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VERTICAL TRANSMISSION
PREVENTION
Best Practices
www.hivnet.ubc.ca
Amy Slogrove
19 July 2016
CTN PMTCT Symposium
AIDS 2016, Durban, South Africa
www.hivnet.ubc.ca
New HIV Infections in Children: 2001-2015
150 000
But: 1.5 million women living with HIV give birth each year – unchanged
>50% of pregnant women in LMICs do not receive an HIV-test
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Hot off the press...
Key updates related to
PMTCT
Best practices for a public
health approach in high
prevalence settings
www.hivnet.ubc.ca
Overview
1.
Timing of HIV Testing
• Pregnant women & infants
2.
Maternal Antiretroviral Therapy (ART)
• Maternal Health & PMTCT
3.
Infant Prophylaxis
4.
Research Gaps / Responsibilities
5.
Take Home Messages
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Timing of HIV Testing: pregnant women
HIV Viral Load
Highest
Risk
Time
Summary
• Routine component of care
• All HIV-negative pregnant women retested
third trimester, labour, postpartum
• Lactating mothers retested periodically
Evidence
• 4% of breastfeeding women acquired
HIV-infection during pregnancy or
while breastfeeding (Kenya, Malawi, SA)
•
20% of postpartum transmission due to new
HIV-infection in women while
pregnant/breastfeeding (Zimbabwe)
www.hivnet.ubc.ca
Timing of HIV Testing: pregnant women
HIV Viral Load
Highest
Risk
Time
www.hivnet.ubc.ca
Timing of HIV Testing: HIV-exposed infants
Waning of infant maternally-derived
antibody levels
Birth
Summary
• 4-6 weeks all HEI: virologic testing (DNA-PCR)
• 9 months all HEI: screen with serologic test, if
reactive confirm with virologic test
• Breastfeeding HEI: serologic test @ 18 months
or 3 months after breastfeeding cessation
9 months
18 months
Evidence
• CHER trial – rapid HIV progression < 12
weeks of age
• Rapid serologic tests @ 9 months –
sensitivity 99.8% (95%CI 99.5-100%)
•
Discussion around value of PCR @ birth
www.hivnet.ubc.ca
Timing of HIV Testing: Outside of PMTCT Programs
Inpatient Outpatient
Developmental
Delay
PMTCT
programs
Summary:
More testing
• Inpatient care (diarrhoea, pneumonia, sepsis)
• Outpatient care (malnutrition, IMCI & TB clinics)
• (Developmental delay)
• Parents, siblings diagnosed with HIV
Parent/Sibling
Evidence
• 22% of paediatric inpatients – undiagnosed
HIV infection (Systematic review)
• 25% of malnutrition clinic attendants
(Eastern & Southern Africa)
• Highly acceptable to parents & caregivers
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Maternal ART
Summary
• Simple!
• Better for maternal health
• Better for PMTCT
• Better for programs
Evidence
• RCTs: TEMPRANO & START - adults
• PROMISE: HIV transmission with triple
ART (0.6%) vs. AZT+sdNVP (1.8%)
• Malawi, South Africa – program
feasibility
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Maternal ART
www.hivnet.ubc.ca
Infant Prophylaxis
Summary
High risk infants – born to women with:
•
•
•
•
< 4 weeks ART prior to delivery
Viral load > 1000 copies/ml within 4 weeks
prior to delivery
Incident HIV infection during pregnancy or
while breastfeeding
HIV only identified postpartum
 Infant dual prophylaxis (AZT+NVP)
•
•
Breastfed – 12 weeks
Formula – 6 weeks
Not high risk
•
•
Mothers on ART > 4 weeks
VL < 1000 during last 4 weeks of pregnancy
 Infant NVP prophylaxis
•
•
Breastfed – 6 weeks
Formula – 4 to 6 weeks
Evidence
•
•
HPTN040 – no ARVs during pregnancy;
2/3 drug infant prophylaxis better than 1
HPTN046 – breastfed infants, mothers
on ART; no difference in PN transmission
with 6 weeks vs. 6 months of infant NVP
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Infant Prophylaxis – just a bridge
Maternal viral load & duration of maternal ART
are key determinants of transmission risk
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Research Gaps / Responsibilities
• Maternal & Infant HIV Testing
• Better understanding of mothers responses to negative HIV results – testing fatigue?
• Does birth testing add value for PMTCT programs, infants & families?
• Universal maternal ART
• TDF/3TC/EFV as effective for PMTCT as the LPV/r based PROMISE regimens?
• Effect of ART on pregnancy outcomes & short/ long-term HIV-exposed infant outcomes?
• Infant prophylaxis
• Is NVP+AZT the right dual therapy combination for high risk infants?
• What is appropriate prophylaxis for infants of mothers on failing regimens / with drug
resistance ?
• Breastfeeding
• Family & community acceptability of interventions, services, delivery
strategies
www.hivnet.ubc.ca
Take Home Messages
1.
Test, test & test again
• Pregnant women, HIV-exposed infants &
outside of PMTCT programs
2.
Universal maternal ART
• Best for maternal health & also most
effective for PMTCT
3.
Infant prophylaxis
• Only a bridge & high risk infants need a
stronger bridge
4.
Research responsibilities
• Many
5.
Invest in research competencies
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Acknowledgments
CTN International Postdoctoral Fellowship Award 2013-2014
Joel Singer & Jacquie Sas
Stellenbosch University
University of British Columbia
University of Cape Town