1. Prevention of Mother to Child Transmission of HIV

2. Describe the magnitude of the problem
Session Objectives
By the end of this session participants would be able to:
Describe the magnitude of the problem
and its impact;
Describe the routes, rates and risks of
HIV transmission from mother to child.

3. Magnitude of the Problem
MTCT most significant source of HIV infection in children below age 15.
More than 5 million children infected since beginning of epidemic.
Almost 4 million children have died.
90% of MTCT occurs in Africa.
Transmission higher in developing countries than in industrialized countries due to lack of treatment.

4. Estimated impact of AIDS on under-5 child mortality rates, select African countries, 2010
250
Deaths per 1000 live births
200
Without AIDS
With AIDS
150
100
HIV/AIDS is threatening child survival in many developing countries.
This slide shows that unless we do more than what we currently are doing, under-5 child mortality rates will significantly increase by the year As you can see, in Botswana, Zambia, Zimbabwe and Kenya U5MRs will more than double.
Let us leave the statistics behind and dwell on where we are with PMTCT implementation at both global and regional levels. 50
Botswana
Kenya
Malawi
Tanzania
Zambia
Zimbabwe
Source: US Census Bureau

5. Routes, Rates,and Risk Factors of Vertical Transmission

6. HIV Transmission to Infants
Less than 60 % of babies born to HIV-positive mothers become infected
Peri-natal
In utero (during pregnancy)
Intrapartum (during delivery)
Post-natal
Breastfeeding (risk of increases over time. The longer the baby is breastfed the greater the risk of infection)

7. Father Mother Infant Routes of MTCT of HIV Intercourse Pregnancy
Labor & Delivery
Breastfeeding
Infant

8. Risk Factors during Breastfeeding
Prematurity
Duration of breastfeeding
Infant immune responses
Mixed feeding
Maternal viral load
Mastitis
Mastitis, an inflammatory process in the breast, may be common in lactating women in Africa and is associated with both higher HIV load in breast milk and mother-to-child transmission of HIV

9. Balancing the Risks of BF and Formula Feeding
12 months
24 months
6 months
14 wks
6 wks
Child age
Source: Nduati et al. JAMA 2000

10. Weighing the Risks and Benefits of Breastfeeding with HIV
Replacement feeding prevents transmission of HIV through breastfeeding
But:
Essential to have sterile water
Risk of death due to artificial feeding?
Cost of replacement feeding?
Stigma if not breastfeeding?
Early return of fertility?

11. Risk Factors for MTCT during Pregnancy and Delivery
Maternal Factors
Stage of maternal HIV disease (viral load)
Maternal nutritional status
Disruption of placental barrier integrity
STD during pregnancy
Factors related to the child
Genetic characteristics suspected as potential risk
Obstetrical Factors
Vaginal delivery (versus C-section)
First-born of twins
Pre-term delivery
Hemorrhage during labor
Bloody amniotic fluid
Invasive procedures
Viral Factors
MTCT rates higher for HIV-1 than for HIV-2

12. Benefits of Breastfeeding
Benefits for Infants
Adequate nutrition
Provides protective against infections through maternal antibodies
Increase intellectual potential (?)
Promotes bonding between mother and infant
Benefits for Mothers
Facilitates uterine contraction
Protects against excessive blood loss
Delays the return of normal menstruation
Contributes to child spacing
Conforms to social norms

13. Rates of Vertical Transmission Without ART
Pregnancy/delivery/breastfeeding…………35%
(no intervention)
Pregnancy/delivery/replacement feeding….20%
(BF contributes 15%)

14. Risk of Transmission Transmission Rate (%) Timing No BF
BF through 6 months
BF through months
During pregnancy
5 – 10
During labor
10 – 20
Through BF
Early infection
(first 2 months)
Late infection
(after 2 months)
1 – 5
Overall
15 – 30
25 – 35
30 – 45
Source: De Cock KM et al

15. The Variable Risk of MTCT

16. Probability of MTCT of HIV (No intervention)
Mother
Pregnancy/delivery
HIV+ Infants
(20)
HIV- Infants
(80)
Post partum & BF
HIV+
(12)
HIV-
(68)
Estimated outcome based on 100 single births to HIV infected mothers

17. Probability of MTCT of HIV (Nevirapine)
Mother
Pregnancy/delivery
HIV+ Infants
(10)
HIV- Infants
(90)
Post partum & BF
HIV+
(14)
HIV-
(76)
Estimated outcome based on 100 single births to HIV infected mothers

18. Strategies for the Prevention of MTCT

19. A Comprehensive Approach to Prevent HIV Infection in Infants and Young Children
WHO, 2000

20. Four Integrated Strategies to Reduce Pediatric AIDS (WHO/UNICEF 4 Pillars of MTCT)
3. Prevention of
transmission from mother to child
1. Primary
prevention of HIV in young adults
4. MTCT-Plus: care and support for HIV+ women, their infants, and families
2. Prevention of
unwanted pregnancies
among HIV+ women
(family planning)

21. MTCT Prevention components and their contribution to the four-pronged strategy
1. Primary HIV prevention in parents-to-be
2. Prevention of unwanted pregnancy in HIV+ women
3.Prevention of HIV transmission from MTC
4. MTCT-Plus: care & support for HIV+ women and families
IEC on prevention and care 
Condom promotion
VCT
Family Planning (dual protection)
STI treatment
Antenatal care
Prophylactic ART regimens
Safe delivery practices
Support for safer infant feeding
Community action to reduce stigma and discrimination and increase support for programs
Clinical and community care

22. Strategy 1: Primary Prevention of HIV Infection
Safe sexual behavior and condom use
Reproductive health services
Management of STIs
VCT
HIV prevention interventions aimed at pregnant and lactating women, and women of child bearing ages

23. Strategy 2: Prevention of Unintended Pregnancies in HIV+ Women
Strengthening family planning services
To prevent unintended pregnancies
To delay subsequent pregnancies
To replace the contraceptive effect of breastfeeding
Access to safe abortion services where allowed by law
VCT so that they know their HIV status

24. Strategy 3: Prevention of Transmission in HIV+ Women
Pregnancy and delivery
Antiretroviral therapy (ART)
Vaginal disinfection (little evidence of success and can increase inflammation)
Improved obstetrical practices (avoid unnecessary invasive procedures, safer delivery)
Treatment of STIs
Breastfeeding
Good nutrition and good BF technique instruction
Short course ART for baby

25. Strategy 4: MTCT-Plus Secondary HIV prevention
Clinical care (including ART)
Community care
Stigma reduction
OVC services
Impact mitigation

26. Approach to HIV VCT in ANC Settings
"Opt in" approach:
HIV VCT is offered to pregnant women as a separate intervention from routine ANC and women are requested to provide explicit consent to receive the intervention (VCT)
"Opt out" approach:
HIV is offered to pregnant women as part and parcel of routine ANC and women are given the option to refuse the intervention based on their personal/individual situation