Title: Advantages and risks for a child to be exposed to the triple prophylaxis during pregnancy and breastfeeding What is the best for the child ?
1Advantages and risks for a child to be exposed to
the triple prophylaxis during pregnancy and
breastfeedingWhat is the best for the child ?
2What is the best for the child?
- Not to be HIV infected
- If infected to be treated as soon as possible
- This suppose
- Undetectable VL in mother during pregnancy
- Access to early diagnosis (PCR)
3PMTCT and triple prophylaxis
- Most protocols include triple therapy from 28
weeks to. 6 months if the child is breastfed - WHO 2006 . AZT monotherapy from 28 w to delivery
and then NVP, AZT,3TC - Triple prophylaxis should be proposed starting
from 28 weeks until 6 months if breast feeding
4PMTCT and triple prophylaxis
- Child is exposed to ARV at two different periods
through two different mechanisms - During pregnancy (transplacental transfer)
- During breast feeding (through breast milk)
- Which prophylaxis ?
- AZT 3TC EFV
- Or ?
5Advantages of triple prophylaxis for the child
- During the whole process (pregnancy
breastfeeding) - low and efficient PMTCT
- During breastfeeding it allows
- Respect of breastfeeding
- Nutritional advantages
- Immunological advantages
- Respect of cultural practices
- Decreased stigmatization for the mother
6Benefits of breast feeding with triple prophylaxis
- Low risk of transmission
- Amata study 1.6 (0.6 BF)
- Mitra plus study 5 ( 0.9 BF)
- Kisumu breast feeding study 5.9 (3.5 BF by
12 months)
7Risks of triple prophylaxis for the child
- During the whole process (pregnancy
breastfeeding) - Persistent risk of MTC transmission even if very
low (lt 1 on 6 months) - Risk of ART toxicity (placental and breast milk
transfer) - Risk of acquired resistances and impact on future
treatment in case of contamination
8Is there a risk of toxicity in breastfed children
with mother on ART ?
CROI 2008 abstract 72 M.Mirochnick et al
- Analysing 45 plasma, 35 breast milk and 42 DBS
obtained from 15 infants-mothers pairs with
mother receiving AZT 3TC NVP (Kisumu
breasttfeeding study / Uganda) it appears that - In BM
- ZDV low concentrations
- 3TC concentrates in BM ( gt plasma)
- NVP concentrates in BM ( gt 3400 ng/ml
therapeutic drug monitoring program in some
children (risk of potential drug toxicity,
partial HIV suppession and development of drug
resistance)
9Is there a risk of acquired resistance in the
child ?
- Yes through 2 mecanisms
- Transmisssion of a resistant virus
- Acquired resistance due to ARV concentration in
breast milk
10Child and triple prophylaxis during pregnancy and
breast feeding
- Balance beetween benefits and risks
- Low transmission vs acquired resistances
- No life (80 mortality within 2 years) against
life with.
11Triple prophylaxis and late coming of the mother
or incomplete protocols
- Mothers VL should be undetectable at the time of
the onset of breast feeding
12Should we treat the child and not the mother ?
- Yes, it is possible to give prophylaxis to the
child - But it acts in a different way
- Mother indetectable VL
- Infant post exposure prophylaxis
13SIMBA (Stopping Infection from Mother-to-child
from Breastfeeding in Africa) Prophylaxie chez
lenfantVyankandondera J et al. IAS Meeting,
Paris France 2003
Protection de lenfant par une prophylaxie de 6
mois par 3TC vs NVP avec un allaitement maternel
exclusif
Bras 1
Mère AZT ddI x 1 sem
AZT ddI début 36 s
AZT ddI
Enfant 3TC x 6 mois
Bras 2
AZT ddI
AZT ddI début 36 s
Mère AZT ddI x 1 sem
Enfant NVP x 6 mois
14SIMBAPackage résultats 2 de transmission
Intrapartum/Postnatale . Vyankandondera J et al.
IAS Meeting, Paris, France 2003
Naissance
lt 4 sem.
4 sem. 6mois
Taux de transmission
6
1
1
8
(Pas de différence significative entre les 2 bras
3TC vs NVP)
15Which prophylaxis for the child ?
- Acording to WHO 2006
- Sd-NVP and AZT for one week
- If the mother receives less than four weeks of
AZT before delivery, the AZT dose for the infant
should be extended to four weeks - If prophylaxis to protect breast feeding
- AZT 3TC NVP
16Which treatment if the child is infected ?
- WHO april 2008
- All infants under 12 months of age with confirmed
HIV infection should be started on antiretroviral
therapy, irrespective of clinical or
immunological stage.
17Criteria to start ART(WHO april 2008)
age lt 12 months 12 35 months 36 59 months 5 yo and gt
CD4 Treat all lt 20 lt 20 lt 15
Absolute CD4 Treat all lt 750 lt 350 lt 200
18WHO april 2008
- RECOMMENDATION
- For HIV infected infants with a history of
exposure to single dose nevirapine or
non-nucleoside reverse transcriptase inhibitor
containing maternal antiretroviral therapy or
preventive antiretroviral regimens, a protease
inhibitor-based triple antiretroviral therapy
regimen should be started. - Where protease inhibitors are not available,
affordable or feasible, nevirapine-based therapy
should be used.
19Recommended first line regimen in children
ABC 3TC
AZT 3TC LPV/r
AZT ABC
20Conclusion 1
- PMTCT with triple therapy lower the risk of MTC
transmission - Formula feeding is without risk for HIV
transmission but - Alternative feeding option should be proposed as
triple prophylaxis protected breast feeding for 6
months
21Conclusion 2
- But for an efficient PMTCT efforts should be
made on - Follow up of the children (too many lost for
follow up) - Organization of PMTCT in term of
- Human resources
- monitoring (laboratory exam)
- Community support
22Thank You !