Dr. Laura GuayVice President for Research

Elizabeth Glaser Pediatric AIDS Foundation

J2J Global Media Training on HIV/AIDSJuly 14, 2010

Vienna, Austria

HIV in Children:Preventing Mother-to-Child

Transmission

Elizabeth Glaser

Ariel and Jake Glaser

The Elizabeth Glaser Pediatric AIDS Foundation

HIV Disease Course

• HIV antibody tests – When exposed to HIV (or any infection) the body

makes antibodies to fight the infection– Standard HIV tests measure these antibodies (EIA,

rapid tests, western blot) – HIV antibodies from an HIV-infected woman cross

the placenta and enter the baby’s blood

• HIV detection tests– These tests measure the actual parts of the HIV

virus itself (PCR, p24 antigen, viral culture)– These tests can identify HIV infection in a very

young baby

Diagnosis of HIV

WHO’s 4-Component Strategy for MTCT Prevention

Prevention of HIV in women,

especially young

women

Prevention of unintended pregnancies

in HIV-infected women

Prevention of transmission from an HIV-

infected woman to her

infant

Support for HIV-infected

women, their infants, and

families

Component

1

Component

2

Component

3

Component

4

Year

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 20070

400 000

500 000

600 000

200 000

300 000

100 000

This bar indicates the range

New infections among children, 1990–2007

2004 2005 2006 2007 20080%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

10%

15%

24%

34%

45%

6%

12%

18%20%

32%

Pregnant women living with HIV receiving ARVsInfants born to pregnant women living with HIV receiving ARVs

Provision of Antiretroviral Drugs

WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2009

55% of pregnant womennot receiving PMTCT

drugs

68% of HIV-exposed infants

not receiving PMTCT drugs

Benefits of global expansion of PMTCT programs• Provides opportunity for primary prevention for

large number of identified HIV-uninfected women

• Provides opportunity for prevention of HIV infection in children

• Provides opportunity as an entry point into HIV Care for large number of HIV-infected women and their infected infants― However, this is often a missed opportunity as

ongoing HIV care and treatment is not available

- about 30 out of 100 babies born to these women will get HIV.

If women with HIV do not take any HIV drugs during pregnancy and they breastfeed -

Timing of HIV transmission to the infant

During pregnancy Around labour/delivery During Breastfeeding

If women and newborns take 1 dose of the drug nevirapine around the time the baby is born -

- only ~16 out of 100 babies will getHIV from their mothers.

If women and newborns take a combination of HIV drugs during pregnancy and after delivery -

- as few as 4-6 out of 100 babies will get HIV from their mothers.

United NationsSCN NewsMay 1991

“Use my pictureif it will help,“I don’t wantother people tomake the samemistake”.

Breast Feeding vs Bottle Feeding

2009 Revised WHO guidelines

Key Changes in 2009 Revised WHO guidelines•Begin ART at CD4 cell count of 350 rather than 200

•Start ARV prophylaxis earlier in pregnancy

•Provide ARV prophylaxis during breastfeeding• Provide single drug Nevirapine daily to infants OR• Provide three drug ARV prophylaxis to the mother

•National authorities should decide whether MCH services will recommend HIV-infected mothers to:• Breastfeed and receive ARV interventions OR• Avoid all breastfeeding

(Taking into account socioeconomics, health services, and local infant mortality and under-nutrition)

Infant HIV diagnosis• Early diagnosis of HIV infection in children born

to HIV-infected women is critical― Allows early identification of children who will

benefit from antiretroviral treatment, appropriate infant feeding choices, prophylaxis, and close medical follow-up

― Decreases the psychological stress of uncertainty for the parents

• HIV detection tests must be used in first 12-18 mos., then standard antibody tests are accurate

• Early infant diagnosis using dried blood spots has made services available even in remote areas

Infant Survival by HIV Infection Status -HIVNET 012 cohort

Proportion

alive

Age (years)

Goals of an HIV Care Program

• Prevention of opportunistic infections

• Early identification of complications and their appropriate management

• Use of antiretroviral therapy to maintain and restore the immune system

• Provision of support for HIV-infected persons, including psychosocial

• Engage patients/families in HIV care and prevention through education, support and outreach

• Establish strong links to community resources

Basic Medical Care

• Close Follow-Up and Health Monitoring- Prompt treatment of acute illnesses

• Childhood Immunization

• Vitamin A Supplementation

• General Health Education (safe water, bednets)

• Management of Diarrhea

• Growth Monitoring & Nutrition Education - Early intervention/support

WHO Indications for Initiation of ARV Therapy in Children < 2 Years• Initial WHO guidelines for ART in infants and

children (2006) recommended starting therapy according to clinical/immunologic criteria

• Studies in infants showed that there was a ~75% decrease in death when ART was started immediately rather than waiting

• WHO revised recommendations in April 2008 such that ALL infants < 1 yr diagnosed with HIV infection should receive ART immediately

• Recent revised WHO guidelines increased this to all infants < 2 yrs of age

Negotiating the PMTCT Activities

?

Negotiating the PMTCT Activities (PMTCT = MCH)

The Way Forward

Challenges:• High initial implementation costs• Community sensitization/mobilization lacking• Integration of PMTCT within antenatal clinic can be

difficult• Access to women who don’t deliver in health facility• Very low numbers of partners involved • Inadequate infant feeding education• Poor postnatal follow-up

Successes:• Despite the challenges, we know this can be done, we

have done it• We are making great progress worldwide, but we all

need to keep pushing forward

Tunaweza: Together, we can…

Eliminate Pediatric HIV