Advances in EMTCT Graham P Taylor Section of Retrovirology and GU Medicine Division of Infection
Advances in EMTCT
Targets Progress Challenges
EMTCT overall targets
2009 2015 Number of HIV+ women delivering 1,490,000 743,000 New paediatric HIV infections 430,000 <43,000 HIV-associated maternal deaths 42,000 21,000 Under 5â&#x20AC;&#x2122;s deaths due to HIV 162,000 <81,000 ART coverage among children 21% 100%
Global Monitoring Framework and Strategy For the Global Plan for the elimination of new HIV infections in children by 2015 and keeping their mothers alive
EMTCT Prong targets
Prong 1: New HIV infection ď&#x201A; 15-49 Prong 2: Unmet need for Family Planning Prong 3.1:HIV MTCT rate (non-breast-feeding) Prong 3.2: Maternal ARV coverage Prong 3.3: Breast-feeding ARV coverage Prong 4: ARV coverage pregnant women
2009 1,070,000 11% 29% 48% Incl sdNVP N/A 34% (20100
Global Monitoring Framework and Strategy For the Global Plan for the elimination of new HIV infections in children by 2015 and keeping their mothers alive
2015 535,000 100% <5% (<2%) 90% 90% 90%
The Global Planâ&#x20AC;Ś.. 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-tochild 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 progress 2011: 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 behind 2014: 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
http://www.emtct-iatt.org/priority-countries/ accessed 11 October 2014 Global update on the Health Sector Response 2014
â&#x20AC;&#x153;Virtual eliminationâ&#x20AC;? of MTCT in Europe? 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
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
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 â&#x20AC;˘ Systems â&#x20AC;˘ Persons
UK Retention in Care
% of all HIV infected persons
100 90 80 70 60 50 40 30 20 10 0 HIV infection Diagnosed
Linked to Care
cART
<400 on cART
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 â&#x20AC;˘ Systems â&#x20AC;˘ Persons Inequality in access to care
Ukraine: lower middle income country Implementation of WHO Option B started in 2008 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 2010 MTCT rate among women receiving cART: 1.4% (95%CI 0.8, 2.2%)
â&#x20AC;˘ 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 +/sdNVP Geographic and socio-demographic inequities in receipt of Bailey et al, WHO Bulletin, 2013, 91:491-500 cART
Future Challenges
Sustainability â&#x20AC;˘ Systems â&#x20AC;˘ Persons Inequality in access to care Smaller gains for greater effort
A small % of women receive no antenatal ARVs, but contribute a high % of transmissions Infant HIV infections 9%
40%
Data from European Collaborative Study (Western Europe), 2000-2009
European Collaborative Study 2011
Audit of perinatal HIV in the UK, 2006-13 Problems identified:
70% â&#x2030;Ľ1 social issue 28% immigration issue 26% housing problems 11% mental health problems 10% drug abuse 7% intimate partner violence Byrne et al 2014, CHIVA conference
Future Challenges
Sustainability â&#x20AC;˘ Systems â&#x20AC;˘ Persons Inequality in access to care Smaller gains for greater effort More pregnant women not less
The targetâ&#x20AC;Ś..
Number of HIV+ women delivering New paediatric HIV infections HIV-associated maternal deaths Under 5â&#x20AC;&#x2122;s deaths due to HIV ART coverage among children
2009 1,490,000 430,000 42,000 162,000 21%
2015 743,000 <43,000 21,000 <81,000 100%
Increasing pregnancy rates among HIVpositive women in the UK
Estimates suggest that 1 in 12 women with HIV aged 16-35 became pregnant in 2009
Pregnancy incidence among women accessing HIV clinical care, 2000-2009
Huntington et al 2013 AIDS
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 a level low enough that mother-to-child transmission of HIV would no longer be considered a major public health problem.
â&#x20AC;&#x153;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 prophylaxisâ&#x20AC;? ACOG 2004
Thank you for listening .
Now let me sleep
Many thanks to Inga Latysheva, Karoline Aebi-Popp, Claire Townsend, Heather Bailey, Laura Byrne, Pat Tookey, Helen Peters and Claire Thorne