Estimating the Impact and Needs for Children and PMTCT Making sense: Understanding the numbers: from HIV surveillance to national and global HIV burden estimates John Stover, Futures Institute 7 August 2008, Mexico City

Approach to Estimates and Projections Surveillance and survey data EPP/Workbook Adult HIV prevalence Population estimates UNAIDS epidemic patterns Spectrum Number infected New infections AIDS deaths Orphans Treatment needs Program type and coverage -MTCT -Adult ART -Child treatment (CTX, ART)

Births to HIV+ Women Total fertility rates and age distribution of fertility for the general population are from UN Population Division Fertility of HIV+ women is adjusted: –15-19: 150% Accounts for known sexual activity –20-49: 70% Accounts for effects of HIV and previous STIs –Lewis JJC, Ronsmans C, Ezeh A, Gregson S. The population impact of HIV on fertility in sub-Saharan Africa AIDS 18 (suppl 2):S35-43.

Prevention of Mother to Child Transmission of HIV 1.Primary prevention for women 2.Family planning to prevent unintended pregnancies among HIV+ women 3.Preventing the vertical transmission from mother to child 1.HIV testing and counseling 2.Antiretroviral prophylaxis 3.Safe delivery 4.Counseling and support for safer infant feeding 4.Treatment, care and support for women and children living with HIV

Antiretroviral Prophylaxis to Prevent Mother to Child Transmission Single dose Nevirapine Dual ARV –AZT from 28 weeks, single dose Nevirapine at delivery, maternal 7-day tail of AZT and 3TC, one week of AZT for infant Triple prevention ART Triple treatment ART

Probability of Transmission TreatmentMixed FeedingReplacement Feeding Exclusive Breastfeeding None30.5%20%23% SD NVP21.5%11%14% Dual ARV14.5%4%7% Triple ARV4%2%3% SD NVP: Jackson 2003, Moodley 2003 Dual ARV: Ditrame 2005, Triple ARV: UNICEF/UNAIDS/WHO/UNFPA Infant feeding: Iliff 2005, Rollins 2006, BHITS Methods summary: Stover et al. 2008

Percentage of Pregnant Women with HIV Receiving Antiretrovirals to Prevent MTCT in Low- and Middle-Income Countries Source: Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, Progress Report 2008, WHO, June 2008.

Distribution of ARV Regimens, 2007 Source: Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector, Progress Report 2008, WHO, June 2008.

Progression from HIV Infection to AIDS Death (Children) New HIV Infection Need for Treatment ARTAIDS Death Age-dependent

Progression from New Infection to AIDS Death Marston M, Zaba B, Salomon JA, Brahmbhatt H, Bagenda D. Estimating the Net Effect of HIV on Child Mortality in African Populations Affected by Generalized HIV Epidemics. J Acquir Immun Defic Syndr 38:2, February 1, 2005

Progression from New Infection to Need for Treatment Need for treatment based on mortality among children with MSD from Newell M-L, Coovadia H, Cortina-Borja M, Rollins NC, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. The Lancet 2004;364:

Child Treatment: Co-trimoxazole WHO recommendation: all HIV-exposed children until they are no longer exposed to HIV and confirmed to be HIV-negative Impact: 33% reduction in mortality in first four years, 17% in year 5, 0% after year 5 –Chintu et al 2004 – Zambia Most national policies now include co- trimoxazole prophylaxis Current coverage is only about 4%

Child Treatment: ART Need for treatment is currently based on the estimated proportion progressing to Moderate-to-Severe Disease WHO recommendation –For children over one year of age, start ART on the basis of immunological and clinical criteria, operationalized in model on basis of progression to death –For children under one, start ART as soon as HIV infection is confirmed

Child Treatment: ART Impact –Studies Fassinou et al, Cote d’Ivoire, 2004 Rouet et al, Cote d’Ivoire, 2006 Puthanakit et al, Thailand, 2005 –Survival on ART < 1 year : 80% >=1, first year: 90% >=1, subsequent years: 95%

Western & Central Europe1300 [<1000 – 1800] Middle East & North Africa [ – ] Sub-Saharan Africa 1.8 million [1.7 – 2.0 million] Eastern Europe & Central Asia [9100 – ] South & South-East Asia [ – ] Oceania1100[1200] North America 4400 [2600 – 7300] Latin America [ – ] East Asia7800 [5300 – ] Caribbean [9400 – ] Children (<15 years) estimated to be living with HIV, 2007 Total: 2.0 million (1.9 – 2.3 million)