PMTCT of HIV and MTCT plus

PMTCT of HIV and MTCT PlusNkeramahame Juvenal, MBChB (MUK)

Outline

• Definitions

• MTCT of HIV

• Burden of MTCT

• History of PMTCT of HIV

• Option B+

• EMTCT

Definitions

HIV infection - presence of HIV virus in blood without necessarily having symptoms or signs of disease

HIV disease - presence of signs and symptoms due to infection with HIV AIDS – clinical syndrome suggestive of advanced HIV infection MTCT – when the HIV virus is passed from the mother to her child during

pregnancy, birth or breastfeeding PMTCT – the package of services given to women to prevent acquisition of

HIV and/or reduce risk of MTCT PMTCT Plus – provision of ART and support to HIV infected mothers, their

babies and family members to ensure proper nurturing, care and protection of the child

eMTCT – Uganda’s strategy for virtual elimination of MTCT using option B+

MTCT of HIV

• About 30-35% of HIV-infected mothers with infect their babies if no intervention.

• Peripartum HIV transmission can be reduced to under 5% in resource limited settings using a feasible ART regimen

• B/F causes about 1/3 – ½ all infant HIV infections and reducing postnatal transmission through B/F, whilst maintaining child survival, is an urgent priority.

• Evidence highlights the impact of breastfeeding duration & pattern, and hazards associated with the avoidance of breastfeeding in different settings

• About 90% of HIV-infected children in SSA acquire HIV through MTCT

MTCT

MTCT can occur

• during pregnancy

• during delivery or

• through breastfeeding

Rates of MTCT….Decock et al., JAMA, 2000,283:1175-1182

Time of transmission Absolute transmission rate (%)

During pregnancy 5-10

During labour and delivery 10-20

During breast feeding 5-20

Overall without b/feeding 15-30

Overall with b/feeding through 6 months 25-35

Overall with b/feeding through 18 -24 months 30-45

Burden of MTCT

• Annually about 25,000 to 40,000 babies get HIV infection in Uganda.

• 0.6% U5s are infected with HIV

• Over 90% of HIV infected children acquire it from MTCT

• In Uganda, 66% of the HIV infected children do not survive to celebrate their 3rd birthday with no intervention

Risk factors for MTCT

Source: WHO, CDC Prevention of Mother to Child Transmissionof HIV Generic Training Package, July 2008

Maternal and neonatal factors that may increase the risk of HIV transmission

Pregnancy Labour and delivery Breastfeeding

High maternal viral load (new infection or advanced AIDS)

Viral, bacterial, or parasitic placental infections, such as Malaria

Sexually transmitted infections (STIs)

Low CD4+ count Virulent HIV strain

High maternal viral load Prolonged rupture of

membranes for >4 hours Prolonged labour Vaginal delivery Assisted vaginal delivery Invasive delivery procedures

(e.g. episiotomy, artificial rupture of membranes)

Chorioamnionitis (fromuntreated STI or otherinfection)

Preterm delivery Low birth weight

High maternal viral load Long duration of breastfeeding Mixed feeding (giving water,

other liquids, or solid foods in addition to breastfeeding)

Breast abscesses, nipplefissures, mastitis

Oral disease in the baby (e.g. thrush or sores)

History of PMTCT

PMTCT is a dynamic and rapidly changing field.

2010 WHO Guidelines

Option A

Treatment or prophylaxis dependent on CD4 count

CD4 ≤350 or WHO stage 3 or 4 regardless of CD4 count:

Life-long ART

CD4 >350, and WHO stages 1 and 2:

Antenatal and intrapartum prophylaxis (AZT, sdNVP, TDF/FTC)

Extended infant NVP syrup for BF infants

Option B

All HIV infected pregnant women initiated on

ART regardless of CD4 count

CD4 ≤350, or WHO stage 3 or 4

life-long ART

CD4 ≤350, or WHO stage 3 or 4

life-long ART

CD4 >350 and WHO stages 1 and 2, stop

ART after delivery if FF, or after cessation

of BF if BF

2012 WHO ProgrammaticUpdateOption B+

Life-long ART for all HIV infected

pregnant women regardless of CD4 count

Advantages of Option B+

Simplification of PMTCT regimen requirements

No need for CD4 count to determine eligibility

Extended protection from MTCT in future pregnancies from conception

Strong & continuing prevention benefit against sexual transmission in serodiscordant couples/partners

Improved benefit for the woman’s health in between pregnancies

Simple community message; start ARVs, continue for life

Interventions in PMTCT

HIV testing and counselling during ANC, labour and delivery and postpartum

Provision of antiretroviral (ARV) drugs to mother and infant

Modified safer obstetric practices e.g elective c/section

Infant feeding information, counselling and support

Modified infant feeding practices

Referrals to comprehensive treatment, care and social support for mothers and families with HIV infection

Specific interventions

WHO Clinical staging of HIV disease.

Initiate ART treatment as soon as possible during pregnancy labour/delivery and through BF and for the entire life of the women

Special ART adherence counseling for treatment as prevention

Special support and follow up of discordant couples

Linkage to ART center for lifelong chronic care using referral system

Infant feeding counseling and support based on knowledge of HIV status

Maternal nutrition including assessment, counseling and support

Specific interventions

Co-trimoxazole prophylaxis

Malaria prevention and treatment

Additional counseling and provision of family planning services

TB screening and treatment

Counsel on other prevention interventions, such as safe drinking water

Supportive care, including, psycho social support, adherence support, and palliative care including pain and symptom management

Provide outreach services for clients and family members unable to come back for routine follow up.

De-worming

Counseling and referral for women with history of harmful alcohol or drug use

Effectiveness of PMTCT

ARV prophylaxis in labour alone reduces MTCT in B/F popn by 41-47% after SVD

If ARV prophylaxis is started in the last month of preg, reduction is by up to 63%

Current recommendations of ART started early can reduce MTCT to <2%

Breastfeeding a major source of MTCT can be addressed by use of ART during B/F

Comprehensive Approach Of PMTCT

1. Primary prevention

• ABC-mutual faithfulness

• access to condoms

• HCT

• Prevention and early treatment of STIs

• Counselling for HIV negative men and women

• Male circumcision

• Prevention of blood-to-blood transmission

Comprehensive approach to PMTCT….

2. Prevention of unintended pregnancies among women who are HIV-infected

• Address FP and contraceptive needs of the woman

3. Prevention of HIV transmission from women infected with HIV to their Infants

• HCT

• ART to mother and infant

• Modified obstetric practices

• Modified infant feeding practices

• Infant feeding information, counselling and support

• Referrals to comprehensive treatment, care and social support for mothers and families affected

Comprehensive approach to PMTCT….

4. Provision of treatment, care and support to women infected with HIV, their infants and their families

To promote long-term care of women who are HIV-infected and their families

Care and treatment with ARV therapy for the long-term health of women and families.

Symptom management

Prevention and treatment of HIV-related conditions

Reproductive health care, including family planning and contraception counselling

Nutritional support

Psychosocial and community support

Palliative care, if indicate

Barriers to universal access to PMTCT Weak healthcare systems, including inadequate antenatal care (ANC)

Limited access to pre-test counselling, either because systems are not in place or providers are not routinely offering testing

Lack of effective coordination to oversee implementation

Inadequate community engagement

Stigma and discrimination

Lack of awareness that HIV can be passed from mother-to-child

Inadequate access to ARV therapy or prophylaxis

“Universal Access” is the idea that everyone has a right to the prevention, care, support and treatment related to HIV and AIDS.

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

World Health Organization. Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: recommendations for a

public health approach, 2010 version

World Health Organization. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection:recommendations for a public health approach, June 2013.

World Health Organization. Prevention of Mother-to-Child Transmission of HIV: Generic Training Package, January 2008

World Health Organization. Use of antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: Programmatic update, 2012