1. Caring for Mothers and Children: Towards the Millennium Development Goals Philippa Musoke MBChB Department of Paediatrics and Child Health Makerere University Kampala UGANDA and MU-JHU Research Collaboration

2. Outline of Presentation Maternal and under five child mortality HIV infection in women and children Prevention of mother-to-child HIV transmission Achieving the Millennium Development goals

3. Maternal and Child Mortality: the Global Picture 500,000 women die annually (1 women dies / minute) –99% from low and middle income countries 8 million children < 5 years die annually (1 child dies/ 3 sec) –> 90% from low and middle income countries 4 million newborns die annually Contribute to 30 - 50% of all under five deaths Most of these deaths are preventable and related to infectious diseases and malnutrition In this day and age………... this is unacceptable !

4. Causes of under five mortality Global 2008

5. Prevalence of under nutrition in regions of the world, 2008

6. Proportion of under 5 mortality attributable to HIV Sub-Saharan Africa Stanecki K et al Sex trans Infect 2010

7. Global distribution of causes of maternal deaths 1997-2007

8. MM Ratio for 2000 by world region and medical cause Lancet 2006

9. INTERNATIONAL COMMITMENTS UN Millennium Development goals (MDGs by 2015) –PMTCT affects MDG 4, 5 & 6 and 3 G8 Nations - Universal access for HIV prevention, care & treatment by 2010 UNGASS 2001 – reduce # of HIV infected infants by 50% (2010) –Ensure 80% women accessing antenatal care receive PMTCT services Abuja Call to Action in 2005 “Call to Action” for an AIDS free generation UNICEF – “Unite for children Unite Against AIDS”

10. Prevention of Mother to Child Transmission of HIV contributes to multiple MDGs  MDG 4 - reduction in child mortality  MDG 5 – reduction in maternal mortality  MDG 6 – combat HIV/AIDS, malaria and other diseases  MDG 3 - promote gender equality and empower women  MDG 1 – reduce underweight

11. WHO – The 4 prongs of PMTCT Primary Prevention of HIV infection Prevention of unintended pregnancies in HIV infected women Prevention of HIV transmission from HIV infected women to their infants Provision of treatment, care and support for HIV infected women, their infants and their families

12. Virtual elimination of mother-to-child transmission of HIV is possible !

13. MTCT HIV transmission by CD4 cell count Children and AIDS 5 th Stocktaking report 2010

14. Coverage and health-seeking behavior go together Typology ATypology B Typology C Typology D Botswana – 99% South Africa – 88% Namibia – 88% Swaziland -88% > 80% ARV coverage 60-79% ARV coverage 30-59% ARV coverage<30% ARV coverage Ghana - 27% Cameroon - 27% India – 26% Ethiopia – 20% Malawi – 58% Zimbabwe – 56% Cote d’Ivoire – 54% Uganda – 53% Kenya – 73% Tanzania – 70% Mozambique – 70% Zambia – 69% Lesotho – 64% Angola – 19% Nigeria – 13% Burundi – 12% Chad – 6% DRC – 6% ARV coverage (2009). Slide courtesy of Chewe Luo.

15. Maternal antiretroviral therapy improves health and survival of mother and infant Maternal antiretroviral therapy – improves maternal health – Improves maternal survival A mother who is alive and healthy – Improves child survival and child health – Improves health seeking behaviour for herself and her infant

16. Stopped Breastfeeding Continued Breastfeeding Early Cessation of Breastfeeding Was Particularly Harmful for Children Who Became HIV-Infected p = 0.01 Survival of HIV-infected Children with Positive Results before Age 4 Months by Group Assignment (Abrupt vs Standard Weaning) Kuhn L et al. NEJM 2008

17. Early Infant HIV diagnosis using DBS for HIV DNA PCR Blood collected by dried blood spots (DBS) Collection of specimens from remote places Easy storage of samples Centralized testing for HIV DNA PCR – reduces costs Early HIV infected infants diagnosis Referral of infected infants for early care and treatment Photo by Pathfinder Kenya PMTCT

18. Percentage of children <15 years receiving antiretroviral therapy by region, 2009

19. PMTCT Benefits Reduced the number of HIV infected children Increased number of infected children on ART with improved survival GLOBAL MORTALITY reduced in children < 5 years Increased the number of women on ART with improvement in their health and survival – Leading to improve health and survival of HIV exposed and infected children – Reduced the number of orphans

20. Scale-up of PMTCT Commitment required from ALL Decentralization and improvement of service delivery Integration –PMTCT into routine antenatal, delivery and postnatal care –Paediatric HIV care into routine MNCH services –Paediatric HIV treatment into existing treatment programs Linkage of mother and infected partner to HIV care and treatment UNAIDS

21. MDG 4 Goal 4: Reduce child mortality rates Target 4A: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate –Under-five mortality rate –Infant (under 1) mortality rate –Proportion of 1-year-old children immunized against measles UNICEF/Pirozzi

22. Achieving the MDGs – Global progress 2008

23. Proportion of under 5’s who received survival intervention ( 42 countries) Stanecki K et al Sex Transm Infect 2010

24. Reducing neonatal mortality Improving maternal health Reducing maternal mortality Delivery with a skilled birth attendant Identification of early danger signs in new born infants and referral for appropriate care

25. Rotavirus vaccine Rotavirus accounts for 39% of all diarrhoeal disease worldwide –500,000 children die from rotavirus disease per year Rotavirus vaccines can prevent severe diarrhoeal disease –Efficacy ranges 50%-90% (lower in regions with higher mortality) –RotaTeq and Rotarix vaccines – available internationally Effective in HIV infected children (57% - Steele AD et al PIDJ 2011) WHO, Rotavirus position paper: Weekly epidemiological report 2009

26. Pneumococcal Vaccine Pneumococcal disease –Leads to 700, 000-1 million deaths per year Polyvalent conjugated pneumococcal vaccine –Invasive disease reduced by 75- 100 % in both resource-rich and resource-poor countries – Effective in HIV infected children but lower efficacy (Thanee C et al Vaccine 2011, Madhi SA et al PIDJ 2005) WHO, Pneumococcal vaccine position paper: Weekly epidemiological record 2007

27. Malaria Vaccine Malaria causes 10% of under five deaths worldwide RTS,S/AS01E lead candidate vaccine Randomized clinical trial of 894 children ( age 5-17 months) from Tanzania and Kenya 447 malaria vaccine vs 447 rabies vaccine Protective efficacy - (per protocol analysis) –46% (24.1 -63.1) p=0.0004 after 15 months of FU Promising results but higher efficacy required Olotu A et al Lancet Inf Dis 2011

28. Global Alliance for Vaccines and Immunizations (GAVI) “Saving childrens lives” – June 13 th 2011 London Major public and private donors – $ 4.3 M GAVI committed to immunizing 250 million children in the next 5 years ( $ 7.6 M)

29. MDG 5 Goal 5: Improve maternal health Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio –Maternal mortality ratio –Proportion of births attended by skilled health personnel Target 5B: Achieve, by 2015, universal access to reproductive health –Contraceptive prevalence rate –Adolescent birth rate –Antenatal care coverage –Unmet need for family planning UNICEF

30. Reduction in maternal mortality Education of the girl child Economic empowerment of women Family planning and child spacing Access to a skilled birth attendant for delivery PMTCT –ART for their own health and for PMTCT

31. Unmet needs for family planning in countries with generalized epidemic, 2006-2008 (> 30%) UNAIDS Report 2010

32. Coverage of skilled birth attendant at delivery, 2008

33. Trends in maternal mortality in select countries MDG report 2010

34. Conclusion It is a human right for every woman to survive pregnancy and child birth and their child to reach their 5 th birthday The interventions needed to prevent the majority of maternal and child deaths are well known …. – And yet MOST countries will not achieve the MDGs unless drastic measures are taken THEREFORE governments, civil societies and international donors need to commit to scale up these well known high impact, low cost interventions that can prevent most of these deaths

35. ELIMINATE PAEDIATRIC HIV and Care for the Mother and Child LET US KEEP THE PROMISE THANK YOU

36. Acknowledgements C Giaquinto MG Fowler D Mbori-Ngacha L Mofenson