HIV in Children: Preventing Mother-to-Child Transmission

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

Elizabeth Glaser

Ariel and Jake Glaser

The Elizabeth Glaser Pediatric AIDS Foundation

HIV Disease Course

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 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

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

600 000
500 000
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300 000
200 000
100 000
0
1990
1991
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1993
1994
1995
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1997
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2007
Year
This bar indicates the range
New infections among children, 1990–2007

Provision of Antiretroviral Drugs
55% of pregnant womennot receiving PMTCT drugs
68% of HIV-exposed infantsnot receiving PMTCT drugs
WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2009

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

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.

Timing of HIV transmission to the infant
During pregnancyAround labour/deliveryDuring 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 getHIV 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 12-18 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

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HIV in Children: Preventing Mother-to-Child Transmission

by Elizabeth Glaser Pediatric AIDS Foundation on Jul 15, 2010

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HIV in Children: Preventing Mother-to-Child Transmission Presentation Transcript