PMTCT Prevention Mother-To-Child Trasmission Eleni Kakalou, MD MSc International Medicine-Health Crises Management

MTCT in figures 2007: children infected with HIV, 90% in Sub- Saharan Africa Without any intervention 20-40% of infants will be infected: 15-30% at birth 5-20% during breastfeeding period In the West vertical trasmission bears a risk below 1% with HAART and formula feeding (Ceasarian section seems have no place with optimal HAART) and HIV care incorporates technical support for child bearing under the lowest risk conditions

PMTCT other functions Prevention of malaria episodes in pregnancy (IPT: Interminent Preventive Treatment) Prevention of future infection in parents Family planning services Prevention of infection during breastfeeding (dual protection for seronegative mothers) Safe childbearing practices for seropositive parents in resource poor settings Preventive routine care for infants born to seronegative mothers (until 18 months of age that HIV status can be determined)

PMTCT interventions SD NVP for mother and child at birth ΑΖΤ at 28 th WK ΑΖΤ+3TC+NVP SD for mother at birth, NVP to the neonate after birth AZT+3TC for 7 days to mother after birth and AZT for 7days to the neonate HAART from the 2 nd trimester

Breastfeeding practices 100% prevention by use of formula feeding only when it is: Acceptable, Applicable, Finnancially feasible, Guaranteed supply and Safe within the particular conditions of a certain context, program and/or client Exclusive breastfeeding for 6 months with intensive training and psychosocial support to the mother (breastfeeding support groups, male involvement programs, community mobilization and participation in designing services)

Problems arising with different approaches SD NVP: only 50% reduction in vertical transmission, increases risk of resistance development in mothers and neonates (40-65% emergence of resistance with SD NVP) ΑΖΤ+3TC: better results but still not good enough plus need of disclosure of status for the HIV+ mother HAART: best results (<2%) but need for disclosure costs increased increased burden on health services huge needs in human resources

The cascade of failure Attendance Offer HIV test Acceptance of HIV test Receive result Offer HAART/drug regimen Accept drug regimen Take drugs properly Baby receives drugs Safe breastfeeding practices

UNICEF pilot studies women in ANC in 12 countries: 71% received counselling and offered the HIV test 70% accepted testing and received results 49% accepted a drug regimen and collected the drugs 1 out of 4 women completed any drug regimen Ζambia: only 30% of women received SD NVP and from them only 70% took at birth

Obstacles Stigmatization Need for disclosure Long distances to health infratsructures Lack of money-resources Overloaded services Untrained personnel Drug costs 2006: only 23% of women received drugs for PMTCT

Strategies for success Adequate training, infra-structures and resources Adequate staff and incentives given Group counseling before testing Support groups and community mobilization Male involvement approach: involving men as a routine practice in all ANC or MCH services in order to reduce stigma nad by linking to treatment and care programs (PMTCT Plus) Botswana: 95% of pregnant women has access to necessary services and between <4% of babies born to seropositive mothers got infected

International initiatives for PMTCT PEPFAR The Call to Action Project UN Interchange Task Team on MTCT MTCT-Plus The Global Fund

References 'Prevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice', De CockPrevention of mother-to-child HIV transmission in resource-poor countries: translating research into policy and practice et al, JAMA 283(9), March 2000 'AIDS epidemic update', UNAIDS/WHO, December 2005AIDS epidemic update 'Questions & Answers II - Basic facts about the HIV/AIDS epidemic and its impact', UNAIDS/WHO, June 2005Questions & Answers II - Basic facts about the HIV/AIDS epidemic and its impact 'Questions & Answers III - Selected issues: prevention and care', UNAIDS/WHO, June 2005Questions & Answers III - Selected issues: prevention and care 'Integrating family planning and prevention of mother-to-child HIV transmission in resource-limited settings', Duerr et al, TheIntegrating family planning and prevention of mother-to-child HIV transmission in resource-limited settings Lancet 366(9481), 16 July 2005 'Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDSReduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group076 Study Group',Connor et al, NEJM 331(18), 3 November 1994 'Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV- 1 in Kampala, Uganda: HIVNET 012 randomised trial1 in Kampala, Uganda: HIVNET 012 randomised trial', Guay et al, The Lancet 354(9181), 4 September 1999 'Prevalence of resistance to nevirapine in mothers and children after single-dose exposure to prevent vertical transmission of HIV-Prevalence of resistance to nevirapine in mothers and children after single-dose exposure to prevent vertical transmission of HIV- 1: a meta-analysis1: a meta-analysis', Arrive et al, International Journal of Epidemiology 36(5), October 2007 'Intrapartum Exposure to Nevirapine and Subsequent Maternal Responses to Nevirapine-Based Antiretroviral Therapy', JourdainIntrapartum Exposure to Nevirapine and Subsequent Maternal Responses to Nevirapine-Based Antiretroviral Therapy et al, NEJM 351(3), 15 July 2004 'Response to Antiretroviral Therapy after a Single, Peripartum Dose of Nevirapine', Lockman et al, NEJM 356(2), January 2007Response to Antiretroviral Therapy after a Single, Peripartum Dose of Nevirapine 'Virologic Response to NNRTI Treatment among Women Who Took Single-dose Nevirapine 18 to 36 Months Earlier', Coovadia etVirologic Response to NNRTI Treatment among Women Who Took Single-dose Nevirapine 18 to 36 Months Earlier al, 13th Conference on Retroviruses and Opportunistic Infections, February 2006 Prevalence of resistance to nevirapine in mothers and children after single-dose exposure to prevent vertical transmission of HIV- 1: a meta-analysis1: a meta-analysis', Arrive et al, International Journal of Epidemiology 36(5), October 2007 'Breast-Milk Shedding of Drug-Resistant HIV-1 Subtype C in Women Exposed to Single-Dose Nevirapine', Lee et al, J Infect DisBreast-Milk Shedding of Drug-Resistant HIV-1 Subtype C in Women Exposed to Single-Dose Nevirapine 192(7), 1 October 2005 'Questions and Answers - The HIVNET 012 Study and the Safety and Effectiveness of Nevirapine in Preventing Mother-to-Questions and Answers - The HIVNET 012 Study and the Safety and Effectiveness of Nevirapine in Preventing Mother-to- InfantTransmission of HIVInfantTransmission of HIV', NIH, 7 April 2005 The Global Fund; Press release The Global Fund; Press release 'Questions & Answers III - Selected issues: prevention and care', UNAIDS/WHO, June 2005Questions & Answers III - Selected issues: prevention and care MTCT Plus website