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Prevention of Mother to Child Transmission of HIV. Session Objectives. By the end of this session participants would be able to: Describe the m agnitude of the problem and its impact; Describe the routes, rates and risks of

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Presentation Transcript
session objectives

Session Objectives

By the end of this session participants would be able to:

Describe the magnitude of the problem

and its impact;

Describe the routes, rates and risks of

HIV transmission from mother to child.

magnitude of the problem
Magnitude of the Problem
  • MTCT most significant source of HIV infection in children below age 15.
  • More than 5 million children infected since beginning of epidemic.
  • Almost 4 million children have died.
  • 90% of MTCT occurs in Africa.
  • Transmission higher in developing countries than in industrialized countries due to lack of treatment.
estimated impact of aids on under 5 child mortality rates select african countries 2010
Estimated impact of AIDS on under-5 child mortality rates, select African countries, 2010

250

Deaths per 1000 live births

200

Without AIDS

With AIDS

150

100

50

0

Botswana

Kenya

Malawi

Tanzania

Zambia

Zimbabwe

Source: US Census Bureau

hiv transmission to infants
HIV Transmission to Infants
  • Less than 60 % of babies born to HIV-positive mothers become infected
  • Peri-natal
    • In utero (during pregnancy)
    • Intrapartum (during delivery)
  • Post-natal
    • Breastfeeding (risk of increases over time. The longer the baby is breastfed the greater the risk of infection)
routes of mtct of hiv
Routes of MTCT of HIV

Father

Intercourse

Mother

Pregnancy

Labor & Delivery

Breastfeeding

Infant

risk factors during breastfeeding
Risk Factors during Breastfeeding
  • Prematurity
  • Duration of breastfeeding
  • Infant immune responses
  • Mixed feeding
  • Maternal viral load
  • Mastitis
balancing the risks of bf and formula feeding
Balancing the Risks of BF and Formula Feeding

12 months

24 months

6 months

14 wks

6 wks

Child age

Source: Nduati et al. JAMA 2000

weighing the risks and benefits of breastfeeding with hiv
Weighing the Risks and Benefitsof Breastfeeding with HIV
  • Replacement feeding prevents transmission of HIV through breastfeeding
  • But:
    • Essential to have sterile water
    • Risk of death due to artificial feeding?
    • Cost of replacement feeding?
    • Stigma if not breastfeeding?
    • Early return of fertility?
risk factors for mtct during pregnancy and delivery
Maternal Factors

Stage of maternal HIV disease (viral load)

Maternal nutritional status

Disruption of placental barrier integrity

STD during pregnancy

Factors related to the child

Genetic characteristics suspected as potential risk

Obstetrical Factors

Vaginal delivery (versus C-section)

First-born of twins

Pre-term delivery

Hemorrhage during labor

Bloody amniotic fluid

Invasive procedures

Viral Factors

MTCT rates higher for HIV-1 than for HIV-2

Risk Factors for MTCT during Pregnancy and Delivery
benefits of breastfeeding
Benefits of Breastfeeding
  • Benefits for Infants
    • Adequate nutrition
    • Provides protective against infections through maternal antibodies
    • Increase intellectual potential (?)
    • Promotes bonding between mother and infant
  • Benefits for Mothers
    • Facilitates uterine contraction
    • Protects against excessive blood loss
    • Delays the return of normal menstruation
    • Contributes to child spacing
    • Promotes bonding between mother and infant
    • Conforms to social norms
rates of vertical transmission without art
Rates of Vertical Transmission Without ART
  • Pregnancy/delivery/breastfeeding…………35%

(no intervention)

  • Pregnancy/delivery/replacement feeding….20%

(BF contributes 15%)

risk of transmission
Risk of Transmission

Source: De Cock KM et al. 2000.

probability of mtct of hiv no intervention
Probability of MTCT of HIV(No intervention)

Mother

Pregnancy/delivery

HIV+ Infants

(20)

HIV- Infants

(80)

Post partum & BF

HIV+

(12)

HIV-

(68)

Estimated outcome based on 100 single births to HIV infected mothers

probability of mtct of hiv nevirapine
Probability of MTCT of HIV(Nevirapine)

Mother

Pregnancy/delivery

HIV+ Infants

(10)

HIV- Infants

(90)

Post partum & BF

HIV+

(14)

HIV-

(76)

Estimated outcome based on 100 single births to HIV infected mothers

four integrated strategies to reduce pediatric aids who unicef 4 pillars of mtct
Four Integrated Strategies to Reduce Pediatric AIDS (WHO/UNICEF 4 Pillars of MTCT)

3. Prevention of

transmission from mother to child

1. Primary

prevention of HIV in young adults

4. MTCT-Plus: care and support for HIV+ women, their infants, and families

2. Prevention of

unwanted pregnancies

among HIV+ women

(family planning)

strategy 1 primary prevention of hiv infection
Strategy 1: Primary Prevention of HIV Infection
  • Safe sexual behavior and condom use
  • Reproductive health services
  • Management of STIs
  • VCT
  • HIV prevention interventions aimed at pregnant and lactating women, and women of child bearing ages
strategy 2 prevention of unintended pregnancies in hiv women
Strategy 2: Prevention of Unintended Pregnancies in HIV+ Women
  • Strengthening family planning services
    • To prevent unintended pregnancies
    • To delay subsequent pregnancies
    • To replace the contraceptive effect of breastfeeding
  • Access to safe abortion services where allowed by law
  • VCT so that they know their HIV status
strategy 3 prevention of transmission in hiv women
Strategy 3: Prevention of Transmission in HIV+ Women
  • Pregnancy and delivery
    • Antiretroviral therapy (ART)
    • Vaginal disinfection (little evidence of success and can increase inflammation)
    • Improved obstetrical practices (avoid unnecessary invasive procedures, safer delivery)
    • Treatment of STIs
  • Breastfeeding
    • Good nutrition and good BF technique instruction
    • Short course ART for baby
strategy 4 mtct plus
Strategy 4: MTCT-Plus
  • Secondary HIV prevention
  • Clinical care (including ART)
  • Community care
  • Stigma reduction
  • OVC services
  • Impact mitigation
approach to hiv vct in anc settings
Approach to HIV VCT in ANC Settings
  • "Opt in" approach:
    • HIV VCT is offered to pregnant women as a separate intervention from routine ANC and women are requested to provide explicit consent to receive the intervention (VCT)
  • "Opt out" approach:
    • HIV is offered to pregnant women as part and parcel of routine ANC and women are given the option to refuse the intervention based on their personal/individual situation