1. 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

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

3. 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.

4. 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 weeks
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
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

5. 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 weeks
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
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.

6. 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

7. 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

8. The MTCT-Plus Initiative
A multi-country HIV care and treatment program ( )
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

9. 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

10. 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

11. 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

12. 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. )

13. 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

14. 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

16. 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

17. 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)