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PMTCT HIV AND SYPHILIS
IMPLEMENTATION
Dr John Kinuthia, MBChB, MMED, MPH
Consultant Obstetrician & Gynaecologist
Honorary Lecturer, Department of Obstetrics & Gynaecology, UoN
Head, Research & Programs, Kenyatta National Hospital
20th International AIDS Conference , July 20th 2014, Melbourne, Australia.
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Background
• ~1.6M Kenyans living with HIV
o10% children <14 years
Men
= 4.4%
Women = 6.9%
Pregnant = 6.5%
o 57% women
• 11000 new infections among
children in 2012
HIV prevalence among adults and
adolescents aged 15–64 years by region*
• PMTCT program in Kenya implemented in 2000
• In 2012, >9,000 health facilities offering PMTCT
services
*KAIS 2012
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Trends in HIV screening during pregnancy
in Kenya
KDHS 2003; #KAIS 2008-9; *Kinuthia 2010; **Kiarie 2011;***KAIS 2012
4
New HIV infections among children reducing
Estimated number of new infections in children aged (0-14): Global trends and
projections 2001-20015
oIncreased HIV
otesting*
oIncreased availability
o& use of ARVs*
• PMTCT programs focus on women with chronic HIV
infection
• Women in window period & those infected after HIV after
after HIV testing go unrecognized
o Increased HIV incidence during pregnancy reported**
o Increased MTCT risk***
*UNAIDS, 2013;NASCOP, 2011;**Drake 2014; Kinuthia 2010;Gray 2005;*** Kourtis, 2010; Ioannidis, 1999;
Pitt ,1997; Garcia,1999; Mofenson,1999
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HIV-1 incidence during pregnancy and
postpartum Kinuthia CROI 2014
Ahero Hospital
HIV prevalence at ANC 22%
• Prospective cohort
• Study population
o HIV-1 rapid antibody test negative
– Day of enrolment or within 3 months
o Resident until 9 months postpartum
• RPR as part of ANC
• HIV testing
o Pooled nucleic acid amplification test
(NAAT)
– 10 samples
Rapid test
≤3 months
-ve
NAAT test
Pooled
Bondo Hospital
HIV prevalence at ANC 26%
-ve
Serial NAAT
+ve
Individual NAAT
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Antenatal care services & enrolment
Clinical ANC
HTC
Registration
•
•
•
•
•
Palpation
Hematinic
IPT and ITN
TT injection
Infant feeding
coundeling
• ARVs
• 38 (0.9%) Declined
• 799 (18.8%) HIV-1+ve
• 3408 (80.3%) HIV-1-ve
• 4245 women
• May 2011-June 2013
_
Review
Nurse/clinician
MCH Clinic
Antenatal profile
•
•
•
•
Hemoglobin
RPR
Blood group
Urinalysis
Laboratory
Laboratory
Study clinic
Home
*2351 women met eligibility criteria
• 1304 (56%) enrolled*
• RPR 1020 (78.2%)
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Baseline characteristics (n=1304)
Characteristic
N
n (%) or Median (IQR)
Age
1304
22
(19 - 27)
Education level (years)
1304
8
(7 - 10)
Married
1304
1022
(78)
Marriage duration (years)
1019
4
(1 - 8)
Partner age difference*
1171
6
(4 - 10)
Gravida
1304
2
(1 - 4)
87
(7)
18
841
445
(1)
(64)
(34)
History of STI
Partner HIV status
Positive
Negative
Unknown
* Years older
1304
8
HIV-1 incidence
Pre-enrollment
Rapid test
≤3 months
Enrollment
NAAT test
pooled
Follow up
-ve
+ve
Serial NAAT
Individual NAAT
2.34
(0.56 – 4.34)
24 New HIV infections
5 Seroconversion detected at enrollment
-ve
+ve
+ ve repeat rapid
antibody test
5 Acute infection detected at enrollment
-ve
+ve
- ve repeat rapid
antibody test
14 Acute infection detected during follow-up
+ ve NAAT test
-ve
–ve
Incidence rate
95% CI
1.11
(0.61 – 2.00)
5.00
(0.62 – 19.38)
3.11
(0.38 – 5.84)
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Correlates of acute HIV-1 infection
OR
(95% CI)
p
Age (per year increase)
1.0
0.9 – 1.0
0.2
Married
0.7
0.3 – 1.7
0.4
Shorter marriage duration (yrs)
1.14
0.3 – 1.7
0.05
Partner age difference*
1.00
0.98 – 1.02
0.88
History of STI
3.8
1.4 – 10.6
0.01
CT
2.6
0.7 – 8.8
0.14
GC
1.8
0.2 – 14.1
0.58
TV
1.2
0.7 – 2.3
0.50
Syphilis
10.0
2.0 – 46.0
0.005
2.6
1.2 – 5.8
0.019
BV
10
Baseline STIs/genital tract Infections
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Challenge of incident maternal HIV
infections to eMTCT
• High HIV viral load*
• Mother not known to
be HIV infected
•
Infant infection due to
The contribution of maternal HIV seroconversion
during
late pregnancy
and breastfeeding
• Maternal
infection
afterto
mother-to-child transmission of HIV**
• ANC testing
J Acquir Immune Defic Syndr. 2012 ;59(4):417-25.
CROI (2008)
2009. Montreal.
Abstract 91
o16th
26%
to 34%
• No HIV PMTCT
intervention
o No maternal ARV
o No infant ARV
o Obstetrical interventions
HIV Incidence in Pregnancy and the First Post(2014) in South Africa**
partum Year and Implications for PMTCT
Programs, Francistown, Botswana, 2008
o 43% of infant infections
“In this
mature and successful
PMTCT
iBotswana
in 2007***
programme, new and undetected
maternal infections may be causing
nearly half of infant infections.” Lul et al
o Enhanced counseling on
exclusive breastfeeding
*Kourtis 2010; Ioannidis 1999; Pitt 1997; Garcia1999; Mofenson 1999; **Johnson 2012; ***Lul CROI 2009
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HIV retesting in pregnancy
• High acceptability*
• Cost effective **
Obstet Gynecol. 2003 Oct;102(4):782-90.
Human immunodeficiency virus retesting during
pregnancy: costs and effectiveness in preventing
perinatal transmission**
• 6.2 per 1000 person-years HIV incidence
• Limitation
o Increased workload
o Overstretched workforce
o Late initiation of ANC
• 192 infections in women detected
• 37 infant infections prevented
• 655 infant life-years saved per 100,000
women tested
• 5.2 million US$ net saving
o Miss infection during window
period
• Role of more sensitive
“Second test would result in net savings in
populations with HIV incidence of 1.2 per
1000 person-years or higher” Sansom
assays***
*Willams 2013; Kinuthia2010; **Soorapanth 2006;Sansom 2003; ***Busch1997;Morandi 1998;Quinn 2000; Hecht 2002
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• HAART for HIV infected pregnant and breast
feeding women irrespective of CD4 count, WHO
stage
• Option A and B is being phased out
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Syphilis in pregnancy
PLoS Med. 2013;10(2)
Bull World Health Organ. 2013 Mar 1;91(3):217-26
Global estimates of syphilis in pregnancy and
associated adverse outcomes: analysis of
multinational antenatal surveillance data
Untreated maternal syphilis and adverse
outcomes of pregnancy: a systematic review
and meta-analysis
Still births or
early
neonatal
deaths,
215000
Premature
or low birth
weight
infants,
65000
Prematurity
or low birth
weight, 6%
Neonatal
death, 9%
Neonatal
deaths,
90000
Congenital
syphilis,
150000
. *Newman;**Gomez
Not affected,
49%
Congenital
syphilis, 15%
Fetal loss or
stillbirth,,
21%
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Syphilis increase risk of HIV
AIDS. 2006 Sep 11;20(14):1869-77.
Maternal syphilis infection is associated with
increased risk of mother-to-child transmission of HIV
in Malawi
Int J Gynaecol Obstet. 1998 Dec;63(3):247-52.
Maternal syphilis and vertical perinatal transmission
of human immunodeficiency virus type-1 infection
• Maternal syphilis associated with
• Concurrent maternal syphilis infection
Intrauterine HIV MTCT, after
adjusting for maternal log10 HIV-1
viral load and low birth weight
ARR, 2.77; 95% CI, 1.40–5.46]
• Maternal syphilis associated with
Intrapartum/postpartun MTCT after
adjusting for recent fever, breast
infection, LBW and maternal log10
HIV-1 viral load
ARR, 2.74; 95% CI, 1.58–4.74)
Mwapasa 2006
associated vertical HIV transmission
compared with only history of treated
syphilis 100% vs. 21%, P = 0.01 or
100% vs. 14% ,p = 0.0015 for
women with no history of syphilis
• Non-Zidovudine exposed women with
concurrent syphilis transmitted HIV to
their infants compared to those with
only a history of syphilis
100% vs. 0% (P = 0.006)
Lee 1998
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Prevalence of syphilis and HIV among
pregnant women - Kenya
VDRL
Positive,
1.6%
HIV &
VDRL
negative,
89.5%
HIV
positive,
8.9%
HIV positive,
6.5%
HIV negative,
93.5%
KAIS 2007
KAIS 2012
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Screening for syphilis during pregnancy
• Routine test in antenatal care
• 1st ANC visit
o CDC recommends repeat in 3rd trimester*
Counselling experience among women aged
15 -54 years attending ANC**
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
90.1%
76.6%
47.2%
Counselled on MTCT
Counselled on HIV testing
Counselled on syphilis
screening
• Non-treponomal tests
o RPR/RPR
*CDC 2002;** KAIS 2012
• Barriers to screening
o
o
o
o
Cost
ANC non-attendance
Stock out of test kits
Wait time for results
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Correlates of Syphilis infection (n=1020)
OR
(95% CI)
Age (years)
1.05
(0.97-1.16)
0.2
Education (years)
0.82
(0.64-1.05)
0.11
Married
3.12
(0.40-24.3)
0.3
Ever trade sex
1.22
(0.54-2.73)
0.63
History of STI
10.36
(3.20-33.55)
<0.001
Partnership duration (yrs)
1.09
(1.00-1.19)
0.055
Unknown partner HIV status
1.71
(0.53-5.42)
0.37
Multiple sex partners
11.36
(1.30-98.7)
0.03
*yrs=years
p
19
X
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Dual eliminations strategies supports
attainment of MDGs
• Prevent Congenital syphilis
• Fewer spontaneous abortions
•
• Fewer still births
• Reduced risk of HIV acquisition
• Reduced HIV shedding
• Reduce risk of MTCT of HIV
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Why combine efforts towards elimination
of MTCT of HIV and syphilis
• Sexually transmitted infections that can affect
foetus/infant
• ANC entry point for care
• Point of care testing possible
• Effective interventions available
o Syphilis treatable
o PMTCT of HIV reduce risk to <2%
• Combined services more efficient
Acknowledgements
•
Mama Salama Study participants
•
Ahero and Bondo study staff
•
Research team
:
•
KNH/UoN
• John Kinuthia
• Daniel Matemo
• James Kiarie
•
UW
• Grace John-Stewart
• Alison Drake
• Katherine Odem-Davis
• Barbara Lohman Payne
• Barbra Richardson
• Jennifer Slyker
• Jennifer Unger
• Julie Overbaugh
• Scott McClelland
• Carey Farquhar
• Anjuli Wagner
• Gwen Ambler
•
CDC/KEMRI
• Clement Zeh
• Lisa Mills
• Funding
• NIH (P01 HSD 064915)
• CFAR (P30 AI27757)