Prevention of HIV infection in infants World Overview And current recommendations

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Prevention of HIV infection in infantsWorld
OverviewAnd current recommendations

• Philippe Gaillard
• World Health Organization
• Department HIV Prevention
• MTCT Unit
• Consultation Communication - Prevention MTCT
• Cuernavaca - Mexico - 6 to 8 February 2002

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Mother-to-child transmission of HIVMagnitude
Source De Cock, JAMA 2000
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Mother-to-child transmission of HIVRisk factors

• Maternal
• Advanced HIV disease (? viral load, AIDS
  symptoms, ?CD4)
• Vitamin A deficiency
• Chorioamnionitis
• Obstetric
• Mode of delivery
• Duration of ROM
• Invasive procedures
• HIV in vagina/cervix

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Mother-to-child transmission of HIVRisk factors
(2)

• Paediatric
• Low birth weight - Prematurity
• Through breastfeeding
• Advanced maternal HIV disease (? viral load, AIDS
  symptoms, ?CD4)
• Longer duration
• Breast pathology
• Infant feeding patterns (mixed feeding?)

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UNGASS Goal

• During the UN special session on HIV/AIDS in June
  2001, 189 countries agreed on the following
  commitment
• By 2005, reduce the proportion of infants
  infected with HIV by 20 per cent, and by 50 per
  cent by 2010

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Prevention of HIV infection in infants3-pronged
framework
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Prevention of HIV in women, especially young women
Prevention of unintended pregnancies in HIV
infected women
Prevention of transmission from HIV-infected
woman to her infant
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Primary prevention

• With particular emphasis on
• Adolescent
• Young women
• Prevention of HIV acquisition during pregnancy
  and delivery

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Prevention of unintended pregnancies

• Reinforcing family planning services
• Expanding knowledge of HIV status to allow women
  and their partner to make informed decisions on
  future reproductive life
• Ensure that HIV-infected women and their partner
  make informed reproductive choices
• Termination of pregnancy where this is legal

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Prevention of HIV transmission from HIV-infected
women to their infant

• The prevention of mother-to-child HIV
  transmission should be part of the minimum
  standard package of care for women who are known
  to be HIV infected and their infants

WHO/IATT Technical Consultation on MTCT (October
2000)
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Prevention of HIV transmission from HIV-infected
women to their infant

• Interventions
• Antiretrovirals prophylactic regimens / treatment
• Safer obstetrical practices
• Safer infant feeding practices

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Prevention of HIV transmission from HIV-infected
women to their infant

• MTCT rates in developed countries lt 5
  (intensive ARV regimens or treatment, elective
  CS, no breastfeeding)
• MTCT rates with ARV MTCT prophylactic regimens in
  breastfeeding populations in developing countries
  20

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Prevention of HIV transmission from HIV-infected
women to their infant

• Use of antiretrovirals
• Benefits of antiretrovirals outweigh potential
  adverse effects
• 18 prophylactic regimens safe and efficient to
  reduce MTCT
• Different antiretrovirals (ZDV, ZDV3TC, NVP)
• Different timing
• Different efficacy
• Choice based on feasibility, efficacy and cost

WHO/IATT Technical Consultation on MTCT (October
2000)
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Prevention of HIV transmission from HIV-infected
women to their infant

• Safer obstetrical practices
• Elective caesarean section where possible
• Limit invasive procedures to medical indications
• Episiotomy
• Artificial rupture of membranes
• Foetal scalp monitoring ...

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Prevention of HIV transmission from HIV-infected
women to their infant

• Safer infant feeding practices
• Replacement feeding when acceptable, feasible,
  affordable, sustainable and safe
• Exclusive breastfeeding otherwise, with
  breastfeeding cessation as soon as feasible
• Local assessment to identify range of options in
  a particular context

WHO/IATT Technical Consultation on MTCT (October
2000)
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Prevention of HIV transmission from HIV-infected
women to their infant

• Safer infant feeding practices - counselling
• All HIV infected mothers should receive
  counselling on infant feeding (information,
  guidance in her choice, support, BF techniques)
• Adequate number of counsellors
• Information and education on MTCT urgently
  directed to general public, affected communities
  and families

WHO/IATT Technical Consultation on MTCT (October
2000)
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Prevention of HIV transmission from HIV-infected
women to their infant

• All interventions to reduce MTCT require
  knowledge of maternal HIV status, thus widespread
  implementation of VCT

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Thailand 1990-99 AIDS cases in children 0 - 4
years
MTCT prevention programme
Source MoPH, Thailand, 2000
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Source UNICEF Oct 2001
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Cascade of interventions and challenges
Pregnant
ANC
Pre-test counselling
Test accepted
Results given
HIV positive
ARV initiated
ARV completed
Safer infant feeding
Infections averted
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Prevention of unintended pregnancies in HIV
infected women
Prevention of transmission from HIV-infected
woman to her infant
Requires information, knowledge,
readiness behaviour change, support
Communication
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