Prevention of Mother to Child

HIV Transmission

Dr. Laura Guay

Vice President for Research
Elizabeth Glaser Pediatric AIDS Foundation

July 15, 2009

Cape Town, South Africa
HIV Disease Course
 Diagnosis of HIV
• 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 women 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
 WHO’s 4-Component Strategy for
MTCT Prevention

Prevention of HIV Prevention of Prevention of Support for HIV

in women, unintended transmission infected women,
especially young pregnancies in from an HIV their infant, and
women HIV-infected infected woman family
women to her infant

Component Component Component Component

1 2 3 4
 New infections among children, 1990–2007

600 000

500 000

400 000

300 000

200 000

100 000

0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

This bar indicates the range

 Access to Mother-to-Child Prevention

67% of pregnant women

not receiving PMTCT drugs

80% of HIV-exposed infants

not receiving PMTCT drugs

WHO, UNAIDS, UNICEF - Towards Universal Access: Progress Report 2008

 Benefits of global expansion of PMTCT
programs
• Provides opportunity for primary prevention for
large number of HIV uninfected women identified

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

about 30 out of 100 babies born to these women will

get HIV
 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 get HIV 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 Nations
SCN News
May 1991

“Use my picture
if it will help,
“I don’t want
other people to
make the same
mistake”.
 Revised WHO Guidelines for infant feeding for HIV
infected women in resource-limited settings

• Balances risk of HIV transmission through BF with increased illness

and death associated with not BF
• The best option depends on a woman’s health status/the local situation;
should take greater consideration of the counseling/support she can
receive
• Exclusive BF is recommended for the first 6 months of life unless
replacement feeding is acceptable, feasible, affordable, sustainable and
safe (AFASS) before that time
• When replacement feeding is AFASS, avoidance of all BF is
recommended
• At 6 months if replacement feeding is still not AFASS, continuation of
BF with additional foods is recommended. All BF should stop once a
nutritionally adequate and safe diet without breast milk can be
provided.
 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,
 -Early endpoint in implementation program evaluation and HIV
clinical trials

• 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

HIV neg 92.1 %

HIV pos 43.2 %

evil a noi t r opor P

---- HIV Negative

---- HIV Positive

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 < 1 Year
• Initially WHO guidelines for ART in children (2006)
recommended starting therapy according to clinical
and/or immunologic criteria

• Recent data from a study in South Africa where infants

were put into one group that started therapy immediately
or a second group where therapy started when WHO
criteria were met showed ~75% decrease in death when
ART was started immediately

• Therefore, WHO revised recommendations in April 2008

such that ALL infants diagnosed with HIV infection in the
first year of life should receive ART immediately
Negotiating the PMTCT Activities

?
Negotiating the PMTCT Activities cont.
 The way forward
Challenges:
• High initial implementation costs
• Community sensitization/mobilization lacking
• Integration of PMTCT within ANC difficult
• Access to women who don’t deliver in health facility
• Very low numbers of partners involved
• Changing infant feeding education/practices
• 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.