Prevention of mothertochild HIV transmission PMTCT

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Prevention of mother-to-child HIV
transmission(PMTCT)
5th IAS Conference on HIV Pathogenesis, Treatment
and Prevention Cape Town, July 2009

• Louise Kuhn
• Columbia University

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1994 .. a door is openedAntiretrovirals work to
prevent transmission!
Connor EM, Sperling RS, Gelber R et al. for The
Pediatric AIDS Clinical Trials Group Protocol 076
Study Group New England Journal of Medicine 1994
3311173-1180.
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The long road ahead .
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Success of PMTCT research continues a select
history
1994 PACTG 076 proof of concept
1999 Short course oral AZT
1999 HIVNET 012 Single-dose nevirapine
2003 Post-exposure prophylaxis
2004 Combination drugs
2007 Integration with treatment programs
2008 Extended infant prophylaxis thru BF
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Photo credit Treatment Action Campaign, South
Africa June 2001 http//www.tac.org.za Protest to
demand access to Nevirapine for prevention of
mother-child HIV transmission
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Success of PMTCT cont. implementation

• IT IS HAPPENING!
• Global commitment to implementation
• Creative adaptations
• Leverage for HIV treatment
• Platform for services
• BUT .

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Are we there yet?
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We can do better

• Coverage is poor
• Lack of coordination between treatment and
  prevention services
• Suboptimal antiretroviral regimens used
• Poor quality counseling
• Lack of follow-up

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Quote from HIV mother about her experiences in
infant diagnosis program in Soweto

• I told myself that just like in soccer I
  should prepare myself to either win or lose,
  positive or negative
• Lazarus R, Struthers H, Volari A.
• AIDS Care 2009 21 329-334.

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Transmission rates among breast-fed infants born
to HIV-infected mothers
No intervention
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With short course AZTNVP
Denominator all infants born to HIV-infected
mothers
Denominator infants who are
infected
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This is not the time to put our heads in the sand
..
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Breakthroughs in interventions to reduce
postnatal HIV transmission

• Lactation support
• Continued HAART to the mother
• Extended infant prophylaxis

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Quality of breast feeding influences HIV
transmission
Coutsoudis A, et al. Lancet 1999 354 471-6.
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Standard regimens to all
Optimized regimens
HAART WORKS
Only to women who need it
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Why treating only women with low CD4 counts
reduces postnatal HIV transmission
Population of pregnant HIV women
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If we introduce antiretroviral therapy .
Population of pregnant HIV women
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Extended antiretroviral prophylaxis with
nevirapine to the infant reduces breast milk HIV
transmission
Kumwenda et al. New England Journal of Medicine
2008 359 119-129.
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Behind every rainbow there is a dark cloud
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Increased mortality with abstinence from
breastfeeding in a program in rural Rakai, Uganda
Kagaayi J, Gray RH, Brahmbhatt H. et al. PLoS
ONE 2008 December 3 e3877
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Increased mortality with abstinence from
breastfeeding in a clinical trial in urban
Botswana
Thior I, Lockman S, Smeaton LM et al. JAMA 2006
296 794-805
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Increased mortality with abstinence from
breastfeeding in a clinical trial in urban
Botswana
Does no benefit no harm ?
Thior I, Lockman S, Smeaton LM et al. JAMA 2006
296 794-805
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No benefit means deaths caused HIV
prevented
0-6 months Thior et al. Botswana
6-24 months ZEBS Zambia
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With ARVs , abstinence from breastfeeding or
early weaning lead to worse outcomes deaths gt
HIV prevented
0-6 months Thior et al. Botswana
6-24 months ZEBS Zambia
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In women with higher CD4 counts, early weaning
had worse outcomes
Continued BF
Stopped BF lt 4 m
Kuhn L, Aldrovandi G, Sinkala M et al. PLoS ONE
2009 June 4 e6059
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Should we burn down the forest to save the trees?
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Lets get to the pointHIV prevention is not
enough
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Children need to be protected from other diseases
as well as HIV
HIV-exposed child
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Conclusions

• Achievements and challenges
• HIV treatment and PMTCT can and should work
  hand-in-hand
• All pregnant lactating women with CD4 counts
  lt350 must be provided with HAART
• Breast milk transmission can be reduced by
  maternal HAART or by extended infant ARV regimens
• PMTCT and child survival programs must be linked

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Conclusion

• We have the knowledge to prevent mother-to-child
  HIV transmission, promote maternal health and
  ensure child survival.

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Acknowledgments
ZEBS Moses Sinkala, Chipepo Kankasa, Don Thea,
Grace Aldrovandi
Elaine Abrams, Zena Stein, Stephen Arpadi Jeffrey
Stringer, Sten Vermund, Marc Bulterys, Prisca
Kasonde, Cheswa Vwalika, Mwiya Mwiya, Chewe Luo,
Elwyn Chomba, Ellen Piwoz Anna Coutsoudis, Jerry
Coovadia, Nigel Rollins, Ruth Bland Glenda Gray,
Tammy Meyers, Ashraf Coovadia, Caroline Tiemessen
Lynne Mofenson, Kevin Ryan, NICHD
Health care workers, parents and children
participating in studies
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Lets join together to protect our children.
Enkosi!
5th IAS Conference on HIV Pathogenesis, Treatment
and Prevention Cape Town, July 2009