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HIV/AIDS and Maternal and Child Health Programs in Resource-Constrained Settings. Paula E. Brentlinger, MD, MPH Department of Global Health; International Training and Education Center on HIV (I-TECH) February 2010. Today’s Plan. HIV epidemiology in women and children: Historical notes

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Hiv aids and maternal and child health programs in resource constrained settings l.jpg

HIV/AIDS and Maternal and Child Health Programs in Resource-Constrained Settings

Paula E. Brentlinger, MD, MPH

Department of Global Health;

International Training and Education Center on HIV (I-TECH)

February 2010


Today s plan l.jpg
Today’s Plan Resource-Constrained Settings

HIV epidemiology in women and children: Historical notes

Prevention and treatment: Historical notes

Misconceptions (historic and recent) re HIV in women and children, and evidence to refute them

New WHO guidelines for PMTCT and infant feeding (2009)

Some operational issues


Hiv epidemiology in women and children the earliest data 1970s 80s l.jpg
HIV Resource-Constrained Settingsepidemiologyinwomenandchildren: Theearliest data (1970s-80s)


First years of aids epidemic us data women and children absent l.jpg
First Resource-Constrained SettingsYearsofAIDSEpidemic (US Data): WomenandChildrenAbsent!

“Since 1981, anoutbreakofacquiredimmunedysfunctionmanifestedbyopportunisticinfectionsandneoplasticdisorderssuch as Kaposi’s sarcoma andmalignantlymphomashasbeenreportedin more than 1000 homosexualmen.”

Metroka CE et al. Generalizedlymphadenopathyinhomosexualmen. AnnIntMed 1983;99:585-91.


Slide5 l.jpg

Slightly Resource-Constrained SettingsLater: AIDSEpidemic (US Data): InfectioninWomenOccursbutIsRare: MostInfections Are AssociatedwithStigmatizedBehavior

CohortofAIDSpatients, New Haven, Connecticut, 1981-7:

76% male.

Meansof HIV acquisition (mayoverlap):

Bloodtransfusion: 6%

Heterosexualsex: 15%

IVDU: 48%

MSM: 45%

Justice ACet al. A newprognosticstagingsystem for theacquiredimmunodeficiencysyndrome. NEngJMed 1989;320:1388-93.


Slide6 l.jpg

Estimated new HIV infections by transmission category, extended back calculation model, 50 US states and the District of Columbia, 1977–2006

80 000

70 000

60 000

MSM / IDU

Heterosexual

50 000

Infections

40 000

30 000

20 000

10 000

0

1977-

1979

1980-

1981

1982-

1983

1984-

1985

1986-

1987

1988-

1990

1991-

1993

1994-

1996

1997-

1999

2000-

2002

2003-

2006

Period

Men who have sex with men (MSM)

Injecting drug use (IDU)

Tick marks denote the beginning and end of a year. The model specified periods within which the number of HIV infections was assumed to be approximately constant.

Source: Hall et al. (2008a).

Figure 23


Women hiv and king county l.jpg
Women, HIV, and King County extended back calculation model, 50 US states and the District of Columbia, 1977

“LivinginOlympiaIfeltalone, likeIwastheonlywomanintownwiththisdisease [AIDS]. Igot a lotofsupportfromallofthewonderful gay men....Iattendedtheirsupportgroupeveryweek, butfeltIneededanotherwoman to talkwith, someonewhocouldidentifywithhavingkids.”

“AnnaB.” Reflectionsontakingpills, being a mom, andlivingin a ruralcommunity. STEP Perspective, 1998;98(2):7.


Not only can women be infected babies can be infected vertically l.jpg
Not extended back calculation model, 50 US states and the District of Columbia, 1977OnlyCanWomenBeInfected: BabiesCanBeInfectedVertically

Cowan MJ et al. Maternal transmission of acquired immune deficiency syndrome. Pediatrics 1984;73:382-6.

Lapointe N et al. Transplacental transmission of HTLV-III virus. N Engl J Med 1985;312:1325-6.


Perinatal infection is doom l.jpg
Perinatal Infection is Doom extended back calculation model, 50 US states and the District of Columbia, 1977

CohortofHIV-infectedchildrenbornbetween 1979 and 1987, Florida:

“Themediansurvivaltimeofall 172 childrenwas 38 monthsfromthetimeofdiagnosis. Mortalitywashighestinthefirstyearoflife (17%).....childrenwithperinatallyacquiredHIV-1infectionhave a verypoorprognosis.”

Scott GBet al. Survivalinchildrenwithperinatallyacquiredhumanimmunodeficiencyvirustype-1infection. NEnglJMed 1989;321:1791-6.


Pattern of infection different in women in africa l.jpg
Pattern extended back calculation model, 50 US states and the District of Columbia, 1977ofInfectionDifferentinWomeninAfrica

“Antibody to humanT-celllymphotrophicvirustypeIII (HTLV-III) wasdetectedintheserumof 66% ofprostitutesoflowsocioecononomic status............therelativelyhighfemale:male ratio of cases ofAIDSinAfrica (1:1 in Zaire, comparedwith 1:16 intheUnitedStates)...raisesthepossibilitythat perinatal transmissionmayresultinhigh rates oftheinfectionamonginfantsandchildren...”

KreissJKet al. AIDSvirusinfectionin Nairobi prostitutes. NEnglJMed 1986;314:414-8.


1990s something can be done for some people l.jpg
1990s extended back calculation model, 50 US states and the District of Columbia, 1977: Somethingcanbedone! (for somepeople)


Slide12 l.jpg

HAART: Highly active antiretroviral therapy extended back calculation model, 50 US states and the District of Columbia, 1977

PMTCT: Prevention of mother-to-child transmission


Slide13 l.jpg
Impact of extended back calculation model, 50 US states and the District of Columbia, 1977HAART in Developed Countries: % survival 10 years after HIV infection in US, Canada, and Europe, by patient age

Source: CASCADE Collaboration (Porter K), 2003


The 1 st pmtct trial pactg 076 l.jpg
The 1 extended back calculation model, 50 US states and the District of Columbia, 1977st PMTCT Trial (PACTG 076)

Monotherapy with zidovudine (AZT) in late pregnancy reduced HIV transmission during pregnancy and childbirth by 67% (25.5% with placebo vs. 8.3% with zidovudine) in PACTG 076 trial.

Connor E, N Engl J Med 1994.


Course of hiv epidemic worldwide after invention of haart and pmtct women and children l.jpg
Course extended back calculation model, 50 US states and the District of Columbia, 1977of HIV EpidemicWorldwideafterInventionofHAARTandPMTCT: WomenandChildren


Slide17 l.jpg

HIV prevalence (%) among pregnant women attending antenatal clinics in sub-Saharan Africa, 1997–2007

Southern Africa

Botswana

50

Burkina Faso

Lesotho

40

Mozambique

30

Namibia

NOTE: Analysis restricted to consistent surveillance sites for all countries except South Africa (by province) and Swaziland (by region)

Median HIV prevalence (%)

20

South Africa

Ghana

Swaziland

10

Zimbabwe

0

1997–

1998

1997–

1998

1997–

1998

1999–

2000

1999–

2000

1999–

2000

2001

2001

2001

2002

2002

2002

2003

2003

2003

2004

2004

2004

2005

2005

2005

2006

2006

2006

2007

2007

2007

Eastern Africa

West Africa

20

20

15

15

Ethiopia

10

10

Median HIV prevalence (%)

Median HIV prevalence (%)

Côte d'Ivoire

5

5

Kenya

Senegal

0

0

2.9

Source: National surveillance reports and UNAIDS/WHO/UNICEF, Epidemiological Fact Sheets on HIV and AIDS.  July 2008.


Slide18 l.jpg

2.5 clinics in sub-Saharan Africa, 1997–2007

Millions

2.0

1.5

1.0

0.5

0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Year

This bar indicates the range around the estimate

Children living with HIV globally, 1990–2007

2.5


Global summary of the aids epidemic 2008 who l.jpg
Global clinics in sub-Saharan Africa, 1997–2007SummaryoftheAIDSEpidemic, 2008 (WHO)

AIDS related deaths in 2008:

Total: 2.0 million

Adults: 1.7 million

Children (under 15 years): 280,000


Slide20 l.jpg

Estimated number of Life-years added due to antiretroviral therapy,

by region, 1996–2008

8

7.2 million

7

6

5

(millions)

4

3

2.3 million

2

1.4 million

1

590 000

73 000

40 000

49 000

7500

0

Western

Europe

and North

America

Sub-

Saharan

Africa

Latin

America

Asia

Eastern

Europe

and Central

Asia

Caribbean

Oceania

Middle

East

and North

Africa

Figure VII


Misconceptions historic and recent re hiv in women and children and evidence to refute them l.jpg
Misconceptions (historic and recent) re HIV in women and children, and evidence to refute them

HIV preventioninwomenissimple.

HIV+ pregnantwomen are usuallyinstageI

Short-courseperipartumARVswill do thejob

Vertical HIVtransmissionistheonlyoutcomeofinterest

Breast-feedingisbadifthemotheris HIV+

AIDStreatmentisimpossibleinAfrica (and similar settings)

HIV-infectedchildren are justlikelittlerHIV-infectedadults


Misconception 1 hiv prevention in women is simple just say no l.jpg
Misconception children, and evidence to refute them 1: HIVpreventioninwomenissimple (“justsay no”)


Slide23 l.jpg

Distribution of new infections by mode of exposure children, and evidence to refute them

in Ghana and Swaziland, 2008

100

No risk

80

Medical injections

Blood transfusions

Injecting drug use (IDU)

Partners IDU

60

Sex workers

%

Clients

Partners of Clients

40

Men who have sex with men (MSM)

Female partners of MSM

Engaged in casual sex (CS)

20

Partners of CS

Low-risk heterosexual

0

Ghana

Swaziland 1

Swaziland 2

Note: sensitivity analysis for Swaziland used different data sources.

Sources: Bosu et al. (2009) and Mngadi et al. (2009).

Figure 3


Hiv transmission within marriage l.jpg
HIV transmission within marriage children, and evidence to refute them

HIV incidencein Uganda, 2004-5:

Ofnew HIV infections (withinpreceding 155 days):

65% inmarriedpersons

26% divorcedorwidowed

9% nevermarried

FromHladiketal, CROI abstract 123, Feb 2008


Prevention of sexual transmission to women 1 l.jpg
Prevention of sexual transmission to women (1): children, and evidence to refute them

Condoms work if used:

In female sex workers in Nigeria and Benin (15% IDU), increased condom use associated with reductions in:

HIV acquisition (none vs 3/100 py)

Syphilis acquisition (5% vs 10%)

Gonorrhea acquisition (7% vs 11%)

Busari et al, CROI abstract 30, 2008


Condoms 2 l.jpg
Condoms (2) children, and evidence to refute them

Other successful targeted condom programs:

  • Targeted condom promotion (condom distribution plus individual and group counseling) in female commercial sex workers in Kenya. Condom use associated with threefold reduction of risk of HIV seroconversion.

  • Condom use and HIV education in female sex workers in India led to decreased HIV incidence (by about 67%) in intervention group.

  • Targeted condom distribution and HIV education in male army conscripts in Thailand led to 50% reduction in HIV incidence.

    Merson M, et al. AIDS 2000.


Condoms 3 l.jpg
Condoms (3) children, and evidence to refute them

  • In one study in Nicaragua, provision of free condoms to users of rent-by-the hour motels only led to condom use in 62.1% of (presumed) commercial sexual encounters and 24.5% of non-commercial sexual encounters. Addition of educational materials actually decreased condom use slightly – odds ratio for condom use (commercial sex) when health education was also provided was 0.89 (95% CI 0.84 – 0.94).

  • One review of interventions to promote condom use: Effect range (“reduction in non-use of condoms”) ranged from 1% to 57%, depending on strategy and target.

    Egger M et al. Lancet 2000.

    Stover J et al, Lancet 2002.


Prevention of sexual transmission to women 2 l.jpg
Prevention children, and evidence to refute themof sexual transmission to women (2)

Male circumcision does not seem to work (for women):

In Uganda, serodiscordant (husband HIV+, wife HIV-) randomized to circumcision vs none:

HIV transmission to wives13.8/100 py in circumcision group

9.6/100py in non-circumcision group

Wawer et al, CROI abstract 33 LB, 2008


Prevention of sexual transmission to women 3 l.jpg
Prevention children, and evidence to refute themof sexual transmission to women (3)

“More than 6000 women at three sites in South Africa participated in the $40 million, placebo-controlled trial [of Carraguard, a candidate microbicide with in vitro activity against HIV]…

"Carraguard was shown to be safe but not effective against HIV," said principal investigator Khatija Ahmed, [who] reported a statistically insignificant difference in infection rates: 151 women in the placebo group versus 134 who received Carraguard. Women said they used the gel only 44.1% of the time, and just 10% said they always used it before sex.”

Science, 22 Feb 2008 (Cohen J)


Prevention of sexual transmission to women 4 l.jpg
Prevention children, and evidence to refute themof sexual transmission to women (4)

Controlling herpes in women (and MSM) also does not seem to work to prevent HIV acquisition:

HIV acquisition with herpes suppressive therapy: 3.9/100 py

HIV acquisition without: 3.3/100 py

Celum C et al, CROI abstract 32LB, 2008


Prevention of sexual transmission to women 5 l.jpg
Prevention children, and evidence to refute themof sexual transmission to women (5)

If a woman’s seropositive male partner successfully reduces HIV viral load with HAART, sexual transmission is reduced:


Risk of sexual transmission of hiv and partner viral load l.jpg
Risk children, and evidence to refute themof sexual transmissionof HIV andpartner viral load

HIV+ partner VL Transmission/100py

<400 c/mL 0

400-3500 4.8

3500-50,000 14.0

>50,000 23.0

FromBartlett, 2007


Prevention of sexual transmission to women 7 l.jpg
Prevention children, and evidence to refute themof sexual transmission to women (7)

Voluntary counseling and testing (VCT)

  • Random assignment of individual or couple participants to VCT vs. health education alone in Kenya, Tanzania, and Trinidad. Outcome was reduction of unprotected intercourse with non-primary sexual partners (not reduction of HIV transmission). In men, 35% reduction with VCT vs. 13% with health education alone; in women 39% vs. 17%. Counseling visits were unlimited before and after HIV testing. Subsequent seroconversion of HIV-negative not reported.

    The Voluntary HIV-1 Counseling and Testing Efficacy Study Group. Lancet 2000;356:103-112.


Vct 2 l.jpg
VCT (2) children, and evidence to refute them

Some aftermath of VCT: For women who were HIV+ and disclosed their status to a partner: 14% reported break-up of marriage, 26% breakup of sexual relationship, 7% physical abuse, 3% neglected or disowned by family (vs. 1%, 14%, 4%, and 2% if HIV-negative and disclosed).

Grinstead O, et al. AIDS 2001.


Vct 3 l.jpg
VCT (3) children, and evidence to refute them

Study of effect of VCT on sexual risk behavior and HIV acquisition in Rakai, Uganda, concluded:

“In this rural cohort where VCT services are free and accessible, there is self-selection of individuals accepting VCT, and no impact of VCT on subsequent sexual risk factors or HIV incidence.”

Matovu J et al, AIDS 2005.


Hiv vaccines step trial buchbinder et al lancet 2008 l.jpg
HIV children, and evidence to refute themvaccines: STEPtrial(Buchbinderetal, Lancet 2008)


Cheap solutions cut aids toll for poor kenyan youths nyt 6 aug 2006 l.jpg
children, and evidence to refute themCheapSolutionsCutAIDSToll for PoorKenyanYouths” (NYT, 6 Aug 2006)

“....whengirlsweregivenfreeschooluniformsinsteadofhaving to pay $6 forthem – the principal remainingeconomicbarrier to educationinKenya – theyweresignificantlylesslikely to dropoutandbecomepregnant...”

“...classroom debates andessay-writingcontestsonwhetherstudentsshouldbetaughtaboutcondoms to prevent HIV increasedthe use ofcondomswithoutincreasing sexual activity...”


Best hiv prevention advice for women l.jpg
Best children, and evidence to refute them HIV preventionadvice for women:

Stayinschool

Delay sexual debut (stayinschool)

Avoidunsafesexandunsafepartners

Post-exposureprophylaxisinselectedsituations (rape)

Ifpartneris positive, getpartneron antiretrovirals (reduce viral load); usecondoms

Hope for aneffective HIV vaccineormicrobicide...


Slide40 l.jpg
Misconception children, and evidence to refute them 2: HIV+ pregnantwomen are usuallystillinstage 1 (soweonlyreallyneed to worryaboutthebaby’shealth)

InitialPMTCTstrategyindevelopingcountries:

Single-dose nevirapine tomotherandinfantatbirth (laterupdated to othershort-course2-drugARVcombinations).

NO HAART for HIV-infectedmothers.

[Avoidbreast-feedingifbetteroptionsavailable.]


Mtct data health status of pregnant hiv women on enrollment tonwe gold et al 2007 l.jpg
MTCT children, and evidence to refute them+ data: Health Status ofPregnant HIV+ WomenonEnrollment (Tonwe-Goldetal.2007)


Causes of maternal death in mozambique ordi et al 2009 l.jpg
Causes children, and evidence to refute themof Maternal DeathinMozambique (Ordietal 2009)


Maternal mortality in mozambique 2 l.jpg
Maternal children, and evidence to refute themMortalityinMozambique (2)


Hazard ratio for post partum mortality of hiv vs hiv mothers in zimbabwe l.jpg
Hazard children, and evidence to refute them ratio forpost-partummortalityof HIV+ vsHIV-mothersin Zimbabwe


Maternal mortality africa from khan l.jpg
Maternal mortality, Africa, from children, and evidence to refute them Khan


Developed country data fiori et al 2004 l.jpg
Developed-country children, and evidence to refute them data (Fiorietal 2004)


Misconception 3 short course peripartum arvs will do the job for both mother and infant l.jpg
Misconception children, and evidence to refute them 3: Short-courseperipartumARVswill do thejob (for bothmotherandinfant)


Slide48 l.jpg

sdNVP children, and evidence to refute them

No

ART

HAART

pre-preg

HAART

during

preg

AZT

>4 wk

+sdNVP

AZT

>4wk

alone

AZT

<4 wk

alone

AZT

<4 wk

+sdNVP

MTCT at Age 6 Weeks by ARV Regimen Botswana National Data Oct 2006-Nov 2007Tlale J et al. IAS Mexico City Aug 2008 (Abs ThAC04), quoted in Mofenson L 2008

Most Women Formula Feed Their Infants


Slide49 l.jpg

Increased Risk OI/Death/non-AIDS Morbidity with STI children, and evidence to refute themSMART Study Group. NEJM 2006;355:2283-96 (from Mofenson L 2008)

Death from any Cause

OI or Death from any Cause

Hazard ratio 2.6 (1.9-3.7)

Hazard ratio 1.8 (1.2-2.9)

Major CV, Renal, Hepatic Disease

Grade 4 Adverse Event

Hazard ratio 1.2 (1.0-1.5)

Hazard ratio 1.7 (1.1-2.5)

Interrupt

Interrupt

Continue

Continue

Interrupt

Continue

Interrupt

Interrupt

Continue


Viral load rebound and cd4 decline in mothers after discontinuation of pmtct regimens l.jpg
Viral children, and evidence to refute themloadreboundandCD4 decline inmothersafterdiscontinuationofPMTCTregimens

Viral loadreboundpost-partum:

84.7% ofwomenwhotookshort-coursePMTCTregimensthenstopped

15.3% ofwomenwhocontinuedART

VLreboundassociatedwithCD4 decline

34% ofwomenwithVLrebound

2% ofwomenwith no VLrebound

Cavalloet al. AbstractTUPECO46 IAS 2009


Pmtct and drug resistance in moms from lockman 2007 l.jpg
PMTCT and drug children, and evidence to refute themresistance in moms (from Lockman, 2007)

Mashi study, Botswana:

6-month likelihood of ARV failure in moms:

AZT + 1-dose NVP: 18.4%

AZT alone: 5.0%

If woman started ART < 6 months PP:

NVP + AZT 41.0%

AZT alone 0

Starting ART > 6 months PP

NVP+AZT 12.0%

AZT alone 7.8%


Pmtct and drug resistance in infants l.jpg
PMTCT children, and evidence to refute them and drug resistance in infants

Mashi study results for infants:

Virologic failure at 6 months of HAART:

AZT+ NVP 76.9%

AZT alone 9.1%


Slide53 l.jpg
Misconceptions children, and evidence to refute them 4 and 5: Vertical HIV transmissionistheonlyoutcomeofinterest; Breast-feedingisbadifmomis HIV+


Infant growth pre haart hiv infants patel et al 2010 l.jpg
Infant children, and evidence to refute themgrowth, pre-HAART, HIV+ infants (Pateletal, 2010)


Infant growth vs water supply patel et al l.jpg
Infant children, and evidence to refute themgrowth vs watersupply (Patelet al.)


Vertical hiv transmission and placental malaria 1 brahmbhatt 2008 l.jpg
Vertical children, and evidence to refute themHIVTransmissionandPlacentalMalaria (1) (Brahmbhatt 2008)


Maternal haart studies in bf populations or bf ff populations cumulative mtct at 6 months l.jpg
Maternal children, and evidence to refute themHAART Studies in BF Populations (or BF-FF Populations): CumulativeMTCT at 6 Months

Highly likely that 95% CI overlap

between studies

(3-18)

(2.9-7.1)

(0.7-4.8)

# Tested at 6 Mos: 467 251 500501 176 61 107

GA Started: 27 28 34 34 28 34 24


Slide58 l.jpg
Vertical children, and evidence to refute themHIVTransmission: Breast-feedingmotherson triple ART vs. short-courseZDV+3TC+NVP (deVicenzietal 2009)


Mortality haart breast feeding homsy et al jaids jan 2010 l.jpg
Mortality children, and evidence to refute them, HAART, Breast-feeding (Homsyetal, JAIDS Jan 2010)


Homsy et al continued l.jpg
Homsy et al., continued children, and evidence to refute them


Obstetrical interventions and hiv transmission l.jpg
Obstetrical children, and evidence to refute theminterventionsand HIV transmission

Anincompletelistofobstetricalinterventionsorchoicesthatincreaselikelihoodof vertical transmission:

Choosingprolonged labor overcaesareandelivery (especiallywithprolongedruptureofmembranes)

Episiotomy

Placementofinternalmonitors

Artificial ruptureofmembranes

Forcepsdeliveries


Misconception 6 aids treatment is impossible in africa and similar settings l.jpg
Misconception children, and evidence to refute them 6: AIDStreatmentisimpossibleinAfrica (and similar settings)


Impact of haart in south africa l.jpg
Impact of HAART in South Africa children, and evidence to refute them

Medecins sans Frontieres project in Khayelitsha: Of 1st 287 [adult] patients started on HAART,

86.3% still alive at 24 months

Median CD4 count gain 288 at 24 months

Viral load < 400 copies/ml in 69.7% of patients at 24 months

Coetzee D, et al. AIDS 2004.


Mortality on haart developed vs developing countries from art linc l.jpg
Mortality on children, and evidence to refute themHAART: developed vs. developing countries (from ART-LINC)


Misconception 7 hiv infected children are like little hiv infected adults l.jpg
Misconception children, and evidence to refute them 7: HIV-infectedchildren are likelittleHIV-infectedadults


Aids and children 1 l.jpg
AIDS and Children (1) children, and evidence to refute them

Cause-specific mortality in South Africa:

Age group % deaths from AIDS

0-28 days 5.0%

29 days – 1 year 34.0%

1-4 years* 61.0%

5-9 years* 33.0%

10-14 years* 17.0%

* Most common cause of death in this age group

Garrib A et al, 2006.


Little et al 2007 l.jpg
Little et al 2007 children, and evidence to refute them


Cher violari et al nejm 2008 l.jpg
CHER children, and evidence to refute them(Violari et al, NEJM 2008)


Cher cont d l.jpg
CHER, cont’d children, and evidence to refute them


Who policy 2009 the radical changes l.jpg
WHO children, and evidence to refute themPolicy, 2009: The Radical Changes

Mothersknown to beHIV-infectedshouldbeprovidedwithlifelongantiretroviraltherapyorantiretroviralprophylaxisinterventions to reduce HIV transmissionthroughbreastfeedingaccording to WHOrecommendations.

Mothersknown to beHIV-infectedshouldexclusivelybreastfeedtheirinfants for thefirst 6 monthsoflife, introducingappropriatecomplementaryfoodsthereafter, and continue breast-feeding for thefirst 12 monthsoflife.


Slide72 l.jpg

3.9 children, and evidence to refute them

4.5

1.9

3.5

2.3

7.4

7.3

7.6

13.3

20.8

7.6

15.5

Why CD4 Threshold of <350 for Treatment?Includes Most Maternal Deaths and Postnatal Infections ZEBS Study – Thea D et al. 2008 (quoted in Mofenson L 2008)

84% of maternal deaths

82% of postnatal infections

CD4 < 200: 55% of maternal deaths, 47% of postnatal infections


Will this be easy l.jpg
Will This Be Easy? children, and evidence to refute them


Slide74 l.jpg

PMTCT Cascade: Most Critical Thing for PMTCT is Number of Women Completing Cascade

P. Barker, WHO Mtg Nov 2008

100 HIV+ mothers

Missed - no PMTCT

Overall Program

Effectiveness

(early MTCT)

Enter into program

attend ANC clinic 92%

8

sdNVP: 19.5% tx

92

AZT/sdNVP: 17.5% tx

Counseled and tested for HIV, CD4 75%

HAART: 17.1% tx

68

32

Get ARVs (pre- and perinatal) 50%

34

66

No ARV

(25% MTCT):

16.5 infected

sdNVP (8% MTCT): 3 infected

AZT/sdNVP (3% MTCT): 1 infected

HAART (2% MTCT): 0.6 infected


Special considerations re arv use in women of reproductive age l.jpg
Special considerations re ARV use in Women Completing Cascadewomen of reproductive age

Some ARVs are probably teratogenic (based on animal studies) and should not be given in pregnancy or to women at risk of pregnancy.

Some ARVs appear to have increased toxicity in pregnancy (e.g. DDI and D4T in combination).

Some ARV side effects more common in women (e.g. nevirapine rash and hepatotoxicity).

Drug-drug interactions involving contraceptions and ARVs


Special considerations re art in children l.jpg
Special Women Completing CascadeconsiderationsreARTinchildren

  • HIV infectionprogressesveryrapidly (months to afewyears) to AIDS anddeathininfants; earlydiagnosisandtreatment are essential

  • Dosingisdifferentinchildrenbecauseofdifferencesinweightanddrugmetabolism; increase dose aschildgrows

  • LiquidformulationsofARVs for kids are harder to acquireandhandlethanpillformulations for adults


Arvs are not a panacea l.jpg
ARVs are not a panacea Women Completing Cascade

HAART does NOT eliminate competing risks for mortality and morbidity – e.g. diarrhea, pneumonia, malaria, TB, malnutrition, eclampsia, or obstetrical hemorrhage – although incidence of many infections may decrease as HAART treatment restores immune function.

HAART is NO substitute for food, housing, literacy, or live parents (for mothers or infants).

HAART does not cure AIDS. (HIV is not completely eliminated by treatment.)

Getting the drugs into a country is not the same as getting the health system to work


Key points l.jpg
Key points Women Completing Cascade

Worldwide, the HIV epidemic in women is immense (and linked to the pediatric HIV epidemic).

Interventions that are also aimed at improving the health of the mother (or entire family!) and at reducing competing causes of mortality and morbidity (HIV-related and not) are more effective than “PMTCT” alone.


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