Estimating the Impact and Needs for Children and PMTCT

1
Estimating the Impact and Needs for Children and
PMTCT

• Making sense Understanding the numbers from HIV
  surveillance to national and global HIV burden
  estimates
• John Stover, Futures Institute
• 7 August 2008, Mexico City

2
Approach to Estimates and Projections
Surveillance and survey data
EPP/Workbook
Program type and coverage -MTCT -Adult ART -Child
treatment (CTX, ART)
Adult HIV prevalence
UNAIDS epidemic patterns
Spectrum
Population estimates

• Number infected
• New infections
• AIDS deaths
• Orphans
• Treatment needs

3
Births to HIV Women

• Total fertility rates and age distribution of
  fertility for the general population are from UN
  Population Division
• Fertility of HIV women is adjusted
• 15-19 150
• Accounts for known sexual activity
• 20-49 70
• Accounts for effects of HIV and previous STIs
• Lewis JJC, Ronsmans C, Ezeh A, Gregson S. The
  population impact of HIV on fertility in
  sub-Saharan Africa AIDS 18 (suppl 2)S35-43.

4
Prevention of Mother to Child Transmission of HIV

• Primary prevention for women
• Family planning to prevent unintended pregnancies
  among HIV women
• Preventing the vertical transmission from mother
  to child
• HIV testing and counseling
• Antiretroviral prophylaxis
• Safe delivery
• Counseling and support for safer infant feeding
• Treatment, care and support for women and
  children living with HIV

5
Antiretroviral Prophylaxis to Prevent Mother to
Child Transmission

• Single dose Nevirapine
• Dual ARV
• AZT from 28 weeks, single dose Nevirapine at
  delivery, maternal 7-day tail of AZT and 3TC, one
  week of AZT for infant
• Triple prevention ART
• Triple treatment ART

6
Probability of Transmission
SD NVP Jackson 2003, Moodley 2003 Dual ARV
Ditrame 2005, Triple ARV UNICEF/UNAIDS/WHO/UNFPA
Infant feeding Iliff 2005, Rollins 2006, BHITS
2006. Methods summary Stover et al. 2008
7
Percentage of Pregnant Women with HIV Receiving
Antiretrovirals to Prevent MTCT in Low- and
Middle-Income Countries
Source Towards Universal Access Scaling up
priority HIV/AIDS interventions in the health
sector, Progress Report 2008, WHO, June 2008.
8
Distribution of ARV Regimens, 2007
Source Towards Universal Access Scaling up
priority HIV/AIDS interventions in the health
sector, Progress Report 2008, WHO, June 2008.
9
Progression from HIV Infection to AIDS Death
(Children)
New HIV Infection
Need for Treatment
Age-dependent
ART
AIDS Death
Age-dependent
10
Progression from New Infection to AIDS Death
Marston M, Zaba B, Salomon JA, Brahmbhatt H,
Bagenda D. Estimating the Net Effect of HIV on
Child Mortality in African Populations Affected
by Generalized HIV Epidemics. J Acquir Immun
Defic Syndr 382, February 1, 2005
11
Progression from New Infection to Need for
Treatment
Need for treatment based on mortality among
children with MSD from Newell M-L, Coovadia H,
Cortina-Borja M, Rollins NC, Gaillard P, Dabis F.
Mortality of infected and uninfected infants born
to HIV-infected mothers in Africa a pooled
analysis. The Lancet 20043641236-43.
12
Child Treatment Co-trimoxazole

• WHO recommendation all HIV-exposed children
  until they are no longer exposed to HIV and
  confirmed to be HIV-negative
• Impact 33 reduction in mortality in first four
  years, 17 in year 5, 0 after year 5
• Chintu et al 2004 Zambia
• Most national policies now include co-trimoxazole
  prophylaxis
• Current coverage is only about 4

13
Child Treatment ART

• Need for treatment is currently based on the
  estimated proportion progressing to
  Moderate-to-Severe Disease
• WHO recommendation
• For children over one year of age, start ART on
  the basis of immunological and clinical criteria,
  operationalized in model on basis of progression
  to death
• For children under one, start ART as soon as HIV
  infection is confirmed

14
Child Treatment ART

• Impact
• Studies
• Fassinou et al, Cote dIvoire, 2004
• Rouet et al, Cote dIvoire, 2006
• Puthanakit et al, Thailand, 2005
• Survival on ART
• lt 1 year 80
• gt1, first year 90
• gt1, subsequent years 95

15
Children (lt15 years) estimated to be living with
HIV, 2007
Eastern Europe Central Asia 12 000 9100 15
000
Western Central Europe 1300 lt1000 1800
North America 4400 2600 7300
East Asia 7800 5300 11 000
Middle East North Africa 26 000 18 000 34
000
Caribbean 11 000 9400 12 000
South South-East Asia 140 000 110 000 180
000
Sub-Saharan Africa 1.8 million 1.7 2.0 million
Latin America 44 000 37 000 58 000
Oceania 1100 1200
Total 2.0 million (1.9 2.3 million)