The elimination equation: understanding the path to an AIDS-free generation James McIntyre Anova Health Institute & School of Public Health & Family Medicine, University of Cape Town
Elimination of perinatal HIV transmission UNAIDS: Global Plan Towards The Elimination Of New HIV Infections Among Children By 2015 And Keeping Their Mothers Alive 2011-2015
What is Elimination? Eradicate? Eliminate? Virtually eliminate?
Elimination? The term elimination can: evoke fear and be disempowering for people living with HIV prevent people from accessing necessary services and, subsequently, from being able to prevent transmitting HIV to their child, if these services are associated with the term The Inter-agency Task Team for Prevention and Treatment of HIV Infection in Pregnant Women, Mothers, and their Children be understood to mean eliminating women living with HIV or infants living with HIV in order to eliminate mother-to-child transmission.
What is Elimination? The Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive was launched at the United Nations General Assembly High Level Meeting on AIDS in 2011 The Global Plan has set two targets to be met by 2015: Global Target 1: Reduce the number of new HIV child infections by 90 percent Global Target 2: Reduce the number of AIDS-related maternal deaths by 50 percent
Elimination of MTCT by 2015? From talking to action... We can prevent mothers dying and babies becoming infected with HIV. That is why I am calling for the virtual elimination of mother-to-child transmission of HIV by 2015 Michel Sidibe, UNAIDS, December 2009 "With the momentum being generated by the global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, the international community has set a strong course to achieve an Aids-free generation. Michel Sidibe, UNAIDS, July 2012
Working towards an AIDS free generation by 2015
Making progress: treatment access UNAIDS 2012
Making progress UNAIDS 2012
Making progress: PMTCT The cumulative number of new infections averted in children more than doubled between 2009 and 2011 in low- and middle income countries 600 000 infections averted since 1995 Estimated 300 000 infections in sub Saharan Africa in 2011 26% reduction from 2009 UNAIDS 2012
Making progress: PMTCT UNAIDS 2012
Making progress: PMTCT Among the 22 priority countries, Botswana, South Africa and Swaziland have achieved 90% coverage for PMTCT with dual and triple therapy regimens Ghana, Namibia, Zambia and Zimbabwe on track to achieve this BUT Coverage of effective PMTCT regimens of 27% in west and central Africa, 6% in North Africa and Middle East, and 19% in Asia UNAIDS 2012
Making progress Decline in new HIV infections among children 2009-2011 UNAIDS 2012
PMTCT: the four pronged strategy Primary prevention of HIV in parents-to-be Prevention of unwanted pregnancies Prevention of transmission from HIV-infected mother to infant Appropriate treatment and care
Combination PMTCT PMTCT led the way with combination prevention approaches: in promoting a fourpronged combination prevention approach in using treatment for prevention.
PMTCT elements Preventing transmission from a pregnant woman to her child requires: voluntary and confidential counselling and testing for pregnant women antiretroviral prophylaxis for pregnant women with HIV and their newborn baby or antiretroviral therapy for the mother if eligible; safe delivery practices; guidance in selecting and maintaining a suitable infant-feeding option in order to prevent transmission through breast milk
PMTCT Options
Health Systems are in Crisis Wafaa El Sadr, 2009
The Cascade effect A business case for Options B and B+ BLC & UNICEF 2012
The problems of Option A While Option A has been successfully implemented in a number of high burden countries, generally it has been difficult to implement in many low-resource settings due to the changes in drugs delivered across the care continuum (antenatal, delivery and postpartum) and the requirement for timely CD4 testing to determine which women should initiate ART for their own health WHO 2012 Loss to follow up prior to initiation of treatment for eligible women. Unavailability of labor and delivery regimen at birth site. Higher risk of transmission during breastfeeding. Procurement and supply chain management difficulties. Complex patient management BLC & UNICEF 2012
The potential of Option B and B+ Options B and specifically B+ are likely to prove preferable to Option A for operational, programmatic and strategic reason WHO 2012 Options B and B+ offer significant operational advantages over Option A There are added clinical benefits of Options B and B+. Many historical barriers to optimizing Options B and B+ have been overcome. The costs averted by Option B exceed the spending it requires over Option A. The additional benefits of Option B+ may exceed its associated costs. BLC & UNICEF 2012
Safety is paramount
What s changed since 2010? Safety, regulatory, and operational barriers to implementation of Options B and B+ have been overcome Reduction of concerns about the safety of efavirenz. Approval of TDF/3TC/EFV fixed dose combination. Affordability of TDF/3TC/EFV fixed dose combination. Options B and B+ facilitate operational simplifications Simplifications for the mother. Simplifications for the infant. Simplifications for the provider WHO 2012
What s changed?
A developing PMTCT mythology: Beware misinterpretations and extrapolations of the options, even in high level publications: Not only will option A not protect the health of the women with lower CD4 counts but it is also less effective than option B in stopping transmission from mother to child when mothers are at advanced stages of HIV disease UNAIDS 2012
Don t underestimate the stigma of taking ARV Adherence to PMTCT interventions, even as short-term and simple dosing regimens, has been affected by the stigma of treatment, and the fear of side effects Community education and preparation is crucial to success
PMTCT: Improving linkages Prevention of new infections in women Family planning & reproductive health services Prevention of transmission to sexual partners Prevention of transmission to infants PMTCT services Nutrition Support services Infant diagnosis and care Pre-ART care Male health care Circumcision Antiretroviral therapy
Re-engineered DHS Model District Hospital Specialist Support Teams Community Health Centres Office of Standards Compliance District/Sub-district Management Team PHC Clinic Doctor PHC Nurse Nurse Pharmacy assistant Counsellor Schools School Health Teams Health Services Community Households Ward-based PHC Outreach Teams Schools Households Crèches Environmental Health Epidemics Disease Outbreaks Contracted Private Providers Local Government Environmental Health Water Sanitation Refuse removal Pest and vector control 28
Towards elimination of MTCT in low resource settings Good regimens are not enough: health systems matter 6 s Access to PMTCT services Acceptance of testing ART for those in need Appropriate PMTCT regimen Attitude of staff and community Advocacy
What is still needed? Although sub- Saharan Africa accounts for 23.5 million of the 34 million people living with HIV globally, it imports more than 80% of its antiretroviral drugs. UNAIDS, 2011: Global Plan Towards The Elimination Of New HIV Infections Among Children By 2015 And Keeping Their Mothers Alive 2011-2015
Getting to Zero Need to address new challenges: Incident infections during pregnancy and breastfeeding Pregnant women on second line regimens Continued vigilance for safety and resistance 1164 days left to achieve elimination by 2015
Turning the tide
An AIDS free generation The vision of an AIDS-free generation is so compelling, and the science is behind us. I believe we will all rise to meet the challenge. Hilary Clinton 2012
emtct: The limination equation
emtct: The elimination equation
emtct: The elimination equation Elimination = Mothers x Combination PMTCT x Coverage
Making the impossible, possible The difficult is what takes a little time; the impossible is what takes a little longer Fridtjof Nansen, (1861 1930) 1922 Nobel Peace Prize Winner