Best Practices Amy Slogrove 19 July 2016 CTN PMTCT Symposium AIDS 2016 Durban South Africa New HIV Infections in Children 20012015 But 15 million women living with HIV give birth each year unchanged ID: 597294
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Slide1
VERTICAL TRANSMISSION PREVENTION
Best
Practices
Amy
Slogrove
19 July 2016
CTN PMTCT Symposium
AIDS 2016, Durban, South AfricaSlide2
New
HIV Infections in Children: 2001-2015
But:
1.5 million women living with HIV give birth each year – unchanged >50% of pregnant women in LMICs do not receive an HIV-test
150 000Slide3
Hot off the press...
Key updates related to PMTCT
Best practices for a public health approach in high prevalence settingsSlide4
Overview
Timing of HIV Testing
Pregnant women & infants
Maternal Antiretroviral Therapy (ART)Maternal Health & PMTCT Infant ProphylaxisResearch Gaps / Responsibilities
Take Home MessagesSlide5
Timing of HIV Testing: pregnant women
Summary
Routine component of care
All HIV-negative pregnant women retested third trimester, labour, postpartum
Lactating mothers retested periodically
Evidence
4% of breastfeeding women acquired HIV-infection
during
pregnancy or while breastfeeding
(Kenya, Malawi, SA)
20% of postpartum transmission due to
new
HIV-infection in women while pregnant/breastfeeding (Zimbabwe)
Time
HIV Viral Load
Highest RiskSlide6
Timing of HIV Testing: pregnant women
Time
HIV Viral Load
Highest RiskSlide7
Timing of HIV Testing: HIV-exposed infants
Summary
4-6 weeks all HEI:
virologic
testing (DNA-PCR)9 months all HEI: screen with serologic test, if reactive confirm with virologic test
Breastfeeding HEI: serologic test @ 18 months or 3 months after breastfeeding cessation
B
irth
9 months
18 months
Waning
of infant maternally-derived
antibody levels
Evidence
CHER trial – rapid HIV progression < 12 weeks of age
Rapid serologic tests @ 9 months – sensitivity 99.8%
(95%CI 99.5-100%)
Discussion around value of PCR @
birthSlide8
Timing of HIV Testing: Outside of PMTCT Programs
Summary:
More testing
Inpatient care
(diarrhoea, pneumonia, sepsis) Outpatient care
(malnutrition, IMCI & TB clinics)
(
D
evelopmental delay)
Parents, siblings diagnosed with HIV
Evidence
22% of
paediatric
inpatients – undiagnosed HIV infection (Systematic review)
25% of malnutrition clinic attendants (Eastern & Southern Africa)
Highly acceptable to parents & caregivers
PMTCT programs
Inpatient
Outpatient
Developmental
Delay
Parent/SiblingSlide9
Maternal ART
Summary
Simple!
Better for maternal health
Better for PMTCTBetter for programs
Evidence
RCTs: TEMPRANO & START - adults
PROMISE: HIV transmission with triple ART (0.6%) vs.
AZT+sdNVP
(1.8%)
Malawi, South Africa – program feasibilitySlide10
Maternal ARTSlide11
Infant Prophylaxis
Summary
High risk infants
– born to women with:
< 4 weeks ART prior to deliveryViral load > 1000 copies/ml within 4 weeks prior to deliveryIncident HIV infection during pregnancy or while breastfeedingHIV only identified postpartum
Infant dual prophylaxis
(AZT+NVP)
Breastfed – 12 weeks
Formula – 6 weeks
Not high risk
Mothers on ART > 4 weeks
VL < 1000 during last 4 weeks of pregnancy
Infant NVP prophylaxis
Breastfed – 6 weeks
Formula – 4 to 6 weeks
Evidence
HPTN040
– no ARVs during pregnancy; 2/3 drug infant prophylaxis better than 1
HPTN046
– breastfed infants, mothers on ART; no difference in PN transmission with 6 weeks vs. 6 months of infant NVPSlide12
Infant Prophylaxis – just a bridge
Maternal viral load & duration of maternal ART
are key determinants of transmission riskSlide13
Research Gaps / Responsibilities
Maternal & Infant HIV Testing
Better understanding of mothers responses to negative HIV results – testing fatigue?
Does birth testing add value for PMTCT programs, infants & families?Universal maternal ARTTDF/3TC/EFV as effective for PMTCT as the LPV/r based PROMISE regimens?Effect of ART on pregnancy outcomes & short/ long-term HIV-exposed infant outcomes?Infant prophylaxisIs NVP+AZT the right dual therapy combination for high risk infants?
What is appropriate prophylaxis for infants of mothers on failing regimens / with drug resistance ?BreastfeedingFamily & community acceptability of interventions, services, delivery strategiesSlide14
Take Home Messages
Test, test & test again
Pregnant women, HIV-exposed infants & outside of PMTCT programs
Universal maternal ARTBest for maternal health & also most effective for PMTCTInfant prophylaxisOnly a bridge & high risk infants need a stronger bridgeResearch responsibilities
ManyInvest in research competenciesSlide15
CTN International Postdoctoral
Fellowship
Award 2013-2014Joel Singer & Jacquie SasStellenbosch University
University of British ColumbiaUniversity of Cape Town
Acknowledgments