Prevention of Vertical Transmission: The role of families Elaine J. Abrams, MD Harlem Hospital and the International Center for AIDS Care and Treatment Programs Columbia University

Prevention of vertical transmission: Spectrum of care for mother & child

Effective ‘PMTCT’ is a long term intervention for women Non-pregnant: Family planning (FP) counseling Preconception Care Partner HIV testing Antepartum: PITC in ANC CD4 Testing ART treatment or prophylaxis Adherence support Infant feeding (IF) counseling Safe Motherhood Birth Preparedness Intrapartum: PITC in L&D CD4 testing ARV prophylaxis Safe Delivery IF counseling FP counseling 1-8 Weeks Post Partum: Maternal postpartum follow-up Enrollment into HIV care ART treatment or prophylaxis during BF 2-6 Months Post Partum: Repeat CD4 (6 months pp) ART treatment or BF prophylaxis 6-9 Months Post Partum: FP counseling IF counseling Adherence support 9-12 Months Post Partum: ART treatment or BF prophylaxis FP counseling IF counseling Adherence support 12-18 Months Post Partum: ART treatment FP counseling Adherence support Repeat CD4 PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum Effective PMTCT includes a series of biomedical and psychosocial interventions administered throughout the reproductive live of the woman living with HIV The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

Effective ‘PMTCT’ is a long term intervention for infants & children Birth: ART prophylaxis FU appt at 6 weeks 1-8 Weeks : Infant prophylaxis during BF PCR testing at 4-6weeks Growth & developmental monitoring CTX initiation at 6 weeks 2-6 Months: Infant prophylaxis during BF Growth & developmental monitoring CTX continuation HIV infected infants: HAART initiation CD4 testing 6-9 Months: Infant prophylaxis during BF Growth & developmental monitoring CTX continuation Repeat HIV test 6weeks post BF cessation IF support HIV infected infants: HAART initiation 9-12 Months : Infant prophylaxis during BF Growth & developmental monitoring CTX continuation Repeat HIV test 6weeks post BF cessation 12-18 Months: Determine final infection status: antibody testing at >12-18mos Child discharged from PMTCT program The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development. Illustrations by Petra Rohr-Rouendaal, 2010

PMTCT Spectrum of Care Happy Healthy Family Non-pregnant: Family planning (FP) counseling Preconception Care Partner HIV testing Antepartum: PITC in ANC CD4 Testing ART treatment or prophylaxis Adherence support Infant feeding (IF) counseling Safe Motherhood Birth Preparedness Intrapartum: PITC in L&D CD4 testing ARV prophylaxis Safe Delivery IF counseling FP counseling 1-8 Weeks Post Partum: Maternal postpartum follow-up Enrollment into HIV care ART treatment or prophylaxis during BF Adherence support 2-6 Months Post Partum: Repeat CD4 (6 months pp) ART treatment or BF prophylaxis 6-9 Months Post Partum: FP counseling IF counseling Adherence support 9-12 Months Post Partum: ART treatment or BF prophylaxis FP counseling IF counseling Adherence support 12-18 Months Post Partum: ART treatment FP counseling Adherence support Repeat CD4 Happy Healthy Family Discharged from PMTCT Program Engaged in family-focused HIV care services PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum PMTCT Spectrum of Care Birth: ART prophylaxis FU appt at 6 weeks 1-8 Weeks : Infant prophylaxis during BF PCR testing at 4-6weeks Growth & developmental monitoring CTX initiation at 6 weeks 2-6 Months: Infant prophylaxis during BF Growth & developmental monitoring CTX continuation HIV infected infants: HAART initiation CD4 testing 6-9 Months: Infant prophylaxis during BF Growth & developmental monitoring CTX continuation Repeat HIV test 6weeks post BF cessation IF support HIV infected infants: HAART initiation 9-12 Months : Infant prophylaxis during BF Growth & developmental monitoring CTX continuation Repeat HIV test 6weeks post BF cessation 12-18 Months: Determine final infection status: antibody testing at >12-18mos Child discharged from PMTCT program The images in this were created by University Research Co., LLC with funding from the United States Agency for International Development.

Prevention of vertical transmission is a family-centered intervention Addresses the health of the maternal-child dyad Provides an unparalleled opportunity to engage other family members in HIV and other health and social services Partner, husband, children, extended family members HIV services include testing, prevention, care and treatment Offers a platform to initiate other health services TB screening, diagnosis, treatment Early infant interventions Effective PMTCT prevents orphanhood

Family involvement enhances prevention of vertical transmission Partner testing in PMTCT programs has been associated with greater use of antiretrovirals for prophylaxis higher acceptance of post-test counseling increased spousal communication about HIV and sexual risk Using PMTCT services as an entry point into HIV care and treatment for women, partners and family members has been associated with high rates of retention and ART adherence Family-focused home based HIV testing, care and treatment services can improve health outcomes for HIV positive and negative family members Disclosure of HIV status has been associated with better pediatric outcomes

The MTCT-Plus Initiative A multi-country HIV care and treatment program (2003-2010) PMTCT entry point for pregnant & postpartum women to engage in HIV care and treatment PMTCT as an entry point to identify HIV-infected partners, children and family members and engage in HIV care and treatment Reframes PMTCT in the context of the reproductive lives of women living with HIV Recognizes that pregnancy is a normal and expected aspect of a woman’s life and aims to support and maximize the health of the woman, her child and her family Model for Family-Focused HIV services

The MTCT-Plus Initiative Factors shaping the MTCT-Plus model of care HIV is a multi-generational family disease: multiple family members living with HIV All family members are affected when any individual within the family has HIV Most HIV care occurs within households and families Women and children have multiple needs that may impact on adherence to care & treatment Families can be important sources of support for successful treatment Cultural and community factors impact access and adherence MTCT-Plus approach to HIV care & treatment MTCT-Plus approach to HIV care & treatment Comprehensive HIV primary care inclusive of antiretroviral therapy to all family members Family-centered care Inclusive of infants and children Attention to psychosocial, behavioral, structural, and environmental issues Care provided by multidisciplinary teams of health providers Involvement of person living with HIV and outreach to community resources HIV care and treatment for staff living with HIV

MTCT-Plus Sites Uganda: Kenya: Cote d’Ivoire: Thailand: Nigeria: St. Francis Hospital Nysambya, Kampala Mulago Hospital, Kampala Kenya: Moi University College of Health Sciences, Eldoret Nyanza Provincial General Hospital, Kisumu Cote d’Ivoire: Formation Sanitaire Urban de Yopougon-Attié Formation Sanitaire Urban d’Abobo-Attié Thailand: Police Hospital Clinic Chulalongkorn Hospital Clinic Thammasat University Hospital Sriracha Hospital Sirikit Hospital Nigeria: Ogoja (Cross River State) Kafanchan (Kaduna State) Rwanda: Treatment and Research AIDS Center, Kigali Cameroon: Nkwen clinic M’bingo Hospital Clinic Mboppi Hospital Clinic Banso Hospital Clinic Mutengene Hospital Clinic Zambia: Mtendere Health Clinic, Lusaka Chelstone Clinic, Lusaka South Africa: Cato Manor Clinic, Durban Perinatal HIV Research Unit, University of Witswatersrand, Johannesburg Langa Health Clinic, Cape Town Mozambique: Beira Hospital Clinic Chimoio Hospital Clinic

HIV-infected partners Women attending ANC clinics Enrollment into PMTCT programs PMTCT programs Enrollment into MTCT-Plus HIV-infected partners and children Long-term HIV care services: Family-centered services Clinical & CD4 monitoring Antiretroviral therapy Screening and treatment for OI, TB Psychological & social support Nutritional counseling & support Outreach activities MTCT-Plus

Enrollment in the MTCT-Plus Initiative Total Adults and Children Receiving HIV Care 16,457 Adults Receiving HIV Care 9,718 (59%) Adults on ART 3,933 (40%) Women Enrolled During Pregnancy 4,275 (44%) Male Partners Enrolled 1,569 (16%) Children Enrolled 6,739 Children Enrolled Before 18 Months of Age 6,164 (91%) Other Children in the Household Enrolled (sibling/other) 419 (6%) Children on ART 512 (8%) Health Care Workers or their Family Members 306 PLT Updated Statistics: Total receiving HIV Care – 16,457 Adults receiving HIV Care – 9,718 Adults on ART – 3,933 Pregnant Women Enrolled Antepartum – 4,275 Male Partners Enrolled – 1,569 Children Enrolled – 6,739 Children Enrolled before 18 months of age – 6,164 Other Children in the household enrolled (sibling to index or other) – 419 Children on ART – 512 HCW/HCW Family Members enrolled - 306 Would like a similar table with updated information and the following changes: Title: no date – just enrollment highlights Would also substitute HIV for HIV/AIDS in all places Instead of pregnant women enrolled antepartum – classify as women enrolled during pregnancy In addition to children receiving HIV care would add: Children enrolled during infancy (can county any kids enrolled <18 months or whatever is easy cut-off) (We were also able to acquire more recent supplementary data which further illuminate the potential of this model to improve overall family health: from January 2003 through April 2008, 16,457 individuals (9718 adults and 6739 children) enrolled in MTCT-Plus Initiative programs in Cameroon, Cote d’Ivoire, Kenya, Mozambique, Rwanda, South Africa, Uganda, Zambia and Thailand. Overall, 4275 (45%) women enrolled during pregnancy and 3611 (37%) women enrolled during the postpartum period. Additionally, 1569 male partners and 449 older children living with HIV infection were enrolled and able to access comprehensive HIV care and treatment services. More than 6000 women chose to enroll their newborn child into the follow-up program where a battery of services – including early infant diagnosis, opportunistic infection prophylaxis, growth monitoring and antiretroviral treatment – were provided. HIV infection status was determined in more than 70% of the exposed infants, an unusually high percent compared with traditional PMTCT programs; approximately 10% of exposed infants were found to be HIV-infected. )

Partner enrollment varied by country and site in the MTCT-Plus Initiative % women enrolling a partner PLT note: I included “other” adult in the HH because it seemed pertinent to the inclusive idea of family – that can be taken out if you want

Findings from the MTCT-Plus Initiative The majority of women enrolled during pregnancy received multi-drug ART regimens: 47% received short course ARV prophylaxis 20% initiated HAART 30% received single-dose nevirapine Women initiating HAART during pregnancy exhibited excellent immunologic response with an average increase of 451 cells/mm3 after 30 months on treatment Retention in care for those initiating ART was high: 82% for pregnant women, 86% for men, and 87% of non-pregnant women at 30 months of follow-up Women receiving HAART were almost twice as likely to become pregnant compared with those in care, likely reflecting improved health and future outlook Photo – old M+ or cameroon PLT note: Photo is from Cameroon

Conclusions HIV infection affects the health and well being of families as well as individuals Most HIV prevention, care and treatment programs have been established to address the needs of the individual, neglecting the family Prevention of vertical transmission services offer an unequaled opportunity to Address the comprehensive health needs of the mother and child Engage partners, children and other family members in HIV testing, care and treatment services Enhance PMTCT outcomes by engaging family members To date, few models of family-focused PMTCT have been trialed or evaluated Renewed global attention and commitment to health needs of women and children provides an opportunity to focus attention on the importance of families as a means to keep families healthy and children free of HIV infection

Special thanks to Patricia Toro, Chloe Teasdale, Wafaa El-Sadr, Fatima Tsiouris, Theresa S. Betancourt, Ryan McBain, Mary C. Smith Fawzi Film Credits: By Gideon Mendel Editor Mo Stoebe Field Producer Patricia Toro Text Editor Katie Boot Composer Geoffrey Kigundu Music by MU-JHU Cares MDD Group and Florence Kaweesa Add’l Sound Design Adam Lieber Bill and Melinda Gates Foundation William and Flora Hewlett Foundation Robert Wood Johnson Foundation Henry J. Kaiser Family Foundation John D. and Catherine T. MacArthur Foundation MTCT-Plus Initiative David and Lucile Packard Foundation Rockefeller Foundation Starr Foundation U.S. Agency for International Development (USAID)