elimination of mother to child hiv: is the end sight? · elimination of mother to child...

Elimination of mother to child transmission of HIV: is the end 

really in sight?Lisa L. Abuogi, MD

University of Colorado, DenverDec 3, 2014

Outline

• Background• History of prevention of mother to child transmission

• The Global Plan to eliminateMTCT• Current progress• Gaps• Conclusion

Middle East & North Africa16 000

[11 000 – 22 000]

Sub-Saharan Africa2.9 million

[2.6 million – 3.2 million]

Eastern Europe & Central Asia14 000

[13 000 – 14 000]

Latin America35 000

[27 000 – 54 000]

Caribbean17 000

[14 000 – 20 000]

Children (<15 years) estimated to be living with HIV2013

Total: 3.2 million [2.9 million – 3.5 million]

Asia and the Pacific210 000

[190 000– 270 000]

North America and Western and Central Europe2800

[2300 – 3600]

Middle East & North Africa2300

[1500 – 3400]

Sub-Saharan Africa210 000

[180 000 – 250 000]

Eastern Europe & Central Asia

<1000 [<1000 – 1200]

Latin America1800

[<1000 – 7400]

Caribbean<1000

[<500 – <1000]

Estimated number of children (<15 years) newly infected with HIV2013

Total: 240 000 [210 000 – 280 000]

Asia and the Pacific22 000

[18 000– 32 000]

North America and Western and Central Europe<500

[<200 – <500]

MTCT in the US

• With treatment during pregnancy and delivery and the avoidance of breastfeeding– <1% transmission

• In 2010, an estimated 217 children < 13 years were diagnosed with HIV in the US (CDC) 

• The number of women with HIV giving birth in US increased ~ 30%, from 6,000–7,000 in 2000 to 8,700 in 2006 (CDC) 

MTCT in Colorado

• Between 2008‐2012 ~20‐30 HIV exposed infants are born annually

• Last reported perinatal transmissions occurred in 2008 N=4– 2/4 were born outside the US

Colorado Department of Public Health and Environment, June 2014

Background

• 90% of HIV infections in children are a result of mother to child transmission

History of perinatal transmission

• 1982 1st report of HIV in children• 1983 vertical transmission confirmed• 1985 1st US guidance for pregnant women• 1987 AZT in pregnancy and delivery reduces transmission by 67%

• 1995 Universal “opt out” testing during antenatal care

• Late 1990’s Botswana launches first PMTCT with short course AZT

• 1997 WHO recommends replacement feeding

History continued• 2000s

– Single dose nevirapine with/out AZT– Most women in resource limited countries don’t receive

• 2003 rapid weaning recommended• 2006 exclusive breastfeeding and gradual weaning, emphasis on ARV prophylaxis

• 2010 WHO PMTCT guidelines Option A vs Option B• 2011 Global plan for the elimination of mother to child transmission

• 2011 Malawi is the 1st country to implement Option B+• 2013 WHO guidelines recommend continuous ART therapy for pregnant women, preferably life long

WHO 2010

WHO Programmatic Update April 2012

• Advantages of Option B+– Simplification of regimen and service delivery– Harmonization with ART programs– Protection against MTCT in current AND future pregnancies

– Avoids stopping and starting of ARVs– Prevention of transmission in discordant couples– Improved clinical outcomes for women

WHO Consolidated Guidelines 2013

• ALL HIV infected pregnant and breastfeeding women should start ART and continue for life

Progress

• 1.1 million HIV infections averted in children < 15 years

• New cases of pediatric infections declined by more than 50% between 2005‐ 2013

Countdown to Zero

• In 2011, Joint United Nations Programme on HIV/AIDS announced a plan to eliminate new HIV infections among children by 2015

There are 22 priority countries for the Global Plan

1. Angola

2. Botswana

3. Burundi

4. Cameroon

5. Chad

6. Côte d’Ivoire

7. DR Congo

8. Ethiopia

9. Ghana

10. India

11. Kenya

12. Lesotho

13. Malawi

14. Mozambique

15. Namibia

16. Nigeria

17. South Africa

18. Swaziland

19. Tanzania

20. Uganda

21. Zambia

22. Zimbabwe

89%of all HIV-positive pregnant women in low- and middle-income countries in 2011

These countries accounted for

2015 Goals

• Reduce the number of new HIV infections among children by 90% from a baseline of 2009

• Reduce MTCT rate <5% among breastfeeding populations, <2% among non‐breastfeeding populations

maternaldeaths

50%reduction inAIDS-related

Progress Toward Global Plan Targets

Source: Towards Universal Access, 2011; Global Report, UNAIDS, 2012

Baseline

28%

34%

16%

0.5%

Baseline

26%21%

61%

48%

21%

28%

90%

5%

90% 90%

50%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Reduce new cases ofpediatric HIV infection

MTCT rate Maternal ARVcoverage

ART coverage formothers

Reduction in maternalAIDS deaths

ART coverage forchildren

2009 Baseline

2011

2015 Target

MTCT in 21 priority countries

The gap in treatment and prophylaxis coverage is uneven among low- and middle-income countries

Source: UNAIDS 2012

Nigeria29%

Mozambique, 7%

Uganda, 8%

India, 6%Ethiopia, 5%

Dem. Rep. of Congo, 5%

Zimbabwe, 5%

Malawi, 5%

Kenya, 5%

Tanzania, 4%

Cameroon, 2%Chad, 2%

Zambia, 2%

Lesotho, Côte d'Ivoire, Angola, Chad, Botswana,

Swaziland, Ghana, Rwanda, Namibia,

Brazil, South Sudan, South

Africa, 3%

Other low- and middle-income countries, 13%

The share of each low- and middle-income country in the total shortfall in providing antiretroviral medication to HIV-positive pregnant women to prevent new HIV infections among children.

New HIV infections among children, 2009–2011

Note: The baseline year for the Global Plan is 2009. Some countries had already made important progress in reducing the number of new HIV infections among children in the years before 2009, notablyBotswana which by 2009 already had 92% coverage of antiretroviral regimens among pregnant women and a transmission rate of 5% (see table pp122–123). In countries with high coverage, furtherdeclines are much harder to achieve.

Will reach the target if the2009–2011 decline of more than30% continues through 2015.

Can reach the target if thedecline in 2009–2011 of20–30% is accelerated.

In danger of not reaching thetarget, with a decline in 2009–2011 of less than 20%.

Source: UNAIDS Estimates 2012

Reality check• Even if the goal is met, roughly 40 000 infants will continue to be infected each year

• Only 67% of pregnant women with HIV received the most effective PMTCT treatment in low and middle income countries

Joint United Nations Programme on HIV/AIDS. Countdown tozero: global plan towards the elimination of new HIV infectionsamong children by 2015 and keeping their mothers alive, 2011–2015. Geneva, Switzerland: UNAIDS; 2011

Number of new infections in children=

Number of HIV+ pregnant women

Mother to child transmission 

rateX

4 prongs of PMTCT

Primary prevention of HIV in women

Primary prevention of HIV in women

Prevention of 

unintended pregnancies

Prevention of 

unintended pregnancies

Prevention of mother to 

child transmission

Prevention of mother to 

child transmission

Care for HIV 

infected women and 

children

Care for HIV 

infected women and 

children

Primary prevention of HIV in women

• Know your status• Treatment of discordant couples• Empowerment

Slight decline in new HIV infections among women 15-49, 21 priority countries

0

200000

400000

600000

800000

1000000

1200000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011Source: UNAIDS Estimates 2012

Unmet family planning need

0510152025303540

Percen

t

Survey 1Survey 2

Source: Demographic and Health Surveys 2000-2011

Reducing MTCT

TEST TREAT RETAIN

Figure1. Kenya Prevention of Mother to Child Transmission CascadeTowards the elimination of mother‐to‐child transmission of HIV in KenyaA framework for eMTCT (NASCOP) Draft 20122

PMTCT Care Continuum

Where are the gaps?

• ~50% of HIV‐infected pregnant women are lost between ANC registration and delivery

• ~34% of HIV‐exposed infants are lost to follow‐up by 3 months 

• 45% of infants are lost after HIV testing

Gaps

• Access• Acceptability• Identification• Right treatment• Stigma, discrimination, GBV• Training of HCW• Adherence• Retention• Primary prevention

Infant Morbidity and Mortality Review

Okoko N.A.1, Owuor K.1, Lewis-Kulzer J.1,3, Owino G.1, Ogolla I.1, Wandera R.4, Bukusi E.A.1,3, Cohen C.R.1,3, Abuogi L.1,2

45 cases and 45 controls compared

Maternal factors lack of awareness of HIV status (OR 5.60, 95%CI 2.16‐14.50),  failure to access anti‐retroviral prophylaxis (OR 22.22, 95%CI 5.84‐84.57),  poor maternal adherence (OR 8.06, 95%CI 3.65‐17.80)

Infant‐related factors  late enrolment of infant to follow up (OR = 7.14, 95%CI 2.63‐16.67),  poor adherence to infant prophylaxis (OR=8.32, 95%CI 3.24 –21.38),  mixed infant feeding (OR = 7.14, 95% CI 2.78‐20.0)

Mothers of cases were also significantly less likely to report having received clinic‐based HIV education and counseling or to report good counseling on medications

Vertical Transmission eliminated

TDF+3TC+EFV Continuous life long HAART for pregnant women

PROMISE StudyNov 17, 2014

Interim results of the PROMISE Studyconfirming that triple ARVs 

for pregnant women are more effective in preventing mother‐to‐child transmission of HIV during pregnancy 

than a single drug‐based regimen

Hope• Less than 200,000 new pediatric infections in 2013– 1st time since 1990s

• Decline in new pediatric infections in ALL 21 priority countries

• The proportion of pregnant women living with HIV who received antiretroviral medicines for PMTCT has doubled in the past                                   5 years, from 33%  to 68% 

• Drug regimens being received                                   are more efficacious

Lisa.abuogi@ucdenver.edu