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Infant Survival: Meeting the Challenges of Maternal-Child HIV

Infant Survival: Meeting the Challenges of Maternal-Child HIV. Doug Watson MD (Robb Sheneberger MD) University of Maryland, School of Medicine Institute of Human Virology Monday August 11 Sixth Annual Tract I Meeting. AIDSRelief Tanzania Challenges.

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Infant Survival: Meeting the Challenges of Maternal-Child HIV

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  1. Infant Survival:Meeting the Challenges of Maternal-Child HIV Doug Watson MD (Robb Sheneberger MD) University of Maryland, School of Medicine Institute of Human Virology Monday August 11 Sixth Annual Tract I Meeting

  2. AIDSRelief Tanzania Challenges • Only 56% of women who were first seen in either ANC (99% tested) or L&D (28% tested)received HIV CT (but 60% of women were first seen in L&D) • Only 47% of known positives received any ARV, and 95% of those getting any ARV prophylaxis received only sd-NVP

  3. Age Range of Children on ART 536 total charts reviewed. Overall median age for population was 6.5 years

  4. Proportion of Patients VL <200c/mm3 N=466 N=536 85.4% On Treatment 74.2% ITT (missing=failure) Same country adult suppression on treatment 94.6%

  5. Regimen Choice and Suppression p<.001 Children on a Lop/r containing 1st regimen were 11.69 times (Pearson Chi2 = 11.6954) more likely to be suppressed at review than patients on 1st regimen that did not contain Lop/r

  6. NVP and Suppression p<.0001 Children on a NVP containing 1st regimen were 17.98 times (Pearson Chi2 = 17.9804) more likely to have viral failure at review than patients on 1st regimen that did not contain NVP

  7. Common Problems with Care of Infected Children • Where are they? Average age at ART initiation is 6.5 years meaningmost die before diagnosis and treatment • Delay in infant diagnosis • Unavailability or tardiness of DNA PCR • Lack of understanding of clinical diagnosis- developmental milestones and growth curves • ART guidelines that do not recommend treatment of children at high risk of progression (initiating treatment at much too advanced disease in children)

  8. Common Problems with Care of Infected Children • Use of NVP-based regimen in children exposed to NVP • Dosing errors (under dosing) • Need for child-specific approach to care & adherence • Not recognizing treatment failure • Limited options after prolonged initial thymidine based regimen failure

  9. Problem: Opportunities to reduce morbidity and mortality in HIV-infected and –affected children are being missed. Response: University of Maryland/IHV AIDSRelief integrated Maternal-Child HIV care strategy

  10. Minimize transmission from mother to child • Establish community-based identification of infected pregnant women • Engage pregnant women into comprehensive HIV care system • A maternal-child focused approach within a comprehensive HIV care system rather than a vertically-integrated “PMTCT” program • Earlier and more aggressive ART for pregnant women • ARV prophylaxis to protect breastfeeding infants • Data on maternal HAART more mature at this point than ARV prophylaxis to infant

  11. Provide a package of support for HIV-exposed infants • Enroll infected pregnant women and exposed infants in AR program and provide package of care until 2 years of age • Infant nutrition counseling • Starting in antenatal period and continuing through infancy • More evidence-based: Base counseling on risk of HIV infection or death from substitute feeding for the individual infant • Facilitate general availability of robust early infant virologic diagnosis • Emphasize clinical diagnosis in interim

  12. Rapidly diagnose infants and children • Facilitate general availability of robust early infant virologic diagnosis • Training on importance of early diagnosis of infants and children • Broad testing of children: every child should have his HIV-exposure or HIV-infection status determined • Multiple entry points: Children and siblings of patients, child health center attendees, in-patients, orphanages, community-based testing, etc.

  13. Ensure long-term health of infected children • Evidence-based, non-discriminatory identification of children who require ART • Many current guidelines do not treat children at much higher risk of progression than adult guidelines allow • Selection of regimens that maximize prospect for long-term viral suppression with minimal toxicity • NVP based regimens with high viral loads and after sd-NVP exposure inadequate • Failure of current standard thymidine regimens leaves few options • Child-focused clinical services

  14. Engage mothers and families in HIV care • Testing of children & partners of infected women • The best OVC strategy is to prevent Vulnerable Children from becoming Orphans • Family-based tracking • Family clinic: parents and children seen at same time • Engagement of parents in care, particularly fathers

  15. Measure meaningful outcomes applied across the community • Use ANC seroprevalence and census data to estimate proportion of infected pregnant women who engage in care in communities served by AR • Monitoring maternal-child care “cascade” on site-specific basis to identify system gaps • Link mothers and children • Determine final infection status • Determine infant survival (12 months) and at 18 & 24 months • Pediatric targeted evaluation of viral suppression • Use outcomes data to advance program

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