Nesheim NHPC Elimination Slides

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Elimination of Perinatal HIV Transmission in the United States

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Nesheim NHPC Elimination Slides

  1. 1. Elimination of Perinatal HIV Transmission in the United States Steven Nesheim, M.D. Centers for Disease Control and Prevention National HIV Prevention Conference August, 2009
  2. 2. MCT Rate Estimates: Industrialized Countries • 1985-7 50%1 • 1988-9 332-40%3 24%4 • 1992 145 -24%6 • 1994 25%7 (1)Scott. JAMA1985;253:363. Semprini BMJ 1987;294:610. (2) Italian Multicentre Study Lancet 1988;2:1043-1045. Blanche NEJM 1989;320:1643-1648. (3) Johnson.AJDC 1989;143:1147-1153. (4) ECS Lancet 1988;2:1039-1042. (5) ECS Lancet 1992;339:1007-1012. (6) Gabiano Ped 1992;90:369-374. (7) Connor NEJM 1994;331:1173
  3. 3. ACTG 076 & USPHS ZDV Recs CDC HIV Testing Recs ~95% reduction
  4. 4. Estimated numbers of AIDS cases in children <13 years of age, by year of diagnosis, 1992–2006—50 states and the District of Columbia (Revised March 2008) 1000 896 881 799 800 Number of cases 669 600 511 400 328 241 195 200 127 123 106 70 53 53 38 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year of diagnosis Note. These numbers do not represent reported case counts. Rather, these numbers are point estimates, which result from adjustments of reported case counts. The reported case counts are adjusted for reporting delays. The estimates do not include adjustment for incomplete reporting. Source: HIV/AIDS Surveillance Report, Volume 18, March 2008, Figure 1
  5. 5. Number of perinatally infected infants by year of birth & year reported, in 33 states with HIV infection reporting since 2001—United States. Number infected Total Year of Report infants in birth Reported cohort (95% CI)* Birth 2001 2002 2003 2004 2005 Year 2001 39 74 31 8 10 162 277 (224-346) 2002 29 50 21 9 109 204 (161-276) 2003 25 34 27 86 167 (127-224) 2004 25 33 58 138 ( 96-186) *Data from 33 states with HIV infection reporting were extrapolated to the entire United States. Estimates include adjustments for delays in reporting, and underreporting of cases. McKenna, Hu. AJOG 2007, Sept. 197: S10-16
  6. 6. Estimated number of births to women living with HIV infection, 2000-2006, United States 9000 8500 8000 7500 7000 6500 6000 5500 2000 2001 2002 2003 2004 2005 2006 High Estimate Low Estimate 2006 estimate (8,650 – 8900) is ~30% > 2000 estimate (6075 – 6422) Office of Inspector General (Fleming), 2002 Whitmore, et al. CROI, 2009
  7. 7. Figure 1. Estimation of the number of HIV-infected infants, United States, 2005 Modeled estimate of HIV+ Modeled estimate of HIV+ women aged 13-44 diagnosed women aged 13-44 undiagnosed and living with HIV without AIDS and living with HIV without AIDS (using Poisson Regression) (using back-calculation) N=78,365 N=38,312 Estimated number Estimate of total number of HIV-infected of women aged 13-44 women aged 13-44 living with HIV living with AIDS without AIDS (diagnosed+undiagnosed) N=55,702 N=107,859-116,677 Estimated births to Estimated births to Estimated births to women living with women living with HIV women living with without AIDS immunologic AIDS clinical AIDS N=7,017-7,089 N=881 N=715 Estimated total births N=8,613-8,685 Est. 30% (2584- Est. 69% (5909- 2605) receive < 3 6078) receive all arms of ARV. 3 arms of ARV. 6.3% infected 1.3% infected Estimated total infections N=215-370
  8. 8. HIV infected infants in the United States: model estimates from 1978-2005 1800 PACTG 076, 1994 1600 1400 # in f e c t e d in f a n t s 1200 1000 800 600 400 200 0 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 Davis (1978-93) Lindegren (1991, 1995-96) OIG (2000) McKenna (2001-04) Taylor (2005) Davis et al., JAMA 1995;274:952-5. McKenna & Hu, AJOG 2007 Sep;197(3Suppl):S10-6. Lindegren et al., JAMA 1999;282:531-8. Taylor et al., unpublished, 2008. Office of Inspector General (Fleming), 2002.
  9. 9. MCT Rates in Industrialized Countries in the HAART Era Mother-child transmission rate Country Author Years Women Overall VL<50 with NVP w/o NVP w/mat. ARVs % C/S USA-WITS Cooper 1996-2000 1542 3.5% 5.0% 1.1% (HAART) USA, Dorenbaum Europe, Brazil, Bahamas 1997-2000 1270 1.4% 1.6% France Warszawski 1997-2004 5721 1.3% 0.4% European ECS 1997-2004 1983 2.87% Collab. Study 2001-2003 0.99% Sweden Navér 1999-2003 184 0.6% 80.3% 2000-2003 0.0% Spain Fernández- Ibieta 2000-2005 632 1.4% United Townsend 0.8% Kingdom 2000-2006 2100 1.2% 0.1% (>2wks ARV) Cooper ER, et al. JAIDS. 2002 Apr 15;29(5):484-94. ; Dorenbaum A, et al. JAMA. 2002 Jul 10;288(2):189-98.;European Collaborative Study. Mother-to-child transmission of HIV infection in the era of highly active antiretroviral therapy. CID. 2005 Feb;40:458-465.; Navér L, et al. JAIDS. 2006 Aug 1;42(4):484-9. Townsend CL, et al. AIDS. 2008, in press.; Warszawski J, et al. AIDS. 2008 Jan 11;22(2):289-99. Fernández-Ibieta M, et al. An Pediatr (Barc). 2007 Aug;67(2):109-15.
  10. 10. Perinatal Prevention Cascade Missed Opportunities Data Needs Number of HIV-infected women of HIV-infected woman childbearing age by state, race/ethnicity Number of HIV-infected women Become Pregnant giving birth (or exposed infants) % of all women (and HIV+) with Inadequate Prenatal Care adequate prenatal care % of all women (and HIV+) No (or late) HIV Test tested in pregnancy % of HIV+ women with ARV No ARV Prophylaxis prophylaxis in pregnancy Child Infected HIV transmission rate and number of infected infants
  11. 11. Missed Opportunities—Enhanced Perinatal Surveillance (EPS), 1999-2003, 24 sites, United States 8596 HIV-exposed singleton births with known HIV infection status – 7605 (88%) had prenatal care • 7151 (94%) had HIV testing –6553 (92%) had ARV during pregnancy » 4636 (70%) had ARV during Labor/Delivery Whitmore, S. Outcomes of Missed Opportunities for HIV Perinatal Prevention. National HIV Prevention Conference, 2007.
  12. 12. Prenatal HIV testing rates— national data, United States • 69% 2002 National Survey of Family Growth1 • 50-96% 2003 DHAP/RTI chart review2 • 45-96% 2004-6 Pregnancy Risk Assessment and Monitoring System (PRAMS)3 • 74% 2006 National Hepatitis B Hospital Survey4 1Anderson J, Sansom S, Mat Chil Health J 2006;10:413; 2Taylor A, unpublished data; 3Taylor A, Prev Conf 2009; 4Fitz Harris L, Prev Conf 2009.
  13. 13. Elimination of Perinatal HIV in the Unites States—Why? It is feasible We know how We have the tools Missed opportunities account for most remaining transmissions Cost-savings potentially $25,000,000/yr Discounted lifetime medical care cost for an HIV-infected child= $250,000 > 100 perinatal infections per year remaining It’s the right thing to do.
  14. 14. Racial/ethnic distribution in total population, infants aged ≤ 1 year, persons aged ≥13 years with diagnoses of HIV infection & children with diagnoses of perinatal HIV infection, 34 states, 2004-2007 5% 7% 2% 2% 4% 17% 11% 34% 16% 14% 56% Other 70% White 19% Hispanic Black 67% 69% 22% 45% 12% 13% 15% Total Infants aged Males aged Females aged Children aged Population <1 year >13 yrs with dx >13 yrs with dx <13 years with of HIV of HIV dx of perinatal infection infection HIV infection CDC. MMWR, Feb 5, 2010, Vol. 59 No. 4 (slide updated after publication)
  15. 15. Elimination of Perinatal HIV Transmission in the Unites States— Goal Proposed by Consultants Incidence < 1/100,000 live births < 40 cases annually among a 4 million birth cohort Transmission Rate < 1% e.g., < 87 cases in 2006 (8700 HIV-exposed births) Both goals represent a reduction of >100 cases per year.
  16. 16. Will the annual number of perinatal HIV infections in the United States continue to decline without additional effort and expense? Annual number of HIV-exposed births is increasing (30% increase from 2000 to 2006) Hardest-to-reach HIV-infected women & their infants pose an ongoing, significant challenge Evidence suggests that the annual number of HIV-infected infants is stable or increasing
  17. 17. Proposed Strategy to Eliminate Perinatal HIV Transmission in the U.S. Family Planning, Preconception Care, Prenatal Care and Universal HIV Testing for Pregnant Women Comprehensive, Real-time Case Finding: Perinatal HIV Services Coordinator g rtin re po s ure po Ex Case Review & Data reporting/ Community Surveillance Action (FIMR/HIV) Clinical and Psychosocial Long-term Follow-up Case Management
  18. 18. Brown’s Law "…as a disease control program approaches the end point of eradication, it is the program, not the disease, which is more likely to be eradicated… due to the increase of the cost in skill, effort, and resources to trace the last remaining cases and treat them; and to the increase in the disinterest of society in bearing that cost." Brown WJ. The first step toward eradication. In: Proceedings of the World Forum on Syphilis and other Treponematoses (Washington, DC). Washington, DC; US Government Printing Office, 1964:21-5.
  19. 19. Elimination of perinatal HIV in the United States—key points The target population, i.e., HIV-infected (pregnant) women is increasing: 30% increase HIV-exposed births/year between 2000-2006 Further increase may occur due to effects of: Increasing number of HIV-infected women of childbearing age Longer survival and increased well-being of HIV- infected women Safer conception methods (PrEP, assisted reproductive technologies, etc.)
  20. 20. Elimination of perinatal HIV in the United States—key points The stark racial/ethnic disparity in HIV MCT deserves further attention & action. Not a one-time accomplishment, i.e., an ongoing, annual effort

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