1. Prevention of Mother to Child HIV Transmission Dr. Laura Guay Vice President for Research Elizabeth Glaser Pediatric AIDS Foundation July 15, 2009 Cape Town, South Africa

5. HIV Disease Course

6. Diagnosis of HIV 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 women 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

7. 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 infant, and family Component 1 Component 2 Component 3 Component 4 WHO’s 4-Component Strategy for MTCT Prevention

10. Access to Mother-to-Child Prevention WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2008 67% of pregnant women not receiving PMTCT drugs 80% of HIV-exposed infants not receiving PMTCT drugs

11. Benefits of global expansion of PMTCT programs Provides opportunity for primary prevention for large number of HIV uninfected women identified 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

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

13. Timing of HIV transmission to the infant During pregnancy Around labour/delivery During Breastfeeding

14. 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

15. 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

17. Balances risk of HIV transmission through BF with increased illness and death associated with not BF The best option depends on a woman’s health status/the local situation; should take greater consideration of the counseling/support she can receive Exclusive BF is recommended for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS) before that time When replacement feeding is AFASS, avoidance of all BF is recommended At 6 months if replacement feeding is still not AFASS, continuation of BF with additional foods is recommended. All BF should stop once a nutritionally adequate and safe diet without breast milk can be provided. Revised WHO Guidelines for infant feeding for HIV infected women in resource-limited settings

18. 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,  -Early endpoint in implementation program evaluation and HIV clinical trials HIV detection tests must be used in first 12-18 mos., then standard antibody tests are accurate Early infant diagnosis using dried blood spots has made services available even in remote areas

19. Infant Survival by HIV Infection Status- HIVNET 012 cohort Proportion alive ---- HIV Negative ---- HIV Positive Age (years) 92.1 % 43.2 % HIV neg HIV pos

20. 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

21. 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

22. WHO Indications for Initiation of ARV Therapy in Children < 1 Year Initially WHO guidelines for ART in children (2006) recommended starting therapy according to clinical and/or immunologic criteria Recent data from a study in South Africa where infants were put into one group that started therapy immediately or a second group where therapy started when WHO criteria were met showed ~75% decrease in death when ART was started immediately Therefore, WHO revised recommendations in April 2008 such that ALL infants diagnosed with HIV infection in the first year of life should receive ART immediately

23. Negotiating the PMTCT Activities ?

24. Negotiating the PMTCT Activities cont.

25. The way forward Challenges: High initial implementation costs Community sensitization/mobilization lacking Integration of PMTCT within ANC difficult Access to women who don’t deliver in health facility Very low numbers of partners involved Changing infant feeding education/practices 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.