Prevention of Mother to Child Transmission of HIV

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• Prevention of Mother to Child Transmission of HIV

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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.

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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.

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Estimated impact of AIDS on under-5 child
mortality rates select African countries 2010
250
Deaths per 1000 live births
200
Without AIDS
With AIDS
150
100
50
0
Botswana
Kenya
Malawi
Tanzania
Zambia
Zimbabwe
Source US Census Bureau
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Routes Ratesand Risk Factors of Vertical
Transmission
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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)

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Routes of MTCT of HIV
Father
Intercourse
Mother
Pregnancy
Labor Delivery
Breastfeeding
Infant
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Risk Factors during Breastfeeding

• Prematurity
• Duration of breastfeeding
• Infant immune responses
• Mixed feeding
• Maternal viral load
• Mastitis

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Balancing the Risks of BF and Formula Feeding
12 months
24 months
6 months
14 wks
6 wks
Child age
Source Nduati et al. JAMA 2000
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Weighing the Risks and Benefitsof 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

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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

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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

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Rates of Vertical Transmission Without ART

• Pregnancy/delivery/breastfeeding35
• (no intervention)
• Pregnancy/delivery/replacement feeding.20
• (BF contributes 15)

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Risk of Transmission
Source De Cock KM et al. 2000.
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The Variable Risk of MTCT
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Probability of MTCT of HIV(No intervention)
Mother
Pregnancy/delivery
HIV Infants (20)
HIV- Infants (80)
Post partum BF
HIV (12)
HIV- (68)
Estimated outcome based on 100 single births to
HIV infected mothers
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Probability of MTCT of HIV(Nevirapine)
Mother
Pregnancy/delivery
HIV Infants (10)
HIV- Infants (90)
Post partum BF
HIV (14)
HIV- (76)
Estimated outcome based on 100 single births to
HIV infected mothers
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Strategies for the Prevention of MTCT
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A Comprehensive Approach to Prevent HIV Infection
in Infants and Young Children
WHO 2000
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Four Integrated Strategies to Reduce Pediatric
AIDS (WHO/UNICEF 4 Pillars of MTCT)
3. Prevention of transmission from mother to
child
1. Primary prevention of HIV in young adults
4. MTCT-Plus care and support for HIV women
their infants and families
2. Prevention of unwanted pregnancies among HIV
women (family planning)
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(No Transcript)
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Strategy 1 Primary Prevention of HIV Infection

• 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

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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

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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

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Strategy 4 MTCT-Plus

• Secondary HIV prevention
• Clinical care (including ART)
• Community care
• Stigma reduction
• OVC services
• Impact mitigation

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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