A Call to Action Children – The missing face of AIDS

Unite for Children Unite Against AIDS Dr Chewe Luo MD (Paed); MTrop Paed; PhD Team Leader and Senior Adviser Country Programmes’ Scale up HIV Section Programme Division UNICEF NY ICASA, Addis Ababa, Ethiopia 1/3/2010 Global perspective on the importance of early infant diagnosis advancing the elimination of mother to child transmission of HIV

Presentation outline Coverage of PMTCT HIV disease Burden in children Impact of early treatment WHO Guidelines and EID as a gateway to care and treatment Coverage of ART in children Challenges with current EID platform

Proportion of HIV positive pregnant women receiving ARVs for PMTCT (prevention and treatment)

HIV infection in women and children GlobalSub-Saharan Africa Number of women living with HIV 16.8 million11.8 million (72%) Number of pregnant women living with HIV 1.48 million1.37 million (93%) Number of children living with HIV 3.4 million3.1 million (91%) Number of children newly infected with HIV 390,000350,000 (90%) Number of children dying from HIV 250,000230,000 (92%) Source: UNAIDS World AIDS Day Report, 2011; WHO, UNAIDS and UNICEF. Global HIV/AIDS Response: Epidemic Update and Health Sector Progress Towards Universal Access Progress Report 2011

AIDS remains the main cause of child mortality in countries with high HIV prevalence Percentage of deaths attributable to HIV in children under 5 years old, 2008

WHO may CD4% in HIV-infected Infants and Children (South Africa) CD4+ % Years Atypical mycobacteria Cryptococcocus PCP & CMV Bronchiectasis Intercurrent bacterial infections Tuberculosis Mark Cotton 2005

Data from African Perinatal Prevention Trials from Breastfeeding HIV Transmission Study Meta-Analysis: Without treatment 53% of HIV infected children will die at 2 Years of Age Newell et al. Lancet 2004;364: Median survival 1.6 years By age 2.5 years, 60% mortality

Observed and fitted likely HIV/AIDS-related deaths, Age 1-11 months, South Africa, Cotton 2005

10 CHER Trial Part A n= 375 HIV infection diagnosed before 12 weeks and CD4% >25% Arm 1 Deferred treatment N=125 Arm 2 Short course (to first birthday) N=125 Arm 3 Long course ( to second birthday) N=125 FOLLOW UP For a minimum of 3.5 years ART (start or re-start) when CD4% <20% or clinical event (<25% from August 2006) Cotton et al 2010

Time to Death (months) Failure Probability DeferredImmediate CHER: 76% Reduction in the Risk of Death with Immediate (Arms 2 & 3) Compared to Deferred (Arm 1) HAART Patients at risk Arm 2 & Arm Arm 1 Month 12Month 9Month 6Month 3 Month 0 P = Most deaths occurred within first 6 months (i.e., before age 10 months) immediate deferred 16% 4%

Paediatric HIV treatment Recommendations WHO 2010 AdultsChildrenRCT Evidence When to start <350 CD4 cells or WHO clinical stage 3/4 "Test & Treat" all infants (up to age 2 years) irrespective of CD4 or clinical stage CHER Early HIV diagnosis and early ART reduced early infant mortality by 76% and disease progression by 75% What to start with Use 2NRTIs plus an NNRTI as first line In children <2 years who are exposed to NNRTIs during PMTCT, use 2 NRTIs plus LPVr as first line ART P1060 Cohort 1 In young children <3 years exposed to sdNVP for PMTCT, starting ART with a NVP- based regimen resulted in twice as much failure as PI- based therapy

EID: The gateway to universal access to comprehensive package of prevention & care in children CARE TREATMENT AND SUPPORT FOR ALL HIV EXPOSED Early diagnostic testing for HIV infection Infant feeding counselling and support / Post natal antiretrovirals Co-trimoxazole prophylaxis Assessment, management and follow up of common conditions Regular Growth monitoring, developmental assessment and support Immunization Prevention, screening and management of tuberculosis Prevention and treatment of malaria Care and support for for uninfected Care and support where status still unconfirmed Care for the infected child Early Diagnosis Shaffique, 2010

Percentage of children living with HIV receiving antiretroviral therapy in low- and – middle income countries, 2005, 2009, and 2010

Proportion of children living with HIV receiving antiretroviral therapy in 25 high-burden countries,

Children in Low-Resource Countries Who Receive ART are Starting Treatment When Already Severely Immune Deficient Baseline Median Age Baseline Median CD4 % RNA undetectable on HAART Janssens/Cambodia 2007 N= yrs 6% 74% <400 (17 mos) George/Haiti 2007 N= yrs 12% 56% <50 (12 mos) Wamawala/Kenya 2007 N= yrs 6% 67% <400 (6 mos) Reddi/S Africa 2007 N= yrs 8% 80% <50 (12 mos) Puthanakit/Thailand 2007 N= yrs 5% 70% <50 (3.7 yrs) Kamya/Uganda 2007 N= yrs 8.6% 74% <400 (12 mos) Kekitiinwa/Uganda 2008 Abs 584 N= yr 8% 70% <400 (6 mos) Lynn Mofensen CROI 2009

DNA HIV Testing of HIV exposed infants (2010) In 2010, 65 countries provided data up from 54 countries in 2009 and 28% (24% – 30%) of infants were reported to have been tested for HIV with DNA PCR within the first two months of birth, compared to 6% [5%- 7%] in 2009.

EID in the context of the continuum of care

Less than half of infants ever tested were tested in the first 2 months of life (2008)

Conclusions The landscape of early infant diagnosis remains challenging Many children are tested late Attrition is still high with dry blood spots DNA PCR testing New innovations are needed to simplify approaches Point of care technologies will help address some of the challenges in remote settings

Acknowledgements Lynn Mofensen Sangeeta Tripathi Mark Cotton