment

MTCT-Plus Sites

Cote d’Ivoire:Formation Sanitaire Urban de Yopougon-AttiéFormation Sanitaire Urban d’Abobo-Attié

Nigeria:Ogoja (Cross River State)Kafanchan (Kaduna State)

Cameroon:Nkwen clinicM’bingo Hospital ClinicMboppi Hospital ClinicBanso Hospital ClinicMutengene Hospital Clinic

South Africa:Cato Manor Clinic, DurbanPerinatal HIV Research Unit, University of Witswatersrand, JohannesburgLanga Health Clinic, Cape Town

Mozambique:Beira Hospital Clinic Chimoio Hospital Clinic

Thailand:Police Hospital Clinic Chulalongkorn Hospital ClinicThammasat University Hospital Sriracha HospitalSirikit Hospital

Zambia:Mtendere Health Clinic, LusakaChelstone Clinic, Lusaka

Rwanda:Treatment and Research AIDS Center, Kigali

Uganda:St. Francis Hospital Nysambya, KampalaMulago Hospital, Kampala

Kenya:Moi University College of Health Sciences, EldoretNyanza Provincial General Hospital, Kisumu

Women attending ANC clinics

Enrollment into MTCT-Plus

Long-term HIV care services:• Family-centered services• Clinical & CD4 monitoring• Antiretroviral therapy

• Screening and treatment for OI, TB• Psychological & social support • Nutritional counseling & support• Outreach activities

Enrollment into PMTCT programs

HIV-infected partners

and children

PMTCT program

sM

TCT-Plus

Enrollment in the MTCT-Plus Initiative

Total Adults and Children Receiving HIV Care 16,457

Adults Receiving HIV Care 9,718 (59%)

Adults on ART 3,933 (40%)

Women Enrolled During Pregnancy 4,275 (44%)

Male Partners Enrolled 1,569 (16%)

Children Enrolled 6,739

Children Enrolled Before 18 Months of Age 6,164 (91%)

Other Children in the Household Enrolled (sibling/other) 419 (6%)

Children on ART 512 (8%)

Health Care Workers or their Family Members 306

Partner enrollment varied by country and site in the MTCT-Plus Initiative

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Findings from the MTCT-Plus Initiative • The majority of women enrolled during

pregnancy received multi-drug ART regimens:– 47% received short course ARV prophylaxis – 20% initiated HAART– 30% received single-dose nevirapine

• Women initiating HAART during pregnancy exhibited excellent immunologic response with an average increase of 451 cells/mm3 after 30 months on treatment

• Retention in care for those initiating ART was high: 82% for pregnant women, 86% for men, and 87% of non-pregnant women at 30 months of follow-up

• Women receiving HAART were almost twice as likely to become pregnant compared with those in care, likely reflecting improved health and future outlook

• Photo – old M+ or cameroon

Conclusions• HIV infection affects the health and well being of families as well as

individuals• Most HIV prevention, care and treatment programs have been

established to address the needs of the individual, neglecting the family• Prevention of vertical transmission services offer an unequaled

opportunity to– Address the comprehensive health needs of the mother and child– Engage partners, children and other family members in HIV testing, care and

treatment services– Enhance PMTCT outcomes by engaging family members

• To date, few models of family-focused PMTCT have been trialed or evaluated

• Renewed global attention and commitment to health needs of women and children provides an opportunity to focus attention on the importance of families as a means to keep families healthy and children free of HIV infection

MTCT-Plus Initiative Bill and Melinda Gates FoundationWilliam and Flora Hewlett FoundationRobert Wood Johnson FoundationHenry J. Kaiser Family FoundationJohn D. and Catherine T. MacArthur Foundation

David and Lucile Packard FoundationRockefeller FoundationStarr Foundation U.S. Agency for International Development (USAID)

Special thanks to Patricia Toro, Chloe Teasdale, Wafaa El-Sadr, Fatima Tsiouris, Theresa S. Betancourt, Ryan McBain, Mary C. Smith Fawzi

Film Credits:By Gideon MendelEditor Mo StoebeField Producer Patricia ToroText Editor Katie BootComposer Geoffrey KigunduMusic by MU-JHU Cares MDD Group and Florence KaweesaAdd’l Sound Design Adam Lieber