1.  Reduction in Perinatal Transmission of the HIV in Barbados after intervention with anti-retroviral therapy. M. Anne St John Consultant Paediatrician, Queen Elizabeth Hospital, Barbados

2. Categories of Transmission in Reported AIDS Cases in CMC: 1982-2000 (CAREC)

3. Status of Paediatric HIV/AIDS in the Caribbean Caribbean region 2nd highest in prevalence to Sub-Saharan region (UNAIDS) In 2001, 3 million lives claimed 580,000 deaths in paediatric cases (CAREC) In 2000, estimated 3000 children born to infected mothers, 1000 infants newly infected

4. >90% paediatric HIV/AIDS cases result through mother to child transmission

6.  Prevalence of HIV among Pregnant Women in Selected Caribbean Countries

8.  Trends in pregnant women Year Deliveries Exposed infants Rate/1000 del. 2001 3632287.7 2002 3417226.4 2003 3450174.9

9. Estimate of Incidence of HIV Among Infants in 4 CMCs: 2000 (CAREC) Jamaica: 225 children or 5 per 1000 live births Trinidad & Tobago: 108 children or 6 per 1000 live births Belize: 105 children or 15 per 1000 live births Guyana: 420 children or 21 per 1000 live births Barbados: --------------------1.5 per 1000 live births

11.  Paediatric HIV Surveillance and follow-up care Surveillance from 1985 paediatric HIV/AIDS cases (after index case of paed.HIV was Dx in B/dos) Referral of infected infants, to ONE follow-up clinic, QEH Also infants exposed in utero i.e infants born to HIV infected pregnant women also followed until HIV status determined

12.  Approach to reducing prevalence of paediatric HIV/AIDS Reduce prevalence in childbearing women Reduce transmission * perinatal/MTCT - via transplacental route -breast feeding sexual abuse blood products

14. >90% paediatric HIV/AIDS cases result through mother to child transmission Without ART in pregnancy: MTCT 15%- 30%, (no breast- feeding) With breast-feeding: transmission 43%-50%

15. MTCT of HIV:Influential factors Significant % reduction depending on protocol depending on if breast-feeding compliance factors

17.  Pediatric AIDS Clinical Trial Group Original multicentre study: New England Journal of Medicine report --1994 AIDS Clinical Trial Group PACTG 076 protocol collaborative study, many thousand patients Long course ZDV Rx of pregnant women and non breast- fed infants reduced transmission from 25.5% to 8.3% Relative Reduction 67.5%

18.  Reduction in perinatal transmission and mortality from Human Immunodeficiency Virus after intervention with Zidovudine. Barbados study ‘96-2000 Modified ACTG protocol (no CD4 counts): reduced transmission from 27.1% to 5.5%-- non breast-fed infants Relative Reduction 79.7% Published: J. Ped.Inf.Dis.2003: St John, Cave, Kumar

19. Prospective historic case controlled study Infected pregnant women and liveborns (>95% HIV screening of pregnant women) Modified ACTG 076 protocol ZDV orally qid commencing from 14 and 34 weeks gestation until term, IV in labour. Neonate treated for 6 weeks orally qid Maternal CD4, V.L not monitored (unavailable)

20.  Efficacy of Nevirapine Administration on the Mother to Child Transmission of HIV using a modified HIVNET 012 regimen. Barbados Study: Sept. 2000-July 2003 (abstract: St John, WIMJ) Nevirapine administered to pregnant women at onset of labour, to infant soon after birth Transmission rate in nevirapine treated mother infant group 8.8% 68.6% reduction in transmission rate Statistically significant (p=0.03)

21.  Conclusions 2 year study: nevirapine protocol very effective in reducing MTCT of HIV But less efficacious than zidovudine protocol used previously (NVP transmission rate 8.3%; ZDV rate 5.5% in previous study). 2.5% survival in infected infants 5.2% deaths to date

22.  Recommendation…19 years of studying paediatric HIV/AIDS cases in Barbados More effort: To reduce the overall prevalence on HIV in the population To attain and maintain 100% HIV screening of pregnant women Achieve a zero transmission of MTCT of HIV.

23. Recomendations Review protocol used for reducing MTCT of HIV, re-adopt ZDV protocol NVP reserved for late /undiagnosed pregnant women and infants to further optimise the reduction in MTCT of HIV.

24. Thank you!