1. PMTCT around the world Where are we? PMTCT Experts Roundtable Geneva, 23-34 June 2008

2. WHO protocol: women in need of ART  treat For the newborn  AZT for 1 or 4 weeks (depending on the time on ART of the mother)

3. Women not needing ART

4. Infant feeding When replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS), avoidance of all breastfeeding by HIV+ mother is recommended. Exclusive breastfeeding is recommended for HIV+ women for the first 6 months unless replacement feeding is AFASS for them and their infant. Continue beyond 6 months (add complementary food) if RF still not AFASS

5. US Guidelines Ante-partum HAART (avoid EFV, TDF, NFV, d4T+ddI) started after 1 st trimester (before if for her own health). Elective C/S for women with HIV RNA >1,000 IV AZT during delivery Avoidance of breastfeeding AZT 6 weeks for the newborn

6. IMPLEMENTATION From Toward Universal Access Progress Report 2008

7. HIV testing and Counselling 18% of pregnant women received an HIV test18% of the total estimated number of pregnant women in low- and middle-income countries (20.6 million of 115 million pregnant women) received an HIV test in 2007 (from 16% in 2006 and 10% in 2004) Testing coverage varies between 4% in Nigeria and 65% in Zambia Antenatal care is relatively high in most of low- and middle income countries (75%) but PICT is still not implemented

8. Antiretrovirals for PMTCT 33% of HIV+ pregnant women received ARV for PMTCT33% of HIV+ pregnant women received ARV for PMTCT (491.000/1.5 mil). From 23% in 2006 and 10% in 2004. Some dramatic success in reducing transmission: –From 30.5% to 11.4% (2001-2007) in Cambodia –From 30.5% to 8.9% (2001-2007) in Rwanda

9. Coverage for ARV in PMTCT - 2007

10. Big differences among countries

11. Coverage of infant prophylaxis 20% by the end of 200720% by the end of 2007 (7% in 2004, 18% in 2006) Widening gap between coverage of antiretroviral for mothers and for infants

12. Antiretroviral regimens used for PMTCT - 2007 60 countries provided disaggregated data (accounting for 60% of the total estimated HIV+ pregnant women): –49% of women received single dose NVP –26% received a combination of 2 ARV –8% receiving a combination of three ARV –Only 7% received ARV for their own health in SSA

13. Availability of CD4 testing in ANC 2007

14. Infant feeding Difficult to have reliable data Exclusive breastfeeding worldwide (< 6 months) increased of 5-6 percentage points in the last 15 years (!) 39% in 2005 (?)

15. Infant management Only 8% were tested within 2 months of birth.Only 8% of the 715.000 children born to HIV+ women in 2007 were tested within 2 months of birth (data from 77 (71%) countries). Only 4% received CTX prophylaxisOnly 4% of exposed children (1.5 Millions) received CTX prophylaxis within 2 months of birth

16. Conclusions Big differences in the recommended protocol between countries Implementation of PMTCT program in low and middle income countries: –Low coverage of testing in ANC, but improving –Sd NVP still widely used –ANC/PMTCT not used as entry point for access to treatment