Elimination of mother to child transmission of HIV: is the end really in sight? Lisa L. Abuogi, MD University of Colorado, Denver Dec 3, 2014
Outline Background History of prevention of mother to child transmission The Global Plan to eliminate MTCT Current progress Gaps Conclusion
Children (<15 years) estimated to be living with HIV 2013 Eastern Europe & Central Asia 14 000 [13 000 14 000] North America and Western and Central Europe 2800 [2300 3600] Caribbean 17 000 [14 000 20 000] Latin America 35 000 [27 000 54 000] Middle East & North Africa 16 000 [11 000 22 000] Sub-Saharan Africa 2.9 million [2.6 million 3.2 million] Asia and the Pacific 210 000 [190 000 270 000] Total: 3.2 million [2.9 million 3.5 million]
Estimated number of children (<15 years) newly infected with HIV 2013 North America and Western and Central Europe <500 [<200 <500] Caribbean <1000 [<500 <1000] Latin America 1800 [<1000 7400] Middle East & North Africa 2300 [1500 3400] Sub-Saharan Africa 210 000 [180 000 250 000] Eastern Europe & Central Asia <1000 [<1000 1200] Asia and the Pacific 22 000 [18 000 32 000] Total: 240 000 [210 000 280 000]
MTCT in the US With treatment during pregnancy and delivery and the avoidance of breastfeeding <1% transmission In 2010, an estimated 217 children < 13 years were diagnosed with HIV in the US (CDC) The number of women with HIV giving birth in US increased ~ 30%, from 6,000 7,000 in 2000 to 8,700 in 2006 (CDC)
MTCT in Colorado Between 2008 2012 ~20 30 HIV exposed infants are born annually Last reported perinatal transmissions occurred in 2008 N=4 2/4 were born outside the US Colorado Department of Public Health and Environment, June 2014
Background 90% of HIV infections in children are a result of mother to child transmission
History of perinatal transmission 1982 1 st report of HIV in children 1983 vertical transmission confirmed 1985 1 st US guidance for pregnant women 1987 AZT in pregnancy and delivery reduces transmission by 67% 1995 Universal opt out testing during antenatal care Late 1990 s Botswana launches first PMTCT with short course AZT 1997 WHO recommends replacement feeding
History continued 2000s Single dose nevirapine with/out AZT Most women in resource limited countries don t receive 2003 rapid weaning recommended 2006 exclusive breastfeeding and gradual weaning, emphasis on ARV prophylaxis 2010 WHO PMTCT guidelines Option A vs Option B 2011 Global plan for the elimination of mother to child transmission 2011 Malawi is the 1 st country to implement Option B+ 2013 WHO guidelines recommend continuous ART therapy for pregnant women, preferably life long
WHO 2010
WHO Programmatic Update April 2012 Advantages of Option B+ Simplification of regimen and service delivery Harmonization with ART programs Protection against MTCT in current AND future pregnancies Avoids stopping and starting of ARVs Prevention of transmission in discordant couples Improved clinical outcomes for women
WHO Consolidated Guidelines 2013 ALL HIV infected pregnant and breastfeeding women should start ART and continue for life
Progress 1.1 million HIV infections averted in children < 15 years New cases of pediatric infections declined by more than 50% between 2005 2013
Countdown to Zero In 2011, Joint United Nations Programme on HIV/AIDS announced a plan to eliminate new HIV infections among children by 2015
There are 22 priority countries for the Global Plan 1. Angola 2. Botswana 3. Burundi 4. Cameroon 5. Chad 6. Côte d Ivoire 7. DR Congo 8. Ethiopia 9. Ghana 10. India 11. Kenya 12. Lesotho 13. Malawi 14. Mozambique 15. Namibia 16. Nigeria 17. South Africa 18. Swaziland 19. Tanzania 20. Uganda 21. Zambia 22. Zimbabwe These countries accounted for 89% of all HIV-positive pregnant women in low- and middleincome countries in 2011
2015 Goals Reduce the number of new HIV infections among children by 90% from a baseline of 2009 Reduce MTCT rate <5% among breastfeeding populations, <2% among non breastfeeding populations 50% reduction in AIDS-related maternal deaths
Progress Toward Global Plan Targets 100% 100% 90% 90% 90% 90% 80% 70% 60% 61% 2009 Baseline 2011 2015 Target 50% 48% 50% 40% 34% 30% 20% 26% 28% 21% 16% 21% Baseline 28% 10% 0% Baseline Reduce new cases of pediatric HIV infection 5% MTCT rate Maternal ARV coverage ART coverage for mothers 0.5% Reduction in maternal AIDS deaths ART coverage for children Source: Towards Universal Access, 2011; Global Report, UNAIDS, 2012
MTCT in 21 priority countries
The gap in treatment and prophylaxis coverage is uneven among low- and middle-income countries The share of each low- and middleincome country in the total shortfall in providing antiretroviral medication to HIVpositive pregnant women to prevent new HIV infections among children. Lesotho, Côte d'ivoire, Angola, Chad, Botswana, Swaziland, Ghana, Rwanda, Namibia, Brazil, South Sudan, South Africa, 3% Chad, 2% Cameroon, 2% Zambia, 2% Tanzania, 4% Kenya, 5% Other low- and middle-income countries, 13% Nigeria 29% Malawi, 5% Uganda, 8% Zimbabwe, 5% Dem. Rep. of Congo, 5% Ethiopia, 5% India, 6% Mozambique, 7% Source: UNAIDS 2012
New HIV infections among children, 2009 2011 Will reach the target if the 2009 2011 decline of more than 30% continues through 2015. Can reach the target if the decline in 2009 2011 of 20 30% is accelerated. In danger of not reaching the target, with a decline in 2009 2011 of less than 20%. Note: The baseline year for the Global Plan is 2009. Some countries had already made important progress in reducing the number of new HIV infections among children in the years before 2009, notably Botswana which by 2009 already had 92% coverage of antiretroviral regimens among pregnant women and a transmission rate of 5% (see table pp122 123). In countries with high coverage, further declines are much harder to achieve. Source: UNAIDS Estimates 2012
Reality check Even if the goal is met, roughly 40 000 infants will continue to be infected each year Only 67% of pregnant women with HIV received the most effective PMTCT treatment in low and middle income countries Joint United Nations Programme on HIV/AIDS. Countdown to zero: global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, 2011 2015. Geneva, Switzerland: UNAIDS; 2011
Number of new infections in children= Number of HIV+ pregnant women X Mother to child transmission rate
4 prongs of PMTCT Primary prevention of HIV in women Prevention of unintended pregnancies Prevention of mother to child transmission Care for HIV infected women and children
Primary prevention of HIV in women Know your status Treatment of discordant couples Empowerment
Slight decline in new HIV infections among women 15-49, 21 priority countries 1200000 1000000 800000 600000 400000 200000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: UNAIDS Estimates 2012
Unmet family planning need Percent 40 35 30 25 20 15 10 5 0 Survey 1 Survey 2 Source: Demographic and Health Surveys 2000-2011
Reducing MTCT TEST TREAT RETAIN
PMTCT Care Continuum Figure1. Kenya Prevention of Mother to Child Transmission Cascade Towards the elimination of mother to child transmission of HIV in Kenya A framework for emtct (NASCOP) Draft 2012 2
Where are the gaps? ~50% of HIV infected pregnant women are lost between ANC registration and delivery ~34% of HIV exposed infants are lost to follow up by 3 months 45% of infants are lost after HIV testing
Gaps Access Acceptability Identification Right treatment Stigma, discrimination, GBV Training of HCW Adherence Retention Primary prevention
Infant Morbidity and Mortality Review 45 cases and 45 controls compared Maternal factors lack of awareness of HIV status (OR 5.60, 95%CI 2.16 14.50), failure to access anti retroviral prophylaxis (OR 22.22, 95%CI 5.84 84.57), poor maternal adherence (OR 8.06, 95%CI 3.65 17.80) Infant related factors late enrolment of infant to follow up (OR = 7.14, 95%CI 2.63 16.67), poor adherence to infant prophylaxis (OR=8.32, 95%CI 3.24 21.38), mixed infant feeding (OR = 7.14, 95% CI 2.78 20.0) Mothers of cases were also significantly less likely to report having received clinic based HIV education and counseling or to report good counseling on medications Okoko N.A. 1, Owuor K. 1, Lewis-Kulzer J. 1,3, Owino G. 1, Ogolla I. 1, Wandera R. 4, Bukusi E.A. 1,3, Cohen C.R. 1,3, Abuogi L. 1,2
Vertical Transmission eliminated TDF+3TC+EFV Continuous life long HAART for pregnant women
PROMISE Study Nov 17, 2014 Interim results of the PROMISE Study confirming that triple ARVs for pregnant women are more effective in preventing mother tochild transmission of HIV during pregnancy than a single drug based regimen
Hope Less than 200,000 new pediatric infections in 2013 1 st time since 1990s Decline in new pediatric infections in ALL 21 priority countries The proportion of pregnant women living with HIV who received antiretroviral medicines for PMTCT has doubled in the past 5 years, from 33% to 68% Drug regimens being received are more efficacious
Lisa.abuogi@ucdenver.edu