Upload
hakiet
View
215
Download
0
Embed Size (px)
Citation preview
10th annual International Workshop on HIV Pediatrics 2018
Session 3: Prevention of Mother-to-child transmission
Steigenberger Hotel Amsterdam, the Netherlands | Saturday, July 21, 2018
Maria H. Kim, MD, MSc
Assistant Professor of Pediatrics, Baylor College of Medicine
Research and Implementation Director, Tingathe Program, Baylor Children’s Foundation Malawi
Implementation Director, Technical Support to PEPFAR Programs in the Southern African Region, Baylor
Children’s Foundation Malawi
Updates on PMTCT from Malawi, the
country where Option B+ started
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Nothing to disclose
• Malawi’s B+ program
• How is it going?A review of Malawi’s current PMTCT data: successes and challenges
• Why has it worked?Enabling factors including task shifting
• What remainsDolutegravir dilemma, further optimizing retention and infant testing, and
closing the gaps
Objectives
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
• Malawi- the first country to implement Option B+: universal life-long treatment for all pregnant and lactating women
• Option B + theorized benefits: effective reduction of vertical transmission. maternal health, reduced partner transmission, effective, cost-effectiveness, simplified delivery of PMTCT care
• Initiated July 2011
• Resulted in a dramatic and immediate (7-fold) increase in PMTCT uptake
• By 2014, 20+ countries had endorsed Option B+ for their national PMTCT programs
Malawi’s Option B+ Program
Excellent PMTCT coverage
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
MALAWI PMTCT COVERAGE amongst pregnant women living with HIV, 2009 - 2018
Malawi PMTCT coverage (percentage of HIV+ pregnant women receiving any prophylaxis to prevent mother-to-child transmission), Spectrum 2016, 2009 - 2018
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Very good ART coverage amongst pregnant women living
with HIV
Malawi Treatment Coverage for HIV+ Women (percentage of HIV+ pregnant women receiving ART for both PMTCT and treatment,, Spectrum 2016, 2009 - 2018
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Vertical transmission has decreasedSpectrum estimates
Malawi MTCT Rate at 6 weeks, Spectrum 2016
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
HIV+ infants are being linked to ART
EID 2-12 mons Confirmed Infected (DNA-PCR) vs Started on ART, MoH DHA data 2015 – 2018Percentage of infants testing positive who are started on ART
90%
97%
59%
93%
83%82%
114%
118%
92%
81%91%
75%
77%69%
73%
80%94%
96%
87%
75%91%88%93%70%
84%
107%
91%
0
20
40
60
80
100
120
140
160
Jan Feb Mar Apr May Jun Jul Aug Sep Nov Dec Oct Jan Feb Mar Apr May Jun Jul Aug Sep Nov Dec Oct Jan Feb Mar
2016 2017 2018
MALAWI EID TEST TO TREATMENT LINKAGE 2 - 12 mons 2016 - 2018
Confirmed Infected + PSHD Started ART
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
More women are already on ART when becoming pregnant
Malawi Department of HIV and AIDS, National Quarterly Reports Q3 2017
2.1
12 3.3
42
4.2
11
4.1
61
4.3
40
5.0
46
5.2
71
5.3
35
5.1
78 6.5
79
6.6
89
6.5
98
6.3
50
7.4
01
7.2
19
7.4
52
6.8
57 7.9
85
7.7
14
8.2
05
8.4
14
8.5
97
1.1
90
1.2
19
1.2
45
1.2
42
1.1
41
1.2
57
3.5
61
7.5
99
7.4
81
6.0
94 7.9
74
6.6
71
7.0
20
7.1
09
6.7
49
6.5
44
6.8
91
6.3
42 7.0
03
6.4
71
6.1
27
6.2
72
6.4
87
6.2
92
6.6
85
6.6
51 6.4
55
5.9
12
6.3
19
5.5
84
5.7
55
1.3
94
6.8
39
4.4
78
2.6
98
2.6
89
2.2
97
2.2
89
2.1
62
1.8
34
1.7
21
1.8
10
1.5
45
1.8
09
1.7
52
1.7
23
1.5
93 1.6
90
1.7
23
2.0
26
1.8
85
1.4
28
1.2
47
1.6
30
1.5
36
1.6
77
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2010 2011 2012 2013 2014 2015 2016 2017
PREGNANT AND BREASTFEEDING WOMEN LIVING WITH HIV STARTING OR ALREADY ON ART
Women at maternity or ART when getting pregnant Pregnant women starting ART Breastfeeding women starting ART
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Vertical transmission has decreased, but there are gaps
EID Transmission Rate for 2 and 12 mons, MoH DHA data from 2016 - 2018
0,8%0,8%
1,1%
0,9%
0,7%0,8%
1,1%0,9%
0,6%
1,2%
0,9%1,0%1,0%
0,7%0,7%
1,3%1,2%
0,6%
1,4%
1,1%
0,6%0,7%
0,6%0,5%
1,2%
0,7%0,7%
1,2%
2,0%2,1%
1,9%1,9%1,8%
1,9%1,8%
1,3%
1,8%
1,5%
1,9%1,8%
2,0%2,2%
2,3%
2,1%
2,3%2,2%
1,7%
2,0%
1,7%1,7%
1,9%2,0%2,1%
1,9%
0,0%
0,5%
1,0%
1,5%
2,0%
2,5%
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016 2017 2018
MALAWI EID TRANSMISSION RATE 2 - 12 mons 2016 - 2018
2 mons Rate 12 mons Rate
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Spectrum estimates vertical transmission is 6.9% vs.
Early infant diagnosis program data yield <3%
Early infant diagnosis testing improving but could be
further optimized
EID Coverage 2-12 mons, MoH DHA data 2016 - 2018
57
%
46
%
45
%
50
%
49
%
49
%
54
%
55
%
51
% 57
%
57
%
55
%
76
%
69
%
68
% 79
%
75
%
69
% 80
% 78
%
73
% 81
%
77
%
76
% 82
% 77
%
76
%
0
200
400
600
800
1000
1200
1400
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016 2017 2018
Malawi’s Early Infant Diagnosis program, TOTAL CHILDREN REGISTERED vs TOTAL TESTED
2 - 12 months of age 2016 - 2018
Total children registered Total Tested
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Retention not optimal
Malawi MoH DHA data Q4 2015 – Q3 2017
76
%
69
%
66
%
65
%
75
%
69
%
66
%
65
%
77
%
71
%
68
%
66
%
76
%
70
%
65
%
65
%
78
%
70
%
64
%
63
%
79
%
73
%
67
%
65
%
80
%
75
%
69
%
65
%
82
%
76
%
69
%
64
%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
6 mons 12 mons 24 mons 36 mons
Pregnant and lactating women alive and on ART 6-, 12-, 24- and 36- months post ART initiation. Q4 2015 - Q3 2017
Q4 2015 Q1 2016 Q2 2016 Q3 2016
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Site level variability, 12 month retention Option B+
MoH DHA data 2018
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
• Political will and strong leadership from the Department of HIV and AIDS
Key factors enabling continued success
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
• Funding support• Involvement of broad base of key stakeholders including PLHIV and
Implementing partners • Robust data system to track progress with quarterly supervisions• Procurement and supply chain systems tightly monitored• Integration of PMTCT/ART and antenatal care• Malawi’s experience with and innovation around task-shifting
• Malawi’s history of successful task-shifting- enabling non-doctor cadres to initiate ART, helped launch Option B+ in Malawi
• Malawi’s leadership in task-shifting continues to help move Malawi beyond B+ and address ongoing gaps in PMTCT/MCH care
• In 2015, Malawi initiated the HIV Diagnostic Assistant (HDA) program, a new cadre of health worker focused primarily on HIV diagnostic testing (HTC, EID and VL)
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Malawi’s innovation: the HIV diagnostic assistant (HDA)
Impact of HIV Diagnostic Assistants (HDAs)
• We reviewed data from 457 HDA sites pre-HDA deployment (October 2013 to June 2015) and post- HDA deployment (July 2015 to December 2017
• We compared several measures including HIV testing, syphilis testing at ANC and early infant diagnosis testing
* Flick RJ, Simon K, Nyirenda R, Namachapa K, Hosseinipour MH, Schooley A, Kavuta E, Theu J, Kazembe PN, Ahmed S, Kim MH. The HIV diagnostic assistant—early findings from a novel HIV testing cadre in Malawi. Publication in progress
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
• We evaluated changes in the slope and level of these HIV testing measures through single-group interrupted time-series analysis
Number of persons tested for HIV increased post deployment
HIV testing before and after HDA
deployment
Dashed vertical line indicates HDA deployment at July 2015. Solid
lines reflect regression of values before and after deployment. Dashed
horizontal line represents pre-deployment trend projected
(counterfactual outcome).
* Flick RJ, Simon K, Nyirenda R, Namachapa K, Hosseinipour MH, Schooley A, Kavuta E, Theu J, Kazembe PN, Ahmed S, Kim MH. The HIV diagnostic assistant—early findings from a novel HIV testing cadre in Malawi. Publication in progress
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Trend
before
deployment
Trend
after
deployment
Trend
difference p
Level
difference p
1508 4950 3442 0.001 35588 0.031
PMTCT related outcomes: improved early infant diagnosis testing
and syphilis testing
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Trend
before
deployment
Trend
after
deployment
Trend
difference p
Level
difference p
Pregnant women
tested for syphilis -120 1229 1349 <0.0001 6640 0.001
Number of infants
receiving early infants
diagnosis testing by 2
months of age 1 67 65 <0.0001 -266 0.05
* Flick RJ, Simon K, Nyirenda R, Namachapa K, Hosseinipour MH, Schooley A, Kavuta E, Theu J, Kazembe PN, Ahmed S, Kim MH. The HIV diagnostic assistant—early findings from a novel HIV testing cadre in Malawi. Publication in progress
proportion of positive syphilis test results is now
very close to the syphilis prevalence estimated
from the 2010 ANC sentinel surveillance round
• Further optimization of maternal retention and EID testing coverage (plan to scale up POC EID testing)
• Support for large numbers of treatment experienced women
• Closing the other gaps (women who don’t receive prophylaxis, new infections amongst women during pregnancy and postpartum)
• Addressing other maternal health concerns (mental health)
What next?
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
The challenge with dolutegravir
• Malawi’s plan was to transition to Dolutegravir (DTG)- based ART regimens because of evidence that they are more potent, durable, convenient, better tolerated and have fewer drug interactions.
• Concern regarding safety of DTG-based ART regimens for use in early pregnancy.
What are we doing about dolutegravir (DTG)?
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
Malawi’s Plan
• Tenofovir/lamivudine/efavirenz will remain the standard 1st line for women who may get pregnant while on ART from 30kg+
• DTG-based ART regimens will be introduced for eligible patient groups from the beginning of 2019. ➢ Eligible groups: males from 30kg+ and women aged 45 years+ or with permanent
contraception
• Malawi created and successfully scaled up B+, a highly effective
PMTCT program
• Malawi has sustained B+ successes with excellent PMTCT and maternal
ART coverage, efforts to retain women and infants, and decreasing vertical
transmission moving close to elimination
• Malawi has also moved beyond B+, innovating and addressing other gaps
in PMTCT such as syphilis and EID testing coverage with interventions such
as its HDA program.
Conclusions
10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands
• Malawi seeks to continue to improve and grow, and much work remains
• Malawi Department of HIV & AIDS (DHA)• BIPAI network and leadership• Baylor Children’s Foundation Malawi• Technical Support to PEPFAR Programs in the
Southern African Region • Tingathe outreach program• USAID• PEPFAR• Spectrum Help Desk• Presentation technical guidance and support:
Elaine Abrams, Rose Nyirenda, Peter N. Kazembe, Stephen Chu, Katie Simon, ShaffiqEssajee, Saeed Ahmed
Acknowledgements10th annual International Workshop on HIV Pediatrics 2018 Session 3: PMTCT | July 21, 2018 | Steigenberger Hotel Amsterdam, the Netherlands