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WHO guidelines on use of antiretroviral drugs for the prevention of mother-to-child transmission of HIV Dr Tin Tin Sint Department of HIV/AIDS World Health.

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Presentation on theme: "WHO guidelines on use of antiretroviral drugs for the prevention of mother-to-child transmission of HIV Dr Tin Tin Sint Department of HIV/AIDS World Health."— Presentation transcript:

1 WHO guidelines on use of antiretroviral drugs for the prevention of mother-to-child transmission of HIV Dr Tin Tin Sint Department of HIV/AIDS World Health Organization

2 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Mother-to-child transmission of HIV  Without any intervention 15%-45% of infants born to mothers living with HIV will become infected  Virtual elimination of MTCT have been achieved in developed countries (<2%)  A comprehensive package is needed:  Primary prevention in parents-to-be  Prevention of unintended pregnancies among HIV-infected women  Prevention of HIV transmission from women living with HIV to their infants  Provision of appropriate treatment, care and support to all those infected and affected

3 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access The evolution of interventions and national programmes  Research on use of ARV for PMTCT started in the '90s with reported efficacy of various regimen in the late '90s (Shaffer et al.; Wiktor et al.; Guay et al.)  Several regimens using mono-, dual-, or combination prophylaxis found to be efficacious  Pilot projects to define implementation feasibility carried out in resource-limited settings  Recent scale up of pilot projects to national programmes (88 out of 109 reporting countries)

4 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Current WHO 2006 recommendations: HIV testing and counselling 1.All pregnant women should be offered HIV testing and counselling as part of routine ANC  First step in providing targeted interventions including PMTCT  Using provider-initiated testing and counselling should be the norm and greatly increases access to the services  Rapid testing with same day result should enable more clients to be aware of their own serostatus and therefore increases uptake of services  Only, about 18% of total estimated number of pregnant women in low- and middle-income countries received an HIV test (2007)

5 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Percentage of pregnant women in low- and middle- income countries receiving an HIV test (2004-2007) Source: Universal Access Report, 2007

6 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Current WHO 2006 recommendations: screening for ART eligibility 2.When a pregnant woman is identified with HIV eligibility for ART must be assessed using clinical staging and/or CD4 cell count, and ART provided as necessary  High viral load and low CD4 means high transmission  Women with low CD4 are those who needs ART  Providing ART to pregnant women in need will address the health issue of the mother and in addition significantly reduce MTCT  Only 12% of pregnant women identified as HIV-positive during ANC were assessed for eligibility (2007)

7 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Eligibility criteria WHO clinical stage CD4 testing not available CD4 testing available 1 Do not treat (A-III) Treat if CD4 <200 cells/mm 3 (A-III) 2 Do not treat (A-III) 3 Treat (A-III) Treat if CD4 <350 cells/mm 3 (A-III) 4 Treat (A-III) Treat irrespective of CD4 cell count (A-III)

8 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Recommended regimens for treating pregnant women and prophylactic regimen for infants  For women, including pregnant women, who need ART for their own health: * If the mother receives < 4 wks of ART during pregnancy, give 4 wks of infant AZT Mother AntepartumAZT + 3TC + NVP twice daily IntrapartumAZT + 3TC + NVP twice daily PostpartumAZT + 3TC + NVP twice daily InfantAZT x 7 days*

9 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Current WHO 2006 recommendations: more efficacious regimens for prophylaxis 3.If not eligible for therapy, use more efficacious prophylactic regimens  Combination ARVs are more effective and reduces resistance  Risk of transmission at 18 months 20% with no ARV (WITS)* 10.4% with AZT monotherapy (WITS)* 3.8% with dual-ARV (WITS)* 1.2% with triple-ARV (WITS)* 15.7% with single-dose nevirapine vs. 25.8% with AZT (HIVNET 012)** *Cooper E et al. JAIDS 2002**Jackson JB et al. Lancet 2003

10 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Recommended regimens for treating pregnant women and prophylactic regimen for infants  Women who do not need ART should be offered ARV prophylaxis for MTCT prevention: The recommended prophylactic regimen is: Mother Antepartum AZT starting at 28 wks of pregnancy or as soon as thereafter Intrapartum Sd-NVP + AZT/3TC Postpartum AZT/3TC for 7 days Infant Single dose NVP plus one week AZT* * If the mother receives < 4 wks of ART during pregnancy, give 4 wks of infant AZT

11 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access More efficacious regimens  Combination prophylaxis regimen lowers transmission rate  AZT given for a longer period during pregnancy is more efficacious  Nevirapine is important in preventing early postnatal transmission through breastfeeding due to its long half- life  Addition of 3TC is to prevent resistance to nevirapine (for future treatment options)

12 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Different approaches for using ARV prophylaxis to prevent HIV infection in infants RankingTime of administration PregnancyLabourPostpartum MaternalInfant RecommendedAZT (>28 wks gestation) Sd-NVP + AZT/3TC AZT/3TC x 7 days Sd NVP + AZT x 7 days AlternativeAZT (>28 wks gestation) Sd-NVP Sd NVP + AZT x 7 days Minimum -- Sd-NVP + AZT/3TC AZT/3TC x 7 daysSd NVP Minimum--Sd-NVPSd NVP

13 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Distribution of ARV regimens for PMTCT (2007) Source: Universal Access Report, 2007

14 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access ARV prophylaxis for PMTCT among pregnant women who have not received antenatal ART or prophylaxis RankingTime of administration LabourPostpartum MaternalInfant Recommended Sd-NVP + AZT/3TC AZT/3TC x 7 daysSd NVP + AZT x 4 wks Alternative AZT + 3TCAZT/3TC x 7 days Minimum Sd-NVP + AZT/3TC AZT/3TC x 7 daysSd NVP Minimum Sd-NVPSd NVP

15 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access ARV prophylaxis for infants born to HIV-positive women who have not received ART or ARV prophylaxis RankingTime of administration Infant Postpartum RecommendedSd-NVP + AZT x 4 weeks 1 AlternativeSd-NVP + AZT x 1 week MinimumSd NVP 1 NVP administered immediately after birth, if possible within 12 hours after delivery, is likely to result in a larger reduction in transmission than later initiation. Data on added efficacy of 4 weeks of infant AZT in this situation limited

16 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Setting priorities  The health of the mother is the first priority  Identify most effective interventions that can be provided to a maximum number of women  Quality of services should not be neglected while scaling up  Improved child survival should be the outcome

17 Prevention of HIV infection in pregnant women, mothers and their children 2008 Towards Universal Access Review of evidence WHO systematically reviews available evidence and programme performance, and will convene an expert consultation in late 2008 Department of HIV/AIDS Department of Child and Adolescent Health and Development Department of Reproductive Health and Research


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