Children living with HIV/AIDSChildren living with HIV/AIDS

New HIV infections in children in 1999New HIV infections in children in 1999

Child deaths due to HIV/AIDS in 1999Child deaths due to HIV/AIDS in 1999

Cumulative number of child deaths due to HIV/AIDSCumulative number of child deaths due to HIV/AIDS

June-2000 global estimatesJune-2000 global estimatesChildren (<15 years)Children (<15 years)

1.3 million

620 000

500 000

3.8 million

Estimated impact of AIDS on under-5 child Estimated impact of AIDS on under-5 child mortality rates – mortality rates – Selected African countries, Selected African countries,

20102010

Source: US Bureau of the Census

250

200

150

100

50

0

per 1000 live births with AIDS

Botswana Kenya Malawi Tanzania Zambia Zimbabwe

without AIDS

Prevention of Mother to Child Transmission (PMTCT). during late pregnancy. during labor. through breast-feeding

Prevention of

unwanted pregnancies

(Family Planning)

Three integrated strategies to reduce Three integrated strategies to reduce paediatricpaediatric AIDS AIDS

Three integrated strategies to reduce Three integrated strategies to reduce paediatricpaediatric AIDS AIDS

Primary HIV prevention in parents to be

Primary HIV prevention in the context of Primary HIV prevention in the context of pregnancypregnancy

Primary HIV prevention in the context of Primary HIV prevention in the context of pregnancypregnancy

Information, Education and Communication programmesInformation, Education and Communication programmes

Screening and treatment of Sexually Transmitted Infections Screening and treatment of Sexually Transmitted Infections

Condom promotionCondom promotion

HIV counsellingHIV counselling NB: The risk of MTCT increases when the NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeedingmother is infected during pregnancy or breastfeeding

Information, Education and Communication programmesInformation, Education and Communication programmes

Screening and treatment of Sexually Transmitted Infections Screening and treatment of Sexually Transmitted Infections

Condom promotionCondom promotion

HIV counsellingHIV counselling NB: The risk of MTCT increases when the NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeedingmother is infected during pregnancy or breastfeeding

Benefits of information, counselling and Benefits of information, counselling and voluntary HIV testing for the communityvoluntary HIV testing for the communityBenefits of information, counselling and Benefits of information, counselling and voluntary HIV testing for the communityvoluntary HIV testing for the community

Widespread availability and use of counselling and voluntary Widespread availability and use of counselling and voluntary

HIV testing can :HIV testing can :

Reduce fear, ignorance and stigma surrounding HIVReduce fear, ignorance and stigma surrounding HIV

Stimulate a community response in support to those Stimulate a community response in support to those

needing careneeding care

Contribute to an environment supportive of safer sexual Contribute to an environment supportive of safer sexual

behaviourbehaviour

Reduce spillover of artificial feeding to HIV(-) mothersReduce spillover of artificial feeding to HIV(-) mothers

Widespread availability and use of counselling and voluntary Widespread availability and use of counselling and voluntary

HIV testing can :HIV testing can :

Reduce fear, ignorance and stigma surrounding HIVReduce fear, ignorance and stigma surrounding HIV

Stimulate a community response in support to those Stimulate a community response in support to those

needing careneeding care

Contribute to an environment supportive of safer sexual Contribute to an environment supportive of safer sexual

behaviourbehaviour

Reduce spillover of artificial feeding to HIV(-) mothersReduce spillover of artificial feeding to HIV(-) mothers

Family Planning StrengtheningFamily Planning StrengtheningFamily Planning StrengtheningFamily Planning Strengthening To prevent To prevent unwantedunwanted pregnancies pregnancies

HIV should never be used as a reason to pressurise women HIV should never be used as a reason to pressurise women into having or not having childreninto having or not having children

To delay subsequent pregnanciesTo delay subsequent pregnancies

For the health of mothers, WHO recommends a minimum of For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. 2 years between pregnancies.

To replace the contraceptive effect of breastfeedingTo replace the contraceptive effect of breastfeeding

Avoidance of breastfeeding for PMTCT should not lead to Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancyrapid, unplanned subsequent pregnancy

To prevent To prevent unwantedunwanted pregnancies pregnancies

HIV should never be used as a reason to pressurise women HIV should never be used as a reason to pressurise women into having or not having childreninto having or not having children

To delay subsequent pregnanciesTo delay subsequent pregnancies

For the health of mothers, WHO recommends a minimum of For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. 2 years between pregnancies.

To replace the contraceptive effect of breastfeedingTo replace the contraceptive effect of breastfeeding

Avoidance of breastfeeding for PMTCT should not lead to Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancyrapid, unplanned subsequent pregnancy

Prevention of MTCT through antiretroviralsPrevention of MTCT through antiretroviralsPrevention of MTCT through antiretroviralsPrevention of MTCT through antiretrovirals

Mechanisms of action:Mechanisms of action:

Ante and intra-partum regimen:Ante and intra-partum regimen:

Reduce viral load in mother ’s blood and genital fluids Reduce viral load in mother ’s blood and genital fluids

during pregnancy, labor and deliveryduring pregnancy, labor and delivery

Post-partum regimen:Post-partum regimen:

Act as post-exposure prophylaxis (viral particles Act as post-exposure prophylaxis (viral particles

eventually transmitted during birth are eliminated)eventually transmitted during birth are eliminated)

Mechanisms of action:Mechanisms of action:

Ante and intra-partum regimen:Ante and intra-partum regimen:

Reduce viral load in mother ’s blood and genital fluids Reduce viral load in mother ’s blood and genital fluids

during pregnancy, labor and deliveryduring pregnancy, labor and delivery

Post-partum regimen:Post-partum regimen:

Act as post-exposure prophylaxis (viral particles Act as post-exposure prophylaxis (viral particles

eventually transmitted during birth are eliminated)eventually transmitted during birth are eliminated)

Non-antiretroviral based intervention to Non-antiretroviral based intervention to prevent MTCT at birthprevent MTCT at birth

Non-antiretroviral based intervention to Non-antiretroviral based intervention to prevent MTCT at birthprevent MTCT at birth

Ceasarian section :Ceasarian section : 50% risk reduction if performed before 50% risk reduction if performed before

onset of labouronset of labour

Avoidance of unnecessary invasive proceduresAvoidance of unnecessary invasive procedures (episiotomy, (episiotomy,

rupture of membranes…) : reduce infant contact with rupture of membranes…) : reduce infant contact with

mother ’s infected blood and genital fluidsmother ’s infected blood and genital fluids

Vaginal lavageVaginal lavage with chlorhexidine : may be protective in with chlorhexidine : may be protective in

case of prolonged rupture of membrane (>4 hours before case of prolonged rupture of membrane (>4 hours before

delivery)delivery)

Vitamin A supplementation :Vitamin A supplementation : not effective to reduce MTCT not effective to reduce MTCT

Ceasarian section :Ceasarian section : 50% risk reduction if performed before 50% risk reduction if performed before

onset of labouronset of labour

Avoidance of unnecessary invasive proceduresAvoidance of unnecessary invasive procedures (episiotomy, (episiotomy,

rupture of membranes…) : reduce infant contact with rupture of membranes…) : reduce infant contact with

mother ’s infected blood and genital fluidsmother ’s infected blood and genital fluids

Vaginal lavageVaginal lavage with chlorhexidine : may be protective in with chlorhexidine : may be protective in

case of prolonged rupture of membrane (>4 hours before case of prolonged rupture of membrane (>4 hours before

delivery)delivery)

Vitamin A supplementation :Vitamin A supplementation : not effective to reduce MTCT not effective to reduce MTCT

Prevention of MTCT after birthPrevention of MTCT after birthPrevention of MTCT after birthPrevention of MTCT after birth Avoidance of breastfeedingAvoidance of breastfeeding = Replacement feeding: = Replacement feeding:

First 4-6 months:First 4-6 months:

- Commercial infant formula- Commercial infant formula

- home made infant formula (diluted animal milk + sugar + - home made infant formula (diluted animal milk + sugar + vitamins)vitamins)

From 6 months to 2 years:From 6 months to 2 years:

- Enriched family foods- Enriched family foods Exclusive breastfeeding + early weaningExclusive breastfeeding + early weaning (as soon as (as soon as

replacement feeding is feasible and safe)replacement feeding is feasible and safe)

Avoidance of breastfeedingAvoidance of breastfeeding = Replacement feeding: = Replacement feeding:

First 4-6 months:First 4-6 months:

- Commercial infant formula- Commercial infant formula

- home made infant formula (diluted animal milk + sugar + - home made infant formula (diluted animal milk + sugar + vitamins)vitamins)

From 6 months to 2 years:From 6 months to 2 years:

- Enriched family foods- Enriched family foods Exclusive breastfeeding + early weaningExclusive breastfeeding + early weaning (as soon as (as soon as

replacement feeding is feasible and safe)replacement feeding is feasible and safe)

The variable risk of MTCT of HIV The variable risk of MTCT of HIV (with and without preventive interventions)(with and without preventive interventions)

The variable risk of MTCT of HIV The variable risk of MTCT of HIV (with and without preventive interventions)(with and without preventive interventions)

0% 25% 50% 75% 100%

ARV, no breastfeeding, C-section

ARV, no breastfeeding

no ARV, no breastfeeding

ARV, prolonged breastfeeding

no ARV, prolonged breastfeeding

Infected Uninfected

ARV regimen of proven efficacyARV regimen of proven efficacyARV regimen of proven efficacyARV regimen of proven efficacy

Antenatal Intrapartum Postnatal

ZDV long

ZDV short

ZDV+3TC (1)

ZDV+3TC (2)

NVP

Infant

Infant+Mother

Infant+Mother

14wk 36wkOnset of labour Delivery

Birth 1wk PP 6wk PP

Infant

Balancing the risks of breastfeeding and Balancing the risks of breastfeeding and formula feedingformula feeding

Balancing the risks of breastfeeding and Balancing the risks of breastfeeding and formula feedingformula feeding

0%

10%

20%

30%

40%

HIV Infection rate-Breast-feeding HIV Infection rate-Formula feedingMortality rate-Breastfeeding Mortality rate-Formula feeding

6 wks

14 wks

6 months12 months 24 months

Child age

Source: Nduati et al. JAMA 2000

A cascade of interventionsA cascade of interventionsA cascade of interventionsA cascade of interventions

P Pregnant

Pre-test counsellingTest accepted

Results given

ARV initiated

ARV completedSafer infant feeding

ANC

Infections averted

Botswana pilot programme example Botswana pilot programme example First 8 monthsFirst 8 months

Botswana pilot programme example Botswana pilot programme example First 8 monthsFirst 8 months

P HIV+ Pregnant

Pre-test counsellingTest accepted

Results givenARV initiated

ARV completed

Safer infant feeding

ANC

Infections averted (estimated)

N=2900

N=2900

N=1650

N=754

N=435

232

174

N=638

70

Botswana: Challenges and ResponsesBotswana: Challenges and ResponsesBotswana: Challenges and ResponsesBotswana: Challenges and Responses

Challenges :Challenges :

Offer pre-test counselling to all womenOffer pre-test counselling to all women

Increase acceptability of HIV testIncrease acceptability of HIV test

Responses :Responses :

Train all mid-wives and doctors in HIV counsellingTrain all mid-wives and doctors in HIV counselling

Develop communication programmesDevelop communication programmes

Involve partners and/or other significant relativesInvolve partners and/or other significant relatives

Challenges :Challenges :

Offer pre-test counselling to all womenOffer pre-test counselling to all women

Increase acceptability of HIV testIncrease acceptability of HIV test

Responses :Responses :

Train all mid-wives and doctors in HIV counsellingTrain all mid-wives and doctors in HIV counselling

Develop communication programmesDevelop communication programmes

Involve partners and/or other significant relativesInvolve partners and/or other significant relatives