Transcript Document

Prevention of Mother to
Child Transmission of HIV
Session Objectives
 By the end of this session participants would
be able to:
 Describe the magnitude of the problem
and its impact;
 Describe the routes, rates and risks of
HIV transmission from mother to child.
Magnitude of the Problem
• MTCT most significant source of HIV
infection in children below age 15.
• More than 5 million children infected
since beginning of epidemic.
• Almost 4 million children have died.
• 90% of MTCT occurs in Africa.
• Transmission higher in developing
countries than in industrialized
countries due to lack of treatment.
Estimated impact of AIDS on under-5 child
mortality rates, select African countries, 2010
250
Without AIDS
200
With AIDS
150
100
50
0
Botswana Kenya
Malawi
Source: US Census Bureau
Tanzania
Zambia
Zimbabwe
Routes, Rates,and Risk Factors of Vertical
Transmission
HIV Transmission to Infants
• Less than 60 % of babies born to HIV-positive
mothers become infected
• Peri-natal
– In utero (during pregnancy)
– Intrapartum (during delivery)
• Post-natal
– Breastfeeding (risk of increases over time. The
longer the baby is breastfed the greater the risk of
infection)
Routes of MTCT of HIV
Father
Intercourse
Mother
Pregnancy
Labor & Delivery
Breastfeeding
Infant
Risk Factors during Breastfeeding
UNICEF/Pirozzi
• Prematurity
• Duration of breastfeeding
• Infant immune responses
• Mixed feeding
• Maternal viral load
• Mastitis
Balancing the Risks of BF and Formula
Feeding
HIV Infection rate-Breast-feeding
Mortality rate-Breastfeeding
40%
12 months
6 months
30%
HIV Infection rate-Formula feeding
Mortality rate-Formula feeding
24
months
14 wks
6 wks
20%
10%
Child age
0%
Source: Nduati et al. JAMA 2000
Weighing the Risks and Benefits
of Breastfeeding with HIV
• Replacement feeding prevents transmission of
HIV through breastfeeding
• But:
– Essential to have sterile water
– Risk of death due to artificial feeding?
– Cost of replacement feeding?
– Stigma if not breastfeeding?
– Early return of fertility?
Risk Factors for MTCT during
Pregnancy and Delivery
• Maternal Factors
– Stage of maternal HIV
disease (viral load)
– Maternal nutritional status
– Disruption of placental
barrier integrity
– STD during pregnancy
• Factors related to the child
– Genetic characteristics
suspected as potential risk
• Obstetrical Factors
– Vaginal delivery (versus
C-section)
– First-born of twins
– Pre-term delivery
– Hemorrhage during
labor
– Bloody amniotic fluid
– Invasive procedures
• Viral Factors
– MTCT rates higher for
HIV-1 than for HIV-2
Benefits of Breastfeeding
• Benefits for Infants
– Adequate nutrition
– Provides protective against infections through
maternal antibodies
– Increase intellectual potential (?)
– Promotes bonding between mother and infant
• Benefits for Mothers
– Facilitates uterine contraction
– Protects against excessive blood loss
– Delays the return of normal menstruation
– Contributes to child spacing
– Promotes bonding between mother and infant
– Conforms to social norms
Rates of Vertical Transmission Without
ART
• Pregnancy/delivery/breastfeeding…………35%
(no intervention)
• Pregnancy/delivery/replacement feeding….20%
(BF contributes 15%)
Risk of Transmission
Transmission Rate (%)
Timing
No BF
BF through 6
months
BF through
18-24 months
During pregnancy
5 – 10
5 – 10
5 – 10
During labor
10 – 20
10 – 20
10 – 20
Early infection
(first 2 months)
5 – 10
5 – 10
Late infection
(after 2 months)
1–5
5 – 10
25 – 35
30 – 45
Through BF
Overall
15 – 30
Source: De Cock KM et al. 2000.
The Variable Risk of MTCT
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%
Probability of MTCT of HIV
(No intervention)
Mother
Pregnancy/delivery
HIV+ Infants
HIV- Infants
(20)
(80)
Post partum & BF
HIV+
(12)
Estimated outcome based on 100 single births to HIV infected mothers
HIV(68)
Probability of MTCT of HIV
(Nevirapine)
Mother
Pregnancy/delivery
HIV+
Infants
(10)
HIV- Infants
(90)
Post partum & BF
HIV+
(14)
Estimated outcome based on 100 single births to HIV infected mothers
HIV(76)
UNICEF/90-033/Sprague
Strategies for the Prevention of
MTCT
A Comprehensive Approach to Prevent HIV
Infection in Infants and Young Children
WHO, 2000
Four Integrated Strategies to Reduce
Pediatric AIDS
(WHO/UNICEF 4 Pillars of MTCT)
1. Primary
prevention of
HIV in young
adults
2. Prevention of
unwanted pregnancies
among HIV+ women
(family planning)
3. Prevention of
transmission
from mother to
child
4. MTCT-Plus:
care and support
for HIV+
women, their
infants, and
families
1. Primary
HIV
prevention in
parents-to-be
2. Prevention
of unwanted
pregnancy in
HIV+ women
3.Prevention
of HIV
transmission
from MTC
4. MTCT-Plus:
care &
support for
HIV+ women
and families
IEC on prevention and care
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Condom promotion
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VCT
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Family Planning (dual protection)
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STI treatment
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MTCT Prevention
components and their
contribution to the
four-pronged strategy
Antenatal care
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Prophylactic ART regimens
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Safe delivery practices
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Support for safer infant feeding
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Community action to reduce
stigma and discrimination and
increase support for programs
Clinical and community care
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Strategy 1: Primary Prevention of HIV
Infection
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Safe sexual behavior and condom use
Reproductive health services
Management of STIs
VCT
HIV prevention interventions aimed at
pregnant and lactating women, and women
of child bearing ages
Strategy 2: Prevention of Unintended
Pregnancies in HIV+ Women
• Strengthening family planning services
– To prevent unintended pregnancies
– To delay subsequent pregnancies
– To replace the contraceptive effect of
breastfeeding
• Access to safe abortion services where
allowed by law
• VCT so that they know their HIV status
Strategy 3: Prevention of Transmission in
HIV+ Women
•
Pregnancy and delivery
– Antiretroviral therapy (ART)
– Vaginal disinfection (little evidence of success and
can increase inflammation)
– Improved obstetrical practices (avoid unnecessary
invasive procedures, safer delivery)
– Treatment of STIs
•
Breastfeeding
– Good nutrition and good BF technique instruction
– Short course ART for baby
Strategy 4: MTCT-Plus
• Secondary HIV prevention
• Clinical care (including
ART)
• Community care
• Stigma reduction
• OVC services
• Impact mitigation
Approach to HIV VCT in ANC Settings
• "Opt in" approach:
– HIV VCT is offered to pregnant women as a
separate intervention from routine ANC and
women are requested to provide explicit
consent to receive the intervention (VCT)
• "Opt out" approach:
– HIV is offered to pregnant women as part and
parcel of routine ANC and women are given
the option to refuse the intervention based on
their personal/individual situation