Download to read offline
![35.3 million [32.2 million – 38.8 million]
32.1 million [29.1 million – 35.3 million]
17.7 million [16.4 million – 19.3 million]
3.3 million [3.0 million – 3.7 million]
2.3 million [1.9 million – 2.7 million]
2.0 million [1.7 million – 2.4 million]
260 000 [230 000 – 320 000]
1.6 million [1.4 million – 1.9 million]
1.4 million [1.2 million – 1.7 million]
210 000 [190 000 – 250 000]
Number of people living
with HIV
People newly infected
with HIV in 2012
AIDS deaths in 2012
Total
Adults
Women
Children (<15 years)
Total
Adults
Children (<15 years)
Total
Adults
Children (<15 years)
Global summary of the AIDS epidemic 2012](https://image.slidesharecdn.com/2014hivpreventionandcontrol1-220810084127-bc7e0dd9/85/2014_HIV_prevention_and_control-1-pptx-3-320.jpg)
![The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available
information.
Regional HIV and AIDS statistics and features 2012
TOTAL 35.3 million
[32.2 million – 38.8 million]
2.3 million
[1.9 million – 2.7 million]
Adults and children
newly infected with HIV
Adults and children
living with HIV
Sub-Saharan Africa
Middle East and North Africa
South and South-East Asia
East Asia
Latin America
Caribbean
Eastern Europe and Central Asia
Western and Central Europe
North America
Oceania
25.0 million
[23.5 million – 26.6 million]
3.9 million
[2.9 million – 5.2 million]
1.5 million
[1.2 million – 1.9 million]
1.3 million
[1.0 million – 1.7 million]
1.3 million
[980 000 – 1.9 million]
1.6 million
[1.4 million – 1.8 million]
270 000
[160 000 – 440 000]
86 000
[57 000 – 150 000]
130 000
[89 000 – 190 000]
48 000
[15 000 – 100 000]
260 000
[200 000 – 380 000]
880 000
[650 000 – 1.2 million]
250 000
[220 000 – 280 000]
860 000
[800 000 – 930 000]
51 000
[43 000 – 59 000]
32 000
[22 000 – 47 000]
81 000
[34 000 – 160 000]
12 000
[9400 – 14 000]
29 000
[25 000 – 35 000]
2100
[1500 – 2700]
1.6 million
[1.4 million – 1.9 million]
Adult & child
deaths due to AIDS
1.2 million
[1.1 million – 1.3 million]
220 000
[150 000 – 310 000]
52 000
[35 000 – 75 000]
91 000
[66 000 – 120 000]
20 000
[16 000 – 27 000]
17 000
[12 000 – 26 000]
41 000
[25 000 – 64 000]
11 000
[9400 – 14 000]
7600
[6900 – 8300]
1200
[<1000 – 1800]
0.8%
[0.7% - 0.9%]
Adult prevalence
(15‒49) [%]
4.7%
[4.4% – 5.0%]
0.3%
[0.2% – 0.4%]
0.4%
[0.3% – 0.5%]
0.7%
[0.6% – 1.0%]
0.5%
[0.4% – 0.8%]
0.1%
[0.1% – 0.2%]
<0.1%
[<0.1% – 0.1%]
1.0%
[0.9% – 1.1%]
0.2%
[0.2% – 0.2%]
0.2%
[0.2% – 0.3%]](https://image.slidesharecdn.com/2014hivpreventionandcontrol1-220810084127-bc7e0dd9/85/2014_HIV_prevention_and_control-1-pptx-4-320.jpg)
2014_HIV_prevention_and_control[1].pptx
- 1. HIV/AIDS, Prevention &Control Strategies By Makeda S (BSC,MPH/RH) August 10, 2022 1
- 2. Objectives At the endof this lecture the students will be able to: Describe the global epidemiology of HIV/AIDS Discuss the prevention and control strategies of HIV/AIDS Discuss about PMTCT August 10, 2022 2
- 3. 35.3 million [32.2million – 38.8 million] 32.1 million [29.1 million – 35.3 million] 17.7 million [16.4 million – 19.3 million] 3.3 million [3.0 million – 3.7 million] 2.3 million [1.9 million – 2.7 million] 2.0 million [1.7 million – 2.4 million] 260 000 [230 000 – 320 000] 1.6 million [1.4 million – 1.9 million] 1.4 million [1.2 million – 1.7 million] 210 000 [190 000 – 250 000] Number of people living with HIV People newly infected with HIV in 2012 AIDS deaths in 2012 Total Adults Women Children (<15 years) Total Adults Children (<15 years) Total Adults Children (<15 years) Global summary of the AIDS epidemic 2012
- 4. The ranges aroundthe estimates in this table define the boundaries within which the actual numbers lie, based on the best available information. Regional HIV and AIDS statistics and features 2012 TOTAL 35.3 million [32.2 million – 38.8 million] 2.3 million [1.9 million – 2.7 million] Adults and children newly infected with HIV Adults and children living with HIV Sub-Saharan Africa Middle East and North Africa South and South-East Asia East Asia Latin America Caribbean Eastern Europe and Central Asia Western and Central Europe North America Oceania 25.0 million [23.5 million – 26.6 million] 3.9 million [2.9 million – 5.2 million] 1.5 million [1.2 million – 1.9 million] 1.3 million [1.0 million – 1.7 million] 1.3 million [980 000 – 1.9 million] 1.6 million [1.4 million – 1.8 million] 270 000 [160 000 – 440 000] 86 000 [57 000 – 150 000] 130 000 [89 000 – 190 000] 48 000 [15 000 – 100 000] 260 000 [200 000 – 380 000] 880 000 [650 000 – 1.2 million] 250 000 [220 000 – 280 000] 860 000 [800 000 – 930 000] 51 000 [43 000 – 59 000] 32 000 [22 000 – 47 000] 81 000 [34 000 – 160 000] 12 000 [9400 – 14 000] 29 000 [25 000 – 35 000] 2100 [1500 – 2700] 1.6 million [1.4 million – 1.9 million] Adult & child deaths due to AIDS 1.2 million [1.1 million – 1.3 million] 220 000 [150 000 – 310 000] 52 000 [35 000 – 75 000] 91 000 [66 000 – 120 000] 20 000 [16 000 – 27 000] 17 000 [12 000 – 26 000] 41 000 [25 000 – 64 000] 11 000 [9400 – 14 000] 7600 [6900 – 8300] 1200 [<1000 – 1800] 0.8% [0.7% - 0.9%] Adult prevalence (15‒49) [%] 4.7% [4.4% – 5.0%] 0.3% [0.2% – 0.4%] 0.4% [0.3% – 0.5%] 0.7% [0.6% – 1.0%] 0.5% [0.4% – 0.8%] 0.1% [0.1% – 0.2%] <0.1% [<0.1% – 0.1%] 1.0% [0.9% – 1.1%] 0.2% [0.2% – 0.2%] 0.2% [0.2% – 0.3%]
- 5. About 6,300 newHIV infections a day in 2012 About 95% are in low- and middle-income countries About 700 are in children under 15 years of age About 5,500 are in adults aged 15 years and older, of whom: ─ almost 47% are among women ─ about 39% are among young people (15-24)
- 6. HIV in Ethiopia Ethiopia is one of the countries most affected by the HIV epidemic. With an estimated 790,000 HIV positive people and nearly one million AIDS orphans Despite this, HIV prevalence among the adult population is lower than many sub- Saharan African countries. Adult HIV prevalence in 2011 according to the Ethiopian Demographic Survey was estimated to be 1.5% (1.9% in females compared to 1.0% in males). Women continue to bear the brunt of the epidemic with females accounting for 60% of the population of people living with HIV in the country in 2011. In addition children under 15 years are also heavily affected and account for over 20% of people living with HIV in 2011 August 10, 2022 6
- 7. Overview the magnitudeof HIV 10 August 2022 7 EDHS,2011
- 8. HIV prevalence inUrban and rural Ethiopia 10 August 2022 8 EDHS,2011
- 9. Cont…. HIV prevalenceis six and a half times higher among women living in urban areas (5.2%) than among women living in rural areas (0.8%). HIV estimates vary by age, with HIV prevalence highest among women age 30-34 and men age 35-39. HIV prevalence also varies by region, ranging from a low of 0.9% in SNNP to 6.5% in Gambela. HIV prevalence varies dramatically by marital status. Less than 1% of never-married women and men are HIV-positive, compared with 12% of widowed women and 14.5% of widowed men. HIV prevalence is also higher among women and men who are divorced or separated. 10 August 2022 9
- 10. 10 August 202210 EDHS,2011
- 11. August 10, 202211 EDHS,2011
- 12. August 10, 202212 In Ethiopia
- 13.
- 14. Risk of HIVinfection by mode of exposure & contribution for global infections Exposure mode Transmission rate per exposure % of global infection Blood transfusion >90% 5-10% MTCT 25-40% LDC 15-25% MDC 2-3% Unprotected sex 0.1-1% 70-80% Injecting drug use <1% 5-10% Needle stick & other medical exposure <0.5% 0.01% Household contact from exposure to blood rare negligible
- 15. Homosexual/bisexual Intravenousdrug users Promiscuous heterosexuals Blood product and organ recipients Children of infected individuals Health/laboratory workers Partners of HIV-infected individuals RISK GROUPS
- 16. HIV/AIDs Prevention Despiteintensive research on HIV/AIDS neither a cure nor a Vaccine is found up to now except life prolonging drugs. Therefore, as the epidemic is continuing to spread, Prevention continues to be the backbone of the effort to curb the epidemic August 10, 2022 18
- 18. Why prevention? Without cure,the burden of HIV is determined by incidence and mortality (estimates 2012) 35.0 million people living with HIV/AIDS 3 million on ART during 3-5 years 1.6 million AIDS related Deaths 2.3 million New HIV infections in one August 10, 2022 20
- 19. Principles of effectiveHIV Prevention programs Comprehensive Must be wide in scope, using the full range of policy and programmatic interventions known to be effective. Optimal coverage, scale and intensity HIV prevention programming must be implemented in optimal coverage, scale and intensity to make a critical difference. August 10, 2022 21
- 20. Principles… First stepin Prevention Planning “Know your epidemic” and understand current response Prevalence (incidence) data by region The context and the drivers Timing of interventions and timing of declines Integrated Bio-behaviour surveys among MARPs M&E of Behaviour and social change interventions Modelling : modes of transmission August 10, 2022 22
- 21. Principles… Evidence-based HIVprevention actions must be evidence based on what is known and proven to be effective Based on experience & research findings August 10, 2022 23
- 22. Principles… Community participation Participation of those for whom HIV prevention programs are planned is critical for their impact. E.g. PLWHAs Based on Human rights All HIV prevention programs must have as their fundamental basis the promotion, protection and respect of human rights including gender equality. August 10, 2022 24
- 23. Prevention strategies successfulprevention programs encompass:: Interventions aimed at decreasing the risk of infection Interventions that address vulnerability Interventions that address impact reduction August 10, 2022 25
- 24. Strategies… Risk reduction There must be prevention interventions that address the modes of HIV transmission Heterosexual intercourse is the most common mode of transmission in resource-poor countries August 10, 2022 26
- 25. Strategies… Addressing Keyrisk factors in Heterosexual Transmission is essential Risk factors for hetro-sexual transmission: Frequent change of sexual partners Unprotected sexual intercourse Presence of STIs and poor access to STI treatment Lack of male circumcision Other risks Injecting drugs using, Blood transfusion without test Contaminated needles or any sharp materials August 10, 2022 27
- 26. Strategies… Vulnerability reduction Biological vulnerability Socio-Economic vulnerability Informational/educational vulnerability Cultural/social vulnerability Impact reduction Demographic impact Socio-economic impact Health care system impact Education sector impact Etc. August 10, 2022 28
- 27. Strategies… Two levelsof action Policy level action Program level action August 10, 2022 29
- 28. Policy level action Ensure that human rights are promoted, protected and respected and that measures are taken to eliminate discrimination and combat stigma. Build and maintain leadership from all sections of society, including governments, affected communities, NGOs, FBOs(faith based organaization), the education sector, media, the private sector and trade unions. Involve people living with HIV, in the design, implementation and evaluation of prevention strategies , addressing the distinct prevention needs. August 10, 2022 30
- 29. Policy level action… Address cultural norms and beliefs, recognizing both the key role they may play in supporting prevention efforts and the potential they have to fuel HIV transmission. Promote gender equality and address gender norms and relations to reduce the vulnerability of women and girls, involving men and boys in this effort. August 10, 2022 31
- 30. Policy level action… Promote widespread knowledge and awareness of how HIV is transmitted and how infection can be averted. Promote the links between HIV prevention and sexual and reproductive health . Support the mobilization of community-based responses throughout the continuum of prevention, care and treatment August 10, 2022 32
- 31. Policy level action… Promote programs targeted at HIV prevention needs of key affected groups and populations. Mobilizing and strengthening financial , and human and institutional capacity across all sectors, particularly in health and education. August 10, 2022 33
- 32. Policy level action… Review and reform legal frameworks to remove barriers to effective, evidence based HIV prevention, combat stigma and discrimination and protect the rights of people living with HIV or vulnerable or at risk to HIV. Ensure that sufficient investments are made in the research and development of, and advocacy for, new prevention technologies August 10, 2022 34
- 33. Program level strategies 1.IEC/BCC IEC/BCC is a vital component of all interventions focused on reduction of risk and vulnerability BCC reduce vulnerability to HIV/AIDS among individuals and communities. August 10, 2022 35
- 34. Program level strategies…. IEC/BCC For effective prevention of HIV/AIDS: Understanding basic facts about HIV/AIDS Access to appropriate services Supportive environment for safe behaviors. Reduce high risk behavior by promoting delayed onset of sexual activity, abstinence, faithfulness, use of condoms, early and effective treatment of STIs and reduce stigma and discrimination August 10, 2022 36
- 35. Program level strategies…. IEC/BCC through: • Community drama • Peer education sessions • Group discussions with youth • Social marketing of condoms • Creating social norm change to support risk reduction • Community dialogue • Mass-media • Mini-media • Etc August 10, 2022 37
- 36. Program level strategies…. 2.Condom Promotion and Distribution • Providing an alternative protective mechanism for those who cannot limit themselves to abstinence or faithful sexual partnership through improved availability and accessibility of condoms 3. Blood Safety 5%-10% of all HIV infections worldwide have been acquired through transfusion of contaminated blood and blood products. Ensuring availability of HIV-free blood in health facilities By appropriate selection of donors/risk analysis Appropriate Screening of blood before transfusion August 10, 2022 38
- 37. Program level strategies…. 4.Management STIs • Improve awareness on prevention of STIs, their symptoms and the need for early treatment • Improve access to quality STI treatment services • Scale-up symptomatic management of STIs August 10, 2022 39
- 38. Program level strategies…. 5.PITC- includes a provider-initiated HIV test and counseling. all clients visiting health facilities should be offered an HIV test. The test is usually offered by health care workers as part of regular medical care and is performed unless the client declines the test. The main reasons for testing clients in clinical settings include: HIV/AIDS is a serious disease that requires care and treatment. Life-saving therapy for HIV is becoming more available. August 10, 2022 40
- 39. Program level strategies…. 6.Universal Precautions and Post-Exposure Prophylaxis (PEP) Prevent HIV transmission in health care settings by: Personal protection Appropriate disinfection/sterilization Post exposure prophylaxis (PEP) August 10, 2022 41
- 40. Program level strategies…. 7.Care, Support and treatment Provide clinical care including ARV Therapy and TB treatment to extend and enhance the quality of PLWHA's care and support Mitigate the adverse socioeconomic impact of HIV/AIDS by providing appropriate psychosocial and economic support to PLWHA and AIDS orphans and vulnerable children (OVC) Nutrition Income generating activities August 10, 2022 42
- 41. Program level strategies…. 8.Legal and Human Rights (HR) Ensure that the legal rights of PLWHA, their families and the vulnerable groups are respected, protected and Their special needs progressively realized and public security maintained, by enacting legislation and availing legal services August 10, 2022 43
- 42. 9. Research andSurveillance Monitor trends of the HIV epidemic and its impacts Study the associated factors Assess the performance of interventions and Draw lessons so as to make evidence-based decisions on issues pertaining to HIV/AIDS August 10, 2022 44
- 43. Program level strategies…. 10.Mainstreaming Develop HIV/AIDS mainstreaming into the core mandate, activities and business of all sectors and organizations August 10, 2022 45
- 44. Program level strategies…. 11.Capacity Building Develop the implementation capacity of all actors through infrastructure development, training and experience sharing for an intensified, better coordinated and effective response Establish effective coordination and information sharing among the different actors in order to avoid duplication of efforts and fulfil the information need of actors August 10, 2022 46
- 45. Program level strategies…. 12.PMTCT Minimize the vertical transmission of HIV by increasing coverage of and access to PMTCT Mother to Child Transmission of HIV During pregnancy--- 5-10% During labor/delivery---10-20% During breastfeeding---5-20% Overall without breastfeeding---15-30% Overall with breast feeding for 6 month-25-35% Overall with breast feeding 18-24 month 30-45% 10 August 2022 47
- 46. Goals of PMTCTprograms ● An HIV-positive mother can pass HIV on to her baby any time during pregnancy, labor, delivery and breastfeeding, so the transmission of the virus must be blocked at each stage ● PMTCT programs aim to: o Reduce and ultimately eliminate new pediatric HIV infections—in Ethiopia more than 95% from MTCT o Serve as entry point to HIV care and support services for women and their families o Provide opportunity for testing and passing HIV prevention messages to women and their families 10 August 2022 48
- 47. UNFPA 4 prongedapproaches to PMTCT August 10, 2022 49
- 48. Two Key Approachesfor PMTCT 10 August 2022 50 Maternal/Infant ART prophylaxis Maternal lifelong ART Lifelong ART for HIV-infected women in need of treatment for their own health, which is also safe and effective in reducing MTCT Highlights importance of CD4 testing to determine ART eligibility ARV prophylaxis to prevent HIV transmission from mother to child during pregnancy, delivery and breastfeeding for HIV-infected women not in need of treatment 1-10
- 49. WHO Staging ofHIV/AIDS Stage I - asymptomatic Stage II - mild disease e.g., mild to moderate upper respiratory infections, weight loss Stage III - moderate disease such as prolonged unexplained diarrhoea Stage IV - advanced “AIDS-defining” diseases, such as HIV encephalopathy, CNS toxoplasmosis 10 August 2022 51
- 50. Determining Eligibility forHAART Determine WHO clinical staging Most pregnant women are asymptomatic (stage 1 or 2 disease) Clinical staging identified only 23% of eligible women compared to 94% identified using CD4 Clinical staging alone will miss over 75% of pregnant women who are eligible for ART 10 August 2022 52 Carter, Dugan, Abrams et al. JAIDS , November 1, 2010.
- 51. Key WHO Recommendations 1.Lifelong Antiretroviral Treatment for Pregnant Women who Qualify: Earlier ART initiation to improve maternal health and infant outcomes 2. Maternal-Infant Antiretroviral Prophylaxis: Earlier initiation and longer provision of ARV prophylaxis for HIV-infected pregnant women who do not need ART for their own health, with continued (maternal/infant) prophylaxis during breastfeeding 3. Infant Feeding: Improve HIV-free survival of HIV-exposed Infants (HEI) by supporting safer breastfeeding practices in the presence of ARVs (elimination of AFASS criteria) 1-11 10 August 2022 53
- 52. Immunologic and ClinicalCriteria for Lifelong ART 10 August 2022 54 WHO 2009 1-13
- 53. Immunologic and ClinicalCriteria for PMTCT Antiretroviral Prophylaxis (Option A or Option B) 10 August 2022 55 WHO 2009 1-21
- 54. Evolution of WHOPMTCT ARV Recommendations 2001 2006 2010 2004 Launch July 2013 PMTCT 4 weeks AZT; AZT+ 3TC, or SD NVP AZT from 28 wks + SD NVP AZT from 28wks + sdNVP +AZT/3TC 7days Option A (AZT +infant NVP) Option B (triple ARVs) Option B or B+ Moving to ART for all PW/BF ART No recommendatio n CD4 <200 CD4 <200 CD4 <350 CD4 <500 Move towards: more effective ARV drugs, extending coverage throughout MTCT risk period, and ART for the mother’s health
- 55. PMTCT Guidelines New2010 guidelines- recommended that all HIV- positive mothers, identified during pregnancy, should receive a course of antiretroviral drugs to prevent mother-to-child transmission; two treatment options were recommended under the 2010 guidelines- Option A and Option B. All infants born to HIV-positive mothers should also receive a course of antiretroviral drugs and should be exclusively breastfed for 6 months and complementary fed for up to a year. 10 August 2022 58
- 56.
- 57. Eligible Pregnant Women& Their Infants MATERNAL TREATMENT Start ART as soon as possible for women with CD4 < 350 or WHO Clinical Stage 3 or 4 Initiate ART at any gestational age REGIMENS INFANT ARV Prophylaxis Infants (breast feeding and formula feeding): Once daily NVP or twice daily AZT from birth until 4 - 6 weeks of age 10 August 2022 60 Preferred Regimen Alternative Regimen AZT + 3TC + NVP AZT + 3TC + EFV* TDF + 3TC(FTC) + NVP TDF + 3TC(FTC) + EFV* *EFV to be avoided in 1st trimester WHO 2009 1-17
- 58. First line HAARTregimens for eligible pregnant women in Ethiopia AZT + 3TC + NVP for life given as follows: • Start as soon as possible even in first trimester • Note that NVP requires a graduated dose increase: • Give 200 mg once a day for 14 days, then increase to 200 mg twice a day • Give 3TC- 150mg and AZT- 300mg po twice daily can be dispended as a fixed dose preparation • Continue ART through out pregnancy, childbirth, breastfeeding and thereafter for life. 10 August 2022 61
- 59. HAART for PregnantWomen 62 • AZT is preferable in the backbone regimen for pregnant women • Severe anaemia should be ruled out before starting treatment. • Do not start a regimen containing AZT in women if the haemoglobin is <7g/dL • If mother is anemic (Hb < 7 g/dL) use TDF instead of AZT • If possible use Fixed dosed combination to reduce pill burden and improve adherence • AZT+3TC+NVP
- 60. Summary of PMTCTRecommendations for eligible pregnant HIV-infected woman Mother Eligible for HAART Antenatal (During pregnancy) Start HAART as soon as possible, with AZT + 3TC + NVP. If mother is anemic (Hb < 7 g/dL) use TDF instead of AZT. Intrapartum (During labor) Continue regular schedule of HAART every 12 hours (no additional ARV prophylaxis) Postpartum (After delivery) Continue regular schedule of HAART every 12 hours Infant NVP daily for 6 weeks regardless of the mode of infant feeding 10 August 2022 63
- 61. Option A-Maternal AZTplus extended infant prophylaxis in Ethiopia The FMOH has opted for Option A of the 2010 WHO PMTCT recommendations Priority is on starting prophylaxis earlier in pregnancy at 14 weeks Provide extended infant prophylaxis for the duration of breastfeeding 10 August 2022 64
- 62. Prophylaxis Regimens forPregnant Women & Their Infants - Option A 10 August 2022 65 MATERNAL ANTIRETROVIRAL PROPHYLAXIS Initiate as early as 14 weeks gestation through delivery REGIMENS INFANT ANTIRETROVIRAL PROPHYLAXIS Breastfeeding Infant: Once daily NVP from birth through duration of breastfeeding until one week after last exposure to breast milk** Non-breastfeeding Infant: Once daily NVP or sd-NVP + twice daily AZT from birth to 4-6 weeks of age Antepartum Intrapartum Postpartum Daily AZT from 14wks sd-NVP, AZT + 3TC* AZT + 3TC for 7 days* *sd-NVP and AZT+3TC intra- and post-partum can be omitted if mother receives > 4 wks AZT during pregnancy WHO 2009 * *Infant feeding guidelines recommend breast feeding up to 12 months of age 1-23
- 63. Infant Feeding Recommendations,2010 ONE NATIONAL infant feeding strategy 1-28 BREASTFEEDING IN THE PRESENCE OF ARV INTERVENTIONS • Exclusive breastfeeding for the first 6 months of life • Introduce complementary foods at 6 months • Continued breastfeeding up to 12 months of life (Breastfeeding should then only stop once a nutritionally adequate and safe diet, without breastmilk, can be provided OR AVOID ALL BREASTFEEDING • Formula provision at national level – NO AFASS Assessment 10 August 2022 67
- 64. Proposed Extended Simplified InfantNVP Dosing Recommendations Birth -6 weeks • Birth Weight < 2,500 gram • Birth Weight >2,500 gram 10 mg/daily 15mg/daily >6 weeks to 6 months 20mg/daily >6 to 9 months 30mg/daily >9 months to end of BF 40mg/daily 10 August 2022 69 WHO 2010 Infant ARV prophylaxis dosing
- 65. Summary of PMTCTRecommendations for ineligible pregnant HIV-infected woman Mother NOT eligible for HAART Antenatal (During pregnancy) Start AZT 300mg po twice a day at 14 weeks or as soon thereafter. Intrapartum (During labor) sd-NVP at onset of labor* AZT + 3TC during labor and delivery* Postpartum (After delivery) AZT + 3TC for 7 days postpartum* Infant Breast Feeding Infant - daily NVP from birth and for duration of breast feeding. Stop NVP one week after complete cessation of breastfeeding Non breastfeeding infant- NVP for 6 weeks 10 August 2022 70
- 66. Prophylaxis Regimens forPregnant Women & Their Infants - Option B 10 August 2022 71 MATERNAL ANTIRETROVIRAL PROPHYLAXIS • Initiate as early as 14 weeks gestation through delivery • If breast feeding , continue until 1 week after weaning INFANT ANTIRETROVIRAL PROPHYLAXIS Breastfeeding and Non-breastfeeding Infants: Daily NVP or twice daily AZT from birth until 4-6 weeks of age RECOMMENDED PROPHYLAXIS REGIMENS AZT + 3TC + LPV/r AZT + 3TC + ABC AZT + 3TC + EFV TDF + ETC (FTC) + EFV WHO 2009 1-25
- 67. Option B+ Supplementary2012 guidelines-In 2012, the WHO released a programmatic update to the 2010 HIV and AIDS guidelines on PMTCT. The update outlined a third additional option for preventing mother-to-child transmission of HIV - Option B+. This approach is similar to Option B, but suggests giving the mother triple ARVs as soon as they are diagnosed, continuing for life, regardless of CD4 count. The decision to adopt either the Option A, B or B+ approach should be made at a country level. The Option B+ approach has a number of advantages, 10 August 2022 72
- 68. PMTCT Prophylaxis OptionsUsed by Selected Countries in Africa & Asia, 2012 10 August 2022 73 Option A Cameroon India* Lesotho Zimbabwe DRC Myanmar Ethiopia Malaysia Kenya* Vietnam Mozambique Swaziland South Africa* Tanzania Uganda* Zambia* Nigeria Angola Namibia* Option B Bangladesh Afghanistan Bhutan Maldives Nepal Pakistan Sri Lanka Chad Burundi Botswana Cote D’Ivoire Ghana Rwanda Option B+ Malawi Source: www.aidsdatahub.org based on WHO, UNAIDS, & UNICEF (2011). Towards Universal Access Health Sector Response Country Reports 2011 (preliminary data) * Countries considering switch to option B/B+
- 69. PMTCT Options A,B, B+ August 10, 2022 74
- 70. Rationale: Shift fromOption A to B+ or B Major issue now is not “when to start” or “what to start” but “whether to stop” BENEFITS FOR MOTHER AND CHILD BENEFITS FOR PROGRAM DELIVERY & PUBLIC HEALTH Ensures all ART eligible women initiate treatment Reduction in number of steps along PMTCT cascade Prevents MTCT in future pregnancies Same regimen for all adults (including pregnant women) Potential health benefits of early ART for non-eligible women Simplification of services for all adults Reduces potential risks from treatment interruption Simplification of messaging Improves adherence with once daily, single pill regimen Protects against transmission in discordant couples Reduces sexual transmission of HIV Cost effective
- 71. FIRST-LINE REGIMENS (PREFERREDARV REGIMENS) TARGET POPULATION 2010 ART GUIDELINES 2013 ART GUIDELINES STRENGTH & QUALITY OF EVIDENCE HIV+ ARV-NAIVE ADULTS AZT or TDF + 3TC (or FTC) + EFV or NVP TDF + 3TC (or FTC) + EFV (as fixed-dose combination) Strong, moderate- quality evidence HIV+ ARV-NAIVE PREGNANT WOMEN AZT + 3TC + NVP or EFV HIV/TB CO-INFECTION AZT or TDF + 3TC (or FTC) + EFV HIV/HBV CO-INFECTION TDF + 3TC (or FTC) + EFV Summary of Changes in Recommendations: What to Start in Adults
- 72. No increased riskof birth defects with EFV when compared with other ARVs Evidence Summary: Safety of EFV and TDF in Pregnancy o Systematic review (including Antiretroviral Pregnancy Registry), reported outcomes for 1502 live births to women receiving EFV in the first trimester and found no increase in overall birth defects o Excludes > 3 fold increased risk in overall birth defects Source: Ford N et al. AIDS, 2011. Ford N et al. AIDS, 2013. Ekouevi DK et al.J AIDS, 2011. WHO, Geneva Use of EFV during pregnancy. 2012. http://www.who.int/hiv/pub/treatment2/efavirenz/en Nightingale SL. JAMA, 1998. British HIV Association. Guidelines for the management of HIV infection in pregnant women. HIV Medicine. 2012. De Santis M et al. Arch of Int Medicine, 2002. Source: Antiretroviral Pregnancy Registry Steering Committee http://www.APRegistry.com Siberry GK et al. AIDS, 2012 EFV o Potential concerns include renal toxicity, adverse birth outcomes and effects on bone density o Systematic review assessed the toxicity of fetal exposure to TDF in pregnancy • In Antiretroviral Pregnancy Registry, prevalence of all birth defects with TDF exposure in 1st trimester was 2.4% (same as background) o Limited studies showed no difference in fetal growth between exposed/unexposed o No studies of TDF among lactating women, who normally have bone loss during breastfeeding o Current data reassuring o More extensive studies ongoing TDF
- 73. The reasons oftransition in PMTCT Regimens oComplexity of Option A •Different treatment and prophylaxis regimens through pregnancy and breastfeeding •Difficulty of long-term NVP dosing for infants •Requirement for CD4 to determine eligibility •Follow up along the PMTCT cascade is very low August 10, 2022 78
- 74. Option B+ inEthiopia On February 20, 2013, Ethiopia’s State Minister of Health, launched the Option B+ implementation in the presence of different partners working in the area of Preventing Mother to Child Transmission of HIV (PMTCT), HIV, and Maternal New-born and Child Health The Federal Ministry of Health developed an operational plan to phase in Option B+ services in all PMTCT facilities by the end of 2013 10 August 2022 79
- 75. Cont…. Ethiopia hasbeen implementing the one year accelerated PMTCT plan for Option A since December 2011. Option A treatment or prophylaxis is dependent on CD4 count. It requires a variety of drugs across the continuum which creates complexity in patient management. The lessons learned from implementing the accelerated PMTCT plan for Option A will be a major input while moving towards Option B+ implementation. In Ethiopia, where half of new HIV infections are the result of mother to child transmission, effective implementation of Option B+ could be an important step toward an HIV free generation. 10 August 2022 80
- 76. Programmatic considerations forB+ Initiate all HIV+ pregnant and breastfeeding women on ART Operational and programmatic advantages to lifelong ART for pregnant and breastfeeding women (“B+”), particularly in settings with: Avoid start – stop –start approach Generalized epidemics High fertility (though need to strengthen FP) Long duration of breastfeeding Limited access to CD4 to determine ART eligibility High partner serodiscordance rates National programmes need to decide B or B+ Programmatic considerations for B+
- 77. ARVs and breastfeeding 2013(no change from 2010) National agencies should decide between promoting mothers with HIV to either breastfeed and receive ARV interventions or to avoid all breastfeeding Where the national choice is to promote BF, mothers whose infants are HIV uninfected or of unknown HIV status should: • exclusively breastfeed their infants for the first six months of life • introduce appropriate complementary foods thereafter, and continue breastfeeding for the first 12 months of life • breastfeeding should then only stop once a nutritionally adequate and safe diet without breast-milk can be provided (strong recommendation, high-quality evidence for the first 6 months; low-quality evidence for the recommendation of 12 months)
- 78. BARRIERS AGAINST HIV/AIDSCONTROL Status of women Low condom acceptance (esp. non-commercial sex) Dependence on external support Long-term sustainability of external support Low awareness/acceptance of vulnerability (women/youth) Low acceptance of testing (misguided emphasis on “opt-in” and individual rights) Insufficient funds for prevention/intervention Stigma (risk groups, HIV-infected, those seeking testing)
- 79. BARRIERS AGAINST HIV/AIDSCONTROL High proportion of uncircumcised men Cost and complexity of adult circumcision Low acceptance of circumcision Low literacy rates Vaccine unlikely in the near future Cost of control and treatment Reaching unknown HIV-infected persons Continuum of care
- 80. Key research questions:Pregnant Women ARV toxicity surveillance: • Safety of early, lifelong ART for pregnant and breastfeeding women? • Maternal toxicity, pregnancy toxicity (stillbirth, low birth weight, prematurity, birth defects) and infant toxicity? Mother-to-child transmission and mother and child health impact: • Impact on overall HIV-free survival and and overall MTCT rate (at the end of breastfeeding as well as at 6-weeks)? • Impact on maternal morbidity and mortality, sexual transmission, and the long-term success of first-line ART? Adherence and retention: • Acceptability of ART to women, especially those who initiate lifelong ART before they meet «adult eligibility» criteria» • Adherence and retention rates for women with both low and high CD4? • Health systems and community interventions needed to achieve high levels of adherence and retention in setting of universal ART?
- 81. References WHO,HIV/AIDS Estimatesand Projections in Ethiopia, 2011-2016 PMTCT guideline in Ethiopia , 2010 UNAIDS report on the global AIDS epidemic | 2012 Source: Ford N et al. AIDS, 2011. Ford N et al. AIDS, 2013. Ekouevi DK et al.J AIDS, 2011. WHO, Geneva Use of EFV during pregnancy. 2012. http://www.who.int/hiv/pub/treatment2/efavirenz/en Nightingale SL. JAMA, 1998. British HIV Association. Guidelines for the management of HIV infection in pregnant women. HIV Medicine. 2012. De Santis M et al. Arch of Int Medicine, 2002. Source: Antiretroviral Pregnancy Registry Steering Committee http://www.APRegistry.com Siberry GK et al. AIDS, 2012 Use of Antiretroviral drugs for treating Pregnant Women and Preventing HIV infection in infants executive summary,April 2012 programmatic update FHAPCO/UNAIDS EPP Spectrum HIV estimates Ethiopian Demographic Survey 2011 The Ethiopia 2012 Global AIDS progress report UNAIDS. Comprehensive HIV prevention, Report on Global AIDS epidemic, 2009. WHO. WHO Africa Region: Ethiopia, HIV/AIDS in Ethiopia, 2007. available at: www.who.int/countries/eth/en/ WHO/CDC. Prevention of Mother to Child transition of HIV, Generic training Package: Participant manual, 2004. UNAIDS. Practical Guide for Intensifying HIV prevention towards universal access, 2007. UNFPA. Voluntary Counselling & Testing (VCT) for HIV prevention, program brief, 2002. . 86
- 82. Thank you! August 10,2022 87