Transcript Slides - View the full AIDS 2016 programme

VERTICAL TRANSMISSION
PREVENTION
Best Practices
www.hivnet.ubc.ca
Amy Slogrove
19 July 2016
CTN PMTCT Symposium
AIDS 2016, Durban, South Africa
www.hivnet.ubc.ca
New HIV Infections in Children: 2001-2015
150 000
But: 1.5 million women living with HIV give birth each year – unchanged
>50% of pregnant women in LMICs do not receive an HIV-test
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Hot off the press...
Key updates related to
PMTCT
Best practices for a public
health approach in high
prevalence settings
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Overview
1.
Timing of HIV Testing
• Pregnant women & infants
2.
Maternal Antiretroviral Therapy (ART)
• Maternal Health & PMTCT
3.
Infant Prophylaxis
4.
Research Gaps / Responsibilities
5.
Take Home Messages
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Timing of HIV Testing: pregnant women
HIV Viral Load
Highest
Risk
Time
Summary
• Routine component of care
• All HIV-negative pregnant women retested
third trimester, labour, postpartum
• Lactating mothers retested periodically
Evidence
• 4% of breastfeeding women acquired
HIV-infection during pregnancy or
while breastfeeding (Kenya, Malawi, SA)
•
20% of postpartum transmission due to new
HIV-infection in women while
pregnant/breastfeeding (Zimbabwe)
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Timing of HIV Testing: pregnant women
HIV Viral Load
Highest
Risk
Time
www.hivnet.ubc.ca
Timing of HIV Testing: HIV-exposed infants
Waning of infant maternally-derived
antibody levels
Birth
Summary
• 4-6 weeks all HEI: virologic testing (DNA-PCR)
• 9 months all HEI: screen with serologic test, if
reactive confirm with virologic test
• Breastfeeding HEI: serologic test @ 18 months
or 3 months after breastfeeding cessation
9 months
18 months
Evidence
• CHER trial – rapid HIV progression < 12
weeks of age
• Rapid serologic tests @ 9 months –
sensitivity 99.8% (95%CI 99.5-100%)
•
Discussion around value of PCR @ birth
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Timing of HIV Testing: Outside of PMTCT Programs
Inpatient Outpatient
Developmental
Delay
PMTCT
programs
Summary:
More testing
• Inpatient care (diarrhoea, pneumonia, sepsis)
• Outpatient care (malnutrition, IMCI & TB clinics)
• (Developmental delay)
• Parents, siblings diagnosed with HIV
Parent/Sibling
Evidence
• 22% of paediatric inpatients – undiagnosed
HIV infection (Systematic review)
• 25% of malnutrition clinic attendants
(Eastern & Southern Africa)
• Highly acceptable to parents & caregivers
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Maternal ART
Summary
• Simple!
• Better for maternal health
• Better for PMTCT
• Better for programs
Evidence
• RCTs: TEMPRANO & START - adults
• PROMISE: HIV transmission with triple
ART (0.6%) vs. AZT+sdNVP (1.8%)
• Malawi, South Africa – program
feasibility
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Maternal ART
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Infant Prophylaxis
Summary
High risk infants – born to women with:
•
•
•
•
< 4 weeks ART prior to delivery
Viral load > 1000 copies/ml within 4 weeks
prior to delivery
Incident HIV infection during pregnancy or
while breastfeeding
HIV only identified postpartum
 Infant dual prophylaxis (AZT+NVP)
•
•
Breastfed – 12 weeks
Formula – 6 weeks
Not high risk
•
•
Mothers on ART > 4 weeks
VL < 1000 during last 4 weeks of pregnancy
 Infant NVP prophylaxis
•
•
Breastfed – 6 weeks
Formula – 4 to 6 weeks
Evidence
•
•
HPTN040 – no ARVs during pregnancy;
2/3 drug infant prophylaxis better than 1
HPTN046 – breastfed infants, mothers
on ART; no difference in PN transmission
with 6 weeks vs. 6 months of infant NVP
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Infant Prophylaxis – just a bridge
Maternal viral load & duration of maternal ART
are key determinants of transmission risk
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Research Gaps / Responsibilities
• Maternal & Infant HIV Testing
• Better understanding of mothers responses to negative HIV results – testing fatigue?
• Does birth testing add value for PMTCT programs, infants & families?
• Universal maternal ART
• TDF/3TC/EFV as effective for PMTCT as the LPV/r based PROMISE regimens?
• Effect of ART on pregnancy outcomes & short/ long-term HIV-exposed infant outcomes?
• Infant prophylaxis
• Is NVP+AZT the right dual therapy combination for high risk infants?
• What is appropriate prophylaxis for infants of mothers on failing regimens / with drug
resistance ?
• Breastfeeding
• Family & community acceptability of interventions, services, delivery
strategies
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Take Home Messages
1.
Test, test & test again
• Pregnant women, HIV-exposed infants &
outside of PMTCT programs
2.
Universal maternal ART
• Best for maternal health & also most
effective for PMTCT
3.
Infant prophylaxis
• Only a bridge & high risk infants need a
stronger bridge
4.
Research responsibilities
• Many
5.
Invest in research competencies
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Acknowledgments
CTN International Postdoctoral Fellowship Award 2013-2014
Joel Singer & Jacquie Sas
Stellenbosch University
University of British Columbia
University of Cape Town