This document discusses HIV/AIDS prevention and control strategies. It begins by providing global statistics on people living with HIV/AIDS and new infections. It then discusses HIV epidemiology in Ethiopia, risk groups, modes of transmission, and principles of effective prevention programs. The prevention strategies discussed include risk reduction by addressing key factors in heterosexual transmission, vulnerability reduction, and impact reduction. Policy-level actions proposed include promoting human rights, leadership, community involvement, gender equality, awareness, and targeted programs.

1. HIV/AIDS, Prevention & Control
Strategies
By Makeda S (BSC,MPH/RH)
August 10, 2022 1

2. Objectives
At the end of 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 [32.2 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

4. 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%]

5. About 6,300 new HIV 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 magnitude of HIV
10 August 2022 7
EDHS,2011

8. HIV prevalence in Urban and rural
Ethiopia
10 August 2022 8
EDHS,2011

9. Cont….
 HIV prevalence is 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 2022 10
EDHS,2011

11. August 10, 2022 11
EDHS,2011

12. August 10, 2022 12
In
Ethiopia

13. Blood
Semen/genital secretions
Vertical(MTCT)
MODES OF TRANSMISSION

14. Risk of HIV infection 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
 Intravenous drug 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
 Despite intensive 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 effective HIV 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 step in 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
 HIV prevention 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
 successful prevention 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 Key risk 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 levels of 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 and Surveillance
 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 PMTCT programs
● 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 pronged approaches to PMTCT
August 10, 2022 49

48. Two Key Approaches for 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 of HIV/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 for HAART
 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 Clinical Criteria for
Lifelong ART
10 August 2022 54
WHO 2009
1-13

53. Immunologic and Clinical Criteria for PMTCT
Antiretroviral Prophylaxis (Option A or Option B)
10 August 2022 55
WHO 2009
1-21

54. Evolution of WHO PMTCT 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
 New 2010 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. 10 August 2022 59

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 HAART regimens 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 Pregnant Women
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 PMTCT Recommendations 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 AZT plus 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 for Pregnant
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
Infant NVP 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 PMTCT Recommendations 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 for Pregnant
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+
 Supplementary 2012 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 Options Used 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 from Option 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 (PREFERRED ARV 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 risk of 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 of transition 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
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74. Option B+ in Ethiopia
 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 has been 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 for B+
 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/AIDS CONTROL
 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/AIDS CONTROL
 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 Estimates and 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