Elimination of mother to child transmission of hiv

Elimination of Mother-to-Child Transmission of HIV

Moving Beyond the Talk

Arlington, March 23, 2011 Justin Mandala

Presented by Barbara Sow, 6 Feb, 2012

Overview

1. Basic facts about PMTCT

2. Defining “Elimination of MTCT”

3. What tools do we have to eliminate MTCT?

4. How much would it cost?

5. Where to focus efforts?

6. What role for Peace Corps?

7. Summary

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1. Basic facts about PMTCT

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Basic facts: Magnitude & Risk of MTCT

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Critical Time RateDuring pregnancy 5 to 10%During labor and delivery 10 to 20%During breastfeeding 10 to 20%

• 370,000 children infected in 2009; 90% through MTCT

• 2.5 million children were living with HIV in 2009; 260,000 died of AIDS

• Risk of MTCT without intervention = 15 to 45 %

Basic facts: Risk of MTCT with interventions

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Type of intervention MTCT rate

Short course ARV with breastfeeding 15 to 25%

Short course ARV, no breastfeeding 5 to 15%

Highly effective ARVs, with breastfeeding < 5%

Highly effective ARVs, no breastfeeding < 2%

• Breast- or Formula-feeding? not an easy choice…

• PMTCT reduces the risk…

3. Core PMTCT:- Use of ARV,- Safe Obstetrical practices- Safe infant feeding

2. Prevention of unwanted

Pregnancies in HIV+ women

1. Primary prevention

4. Long term follow-up of mother-infant pair

Basics facts: Global Strategic Response to MTCT

2. Defining “Elimination of MTCT”

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“Elimination of MTCT”: Definition

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• MTCT rate of less than 5% (at 12 months of age) among children born to HIV-positive mothers in breastfeeding populations

• MTCT rate of less than 2% at 6 weeks of age among children born to HIV-positive mothers or in “formula feeding” settings

• 90% reduction in new pediatric infections

Elimination of MTCT should translate into this: from the 2009 baseline, by 2015

“Elimination of MTCT”: clarifications

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• “Elimination” can be sensitive/ stigmatizing for PLHIV

• Elimination is not considered in its strict definition: “elimination of an infection is reduction to zero incidence of infection caused by

specific agent, in defined area; e.g. polio”

• “5% MTCT” as a definition focuses only on prong-3 and does not consider “HIV-free survival” the ultimate goal of PMTCT.

• “Virtual or Effective elimination” vs. “Elimination”… better to use “Elimination” because it is simpler

3. What tools do we have to “Eliminate MTCT”?

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Tools to eliminate MTCT: The momentum

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• PMTCT is a top political global agenda:– MDGs: by 2015… # 4: Reduce child mortality by 2/3, #5: Improve

maternal health, #6: Halve & begin to reverse the spread of HIV/AIDS

– PEPFAR high commitment:

Tools to eliminate MTCT: the cash

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• PEPFAR :– US $ 100 m in 2010-2011– 6 priority countries: Malawi, Mozambique, Nigeria, South Africa, Tanzania and Zambia.– Targets: 80% coverage of HIV testing and 85% coverage of most optimal ARV by 2014

at the population/ national level

• Global funds is reprogramming $ to prioritize PMTCT– Round 9 proposal equals US$ 7m over 5 years– After reprogramming US$39m over 2 years– Targets: … at least 80% of HIV-positive mothers reached through Global-Fund

supported programs receive the most optimal PMTCT regimen

Tools to eliminate MTCT: all prongs need to contribute…

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• 50% reduction of HIV incidence

• Zero unmet need for FP

• Optimum ARV regimens to 90%

• ARV during breastfeeding;

• "Elimination" = aspirational goal

Courtesy of UNAIDS

1. Antiretroviral treatment (ART) should be initiated at early stage of HIV/AIDS when CD4 count is 350 cell/mm3 (not 250 anymore).

2. ARV prophylaxis should start as early as 14 week (not 28 week anymore) pregnancy with up to 3 ARV combination.

3. In case of breastfeeding, ARV should be given to infants of mother and breastfeeding should stop at 12 months if PCR is negative.

Tools to eliminate MTCT: “Prong-3 new guidelines” (1)

Three major changes with the new guidelines:

If breastfeeding, ARVs should be provided…

• Either to the infant: NVP until 1 week after all exposure to breast milk has ended

• Or to the mother: triple ARV combination until 1 week after all exposure to breast milk has ended

Tools to eliminate MTCT: “Prong-3 new guidelines” (2)

Breastfeeding by HIV+ mothers is now safer…

4. How much would it cost?

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How much would it cost?: US$ 94 to 360 millions/ year

17Courtesy of PEPFAR

• Up to US$391 million in formula feeding scenario

• This is only drug cost

• ARV option selected can make a huge difference

• Focus countries: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, SA, Tanzania, Uganda, Vietnam and Zambia,

How much would it cost?: Cost of inaction

18Courtesy of PEPFAR

• What about the quality of life?

• What about the cost on families?

5. Where do we focus efforts?

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Where to focus efforts: 25 countries with highest burden of MTCT

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Sources: HIV incidence – Spectrum models, Contraceptive prevalence and unmet need – Household surveys, ARV coverage – Universal Access report, ANC coverage – household surveys, Median duration of breastfeeding – household surveys.

6. What role for Peace Corps?

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What role for Peace Corps ?:

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• Be involved in national technical discussions– Participate in discussions between MOH and NGOs regarding role of

community level

– Participate in launching activities of MTCT elimination

• Document activities to share with PEPFAR and Global Fund illustrating contributions

What role for PCV? , “make things happen”

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• Implement activities for each prong:• Primary prevention: condom promotion and distribution,

strategic behaviour communication (SBC); promote VCT, promote couple testing

• Promotion of Reproductive Health services for HIV + women during post-test follow-up: Family planning and ANC

• PMTCT package: • promote assisted delivery (transport, household support)• Promote appropriate infant feeding (12 month BF)• Promote post-natal services for mother and child pair

• Data collection and reporting• Accompany health centers/health posts in collecting and

analyzing data (graphs, monthly updates, etc)

What role for PCV: measuring progress

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7. In Summary

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In Summary

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• Elimination of MTCT is an aspirational goal that will further PMTCT

• We have the momentum and the tools but the health system and community involvement are challenges

• We cannot afford the cost of inaction

• Bottleneck analysis and innovative approaches are needed

• Quality and use of data will be critical

• Peace Corps has a great role to play:

– Good presence in high burden and priority countries

– Peace Corps can make things happen at the community level!

Thanks!