Eliminating vertical transmission Rights here, right now

1. Eliminating vertical transmission Rights here, right now Elaine J. Abrams International Center for AIDS Care and Treatment Programs and Harlem Hospital Center, Columbia University

2. Global summary of HIV epidemic in children, 2008 2.1 million children < 15 years of age living with HIV infection 430,000 new infections in children 1,200 new infections daily 390,000 pediatric deaths attributed to HIV 90% of new pediatric infections attributed to vertical transmission UNAIDS, AIDS Epidemic Update 2009

3. Low rates of vertical transmission reported in Europe, US, Brazil

4. Estimated number of new pediatric infections with and without VT prophylaxis globally, 1996-2008 UNAIDS, AIDS Epidemic Update2009

5. Key concepts in vertical transmission (I) Transmission can occur during pregnancy, labor & delivery, and postpartum during breast feeding Not all infants born to women living with HIV will acquire HIV infection Estimated risk 25-45% without any intervention

6. Key concepts in vertical transmission (II) Multiple factors influence the risk of VT Women with advanced HIV disease are at highest risk of transmission And highest risk for disease progression and death Antiretroviral medications given during pregnancy, labor & delivery, and breast feeding significantly decrease VT risk And can reduce maternal morbidity and mortality

7. High viral load at delivery increases risk of vertical transmission

8. Women eligible for ART are at high risk for vertical transmission & mortality

9. Maternal health influences child health outcomes Children born to women with advanced HIV disease are at higher risk of developing AIDS or dying if HIV infected (Shearer, NEJM, 1997) death if HIV exposed but uninfected (Marinda, PIDJ 2007) ART and cotrimoxazole use among adults was associated with 81% reduction in death in uninfected children <10 years old 93% reduction in orphanhood (Mermin, Lancet 2008)

10. Four Pillars of Prevention of Vertical Transmission of HIV

11. In Sub-Saharan Africa 60% of adults and 75% of youth living with HIV are women Female youth are at disproportionally high risk of acquiring HIV 3-5-fold higher prevalence among young girls vs. boys in several high prevalence countries (WHO, 2009) High HIV incidence reported during pregnancy and postpartum period, reported ranges 1.6%-13.8% per 100 pt-yrs of pregnancy (Morrison, AIDS 2007; Moodley, AIDS 2009; Gray, Lancet 2005; Bernasconi, J of Clin Vir 2010)

12. For women living in countries with generalized epidemics, the greatest risk of acquiring HIV infection is through marriage 60% - 95% of new heterosexually acquired infections estimated to occur within marriage or cohabitation (Dunkle, Lancet 2008) Gender and power inequity put women at increased risk for HIV acquisition Incidence of HIV infection significantly higher in women who report history of physical or intimate sexual violence (Jewkes, Lancet 2010)

13. To date, few prevention methods available to women Primarily male and female condom Promising news from CAPRISA 004, tenofovir microbicide gel Reported decline in HIV prevalence among youth in 15 countries (UNAIDS, 2010) Evidence of positive changes in sexual behavior: older sexual debut, greater condom use; fewer partners New findings of effective structural intervention for prevention of HIV infection in young girls in Malawi Cash payments associated with school attendance and lower HIV prevalence (IAS 2010)

14. Estimated 80 million unintended pregnancies annually among women High unmet need for family planning among women living with HIV High rates of unintended pregnancies reported about women living with HIV in high prevalence countries, 50%- 90% (Desgrees-du-Lou, Int J STD AIDS 2002; Bangendanye, 3rd Ped CLS 2007; Rochet, JAMA 2006; Homsy, PLosOne 2009) Increasing family planning/contraceptive use can be an effective strategy to prevent new pediatric infections (Hladik, PLoSOne 2009)

15. Shifting paradigm around childbearing with increased ART availability and improved health Many individuals with HIV express a desire to have a child Women on ART in Nairobi slum describe motherhood as proof of recovery and a way to regain self status (Awiti, BMC Womens Health 2010) Higher pregnancy incidence reported among women receiving ART in HIV programs (Myer, PLoS One 2010) Ensuring Safe Motherhood

16. Multiple factors influence reproductive decisions in individuals living with HIV

17. Four Pillars of Prevention of Vertical Transmission of HIV

18. Single-dose nevirapine (sd-NVP) for prevention of vertical transmission

19. Substantial global effort to prevent vertical transmission of HIV More than a decade of field work aimed to reduce the number of new pediatric infections VT prevention programs among the first HIV ARV programs in high prevalence, low resource countries Principle efforts have included: HIV testing in antenatal and maternity services Provision of short course antiretroviral prophylaxis to mother and newborn Infant feeding counseling

20. Low uptake of HIV testing & ARV prophylaxis in low & middle income countries Adapted from UNICEF, Fourth Stocktaking Report 2009 . .

21. Uptake of ARV prophylaxis varies by region and country in Sub-Saharan Africa Adapted from UNICEF, Third Stocktaking Report 2009

22. Rates of ART prophylaxis coverage in countries with largest number of pregnant women with HIV

24. Low uptake of services for prevention of vertical transmission In Ethiopia, low ANC utilization accounts for poor uptake In Nigeria, limited ANC utilization and poor penetration of services account for large unmet need Adapted from UNICEF, Fourth Stocktaking Report 2009

25. Key elements of WHO 2006 guidelines for prevention of vertical transmission

26. Limited depth of services for prevention of vertical transmission Slow transition from sd-NVP(sd-NVP) to multi-drug, more efficacious prophylaxis regimens Slow adaptation and incomplete implementation of 2006 WHO guidelines Neglect of health needs of the woman 34% of women testing HIV positive were assessed for ART eligibility 24% reported having CD4 testing Low rate of ART initiation during pregnancy for eligible women Weak linkages with HIV care services for long-term follow-up WHO, Towards Universal Access, 2009; UNICEF, Third Stocktaking Report 2009

27. Distribution of ART regimens for PMTCT in low & middle countries, 2007-2008 UNICEF, Third Stocktaking Report 2009

29. Multiple barriers to eligible women initiating ART during pregnancy

30. Limited depth of services for the HIV-exposed infant Low rate of infant prophylaxis Only 32% of HIV exposed infants received ARV prophylaxis in 2008 Infant feeding guidance complex and difficult to implement Low uptake of exclusive breast feeding

31. �PMTCT� services often end at delivery Weak systems for infant follow-up 8% of HIV-exposed infants born to HIV+ women initiated cotrimoxazole by 2 months of age (2008) 15% of HIV-exposed had early diagnostic testing within 2 months of age (2008) Final infection status rarely determined after weaning UNICEF, Third Stocktaking Report 2009

32. Children lag behind adults in the ART scale-up 275,000 children have initiated ART worldwide; Only 38% of estimated need Few infants starting ART WHO recommends ART for all infants (<12months of age) High loss to follow-up rate at each step from delivery to infant testing through engagement in HIV care

33. The MCH: medical home for women and young children

34. Vertical transmission prevention & MCH services

35. HIV care and antiretroviral treatment (ART) services

37. Comprehensive services for prevention of vertical transmission and HIV care & treatment

38. Decline in early life mortality with PMTCT and ART services in KwaZulu-Natal, South Africa

39. Accomplishments in vertical transmission prevention Vertical transmission rate <5% in Botswana with scale-up of ART and VT prevention services Assessment of early transmission among children in immunization clinic in KwaZulu Natal, South Africa 7% in 2008-2009 vs. 21% in 2004-2005 Multiple country and program reports documenting lower transmission rates among women/infants receiving PMTCT interventions

40. Rights here, right now�. Sound scientific evidence base for use of antiretroviral therapy to prevent HIV vertical transmission New guidelines for use of ART for treatment of pregnant women and prevention of vertical transmission as well as for infant feeding Successful experience of implementing complex care paradigm for HIV treatment of adults and children Highly visible interest and commitment from UN family, international agencies and donors: Virtual elimination of mother-to-child transmission