1. l Children living with HIV/AIDS l New HIV infections in children in 1999 l Child deaths due to HIV/AIDS in 1999 l Cumulative number of child deaths due to HIV/AIDS June-2000 global estimates Children (<15 years) 1.3 million 620 000 500 000 3.8 million

2. Estimated impact of AIDS on under-5 child mortality rates – Selected African countries, 2010 Source: US Bureau of the Census 250 200 150 100 50 0 per 1000 live births with AIDS BotswanaKenyaMalawiTanzaniaZambiaZimbabwe without AIDS

3. Prevention of Mother to Child Transmission (PMTCT). during late pregnancy. during labor. through breast-feeding Prevention of unwanted pregnancies (Family Planning) Three integrated strategies to reduce paediatric AIDS Primary HIV prevention in parents to be

4. Primary HIV prevention in the context of pregnancy l Information, Education and Communication programmes l Screening and treatment of Sexually Transmitted Infections l Condom promotion l HIV counselling NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeeding l Information, Education and Communication programmes l Screening and treatment of Sexually Transmitted Infections l Condom promotion l HIV counselling NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeeding

5. Benefits of information, counselling and voluntary HIV testing for the community Widespread availability and use of counselling and voluntary HIV testing can : l Reduce fear, ignorance and stigma surrounding HIV l Stimulate a community response in support to those needing care l Contribute to an environment supportive of safer sexual behaviour l Reduce spillover of artificial feeding to HIV(-) mothers Widespread availability and use of counselling and voluntary HIV testing can : l Reduce fear, ignorance and stigma surrounding HIV l Stimulate a community response in support to those needing care l Contribute to an environment supportive of safer sexual behaviour l Reduce spillover of artificial feeding to HIV(-) mothers

6. Family Planning Strengthening l To prevent unwanted pregnancies HIV should never be used as a reason to pressurise women into having or not having children HIV should never be used as a reason to pressurise women into having or not having children l To delay subsequent pregnancies For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. l To replace the contraceptive effect of breastfeeding Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancy Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancy l To prevent unwanted pregnancies HIV should never be used as a reason to pressurise women into having or not having children HIV should never be used as a reason to pressurise women into having or not having children l To delay subsequent pregnancies For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. l To replace the contraceptive effect of breastfeeding Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancy Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancy

7. Prevention of MTCT through antiretrovirals Mechanisms of action: l Ante and intra-partum regimen: Reduce viral load in mother s blood and genital fluids during pregnancy, labor and delivery Reduce viral load in mother s blood and genital fluids during pregnancy, labor and delivery l Post-partum regimen: Act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated) Act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated) Mechanisms of action: l Ante and intra-partum regimen: Reduce viral load in mother s blood and genital fluids during pregnancy, labor and delivery Reduce viral load in mother s blood and genital fluids during pregnancy, labor and delivery l Post-partum regimen: Act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated) Act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated)

8. Non-antiretroviral based intervention to prevent MTCT at birth l Ceasarian section : 50% risk reduction if performed before onset of labour l Avoidance of unnecessary invasive procedures (episiotomy, rupture of membranes…) : reduce infant contact with mother s infected blood and genital fluids l Vaginal lavage with chlorhexidine : may be protective in case of prolonged rupture of membrane (>4 hours before delivery) l Vitamin A supplementation : not effective to reduce MTCT l Ceasarian section : 50% risk reduction if performed before onset of labour l Avoidance of unnecessary invasive procedures (episiotomy, rupture of membranes…) : reduce infant contact with mother s infected blood and genital fluids l Vaginal lavage with chlorhexidine : may be protective in case of prolonged rupture of membrane (>4 hours before delivery) l Vitamin A supplementation : not effective to reduce MTCT

9. Prevention of MTCT after birth l Avoidance of breastfeeding = Replacement feeding: First 4-6 months: - Commercial infant formula - home made infant formula (diluted animal milk + sugar + vitamins) From 6 months to 2 years: - Enriched family foods l Exclusive breastfeeding + early weaning (as soon as replacement feeding is feasible and safe) l Avoidance of breastfeeding = Replacement feeding: First 4-6 months: - Commercial infant formula - home made infant formula (diluted animal milk + sugar + vitamins) From 6 months to 2 years: - Enriched family foods l Exclusive breastfeeding + early weaning (as soon as replacement feeding is feasible and safe)

10. The variable risk of MTCT of HIV (with and without preventive interventions)

11. ARV regimen of proven efficacy Antenatal Intrapartum Postnatal ZDV long ZDV short ZDV+3TC (1) ZDV+3TC (2) NVP Infant Infant+Mother 14wk 36wk Onset of labour Delivery Birth 1wk PP 6wk PP Infant

12. Balancing the risks of breastfeeding and formula feeding 6 wks 14 wks 6 months 12 months 24 months Child age Source: Nduati et al. JAMA 2000

13. A cascade of interventions P Pregnant Pre-test counselling Test accepted Results given ARV initiated ARV completed Safer infant feeding ANC Infections averted

14. Botswana pilot programme example First 8 months P HIV+ Pregnant Pre-test counselling Test accepted Results given ARV initiated ARV completed Safer infant feeding ANC Infections averted (estimated) N=2900 N=1650 N=754 N=435 232 174 N=638 70

15. Botswana: Challenges and Responses Challenges : l Offer pre-test counselling to all women l Increase acceptability of HIV test Responses : l Train all mid-wives and doctors in HIV counselling l Develop communication programmes l Involve partners and/or other significant relatives Challenges : l Offer pre-test counselling to all women l Increase acceptability of HIV test Responses : l Train all mid-wives and doctors in HIV counselling l Develop communication programmes l Involve partners and/or other significant relatives