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Elimination of Mother-to-Child HIV Transmission: Knowledge to Practice

Elimination of Mother-to-Child HIV Transmission: Knowledge to Practice. Countdown to Zero. Believe it. …………….. Do it. Rangsima Lolekha, MD Chief, eMTCT and Pediatrics Section Global AIDS Program Thailand/Asia Regional Office CDC Southeast Asia Regional Office. Outlines.

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Elimination of Mother-to-Child HIV Transmission: Knowledge to Practice

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  1. Elimination of Mother-to-Child HIV Transmission: Knowledge to Practice Countdown to Zero Believe it. …………….. Do it. Rangsima Lolekha, MD Chief, eMTCT and Pediatrics Section Global AIDS Program Thailand/Asia Regional Office CDC Southeast Asia Regional Office

  2. Outlines • Global goals to elimination of MTCT and AIDS Free Generation • Key summary of PMTCT interventions and new Thai PMTCT guidelines 2014 • Situation of MTCT rate and early infant access to treatment and care in Thailand • UNAIDS recommendations for Country Implementation Action: 10-Point Plan towards eMTCT

  3. Global Goal: Towards EMTCT by 2015 • Global Target #1: Reduce the number of new HIV infections among children by 90% • Global Target #2: Reduce the number of AIDS-related maternal deaths by 50% Launched by UNAIDS and PEPFAR: calls for exceptional global and national efforts • Reduce MTCT of HIV to • <5% in breast-fed population • <2% in non-breastfed population

  4. Millennium Development Goals and EMTCT The EMTCT contributes directly towards achieving four of the MDGs MDG3: Promote gender equality and empower women MDG4: Reduce child mortality MDG5: Improve maternal health MDG6: Combat HIV/AIDS, malaria and other diseases

  5. Key elements of prevention of HIV transmission to babies and keeping their mothers alive

  6. The Virtual Elimination of MTCT of HIV is PossibleEstimated New HIV infections among children 0-14:Different scenarios for 25 countries with largest numbers of HIV+ pregnant women Source: Mahy M, Stover J, Kiragu K, et al. What will it take to achieve virtual elimination of mother-to-child transmission of HIV? An assessment of current progress and future needs. Sex Trans Infect (Suppl) 2010.

  7. Monitoring Framework for 2015

  8. Post partum through breastfeeding In utero Delivery 36 wk -labor During labor 0-14 wk 14-36 wk 0-6 month 6-24 month 7% 3% 1% 4% 12% 8% Estimated Risk and Timing of Mother-To-Child (MTCT) HIV Transmission Source: De Cock KM, et al. JAMA. 2000; 283 (9): 1175-82Kourtis et al. JAMA 2001; DeCock et al. JAMA 2000 The risk of perinatal transmission can now be less than 2% (1 in 50) with: Highly effective ARV therapy (HAART), elective cesarean section as appropriate; formula feeding

  9. PMTCT is the most effective intervention among prevention technologies reducing HIV transmission cART vs. no ARV (076 placebo) (0.8% vs. 25.5%) US/Europe 2006 97% Option A vs. no ARV S Africa (1.5% vs. 22%) Dihn 2011, IAS; Rundare 2012, CROI 93% Karim SSA et al. Lancet 2011;378:e23-25 Adapted from Mofenson L’s slide

  10. Summary of peripartum transmission probabilities by ART regimen and maternal CD4 count (The UNAIDS reference group on estimates, modelling and projections) Incident peripartum infections with no ARV prophylaxis (range of reported transmission probabilities) = 30% (13-30%) The risk of perinatal transmission can now be less than 2% with HAART and formula feeding Rollins N et al. STI 2012

  11. Postnatal Transmission rate per month of any breastfeeding probabilities by ART and maternal CD4 count(The UNAIDS reference group on estimates, modelling and projections) Incident postnatal infections with no ARV prophylaxis (range of reported transmission probabilities) = 28% (14-56%) The risk of perinatal transmission can now be less than 5% with HAART and exclusive BF for 12 mo Rollins N et al. STI 2012

  12. The Mississippi Baby: Functional Cure of HIV Persaud D, 2013 CROI, Abstract 48LB

  13. The Way Forward: Mimicking the Mississippi baby Early diagnosis of infected babies Nation-wide active enrollment Triple ART Including to high-risk Infants immediately after birth Immediate ART to minimize latently infected cells ART interruption in clinical trial Control HIV viremia

  14. Thai GL 2014 สูตรยาต้านไวรัสและระยะเวลาในการให้ยาต้านไวรัสสำหรับหญิงตั้งครรภ์ที่ไม่เคยได้รับยาต้านไวรัสก่อนเริ่มตั้งครรภ์ -ขนาดยา: AZT 200-300 mg q 12 ชม.; 3TC 150 mg q 12 ชม.; AZT + 3TC (300 + 150) q 12 ชม.; LPV/r (200/50) 2 เม็ด q 12 ชม.; EFV 600 mg q24 ชม. • # ในกรณีที่มีอย่างน้อย 1 ข้อต่อไปนี้: • ไม่แน่ใจว่าหญิงตั้งครรภ์จะสมัครใจกินยาต่อหลังคลอดหรือไม่ CD4 >500 cells/mm3 • มีประวัติสามีของหญิงตั้งครรภ์รับการรักษาด้วยยาต้านไวรัสและสงสัยการดื้อยา • หญิงตั้งครรภ์เคยรับยาสูตร AZT+SD NVP มาก่อน

  15. Thai HIV Treatment and Care Guidelines 2014:PMTCT Recommendations • Early HIV diagnosis and immediate lopinavir/r-ART in all HIV-infected infants. The triple-ARV prophylaxis regimen for children at high risk for HIV similar to that in the Mississippi baby. *Infants at high risk for HIV infection: those born to mothers with no ANC, <4 weeks of triple-ART or failing ART (VL>50 copies/mL)

  16. สูตรยาต้านไวรัสเพื่อป้องกันการถ่ายทอดเชื้อเอชไอวีจากแม่สู่ลูกในไทยกรณีไม่ฝากครรภ์หรือเสี่ยงสูงต่อการที่ทารกจะติดเชื้อ 2014 เสี่ยงสูง: ART < 4 wk, poor adherence, VL>50 at 36 wk GA/delivery, recent exposure • ไม่ต้องให้ SD NVP ในหญิงตั้งครรภ์ที่คาดว่าจะคลอดภายใน 2 ชั่วโมง • ถ้าแม่ไม่ได้ SD NVP ไม่จำเป็นต้องให้ tail: AZT+3TC+LPV/r แต่ให้ HAART ต่อตามแนวทางการรักษาในผู้ใหญ่

  17. Timeline for EID and early HIV treatment and care for infants born to HIV+ mothers AZT/3TC/NVP 0 1 mo 2 mo 4 mo ……........12-18 mo age PCR+ at 1 mo AZT+3TC+LPV/r PCR+ at 2 mo AZT+3TC+LPV/r AZT+3TC+LPV/r PCR+ at 4 mo *ให้เก็บเลือดทารกทุกรายที่คลอดจากแม่ติดเชื้อเอชไอวีใส่กระดาษกรองไว้ (dried blood spot) เหมือนตรวจคัดกรองไทรอยด์เมื่อแรกเกิด และส่งเลือดไปที่กรมวิทยาศาสตร์ทางการแพทย์พร้อมการส่งตรวจคัดกรองไทรอยด์ ในกรณีที่เด็กติดเชื้อเอชไอวีจากผล PCR ที่ 1-2 เดือน หากมีเลือดเก็บไว้ที่แรกเกิดทางกรมวิทยาศาสตร์ทางการแพทย์จะตรวจ DNA PCR เพิ่มเติมให้เพื่อวินิจฉัยว่าเป็นการติดเชื้อตั้งแต่ในครรภ์หรือระหว่างคลอด ซึ่งอาจมีผลต่อแผนการรักษาในอนาคต

  18. MTCT Rates 2013: 1.7% (accessed to PCR only) Weighted Average: 2.3% AIDS Zero portal website

  19. Cascade of ARV-PMTCT/ART among Mothers NAP-Plus Database, NHSO 2009-2012 (58.3%) * Under reported Receipt of ARV (%) by Women Giving Birth with HIV-Seropositive (2013-14) 79% for Rx 2012: N = 2,461 (65% report) 2013: N = 3,193 (79% report) Source: DOH as of 17/04/2014

  20. Cascade from Early Infant Diagnosis to Antiretroviral Treatment 2008-2011 EID program evaluation 2008-2011: Thai MOPH, CDC Thailand, UNICEF-Thailand

  21. HIV Treatment Cascade in the Real World • In a perfect world, all HIV infected individuals would follow the same pathway in the spectrum of engagement into care: • In the real world, there is leakage between each of these steps and individuals are often lost-to-follow-up. • Understanding the leakage points and their causes are essential to optimize the effectiveness of HIV treatment program. • Comprehensively monitoring in standardized metrics is needed

  22. Country Implementation Action: 10-Point Plan (1) • Conduct a strategic assessment of key barriers to eMTCT • Develop or revise nationally-owned plans towards eMTCT • Assess the available resources for eMTCT and develop a strategy to address unmet needs • Implement and create demand for a comprehensive, integrated package of HIV prevention and treatment interventions and services • Strengthen synergies and integration fit to context between HIV prevention and treatment and related health services to improve maternal and child health outcomes UNAIDS: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive 2011-15

  23. Country Implementation Action: 10-Point Plan (2) • Enhance the supply and utilization of human resources for health • Evaluate and improve access to essential medicines and diagnostics and strengthen supply chain operations • Strengthen community involvement and communication • Better coordinated technical support to enhance service delivery • Improve outcomes assessment, data quality, and impact assessment UNAIDS: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive 2011-15

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