WGHA Discovery Series: Cathering Wilfert

2,157 views

Published on

Washington Global Health Alliance Discovery Series

Catherine Wilfert, MD [
December 1, 2008
'Global Prevention of Mother to Child Transmission of HIV-1'

Published in: Education, Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
2,157
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
0
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • WGHA Discovery Series: Cathering Wilfert

    1. 1. Global Prevention of Prevention of Mother to Child transmission of HIV-1 The Devil is in the Details Catherine M Wilfert MD Dec 1, 2008
    2. 2. EGPAF International Family AIDS Initiatives <ul><li>Acknowledges all of the host countries for supporting this work </li></ul><ul><li>Thank all of our staff in the US and in country </li></ul><ul><li>Thank all the people we serve </li></ul><ul><li>Pictures were taken with permission and do not imply anything about serostatus of persons </li></ul>
    3. 3. The Devil is in the Details <ul><li>Brief overview of PMTCT </li></ul><ul><li>EGPAF PMTCT </li></ul><ul><li>Breast Feeding </li></ul><ul><li>Treatment of Moms </li></ul><ul><li>Care & Treatment especially infants </li></ul><ul><li>Prevention & prevalence </li></ul>
    4. 5. Biological Factors affecting Perinatal Transmission of HIV Maternal Placental Fetal Duration of Ruptured Membranes Breast Feeding T.Quinn HIV-1 RNA ART Prx C-Section ART Prx
    5. 6. HIV Mother-To-Child Transmission Rates without ARV with 18-24 months BF Derived From 3 Controlled Clinical Trials
    6. 8. 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
    7. 10. <ul><li>Family-Centered HIV/AIDS Prevention and Treatment Programs </li></ul><ul><li>______________________________________________________ </li></ul><ul><ul><li>HIV prevention services </li></ul></ul><ul><ul><li>for pregnant women and infants </li></ul></ul><ul><ul><li>Treatment and care services </li></ul></ul><ul><ul><li>for children and families </li></ul></ul><ul><li>Program Model </li></ul><ul><ul><li>• Partner with host governments </li></ul></ul><ul><ul><li>• De-centralized community focus </li></ul></ul><ul><ul><li>• Training and technical assistance </li></ul></ul><ul><ul><li>• Capacity building for sustainability </li></ul></ul><ul><ul><li>• Program monitoring & evaluation </li></ul></ul><ul><ul><li>• Infrastructure and logistics development </li></ul></ul>
    8. 11. EGPAF Country Programs 2000 8 sites in 6 countries 2008 >3000 sites in 17 countries South Africa Rwanda Uganda Kenya Thailand Angola D.R. Congo Malawi Tanzania Zambia Zimbabwe Russia Swaziland Dominican Republic Cameroon India Georgia Honduras Mozambique Cote d’Ivoire China
    9. 12. HIV Prevention : EGPAF Impact ______________________________________________________________ • More than 6.2 million pregnant women reached to date with services to prevent transmission to their babies (PMTCT) • 2007 EGPAF programs accounted for 28% of global PMTCT treatments • 2008 will reach more than 1.7 million women in 17 countries • Continuous service refinement and performance improvement
    10. 13. Cumulative PMTCT Cascade All Countries 2000-2008
    11. 14. Cumulative PMTCT Cascade: Africa 2000-2008
    12. 16. EGPAF Africa: Women Reported to Receive Prophylaxis for PMTCT
    13. 17. Number Trends With Time
    14. 18. Percent Uptake With Time
    15. 20. Swaziland Cumulative PMTCT Cascade
    16. 21. Uganda Cumulative PMTCT Cascade
    17. 22. Reported Supervised Delivery Rates in All Countries First ANC = 2,864,694 Deliveries = 1,798,949 (61%) # HIV + = 179,078 # HIV+ del = 89,761(52%) # on Rx = 10,401 # del on Rx = 8120(78%)
    18. 23. Breastfeeding Postnatal Transmission: Accounts for at Least One-Third of all Transmissions Among Breastfeeding Women MG Fowler 0% 20% 40% 60% 80% 100% Early Antenatal (<36 wks) Late Antenatal (36 wks to labor) Labor and Delivery Late Postpartum (6-24 months) Early Postpartum (0-6 months) Proportion of infections
    19. 25. Breastfeeding + 6 Months AZT (then Weaning) Did Not Reduce MTCT Rates to Those in Formula Fed Infants Thior I et al. JAMA 2006;296:794-805 Formula Breastfeeding + AZT P=0.02 Infection btn birth - 7 months was 5.7% Infection btn birth-7 months was 1.8%
    20. 26. Mashi: Cumulative Rate of Death by Infant Feeding Thior I et al. JAMA 2006;296:794-805 Formula Breastfeeding + AZT overall p=0.21 7 month difference Significantly More Early Deaths With Formula Feeding p=0.003
    21. 27. Cumulative Rate of HIV Infection or Death by Infant Feeding Thior I et al. JAMA 2006;296:794-805 Formula Breastfeeding + AZT P=0.48 Resulting in No Difference in HIV-Free Survival
    22. 29. SWEN: 6-Week NVP Reduces Risk of HIV Infection or Death at Age 6 Wks and 6 Mos RR 0.58, p=0.008 RR 0.73, p=0.028
    23. 30. SWEN: Visit-Specific Breastfeeding Frequencies: Decreases from 73% at 14 wks to 31-32% at 6 mos
    24. 31. Probability of HIV-1 Infection or Death in Infants Uninfected at Birth by Treatment Arm: PEPI-Malawi Age 1 wk 6 wks 9 wks 14 wks 6 mos 9 mos 12 mos 15 mos 18 mos 24 mos Estimates (%) Control 0.6 6.7 9.3 10.7 13.2 16.8 18.1 20.5 22.6 24.1 Extended NVP 0.6 3.3 4.2 4.7 6.6 10.6 13.9 16.0 19.0 20.9 Extended NVP+ZDV 0.5 2.8 4.1 5.1 8.2 11.2 15.0 16.5 18.6 22.0
    25. 33. PEPI-Malawi: Visit-Specific Breastfeeding Frequencies Among HIV Uninfected Infants at Prior Visit Decreases from 89-91% at 6 mos to 22-25% at 9 mos
    26. 34. Stopped breastfeeding Continued breastfeeding No Overall Benefit in HIV-Free Survival to Early Cessation vs. Continued Breastfeeding Thea D et al. 14 th CROI, 2007, Los Angeles, CA Abs. LB p = 0.21 Overall HIV-free Survival among Children without HIV & Still Breastfeeding at Age 4 Months of Age by Group Assignment (Abrupt vs Standard Weaning)
    27. 35. Breastfeeding Women With Low CD4 Are at Most Risk of Infecting Their Infants: Zimbabwe Iliff PJ et al. AIDS 2005;19:699-708 Postnatal HIV Infection from Age 6 Weeks - 18 Months (N=2,055) Women Who Would be Eligible for HAART
    28. 37. HIV + Women, Reported Access to Care and Treatment Services
    29. 38. <ul><li>Care and Treatment : EGPAF Impact </li></ul><ul><li>_______________________________ </li></ul><ul><ul><li>• HIV/AIDS Care and Support </li></ul></ul><ul><ul><li>More than 470,000 people enrolled, </li></ul></ul><ul><ul><li>including over 39,000 children </li></ul></ul><ul><ul><li>• HIV/AIDS treatment (2008) </li></ul></ul><ul><ul><li>More than 220,000 people treated, </li></ul></ul><ul><ul><li>including over 30,000 children </li></ul></ul>
    30. 39. 2 year Mortality (Zvitambo ) Marinda et al. Ped Inf Dis J 2007;26:519-26 NE - not exposed; NI - HIV-exposed uninfected; PN - postnatal, IP - intrapartum; IU - in utero HIV status 9510 3135 381 508 258
    31. 40. M Project HEART (EGPAF): Percentage Distribution of Children Ever on ART at the End of Sept 2008
    32. 41. Cher Study: Time to Death (NEJM 359:2233,2008) Time to Death (months) Failure Probability Arm 1 Arm 2 & 3 Patients at risk P = 0.0002 Early Treatment 0.00 0.20 0.40 0.60 0.80 1.00 0 3 6 9 12 70 137 184 241 252 Arm 2 & Arm 3 32 56 85 112 125 Arm 1 Month 12 Month 9 Month 6 Month 3 Month 0
    33. 42. Cher Study; NEJM 359:2241 <ul><li>After diagnosis 9 infants died or had disease progression prior to screening </li></ul><ul><li>During screening 122/532 (23%) required therapy (CD4 < 25%, symptomatic) or died </li></ul><ul><li>Median age 7.4 weeks for randomization to treatment or deferred treatment of 377 infants </li></ul><ul><li>By 40 weeks of evaluation 66% of infants in deferred treatment group needed ARV </li></ul><ul><li>Early treatment reduced early infant mortality by 76% and HIV progression by 75% </li></ul>
    34. 44. HIV Exposed Infants: Number Reported At Regular Well Child Visits 66,009 * 80,967 * 117,788 * * Number of HIV Exposed Infants
    35. 45. PMTCT In Low Prevalence Settings <ul><li>The program needs to accrue additional benefits besides HIV infections averted </li></ul><ul><li>HIV free survival of infants is first step </li></ul><ul><li>Lower morbidity of diseases that can be identified and averted/treated in ANC and postnatal care is second step </li></ul><ul><li>Decreased maternal mortality </li></ul>
    36. 47. Total Cost of PMTCT Program
    37. 48. HIV Infections Averted
    38. 50. Cost per Infection Averted
    39. 51. Cost per Woman Served
    40. 53. Four Intervention Opportunities YEARS Treatment Of HIV INFECTED Adapted from: Cohen et al, JCI, 2008 Cohen IAS 2008 YEARS Seronegative Exposure Unknown Behavioral, Structural Circumcision Condoms Behavior Change Hours/Months ART PrEP EXPOSED Predelivery Delivery 72h ART PEP Vaccines EXPOSED Postdelivery
    41. 54. Uncorrected Seroprevalence Reported in ANC
    42. 55. Yearly Seroprevalence
    43. 56. Decline in Seroprevalence Among Women Accessing PMTCT Services in Selected Countries Submitted to AIDS, ,Agbessi et al

    ×