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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
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Elizabeth Glaser
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Ariel and Jake Glaser
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The Elizabeth Glaser Pediatric AIDS Foundation
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HIV Disease Course
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• 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
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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
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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
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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
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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
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- 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 -
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Timing of HIV transmission to the infant
During pregnancy Around labour/delivery During Breastfeeding
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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.
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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.
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United NationsSCN NewsMay 1991
“Use my pictureif it will help,“I don’t wantother people tomake the samemistake”.
Breast Feeding vs Bottle Feeding
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2009 Revised WHO guidelines
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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)
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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
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Infant Survival by HIV Infection Status -HIVNET 012 cohort
Proportion
alive
Age (years)
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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
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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
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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
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Negotiating the PMTCT Activities
?
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Negotiating the PMTCT Activities (PMTCT = MCH)
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The Way ForwardChallenges:• 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
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Tunaweza: Together, we can…
Eliminate Pediatric HIV