10.00 DiGibb RCOG 27Nov2015 · The Conduct of Placebo-Controlled Trials Raised New Controversies...
Transcript of 10.00 DiGibb RCOG 27Nov2015 · The Conduct of Placebo-Controlled Trials Raised New Controversies...
HIV in the Next Generation:
the Rocky Road to Elimination
(focus on Africa)
Medical Research Council Clinical Trials Unit at University College London
Di Gibb
REALITY
Outline
• Millennium Development Goals
• Prevention of Mother-To-Child Transmission (pMTCT)
• Where have we come from?
• Strategies for pMTCT– From Option A to Option B plus
• Paediatric diagnosis & linkage to care• Where are all the children?
• Prevention of HIV in adolescents
Where are We in 2015?
Millennium
Development
Goals 4, 5 & 6
Integration of MDGs*
Reduce HIV/AIDS
Increase Child Survival
*Double Dividend:
An initiative between UNICEF, WHO and ElGPAF, launched 2013.
Sources: 1. UNAIDS. The gap report 2014
2. Prendergast A et al. Arch Dis Child 2015
3. Chopra M et al. Arch Dis Child 2015
Where are We in 2015?
eMTCT
(Virtual) Elimination
of Mother to Child
Transmission
Millennium
Development
Goals 4, 5 & 6
Integration of MDGs*
Reduce HIV/AIDS
Increase Child Survival
� MTCT <5% in
breastfed infants
� <40,000 new
infections/year
(UNAIDS Global Plan
2011-2015)
*Double Dividend:
An initiative between UNICEF, WHO and ElGPAF, launched 2013.
Sources: 1. UNAIDS. The gap report 2014
2. Prendergast A et al. Arch Dis Child 2015
3. Chopra M et al. Arch Dis Child 2015
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
100,000
200,000
300,000
400,000
500,000
600,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
PM
TC
T c
overa
ge
New
HIV
in
fecti
on
s (
#)
Trends in new HIV infections among children (aged 0-14) and coverage of maternal ARVs form PMTCT in all
low- and middle-income countries, 2001-2012Maternal ARVs for PMTCT
New HIV infections in children (0-4)
Source: UNAIDS 2013 HIV and AIDS estimates, 2014, and UNAIDS/WHO/UNICEF Global AIDS Response Progress Reporting (GARPR)/Universal Access
Elimination (virtual) of Paediatric HIV:
Sources: 1. UNAIDS. 2013 HIV and AIDS estimates, 2014
2. UNAIDS/WHO/UNICEF. Global AIDS Response Progress Report /Universal Access data, 2006-14
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
100,000
200,000
300,000
400,000
500,000
600,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
PM
TC
T c
overa
ge
New
HIV
in
fecti
on
s (
#)
Trends in new HIV infections among children (aged 0-14) and coverage of maternal ARVs form PMTCT in all
low- and middle-income countries, 2001-2012Maternal ARVs for PMTCT
New HIV infections in children (0-4)
Source: UNAIDS 2013 HIV and AIDS estimates, 2014, and UNAIDS/WHO/UNICEF Global AIDS Response Progress Reporting (GARPR)/Universal Access
In 2013:
*240,000 children acquired HIV
~660 new infections/day
*3.2 million children <15 years
living with HIV
91% in SubSaharan Africa
Elimination (virtual) of Paediatric HIV:
not there yet!
Sources: 1. UNAIDS. 2013 HIV and AIDS estimates, 2014
2. UNAIDS/WHO/UNICEF. Global AIDS Response Progress Report /Universal Access data, 2006-14
“Virtual elimination” of
MTCT in Europe
Jasseron et al 2011, von Linstow et al 2010, Naver et
al 2006, Chiappini et al 2011, Prieto et al 2012, ECS
unpublished data, Personal comm. Inga Latysheva
MTCT rates 2000-2011
� 33 infected infants among 5788
singleton live births
UK and Ireland
Country MTCT Time period
France 1.0% 2005-2009
Italy 1.0% 2005-2010
Denmark 0.5% 2000-2008
Sweden 0.6% 1999-2003
Spain 1.6% 2000-2007
Ukraine 4.1% 2008-2010
Russia 3-4% 2010
UK 0.57% 2007-2011
1987:
HIV Treatment Era Begins
� AZT (ZDV) approved by FDA in
March 1987 for treatment of adults
� Despite concerns about AZT toxicity, given high mortality of
paediatric AIDS, paediatric and obstetric researchers proposed
giving AZT to infected pregnant women to reduce MTCT.
“Treatment as Prevention”: PMTCT With AZT in 1991
� Giving a potentially toxic drug to
pregnant women and exposing their
fetuses was highly controversial.
� Before approving the 076 trial, the FDA held a
special public meeting to discuss the ethics of
giving AZT to pregnant women.
The AZT Regimen in PACTG 076 Was Designed to
Target Multiple Potential Time Points of Transmission
Pregnancy
AZT 100 mg
5 times daily
TARGET:
In Utero(after 1st trimester)
enrollment
CD4 >200
DSMB Stopped PACTG 076 Trial at
First Interim Efficacy Analysis in February 1994
Placebo 25.5%
Zidovudine 8.3%
First demonstration of treatment as prevention!
67% Reduction Transmission
Feb
1994
Dec
1994
076: Moving Rapidly from Evidence to Policy and
Implementation in Less than One Year
Feb 18
DSMB
stops
study Feb 21
First
press
report
March
NIH-
led
Public
Health
Service
Task
Force
set up
Jun 6
Public
hearing to
debate
guideline
s
Apr 29
Interim
guidance
for use of
AZT in
pregnant
women
Aug 4
PHS Task Force
issues expanded
recommendations
for use of AZT for
PMTCT
Aug 8
FDA
approves
new labeling
for AZT to
include
PMTCT
Dec 5
Medicaid
coverage
for AZT
PMTCT
required
in all
states
Nov 3
Results
In
NEJM
Translation of Trial Results into Practice – US
Global HIV Epidemic in Children
� After 1994, pMTCT implemented in resource-rich countries
& attention turned to the developing world, where most HIV-
infected children live.
� By 1994, an estimated 1 million HIV-infected infants born.
No. children 0-14 years living with HIV globally
World Health Organization Response to
PACTG 076 Results
� June 23-25 1994, WHO held a meeting of scientists & MOH to
discuss implications of 076 trial for the developing world.
� Concluded that best approach was to do randomized, placebo-
controlled trials of shorter and simpler regimens of AZT.
“ZDV regimen studied in ACTG 076 not applicable [high cost; operational
requirements] in parts of the world where most MTCT of HIV occurs,
placebo-controlled trials offer the best option for obtaining rapid and
scientifically valid results#no other effective alternative #.”
The Conduct of Placebo-Controlled Trials
Raised New Controversies
� Despite controversy, several critical placebo-controlled trials of
shorter AZT regimens developed for developing countries.
� Investigators collaborated and shared trial design, endpoints,
and conducted meta-analyses.
� Trials built sequentially on each other to enable evolving and
improving PMTCT standards for developing world.
1994 2015
Building the Evidence Road for PMTCT
BF
1994 US
PACTG 076: AZT
1999 Thailand
Bangkok CDC: Short
AZT 1999 Cote d’Ivoire
Wiktor CDC: Short
AZT 1999 Uganda
HIVNET 012: sd
NVP
2002 Cote d’Ivoire
DITRAME+: Short AZT +
sd NVP 2004 Thailand
PHPT-2: Short AZT + SD
NVP
2006 Botswana
MASHI: Infant
AZT 2008 Ethiopia, India, Uganda
SWEN: Infant NVP 6
wk 2008 Malawi
PEPI-Malawi: Infant NVP or
NVP/AZT 14 wk2009 Tanzania
MITRA-plus: Maternal ARV
6 mo2010 BotswanaMma Bana: Maternal
ARV 6 mo2010 Malawi
BAN: Infant NVP vs. Maternal
ART 6 mo
2014 Africa
HPTN 046: Infant NVP 6
mo
2000 Thailand
PHPT: Short vs Long
AZT
Modified from James McIntyre MD
2011 Africa
Kesho Bora: Maternal ART
6 mo
FF
2015 Africa
PROMISE: Maternal ART 2015 Africa
ANRS 12714: Infant 3TC or LPV/r 12 mos
CD4 < 350
PregnancyLabor &
DeliveryBreastfeeding
New
Pregnancy
Attend
Antenatal
care
HIV
test
CD4,
WHO
stage
CD4
result
STOP
Maternal triple ART prophylaxis STOP
Maternal lifelong ART (CD4 <350, WHO 3,4)
CD4 > 350
AZT Daily Infant NVPSD NVP and
AZT/3TC for 7 daysOption A
Option B
Re-
identify
at ANC
CD4,
WHO
stage
Re-
identify
at ANC
CD4,
WHO
stage
WHO Guidelines 2010: Option A or Option B
0
0.5
1
1.5
2
Transmission Risk by Study Arm
0.5%0.6%
Maternal ZDV
etc & infant
NVP – Option A
TDF/FTC +
LPV/RTV
1.8% Difference (CI)
-1.28% (-2.11 to -0.44)
ZDV/3TC+
LPV/RTV
Triple antiretroviral therapy is best for
reducing MTCT(Fowler MG, Abstract 31LB, CROI 2015)
Evolution of WHO PMTCT Guidelines Over Time - As New Evidence Becomes Available
Treatment No rec ART if
CD4 <200
ART if CD4
<200
ART if CD4
<350
ART if CD4
<500
PMTCT 4
weeks
AZT or
sdNVP
AZT from
28 wks +
sdNVP
AZT from
28 wks +
sdNVP +
AZT/3TC
7d “tail”
Option A
AZT/sdNVP +
infant NVP if BF
Option B
ART preg/BF
Option B
ART preg/BF
Option B+
Life-long ART
2001 2006 20102004 2013
Breakthrough:
prevention of
breastmilk MTCT
− Use of more
effective drugs
− Extend coverage
through BF
− ART for maternal
health
− Program
simplification
New guidelines recommend universal ART
for pregnant and breastfeeding women
IN 2015: ART should be initiated in all pregnant and breastfeeding
women living with HIV regardless of WHO clinical stage and at any
CD4 cell count and continued lifelong
Strong recommendation, moderate-quality evidence
• In 2010 we had Option A and B
• In 2013 Option A no longer recommended; instead Option B and B+
• Now lifelong ART for ALL people diagnosed with HIV Therefore, the
new guidelines do not speak of “options” but “universal ART”
• But the rationale behind this isn’t from PMTCT literature….
• Europe 33%, S. America 25%, Africa 21%, N. America 11%, Asia 10%
• Median age 36 years; 25% women
• Med CD4: 651 (range 503 to 2296) and Med VL: 12,000
• Patients randomized to early start or waiting till CD4 fall <350
• Trial was closed early by the DSMB because of higher than
expected benefit of ART
The START trial enrolled over 4000 people
with CD4>500 at 211 sites in 35 countries
Source: N Engl J Med 2015; 373:795-807
Overall there were 42 “events” in the immediate arm and 96 in the deferred arm p=<0.001
No difference in drug toxicities between arms and no evidence of harm caused by ART even
in clients with HIV CD4
When looking at the primary outcome of
death or severe disease, immediate ART was protective
July 2015
START
Strong recommendations for all
BHIVA 2015
US 2015
WHO 2015
EACS 2015
New ART initiations among pregnant and breastfeeding women, percentage of all new ART initiations
attributed to this population, Malawi 2008-2012 (CDC, MMWR 2013)
B Plus in Malawi – starting in 2011
In1st year of B+ implementation, the
number of pregnant and
breastfeeding women initiating ART
increased 748%
(CDC, MMWR 2013)
2004-2008, only 9% of
HIV+ pregnant women
started on ART (Braun et al, JAIDS, 2010)
BENEFITS HARMS
Prevent transmission in future pregnancies Additional risk of toxicity because of additional
time on ART
Reduced transmission to uninfected
partners
Programmes are seeing high rates of LTFU; may
have implications for resistance
Avoid stopping and restarting ART for future
pregnancies
Potential risk of loss in transition from MCH
delivered ART services to routine ART services
No need to establish eligibility prior to
initiating ART regimen
Increased net immediate cost (although maybe
cost effective in the long term)
Improved maternal mortality & slower
disease progression with continuous vs.
interrupted ART
Additional potential risk of resistance, especially if
women stop ART or are poorly compliant
Balance of Risks and Benefits for universal ART
No studies comparing Option B with B+
But…. there are data on stopping ART
• Postpartum women discontinuing ART experience CD4
decline; heterogeneity from studies:
• CD4 at BASELINE of <500, resulted in 6-20% of women
reaching treatment threshold within 6 months of stopping
(vs only 1.5% if CD4 >500)
• May present for next pregnancy with CD4 below threshold
for ART initiation (also suggested from UK data)
Policies adopted in 144 LMIC
80% - Option B+
For most countries, Universal ART for
pregnant women (B+) is already national policy
“…..reduction in the number of HIV-positive
children born by HIV positive mothers
from 6% to 2%, following the
introduction of the option B+ treatment”
New Vision, Uganda, January 28, 2015
0
100,000
200,000
300,000
400,000
500,000
600,000
2000 2014
Nu
mb
er o
f ch
ild
ren
Inception of Global
Plan13% decline between
2000 and 200848% decline between
2009 and 2014
Source: UNAIDS Estimates derived from GARPR 2015 data
New Paediatric HIV infections among the 21 Global
Plan countries dropped below 200,000 in 2014
1115
2126
46
66
1013
1923
2731
0
10
20
30
40
50
60
70
80
90
100
2009 2010 2011 2012 2013 2014
An
tire
tro
vir
al t
he
rap
y c
ov
era
ge
(%
)
Aggregate antiretroviral coverage for children (0-14) and pregnant women across 21 Global Plan priority Countries, 2014
Pregnant Women ART Coverage
Child ART Coverage
Source: UNAIDS Estimates derived from GARPR 2015 data
ART access for pregnant women has
Increased with the adoption and implementation of B+
BUT
Is the policy shift to Universal ART for
Pregnant and Breastfeeding women
the magic bullet to control MTCT?
� HIV testing still low; in 2013 only 44% of pregnant women were HIV tested,
73% of HIV+ women received any ARV in 2014, and 50% infants received
infant ARV prophylaxis.
Testing and ART for pregnant women remain inadequate
Adapted from WHO Global HIV/AIDS Updates
44%
73%
50%
94% 85%
96%
94
59
100
66 66
50
74
91
79
64
72
88
39
72
2720
11
45
12
31
0
66
5349
43 42 4138 37 37
30 29 29
22 2217 16
15
14 12 11
8
0
10
20
30
40
50
60
70
80
90
100
Nam
ibia
Botswana
South Africa
Swaziland
Zam
bia
Kenya
Zimbabw
e
Uganda
Mozambique
Malaw
i
Lesotho
Tanzania
Ghana
Ethiopia
Burundi
Côte d'Ivoire
Dem
ocratic Republic…
Angola
Nigeria
Cam
eroon
Chad
An
tire
tro
vir
al t
he
rap
y c
ov
era
ge
(%
)
Antiretroviral Coverage for children (0-14 years) and pregnant
women in 21 Global Plan priority countries, 2014
Pregnant
Women ART
CoverageChild ART
Coverage
Source: UNAIDS Estimates derived from GARPR 2015 data
But when you look at individual countries
there is a lot of heterogeneity in terms of coverage
PMTCT Coverage: • Significant reduction in MTCT rate
from 30% in 2009 and 5.3% in 2014
• ARV prophylaxis for pregnant
women has remained high at 84% in
2010 and 2014
• HIV exposed infants receiving ARV
prophylaxis for PMTCT increased
from 74% in 2010 to 88% in 2014
• Rapid expansion of Option B+ to
1,457 health facilities
Zimbabwe MTCT Rates & eMTCT Coverage, 2002-2013/4
Main Challenges:
Late booking and home deliveries
Loss to follow for HIV exposed infants
Goal: Reducing new Pediatric infections
by 90% & a MTCT of HIV < 5% end 2015
0
5
10
15
20
25
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2013
MTC
T R
ate
(%
)
Year
Trends in MTCT Rates at 6
weeks, 2002 - 2013
02000400060008000
100001200014000
started ART during
breastfeedingstarted ART in pregnancy
on ART pre-pregnancy
pregnant women
Source: Integrated HIV Program Report MOH,
Malawi April-June 2014
97% women
come to ANC but
~15% not tested
~23% new B+
women lost <6m
~30% new B+
women lost by 24m
pMTCT Cascade (Continuum) with Option B+Malawi HIV Programme Report April-June 2014
Retention on ART in adults in rural Zimbabwe
ICASA conference, Harare 2015
Retention on ART 12 months post initiation
N Deaths Losses Retention
Men & non B+ women 1,120 17 40 93% (91%-95%)
B+ women 386 3 55 79% (69%-87%)
0.00
0.25
0.50
0.75
1.00
0 3 6 9 12Time since ART initiation
Men & non B+ women
B+ women;
retention better
If start ART during
breastfeeding
Safety of EFV and TDF in pregnancy
Systematic review (11 studies; Antiretroviral
Pregnancy Registry data):
• outcomes of 1,290 live births in women
receiving EFV in 1st trimester;
no increase in overall birth defects
Insufficient data to exclude >3 X risk in low-
incidence birth defects – e.g. neural tube
defects
Systematic review (11 studies; Antiretroviral
Pregnancy Registry data):
• outcomes of 1,290 live births in women
receiving EFV in 1st trimester;
no increase in overall birth defects
Insufficient data to exclude >3 X risk in low-
incidence birth defects – e.g. neural tube
defects
Efavirenz
Risk of birth defects with EFV not increased
Tenofovir
TDF in pregnancy are limited
Concerns include renal toxicity, adverse birth
outcomes, effects on bone density
Systematic review of foetal exposure to TDF:
• In Antiretroviral Pregnancy Registry,
prevalence of 2.4% with TDF 1st trimester
exposure for all birth defects (same as
background)
• No association with neuro-developmental
outcomes in infants 9-15 month
• Lower 12 month growth with TDF exposure
• Promise trial had increased early deaths with
LPV/r and TDF
Concerns include renal toxicity, adverse birth
outcomes, effects on bone density
Systematic review of foetal exposure to TDF:
• In Antiretroviral Pregnancy Registry,
prevalence of 2.4% with TDF 1st trimester
exposure for all birth defects (same as
background)
• No association with neuro-developmental
outcomes in infants 9-15 month
• Lower 12 month growth with TDF exposure
• Promise trial had increased early deaths with
LPV/r and TDF
Ford N et al. AIDS, 2011; Ford N et al. AIDS, 2013; Ekouevi DK et al. JAIDS, 2011; WHO, Geneva Use of EFV in pregnancy, 2012; Antiretroviral Pregnancy Registry Steering
Committee http://www.APRegistry.com Siberry GK et al. AIDS, 2012; Gibb DM, et al. Pregnancy and infant outcomes among HIV-infected women taking long term ART
with and without tenofovir, PLoS Med 2012; Sirois PA, et al. Safety of perinatal exposure to antiretroviral medications: developmental outcomes in infants, PIDJ 2013.
Option B+ & eMTCT?
• Triple ART is best for reducing MTCT
• Coverage increasing but eliminating MTCT has a way to go
• B+ has benefits:
– Reduce pMTCT in future pregnancies
– simplicity; ↑rollout of ART for all alongside pMTCT
– reducing partner transmission
– improving maternal health
• The BIG risk is failure to retain in care and its consequences
– Involvement of male partners is important
In 6 priority countries, less than 1 in 20 HIV-exposed children had
early infant diagnostic services, and in 2, less than 1 in 10.
PMTCT Does Not End at Delivery:Infants Are Not Being Diagnosed
0
20
40
60
80
100
Swaziland
South Africa
Botswana
Namiba
Zambia
Zimbabwe
Kenya
Uganda
Lesotho
Mozambique
Ghana
Tanzania
Cameroon
Ethiopa
Angola
Burundi
Cote d'Ivoire
DRC
Nigeria
Chad
8978
58 56 55 5042 36 36 35 30 26 24 21 17 17 15 10 4 4
Source: Global Update
on the Health Sector
Response to HIV
2014
Access to Early Infant Diagnosis in 21 Priority Countries 2013
Only 44% of HIV-Exposed Infants
Received Early Infant Diagnostic
Testing
% w
ith v
iral te
st by a
ge 2
mo
05101520253035
0
10000
20000
30000
40000
50000
NASCOP, MOH Kenya, 2014
Early Infant Diagnosis Tests & Results by Entry point: Kenya 2014
9%6% 7%8%
21%31%
11%
Nu
mb
er o
f te
sts
% p
ositiv
e
Testing all Children admitted to Malnutrition and Acute
Care Units must be High priority
Stunting Wasting
Engagement with Communities is Vital� If parents (mother) dies, child often
returns to the village
� grandmother carers cannot easily travel
� Stigma and lack of male involvement
� In 30/1351 households in a survey in
North Uganda, informants “worried
a child in the household had HIV”
but “did not know where to test”
Engagement with Communities is Vital� If parents (mother) dies, child often
returns to the village
� grandmother carers cannot easily travel
� Stigma and lack of male involvement
� In 30/1351 households in a survey in
North Uganda, informants “worried
a child in the household had HIV”
but “did not know where to test”
What is Needed:
At Primary Health Facilities
� Knowledge of paediatric HIV
� On-site
mentorship
� Health system
strengthening
� Innovative ways to engage Men:
� At ANC
� Bring in the
children
0
10
20
30
40
50
60
70
80
90
100
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
rate/1000
Year
Infant Mortality Rates 2000-2015
Deaths = 1,043, Births = 24,082, Person Years = 26,772
Rate/Exposure Rate/Live Births
Deaths in Infants and 1-4year-olds
At home and in health facilities
Africa Centre Demographic surveillance
Rural KZN
South Africa
~40% infant die at home
~60% 1-4 year-olds die at home
WHY and what of?
How much is undiagnosed HIV
Despite good pMTCT coverage?
Summary: Early Diagnosis and Treatment
• Without early HIV diagnosis and ART, 50% children die <2 yrs
• Very early diagnosis & treatment reduces viral reservoirs and
has future potential BUT >90% infected children are to be
found outside pMTCT settings
• Provider initiated testing & linkage to care and ART needs to
be increased at multiple entry points
• …and near where children live (strengthening capacity at
lower level health centres (supply))
• Community mobilisation to understand HIV in children and
bring for testing and treatment (demand)
Outline
• Milenium Development Goals
• Prevention of Mother-To-Child Transmission (pMTCT)
• Where have we come from?
• Strategies for pMTCT
– From Option A to Option B plus
• Paediatric diagnosis & linkage to care
• Where are all the children?
• Management of HIV-infected adolescents and Prevention of HIV in adolescents
10,798 persons with perinatal HIV
living in the US in 2010CDC HIV Surveillance Report 2011
24%
76%
Perinatal HIV in the US and UK
0%
20%
40%
60%
80%
100%
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Percent
Year
20+
15-19
10-14
5-9
1-4
<1
Age by year of follow-
up,1996-2013
…and UK/Ireland
Introduction
• Often , adolescents fall through
the cracks and prefer not to
seek care
• There is no primary health care
offered to adolescents in many
African Health care institutions
Responding to the needs of Teenagers
• Simpler and more ‘forgiving’ ART regimens:
– Once daily
– Long-acting Injectables
– ‘Weekend breaks’ (BREATHER Trial (PENTA 16))
• Non-judgemental information
• Peer support
UNICEF / UNAIDS
HIV Incidence Among Young WomenMore Than 1/3 New HIV Infections Globally Occur
Among Young Women in AfricaEstimated number of new HIV infections per week among young women
aged 15-24 years in East and Southern Africa, 2012
Source: PEPFAR and UNAIDS 2013
New Attention Being Paid to
Global Adolescent HIV Infections
Dec 2014: PEFPAR, Bill & Melinda Gates & Nike
Foundations announced $210 million initiative
to reduce new HIV infection in adolescent girls
& young women in 10 countries.
Feb 2015: UNAIDS, UNICEF, UNFPA,
WHO, PEPFAR, Global Fund, MTV Staying
Alive Foundation launched All-In:
Action against adolescent AIDS epidemic:
− Engergize, mobilize, empower youth
− Better data collection to inform programs
− Innovation to adapt services to youth
− Adolescent HIV on political agenda
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
100,000
200,000
300,000
400,000
500,000
600,000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
PM
TC
T c
overa
ge
New
HIV
in
fecti
on
s (
#)
Trends in new HIV infections among children (aged 0-14) and coverage of maternal ARVs form PMTCT in all
low- and middle-income countries, 2001-2012Maternal ARVs for PMTCT
New HIV infections in children (0-4)
Source: UNAIDS 2013 HIV and AIDS estimates, 2014, and UNAIDS/WHO/UNICEF Global AIDS Response Progress Reporting (GARPR)/Universal Access
In 2013: *240,000 children acquired HIV
~660 new infections/day
*3.2 million children <15 years
living with HIV
91% in SubSaharan Africa
Elimination (virtual) of Paediatric HIV:
not there yet!
Sources: 1. UNAIDS. 2013 HIV and AIDS estimates, 2014
2. UNAIDS/WHO/UNICEF. Global AIDS Response Progress Report /Universal Access data, 2006-14
Summary� PMTCT and eMTCT
� Increasing coverage is priority; some way to go to eMTCT
� Reduce new HIV infections in women & unmet family planning needs
� Infant/Child diagnosis is challenging
� Priority to increase testing and linkage to care outside pMTCT settings, near
where children live and to involve communites
� Adolescence through to adulthood
� There is an imperative to address wider needs of adolescents
� Reducing pregnancies and preventing HIV
� Long term follow up into adulthood is the responsibility of success
We have come a long way
BUT there is more work to be done!
Thanks to: Lynne Mofensen and
Shaffiq Essajee (WHO)