# Presentation: 515030

## Prevention of Mother-Child HIV Transmission (PMTCT)

- GAP Laboratory Review
- May 14, 2003

## Objectives of the Talk

- PMTCT Background
- President’s PMTCT Initiative
- PMTCT Program Activities
- Expanded Plan for AIDS Relief
- Laboratory Issues and Needs

## Why PMTCT?

-  720,000 new mother-to-child HIV infections in 2001
- 2,000 new infections each day
- Erasing child survival gains
- Transmission risk can be reduced by at least 50%
- Feasible, affordable in low-resource settings
- Opportunities for primary prevention, access to partners, family care and treatment

## Perinatal HIV Transmission

- Background transmission risk: 30-45%
- 15-30% risk during pregnancy and delivery
- 10-20% additional risk postpartum via breastfeeding
- Transmission risk with interventions:
- 	20-25%		No breastfeeding
- 	15-25% 	Short-course ARV + breastfeeding
- 	  **5-15%**** ****	****Short-course ARV, no BF**
-       1-5%		Combination short-course ARV’s, no BF
- 	  1%	 	2 or 3 ARV’s +C-section, no BF

## Advantages of Nevirapine for Preventing  Perinatal HIV Transmission in Africa

- Single dose to mother (200mg) in labor, single dose (2mg/kg; 6mg) to newborn
- Rapidly absorbed after oral dosing
- Rapid transfer across placenta
- Rapid drop in HIV viral load
- Long acting: sustained high levels in infant
- Low-cost
- Limited/ no side effects (single dose)

## Emerging New Data on PMTCT

- Short-course combination therapy highly effective
- Short-course AZT/3TC highly effective
- Short-course AZT + NVP more effective than either regimen alone
- Prophylaxis to the infant alone (either AZT or NVP) partially effective

## GAP PMTCT Technical StrategyIn direct collaboration with MOH, help implement feasible interventions to decrease HIV MTCT in resource-poor settings, and to assure that these interventions:•  are integrated within MCH programs•  strengthen antenatal care•  promote the health of the mother•  enhance HIV primary prevention    efforts in the community•  can be expanded to scale 

## GAP PMTCT Technical StrategyKey Interventions

- ANC C&T (routine, right of refusal)
-     	    *integrated as part of MCH care*
- 2)   Short-course ARV prophylaxis
-       *NVP or short-course AZT*
- 3)   Minimize breastfeeding transmission risk
-       *replacement feeding or early weaning*

## GAP PMTCT Illustrative Activities-   Demonstration projects-   Centers of excellence-   Laboratory capacity-   Community IEC, primary prevention -   Implementation manuals 

- -   Videos for ANC MTCT
-    Database support- national monitoring
-    Monitoring and evaluation
-    Linkages to surveillance and care
-    Training
-    Operational research
*Support projects that can be expanded to scale*  _ _

## President’s PMTCT Initiative(announced June 2002)

- Reach up to           1 million women annually
- Reduce mother-to-child HIV transmission by    up to 40% among women treated

*WHO/P. Virot*

## Designated Countries in the President’s Mother-to-Child Initiative

_**Africa**_
- Botswana
- Côte d’Ivoire
- Ethiopia
- Kenya
- Mozambique
- Namibia
- Nigeria
- Rwanda

- South Africa
- Tanzania
- Uganda
- Zambia
_**Caribbean**_
- Guyana
- Haiti
- 15.  CAREC (Caribbean Regional Epidemiology Centre)

**Notes:**
The Administration selected these 14 countries based on 
the burden of HIV/AIDS, particularly as indicated by ANC data, 
the level of infrastructure to support targeted efforts to prevent mother-to-child HIV transmission, 
the individual country governments’ commitment to preventing HIV and treating those infected.

## Baseline Assessment Findings: Antenatal HIV Prevalence in PMTCT Initiative Countries

## Baseline Assessment Findings: Estimated Number of HIV+ Women Delivered Annually

- (664)

## Core Program Elements

- _ANC C&T_:  Counseling and testing services at ANC and labor and delivery
- _PMTCT ARV_:  Short-course antiretroviral prophylaxis for HIV-infected pregnant women and HIV-exposed infants (NVP)
- _Infant Feeding_: Counseling and support for safe infant feeding practices
- _Family Planning_: Counsel_i_ng and/or referral for family planning

## Expanded Program Elements for the Presidential PMTCT Initiative

- Integration of prevention strategies for pregnant HIV negative women
- Integration of PMTCT services into MCH services
- _PMTCT-PLUS_: Provide ongoing care and support for mothers, infants and family members (may include ARV treatment, palliative care, psychosocial support)
- Community mobilization to enhance PMTCT/ MCH activities
- Strengthen health, family planning, and safe motherhood programs

## GAP UTAP Partners

- University of North Carolina, Chapel Hill*
- Baylor College of Medicine
- Columbia University*
- Harvard Medical School
- Johns Hopkins University/ JHPIEGO*

- Tulane University
- University of Maryland*
- Howard University
- University of Medicine and Dentistry of New Jersey*
- University of California, San Francisco

-       (* Primary PMTCT)

## President’s Emergency Plan for AIDS Relief[Proposed for FY ’04,  $15 Billion, 5 years]

**Prevent 7 million new infections **
**    ****(60 percent of projected new infections)**
*    **Large-scale prevention efforts, including VCT. Availability of treatment will enhance prevention efforts by providing incentive for testing.  *
**Treat 2 million HIV-infected people**** **** **
*    **First global effort to provide advanced ARV treatment on large scale in poorest, most affected countries.*
**Care for 10 million HIV-infected individuals and AIDS orphans**
*    **Range of care, including support for AIDS orphans. *

**Notes:**
$15B over 5 years, including $10B new money

PMTCT initiative seen as a model for this effort; same 14 countries:
In Africa:
Botswana
Cote d’Ivoire
Ethiopia
Kenya
Mozambique
Namibia
Nigeria
Rwanda
South Africa
Tanzania
Uganda
Zambia and, 
in the Caribbean,
Guyana
Haiti

## PMTCT Lab Issues

- Laboratory capacity and QA are key components of PMTCT and PMTCT-PLUS
- Need national level capacity
- National program
- Reference and specialized testing
- Facility level capacity
- Will vary according to facility level

## PMTCT Lab Issues (2)

- Role of lab testing:
- Diagnosis
- mother-rapid testing, coordinate with syphilis testing, in-labor testing
- infant
- Illness staging for treatment decisions
- simplified CD4, viral load testing
- resistance monitoring (?at program level)
- Collection strategies:
- dried blood spots