L Children living with HIV/AIDS l New HIV infections in children in 1999 l Child deaths due to...
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Children living with HIV/AIDSChildren living with HIV/AIDS
New HIV infections in children in 1999New HIV infections in children in 1999
Child deaths due to HIV/AIDS in 1999Child deaths due to HIV/AIDS in 1999
Cumulative number of child deaths due to HIV/AIDSCumulative number of child deaths due to HIV/AIDS
June-2000 global estimatesJune-2000 global estimatesChildren (<15 years)Children (<15 years)
1.3 million
620 000
500 000
3.8 million
Estimated impact of AIDS on under-5 child Estimated impact of AIDS on under-5 child mortality rates – mortality rates – Selected African countries, Selected African countries,
20102010
Source: US Bureau of the Census
250
200
150
100
50
0
per 1000 live births with AIDS
Botswana Kenya Malawi Tanzania Zambia Zimbabwe
without AIDS
Prevention of Mother to Child Transmission (PMTCT). during late pregnancy. during labor. through breast-feeding
Prevention of
unwanted pregnancies
(Family Planning)
Three integrated strategies to reduce Three integrated strategies to reduce paediatricpaediatric AIDS AIDS
Three integrated strategies to reduce Three integrated strategies to reduce paediatricpaediatric AIDS AIDS
Primary HIV prevention in parents to be
Primary HIV prevention in the context of Primary HIV prevention in the context of pregnancypregnancy
Primary HIV prevention in the context of Primary HIV prevention in the context of pregnancypregnancy
Information, Education and Communication programmesInformation, Education and Communication programmes
Screening and treatment of Sexually Transmitted Infections Screening and treatment of Sexually Transmitted Infections
Condom promotionCondom promotion
HIV counsellingHIV counselling NB: The risk of MTCT increases when the NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeedingmother is infected during pregnancy or breastfeeding
Information, Education and Communication programmesInformation, Education and Communication programmes
Screening and treatment of Sexually Transmitted Infections Screening and treatment of Sexually Transmitted Infections
Condom promotionCondom promotion
HIV counsellingHIV counselling NB: The risk of MTCT increases when the NB: The risk of MTCT increases when the mother is infected during pregnancy or breastfeedingmother is infected during pregnancy or breastfeeding
Benefits of information, counselling and Benefits of information, counselling and voluntary HIV testing for the communityvoluntary HIV testing for the communityBenefits of information, counselling and Benefits of information, counselling and voluntary HIV testing for the communityvoluntary HIV testing for the community
Widespread availability and use of counselling and voluntary Widespread availability and use of counselling and voluntary
HIV testing can :HIV testing can :
Reduce fear, ignorance and stigma surrounding HIVReduce fear, ignorance and stigma surrounding HIV
Stimulate a community response in support to those Stimulate a community response in support to those
needing careneeding care
Contribute to an environment supportive of safer sexual Contribute to an environment supportive of safer sexual
behaviourbehaviour
Reduce spillover of artificial feeding to HIV(-) mothersReduce spillover of artificial feeding to HIV(-) mothers
Widespread availability and use of counselling and voluntary Widespread availability and use of counselling and voluntary
HIV testing can :HIV testing can :
Reduce fear, ignorance and stigma surrounding HIVReduce fear, ignorance and stigma surrounding HIV
Stimulate a community response in support to those Stimulate a community response in support to those
needing careneeding care
Contribute to an environment supportive of safer sexual Contribute to an environment supportive of safer sexual
behaviourbehaviour
Reduce spillover of artificial feeding to HIV(-) mothersReduce spillover of artificial feeding to HIV(-) mothers
Family Planning StrengtheningFamily Planning StrengtheningFamily Planning StrengtheningFamily Planning Strengthening To prevent To prevent unwantedunwanted pregnancies pregnancies
HIV should never be used as a reason to pressurise women HIV should never be used as a reason to pressurise women into having or not having childreninto having or not having children
To delay subsequent pregnanciesTo delay subsequent pregnancies
For the health of mothers, WHO recommends a minimum of For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. 2 years between pregnancies.
To replace the contraceptive effect of breastfeedingTo replace the contraceptive effect of breastfeeding
Avoidance of breastfeeding for PMTCT should not lead to Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancyrapid, unplanned subsequent pregnancy
To prevent To prevent unwantedunwanted pregnancies pregnancies
HIV should never be used as a reason to pressurise women HIV should never be used as a reason to pressurise women into having or not having childreninto having or not having children
To delay subsequent pregnanciesTo delay subsequent pregnancies
For the health of mothers, WHO recommends a minimum of For the health of mothers, WHO recommends a minimum of 2 years between pregnancies. 2 years between pregnancies.
To replace the contraceptive effect of breastfeedingTo replace the contraceptive effect of breastfeeding
Avoidance of breastfeeding for PMTCT should not lead to Avoidance of breastfeeding for PMTCT should not lead to rapid, unplanned subsequent pregnancyrapid, unplanned subsequent pregnancy
Prevention of MTCT through antiretroviralsPrevention of MTCT through antiretroviralsPrevention of MTCT through antiretroviralsPrevention of MTCT through antiretrovirals
Mechanisms of action:Mechanisms of action:
Ante and intra-partum regimen:Ante and intra-partum regimen:
Reduce viral load in mother ’s blood and genital fluids Reduce viral load in mother ’s blood and genital fluids
during pregnancy, labor and deliveryduring pregnancy, labor and delivery
Post-partum regimen:Post-partum regimen:
Act as post-exposure prophylaxis (viral particles Act as post-exposure prophylaxis (viral particles
eventually transmitted during birth are eliminated)eventually transmitted during birth are eliminated)
Mechanisms of action:Mechanisms of action:
Ante and intra-partum regimen:Ante and intra-partum regimen:
Reduce viral load in mother ’s blood and genital fluids Reduce viral load in mother ’s blood and genital fluids
during pregnancy, labor and deliveryduring pregnancy, labor and delivery
Post-partum regimen:Post-partum regimen:
Act as post-exposure prophylaxis (viral particles Act as post-exposure prophylaxis (viral particles
eventually transmitted during birth are eliminated)eventually transmitted during birth are eliminated)
Non-antiretroviral based intervention to Non-antiretroviral based intervention to prevent MTCT at birthprevent MTCT at birth
Non-antiretroviral based intervention to Non-antiretroviral based intervention to prevent MTCT at birthprevent MTCT at birth
Ceasarian section :Ceasarian section : 50% risk reduction if performed before 50% risk reduction if performed before
onset of labouronset of labour
Avoidance of unnecessary invasive proceduresAvoidance of unnecessary invasive procedures (episiotomy, (episiotomy,
rupture of membranes…) : reduce infant contact with rupture of membranes…) : reduce infant contact with
mother ’s infected blood and genital fluidsmother ’s infected blood and genital fluids
Vaginal lavageVaginal lavage with chlorhexidine : may be protective in with chlorhexidine : may be protective in
case of prolonged rupture of membrane (>4 hours before case of prolonged rupture of membrane (>4 hours before
delivery)delivery)
Vitamin A supplementation :Vitamin A supplementation : not effective to reduce MTCT not effective to reduce MTCT
Ceasarian section :Ceasarian section : 50% risk reduction if performed before 50% risk reduction if performed before
onset of labouronset of labour
Avoidance of unnecessary invasive proceduresAvoidance of unnecessary invasive procedures (episiotomy, (episiotomy,
rupture of membranes…) : reduce infant contact with rupture of membranes…) : reduce infant contact with
mother ’s infected blood and genital fluidsmother ’s infected blood and genital fluids
Vaginal lavageVaginal lavage with chlorhexidine : may be protective in with chlorhexidine : may be protective in
case of prolonged rupture of membrane (>4 hours before case of prolonged rupture of membrane (>4 hours before
delivery)delivery)
Vitamin A supplementation :Vitamin A supplementation : not effective to reduce MTCT not effective to reduce MTCT
Prevention of MTCT after birthPrevention of MTCT after birthPrevention of MTCT after birthPrevention of MTCT after birth Avoidance of breastfeedingAvoidance of breastfeeding = Replacement feeding: = Replacement feeding:
First 4-6 months:First 4-6 months:
- Commercial infant formula- Commercial infant formula
- home made infant formula (diluted animal milk + sugar + - home made infant formula (diluted animal milk + sugar + vitamins)vitamins)
From 6 months to 2 years:From 6 months to 2 years:
- Enriched family foods- Enriched family foods Exclusive breastfeeding + early weaningExclusive breastfeeding + early weaning (as soon as (as soon as
replacement feeding is feasible and safe)replacement feeding is feasible and safe)
Avoidance of breastfeedingAvoidance of breastfeeding = Replacement feeding: = Replacement feeding:
First 4-6 months:First 4-6 months:
- Commercial infant formula- Commercial infant formula
- home made infant formula (diluted animal milk + sugar + - home made infant formula (diluted animal milk + sugar + vitamins)vitamins)
From 6 months to 2 years:From 6 months to 2 years:
- Enriched family foods- Enriched family foods Exclusive breastfeeding + early weaningExclusive breastfeeding + early weaning (as soon as (as soon as
replacement feeding is feasible and safe)replacement feeding is feasible and safe)
The variable risk of MTCT of HIV The variable risk of MTCT of HIV (with and without preventive interventions)(with and without preventive interventions)
The variable risk of MTCT of HIV The variable risk of MTCT of HIV (with and without preventive interventions)(with and without preventive interventions)
0% 25% 50% 75% 100%
ARV, no breastfeeding, C-section
ARV, no breastfeeding
no ARV, no breastfeeding
ARV, prolonged breastfeeding
no ARV, prolonged breastfeeding
Infected Uninfected
ARV regimen of proven efficacyARV regimen of proven efficacyARV regimen of proven efficacyARV regimen of proven efficacy
Antenatal Intrapartum Postnatal
ZDV long
ZDV short
ZDV+3TC (1)
ZDV+3TC (2)
NVP
Infant
Infant+Mother
Infant+Mother
14wk 36wkOnset of labour Delivery
Birth 1wk PP 6wk PP
Infant
Balancing the risks of breastfeeding and Balancing the risks of breastfeeding and formula feedingformula feeding
Balancing the risks of breastfeeding and Balancing the risks of breastfeeding and formula feedingformula feeding
0%
10%
20%
30%
40%
HIV Infection rate-Breast-feeding HIV Infection rate-Formula feedingMortality rate-Breastfeeding Mortality rate-Formula feeding
6 wks
14 wks
6 months12 months 24 months
Child age
Source: Nduati et al. JAMA 2000
A cascade of interventionsA cascade of interventionsA cascade of interventionsA cascade of interventions
P Pregnant
Pre-test counsellingTest accepted
Results given
ARV initiated
ARV completedSafer infant feeding
ANC
Infections averted
Botswana pilot programme example Botswana pilot programme example First 8 monthsFirst 8 months
Botswana pilot programme example Botswana pilot programme example First 8 monthsFirst 8 months
P HIV+ Pregnant
Pre-test counsellingTest accepted
Results givenARV initiated
ARV completed
Safer infant feeding
ANC
Infections averted (estimated)
N=2900
N=2900
N=1650
N=754
N=435
232
174
N=638
70
Botswana: Challenges and ResponsesBotswana: Challenges and ResponsesBotswana: Challenges and ResponsesBotswana: Challenges and Responses
Challenges :Challenges :
Offer pre-test counselling to all womenOffer pre-test counselling to all women
Increase acceptability of HIV testIncrease acceptability of HIV test
Responses :Responses :
Train all mid-wives and doctors in HIV counsellingTrain all mid-wives and doctors in HIV counselling
Develop communication programmesDevelop communication programmes
Involve partners and/or other significant relativesInvolve partners and/or other significant relatives
Challenges :Challenges :
Offer pre-test counselling to all womenOffer pre-test counselling to all women
Increase acceptability of HIV testIncrease acceptability of HIV test
Responses :Responses :
Train all mid-wives and doctors in HIV counsellingTrain all mid-wives and doctors in HIV counselling
Develop communication programmesDevelop communication programmes
Involve partners and/or other significant relativesInvolve partners and/or other significant relatives