งานนำเสนอเรื่อง: "Elimination of Mother-to-Child HIV Transmission: Knowledge to Practice"— ใบสำเนางานนำเสนอ:
1 Elimination of Mother-to-Child HIV Transmission: Knowledge to Practice Countdown to ZeroBelieve it.……………..Do it.Rangsima Lolekha, MDChief, eMTCT and Pediatrics SectionGlobal AIDS Program Thailand/Asia Regional OfficeCDC Southeast Asia Regional Office
2 Outlines Global goals to elimination of MTCT and AIDS Free Generation Key summary of PMTCT interventions and new Thai PMTCT guidelines 2014Situation of MTCT rate and early infant access to treatment and care in ThailandUNAIDS recommendations for Country Implementation Action: 10-Point Plan towards eMTCT
3 Global Goal: Towards EMTCT by 2015 Global Target #1: Reduce the number of new HIV infections among children by 90%Global Target #2: Reduce the number of AIDS-related maternal deaths by 50%Launched by UNAIDS and PEPFAR: calls for exceptional global and national effortsReduce MTCT of HIV to<5% in breast-fed population<2% in non-breastfed population
4 Millennium Development Goals and EMTCT The EMTCT contributes directly towards achieving four of the MDGsMDG3: Promote gender equality and empower womenMDG4: Reduce child mortalityMDG5: Improve maternal healthMDG6: Combat HIV/AIDS, malaria and other diseases
5 Key elements of prevention of HIV transmission to babies and keeping their mothers alive Key elements of eliminating new HIV infections among children and keeping their mothers alive1. Preventing new HIV infections among women of reproductive age.2. Helping women living with HIV avoid unintended pregnancies.3. Ensuring that pregnant women have access to HIV testing and counselling; and that those who test positive have access to antiretroviral medicines to prevent transmission during pregnancy, delivery or breastfeeding.4. Providing HIV care, treatment and support for women, children living with HIV and their families.
6 The Virtual Elimination of MTCT of HIV is Possible Estimated New HIV infections among children 0-14: Different scenarios for 25 countries with largest numbers of HIV+ pregnant womenData from 25 countries with the largest numbers of HIV+pregnant women were used to create different scenarios to evaluate different PMTCT interventions. A Spectrum model was used to estimate new child HIV infections as a measure of the impact of interventions.If 90% of women reached with services matching WHO GL, there will be 60% reduction in new HIV infections among children in 2015If 90% of women reached with services matching WHO GL, and incidence of new infection reduced by 50% and eliminate unmet need for family planning, there will be 80% reduction in new HIV infected childrenIf 90% of women reached with services matching WHO GL, and incidence of new infection reduced by 50% and eliminate unmet need for family planning and restricted BF to 12 mo, there will be 90% reduction in new HIV infected children by 2015.To achieve virtual elimination of new child infections, PMTCT program must achieve high coverage of more effective ARV interventions and safer infant feeding practices. In addition a comprehensive approach including meeting unmet family planning needs and reducing new HIV infections among reproductive age women is required.Source: Mahy M, Stover J, Kiragu K, et al. What will it take to achieve virtual elimination of mother-to-child transmission of HIV? An assessment of current progress and future needs. Sex Trans Infect (Suppl) 2010.
8 Estimated Risk and Timing of Mother-To-Child (MTCT) HIV Transmission In uteroDuring labor4%12%Post partum through breastfeeding1%0-14 wk14-36 wk36 wk -laborDelivery8%7%0-6 month6-24 month3%Overall without breastfeeding20-25 %Overall with breastfeeding till 6 months25-30 %Overall with breast feeding till months30-35 %Trainers reviews the estimated risk by timing of delivery. Highlight on overall transmission rate without any intervention stratified by breastfeeding performance.Source: De Cock KM, et al. JAMA. 2000; 283 (9): Kourtis et al. JAMA 2001; DeCock et al. JAMA 2000The risk of perinatal transmission can now be less than 2% (1 in 50) with:Highly effective ARV therapy (HAART), elective cesarean section as appropriate; formula feeding
9 PMTCT is the most effective intervention among prevention technologies reducing HIV transmission cART vs. no ARV (076 placebo) (0.8% vs. 25.5%) US/Europe %Option A vs. no ARV S Africa (1.5% vs. 22%) Dihn 2011, IAS; Rundare 2012, CROI %Karim SSA et al. Lancet 2011;378:e23-25Adapted from Mofenson L’s slide
10 Summary of peripartum transmission probabilities by ART regimen and maternal CD4 count (The UNAIDS reference group on estimates, modelling and projections)Incident peripartum infections with no ARV prophylaxis(range of reported transmission probabilities) = 30% (13-30%)The risk of perinatal transmission can now be less than 2% with HAART and formula feedingIncident infections occuring during pregnancy are estimated to be associated with a 30% probability of MTCT. Tx rate was high among women with CD4 count<200 compared with those with higher CD4 count. With WHO 2010 recommended regimens options A or B are estimated to be associated with a 2% peripartum transmission probability. Peripartum Tx rate was lowest for women who were taking ART before pregnancy (0.5%)Rollins N et al. STI 2012
11 Postnatal Transmission rate per month of any breastfeeding probabilities by ART and maternal CD4 count (The UNAIDS reference group on estimates, modelling and projections)Incident postnatal infections with no ARV prophylaxis(range of reported transmission probabilities) = 28% (14-56%)The risk of perinatal transmission can now be less than 5% with HAART and exclusive BF for 12 moIncident infections occuring during breastfeeding are estimated to be associated with a 28% probability of postnatal MTCT. Tx rate was high among women with CD4 count<350 compared with those with higher CD4 count. With WHO 2010 recommended regimens are estimated to be associated with a 0.2% transmission probability per month. Postnatal MTCT rate was lowest for women who were taking ART before pregnancy (0.16%/month) in one report only 0.07%/mo.Rollins N et al. STI 2012
12 The Mississippi Baby: Functional Cure of HIV Persaud D, 2013 CROI, Abstract 48LB
13 Mimicking the Mississippi baby The Way Forward:Mimicking the Mississippi babyEarly diagnosis of infected babiesNation-wideactive enrollmentTriple ARTIncluding to high-riskInfants immediately after birthImmediate ART tominimize latentlyinfected cellsART interruption inclinical trialControl HIV viremia
15 Thai HIV Treatment and Care Guidelines 2014: PMTCT Recommendations Thai HIV Rx and care guidelines toward eMTCT and ped cure 2013 categorized babies into 2 groups.Babies with standard-risk (mothers receive ANC or suppressed viral load) In this group during antenatal period, pregnatn women should receive LPV/r or EFV-based HAART, intrapartum AZT 300 mg oral q 3 hrs and infants receive AZT for 4 wks.Babies with high risk for MTCT include babies born to mothers with no ANC, receive ARV<4 wks or failing ART with high VL near time of delivery. This group, a baby should receive AZT/3TC/NVP for 6 wks. No BF. And obtain blood test for HIV DNA PCR at 1, 2, 4 mo, if + immediated LPV/r as soon as possible. This is similar to that in the Mississippi baby that might lead to functional cure in baby.Early HIV diagnosis and immediate lopinavir/r-ART in all HIV-infected infants. The triple-ARV prophylaxis regimen for children at high risk for HIV similar to that in the Mississippi baby.*Infants at high risk for HIV infection: those born to mothers with no ANC, <4 weeks of triple-ART or failing ART (VL>50 copies/mL)
17 Timeline for EID and early HIV treatment and care for infants born to HIV+ mothers StandardriskAZTPCR 1PCR 2HIV antibodyHigh riskPCR 1PCR 2PCR 3HIV antibodyAZT/3TC/NVPmo mo mo …… mo agePCR+ at 1 moAZT+3TC+LPV/rPCR+ at 2 moAZT+3TC+LPV/rPCR+ at 4 moAZT+3TC+LPV/r*ให้เก็บเลือดทารกทุกรายที่คลอดจากแม่ติดเชื้อเอชไอวีใส่กระดาษกรองไว้ (dried blood spot) เหมือนตรวจคัดกรองไทรอยด์เมื่อแรกเกิด และส่งเลือดไปที่กรมวิทยาศาสตร์ทางการแพทย์พร้อมการส่งตรวจคัดกรองไทรอยด์ ในกรณีที่เด็กติดเชื้อเอชไอวีจากผล PCR ที่ 1-2 เดือน หากมีเลือดเก็บไว้ที่แรกเกิดทางกรมวิทยาศาสตร์ทางการแพทย์จะตรวจ DNA PCR เพิ่มเติมให้เพื่อวินิจฉัยว่าเป็นการติดเชื้อตั้งแต่ในครรภ์หรือระหว่างคลอด ซึ่งอาจมีผลต่อแผนการรักษาในอนาคต
18 MTCT Rates 2013: 1.7% (accessed to PCR only) Weighted Average: 2.3%AIDS Zero portal website
19 Cascade of ARV-PMTCT/ART among Mothers NAP-Plus Database, NHSO(58.3%)* Under reportedReceipt of ARV (%) by Women Giving Birth with HIV-Seropositive ( )79% for Rx2012: N = 2,461 (65% report)2013: N = 3,193 (79% report)Source: DOH as of 17/04/2014
20 Cascade from Early Infant Diagnosis to Antiretroviral Treatment However, when we look at the cascade from idenfing HIV-exposed infants, making diagnosis, providing CD4 counting and initiating ART. we still found the substantial leakage in the cascade. This leads to the Active Case Management Program that I mentioned in the very beginning.EID program evaluation : Thai MOPH, CDC Thailand, UNICEF-Thailand
21 HIV Treatment Cascade in the Real World In a perfect world, all HIV infected individuals would follow the same pathway in the spectrum of engagement into care:HIVInfectedHIV DiagnosedLinked to HIV CareRetained in HIV CareNeed ARTOn ARTAdherent/SuppressedIn the real world, there is leakage between each of these steps and individuals are often lost-to-follow-up.Understanding the leakage points and their causes are essential to optimize the effectiveness of HIV treatment program.Comprehensively monitoring in standardized metrics is needed
22 Country Implementation Action: 10-Point Plan (1) Conduct a strategic assessment of key barriers to eMTCTDevelop or revise nationally-owned plans towards eMTCTAssess the available resources for eMTCT and develop a strategy to address unmet needsImplement and create demand for a comprehensive, integrated package of HIV prevention and treatment interventions and servicesStrengthen synergies and integration fit to context between HIV prevention and treatment and related health services to improve maternal and child health outcomesUNAIDS: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive
23 Country Implementation Action: 10-Point Plan (2) Enhance the supply and utilization of human resources for healthEvaluate and improve access to essential medicines and diagnostics and strengthen supply chain operationsStrengthen community involvement and communicationBetter coordinated technical support to enhance service deliveryImprove outcomes assessment, data quality, and impact assessmentUNAIDS: Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive
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