Transcript PMTCT Prevention Mother-To-Child Trasmission

PMTCT
Prevention Mother-To-Child Trasmission
Eleni Kakalou, MD
MSc International Medicine-Health
Crises Management
MTCT in figures
• 2007: 370.000 children infected with HIV, 90% in SubSaharan Africa
• Without any intervention 20-40% of infants will be infected:
15-30% at birth
5-20% during breastfeeding period
• In the West vertical trasmission bears a risk below 1% with
HAART and formula feeding (Ceasarian section seems have
no place with optimal HAART) and HIV care incorporates
technical support for child bearing under the lowest risk
conditions
PMTCT other functions
• Prevention of malaria episodes in pregnancy
(IPT: Interminent Preventive Treatment)
• Prevention of future infection in parents
• Family planning services
• Prevention of infection during breastfeeding
(dual protection for seronegative mothers)
• Safe childbearing practices for seropositive
parents in resource poor settings
• Preventive routine care for infants born to
seronegative mothers (until 18 months of age
that HIV status can be determined)
PMTCT interventions
• SD NVP for mother and child at birth
• ΑΖΤ at 28th WK
• ΑΖΤ+3TC+NVP SD for mother at birth,
NVP to the neonate after birth
AZT+3TC for 7 days to mother after birth
and AZT for 7days to the neonate
• HAART from the 2nd trimester
Breastfeeding practices
• 100% prevention by use of formula feeding only
when it is:
Acceptable, Applicable, Finnancially feasible,
Guaranteed supply and Safe within the
particular conditions of a certain context,
program and/or client
• Exclusive breastfeeding for 6 months with
intensive training and psychosocial support to
the mother (breastfeeding support groups, male
involvement programs, community mobilization
and participation in designing services)
Problems arising with different
approaches
• SD NVP: only 50% reduction in vertical
transmission, increases risk of resistance
development in mothers and neonates (40-65%
emergence of resistance with SD NVP)
• ΑΖΤ+3TC: better results but still not good
enough plus need of disclosure of status for the
HIV+ mother
• HAART: best results (<2%) but need for
disclosure
costs increased
increased burden on health services
huge needs in human resources
The cascade of failure
Attendance
Offer HIV test
Offer HAART/drug
regimen
Receive result
Acceptance of HIV test
Safe breastfeeding
practices
Accept drug regimen Baby receives drugs
Take drugs properly
UNICEF pilot studies
• 500.000.000 women in ANC in 12 countries:
• 71% received counselling and offered the HIV
test
• 70% accepted testing and received results
• 49% accepted a drug regimen and collected the
drugs
• 1 out of 4 women completed any drug regimen
• Ζambia: only 30% of women received SD NVP
Obstacles
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Stigmatization
Need for disclosure
Long distances to health infratsructures
Lack of money-resources
Overloaded services
Untrained personnel
Drug costs
2006: only 23% of women received drugs for
PMTCT
Strategies for success
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Adequate training, infra-structures and resources
Adequate staff and incentives given
Group counseling before testing
Support groups and community mobilization
Male involvement approach: involving men as a routine
practice in all ANC or MCH services in order to reduce
stigma nad by linking to treatment and care programs
(PMTCT Plus)
• Botswana: 95% of pregnant women has access to
necessary services and between 2006-2007 <4% of
babies born to seropositive mothers got infected
International initiatives for PMTCT
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PEPFAR
The Call to Action Project
UN Interchange Task Team on MTCT
MTCT-Plus
The Global Fund
References
'Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and
practice', De Cock
et al, JAMA 283(9), March 2000
'AIDS epidemic update', UNAIDS/WHO, December 2005
'Questions & Answers II - Basic facts about the HIV/AIDS epidemic and its impact', UNAIDS/WHO, June 2005
'Questions & Answers III - Selected issues: prevention and care', UNAIDS/WHO, June 2005
'Integrating family planning and prevention of mother-to-child HIV transmission in resource-limited settings',
Duerr et al, The
Lancet 366(9481), 16 July 2005
'Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.
Pediatric AIDS
Clinical Trials Group Protocol
076 Study Group',Connor et al, NEJM 331(18), 3 November 1994
'Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child
transmission of HIV1 in Kampala, Uganda: HIVNET 012 randomised trial', Guay et al, The Lancet 354(9181), 4 September 1999
'Prevalence of resistance to nevirapine in mothers and children after single-dose exposure to prevent vertical
transmission of HIV1: a meta-analysis', Arrive et al, International Journal of Epidemiology 36(5), October 2007
'Intrapartum Exposure to Nevirapine and Subsequent Maternal Responses to Nevirapine-Based Antiretroviral
Therapy', Jourdain
et al, NEJM 351(3), 15 July 2004
'Response to Antiretroviral Therapy after a Single, Peripartum Dose of Nevirapine', Lockman et al, NEJM
356(2), January 2007
'Virologic Response to NNRTI Treatment among Women Who Took Single-dose Nevirapine 18 to 36 Months
Earlier', Coovadia et
al, 13th Conference on Retroviruses and Opportunistic Infections, February 2006
Prevalence of resistance to nevirapine in mothers and children after single-dose exposure to prevent vertical