Advances in EMTCT

Graham P TaylorSection of Retrovirology and GU MedicineDivision of Infection

Advances in EMTCT

TargetsProgress

Challenges

EMTCT overall targets

2009 2015Number of HIV+ women delivering 1,490,000 743,000

New paediatric HIV infections 430,000 <43,000HIV-associated maternal deaths 42,000 21,000

Under 5’s deaths due to HIV 162,000 <81,000ART coverage among children 21% 100%

Global Monitoring Framework and StrategyFor the Global Plan for the elimination of new HIV infections in children by 2015 and keeping their mothers alive

EMTCT Prong targets

2009 2015Prong 1: New HIV infection 15-49 1,070,000 535,000Prong 2: Unmet need for Family Planning 11% 100%Prong 3.1:HIV MTCT rate(non-breast-feeding)

29% <5% (<2%)

Prong 3.2: Maternal ARV coverage 48%Incl sdNVP

90%

Prong 3.3: Breast-feeding ARV coverage N/A 90%Prong 4: ARV coverage pregnant women 34%

(2010090%

Global Monitoring Framework and StrategyFor the Global Plan for the elimination of new HIV infections in children by 2015 and keeping their mothers alive

The Global Plan…..

Shifts the focus from programmes to impact -that is, from scale up of PMTCT programmes to the elimination of MTCT by 2015. The Global Plan aims to reduce new child HIV infections by 90% and reduce HIV-associated deaths of women during pregnancy, childbirth, and puerperium by 50% from the 2009 baseline; and to reduce MTCT transmission of HIV to less than 5%, a level low enough that mother-to-child transmission of HIV would no longer be considered a major public health problem.

Milestones Completed (Global)

2011: The GSGS has supported countries in conducting rapid assessment of their status in achieving elimination of new HIV infects among children and keeping their mothers alive. 19 (86%) out of the 22 priority countries have completed national baseline assessments.

2011: IATT has provided requested support to countries in reviewing and revising national guidelines on treatment of pregnant women living with HIV, PMTCT and infant feeding and HIV.

2013: New global guidelines for ARV prophylaxis and ART have been issued, recommending simpler and more effective drug regimens and approaches.

Milestones in progress2011: The GSG has developed and activated mechanism for rapid response technical assistance to meet country-defined needs. Strategy for providing technical assistance to priority countries is in place and is accepting and responding to TA requests.

2012: IATT has provided requested support to countries in conducting policy reviews to decentralize and task shift essential HIV activities to the primary care level and the community level.

2012: Development partners will have aligned their financial and technical assistance with revised national action plans for elimination of new HIV infections among children and keeping their mothers alive.

2013: The estimated number of HIV-associated deaths to women during pregnancy, childbirth and deaths is reduced by 25%

Milestones behind2014: The estimated number of new HIV infections in children is reduced by two-thirds from the 2009 level.

2014: The estimated number of HIV-associated deaths to women during pregnancy, childbirth and deaths is reduced by one-third from 2009 level.

2014: Fifteen of the 22 priority countries will have met the two overall Global Plan targets.

2015: All countries will have met the 2 overall Global Plan targets for elimination of new HIV infections among children and keeping their mothers alive.

Globally - incidence of HIV declining

Global update on the Health Sector Response 2014

HIV mother-to-child transmission rate

Global update on the Health Sector Response 2014http://www.emtct-iatt.org/priority-countries/ accessed 11 October 2014

“Virtual elimination” of MTCT in Europe?

Jasseron et al 2011, von Linstow et al 2010, Naver et al 2006, Chiappini et al 2011, Prieto et al 2012, personal comm. Inga Latysheva, Townsend et al 2014

Country MTCT rate Time period

France 1.0% 2005-2009

Italy 1.0% 2005-2010

Denmark 0.5% 2000-2008

Sweden 0.6% 1999-2003

Spain 1.6% 2000-2007

Ukraine 4-5% 2008-2010

Russia 3-4% 2010-2012

UK 0.57% 2007-2011

Mothers receiving ARV therapy during pregnancy

http://www.emtct-iatt.org/priority-countries/ accessed 11 October 2014

http://www.who.int/hiv/data/en/ accessed 11 October 2014

Breast-feeding Infant-Mother pairs receiving ARV therapy or prophylaxis

http://www.emtct-iatt.org/priority-countries/ accessed 11 October 2014

Reduction in number of new paediatric HIV infections

http://www.emtct-iatt.org/priority-countries/ accessed 11 October 2014

new Paediatric HIV infections declining

Global update on the Health Sector Response 2014

Pregnant women in need of ART for own health receiving life-long ART

http://www.emtct-iatt.org/priority-countries/ accessed 11 October 2014

Future Challenges

Sustainability• Systems• Persons

UK Retention in Care

0102030405060708090

100

HIV infection Diagnosed Linked toCare

cART <400 on cART

% o

f all

HIV

infe

cted

per

sons

23 New HIV diagnoses and number of persons accessing HIV care in the United Kingdom: 2014

US Retention in Care

40%

40%

Future Challenges

Sustainability• Systems• PersonsInequality in access to care

Ukraine: lower middle income country Implementation of WHO Option B started in 2008

Bailey et al, WHO Bulletin, 2013, 91:491-500

Deliveries in a Ukraine cohort 2008-2010 (N=3535)Among women needing ART for PMTCT only (68% of total), the % on cART increased from 12% in 2008 to 55% in 2010MTCT rate among women receiving cART: 1.4% (95%CI 0.8, 2.2%)

• MTCT rate overall in 2010 = 4.1% (95% CI 3.4, 4.9%)

In 2010, supplies of cART insufficient for all pregnant women, hence nearly half continued to receive ZDVm +/-sdNVPGeographic and socio-demographic inequities in receipt of cART

Future Challenges

Sustainability• Systems• PersonsInequality in access to careSmaller gains for greater effort

A small % of women receive no antenatal ARVs, but contribute a high % of transmissions

9%40%

Infant HIVinfections

Data from European Collaborative Study (Western Europe), 2000-2009

European Collaborative Study 2011

Problems identified:Audit of perinatal HIV in the UK, 2006-13

Byrne et al 2014, CHIVA conference

70% ≥1 social issue

28% immigration issue

26% housing problems

11% mental health problems

10% drug abuse7% intimate partner violence

Future Challenges

Sustainability• Systems• PersonsInequality in access to careSmaller gains for greater effortMore pregnant women not less

The target…..

2009 2015Number of HIV+ women delivering 1,490,000 743,000

New paediatric HIV infections 430,000 <43,000HIV-associated maternal deaths 42,000 21,000

Under 5’s deaths due to HIV 162,000 <81,000ART coverage among children 21% 100%

Increasing pregnancy rates among HIV-positive women in the UK

Huntington et al 2013 AIDS

Pregnancy incidence among women accessing HIV clinical care, 2000-2009

Estimates suggest that 1 in 12 women with HIV aged 16-35 became

pregnant in 2009

Repeat pregnancies among HIV-positive women, data from UK and Ireland

• Rate of repeat pregnancies: 7.0 per 100 woman-yrs• Increasing proportion of pregnancies in diagnosed

women are second and subsequent• 40% in 2009, but levelling off since 2011 at just

under 50% National Study of HIV in Pregnancy and Childhood, French et al 2012

The number of women of child-bearing potential will increase

Moving towards elimination

“Every infant infected with HIV through vertical transmission

represents a sentinel health event that signals either a missed

prevention opportunity, or, more rarely, a failure of prophylaxis”

ACOG 2004

a level low enough that mother-to-child transmission of HIV would no longer be considered a major public health problem.

Thank you for listening .

Many thanks to Inga Latysheva, Karoline Aebi-Popp, Claire Townsend, Heather Bailey, Laura Byrne, Pat Tookey, Helen Peters and Claire Thorne

Now let me sleep