HIV in Children: Preventing Mother-to-Child Transmission (Dr. Laura Guay)
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Transcript of HIV in Children: Preventing Mother-to-Child Transmission (Dr. Laura Guay)
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Dr. Laura Guay
Vice President for Research
Elizabeth Glaser Pediatric AIDS Foundation
J2J Global Media Training on HIV/AIDS
July 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 bodymakes 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 babys 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 veryyoung baby
Diagnosis of HIV
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WHOs 4-Component Strategy for MTCT
Prevention
Prevention
of HIV in
women, especially young
women
Prevention of
unintended
pregnanciesin HIV-
infected
women
Prevention of
transmission
from an HIV-infected
woman to her
infant
Support for
HIV-infected
women, theirinfants, 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 2007
0
400 000
500 000
600 000
200 000
300 000
100 000
This bar indicates the range
New infections among children, 19902007
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10%
15%
24%
34%
45%
6%
12%
18%20%
32%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
2004 2005 2006 2007 2008
Pregnant women living with HIV receiving ARVs
Infants 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
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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 HIVCare 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 get
HIV 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 Nations
SCN News
May 1991
Use my picture
if it will help,
I dont want
other people to
make the same
mistake.
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 breastfeedingProvide 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-
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Infant HIV diagnosis
Early diagnosis of HIV infection in children bornto HIV-infected women is critical Allows early identification of children who will
benefit from antiretroviral treatment, appropriateinfant 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 spotshas made services available even in remoteareas
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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 theirappropriate management
Use of antiretroviral therapy to maintain andrestore the immune system
Provision of support for HIV-infectedpersons, including psychosocial
Engage patients/families in HIV care andprevention through education, support andoutreach
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 (safewater, bednets)
Management of Diarrhea
Growth Monitoring & Nutrition Education
- Early intervention/support
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WHO Indications for Initiation ofARV
Therapy in Children < 2 Years
Initial WHO guidelines for ART in infants andchildren (2006) recommended starting therapyaccording to clinical/immunologic criteria
Studies in infants showed that there was a~75% decrease in death when ART was startedimmediately rather than waiting
WHO revised recommendations in April 2008
such that ALL infants < 1 yr diagnosed with HIVinfection 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 Forward
Challenges: High initial implementation costs
Community sensitization/mobilization lacking
Integration of PMTCT within antenatal clinic can bedifficult
Access to women who dont 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 allneed to keep pushing forward
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