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Turning the Tide on HIV/AIDS in Children and Youth Dr Chewe Luo, MD(Paed), MTropPaed, PhD Senior Programme Adviser HIV Section, UNICEF Programme Division New York. Outline. What does turning the tide mean? Eliminating new HIV infections in children

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slide1

Turning the Tide on HIV/AIDS in Children and Youth

Dr Chewe Luo, MD(Paed), MTropPaed, PhD

Senior Programme Adviser

HIV Section, UNICEF Programme Division

New York

outline
Outline

What does turning the tide mean?

  • Eliminating new HIV infections in children
  • Early diagnosis and treatment of HIV infected children
  • Adolescent Prevention and Treatment
  • Call to Action
key concepts in vertical transmission
Key concepts in vertical transmission

Transmission timeline

  • 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

Source: DeCock et al. JAMA.2000; 283:1175-1182.

67 reduction in perinatal transmission with pactg 076 azt regimen
67% Reduction in Perinatal Transmission withPACTG 076 AZT Regimen

DSMB halted trial early in Feb 1994

Incidence of Perinatally-Acquired AIDS United States, 1985-2000

Source: www.cdc.gov/hiv/perinatal/resources

overall target 1 reduce the number of new hiv infections among children by 90 by 2015
Source: 1. UNAIDS. Together we will end AIDS. 2012

2 . HIV/AIDS Response – Epidemic Update and Health Sector Progress Towards Universal Access 2011

Overall Target 1: Reduce the Number of New HIV Infections among children by 90% by 2015
slide6
Source: UNAIDS. Together we will end AIDS. 2012 Overall Target 2: Reduce the Number of HIV-associated maternal deaths to women during pregnancy, delivery and puerperium by 50% by 2015
prevention of mother to child transmission of hiv body of scientific research
Prevention of mother-to-child transmission of HIV: Body of scientific research

1994

2010

1994 U.S. AZT Trial ACTG 076

1998 Thai Bangkok short AP/IP AZT trial

1998 Cote d‘Ivoire short AP/IP AZT trials (breastfeeding)

1999 PETRA AZT+3TC trial (partly breastfeeding)

Source: McIntyre J, Perinatal HIV Clinical Trials

1999 Uganda 2-dose IP/PP NVP trial (HIVNET 012)

2000 Thailand PHPT-1 Long vs short AZT regimens

2002 Cote d’Ivoire DITRAME Plus 1201.0 AZT & IP/PP NVP

2003 DITRAME Plus 1201.1 AZT+3TC & IP/PP NVP

2004 Thailand PHPT-2 AZT & IP/PP NVP

2008 PEPI NVP + short vs long AZT for infant (breastfeeding)

2009 Mma Bana comparative trial for CD4<200 (breastfeeding)

slide8

Coverage of antiretroviral medicine for preventing mother-to-child transmission: most effective regimens, low- and middle-income countries, by region, 2011

Source: UNAIDS. Together we will end AIDS 2012

the decline in new hiv infections in children was roughly 10 8 from 2010 to 2011
The decline in new HIV infections in children was roughly 10.8% from 2010 to 2011

Source: 1. UNAIDS 2012 estimates

2. UNICEF/BLC Discussion Paper and Methodology - Business Case for Options B/B+ , 2012

slide10

Global Plan Targets

Source: Countdown to zero: Global Plan towards the elimination of new infections among children by 2015 and keeping their mothers alive 2011-2015

who guidelines for pmtct and infant feeding 2010 and 2012 update
WHO guidelines for PMTCT and infant feeding (2010 and 2012 Update)

Source: : 1. WHO 2010 PMTCT Guidelines

2. WHO Programmatic Update 2012

pmtct prophylaxis options used by selected countries in africa asia 2012
PMTCT Prophylaxis Options Used by Selected Countries in Africa & Asia, 2012

* Countries considering switch to option B/B+

Source: www.aidsdatahub.org based on WHO, UNAIDS, & UNICEF (2011). Towards Universal Access Health Sector Response Country Reports 2011 (preliminary data)

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Potential Impact and Cost-Effectiveness of Scenarios “A” and “B” of the 2009 PMTCT Guidelines – 15 Focus Countries, 2010

Source: Auld AF et al. XVIII IAS Conf, Vienna, July 2010 Abs

bottlenecks in the implementation of option a
Bottlenecks in the implementation of Option A

Source: UNICEF/BLC Discussion Paper and Methodology - Business Case for Options B/B+ , 2012

women eligible for art are at highest risk for mother to child hiv transmission and mortality
Women Eligible for ART Are At Highest Risk for Mother-to-Child HIV Transmission and Mortality
  • Cohort 1,025 pregnant women in Zambia prior to HAART availability
  • Analyzed MTCT/mortality by eligibility for ART with current WHO criteria (CD4 <350 or WHO Stage 3 or 4)

Source: Kuhn L et al. AIDS 2010;24:1374-7

mortality risk in hiv positive postpartum women with high cd4
Mortality risk in HIV-positive postpartum women with high CD4

Data: Hargrove AIDS 2010; Model: Williams JID 2006.

double orphaning is projected to increase by 2016
Double Orphaning is projected to increase by 2016…

Source: Belsey, M. A., L. Sherr. An International Interdisciplinary Journal for Research, Policy and Care; 6 (3):185-200.

malawi proposed option b life long art
Malawi: Proposed “Option B+”Life-Long ART
  • Rationale:
    • Without CD4, women who need treatment for their own health will not receive appropriate ART with Option A
    • Obtaining CD4 has been a barrier to PMTCT implementation in countries with heavily constrained health systems
    • Prolonged breastfeeding up to 2 years
    • High fertility rates with an average of 5.6
    • New potential benefit to uninfected sexual partners

Lancet 2011;378:282-4

malawi option b scale up
Malawi: “Option B+” Scale Up

Six-fold increase in number of pregnant & breastfeeding women starting ART (from 1200 in Q2 to 15,000 in Q4)

Source: Courtesy of Dr Erik Schouten, unpublished data, Malawi

malawi progress on key indicators for the global plan for eliminating mother to child transmission
Malawi: Progress on key indicators for the Global Plan for eliminating mother-to-child transmission

* 2009 value is not directly comparable to data from 2010 and later because single-dose nevirapine was excluded from the calculation starting in 2010.

Source: . 2012 UNAIDS estimates for Malawi: ARV/ART coverage among HIV+ pregnant women (Progress in 22 priority countries on key indicators for the Global Plan for eliminating mother-to-child transmission)

option b benefits
Option B+ Benefits

Source: UNICEF/BLC Discussion Paper and Methodology - Business Case for Options B/B+ , 2012

acute infection in mothers associated with mtct
Acute Infection in Mothers Associated with MTCT
  • Risk of MTCT in infants of mothers with acute infection during pregnancy or lactation is increased ~3-fold over mothers with chronic HIV.
unmet need for family planning
Unmet Need for Family Planning

Unmet need for family planning by HIV serostatus based on data from Demographic and Health Surveys in six countries

Sources: UNAIDS calculations of data from Demographic and Health Surveys (MEASURE DHS:

all surveys by country [web site] (25)) and Millennium Development Goals indicators [web site] (36).

aThe difference between women living with HIV and HIV-negative women is statistically significant.

Millenium Development Goals Indicators ( http://mdgs.un.org/unsd/mdg/data.aspx)

slide25
Percentage of children living with HIV receiving antiretroviral therapy in low- and middle- income countries, 2005, 2009, 2010, and 2011

Source: WHO, UNAIDS and UNICEF. Global HIV/AIDS Response: Epidemic Update and Health Sector Progress Towards Universal Access Progress Report 2011

trends in pediatric age distribution at art initiation 2005 2010
Trends in pediatric age distribution at ART initiation (2005-2010)

Source: McNairy M. et al. Retention of HIV+ Children on ART in ICAP-supported HIV Care and Treatment Programs. Paper # 959, 19th CROI, Seattle, USA 2012

follow up of infants testing positive via eid at review sites
Follow up of infants testing positive via EID at Review Sites

Source: UNICEF. EID Review Country Reports 2009

viral load and eid product pipeline
Viral Load and EID Product Pipeline

Source: UNITAID HIV/AIDS Diagnostic Landscape 2nd Edition 2012

paediatric antiretrovirals simplified dosing formats and analysing their adverse events

CHAPAS-1 trialPK sub-study 2007

FDA licensing

Paediatric Antiretrovirals: simplified dosing formats and analysing their adverse events

CHAPAS-2 LPV/r liquid vs tablets vs sprinkles PK study

3TC/ZDV/NVP Baby

3TC/ABC Baby and Junior

CHAPAS-3 Looking at specific

toxicities in children

Efavirenz 600mg2 x 300mg

3 x 200mg

d4T vs

AZT vs

ABC

Source: Dr Gibb for the Chapas Trials

in 2011 36 of new hiv infections worldwide occurred in young people ages 15 24
In 2011, 36% of new HIV infections worldwide occurred in young people (ages 15-24)

Source: UNAIDS., updated 2012 estimates.

increasing hiv prevalence in adolescents
Increasing HIV Prevalence in Adolescents

Source: 1. National Institute of Health (INS), National Institute of Statistics (INE) and ICF Macro. 2010. National Enquiry on HIV/AIDS Prevalence, Behavior Risks and Information in Mozambique 2009. 2 . Shisana O et al. South African national HIV prevalence, incidence, behaviour and communication survey 2008: A turning tide among teenagers?

prevention and treatment interventions for adolescents
Prevention and Treatment Interventions for Adolescents

Source: UNICEF Making the Case for Adolescents, unpublished data , 2012

call to action
Call to Action
  • Simplify our programmatic approaches to allow integration of PMTCT/ART in maternal child health services at the lowest levels of care – to optimize treatment access, adherence and retention
  • Introduce innovative approaches to expand provider initiated HIV testing to adolescents, pregnant women and their partners
  • Expand early infant diagnosis and integrate paediatric HIV treatment and care at lower level facilities and child survival programs
  • Collaborate with community groups, including women living with HIV, to enhance support to women and their families to maintain good adherence and retention in care and treatment
  • Focus on how to effectively deliver high impact interventions to adolescent to achieve the best prevention and treatment benefits
acknowledgments
Acknowledgments
  • Dr Elaine Abrams
  • Dr Wafaa El-Sadr
  • Dr Diana Gibb
  • Dr Priscilla Idele
  • Dr Susan Kasedde
  • Malawi Ministry of Health
  • Mr Craig McClure
  • Dr Lynne Mofenson
  • Mr Tyler Porth
  • Dr Juliana Silva
  • UNICEF Regional and Country Advisors
  • Dr Rachel Yates