PREVENTION OF PERINATAL TRANSMISSION OF HIV1

1
PREVENTION OF PERINATAL TRANSMISSION OF HIV-1

• Chokechai Rongkavilit
• Pediatric Infectious Diseases
• Childrens Hospital of Michigan
• PACTU 5041

2
Objectives

• To review the current global situation
• To review clinical trials related to perinatal
  HIV transmission
• To review strategies for prevention of perinatal
  HIV transmission
• To review global response to prevent perinatal
  HIV transmission

3
Global Situation

• Most HIV-infected children are in developing
  countries, mainly Africa.
• More than 95 of HIV-infected children acquire
  HIV through vertical transmission from their
  mothers.
• 7000 women of child bearing age acquire HIV each
  day worldwide.
• 2000 infants become infected every day worldwide.

UNAIDS Report 2004
4
Global summary of the HIV/AIDS epidemic
UNAIDS
5
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6
280-370 infants are born infected with HIV in US
each year
7
Key Factors in Reducing Perinatal HIV
Transmission in the US

• Access to prenatal care
• HIV counseling and testing
• Mandatory counseling during antenatal visits
• Voluntary testing
• Rapid testing in labor
• Secure supply of antiretroviral drugs
• For treatment of mothers maximize maternal
  health
• For perinatal prevention
• Feasibility of elective c-section
• Safe breast milk replacement
• Care of mother/partner and child after delivery

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9
HIV Prevalence trends among antenatal clinic
attendees in South Africa 1990-2002
South Africa Department of Health Report 2004
10
Case Study

• During a rotation in Thailand, you see a
  pregnant woman whom you just discovered to have
  HIV. She is now 4 month pregnant.
• What care would you provide to her at this point?
• What else would you suggest to her and her
  husband?
• Once she is in labour, what care would you
  provide to her?
• Once the child is born, what care would you
  provide to the child?
• She asks you about the likelihood of her unborn
  child being infected and about breast feeding.
  What would you advise?
• She lives with her in-laws and she is afraid that
  they might find out about HIV. What would be your
  advice?

11
Risk Factors for Vertical Transmission

• Maternal Factors
• advanced HIV disease high HIV RNA, low CD4
• co-infection sexually transmitted diseases
• drug abuse
• obstetric complications prolonged rupture of
  amniotic membrane
• Mode of delivery vaginal versus c-section
• breast-feeding

12
Risk Factors for Vertical Transmission

• Fetal / placental factor
• chorioamnionitis
• disruption of placenta maternal-fetal blood
  exchange
• birth trauma
• Twin 1st twin has higher risk
• prematurity

13
Obstetric Factors
N 1632

• RR P value
• Cervicovaginal infection 1.3 (1.1-1.7) 0.018
• Prolonged membrane rupture 1.4
  (1.1-1.8) 0.009
• Preterm labor
• STD 1.5 (1.1-2.0) 0.003
• bleeding at labor 1.9 (1.1-3.2) 0.020
• invasive procedure 1.9 (1.3-2.7) 0.007

Mandelbrot, et al. Am J Ob Gyn 1996
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Perinatal Transmission Rate

• Baseline transmission (without intervention)
• Europe/US 16-20
• Asia 19-24
• Africa 25-40
• Breastfeeding increases risk by 5-20

15
Timing of Transmission
in utero
intrapartum
postnatal

• In utero infection 30
• Intrapartum infection 70

16
Timing of Transmission
French cohort Markov model
Proportion of infants infected
Delivery
4 weeks
8 weeks
1st 2nd trimester
Rouzioux C, et al. Am J Epidemiol 1995 142 1330
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Evolution of Clinical TrialsAdvance in
Prevention of Perinatal HIV Transmission
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PACTG 076USA/France

• Placebo controlled
• Antepartum ZDV 100 mg, 5 times daily
• Intrapartum intravenous ZDV
• Neonatal ZDV for 6 weeks
• No breastfeeding

Connor EM, at al. N Engl J Med 19943311173
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ACTG 076
AP
IP
NN
Began at 14-34 weeks Median duration 11 weeks
P Sperling RS, et al. N Engl J Med 19963351621
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CDC-Thailand Study

• Placebo controlled
• Antepartum ZDV 300 mg twice daily
• Intrapartum oral ZDV 300 mg every 3 hours
• Neonatal none
• No breastfeeding

Shaffer N, et al. Lancet 1999353773
21
CDC-Thailand Study
AP
IP
Began at 36 weeks Median duration 25 days
P 0.006
Shaffer N, et al. Lancet 1999353773
22
RETRO-CICote dIvoire

• Placebo controlled
• Antepartum ZDV 300 mg twice daily
• Intrapartum ZDV 300 mg every 3 hours
• Neonatal none
• Predominantly breastfeeding

Witkor SZ, et al. Lancet 1999353781
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RETRO-CI
AP IP
Began at 36 weeks Median duration 27 days
4 weeks 3 months
P Witkor SZ, at al. Lancet 1999353781
24
DITRAMECote dIvoire/Burkina Faso

• Placebo controlled
• Antepartum ZDV 300 mg twice daily
• Intrapartum single dose of 600 mg at labor
• Postpartum ZDV 300 mg twice daily for 7 d
  to mothers
• Predominantly breastfeeding

Dabis F, et al. Lancet 1999353786
25
DITRAME
AP IP PP
Began at 36-38 weeks Median duration 21 days
45 days 6 months
P Dabis F, et al. Lancet 1999353786
26
Short-Course ZDV Trials
AP
IP
IP AZV was given orally No neonatal ZDV component
Began at 36 weeks
50
37
38
Breastfeeding
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New York State Study

• Data from PCR testing service of NY State
  Department of Health
• Partial or full ACTG 076 protocol

Wade NA, et al. N Engl J Med 19983391409
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New York State Study
Transmission rate
AP IP NN
6.1 10 9.3 18.4 26.6
within 48 hrs after 72 hrs
NONE
Wade NA, et al. N Engl J Med 19983391409
29
Perinatal HIV Prevention TrialHarvard Northern
Thailand

• Define optimal duration of prophylaxis
• antepartum at 28 wk neonatal for 6 wk (LL)
• antepartum at 28 wk neonatal for 3 d (LS)
• antepartum at 35 wk neonatal for 6 wk (SL)
• antepartum at 35 wk neonatal for 3 d (SS)
• Non-breastfeeding

Lallemant M, et al. N Engl J Med 2000343982
30
Perinatal HIV Prevention Trial
N 1437

• transmission rate

AP IP NN
6.5 (4.1-8.9) 4.7 (2.4-7.0) 8.6
(5.6-11.6) 10.5 (6.4-14.4)
28 wk
6 wk
28 wk
3 d
35 wk
6 wk
35 wk
3 d
P NS early termination
Lallemant M, et al. N Engl J Med 2000343982
31
Thai Red Cross ZDV Donation Program to Prevent
Vertical Transmission of HIV Effects of the
Modified ACTG 076 Regimen

• M. Khongphatthanayothin, C. Rongkavilit, S.
  Sirivichayakul, W. Poolcharoen, C. Kunanusont,
  DB. Bien, U. Thisyakorn, P. Phanuphak

AIDS 2000142921
32
Program Objective

• To reduce vertical HIV transmission by procuring
  public donation of ZDV and offering the
  medication at no cost to HIV-infected pregnant
  women.
• Under the patronage of HRH Princess Soamsawali
  and in collaboration with Ministry of Public
  Health, UNAIDS and UNICEF.

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Modified ZDV Regimen

• Antepartum (start at 14-34 weeks gestation)
• morning dose 200 mg
• evening dose 300 mg
• Intrapartum
• 300 mg orally every 3 hours till delivery
• Infant
• 2 mg/kg four times daily for 6 weeks

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Analysis

• Analysis was limited to those with at least 1 HIV
  DNA PCR done in infants at 4 weeks of age.
• HIV PCR was performed by dried blood spot
  technique.

35
Results

• From June 1996 - August 1999, ZDV had been
  provided to 2,891 pregnant woman-infant pairs
  from 81 hospitals in 40 provinces throughout
  Thailand.
• 726 infants of 719 women had 1 PCR done at 1
  month of age.
• 43 infants were HIV-infected.
• Transmission rate was 6.0 (95 CI, 4.4 - 8.0).

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Results
P 0.21
Thisyakorn U, et al. AIDS 2000142921
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Efficacy of ACTG 076 Regimen
Study Transmission
rate
38
HIV-NET 012Uganda and US NIH

• Randomized ZDV vs nevirapine (NVP)
• ZDV 600 mg at onset of labor
• 300 mg every 3 hrs till delivery
• 4 mg/kg BID for 1 wk to infants
• NVP 200 mg at onset of labor
• one dose of 2 mg/kg to infants
  within 72 h
• Predominantly breastfeeding (99, median 9 mo)

Guay LA, et al. Lancet 1999 354 795
39
HIV-NET 012Uganda and US NIH
This simple, inexpensive nevirapine regimen
significantly decreased MTCT in less-developed
countries.
P Guay LA. Lancet 1999 354 795 Jackson JB. Lancet
2003 362 859
40
Cost-Effectiveness in Developing World
in US dollars
Teeraratkul A, et al. 5th Congress on AIDS in
Asia and Pacific, 1999 Marseille E, et al. Lancet
1999 354 803
41
French Perinatal Study

• Prospective, non-randomized
• Antepartum ZDV (ACTG 076)
• 3TC started at 32 weeks
• Intrapartum ZDV IV 3TC
• Neonatal ZDV 3TC 2 mg/kg BID for 6 wks
• Compare with ZDV monotherapy cohort
• No breastfeeding

Blanche S, et al. 6th CROI 1999
42
French Perinatal Study
AP IP NN
Transmission rate
ZDV 3TC 2.6 (5/194) ZDV
6.5 (53/810)
Blanche S, et al. 6th CROI 1999
43
French Perinatal Study

• M184V mutation occurred in 40 of women after
  delivery
• 2 infants exposed to ZDV3TC developed
  mitochondrial myopathy

Blanche S, et al. 6th CROI 1999
44
PETRA StudyTanzania/Uganda/South Africa

• Various regimens of ZDV3TC
• Antepartum ZDV 300 mg BID
• 3TC 150 mg BID
• Intrapartum ZDV 300 mg every 3 hrs
• 3TC 150 mg BID
• Neonatal ZDV 4 mg/kg BID
• 3TC 2 mg/kg BID
• Predominantly breastfeeding

Petra study team. Lancet 20023591178
45
PETRA Study
Transmission rate Wk 6 Mo 18
N1797
AP IP NN

• Arm A 5.7 15
• Arm B 8.9 18
• Arm C 14.2 20
• Arm D 15.3 22

At 36 weeks 1 week
Petra study team. Lancet 20023591178
46
SAINT StudySouth Africa

• ZDV3TC vs nevirapine (n1319)

Transmission at 8 wk Including
(excluding) intrauterine infection
PP
ZDV 3TC (PETRA B)
9.3 (3.6)
IP
NN
1 week
PP
NVP
12.3 (5.7)
IP
NN
single dose
P 0.1
Breastfeeding 40 PP maternal drug to provide
protection against early breast feeding
transmission
Moodley D. J Infect Dis 2003187725
47
ZDVNVP Trial, Malawi
IP
NN
NVP
NVP ZDV or 7 days
It is not necessary to add ZDV in full NVP
regimen. P0.36
Taha TE. JAMA 2004292202
48
Perinatal HIV Prevention Trial, Thailand
Combination of ZDV and single-dose NVP
Transmission 1.9 (12/627) 2.8 (17/611) 6.3
(22/348)
Mother
Infant
NVP/NVP
ZDV
ZDV
NVP/PLC
ZDV
PLC/PLC
28 wk GA
1 wk
No breastfeeding Adding NVP in the short-course
ZDV is beneficial. The result lead to
modification of Thailands national guideline to
implement ZDVNVP as prophylactic regimen.
Lallemant M. NEJM 2004351217
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International PACTG 316

• Multicenter study (USA, Europe, Brazil, Bahamas)
• Assess benefit of adding single-dose NVP to
  standard ARV
• Mother standard ARV (ZDV at minimum) plus NVP
  (vs placebo) at labour
• Infant standard ZDV plus NVP (vs placebo)
• Mother (n1270)
• Median CD4, 434 Median HIV RNA,
• 22 on ZDV
• 28 on ZDV3TC
• 49 on combination ARV therapy
• Elective C-section 34 (0-81)

Dorenbaum A. JAMA 2002288189
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International PACTG 316

• Transmission rate
• NVP 1.4 (CI, 0.6-2.7)
• Placebo 1.6 (CI, 0.8-2.9)
• No benefit from additional NVP when women already
  received antenatal ARV (HAART), had good
  virologic response, had access to elective
  c-section and formula feeding.

51
NVAZ Trial, Malawi

• Counseling and testing in antenatal clinics are
  often not available in many developing countries.
• Most women present only hours before delivery,
  unaware of HIV status, and with little time to
  administer NVP before delivery.
• Protective concentrations of NVP in cord blood
  are achieved only when intrapartum NVP is given
  2 h before delivery.
• Therefore, strategies of ARV prophylaxis in
  neonates only were evaluated.

Taha TE. Lancet 20033621171
52
NVAZ Trial, Malawi

• Mother in advanced labour and did not receive
  intrapartum NVP
• Infants randomized
• NVP single dose
• NVP single dose AZT 4 mg/kg bid for 7 days
• Figure shows net HIV status at 6-8 wk of age
  (green) and when in utero infection was excluded
  (red)
• 36 reduction in transmission

Combination of AZT/NVP is more effective in
infants when mothers receive no ARV during
pregnancy and delivery
Taha TE. Lancet 20033621171
53
International perinatal HIV studies
delivery 1 wk
6 wk
14 wk
36 wk
labor
28 wk
Transmission rate
7.6
ACTG 076
FF
9.5
Thai/CDC
6.5
PHPT LL
4.7
PHPT LS
1.9
PHPT
15
Retro-CI
17
DITRAME
8
PETRA-A
12
PETRA-B
BF
19
PETRA-C
12
HIVNET012
10
SAINT
16
MALAWI
15
NVAZ
AZT
AZT3TC
NVP
54
WHO Guidelines 2004
55
US Guidelines 2004
Consider elective C-section for those with VL
1000 near delivery (36 wk)
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Long-term Effects of ARV Exposure In Utero

• PACTG 219
• Observational study to assess late effects of in
  utero and neonatal exposure to antiretrovirals
• Assessment of growth, cognitive/developmental
  function and quality of life until age 21 years

Culnane M, at al. JAMA 1999281151
57
Long-term Effects of ARV Exposure In Utero

• 234 uninfected children from ACTG 076
• 122 in ZDV arm and 112 in placebo arm
• As of Feb 1997, median age 4.2 y (3.2-5.6 y)
• No deaths or malignancies
• No difference in growth/development
• One child in ZDV arm developed mild
  cardiomyopathy.

Culnane M, et al. JAMA 1999281151
58
Long-term Effects of ARV Exposure In Utero

• Persistent mitochondrial dysfunction
• NRTI and inhibition of DNA polymerase gamma
• French National Epidemiology Network
• 8 children with mitochondrial dysfunction
• 4 exposed to ZDV/3TC, 4 to ZDV in utero
• Clinical none, seizure, cognitive impairment,
  myopathy
• Lab lactic acidosis, ?LFT, abnormal electron
  microscopy and mitochondrial enzyme functions
• 2 died.

Blanche S, et al. Lancet 1999 354 1084
59
Long-term Effects of ARV Exposure In Utero

• US cohorts
• 20,000 children born to HIV-infected mother
• 223 deaths reported
• None had evidences suggestive of mitochondrial
  diseases
• Ongoing assessments in other US cohorts

Perinatal Safety Review Working Group. JAIDS
200025261
60
Long-term Effects of ARV Exposure In Utero

• Incorporation of ZDV into DNA of infants exposed
  in utero
• DNA was extracted from cord blood PBMC in infants
  exposed to ZDV in utero.
• ZDV-DNA incorporation was found in 15 of 22
  infants.
• Long-term consequences are unknown.

Olivero OA, et al. AIDS 1999 13 919
61
Impact of Modes of Delivery

• French Perinatal Cohort
• 902 mothers received ZDV

Vaginal delivery 6.6 Emergent C-section
11.4 Elective C-section 0.8
P 0.002
Mandelbrot L, at al. JAMA 199828055
62
Impact of Modes of Delivery

• California Cohort

P 0.02
30-40 of the subjects received ZDV regimen.
Towers CV, et al. J Obstet Gynecol 1998179708
63
Impact of Modes of Delivery

• European Cohort

European Mode of Delivery Collaboration. Lancet
19993531035
64
Impact of Modes of Delivery

• European Cohort

60-70 of mothers were on ZDV during pregnancy.
European Mode of Delivery Collaboration. Lancet
19993531035
65
Impact of Modes of Delivery

• North American and European Cohort

N 8533
International Perinatal HIV Group. N Engl J Med
1999340977
66
Impact of Maternal Viral Load
ACTG 076
Sperling RS, et al. N Engl J Med 19963351621
67
Impact of Maternal Viral Load
Women Infants Transmission Study N552
HIV RNA copies/ml
Garcia PM. NEJM 1999341394
68
Impact of Maternal Viral Load

• ACTG 076
• ZDV treatment was associated with only a small
  reduction in HIV RNA (median 0.24 log).
• Transmission occurred at all HIV RNA values,
  independent of maternal CD4 levels.
• ZDV is protective at all levels of maternal HIV
  RNA.

69
Impact of Maternal Viral Load
70
Effect of C-section on MTCT in women on HAART
Transmission rate compared for elective c-section
vs all other modes of delivery. -HIV RNA vs 1000 copies/ml -1 drug vs multiple drugs
Elective c-section may not provide additional
benefit in women on HAART with HIV RNA Shapiro D. CROI 2004
71
HIV Transmission via Breast FeedingMajor Issue
in Developing World
Approximately 1/3 to ½ of HIV infections in
children occur via breast feeding. Alternatives
to breast feeding are often unaffordable and
sometimes unsafe, due to lack of clean water.
72
Impact of BreastfeedingMalawi (1994-97)
672 infants with negative HIV PCR at the first
postnatal visit (median 1.7 mo)
Miotti PG, et al. JAMA 1999 282 744
73
Impact of Infant FeedingKenya (1992-98)

• A randomized trial
• 197 in breastfeeding arm
• 204 in formula feeding arm
• Of note less compliant in the formula feeding
  arm (70 vs 96)

Nduati R, et al. JAMA 2000 283 1167
74
Impact of Infant FeedingA randomized trial in
Kenya, 1992-98 197 in breast feeding arm 204
in formula feeding armOf note less compliant in
the formula feeding arm (70 vs 96)
Nduati R, et al. JAMA 2000 283 1167
75
Impact of BreastfeedingSouth Africa (1995-98)

• A study assessing feeding practice during the
  first 3 months of life
• All women were counseled of transmission risk by
  breastfeeding, and informed choice was made.
• 156 never breastfed
• 103 exclusively breastfed
• 288 received mixed feeding

Coutsoudis A, et al, Lancet 1999 354 471
76

Coutsoudis A, et al, Lancet 1999 354 471
77
Breast milk infectivityKenya
Randomized trial of breast feeding vs formula
feeding Infants with negative HIV PCR at 6 wk of
age were followed.
Probability of breast milk transmission was
0.0003 per day of breast feeding. Similar to
probability of heterosexual transmission per
unprotected sex act
Richardson BA. J Infect Dis 2003187736
78
Breast Milk Transmission

• Median HIV RNA in colustrum/early milk is higher
  than that in breast milk collected 14 days after
  delivery.
• High maternal plasma HIV RNA and low maternal CD4
  count are associated with higher breast milk HIV
  RNA.
• Breast feeding mothers who transmit virus have
  higher breast milk HIV RNA.
• Strategies to lower viral load and improve CD4
  count could reduce breast milk transmission (ie,
  HIV therapy, multivitamin)
• Mothers with advanced disease should avoid breast
  feeding.

Rousseau CM. J Infect Dis 2003187741
79
Studies to Prevent Postnatal Transmission (breast
feeding)

• ARV to women during breast feeding
• Optimal duration of treatment
• Combination therapy
• ARV to infants during breast feeding
• Duration and frequency of infant treatment
• Combination therapy
• Exclusive breast feeding
• Early weaning
• Safer breast feeding heated breast milk

80
SIMBA Study (Rwanda Uganda)Neonatal
prophylaxis against breast milk transmission

• Mothers received ZDVddI from 36 wk GA till 1 wk
  postpartum.
• Infants were randomized to receive NVP vs 3TC for
  up to 7 months during breastfeeding
• Transmission rate at 4 weeks 6.9 and at 6
  months 7.8 in both arms
• Risk of postnatal transmission between week 4 and
  month 6 was 1 (compared with 4.2 in historical
  data).

Vyankandondera J. IAS Conference, Paris 2003
81
Viral Resistance

• ACTG 076
• 1 in 39 (2.6) women developed mutation at codon
  70 during study.
• None developed mutation at codon 215.
• 1 of 2 women with K70R mutation (1 with the
  mutant prior to entry) transmitted both wild type
  and resistant strain to infant.

Eastman PS, et al. J Infect Dis 1998 177557
82
Viral Resistance

• Women and Infants Transmission Study Group (USA)
• Gene sequencing of reverse transcriptase region
  of 142 isolates from pregnant women
• 24 of isolates had ZDV resistance mutation
• Using the multivariate analysis, those with ZDV
  resistance mutation had a 5-fold risk of
  perinatal transmission (adjusted OR 5.2, 95 CI
  1.4-18.9, P0.01)

Welles SL, et al. AIDS 2000 14 263
83
Viral Resistance

• HIVNET006
• Plasma were collected at 6 wk after nevirapine.
• 3 of 14 women developed K103N mutation (1/3
  transmitters and 2/11 non-transmitters).
• 2 of these 3 had a K/N mixture, suggesting recent
  selection of the resistant variant.
• 2 women had pre-dose samples, and none had K103N
  mutation.

Becker-Pergola G, et al. CROI 2000
84
Rates of NVP Resistance in Women after pMTCT
Treatment
NVP resistance became undetectable 6-12 months.
85
Rates of NVP Resistance in Infants after pMTCT
Treatment
86
Intrapartum NVP and subsequent response to
NVP-based therapy in mothers

• 269 Thai women with CD4 NVP intrapartum
• HIV genotyping at 10 days postpartum
• 32 of NVP group had NVP resistance (K103N)
• Treated with D4T, 3TC, NVP
• Decreased virologic response to treatment among
  women who received intrapartum NVP
• No difference in clinical or immunologic outcomes

Jourdain G. NEJM 2004351229
87
Reduction of NVP resistance in mothers, South
Africa

• Aim to reduce NVP resistance in mothers receiving
  NVP for PMTCT
• Mothers and infants were randomized to
• SD NVP
• SD NVP combivir (AZT/3TC) for 4 days
• SD NVP combivir (AZT/3TC) for 7 days

McIntyre J. XV International AIDS Conference,
Bangkok 2004, LbOrB09
88
Combination Antiretroviral Therapy
WITS Trends in transmission rate and maternal
antiretroviral therapy 1990-1999
Cooper ER. JAIDS 200229484
89
Missed Opportunities for Perinatal HIV Prevention

• CDC Pediatric Spectrum of Disease Project
• 4,755 HIV-exposed infants in 6 US sites in
  1996-2000
• 92 had prenatal care, 92 of which had HIV
  testing before delivery
• The use of ZDV ( other drugs) increased from 78
  to 87

Peters V. Pediatrics 20031111186
90
Missed Opportunities for Perinatal HIV Prevention

• 20 of the cohort had at least 1 missed
  opportunity for perinatal HIV prevention
  (prenatal care, prenatal HIV testing, prenatal
  ARV)

Peters V. Pediatrics 20031111186
91
Missed Opportunities and Barriers for Perinatal
HIV Prevention
www.usaids.gov Global HIV Prevention Working
Group. UNAIDS 2003
92
Prevention Strategies

• Prenatal
• Rapid scale-up of pMTCT programs to include
  counseling, testing and full options of
  intervention
• Opt-out strategy HIV testing (universal testing
  with rights to refusal)
• 95 of pregnant women agree to testing
• Access to antiretroviral drugs HAART for
  pregnant women meeting treatment criteria or per
  countrys guidelines

93
Prevention Strategies

• Intrapartum
• Rapid HIV testing if maternal HIV status is
  unknown
• (sensitivity 100, specificity 99.9, turnaround
  time 66 min)
• Proper obstetric care
• Elective cesarean delivery, especially those with
  plasma HIV 1,000 copies/ml
• Antiretroviral drugs variety of regimens based
  on local capacity and scientific merit

MIRIAD Study Group. JAMA 2004292219
94
Prevention Strategies

• Postpartum
• Avoid breast feeding or wean early
• Prompt antiretroviral drugs to infants after
  birth
• Promotion of maternal and child health
• Infants follow-up
• PCR during early infancy
• HIV antibody
• Care of women, her child and her partner

95
Care of Infants Born to HIV-Infected Women
HIV antibody at 12-18 mo Routine well-child
vaccination should be followed.
AAP. Pediatrics 2004114497
96
Barriers to Prevention of Perinatal HIV
Transmission

• Lack of infrastructure to promote maternal and
  child health
• Limited HIV counseling and testing services
• Stigmatization and discrimination community,
  health personnel
• Domestic violence following disclosure to the
  partner
• Cost of antiretroviral drugs and infant formula
• Lack of social support for those choosing
  alternatives to breastfeeding (stigma and
  culture)
• Minimal interest among policy makers and country
  leaders
• Limited support from developed countries

97
Future Research Related to PMTCT

• Intervention treatment strategies
• Vaginal microbicide
• new antiretroviral drugs tenofovir
• preventive HIV vaccines
• Safe infant feeding
• Long-term safety of combination ARV therapy in
  pregnant women and infants

98
Future Research Related to PMTCT

• Control of NVP resistance addition of ARV to NVP
• Treatment of mothers (and infected infants) after
  NVP prophylaxis
• Pediatric and neonatal data on antiretroviral
  drugs
• Family-centered care in resource-limited setting

99
Future Research Related to PMTCT

• Social science
• Counseling and testing tools applicable to even
  the most resource-poor countries
• Risk-behavior modification or interventions with
  increasing access to counseling, testing and care
  in developing countries
• Risk-behavior modification in youth in developing
  countries
• Family planning in HIV-affected couples
• How the society can best assist orphans into
  adulthood

100
Conclusion

• Known risk factors for perinatal HIV transmission
• There are many interventions to reduce perinatal
  HIV transmission. No One size fits all, but
  Access for All
• Every effort must be made to prevent one child
  from HIV. It is never too late to initiate
  prophylaxis.

101

• Perhaps the best strategy of all to prevent
  vertical transmission is to protect women from
  becoming infected.
• Public education
• Pre-marital HIV counseling and testing
• Faithfulness of her partner
• Empower girls and women to be able to take care
  of herself and take control of her life

102
By compassion we make others' misery our own,
And so, by relieving them, we relieve ourselves
also. --Thomas Browne