Dr. Laura Guay Vice President for Research Elizabeth Glaser Pediatric AIDS Foundation J2J Global Media Training on HIV/AIDS July 14, 2010 Vienna, Austria HIV in Children: Preventing Mother-to-Child Transmission

Elizabeth Glaser

Ariel and Jake Glaser

The Elizabeth Glaser Pediatric AIDS Foundation

HIV Disease Course

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, rapid tests, western blot) – HIV antibodies from an HIV-infected woman cross the placenta 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 Diagnosis of HIV

WHO’s 4-Component Strategy for MTCT Prevention 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 infants, and families Component 1 Component 2 Component 3 Component 4

New infections among children, 1990–2007

Provision of Antiretroviral Drugs WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report % of pregnant women not receiving PMTCT drugs 68% of HIV-exposed infants not receiving PMTCT drugs

Benefits of global expansion of PMTCT programs Provides opportunity for primary prevention for large number of identified HIV-uninfected women Provides opportunity for prevention of HIV infection in children Provides opportunity as an entry point into HIV Care for large number of HIV-infected women and their infected infants ―However, this is often a missed opportunity as ongoing HIV care and treatment is not available

- about 30 out of 100 babies born to these women will get HIV. If women with HIV do not take any HIV drugs during pregnancy and they breastfeed -

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 their mothers.

Breast Feeding vs Bottle Feeding

2009 Revised WHO guidelines

Key Changes in 2009 Revised WHO guidelines Begin ART at CD4 cell count of 350 rather than 200 Start ARV prophylaxis earlier in pregnancy Provide ARV prophylaxis during breastfeeding Provide single drug Nevirapine daily to infants OR Provide three drug ARV prophylaxis to the mother National authorities should decide whether MCH services will recommend HIV-infected mothers to: Breastfeed and receive ARV interventions OR Avoid all breastfeeding (Taking into account socioeconomics, health services, and local infant mortality and under-nutrition)

Infant HIV diagnosis Early diagnosis of HIV infection in children born to HIV-infected women is critical ―Allows early identification of children who will benefit from antiretroviral treatment, appropriate infant feeding choices, prophylaxis, and close medical follow-up ―Decreases the psychological stress of uncertainty for the parents HIV detection tests must be used in first mos., then standard antibody tests are accurate Early infant diagnosis using dried blood spots has made services available even in remote areas

Infant Survival by HIV Infection Status - HIVNET 012 cohort Proportion alive Age (years)

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 restore the 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 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 - Early intervention/support

WHO Indications for Initiation of ARV Therapy in Children < 2 Years Initial WHO guidelines for ART in infants and children (2006) recommended starting therapy according to clinical/immunologic criteria Studies in infants showed that there was a ~75% decrease in death when ART was started immediately rather than waiting WHO revised recommendations in April 2008 such that ALL infants < 1 yr diagnosed with HIV infection should receive ART immediately Recent revised WHO guidelines increased this to all infants < 2 yrs of age

Negotiating the PMTCT Activities ?

Negotiating the PMTCT Activities (PMTCT = MCH)

The Way Forward Challenges: High initial implementation costs Community sensitization/mobilization lacking Integration of PMTCT within antenatal clinic can be difficult Access to women who don’t deliver in health facility Very low numbers of partners involved Inadequate infant feeding education Poor postnatal follow-up Successes: Despite the challenges, we know this can be done, we have done it We are making great progress worldwide, but we all need to keep pushing forward

Tunaweza: Together, we can… Eliminate Pediatric HIV