Caring for Mothers and Children: Towards the Millennium

Development Goals

Philippa Musoke MBChBDepartment of Paediatrics and Child HealthMakerere UniversityKampala UGANDA andMU-JHU Research Collaboration

Outline of Presentation• Maternal and under five child mortality

• HIV infection in women and children

• Prevention of mother-to-child HIV transmission

• Achieving the Millennium Development goals

Maternal and Child Mortality: the Global Picture

• 500,000 women die annually (1 women dies / minute)– 99% from low and middle income countries

• 8 million children < 5 years die annually (1 child dies/ 3 sec)– > 90% from low and middle income countries

• 4 million newborns die annually• Contribute to 30 - 50% of all under five deaths

Most of these deaths are preventable and related to infectious diseases and malnutrition

In this day and age………... this is unacceptable !

Causes of under five mortalityGlobal 2008

Prevalence of under nutrition in regions of the world, 2008

Proportion of under 5 mortality attributable to HIV Sub-Saharan Africa

Stanecki K et al Sex trans Infect 2010

Global distribution of causes of maternal deaths 1997-2007

MM Ratio for 2000 by world region and medical cause

Lancet 2006

INTERNATIONAL COMMITMENTS

• UN Millennium Development goals (MDGs by 2015)– PMTCT affects MDG 4, 5 & 6 and 3

• G8 Nations - Universal access for HIV prevention, care & treatment by 2010

• UNGASS 2001 – reduce # of HIV infected infants by 50% (2010) – Ensure 80% women accessing antenatal care receive

PMTCT services

• Abuja Call to Action in 2005 “Call to Action” for an AIDS free generation

• UNICEF – “Unite for children Unite Against AIDS”

Prevention of Mother to Child Transmission of HIV contributes to multiple MDGs

MDG 4 - reduction in child mortality

MDG 5 – reduction in maternal mortality

MDG 6 – combat HIV/AIDS, malaria and other diseases

MDG 3 - promote gender equality and empower women

MDG 1 – reduce underweight

WHO – The 4 prongs of PMTCT• Primary Prevention of HIV infection

• Prevention of unintended pregnancies in HIV infected women

• Prevention of HIV transmission from HIV infected women to their infants

• Provision of treatment , care and support for HIV infected women, their infants and their families

Virtual elimination of mother-to-child transmission of HIV is possible!

MTCT HIV transmission by CD4 cell count

Children and AIDS 5th Stocktaking report 2010

Coverage and health-seeking behavior go together

Typology A Typology B

Typology C Typology D

Botswana – 99% South Africa – 88% Namibia – 88% Swaziland -88%

> 80% ARV coverage 60-79% ARV coverage

30-59% ARV coverage <30% ARV coverageGhana - 27%Cameroon - 27%India – 26%Ethiopia – 20%

Malawi – 58%Zimbabwe – 56%Cote d’Ivoire – 54% Uganda – 53%

Kenya – 73%Tanzania – 70%Mozambique – 70%Zambia – 69%Lesotho – 64%

Angola – 19%Nigeria – 13%Burundi – 12%Chad – 6%DRC – 6% AR

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Maternal antiretroviral therapy improves health and survival of mother and infant

• Maternal antiretroviral therapy– improves maternal health– Improves maternal survival

• A mother who is alive and healthy– Improves child survival and child health– Improves health seeking behaviour for herself and

her infant

Stopped Breastfeeding

Continued Breastfeeding

Early Cessation of Breastfeeding Was ParticularlyHarmful for Children Who Became HIV-Infected

p = 0.01

Survival of HIV-infected Children with Positive Results before Age 4 Months by Group Assignment (Abrupt vs Standard Weaning)

Kuhn L et al. NEJM 2008

Early Infant HIV diagnosis using DBS for HIV DNA PCR

Blood collected by dried blood spots (DBS)

•Collection of specimens from remote places

•Easy storage of samples

•Centralized testing for HIV DNA PCR – reduces costs

•Early HIV infected infants diagnosis

•Referral of infected infants for early care and treatment

Photo by Pathfinder Kenya PMTCT

Percentage of children <15 years receiving antiretroviral therapy by region, 2009

PMTCT Benefits• Reduced the number of HIV infected children• Increased number of infected children on ART with

improved survivalGLOBAL MORTALITY reduced in children < 5 years• Increased the number of women on ART with

improvement in their health and survival– Leading to improve health and survival of HIV exposed

and infected children– Reduced the number of orphans

Scale-up of PMTCT Commitment required from ALL • Decentralization and improvement of service delivery

• Integration – PMTCT into routine antenatal, delivery and postnatal care

– Paediatric HIV care into routine MNCH services

– Paediatric HIV treatment into existing treatment programs

• Linkage of mother and infected partner to HIV care and treatment

UNAIDS

MDG 4

• Goal 4: Reduce child mortality rates• Target 4A: Reduce by two-thirds, between

1990 and 2015, the under-five mortality rate – Under-five mortality rate– Infant (under 1) mortality rate– Proportion of 1-year-old children immunized

against measles

UNICEF/Pirozzi

Achieving the MDGs – Global progress 2008

Proportion of under 5’s who received survival intervention ( 42 countries)

Stanecki K et al Sex Transm Infect 2010

Reducing neonatal mortality• Improving maternal health

• Reducing maternal mortality

• Delivery with a skilled birth attendant

• Identification of early danger signs in new born infants and referral for appropriate care

Rotavirus vaccine • Rotavirus accounts for 39% of all diarrhoeal disease

worldwide– 500,000 children die from rotavirus disease per year

• Rotavirus vaccines can prevent severe diarrhoeal disease– Efficacy ranges 50%-90% (lower in regions with higher

mortality)– RotaTeq and Rotarix vaccines – available internationally

• Effective in HIV infected children (57% - Steele AD et al PIDJ 2011)

WHO, Rotavirus position paper: Weekly epidemiological report 2009

Pneumococcal Vaccine• Pneumococcal disease

– Leads to 700, 000-1 million deaths per year

• Polyvalent conjugated pneumococcal vaccine– Invasive disease reduced by 75- 100 % in both

resource-rich and resource-poor countries

– Effective in HIV infected children but lower efficacy (Thanee C et al Vaccine 2011, Madhi SA et al PIDJ 2005)

WHO, Pneumococcal vaccine position paper: Weekly epidemiological record 2007

Malaria Vaccine

• Malaria causes 10% of under five deaths worldwide

• RTS,S/AS01E lead candidate vaccine• Randomized clinical trial of 894 children ( age 5-17 months)

from Tanzania and Kenya• 447 malaria vaccine vs 447 rabies vaccine

• Protective efficacy - (per protocol analysis)– 46% (24.1 -63.1) p=0.0004 after 15 months of FU

• Promising results but higher efficacy required

Olotu A et al Lancet Inf Dis 2011

Global Alliance for Vaccines and Immunizations (GAVI)

“Saving childrens lives” – June 13th 2011 London

• Major public and private donors – $ 4.3 M

• GAVI committed to immunizing 250 million children in the next 5 years ( $ 7.6 M)

MDG 5 • Goal 5: Improve maternal health• Target 5A: Reduce by three quarters, between 1990

and 2015, the maternal mortality ratio – Maternal mortality ratio– Proportion of births attended by skilled health personnel

• Target 5B: Achieve, by 2015, universal access to reproductive health – Contraceptive prevalence rate– Adolescent birth rate– Antenatal care coverage– Unmet need for family planning

UNICEF

Reduction in maternal mortality • Education of the girl child

• Economic empowerment of women

• Family planning and child spacing

• Access to a skilled birth attendant for delivery

• PMTCT– ART for their own health and for PMTCT

Unmet needs for family planning in countries with generalized epidemic, 2006-2008 (>

30%)

UNAIDS Report 2010

Coverage of skilled birth attendant at delivery, 2008

Trends in maternal mortality in select countries

MDG report 2010

Conclusion• It is a human right for every woman to survive pregnancy

and child birth and their child to reach their 5th birthday

• The interventions needed to prevent the majority of maternal and child deaths are well known ….– And yet MOST countries will not achieve the MDGs unless

drastic measures are taken

THEREFORE governments, civil societies and international donors need to commit to scale up these well known high impact, low cost interventions that can prevent most of these deaths

ELIMINATE PAEDIATRIC HIV and Care for the Mother and Child

LET US KEEP THE PROMISE

THANK YOU

Acknowledgements• C Giaquinto• MG Fowler• D Mbori-Ngacha• L Mofenson