This document discusses several priorities related to perinatal, paediatric, and adolescent HIV. Priority 1 is early diagnosis of infant infection through tests like HIV DNA and RNA that can detect infection before antibodies are present. Priority 2 is ensuring appropriate paediatric HIV treatment formulations that are palatable, easy to administer, and stable for storage and transport. Priority 3 is obtaining long-term outcome data on rates of HIV transmission through breastfeeding while the mother is on combination antiretroviral therapy (cART). The document also discusses challenges in adolescent HIV including mental health issues, risk behaviors, and loss to follow up during transition from paediatric to adult care.
1) The document discusses pharmacological principles for treating HIV in pregnant women to reduce mother-to-child transmission.
2) Updated perinatal guidelines from 2007 recommend initiating HAART after 14 weeks of gestation and continuing treatment throughout pregnancy, labor, and delivery.
3) Clinical scenarios provide examples of applying the guidelines, such as recommending HAART, scheduled C-sections if viral load is high, and 6 weeks of infant ZDV treatment starting within hours of birth.
Early diagnosis of HIV in infants is crucial because HIV progresses rapidly in infants and mortality is high without treatment. By age 1, one-third of infected infants will have died, and by age 2 half will have died. Early initiation of antiretroviral therapy (ART) in infected infants under 12 weeks of age can reduce mortality by 76% and HIV progression by 75%. The goals of early infant diagnosis are to identify infected infants before clinical disease develops so interventions and ART can begin. Diagnosis is typically done through RNA or DNA PCR testing of dried blood spots or whole blood samples at ages 6 weeks, 10 weeks, 14 weeks, and later intervals. Point-of-care testing using p24 antigen detection is also possible
HIV 1 and 2 belong to the Lentivirus genus and Retroviridae family. They contain two copies of single-stranded RNA and encode viral core, enzyme, and envelope proteins. Vertical transmission from mother to child is the primary route of infection in children, which can occur prenatally, during delivery, or through breastfeeding. Combination antiretroviral therapy is the standard treatment and involves two nucleoside reverse transcriptase inhibitors plus a non-nucleoside reverse transcriptase inhibitor or protease inhibitor.
The 2013 consolidated WHO guidelines provide recommendations for treating and preventing HIV across the continuum of care. Key features include:
- Simplified once-daily ART regimens including TDF+FTC/3TC+EFV as the preferred first-line regimen for adults and adolescents.
- "Option B+" is recommended - lifelong ART for all pregnant and breastfeeding women for prevention of mother-to-child transmission.
- Earlier treatment is recommended - ART is to be initiated in all individuals with CD4 ≤500 cells/mm3 or clinical stage 3/4 disease regardless of CD4 count.
Lessons Learned for Strengthening Early Infant Diagnosis of HIV ProgramsHFG Project
This document summarizes lessons learned for strengthening early infant diagnosis (EID) of HIV programs in sub-Saharan Africa based on a literature review and the Health Finance and Governance project's work in Kenya. The main challenges identified are patient loss to follow up throughout the EID testing process, long turnaround times between sample collection and result receipt, and failure to initiate antiretroviral therapy for HIV-positive infants. Countries have implemented interventions like community outreach, point-of-care testing, and data dashboards to address these challenges. In Kenya, EID testing costs were measured and turnaround times analyzed, finding an average of 43 days between sample collection and result receipt.
The document summarizes Swaziland's experience with early infant diagnosis (EID) and treatment of HIV-infected children. It discusses how establishing in-country DNA PCR testing significantly reduced turnaround time for EID results. It also describes how focused follow-up of results led to more than doubling the number of infants initiating antiretroviral treatment, from 18 to 44. The document concludes that successful EID programs require investments in both laboratory infrastructure and programming to ensure test results are effectively communicated and used to start life-saving treatment for HIV-positive infants.
Preventing MTCT in Africa: Using New Paradigms - A Dr Besser Presentationmothers2mothers
The document discusses challenges with preventing mother-to-child transmission of HIV in Africa, including high HIV prevalence rates, low access to treatment and care, and difficulties with infant feeding options. It presents data showing that integrated programs that provide testing, counseling and antiretroviral treatment can significantly reduce transmission rates from 25% to as low as 1%, but coverage remains a challenge due to weaknesses in health systems.
1) The document discusses pharmacological principles for treating HIV in pregnant women to reduce mother-to-child transmission.
2) Updated perinatal guidelines from 2007 recommend initiating HAART after 14 weeks of gestation and continuing treatment throughout pregnancy, labor, and delivery.
3) Clinical scenarios provide examples of applying the guidelines, such as recommending HAART, scheduled C-sections if viral load is high, and 6 weeks of infant ZDV treatment starting within hours of birth.
Early diagnosis of HIV in infants is crucial because HIV progresses rapidly in infants and mortality is high without treatment. By age 1, one-third of infected infants will have died, and by age 2 half will have died. Early initiation of antiretroviral therapy (ART) in infected infants under 12 weeks of age can reduce mortality by 76% and HIV progression by 75%. The goals of early infant diagnosis are to identify infected infants before clinical disease develops so interventions and ART can begin. Diagnosis is typically done through RNA or DNA PCR testing of dried blood spots or whole blood samples at ages 6 weeks, 10 weeks, 14 weeks, and later intervals. Point-of-care testing using p24 antigen detection is also possible
HIV 1 and 2 belong to the Lentivirus genus and Retroviridae family. They contain two copies of single-stranded RNA and encode viral core, enzyme, and envelope proteins. Vertical transmission from mother to child is the primary route of infection in children, which can occur prenatally, during delivery, or through breastfeeding. Combination antiretroviral therapy is the standard treatment and involves two nucleoside reverse transcriptase inhibitors plus a non-nucleoside reverse transcriptase inhibitor or protease inhibitor.
The 2013 consolidated WHO guidelines provide recommendations for treating and preventing HIV across the continuum of care. Key features include:
- Simplified once-daily ART regimens including TDF+FTC/3TC+EFV as the preferred first-line regimen for adults and adolescents.
- "Option B+" is recommended - lifelong ART for all pregnant and breastfeeding women for prevention of mother-to-child transmission.
- Earlier treatment is recommended - ART is to be initiated in all individuals with CD4 ≤500 cells/mm3 or clinical stage 3/4 disease regardless of CD4 count.
Lessons Learned for Strengthening Early Infant Diagnosis of HIV ProgramsHFG Project
This document summarizes lessons learned for strengthening early infant diagnosis (EID) of HIV programs in sub-Saharan Africa based on a literature review and the Health Finance and Governance project's work in Kenya. The main challenges identified are patient loss to follow up throughout the EID testing process, long turnaround times between sample collection and result receipt, and failure to initiate antiretroviral therapy for HIV-positive infants. Countries have implemented interventions like community outreach, point-of-care testing, and data dashboards to address these challenges. In Kenya, EID testing costs were measured and turnaround times analyzed, finding an average of 43 days between sample collection and result receipt.
The document summarizes Swaziland's experience with early infant diagnosis (EID) and treatment of HIV-infected children. It discusses how establishing in-country DNA PCR testing significantly reduced turnaround time for EID results. It also describes how focused follow-up of results led to more than doubling the number of infants initiating antiretroviral treatment, from 18 to 44. The document concludes that successful EID programs require investments in both laboratory infrastructure and programming to ensure test results are effectively communicated and used to start life-saving treatment for HIV-positive infants.
Preventing MTCT in Africa: Using New Paradigms - A Dr Besser Presentationmothers2mothers
The document discusses challenges with preventing mother-to-child transmission of HIV in Africa, including high HIV prevalence rates, low access to treatment and care, and difficulties with infant feeding options. It presents data showing that integrated programs that provide testing, counseling and antiretroviral treatment can significantly reduce transmission rates from 25% to as low as 1%, but coverage remains a challenge due to weaknesses in health systems.
This document summarizes the work of mothers2mothers (m2m) in preventing mother-to-child transmission of HIV. It describes how m2m uses mentor mothers to educate and support HIV-positive pregnant women and new mothers, with the goals of preventing HIV transmission to babies, keeping mothers and infants healthy, and empowering mothers. The model employs and trains local HIV-positive women to mentor others in health facilities and communities. An evaluation found that m2m significantly increases utilization of PMTCT services and improves psychosocial outcomes for participants. m2m has expanded from South Africa to 11 countries in sub-Saharan Africa.
This document summarizes a presentation on new and investigational antiretrovirals given at the UC San Diego HIV & Global Health Rounds. The presentation reviewed fostemsavir, cabotegravir/rilpivirine, leronlimab, islatravir, and lenacapavir. For each drug, the presenter discussed indications, dosing, efficacy and safety data from clinical trials, resistance profiles, and potential advantages and limitations. The goal of the HIV & Global Health Rounds is to provide clinicians and researchers with the most up-to-date information on HIV, hepatitis, tuberculosis, and other infectious diseases.
2018 Prevention of Mother to Child Transmission of HIV InfectionHelen Madamba
The document discusses prevention of mother-to-child transmission (PMTCT) of HIV in the Philippines. It outlines the objectives of discussing PMTCT program prongs, HIV epidemiology in the Philippines, transmission and management principles, and screening/testing during pregnancy. It provides statistics on increasing HIV prevalence in the Philippines, especially among men who have sex with men, IV drug users, and teenagers/single mothers. Modes of HIV transmission include unprotected sex and needle sharing. The document emphasizes screening, counseling, and ARV treatment during pregnancy and delivery to reduce mother-to-child transmission risk, as well as strategies to prevent unintended pregnancy and support women living with HIV.
The PPTCT program in India provides services through ICTCs to test pregnant women for HIV and prevent mother-to-child transmission. If tested positive, women receive counseling, ART treatment, monitoring, and are encouraged to have institutional deliveries. Infants receive post-exposure prophylaxis. The goal is to eliminate vertical transmission through antenatal, intrapartum, postnatal care and promoting safe infant feeding practices.
This aims to increase awareness on the Philippine HIV Epidemic, how it affects pregnancy and how it can be managed for prevention of mother to child transmission of HIV.
This document provides guidelines for treating and preventing HIV infection in Kenya in 2016. It summarizes recommendations for HIV testing and linkage to care, initial evaluation and follow up of people living with HIV, the standard package of care including antiretroviral therapy and prevention services, adherence preparation and monitoring, antiretroviral therapy for infants/children/adults, prevention of mother-to-child transmission, and the use of antiretrovirals for pre-exposure prophylaxis. The guidelines are intended to help healthcare workers in Kenya provide comprehensive HIV prevention and treatment services in line with best practices.
This is a lecture given to medical students of Cebu Institute of Medicine under the reproductive module. It contains a discussion of principles of HIV infection screening, diagnosis, staging and management, especially during pregnancy.
HIV treatment and PrEP options have advanced significantly since 2015. Key points:
1) Treatment as prevention is now recommended, with antiretroviral therapy shown to reduce HIV transmission by 96% and dramatically lower prevalence over time if treatment is scaled up.
2) PrEP using daily oral Truvada was found to reduce HIV risk by up to 92% in multiple studies when taken consistently, though adherence is important. Intermittent or on-demand PrEP was also found highly effective in some populations.
3) Several real-world demonstration projects confirmed PrEP's effectiveness in different settings and populations, with up to 86% reduced risk of HIV acquisition when PrEP was provided.
Elimination of mother to child transmission of hivstompoutmalaria
The document discusses eliminating mother-to-child transmission of HIV by 2015. It provides facts on the magnitude of MTCT, defines elimination as reducing the transmission rate to below 5%, and outlines the tools and costs required. These include ARV regimens, family planning services, and focused efforts in the 25 highest burden countries. Peace Corps volunteers could help implement prevention activities and promote services to measure progress towards elimination goals.
HIV in Pregnancy
Dr. ARCHANA VERMA
1) HIV is a retrovirus that can be transmitted from mother to child during pregnancy, childbirth, or breastfeeding. Left untreated, the risk of mother-to-child transmission is 15-45%.
2) Treatment involves antiretroviral therapy for the mother during pregnancy and delivery, and for the newborn for 4-6 weeks to prevent transmission. Mode of delivery and avoiding breastfeeding can also reduce risk.
3) With treatment, the risk of mother-to-child HIV transmission can be reduced to less than 2%. Proper antenatal care, delivery management, and postpartum care and testing of
This document summarizes guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV in Ethiopia. It outlines the epidemiology of HIV in women and children, defining MTCT and PMTCT. Risks of MTCT are highest without intervention, ranging from 20-45%. The national PMTCT strategy includes: primary HIV prevention; preventing unintended pregnancies in HIV+ women; preventing transmission from mother to child; and treatment, care and support of women and families. Key components are counseling and testing, antenatal care, labor/delivery care, postpartum care, infant care including ARV prophylaxis, and lifelong ART for eligible mothers. National guidelines have opted for WHO PMTCT
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
This document summarizes key information from an HIV & Global Health Rounds presentation on updates from the 2020 Conference on Retroviruses and Opportunistic Infections (CROI 2020). The presentation covered the global HIV epidemic, contraception and prevention, treatment as prevention, pre-exposure prophylaxis (PrEP), and HIV vaccines. Highlights included findings from the ECHO contraceptive study showing no increased HIV risk from various contraceptives, modest reductions in HIV incidence from universal test and treat trials, long-term efficacy and safety data from the DISCOVER PrEP trial, and the failure of the HVTN 702 vaccine trial to show efficacy.
The document outlines the management of HIV infected children. It discusses the epidemiology and transmission of HIV in children in Kenya. It describes the natural disease progression of HIV in children as either rapid, intermediate, or slow progression. It also covers the diagnosis of pediatric HIV using clinical, laboratory, and immunological criteria, as well as the WHO and CDC clinical staging systems for HIV in children.
Prevention of Mother to Child Transmission of HIV 2017Helen Madamba
This is a lecture delivered during the Integrated Orientation on HIV/AIDS and TBHIV Collaboration by the Department of Health Region 7 at Bohol Tropics Resort, Tagbilaran City, Bohol
Physician and public health researcher Mitchell Besser visited the School of Public Affairs on Oct. 4, delivering a presentation on the prevention of mother-to-child transmission of HIV in Africa. Besser is the founder of Mothers2mothers, an organization that trains mothers with HIV to work in health centers to educate and support pregnant women who are HIV-positive.
Besser talked about "task shifting" some of the responsibilities of health care education from nurses and doctors (that are always in short supply and high demand) to the mothers, and utilizing new technologies such as mobile phones to expand the scope of care.
As an obstetrician and gynecologist, Dr. Besser professional career has been dedicated to the public health needs of women. In 1999, Dr. Besser joined the University of Cape Town's Department of Obstetrics and Gynecology, assisting with the development of services to meet the needs of pregnant women living with HIV and to prevent the transmission of HIV from mothers to their children (PMTCT). Dr. Besser recognized the need for an education and psychosocial support program that would contribute to PMTCT services achieving the best medical and social outcomes. Hoping to fill this void, he founded mothers2mothers in which mothers with HIV are employed to work in health centers, educating and supporting pregnant women and new mothers with HIV; reducing the workload of doctors and nurses and increasing the effectiveness of interventions that reduce the number of babies born with HIV and keep mothers healthy and alive to raise their children. Since its inception in 2001, the program has grown to provide services in more than 680 health care facilities in nine countries in Africa, with more than 3 million contacts with woman each year, reaching 20% of the HIV-positive pregnant women in the world. Dr. Besser has received Global Health Council’s Best Practice Award, Skoll Award for Social Entrepreneurship, Presidential Citizens Award of the United States Government and is an Ashoka and Schwab Fellow. He has presented at TED, appeared on BBC’s Forum and has given a Friday Evening Discourse at the Royal Institution of Great Britain.
1) The document discusses eliminating pediatric HIV/AIDS through preventing mother-to-child transmission (PMTCT). It outlines the four components of the WHO's PMTCT strategy and improvements in reducing new HIV infections among children from 600,000 in 1990 to 370,000 in 2009.
2) While PMTCT programs have expanded, only about half of pregnant women and infants receive antiretroviral drugs. Early diagnosis and lifelong treatment are critical for infants to survive.
3) Goals for HIV care programs include preventing opportunistic infections, early identification and management of complications, and engaging patients in care, treatment and prevention through education and support. With continued progress, the document argues that virtual elimination of pediatric HIV
This document summarizes the work of mothers2mothers (m2m) in preventing mother-to-child transmission of HIV. It describes how m2m uses mentor mothers to educate and support HIV-positive pregnant women and new mothers, with the goals of preventing HIV transmission to babies, keeping mothers and infants healthy, and empowering mothers. The model employs and trains local HIV-positive women to mentor others in health facilities and communities. An evaluation found that m2m significantly increases utilization of PMTCT services and improves psychosocial outcomes for participants. m2m has expanded from South Africa to 11 countries in sub-Saharan Africa.
This document summarizes a presentation on new and investigational antiretrovirals given at the UC San Diego HIV & Global Health Rounds. The presentation reviewed fostemsavir, cabotegravir/rilpivirine, leronlimab, islatravir, and lenacapavir. For each drug, the presenter discussed indications, dosing, efficacy and safety data from clinical trials, resistance profiles, and potential advantages and limitations. The goal of the HIV & Global Health Rounds is to provide clinicians and researchers with the most up-to-date information on HIV, hepatitis, tuberculosis, and other infectious diseases.
2018 Prevention of Mother to Child Transmission of HIV InfectionHelen Madamba
The document discusses prevention of mother-to-child transmission (PMTCT) of HIV in the Philippines. It outlines the objectives of discussing PMTCT program prongs, HIV epidemiology in the Philippines, transmission and management principles, and screening/testing during pregnancy. It provides statistics on increasing HIV prevalence in the Philippines, especially among men who have sex with men, IV drug users, and teenagers/single mothers. Modes of HIV transmission include unprotected sex and needle sharing. The document emphasizes screening, counseling, and ARV treatment during pregnancy and delivery to reduce mother-to-child transmission risk, as well as strategies to prevent unintended pregnancy and support women living with HIV.
The PPTCT program in India provides services through ICTCs to test pregnant women for HIV and prevent mother-to-child transmission. If tested positive, women receive counseling, ART treatment, monitoring, and are encouraged to have institutional deliveries. Infants receive post-exposure prophylaxis. The goal is to eliminate vertical transmission through antenatal, intrapartum, postnatal care and promoting safe infant feeding practices.
This aims to increase awareness on the Philippine HIV Epidemic, how it affects pregnancy and how it can be managed for prevention of mother to child transmission of HIV.
This document provides guidelines for treating and preventing HIV infection in Kenya in 2016. It summarizes recommendations for HIV testing and linkage to care, initial evaluation and follow up of people living with HIV, the standard package of care including antiretroviral therapy and prevention services, adherence preparation and monitoring, antiretroviral therapy for infants/children/adults, prevention of mother-to-child transmission, and the use of antiretrovirals for pre-exposure prophylaxis. The guidelines are intended to help healthcare workers in Kenya provide comprehensive HIV prevention and treatment services in line with best practices.
This is a lecture given to medical students of Cebu Institute of Medicine under the reproductive module. It contains a discussion of principles of HIV infection screening, diagnosis, staging and management, especially during pregnancy.
HIV treatment and PrEP options have advanced significantly since 2015. Key points:
1) Treatment as prevention is now recommended, with antiretroviral therapy shown to reduce HIV transmission by 96% and dramatically lower prevalence over time if treatment is scaled up.
2) PrEP using daily oral Truvada was found to reduce HIV risk by up to 92% in multiple studies when taken consistently, though adherence is important. Intermittent or on-demand PrEP was also found highly effective in some populations.
3) Several real-world demonstration projects confirmed PrEP's effectiveness in different settings and populations, with up to 86% reduced risk of HIV acquisition when PrEP was provided.
Elimination of mother to child transmission of hivstompoutmalaria
The document discusses eliminating mother-to-child transmission of HIV by 2015. It provides facts on the magnitude of MTCT, defines elimination as reducing the transmission rate to below 5%, and outlines the tools and costs required. These include ARV regimens, family planning services, and focused efforts in the 25 highest burden countries. Peace Corps volunteers could help implement prevention activities and promote services to measure progress towards elimination goals.
HIV in Pregnancy
Dr. ARCHANA VERMA
1) HIV is a retrovirus that can be transmitted from mother to child during pregnancy, childbirth, or breastfeeding. Left untreated, the risk of mother-to-child transmission is 15-45%.
2) Treatment involves antiretroviral therapy for the mother during pregnancy and delivery, and for the newborn for 4-6 weeks to prevent transmission. Mode of delivery and avoiding breastfeeding can also reduce risk.
3) With treatment, the risk of mother-to-child HIV transmission can be reduced to less than 2%. Proper antenatal care, delivery management, and postpartum care and testing of
This document summarizes guidelines for the prevention of mother-to-child transmission (PMTCT) of HIV in Ethiopia. It outlines the epidemiology of HIV in women and children, defining MTCT and PMTCT. Risks of MTCT are highest without intervention, ranging from 20-45%. The national PMTCT strategy includes: primary HIV prevention; preventing unintended pregnancies in HIV+ women; preventing transmission from mother to child; and treatment, care and support of women and families. Key components are counseling and testing, antenatal care, labor/delivery care, postpartum care, infant care including ARV prophylaxis, and lifelong ART for eligible mothers. National guidelines have opted for WHO PMTCT
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
This document summarizes key information from an HIV & Global Health Rounds presentation on updates from the 2020 Conference on Retroviruses and Opportunistic Infections (CROI 2020). The presentation covered the global HIV epidemic, contraception and prevention, treatment as prevention, pre-exposure prophylaxis (PrEP), and HIV vaccines. Highlights included findings from the ECHO contraceptive study showing no increased HIV risk from various contraceptives, modest reductions in HIV incidence from universal test and treat trials, long-term efficacy and safety data from the DISCOVER PrEP trial, and the failure of the HVTN 702 vaccine trial to show efficacy.
The document outlines the management of HIV infected children. It discusses the epidemiology and transmission of HIV in children in Kenya. It describes the natural disease progression of HIV in children as either rapid, intermediate, or slow progression. It also covers the diagnosis of pediatric HIV using clinical, laboratory, and immunological criteria, as well as the WHO and CDC clinical staging systems for HIV in children.
Prevention of Mother to Child Transmission of HIV 2017Helen Madamba
This is a lecture delivered during the Integrated Orientation on HIV/AIDS and TBHIV Collaboration by the Department of Health Region 7 at Bohol Tropics Resort, Tagbilaran City, Bohol
Physician and public health researcher Mitchell Besser visited the School of Public Affairs on Oct. 4, delivering a presentation on the prevention of mother-to-child transmission of HIV in Africa. Besser is the founder of Mothers2mothers, an organization that trains mothers with HIV to work in health centers to educate and support pregnant women who are HIV-positive.
Besser talked about "task shifting" some of the responsibilities of health care education from nurses and doctors (that are always in short supply and high demand) to the mothers, and utilizing new technologies such as mobile phones to expand the scope of care.
As an obstetrician and gynecologist, Dr. Besser professional career has been dedicated to the public health needs of women. In 1999, Dr. Besser joined the University of Cape Town's Department of Obstetrics and Gynecology, assisting with the development of services to meet the needs of pregnant women living with HIV and to prevent the transmission of HIV from mothers to their children (PMTCT). Dr. Besser recognized the need for an education and psychosocial support program that would contribute to PMTCT services achieving the best medical and social outcomes. Hoping to fill this void, he founded mothers2mothers in which mothers with HIV are employed to work in health centers, educating and supporting pregnant women and new mothers with HIV; reducing the workload of doctors and nurses and increasing the effectiveness of interventions that reduce the number of babies born with HIV and keep mothers healthy and alive to raise their children. Since its inception in 2001, the program has grown to provide services in more than 680 health care facilities in nine countries in Africa, with more than 3 million contacts with woman each year, reaching 20% of the HIV-positive pregnant women in the world. Dr. Besser has received Global Health Council’s Best Practice Award, Skoll Award for Social Entrepreneurship, Presidential Citizens Award of the United States Government and is an Ashoka and Schwab Fellow. He has presented at TED, appeared on BBC’s Forum and has given a Friday Evening Discourse at the Royal Institution of Great Britain.
1) The document discusses eliminating pediatric HIV/AIDS through preventing mother-to-child transmission (PMTCT). It outlines the four components of the WHO's PMTCT strategy and improvements in reducing new HIV infections among children from 600,000 in 1990 to 370,000 in 2009.
2) While PMTCT programs have expanded, only about half of pregnant women and infants receive antiretroviral drugs. Early diagnosis and lifelong treatment are critical for infants to survive.
3) Goals for HIV care programs include preventing opportunistic infections, early identification and management of complications, and engaging patients in care, treatment and prevention through education and support. With continued progress, the document argues that virtual elimination of pediatric HIV
This document provides statistics on the global HIV epidemic in 2018 from UNAIDS as well as information on HIV in India. Some key points:
- 37.9 million people globally were living with HIV in 2018. 1.7 million became newly infected that year while 23.3 million were accessing antiretroviral therapy.
- India has the third largest HIV epidemic in the world. In 2015, the national adult prevalence was 0.26%. Prevalence is highest in certain states like Mizoram (2.04%) and Manipur (1.43%).
- Children account for 6.54% of total PLHIV in India. Early infant diagnosis, appropriate infant feeding and prophylaxis
This document discusses HIV/AIDS in children. It provides epidemiological data showing that in 2020, 300,000 children were newly infected with HIV. The three main modes of HIV transmission to children are vertical (mother-to-child), through blood, and sexually. HIV progresses more rapidly in children than adults due to their immature immune systems. Treatment involves antiretroviral drugs and monitoring to support adherence. Vaccines are generally recommended for HIV-infected children, though some live vaccines may not be safe depending on immune status.
The document provides information on paediatric HIV including:
- The natural history of paediatric HIV infection fits into 3 categories from rapid to long term progression.
- Over 90% of the 2.1 million children living with HIV are in sub-Saharan Africa due to high maternal infection rates and PMTCT inefficiency.
- Predictors of rapid disease progression in infants include high maternal viral load, early infant infection, and low CD4 counts.
HIV positive mother and her bABY, RISK OF TRANSMISSION, ANTENATAL CARE, INTRA...LalrinchhaniSailo
Globally, an estimated 1.3 million women and girls living with HIV become pregnant each year. In the absence of intervention, the rate of transmission of HIV from a mother living with HIV to her child during pregnancy, labour, delivery or breastfeeding ranges from 15% to 45%. As such, identification of HIV infection should be immediately followed by an offer of linkage to lifelong treatment and care, including support to remain in care and virally suppressed and an offer of partner services.
In 2019, 85% of women and girls globally had access to antiretroviral therapy (ART) to prevent mother-to-child transmission (MTCT). However, high ART coverage levels do not reflect the continued transmission that occurs after women are initially counted as receiving treatment. Achieving retention in care and prevention of incident HIV infections in uninfected populations remain high priorities to reach global elimination targets. Since the global shift to, and accelerated rollout of, highly effective, simplified interventions based on lifelong ART for pregnant women living with HIV, virtual elimination of MTCT – also known as vertical transmission – has been shown to be feasible.
Dr. Laura Guay, the Foundation’s Vice President of Research, also conducted a journalist training today sponsored by the National Press Foundation, teaching reporters about some of the most misunderstood issues concerning HIV and children
Washington Global Health Alliance Discovery Series
Catherine Wilfert, MD [
December 1, 2008
'Global Prevention of Mother to Child Transmission of HIV-1'
Jill Blumenthal, MD
Assistant Professor of Medicine
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Module 4 hiv infection & art in childrenDavid Ngogoyo
This document provides an overview of managing HIV infected children. It covers the epidemiology and transmission of HIV in children, the natural progression of disease, diagnosis and staging, prevention and treatment of common HIV conditions, and antiretroviral therapy for children. Key points include mother-to-child transmission being the most common mode of transmission, diagnostic criteria involving virologic tests for children under 18 months and antibody tests after 18 months, and natural history patterns including rapid, intermediate, and slow disease progression in African children.
1. 27 million people globally were accessing antiretroviral therapy in 2021, representing 75% of all people living with HIV. There were 37.7 million people living with HIV globally in 2021, a 21% increase from 2010. 1.5 million people became newly infected with HIV in 2021.
2. In India, there were an estimated 23 lakh people living with HIV nationally in 2021. Approximately 57,550 new HIV infections occurred in 2021, representing a 48% decrease from 2010. Around 51,000 people died of AIDS-related illnesses in India in 2021.
3. Key data on HIV in India in 2021 include: prevalence of 0.67% among 15-49 year olds,
This document provides information on the care of children with HIV/AIDS. It discusses what HIV is, how it is transmitted, the stages of infection, diagnosis, treatment including antiretroviral therapy, prevention of mother-to-child transmission, and the nursing care of children with HIV/AIDS. The nursing care involves supporting the emotional needs of the child and family, maintaining nutrition, treating infections early, ensuring immunization when appropriate, and providing a good quality of life.
1. HIV attacks T-cells in the immune system, leading to AIDS in advanced stages. Children progress more rapidly than adults, with half of untreated children dying within 2 years.
2. In India, around 2.4 million people live with HIV, with 25,000 new infections annually in children, most occurring during pregnancy or birth. Approximately 5,000 infected children progress to AIDS each year.
3. HIV is diagnosed through PCR testing in children under 18 months or antibody testing along with clinical symptoms in older children. Management includes cotrimoxazole prophylaxis, antiretroviral therapy, treatment of opportunistic infections, adequate nutrition and immunization.
The document provides an overview of HIV in pregnancy including:
1. The history, virology, global scenario, burden in India, routes of transmission, testing and management during the ante-natal, intra-partum, and post-natal periods are discussed.
2. Guidelines for prevention of mother-to-child transmission through antiretroviral therapy, delivery method, feeding options and infant prophylaxis and care are provided.
3. Staging of HIV disease and treatment criteria including when to start antiretroviral therapy during pregnancy based on CD4 count and clinical stage are outlined.
Standard Treatment Guidelines
serve as an important vehicle in assisting the doctor in decision making & providing the best treatment options for her patients.
Dr. Pradeep Katwal presented on adult immunization. He discussed how vaccines have led to the eradication of smallpox and near eradication of diseases like diphtheria. He reviewed the immunological basis of vaccines and highlighted various vaccines recommended for adults including influenza, pneumococcal, hepatitis A/B, HPV and herpes zoster vaccines. Adult immunization is important to reduce the burden of vaccine-preventable diseases and protect high risk groups.
Similar to 2016 Sessions: Perinatal, Paediatric and adolescence: What are the HIV Priorities (20)
The document discusses neuroplasticity and rapid maturation in the teen brain related to independence, identity, peer approval and sex. It also discusses how slow developing brain input influences neuronal wiring and the power of pornography. Finally, it outlines the typical stages of the sexual response cycle from emotional intimacy and neutrality to arousal, desire, and satisfaction or orgasm.
This document discusses topics related to gender identity and transgender health. It provides definitions for terms like cisgender, transgender, gender non-binary, gender fluid, and gender spectrum. It examines theories of gender identity development and discusses challenges faced by the transgender community, like higher risks for HIV and other STIs. Guidelines are presented for screening and risk assessment of transgender individuals to address their specific healthcare needs. References are also provided for further reading.
1) Hepatitis B vaccination faces several challenges, including ensuring safety, demonstrating efficacy of recombinant vaccines, determining duration of protection, addressing cost and non-responders.
2) Studies showed plasma-derived and recombinant vaccines provided protection for decades, though antibody levels declined over time. Cellular immune responses persisted despite low antibody levels.
3) Global elimination of Hepatitis B is possible by 2090 through high coverage birth dose vaccination, treatment of high-risk groups, and developing a cure for chronic infection. However, this will require significant ongoing financial investment.
This document summarizes information about hepatitis B and C co-infection with HIV. It notes that co-infection leads to faster progression of liver disease and higher rates of liver cancer and mortality. Treatment for both viruses is important, with newer regimens like tenofovir alafenamide having comparable efficacy to tenofovir disoproxil fumarate but being more tolerable with less bone and kidney toxicity. Achieving a sustained virologic response reduces complications of liver disease and improves overall health outcomes.
This document summarizes immunotherapy for genital HPV infection. It discusses the life cycle of HPV and how it avoids detection by the immune system. Immunotherapeutic strategies aim to make HPV antigens accessible to antigen-presenting cells to stimulate cytotoxic T-cells. Treatment options discussed include photodynamic therapy, cryotherapy, laser ablation, surgery, imiquimod cream, and intralesional immunotherapy with killed Mycobacterium w vaccine. A randomized clinical trial found that intralesional Mycobacterium w vaccine and topical imiquimod cream were similarly effective in clearing anogenital warts, though the vaccine was associated with a self-limiting granulomatous reaction.
1) Anal cancer risk is greatly increased in people with HIV, especially gay and bisexual men with HIV who are at around 100 times higher risk compared to the general population.
2) HPV vaccination is recommended for those under 26 to prevent anal cancer and precancers, but there is no evidence of benefit in older populations.
3) If anal cancer precancers are found, there is no evidence that screening or treatment improves outcomes and treatments have very high failure rates.
4) An annual digital anal exam is recommended for MSM over 50 with HIV to aid early detection of anal cancer.
Novel Strategies to Improve STI Screening discusses strategies to improve screening for sexually transmitted infections (STIs). It notes that early diagnosis of STIs is crucial but screening remains rare in resource-limited settings. The document discusses developing point-of-care tests that meet the WHO ASSURED criteria of being affordable, sensitive, specific, user-friendly, rapid, equipment-free and deliverable. It describes developing a DNA biosensor to detect Neisseria gonorrhoeae that shows potential to diagnose STIs in clinical samples sensitively and specifically. While integration with microfluidics and further clinical studies are needed, biosensors combined with communication technologies may help improve STI screening.
Antimicrobial resistance has been an ongoing issue since the discovery of early antimicrobial treatments. Resistance first emerged in the early 1900s in Neisseria gonorrhoeae and has since developed to nearly all classes of antimicrobials used to treat it. Resistance is now widespread globally to previously effective drugs. New treatment guidelines must consider emerging resistance patterns and combine antimicrobials to preserve effectiveness. Ongoing surveillance is also needed to monitor resistance trends and ensure optimal treatment strategies.
PrEP has been successful in preventing HIV transmission but has led to increased bacterial STI rates. Research suggests PrEP using antibiotics may help control STIs by reducing transmission, though evidence is limited. Doxycycline treatment in one study reduced STI incidence in HIV+ men. However, widespread antibiotic use risks antimicrobial resistance. PrEP for STIs needs more research on effects and should be part of comprehensive prevention strategies that consider targeting, monitoring, and equity. It may contribute to global goals if risks like resistance are addressed.
Syphilis remains a major public health problem globally despite efforts to eliminate it. It is reemerging in many countries due to various factors like increased commercial sex work, migration, and lack of condom use. Prevalence is high among high-risk groups like sex workers, MSM, and drug users. While rates decreased in some areas like India and China in the 2000s, most regions have seen a rise in syphilis cases over the last decade. Enhanced screening, treatment, contact tracing and education of at-risk populations are needed to improve syphilis control and work towards elimination.
The document discusses the diagnosis of various vaginal conditions. It begins by covering vaginal physiology and changes that can occur over a woman's lifetime. It then discusses the most common physiological and pathological causes of vaginal symptoms, including infections like bacterial vaginosis, yeast, and trichomoniasis. The document provides details on evaluating patients with vaginal complaints through symptoms, clinical examination, pH, wet mount, gram stain, and other tests. It also provides examples of diagnostic approaches and classifications of common vaginal infections and conditions.
This document summarizes the National Programme for Tuberculosis Control and Chest Diseases (NPTCCD) in Sri Lanka. It provides statistics on TB case detection and treatment outcomes from 2005-2017. It identifies challenges such as insufficient case finding and inconsistent monitoring/evaluation. Opportunities include Sri Lanka's strong primary care network and availability of private hospitals. The document recommends priorities like strengthening contact tracing and screening of high-risk groups. It proposes pilot districts to improve case finding and treatment outcomes. Overall, it calls for strengthened leadership, resources and collaboration across sectors to accelerate TB control efforts and meet WHO targets to end TB in Sri Lanka.
1. Early detection of HIV-TB co-infection is challenging but important as TB is a leading cause of death among people living with HIV. New diagnostic approaches like Xpert MTB/RIF can improve detection rates.
2. TB is more difficult to diagnose, spreads faster, and is more deadly in people living with HIV. The risk of developing active TB increases with lower CD4 counts.
3. Screening and testing algorithms along with new tests like Xpert MTB/RIF, LF-LAM, and treatment of latent TB are recommended to reduce the high TB mortality among people living with HIV.
This document discusses cancers that are more common among people living with HIV/AIDS compared to the general population. It notes that HIV weakens the immune system, making people more susceptible to infections that can lead to cancer. It highlights that HIV-positive individuals are at higher risk for cancers caused by viruses like Kaposi Sarcoma herpesvirus, Epstein-Barr virus, human papillomavirus, and hepatitis B and C. The introduction of antiretroviral therapy has reduced rates of Kaposi sarcoma and non-Hodgkin's lymphoma but not cervical cancer. Regular cancer screening is important for HIV-positive people according to guidelines.
This document summarizes Sri Lanka's efforts to eliminate mother-to-child transmission of HIV from 2002 to the present. It outlines key milestones in Sri Lanka's prevention of mother-to-child transmission (PMTCT) program, including expanding antiretroviral treatment options for pregnant women and their babies over time. Charts show increasing HIV testing rates among pregnant women and decreasing numbers of babies born with HIV despite more women receiving PMTCT services. Sri Lanka aims to achieve elimination of mother-to-child transmission of HIV by the end of 2017.
Strategic communication is needed to achieve global and local HIV prevention goals. While Sri Lanka's HIV epidemic remains low, targeted interventions have reached thousands of high-risk groups. Recent data shows the majority of new HIV cases are from the general population. Therefore, mass communication programs targeting the general public through various media and life skills education are needed to significantly reduce new infections and end the AIDS epidemic by 2030, as required by global targets.
More from Sri Lanka College of Sexual Health and HIV Medicine (20)
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
2. PERINATAL
Abigail 18 years.
Known HIV positive 6 years.
Attending sixth-form college.
On a fixed dose combination, one tablet, once per day
Books at 22 weeks
CD4 count 220 cells/µL
HIV viral load 132,453 HIV RNA copies/ml
Non-adherentWhat is your
diagnosis?
3. PERINATAL
You offer Abigail:
CNS/ Psychology adherence support
New therapy: Tenofovir/FTC/Darunavir/ritonavir
Reviewed 26/40
HIV viral load 96,432 HIV RNA copies/ml
Non-adherent
What is your
diagnosis?
4. PERINATAL
Abigail
Eight weeks later: presents in labour
Treatment: sd Nevirapine,
double dose Tenofovir,
sd Raltegravir
Delivers vaginally
Baby treatment zidovudine/lamivudine/nevirapine
What do you want to know?
Is the baby already
infected?
5. 5
Final Results From the 6-Year Randomized CHER
(Children with HIV Early antiRetroviral) Trial in South Africa
Mark Cotton, Avy Violari, Diana Gibb, Kennedy Otwombe, Deirdre
Josipovic, Ravindre Panchia, Patrick Jean-Phillipe, Edward
Handelsman, James McIntyre and Abdel Babiker
CROI 2012
6. 6
CHER Trial
Part A n=375
HIV infection diagnosed before 12 weeks and CD4% ≥25%
ART-Deferred
Defer ART until clinical
progression or CD4%
drop
N=125
ART-40W
Early ART to 40
weeks; then STOP,
until progression
N=125
ART-96W
Early ART to 96
weeks; then STOP,
until progression
N=125
Follow: up to 6 years
Primary endpoint: time to failure of first line ART
ART (start or re-start) when CD4% <20% or clinical event
1st
-line ART: Kaletra® + ZDV+3TC
Design
7. Proportion of children on ART
7
Overall proportion of time spent on ART
ART-Def 81%
ART-40W 70%
ART-96W 69%
Week on study
ART-DefART-Def
ART-40W
ART-96W
ProportiononART
8. 0.000.250.500.751.00
Proportionreachingprimaryendpoint
126 116 111 107 106 83ART-96W
125 114 106 99 97 74ART-40W
125 97 94 91 89 72ART-Def
Number at risk
0 48 96 144 192 240
Weeks since randomisation
ART-Def ART-40W ART-96W
HR (95% CI) relative to ART-Deferred
ART-40W: 0.73 (0.46 – 1.17, p=0.19)
ART-96W: 0.58 (0.35 – 0.96, p=0.03)
ART-40/96W: 0.65 (0.43 - 0.98, p=0.04)
Time to Primary Outcome
ART-Deferred vs ART-40W vs ART-96W
Death or failure of 1st
line ART
9. Progression to severe CDC B or CDC C or death
9
0.000.250.500.751.00
Proportionwithclinicalfailure
126 105 96 89 88 68ART-96W
126 106 85 83 82 67ART-40W
125 79 72 71 70 57ART-Def
Number at risk
0 48 96 144 192 240
Weeks since randomisation
ART-Def ART-40W ART-96W
HR (95% CI) relative to ART-Deferred
ART-40W: 0.5 (0.3 – 0.8, p=0.005)
ART-96W: 0.4 (0.3 – 0.7, p=0.0003)
Proportion
10. Priority 1. Early diagnosis of infant infection
HIV infected children should be
started on ART straight away as
this prevents AIDS, death,
severe neurological sequelae
and preserves immune
function.
Paediatric European Network for Treatment of AIDS Treatment
Guideline 2016 update: antiretroviral therapy
recommended for all children living with HIV
11. What test do you want in the baby?
1. HIV Ab
2. HIV DNA
3. HIV RNA
1. HIV Ab - is a test of maternal status
2. HIV DNA – not affected by maternal or neonatal therapy
3. HIV RNA - Sensitive and increasingly available
– maternal infection detected by this method
False negative if early HIV infection has been treated
transplacentally
12. More results - outcome 1
At delivery maternal HIV viral load 4,377 HIV RNA copies/ml
Further history indicates that Abigail took Atripla intermittently
Baby: Day 1 sample HIV DNA detected
What are your treatment options?
14. What are your treatment options?
a) pre-term and nil by mouth – ZDV IV
b) Pre-term and enterally fed –
zidovudine/lamivudine/nevirapine/lopinavir
c) Term and enterally fed -
zidovudine/lamivudine/nevirapine/lopinavir
15. Priority 2. Paediatric formulations and parenteral
formulations
(1)safe and effective ART for children,
(2)palatable and easy-to-swallow medications,
(3)fixed-dose combinations to decrease pill burden,
(4)once-a-day formulations to lengthen dosing intervals,
(5)medications that are easy to transport and store,
(6)formulations that are simple for caregivers to
administer
AIDS Res Treat. 2016; 2016: 1654938. Published online 2016 Jun 16. doi: 10.1155/2016/1654938
The Need for Pediatric Formulations to Treat Children with HIV
Adrienne F. Schlatter, Andrew R. Deathe,and Rachel C. Vreeman
16. Alternative scenario – Abigail’s baby is not infected
At delivery maternal HIV viral load 4,377 HIV RNA
copies/ml
Further history indicates that she took Atripla
intermittently
Baby: Day 1 sample HIV DNA not detected
Abigail has been taking her medications correctly for
the last two weeks
and decides to breast feed her baby
17. WHO HIV and Infant Feeding Guidelines 2016
Mothers living with HIV should
breastfeed for at least 12 months and
may continue breastfeeding for up to
24 months or longer (similar to the
general population) while being fully
supported for ART adherence.
18. Breast-feeding related HIV Transmission during ARVs
Study Intervention (PP) Transmission Rate Reference
Vit A RCT n 103
156
288
Observational study
15 months FU
Exclusive BF 25%
Never BF 20%
Mixed feeding 35%
Coutsoudis et al
AIDS 2001;15:379-
387
DREAM n 341
Mozambique
Observational study
HAART + 6/12 Excl BF
Observed 2.8%
Expected 40%
Marazzi et al, PIDJ,
2009; 28:483-7
n 441
Tanzania
Observational study
HAART + 6/12 Excl BF
6/52 4.1%
6/12 5.1%
Kilewo et al, JAIDS,
2009; 52: 406-16
n 102
Uganda
Observational study
HAART + 6/12 Excl BF
No Transmissions
19% MR
Homsy et al, JAIDS,
2010;53:28-35
Maternal n 227
Choice n 305
Breast Fed
Formula-Fed
0.5%
0 %
Peltier et al, AIDS
2009;23:2415-2413
Mma Bana n 265
Rwanda 265
RCT 170
Trizivir
CBV/Kaletra
CBV/NVP
0.7%
0 %
0 %
Shapiro et al, NEJM,
2010;362:2282-2294
BAN n 851
Malawi 848
RCT 668
CBV/NVP or Kaletra
Infant NVP
Nutritional supplements
3.0%
1.8%
6.4%
Chesale et al, NEJM,
2010;362:2271-2281
19. Efficacy of WHO recommendation for continued
breastfeeding and maternal cART
Ngoma M et al JIAS 2015;18 19352
ExclBF
Complementary
BF
COB
ZDV/3TC/LPV/Rit from 14 –
26 GA weeks to beyond
Cessation of Breast feeding
20. Priority 3. Long-term outcome data on transmission
through breast-feeding whilst on cART – what is best?
22. N 389 514 671 891 1150 1357 1509 1607 1645
433 577 779 1027 1251 1444 1569 1646 1541
Note: Data are for all children and young people alive who were ever in follow-up from 1996 onwards, including children who have since
transferred to adult care; those who subsequently died or were lost to follow-up are excluded from the year of death or loss to follow-up.
All paediatric infections are included, regardless of mode of acquisition (94% perinatal). CHIPS includes all diagnosed HIV-infected
children known to be living in the UK/Ireland, of whom ~55% were born abroad. Data for 2013 are incomplete as subject to reporting
delay.
Age of UK/Irish paediatric cohort
by year of follow-up, 1996-2013
>60% 16+
23. HIV is the leading cause of death among adolescents in
Africa
• Adolescence is the only age group in which AIDS
deaths increased between 2005 and 2012
• 36.7 million people living with HIV - 1.8 million
between 10-19 years old – majority perinatally
infected
• 2.1 million new HIV infections: 250,000 in 10-19
year olds in 2015
• Young women aged 15–24 years are
disproportionately affected, accounting for 20%
of all new diagnoses, even though they represent
just 11% of the adult population
24. 11 deaths
Transfer: median age 17 yrs, CD4 120. At death: 21 yrs, CD4 27
Causes: suicide (2), end stage AIDS (3), respiratory infections (2)
PML, CNS lymphoma, ICH and Toxoplasmosis.
9/11 mental health diagnosis
All had treatable virus in year of death
11 deaths
Transfer: median age 17 yrs, CD4 120. At death: 21 yrs, CD4 27
Causes: suicide (2), end stage AIDS (3), respiratory infections (2)
PML, CNS lymphoma, ICH and Toxoplasmosis.
9/11 mental health diagnosis
All had treatable virus in year of death
25. What happens in chronic disease?
Renal transplant: 35% lost graft within 36 months of transfer
Watson A 2000
Diabetes: 10-69% no medical f/up after paediatric care
Pacaud D 1996, Frank
M 1996
26. 19.8% were LTFU in the year after turning 22 years.
Independent associations with LTFU were:
1) Receiving care at an adult versus pediatric HIV
clinic (AOR, 2.91; 95% CI, 1.42-5.93),
2) having fewer than four primary HIV visits/year
(AOR, 2.72; 95% CI, 1.67-4.42),
3) Having antiretroviral therapy prescription
(AOR, 0.50; 95% CI, .41-.60)
LTFU was prevalent at each age transition,
19.8% were LTFU in the year after turning 22 years.
Independent associations with LTFU were:
1) Receiving care at an adult versus pediatric HIV
clinic (AOR, 2.91; 95% CI, 1.42-5.93),
2) having fewer than four primary HIV visits/year
(AOR, 2.72; 95% CI, 1.67-4.42),
3) Having antiretroviral therapy prescription
(AOR, 0.50; 95% CI, .41-.60)
LTFU was prevalent at each age transition,
Agwu et al.
27. • 237 PaHIV median age 20 yrs
• median age HIV diagnosis 6 yrs
• 22% psychiatric diagnosis:
depression > psychosis > anxiety
• 25% psychological diagnosis:
anxiety, depression, self harm, risk
behaviours
• association with lower CD4 count
(p<0.002)
Marthe Le Provost – AALPHI
cohort
UK risk factors for
Adolescent Mental Health
Black ethnicity
Migrant population
Parental unemployment
Looked after child
Poverty
UK risk factors for
Adolescent Mental Health
Black ethnicity
Migrant population
Parental unemployment
Looked after child
Poverty
28. current smoking 1.32 (1.13, 1.54)
illegal drugs 1.49 (1.15, 1.92)
early sexual debut 1.33 (1.03, 1.72)
eating disorder 1.44 (1.26, 1.74)
antisocial acts 1.48 (1.26, 1.74)
attempted suicide 2.24 (1.55, 3.24)
more likely to report 3 or > 4 simultaneous behaviours
JC Suris et al, 2007 J Begent CHIVA 2010
RISK BEHAVIOURS IN YOUTH
WITH CHRONIC CONDITIONS
32. Afternoons, walk-in, MDT, sexual health,
Contraception, peer support, vaccination,
social care, finances
33. OPD REMINDER
ART ALARM
ART SWITCH PIC
ADHERENCE APP
MD2Me – Generic 2/12 Web-based & text-delivered disease management and
skill-based intervention with trends towards improved transition readiness
HUANG et al PEDIATRICS
Volume 133;6, June 2014
34. ATTENDANCE
Text reminders
Walk in any Wednesday – no questions asked
If DNA; calls, texts, letters, whats app, local service, past
paediatric healthcare team, community nursing, GP
Never “discharged” due to DNA
Re-engage at crisis points – admission, transfer in if local
hospital
5/157 (3%) not seen in 900 in last year: HMP (2), agrophobia
and alcoholism (1) – home visits and bloods, contactable
by phone only (1), LTFU (1); university- GP trying to chase
LTNP
36. Priority 5: Long-acting ART –ECLAIR and LATTE-2
92% had SE mostly pain
Murray M et al CROI 2016
Cabotegravir Integrase Inhibitor oral
T/2 40 hours,
IM nanosuspension T/2 20-40 days
Rilpivirine (RPV) T/2 oral 50h 300mg/ml
nanosuspension IM T/2 30-90d. CAB +
RPV oral was at least as effective as
Efavirenz based triple therapy (LATTE)
Margolis D et al CROI 2014
Margolis D et al CROI 2016
37. Bridging Worlds: Perinatally infected youth in
adult care
DR CAROLINE FOSTER
IMPERIAL COLLEGE HEALTHCARE NHS TRUST LONDON
September 2016
Massive thanks to Caroline
Foster our adolescent
doctor!
38. RIVER - Research into eradication of HIV reservoirs
Early HIV
infection
Quadruple
Therapy
HIV
Vaccination
Vorinostat
‘Kick’
39. Unmask latent infection
Anatomical hidden reservoirs – gut, genitalia, brain
poor HAART penetration
Functional reservoirs - long-lived latently infected
cells
HIV infected central memory cells (TCM)
HIV infected transitional memory cells (TTM)
HIV infected T memory stem cells (Tscm)
high proliferative potential
Buzon M et al CROI 2013
NEW
40. Unmask latent infection
Histone deactelylase inhibitors
Sodium valproate
Vorinostat
B-catenin inhibitors
Stops stem cells from differentiating into
memory cells
T-cell activation
IL-2
Interferon-α2b
IL-7 – not effective in ERAMUNE
44. Virological studies to detect residual HIV
in this very-early treated child
Proviral DNA
Copies/
10*6 cells
Cells tested /well
(No replicates pos)
PBMC
24/12
26/12
<2.7
4.2
122,000 (0/2)
133,000 (1/6)
Resting CD4 T-cells
24/12
26/12
<3.5
<2.5
96,500 (0/3)
134,000 (0/6)
Enriched for
activated T-cells
24/12
26/12
< 2.2
<2.6
154,000 (0/6)
130,000 (0/6)
Monocyte-derived
adherent cells
24/12
26/12
37.6
<11.5
14,300 (1/3)
29,000 (0/6)
HIV RNA
Plasma
24/12
26/12
1 copy/ml
<2 copies/ml
n/a
n/a
Infectious virus from
resting CD4+
24/12
Not
recovered
n/a
Persaud et al. CROI 2013. Abst. 48LB
Editor's Notes
Infants &lt;12w of age CD4 &gt;= 25%
Deferred arm & 2 early ART Arms, one for 40W & the other for 96w
Followed by interruption
Restarting criteria – CD4 & clinical
HIV associated encephalitis
This prevents AIDS, death, severe neurological sequelae and preserves immune function. Treatment should be continued indefinately.
DREAM – 4 transmissions after 6/52 – 1.3% HAART – CBV/NVP
Uganda study high MR – 63% due to severe mortality and higher if breast-fed &lt;5 months
In UK number of children with HIV decreasing – number of adolescents increasing
9 BLACK AFRICAN, 9 BORN ABROAD
4 deaths in community, 1 in hospice, 6 in hospital
ÉCLAIR was a placebo controlled study of LA cabotegravir IM every 12 weeks x 3 doses in Men at high risk of acquiring HIV in USA. 92% had s/e mostly pain compared with 27% with the saline placebo injections. 79% were happy to continue after 3rd dose.
In LATTE oral suspensions of CAB and RLP were equivalent to EFZ based triple therapy
High proliferative potential – means behaving more like HTLV-1 infected cells – with viral replication by cell division
Potential to combine effects – eg B catenin with panobinostat
TFC – Transcription Factor centre
HAT – Histone acetyl transferase
Viral load was relatively low for a baby and viral load became undetectable and you can see that the baby was attending regularly up to 18 months when she disappeared from care. The surprise was that having been off therapy for 6 – 9 months (based on MCV) HIV remained undetectable
She was extensively investigated and if present, as these data show, HIV was only detected at very low levels pretty much at the limit of detection of the assay.
Immunological she was normal not showing the immune activation expected, she has seroreverted and had no detected cellular responses to HIV. One can argue about what to call this and whether this finding is due to the therapy are whether she is an elite controller, or better. Loss of antibodies has been reported in babies treated early and effectively on treatment but her she’s been off treatment for 9 months at least.
Is this situation akin to elite controllers or better?
There have now been a number of similar cases of functional cure – one from Germany and 14 from a French cohort – VISCONTI – (presented at IAS)