Elimination of mother to child transmission of hiv
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Elimination of mother to child transmission of hiv Presentation Transcript

  • 1. Elimination of Mother-to-Child Transmission of HIV Moving Beyond the Talk Arlington, March 23, 2011 Justin Mandala Presented by Barbara Sow, 6 Feb, 2012
  • 2. Overview
    • Basic facts about PMTCT
    • Defining “Elimination of MTCT”
    • What tools do we have to eliminate MTCT?
    • How much would it cost?
    • Where to focus efforts?
    • What role for Peace Corps?
    • Summary
  • 3. 1. Basic facts about PMTCT
  • 4. Basic facts: Magnitude & Risk of MTCT
    • 370,000 children infected in 2009; 90% through MTCT
    • 2.5 million children were living with HIV in 2009; 260,000 died of AIDS
    • Risk of MTCT without intervention = 15 to 45 %
    Critical Time Rate During pregnancy 5 to 10% During labor and delivery 10 to 20% During breastfeeding 10 to 20%
  • 5. Basic facts: Risk of MTCT with interventions
    • Breast- or Formula -feeding? not an easy choice…
    • PMTCT reduces the risk…
    Type of intervention MTCT rate Short course ARV with breastfeeding 15 to 25% Short course ARV, no breastfeeding 5 to 15% Highly effective ARVs, with breastfeeding < 5% Highly effective ARVs, no breastfeeding < 2%
  • 6.
    • 3 . Core PMTCT:
    • Use of ARV,
    • Safe Obstetrical practices
    • Safe infant feeding
    2 . Prevention of unwanted Pregnancies in HIV+ women 1 . Primary prevention 4 . Long term follow-up of mother-infant pair Basics facts: Global Strategic Response to MTCT
  • 7. 2. Defining “Elimination of MTCT”
  • 8. “ Elimination of MTCT”: Definition
    • MTCT rate of less than 5% (at 12 months of age) among children born to HIV-positive mothers in breastfeeding populations
    • MTCT rate of less than 2% at 6 weeks of age among children born to HIV-positive mothers or in “formula feeding” settings
    • 90% reduction in new pediatric infections
    Elimination of MTCT should translate into this: from the 2009 baseline , by 2015
  • 9. “ Elimination of MTCT”: clarifications
    • “ Elimination” can be sensitive/ stigmatizing for PLHIV
    • Elimination is not considered in its strict definition: “ elimination of an infection is reduction to zero incidence of infection caused by specific agent, in defined area; e.g. polio ”
    • “ 5% MTCT” as a definition focuses only on prong-3 and does not consider “HIV-free survival” the ultimate goal of PMTCT.
    • “ Virtual or Effective elimination” vs. “Elimination”… better to use “Elimination” because it is simpler
  • 10. 3. What tools do we have to “Eliminate MTCT”?
  • 11. Tools to eliminate MTCT: The momentum
    • PMTCT is a top political global agenda:
      • MDGs : by 2015… # 4 : Reduce child mortality by 2/3, #5 : Improve maternal health , #6 : Halve & begin to reverse the spread of HIV/AIDS
      • PEPFAR high commitment :
  • 12. Tools to eliminate MTCT: the cash
    • PEPFAR :
      • US $ 100 m in 2010-2011
      • 6 priority countries: Malawi, Mozambique, Nigeria, South Africa, Tanzania and Zambia.
      • Targets: 80% coverage of HIV testing and 85% coverage of most optimal ARV by 2014 at the population/ national level
    • Global funds is reprogramming $ to prioritize PMTCT
      • Round 9 proposal equals US$ 7m over 5 years
      • After reprogramming US$39m over 2 years
      • Targets: … at least 80% of HIV-positive mothers reached through Global-Fund supported programs receive the most optimal PMTCT regimen
  • 13. Tools to eliminate MTCT: all prongs need to contribute…
    • 50% reduction of HIV incidence
    • Zero unmet need for FP
    • Optimum ARV regimens to 90%
    • ARV during breastfeeding;
    • &quot;Elimination&quot; = aspirational goal
    Courtesy of UNAIDS
  • 14.
    • Antiretroviral treatment (ART) should be initiated at early stage of HIV/AIDS when CD4 count is 350 cell/mm3 (not 250 anymore).
    • ARV prophylaxis should start as early as 14 week (not 28 week anymore) pregnancy with up to 3 ARV combination.
    • In case of breastfeeding, ARV should be given to infants of mother and breastfeeding should stop at 12 months if PCR is negative.
    Tools to eliminate MTCT: “Prong-3 new guidelines” (1) Three major changes with the new guidelines:
  • 15.
    • If breastfeeding, ARVs should be provided…
    • Either to the infant: NVP until 1 week after all exposure to breast milk has ended
    • Or to the mother: triple ARV combination until 1 week after all exposure to breast milk has ended
    Tools to eliminate MTCT: “Prong-3 new guidelines” (2) Breastfeeding by HIV+ mothers is now safer…
  • 16. 4. How much would it cost?
  • 17. How much would it cost?: US$ 94 to 360 millions/ year Courtesy of PEPFAR
    • Up to US$391 million in formula feeding scenario
    • This is only drug cost
    • ARV option selected can make a huge difference
    • Focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, SA, Tanzania, Uganda, Vietnam and Zambia,
  • 18. How much would it cost?: Cost of inaction Courtesy of PEPFAR
    • What about the quality of life?
    • What about the cost on families?
  • 19. 5. Where do we focus efforts?
  • 20. Where to focus efforts: 25 countries with highest burden of MTCT
    • Sources:
    • HIV incidence – Spectrum models, Contraceptive prevalence and unmet need – Household surveys, ARV coverage – Universal Access report, ANC coverage – household surveys, Median duration of breastfeeding – household surveys.
  • 21. 6. What role for Peace Corps?
  • 22. What role for Peace Corps ?:
    • Be involved in national technical discussions
      • Participate in discussions between MOH and NGOs regarding role of community level
      • Participate in launching activities of MTCT elimination
    • Document activities to share with PEPFAR and Global Fund illustrating contributions
  • 23. What role for PCV? , “ make things happen ”
    • Implement activities for each prong:
      • Primary prevention: condom promotion and distribution, strategic behaviour communication (SBC); promote VCT, promote couple testing
      • Promotion of Reproductive Health services for HIV + women during post-test follow-up: Family planning and ANC
      • PMTCT package:
        • promote assisted delivery (transport, household support)
        • Promote appropriate infant feeding (12 month BF)
        • Promote post-natal services for mother and child pair
      • Data collection and reporting
        • Accompany health centers/health posts in collecting and analyzing data (graphs, monthly updates, etc)
  • 24. What role for PCV: measuring progress
  • 25. 7. In Summary
  • 26. In Summary
    • Elimination of MTCT is an aspirational goal that will further PMTCT
    • We have the momentum and the tools but the health system and community involvement are challenges
    • We cannot afford the cost of inaction
    • Bottleneck analysis and innovative approaches are needed
    • Quality and use of data will be critical
    • Peace Corps has a great role to play:
      • Good presence in high burden and priority countries
      • Peace Corps can make things happen at the community level !
  • 27. Thanks!