Infant Survival:Meeting the Challenges of Maternal-Child HIV

Doug Watson MD (Robb Sheneberger MD)University of Maryland, School of Medicine

Institute of Human VirologyMonday August 11

Sixth Annual Tract I Meeting

AIDSRelief Tanzania Challenges

• Only 56% of women who were first seen in either ANC (99% tested) or L&D (28% tested) received HIV CT (but 60% of women were first seen in L&D)

• Only 47% of known positives received any ARV, and 95% of those getting any ARV prophylaxis received only sd-NVP

Age Range of Children on ART

Age Range(years)

N= %

< 5 186 34.70%

5 – 7 104 19.40%

7 – 12 236 44.03%

>12 10 1.87%

536 total charts reviewed. Overall median age for population was 6.5 years

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Detectable

Suppressed

Proportion of Patients VL <200c/mm3

85.4% On Treatment 74.2% ITT (missing=failure)

N=466 N=536

Same country adult suppression on treatment 94.6%

Regimen Choice and Suppression

ARV RegimenN=466

Detectable Suppressed

1st line regimen containing NNRTI

17.87%(n=62)

82.13%(n=285)

1st line regimen containing LPV/r

5.04%(n=6)

94.96%(n=113)

p<.001Children on a Lop/r containing 1st regimen were 11.69 times (Pearson Chi2 = 11.6954) more likely to be suppressed at review than patients on 1st regimen that did not contain Lop/r

NVP and Suppression

ARV RegimenN=466

Detectable Suppressed

1st line regimen not containing NVP( EFV or LPV/r)

9.09%(n=26)

90.91%(n=260)

1st regimen containing NVP

23.33%(n=42)

76.67%(n=138)

p<.0001Children on a NVP containing 1st regimen were 17.98 times (Pearson Chi2 = 17.9804) more likely to have viral failure at review than patients on 1st regimen that did not contain NVP

Common Problems with Care of Infected Children

• Where are they? Average age at ART initiation is 6.5 years meaning most die before diagnosis and treatment

• Delay in infant diagnosis• Unavailability or tardiness of DNA PCR• Lack of understanding of clinical diagnosis-

developmental milestones and growth curves

• ART guidelines that do not recommend treatment of children at high risk of progression (initiating treatment at much too advanced disease in children)

Common Problems with Care of Infected Children

• Use of NVP-based regimen in children exposed to NVP

• Dosing errors (under dosing)• Need for child-specific approach to care &

adherence• Not recognizing treatment failure• Limited options after prolonged initial

thymidine based regimen failure

Problem: Opportunities to reduce morbidity and mortality in HIV-infected and –affected children are being missed.

Response: University of Maryland/IHV AIDSRelief integrated Maternal-Child HIV care strategy

• Establish community-based identification of infected pregnant women

• Engage pregnant women into comprehensive HIV care system• A maternal-child focused approach within a

comprehensive HIV care system rather than a vertically-integrated “PMTCT” program

• Earlier and more aggressive ART for pregnant women

• ARV prophylaxis to protect breastfeeding infants• Data on maternal HAART more mature at this

point than ARV prophylaxis to infant

Minimize transmission from mother to child

Provide a package of support for HIV-exposed infants

• Enroll infected pregnant women and exposed infants in AR program and provide package of care until 2 years of age

• Infant nutrition counseling• Starting in antenatal period and continuing

through infancy• More evidence-based: Base counseling on risk of

HIV infection or death from substitute feeding for the individual infant

• Facilitate general availability of robust early infant virologic diagnosis• Emphasize clinical diagnosis in interim

Rapidly diagnose infants and children

• Facilitate general availability of robust early infant virologic diagnosis

• Training on importance of early diagnosis of infants and children

• Broad testing of children: every child should have his HIV-exposure or HIV-infection status determined• Multiple entry points: Children and siblings of

patients, child health center attendees, in-patients, orphanages, community-based testing, etc.

Ensure long-term health of infected children

• Evidence-based, non-discriminatory identification of children who require ART• Many current guidelines do not treat children at

much higher risk of progression than adult guidelines allow

• Selection of regimens that maximize prospect for long-term viral suppression with minimal toxicity• NVP based regimens with high viral loads and

after sd-NVP exposure inadequate• Failure of current standard thymidine regimens

leaves few options

• Child-focused clinical services

Engage mothers and families in HIV care

• Testing of children & partners of infected women

• The best OVC strategy is to prevent Vulnerable Children from becoming Orphans• Family-based tracking• Family clinic: parents and children seen at same

time• Engagement of parents in care, particularly

fathers

Measure meaningful outcomes applied across the community

• Use ANC seroprevalence and census data to estimate proportion of infected pregnant women who engage in care in communities served by AR

• Monitoring maternal-child care “cascade” on site-specific basis to identify system gaps• Link mothers and children

• Determine final infection status• Determine infant survival (12 months) and at

18 & 24 months• Pediatric targeted evaluation of viral

suppression• Use outcomes data to advance program