Title: Towards Universal Access
1Towards Universal Access
Antiretroviral Drugs for Treating Pregnant Women
and Preventing HIV Infection in Infants in
Resource-Limited Settings
Recommendations for a Public Health
Approach BASED ON WHO GUIDELINES
Dr. S.K CHATURVEDI Dr. KANUPRIYA CHATURVEDI
2OBJECTIVES
- To understand the role of antiretroviral in
prevention of mother to child transmission of HIV - To understand the rationale behind the new
guidelines - To know about the new WHO guidelines on use of
antiretroviral in prevention of mother to child
transmission of HIV(PMTCT) - To be able to select appropriate interventions
for prevention of MTCT of HIV
3Global inequities in the prevention of
mother-to-child transmission of HIV
- More than 95 of paediatric HIV infection occurs
in resource-limited settings - Virtual elimination of HIV infection in infants
with MTCT rates - Low coverage and uptake in resource-limited
settings - Less than 15 of pregnant women tested for HIV
- Less than 10 are offered ARV prophylaxis
- Less than 5 of HIV-infected women in need of
treatment are offered ART
4Timing of MTCT
- HIV-1 transmission can occur during intrauterine,
intrapartum, and post-partum period. The
estimates of timing of vertical transmission
differ between breast-feeding and
non-breast-feeding population. - Various studies have shown that the estimates for
intrauterine, intrapartum, and postpartum period
as ranging between 23-30 , 45-50, and 30-35
among breast-feeding population - The efficiency of MTCT of HIV-2 was reported to
be 1.2 when compared to 24.7 of HIV-1 that is
almost 20 times lesser than that of HIV-1.. - NNRTIs such as Nevirapine is not effective
against reducing the risk of transmission of
HIV-2. - In breastfeeding populations, up to 44 of the
infections can be attributed to breastfeeding,
depending on the duration of breastfeeding and
through risk factors such as presence of
mastitis, breast abscess and other local factors.
5Comprehensive approach to prevent HIV infection
in infants
- Prevention of
- HIV in
- parents to be
Prevention of unintended pregnancies among
HIV-infected women
Prevention of transmission from an HIV-infected
woman to her infant
Care and support for HIV-infected women, their
infants and their families
6WHO Guidelines for PMTCT
- 2000 Initial guidance
- 2004 Adoption of simplified and standardized
regimens - 2005 Updated guidelines on the use of
ARV drugs for treating pregnant women and
preventing HIV infection in infants - 2006 Updated to incorporate new evidence
align with the international commitment to
universal access to HIV prevention, care,
treatment and support services
7A Public Health approach to PMTCT services
The main purpose of adopting a public health
approach is to ensure access to high-quality
services at the population level, while striking
a balance between the best proven standard of
care and what is feasible on a large scale in
resource-constrained settings.
8The need for effective PMTCT Regimens for
resource-limited settings
MTCT has been reduced to bear 0.6 of the global paediatric HIV burden
9Evidence-based recommendations taking into
account scientific evidence and programmatic
experiences
- Recommendations based on evidence from
- randomized controlled trials
- high-quality scientific studies for
non-treatment-related options - observational cohort data,
- expert opinion where evidence is lacking or
inconclusive
10Evidence from short course PMTCT studies
- Efficacy of AZT alone or AZT/3TC regimens
decreases with breastfeeding, particularly with
prolonged breastfeeding - In contrast, efficacy of sd-NVP less affected by
breastfeeding - A combination regimen of AZT plus sd NVP is more
effective than single drug regimens in
formula-fed and breastfeeding populations - AZT plus sd NVP is equally effective as a more
complex regimen of AZT/3TC sd NVP and an
AP-IP-PP regimen of AZT/3TC
11Evidence from short course PMTCT studies
- Estimated 20-30 of pregnant women meet WHO
criteria for initiating ART for their own health - Advanced disease, low CD4 are associated with
higher MTCT, even in women receiving short-course
ARV prophylaxis - Risk of NVP resistance after sd-NVP, given alone
or with other ARVs, significantly higher in women
with indication of ART - An AZT/3TC tail given at the time of Sd-NVP and
for a short time in the postpartum reduces
development of NVP resistance
12Initiating ARV treatment in pregnant women
(based on clinical stage and availability of
immunological markers)
13Recommended regimens for treating pregnant women
and prophylactic regimen for infants
- Women, including pregnant women, who need ART for
their own health should receive this - Women who do not need ART should be offered ARV
prophylaxis for MTCT prevention
The recommended prophylactic regimen
is Mother Antepartum AZT starting at 28 wks
of pregnancy or as soon as thereafter Intrapartu
m Sd-NVP AZT/3TC Postpartum AZT/3TC for 7
days Infant Single dose NVP plus one week AZT
14Recommended first-line ARV regimens for treating
pregnant women and prophylactic regimen for
infants
If the mother receives pregnancy, give 4 wks of infant AZT
15Different approaches for using ARV prophylaxis to
prevent HIV infection in infants
1 If the woman receives at least 4 wks of AZT
during pregnancy, omission of maternal NVP dose
may be considered the infant NVP dose must be
given immediately at birth Infant 4 wks of AZT
instead of 1 wk and women do not require 7-day
tail of AZT and 3TC. 2 If the mother
receives of infant AZT recommended
16ARV prophylaxis for MTCT prevention among
pregnant women who have not received antenatal
ART or prophylaxis
17ARV prophylactic regimens for infants born to
HIV-positive women who have not received
antepartum or intrapartum ART or ARV prophylaxis
NVP administered immediately after birth, if
possible within 12 hours after delivery, is
likely to result in a larger reduction in
transmission than later initiation. Data on
added efficacy of 4 weeks of infant AZT in this
situation limited
18Special considerations in the guidelines
- Pregnant women living with HIV who have anaemia
- Pregnant women living with HIV who have active
tuberculosis - Management of injecting drug-using pregnant women
living with HIV - Pregnant women with HIV-2 infection
- Women with primary HIV infection during pregnancy
19Antiretroviral drugs for preventing HIV postnatal
transmission through breastfeeding
- Current UN recommendations on HIV and infant
feeding remain valid, irrespective of whether a
woman is receiving ART - Women receiving ART who are breastfeeding should
continue their ARV regimen - The use of ARV drugs in the mother and/or infant
solely to prevent MTCT through breastfeeding is
currently not recommended
20Continuum of care for HIV-exposed children
- Immunization
- Growth monitoring
- Co-trimoxazole prophylaxis
- Postnatal longitudinal follow up, including
diagnosis - Early diagnosis of HIV infection
- Nutritional support as necessary
- HIV/AIDS care, treatment and support services
21Guiding principles of the Guidelines
Integrated delivery of PMTCT interventions within
MCH services
WHO comprehensive strategic approach to the
prevention of HIV in infants and young children
A public health approach for
increasing access to PMTCT services
Necessity for highly effective ARV regimens for
eliminating HIV infection in infants and young
children
Women's health as the overarching priority in
decisions about ARV treatment during pregnancy
22KEY POINTS
- More than 90 transmission occurs in low resource
countries - MTCT can be reduced to low levels2
- Increasing evidence of resistance to single dose
Nevirapine - New WHO guidelines for selection of appropriate
drugs available