2009 Research Symposium Hilton Hotel, Barbados Dec 2-3rd, 2009

M. Anne St John*, Kemi Mascoll*, I. Waterman**. *Queen Elizabeth Hospital, Barbados. **Ladymeade Reference Unit, Ministry of Health, Barbados Further Reduction in Mother To Child Transmission of HIV in Barbados following intervention with HAART for PMTCT.

Background to the study…

WHO statistics 2007 :increasing HIV cases globally -approximately 8 million in 1990 to ->33 million end 2007, still growing. - estimates 67% PLWA sub-Saharan Africa.

UNAIDS/WHO globally: 2.7 M < 15 yrs HIV (33.2M) 2007 Children 17% new cases - 420,000 of 2.5 M 14% mortality - 290,000 of 2.1 M ; 6% of PLWA

Caribbean region - 29 nations 2nd highest HIV prevalence - 3% Approx. 230,000 PLWHA HIV leading cause of mortality in yr Transmission Heterosexual 60% Homo/ bisexual 15% Mother to child 6-7%

Caribbean Epidemiology Centre CAREC (Trinidad) Surveillance: 6% total HIV/AIDS cases children

Paediatric HIV infection > 90% MTCT transmission sexual abuse tainted blood products unsterile surgical procedures - ear piercing/ body tattooing

MTCT of HIV- pregnancy (30 to 50%) Transplacental During gestation

MTCT of HIV- intrapartum (50 to 70%) Labour Deliver y

MTCT of HIV- Post partum Breast feeding (15 to 35%)

Mother to child transmission (MTCT) Without PMTCT prophylaxis treatment transmission rate: 25 to 30%

Barbados HIV prevalence Pregnant women % in the late1990’s - 0.6% in 2007 Steady state figures for the last decade

HIV prevalence in pregnant women in the Caribbean Country Prevalence Year Haiti 3.3% 2008 Belize 2.5% 2005 Bahamas 2.7% 2005 Dominican Republic 2.0% 2000 Suriname 1.7% 2005 Guyana 1.5%2008 Jamaica 1.5% 2005 Trinidad and Tobago 1.2% 2002 Barbados 0.6% 2007 Antigua St Vincent0.4%2008 Cuba 0.04% 2000 sources: UNAIDS & C’bbean workshop CCAS 2008.

Exciting development in mid 90’s Glow behind dark clouds cast by the devastating HIV/AIDS epidemic

Major advance in global pandemic Prevention of mother to child transmission PMTCT

Most effective intervention : PMTCT prophylaxis trials initiated, protocols a)Study published in 1994 in the N. Engl. J Med. PACTG-076 protocol long course zidovudine 8.3 % transmission vs 25.5% (Connor et al.) b) Short course zidovudine - less successful c) Single dose nevirapine HIV NET 012 tried later (Africa), some limitations

The prevention of mother to child transmission (PMTCT) of HIV programme initiative in Barbados commenced in 1995, after the original report of successful treatment with zidovudine.

Caribbean region Success stories -mid 90’s: early PMTCT programmes pioneers (Bahamas, Barbados, Bermuda)

Reduction in Perinatal transmission and mortality from HIV after intervention with Zidovudine in Barbados. Ped. Inf. Dis J. 2003: St John, Kumar, Cave. 151 sero-positive pregnant women infants ZDV treated : 59 untreated controls Treated transmission rate 5.5% vs 27% untreated 1 deathin treated vs 3 deaths in non-treated Relative risk reduction [79.7%] p =

Efficacy of Nevirapine Administration on the Mother to Child Transmission of HIV using a HIVNET 012 regimen. West Ind. Med J. 2003; 52:19 (suppl 3) St John, Kumar, Carmichael, Abayomi. 74 infected mothers 75 infants Reduction 8% transmission in treated group not statistically significant comparatively

Intervention Initiated Government of Barbados loan, World Bank Dedicated centre Ladymeade Reference Unit - 5 day week clinic, staffed, trained, provision of specialised follow-up care and services (HIV) - state of the art lab., flow cytometry (regional centre) for HIV tests (twice/wk then daily- CD4’s, VL’s,) close to the hospital. ART drugs FREE to all infected individuals

Therapy prescribed Pregnant women: Triple therapy HAART recommended for all pregnant women for entire duration of pregnancy - AZT + 3TC combined - NVP/ PI

Current Study Further Reduction in Mother To Child Transmission of HIV in Barbados following intervention with HAART for PMTCT. West Indian Med. J 2008 ( suppl.3) St John, Mascoll, Waterman.

Queen Elizabeth Hospital, Barbados- tertiary care, 600 beds. Island infant deliveries : 3500 per year (>90%) at QEH.

Objective: To determine the outcome of MTCT of HIV following intervention with anti-retroviral prophylaxis during the last 5 years in Barbados.

Design and Methods. From January 2002 to Dec 2006 historical prospective prospective study conducted consenting HIV infected pregnant women had been treated with anti-retroviral drugs for PMTCT prophylaxis. Infants received week course of oral zidovudine or one dose nevirapine plus one month of ZDV according to protocol none were breast fed.

Specific clinic follow-up 2 successive visits for PCR testing, also at 1 year and 18 months (Paediatric general clinic) to determint their HIV status by Paediatric specialist (ID), dedicated PH nurse- midwife Meticulous tracking of parent defaulters P/Clinic collaboration

Mothers and respective infants were followed –up after discharge with ongoing counselling at clinic visits and defaulting patients were tracked to ensure follow–up.

Data was collected by review of patient medical records and collated on Microsoft Excel programme. The transmission rate in treated pregnant women was calculated. Statistical analysis of data was performed using the Fisher Exact Test.

Results: 16,682 live births at the QEH in the 5 year study period. 119 live births in HIV infected pregnant women. 3 (2.5 %) infected infants born to infected pregnant women who received HAART. None of the infants died.

Conclusion: This study demonstrated that the intervention using a ART protocols in HIV infected pregnant women in Barbados during the past 5 years has resulted in the most significant reduction in mother to child transmission on the island to date.

Addendum No new cases of Paediatric HIV through MTCT in the past 3 years.

References http// WHO Technical and operational recommendations are available at: JC602- HIVSurvGuidel_en.pdf s/en/HIV_Report15http:// s/en/HIV_Report15 data.unaids.org/pub/EPISlides/2007/2007_epiupdate _en.pdf WHO- management of HIV infection and antiretroviral therapy in infants and children. A clinical manual Who technical publication No 51.

Thank you !