Elimination of mother to child transmission of hiv


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Elimination of mother to child transmission of hiv

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