Elimination of New HIV Infections among Children by 2015 and Keeping their Mothers Alive: Rationale for the call to action, progress to date and dealing with realities Rene Ekpini, MD, MPH Senior Adviser, Maternal Health UNICEF, New York
Global summary of HIV epidemic in women and children, 2012 GLOBAL SUB-SAHARAN AFRICA Number Number % of global total Number of people living with HIV 35.3 million 25.1 million 71% Number of women 15+ years living with HIV Number of pregnant women living with HIV Number of children <15 years living with HIV Number of children <15 years newly infected with HIV Number of children <15 years dying of AIDS-related causes 16.1 million 12.9 million 80% 1.5 million 1.4 million 91% 3.3 million 3.0 million 91% 260,000 230,000 89% 210,000 190,000 91% Source: UNAIDS 2012 HIV and AIDS estimates
New HIV infections among children (0-14) by region, 2012 Source: UNAIDS 2012 HIV and AIDS estimates
We know what works: Impressive body of scientific evidence on the use of antiretrovirals for PMTCT 1999 PETRA AZT+3TC trial (partly 1998 breastfeeding) Thai Bangkok short AP/IP AZT trial 2002 Cote d Ivoire DITRAME Plus 1201.0 AZT & IP/PP NVP 2004 Thailand PHPT-2 AZT & IP/PP NVP 2009 Mma Bana comparative trial for CD4<200 (breastfeeding) 1994 2010 1994 U.S. AZ Trial ACTG 076 1998 Cote d Ivoire short AP/IP AZT trials (breastfeeding) 1999 Uganda 2-dose IP/PP NVP trial (HIVNET 012) 2000 Thailand PHPT-1 Long vs short AZT regimens 2003 DITRAME Plus 1201.1 AZT+3TC & IP/PP NVP 2008 PEPI NVP + short vs long AZT for infant (breastfeeding)
Global plan goal and targets Reduce HIV-related maternal deaths by 50% Reduce number of new HIV infections among children by 90% Reduce HIV-related infant deaths by >50% For Childbearing Women For Women Living with HIV For Pregnant Women Living with HIV Reduce new infections in women by Reduce unmet need for family planning by Provide ART to 90% of pregnant women in need Provide ART to all HIV-infected children Provide ARV to 100% of pregnant women to reduce EMTC to 50% 100% <5%
Coverage of maternal ARVs for PMTCT among 21 global plan priority countries, sub-saharan Africa, 2012 Low coverage (less than 40%) Moderate coverage (40-79%) High coverage (80% or more) Zambia Botswana Ghana Namibia Mozambique Swaziland South Africa Zimbabwe Uni Rep of Tanzania Uganda Cote d'ivoire Cameroon Malawi Lesotho Burundi Kenya Ethiopia Angola Nigeria Chad DRC 17 17 14 13 41 54 53 60 58 64 68 72 77 86 83 83 82 >95 >95 95 94 Total 21 African GP Priority Countries: 64% 0 10 20 30 40 50 60 70 80 90 100 ARV COVERAGE (%) Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response Progress Reporting, and UNAIDS 2012 HIV and AIDS estimates.
Country progress in reducing new HIV infections among children aged 0 14 years in 21 global plan priority countries in sub-saharan africa (SSA), 2009 2012 RAPID DECLINE (50 per cent or more) Ghana (76%) Namibia (58%) Zimbabwe (55%) Malawi (52%) Botswana (52%) Zambia (50%) Ethiopia (50%) MODERATE DECLINE (30 49 per cent) United Rep. of Tanzania (49%) South Africa (46%) Mozambique (45%) Uganda (45%) Kenya (44%) Swaziland (38%) Burundi (31%) SLOW DECLINE (less than 30 per cent) Cameroon (29%) Côte d'ivoire (27%) Lesotho (17%) Dem. Rep. of the Congo (15%) Nigeria (10%) Chad ( 9%) Angola (9%) Overall decline in 21 SSA Global Plan priority countries (37%) Source: UNICEF update to a table published in the Joint United Nations Programme on HIV/AIDS, Global Report: UNAIDS report on the global AIDS epidemic, 2013
Estimated number of new HIV infections in children (aged 0 14): global trend, annual rates of reduction and projections, 2001 2015 NUMBER OF NEW HIV INFECTIONS 600.000 500.000 400.000 300.000 200.000 100.000 26% decline over 8 years (avg. 18,000 per year) 2001 2009 GLOBAL PLAN LAUNCHED 35% decline over 3 years (avg. 47,000 per year) 2009 2012 85% decline needed over 3 years (avg. 74,000 per year) 2012 2015 GLOBAL PLAN TARGET 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: UNICEF analysis of UNAIDS 2012 HIV and AIDS estimates.
The five key catalysts 2 1 Strong political leaderships and commitments Prioritization of MTCT elimination for resource allocation by national governments and donors Programmatic shifts towards treatment simplification and optimization for PMTCT in line with 2013 WHO guidelines 3 4 More efforts toward decentralization of PMTCT services down to districts and primary health care facilities Increased global and national accountability through more systematic tracking of progress 5
Treatment simplification and optimization for better convergence of PMTCT and ART Too many hurdles Infant prophylaxis.. Regimen selection CD4 count Clinical staging HIV testing Attend ANC 1 pill a day for all pregnant and breastfeeding women living with HIV Simplification Optimization
Most Global Plan priority countries have transitioned to ART for all pregnant and breastfeeding women living with HIV After 2010 WHO ARV guidelines June 2013 2013 March 2014 Option A Option B Option B+ Planned/piloting Option B+ Implementing Not a priority country
Donor contributions continue to play a critical role in funding the AIDS response >=75% 1. Burundi-2010 Percentage of HIV funding coming from international sources in Global Plan priority countries reporting, most recent year 2. Cote d Ivoire- 2009 3. DRC- 2010 4. Ghana- 2010 50-74% 1. Cameroon- 2010 25-49% <25% 5. Kenya- 2010 6- Malawi- 2011 7- Zimbabwe- 2011 2. Chad- 2011 3. Nigeria- 2010 4. Swaziland- 2009 1. Angola- 2011 2. Namibia- 2010 1. Botswana- 2011 2. South Africa- 2009 Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2012 - Kaiser Family Foundation & UNAIDS
A significant number of pregnant women are still not accessing PMTCT because they are not attending ANC or not tested for HIV 8.000.000 7.000.000 6.000.000 Pregnant women not attending ANC or being tested for HIV Pregnant women attending ANC, but not tested for HIV Pregnant women attending ANC and tested for HIV Estimated number of pregnant women 5.000.000 4.000.000 3.000.000 2.000.000 1.000.000 0 Botswana Cameroon Chad Côte d'ivoire DR Congo Ethiopia Ghana Kenya Nigeria Tanzania Zambia Data sources: United Nations Population Division estimates, 2013; UNAIDS, WHO, UNICEF 2013 GARPR/ Universal Access reporting
9,0 8,0 7,0 6,0 More targeted approaches are needed to ensure equity, maximize investments and achieve impact 7,9 7,2 6,1 5,8 5,4 Unmet need for ARVs for PMTCT in Anambra State, Nigeria, 2013 5,0 4,0 4,5 4,4 4,4 4,2 4,2 4,0 3,7 3,6 3,0 3,0 2,5 2,0 1,8 1,8 1,5 1,5 1,0 0,9 0,8 0,0
Transforming MNCH services for nationwide implementation of ART for all pregnant and breastfeeding women living with HIV CROI 2014 Poster Abstract 882 In Rwanda, while ART for PMTCT use increased and AZT alone decreased after Option B became national policy, the % of women who were receiving no ARV at delivery also increased. cart NO ARV AZT
Transforming MNCH services for integration and rapid expansion of ART: what would it require? Task-shifting and sharing for ART initiation by nurses and midwives 1 Establishing facility and community systems to improve ART adherence, follow-up care, retention of mother-baby pairs and linkage to chronic ART 2 Re-organization of service delivery systems including quality improvement especially in the postnatal & strengthening the performance of the MNCH platform 5 Reliable procurement and supply management to avoid HIV test kits and ARV stockouts Establish systems for clinical and laboratory monitoring 3 4
More effort is needed to prevent unintended pregnancies among women living with HIV More guidance is available There is evidence that integrated Family Planning-HIV services are feasible The Zambia Prevention, Care and Treatment Partnership (ZPCT) II Model of SRH/HIV Integration Tanzania model of Integration of FP into HIV services through effective facilitated referrals within health facilities NAKURU Kenya: a model of community-based integrated SRH and HIV services Elements for success include training of providers, task shifting and sharing, facilitated referrals, commodity security, supportive supervision and mentoring and community involvement
Continuing new HIV infections in women of childbearing age in sub-saharan Africa Acute HIV in Pregnancy, Kenya: incidence and and risk Factors - Kinuthia J et al. CROI 2014, Oral Abstract 68 Prospective study in 2 district hospitals; between 5/11-6/13, 26% antenatal prevalence HIV 1,305 pregnant women HIVseronegative at enrollment/prior 3 mos, f/u to 9 mos PP 24/1,305 seroconverted - incidence 2.63/100 pt-yrs 13 seroconverted during pregnancy 11 seroconverted during breastfeeding 6/24 (29%) had symptoms of acute HIV 2/24 infants (8.5%) were HIV-infected HIV incidence in pregnancy in low-resource countries ranges between 1.3-10.7 with an increased risk of HIV acquisition during pregnancy and in the postnatal This require integrated programme strategies and interventions to test and treat male partners, with special attention to discordant couples
Sixty percent of adolescents living with HIV are girls Source (Swaziland, Zimbabwe, Zambia): Gouws, E. et al, The epidemiology of HIV infection among young people aged 15 24 years in southern Africa. AIDS 2008, 22 (suppl 4): s5 s16 Source (Botswana): Central Statistics Office, Botswana AIDS Impact Survey III, 2008
Failure of PMTCT programme to provide follow up care for mothers and children HIV T&C ANTENATAL ARVs for PMTCT Maternal ART POSTNATAL EID Paediatric ART Botswana >95% >95% >95% 38% >95% Zambia >95% >95% 88% 61% 38% Zimbabwe 90% 82% 70% 34% 45% Uganda 65% 72% 47% 30%** 33% Malawi 72% 60% 86% 4% 36% Kenya 85% 53% 58% 39% 38% Lesotho 48% 58% 50% 69%** 25% Burundi 51% 54% 47% 11% 21% Nigeria 19% 17% 18% 4% 12% DRC 9% 13% 18% 6% 9% UNICEF, Children and AIDS Sixth Stocktaking Report, 2013; UNAIDS, WHO, UNICEF 2013 GARPR
Rethinking the programme elements of emtct 1 Test and Treat (ART) Lifelong ART for HIV+ pregnant and BF women Primary prevention & ART for sexual partners Prevention of unintended pregnancies (FAMILY PLANNING) Curing HIV infected newborns Targeted interventions for ADOLESCENT GIRLS Primary prevention of incident infections during pregnancy and breastfeeding 3
Strategic shifts Mainstreaming EMTCT in the global maternal and child health and survival agenda and national development strategies for a broader impact beyond HIV Implementing test and treat approach as an importunity to strengthen the performance of the MNCH platform with special attention to integrated service delivery at the PHC level Rethinking the MNCH postnatal care delivery system to improve maternal and child health outcomes in the context of HIV
Strategic shifts Foster and support integration and linkages across health and other platforms including integrating follow-up and referral systems for HIV-exposed infants within facility level and outreach platforms for immunization, growth monitoring and community case management of childhood illnesses services Alignment of partners priorities with actual country needs, especially at the decentralized level through data driven planning that identifies where and on what to focus investments
Dealing with the realities Health systems strengthening to address inequity, promote social justice, maximize investments and synergies
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