June-2000 global estimates

Children (<15 years)

 Children living with HIV/AIDS  New HIV infections in children in 1999  Child deaths due to HIV/AIDS in 1999  Cumulative number of child deaths due to HIV/AIDS

1.3 million 620 000 500 000 3.8 million

Estimated impact of AIDS on under-5 child mortality rates – Selected African countries, 2010 with AIDS 250 per 1000 live births without AIDS 200 150 100 50 0 Botswana Kenya Malawi Tanzania Zambia Zimbabwe

Source: US Bureau of the Census

Three integrated strategies to reduce paediatric AIDS

Prevention of unwanted pregnancies (Family Planning) Primary HIV prevention in parents to be Prevention of Mother to Child Transmission (PMTCT) . during late pregnancy . during labor . through breast-feeding

Primary HIV prevention in the context of pregnancy

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Information, Education and Communication programmes

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Screening and treatment of Sexually Transmitted Infections

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Condom promotion

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HIV counselling NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeeding

Benefits of information, counselling and voluntary HIV testing for the community Widespread availability and use of counselling and voluntary HIV testing can :



Reduce fear, ignorance and stigma surrounding HIV

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Stimulate a community response in support to those needing care

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Contribute to an environment supportive of safer sexual behaviour

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Reduce spillover of artificial feeding to HIV(-) mothers

Family Planning Strengthening

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To prevent unwanted pregnancies HIV should never be used as a reason to pressurise women into having or not having children

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To delay subsequent pregnancies For the health of mothers, WHO recommends a minimum of 2 years between pregnancies.

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To replace the contraceptive effect of breastfeeding Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancy

Prevention of MTCT through antiretrovirals Mechanisms of action:

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Ante and intra-partum regimen: Reduce viral load in mother ’s blood and genital fluids during pregnancy, labor and delivery

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Post-partum regimen: Act as post-exposure prophylaxis (viral particles eventually transmitted during birth are eliminated)

Non-antiretroviral based intervention to prevent MTCT at birth

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Ceasarian section : 50% risk reduction if performed before onset of labour

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Avoidance of unnecessary invasive procedures (episiotomy, rupture of membranes…) : reduce infant contact with mother ’s infected blood and genital fluids

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Vaginal lavage with chlorhexidine : may be protective in case of prolonged rupture of membrane (>4 hours before delivery)

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Vitamin A supplementation : not effective to reduce MTCT

Prevention of MTCT after birth

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Avoidance of breastfeeding = Replacement feeding:

First 4-6 months:

- Commercial infant formula - home made infant formula (diluted animal milk + sugar + vitamins)

From 6 months to 2 years:

- Enriched family foods

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Exclusive breastfeeding + early weaning (as soon as replacement feeding is feasible and safe)

The variable risk of MTCT of HIV (with and without preventive interventions) no ARV, prolonged breastfeeding ARV, prolonged breastfeeding no ARV, no breastfeeding ARV, no breastfeeding ARV, no breastfeeding, C-section Infected Uninfected 0% 25% 50% 75% 100%

ZDV long ZDV short ZDV+3TC (1) ZDV+3TC (2) NVP ARV regimen of proven efficacy Antenatal Intrapartum Postnatal

Infant Infant+Mother Infant+Mother Infant 14wk 36wk Onset of labour Birth Delivery 1wk PP 6wk PP

Balancing the risks of breastfeeding and formula feeding 40% 30%

HIV Infection rate-Breast-feeding Mortality rate-Breastfeeding 12 months 6 months 14 wks 6 wks HIV Infection rate-Formula feeding Mortality rate-Formula feeding 24 months

20% 10% 0%

Child age Source: Nduati et al. JAMA 2000

P

A cascade of interventions

Pregnant  ANC Pre-test counselling Test accepted Results given ARV initiated ARV completed Safer infant feeding Infections averted

Botswana pilot programme example First 8 months

HIV+ Pregnant 

N=2900 N=754 N=638 N=435 N=1650

Test accepted Pre-test counselling Results given ARV initiated

232

ARV completed

ANC 174

Safer infant feeding

70

Infections averted (estimated)

Botswana: Challenges and Responses Challenges :



Offer pre-test counselling to all women

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Increase acceptability of HIV test Responses :

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Train all mid-wives and doctors in HIV counselling

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Develop communication programmes

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Involve partners and/or other significant relatives